Ablation of bone cells by electroporation

Short intense electrical pulses transiently increase the permeability of the cell membrane, an effect known as electroporation. This can be combined with antiblastic drugs for ablation of tumours of the skin and subcutaneous tissue. The aim of this study was to test the efficacy of electroporation when applied to bone and to understand whether the presence of mineralised trabeculae would affect the capability of the electric field to porate the membrane of bone cells. Different levels of electrical field were applied to the femoral bone of rabbits. The field distribution and modelling were simulated by computer. Specimens of bone from treated and control rabbits were obtained for histology, histomorphometry and biomechanical testing. After seven days, the area of ablation had increased in line with the number of pulses and/or with the amplitude of the electrical field applied. The osteogenic activity in the ablated area had recovered by 30 days. Biomechanical testing showed structural integrity of the bone at both times. Electroporation using the appropriate combination of voltage and pulses induced ablation of bone cells without affecting the recovery of osteogenic activity. It can be an effective treatment in bone and when used in combination with drugs, an option for the treatment of metastases.

Nonmetastatic Ewing family tumors: high-dose chemotherapy with stem cell rescue in poor responder patients. Results of the Italian Sarcoma Group/Scandinavian Sarcoma Group III protocol

BACKGROUND

High-dose chemotherapy (HDT) was added to conventional chemotherapy in Ewing sarcoma family tumor (EFT) patients, poor responders (PRs) to induction chemotherapy in order to improve their survival.

PATIENTS AND METHODS

Patients aged ≤40 years with nonmetastatic Ewing sarcoma (ES) received vincristine (V), doxorubicin (A), cyclofosfamide (C), actinomycin (Ac), ifosfamide (I) and etoposide (E) (VACAc-IE regimen) as induction chemotherapy. As maintenance treatment, good responders (GR) received nine cycles of VACAc-IE regimen. PRs received three cycles of VAC-IE, mobilizing cycle with CE and HDT with Busulfan and Melphalan with stem cell support.

RESULTS

Three hundred patients [median age 15 years (3-40 years)] entered the study. One patient refused local treatment, 242 (81%) underwent surgery [with radiotherapy (RT) in 80] and 57 (19%) RT alone. No toxic deaths were recorded. Overall GR were 146 (49%). Twenty-eight PR did not receive HDT. At a median follow-up of 64 months (21-116 months), 5-year overall and event-free survival (EFS) were 75% and 69%, respectively. Five-year EFS was 75% for GR, 72% for PR treated with HDT and 33% for PR who did not receive HDT.

CONCLUSIONS

High-dose therapy added to the VACA-IE regimen in PR patients is feasible and effective. Selected groups of patients with ES can benefit from HDT.

Survival in high-grade osteosarcoma: improvement over 21 years at a single institution

BACKGROUND

The purpose of this study was to analyze improvements in overall survival over 21 years (1982-2002), with a 5-year minimum follow-up, in the largest series from a single center ever reported.

MATERIALS AND METHODS

All diagnoses of high-grade osteosarcoma were included despite histological varieties, age, site and stage. Of the 1656 cases observed, 198 patients were excluded (41 consultation only, 129 low-grade varieties, and 28 lost to follow-up). Within 1458 included patients, 1032 had characteristics to be enrolled in conventional clinical trials (classic histology, age <41, localized, and extremity disease). Data are also analyzed in subgroups to define patients who benefited most.

RESULTS

With a median follow-up of 12 years (5-25 years), 754 patients (51.7%) are alive, of whom 613 continuously disease free. Survival at 5, 10, and 15 years is 57%, 52%, and 51%, respectively. Patients candidates for clinical trials have a survival rate of 68%, 64%, and 61%, respectively. Survival for the other patients is 30%, 25%, and 24%, respectively. Trend (joinpoint statistical analysis at real 5-year follow-up) shows a yearly statistically significant improvement of 1.31% (95% confidence interval 0.5% to 2.1%) from 51% for patients treated in 1982 to 68% for those treated in 2002. Patients who statistically benefited were those who relapsed or presented with metastatic disease at diagnosis or had axial tumors.

CONCLUSIONS

Despite the lack of new drugs for osteosarcoma, survival has statistically improved, especially for those patients with the worst outcome. Aggressive treatments are recommended for all patients including those with poor prognosis.

Muscle fibers inside a fat tumor: a non-specific imaging finding of benignancy

INTRODUCTION

The differential diagnosis between benign and low-grade well-differentiated malignant lipomatous tumors might be very difficult for both the radiologist and the pathologist, although it has practical consequences. Among the criteria, muscular fibers detected inside the lesion are considered radiologically and histologically as a reliable sign of a benign intramuscular lipoma. New genetic criteria are now available. We report two cases of fat tumors containing muscular fibers both radiologically and histologically, but which are definitely malignant, considering genetic criteria.

MATERIAL AND METHODS

Two cases of soft tissue fat tumors, containing muscular fibers on imaging examinations as well as histologically, had an aggressive behaviour, suggesting malignancy. Genetic criteria were therefore used to confirm the clinical impression.

RESULTS

MDM2 and CDK4 confirmed the malignancy in the two cases.

CONCLUSION

Intra lesional muscular fibers detected on imaging or histological examinations should not be considered as a completely reliable sign of a benign intramuscular lipoma. In case of atypical clinical behaviour, genetic criteria should be used to prove the aggressiveness of the tumor.

Tumours and tumour-like lesions of the hip in the paediatric age: a review of the Rizzoli experience

Bone tumours and tumour-like lesions of the hip in children are rare. Signs and symptoms of these tumours are generally nonspecific. Delay of diagnosis is not uncommon. A high index of suspicion in young patients presenting with persistent pain and without history of trauma, that is unresolved with conservative therapy should prompt further investigation, including radiographs or computed tomography scan of the pelvis. In the experience of the Istituto Rizzoli, in patients less than 14 years (mean 9 years, ranged from 6 months to 14 years), 752 tumours and tumours-like lesions occurred in the pelvis or proximal femur, involving the hip. Tumour-like lesions accounted for 322 cases (simple bone cyst in 255, eosinophilic granuloma in 43, aneurismal bone cyst in 34), benign tumours for 340 cases (osteoid osteoma in 229, fibrous dysplasia in 63, exostosis in 48) and malignant tumours for 80 cases (Ewing's sarcoma in 53 and osteosarcoma in 27). The epidemiology, pathology, clinical presentation, and radiograph findings are discussed for each of these tumours.Treatment of these tumours differs from observation or minimally invasive treatment for most pseudotumoural lesions, intralesional excision or termoablation for benign bone tumours and wide resection for malignant bone tumours. In this latter group, chemotherapy is required and often administered pre- and postoperatively.

Chordoma of the mobile spine: A retrospective analysis on 146 patients from two reference centers

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Background: The natural history of chordoma is still poorly known. Methods: We reviewed a large series of patients (pts) from two major reference centers for chordoma. All pts presenting at Istituto Ortopedico Rizzoli, Bologna, and Istituto Nazionale Tumori, Milan, Italy, over 25 years, were reviewed. Clinical and pathologic characteristics were recorded. Local recurrence, distant metastasis, and overall survival (OS) were analyzed both from time of diagnosis and from time of local recurrence/distant metastasis. A multivariable analysis to identify independent prognostic factors was carried out. PDGFR and brachyury expression analysis is ongoing. Results: One hundred forty-six consecutive pts were identified (sacrum 79%, lumbar spine 15%, cervical-dorsal spine 6%; extension at diagnosis: localized 90%, locally-advanced 5%, metastatic 5%; median size 10 cm, IQ range: 6–14). Median follow-up was 140 months (IQ range: 80–205). The 5/10-year OS, local relapse-free survival (LRFS) and distant relapse-free survival (DRFS) were respectively: 76/52%, 51/32%, 86/72%. For pts with primary disease, size independently predicted OS (p-value: 0.004), LRFS (p-value: 0.006) and DRFS (p-value: 0.02), while surgical margins independently predicted only LRFS (p-value: 0.0001) with a trend for OS (p-value 0.1007). Radiotherapy performed in 44 pts did not influence LRFS nor OS, but only 9 pts received >60 Gy. The 5/10-year OS, LRFS, DRFS after the first local relapse were 54/24%, 50/45%, 64/61%. Size of the recurrence and quality of surgical margins did not influence post-relapse OS. The 5/10-year OS after the second local relapse were 20/0%. The overall incidence of metastases was 32% (commonest site: lung). The 5/10-year post-metastases OS was 35/0% (median 3 years). Results on PDGFR and brachyury expression will be provided. Conclusions: Tumor size and surgical margins affected outcome only on initial presentation. Incidence of distant metastases was higher than expected, although with a more indolent course than generally supposed. In spite of its indolent behavior, long-term prognosis was poor, with 26% of pts being continuously disease-free at 10 years. This series may provide an external control for studies on novel targeted agents, which are proving effective in such a rare tumor.

No significant financial relationships to disclose.

Survival in high-grade osteosarcoma: Improvement in a 21-year period at a single institution

10515

Background: After the introduction of pre-operative chemotherapy in the early 1980s, treatment of osteosarcoma had not advantages from new drugs/modalities. Aim of this work is to analyze improvements in overall survival for patients treated over 21 years (1982–2002), with a 5-year minimum follow-up, in the largest series from a single institute ever reported, including all high grade osteosarcomas, despite histology varieties, age, site, and stage. Data are also analyzed in subgroups to define patients who benefited most. Methods: All diagnoses of high grade osteosarcoma were included. Of the 1,656 consecutive cases observed, 198 patients were excluded (41 consultation only, 129 low-grade varieties and 28 lost to follow-up). Within 1,456 included patients, 1,032 had characteristics to be enrolled in conventional clinical trials (classic histology, age < 41, localized and extremity disease). Results: Considering all patients, with a median follow-up of 12 years (5–25 yrs), 754 (51.7%) are alive, 613 continuously disease-free. Survival at 5, 10, and 15 years is 57%, 52%, and 51% respectively. Patients candidates for clinical trials have a survival rate of 68%, 64%, and 61% respectively. Survival for the other patients is 30%, 25%, and 24% respectively. Jointpoint Statistical Analysis at real 5-year follow-up shows a yearly statistically significant improvement in survival of 1.31% (95% CI 0.5–2.1), from 51% for patients treated in 1982 to 68% for those treated in 2002. Within the subgroups, survival statistically improved in patients candidates to protocols, those who relapsed, or presented with metastatic disease at diagnosis, or had axial tumors. Surgery was also analyzed, with a statistical significant increase in the percentage of limb salvage procedures without an increased rate of local recurrences. Conclusions: Despite the lack of new drugs for osteosarcoma, survival has statistically improved, especially for those patients with the worst outcome. Aggressive treatments are therefore recommended for all patients including those with poor prognosis.

No significant financial relationships to disclose.

Genetic and molecular alterations in rhabdomyosarcoma: mRNA overexpression of MCL1 and MAP2K4 genes

Rhabdomyosarcoma, the most common soft tissue sarcoma in childhood, belongs to the small round cell tumor family and is classified according to its histopathological features as embryonal, alveolar and pleomorphic. In this study we propose to explore genetic alterations involved in rhabdomyosarcoma tumorigenesis and assess the level of mRNA gene expression of controlling survival signalling pathways. For genetic and molecular analysis, array-based comparative genomic hybridization, combined with Real Time PCR using the comparative method, was performed on 14 primary well-characterized human primary rhabdomyosarcomas. Multiple changes affecting chromosome arms were detected in all cases, including gain or loss of specific regions harbouring cancer progression-associated genes. Evaluation of mRNA levels showed in the majority of cases overexpression of MCL1 and MAP2K4 genes, both involved in cell viability regulation. Our findings on rhabdomyosarcoma samples showed multiple copy number alterations in chromosome regions implicated in malignancy progression and indicated a strong expression of MAP2K4 and MCL1 genes, both involved in different biological functions of complicated signalling pathways.

Lipid-altering efficacy and safety of simvastatin 80 mg/day: long-term experience in a large group of patients with hypercholesterolemia. World Wide Expanded Dose Simvastatin Study Group

BACKGROUND

Elevated levels of low-density lipoprotein (LDL) cholesterol promote the development of atherosclerosis and coronary heart disease.

HYPOTHESIS

Simvastatin 80 mg/day will be more effective than simvastatin 40 mg/day at reducing LDL cholesterol and will be well tolerated.

METHODS

Two similar, randomized, multicenter, controlled, double-blind, parallel-group, 48-week studies were performed to evaluate the long-term lipid-altering efficacy and safety of simvastatin 80 mg/day in patients with hypercholesterolemia. One study conducted in the US enrolled patients meeting the National Cholesterol Education Program (NCEP) LDL cholesterol criteria for pharmacologic treatment. In the other multinational study, patients with LDL cholesterol levels > or = 4.2 mmol/l were enrolled. At 20 centers in the US and 19 countries world-wide, 1,105 hypercholesterolemic patients, while on a lipid-lowering diet, were randomly assigned at a ratio of 2:3 to receive simvastatin 40 mg (n = 436) or 80 mg (n = 669) once daily for 24 weeks. Those patients completing an initial 24-week base study were enrolled in a 24-week blinded extension. Patients who had started on the 80 mg dose in the base study continued on the same dose in the extension, while those who had started on the 40 mg dose were rerandomized at a 1:1 ratio to simvastatin 40 or 80 mg in the extension.

RESULTS

There was a significant advantage in the LDL cholesterol-lowering effect of the 80 mg dose compared with that of the 40 mg dose, which was maintained over the 48 weeks of treatment. The mean percentage reductions (95% confidence intervals) from baseline in LDL cholesterol for the 40 and 80 mg groups were 41% (42, 39) and 47% (48, 46), respectively, for the 24-week base study, and 41% (43, 39) and 46% (47, 45), respectively, after 48 weeks of treatment (p < 0.001 between groups). Larger reductions in total cholesterol and triglycerides were also observed with the 80 mg dose compared with the 40 mg dose at Weeks 24 and 48. Both doses were well tolerated, with close to 95% of patients enrolled completing the entire 48 weeks of treatment. Myopathy (muscle symptoms plus creatine kinase increase > 10 fold upper limit of normal) and clinically significant hepatic transaminase increases (> 3 times the upper limit of normal) occurred infrequently with both doses. There was no significant difference between the groups in the number of patients with such increases, although there were more cases for both with the 80 mg dose.

CONCLUSIONS

Compared with the 40 mg dose, simvastatin 80 mg produced greater reductions in LDL cholesterol, total cholesterol, and triglycerides. Both doses were well tolerated.

Osteosarcoma in patients over 65 years old

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Background: Few data are available in literature about osteosarcoma in patients older than 65.We reviewed the incidence and outcome of osteosarcoma in elderly over 65 in our casistic. Materials and Methods: Patients with high grade osteosarcoma treated in our Institute from 1961 to 2006 aged >65. End point was overall survival (OS). Results: 43 patients aged more than 65 treated for high grade osteosarcoma at our Institute were found: 22 male and 21 females, median age was 69 (range 65–80), 29 had localized disease and 13 were metastatic, 33 had extremity localization and 10 axial, 29 patients had a primitive osteosarcoma and 13 (30%) had a sarcoma in Paget's disease, 1 pt ha post-RT osteosarcoma. Median interval from symptoms to diagnosis was 4 months (0–73) 32 out of 43 received surgery for primitive tumour: 18 had a resection with endoprosthesis, 13 had amputation, 1 pt had palliative surgery, the others received palliative RT, 14 patients received chemotherapy (anthracycline, cisplatin, ifosfamide).2 major complication related to chemotherapy were observed: one toxic death and one septic shock. Twenty-one patients reached a disease free status after surgery. Median OS for all 43 pts was 19 months (SE 3),mean 35 mos (range 3–229), 3 years OS for the all group was 25%. Three years OS (Kaplan-Meyer) for pts with localized disease was 41,5% vs 0% for metastatic pts, 3 yrs OS for pts who had surgery was 30% compared to 0% for those without surgical treatment.Significant prognostic factors (Breslow statistic) were: localized vs metastatic (P<0,004) and surgery vs no surgery (P<0.00005,) The other variables (sex, type of surgery, chemotherapy) were not statistically significant.In another study on patients aged 40–60 with localized osteosarcoma of the extremity we found an OS at 8 years of 62%. Conclusions: Osteosarcoma in this subgroup of elderly is frequently associated to Paget disease and their OS is worse compared to adult of younger age. We need to improve our strategy of treatment to increase the cure rate of these elderly patients.

No significant financial relationships to disclose.

Histologically verified lung metastases in benign giant cell tumours--14 cases from a single institution

From 1975 to 1997, 649 cases of benign giant cell tumours of the bone were treated at the Istituto Rizzoli. Fourteen patients (2.1%) experienced lung metastases after a mean of 35.2 months. The time interval between the diagnosis and the appearance of the lung metastases ranged from 3 months to 11.9 years. Metastasectomy was performed in all patients. Histologically, the metastases were identical to the primary bone lesions. Two patients with unresectable multiple metastases received additional chemotherapy. After a follow-up of 70 months (range: 8.2 to 185 months), all patients are alive. Ten patients showed no evidence of disease, one of these after a second resection of metastases, and four patients presented stable disease with multiple lung metastases. Local recurrence of the bone lesion occurred in seven patients before or simultaneously to the metastases. In contrast to previous reports, we could not detect a predominance of the distal radius, but all of the patients had a stage III tumour according to the Enneking criteria of benign lesions. We conclude that even metastatic benign giant cell tumours have an excellent prognosis after adequate resection. No prognostic factors despite high-grade lesions were detectable.

Six drugs induction chemotherapy for patients with localised Ewing sarcoma (ES): A pilot study

9537

Background: Vincristine (V), doxorubicin (A), cyclophosphamide (C), ifosfamide (I), actinomycin-D (Ac) and etoposide (E) are the standard drugs active against ES. Feasibility and efficacy of a six drugs induction treatment were investigated in a monoinstitutional study. Methods: Between March 1998 and May 1999, nonmetastatic ES aged ≤ 50 years were enrolled. Induction treatment: VAC (V 2 mg, A 80 mg/m2, C 1200 mg/m2, weeks 0 and 6), IVAc (I 9 g/m2, V 2 mg, Ac 2 mg, week 3), IE (I 9 g/m2, E 450 mg/m2, week 9). Local treatment, surgery whenever possible, was planned on week 12. Maintenance treatment: alternating courses of VAC-IVAc-IE (three times). In surgically treated patients, chemoinduced necrosis was evaluated and graded: grade III (complete necrosis), II (persistence of microfoci of viable tumor cells) and I (persistence of macrofoci of tumor cells). Results: 34 patients were enrolled; median age was 19 years (6–50); 22 were males and 12 females. Site: extremity 22 (65%), axial location 12 (35%). Despite a large use of G-CSF (94% of cycles), grade IV leukopenia was common (60% of cycles). Nevertheless, febrile neutropenia was observed in only 10.6% of cycles. Grade IV thrombocytopenia occurred in 12.5% of cycles. Platelet and red blood cell transfusions were required in 4% and 11% of cycles, respectively. No toxic deaths were recorded. Local treatment: surgery in 24 patients (70%), followed by post operative radiation (RT) in 6 of them; RT in 10 patients (30%). Chemoinduced necrosis was grade III in 29% of patients, grade II in 34% and grade I in 37%. With a median follow-up of 80 months (1–69) 5 years overall survival (OS) was 62%. 5 years Event free survival (EFS) was 56%. 5 years EFS according to site was: extremity 68%, axial location 33% (p < 0.02); according to local treatment was: surgery 61% (with RT 67%), RT 30% (p = 0.027); according to chemoinduced necrosis: grade III 86%, II 50%, I 55% (p = 0.26). Conclusions: The treatment is feasible. Surgery was possible in 70% of patients with a high cure rate for patients with a grade III chemoinduced necrosis.

No significant financial relationships to disclose.

Molecular alterations of monophasic synovial sarcoma: loss of chromosome 3p does not alter RASSF1 and MLH1 transcriptional activity

Differential diagnosis of monophasic synovial sarcoma requires the detection of specific biological markers. In this study we evaluated the presence of molecular alterations in 15 monophasic synovial sarcomas. Multiple changes affecting chromosome arms were detected by CGH-array in all microdissected cases available, and an association between gain or loss of specific regions harbouring cancer progression-associated genes and aneuploid status was found. The most frequent alteration was loss of 3p including 3p21.3-p23 region that, however, did not involve the promoter regions of the corresponding genes, RASSF1 and MLH1. Using Real-Time PCR, mRNA levels of both resulted moderately high compared to normal tissue; however, the weak to absent protein expression suggests RASSF1 and MLH1 post-transcription deregulation. Moreover, immunohistochemical analysis revealed that both mesenchymal and epithelial antigens were present in diploid tumours. These findings confirm the genetic complexity of monophasic synovial sarcoma and underline the need to integrate different analyses for a better knowledge of this tumour, essential to investigate new diagnostic and prognostic markers.