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• W2022503543 abstract "The commonest primary malignant bone tumor is osteosarcoma. This lesion is frequently a topic at conferences and seminars probably because the roentgenographic appearance and the histopathologic features provide challenging diagnostic possibilities. Osteosarcoma is defined as a tumor, the malignant cells of which produce osteoid in at least small foci. Interestingly, despite 2 to 3 decades of publications on ancillary chemotherapy, no unanimity exists on which chemotherapeutic agents should be used or even whether chemotherapy is definitely indicated for osteosarcoma. When Coventry and I first published our experience with osteosarcoma more than 20 years ago1Dahlin DC Coventry MB Osteogenic sarcoma: a study of six hundred cases.J Bone Joint Surg [Am]. 1967; 49: 101-110PubMed Google Scholar and indicated that the likelihood of survival with surgical therapy alone was 20%, many colleagues from around the world said that the figure was unrealistically high. Actually, very few investigators had follow-up on a substantial number of cases. Within a few years, the 20% survival figure became recognized as valid and was accepted as a baseline for comparison of results with new treatment modalities. Differences among the various types of osteosarcoma eventually became recognized.2Dahlin DC Unni KK Osteosarcoma of bone and its important recognizable varieties.Am J Surg Pathol. 1977; 1: 61-72Crossref PubMed Scopus (169) Google Scholar For example, in comparison with ordinary sarcomas, osteosarcomas of the jaws are associated with a better prognosis, as are the relatively uncommon, low-grade, central osteosarcomas, the parosteal osteosarcomas (which are usually grade 1 or 2), and the periosteal osteosarcomas (which are of lower grade than the average osteosarcoma). Patients with other osteosarcomas, such as osteosarcomas in Paget's disease of bone and those that result from dedifferentiation of chondrosarcoma, have a notoriously poor prognosis. Each of these variants of osteosarcoma should be excluded in the evaluation of new treatment modalities. Likewise, those osteosarcomas difficult or impossible to remove completely, such as those that originate in the spine or skull, must be considered separately. As a further complication of assessment of new treatment modalities for osteosarcoma, evidence was found that patients with osteosarcoma might have a better survival in more recent years than in the past.3Taylor WF Ivins JC Dahlin DC Edmonson JH Pritchard DJ Trends and variability in survival from osteosarcoma.Mayo Clin Proc. 1978; 53: 695-700PubMed Google Scholar The study that proclaimed this change in survivorship cast serious doubt on the use of historical controls in the evaluation of new drugs. At least some of the better prognoses that had been attributed to chemotherapy were thought to be due to the time at which the therapy was instituted. The evaluation of treatment of osteosarcoma is also complicated by the unknown selection factors that may play a role in the determination of what type of patient may gravitate to any referral center, as noted by Beard and associates in this issue of the Proceedings (pages 332 to 336). In the ensuing 20 years since publication of the data indicating a survivorship of 20%, several different approaches to therapy for osteosarcoma have been reported in the literature. These new techniques have included prophylactic x-ray therapy to the pulmonary fields, preoperative radiation therapy to the primary tumors, immunotherapy by a variety of means, and ancillary therapy with interferon and transfer factor. Most institutions no longer use any of these modalities of therapy because they have not proved to be of appreciable value. Some of them have actually been detrimental. Surgical removal of metastatic pulmonary deposits has proved to be beneficial for some patients, and this therapeutic modality has gained widespread acceptance. Chemotherapy ancillary to surgical removal of the primary tumor has also gained acceptance in most medical centers. The specific chemotherapeutic agents to be used are still subject to controversy. Currently, cisplatin and methotrexate are probably the most frequently used agents. Whether the chemotherapy should be given before or after the definitive surgical procedure is also somewhat controversial. Advocates of preoperative chemotherapy indicate that limb-saving procedures are sometimes facilitated, especially for those patients who have a good response to the chemotherapy. In the past, an ablative operation almost routinely meant amputation, sometimes of the radical type that has been called hindquarter or forequarter amputation. In recent years, an increasing percentage of patients suffering from osteosarcoma are being subjected to the less mutilating, limb-sparing procedures. Successful local resections can be done for smaller or lower grade tumors or for those patients who have a good response to preoperative chemotherapy. Patients with Ewing's tumor are treated with local radiation therapy or by removal of the tumor by amputation or a lesser procedure, depending on such factors as the location and the size of the primary sarcoma and the patient's age. Use of adjunctive multiagent chemotherapy is now almost routine. Ancillary chemotherapy has been associated with a dramatic increase in the likelihood of cure for patients with Ewing's sarcoma. Sometimes a dramatic response to chemotherapy occurs in patients with tumors such as myeloma. No well-accepted ancillary chemotherapy is available for certain types of primary malignant lesions of bone, such as chondrosarcoma and fibrosarcoma. For selected tumors of these and other miscellaneous types, ancillary radiation therapy may be used. One result seems certain. The reported prognosis associated with osteosarcomas and some other bone tumors seems to be improving. Some investigators credit this improvement to a wide variety of chemotherapeutic agents. Although no unanimity exists about the ancillary drugs of choice, chemotherapy will continue to have a role in the management of many primary tumors of bone, including osteosarcoma." @default.
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• W2022503543 title "Malignant Bone Tumors: Improvement in Prognosis" @default.
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• W2022503543 doi "https://doi.org/10.1016/s0025-6196(12)64865-4" @default.
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