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The development of effective chemotherapy for osteosarcoma in the 1980s led to a drastic improvement in survival. This, along with advances in imaging modalities, allowed safe and effective limb salvage surgery to evolve.
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Survival has reached a plateau since the 1990s, while progress in limb salvage surgery continues to be made.
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Following patients for late effects of chemotherapy and surgery for osteosarcoma is critical now that most patients are long-term survivors.
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Future efforts are needed to
Update on Survival in Osteosarcoma
Section snippets
Key points
History and background
Osteosarcoma is a primary malignant tumor that arises in bone, in which the malignant cells produce osteoid (Fig. 1). There are many subtypes, but the most common and the focus of this article is high-grade conventional osteosarcoma. It is the most common primary sarcoma of bone, but is still quite rare. Osteosarcomas represent fewer than 1% of cancers overall, with an incidence of 5 per 1,000,000 children age 19 and younger in the United States.5 It is slightly more common in male than female
Prognostic factors
Many of the clinical trials and several large retrospective studies have demonstrated the importance of several factors affecting prognosis in high-grade osteosarcoma.
Nonmetastatic
The determination of which chemotherapeutic agents to use for patients with osteosarcoma was largely empiric, based on some agents’ success in other tumor types. Collaboration across centers and countries has demonstrated the effectiveness of current regimens, although there is no consensus on which medications and what dosing should be used. Most protocols today involve doxorubicin, cisplatin, and high-dose methotrexate, termed MAP (Methotrexate, doxorubicin/Adriamycin, cisPlatin).30 High-dose
Surgery
As survival in osteosarcoma has plateaued, the numbers of patients having limb salvage surgery continues to grow.4 The quality and nature of surgical resection for osteosarcoma has a great impact on survival. Although there are myriad approaches to resection and reconstruction of a bone affected by osteosarcoma, some important requirements hold true for all.
Late effects of therapy
Now that roughly two-thirds of patients presenting with nonmetastatic osteosarcoma will be long-term survivors of their disease, it has become apparent that they are at risk for certain late effects of treatment due to the chemotherapy and surgery.
Chemotherapy
There have been almost no promising developments in chemotherapy since the 1980s, and as a result, survival in patients with localized disease has reached a plateau. Two recent and very thorough meta-analyses highlighted this and have brought the discussion to the forefront again.3, 4 The only new agent with any meaningful impact on survival is the immune modulator liposomal muramyl-tripeptide phosphatidyl ethanolamine (L-MTP-PE, mifamurtide), with 8% improvement in overall survival at 6 years.
Summary
Survival in osteosarcoma has improved drastically since the development of effective chemotherapy in the 1970s to 1980s, but has now reached a plateau over several decades. If further gains are to be made, further collaboration is key, and osteosarcoma has been a role model for that in the past. Our goals are to improve survival not only for patients with localized disease, but especially for those with metastatic, relapsed, and/or refractory disease in whom prognosis has remained poor; to
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The author has nothing to disclose.