Survival of pediatric patients after relapsed osteosarcoma: the St. Jude Children's Research Hospital experience

Combination of gemcitabine and docetaxel: a regimen overestimated in refractory metastatic osteosarcoma?

Background

The combination of gemcitabine and docetaxel (GT) has been demonstrated to be effective against various types of solid tumors, including sarcoma. However, the regimen has not been confirmed in large, well-designed clinical trials in refractory metastatic osteosarcoma.

Methods

We retrospectively reviewed the records of patients with refractory metastatic osteosarcoma at Peking University People’s Hospital who were treated with gemcitabine (1000 mg/m²) intravenously (IV) on Day 1 and Day 8, and docetaxel (75 mg/m²) IV on Day 8, repeated every 21 days.

Results

A total of 52 patients with a median age of 18.4 years were treated with GT at the Peking University People’s Hospital from August 2012 to August 2017. A total of 174 courses were administered. Only five patients with pulmonary metastasis achieved a best response of stable disease (SD), while all other patients had progressive disease. The result was disappointing with an ORR of 0%, a DCR of 9.6%, and a median DOR of 3.5 months. Grade 3 or 4 toxicities were observed in 69 (39.7%) courses and in 28 (53.8%) patients, most of which were myelosuppression, especially thrombocytopenia. No fatal adverse effect (AE) was found.

Conclusion

The combination of gemcitabine and docetaxel (GT) as a salvage regimen is well-tolerated but not as effective as expected in refractory metastatic osteosarcoma. This report highlights the need for the development of new approaches with higher activity in these patients.

Current status of immunotherapy for sarcomas

Although the development of anticancer drugs has improved the outcomes of bone and soft tissue sarcomas, the clinical outcome of patients with relapsed sarcomas remains unsatisfactory due to therapeutic toxicities and resistance to anticancer drugs. Therefore, novel therapeutic modalities are needed to improve the outcome of patients with bone and soft tissue sarcomas. Dendritic cells present tumor antigens and stimulate immune responses, and immune cells, such as cytotoxic T lymphocytes, kill tumor cells by recognizing tumor antigens. However, immune-suppressive conditions by immune regulator PD-1, CTLA-4 and regulatory T cells help tumor growth and progression. In this report, current immunotherapies including cellular immunotherapy and checkpoint inhibitors are introduced, and the advantages and disadvantages of the treatments are discussed.

Mechanisms of oxidative stress, apoptosis, and autophagy involved in graphene oxide nanomaterial anti-osteosarcoma effect

Background

Graphene and its derivative graphene oxide (GO) have been implicated in a wide range of anticancer effects.

Purpose

The objective of this study was to systematically evaluate the toxicity and underlying mechanisms of GO on two osteosarcoma (OSA) cancer cell lines, MG-63 and K₇M₂ cells.

Methods

MG-63 and K₇M₂ cells were treated by GO (0–50 µg/mL) for various time periods. Cell viability was tested by MTT and Live/Dead assays. A ROS Detection Kit based on DHE oxidative reaction was used for ROS detection. An Annexin V-FITC Apoptosis Kit was used for apoptosis detection. Dansylcadaverine (MDC) dyeing was applied for seeking unspecific autophagosomes. Western blot and Immunofluorescence analysis were used for related protein expression and location.

Results

K₇M₂ cells were more sensitive to GO compared with MG-63 cells. The mechanism was attributed to the different extent of the generation of reactive oxygen species (ROS). In K₇M₂ cells, ROS was easily stimulated and the apoptosis pathway was subsequently activated, accompanied by elevated expression of proapoptosis proteins (such as caspase-3) and decreased expression levels of antiapoptosis proteins (such as Bcl-2). A ROS inhibitor (N-acetylcysteine) could alleviate the cytotoxic effects of GO in K₇M₂ cells. However, the production of ROS in MG-63 cells was probably inhibited by the activation of an antioxidative factor, nuclear factor-E2-related factor-2, which translocated from the cytoplasm to the nucleus after GO treatment, while a nuclear factor-E2-related factor-2 inhibitor (ML385) significantly increased ROS production in MG-63 cells when combined with GO treatment. In addition, autophagy was simultaneously stimulated by characteristic autophagosome formation, autophagy flux, and increased the expression level of autophagy-related proteins (such as LC3I to LC3II conversion, ATG5, and ATG7).

Conclusion

This paper proposes various underlying mechanisms of the anticancer effect of GO. The novel synthetic use of GO with an oxidizing agent is the key step for further potential applications in clinical OSA cancer therapy.

miR‑188 suppresses tumor progression by targeting SOX4 in pediatric osteosarcoma

microRNA‑188 (miR‑188) acts as a tumor suppressor in various types of human cancer, including glioma, oral squamous cell carcinoma and hepatocellular carcinoma. However, the function and mechanism of miR‑188 in pediatric osteosarcoma (OS) have yet to be investigated. In the present study reverse transcription‑quantitative polymerase chain reaction revealed that miR‑188 expression was significantly downregulated in pediatric OS tissues and cell lines. miR‑188 overexpression markedly suppressed OS cell proliferation, migration and invasion, and induced cellular apoptosis. An in vivo assay demonstrated that miR‑188 overexpression inhibited tumor growth. miR‑188 targeted SOX4 to regulate its expression. miR‑188 expression was inversely correlated with SOX4 in pediatric OS tissues. SOX4 restoration abrogated the inhibitory effects of miR‑188 on OS cells. The results of the present study indicated that miR‑188 suppressed pediatric OS progression by targeting SOX4.

Validation of prognostic scoring and assessment of clinical benefit for patients with bone sarcomas enrolled in phase I clinical trials

Background

We sought to validate the Royal Marsden Hospital (RMH) and MD Anderson Cancer Center (MDACC) prognostic scoring systems for the selection of bone sarcoma patients for phase I clinical trials and to identify additional risk factors related to survival.

Patients and Methods

We retrospectively reviewed the baseline characteristics and outcomes of 92 bone sarcoma patients who were referred to MDACC's Phase I Clinical Trials Program.

Results

Ninety-two patients with Ewing sarcoma (N = 47), osteosarcoma (N = 22), chondrosarcoma (N = 16), and other tumors (N = 7) were evaluated; 78 were enrolled in at least 1 of 43 different phase I trials. The median overall survival (OS) was 8.8 months (95% confidence interval [CI] = 6.8–13.7 months). Independent factors that predicted shorter survival were male sex, >2 metastatic sites, >3 previous therapies, hemoglobin level <10.5 g/dL, platelet count >200 x10³/L, creatinine level ≥1.3 mg/dL, and lactate dehydrogenase level >ULN. Patients with good RMH scores (0-1) had longer OS than patients with poor RMH scores (2-3) (HR = 5.8, 95% CI = 2.9–11.0; P < 0.0001), as did patients with low MDACC scores (0-1) as compared to patients with higher MDACC scores (2–4) (HR = 3.2, 95% CI = 1.9–5.6; P < 0.0001).

Conclusion

The RMH prognostic score can be used to predict the OS of bone cancer patients referred for phase I trials. The MDACC score added no value to the RMH score and therefore does not have a role in assessment of patients with bone tumors. Patients with advanced bone sarcomas should be considered for phase I trials.

FDG PET/CT appearance of local osteosarcoma recurrences in pediatric patients

BACKGROUND

Osteosarcoma is the most common pediatric malignant bone tumor, frequently surgically managed with limb salvage rather than amputation. Local recurrences are seen in up to 9% of osteosarcoma patients, with CT and MRI imaging often limited by metal artifacts.

OBJECTIVE

To describe the [F-18]2-fluoro-2-deoxyglucose (FDG) PET/CT appearance of local osteosarcoma recurrences with correlation to findings on other imaging modalities.

MATERIALS AND METHODS

A retrospective review of pediatric osteosarcoma patients imaged with FDG PET/CT was performed in patients with pathologically proven local recurrences. FDG PET/CT findings were reviewed and correlated with available comparison imaging studies.

RESULTS

Ten local osteosarcoma recurrences in eight pediatric osteosarcoma patients were imaged with FDG PET/CT. All eight patients had a local recurrence after limb salvage; two patients had a second local recurrence after amputation. All local recurrences were seen with FDG PET/CT, demonstrating solid (n=5) or peripheral/nodular (n=5) FDG uptake patterns. Maximum standard uptake values (SUVs) ranged from 3.0 to 15.7. In five recurrences imaged with FDG PET/CT and MRI, MRI was limited or nondiagnostic in three. In four recurrences imaged with FDG PET/CT and bone scan, the bone scan was negative in three.

CONCLUSION

Local osteosarcoma recurrences are well visualized by FDG PET/CT, demonstrating either solid or peripheral/nodular FDG uptake with a wide range of maximum SUVs. FDG PET/CT demonstrates the full extent of local recurrences, while MRI can be limited by artifact from metallic hardware. PET/CT appears to be more sensitive than bone scan in detecting local osteosarcoma recurrences.

Conditional survival of pediatric, adolescent, and young adult soft tissue sarcoma and bone tumor patients

BACKGROUND

Survival estimates for soft tissue sarcomas (STS) and malignant bone tumors (BT) diagnosed in pediatric, adolescent, and young adult patients are not easily available. We present survival estimates based on a patient having survived a defined period of time (conditional survival). Conditional survival estimates for the short-term were calculated for patients from diagnosis to the first five years after diagnosis and for patients surviving in the long-term (up to 20 years after diagnosis).

METHODS

We identified 703 patients who were diagnosed with a STS or BT at age ≤25 years from January 1, 1986 to December 31, 2012 at a large pediatric oncology center in Salt Lake City, Utah, United States. We obtained cancer type, age at diagnosis, primary site, and demographic data from medical records, and vital status through the National Death Index. Cancer stage was available for a subset of the cohort through the Utah Cancer Registry. Cox proportional hazards models, adjusted for age and sex, calculated survival estimates for all analyses.

RESULTS

Short-term survival improves over time for both sarcomas. Short-term survival for STS from diagnosis (Year 0) did not differ by sex, but short-term survival starting from 1-year post diagnosis was significantly worse for male patients (Survival probability 1-year post-diagnosis [SP1]:77% [95% CI:71-83]) than female patients (SP1:86% [81-92]). Survival for patients who were diagnosed at age ≤10 years (Survival probability at diagnosis [SP0]:85% [79-91]) compared to diagnosis at ages 16-25 years (SP0:67% [59-75]) was significantly better at all time-points from diagnosis to 5-years post-diagnosis. Survival for axial sites (SP0:69% [63-75]) compared to extremities (SP0:84% [79-90]) was significantly worse from diagnosis to 1-year post-diagnosis. Survival for axial BT (SP0: 64% [54-74] was significantly worse than BT in the extremities (SP0:73% [68-79]) from diagnosis to 3-years post diagnosis. Relapsed patients of both sarcoma types had significantly worse short-term survival than non-relapsed patients. Long-term survival for STS in this cohort is 65% at diagnosis, and improves to 86% 5-years post-diagnosis. BT survival improves from 51% at diagnosis to 78% at 5-years post-diagnosis.

CONCLUSION

Conditional survival for short- and long-term STS and BT improve as time from diagnosis increases. Short-term survival was significantly affected by patients' sex, age at diagnosis, cancer site, and relapse status.

Early Lymphocyte Recovery and Outcome in Osteosarcoma

BACKGROUND

Early lymphocyte recovery following chemotherapy has been associated with improved outcome in many cancers, including in one small study of osteosarcoma patients.

MATERIALS AND METHODS

To confirm this finding, we retrospectively reviewed data from 53 patients with newly diagnosed osteosarcoma who had blood counts on day 14 (±1 d) following the first cycle of cisplatin and doxorubicin.

RESULTS

The median absolute lymphocyte count (ALC) 14 days after starting the first cycle of chemotherapy (ALC-14) was 1990 cells/μL (range: 600 to 6470). For 32 patients with an ALC-14≥1800 cells/μL, the 5-year progression-free survival (PFS) was 69%, compared with 33% for patients with an ALC-14 of <1800 cell/μL (P=0.036). In multivariable analysis of factors including age, sex, metastatic disease, and favorable histologic response to induction chemotherapy, ALC-14 was significantly associated with PFS (P=0.0081) and overall survival (P=0.0131). The use of ALC-14 appears to further stratify PFS and overall survival among patients when grouped by histologic response.

CONCLUSIONS

We confirmed that early lymphocyte recovery was associated with outcome in pediatric osteosarcoma. Although presumably reflecting immune-mediated tumor control, the precise mechanism for this is unclear. Further study of peripheral blood lymphocyte subpopulations in prospectively treated patients is underway.

Treatment pathway of bone sarcoma in children, adolescents, and young adults

When pediatric, adolescent, and young adult patients present with a bone sarcoma, treatment decisions, especially after relapse, are complex and require a multidisciplinary approach. This review presents scenarios commonly encountered in the therapy of bone sarcomas with the goal of objectively presenting a consensus, multidisciplinary management approach. Little variation was found in the authors' group with respect to local control or systemic therapy. Clinical trials were universally prioritized in all settings. Decisions regarding relapse therapies in the absence of a clinical trial had very minor variations initially, but a consensus was reached after a literature review and discussion. This review presents a concise document and figures as a starting point for evidence‐based care for patients with these rare diseases. This framework allows prospective decision making and prioritization of clinical trials. It is hoped that this framework will inspire and focus future clinical research and thus lead to new trials to improve efficacy and reduce toxicity. Cancer 2017;123:2206–2218. © 2017 American Cancer Society.

This review presents a pathway for the management of common clinical scenarios that arise in the treatment of bone sarcomas in children, adolescents, and young adults. Clinical trials should be prioritized when they are available, and for those times when trials are unavailable, a consensus, multidisciplinary management approach to bone sarcomas is presented.

Phase 1/2 study of immunotherapy with dendritic cells pulsed with autologous tumor lysate in patients with refractory bone and soft tissue sarcoma

BACKGROUND

There are limited options for the curative treatment of refractory bone and soft tissue sarcomas. The purpose of this phase 1/2 study was to assess the immunological and clinical effects of dendritic cells (DCs) pulsed with autologous tumor lysate (TL) in patients with advanced bone and soft tissue sarcomas.

METHODS

Thirty-seven patients with metastatic or recurrent sarcomas were enrolled in this study. Peripheral blood mononuclear cells obtained from the patients were suspended in media containing interleukin 4 (IL-4) and granulocyte-macrophage colony-stimulating factor. Subsequently, these cells were treated with TL, tumor necrosis factor α, and OK-432. The DCs were injected into the inguinal or axillary region. One treatment course comprised 6 weekly DC injections. The toxicity, clinical response (tumor volume, serum interferon-γ [IFN-γ], and serum IL-12), and oncological outcomes were observed.

RESULTS

In total, 47 courses of DC therapy were performed in 37 patients. No severe adverse events or deaths associated with the DC injections were observed in the study patients. Increased serum IFN-γ and IL-12 levels were observed 1 month after the DC injection. Among the 37 patients, 35 patients were assessed for clinical responses: 28 patients showed tumor progression, 6 patients had stable disease, and 1 patient showed a partial response 8 weeks after the DC injection. The 3-year overall and progression-free survival rates of the patients were 42.3% and 2.9%, respectively.

CONCLUSIONS

Although DC therapy appears safe and resulted in an immunological response in patients with refractory sarcoma, it resulted in an improvement of the clinical outcome in only a small number of patients. Cancer 2017;123:1576-1584. © 2017 American Cancer Society.

Osteosarcoma follow-up: chest X-ray or computed tomography?

Background

In patients with relapsed osteosarcoma, the surgical excision of all metastases, defined as second complete remission (CR-2), is the factor that mainly influences post-relapse survival (PRS). Currently a validated follow-up policy for osteosarcoma is not available, both chest X-ray and computed tomography (CT) are suggested for lung surveillance. The purpose of this study is to evaluate whether the type of imaging technique used for chest surveillance, chest X-ray or CT, influenced the rate of CR-2 and prognosis in patients with recurrent osteosarcoma.

Methods

Patients up to 40 years with extremity osteosarcoma enrolled in consecutive clinical trials and treated at the Rizzoli Institute from 1986 to 2009 were identified. Only patients who had lung metastases alone as first pattern of recurrence were considered for the analysis. The rate of CR-2, overall survival (OS) and PRS were the end-points of the study.

Results

The median follow-up was 47 months (1–300), 215 patients were eligible. Lung metastases were detected by chest X-ray in 100 (47%) patients, by CT in 112 (52%) and by symptoms in 3 (1%). CR-2 rate was 60% for patients followed by X-rays and 88% for those followed by CT (p < .0001). 5-year PRS was 30% (95% CI 21–39) in the X-ray group and 49% (95% CI 39–59) in the CT group (p = .0004). 5-year OS was 35% (95% CI 26–44) in the X-ray group and 60% (95% CI 51–70) in the CT group (p = .004).

Conclusions

A follow-up strategy with chest CT leads to a higher rate of CR-2 and significantly improves PRS and OS in osteosarcoma, compared to chest X-ray.

The clinical significance of the Ezrin gene and circulating tumor cells in osteosarcoma

Purpose

The aim of this study was to investigate the clinical significance of circulating tumor cells (CTCs) in the peripheral blood of an osteosarcoma and the Ezrin gene expressed in CTCs.

Patients and methods

CTC enrichment was done with CanPatrol™ CTC enrichment technique in 41 patients with osteosarcoma. The characterization of CTCs was performed using a multiple messenger RNA in situ analysis (MRIA). The expression of the Ezrin gene in CTCs was detected by RNA probe technology. The correlations of CTC counts, cell type and the expression level of the Ezrin gene with clinical stage and metastasis of osteosarcoma were analyzed using SPSS 16.0 software.

Results

The CTC counts correlated significantly with Enneking stage (P<0.001). The ratio of mesenchymal CTCs correlated with the distant metastases (P<0.001). Ezrin gene expression in CTCs correlated significantly with distant metastases (χ²=152.51, P=0.000).

Conclusion

The ratio of mesenchymal CTCs in the peripheral blood of osteosarcoma correlates with distant metastases. High expression of Ezrin gene in CTCs correlates with distant metastases.

A 20-year retrospective analysis of CT-based pre-operative identification of pulmonary metastases in patients with osteosarcoma: A single-center review

PURPOSE

Cooperative studies support complete metastasectomy in osteosarcoma (OS). Pre-operative CT is used to identify and quantify metastases and can facilitate minimally invasive techniques. Here we assess the accuracy of pre-operative CT compared to findings at thoracotomy and its change over time.

METHODS

We reviewed OS thoracotomies performed at our institution from 1996 to 2015. The number of metastases identified on pre-operative chest CT was compared to the number of metastases seen on pathology (both metastases with viable cells and non-viable, osteoid-only metastases).

RESULTS

Eighty-eight patients underwent 161 thoracotomies with a median of 14days (range, 1-85) between CT and surgery, a median of 2 CT-identified lesions (range, 0-15), and a median of 4 resected lesions (range, 1-25). In 56 (34.8%) cases, more metastases were found surgically than were seen on CT, and among these, 34 (21.1%) had a greater number of viable metastases. There was poor overall correlation between CT and pathology findings (Kendall Tau-b=0.506), regardless of CT slice thickness, decade of thoracotomy, or total number of CT-identified lesions.

CONCLUSIONS

CT accuracy in pre-operatively quantifying OS pulmonary metastases has not improved in recent decades. Consequently, we recommend an open technique with direct lung palpation for complete identification and resection of OS pulmonary metastases.

LEVEL OF EVIDENCE

Level IV, retrospective study with no comparison group.

Patient/parent perspectives on genomic tumor profiling of pediatric solid tumors: The Individualized Cancer Therapy (iCat) experience

BACKGROUND

Genomic tumor profiling (GTP) plays an important role in the care of many adult cancer patients. Its role in pediatric oncology is still evolving, with only a subset of patients currently expected to receive clinically significant results. Little is known about perspectives of pediatric oncology patients/parents on GTP.

PROCEDURE

We surveyed individuals who previously underwent GTP through the iCat (Individualized Cancer Therapy) pilot study of molecular profiling in children with relapsed, refractory, and high-risk solid tumors at four pediatric cancer centers. Following return of profiling results, a cross-sectional survey was offered to the patient, if he or she was 18 years or older at enrollment, or parent, if he or she was under 18 years of age. Forty-five surveys (85% response) were completed.

RESULTS

Eighty-nine percent (39/44) of respondents reported hoping participation would help find cures for future patients, while 59% (26/44) hoped it would increase their/their child's chance of cure. Most had few concerns about GTP, but 12% (5/43) worried they would learn their/their child's cancer was less treatable or more aggressive than previously thought. Sixty-four percent (29/45) reported feeling their participation had helped others and 44% (20/45) felt they had helped themselves/their own child, despite only one substudy subject receiving targeted therapy matched to GTP findings. Fifty-four percent (21/39) wished to receive all available profiling data, including findings unrelated to cancer and of unclear significance.

CONCLUSIONS

Participants in pediatric GTP research perceive benefits of GTP to themselves and others, but expectations of personal benefits of GTP may exceed actual positive impact. These issues warrant consideration during consent discussions about GTP research participation.

Surgical treatment of pulmonary metastases in pediatric solid tumors

Most children who succumb to solid malignancies do so because of the burden of metastatic disease or due to complications associated with the therapy administered to treat metastatic disease. Approximately one-quarter of children with solid tumors will present with metastatic disease, and an additional 20% ultimately develop metastatic disease, most commonly in the lung. The role of surgery in the treatment of metastatic solid tumors, given its disseminated nature, is not intuitive, yet there are circumstances in which surgical resection of metastatic disease can potentially be curative. However, the utility of surgery is very much dependent on histology, and generally is most appropriate for those malignancies with histologies that are refractory to other adjuvant therapies.

MiR-24-BIM-Smac/DIABLO axis controls the sensitivity to doxorubicin treatment in osteosarcoma

Emerging evidence shows that microRNAs (miRNAs) act as critical regulators in the progression and chemoresistance of multiple tumors, including osteosarcoma (OS). In this study, we found that the level of miR-24 was increased in OS patients’ serum, tumor tissues and OS cell lines. Furthermore, we found that knockdown of miR-24 by its specific inhibitors significantly increased the therapeutic effect of doxorubicin (DOX) on OS cell lines (MG-63 and HOS). Moreover, miR-24 inhibitors resensitized the doxorubicin-resistant MG-63 cells (MG-63/R) and HOS cells (HOS/R) to DOX. As the gene of Bcl-2 interacting mediator of cell death (BIM) was proved to be a target of miR-24 in MG-63/R cells, we further observed that the miR-24 inhibitors promoted the DOX-induced apoptosis via mitochondrial pathway. In addition, results of immunoprecipitation showed the release of second mitochondria derived activator of caspase/ direct IAP binding protein with low pI (Smac/DIABLO) abolished the biological activity of X-linked inhibitor of apoptosis protein (XIAP) by binding with it, which subsequently induced the activation of caspase 9, 7 and 3. In summary, those results strongly suggest that the miR-24-BIM-Smac/DIABLO axis might be a novel target for the treatment of OS.

Higher Gemcitabine Dose Was Associated With Better Outcome of Osteosarcoma Patients Receiving Gemcitabine-Docetaxel Chemotherapy

BACKGROUND

Efficacy of gemcitabine and docetaxel (GEM + DOC) chemotherapy in patients with recurrent or refractory osteosarcoma was evaluated.

METHODS

Data of 53 patients from 9 institutions, who received GEM (675 or 900 mg/m(2) on days 1 and 8) and DOC (100 mg/m(2) on day 8), were retrospectively reviewed.

RESULTS

GEM + DOC was administered as adjuvant (n = 25) or palliative chemotherapy (n = 28). Patients received a median 3 courses (range, 1-10 courses). Objective response rate (CR + PR, where CR is complete response and PR is partial response) and disease control rate (CR+ PR + SD, where SD is stable disease) were 14.3% and 28.6%, respectively. Disease control rate was higher in patients receiving 900 mg/m(2) GEM than in patients receiving 675 mg/m(2) (50.0% vs. 12.5%, P = 0.03). Higher GEM dose was associated with better survival, both in adjuvant (1-year overall survival, 90.9 ± 8.7% vs. 38.5 ± 13.5%, P = 0.002) and palliative settings (50.0 ± 14.4% vs. 31.3 ± 11.6%, P = 0.04).

CONCLUSIONS

Further studies are necessary to investigate the efficacy of more aggressive and higher doses of GEM + DOC chemotherapy in osteosarcoma.

Oncological outcome after lung metastasis in patients presenting with localized chondrosarcoma at extremities: Tokai Musculoskeletal Oncology Consortium study

The oncological outcome after lung metastasis in patients with chondrosarcoma of the extremities has not been reported. Between June 2000 and June 2013, 179 patients with chondrosarcoma in the extremities were treated at eleven hospitals. Twenty consecutive patients (11.2%) developed lung metastases after initial treatment of primary chondrosarcoma in the extremities. We investigated the oncological outcome of 20 chondrosarcoma patients with lung metastasis. There were 14 males and six females with a mean age of 49 years. The mean duration between primary surgery and appearance of lung metastases was 34 months. The mean follow-up period was 48 months. We excluded patients with lung metastasis at the time of presentation from this study. At the final follow-up, four of 20 patients had no evidence of disease, four were alive with disease, and twelve had died of disease. The 3- and 5-year survival rates after lung metastasis were 51.5% and 45.7%, respectively. Tumor grade, extrapulmonary metastasis, and treatment for lung metastases including metastasectomy and radiofrequency ablation were identified by univariate analysis to be significant prognostic factors for oncological analysis. In conclusion, this study evaluated the oncological outcome in patients with chondrosarcoma of the extremities with lung metastasis. Although a large-scale study might be required to confirm the results of this study, we suggest that metastasectomy and/or radiofrequency ablation should be considered to improve postmetastatic survival.

Pediatric Oncology Provider Views on Performing a Biopsy of Solid Tumors in Children with Relapsed or Refractory Disease for the Purpose of Genomic Profiling

BACKGROUND

Patients with relapsed and refractory solid tumors have a poor prognosis. Recent advances in genomic technology have made it feasible to screen tumors for actionable mutations, with the anticipation that this may provide benefit to patients.

METHODS

Pediatric oncologists were emailed an anonymous 34-question survey assessing their willingness to offer a rebiopsy to patients with relapsed disease for the purpose of tumor genomic profiling. They were presented with two scenarios evaluating morbidity and invasiveness of the procedures using the clinical examples of medulloblastoma and Ewing sarcoma.

RESULTS

A total of 195 pediatric oncologists responded to the questionnaire. Morbidity and invasiveness of the procedure demonstrated significant differences in provider willingness to refer their patients for rebiopsy. The pretest probability was a major variable influencing provider willingness to offer a rebiopsy. Respondents were more likely to offer a rebiopsy if the likelihood was high that the results would have an impact on clinical management than if the biopsy was for histologic confirmation alone (mean 89 vs. 56 %; p = 0.017). Compared with the rate of a rebiopsy for histologic confirmation, significantly fewer providers were willing to offer a rebiopsy if they were led to believe the likelihood of finding an actionable mutation was low (mean 45 vs. 56 %; p = 0.021).

CONCLUSION

The scenario showed that the pretest probability of finding an actionable mutation was influential in determining provider willingness to offer a rebiopsy for the purpose of tumor genomic profiling. Further research is warranted to evaluate the benefit of tumor genomic profiling in terms of patient outcomes.

EMMPRIN, SP1 and microRNA-27a mediate physcion 8-O-β-glucopyranoside-induced apoptosis in osteosarcoma cells

Physcion 8-O-β-glucopyranoside (PG), the main active ingredient of Rumex japonicus, induces apoptosis and causes cell cycle arrest in human lung cancer cells. However, its anti-tumor effects are not fully understood. In this study, we explored the mechanisms underlying PG induced apoptosis in the osteosarcoma cell line MG-63. Our results showed that PG exerted anti-proliferative effects and induced apoptosis in MG-63 cells via the intrinsic mitochondrial pathway, accompanied by loss of mitochondrial membrane potential (MMP) and cytochrome C release from the mitochondria. In addition, physcion treatment significantly inhibited extracellular matrix metalloproteinase inducer (EMMPRIN) expression in MG-63 cells, in a dose-dependent manner; meanwhile, EMMPRIN protein overexpression markedly reduced PG-induced apoptosis. Moreover, our findings suggested that the modulatory effects of PG on EMMPRIN were due, at least in part, to regulation of an ROS-miR-27a/ZBTB10-Sp1 transcription factor pathway.

[Treatment Outcomes and Prognostic Factors of Pulmonary Metastasectomy for Bone and Soft Tissue Sarcoma: a High Volume Academic Institution Experience]

背景与目的

肺是骨与软组织肉瘤最常见的远隔转移脏器，肺转移严重影响患者长期生存。肺转移瘤切除术有助于改善预后，然而对其临床地位、适应证及预后影响因素的认识目前仍存在争议。由于发病率较低难以开展随机对照研究，同时国际单中心大宗病例回顾研究也极为罕见，国内尚无类似报道。本研究旨在回顾本组单中心大样本肺转移性骨与软组织肉瘤的外科治疗结果，并且对预后影响因素进行分析。

方法

2007年1月-2015年12月期间，经病理确诊为骨与软组织肉瘤，已在多学科综合治疗框架下完成原发病灶根治性切除，并且至少经过1次肺转移瘤切除术的所有患者均纳入分析。收集相关临床变量，运用Cox风险比例回归法进行单因素及多因素分析寻找与预后影响因素。

结果

144例骨与软组织肉瘤患者符合纳入标准，总共行155次肺转移瘤切除术。多因素分析结果提示非R0切除、无病间期 < 1年、肺转移灶数目≥3枚、肺转移灶的长径总和≥45 mm均是预后的独立危险因素。

结论

积极行肺转移瘤外科治疗有助于改善转移性骨与软组织肉瘤患者的长期预后。R0切除，无病间期时间较长，转移瘤数目较少及长径总和较小是本组患者良好的预后因素。

Outcomes of Adolescent and Adult Patients with Lung Metastatic Osteosarcoma and Comparison of Synchronous and Metachronous Lung Metastatic Groups

Osteosarcomas with lung metastases are rather heterogenous group. We aimed to evaluate the clinicopathological characteristics and outcomes of osteosarcoma patients with lung metastases and to compare the synchronous and metachronous lung metastatic groups. A total of 93 adolescent and adult patients with lung metastatic osteosarcoma, from March 1995 to July 2011, in a single center, were included. Sixty-five patients (69.9%) were male. The median age was 19 years (range, 14–74). Thirty-nine patients (41.9%) had synchronous lung metastases (Group A) and 54 patients (58.1%) had metachronous lung metastases (Group B). The 5-year and 10-year post-lung metastases overall survival (PLM-OS) was 17% and 15%, respectively. In multivariate analysis for PLM-OS, time to lung metastases (p = 0.010), number of metastatic pulmonary nodules (p = 0.020), presence of pulmonary metastasectomy (p = 0.007) and presence of chemotherapy for lung metastases (p< 0.001) were found to be independent prognostic factors. The median PLM-OS of Group A and Group B was 16 months and 9 months, respectively. In Group B, the median PLM-OS of the patients who developed lung metastases within 12 months was 6 months, whereas that of the patients who developed lung metastases later was 16 months. Time to lung metastases, number and laterality of metastatic pulmonary nodules, chemotherapy for lung metastatic disease and pulmonary metastasectomy were independent prognostic factors for patients with lung metastatic osteosarcoma. The best PLM-OS was in the subgroup of patients treated both surgery and chemotherapy. The prognosis of the patients who developed lung metastases within 12 months after diagnosis was worst.

Follow-up practices for high-grade extremity Osteosarcoma

Background

The optimal conduct of follow-up (FU) of patients with osteosarcoma is uncertain. In the absence of any formal validation of optimal timing and method of surveillance, guidance is provided by oncology societies’ recommendations. FU is designed to detect either local recurrence or metastatic disease at a time when early treatment is still possible and might be effective.

Methods

We performed a retrospective analysis of 101 patients with high-grade extremity osteosarcoma in a single centre. Chest x-ray (CXR) was used as routine surveillance method; however patients with initial lung metastases or previous suspicious findings had computed tomography (CT) scans.

Results

With a median FU time of 30.7 months 34 patients relapsed. Relapse–free survival after 5 years was 61 % (CI 52 %; 73 %), late relapses occurred in only two patients between 2 and 5 years of FU.

Twenty-five of the 34 relapses were detected at routine FU appointments. All 8 local recurrences were noted clinically. Twenty-two patients had metastases confined to the lungs, either detected on CXR or CT. Thirty-two percent of patients with lung metastases only were salvaged successfully.

Conclusions

Routine FU in high-grade osteosarcoma results in clinical detection of local relapse, and detection of lung metastases by CXR at a time when metastatectomy is possible. The optimal time interval for FU appointments is not known, however we recommend more frequent surveillance visits during the two years after treatment. We hypothesize that routine CT scans are not required and propose CXR for detection of lung metastases.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2333-y) contains supplementary material, which is available to authorized users.

Zoledronic acid in metastatic osteosarcoma: encouraging progression free survival in four consecutive patients

Background

Zoledronic acid (ZA) is a third-generation bisphosphonate in widespread clinical use to reduce pain and skeletal events in patients from a variety of malignancies with bone metastases. Pre-clinical studies indicate that ZA inhibits osteosarcoma through direct anti-proliferative effects, immune activation and anti-angiogenic activity.

Methods

The purpose of this study was to evaluate the antitumor efficacy of ZA at standard dose until progression in patients with stage IV osteosarcoma lacking a standard of care treatment option proven to influence survival. Researchers retrospectively reviewed medical records of all patients at our institution with high-grade osteosarcoma presumed to be incurable due to metastases progressive after primary combination chemotherapy who received single agent ZA in an effort to delay progression.

Results

In our four-patient cohort following initiation of ZA, the median progression-free survival was 19 months, and median overall survival was 56+ months. Two of four patients have remained progression-free since starting ZA. The other two initially progressed after 18–20 months on ZA followed by metastasectomy of lung or dural metastases and further stability for over a year following resumption of ZA. After a 20-month progression-free interval on ZA alone, one patient had partial response following addition of pazopanib to ZA that likely contributed to long term disease control. The four patients experienced no significant toxicities despite protracted dosing of ZA for up to 5 years, and none have required chemotherapy since beginning ZA.

Conclusions

Single agent ZA was associated with encouraging progression-free survival in four consecutive patients with metastatic osteosarcoma. Prospective trials of single agent ZA are warranted as protracted maintenance therapy in surgically incurable osteosarcoma relapsed or refractory to first line combination chemotherapy with radiographically measurable metastases.

Serum CEACAM1 Level Is Associated with Diagnosis and Prognosis in Patients with Osteosarcoma

Carcinoembryonic antigen related cell adhesion molecule 1 (CEACAM1) is a trans-membrane multifunctional cell adhesion molecule associated with tumor cell proliferation, apoptosis, angiogenesis, invasion, and migration during tumor development. In the present study, we evaluated serum CEACAM1 level in osteosarcoma patients to explore its diagnostic and prognostic value for this particular malignancy. Sera from 113 patients with primary osteosarcoma, 98 patients with benign bone tumors and 126 healthy controls were obtained. Serum CEACAM1 level was measured with ELISA and correlation with clinicopathological characteristics was further analyzed. Receiver operating curves (ROC), Kaplan-Meier curves, and log-rank analyses as well as Cox proportional hazard models were used to evaluate diagnostic and prognostic significance. The results revealed that serum CEACAM1 level was significantly higher in osteosarcoma patients compared to benign bone tumors and healthy controls (455.2 ± 179.9 vs 287.4 ± 103.2, 260.8 ± 109.7 pg/ml, respectively). Osteosarcoma patients with larger tumors, later-tumor stages, low tumor grades, and distant metastases had much higher CEACAM1 compared to those with smaller tumors, earlier tumor stages, high tumor grades and non-distant metastases (P < 0.05 for all). Multivariate logistic regression analysis confirmed that high serum CEACAM1 level was an independent risk factor for distant metastases (OR = 3.02, 95%CI 1.65–4.17). To distinguish osteosarcoma patients from those with benign bone tumor and healthy controls, ROC/AUC analysis indicated an AUC of 0.81 (sensitivity 0.61; specificity 0.89) and an AUC of 0.77 (sensitivity 0.57; specificity 0.92), respectively. Osteosarcoma patients with higher CEACAM1 had relatively lower survival compared to those with low CEACAM1 (P < 0.01), and multivariate analyses for overall survival revealed that high serum CEACAM1 level was an independent prognostic factor for osteosarcoma (HR = 1.56, 95%CI 1.23–3.28). The present study suggested that elevated serum CEACAM1 level might be a novel diagnostic and prognostic biomarker for osteosarcoma patients.

Postrelapse Prognostic Factors in Nonmetastatic Osteosarcoma: A Single-institution Experience

PURPOSE

The purpose of this study was to analyze the prognostic factors that influence postrelapse survival (PRS) in children and adolescents with initial localized high-grade osteosarcoma.

METHODS/PATIENTS

This is a retrospective evaluation of patients aged 21 years and below with nonmetastatic high-grade osteosarcoma treated at our institution from 1985 to 2011 who developed recurrent disease after achievement of an initial complete response (CR). PRS and postrelapse event-free survival (PREFS) analyses were performed using the Kaplan-Meier method and log-rank test. Multivariate Cox regression analysis was used to determine which variables were independently prognostic.

RESULTS

Thirty-one patients were included. Median age at primary diagnosis was 13.7 years (range, 1.9 to 21.0 y). Median time to first relapse was 16 months (range, 3 to 36 mo). Fourteen patients achieved a second CR (CR2) after surgery±chemotherapy treatment. The 5-year PRS and PREFS were both 26% (95% confidence interval, 14%-49%), with a median follow-up of 99 months (range, 27 to 271 mo). Multivariate analysis showed that achievement of CR2 (P<0.001) and histologic response to first-line treatment (P=0.02) were significantly associated with PRS, whereas time to first relapse did not retain univariate significance.

CONCLUSIONS

Achievement of CR2 and histologic response to preoperative first-line treatment are independent survival prognostic factors in osteosarcoma recurrence.

Tissue expression levels of miR-29b and miR-422a in children, adolescents, and young adults' age groups and their association with prediction of poor prognosis in human osteosarcoma

Osteosarcoma is the most common type of bone cancer in children and adolescents. MicroRNAs (miRNAs) play important roles in the development, differentiation, and function of different cell types and in the pathogenesis of various human diseases. miRNAs are differentially expressed in normal and cancer cells. The investigation of miRNA expression between healthy subjects and patients with osteosarcoma is crucial for future clinical trials. In this study, the expression levels of miRNAs were detected by qRT-PCR. Correlation between expression levels of tow miRNAs and different clinicopathological characteristics were analyzed using the χ (2) test. Survival rate was detected using the log-rank test and Kaplan-Meier method. qRT-PCR was shown that expression levels of miR-29b and miR-422a were strongly decreased in osteosarcoma bone tissue compared with noncancerous bone tissues. Our result indicated that the low expression levels of miR-29b and miR-422a showed strong correlation with large tumor size (P = 0.20; 0.029), advanced TNM stage (P = 0.001; 0.012), distant metastasis (P = 0.008; 0.019), and grade of tumor (P = 0.009; 0.016). Kaplan-Meier survival analysis showed that the low expressions of miR-29b/miR-422a were correlated with shorter time overall survival (log-rank test, P = 0.009; P = 0.013). Moreover, multivariate Cox proportional hazards model indicated that miR-29b and miR-422a (P = 0.024; P = 0.016) were independent prognostic markers of overall survival of patients. Our result indicated that downregulation of miR-29b and miR-422a may be linked to the prediction of poor prognosis, indicating that miR-29b and miR-422a may be a valuable prognostic marker for osteosarcoma patients.

Hyperuricemia has an adverse impact on the prognosis of patients with osteosarcoma

Patients with osteosarcoma have poor prognosis and are often at high risk of death. Identification of prognostic biomarkers for osteosarcoma may aid in improving the survival. Hyperuricemia had been suggested as a poor prognostic factor of several cancers, but the prognostic role of hyperuricemia in osteosarcoma patients had not been assessed. In the present study, we investigated the prognostic role of hyperuricemia at baseline on the overall survival of patients with osteosarcoma. Sixty osteosarcoma patients with hyperuricemia were matched (1:2) to 120 osteosarcoma patients without hyperuricemia with similar age and gender. Data from those patients with osteosarcoma were evaluated retrospectively. The role of hyperuricemia on overall survival was firstly analyzed using the Kaplan-Meier method. Univariate and multivariate Cox regression models were also used to further evaluate the prognostic significance of hyperuricemia. None of the clinicopathological parameters except distant metastasis was associated with hyperuricemia. Kaplan-Meier method showed that patients with hyperuricemia had shorter overall survival compared with those with normouricemia (P < 0.0001, log-rank test). In univariate analysis, hyperuricemia was associated with poorer overall survival in osteosarcoma patients (HR = 2.71, 95 % CI 1.75-4.20; P < 0.0001). In the multivariate analysis, after adjusting for age, gender, serum alkaline phosphatase, stage, tumor size, and metastasis, hyperuricemia was independently associated with poorer overall survival in osteosarcoma patients (HR = 2.28, 95 % CI 1.41-3.69; P = 0.001). In conclusion, hyperuricemia at baseline is associated with poorer overall survival in osteosarcoma patients, and it has an adverse impact on the prognosis of osteosarcoma patients.

Tissue microRNA-126 expression level predicts outcome in human osteosarcoma

Background

MicroRNA-126 has been found to be consistently under-expressed in osteosarcoma tissues and cell lines compared with normal bone tissues and normal osteoblast cells, respectively. The purpose of the present study was to detect the expression levels of miR-126 in osteosarcoma patients and to further investigate the clinicopathological, and prognostic value of miR-126.

Methods

We recruited 122 patients with osteosarcomas from the Department of Orthopedic Surgery, Yantaishan Hospital between May 2008 and April 2013. The expression level of miR-126 was determined by qRT-PCR. Associations between miR-126 expression and various clinicopathological characteristics were analyzed using the χ² test. Survival rate was determined with Kaplan-Meier and statistically analyzed with the log-rank method between groups. Survival data were evaluated through multivariate Cox regression analysis.

Results

miR-126 expression was significantly decreased in osteosarcoma tissues compared to adjacent normal bone tissues (2.421 ± 1.250 vs. 6.212 ± 1.843, P = 0.001). We found that low miR-126 expression had significant association with advanced TNM stage (P <0.001), distant metastasis (P <0.001), and higher tumor grade (P = 0.001). Kaplan-Meier survival analysis showed that the miR-126 low-expression group had significantly shorter overall survival time than those with high-expression (log-rank test, P = 0.008). Furthermore, multivariate Cox proportional hazards model analysis showed that miR-126 expression was independently associated with overall survival of patients with osteosarcoma (HR = 3.102, 95 % CI: 1.113–9.023, P = 0.018).

Conclusions

This is the first study revealing that miR-126 down-expression may be related to the prediction of poor prognosis for osteosarcoma patients, suggesting that miR-126 may serve as a prognostic marker for the optimization of clinical treatments.

Recurrent osteosarcoma with a single pulmonary metastasis: a multi-institutional review

BACKGROUND

Late relapse and solitary lesion are positive prognostic factors in recurrent osteosarcoma.

METHODS

We reviewed the records of 39 patients treated at three major centres for recurrent osteosarcoma with a single pulmonary metastasis more than 1 year after diagnosis. We analysed their outcomes with respect to clinical factors and treatment with chemotherapy.

RESULTS

Median age at diagnosis was 14.6 years. Relapse occurred at a median of 2.5 years (range, 1.2-8.2 years) after initial diagnosis. At relapse, all patients were treated by metastasectomy; 12 (31%) patients also received chemotherapy. There was no difference in time to recurrence or nodule size between the patients who received or did not receive chemotherapy at relapse. Sixteen patients had no subsequent recurrence, 13 of whom survive without evidence of disease. The 5-year and 10-year estimates of post-relapse event-free survival (PREFS) were 33.0±7.5% and 33.0±9.6%, respectively, and of post-relapse survival (PRS) 56.8±8.6% and 53.0±11.0%, respectively. There was a trend for nodules <1.5 cm to correlate positively with PREFS (P=0.070) but not PRS (P=0.49). Chemotherapy at first relapse was not associated with PREFS or PRS.

CONCLUSION

Approximately half of the patients with recurrent osteosarcoma presenting as a single pulmonary metastasis more than 1 year after diagnosis were long-term survivors. Metastasectomy was the primary treatment; chemotherapy did not add benefit.

MiR-451 inhibits cell growth and invasion by targeting CXCL16 and is associated with prognosis of osteosarcoma patients

Recent studies have shown that microRNA-451 (miR-451) was significantly decreased in osteosarcoma tissues and was identified as a tumor suppressor in other types of human cancers. However, its clinical significance and molecular mechanisms in osteosarcoma are still not well understood. MiR-451 levels are evaluated by quantitative reverse transcription-polymerase chain reaction (RT-PCR) in osteosarcoma cell lines and in 68 pairs of osteosarcoma and adjacent noncancerous tissues. Then, the associations of miR-451 expression with clinicopathological features of patients were determined. The effects of miR-451 in osteosarcoma cells were examined by MTT and Matrigel invasion assay. The functional target of miR-451 were determined by bioinformatics analysis and validated by luciferase reporter analyses and Western blot assay. Our results showed that the expression of miR-451 was significantly downregulated in osteosarcoma tissues compared with corresponding noncancerous tissues (P < 0.01). Particularly, statistical analysis of primary human osteosarcoma indicated that decreased expression of miR-451 was correlated with metastasis and recurrence. Moreover, the miR-451 force-expression suppressed cell proliferation and invasion in vitro. Based on bioinformatics analysis, we found that chemokine ligand 16 (CXCL16) was identified as a direct functional target of miR-451. Consistent with the effects of miR-451, silencing CXCL16 could phenocopy the effects of miR-451 on phenotypes of osteosarcoma cells. Furthermore, CXCL16 expression was upregulated in osteosarcoma tissues and inversely associated with miR-451 in human osteosarcoma tissues. Our data reveal a downregulated expression of miR-451 in osteosarcoma tissues, which is inversely associated with CXCL16 levels. These observations demonstrated that miR-451 may play an important role in tumor growth and metastasis in osteosarcoma.

Factors predicting survival following complete surgical remission of pulmonary metastasis in osteosarcoma

Pulmonary metastasectomy (PM) is associated with improved survival of patients with metastatic osteosarcoma; however, the factors affecting survival following achievement of complete surgical remission remain controversial. The main objective of this study was to report the outcomes and prognostic factors of osteosarcoma patients who achieved complete remission (CR) following PM. We analyzed the effect of demographic and disease-related characteristics on the overall survival (OS) of consecutive patients with metastatic osteosarcoma who were treated at a single institution and achieved CR following PM, through univariate and multivariate analyses. Between January, 2000 and August, 2013, 62 patients with metastatic osteosarcoma were treated and followed up at our institution. A total of 25 patients achieved CR following PM and were included in this analysis. The 5-year OS and disease-free survival following PM were 30 and 21%, respectively. The factors correlated with inferior OS in the univariate analysis included chondroblastic subtype, post-chemotherapy necrosis <90% in the primary tumor, metastasis detected during neoadjuvant or adjuvant chemotherapy and pathological identification of tumor cells reaching the visceral pleural surface of any of the resected nodules. In the multivariate analysis, the chondroblastic subtype was the sole independent adverse prognostic factor (HR=4.6, 95% CI: 1.0-21.3, P=0.044). Therefore, factors associated with tumor biology, including poor tumor necrosis in the primary tumor and detection of metastasis during primary chemotherapy, are associated with poor post-metastasectomy survival. In addition, chondroblastic subtype and visceral pleural involvement predicted poor prognosis in our series.

Bilateral anterior sternothoracotomy (clamshell incision): a suitable alternative for bilateral lung sarcoma metastasis in children

Background

The aim of our study was to assess the postoperative course of bilateral anterior sternothoracotomy (BAT) in children with sarcoma metastases, in a curative care perspective.

Methods

We reviewed the records of seven patients younger than 18 years old, who underwent surgical procedures for sarcoma metastasis to the lung between 2000 and 2012. We compared the postoperative course of the BAT group with that of patients who underwent unilateral posterolateral thoracotomies (PLTs) for the same etiology.

Results

Of 17 surgical procedures, there were seven BAT and 10 unilateral PLT. Mean ages at the time of the procedures were 12.9 ± 5.4 years old for BAT, and 17.4 ± 1.9 years old for PLT. Mean operative time was 173 ± 37 minutes in the BAT group, and 145 ± 39 minutes in the PLT group (P = 0.19). Patients received epidural analgesia in all cases; this was for a mean time of 3.8 ± 1.3 days in the BAT group, and 3.21 ± 4 days in the PLT group (P = 0.36). Chest tubes were removed after 3.6 ± 1.3 days in the BAT group, and 3 ± 1.2 days in the PLT group (P = 0.69). Total hospital stay was 7.7 ± 6.6 days in the BAT group, and 7 ± 1.2 days in the PLT group (P = 0.72).

Conclusion

In our experience, BAT seems suitable and shows outcomes similar to those of PLT for sarcoma metastasis resection. The BAT procedure allows the manual exploration of both lungs during a single surgical intervention, and so reduces the delay of further therapies.

Osteosarcoma with metastasis at initial diagnosis: Current outcomes and prognostic factors in the context of a comprehensive cancer center

The aim of this study was to report the outcomes and prognostic factors for a cohort of patients with osteosarcoma who presented with metastasis at initial diagnosis. Data of consecutive patients with osteosarcoma and metastatic disease at initial presentation, who were treated and followed up at a single institution, were retrospectively reviewed. The effect of potential factors on overall survival (OS) was analyzed through univariate and multivariate analysis. Between January, 2000 and March, 2013, a total of 135 patients with osteosarcoma, of whom 21 (16.0%) had distant metastasis at initial presentation, were diagnosed and treated at our center and were included in this analysis. The patients were treated with a strategy that integrates multi-agent chemotherapy and resection of all sites of gross disease whenever feasible. The 5-year OS and event-free survival (EFS) were 23.0% and 11.0%, respectively. The factors associated with inferior OS in the univariate analysis included the osteoblastic variant, extrapulmonary metastasis and failure to achieve complete remission. In the multivariate analysis, the osteoblastic variant [hazard ratio (HR)=4.83, 95% confidence interval (CI): 1.16-20.0, P=0.038] and extrapulmonary metastasis (HR=5.0, 95% CI: 1.40-17.94, P=0.018) were the only independent prognostic factors. The current outcomes of patients with osteosarcoma and metastasis at initial diagnosis remained poor. The osteoblastic subtype and extrapulmonary metastatic sites predicted poor survival in our series. To the best of our knowledge, this is the first report of the correlation between the histological subtype and survival for patients with metastatic disease at initial presentation; therefore, confirmation in future studies is required.

Osteosarcoma in pediatric patients and young adults: a single institution retrospective review of presentation, therapy, and outcome

Background. Little is known about how cumulative chemotherapy delivery influences the poorer outcome observed in young adult (YA, 18–40 years) versus pediatric (<18 years) osteosarcoma patients. Here, we retrospectively examined differences in presentation, therapy, including cumulative chemotherapy dose, and outcome in YA and pediatric patients. Methods. We reviewed 111 cases of high-grade osteosarcoma at Moffitt Cancer Center between 1988 and 2012. Presentation factors, therapies, and survival were compared between YA and pediatric cohorts. Results. The cohorts were equivalent with respect to metastatic status, gender, tumor size, tumor site, and histological subtype. We found that the YA patients tended to have poorer histologic response to neoadjuvant chemotherapy measured by necrosis with 55% and 35% of pediatric versus YA patients responding favorably (P = 0.06). Only 39% of YA patients achieved the typical pediatric dose of methotrexate, doxorubicin, and cisplatin. These patients had a 3-year EFS of 76% (CI 53–100%) versus 47% (CI 26–69%; P = 0.09) in those who received less chemotherapy. Conclusion. Age continues to be a prognostic factor in osteosarcoma. Our study suggests that presentation factors are not associated with prognosis, while poorer response to chemotherapy and lower cumulative dose of chemotherapy delivered to YA patients may contribute to poorer outcomes.

Natural killer cell therapy and aerosol interleukin-2 for the treatment of osteosarcoma lung metastasis

BACKGROUND

Survival of patients with osteosarcoma lung metastases has not improved in 20 years. We evaluated the efficacy of combining natural killer (NK) cells with aerosol interleukin-2 (IL-2) to achieve organ-specific NK cell migration and expansion in the metastatic organ, and to decrease toxicity associated with systemic IL-2.

PROCEDURE

Five human osteosarcoma cell lines and 103 patient samples (47 primary and 56 metastatic) were analyzed for NKG2D ligand (NKG2DL) expression. Therapeutic efficacy of aerosol IL-2 + NK cells was evaluated in vivo compared with aerosol IL-2 alone and NK cells without aerosol IL-2.

RESULTS

Osteosarcoma cell lines and patient samples expressed various levels of NKG2DL. NK-mediated killing was NKG2DL-dependent and correlated with expression levels. Aerosol IL-2 increased NK cell numbers in the lung and within metastatic nodules but not in other organs. Therapeutic efficacy, as judged by tumor number, size, and quantification of apoptosis, was also increased compared with NK cells or aerosol IL-2 alone. There were no IL-2-associated systemic toxicities.

CONCLUSION

Aerosol IL-2 augmented the efficacy of NK cell therapy against osteosarcoma lung metastasis, without inducing systemic toxicity. Our data suggest that lung-targeted IL-2 delivery circumvents toxicities induced by systemic administration. Combining aerosol IL-2 with NK cell infusions, may be a potential new therapeutic approach for patients with osteosarcoma lung metastasis.

A Randomized Study on Postrelapse Disease-Free Survival with Adjuvant Mistletoe versus Oral Etoposide in Osteosarcoma Patients

Background. Osteosarcoma is a highly malignant bone tumour. After the second relapse, the 12-month postrelapse disease-free survival (PRDFS) rate decreases below 20%. Oral Etoposide is often used in clinical practice after surgery as an “adjuvant” outside any protocol and with only limited evidence of improved survival. Viscum album fermentatum Pini (Viscum) is an extract of mistletoe plants grown on pine trees for subcutaneous (sc) injection with immunomodulatory activity. Methods. Encouraged by preliminary findings, we conducted a study where osteosarcoma patients free from disease after second metastatic relapse were randomly assigned to Viscum sc or Oral Etoposide. Our goal was to compare 12-month PRDFS rates with an equivalent historical control group. Results. Twenty patients have been enrolled, with a median age of 34 years (range 11–65) and a median follow-up time of 38.5 months (3–73). The median PRDSF is currently 4 months (1–47) in the Etoposide and 39 months (2–73) in the Viscum group. Patients getting Viscum reported a higher quality of life due to lower toxicity. Conclusion. Viscum shows promise as adjuvant treatment in prolonging PRDFS after second relapse in osteosarcoma patients. A larger study is required to conclusively determine efficacy and immunomodulatory mechanisms of Viscum therapy in osteosarcoma patients.