Osteosarcoma: Drug Therapy

Therapeutic targets

  • Relief of pain
  • Stabilization of bone sections at risk of fracture
  • Reduction of tumor size – preoperatively (before surgery) by chemotherapy (neoadjuvant chemotherapy).
  • Removal of the tumor – see “Surgical therapy“.
  • Healing

Therapy recommendations

Therapy depends on the extent of the bone tumor. Most often, therapy consists of a combination of surgery and chemotherapy (synonym: cytostatic therapy). The duration of total therapy is approximately 9-12 months.

  • Analgesia according to WHO staging scheme:
    • Non-opioid analgesic (paracetamol, first-line agent).
    • Low-potency opioid analgesic (e.g., tramadol) + non-opioid analgesic.
    • High-potency opioid analgesic (eg, morphine) + non-opioid analgesic.
  • Chemotherapeutic agents are used as an independent form of therapy with a curative (curative) or palliative (palliative; without a curative approach) approach.

Therapy sequence

  • due tohigh risk of metastases (formation of daughter tumors) and to reduce the tumor mass before surgery, chemotherapy (= neoadjuvant chemotherapy; induction chemotherapy) is given according to therapy protocol (therapy optimization studies; COSS: Cooperative Sarcoma Study of the GPOH; EURAMOS. European and American Osteosarcoma Study; EURO-B.O.S.S.: for older patients (41-65 years)).
    • Duration: up to 10 weeks
    • Note: Patients with painful spontaneous fracture may not require preoperative chemotherapy.
  • Subsequently tumor extirpation (surgical removal of the tumor) (> 80% of patients can be operated arm and leg preserving).
  • Postoperatively, further chemotherapy is given (= adjuvant chemotherapy).
    • Duration: up to 10 weeks: up to 18 weeks.
  • Osteosarcoma is not very sensitive to radiation.
  • Local recurrences and lung metastases must be surgically removed. If necessary, chemotherapy is administered again. Radiatio (radiotherapy) may be used for inoperable recurrences.

Cytostatics

The following cytostatic drugs can be used in combination (polychemotherapy protocols) for primary malignant bone tumors:

  • Adriamycin (ADR)
  • Bleomycin
  • Cisplatin (DDP)
    • Ensure adequate hydration (fluid intake) for renal protection!
  • Citrovorum factor
  • Cyclophosphamide
  • Dactinomycin
  • Ifosfamide (IFO)
    • Ensure adequate hydration (fluid intake) for renal protection!
    • Application of a uroprotector: Uromitexan
    • High-dose use may cause encephalopathy (pathological/diseased brain changes) → use of methylene blue.
  • Methotrexate with folic acid rescue (HD-MTX).
    • Ensure adequate hydration (fluid intake) for renal protection!
    • Due to increased risk of complications, if necessary, do not use in patients over 40 years!
    • If there is a massive MTX excretion disorder, helps carboxypeptidase G2 (glucarpidase).
  • Vincristine

Cytostatic drugs for local recurrence and pulmonary metastases:

No information on dosages is given here, because changes in the respective regimens are common during chemotherapy.