The rationale for multiple drug chemotherapy in the treatment of osteogenic sarcoma

Predictive value of serum alkaline phosphatase, tumor-specific growth factor, and macrophage migration inhibitory factor for the efficacy of immunotargeted therapy in osteosarcoma patients

OBJECTIVE

To assess the predictive value of serum alkaline phosphatase (ALP), tumor-specific growth factor (TSGF), and macrophage migration inhibitory factor (MIF) for the efficacy of combined immunosuppressive and targeted therapy in osteosarcoma (OS).

METHODS

We retrospectively analyzed clinical data from 161 OS patients treated at Xi'an Honghui Hospital from October 2020 to October 2022. Patients received 12 weeks of therapy with interferon-α (IFN-α) and bevacizumab. Serum levels of ALP, TSGF, and MIF were measured before and after treatment. Based on treatment efficacy, patients were categorized into effective and ineffective groups. Both univariate and logistic regression analyses were utilized to evaluate the influence of these biomarkers on therapy outcomes.

RESULTS

A significant reduction in serum ALP, TSGF, and MIF levels post-treatment was found (all P<0.001). Higher pre-treatment levels of these biomarkers were associated with less effective outcomes (P<0.001).

CONCLUSION

Pre-treatment levels of ALP, TSGF, and MIF are significant independent predictors of response to immunotargeted therapy in OS patients, suggesting their potential role in guiding treatment strategies.

Proximal Femur Replacements for an Oncologic Indication Offer a Durable Endoprosthetic Reconstruction Option: A 40-year Experience

BACKGROUND

Proximal femur replacements (PFRs) are an effective surgical option to treat primary and metastatic tumors causing large bony defects in the proximal femur. Given the relative rarity of these indications, current studies on PFR for oncologic indications are generally limited by patient volume or relatively short-term follow-up. Because recent advances in systemic therapy have improved the prognosis of patients who undergo limb salvage surgery for musculoskeletal tumors, data on the long-term durability of endoprosthetic reconstructions have become increasingly important.

QUESTIONS/PURPOSES

(1) How does the long-term survival of cemented bipolar PFRs compare with patient survival in patients who underwent PFR for benign, aggressive, and metastatic tumors? (2) What are common reasons for revisions of primary PFRs? (3) Which factors are associated with survival of primary PFRs? (4) What is the survivorship free from conversion of bipolar PFRs to THA?

METHODS

Between January 1, 1980, and December 31, 2020, we treated 812 patients with an endoprosthetic reconstruction for an oncologic indication. All patients who underwent a primary PFR for an oncologic indication were included in this study. The study cohort consisted of 122 patients receiving a primary PFR. Eighteen patients did not reach a censored endpoint such as death, revision, or amputation within 2 years. Thirty-three patients died within 2 years of their surgery. Of the 122 patients with primary PFRs, 39 did not reach a censored endpoint and have not been seen within the past 5 years. However, the mean follow-up time for these patients was longer than 10 years. The Social Security Death Index was queried to identify any patients who may have died but might not have been captured by our database To allow for adequate follow-up, endoprosthetic reconstructions performed after December 31, 2020 were excluded. The mean age at the time of the index surgery was 48 ± 22 years. The mean follow-up time of surviving patients was 7 ± 8 years. All PFRs were performed using a bipolar hemiarthroplasty with a cemented stem, and all implants were considered comparable. Demographic, oncologic, procedural, and outcome data including prosthesis survival, patient survival, complication rates, and rates of conversion to THA were analyzed. Patient, prosthesis, and limb salvage survival rates were generated, with implant revision as the endpoint and death as a competing risk. Statistical significance was defined as p < 0.05.

RESULTS

Generally, patients with benign or low-grade (Stage I) disease outlived their implants (100% patient survival through 30 years; p = 0.02), whereas the opposite was true in patients with high-grade, localized Stage II disease (64% patient survival at 5 years [95% CI 49% to 76%]; p = 0.001) or widespread Stage III metastatic disease (6.2% patient survival at 5 years [95% CI 0.5% to 24%]; p < 0.001). Primary PFR implant survival at 5, 10, 20, and 30 years was 97% (95% CI 90% to 99%), 81% (95% CI 67% to 90%), 69% (95% CI 46% to 84%), and 51% (95% CI 24% to 73%), respectively. Eight percent (10 of 122) of primary PFRs were revised for any reason. The most common causes of revision were aseptic loosening (3% [four of 122]), infection (3% [three of 122]), breakage of the implant (2% [two of 122]), and tumor progression (1% [one of 122]). Follow-up time was the only factor that was associated with revision of primary PFRs. Neither segment length nor stem length were associated with revision of primary. Six percent (seven of 122) of PFRs were converted to THA at a mean 15 ± 8 years from the index procedure. Survivorship free from conversion to THA (accounting for death as a competing risk) was 94% (95% CI 85% to 99%), 86% (95% CI 68% to 94%). and 77% (95% CI 51% to 91%) at 10, 20, and 30 years, respectively.

CONCLUSION

Cemented bipolar PFRs for an oncologic indication are a relatively durable reconstruction technique. Given the relative longevity and efficacy of PFRs demonstrated in our study, especially in patients with high-grade or metastatic disease where implant survival until all-cause revision was longer than patient survival, surgeons should continue to seriously consider PFRs in appropriate patients. The relative rarity of these reconstructions limits the number of patients in this study as well as in current research; thus, further multi-institutional collaborations are needed to provide the most accurate prognostic data for our patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Exosomes and osteosarcoma drug resistance

Osteosarcoma (OS) is a primary malignant tumor of bone characterized by the formation of bone tissue or immature bone by tumor cells. Because of its multi-drug resistance, even with the improvement of chemotherapy and the use of targeted drugs, the survival rate of osteosarcoma (OS) is still less than 60%, and it is easy to metastasize, which is a difficulty for many clinicians and researchers. In recent years, with the continuous research on exosomes, it has been found that exosomes play a role in the diagnosis, treatment and chemotherapy resistance of osteosarcoma due to their unique properties. Exosomes can reduce the intracellular accumulation of chemotherapeutic drugs by mediating drug efflux, thus inducing chemotherapeutic resistance in OS cells. Exosomal goods (including miRNA and functional proteins) carried by exosomes also show great potential in affecting the drug resistance of OS. In addition, miRNA carried by exosomes and exosomes exist widely in tumor cells and can reflect the characteristics of parent cells, so it can also be used as a biomarker of OS. At the same time, the development of nanomedicine has given a new hope for the treatment of OS. Exosomes are regarded as good natural nano-carriers by researchers because of their excellent targeted transport capacity and low toxicity, which will play an important role in the field of OS therapy in the future. This paper reviews the internal relationship between exosomes and OS chemotherapy resistance, discusses the broad prospects of exosomes in the field of diagnosis and treatment of OS, and puts forward some suggestions for the study of the mechanism of OS chemotherapy resistance.

Systemic treatment for primary malignant sarcomas arising in craniofacial bones

Introduction

Craniofacial bones may be the site of origin of various sarcomas. We review the various malignancies affecting this region of the body and attempt to put systemic treatment approaches into perspective.

Material and methods

Non-systematic literature review

Results

Conventional types of osteosarcoma, Ewing sarcoma, and chondrosarcoma are the most frequent bone sarcomas occurring in craniofacial region, but variants may occur. The tumors’ biologies and the resulting treatment strategies vary distinctly. As a general rule, local control remains paramount regardless of histology. The efficacy of antineoplastic chemotherapy varies by type of malignancy. It is clearly indicated in Ewing sarcoma and related tumors, potentially of benefit in high-grade osteosarcoma, undifferentiated pleomorphic sarcoma, dedifferentiated and mesenchymal chondrosarcoma, and of no proven benefit in the others.

Conclusions

Various histologies demand various and distinct treatment approaches, with local control remaining paramount in all. The efficacy of systemic treatments varies by type of tumor. Prospective trials would help in all of these to better define systemic treatment strategies.

Origin and Therapies of Osteosarcoma

Simple Summary

Osteosarcoma is the most common malignant bone tumor in children, with a 5-year survival rate ranging from 70% to 20% depending on the aggressiveness of the disease. The current treatments have not evolved over the past four decades due in part to the genetic complexity of the disease and its heterogeneity. This review will summarize the current knowledge of OS origin, diagnosis and therapies.

Abstract

Osteosarcoma (OS) is the most frequent primary bone tumor, mainly affecting children and young adults. Despite therapeutic advances, the 5-year survival rate is 70% but drastically decreases to 20–30% for poor responders to therapies or for patients with metastasis. No real evolution of the survival rates has been observed for four decades, explained by poor knowledge of the origin, difficulties related to diagnosis and the lack of targeted therapies for this pediatric tumor. This review will describe a non-exhaustive overview of osteosarcoma disease from a clinical and biological point of view, describing the origin, diagnosis and therapies.

Surgery Has Positive Effects on Spinal Osteosarcoma Prognosis: A Population-Based Database Study

OBJECTIVE

The treatment of osteosarcoma of the spine remains controversial. Our aim was to explore the treatment of patients with spinal osteosarcoma.

METHODS

We analyzed the data from 727 spinal osteosarcoma patients from the Surveillance, Epidemiology, and End Results database from 1973 to 2015. X-tile software was used to find the optimal cutoff values for age and economic income. The Kaplan-Meier estimator method was used to analyze overall survival and cancer-specific survival. Univariate and multivariate Cox analyses were used to identify the independent prognostic factors. Propensity score matching was used to reduce the possibility of selection bias. A logistic regression model was used to clarify the relevant factors affecting a patient's decision to undergo surgery.

RESULTS

Among 727 eligible spinal osteosarcoma patients, 370 (50.9%) had undergone surgery and 357 (49.1%) had not undergone surgery. Significant differences were found in the effects of patient age at diagnosis, Surveillance, Epidemiology, and End Results historical stage, and tumor grade on the patients' decision to undergo surgery (P < 0.05). Surgery was an independent prognostic factor for overall survival and cancer-specific survival of patients with spinal osteosarcoma. The same results were found after 1:1 propensity score matching. The surgery group had more favorable survival compared with the nonsurgery group.

CONCLUSIONS

Surgery can provide survival benefits for patients with osteosarcoma of the spine. The patients with spinal osteosarcoma who had undergone surgery experienced favorable survival benefits. Thus, surgery can be a suitable treatment for patients with spinal osteosarcoma.

Recurrent spontaneous pneumothoraxes as a complication of osteosarcoma metastases: a case report

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. Osteosarcomas are highly aggressive tumors that historically have had a dismal prognosis. However, the survival rate has improved significantly with the addition of adjuvant and neoadjuvant chemotherapy. Here, we present a case report of a 13-year-old male with a history of a left humeral osteosarcoma whose course was complicated by recurrent sarcoma-related pneumothoraces. Despite recurrent pneumothoraces being a relatively uncommon complication of osteosarcoma, they present a great challenge to providing treatment that optimizes outcomes and quality of life for patients.

Tetrandrine suppresses the growth of human osteosarcoma cells by regulating multiple signaling pathways

Although osteosarcoma (OS) is the most common malignant tumor among juvenile bone tumors, its treatment plan and clinical outcome have not improved significantly in recent decades. Tetrandrine (TET), a Chinese medicine that is usually used in the therapy of silicosis, hypertension and arthritis, has been confirmed by many studies to possess potent antitumour growth properties, but there are different limitations when describing specific mechanisms. Here, we found that TET can obviously prevent the proliferation, migration and invasion of both 143B and MG63 cells and promote their apoptosis in vitro. Our results for luciferase reporter and Western blotting assays show that TET may exert its antitumour activity by regulating multiplex signaling pathways, including the MAPK/Erk, PTEN/Akt, Juk and Wnt signaling pathways. Furthermore, the regulatory effect of TET on OS cells and related signaling pathways was verified again in vivo. Our findings suggest that the anticancer function of TET on human OS may be mediated by its targeting of multiple signaling pathways and that TET may be used as a single drug or in combination with other drugs during the treatment of OS.

Selected using bioinformatics and molecular docking analyses, PHA-793887 is effective against osteosarcoma

To identify novel prognostic and therapeutic targets for osteosarcoma patients, we compared the gene expression profiles of osteosarcoma and control tissues from the GSE42352 dataset in the Gene Expression Omnibus. Differentially expressed genes were subjected to Gene Ontology, Kyoto Encyclopedia of Genes and Genomes, Gene Set Enrichment and protein-protein interaction network analyses. Survival curve analyses indicated that osteosarcoma patients with lower mRNA levels of cyclin-dependent kinase 1 (CDK1) and topoisomerase II alpha had better prognoses. Various computer-aided techniques were used to identify potential CDK1 inhibitors for osteosarcoma patients, and PHA-793887 was predicted to be a safe drug with a high binding affinity for CDK1. In vitro, MTT and colony formation assays demonstrated that PHA-793887 reduced the viability and clonogenicity of osteosarcoma cells, while a scratch assay suggested that PHA-793887 impaired the migration of these cells. Flow cytometry experiments revealed that PHA-793887 dose-dependently induced apoptosis in osteosarcoma cells. Western blotting and enzyme-linked immunosorbent assays indicated that CDK1 expression in osteosarcoma cells declined with increasing PHA-793887 concentrations. These results suggest that PHA-793887 could be a promising new treatment for osteosarcoma.

Mechanisms of Resistance to Conventional Therapies for Osteosarcoma

Osteosarcoma (OS) is the most common primary bone tumor, mainly occurring in children and adolescents. Current standard therapy includes tumor resection associated with multidrug chemotherapy. However, patient survival has not evolved for the past decades. Since the 1970s, the 5-year survival rate is around 75% for patients with localized OS but dramatically drops to 20% for bad responders to chemotherapy or patients with metastases. Resistance is one of the biological processes at the origin of therapeutic failure. Therefore, it is necessary to better understand and decipher molecular mechanisms of resistance to conventional chemotherapy in order to develop new strategies and to adapt treatments for patients, thus improving the survival rate. This review will describe most of the molecular mechanisms involved in OS chemoresistance, such as a decrease in intracellular accumulation of drugs, inactivation of drugs, improved DNA repair, modulations of signaling pathways, resistance linked to autophagy, disruption in genes expression linked to the cell cycle, or even implication of the micro-environment. We will also give an overview of potential therapeutic strategies to circumvent resistance development.

In vitro drug sensitivity (IDS) of patient-derived primary osteosarcoma cells as an early predictor of the clinical outcomes of osteosarcoma patients

PURPOSE

Early prediction of clinical response to conventional chemotherapy is a significant factor in determining an overall treatment strategy for osteosarcoma.

METHODS

Cells were extracted from treatment-naïve biopsies from 16 osteosarcoma patients who received a doxorubicin and cisplatin-based neoadjuvant chemotherapy regimen and their sensitivities to doxorubicin and cisplatin were measured as IC50 values. Associations of in vitro drug sensitivity (IDS) levels and clinical outcomes were examined.

RESULTS

Primary osteosarcoma cells responded to doxorubicin and cisplatin with IC50 values of 0.088 ± 0.032 µM and 16.7 ± 8.5 µM, respectively. The patients with a non-metastatic phenotype and surviving patients showed significantly lower IC50 values for both drugs. ROC analysis defined the optimal IC50 cut-off values for doxorubicin (IDS_dox) and cisplatin (IDS_cpt) as 0.05 µM (AUC 0.82) and 14 µM (AUC 0.87), respectively. Survival analysis found significantly longer disease-free survival (DFS, n = 14) and overall survival (OS, n = 16) times in the patients with low IDS_dox (p = 0.0064 for DFS and p = 0.0102 for OS) and low IDS_cpt (p = 0.0204 for DFS and p = 0.0021 for OS). Interestingly, when the patients with low IDS_cpt and those with low IDS_dox were combined (Group 1), significant associations with prolonged DFS (p = 0.0042, C-statistic 0.78) and OS (p = 0.0010, C-statistic 0.79) were found. In this cohort, histological response to neoadjuvant chemotherapy could predict only OS.

CONCLUSIONS

This study indicates that IDS analysis could potentially be a practical, rapid, and reliable technique for predicting clinical outcomes. It could also be used to identify patients for whom conventional chemotherapy is most appropriate and, in the future, help advance personalized therapy.

Perioperative rh-endostatin with chemotherapy improves the survival of conventional osteosarcoma patients: a prospective non-randomized controlled study

Objective

Anti-angiogenic drugs are an emerging treatment option against malignant tumors. The aim of this study was to determine whether the addition of perioperative rh-endostatin to chemotherapy could improve the probability of distant metastasis-free survival (DMFS) and overall survival (OS) in patients newly diagnosed with non-metastatic conventional osteosarcoma.

Methods

This was a controlled non-randomized clinical study that included 388 patients without clinically detectable metastatic disease enrolled from January 2008 to April 2012. The control treatment group had 272 patients; 180 were male and 92, female, with a median age of 17 years. The treatment group had 58 patients; 36 were male and 22, female, with a median age of 16 years. The control group received preoperative chemotherapy followed by surgery and postoperative chemotherapy. The treatment group received 4 cycles of rh-endostatin perioperatively in addition to chemotherapy as per the control group. Patients were followed up from 6-101 months with a median follow-up period of 50.2 months.

Results

The 5-year DMFS of the control group (61%) was significantly lower than that of the rh-endostatin group (79%) (P = 0.013). The 5-year OS of the control group (74%) was significantly lower than that of the rh-endostatin treatment group (87%) (P = 0.029). No difference in adverse drug reactions was found between these 2 groups.

Conclusions

The addition of perioperative rh-endostatin to chemotherapy could significantly improve the DMFS and OS of patients with non-metastatic osteosarcoma.

Surgical and Functional Outcomes After Limb-Preservation Surgery for Tumor in Pediatric Patients: A Systematic Review

BACKGROUND

Limb-salvage surgery and segmental reconstruction for the treatment of lower extremity osseous tumors in the pediatric population have been described in the literature, but there is little consensus regarding the optimal surgical treatment for this patient population.

METHODS

A systematic review of the literature was performed to identify studies focusing on limb-salvage procedures in pediatric patients who were managed with one of three reconstructions with use of a metallic endoprosthesis, allograft, or allograft-prosthesis composite. Data were segregated according to the excised and reconstructed anatomical location (proximal part of the femur, total femur, distal part of the femur, proximal part of the tibia) and were collated to assess modes of failure and functional outcomes of each reconstruction type for each anatomic location.

RESULTS

Sixty articles met the inclusion criteria; all were Level-IV evidence, primarily consisting of small, retrospective case series. Infection was a primary mode of failure across all reconstruction types and locations, whereas allograft reconstructions were susceptible to structural failure as well. The rate of failure in the pediatric population correlated well with previously published results for adults. The incidence of subsequent amputation was lower in the pediatric population (5.2%) than has been reported in adults (9.5%) (p = 0.013). Meaningful growth of expandable metallic endoprostheses was reported in the literature, with an overall rate of leg-length discrepancy of 13.4% being noted at the time of the latest follow-up. The Musculoskeletal Tumor Society (MSTS) questionnaire was the most consistently used outcome measure in the literature, with average scores ranging from 71.0% to 86.8%, depending on reconstruction type and anatomic location.

CONCLUSIONS

The current state of the literature detailing the surgical and functional outcomes of segmental reconstruction for the treatment of pediatric bone tumors is limited to Level-IV evidence and is complicated by under-segregation of the data by age and anatomical location of the reconstruction. Despite these limitations, pediatric limb-salvage surgery demonstrates satisfactory initial surgical and functional outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

ATF4 regulated by MYC has an important function in anoikis resistance in human osteosarcoma cells

Anoikis resistance is a crucial step in the process of tumor metastasis. This step determines whether the tumor cells will survive when they become detached from the extracellular matrix. However, the specific mechanism of tumor cells to bypass anoikis and become resistant remains to be elucidated. The present study aimed to determine the internal mechanism of bypassing anoikis through comparison of human osteosarcoma cell lines with human normal cell lines. High activating transcription factor 4 (ATF4) and myelocytomatosis oncogene (MYC) expression levels were observed in MG-63 and U-2 OS human osteosarcoma cell lines. It is possible that ATF4 and MYC contribute to tumor progression. Subsequently, the expression levels of ATF4 and MYC in HUVEC and CHON-001 human normal cell lines were upregulated and their adhesion abilities were reduced; whereas their ability to bypass anoikis increased significantly. Simultaneously, after we Following a knock-down of ATF4 and MYC expression levels in MG-63 and U-2 OS human osteosarcoma cell lines, their adhesion ability increased and their ability to bypassing anoikis was significantly reduced. Upregulation of MYC resulted in an upregulation of ATF4, and chromatin immunoprecipitation and luciferase reporter gene technology demonstrated that MYC binds to the promoter of ATF4. These findings suggest that ATF4 regulated by MYC might contribute to resistance to anoikis in human osteosarcoma cells.

Therapeutic effect of neoadjuvant chemotherapy combined with curettage to treat distal femoral osteosarcoma: A case report

RATIONALE

Osteosarcoma is the most common malignant bone tumor in children and adolescents. Metastasis occurs early, the mortality rate is high, and the tumor results in a tremendous physical, mental, and economic burden on patients. Therefore, the treatment of osteosarcoma has been important for orthopedic surgeons. However, treatment has always been a difficult problem globally.

PATIENT CONCERN

We present the case of a 22-year-old girl with increasing local pain in the distal left thigh.

DIAGNOSES

The patient was initially diagnosed as bone cancer according to computed tomography (CT) and X-ray imaging. And the patient was further diagnosed as osteosarcoma via to puncture biopsy of the left distal femur.

INTERVENTIONS

Local arterial infusion chemotherapy, systemic intravenous chemotherapy, and curettage was conducted because of limb salvage program.

OUTCOMES

The patient was doing well with no evidence of local or distant recurrence 7 years after the surgery.

LESSONS

Our case indicated that limb osteosarcoma patients can undergo a limb salvage program of local arterial infusion chemotherapy, systemic intravenous chemotherapy, and curettage.

Prognostic factors and treatment results of high-grade osteosarcoma in norway: a scope beyond the "classical" patient

Purpose. A retrospective study of prognostic factors and treatment outcome of osteosarcoma (OS) during modern chemotherapy era with focus on patients with primary metastatic disease, nonextremity localisation, or age >40 years (nonclassical OS). Methods. A nationwide cohort, comprising 424 high-grade Norwegian bone OS patients, was based on registry sources supplemented with clinical records from hospitals involved in sarcoma management between 1975 and 2009. Results. Only 48% were younger patients with tumour in the extremities and without metastasis at diagnosis (classical OS). A considerable discrepancy in survival between classical and nonclassical OS was observed: 61% versus 26% 10-year sarcoma specific survival. Twice as many of the former received both adequate surgery and chemotherapy compared to the latter. This could only partly explain the differences in survival due to inherent chemoresistance in primary metastatic disease and a higher rate of local relapse among patients with axial tumours. Metastasis at diagnosis, increased lactate dehydrogenase, age > 40 years, and tumour size above median value were all adverse prognostic factors for overall survival. Conclusion. We confirm a dramatic difference in outcome between classical and nonclassical high-grade OS patients, but treatment variables could only partly explain the dismal outcome of the latter.

Dual AO/EB staining to detect apoptosis in osteosarcoma cells compared with flow cytometry

BACKGROUND

The aim of this study was to evaluate the ability of dual acridine orange/ethidium bromide (AO/EB) staining to detect tumor cell apoptosis. According to apoptosis-associated changes of cell membranes during the process of apoptosis, a clear distinction is made between normal cells, early and late apoptotic cells, and necrotic cells.

MATERIAL AND METHODS

We cultured human osteosarcoma cells with 30, 60, and 120 µg/ml kappa-selenocarrageenan. To assess the rates of cell proliferation and apoptosis, cells were fluorescently stained with acridine orange/ethidium bromide (AO/EB) or stained with propidium iodide (PI) and analyzed by flow cytometry. All experiments were repeated at least 3 times.

RESULTS

Normal tumor cells, early and late apoptotic cells, and necrotic cells were examined using fluorescent microscopy. Early-stage apoptotic cells were marked by crescent-shaped or granular yellow-green acridine orange nuclear staining. Late-stage apoptotic cells were marked with concentrated and asymmetrically localized orange nuclear ethidium bromide staining. Necrotic cells increased in volume and showed uneven orange-red fluorescence at their periphery. Cells appeared to be in the process of disintegrating. The percentage of apoptotic osteosarcoma cells detected by dual acridine orange/ethidium bromide (AO/EB) staining was not significantly different from that detected using flow cytometry (P>0.05).

CONCLUSIONS

Our results suggest that dual acridine orange/ethidium bromide staining is an economic and convenient method to detect apoptosis in tumor cells and to test tumor chemosensitivity compared with flow cytometry.

Hyperthermic Isolated Limb Perfusion with TNF alpha and Cisplatin in the Treatment of Osteosarcoma of the Extremities: A Feasibility Study in Healthy Dogs

Purpose. The feasibility of hyperthermic isolated limb perfusion (HILP) with tumor necrosis factor-alpha (TNFalpha ) and cisplatin for the management of osteosarcoma was studied in the canine model.Methods. During seven perfusions in six healthy mongrel dogs (weight 32+/-2 kg) technical aspects of HILP under mild hyperthermia (39- 40) were studied. In five experiments HILP was performed with TNFalpha alone (0.5 mg/l extremity volume), and in two experiments TNFalpha was combined with cisplatin (25 mg/l extremity volume). During the perfusions physiological parameters were monitored and TNFalpha and total cisplatin concentrations were determined.Results. Perfusion conditions (pH, PCO(2) , PO(2), flow and pressure) remained within physiological ranges.Three dogs died within 24 h despite a sublethal systemic concentration of TNFalpha that leaked from the perfusion circuit. Three dogs were terminated; one dog after the second experiment in accordance with Dutch ethical rules; one dog showed an invagination of the small bowel resulting in an ileus; one dog because of necrosis of the perfused limb.Conclusions. This feasibility study in healthy dogs demonstrated that HILP with TNFalpha and cisplatin was associated with a high mortality rate and does not allow us to treat dogs with spontaneous osteosarcoma with TNFalpha and cisplatin HILP. Therefore, an alternative model should be used in the search for the ideal combination of perfusion agents for limb sparing treatment in human osteosarcoma.

Comparison of the outcome of conventional osteosarcoma at two specialist international orthopaedic oncology centres

OBJECTIVE

To determine the prognostic value of patient and treatment parameters in osteosarcoma, and whether these are equally important across international boundaries.

DESIGN

Retrospective, cross-sectional study of 428 patients diagnosed with around-knee osteosarcoma, between 1990 and 1997 in Birmingham, UK, and Bologna, Italy. Disease-free survival (DFS) and overall survival (OS) assessed by Kaplan-Meier, Fisher's PLSD and Cox proportional hazard regression.

RESULTS

Five-year DFS and OS were 56 and 73% at Centre 1, compared to 43 and 60% at Centre 2 (P=0.0022 and P = 0.025, respectively). The most important bad prognostic factors for DFS and OS respectively were raised alkaline phosphatase at diagnosis (P=0.002 and P=0.003), tumour necrosis < 90% following chemotherapy (P=0.001 and P = 0.004) and volume > 150 cm(3) at diagnosis (P=0.04 and P=0.006). The most significant combination of bad prognostic factors was alkaline phosphatase and tumour necrosis. A total of 73% of patients at Centre 1 had greater than 90% necrosis of the tumour following neoadjuvant chemotherapy compared with 29% at Centre 2.

CONCLUSIONS

Tumour-based prognostic factors have similar significance across international boundaries. Chemotherapy effectiveness appears to be a major factor in explaining the survival difference between the two centres.

How can survival be improved in localized osteosarcoma?

Despite numerous chemotherapy trials and the introduction of novel agents, survival in localized osteosarcoma, which plateaued in the mid-1980s, has been recalcitrant to our best efforts. The authors considered that a review of previous and current strategies that target survival might provide a direction for research efforts. Here, the focus is placed mainly on the reappraisal of previous mass chemotherapy trials and prognostic factors, in the hope of contriving a strategy to overcome the current stasis.

The multidisciplinary management of osteosarcoma

Patients with suspected or confirmed osteosarcoma should be evaluated and treated at a comprehensive cancer center within a multidisciplinary sarcoma program that includes pediatric, medical and radiation oncologists, orthopedic and surgical oncologists, musculoskeletal pathologists, and radiologists. Successful treatment involves proper diagnosis, neoadjuvant and adjuvant multi-agent chemotherapy, and aggressive surgery with an emphasis toward limb-preserving procedures. Treatment of osteosarcoma should be undertaken within the framework of large cooperative group clinical trials for children, adolescents, and adults. Patients treated with osteosarcoma should be followed closely both for recurrence of disease and for development of late effects of the treatment of their cancer. The treatment of metastatic, recurrent and/or refractory disease is more controversial. Despite advances in systemic treatment, surgical technique, and supportive care, the overall outcome is still poor.

Management of osteosarcoma

Improving cure rates for osteosarcoma continues to be a major challenge. The clinical management of individual patients is exacting and requires a skilled, experienced team including a surgeon, pathologist, oncologist, and radiologist, with support from specialist nurses and rehabilitation teams. Outcomes from treatment have improved little in 20 years and remain disappointing. Chemotherapy for osteosarcoma is among the most grueling of any given for solid tumors, and treatment of the primary tumor is associated with permanent disability of some degree in a significant proportion of patients. New systemic treatments remain beyond the horizon. In recognition of these difficulties, an international cooperation has begun with the opening of a randomized trial, European and American Osteosarcoma (EURAMOS) 1, in Europe and the United States. This study heralds a new era of clinical investigation into osteosarcoma, with the promise of valuable biologic insights and rapid evaluation of investigational strategies. Osteosarcoma should always be treated under the guidance of a specialist team, and we recommend that whenever possible, patients be offered entry into EURAMOS 1 or other well-designed clinical trials.

Clinicopathologic features, treatment, and prognosis of postirradiation osteosarcoma in patients with nasopharyngeal cancer

OBJECTIVES

Postirradiation osteosarcoma (PIOS) arising after radiation of nasopharyngeal cancer (NPC) is rare and seldom reported. In this article, we report its clinicopathologic features, outcome, and prognostic factors.

STUDY DESIGN

Retrospective cohort study.

METHODS

Fifteen patients with NPC were determined to have PIOS after reviewing 426 patients with osteogenic sarcomas. Their clinical records, image and pathologic slides, and follow-up data after treatment were collected to perform analysis.

RESULTS

The incidence rate of PIOS in NPC was approximately 0.037% (15/40,719), which occupied approximately 3.5% (15/426) among all kinds of osteogenic sarcomas. The latent time of PIOS after irradiation for NPC ranged from 4 to 27 years, with a mean of 13.3 years. The location where PIOS arose included 33.3% (5/15) from maxilla, 46.7% (7/15) from mandible, and 20% (3/15) from a mixture of nasal cavity and paranasal sinuses. Radiologically, soft tissue mass, bone destruction, and tumor new bone formation were the main characteristics. Pathologic subtypes included 53.3% (8/15) of fibroblastic osteosarcoma, 33.3% (5/15) of chondroblastic osteosarcoma, and 13.3% (2/15) of mixed type osteosarcoma. Of 15 patients with PIOS, 12 patients were treated with curative intent, and the remaining 3 patients with palliative intent. For 12 patients who had undertaken ablative surgery, 1 patient had residual tumor, and 6 patients had tumor recurrence. The survival time after treatment for all patients ranged from 7 to 41 months, with a mean of 18 months. Kaplan-Meier estimates of 1 year and 2 year survival rates were 60% and 24%, respectively. Statistical analysis showed that sex and tumor bone formation are significant prognostic factors.

CONCLUSIONS

PIOS in NPC is a highly malignant disease with poorer prognosis than in other sites. Surgery combined with pre- and postoperative chemotherapy might be an effective way to improve survival.

Survival data for 648 patients with osteosarcoma treated at one institution

During the past 30 years, the orthopaedic oncology group at the Massachusetts General Hospital has treated 648 patients with osteosarcoma centrally located in the bone. Using records maintained in a specifically designed computer system, a study was done to assess the factors that seemed to influence the survival outcome. The overall survival for the entire series was 68% at an average followup of 6 +/- 4 years. Death occurred at a mean of 3 +/- 3 years. Patient gender had no effect, but age of the patient was correlated with survival data, with the poorest survival for the older patients. Surgical treatment had no effect on outcome, but the Musculoskeletal Tumor Society stage of the lesion, the presence of metastases or local recurrence, and the chemotherapeutic treatment (very dependent on the drugs available and adjuvant versus neoadjuvant administration at various decades) all had a profound effect. In addition, anatomic location, size of the tumor, and percentage of tumor cells killed after neoadjuvant chemotherapy all had an effect on outcome.

Recurrences following primary osteosarcoma in adolescents and adults previously treated with chemotherapy

In this retrospective analysis, we report on the detailed management of 33 recurrent osteosarcoma patients from a population of 81 adolescents and adults previously treated (between November 1979 and November 1998) at the La Timone Adults Hospital, for an extremity-localised osteosarcoma. The site of the first recurrence was limited to the lung in 24 patients (73%), was local in 4 patients (12%), at multiple sites in 4 patients (12%), and limited to the bone for 1 patient (3%). The median interval between the diagnosis of the primary osteosarcoma and the first recurrence was 16 months (range 4-108 months). For all patients, the treatment combined aggressive chemotherapy and surgical resection of the recurrences whenever possible. 19 patients (58%) achieved a second complete remission. The median follow-up time from the first recurrence was 18 months (range 4-150 months). For all patients, the median overall survival from first recurrence was 17 months (95% confidence interval (CI), 11-22 months) and the projected 3- and 5-year survival rates were 31.6 and 23.7%, respectively. Patients with a second complete remission had a better 5-year survival than patients without (44.6% versus 0%, P=0.001). The achievement of a second complete remission has an independent significant prognostic value for an improved survival. Aggressive surgery with the removal of recurrence sites combined with multi-agent chemotherapy can either cure patients with recurrent osteosarcoma or significantly prolong their survival.

Long-term followup of uncemented tumor endoprostheses for the lower extremity

Between 1982 and 1989, 100 primary lower limb reconstructions were done using the Kotz Modular Femur Tibia Reconstruction System after resection of a malignant tumor. In 32 patients a proximal femur prosthesis was implanted, in 40 patients a distal femur prosthesis was implanted, in 19 patients a proximal tibia component was implanted, in four patients a total femur prosthesis was implanted, and in five patients a total knee prosthesis was implanted. The Kaplan-Meier estimate of the overall survival rate of the prostheses was 85% after 3 years, 79% after 5 years, and 71% after 10 years. The most common reason for implant failure was aseptic loosening in 27% of patients (11 patients; range, 10-121 months) after the initial operation. The other reasons for revision surgery were implant fracture (n 5 4) and infection (n 5 4). Early repair of prostheses-related minor complications, such as worn polyethylene bushings, resulted in a statistically significant reduction of implant failure. After a median followup of 127.5 months after the initial surgery, 51 patients had died and eight patients were lost to followup. Forty-one patients were evaluated clinically and radiologically using the Musculoskeletal Tumor Society score and the radiologic implant evaluation system of the International Symposium on Limb Salvage; these 41 patients had a mean of 80% (range, 40%-100%) of the normal functional capability.

Bilateral recurrent pneumothorax complicating chemotherapy for pulmonary metastatic breast ductal carcinoma: report of a case

Secondary spontaneous pneumothorax (SSP) is a rare complication of chemotherapy for pulmonary metastases and to the best of our knowledge, only 28 cases have been described, most of which occurred in patients with osteosarcoma or germ cell tumors. We present herein the case of a 56-year-old woman in whom bilateral and recurrent SSP was caused by the rupture of pulmonary lacunae induced by chemotherapy, given for bilateral lung metastases secondary to breast carcinoma. Our experience of this case led us to conclude that: patients with pulmonary metastases may develop bilateral and/or recurrent pneumothoraces following chemotherapy; computed tomography scan is essential for defining the cause of SSP; and closed chest tube drainage remains the therapy of choice, while chemical pleurodesis may also be used to prevent recidivant SSP.

Spontaneous pneumothorax in malignancy: a case report and review of the literature

BACKGROUND

Pneumothorax occurring in the absence of obvious lung disease is defined as spontaneous pneumothorax. Spontaneous pneumothorax occurs in a variety of settings in patients with malignancies.

PATIENTS AND METHODS

We present a case report of spontaneous pneumothorax in malignancy and review the literature.

RESULTS

No correlation was found between the occurrence of pneumothorax with age, sex or smoking history. Pneumothorax occurred with a variety of primary tumors. However it was always associated with lung metastases or lung involvement with tumor. In certain cases the metastases were detected after the occurrence of pneumothorax.

CONCLUSIONS

The occurrence of pneumothorax in a patient with malignancy should prompt a search for lung metastases.

Osteosarcoma of the jaw bones. Long-term follow up of 48 cases

To evaluate the incidence and treatment results of osteosarcoma of the jaw (OSJ) in the Netherlands, data from 48 patients with a histologically proven diagnosis of osteogenic sarcoma of the maxilla or mandible were retrospectively analysed. Patient files, covering the period from 1964 to 1992, were obtained from all university hospitals in the Netherlands and the Netherlands Cancer Institute. The incidence of OSJ in the Netherlands is estimated to be at least 0.14 per 1,000,000. The overall 10-year survival was 59%. Distant metastasis occurred in 21% and local recurrences in 31% of the cases. Survival was significantly better in case of radical surgery and small tumours. Long-term survival after treatment of OSJ was good if complete surgical excision was achieved. Radiotherapy should only be considered to prevent local recurrence if surgery is not complete. The possible benefit of current chemotherapy in preventing metastatic disease is still questionable. Since other malignant neoplasms associated with OSJ occurred in 17% of the cases, lifelong follow up is mandatory for the detection of these second primary malignancies.

Treatment results of osteogenic sarcoma. An evaluation of 36 patients treated during 30-year period in south-western Finland

Histological re-evaluation revealed 36 osteogenic sarcoma (OS) patients for analysis in South-Western Finland treated between 1958 and 1987. In 21 cases (58%) the tumour was located in the knee region. The mean age at diagnosis was 28 years (range: 5-62 years) and the follow-up time of the patients was at least 5 years or until death. In 29 patients without metastases at the time of diagnosis, the extent of the primary tumour was T2 in 37% and T3 in 63% of the patients. There were no differences regarding the extent of the primary tumour, delay of the diagnosis, mean age of the patients, or duration of the symptoms while comparing the three decades of the study. Before the 1970s the treatment consisted of surgery with or without radiotherapy in most cases. Since the 1970s the combination of surgical treatment (amputation or wide excision) and adjuvant chemotherapy was the most common treatment modality. Since the late 1970s limb-salvage surgery has been applied in selected cases, and it seems to be justified. None of the patients treated before 1970 survived for 5 years. The 5- and 10-year survival of all 36 patients was 44.4% and 33.6%, respectively. In non-metastatic patients both the 5- and 10-year disease-free survival was 46.7%. A certain group exhibiting a good prognosis was found; the 10-year survival of the 10 patients with OS in extremities, treated with combined chemotherapy and surgery, was 70%. The median survival time was significantly longer for the patients with an intracompartmental tumour extent of T2 (112 months) compared with an extracompartmental extent of T3 (23 months), and for the patients with the primary tumour in the knee region (112 months) compared with other locations (18 months). The long-term survival of the OS patients has improved concomitantly with the multimodality of the treatment.

Hyperthermic isolated regional perfusion with cisplatin in the local treatment of spontaneous canine osteosarcoma: assessment of short-term effects

To increase the effect of cisplatin on locoregional osteosarcoma, the short-term effect of hyperthermic isolated regional perfusion (HIRP) with cisplatin (30 mg/L extremity volume) was studied in 28 dogs with spontaneous osteogenic sarcoma, using clinical, radiological, and histological parameters. Thirty days postoperatively, mortality was 14.3%. Total platinum levels at the start of perfusion were 28.2 +/- 14.3 mg/L. A significant improvement (P < 0.001) in clinical score was observed in the overall group at 6 and 12 weeks after perfusion. The radiological parameter showed a stationary X-ray 2 weeks after perfusion and an improved X-ray 6 weeks after perfusion. Overall histological scores showed a moderate effect according to the Huvos classification. No additional therapeutic effect, according to the three parameters, could be demonstrated by increasing the perfusate temperature by 1 degrees C. HIRP with cisplatin is feasible in the local treatment of spontaneous osteosarcoma in dogs with acceptable locoregional toxicity. However, the histological results were modest, with none of the dogs showing a complete response 6 weeks after perfusion. Therefore, the search for the ideal perfusion agent with substantial contribution to the limb-sparing treatment in human osteosarcoma continues.

Spontaneous pneumothorax complicating chemotherapy for metastatic seminoma. A case report and a review of the literature

BACKGROUND

Spontaneous pneumothorax complicating chemotherapy has been reported mainly in metastatic sarcoma, particularly of the osteogenic type. The main factor in the etiology of spontaneous pneumothorax could be related to tumor lysis and/or rapid rupture of chemosensitive peripheral or subpleural metastasis into the pleural cavity, thus leading to a bronchopleural fistula.

METHODS AND RESULTS

A 49-year-old patient in whom spontaneous pneumothorax developed after successful chemotherapy for metastatic seminoma is described. On chest tube drainage, the lung reexpanded rapidly and the patient became clinically and radiographically symptom free.

CONCLUSION

To the authors' knowledge, this is only the second case of spontaneous pneumothorax complicating chemotherapy-induced rapid regression of lung and mediastinal metastases in patients with seminoma. Spontaneous pneumothorax should be included in the spectrum of chemotherapy-related side effects in chemosensitive solid tumors with lung metastases.

Pneumothorax following induction chemotherapy in patients with lung metastases: a case report and literature review

A 29-year-old patient presented with bilateral pulmonary lesions following surgery for recurrent placental site trophoblastic tumor (PSTT). On day seven after institution of the 'EMA' regimen (etoposide, medium dose methotrexate with folinic acid rescue and actinomycin-D), complete pneumothorax occurred. Closed-system air drainage brought only transient lung expansion and subsequent talc pleurodesis was needed. During follow-up, complete regression of lung metastases was observed. A literature survey of post-chemotherapy pneumothorax in patients with lung metastases disclosed fourteen hitherto reported cases. Including the present PSTT case, non-epithelial gynecologic malignancy (3 patients) ranks second to osteogenic sarcoma (6 cases) with regard to the primary tumor involved.