Treatment Options for Lung-Only Recurrence

Treatment options for patients with osteosarcoma and UPS of bone that has recurred in the lung only include the following:

Surgery to remove the tumor.

Chemotherapy or targeted therapy. For more information, see the Chemotherapy and targeted therapy section.

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Chemotherapy and targeted therapy

Radiation therapy.

Repeated resections of pulmonary recurrences can lead to extended disease control and, possibly, cure for some patients.[13,58] The survival rate is less than 5% for patients with unresectable metastatic disease.[6,59] The 5-year EFS rate ranges from 20% to 45% for patients who have complete surgical resection of all pulmonary metastases.[4,12,13]; [60][Level of evidence C1]

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Factors associated with a better outcome include the following:[4,6,61-63]

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Fewer pulmonary nodules.

Unilateral pulmonary metastases.

Longer intervals between primary tumor resection and metastases.

Tumor location in the periphery of the lung.

Approximately 50% of patients with one isolated pulmonary lesion more than 1 year after diagnosis were long-term survivors after metastasectomy. Chemotherapy did not appear to offer an advantage.[64][Level of evidence C1]

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Control of osteosarcoma requires surgical resection of all macroscopic tumors. However, recommendations are conflicting regarding the surgical approach to the treatment of pulmonary metastases in osteosarcoma. Several options are available to resect pulmonary nodules in a patient with osteosarcoma, including thoracoscopy and thoracotomy with palpation of the collapsed lung. When patients have nodules identified only in one lung, some surgeons advocate thoracoscopy, some advocate unilateral thoracotomy, and some advocate bilateral thoracotomy. Bilateral thoracotomy can be performed as a single surgical procedure with a median sternotomy or a clamshell approach, or by staged bilateral thoracotomies.

Evidence (surgical approach for lung-only recurrence of osteosarcoma and UPS of bone):

The St. Jude Children’s Research Hospital reported on 81 patients who had pulmonary nodules identified at initial presentation in only one lung by computed tomography (CT) scan.[65] They performed unilateral thoracotomy and did not explore the contralateral hemithorax. At the time of thoracotomy, 44 of 81 patients had a solitary nodule identified; 15 of 81 patients had two nodules identified; 16 of 81 patients had three to five nodules identified; and 6 of 81 patients had more than five nodules identified. Additional patients who were considered unresectable were not included in the analysis.

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The St. Jude Children’s Research Hospital reported on 81 patients who had pulmonary nodules identified at initial presentation in only one lung by computed tomography (CT) scan.[65] They performed unilateral thoracotomy and did not explore the contralateral hemithorax. At the time of thoracotomy, 44 of 81 patients had a solitary nodule identified; 15 of 81 patients had two nodules identified; 16 of 81 patients had three to five nodules identified; and 6 of 81 patients had more than five nodules identified. Additional patients who were considered unresectable were not included in the analysis.

Thirty-nine of 81 patients had subsequent pulmonary recurrence; for most patients, recurrence occurred within 6 months.

The St. Jude Children’s Research Hospital reported on 81 patients who had pulmonary nodules identified at initial presentation in only one lung by computed tomography (CT) scan.[65] They performed unilateral thoracotomy and did not explore the contralateral hemithorax. At the time of thoracotomy, 44 of 81 patients had a solitary nodule identified; 15 of 81 patients had two nodules identified; 16 of 81 patients had three to five nodules identified; and 6 of 81 patients had more than five nodules identified. Additional patients who were considered unresectable were not included in the analysis.

Within the first 6 months, 9 of 81 patients had ipsilateral recurrence, and 10 of 81 patients had a contralateral recurrence. By 2 years after initial thoracotomy, 13 of 81 patients had ipsilateral recurrence; 19 of 81 patients had contralateral recurrence; and 2 of 81 patients had bilateral recurrence.

The St. Jude Children’s Research Hospital reported on 81 patients who had pulmonary nodules identified at initial presentation in only one lung by computed tomography (CT) scan.[65] They performed unilateral thoracotomy and did not explore the contralateral hemithorax. At the time of thoracotomy, 44 of 81 patients had a solitary nodule identified; 15 of 81 patients had two nodules identified; 16 of 81 patients had three to five nodules identified; and 6 of 81 patients had more than five nodules identified. Additional patients who were considered unresectable were not included in the analysis.

OS was similar for patients with ipsilateral and bilateral recurrence.

The Memorial Sloan Kettering Cancer Center reported on pulmonary metastatic disease recurrence after initial therapy for osteosarcoma. Fourteen patients had pulmonary nodules identified in only one lung by CT scan. Nine patients were identified less than 2 years from initial diagnosis (early metastases), and five patients were identified more than 2 years from initial diagnosis (late metastases).[62] Seven of nine patients with early metastases had staged contralateral thoracotomies, and six of seven had nodules removed from the contralateral lung, despite negative CT scan findings.

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The Memorial Sloan Kettering Cancer Center reported on pulmonary metastatic disease recurrence after initial therapy for osteosarcoma. Fourteen patients had pulmonary nodules identified in only one lung by CT scan. Nine patients were identified less than 2 years from initial diagnosis (early metastases), and five patients were identified more than 2 years from initial diagnosis (late metastases).[62] Seven of nine patients with early metastases had staged contralateral thoracotomies, and six of seven had nodules removed from the contralateral lung, despite negative CT scan findings.

The lack of a comparison group precludes evaluation of the impact of the contralateral thoracotomy on subsequent EFS or OS.

The Memorial Sloan Kettering Cancer Center reported on pulmonary metastatic disease recurrence after initial therapy for osteosarcoma. Fourteen patients had pulmonary nodules identified in only one lung by CT scan. Nine patients were identified less than 2 years from initial diagnosis (early metastases), and five patients were identified more than 2 years from initial diagnosis (late metastases).[62] Seven of nine patients with early metastases had staged contralateral thoracotomies, and six of seven had nodules removed from the contralateral lung, despite negative CT scan findings.

The same group expanded their analysis to include a retrospective review of 161 thoracotomies performed in 88 patients with osteosarcoma metastatic to the lung.[66] In this expanded series, CT failed to identify one-third of pulmonary metastases confirmed by pathological examination.

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The COG is conducting a randomized trial (AOST2031 [NCT05235165]) to compare the effect of thoracotomy with thoracoscopic surgery to remove lung metastases. For more information, see the Treatment Options Under Clinical Evaluation section.

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External-beam radiation therapy can provide local control of recurrent unresectable disease, symptomatic, and/or metastatic disease. Radiation therapy techniques allow for the delivery of very conformal high doses, known as stereotactic ablative radiation therapy (SABR) or stereotactic body radiation therapy (SBRT). SBRT and SABR administer treatment with high conformality and precision over a short period of time, providing good palliation and local control.[67]

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Treatment Options for Lung-Only Recurrence

Studies cited in this source section

Publication references