Managing Spinal Osteosarcoma After Subtotal Resection
Key findings
- For patients with spinal osteosarcoma who have undergone subtotal resection, revision surgery confers a survival benefit
- Neoadjuvant or adjuvant chemotherapy treatment also confers a survival benefit for patients with spinal osteosarcoma
- Patients who received adjuvant radiation therapy following biopsy or subtotal decompression did not have significantly longer overall survival
It is common for patients with spinal osteosarcoma to undergo subtotal resection of the tumor, then later be referred to a center that can provide comprehensive management. Because this cancer is so rare, it is not known whether such patients benefit from subsequent en bloc resection. And if patients are not surgical candidates, it is not known whether they should have systemic chemotherapy or radiation therapy.
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Neurosurgeon Ganesh M. Shankar, MD, PhD, of Mass General, John H. Shin, MD, director of Metastatic Spine Oncology and Spinal Deformity Surgery at the Mass General Cancer Center, and colleagues conducted a systematic review and meta-analysis to explore these questions. They report in the Journal of Neurosurgery: Spine that after subtotal resection or local recurrence of spinal osteosarcoma, revision surgery may confer a survival advantage compared with intralesional surgery or no surgery. Because of small samples, the authors could not draw conclusions about whether marginal resection was superior to intralesional debulking.
Systemic chemotherapy can be considered after subtotal resection, the authors add, although they found insufficient data to conclusively guide regimen selection. Adjuvant radiotherapy can also be considered after subtotal resection, as it may improve the rate of local control.
The researchers reviewed the medical literature for English-language studies of spinal osteosarcoma that were published between 1966 and 2015. Studies were excluded if they did not separate osteosarcoma from other sarcoma subtypes or if they did not describe outcomes following intralesional or subtotal resection, adjuvant chemotherapy, radiation therapy or additional surgery.
Sixteen eligible studies were identified, and eight of these studies included four or more patients who underwent subtotal resection. Those studies were used for qualitative analysis and were aggregated with the eight smaller case reports for the meta-analysis.
A statistically significant survival benefit was noted in seven patients who underwent revision surgery following prior subtotal decompression, as compared with 82 patients who did not have further surgery (P = .01).
The survival benefit of chemotherapy after initial subtotal resection also reached statistical significance (P < .01). Adjuvant radiation therapy was associated with improved overall survival, but the difference did not reach statistical significance (24 vs 17 months with no adjuvant radiation therapy, P = .06).
The authors note that having to rely on case series and case reports, rather than prospective clinical trials, is a notable limitation of their systematic review. Tumors amenable to subsequent resection, and those inherently more sensitive to adjuvant therapy, would exaggerate a therapeutic effect of these interventions when studied retrospectively.
The authors warn that the strength of these recommendations is weak and the quality of evidence is low (case series) to very low (case reports).
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