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Treatment for osteosarcoma depends on several factors, including the location, extent, and grade of the cancer, if doctors think it can be removed (resected) completely, and on a person’s age and overall health.

Localized, resectable osteosarcoma

These cancers have not been found to have spread to other parts of the body, and all of the visible tumor can be removed (resected) by surgery.

High grade: Most osteosarcomas are high grade, meaning they will probably grow and spread quickly if not treated. The usual treatment for these cancers is as follows:

• Biopsy to establish the diagnosis
• Chemotherapy (chemo), usually for about 10 weeks
• Surgery to remove the tumor, preferably by the same surgeon who did the biopsy. If cancer is found at the edge of the surgery specimen (meaning some cancer might have been left behind), a second surgery might be done to try to remove any remaining cancer. Radiation therapy might be given to the area as well.
• More chemo (for up to a year). If the initial chemo killed most of the cancer cells, the same drugs are often given again after surgery. If the initial chemo didn’t work well, different drugs might be tried (although not all doctors agree that switching drugs is needed).

Chemo is a very important part of treatment for these cancers. Even when imaging tests don’t show that the cancer has spread to distant parts of the body, there are still likely to be very small areas of cancer spread that can’t be detected with tests. If chemo isn’t given, the cancer is more likely to come back after surgery.

In rare cases, surgery might be the first treatment (before chemo), especially for people who are elderly.

Low grade: A small number of osteosarcomas are low grade, meaning they are likely to grow slowly. Patients with low-grade, resectable osteosarcomas can often be cured with surgery alone (without chemo). However, if the tumor removed by surgery is found to be high grade on lab tests, chemo might then be recommended.

Localized, non-resectable osteosarcoma

These cancers have not been found to have spread to other parts of the body, but they can’t be removed (resected) completely by surgery. For example, they may be too large or too close to vital structures in the body to be resected completely.

As with other osteosarcomas, a biopsy is needed first to establish the diagnosis.

Chemotherapy is usually the first treatment for these cancers. If the tumor shrinks enough to become resectable, it is then removed with surgery. This is followed by more chemotherapy for up to a year.

If the tumor still can't be removed completely after chemotherapy, radiation therapy can often be used to try to keep the tumor under control and to help relieve symptoms. More chemo might be another option, either instead of or after radiation therapy. If the first chemo regimen didn’t work very well, different chemo drugs might be tried.

Because these tumors can be hard to treat, a clinical trial of newer treatments may be a good option in many cases.

Metastatic osteosarcoma

These cancers have already spread to distant parts of the body when they are diagnosed. Most often they have spread to the lungs. As with other osteosarcomas, a biopsy is needed first to establish the diagnosis.

Chemotherapy is usually the first treatment for these cancers. If all of the tumors are thought to be resectable after chemotherapy, they are removed with surgery, sometimes in more than one operation. This is followed by more chemo for up to a year.

If some of the tumors remain unresectable after chemo, radiation therapy can often be used to try to keep them under control and to help relieve symptoms. More chemo might be another option, either instead of or after radiation therapy. If the first chemo regimen didn’t work very well, different chemo drugs might be tried.

Newer targeted therapy drugs such as regorafenib (Stivarga), sorafenib (Nexavar), or cabozantinib (Cabometyx) might also be an option at some point as well, although more research will be needed to see how effective these drugs are (see What’s New in Osteosarcoma Research?).

Because these tumors can be hard to treat, clinical trials of newer treatments may be a good option in many cases.

Recurrent osteosarcoma

Recurrent cancer means that the cancer has come back after treatment. It may come back locally (near where the first tumor was) or in other parts of the body. Most of the time, if osteosarcoma recurs it will be in the lungs.

If possible, surgery to remove the tumor(s) is an important part of treatment, as it offers the best chance for long-term survival. If the cancer recurs at the original site on an arm or leg after limb-sparing surgery, amputation of the limb may be recommended.

Chemotherapy is often part of the treatment for recurrent cancers as well. If the cancer is not resectable, chemo might be used to try to shrink the tumor(s), which might then allow surgery to be done. If the cancer is resectable, chemo might be given after surgery. For more advanced cancers, chemo might be used to try to help relieve symptoms. 

Radiation therapy might be part of treatment as well. It can sometimes help keep tumor growth in check and help relieve symptoms.

If the cancer is still growing, newer targeted therapy drugs such as regorafenib (Stivarga), sorafenib (Nexavar), or cabozantinib (Cabometyx) might be an option at some point as well, although more research is needed to see how effective these drugs are (see What’s New in Osteosarcoma Research?).

Because these tumors can be hard to treat, clinical trials of newer treatments may be a good option.