Localized Osteosarcoma
Metastatic Osteosarcoma

Enneking devised a staging system for musculoskeletal neoplasms.[1] Staging was based on the grade, site, and presence of metastases. All conventional osteosarcomas are high grade. Site is graded as intracompartmental or extracompartmental. To be intracompartmental, an osteosarcoma must be confined within the periosteum. Such lesions would be IIA in the Enneking system. The great majority of osteosarcomas extend beyond the periosteum, which makes them IIB. The presence of clinically detectable metastases is graded as stage III in this system. For practical purposes, there are essentially two classes of patients: those who present without clinically detectable metastatic disease (localized osteosarcoma) and those who present with clinically detectable metastatic disease (metastatic osteosarcoma).

Localized tumors are limited to the bone of origin; local skip metastases may be apparent within the bone and have previously been associated with an inferior prognosis.[2] Analysis of the German Cooperative Osteosarcoma Study experience, however, suggests that skip lesions do not confer an inferior prognosis if they are included in planned surgical resection.[3] Approximately one-half of the tumors arise in the femur; of these, 80% are in the distal femur. Other primary sites in descending order of frequency are the proximal tibia, proximal humerus, pelvis, jaw, fibula, and ribs.[4] Compared with osteosarcoma of the appendicular skeleton, osteosarcoma of the head and neck is more likely to be low grade [5] and to arise in older patients. A retrospective analysis identified a trend toward better survival in patients with osteosarcoma of the mandible and maxilla who received adjuvant chemotherapy.[6]

Radiologic evidence of metastatic tumor deposits in the lungs, other bones, or other distant sites is found in 10% to 20% of patients at diagnosis, with 85% to 90% of metastatic disease presenting in the lungs. The second most common site of metastasis is another bone.[7] Metastasis to other bones may be solitary or multiple. The syndrome of multifocal osteosarcoma refers to a presentation with multiple tumors in many bones, often with symmetrical metaphyseal involvement. Multifocal osteosarcoma has an extremely grave prognosis.[4]

References

1. Enneking WF: A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res (204): 9-24, 1986.  [PUBMED Abstract]
   
   
2. Wuisman P, Enneking WF: Prognosis for patients who have osteosarcoma with skip metastasis. J Bone Joint Surg Am 72 (1): 60-8, 1990.  [PUBMED Abstract]
   
   
3. Kager L, Zoubek A, Kastner U, et al.: Skip metastases in osteosarcoma: experience of the Cooperative Osteosarcoma Study Group. J Clin Oncol 24 (10): 1535-41, 2006.  [PUBMED Abstract]
   
   
4. Longhi A, Fabbri N, Donati D, et al.: Neoadjuvant chemotherapy for patients with synchronous multifocal osteosarcoma: results in eleven cases. J Chemother 13 (3): 324-30, 2001.  [PUBMED Abstract]
   
   
5. Patel SG, Meyers P, Huvos AG, et al.: Improved outcomes in patients with osteogenic sarcoma of the head and neck. Cancer 95 (7): 1495-503, 2002.  [PUBMED Abstract]
   
   
6. Canadian Society of Otolaryngology-Head and Neck Surgery Oncology Study Group.: Osteogenic sarcoma of the mandible and maxilla: a Canadian review (1980-2000). J Otolaryngol 33 (3): 139-44, 2004.  [PUBMED Abstract]
   
   
7. Harris MB, Gieser P, Goorin AM, et al.: Treatment of metastatic osteosarcoma at diagnosis: a Pediatric Oncology Group Study. J Clin Oncol 16 (11): 3641-8, 1998.  [PUBMED Abstract]