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Chemotherapy and thoractomy for metastatic osteogenic sarcoma. A model for adjuvant chemotherapy and the rationale for the timing of thoracic surgery

Forty‐five children with osteogenic sarcoma metastatic to the lung were treated with sequential chemotherapy, consisting of high dose methotrexate (HDMTX) with citrovorum factor rescue (CFR), adriamycin, and cyclophosphamide, and the surgical removal of all pulmonary metastases when possible. Fourteen of the 45 patients had complete removal of all metastases at initial thoracotomy, followed by adjuvant chemotherapy. Ten of these 14 patients are surviving (all with no evidence of disease) for from 24–56 months (median 33+months) from the start of treatment. Thirty‐one of the 45 patients had diffuse pulmonary metastases and were treated with chemotherapy followed by multiple thoracotomies and further chemotherapy. Twelve of these 31 patients have no evidence of disease for from 6–41+ months (median 19+ months). The correlation of clinical response, with the surgical and histologic findings at the time of thoracotomy, following chemotherapy in this latter group of patients, has helped us to define the proper dose and scheduling of chemotherapy when used in an adjuvant situation. It also has provided a model for the efficacy of adjuvant chemotherapy in osteogenic sarcoma. In addition, this experience has led us to propose the following guidelines for the management of osteogenic sarcoma patients with pulmonary metastases: 1) pulmonary metastases large enough to be seen on roentgenogram should eventually be removed if possible, 2) patients with late occurring solitary pulmonary metastases should undergo initial surgical removal of pulmonary metastases, followed by “adjuvant” chemotherapy, and 3) patients with rapidly occurring or apparent multiple pulmonary metastases should undergo chemotherapy initially; if pulmonary metastases shrink in size or do not change in size over a period of 2–6 months of chemotherapy, an attempt should be made surgically to excise all “residual” disease prior to the continuation of chemotherapy. This approach to the treatment of osteogenic sarcoma in patients with pulmonary metastases has yielded an unexpectedly high disease‐free and prolonged survival rate, and demonstrates the value of aggressive treatment in this group of patients who classically had an extremely poor prognosis.