Survival from high-grade localised extremity osteosarcoma: combined results and prognostic factors from three European Osteosarcoma Intergroup randomised controlled trials

Is Microscopic Vascular Invasion in Tumor Specimens Associated with Worse Prognosis in Patients with High-grade Localized Osteosarcoma?

BACKGROUND

Other than metastases at diagnosis and histological response to preoperative chemotherapy, there are few reliable predictors of survival in patients with osteosarcoma. Microscopic vascular invasion (MVI) has been identified in the resection specimens of patients with osteosarcoma. However, it is unknown whether the MVI in resected specimens is associated with worse overall survival and higher cumulative incidence of local recurrence or metastasis in a large cohort of patients younger than 40 years with high-grade localized osteosarcoma.

QUESTIONS/PURPOSES

(1) Is MVI associated with worse overall survival and higher cumulative incidence of events (local recurrence or metastasis) in patients younger than 40 years with high-grade localized osteosarcoma? (2) What clinical characteristics are associated with MVI in patients with high-grade localized osteosarcoma?

METHODS

A total of 625 patients younger than 40 years with primary high-grade osteosarcoma between 1997 and 2016 were identified in our oncology database. We included patients younger than 40 years with primary high-grade osteosarcoma who underwent definitive surgery and preoperative and postoperative chemotherapy. The minimum follow-up period was 2 years after treatment. Patients with the following were excluded: metastasis at initial presentation (21%, n = 133), progression with preoperative chemotherapy precluding definitive surgery (6%, n = 38), surgery at another unit (2%, n = 13), lost to follow-up before 2 years but not known to have died (3%, n = 18), and death related to complications of preoperative chemotherapy (1%, n = 4). A retrospective pathologic and record review was conducted in the remaining 419 patients. The median follow-up period was 5 years (interquartile range [IQR] 3 to 9 years). The overall survival of the entire group (n = 419) was 67% [95% CI 63 to 72] at 5 years. Of the 419 patients, 10% (41) had MVI in their resection specimens. The Kaplan-Meier method was used to estimate overall survival. The cumulative incidence of events captured the first event of either metastasis or local recurrence. This analysis was completed with a competing risk framework: deaths without evidence of local recurrence or metastasis were regarded as a competing event. Clinical and histological variables (sex, age, tumor site, tumor largest dimension, surgical margin, chemotherapy-induced necrosis, type of surgery, histologic type of tumor, type of chemotherapy regimen, pathologic fracture, and MVI) were evaluated using the log-rank test or Gray test in the univariate analyses and Cox proportional hazard model or Fine and Gray model in the multivariate analyses.

RESULTS

After adjusting for other factors, multivariate analyses showed that the presence of MVI in resection specimens was associated with worse overall survival and higher cumulative incidence of event (hazard ratio 1.88 [95% CI 1.22 to 2.89]; p = 0.004 and HR 2.33 [95% CI 1.56 to 3.49]; p < 0.001, respectively). A subgroup analysis demonstrated that the relationship between MVI and survival applied only to patients with a poor response to chemotherapy (less than 90% necrosis; overall survival at 5 years, MVI [+] = 24% [95% CI 11 to 39] versus MVI [-] = 60% [95% CI 52 to 66]; p < 0.001 and cumulative incidence of events at 5 years, MVI [+] = 86% [95% CI 68 to 94] versus MVI [-] = 54% [95% CI 46 to 61]; p < 0.001). The MVI (+) group had a higher proportion of patients with a poor response to chemotherapy (85% [35 of 41] versus 53% [201 of 378]; p < 0.001), involved margins (15% [6 of 41] versus 5% [18 of 378]; p = 0.021), and limb-ablative surgery (37% [15 of 41] versus 21% [79 of 378]; p = 0.022) than the MVI (-) group did.

CONCLUSIONS

MVI is associated with lower overall survival and higher cumulative incidence of local recurrence or metastasis, especially in patients with a poor histologic response to preoperative chemotherapy. Future studies in patients treated for osteosarcoma should consider this observation when planning new trials.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Reprograming the tumor immunologic microenvironment using neoadjuvant chemotherapy in osteosarcoma

Tumor-infiltrating immune cells play a crucial role in tumor progression and response to treatment. However, the limited studies on infiltrating immune cells have shown inconsistent and even controversial results for osteosarcoma (OS). In addition, the dynamic changes of infiltrating immune cells after neoadjuvant chemotherapy are largely unknown. We downloaded the RNA expression matrix and clinical information of 80 OS patients from the TARGET database. CIBERSORT was used to evaluate the proportion of 22 immune cell types in patients based on gene expression data. M2 macrophages were found to be the most abundant immune cell type and were associated with improved survival in OS. Another cohort of pretreated OS samples was evaluated by immunohistochemistry to validate the results from CIBERSORT analysis. Matched biopsy and surgical samples from 27 patients were collected to investigate the dynamic change of immune cells and factors before and after neoadjuvant chemotherapy. Neoadjuvant chemotherapy was associated with increased densities of CD3+ T cells, CD8+ T cells, Ki67 + CD8+ T cells and PD-L1+ immune cells. Moreover, HLA-DR-CD33+ myeloid-derived suppressive cells (MDSC) were decreased after treatment. We determined that the application of chemotherapy may activate the local immune status and convert OS into an immune "hot" tumor. These findings provide rationale for investigating the schedule of immunotherapy treatment in OS patients in future clinical trials.

Prognostic factors in osteosarcoma: A study level meta-analysis and systematic review of current practice

Background

A consensus has not yet been reached regarding the abilities of gender, age, tumor size, tumor location, histologic subtypes, and surgery in the prediction of survival in osteosarcoma. We aimed to disclose their prognostic significance by conducting a meta-analysis of all the published data from the last decade.

Materials and Methods

Electronic database searches were conducted in PubMed, Embase, and Web of Science for relevant articles published within the last ten years. The pooled hazard ratio (HR) and corresponding 95% confidence interval (CI) were obtained to evaluate the prognostic values of the target factors.

Results

A total of 18,126 patients from 40 studies were eventually included. Results indicated that gender (male vs. female: 1.21, 95% CI, 1.11–1.32; female vs. male: 0.85, 95% CI, 0.75–0.98), age (12–20 vs. ≤12: 1.37, 95% CI, 1.13–1.65; ≥20 vs. <20: 1.29, 95% CI, 1.08–1.55; ≥40 vs. <40: 1.63, 95% CI, 1.21–2.20; ≥50 vs. <25: 2.60, 95% CI, 1.92–3.53; ≥60 vs. <60: 1.11, 95% CI, 1.06–1.18), tumor location (non-extremities vs. extremities: 2.10, 95% CI, 1.76–2.51; proximal vs. distal femur: 3.68, 95% CI: 1.51–8.96; proximal vs. distal humerus: 3.15, 95% CI: 1.53–6.49), tumor size (≥5 vs. <5: 1.42, 95% CI, 1.09–1.86; >8 vs. ≤8: 1.55, 95% CI, 1.07–2.24; >9 vs. ≤9: 1.44, 95% CI, 1.05–1.96), chemotherapy response (poor vs. good: 2.45, 95% CI, 2.02–2.97; good vs. poor: 0.41, 95% CI, 0.34–0.48), and surgery (yes vs. no: 0.45, 95% CI, 0.36–0.57; amputation vs. salvage: 2.34, 95% CI, 1.47–3.74) were significantly associated with overall survival in osteosarcoma patients.

Conclusion

The meta-analysis demonstrated that male patients, older age, large tumor size, non-extremity osteosarcoma, proximal osteosarcoma, poor chemotherapy response, no surgical treatment, and amputation surgery were correlated with a poor prognosis in osteosarcoma patients.

The efficacy and safety comparison of first-line chemotherapeutic agents (high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide) for osteosarcoma: a network meta-analysis

Background

Osteosarcoma, a primary malignant bone tumor derived from mesenchymal tissue, is the most common type of pleomorphic tumor that occurs in children and adolescents. The aim of this study was to compare the efficacy and safety of high-dose methotrexate (M), doxorubicin (D), cisplatin (C), and ifosfamide (I) in the management of osteosarcoma.

Methods

Electronic databases including PubMed, Cochrane Library, and Embase database were searched for studies published from when the databases were established to July 13, 2019. The network meta-analysis was performed using software R 3.3.2 and STATA version 41.0 after demographic and outcome data extraction. The ranks based on probabilities of interventions for each outcome were performed. In addition, the consistency of direct and indirect evidence was assessed by node splitting.

Results

The network meta-analysis results revealed that MDCI had a significant lower hazard risk of overall survival [MDCI vs MDC: HR = 0.74, 95% CrI (0.23, 0.87); MDCI vs DC: HR = 0.60, 95% CrI (0.16, 0.92)]. In addition, MDCI had a clearly longer progression-free survival time than that of DC [MDCI: HR = 0.88, 95% CrI (0.46, 0.98)]. No significant difference was detected in MDC and DC in OS, PFS, and AEs. The probabilities of rank plot showed that MDCI ranked first in OS (73.12%) and PFS (52.43%). DC was the best treatment in safety, ranked first (75.43%).

Conclusions

MDCI showed its superiority among all chemotherapeutic agents in relation to efficacy and safety, followed by MDC. In addition, MDCI was associated with an increased risk of AEs. According to our analysis, DC was less effective but safer for MDC and MDCI.

Repurposing drugs in oncology: From candidate selection to clinical adoption

Drug repurposing is a strategy that aims to develop novel cancer treatments through the reuse of existing medicines developed in other disease areas. Such a strategy includes the identification of candidate drugs, clinical development, drug licensing, reimbursement and clinical implementation. This review outlines a literature-based approach to candidate selection with illustrative examples in osteosarcoma, pancreatic cancer and perioperative therapies. Key issues related to the development of clinical trials, drug licensing/approval and clinical adoption are explored to highlight some of the obstacles that must be overcome to successfully repurpose a drug as a new therapeutic option.

Metastasis risk prediction model in osteosarcoma using metabolic imaging phenotypes: A multivariable radiomics model

BACKGROUND

Osteosarcoma (OS) is the most common primary bone tumor affecting humans and it has extreme heterogeneity. Despite modern therapy, it recurs in approximately 30-40% of patients initially diagnosed with no metastatic disease, with the long-term survival rates of patients with recurrent OS being generally 20%. Thus, early prediction of metastases in OS management plans is crucial for better-adapted treatments and survival rates. In this study, a radiomics model for metastasis risk prediction in OS was developed and evaluated using metabolic imaging phenotypes.

METHODS AND FINDINGS

The subjects were eighty-three patients with OS, and all were treated with surgery and chemotherapy for local control. All patients underwent a pretreatment 18F-FDG-PET scan. Forty-five features were extracted from the tumor region. The incorporation of features into multivariable models was performed using logistic regression. The multivariable modeling strategy involved cross validation in the following four steps leading to final prediction model construction: (1) feature set reduction and selection; (2) model coefficients computation through train and validation processing; and (3) prediction performance estimation. The multivariable logistic regression model was developed using two radiomics features, SUVmax and GLZLM-SZLGE. The trained and validated multivariable logistic model based on probability of endpoint (P) = 1/ (1+exp (-Z)) was Z = -1.23 + 1.53*SUVmax + 1.68*GLZLM-SZLGE with significant p-values (SUVmax: 0.0462 and GLZLM_SZLGE: 0.0154). The final multivariable logistic model achieved an area under the curve (AUC) receiver operating characteristics (ROC) curve of 0.80, a sensitivity of 0.66, and a specificity of 0.88 in cross validation.

CONCLUSIONS

The SUVmax and GLZLM-SZLGE from metabolic imaging phenotypes are independent predictors of metastasis risk assessment. They show the association between 18F-FDG-PET and metastatic colonization knowledge. The multivariable model developed using them could improve patient outcomes by allowing aggressive treatment in patients with high metastasis risk.

Qualitative study exploring patients experiences of being diagnosed and living with primary bone cancer in the UK

OBJECTIVE

The aim of this study is to explore the experiences of patients with primary bone cancer.

DESIGN

Qualitative study design using semistructured interviews and focus groups.

SETTING

Hospitals across the UK and recruitment through UK sarcoma charities and support groups.

METHODS

Semistructured telephone/face-to-face interviews and focus groups with a purposive sample of 26 participants. Data were analysed using Framework Analysis.

PARTICIPANTS

Patients (n=26) with primary bone cancer aged 13-77 years. The majority were male (69%), white (85%); diagnosed within 4 years (54%); and had lower limb sarcoma (65%). Ten participants had undergone an upper/lower limb amputation (39%).

RESULTS

The health-related quality-of-life domains of physical, emotional and social well-being and healthcare professionals' role were the overarching themes of analysis. The physical domain anchored patient experiences. The intensity and length of treatment, the severity of side-effects, the level of disability after surgery and the uncertainty of their prognosis had an impact on patient's self-image, confidence, mood and identity, and caused disruption to various aspects of the patients' social life, including their relationships (emotional and sexual) and participation in work/school and leisure activities. Adaptation was influenced by the way patients dealt with stress and adversity, with some finding a new outlook in life, and others struggling with finding their 'new normal'. Family and friends were the main source of support. Healthcare professional's expertise and support was critical. Rehabilitation services had a considerable role in patient's physical and emotional well-being, but inequitable access to these services was apparent.

CONCLUSIONS

This study described the impact of primary bone cancer on patients' well-being and adjustment over time with the identification of influencing factors of better/worse experiences. It showed that impact was felt after end of treatment and affected patients at different life stages. Holistic models of survivorship care are needed.

Pediatric Osteosarcoma of Extremities: A 15-year Experience From a Tertiary Care Cancer Center in Upper Egypt

AIM

To assess the outcome and determine predictors of survival in pediatric patients with osteosarcoma of the extremities treated with a unified chemotherapy protocol at a single institution over a 15-year period.

MATERIALS AND METHODS

We performed a retrospective analysis of medical records of 48 pediatric patients with histologically verified osteosarcoma of the extremities diagnosed at South Egypt Cancer Institute and received treatment between January 2001 and December 2015.

RESULTS

With a median follow-up of 61 months for the entire cohort, estimates of overall survival (OS) for 3- and 5-year were 50.9% and 42.1%, respectively. While the estimates of OS for 3- and 5-year in the nonmetastatic group were 79% and 65.2%, respectively. In the multivariable analysis, both metastatic disease at diagnosis and poor response to chemotherapy retained their statistical significance as independent predictors for event-free survival. Whereas for OS, a metastatic disease at diagnosis remained as the lone predictor of a dismal outcome, while a poor response to chemotherapy became marginally associated with an inferior outcome.

CONCLUSIONS

In Upper Egypt, whereas slightly less than two thirds of children with localized osteosarcoma of extremities survives their disease, metastasis at presentation remains the key predictor of dismal survival outcomes.

Evaluating and Predicting the Probability of Death in Patients with Non-Metastatic Osteosarcoma: A Population-Based Study

BACKGROUND Osteosarcoma is one of the most common bone tumors, with strong local aggressiveness and early metastasis. The aim of this study was to describe the epidemiological data and evaluate the prognostic factors for overall survival (OS) and cause-specific survival (CSS) in patients with non-metastatic osteosarcoma. MATERIAL AND METHODS Patients histologically diagnosed with non-metastatic osteosarcoma between 2005 and 2014 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Survival analysis, machine learning, and Lasso regression were used to identify the prognostic factors for OS and CSS, and the accuracy of the nomograms was tested and compared with the American Joint Committee on Cancer (AJCC) staging systems. RESULTS The entire cohort comprised 1000 patients with non-metastatic osteosarcoma. The multivariable analysis suggested that age, tumor size, grade, and American Joint Committee on Cancer (AJCC) T staging were independent prognostic factors for OS and CSS. Additionally, the nomograms based on these results could better predict probability of OS (Internal validation C-index, 0.7095) and CSS (0.7100) compared with the sixth (OS: 0.613; CSS: 0.628) and seventh edition AJCC staging systems (0.602, 0.613). CONCLUSIONS Relatively young age and low histopathological grade were favorable factors for both OS and CSS. Nomograms based on multivariable models worked well in predicting the probability of death for patients with non-metastatic osteosarcoma.

Treatment-Related Prognostic Factors in Managing Osteosarcoma around the Knee with Limb Salvage Surgery: A Lesson from a Long-Term Follow-Up Study

Purpose

The aim of this study was to assess the treatment-related factors associated with local recurrence and overall survival of patients with osteosarcoma treated with limb-salvage surgery.

Patients and Methods

Treatment-related factors were analyzed to evaluate their effects on local recurrence-free survival (LRFS) and overall survival (OS) in 182 patients from 2004 to 2013.

Results

The mean length of follow-up was 73.4 ± 34.7 months (median, 68 months; range, 12-173 months), and 63 patients died by the end of the follow-up. The 5-year and 10-year overall survival rates were 68.6 ± 6.6% and 59.4 ± 10.6%, respectively. Univariate analysis showed that treatment-related prognostic factors for overall survival were prolonged symptom intervals >=60 days, biopsy/tumor resection performed by different centers, previous medical history, incomplete preoperative chemotherapy (<8 weeks), and prolonged postoperative interval >21 days. In the multivariate analysis, biopsy/tumor resection performed by different centers, incomplete implementation of planned new adjuvant chemotherapy, and delayed resumption of postoperative chemotherapy (>21 days) were risk factors for poor prognosis; biopsy/tumor resection performed by different centers and tumor necrosis <90% were independent predictors of local recurrence.

Conclusion

For localized osteosarcoma treated with limb-salvage surgery, it is necessary to optimize timely standard chemotherapy and to resume postoperative chemotherapy to improve survival rates. Biopsies should be performed at experienced institutions in cases of developing local recurrence.

Genome sequencing analysis of blood cells identifies germline haplotypes strongly associated with drug resistance in osteosarcoma patients

BACKGROUND

Osteosarcoma is the most common malignant bone tumor in children. Survival remains poor among histologically poor responders, and there is a need to identify them at diagnosis to avoid delivering ineffective therapy. Genetic variation contributes to a wide range of response and toxicity related to chemotherapy. The aim of this study is to use sequencing of blood cells to identify germline haplotypes strongly associated with drug resistance in osteosarcoma patients.

METHODS

We used sequencing data from two patient datasets, from Inova Hospital and the NCI TARGET. We explored the effect of mutation hotspots, in the form of haplotypes, associated with relapse outcome. We then mapped the single nucleotide polymorphisms (SNPs) in these haplotypes to genes and pathways. We also performed a targeted analysis of mutations in Drug Metabolizing Enzymes and Transporter (DMET) genes associated with tumor necrosis and survival.

RESULTS

We found intronic and intergenic hotspot regions from 26 genes common to both the TARGET and INOVA datasets significantly associated with relapse outcome. Among significant results were mutations in genes belonging to AKR enzyme family, cell-cell adhesion biological process and the PI3K pathways; as well as variants in SLC22 family associated with both tumor necrosis and overall survival. The SNPs from our results were confirmed using Sanger sequencing. Our results included known as well as novel SNPs and haplotypes in genes associated with drug resistance.

CONCLUSION

We show that combining next generation sequencing data from multiple datasets and defined clinical data can better identify relevant pathway associations and clinically actionable variants, as well as provide insights into drug response mechanisms.

Investigating age‑induced differentially expressed genes and potential molecular mechanisms in osteosarcoma based on integrated bioinformatics analysis

Osteosarcoma (OS) is the most common primary bone malignancy. It predominantly occurs in adolescents, but can develop at any age. The age at diagnosis is a prognostic factor of OS, but the molecular basis of this remains unknown. The current study aimed to identify age-induced differentially expressed genes (DEGs) and potential molecular mechanisms that contribute to the different outcomes of patients with OS. Microarray data (GSE39058 and GSE39040) obtained from the Gene Expression Omnibus database and used to analyze age-induced DEGs to reveal molecular mechanism of OS among different age groups (<20 and >20 years old). Differentially expressed mRNAs (DEMs) were divided into up and downregulated DEMs (according to the expression fold change), then Gene Ontology function enrichment and Kyoto Encyclopedia of Genes and Genomes pathway analysis were performed. Furthermore, the interactions among proteins encoded by DEMs were integrated with prediction for microRNA-mRNA interactions to construct a regulatory network. The key subnetwork was extracted and Kaplan-Meier survival analysis for a key microRNA was performed. DEMs within the subnetwork were predominantly involved in ‘ubiquitin protein ligase binding’, ‘response to growth factor’, ‘regulation of type I interferon production’, ‘response to decreased oxygen levels’, ‘voltage-gated potassium channel complex’, ‘synapse part’, ‘regulation of stem cell proliferation’. In summary, integrated bioinformatics was applied to analyze the potential molecular mechanisms leading to different outcomes of patients with OS among different age groups. The hub genes within the key subnetwork may have crucial roles in the different outcomes associated with age and require further analysis.

Survival and prognosis with osteosarcoma: outcomes in more than 2000 patients in the EURAMOS-1 (European and American Osteosarcoma Study) cohort

Background

High-grade osteosarcoma is a primary malignant bone tumour mainly affecting children and young adults. The European and American Osteosarcoma Study (EURAMOS)-1 is a collaboration of four study groups aiming to improve outcomes of this rare disease by facilitating randomised controlled trials.

Methods

Patients eligible for EURAMOS-1 were aged ≤40 years with M0 or M1 skeletal high-grade osteosarcoma in which case complete surgical resection at all sites was deemed to be possible. A three-drug combination with methotrexate, doxorubicin and cisplatin was defined as standard chemotherapy, and between April 2005 and June 2011, 2260 patients were registered. We report survival outcomes and prognostic factors in the full cohort of registered patients.

Results

For all registered patients at a median follow-up of 54 months (interquartile range: 38–73) from biopsy, 3-year and 5-year event-free survival were 59% (95% confidence interval [CI]: 57–61%) and 54% (95% CI: 52–56%), respectively. Multivariate analyses showed that the most adverse factors at diagnosis were pulmonary metastases (hazard ratio [HR] = 2.34, 95% CI: 1.95–2.81), non-pulmonary metastases (HR = 1.94, 95% CI: 1.38–2.73) or an axial skeleton tumour site (HR = 1.53, 95% CI: 1.10–2.13). The histological subtypes telangiectatic (HR = 0.52, 95% CI: 0.33–0.80) and unspecified conventional (HR = 0.67, 95% CI: 0.52–0.88) were associated with a favourable prognosis compared with chondroblastic subtype. The 3-year and 5-year overall survival from biopsy were 79% (95% CI: 77–81%) and 71% (95% CI: 68–73%), respectively. For patients with localised disease at presentation and in complete remission after surgery, having a poor histological response was associated with worse outcome after surgery (HR = 2.13, 95% CI: 1.76–2.58). In radically operated patients, there was no good evidence that axial tumour site was associated with worse outcome.

Conclusions

In conclusion, data from >2000 patients registered to EURAMOS-1 demonstrated survival rates in concordance with institution- or group-level osteosarcoma trials. Further efforts are required to drive improvements for patients who can be identified to be at higher risk of adverse outcome. This trial reaffirms known prognostic factors, and owing to the large numbers of patients registered, it sheds light on some additional factors to consider.

•

Osteosarcoma is a rare disease, and treatment can only improve with international collaboration.

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We have assembled prospectively collected data from treatments of all the patients in the intercontinental European and American Osteosarcoma Study-1 protocol.

•

These consistently treated patients provided a strong data set for reporting survival outcomes and reporting on prognostic factors.

•

The trial reaffirms known prognostic factors, and the most adverse factors were metastases and tumours in the axial skeleton.

•

Owing to the large numbers of patients registered, light is shed on some additional factors to be considered. Around seven in ten patients were still alive five years after diagnosis.

Ewing's Sarcoma of the Head and Neck: Margins are not just for surgeons

Background, Methods

To describe the characteristics, treatments (systemic/local), and outcome (oncological/functional) of French patients with head and neck Ewing's sarcomas (HNES) registered in the Euro‐Ewing 99 (EE99) database. Specific patient‐level data were reviewed retrospective.

Results

Forty‐seven HNES patients in the EE99 database had a median age of 11 years, 89% had bone tumors (skull 55%, mandible 21%, maxilla 11%), 89% had small tumors (<200 mL), and they were rarely metastatic (9%). Local treatment was surgery radiotherapy (55%), exclusively surgery (28%), or radiotherapy (17%). Metastatic relapses occurred in five patients with high relapse risk factors (metastasis at diagnosis, poor histological response, large tumors). Local progression/relapses (LR) after exclusive radiotherapy occurred in three patients with persistent extra‐osseous residue and in four patients considered R0 margins (postchemotherapy surgery, without postoperative radiotherapy [PORT]), reclassified by pathological review as R1a. Pathological review reclassified 72% of R0 margins: 11/18 to R1a and 2/18 to R2. Five patients had confirmed R0 margins after postchemotherapy surgery without PORT and had no LR Eight patients had R2 margins (initial surgery without previous chemotherapy, with PORT) and had no LR With a median follow‐up of 9.3 years, the 3‐year LR rate, EFS, and OS were 84.8%, 78.6%, and 89.3%, respectively. Among the 5‐year survivors, 88% had long‐term sequelae.

Conclusion

To optimize HNES management, patients should be treated from diagnosis in expert centers with multidisciplinary committees to discuss treatment strategy (type of surgery, need for PORT) and validate surgical margins.

Association of macrophage and lymphocyte infiltration with outcome in canine osteosarcoma

Immunotherapeutic strategies have shown promise for the treatment of canine osteosarcoma (cOSA). Very little is known about the immune microenvironment within cOSA, however, limiting our ability to identify potential immune targets and biomarkers of therapeutic response. We therefore prospectively assessed the disease-free interval (DFI) and overall survival time (ST) of 30 dogs with cOSA treated with amputation and six doses of adjuvant carboplatin. We then quantified lymphocytic (CD3+, FOXP3+) and macrophage (CD204+) infiltrates within the primary tumours of this cohort using immunohistochemistry, and evaluated their association with outcome. Overall, the median DFI and ST were 392 and 455 days, respectively. The median number of CD3+ and FOXP3+ infiltrates were 45.8 cells/mm² (4.6-607.6 cells/mm² ) and 8.5 mm² (0-163.1 cells/mm² ), respectively. The median area of CD204+ macrophages was 4.7% (1.3%-23.3%), and dogs with tumours containing greater than 4.7% CD204+ macrophages experienced a significantly longer DFI (P = 0.016). Interestingly, a significantly lower percentage of CD204+ macrophages was detected in cOSA arising from the proximal humerus compared to other appendicular bone locations (P = 0.016). Lymphocytic infiltrates did not appear to correlate with outcome in cOSA. Overall, our findings suggest that macrophages may play a role in inhibiting cOSA progression, as has been suggested in human osteosarcoma.

Survival of adults with cancers of bone or soft tissue in Europe-Report from the EUROCARE-5 study

BACKGROUND

Five-year relative survival (RS) of adults with bone and soft-tissue cancers in Europe was still <60% by 1995-1999. There was large geographical survival variability, mainly for bone tumours, and survival decreased with increasing age at diagnosis.

METHODS

Data from 87 population-based cancer registries in 29 countries, extracted from the EUROCARE-5 database, were used to provide updated estimates of survival and describe trends in survival of adults with cancers of these sites across Europe. We calculated 5-year RS for patients diagnosed in 2000-2007. We estimated 5-year RS by the period approach to assess changes in survival between 1999-2001, 2002-2004 and 2005-2007, and provide reliable predictions for recently diagnosed patients.

RESULTS

Five-year RS was 60% for adults diagnosed with soft-tissue cancer in 2000-2007 and 53% for those with bone cancer. RS declined with increasing age at diagnosis, especially for bone cancer. Survival from bone cancer varied widely between European regions, from 63 to 62% in Northern and Central Europe to 39% in Eastern Europe. Inter-regional variation was much less for soft-tissue cancer. For both site groupings, there was little evidence of change in five-year RS up to 2002-2004, followed by increases of 3-4% during 2005-2007.

CONCLUSIONS

Outcomes for adults with bone and soft-tissue cancer in Europe began to improve around 2005; new therapeutic developments are expected to result in further progress. Survival improvements already achieved must be brought more fully to elderly patients and those in Eastern Europe. European Reference Networks on rare cancers will have a vital role in future progress.

Survival Prediction in High-grade Osteosarcoma Using Radiomics of Diagnostic Computed Tomography

The poor 5-year survival rate in high-grade osteosarcoma (HOS) has not been increased significantly over the past 30 years. This work aimed to develop a radiomics nomogram for survival prediction at the time of diagnosis in HOS. In this retrospective study, an initial cohort of 102 HOS patients, diagnosed from January 2008 to March 2011, was used as the training cohort. Radiomics features were extracted from the pretreatment diagnostic computed tomography images. A radiomics signature was constructed with the lasso algorithm; then, a radiomics score was calculated to reflect survival probability by using the radiomics signature for each patient. A radiomics nomogram was developed by incorporating the radiomics score and clinical factors. A clinical model was constructed by using clinical factors only. The models were validated in an independent cohort comprising 48 patients diagnosed from April 2011 to April 2012. The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. Kaplan-Meier survival analysis was performed. The radiomics nomogram showed better calibration and classification capacity than the clinical model with AUC 0.86 vs. 0.79 for the training cohort, and 0.84 vs. 0.73 for the validation cohort. Decision curve analysis demonstrated the clinical usefulness of the radiomics nomogram. A significant difference (p-value <.05; log-rank test) was observed between the survival curves of the nomogram-predicted survival and non-survival groups. The radiomics nomogram may assist clinicians in tailoring appropriate therapy.

EURO-B.O.S.S.: A European study on chemotherapy in bone-sarcoma patients aged over 40: Outcome in primary high-grade osteosarcoma

INTRODUCTION

The EUROpean Bone Over 40 Sarcoma Study (EURO-B.O.S.S.) was the first prospective international study for patients 41-65 years old with high-grade bone sarcoma treated with an intensive chemotherapy regimen derived from protocols for younger patients with high-grade skeletal osteosarcoma.

METHODS

Chemotherapy based on doxorubicin, cisplatin, ifosfamide, and methotrexate was suggested, but patients treated with other regimens at the investigators' choice were also eligible for the study.

RESULTS

The present report focuses on the subgroup of 218 patients with primary high-grade osteosarcoma. With a median follow-up of 47 months, the 5-year probability of overall survival (OS) was 66% in patients with localized disease and 22% in case of synchronous metastases. The 5-year OS in patients with localized disease was 29% in pelvic tumors, and 70% and 73% for extremity or craniofacial locations, respectively. In primary chemotherapy, tumor necrosis ≥90% was reported in 21% of the patients. There were no toxic deaths; however, hematological toxicity was considerable with 32% of patients experiencing 1 or more episodes of neutropenic fever. The incidence of nephrotoxicity and neurotoxicity (mainly peripheral) was 28% and 24%, respectively. After methotrexate, 23% of patients experienced delayed excretion, in 4 cases with nephrotoxicity.

CONCLUSIONS

In patients over 40 years of age with primary high-grade osteosarcoma, an aggressive approach with chemotherapy and surgery can offer the probability of survival similar to that achieved in younger patients. Chemotherapy-related toxicity is significant and generally higher than that reported in younger cohorts of osteosarcoma patients treated with more intensive regimens.

High-Grade Osteosarcoma of the Foot: Presentation, Treatment, Prognostic Factors, and Outcome of 23 Cooperative Osteosarcoma Study Group COSS Patients

Osteosarcoma of the foot is a very rare presentation of a rare tumor entity. In a retrospective analysis, we investigated tumor- and treatment-related variables and outcome of patients registered in the Cooperative Osteosarcoma Study Group (COSS) database between January 1980 and April 2016 who suffered from primary high-grade osteosarcoma of the foot. Among the 23 eligible patients, median age was 32 years (range: 6–58 years), 10 were female, and 13 were male. The tarsus was the most commonly affected site (n=16). Three patients had primary metastases. All patients were operated: 5 underwent primary surgery and 18 received surgery following preoperative chemotherapy. In 21 of the 23 patients, complete surgical remission was achieved. In 4 of 17 patients, a poor response to neoadjuvant chemotherapy was observed in the resected primary tumors. Median follow-up was 4.2 years (range: 0.4–18.5). At the last follow-up, 15 of the 23 patients were alive and 8 had died. Five-year overall and event-free survival estimates were 64% (standard error (SE) 12%) and 54% (SE 13%), which is similar to that observed for osteosarcoma in general. Event-free and overall survival correlated with primary metastatic status and completeness of surgery. Our findings show that high-grade osteosarcoma in the foot has a similar outcome as osteosarcoma of other sites.

Implant Survival and Complication Profiles of Endoprostheses for Treating Tumor Around the Knee in Adults: A Systematic Review of the Literature Over the Past 30 Years

BACKGROUND

Endoprosthetic replacement has become the mainstream method of reconstruction after tumor resection around the knee for decades, but there is a lack of comprehensive review evaluating the implant outcomes. We performed a systematic review to analyze the implant survival and complication profiles of distal femoral replacement (DFR) and proximal tibial replacement (PTR) in adults, and to evaluate the effects of different fixation methods and hinge mechanisms.

METHODS

A systematic review of 40 studies with 4748 DFR cases and 1713 PTR cases was performed after searching the PubMed and EMBASE databases. Results of the implant longevity, complications, and other relevant data were extracted, recategorized, and analyzed. An additional review of 227 cases of Compress DFR from 6 studies was also performed.

RESULTS

The mean 5-, 10-, 15-, and 20-year implant survival rates of DFR were 78.3%, 70.1%, 61.6%, and 38.3%, slightly higher than those of PTR (75%, 60%, 55.3%, and 25.1%). Aseptic loosening (8.8%) and infection (8.5%) were the most devastating complications in DFR, while in PTR it was infection (16.8%). Cemented or cementless fixation did not significantly affect implant survival or aseptic loosening rate. Rotating-hinge mechanism might improve long-term implant survival and reduce bushing wear, but not necessarily prevented aseptic loosening. The series Kotz modular femur and tibia replacement system/Howmedica modular replacement system/global modular replacement system was one of the most durable implants. The Compress DFR showed no superiority in implant survival and complication profiles over other brands of endoprostheses.

CONCLUSION

Short-term to mid-term implant survival of adult tumor endoprostheses around the knee is acceptable but long-term outcome remains unsatisfactory. Efforts should be made in reducing loosening and infection.

Survival and prognostic factors at time of diagnosis in high-grade appendicular osteosarcoma: a 21 year single institution evaluation from east Denmark

BACKGROUND

Survival of patients with high-grade osteosarcoma (HOS), the most common primary bone cancer, has not improved significantly the last 30 years and the disease remains a major challenge. The purpose of this study is to evaluate survival in relation to prognostic factors at time of diagnosis among patients diagnosed with primary appendicular HOS in East Denmark between 1990 and 2010.

MATERIAL AND METHODS

101 patients (median age = 20 years, female/male ratio = 56/45) diagnosed with primary appendicular high-grade osteosarcoma between 1990 and 2010 were included in this study. Initially, 156 patients diagnosed with osteosarcoma between 1990 and 2010 were identified through the population based Regional Database of Pathology, which covers a population of approximately 2.7 million (east Denmark). 55 patients were excluded due to (A) tumor was low grade (n = 22), (B) located in axial skeleton (n = 18), (C) incorrect diagnosis (n = 11) or (D) biopsy represented a tumor relapse from a former primary osteosarcoma (n = 4). Overall survival was evaluated using the Kaplan-Meier survival analysis and log-rank test. Prognostic factors were analyzed using uni- and multivariate cox-regression method with variables scored equally in the model. p Values <.05 were considered statistically significant.

RESULTS

The probability of 5- and 10-year survival was 51% (95% CI: 41-61) and 46% (95% CI: 36-56), respectively. Metastatic stage at diagnosis and tumor size ≥10 cm measured radiologically at the largest diameter were independent prognostic factors for decreased survival with significant increased hazard-risks of 3.5 (95% CI: 1.9-6.5) and 1.97 (95% CI: 1.1-3.6), respectively.

DISCUSSION

In this single institution evaluation of primary appendicular HOS we found 5-and 10-year survival rates consistent with international standards for this patient group. Distant metastases and tumor size ≥10 cm at the time of diagnosis were independent prognostic factors for decreased survival in our cohort. These results underline the importance of awareness and early referral from the primary sector.

The extremity localized classic osteosarcomas have better survival than the axial non-classics

BACKGROUND

Osteosarcoma is one of the most malignant primary bone cancers, while is rarely reported in China. Of note, very few data of prognosis has been documented in this region. Thus, we carried a retrospective study to identify prognostic factors and to analyze outcomes in patients of both classic and non-classic high-grade osteosarcomas. Classic osteosarcoma is defined as of high-grade histology, age below 40 years, with extremity localized primary tumor, and without detectable metastasis at primary diagnosis.

METHODS

A total of 98 patients (68 classic and 30 non-classic) aged from 4 to 64 years old were diagnosed as high-grade osteosarcoma from 2008 to 2015 in Nanfang Hospital, Guangzhou, China. Univariate and multivariate analyses were performed to identify the independent predictors for overall survival and event-free survival. Kaplan-Meier method was used for survival analysis.

RESULTS

The median overall survival was 117 vs. 21 months, and the median event-free survival was 31 vs. 6 months in classic and non-classic osteosarcoma, respectively. The most frequently found tumor site was around the knee. The classic osteosarcoma had better overall survival and event-free survival than the non-classics. Tumor site and primary metastasis were found to be associated with overall survival and event-free survival in the univariate analysis. In the multivariate Cox regression analysis, tumor site and primary metastasis were each verified as independent prognostic factors. However, no similar result was found in elevated serum alkaline phosphatase or lactate dehydrogenase. Amputation or limb salvage surgery had no significant effect on overall survival and event-free survival in the extremity osteosarcomas. Classic osteosarcomas with extremity tumor site and free of primary metastasis exhibited better overall survival and event-free survival, while the axial and metastatic non-classics exhibited the worse.

CONCLUSIONS

The extremity classic osteosarcomas have better survivals than the axial non-classic cases. Amputation and limb salvage surgery make no significant change in overall survival and event-free survival in the extremity osteosarcomas.

TRIAL REGISTRATION

Nanfang2013071; Date of registration: 7 September 2013 (retrospectively registered).

Survival, complications and functional outcomes of cemented megaprostheses for high-grade osteosarcoma around the knee

PURPOSE

We initiated a retrospective study on the long-term survival of cemented endoprostheses for bone tumours around the knee to answer the following questions: (1) What was the survival of these patients? (2) What was the overall survival of cemented prostheses around the knee? (3) What types of failures were observed in these reconstructions? (4) Did the survival and complications vary according to the site of the implant? (5) What was the functional result after cemented prosthesis replacement around the knee?

METHODS

From January 2006 to December 2013, 108 consecutive patients with an average age of 25 years, who had mature bone development as evidenced by imaging examinations, underwent 108 cemented endoprosthetic knee replacements for osteosarcoma resection. All patients received neoadjuvant chemotherapy using a multi-drug protocol consisting of high dose methotrexate (HDMTX), doxorubicin (ADM), cisplatin (DDP) and high dose ifosfamide (HDIFO). When extensor mechanism reconstruction was required, we ran nonabsorbable sutures through designated holes in the tibial component to fix detached hamstrings and the remaining ligaments in an imbricated fashion as well as reinforced the reconstruction with a medial gastrocnemius flap. Seventy-two (72/108, 66.7%) lesions were located in the distal femur and 36 (36/108, 33.3%) lesions at the proximal tibias. Nineteen patients were staged as IIA and 89 as IIB according to the Enneking staging system. The average follow-up was 53.3 months (range 12-125 months), with a minimum oncological follow-up of one year. Survival, prosthetic failure, complications and functional outcomes were recorded and reassessed at every visit after the primary operation.

RESULTS

At the final follow-up, the oncologic results showed that 33 patients died from metastases, and local recurrence occurred in ten patients. The estimated overall five-year and eight-year survival rates were 71% (95% CI: 62.4-79.65%) and 67.2% (95% CI: 58-76.4%), respectively. In this study, a total of 51 complications occurred in 45 patients, and at the end of follow-up, 59 patients had prostheses in situ. The estimated overall five-year and eight-year implant survival rates were 77.7% (95% CI: 67.9-87.5%) and 54.5% (95% CI: 31.4-77.6%), respectively, when patients who died with their original prostheses were censored. In total, 21 (21/108, 19.4%) implants failed, five due to infections (5/21), eight due to aseptic loosening (8/21), four due to local recurrence (4/21), three due to structural failure (3/21) and one due to soft tissue failure (1/21). The average Musculoskeletal Tumor Society Score (MSTS) at the most recent follow-up was 22.9 (9-30) points on a 30-point scale, which indicated an excellent or good functional outcome. Analysis of the results based on implant site revealed a slight difference of the estimated five-year prosthesis survival between implants located in the distal femur and those located in the proximal tibia [86.1% (95% CI: 75.5-97%) versus 66.9% (95% CI: 49.8-83.9%); P = 0.09]. However, the functional outcomes and complication rates of prostheses located in the distal femur were both better than those located in the proximal tibia.

CONCLUSIONS

With effective management strategies for complications, cemented endoprosthetic reconstruction of the proximal tibia and distal femur using an extensor mechanism reconstruction technique provides a reliable method of reconstruction following tumour resection around the knee. Level of Evidence Level IV, therapeutic study.

Chemotherapy in head and neck osteosarcoma: Adjuvant chemotherapy improves overall survival

BACKGROUND

Osteosarcoma is an aggressive bone malignancy presenting uncommonly in head and neck sites. Surgery is mainstay in treatment. However; trials show an improved survival with addition of chemotherapy in the treatment of extremity osteosarcoma. The head and neck osteosarcomas(HNOs) were excluded in these trials because of atypical presentation and disease course. Further; sufficient numbers were not possible for a trial. We present the largest retrospective study from single institute investigating the role of chemotherapy in the management of HNOs.

PATIENTS AND METHODS

The retrospective cohort of HNOs treated from 2007 to 2015 of a tertiary hospital were charted. The therapeutic and prognostic factors were analyzed for overall survival(OS), disease free survival(DFS), local control(LC) and metastasis(MT) in univariate and multivariate analysis. The minimum and median period of follow up was 12months and 56.04months respectively.

RESULTS

There was a total of 157 patients definitively treated with surgery in the time period. 7 patients had positive margins and all were maxillary or skull base tumors. The multivariate cox regression showed significance of tumor site(p=0.034), margin status (p=0.006), chemotherapy(p=0.025), histological subtype(p=0.012) as predictors of overall survival. The margin status(p=0.002), Radiotherapy(p=0.005) were significant predictors for local recurrence. The age and histology subtype(p=0.058) were borderline significant predictors of metastasis(p=0.065). The KM method for OS of different chemotherapy groups(p=0.013), and survival with and without chemotherapy(p=0.007) was significant. The OS was significantly better with adjuvant chemotherapy among various treatment plans(p=0.034).

CONCLUSION

Adjuvant chemotherapy improved OS while adjuvant radiotherapy improved local control of HNOs.

Perioperative therapies - Enhancing the impact of cancer surgery with repurposed drugs

Surgical resection remains the major modality for modern curative treatment for solid tumours. However, post-surgical recurrence, even following clear-margin resection and adjuvant treatment, remains common in many types of cancer. Reducing recurrence rates, therefore, offers the potential to increase cure rates and increase overall survival. Perioperative therapies, simple interventions during the perioperative period, are designed to address some of the factors which influence post-surgical recurrence. A range of perioperative therapies are introduced and the rationale for further clinical investigation outlined.

Activation Status of Receptor Tyrosine Kinases as an Early Predictive Marker of Response to Chemotherapy in Osteosarcoma

Receptor tyrosine kinases (RTKs) are membrane receptors that play a vital role in various biological processes, in particular, cell survival, cell proliferation, and cell differentiation. These cellular processes are composed of multitiered signaling cascades of kinases starting from ligand binding to extracellular domains of RTKs that activate the entire pathways through tyrosine phosphorylation of the receptors and downstream effectors. A previous study reported that, based on proteomics data, RTKs were a major candidate target for osteosarcoma. In this study, activation profiles of six candidate RTKs, including c-Met, c-Kit, VEGFR2, HER2, FGFR1, and PDGFRα, were directly examined from chemonaive fresh frozen tissues of 32 osteosarcoma patients using a multiplex immunoassay. That examination revealed distinct patterns of tyrosine phosphorylation of RTKs in osteosarcoma cases. Unsupervised hierarchical clustering was calculated using Pearson uncentered correlation coefficient to classify RTKs into two groups-Group A (c-Met, c-Kit, VEGFR2, and HER2) and Group B (FGFR1 and PDGFRα)-based on tyrosine phosphorylation patterns. Nonactivation of all Group A RTKs was associated with shorter overall survival in stage IIB osteosarcoma patients. Percentages of tumor necrosis in patients with inactive Group A RTKs were significantly lower than those in patients with at least one active Group A RTK. Paired primary osteosarcoma cells with fresh osteosarcoma tissue were extracted and cultured for cytotoxicity testing. Primary cells with active Group A RTKs tended to be sensitive to doxorubicin and cisplatin. We also found that osteosarcoma cells with active Group A RTKs were more proliferative than cells with inactive Group A RTKs. These findings indicate that the activation pattern of Group A RTKs is a potential risk stratification and chemoresponse predictor and might be used to guide the optimum chemotherapy regimen for osteosarcoma patients.

pFAK-Y397 overexpression as both a prognostic and a predictive biomarker for patients with metastatic osteosarcoma

Focal adhesion kinase (FAK) is important for tumor cell survival and metastasis in various cancers. However, its expression and prognostic value in patients with metastatic osteosarcoma remain unknown. We investigated the expression of FAK and its phosphorylated form (pFAK-Y397) in osteosarcoma tissues from 53 patients by immunohistochemistry and evaluated their correlations with clinicopathologic characteristics and outcomes. The prognostic values were assessed using Kaplan-Meier survival and Cox regression analyses. Total FAK and pFAK-Y397 were overexpressed in 48 (90.6%) and 33 (62.3%) cases, respectively. pFAK-Y397 overexpression was correlated with poor histologic response after neoadjuvant chemotherapy in patients with osteosarcoma regardless of the presence of metastasis or not. Kaplan-Meier curve showed that patients with metastatic osteosarcoma with pFAK-Y397 overexpression had significantly worse overall survival (OS) than those with non-overexpression (P = 0.044). Multivariate Cox regression analysis confirmed pFAK-Y397 overexpression as an independent prognostic predictor for OS and post metastases OS (PMOS) (P = 0.017, P = 0.006, respectively). Age at diagnosis was also an independent indicator for PMOS (P = 0.003). However, total FAK expression was not correlated with any clinicopathologic characteristics or OS in patients with metastatic osteosarcoma. In conclusion, our findings identified FAK as a common aberrant protein overexpression in various subtypes of osteosarcoma. pFAK-Y397 overexpression can be used as a prognostic biomarker predicting poor OS for patients with metastatic osteosarcoma, and the expression of pFAK-Y397 differentiated good and poor responders to neoadjuvant chemotherapy.

[Effectiveness of unicompartment allografts replacement for bone tumor around the knee]

Objective

To analyze the effectiveness of unicompartment allografts replacement for reconstructing bone defect after bone tumor resection around knee.

Methods

Between January 2007 and January 2014, a total of 9 patients received unicompartment allografts replacement to treat bone tumor around the knee, including 6 males and 3 females, with an average age of 25.8 years (range, 17-38 years). There were 7 patients with bone giant cell tumor (postoperative recurrence of bone giant cell tumor in 1 case) and 2 patients with chondromyxoid fibroma. The tumors were located at the distal femur in 7 cases and proximal tibia in 2 cases, and the tumors were almost at the lateral limbs. The symptom duration was 2-5 months (mean, 3.2 months). The size of lesion ranged from 6 cm×2 cm to 9 cm×4 cm by X-ray film and MRI; and the metastasis was excluded by CT. The length of the allograft was 8.0-9.2 cm (mean, 8.6 cm).

Results

The intraoperative blood loss volume was 400-550 mL (mean, 480 mL); and 0-3 U of erythrocyte was transfused after operation. The continuous exudate of incision occurred in 1 patient, and cured after 3 months; the other incisions healed primarily at 2 weeks after operation. All patients were followed up 3-10 years (mean, 6 years). No operation area infection, allograft bone poor healing or rupture was found. At 1 year after operation, the knee range of motion was 90-110° (mean, 100°); the Musculoskeletal Tumor Society score was 24-29 (mean, 26). Low density area (osteolysis) was found in 6 allografts; no articular surface collapse, hairline fracture, or fracture was found in patients; callus formation was observed in the contact surface between the allograft and the host bone, and the cortical bone showed good continuity.

Conclusion

Unicompartment allografts replacement can provide good support and function in terms of bone tumor resection, and achieve good effectiveness by biological reconstruction.

Bone-Forming Tumors

Bone-forming tumors are defined by neoplastic cells that differentiate along the lines of osteoblasts that deposit neoplastic bone. The morphology and biological spectrum of bone-forming tumors is broad, and their accurate diagnosis requires the careful correlation of their clinical, morphologic, and radiologic characteristics. Immunohistochemical and molecular analyses have an important role in select instances. At present, the identification of neoplastic bone largely depends on histologic analysis, which can be subjective. The major types of osteosarcoma are defined according to their morphology, origin within or on the surface of the bone, and their histologic grade.

Effectiveness of multi-drug regimen chemotherapy treatment in osteosarcoma patients: a network meta-analysis of randomized controlled trials

Background

Osteosarcoma is the most common malignant bone tumour. Due to the high metastasis rate and drug resistance of this disease, multi-drug regimens are necessary to control tumour cells at various stages of the cell cycle, eliminate local or distant micrometastases, and reduce the emergence of drug-resistant cells. Many adjuvant chemotherapy protocols have shown different efficacies and controversial results. Therefore, we classified the types of drugs used for adjuvant chemotherapy and evaluated the differences between single- and multi-drug chemotherapy regimens using network meta-analysis.

Methods

We searched electronic databases, including PubMed (MEDLINE), EmBase, and the Cochrane Library, through November 2016 using the keywords “osteosarcoma”, “osteogenic sarcoma”, “chemotherapy”, and “random*” without language restrictions. The major outcome in the present analysis was progression-free survival (PFS), and the secondary outcome was overall survival (OS). We used a random effect network meta-analysis for mixed multiple treatment comparisons.

Results

We included 23 articles assessing a total of 5742 patients in the present systematic review. The analysis of PFS indicated that the T12 protocol (including adriamycin, bleomycin, cyclophosphamide, dactinomycin, methotrexate, cisplatin) plays a more critical role in osteosarcoma treatment (surface under the cumulative ranking (SUCRA) probability 76.9%), with a better effect on prolonging the PFS of patients when combined with ifosfamide (94.1%) or vincristine (81.9%). For the analysis of OS, we separated the regimens to two groups, reflecting the disconnection. The T12 protocol plus vincristine (94.7%) or the removal of cisplatinum (89.4%) is most likely the best regimen.

Conclusions

We concluded that multi-drug regimens have a better effect on prolonging the PFS and OS of osteosarcoma patients, and the T12 protocol has a better effect on prolonging the PFS of osteosarcoma patients, particularly in combination with ifosfamide or vincristine. The OS analysis showed that the T12 protocol plus vincristine or the T12 protocol with the removal of cisplatinum might be a better regimen for improving the OS of patients. However, well-designed randomized controlled trials of chemotherapeutic protocols are still necessary.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-017-0544-9) contains supplementary material, which is available to authorized users.

A Novel System for the Surgical Staging of Primary High-grade Osteosarcoma: The Birmingham Classification

BACKGROUND

Chemotherapy response and surgical margins have been shown to be associated with the risk of local recurrence in patients with osteosarcoma. However, existing surgical staging systems fail to reflect the response to chemotherapy or define an appropriate safe metric distance from the tumor that will allow complete excision and closely predict the chance of disease recurrence. We therefore sought to review a group of patients with primary high-grade osteosarcoma treated with neoadjuvant chemotherapy and surgical resection and analyzed margins and chemotherapy response in terms of local recurrence.

QUESTIONS/PURPOSES

(1) What predictor or combination of predictors available to the clinician can be assessed that more reliably predict the likelihood of local recurrence? (2) Can we determine a better predictor of local recurrence-free survival than the currently applied system of surgical margins? (3) Can we determine a better predictor of overall survival than the currently applied system of surgical margins?

METHODS

This retrospective study included all patients with high-grade conventional osteosarcomas without metastasis at diagnosis treated at one center between 1997 and 2012 with preoperative chemotherapy followed by resection or amputation of the primary tumor who were younger than age 50 years with minimum 24-month followup for those still alive. A total of 389 participants matched the inclusion criteria. Univariate log-rank test and multivariate Cox analyses were undertaken to identify predictors of local recurrence-free survival (LRFS). The Birmingham classification was devised on the basis of two stems: the response to chemotherapy (good response = ≥ 90% necrosis; poor response = < 90% necrosis) and margins (< 2 mm or ≥ 2 mm). The 5-year overall survival rate was 67% (95% confidence interval [CI], 61%-71%) and 47 patients developed local recurrence (12%).

RESULTS

Intralesional margins (hazard ratio [HR], 9.9; 95% CI, 1.2-82; p = 0.03 versus radical margin HR, 1) and a poor response to neoadjuvant chemotherapy (HR, 3.8; 95% CI, 1.7-8.4; p = 0.001 versus good response HR, 1) were independent risk factors for local recurrence (LR). The best predictor of LR, however, was a combination of margins ≤ 2 mm and a less than 90% necrosis response to chemotherapy (Birmingham 2b HR, 19.6; 95% CI, 2.6-144; p = 0.003 versus Birmingham 1a; margin >2 mm and more than 90% necrosis HR, 1). Two-stage Cox regression model and higher Harrell's C statistic demonstrate that the Birmingham classification was superior to the Musculoskeletal Tumor Society (MSTS) margin classification for predicting LR (Harrell's C statistic Birmingham classification 0.68, MSTS criteria 0.59). A difference in overall survival was seen between groups of the Birmingham classification (log-rank test p < 0.0001), whereas the MSTS margin system was not discriminatory (log-rank test p = 0.14).

CONCLUSIONS

Based on these observations, we believe that a combination of the recording of surgical margins in millimeters and the response to neoadjuvant chemotherapy can more accurately predict the risk of local recurrence than the current MSTS system. A multicenter collaboration study initiated by the International Society of Limb Salvage is recommended to test the validity of the proposed classification and if these findings are confirmed, this classification system might be considered the standard practice in oncology centers treating patients with osteosarcomas and allow more effective communication of margin status for research.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Delay in Diagnosis and Its Effect on Clinical Outcome in High-grade Sarcoma of Bone: A Referral Oncological Centre Study

OBJECTIVE

To investigate delay in diagnosis by both patients and doctors, and to evaluate its effect on outcomes of high-grade sarcoma of bone in a single-referral oncological center.

METHODS

Fifty-four patients with osteosarcoma, 29 with Ewing sarcoma and 19 with chondrosarcoma were enrolled in this retrospective study. Delay in diagnosis was defined as the period between initial clinical symptoms and histopathological diagnosis at our center. The delays were categorized as patient- or doctor-related. Short total delays were defined as <4 months; prolonged delays >4 months were assumed to have prognostic relevance.

RESULTS

Total delay in diagnosis was 688.0 days in patients with chondrosarcoma, which is significantly longer than the 163.3 days for osteosarcoma (P < 0.01) and 160.2 days for Ewing sarcoma (P < 0.01). Most doctor-related delays were at the pre-hospital stage, occurring at the general practitioner (GP)'s office. However, prolonged total delays (≥4 months) did not result in lower survival rates. Five-year-overall survival rates were 67.0% for osteosarcoma, 49.0% for Ewing sarcoma and 60.9% for chondrosarcoma. Survival was significantly lower for patients with metastatic disease for all three types of sarcoma.

CONCLUSION

Prolonged delay in diagnosis does not result in lower survival. Metastatic disease has a pronounced effect on survival. Aggressive tumor behavior results in shorter delays. Minimizing GP-related delays could be achieved by adopting a lower threshold for obtaining plain radiographs at the pre-hospital stage.

Effect of Unplanned Therapy on the Prognosis of Patients with Extremity Osteosarcoma

Unplanned therapy for extremity osteosarcoma can result in erroneous surgical procedures and lack of neoadjuvant chemotherapy before the first operation. Our aim was to compare the prognosis between patients with extremity osteosarcoma who received unplanned therapy and those who received standard treatment. This was a retrospective review of patients with extremity osteosarcoma who received appropriate surgical treatment and neoadjuvant chemotherapy (n = 79) and those who received unplanned therapy (n = 24) between June 2000 and October 2014. Survival rate, local recurrence rate and metastasis rate were compared between the two groups. We found that patients who had unplanned therapy had a higher local recurrence rate (41.7% vs. 21.5%; P = 0.049) and a shorter mean time for recurrence (8.90 vs. 14.59 months; P = 0.018). There was no significant difference between groups in the 5-year survival rate (56.3% vs.67.8%; P = 0.356), metastasis rate (45.8% vs. 30.4%; P = 0.125) and mean time to metastasis (23.18 vs.18.24 months; P = 0.396). Our findings suggest that unplanned therapy for extremity osteosarcoma can result in failure of local control. The use of supplementary interventions after unplanned therapy, such as neoadjuvant chemotherapy and limb salvage surgery, may explain the similar survival and metastasis rates between patients receiving unplanned therapy and those receiving standard treatment.

Assessing the Prognostic Significance of Histologic Response in Osteosarcoma: A Comparison of Outcomes on CCG-782 and INT0133-A Report From the Children's Oncology Group Bone Tumor Committee

BACKGROUND

The prognostic value of histologic response for osteosarcoma may have changed with induction chemotherapy schedules over time. We hypothesized that the increased intensity of induction therapy provided on INT0133 compared to the Children's Cancer Group study CCG-782 would diminish the impact of histologic response on the risk of events after definitive surgery.

METHODS

Retrospective analysis was performed for patients aged <22 with newly diagnosed nonmetastatic osteosarcoma enrolled on CCG-782 and INT0133. Clinical factors were evaluated for association with response and outcome. Good response was defined as <5% viable tumor at resection. Associations of response, study, and postdefinitive surgery event-free survival (EFS-DS) were determined using Cox proportional hazard models. EFS-DS was estimated by Kaplan-Meier methodology.

RESULTS

Data were available for 814 patients (206 CCG-782, 608 INT0133). For good responders, 10-year EFS-DS (±SE) was 75.4% ± 7.7% for CCG-782 and 70.8% ± 3.1% for INT0133. For poor responders, 10-year EFS-DS was 39.9% ± 4.9% for CCG-782 and 58.4% ± 3.1% for INT0133. Histologic response predicted outcome across studies (P < 0.0001). Significant interaction between study and histologic response was observed for EFS-DS (P = 0.011). Using proportional hazards regression, INT0133 poor responders had less risk of events compared to CCG-782 poor responders (relative hazard ratio (RHR) = 0.6:1), but good responders on INT0133 had a greater risk of events compared to CCG-782 good responders (RHR = 1.53:1).

CONCLUSION

We observed an inverse relationship between the predictive value of tumor necrosis and intensity of induction therapy, raising questions about the true prognostic value of histologic response. This highlights the need for novel markers to develop strategies for treatment in future trials.

Histopathologic Features of Prognostic Significance in High-Grade Osteosarcoma

Context .- In osteosarcoma treated with neoadjuvant chemotherapy the extent of tumor necrosis on resection is considered an indicator of treatment response, and this has been shown to correlate with survival in most but not all studies. Objective .- To identify additional histologic variables of prognostic significance in high-grade osteosarcoma. Design .- Slides of pretreatment biopsy and primary postneoadjuvant chemotherapy resections from 165 patients with high-grade osteosarcoma were reviewed. Univariate (Kaplan-Meier) and multivariate (Cox regression) analyses were performed to identify clinical and histomorphologic attributes associated with overall survival. Results .- Univariate analyses confirmed the prognostic significance of metastatic status on presentation, primary tumor size, anatomic site, and histologic subtype. Additionally, the identification of lymphovascular invasion, 10% or more residual viable tumor, and 10 or more mitoses per 10 high-powered fields assessed in posttreatment resections were associated with poor survival, retaining significance in multivariate analyses. Based on results from multivariate analysis, we developed a prognostic index incorporating primary tumor size and site, and significant histologic features assessed on resection (ie, lymphovascular invasion status, mitotic rate, and extent of viable tumor). This scoring system segregates patients into 3 risk categories with significant differences in overall survival and retained significance in an independent validation set of 42 cases. Conclusions .- The integration of clinical and microscopic features improves prognostication of patients with osteosarcoma.

Impact of chemotherapy on the outcome of osteosarcoma of the head and neck in adults

Background

There is an ongoing debate about the value of (neo‐)adjuvant chemotherapy in high‐ and intermediate‐grade osteosarcoma of the head and neck.

Methods

All records of patients older than 16 years diagnosed with osteosarcoma of the head and neck in the Netherlands between 1993 and 2013 were reviewed.

Results

We identified a total of 77 patients with an osteosarcoma of the head and neck; the 5‐year overall survival (OS) was 55%. In 50 patients with surgically resected high‐ or intermediate‐grade osteosarcoma of the head and neck younger than 75 years, univariate and multivariable analysis, adjusting for age and resection margins, showed that patients who had not received chemotherapy had a significantly higher risk of local recurrence (hazard ratio [HR] = 3.78 and 3.66, respectively).

Conclusion

In patients younger than 75 years of age with surgically resected high‐ and intermediate‐grade osteosarcoma of the head and neck, treatment with (neo‐)adjuvant chemotherapy resulted in a significantly smaller risk of local recurrence. Therefore, we suggest (neo‐)adjuvant chemotherapy in patients amenable to chemotherapy. © 2016 The Authors Head & Neck Published by Wiley Periodicals, Inc. Head Neck39: 140–146, 2017

Proximal location in extremity long bones is a poor prognostic factor for osteosarcoma: A retrospective cohort study of 153 patients

BACKGROUND

Osteosarcomas arising in the proximal femur, humerus, and tibia appear to have poorer outcomes than those arising in distal long bones. However, the strength of this association is uncertain, particularly in light of other prognostic factors. Therefore, this retrospective cohort study was performed to compare patient outcomes between proximal and distal tumor location within extremity long bones.

MATERIAL AND METHODS

A total of 153 patients with conventional high-grade osteosarcoma of the extremity long bones, pelvis, or axial skeleton who had undergone neoadjuvant chemotherapy and surgical resection between 1985 and 2010 were identified in the Surgical Pathology files at Vanderbilt Medical Center. Effect of anatomic location within a proximal long bone was assessed using multivariable Cox proportional hazard regression.

RESULTS

Proximal tumor location was a strong predictor of poor prognosis in univariate survival analysis. Multivariate regression analysis showed that after controlling for American Joint Committee on Cancer (AJCC) stage, histologic response to chemotherapy, surgical resection margin status, and histologic type, location in the proximal femur, tibia, and humerus were independent risk factors for death due to osteosarcoma, but not event-free survival.

CONCLUSION

Osteosarcomas of the proximal extremity long bones are associated with decreased disease-specific survival compared to tumors of the distal long bones, even after accounting for other key prognostic covariates.

Melittin inhibits tumor angiogenesis modulated by endothelial progenitor cells associated with the SDF-1α/CXCR4 signaling pathway in a UMR-106 osteosarcoma xenograft mouse model

Endothelial progenitor cells (EPCs) are important in tumor angiogenesis. Stromal cell-derived factor-1α (SDF-1α) and its receptor C-X-C chemokine receptor type 4 (CXCR4) are key in stem cell homing. Melittin, a component of bee venom, exerts antitumor activity, however, the underlying mechanisms remain to be elucidated. The present study aimed to assess the effects of melittin on EPCs and angiogenesis in a mouse model of osteosarcoma. UMR-106 cells and EPCs were treated with various concentrations of melittin and cell viability was determined using the MTT assay. EPC adherence, migration and tube forming ability were assessed. Furthermore, SDF-1α, AKT and extracellular signal-regulated kinase (ERK)1/2 expression levels were detected by western blotting. Nude mice were inoculated with UMR-106 cells to establish an osteosarcoma mouse model. The tumors were injected with melittin, and its effects were assessed by immunohistochemistry and immunofluorescence. Melittin decreased the viability of UMR-106 cells and EPCs. In addition, it decreased EPC adhesion, migration and tube formation when compared with control and SDF-1α-treated cells. Melittin decreased the expression of phosphorylated (p)-AKT, p-ERK1/2, SDF-1α and CXCR4 in UMR-106 cells and EPCs when compared with the control. The proportions of cluster of differentiation (CD)34/CD133 double-positive cells were 16.4±10.4% in the control, and 7.0±4.4, 2.9±1.2 and 1.3±0.3% in tumors treated with 160, 320 and 640 µg/kg melittin per day, respectively (P<0.05). At 11 days, melittin reduced the tumor size when compared with that of the control (control, 4.8±1.3 cm³; melittin, 3.2±0.6, 2.6±0.5, and 2.0±0.2 cm³ for 160, 320 and 640 µg/kg, respectively; all P<0.05). Melittin decreased the microvessel density, and SDF-1α and CXCR4 protein expression levels in the tumors. Melittin may decrease the effect of osteosarcoma on EPC-mediated angiogenesis, possibly via inhibition of the SDF-1α/CXCR4 signaling pathway.

UK guidelines for the management of bone sarcomas

This document is an update of the British Sarcoma Group guidelines published in 2010. The aim is to provide a reference standard for the clinical care of patients in the UK with bone sarcomas. Recent recommendations by the European Society of Medical Oncology, The National Comprehensive Cancer Network and The National Institute for Health and Care Excellence have been incorporated, and the literature since 2010 reviewed. The standards represent a consensus amongst British Sarcoma Group members in 2015. It is acknowledged that these guidelines will need further updates as care evolves. The key recommendations are that bone pain or a palpable mass should always lead to further investigation and that patients with clinico-radiological findings suggestive of a primary bone tumour at any site in the skeleton should be referred to a specialist centre and managed by a fully accredited bone sarcoma multidisciplinary team. Treatment recommendations are provided for the major tumour types and for localised, metastatic and recurrent disease. Follow up schedules are suggested.

Undifferentiated Embryonal Sarcoma of the Liver (UESL): A Single-Center Experience and Review of the Literature

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare and aggressive pediatric malignancy. The purpose of this study was to review the clinical, radiologic, and pathologic features and outcome of children with UESL at our institution, in the United Network of Organ Sharing database and to review the existing literature to define the state of the art for children with UESL. Six children were diagnosed with UESL at the Texas Children's Cancer Center between 1993 and 2014, 12 children underwent liver transplantation registered in the United Network of Organ Sharing database, and 198 children with UESL were described in 23 case series during 1978 to 2014. Patients were treated with multimodal treatment approaches including primary surgical resection, neoadjuvant and/or adjuvant chemotherapy, and liver transplantation resulting in overall survival reported between 20% and 100% with significant improvement over the recent years. We show that complete tumor removal remains the key element of treatment and our single-institutional experience and data in the published literature suggest that combination chemotherapy with ifosfamide and doxorubicin to facilitate complete surgical resection is an effective approach to cure children with UESL.

Adjuvant radiation therapy in resected high-grade localized skeletal osteosarcomas treated with neoadjuvant chemotherapy: Long-term outcomes

PURPOSE

To assess long-term outcomes and toxicity of adjuvant radiotherapy in the post-surgical management of patients with resected high-grade skeletal osteosarcomas.

METHODS AND MATERIALS

Seventy-two patients with primary resected osteosarcomas underwent adjuvant radiotherapy after neoadjuvant chemotherapy from December 1984 to December 2008. Local control (LC), overall survival (OS) and disease-free survival (DFS) were estimated using Kaplan-Meier methods. For survival outcomes potential associations were assessed in univariate and multivariate analyses using the Cox proportional hazards model.

RESULTS

After a median follow-up of 174months (range, 33-363months), 10-year LC, DFS, and OS rates were 82%, 58%, and 73%, respectively. In the multivariate analysis only R1 margin status (p=0.02) remained significantly associated with LC. Patients with tumor necrosis <90% (p=0.04) and R1 resection margin (p=0.05) remained at a significantly higher risk of mortality on multivariate analysis. Six patients (8%) developed grade ⩾3 treatment-related chronic toxicity events. No grade 5 toxicities were reported.

CONCLUSIONS

A multimodal radiotherapy-containing approach is a well-tolerated component of treatment for patients with osteosarcomas undergoing programed resection, allowing low toxicity rates while maintaining high local control rates.