A 16-year-old boy with osteosarcoma of the distal femur completes neoadjuvant chemotherapy and limb salvage surgery. Follow-up CT chest at 6 months reveals three small pulmonary nodules confined to the right lung, consistent with metastases. There is no extrapulmonary disease. What is the most appropriate management?

• A Palliative chemotherapy only
• B Radiotherapy to the chest
• C Switch to second-line chemotherapy
• D Surgical metastasectomy ✓

Explanation

Resectable pulmonary metastases in osteosarcoma are treated with curative intent using metastasectomy. Complete resection of all metastatic disease is associated with long-term survival in 20-40% of patients. Prognostic factors include number of nodules, disease-free interval, and completeness of resection. Palliative chemotherapy alone is inappropriate when complete resection is feasible. Radiotherapy has minimal role in osteosarcoma pulmonary metastases.

Reference: Canale & Beaty, Campbell's Operative Orthopaedics, 13th ed.

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