Demographic Determinants of Survival in Osteosarcoma

Introduction: Osteosarcoma treatment has experienced a renaissance in the last 3 decades with the institution of multimodality treatment involving multiagent chemotherapy and surgery. Yet globally, treatment success has stagnated at about 70% survival at 5 years in most single institution series. We performed survival analyses on 2 national databases in 2 countries and compared these with corresponding institution specific survival. Materials and Methods: All patients with the diagnostic code of non-metastatic intramedullary osteosarcoma in the long bones of the upper and lower limbs less than 30 years of age were selected from the Surveillance Epidemiology and End Result (SEER) database to ensure uniformity with respect to disease and treatment. We studied the factors: ethnicity, gender, age, grade, histology, size, site, surgery, compartmentalisation, number of primaries and venue of treatment for their contribution to survival. In addition, the data were stratified into 3 decades (seventies, eighties and nineties) to account for variations due to the evolution of treatment paradigms and imaging modalities. Results: Institution-specific survival was predictably better than national survival in the 4 databases. One thousand patients were selected from the SEER database. Oriental descent, state-specific treatment, female gender, treatment in the nineties, low-grade disease, intra-compartmental disease, small size, wide resections as opposed to forequarter or hindquarter amputations, and single primaries were good prognostic factors on univariate analysis as well as multivariate analysis (P <0.05). Survival was better in the more affluent states (P <0.05). Males were affected at an older age than females (P = 0.004). Blacks tended to have larger tumours although their overall survival was similar to whites. Orientals were more likely to be treated in the nineties with wide resections for smaller tumours and were located around states associated with good treatment. Orientals in Singapore and the United States had the same survival (P = 0.45). Survival in Orientals in Singapore was not significantly different from other races. The standard of healthcare for osteosarcoma varies greatly across the United States but is uniform in Singapore. Hence the observed differences in the United States were likely due to socioeconomic factors. Conclusion: This analysis confirms the importance of a number of prognostic variables in osteosarcoma and suggests the possibility of an ethnic and economic bias for good survival. Key words: Cancer, Ethnicity, Race, Sarcoma, Socioeconomic

Demographic determinants of survival in osteosarcoma

INTRODUCTION

Osteosarcoma treatment has experienced a renaissance in the last 3 decades with the institution of multimodality treatment involving multiagent chemotherapy and surgery. Yet globally, treatment success has stagnated at about 70% survival at 5 years in most single institution series. We performed survival analyses on 2 national databases in 2 countries and compared these with corresponding institution specific survival.

MATERIALS AND METHODS

All patients with the diagnostic code of non-metastatic intramedullary osteosarcoma in the long bones of the upper and lower limbs less than 30 years of age were selected from the Surveillance Epidemiology and End Result (SEER) database to ensure uniformity with respect to disease and treatment. We studied the factors: ethnicity, gender, age, grade, histology, size, site, surgery, compartmentalisation, number of primaries and venue of treatment for their contribution to survival. In addition, the data were stratified into 3 decades (seventies, eighties and nineties) to account for variations due to the evolution of treatment paradigms and imaging modalities.

RESULTS

Institution-specific survival was predictably better than national survival in the 4 databases. One thousand patients were selected from the SEER database. Oriental descent, state-specific treatment, female gender, treatment in the nineties, low-grade disease, intra-compartmental disease, small size, wide resections as opposed to forequarter or hindquarter amputations, and single primaries were good prognostic factors on univariate analysis as well as multivariate analysis (P <0.05). Survival was better in the more affluent states (P <0.05). Males were affected at an older age than females (P = 0.004). Blacks tended to have larger tumours although their overall survival was similar to whites. Orientals were more likely to be treated in the nineties with wide resections for smaller tumours and were located around states associated with good treatment. Orientals in Singapore and the United States had the same survival (P = 0.45). Survival in Orientals in Singapore was not significantly different from other races. The standard of healthcare for osteosarcoma varies greatly across the United States but is uniform in Singapore. Hence the observed differences in the United States were likely due to socioeconomic factors.

CONCLUSION

This analysis confirms the importance of a number of prognostic variables in osteosarcoma and suggests the possibility of an ethnic and economic bias for good survival.

Pediatric and adolescent synovial sarcoma: multivariate analysis of prognostic factors and survival outcomes

PURPOSE

Treatment of synovial sarcoma (SS) is challenging because of its unpredictable clinical behavior. We reviewed our institutional experience with pediatric SS to identify prognostic indicators and survival outcomes.

METHODS

We retrospectively reviewed all pediatric/adolescent patients (age<22 years) with confirmed SS treated from 1970 to 2010. Patient and clinical characteristics were evaluated for prognostic significance and survival outcomes.

RESULTS

We identified 111 patients. The median age was 15.4 years. Sixty-seven tumors (60%) were monophasic, 42 (38%) were biphasic, and 2 (2%) were of unknown histology. Median follow-up was 5.3 years (range 0.8-36.8 years), 5-year overall survival (OS) was 73%, and 10-year OS was 65%. Greater tumor size (stratified as ≤5 cm, >5 cm, or ≥10 cm) (P=0.001) and depth (P=0.03) correlated with decreased OS. Primary tumor location in the upper extremity correlated with increased OS when compared with lower-extremity and central lesions (P=0.05). Bone and/or neurovascular invasion negatively impacted survival (P=0.02). Multivariate analysis revealed that tumor size (trichotomized) was the dominant and sole factor in discriminating survival risk. Neither radiotherapy nor chemotherapy correlated with improved 5-year survival.

CONCLUSIONS

Tumor size, depth, invasion, and primary location affect survival in pediatric SS. The role of radiotherapy and chemotherapy for SS warrants future study.

Evaluation of local control strategies in patients with localized Ewing sarcoma of bone: A report from the Children’s Oncology Group

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Background: Patients (pts) with Ewing sarcoma (EWS) require local control, either with surgery alone (S), radiation alone (R), or a combination of surgery + radiation (S+R). Optimal choice of local control for disease control remains unclear. Our primary aim was to determine the mode of local control associated with the highest event-free survival (EFS). Methods: Pts with localized EWS of bone treated on INT0091, INT0154, or AEWS0031 phase III trials were included if they had complete local control data, did not have cranial tumors, received local control starting 2-6 months after enrollment, and were randomized to receive standard dose 5-drug chemotherapy every 3 weeks. We used propensity scores to control for differences in age, tumor site, and year of diagnosis between local control groups. We constructed Cox models controlling for local control propensity scores to assess the impact of local control type on EFS and overall survival (OS) from the start of local control. Results: 465 pts were included. Pts selected for S were treated more recently (p < 0.001), more likely to have appendicular tumors (p < 0.001), and younger (p = 0.02). Pts treated with R, compared to S, had higher unadjusted risk of any event (HR 1.70; 95% CI 1.18 - 2.44; p = 0.004) or death (HR 1.84; 95% CI 1.18 – 2.85; p = 0.006). Pts treated with S+R, compared to S, had higher unadjusted risk of death (HR 1.75; 95% CI 1.10 – 2.76; p = 0.02). After adjusting for propensity scores, there was a trend of higher risk of any event for pts treated with R (HR 1.42; 95% CI 0.94 – 2.14; p = 0.10) compared to S, though this was not statistically significant. No other differences in adjusted risk of event or death between local control groups were statistically significant. We confirmed these results with standard Cox models using age, tumor site, and year of diagnosis as covariates. Conclusions: In this large group of uniformly treated pts, investigator choice of local control approach was not significantly related to EFS. These data support current practice of surgical resection when feasible, while validating radiotherapy as a reasonable alternative in selected pts.

Monoclonality of multifocal epithelioid hemangioendothelioma of the liver by analysis of WWTR1-CAMTA1 breakpoints

Similar to other vascular tumors, epithelioid hemangioendothelioma (EHE) can have multifocal presentation in up to 50% of cases. However, whether multifocal EHE represents an unusual pattern of metastasis or multiple separate primary tumors remains to be elucidated. Our recent identification of a WWTR1-CAMTA1 fusion as the genetic hallmark of EHE irrespective of anatomic location was used to clarify this question by comparing the similarity of translocation breakpoints. In our previous study, we found variability of the fusion transcripts of the t(1;3)(p36;q25) translocation among different patients with EHE. Thus, we undertook a molecular analysis of six samples from two patients with multicentric hepatic EHE to test our hypothesis that the presence of identical breakpoints in WWTR1 and CAMTA1 support the monoclonal nature of multifocal EHE. Using reverse transcription-polymerase chain reaction (RT-PCR) and subsequent sequencing, we confirmed an identical WWTR1-CAMTA1 fusion transcript product from different nodules in each patient. Our results confirm that multifocal EHE are monoclonal and thus represent metastatic implants of the same neoplastic clone rather than a "field-effect" or synchronous occurrence of multiple neoplastic clones.

Epithelioid hemangioma of bone and soft tissue: a reappraisal of a controversial entity

BACKGROUND

The controversy surrounding diagnosis of an epithelioid hemangioma (EH), particularly when arising in skeletal locations, stems not only from its overlapping features with other malignant vascular neoplasms, but also from its somewhat aggressive clinical characteristics, including multifocal presentation and occasional lymph node involvement. Specifically, the distinction from epithelioid hemangioendothelioma (EHE) has been controversial. The recurrent t(1;3)(p36;q25) chromosomal translocation, resulting in WWTR1-CAMTA1 fusion, recently identified in EHE of various anatomic sites, but not in EH or other epithelioid vascular neoplasms, suggests distinct pathogeneses.

QUESTION/PURPOSES

We investigated the clinicopathologic and radiologic characteristics of bone and soft tissue EHs in patients treated at our institution with available tissue for molecular testing.

PATIENTS AND METHODS

Seventeen patients were selected after confirming the pathologic diagnosis and fluorescence in situ hybridization analysis for the WWTR1 and/or CAMTA1 rearrangements. Four patients had multifocal presentation. Most patients with EH of bone were treated by intralesional curettage. None of the patients died of disease and only four patients had a local recurrence.

RESULTS

Our results, using molecular testing to support the pathologic diagnosis of EH, reinforce prior data that EH is a benign lesion characterized by an indolent clinical course with an occasional multifocal presentation and rare metastatic potential to locoregional lymph nodes.

CONCLUSION

These findings highlight the importance of distinguishing EH from other malignant epithelioid vascular tumors as a result of differences in their management and clinical outcome.

LEVEL OF EVIDENCE

Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

A probabilistic analysis of completely excised high-grade soft tissue sarcomas of the extremity: an application of a Bayesian belief network

BACKGROUND

It is important to understand the relative importance of prognostic variables in patients with soft tissue sarcomas. The purpose of this study was to describe the hierarchical relationships between features inherent to completely excised, localized high-grade soft tissue sarcomas of the extremity and compare the associations to those previously reported.

METHODS

Data were collected from the Memorial Sloan-Kettering Cancer Center Sarcoma Database. All adult patients with high-grade extremity soft tissue sarcomas who underwent complete excision (R0 margins) at our institution between 1982 and 2010 were included in the analysis. Bayesian belief network (BBN) modeling software was used to develop a hierarchical network of features trained to estimate the likelihood of disease-specific survival. Important relationships depicted by the BBN model were compared to those previously reported.

RESULTS

The records of 1318 consecutive patients met the inclusion criteria, and all were included in the analysis. First-degree associates of disease-specific survival were the primary tumor size; presence of and time to distant recurrence; and presence of and time to local recurrence. On cross-validation, the BBN model was sufficiently robust, with an area under the curve of 0.94 (95 % confidence interval 0.93-0.96).

CONCLUSIONS

We successfully described the hierarchical relationships between features inherent to patients with completely excised high-grade soft tissue sarcomas of the extremity. The relationships defined by the BBN model were similar to those previously reported. Cross-validation results were encouraging, demonstrating that BBN modeling can be used to graphically illustrate the complex hierarchical relationships between prognostic features in this setting.

Evaluation of eIF4E expression in an osteosarcoma-specific tissue microarray

The ability to define osteosarcoma (OS) patients at greatest risk for metastatic progression and nonresponsiveness to conventional therapy is currently not possible. Such biomarkers are needed to predict overall prognosis, probability of metastases at diagnosis, and response to chemotherapy. The tissue microarray (TMA) serves as a powerful tool for detecting and validating protein biomarkers across a variety of patients. We constructed a novel outcome-linked TMA to add to and address shortcomings of currently available OS tissue resources. To test the use of our TMA, we surveyed the expression of eukaryotic initiation factor 4E (eIF4E) in OS patients using immunohistochemistry. Aberrant regulation of translation initiation is a feature of many cancers. eIF4E is central to initiation of protein synthesis. Its expression and activity have been implicated in tumor formation and potentially malignant and/or metastatic progression in some carcinomas. We found that eIF4E was uniformly expressed in OS patient samples. No association was found between eIF4E and outcome in OS patients. This novel OS TMA provided a facile mechanism to assess the role of a relevant protein biomarker in OS.

A novel WWTR1-CAMTA1 gene fusion is a consistent abnormality in epithelioid hemangioendothelioma of different anatomic sites

The classification of epithelioid vascular tumors remains challenging, as there is considerable morphological overlap between tumor subtypes, across the spectrum from benign to malignant categories. A t(1;3)(p36.3;q25) translocation was reported in two cases of epithelioid hemangioendothelioma (EHE), however, no follow-up studies have been performed to identify the gene fusion or to assess its prevalence in a larger cohort of patients. We undertook a systematic molecular analysis of 17 EHE, characterized by classic morphological and immunophenotypic features, from various anatomical locations and with different malignant potential. For comparison, we analyzed 13 epithelioid hemangiomas, five epithelioid angiosarcomas, and four epithelioid sarcoma-like EHE. A fluorescence in situ hybridization (FISH) positional cloning strategy, spanning the cytogenetically defined regions on chromosomes 1p36.3 and 3q25, confirmed rearrangements in two candidate genes from these loci in all EHE cases tested. None of the other benign or malignant epithelioid vascular tumors examined demonstrated these abnormalities. Subsequent reverse transcription-polymerase chain reaction (RT-PCR) confirmed in three EHE the WWTR1-CAMTA1 fusion product. CAMTA1 and WWTR1 have been previously shown to play important roles in oncogenesis. Our results demonstrate the presence of a WWTR1-CAMTA1 fusion in all EHE tested from bone, soft tissue, and visceral location (liver, lung) in keeping with a unique and specific pathological entity. Thus, FISH or RT-PCR analysis for the presence of WWTR1-CAMTA1 fusion may serve as a useful molecular diagnostic tool in challenging diagnoses.

Amplification of the MYC Gene in Osteosarcoma Secondary to Paget's Disease of Bone

Purpose. In a previous series of 25 human osteosarcoma samples studied for MYC gene amplification, we found amplification in two cases (8%), including one arising in association with Paget's disease (pagetic osteosarcoma). Based on this observation, we further investigated the prevalence of MYC gene amplification in pagetic osteosarcomas.Methods. MYC gene amplification was assessed by Southern blot analysis using frozen tissue samples in five cases of pagetic osteosarcoma and 53 cases of primary (non-pagetic) osteosarcoma. Amplification was considered present if the MYC copy number was six or greater.Results. Three out of five patients (60%) with pagetic osteosarcoma showed MYC gene amplification, whereas it was present in only 5/53 patients (9.4%) with primary osteosarcoma. The incidence of MYC amplification in pagetic osteosarcoma was thus significantly higher than that in primary osteosarcoma (p = 0.016).Discussion. The finding that MYC gene amplification may be more common in pagetic than primary osteosarcoma warrants further study and suggests pathogenetic differences between primary osteosarcomas and those arising in the setting of Paget's disease. Three of the four pagetic osteosarcomas from the present study were previously shown to be immunoreactive for p53, suggesting that p53 mutation may also be a frequent genetic lesion in these tumors.

FDG-PET Lacks Sufficient Sensitivity to Detect Myxoid Liposarcoma Spinal Metastases Detected by MRI

Purpose. To document a case of myxoid liposarcoma in which PET scan was less sensitive than MRI in detecting spinal metastasis. Materials and Methods. The case of a 65-year-old female with a history of myxoid liposarcoma (MLS) of the thigh resected 5 years previously and now presenting with low back pain is presented. Her medical oncologist ordered an FDG-PET scan to evaluate distant recurrence. Subsequently, an MRI of her spine was obtained by her surgeon. Results. The FDG-PET scan was obtained 1 week prior to the MRI, and it did not show increased glucose uptake in the spine. Her MRI did show increased signal intensity in her lumbar spine. CT needle biopsy confirmed the lesion to be metastatic MLS. Conclusion. FDG-PET scans are utilized to detect distant recurrence of cancerous lesions. Myxoid liposarcoma has a unique propensity to metastasize to the spine. Previous reports have documented the unreliability of bone scintigraphy to diagnose these metastases. Our report demonstrates that FDG-PET may also lack the sensitivity needed to detect these lesions. We advocate total spine MRI when screening for metastases in this population when they present with back pain.

Atypical subtrochanteric femoral fractures in patients with skeletal malignant involvement treated with intravenous bisphosphonates

BACKGROUND

Atypical subtrochanteric femoral fractures have been identified as a potential complication of long-term bisphosphonate therapy for the treatment of osteoporosis. Patients with skeletal malignant involvement, who receive much higher cumulative doses of bisphosphonates than do patients with osteoporosis, may be at higher risk for the development of these fractures.

METHODS

A retrospective review of the imaging studies and case notes was done for patients with skeletal malignant involvement who received a minimum of twenty-four doses of intravenous bisphosphonates between 2004 and 2007 and were followed until death or the time of the latest review. Patients were classified as having an atypical subtrochanteric femoral fracture if they had a transverse subtrochanteric fracture following low-energy trauma or an impending fracture, together with radiographic findings of diffuse diaphyseal cortical thickening and cortical beaking at the subtrochanteric area.

RESULTS

In the study cohort of 327 patients, we identified four patients who developed an atypical subtrochanteric femoral fracture. All four patients were female, three had breast cancer, and one had myeloma. There was no significant difference between patients who developed an atypical subtrochanteric femoral fracture and those who did not with regard to the doses of intravenous bisphosphonates or the duration of treatment.

CONCLUSIONS

The prevalence of atypical subtrochanteric femoral fractures in patients with skeletal malignant involvement who are managed with high doses of intravenous bisphosphonates is low. All patients in our study who had development of these fractures had prodromal symptoms of thigh pain.

Estimating survival in patients with operable skeletal metastases: an application of a bayesian belief network

Background

Accurate estimations of life expectancy are important in the management of patients with metastatic cancer affecting the extremities, and help set patient, family, and physician expectations. Clinically, the decision whether to operate on patients with skeletal metastases, as well as the choice of surgical procedure, are predicated on an individual patient's estimated survival. Currently, there are no reliable methods for estimating survival in this patient population. Bayesian classification, which includes Bayesian belief network (BBN) modeling, is a statistical method that explores conditional, probabilistic relationships between variables to estimate the likelihood of an outcome using observed data. Thus, BBN models are being used with increasing frequency in a variety of diagnoses to codify complex clinical data into prognostic models. The purpose of this study was to determine the feasibility of developing Bayesian classifiers to estimate survival in patients undergoing surgery for metastases of the axial and appendicular skeleton.

Methods

We searched an institution-owned patient management database for all patients who underwent surgery for skeletal metastases between 1999 and 2003. We then developed and trained a machine-learned BBN model to estimate survival in months using candidate features based on historical data. Ten-fold cross-validation and receiver operating characteristic (ROC) curve analysis were performed to evaluate the BNN model's accuracy and robustness.

Results

A total of 189 consecutive patients were included. First-degree predictors of survival differed between the 3-month and 12-month models. Following cross validation, the area under the ROC curve was 0.85 (95% CI: 0.80–0.93) for 3-month probability of survival and 0.83 (95% CI: 0.77–0.90) for 12-month probability of survival.

Conclusions

A robust, accurate, probabilistic naïve BBN model was successfully developed using observed clinical data to estimate individualized survival in patients with operable skeletal metastases. This method warrants further development and must be externally validated in other patient populations.

Addition of pamidronate to chemotherapy for the treatment of osteosarcoma

BACKGROUND

This study evaluated the safety and feasibility of the addition of pamidronate to chemotherapy for treatment of osteosarcoma.

METHODS

The authors treated 40 patients with osteosarcoma with cisplatin, doxorubicin, and methotrexate with the addition of pamidronate 2 mg/kg/dose (max dose 90 mg) monthly for 12 doses. Survival, event-free survival (EFS), and durability of orthopedic reconstruction were evaluated.

RESULTS

For patients with localized disease, event-free survival (EFS) at 5 years was 72% and overall survival 93%. For patients with metastatic disease, EFS at 5 years was 45% and overall survival 64%. Toxicity was similar to patients treated with chemotherapy alone. Thirteen of 14 uncemented implants demonstrated successful osteointegration. Among allograft reconstructions, there were 2 graft failures, 4 delayed unions, and 6 successful grafts. Overall, 5 of 33 reconstructions failed. There were no stress fractures or growth disturbances.

CONCLUSIONS

Pamidronate can be safely incorporated with chemotherapy for the treatment of osteosarcoma. It does not impair the efficacy of chemotherapy. Pamidronate may improve the durability of limb reconstruction.

Noninvasive imaging with thallium-201 scintigraphy may not correlate with survival in patients with osteosarcoma

BACKGROUND

Histologic response to preoperative chemotherapy is a strong prognostic factor for osteosarcoma (OS). Thallium-201 (Tl-201) scintigraphic response to initial chemotherapy has previously been described as a predictor of histologic response. In the current study, the authors re-examined a series of patients studied using Tl-201 scintigraphy to determine the correlation between changes observed on Tl-201 scintigraphy and event-free survival (EFS).

METHODS

A total of 22 patients with biopsy-proven OS of the extremity underwent Tl-201 imaging before and immediately after preoperative chemotherapy. The maximum pixel counts taken over the tumor divided by those taken of a background region yielded a tumor-to-background ratio (TBR). The percentage of change in the TBR before and after adjuvant chemotherapy, defined as the alteration ratio (AR), was correlated with EFS.

RESULTS

The median AR was 85% (range, 28-100%). The 3-year EFS was 0.72 (95% confidence interval [95% CI], 0.48-0.86) and the 5-year EFS was 0.67 (95% CI, 0.43-0.86). There was no association between AR and EFS detected in this cohort (hazard ratio, 0.99; 95% CI, 0.95-1.02 [Somers rank correlation coefficient, 0.15]).

CONCLUSIONS

Although Tl-201 scintigraphy was used as a tool for the assessment of response to chemotherapy in patients with OS, the AR did not appear to be predictive of EFS in this small group of patients. It is necessary to use the outcome variables of ultimate interest-EFS and overall survival- and not rely on surrogates for outcome to evaluate potential prognostic factors.

Predictive value of magnetic resonance imaging in determining presence of residual disease after marginal excision of unsuspected soft tissue sarcomas of the hand

PURPOSE

Diagnosis of a soft tissue sarcoma of the hand is at times made only in retrospect after marginal excision of a presumed benign soft tissue mass. Magnetic resonance imaging (MRI) helps determine the presence of residual disease and the extent of contamination caused by marginal excision of unsuspected soft tissue sarcomas and assists in the planning of definitive treatment with surgery and radiotherapy when required. We sought to determine the accuracy of MRI in detecting residual sarcoma after marginal excision.

METHODS

We retrospectively studied case records and imaging studies for all patients with soft tissue sarcomas of the hand evaluated and treated at our institution from 1996 to 2005. We included in this study 33 patients who underwent definitive surgery at our center after prior marginal excision. MRI scans done before definitive wide resection were classified as positive or negative for residual tumor. A musculoskeletal radiologist, blinded to the sarcoma type, findings on histopathology, and surgery, reviewed 19 scans to see whether the accuracy could be improved.

RESULTS

There were 8 epithelioid sarcomas, 6 synovial sarcomas, 4 malignant fibrous histiocytomas, 2 leiomyosarcomas, 2 liposarcomas, 2 myxofibrosarcomas, and one each of 9 other diagnoses. A total of 11 were low-grade and 22 were high-grade tumors, with 4 superficial and 29 deep tumors. Pathology examination after definitive wide resection or partial hand amputation showed that 15 patients had residual tumor, 9 gross and 6 microscopic. The sensitivity of MRI in detecting residual soft tissue sarcoma of the hand was 60%, specificity was 78%, positive predictive value was 69%, and negative predictive value was 70%. The sensitivity of MRI in detecting gross residual soft tissue sarcoma of the hand was 89%, specificity was 79%, positive predictive value was 62%, and negative predictive value was 95%. Even when an experienced musculoskeletal radiologist reassessed 19 MRI scans, the accuracy did not improve.

CONCLUSIONS

Magnetic resonance imaging does not reliably detect residual gross or microscopic soft tissue sarcoma after marginal excision of unsuspected soft tissue sarcomas of the hand, with residual tumor not readily distinguished from postoperative change. The absence of disease on MRI should not be used as the sole criterion in determining whether a repeat resection should be performed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Allograft-prosthesis composite reconstruction of the proximal part of the humerus: surgical technique

BACKGROUND

Limb salvage following resection of a tumor in the proximal part of the humerus poses many challenges. Reconstructive options are limited because of the loss of periarticular soft-tissue stabilizers of the glenohumeral joint in addition to the loss of bone and articular cartilage. The purpose of this study was to evaluate the functional outcome and survival of the reconstruction following use of a humeral allograft-prosthesis composite for limb salvage.

METHODS

An allograft-prosthesis composite was used to reconstruct a proximal humeral defect following tumor resection in thirty-six consecutive patients at one institution over a sixteen-year period. The reconstruction was performed at the time of a primary tumor resection in thirty cases, after a failure of a reconstruction following a previous tumor resection in five patients, and following excision of a local recurrence in one patient. The mean duration of follow-up of the living patients was five years. Glenohumeral stability, function, implant survival, fracture rate, and union rate following the reconstructions were measured. Functional outcome and implant survival were analyzed on the basis of the amount of deltoid resection, whether the glenohumeral resection had been extra-articular or intra-articular, and the length of the humerus that had been resected.

RESULTS

One patient sustained a glenohumeral dislocation. Deltoid resection (partial or complete) resulted in a reduced postoperative range of motion in flexion and abduction but had no effect on the mean Musculoskeletal Tumor Society score. Extra-articular resections were associated with lower Musculoskeletal Tumor Society scores. All patients had either mild or no pain and normal hand function at the time of final follow-up. The overall estimated rate of survival of the construct, with revision as the end point, was 88% at ten years. There were three failures due to progressive prosthetic loosening that necessitated removal of the construct. Four patients required an additional bone-grafting procedure to treat a delayed union of the osteosynthesis site.

CONCLUSIONS

An allograft-prosthesis composite used for limb salvage following tumor resection in the proximal part of the humerus is a durable construct associated with an acceptable complication rate. Deltoid preservation and intra-articular resection are associated with a greater range of shoulder motion and a superior functional outcome, respectively.

Correlation between clinical outcome and growth factor pathway expression in osteogenic sarcoma

BACKGROUND

Multiple cell-signaling ligands and receptors-including vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), endothelial growth factor (EGF), v-akt murine thymoma viral oncogene homolog (AKT), platelet-derived growth factor (PDGF), mitogen-activated protein kinase (MAPK), and 70-kilodalton (kD) protein S6 kinase (p70S6 kinase)-reportedly are variably expressed in osteogenic sarcoma. Expression of these proteins may have future implications for prognostication and targeted therapy. The objective of the current study was to determine the relation between clinical outcome and the expression of these proteins.

METHODS

A paraffin-embedded microarray of 48 human osteogenic sarcoma tissue specimens was stained with the antibodies against VEGF, IGF, EGF, AKT, PDGF, MAPK, and p70S6 kinase. Staining for each protein included the total protein and, when applicable, the phosphorylated version of the protein. Immunohistochemical staining was then correlated with patient survival (overall survival [OS] and event-free survival [EFS]), histologic response to chemotherapy, and serum markers.

RESULTS

There was a negative correlation between VEGF receptor 3 (VEGF-R3) and both OS and EFS. VEGF-B was correlated with a poor histologic response to chemotherapy. Serum markers were not correlated with any specific proteins. When using a P value of .05, multiple correlations were observed between proteins of various pathways.

CONCLUSIONS

The current results suggested that the VEGF pathway is a critical signaling pathway in osteogenic sarcoma. These data have identified specific proteins within these pathways toward which future investigations should be directed to further clarify their prognostic potential.