This protocol applies to high-grade osteosarcoma in a specific sub-population: patients who are 40 years of age or older, or those who cannot tolerate high-dose methotrexate. Management in this group requires individualized consideration of age, performance status, and organ function.
For patients over 40 years and those who cannot tolerate high-dose methotrexate, regimens without methotrexate may still be effective. Dosing is not standardised and may vary according to performance status, cardiac and renal function, and other comorbidities.
Management combines chemotherapy with surgical resection, with the specific regimen, sequencing, and adaptations tailored to each patient's profile — the full structured protocol is available via the link below.
For patients over 40 years and those who cannot tolerate HDMTX, regimens without methotrexate may still be effective.
AP alone is considered suitable therapy, although doses are not standardised and may vary according to performance status, cardiac and renal function and other co-morbidities.
For older patients, it is reasonable to consider surgery first, followed by adapted chemotherapy protocols.
The aim of surgery is complete tumour removal, preserving function where possible.
Radiotherapy may be considered for those with inoperable, axial primary osteosarcomas to achieve local tumour control, or for selected patients with axial tumours in the adjuvant setting where there is a high risk of local recurrence and further surgery is felt to be unacceptable.
If there is a good histological necrosis rate (> 90%) after chemotherapy, a closer surgical margin can be considered safe.
Histological response to induction therapy is a robust prognostic indicator.
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