Non-surgical treatment of pulmonary and extra-pulmonary metastases

Studies have demonstrated that chemotherapy alone is usually unsuccessful as exclusive therapy for osteosarcoma (Cancer 95:2202-2201, 2002). Information will be presented for situations where non-surgical alternatives could be considered as useful, if not necessary, adjuncts to chemotherapy. In the thorax these include treatment of pleural effusions, chest wall lesions, central lung or mediastinal osteosarcoma, as well as recurrences in patients with limited pulmonary reserve. Other situations include too many metastases to easily resect, axial osteosarcomas, bone metastases, liver and brain metastases. Non-surgical local control measures include radiation with chemotherapy for radiosensitization, bone-seeking radioisotopes (e.g., 153Sm-EDTMP, 223Ra), bisphosphonates, heat (radiofrequency ablation), freezing and thawing (cryoablation), and intracavitary or regional (aerosol) therapy. Because of the predictable and common pattern of pulmonary metastases in osteosarcoma, aerosol therapy also offers an attractive regional treatment strategy. Principles and use of aerosol cytokines (e.g., GM-CSF, IL-2), and aerosol chemotherapy with gemcitabin will be discussed. Individual cases illustrating strategy and techniques will be presented.