High-Grade Osteosarcoma in Patients Over 40: What to Do When Initial Chemotherapy Did Not Achieve Adequate Tumour Necrosis

Clinical Scenario

This protocol addresses adults over 40 years of age with high-grade resectable osteosarcoma. Conventional osteosarcoma is always high-grade, and the patient's age is a clinically meaningful factor that shapes the overall management approach.

When the Previous Treatment Did Not Reach Its Goal

The initial treatment line — neoadjuvant chemotherapy with doxorubicin, cisplatin, and ifosfamide, followed by wide surgical excision and adjuvant chemotherapy — aims for a histological response of 90% or greater tumour necrosis on the surgical specimen, indicating a good response to preoperative treatment. When this threshold is not met, or when disease recurs subsequently, the protocol described here defines the next step.

Next-Line Approach (Partial Overview)

Management at this stage is centred on a surgical strategy directed at metastatic disease. Alternatives are available for patients who are not surgical candidates. The full structured protocol specifies the clinical decision points and the options in detail.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.annonc.2021.08.1995

Conventional osteosarcoma is always high-grade.

In patients >40 years, preferred regimens combine doxorubicin, cisplatin and ifosfamide [III, B].

The treatment of recurrent osteosarcoma is primarily surgical in patients with isolated lung metastases or LR.

Complete removal of all resectable metastases must be attempted, as more than one-third of patients with a complete second surgical remission survive for >5 years.

Even patients with subsequent recurrences may be cured as long as recurrences are resectable, and repeated thoracotomies are often warranted.

For lung metastases, stereotactic RT, radiofrequency ablation (RFA) or cryotherapy might be used as alternative options in patients unfit for surgery.

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