eMedicine Specialties > Pediatrics: General Medicine > Oncology

Osteosarcoma: Follow-up

Author: Timothy P Cripe, MD, PhD, Associate Professor of Pediatric Hematology/Oncology, University of Cincinnati; Director, Translational Research Trials Office, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
Contributor Information and Disclosures

Updated: Aug 7, 2008

Follow-up

Further Inpatient Care

• Patients receiving chemotherapy generally require inpatient admission for drug administration and monitoring. In protocol CCG-7921, definitive surgery was performed after 2 cycles of induction chemotherapy. Four maintenance cycles were given beginning 2-3 weeks after surgery. Given the assumption of no therapeutic delays, the entire course of treatment lasted approximately 46 weeks.
• If patients have fever and neutropenia, admission is required for intravenous antibiotics and monitoring.
• Admission is required perioperatively for local-control procedures (eg, surgical resection, amputation), usually around week 10 of therapy. Resection of metastatic disease (eg, lung nodules) is usually performed at the same time.
• Patients may require admission for a multitude of other medical problems during chemotherapy. Examples include varicella infection (for intravenous acyclovir and monitoring), mucositis (for pain control, usually with narcotics), dehydration, meningitis, constipation, fungal pneumonia, and cystitis, among others.

Further Outpatient Care

• CBC count: Perform a CBC count twice each week for patients receiving G-CSF. Discontinue G-CSF when the ANC has reached a predetermined level (usually 1 or 5 X 10⁹ [1000 or 5000/µL]).
• Blood chemistries: Monitoring blood chemistries, including monitoring with renal and liver function tests, is important for patients receiving parenteral nutrition or for those who have a history of organ toxicity (especially if nephrotoxic or hepatotoxic antibiotics or other drugs are continued).
• Monitoring for recurrence: After completing chemotherapy, patients should continue to undergo regular blood workup and radiographic scanning on an outpatient basis, with the frequency decreasing over time. In general, these visits occur every 3 months for the first year, every 6 months for the second year and perhaps a third year, and yearly thereafter.
• Long-term follow-up: Five years of longer after patients finish therapy, they are considered long-term survivors. They should be seen annually in a late-effects clinic and monitored with appropriate studies depending on their therapy and toxic effects. Visits may include hormonal, psychosocial, cardiologic, and neurologic evaluations.

Inpatient & Outpatient Medications

• Trimethoprim-sulfamethoxazole: At some treatment centers, clinicians routinely prescribe prophylaxis against pneumocystic pneumonia; others do not.
• Fluconazole: Systemic fungal prophylaxis is not necessary.
• Clotrimazole: Prophylactic therapy for thrush may be discontinued when chemotherapy has been completed.
• Chlorhexidine mouth rinse: Prophylaxis against gingivitis and other mouth infections may be discontinued when chemotherapy is completed.

Transfer

• Pediatrician or general practitioner: Although the major therapy for cancer should take place at a center staffed by pediatric oncologists, the referring physicians should continue to play an important role in children's care throughout treatment. The referring physician can be critical in performing the first evaluation of an illness, particularly if the child lives far from the oncology center.
• Orthopedic surgeon: The orthopedic surgeon is often the first subspecialist to evaluate the patient with a suspected bone tumor. The surgeon's involvement is not only critical to establishing the diagnosis with biopsy but also paramount for local control (amputation vs limb-salvage resection). In addition, the orthopedic surgeon should continue to follow up with patient to assess function of the limb and prosthesis.

Deterrence/Prevention

• No preventive measures for childhood cancers are known.

Complications

• Cardiomyopathy is primarily a result of anthracycline (doxorubicin) use. Patients should receive routine follow-up echocardiography studies after they complete therapy and periodically long-term
• Secondary malignant neoplasms may arise as a result of chemotherapy, particularly with alkylating agents.
• Infertility is a nearly universal effect of the high-dose alkylating agents used to treat osteosarcoma.
• Hearing loss is common due to cisplatin and should be monitored carefully during treatment.²⁴
• Long-term quality-of-life measurements suggests patients with amputations do as well as those with limb-salvage.²⁵

Prognosis

• Patients with the periosteal type of osteosarcoma have a more favorable outcome. In an analysis of 119 patients, the overall survival was 83% at 10 years.²⁶
• The prognosis for patients with conventional high-grade osteosarcoma primarily depends on whether metastases are detectable at diagnosis. Patients who present with metastases or with multifocal disease have a poor prognosis, with long-term survival rates of less than 25%.
• For patients with initially localized disease, the prognosis depends mainly on 2 variables: resectability and the response to chemotherapy. Those who have completely resectable disease and those whose tumors have an excellent histologic response to neoadjuvant chemotherapy have the best likelihood for a cure.
• Before the 1970s, the 5-year survival rate of patients with nonmetastatic osteosarcoma was less than 20%, even with aggressive surgery (mostly amputations).
• The fact that most relapses occurred at metastatic sites (primarily the lung) attests to the fact that most patients have undetectable metastatic disease at diagnosis (ie, micrometastatic disease).
• With the introduction of postoperative (adjuvant) chemotherapy, survival rates began to improve.
• According to data from the NCI SEER program, the 5-year survival rate from 1975-1984 was 49% and from 1985-1994 was 63%.¹ For the latter period, female patients fared slightly better than male patients (5-year survival rates of 70% vs 59%).
• Results of the most recent cooperative group trial conducted by the Children's Oncology Group suggest that the addition of ifosfamide to standard 3 drug regimen was not helpful, but that the addition of the immune-enhancing drug muramyl tripeptide increased 6-year overall survival from 70% to 78% for localized disease.²² The use of MTP-PE requires further investigation before becoming standard therapy.
• Surgical resection of recurrent disease can achieve cure in about 25% of patients.²⁷
• Improving the survival rate and functional outcome and minimizing the short-term and long-term adverse effects remain goals of clinical trials for osteosarcoma.  
• The major challenge is curing patients with unresectable metastatic disease.
  • Strategies currently under consideration include dose intensification (eg, anthracycline dose-escalation facilitated by dexrazoxane cardioprotection), immune modulators, monoclonal antibodies targeting tumor-cell antigens (eg, Her2/neu), and antiangiogenic agents that target components of the tumor vascular supply.
  • High-dose administration of the bone-seeking radioisotope samarium is also under investigation (with autologous stem-cell support) for safety and efficacy in metastatic or nonresectable osteosarcoma limited to bone.
  • Finally, the role of the emerging field of oncolytic viruses for the treatment of osteosarcoma has yet to be explored.

Patient Education

• Chemotherapy: Parents and patients (if appropriate) must undergo formal education about chemotherapy to learn about the adverse effects of their medications. They must know what is expected to happen as a result of the therapy, and they should encouraged to call with any questions.
• Central venous catheters: When patients have central venous catheters that exit the skin (eg, Hickman or Broviac catheters), the patient or the parents must learn to properly care for the line.
  • This care usually involves daily heparin flushes.
  • They must also know their limitations (eg, restriction from swimming).
  • Patients with subcutaneous catheters (eg, Mediport catheters) do not need to perform daily-care routines, but they should learn to apply a topical anesthetic (eg, lidocaine-prilocaine [EMLA] cream) at least 1 hour before an anticipated needle stick.

Miscellaneous

Medicolegal Pitfalls

• Mild symptoms from osteosarcoma are commonly ascribed to other causes, such as growing pains, arthritis, or antecedent trauma. Because the ability to remove the lesion and the functional result partly depend on the local extent of the disease, making the diagnosis as early as possible is imperative.
• Whether metastatic disease represents a distinct tumor subtype is unclear; therefore, whether metastases in most cases can be prevented with early detection is also unclear.
• Early detection and, most importantly, appropriate referral to an orthopedic surgeon and an oncologist should minimize medicolegal issues.

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