Cl

10-7

10-8

0 20 40 60 80 100 120 Time after starting methotrexate (hour) Fig. 21-6. Plasma MTX concentration. (From Pediatric Oncology Group Protocol 9351, with permission.)

CITROVORUM DOSE 1000 mg/m2 q 6hr

100 mg/m2 q 3hr

100 mg/m2 q 3hr

5X10-

5X10-

Radiologic and Pathologic Assessment +

Surgery

Continuation therapy (Figure 21-8) VP = Etoposide 100 mg/m2/day x 5 days = 500 mg/m2/course X 2

Course = Total 1,000mg/m2 IFOS = Ifosfamide 3.5 g/m2/day X 5 days = 17.5 g/m2/course X 2 Course = 35 g/m2 G = GSF 5 |jg/kg/day, begin day 6

Fig. 21-7. Treatment plan for induction therapy. Patients receive two courses of etoposide and ifosfamide, then radiologic assessment and surgery of primary tumor. The pathologic assessment of tumor necrosis is performed after surgery. (From Goorin AM, Harris MB, Berstein M, Ferguson W, Devidas M, Siegal GP, Gebhardt C, Schwartz CL, Link MP, Grier HE. Phase II/III trial of etoposide and high dose ifosfamide in newly diagnosed metastatic osteosarcoma: a Pediatric Oncology Group trial. J Clin Oncol 2002;20[2]:426-33, with permission.)

1. Completeness of surgical resection

2. Late (more than 1-year post-treatment) versus early relapse

3. Unresectable pulmonary hilar involvement, malignant plural effusion, more than 16 nodules on CT or extrathoracic disease

4. Prior treatment (patients who relapse after multiagent chemotherapy have worse survival).

Although there are no controlled studies, adjuvant chemotherapy is recom mended, preferably with the agents that patients have not received before such as ifosfamide, etoposide, cyclophosphamide, topotecan, and irinotecan.

Week

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