Addition of muramyl tripeptide to chemotherapy for patients with newly diagnosed metastatic osteosarcoma: a report from the Children's Oncology Group

BACKGROUND

The addition of liposomal muramyl tripeptide phosphatidylethanolamine (MTP-PE) to chemotherapy has been shown to improve overall survival in patients with nonmetastatic osteosarcoma (OS). The authors report the results of addition of liposomal MTP-PE to chemotherapy for patients with metastatic OS.

METHODS

Intergroup-0133 was a prospective randomized phase 3 trial for the treatment of newly diagnosed patients with OS. The authors compared 3-drug chemotherapy with cisplatin, doxorubicin, and high-dose methotrexate (Regimen A) to the same 3 drugs with the addition of ifosfamide (Regimen B). The addition of liposomal MTP-PE to chemotherapy was evaluated.

RESULTS

Five-year event-free survival (EFS) for patients who received liposomal MTP-PE (n = 46) was 42% versus 26% for those who did not (n = 45) (relative risk for liposomal MTP-PE, 0.72; P = .23; 95% confidence interval [CI], 0.42-1.2). The 5-year overall survival for patients who received MTP-PE versus no MTP-PE was 53% and 40%, respectively (relative risk for liposomal MTP-PE, 0.72; P = 0.27; 95% CI, 0.40-1.3). The comparison of Regimen A with Regimen B did not suggest a difference for EFS (35% vs 34%, respectively; relative risk for Regimen B, 1.07; P = .79; 95% CI, 0.62-1.8) or overall survival (52% vs 43%, respectively; relative risk for Regimen B, 1.1, P = .75; 95% CI, 0.61-2.0).

CONCLUSIONS

When the metastatic cohort was considered in isolation, the addition of liposomal MTP-PE to chemotherapy did not achieve a statistically significant improvement in outcome. However, the pattern of outcome is similar to the pattern in nonmetastatic patients.

Tumour Interstitial Fluid Pressure May Regulate Angiogenic Factors in Osteosarcoma

Purpose: We have previously shown that osteosarcomas have states of increased interstitial fluid pressure (IFP) which correlate with increased proliferation and chemosensitivity. In this study, we hypothesized that constitutively raised IFP in osteosarcomas regulates angiogenesis. Materials and Methods: Sixteen patients with the clinical diagnosis of osteosarcomas underwent blood flow and IFP readings by the wick-in-needle method at the time and location of open biopsy. Vascularity was determined by capillary density in the biopsy specimens. We performed digital image analysis of immunohistochemical staining for CD31, VEGF-A, VEGF-C and TPA on paraffin-embedded tissue blocks of the biopsy samples. Clinical results were validated in a pressurised cell culture system. Results: IFPs in the tumours (mean 33.5 ± SD 17.2 mmHg) were significantly higher (P = 0.00001) than that in normal tissue (2.9 ± 5.7 mmHg). Pressure read-ings were significantly higher in low vascularity tumours compared to high vascularity tumours (P <0.001). In the osteosarcoma cell lines, growth in a pressurised environment was associated with VEGF-A downregulation, VEGF-C upregulation and TPA upregulation. The reverse was seen in the OB cell lines. Growth in the HUVEC cell line was not significantly inhibited in a pressurised environment. Immunohistochemical assessment for VEGF-A (P = 0.01), VEGF-C (P = 0.008) and TPA (P = 0.0001) translation were consistent with the findings on PCR. Conclu-sion: Our data suggest that some molecules in angiogenesis are regulated by changes in IFP. Key words: Angiogenesis, Lymphangiogenesis

Tumour interstitial fluid pressure may regulate angiogenic factors in osteosarcoma

PURPOSE

We have previously shown that osteosarcomas have states of increased interstitial fluid pressure (IFP) which correlate with increased proliferation and chemosensitivity. In this study, we hypothesized that constitutively raised IFP in osteosarcomas regulates angiogenesis.

MATERIALS AND METHODS

Sixteen patients with the clinical diagnosis of osteosarcomas underwent blood fl ow and IFP readings by the wick-in-needle method at the time and location of open biopsy. Vascularity was determined by capillary density in the biopsy specimens. We performed digital image analysis of immunohistochemical staining for CD31, VEGF-A, VEGF-C and TPA on paraffin-embedded tissue blocks of the biopsy samples. Clinical results were validated in a pressurised cell culture system.

RESULTS

IFPs in the tumours (mean 33.5 +/- SD 17.2 mmHg) were significantly higher (P = 0.00001) than that in normal tissue (2.9 +/- 5.7 mmHg). Pressure readings were significantly higher in low vascularity tumours compared to high vascularity tumours (P <0.001). In the osteosarcoma cell lines, growth in a pressurised environment was associated with VEGF-A downregulation, VEGF-C upregulation and TPA upregulation. The reverse was seen in the OB cell lines. Growth in the HUVEC cell line was not significantly inhibited in a pressurised environment. Immunohistochemical assessment for VEGF-A (P = 0.01), VEGF-C (P = 0.008) and TPA (P = 0.0001) translation were consistent with the findings on PCR.

CONCLUSION

Our data suggest that some molecules in angiogenesis are regulated by changes in IFP.

Primary malignant giant-cell tumor of bone has high survival rate

BACKGROUND

Malignant giant-cell tumors (MGCT) comprise 2-9% of all giant-cell tumors (GCTs). The limited existing studies fail to distinguish primary, secondary, or postradiation cancers, making it difficult to design rational treatment strategies. This study compared malignant to benign GCTs and defined the clinical outcome of the patients in a large series of case-matched patients from a single institution.

METHODS

Clinical, radiological, and outcome features were compared between 26 malignant and 244 benign GCTs treated in our institution. Five postradiation cancers were excluded. We also performed a 1:2 case-matched comparison of patients with malignant and benign disease.

RESULTS

Distal femur (P = 0.019), proximal tibia (P = 0.032), and distal tibia (P = 0.049) had a higher frequency of MGCT. Campanacci stage 1 tumors had a low probability of malignancy (P = 0.017). MGCT were less likely to have aneurysmal bone cyst changes. The 5-year recurrence-free status probability was 80% for malignant and 91% for benign cases in matched groups. The difference in the recurrence rate between benign and malignant groups was not statistically significant (P = 0.24). Functional impairment and limited activity were greater in MGCT patients than in benign GCT patients, whether treated by resection/amputation or curettage/cryosurgery.

CONCLUSIONS

We found that malignant and benign GCT have similar epidemiology and that recurrence was higher in MGCT (20 v 9%). Local recurrence for MGCT was not statistically different for excision versus intralesional therapy, but there was little statistical power. Finally, the 16% mortality for patients with MGCT suggests low-grade malignancy.

Compress periprosthetic fractures: interface stability and ease of revision

Periprosthetic fractures after massive endoprosthetic reconstructions pose a reconstructive challenge and jeopardize limb preservation. Compressive osseointegration technology offers the promise of relative ease of prosthetic revision, since fixation is achieved by means of a short intramedullary device. We retrospectively reviewed the charts of 221 patients who had Compress((R)) devices implanted in two centers between December, 1996 and December, 2008. The mean followup was 50 months (range, 1-123 months). Six patients (2.7%) sustained periprosthetic fractures and eight (3.6%) had nonperiprosthetic ipsilateral limb fractures occurring from 4 to 79 months postoperatively. All periprosthetic fractures occurred in patients with distal femoral implants (6/154, 3.9%). Surgery was performed in all six patients with periprosthetic femur fractures and for one with a nonperiprosthetic patellar fracture. The osseointegrated interface was radiographically stable in all 14 cases. All six patients with periprosthetic fracture underwent limb salvage procedures. Five patients had prosthetic revision; one patient who had internal fixation of the fracture ultimately underwent amputation for persistent infection. Periprosthetic fractures involving Compress((R)) fixation occur infrequently and most can be treated successfully with further surgery. When implant revision is needed, the bone preserved by virtue of using a shorter intramedullary Compress((R)) device as compared to conventional stems, allows for less complex surgery, making limb preservation more likely.

LEVEL OF EVIDENCE

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

Early equivalence of uncemented press-fit and Compress femoral fixation

Bone ingrowth promises more durable biologic fixation of megaprostheses. The relative performance of different types of fixation is unknown. We compared the fixation of two forms of biologically fixed femoral components: an intramedullary uncemented press-fit stem (UCS; Group 1, 50 patients) and a Compress((R)) uncemented fixation (CPS; Group 2, 41 patients). In Group 1, the overall Kaplan-Meier prosthetic survival rates were 85% at 5 and 71% at 10 years. Most failures were long-term developments. Aseptic loosening was the primary cause of failure. Stem diameters less than 13.5 mm and a diaphyseal/stem coefficient greater than 2.5 mm were associated with decreased prosthetic survival. In Group 2, the overall rate of CPS survival was 88% at 5 years. Failure of femoral fixation or fracture during the first year was the main reason for revision. Five-year survival rates were similar between the groups and we observed no difference in the functional success of the implants. We found no failures after 1-year followup in Group 2 (CPS). Any difference in prosthetic survival can only be proven by longer-term study or a randomized trial.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship

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.

Telescope allograft method to reconstitute the diaphysis in limb salvage surgery

We propose a surgical technique for structural allograft reconstitution of the diaphysis of long bones, maximizing surface contact between host and allograft bone. This method, analogous to a telescope, overlaps the graft and host bone, theoretically increasing bone surface contact substantially. We report the outcome of 22 telescoped allograft junction sites in 19 patients who lacked sufficient host bone to accommodate a regular-length stemmed implant. This joint-sparing reconstruction preserved 15 of 16 adjacent joints at risk for replacement. Five patients needed additional surgery, but none for nonunion. The diaphyseal length could be reconstructed enough so that a short prosthesis (less than the critical 40% of total bone length) could be used. This biologic method to reconstruct major segments of the diaphysis is best suited for patients with quantitatively or qualitatively deficient residual bone stock after tumor resection or prosthetic revision. We believe it is an excellent technique for revision knee megaprostheses when there is a short remnant of proximal femur.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Valgus ankle deformity after vascularized fibular reconstruction for oncologic disease

BACKGROUND

Previous studies highlight the risk of valgus ankle instability in children following vascularized fibular procedures. We have observed that persistent valgus instability results in valgus deformity in these ankles. The aim of this study was to explore the risk factors associated with valgus ankle deformity following vascularized fibular graft harvest.

METHODS

We present 31 patients with minimum follow-up of 2 years and maximum of 18 years. They underwent regular clinical evaluation of their ankles and routine radiological evaluation when valgus deformity became clinically apparent.

RESULTS

Five patients developed valgus ankle deformities. Risk factors for development of valgus deformity included age under 14 years (P = 0.02) and short [6 +/- standard deviation (SD) 1 cm] residual fibular lengths (P = 0.02). Age-residual fibula index (age in years plus residual distal fibula length in centimeters) under 16 strongly predicted the development of ankle deformity (P = 0.0008). Short residual fibular lengths were not consistently associated with valgus deformity. Children developed focal lateral tibial epiphyseal atrophy and premature antero-medial fusion of the distal fibular physis resulting in a concave-anterior bowing of the fibula. Skeletally mature patients had congruent joints and posterior rotation of the proximal fibula without bowing.

CONCLUSIONS

Mechanical causes cannot solely explain valgus ankle deformity following vascularized fibula harvest. Secondary changes due to growth arrest in the ankle significantly contribute to this deformity.

Tumor interstitial fluid pressure may regulate angiogenic factors in osteosarcoma

We have previously shown that osteosarcomas (OS) have states of increased interstitial fluid pressure (IFP), which correlate with increased proliferation and chemosensitivity. In this study, we hypothesized that constitutively raised IFP in OS regulates angiogenesis. Sixteen patients with the clinical diagnosis of OS underwent blood flow and IFP readings by the wick-in-needle method at the time and location of open biopsy. Vascularity was determined by capillary density in the biopsy specimens. We performed digital image analysis of immunohistochemical staining for CD31, VEGF-A, VEGF-C, and TPA on paraffin-embedded tissue blocks of the biopsy samples. Clinical results were validated in a pressurized cell culture system. Interstitial fluid pressures in the tumors (mean 33.5 +/- SD 17.2 mmHg) were significantly higher (p = 0.00001) than that in normal tissue (2.9 +/- 5.7 mmHg). Pressure readings were significantly higher in low vascularity tumors compared to high vascularity tumors (p < 0.001). In the OS cell lines, growth in a pressurized environment was associated with VEGF-A downregulation, VEGF-C upregulation, and TPA upregulation. The reverse was seen in the OB cell line. Growth in the HUVEC cell line was not significantly inhibited in a pressurized environment. Immunohistochemical assessment for VEGF-A (p = 0.01), VEGF-C (p = 0.008), and TPA (p = 0.0001) translation were consistent with the findings on PCR. Our data suggests that some molecules in angiogenesis are regulated by changes in IFP.

Radius neck-to-humerus trochlea transposition for elbow reconstruction after resection of the proximal ulna: report of 2 cases

The structural and functional deficit created after wide excision of the proximal ulna for malignant bone tumors presents a difficult reconstructive challenge. The purpose of our report was to retrospectively review the outcome of the radius neck-to-humerus trochlea transposition after wide resection of malignant forearm tumors in 2 patients. Good function was obtained using this surgical technique. This surgical option provides a durable biologic solution to a complex reconstructive problem.

Hypoxia markers in human osteosarcoma: an exploratory study

Neoplastic cells growing under hypoxic conditions exhibit a more aggressive phenotype by activating a cascade of molecular events partly mediated by hypoxia-inducible transcription factor (HIF-1alpha) and vascular endothelial growth factor (VEGF). The roles of these markers have been studied previously in several cancer lines. We ascertained the frequency of HIF-1alpha expression, VEGF expression, the degree of neovascularization, and cell proliferation in osteosarcoma samples. Samples from osteosarcoma patients were assessed for HIF-1alpha and VEGF protein expression using immunohistochemistry, neovascularization using antibodies for Factor VIII, and cell proliferation using the Ki-67 labeling index. Associations between these parameters and clinical features were examined. HIF-1alpha staining was positive in 35% of patients and metastases were present in 61% of these HIF-1alpha-positive patients. VEGF protein expression was detected in 69% of patients, 92% of whom were female. We observed an insignificant trend for a higher frequency of VEGF expression in the high-grade as compared to low-grade osteosarcoma. We observed no association between vascular density and proliferation index and any clinical parameters. We found an association between HIF-1alpha expression and metastatic disease and between VEGF expression and female gender.

Polymorphisms and methylation of the reduced folate carrier in osteosarcoma

High-dose methotrexate is a standard component in the treatment of osteogenic sarcoma. Impaired methotrexate uptake associated with decreased reduced folate carrier expression is a common mechanism of methotrexate resistance in osteogenic sarcoma samples. We investigated whether promoter methylation and polymorphisms in the 3' untranslated region are involved in regulating reduced folate carrier expression. In a cohort of 66 osteogenic sarcoma specimens, quantitative methylation-specific polymerase chain reaction and single-strand conformation polymorphism were performed. We found detectable levels of promoter methylation in 84.3% of samples. When related to the reduced folate carrier mRNA levels, a trend was observed that reduced folate carrier expression is lower in samples (median, 0.7) with greater than 10% DNA methylation as compared with those (median, 2.3) with less than 10% DNA methylation. The heterozygous polymorphisms of 2582 T/G and 2617C/T in the 3' untranslated region showed reduced folate carrier expression (median, 0.9) as compared with the wild-type 2582T and 2617C (median, 4.2). The data suggest promoter methylation and polymorphisms in the 3' untranslated region of the reduced folate carrier may be involved in its transcriptional regulation in osteogenic sarcoma. Further study is required to confirm this finding.

Bisphosphonate delivery to tubular bone allografts

Large structural allografts used for reconstruction of bone defects after revision arthroplasty and tumor resection fracture up to 27% of the time from osteolytic resorption around the fixation screw holes and tendon or ligament attachment sites. Treating structural allografts before implantation with bisphosphonates may inhibit local osteoclastic processes and prevent bone resorption and the development of stress risers, thereby reducing the long-term fracture rate. Taking advantage of allografts' open-pore structure, we asked whether passive soaking or positive-pressure pumping was a more efficient technique for delivering bisphosphonates. We treated matched pairs of ovine tibial allografts with fluids containing Tc-99m pamidronate and toluidine blue stain to facilitate indicator distribution analysis via microSPECT-microCT imaging and light microscopy, respectively. Surfactants octylphenoxy polyethoxy ethanol or beractant were added to the treatment fluids to reduce flow resistance of solutions pumped through the allografts. Indicator distribution after 1 hour of soaking produced a thin ring around periosteal and endosteal surfaces, while pumping for 10 minutes produced a more even distribution throughout the allograft. Flow resistance was reduced with octylphenoxy polyethoxy ethanol but unaffected with beractant. Pumped allografts displayed a more homogeneous indicator distribution in less time than soaking while surfactants enhanced fluid movement.

Chordoma and chondrosarcoma gene profile: implications for immunotherapy

Chordoma and chondrosarcoma are malignant bone tumors characterized by the abundant production of extracellular matrix. The resistance of these tumors to conventional therapeutic modalities has prompted us to delineate the gene expression profile of these two tumor types, with the expectation to identify potential molecular therapeutic targets. Furthermore the transcriptional profile of chordomas and chrondrosarcomas was compared to a wide variety of sarcomas as well as to that of normal tissues of similar lineage, to determine whether they express unique gene signatures among other tumors of mesenchymal origin, and to identify changes associated with malignant transformation. A HG-U133A Affymetrix Chip platform was used to determine the gene expression signature in 6 chordoma and 14 chondrosarcoma lesions. Validation of selected genes was performed by qPCR and immunohistochemistry (IHC) on an extended subset of tumors. By unsupervised clustering, chordoma and chondrosarcoma tumors grouped together in a genomic cluster distinct from that of other sarcoma types. They shared overexpression of many extracellular matrix genes including aggrecan, type II & X collagen, fibronectin, matrillin 3, high molecular weight-melanoma associated antigen (HMW-MAA), matrix metalloproteinase MMP-9, and MMP-19. In contrast, T Brachyury and CD24 were selectively expressed in chordomas, as were Keratin 8,13,15,18 and 19. Chondrosarcomas are distinguished by high expression of type IX and XI collagen. Because of its potential usefulness as a target for immunotherapy, the expression of HMW-MAA was analyzed by IHC and was detected in 62% of chordomas and 48% of chondrosarcomas, respectively. Furthermore, western blotting analysis showed that HMW-MAA synthesized by chordoma cell lines has a structure similar to that of the antigen synthesized by melanoma cells. In conclusion, chordomas and chondrosarcomas share a similar gene expression profile of up-regulated extracellular matrix genes. HMW-MAA represents a potential useful target to apply immunotherapy to these tumors.

Impact of Intensity-Modulated Radiation Therapy on Local Control in Primary Soft-Tissue Sarcoma of the Extremity

Purpose

One of the concerns about intensity-modulated radiation therapy (IMRT) is that its tight dose distribution, an advantage in reducing RT morbidity to surrounding normal structures, might compromise tumor coverage. The purpose of this study is to determine if such concern is warranted in soft-tissue sarcoma (STS) of the extremity.

Methods

Between 02/02 and 05/05, 41 adult patients with primary STS of the extremity were treated with limb-sparing surgery and adjuvant IMRT. The margins were positive/within 1 mm in 21. Tumor size was more than 10 cm in 68% of patients and grade was high in 83%. Preoperative IMRT was given to 7 patients (50 Gy) and postoperative IMRT (median dose, 63 Gy) was given to 34 patients. Complete gross resection including periosteal stripping/bone resection was required in 11, and neurolysis/nerve resection in 24.

Results

With a median follow-up time of 35 months, two (4.8%) of 41 patients developed local recurrence. The 5-year actuarial local control rate was 94% (95% CI, 86% to 100%). The local control rate was also 94% for patients with negative or positive/close margin. Other prognostic factors such as age, size, and grade did not impact local control either. The 5-year distant control rate was 61% (95% CI, 45% to 76%) and the overall survival rate was 64% (95% CI, 45% to 84%).

Conclusion

IMRT in STS of the extremity provides excellent local control in a group of patients with high risk features. This suggests that the precision with which IMRT dose is distributed has a beneficiary effect in sparing normal tissue and improving local control.

Platelet-derived growth factor receptor as a prognostic marker and a therapeutic target for imatinib mesylate therapy in osteosarcoma

The purpose of this review was to determine whether imatinib mesylate (STI571, Gleevec) has a role in the treatment of osteosarcoma. The expression of platelet-derived growth factor (PDGF) receptor and its ligand was examined in a panel of surgical specimens obtained from 54 osteosarcoma patients, and then the expression was compared with prognosis. The effects of imatinib mesylate on growth and molecular events in 10 patient-derived osteosarcoma cell cultures were investigated. Immunohistochemical studies demonstrated frequent expression of PDGF-AA (80.4%) and PDGF-alpha receptor (79.6%) and their correlation with inferior event-free survival (P < .05). PDGF-B-B and PDGF-beta-receptor expressions were also frequent (75.4% and 86%, respectively); however, statistically significant inferior event-free survival was not demonstrated (P = .15). In vitro studies demonstrated that imatinib mesylate had a variable cytotoxic effect on various osteosarcoma primary cultures, with an IC(50) of 5.6 microM to 9.5 microM, and blocked the PDGF-induced intracellular signal transduction as well as inhibition of downstream Akt phosphorylation. Mitogen-activated protein kinase (MAPK) was constitutively activated despite PDGF stimulation and imatinib mesylate treatment in 7 of 10 osteosarcoma cultures, perhaps explaining uncontrolled proliferation and relative unresponsiveness to imatinib. Imatinib mesylate could not be viewed as having a role as a single agent at current conventional doses for the treatment of osteosarcoma. These findings predicted activity in osteosarcoma clinical trials and suggested that in vitro model systems predict clinical behavior and that PDGF and its receptor expression could potentially be used for determining prognosis of osteosarcoma.

A comparison of intramedullary and juxtacortical low-grade osteogenic sarcoma

While low-grade juxtacortical and low-grade intramedullary osteogenic sarcomas are histologically indistinguishable, they have been studied as separate entities. We retrospectively reviewed the clinical, radiographic, histologic features and treatment of 59 patients treated surgically to compare the rate of local recurrence, grade progression, and survival between low-grade intramedullary and low-grade juxtacortical osteogenic sarcoma. Forty-five (76%) patients were treated for low-grade juxtacortical osteogenic sarcoma and 14 (24%) were treated for low-grade intramedullary osteogenic sarcoma. Local recurrence rates of 7% were similar for both groups studied. The rate of distant metastases was also similar for both groups. . The rate of dedifferentiation for the entire group was 29%. Dedifferentiated lesions were treated with adjuvant chemotherapy in 16 of 17 cases. Recurrence preceded dedifferentiation in four cases. Five-year survival was over 90% in both groups. Low-grade intramedullary and low-grade juxtacortical osteogenic sarcoma were clinically indistinguishable with identical rates of local recurrence, distant metastases, dedifferentiation, and survival.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Osteosarcoma: the addition of muramyl tripeptide to chemotherapy improves overall survival--a report from the Children's Oncology Group

PURPOSE

To compare three-drug chemotherapy with cisplatin, doxorubicin, and methotrexate with four-drug chemotherapy with cisplatin, doxorubicin, methotrexate, and ifosfamide for the treatment of osteosarcoma. To determine whether the addition of muramyl tripeptide (MTP) to chemotherapy enhances event-free survival (EFS) and overall survival in newly diagnosed patients with osteosarcoma.

PATIENTS AND METHODS

Six hundred sixty-two patients with osteosarcoma without clinically detectable metastatic disease and whose disease was considered resectable received one of four prospectively randomized treatments. All patients received identical cumulative doses of cisplatin, doxorubicin, and methotrexate and underwent definitive surgical resection of primary tumor. Patients were randomly assigned to receive or not to receive ifosfamide and/or MTP in a 2 x 2 factorial design. The primary end points for analysis were EFS and overall survival.

RESULTS

In the current analysis, there was no evidence of interaction, and we were able to examine each intervention separately. The chemotherapy regimens resulted in similar EFS and overall survival. There was a trend toward better EFS with the addition of MTP (P = .08). The addition of MTP to chemotherapy improved 6-year overall survival from 70% to 78% (P = .03). The hazard ratio for overall survival with the addition of MTP was 0.71 (95% CI, 0.52 to 0.96).

CONCLUSION

The addition of ifosfamide to cisplatin, doxorubicin, and methotrexate did not enhance EFS or overall survival for patients with osteosarcoma. The addition of MTP to chemotherapy resulted in a statistically significant improvement in overall survival and a trend toward better EFS.

Multifocal synchronous low-grade intramedullary and juxtacortical osteogenic sarcoma

We report the case of a 41-year-old woman who presented with ipsilateral synchronous low-grade juxtacortical osteogenic sarcoma of the distal femur and low-grade intramedullary osteogenic sarcoma of the proximal tibia. The diagnosis and treatment and a review of the literature also are provided.

Leydig cell tumor after treatment for Ewing's sarcoma

Leydig cell tumors account for 3% of testicular tumors and have never been reported after treatment for Ewing's sarcoma. We report the unusual occurrence of a patient who developed a Leydig cell tumor of the testis 18 years after successful treatment for Ewing's sarcoma. Additional monitoring for second malignancies may become appropriate as long-term survival continues to improve for patients with Ewing's sarcoma.