Osteosarcoma in the first decade of life

Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity

BACKGROUND/PURPOSE

Limb preserving surgery for the treatment of patients with osteosarcoma younger than 10 years old is challenging and some authors have advocated amputation to reduce the risk of complications. The aim of this study was to compare the clinical outcomes and surgical complications of patients with osteosarcoma of the extremity aged <10 years old who were treated with limb salvage and amputation.

PATIENTS AND METHODS

Retrospective review of patients aged <10 years old who were treated for primary osteosarcoma of bone between 2000 and 2018.

RESULTS

We analyzed 82 consecutive patients (32 males, 50 females; median age 8, range 3-9 yrs). Limb-salvage surgery (LSS; n = 65, 79%) and amputation (n = 17, 21%) were performed. Fourteen patients had metastasis at surgery. In patients without metastasis at surgery, the metastasis-free and overall survival rates at 5 years following LSS vs. amputation were 75% vs. 58% (p = 0.162) and 71% vs. 55% (p = 0.516), respectively. The 2-year and 5-year OS rates of the LSS and amputation groups of patients with metastasis at surgery were 88% versus 83% and 50% versus 0%, respectively (p = 0.180). The overall complication rates were 46% post-LSS with 31% requiring re-operation versus 12% post-amputation, with 6% requiring re-operation (p = 0.010).

CONCLUSION

The prognosis of patients with localized osteosarcoma aged <10 years undergoing LSS is similar to those treated with amputation, but LSS is associated with a higher risk of complications and subsequent re-operation.

LEVEL OF EVIDENCE

Level III.

A Nomogram for Predicting Cancer-Specific Survival of Osteosarcoma and Ewing's Sarcoma in Children: A SEER Database Analysis

Background

Osteosarcoma (OSC) and Ewing's sarcoma (EWS) are children's most common primary bone tumors. The purpose of the study is to develop and validate a new nomogram to predict the cancer-specific survival (CSS) of childhood OSC and EWS.

Methods

The clinicopathological information of all children with OSC and EWS from 2004 to 2018 was downloaded from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression analyses were used to screen children's independent risk factors for CSS. These risk factors were used to construct a nomogram to predict the CSS of children with OSC and EWS. A series of validation methods, including calibration plots, consistency index (C-index), and area under the receiver operating characteristic curve (AUC), were used to validate the accuracy and reliability of the prediction model. Decision curve analysis (DCA) was used to validate the clinical application efficacy of predictive models. All patients were divided into low- and high-risk groups based on the nomogram score. Kaplan-Meier curve and log-rank test were used to compare survival differences between the two groups.

Results

A total of 2059 children with OSC and EWS were included. All patients were randomly divided into training cohort 60% (N = 1215) and validation cohort 40% (N = 844). Univariate and multivariate analysis suggested that age, surgery, stage, primary site, tumor size, and histological type were independent risk factors. Nomograms were established based on these factors to predict 3-, 5-, and 8-years CSS of children with OSC and EWS. The calibration plots showed that the predicted value was highly consistent with the actual value. In the training cohort and validation cohort, the C-index was 0.729 (0.702–0.756) and 0.735 (0.702–0.768), respectively. The AUC of the training cohort and the validation cohort also showed similar results. The DCA showed that the nomogram had good clinical value.

Conclusion

We constructed a new nomogram to predict the CSS of OSC and EWS in children. This predictive model has good accuracy and reliability and can help doctors and patients develop clinical strategies.

A Risk-Scoring Model Based on Evaluation of Ferroptosis-Related Genes in Osteosarcoma

Background

Osteosarcoma (OS) is a bone malignancy frequently seen in pediatrics and has high mortality and incidence. Ferroptosis is an important cell death process in regulating the apoptosis and invasion of tumor cells, so constructing the risk-scoring model based on OS ferroptosis-related genes (FRGs) will benefit the evaluation of both treatment and prognosis.

Methods

The OS dataset was screened from the Therapeutically Applicable Research to Generate Effective Treatments (TARGET) database, and OS-related FRGs were found through the Ferroptosis Database (FerrDb) using a multivariate Cox regression model, followed by the generation of the risk scores and a risk-scoring prediction model. Further systematical exploration for immune cell infiltration and assessing the prediction of response to targeted drugs was conducted.

Results

Based on OS-related FRGs, a risk-scoring model of FRGs in OS was constructed. The six FRGs played a role in the carbon metabolism, glutathione metabolism, and pentose phosphate pathways. Results from targeted drug sensitivity analyses were concordant to pathway analyses. The response to targeted drugs statistically differed between the two groups with different risks, and the high-risk group presented a high sensitivity to targeted drugs.

Conclusions

We identified a 6-ferroptosis-gene-based prognostic signature in OS and created and verified a risk-scoring model to predict the prognosis of OS at 1, 3, and 5 years for OS patients independently.

Amputation Predisposes to Higher Cancer-Specific Mortality Than Limb Salvage Surgery in Pediatric Patients With Osteosarcoma of the Limbs: A Propensity Matching Analysis

Objective

With the development of osteosarcoma treatment, limb salvage surgery is gradually replacing amputation as the primary surgical option. Most pediatric osteosarcomas of the limbs undergo limb-salvage surgery. We aimed to use propensity score matching (PSM) analysis test the difference in cancer-specific mortality (CSM) between amputation and limb-salvage surgery in pediatric patients with Osteosarcoma of the limbs. PSM is a statistical method used to deal with data from an Observational Study. The PSM method is designed to reduce the influence of biases and confounding variables to make a more reasonable comparison between experimental and control groups.

Methods

Patient information was downloaded from the SEER (surveillance, epidemiology, and End Results) database from 2004 to 2018. We included all primary pediatric osteosarcoma patients who underwent limb salvage or amputation. Multivariate logistic regression models were used to explore the factors influencing patient choice of amputation. Differences in CSM and other causes of mortality (OSM) between limb salvage and amputation were analyzed using cumulative incidence plots and competitive risk regression tests after 1:1 proportional propensity score matching.

Results

A total of 1,058 pediatric patients with limbs Osteosarcoma were included. Patients who underwent amputations were more likely to be male (OR 1.4, P = 0.024) and more likely to have distant metastasis (OR 2.1, P &lt; 0.001). Before propensity matching, CSM was 1.4 times higher in patients undergoing amputation than in patients undergoing limb salvage (P = 0.017) and 3.4 times higher in OSM (P = 0.007). After adjustment for propensity matching, CSM was 1.5 times higher in patients undergoing amputation than in patients undergoing limb salvage (P = 0.028), but there was no significant difference in OSM (HR 3.2, P = 0.078).

Conclusions

Our results suggested that amputation is associated with a 1.5-fold increase in CSM in pediatric patients with limbs Osteosarcoma. Therefore, in the surgical selection of pediatric patients with Osteosarcoma, limb salvage surgery should be the first choice in the absence of other contraindications.

Construction and Validation of Nomograms for Predicting the Prognosis of Juvenile Osteosarcoma: A Real-World Analysis in the SEER Database

BACKGROUND

Osteosarcoma is one of the most common malignant bone tumors, with a high incidence in adolescence. The objective of this study was to construct prognostic nomograms for predicting the prognosis of juvenile osteosarcoma.

METHODS

Patients with osteosarcoma diagnosed between 2004 and 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. The essential clinical predictors were identified with univariate and multivariate Cox analysis. Nomograms were constructed to predict the 3- and 5-year cancer- specific survival (CSS) and overall survival (OS). Concordance index (C-index) and calibration plots were performed to validate the predictive performance of nomograms.

RESULTS

We enrolled 736 adolescents with osteosarcoma from the SEER database, with 516 samples grouped into a training cohort and 220 samples grouped into a validation cohort. In multivariate analysis of the training cohort, predictors including tumor size, surgery treatment and AJCC stage were found to be associated with OS and CSS, while age was only associated with CSS. Construction of nomograms based on these predictors was performed to evaluate the prognosis of adolescents with osteosarcoma. The C-index and calibration curves also showed the satisfactory performance of these nomograms for prognosis prediction.

CONCLUSION

The developed nomograms are useful tools for precisely predicting the prognosis of adolescents with osteosarcoma, which could enable patients to be more accurately managed in clinical practice.

Gemcitabine for the treatment of patients with osteosarcoma

BACKGROUND

Patients with recurrent or refractory osteosarcoma are considered to have a very poor prognosis, and new regimens are needed to improve the prognosis in this setting. Gemcitabine, a nucleoside antimetabolite, is an analog of deoxycytidine which mainly inhibits DNA synthesis through interfering with DNA chain elongation and depleting deoxynucleotide stores, resulting in gemcitabine-induced cell death. Here we performed a systemic analysis to evaluate gemcitabine based chemotherapy as salvage treatment for patients with recurrent or refractory osteosarcoma.

METHODS

Clinical studies evaluating the impact of gemcitabine based regimens on response and safety for patients with osteosarcoma were identified by using a predefined search strategy. Pooled response rates (RRs) of treatment were calculated.

RESULTS

In gemcitabine based regimens, 4 clinical studies which included 66 patients with recurrent or refractory osteosarcoma were considered eligible for inclusion. Systemic analysis suggested that, in all patients, pooled RR was 12.1% (8/66) in gemcitabine based regimens. Major adverse effects were hematologic toxicity, including grade 3 or 4 anemia, leucopenia and thrombocytopenia in gemcitabine based treatment. No treatment related death occurred in gemcitabine based treatment.

CONCLUSION

This systemic analysis suggests that gemcitabine based regimens are associated with mild activity with good tolerability in treating patients with recurrent or refractory osteosarcoma.

Ifosfamide-containing regimens for treating patients with osteosarcomas

BACKGROUND

This systemic analysis was conducted to evaluate the efficacy and safety of an ifosfamide- containing regimen in treating patients with osteosarcoma.

METHODS

Clinical studies evaluating the efficacy and safety of Ifosfamide-containing regimen on response and safety for patients with osteosarcoma were identified by using a predefined search strategy. Pooled response rate (RR) of treatment were calculated.

RESULTS

When ifosfamide-containing regimens were evaluated, 4 clinical studies which including 134 patients with osteosarcoma were considered eligible for inclusion. Systemic analysis suggested that, in all patients, pooled RR was 44.8% (60/134) in ifosfamide-containing regimens. Major adverse effects were neutropenia, leukopenia, and fatigue inIfosfamide-containing regimens; No treatment related death occurred in cantharidin combined regimens.

CONCLUSION

This systemic analysis suggests that ifosfamide-containing regimens are associated with good response rate and acceptable toxicity in treating patients with osteosarcoma, but this result should be confirmed by randomized clinical trials.

miR-155 inhibitor reduces the proliferation and migration in osteosarcoma MG-63 cells

As the most common malignant primary bone tumor in childhood, osteosarcoma (OS) maintains a high recurrence, despite the significant improvements in the overall survival rate of high-grade OS patients during the recent decades. Therefore, a novel therapy strategy is required for OS treatment. Recently, various microRNAs (miRNAs or miRs) have been confirmed as deregulated in OS, and the miR-155 dysregulation in OS has been discovered by the microarray analysis. In the present study, the regulation of miR-155 on the OS cell proliferation, migration and invasion on the MG-63 cells was explored in vitro. The miR-155 mimics were found to promote cell proliferation, colony formation, migration and invasion significantly, compared to the control miRNA. An miR-155 inhibitor was also used to evaluate whether miR-155 served as a therapeutic target for OS. The results demonstrated that the miR-155 inhibitor significantly reduced the proliferation, colony formation, migration and invasion of the MG-63 OS cells. Thus, the study confirmed the oncogenic regulation on the OS progression of miR-155, which could serve as a therapeutic target with an miR-155 inhibitor.

Characterization of localized osteosarcoma of the extremity in children, adolescents, and young adults from a single institution in South Texas

BACKGROUND

Osteosarcoma is the most common bone malignancy in children, adolescents, and young adults. Most study cohorts have 10% to 15% Hispanic patients that encompass many different Hispanic backgrounds. This study characterizes the effect of mainly Mexican American ethnicity on the outcome of children, adolescents, and young adults with osteosarcoma.

METHODS

A retrospective analysis of demographics, tumor characteristics, response to treatment, and survival outcome of all localized osteosarcoma of the extremity patients below 30 years of age was performed. A Kaplan-Meier estimates with log-rank tests and Cox proportional hazard regression models were used.

RESULTS

Fifty patients (median age, 15; range, 2 to 28 y) with localized high-grade osteosarcoma of the extremity were diagnosed between January 2000 and December 2010. The cohort was 70% Mexican Americans. With a median follow-up of 39 months (range, 5 to 142 mo), patients had a 5-year overall survival and event-free survival of 65% and 48%, respectively. We observed a significantly decreased 5-year event-free survival in patients diagnosed before age 12 relative to patients diagnosed between ages 12 and 29 (11% vs. 57%, P<0.001). We also found that tumor necrosis was not predictive of outcome in our patients.

CONCLUSIONS

The preadolescent patients of predominately Mexican American ethnicity had an increased rate of relapse when compared with previous studies. Tumor necrosis is not directly predictive of outcome in this population.

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

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

Clinical characteristics and prognosis of osteosarcoma in young children: a retrospective series of 15 cases

Background

Osteosarcoma is the most common primary bone malignancy in childhood and adolescence. However, it is very rare in children under 5 years of age. Although studies in young children are limited in number, they all underline the high rate of amputation in this population, with conflicting results being recently reported regarding their prognosis.

Methods

To enhance knowledge on the clinical characteristics and prognosis of osteosarcoma in young children, we reviewed the medical records and histology of all children diagnosed with osteosarcoma before the age of five years and treated in SFCE (Société Française des Cancers et leucémies de l'Enfant) centers between 1980 and 2007.

Results

Fifteen patients from 7 centers were studied. Long bones were involved in 14 cases. Metastases were present at diagnosis in 40% of cases. The histologic type was osteoblastic in 74% of cases. Two patients had a relevant history. One child developed a second malignancy 13 years after osteosarcoma diagnosis.

Thirteen children received preoperative chemotherapy including high-dose methotrexate, but only 36% had a good histologic response. Chemotherapy was well tolerated, apart from a case of severe late convulsive encephalopathy in a one-year-old infant. Limb salvage surgery was performed in six cases, with frequent mechanical and infectious complications and variable functional outcomes.

Complete remission was obtained in 12 children, six of whom relapsed. With a median follow-up of 5 years, six patients were alive in remission, seven died of their disease (45%), in a broad range of 2 months to 8 years after diagnosis, two were lost to follow-up.

Conclusions

Osteosarcoma seems to be more aggressive in children under five years of age, and surgical management remains a challange.

Fifty years of paediatric malignant bone tumours in the West Midlands, UK, 1957-2006: incidence, treatment and outcome

Malignant bone tumours in the paediatric age group (0-14 years) are uncommon; various aetiological theories exist and few reports of incidence, age and sex distributions have been published. We examined the incidence of childhood malignant bone tumours in one large single region of the UK over an extended period of 50 years. The West Midlands specialist regional children's tumour registry holds data on all malignancies and benign brain tumours in children under 15 years in the West Midlands region, which has a population of around 1 million children. Demographic and clinical data have been abstracted and diagnoses reviewed by a panel of expert pathologists. During the period 1957-2006, 259 cases of malignant paediatric bone tumours were diagnosed. There were 153 osteosarcomas, 78 Ewing sarcomas and 28 other primary bone tumours. The overall age standardised rate was 4.66, with no increase over time, although there was a significant increase in the incidence of Ewing sarcomas in the period 1965-92. Sixty-eight per cent of tumours were in patients over 10 years, whereas the incidence in patients under 10 years showed a non-significant increase. Survival rates increased dramatically post-chemotherapy introduction, with Ewing sarcoma demonstrating better survival overall. This is a large study giving an overview of malignant bone tumours in the childhood population of a single region over an extended period, showing results consistent with national reports. It also examines late effects, which were mostly mobility/orthopaedic, although almost one-fifth of patients had cardiac problems and five went on to develop second malignancies.

Patterns of care and survival for patients aged under 40 years with bone sarcoma in Britain, 1980-1994

The purpose of the study was to calculate population-based survival rates for osteosarcoma (OS) and Ewing's sarcoma (ES) in Great Britain during 1980–1994, determine proportions of patients treated at specialist centres or entered in national and international clinical trials, and investigate effects of these factors on survival. Data on a population-based series of 1349 patients with OS and 849 with ES were compiled from regional and national cancer registries, UK Children's Cancer Study Group, regional bone tumour registries and clinical trials. Follow-up was through population registers. Survival was analysed by actuarial analysis with log-rank tests and by Cox's proportional hazards analysis. Five-year survival rates during 1980–1984, 1985–1989 and 1990–1994 were 42% (95% CI: 37, 46), 54% (95% CI: 50, 59) and 53% (95% CI: 48, 57), respectively, for OS and 31% (95% CI: 26, 37), 46% (95% CI: 40, 51) and 51% (95% CI: 45, 57) for ES. Proportions of patients treated at a supraregional bone tumour centre or a paediatric oncology centre in the three quinquennia were 36, 56 and 67% for OS and 41, 60 and 69% for ES. In 1983–1992, 48% of OS patients were entered in a national trial; for ES, 27% were entered in 1980–1986 and 54% in 1987–1994. Survival was similar for trial and nontrial patients with OS. For ES, trial patients had consistently higher 5-year survival than nontrial patients: 1980–1986, 42 vs 30%; 1987–1992, 59 vs 42%; 1993–1994, 54 vs 43%. During 1985–1994, patients with OS or ES whose main treatment centre was a nonteaching hospital had lower survival rates. In multivariate analyses of patients diagnosed during 1985–1994 that also included age, sex, primary site, surgical treatment centre, the results relating to main treatment centre for both OS and ES retained significance but the survival advantage of trial entry for ES became nonsignificant. For both OS and ES diagnosed since 1985, patients whose main treatment centre was a nonspecialist hospital had a lower survival rate.

Ewing Sarcoma of the Mandible in a Child: Interdisciplinary Treatment Concepts and Surgical Reconstruction

Ewing's sarcoma is the second most common primary bone malignancy in childhood and adolescence. We present a standardized interdisciplinary treatment protocol according to the EURO-E.W.I.N.G. 99 study, applied in the treatment of a 7-year-old patient with localized Ewing's sarcoma of the left mandible. After six blocks of VIDE (vincristine/ifosfamide/doxorubicin/etoposide) chemotherapy and stem cells rescue, intensity modulated external radiation with 48.6 Gy and subsequent high dose therapy with busulphan-melphalan were administered. Tumor resection and immediate bony reconstruction was performed using a microvascular fibula graft 10 weeks after radiation. Because of the effective neoadjuvant treatment, no extensive soft tissue resection was necessary. Healing of the osteosynthesis was uneventful. No local or systemic recurrence and no signs of significant facial deformity were found after 12 month follow-up. The presented case underlines the requirement for multidisciplinary protocols involving radiologists, pathologists, oncologists, radiation oncologists, and surgeons for accurate diagnosis and appropriate therapy. To preserve cosmetics and function within the craniofacial area after tumor resection in children, microvascular reconstructive procedures can be successfully performed with a vascularized fibular graft.