Adjuvant High-Dose Thiotepa and Stem Cell Rescue Associated With Conventional Chemotherapy in Relapsed Osteosarcoma

Despite the absence of tumor registry, approximately 150 new cases of osteosarcoma are reported each year in France (100 cases per year in children and 50 cases in adults), of which 15 to 20% are metastatic. The standardized impact rate in the world population is estimated at 3 per million inhabitants per year.

Further to the initial standard care, about 45% of the patients relapse within a median interval of 20 months (range 3 months - 10 years).

Results of the OS94 study and of the investigation performed within the CRLCC indicate that 25 to 30 patients (children and adults) experience an osteosarcoma relapse each year in FRANCE.

Results of the five major published series indicate that the 5-year overall survival rate of patients in first relapse is between 23 and 28%, with a median post-relapse survival of 10 to 17 months. Multiple relapse cases are also reported in the COSS study, with a median time to second relapse of 0.8 year.

At present, there is no reference treatment for the standard care of osteosarcoma relapse in FRANCE.

Some recommendations have been given in the OS94 protocol, but they are generally not followed or they are implemented in a heterogeneous manner.

Thiotepa (N N' N'' triethylenethiophosphoramide), an alkylating agent of the chemical family of ethylene-imines, is known for its antitumor effect in a number of malignant tumors.

Its efficacy in osteosarcoma has been reported in the literature. A retrospective study of the SFCE (French Society for Childhood Cancer, results not yet published) in 45 patients presenting with refractory osteosarcoma or relapse has shown a radiological reaction rate of 30%.

Moreover, a preliminary investigation performed by the CLB in 2007 within the framework of the SFCE study explored all relapse cases diagnosed between the beginning of 2004 and the end of 2006. Results showed that about 35% of the patients with osteosarcoma relapses are treated with high-dose thiotepa while the efficacy and tolerance of this therapeutic strategy have never been assessed.

Altogether, these results led the SFCE osteosarcoma group to propose the evaluation of the efficacy and tolerance of this high-dose thiotepa chemotherapy within a clinical trial and to include the drug in the standard care of osteosarcoma in relapse.

Inclusion criteria

• Age > 1 year and < 50 years
• First osteosarcoma relapse, either local or metastatic, or second relapse after exclusive surgery NB: Whenever possible, only patients with histological evidence of relapse will be included.
• Indication for chemotherapy confirmed by a multidisciplinary committee.
• Surgical resection of all tumor sites must be possible, either as first-line therapy or after chemotherapy.
• Lansky score ≥ 60%, or ECOG Performance Status ≤ 2
• ≥ 21-day interval after first-line chemotherapy
• Blood tests, renal and liver functions within the normal range for age with, in particular, 7 days prior to study entry, blood or serum values as follows:
• blood: neutrophil count > 1 G/L; platelets >100 G/L
• renal: serum creatinine ≤ 1.5 x ULN depending on age; patients with serum creatinine values > 1.5 x ULN are eligible if creatinine clearance is > 70 mL/min/1.73 m²
• liver: total bilirubin < 2 x ULN; ASAT and ALAT ≤ 5 x ULN
• cardiac: isotopic or echographic Left Ventricular Ejection Fraction > 50 %.
• Signed written informed consent; for children, signed consent from the patient (depending on age) and from the parents or legal representative is mandatory
• Documented negative serum βHCG for female patients of childbearing age
• Affiliation with health insurance.

Exclusion criteria

• Patients with multiple relapses for whom surgical resection seems impossible, even after chemotherapy.
• Patients already treated with high-dose chemotherapy regimens
• Patients with a contra-indication to the treatment proposed
• Patients not eligible for leukapheresis
• Two-year follow-up impossible due to social, family, geographic or psychological reasons
• Patient included in another protocol of clinical research
• Pregnant or lactating women.