Complications
Osteosarcoma is the most common post-radiation malignant neoplasm following therapy for a solid cancer in childhood.[4][11]
Evidence suggests that the risk of bone sarcoma increases slowly up to a cumulative radiation organ absorbed dose of 15 Gy and then strongly increases for higher radiation doses of 30 Gy or more compared with patients not treated with radiotherapy.[12]
High-dose methotrexate can cause elevation of serum aminotransferases, non-oliguric acute renal failure, nausea, vomiting, stomatitis, neurological toxicity manifested by acute or subacute encephalopathy, and, less frequently, hypersensitivity pneumonitis. The most important adverse effect is renal impairment, which delays drug clearance with secondary prolonged elevated plasma levels and systemic toxicity.
Doxorubicin causes cardiotoxicity, both acute and delayed, alopecia, nausea, vomiting, discoloration of urine, saliva, sweat and tears, leukopenia, thrombocytopenia, and anaemia.
Ifosfamide can cause central nervous system toxicity or encephalopathy, alopecia, nausea, vomiting, myelosuppression, and haematuria.
The frequency of local recurrence is related to the extent of surgical resection margins and the response to chemotherapy. The rate of local recurrence is reported at 2% to 3% after amputation and 5% to 7% after neoadjuvant (preoperative) chemotherapy and conservative surgery.[14]
Local recurrences are treated on a case-by-case basis depending on the previous therapy (chemotherapy and surgery) that the patient received. Wide resection of recurrent tumour is performed whenever possible. Amputation is another option. For unresectable tumours, radiation is used for local disease control.
Local recurrence is an ominous event and is usually followed by metastatic spread of the tumour.
As with most sarcomas, the lung is the preferred organ for metastases. They can be present at initial diagnosis or usually occur in the first 2 to 3 years post-therapy.
Treatment of lung metastases includes aggressive and even repeated surgical resection with clear margins of every lung nodule.
Generally, bone metastases are harder to treat than lung metastases and have a worse prognosis. Where possible, bone metastases should be treated with wide resection surgery or radiotherapy for unresectable lesions.
The chemotherapy regimens used in metastatic disease have not been confirmed by randomised trials. The most common combination is high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide.[14][39][40]
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