Treatments for childhood osteosarcoma

A child diagnosed with osteosarcoma will have a treatment plan created just for them by their healthcare team. It will be based on important information about the cancer and about the child. When deciding which treatments to offer as part of the plan, the healthcare team will consider the:

• stage of childhood bone cancer

• size of the tumour and where it is
• child’s age
• child's overall health, lifestyle and activity levels

Find out more about your child's healthcare team, helping your child cope with tests and treatment and tips on managing your child's care.

Localized osteosarcoma in children is usually treated with chemotherapy followed by surgery to remove the primary tumour, and then more chemotherapy.

Chemotherapy uses anticancer (cytotoxic) drugs to destroy cancer cells. It may be given before or after surgery to remove the primary tumour. When chemotherapy is given before surgery it is called neoadjuvant chemotherapy. When chemotherapy is given after surgery it is called adjuvant chemotherapy.

Chemotherapy is often given before surgery as the first treatment for localized childhood osteosarcoma. Neoadjuvant chemotherapy is usually given for 10 weeks before surgery.

After at least 10 weeks of neoadjuvant chemotherapy, doctors will use imaging tests to plan for surgery and remove the tumour. Chemotherapy is given after surgery to destroy any cancer cells left behind after surgery and lower the risk of cancer coming back. Adjuvant chemotherapy usually starts 2 to 3 weeks after surgery and continues for 18 weeks.

The most common chemotherapy drugs used for osteosarcoma are:

• high-dose methotrexate
• doxorubicin
• cisplatin
• ifosfamide (Ifex)
• cyclophosphamide
• etoposide (Vepesid)
• carboplatin

The most common chemotherapy combinations used for osteosarcoma are:

• high-dose methotrexate, doxorubicin and cisplatin

• doxorubicin and cisplatin
• ifosfamide and etoposide

Cyclophosphamide and ifosfamide can irritate the bladder. When these chemotherapy drugs are used, mesna (Uromitexan) is also given to protect the bladder.

Find out more about chemotherapy for childhood bone cancer.

The goal of surgery is to remove the entire tumour. A wide resection removes the tumour and some healthy tissue around it. Doctors may use other terms for wide resection, such as wide local excision or en bloc resection. Chemotherapy may be given before surgery.

The type of surgery done will depend mostly on the size of tumour and where it is.

Tumours in the arms or legs are treated with limb-sparing surgery, amputation or rotationplasty.

• Limb-sparing surgery removes a tumour in an arm or leg but does not remove the limb. There may be several options for reconstruction available depending on your child's age, future growth and desired lifestyle.

• Amputation removes part or all of an arm or leg. It may be done when it is not possible to do limb-sparing surgery.
• Rotationplasty is a surgical procedure to treat tumours that occur near the knee.

Tumours in the pelvic (hip) bones can be hard to treat with surgery. Surgery may be done to remove the tumour and the pelvic bones can sometimes be reconstructed after surgery.

Tumours in the lower jawbone may be treated with surgery to remove the lower half of the jaw. The jaw can be rebuilt from other parts of the body.

Find out more about surgery for childhood bone cancer.

Metastatic osteosarcoma in children is usually treated with chemotherapy followed by surgery to remove the primary tumour and the cancer that has spread.

Chemotherapy uses anticancer (cytotoxic) drugs to destroy cancer cells. The most common chemotherapy drugs used for metastatic osteosarcoma are:

• high-dose methotrexate
• doxorubicin
• cisplatin
• ifosfamide
• cyclophosphamide (Procytox)
• etoposide
• carboplatin

The most common chemotherapy combinations used for metastatic osteosarcoma are:

• high-dose methotrexate, doxorubicin and cisplatin

• doxorubicin and cisplatin
• ifosfamide and etoposide

Cyclophosphamide and ifosfamide can irritate the bladder. When these chemotherapy drugs are used, mesna is also given to protect the bladder.

Find out more about chemotherapy for childhood bone cancer.

Surgery is often done after chemotherapy. It is used to remove the primary tumour and metastases. The types of surgery would be the same as those used for localized childhood osteosarcoma.

In some cases, surgery is needed to control pain or repair a broken bone. In these cases, surgery to remove the primary tumour is done before chemotherapy is given.

Find out more about surgery for childhood bone cancer.

The treatments offered for recurrent childhood osteosarcoma are based on:

• how long since the last treatment
• age at first diagnosis
• whether there was metastasis at first diagnosis
• whether the recurrence (the cancer coming back) is local (close to the primary tumour) or metastatic (in another part of the body)
• whether the tumour can be removed
• what treatments were used before

Treatments used for recurrent childhood osteosarcoma include surgery, chemotherapy and targeted therapy.

Surgery may be used to remove tumours that recur in the lungs. Surgery may also be used to remove cancer that recurs in other bones. Find out more about surgery for childhood bone cancer.

Chemotherapy uses anticancer (cytotoxic) drugs to destroy cancer cells. Chemotherapy with one or more of the following drugs may be given, depending on what chemotherapy was used before:

• ifosfamide with or without etoposide

• cyclophosphamide and topotecan
• gemcitabine alone or in combination with docetaxel
• cyclophosphamide and etoposide
• ifosfamide, carboplatin and etoposide
• high-dose methotrexate
• high-dose methotrexate, etoposide and ifosfamide

Find out more about chemotherapy for childhood bone cancer.

Targeted therapy uses drugs to target specific molecules (such as proteins) on cancer cells or inside them to stop the growth and spread of cancer. It may be used to treat recurrent osteosarcoma, usually as part of a clinical trial. Some targeted therapy drugs that may be used include:

• regorafenib

• cabozantinib
• everolimus
• denosumab
• dinutuximab

Find out more about targeted therapy.

Clinical trials look at new and better ways to prevent, find and treat cancer. Many children with cancer are treated in a clinical trial. Because childhood cancer is rare, clinical trials usually involve several different childhood cancer treatment centres. Being part of a trial is always voluntary.

Find out more about clinical trials and enrolling your child in a clinical trial.

Follow-up after treatment is an important part of cancer care. Children will need to have regular follow-up visits, especially in the first 5 years after treatment has finished. These visits allow the healthcare team to watch for recurrence and to check on your child's progress and recovery from treatment. Find out more about follow-up care, life after treatment and long-term survivorship.

Treatment is successful for many children with cancer, but in some cases it isn't. When cancer is advanced, the focus of treatment changes from a cure to quality of life. There is help and support available. Find out more about when a cure is not possible.