This study assessed the therapeutic effect of and adverse reactions to pirarubicin (THP) chemotherapy in osteosarcoma patients with lung metastasis, and analyzed the relationship between THP therapeutic effect and expression of p-glycoprotein and topoisomerase-II. Osteosarcoma patients with lung metastases at relapse were given THP and then cisplatin (DDP) or ifosfamide (IFO). Overall survival in patients receiving THP was 31.00 +/- 7.98 months, progression-free survival was 13.00 +/- 2.46 months. Objective response and partial response rates were 46.88% and 40.63%, respectively. There were no differences in overall survival and progression-free survival between the THP+DDP and THP+IFO regimens. Adverse reactions to THP chemotherapy were mainly gastrointestinal and myelosuppression. The therapeutic effect of THP was correlated with the abrogated expression of pglycoprotein and/or topoisomerase-II positive expression. For osteosarcoma patients with secondary lung metastasis, THP-based chemotherapy regimens are safe and effective as a salvage chemotherapy option.