Initial treatment of osteosarcoma aims to achieve a good clinical response, as evidenced by reduction of pain and discomfort, restoration of function, return of temperature of overlying skin to normal, and reduction in the soft tissue component of the tumour.31
The choice of surgical management and adjuvant antineoplastic agent regimen are most critically influenced by histologic response to neo-adjuvant therapy.
Histologic response is defined as the proportion of tumour cell kill determined on biopsy or resection. A good histologic response is reported as greater than 90% necrosis in the specimen collected and combined with a clinical response lends to a favourable outcome in terms of long-term prognosis and the possibility of limb-sparing surgery.8
Principles of surgical management of bone cancer include:6, 7
- safe removal of tumour
- preservation of as much function as possible
- adequate surgical margins to reduce risk of local recurrence.
Local tumour control may be achieved by either limb-sparing resection or limb amputation. Benefits of limb-sparing surgery (LSS) include the advantage of retention of function and less body mutilation than with primary amputation. However, these benefits are balanced against the potential for longer hospitalisation due to infection, repeated prosthesis lengthening for young individuals, and increased risk of local recurrence if the LSS results in poorer cancer control locally.
Evidence is mixed about whether LSS results in improved quality of life over amputation. However, body image and everyday functional competence were better in individuals following LSS.32 Amputation is generally reserved for individuals with tumours in unfavourable anatomic locations precluding limb-sparing surgery.
Metastatic disease confined to the lung may also be considered for surgical management. Complete surgical resection of lung metastases offers possibility of cure in up to one-third of individuals.19 Individuals who are not surgical candidates may be offered palliative chemotherapy.19
Irrespective of surgical management, poor prognostic factors include metastasis at presentation and poor histologic response to preoperative chemotherapy.
Other factors that may contribute to poor prognosis include large tumour volume, older age, axial tumour location, presence of pathologic fracture and local recurrence after surgery.33
Disease-free survival rates at five years are 10-30% for individuals who present with metastatic disease only in the lungs, and who achieve a complete response to antineoplastic agents in addition to total resection of tumour. Survival rates increase to 50-70% when current multi-agent chemotherapy regimens are used.19
Osteosarcomas are considered relatively radiation resistant,19 though radiotherapy may play a part in palliative or supportive care.6, 7
Summarise the impact across all domains of health of limb amputation in AYA.
Access the NCCN Guidelines Version 1.2015 Bone Cancer.6 (Free resource, but you must register and then click 'Remember me' to bypass the login page in future).
- Identify the indications for neoadjuvant antineoplastic agents for osteosarcoma.
For each of the following drugs commonly used in protocols to treat osteosarcoma:
- Methotrexate (high dose).
- Identify the classification of the drug.
- Discuss potential short and long term toxicities associated with the drug.
- Explain the nursing interventions to prevent, detect early and manage these toxicities.
- Identify other nursing considerations associated with administering these drugs.
Cancer clinical trials and AYA
Advances in cancer treatment in relatively rare AYA cancers rely on global collaboration and research consortiums. Organisations such as the Children's Oncology Group (COG) and institutional partnerships are critical in the global effort to learn more about AYA cancer, to disseminate best evidence in clinical management, and to facilitate and coordinate clinical trials.
Internationally, participation in clinical trials has been identified as important to improved outcomes, particularly for AYA affected by sarcoma, yet AYA are included much less in clinical trials than younger children.5, 16, 34
It has been reported that AYA affected by bone and soft tissue sarcomas in Victoria were significantly less likely to be included in clinical trials than children. Participation in clinical trials for 15-20 year olds was 4% (survival rate 52%) and for 10-15 year olds 33% (with 80% survival).35
Identify why few AYA participate in clinical trials. Discuss how this situation can be improved.
Access the following sites to identify possible trial opportunities for Justin: