OBJECTIVE Primary
osteosarcoma of the spine is a rare osseous
neoplasm. While previously reported retrospective studies have demonstrated that overall patient survival is impacted mostly by en bloc resection and
chemotherapy, the continued management of residual disease remains to be elucidated. This systematic review was designed to address the role of
revision surgery and multimodal adjuvant
therapy in cases in which en bloc excision is not initially achieved. METHODS A systematic literature search spanning the years 1966 to 2015 was performed on PubMed, Medline, EMBASE, and Web of Science to identify reports describing outcomes of patients who underwent biopsy alone, neurological
decompression, or intralesional resection for
osteosarcoma of the spine. Studies were reviewed qualitatively, and the
clinical course of individual patients was aggregated for quantitative meta-analysis. RESULTS A total of 16 studies were identified for inclusion in the systematic review, of which 8 case reports were summarized qualitatively. These studies strongly support the role of
chemotherapy for overall survival and moderately support adjuvant
radiation therapy for local control. The meta-analysis revealed a statistically significant benefit in overall survival for performing revision
tumor debulking (p = 0.01) and also for
chemotherapy at relapse (p < 0.01). Adjuvant
radiation therapy was associated with longer survival, although this did not reach statistical significance (p = 0.06). CONCLUSIONS While the initial therapeutic goal in the management of
osteosarcoma of the spine is
neoadjuvant chemotherapy followed by en bloc marginal resection, this objective is not always achievable given anatomical constraints and other limitations at the time of initial clinical presentation. This systematic review supports the continued aggressive use of
revision surgery and multimodal adjuvant
therapy when possible to improve outcomes in patients who initially undergo subtotal debulking of
osteosarcoma. A limitation of this systematic review is that lesions amenable to subsequent resection or
tumors inherently more sensitive to adjuvants would exaggerate a
therapeutic effect of these interventions when studied in a retrospective fashion.