The multidisciplinary management of osteosarcoma

The fusion gene LRP1-SNRNP25 drives invasion and migration by activating the pJNK/37LRP/MMP2 signaling pathway in osteosarcoma

Through transcriptome sequencing, we previously identified a new osteosarcoma-specific, frequent fusion gene, LRP1-SNRNP25, and found that it played an important role in tumor cell invasion and migration. However, the specific mechanism remains unclear. In this article, whole-genome sequencing further confirmed that the LRP1-SNRNP25 fusion gene is formed by fusion of LRP1 exon 8 and SNRNP25 exon 2. In vitro, scratch and Transwell assays demonstrated that the migration and invasion abilities of LRP1-SNRNP25-overexpressing osteosarcoma cells were significantly increased. To explore the molecular mechanism of the LRP1-SNRNP25 fusion in affecting osteosarcoma cell migration and invasion, we evaluated the migration and invasion-related molecular signaling pathways by western blotting. Some migration- and invasion-related genes, including pJNK and MMP2, were upregulated. Coimmunoprecipitation-mass spectrometry showed that 37LRP can interact with pJNK. Western blotting confirmed that LRP1-SNRNP25 overexpression upregulates 37LRP protein expression. Immunofluorescence staining showed the intracellular colocalization of LRP1-SNRNP25 with pJNK and 37LRP proteins and that LRP1-SNRNP25 expression increased the pJNK and 37LRP levels. Coimmunoprecipitation (co-IP) confirmed that LRP1-SNRNP25 interacted with pJNK and 37LRP proteins. The pJNK inhibitor SP600125 dose-dependently decreased the pJNK/37LRP/MMP2 levels. After siRNA-mediated 37LRP knockdown, the MMP2 protein level decreased. These two experiments proved the upstream/downstream relationship among pJNK, 37LRP, and MMP2, with pJNK the farthest upstream and MMP2 the farthest downstream. These results proved that the LRP1-SNRNP25 fusion gene exerts biological effects through the pJNK/37LRP/MMP2 signaling pathway. In vivo, LRP1-SNRNP25 promoted osteosarcoma cell growth. Tumor growth was significantly inhibited after SP600125 treatment. Immunohistochemical analysis showed that the pJNK, MMP2, and Ki-67 protein levels were significantly increased in tumor tissues of LRP1-SNRNP25-overexpressing cell-injected nude mice. Furthermore, lung and liver metastasis were more prevalent in these mice. In a word, LRP1-SNRNP25 promotes invasion, migration, and metastasis via pJNK/37LRP/MMP2 pathway. LRP1-SNRNP25 is a potential therapeutic target for LRP1-SNRNP25-positive osteosarcoma.

Anlotinib combined with radiotherapy and chemotherapy for recurrent pelvic osteosarcoma treatment: a case report and literature review

At present, the treatment of recurrent pelvic osteosarcoma is too simple, and most of the patients are treated with chemotherapy, radiotherapy, and/or combined surgery. Here, we report a 29-year-old man diagnosed with local recurrent pelvic osteosarcoma. Imaging showed that the tumor had obvious enhancement and abundant blood vessels. There was no indication of surgery. After the patient's consent was obtained, we used anlotinib as a sequential treatment to chemotherapy. During the first course of adjuvant chemotherapy, we treated the patient with intensity-modulated radiotherapy (IMRT) with a total dose of 60 Gy equivalents. No disease recurrence was reported at 25 months after multimodal combination therapy.

FGF2 drives osteosarcoma metastasis through activating FGFR1-4 receptor pathway-mediated ICAM-1 expression

Osteosarcoma is a malignant tumor with high metastatic potential, such that the overall 5-year survival rate of patients with metastatic osteosarcoma is only 20%. Therefore, it is necessary to unravel the mechanisms of osteosarcoma metastasis to identify predictors of metastasis by which to develop new therapies. Fibroblast growth factor 2 (FGF2) is a growth factor involved in embryonic development, cell migration, and proliferation. The overexpression of FGF2 and FGF receptors (FGFRs) has been shown to enhance cancer cell proliferation in lung, breast, gastric, and prostate cancers as well as melanoma. Nonetheless, the roles of FGF2 and FGFRs in human osteosarcoma cells remain unknown. In the present study, we found that FGF2 was overexpressed in human osteosarcoma sections and correlated with lung metastasis. Treatment of FGF2 induced migration activity, invasion activity, and intercellular adhesion molecule (ICAM)-1 expression in osteosarcoma cells. In particular, the downregulation or antagonism of FGFR1-4 suppressed FGF2-induced ICAM-1 expression and cancer cell migration. Furthermore, FGFR1, FGFR2, FGFR3, and FGFR4 were involved in FGF2-induced the phospholipase Cβ/protein kinase Cα/proto-oncogene c-Src signaling pathway and triggered c-Jun nuclear translocation. Subsequent c-Jun upregulation of activator protein-1 transcription activity on the ICAM-1 promoter led to an increased migration of osteosarcoma cells. Moreover, the knockdown of endogenous FGF2 suppressed ICAM-1 expression and migration of osteosarcoma cells. These findings suggest that FGF2/FGFR1-4 signaling promotes metastasis via its direct downstream target gene ICAM-1, revealing a novel potential therapeutic target for osteosarcoma.

Clinicopathological significance of SOX9 and β-catenin expression in pre-neoadjuvant chemotherapy cases of osteosarcoma: molecular and immunohistochemical study

The molecular pathogenesis of osteosarcoma (OS), the most frequent primary malignant bone tumor of all age groups, is still obscure. Since multidrug chemotherapeutic regimens were introduced in the 1970s, survival rates have been stationary. The Wnt-β-catenin signaling cascade and SOX9 have a significant contribution to skeletal growth, development, and tumorigenesis. In the present work, an attempt was made to examine the role and clinicopathological significance of β-catenin and SOX9 in 46 cases of pre-neoadjuvant chemotherapy OS tissues compared to 10 cases of non-neoplastic bone. The mRNA levels of both markers were assessed by qRT-PCR, and protein levels of β-catenin were analyzed by immunohistochemistry. The results were correlated with different clinicopathological parameters. SOX9 mRNA levels were significantly elevated in OS compared to non-neoplastic bone, and higher levels were significantly associated with the occurrence of fluid-fluid levels (indicating blood-containing cystic spaces) and osteolytic radiological pattern. Although β-catenin mRNA and protein levels were higher in OS compared to non-neoplastic bone, only the protein levels reached statistical significance. Higher β-catenin mRNA levels were significantly associated with tumor size, while higher protein levels were significantly associated with the histologic subtype, mitotic count, and radiological pattern. No significant association was noted with any of the other evaluated parameters. OS showing higher SOX9 mRNA expression and lower β-catenin mRNA and protein expression exhibited longer estimated overall survival times approaching statistical significance. To conclude, while high expression of β-catenin and SOX9 suggests their possible involvement in OS development, their prognostic role may need further research.

Quantification of circulating tumour cells over time in dogs with appendicular osteosarcoma

Enumeration of circulating tumour cells (CTC) has shown promise for prognostication and guidance of therapeutic decisions in human cancers. The objective of this study was to enumerate CTC over time in dogs with naturally occurring osteosarcoma (OSA), and to determine correlation with patient outcome. Twenty-six dogs with OSA and no evidence of metastatic disease at the time of amputation were enrolled. Dogs were assessed for lung metastases and CTC prior to and following amputation, and at each chemotherapy visit. Twenty-one dogs completed the study. Nineteen dogs were euthanized and two were alive and free of metastases. Overall survival time ranged from 88 to 1058 days (median survival time (MST) 374 days). Increased serum alkaline phosphatase activity, advanced age, and higher body weight were significantly associated with lower MST. Dogs with OSA had a mean of 356 (0 to 4443) CTC/106 leukocytes. In 12 of 15 dogs that developed radiographic evidence of metastasis, a pre-metastatic CTC spike was retrospectively detectable on average 36.5 (1-100 days) days prior to metastasis and was associated with significantly shorter MST (301 ± 64 vs. 626 ± 55 days; p = .0107). In a multivariable analysis, dogs with a CTC spike were 10× more likely to die compared with those without. These results suggest that a spike in CTC frequency precedes detection of metastasis in dogs with OSA and is associated with shorter survival. More frequent enumeration of CTC in a larger cohort of dogs with OSA may be warranted.

Study on the effect of artificial joint replacement for osteosarcoma

Osteosarcoma is one of the most prevalent primary malignant bone tumors that affects teenagers more than adults. In recent years, artificial femoral replacement has become more and more common. The use of artificial total femoral replacement surgery prevents the need for amputating the damaged limb, preserves the patient's ability to move and bear weight on the leg, lessens the severity of the psychological trauma, and significantly raises the patient's quality of life. To explore the treatment methods and therapeutic effects of artificial femoral replacement in the treatment of femoral osteosarcoma. The clinical data of 11 patients with femoral malignant tumors who underwent artificial femoral replacement from January 2019 to March 2022 were retrospectively analyzed. Among them, 7 males and 4 females, 11 to 40 years old, average 19.36 ± 9.44 years old. The disease duration is 2 to 7 months, with an average of 4.7 months. Before and 3 months after operation, the patients who had tumors were given a score on the visual analog scale, and their quality of life was also measured. At the most recent follow-up, both the Musculoskeletal Tumor Society score and the Harris hip score were analyzed. Eleven patients were followed up for 6 to 58 months, and an average of 21 months. Complications such as wound infection, joint dislocation, and nerve damage did not occur. In 1 patient, popliteal vein thrombus formation, and in 2 patients with osteosarcoma died from tumor progression. Visual analog scale score at 3 months after surgery and the quality-of-life scores were 3.68 ± 1.39 and 40.04 ± 4.31, respectively, which were significantly improved compared to before surgery (5.94 ± 1.19 and 22.42 ± 3.63, respectively, P < .05). At the last interview, Musculoskeletal Tumor Society score is scored from 18 to 29 points, average 22.5 ± 5.9 points, and Harris hip score is scored from 42 to 90 points, with an average score of 69.0 ± 14.7. Artificial total femoral replacement is an effective limb salvage operation in the treatment of osteosarcoma.

Relapsed primary extraskeletal osteosarcoma of liver: A case report and review of literature

BACKGROUND

Extraskeletal osteosarcoma (ESOS) is a highly malignant osteosarcoma that occurs in extraskeletal tissues. It often affects the soft tissues of the limbs. ESOS is classified as primary or secondary. Here, we report a case of primary hepatic osteosarcoma in a 76-year-old male patient, which is very rare.

CASE SUMMARY

Here, we report a case of primary hepatic osteosarcoma in a 76-year-old male patient. The patient had a giant cystic-solid mass in the right hepatic lobe that was evident on ultrasound and computed tomography. Postoperative pathology and immunohistochemistry of the mass, which was surgically removed, suggested fibroblastic osteosarcoma. Hepatic osteosarcoma reoccurred 48 d after surgery, resulting in significant compression and narrowing of the hepatic segment of the inferior vena cava. Consequently, the patient underwent stent implantation in the inferior vena cava and transcatheter arterial chemoembolization. Unfortunately, the patient died of multiple organ failure postoperatively.

CONCLUSION

ESOS is a rare mesenchymal tumor with a short course and a high likelihood of metastasis and recurrence. The combination of surgical resection and chemotherapy may be the best treatment.

Towards the Search for Potential Biomarkers in Osteosarcoma: State-of-the-Art and Translational Expectations

Osteosarcoma represents a rare cause of cancer in the general population, accounting for <1% of malignant neoplasms globally. Nonetheless, it represents the main cause of malignant bone neoplasm in children, adolescents and young adults under 20 years of age. It also presents another peak of incidence in people over 50 years of age and is associated with rheumatic diseases. Numerous environmental risk factors, such as bone diseases, genetics and a history of previous neoplasms, have been widely described in the literature, which allows monitoring a certain group of patients. Diagnosis requires numerous imaging tests that make it possible to stratify both the local involvement of the disease and its distant spread, which ominously determines the prognosis. Thanks to various clinical trials, the usefulness of different chemotherapy regimens, radiotherapy and surgical techniques with radical intent has now been demonstrated; these represent improvements in both prognosis and therapeutic approaches. Osteosarcoma patients should be evaluated in reference centres by multidisciplinary committees with extensive experience in proper management. Although numerous genetic and rheumatological diseases and risk factors have been described, the use of serological, genetic or other biomarkers has been limited in clinical practice compared to other neoplasms. This limits both the initial follow-up of these patients and screening in populations at risk. In addition, we cannot forget that the diagnosis is mainly based on the direct biopsy of the lesion and imaging tests, which illustrates the need to study new diagnostic alternatives. Therefore, the purpose of this study is to review the natural history of the disease and describe the main biomarkers, explaining their clinical uses, prognosis and limitations.

Predictive value of the systemic immune-inflammation index for cancer-specific survival of osteosarcoma in children

Background

Osteosarcoma (OS) is the primary malignant bone tumor that most commonly affects children and adolescents. Recent years effective chemotherapy have improved the 5-year survival in osteosarcoma patients to up to 60%-70%. Still, there is a lack of novel therapeutic strategies to enhance further survival. Our study aimed to evaluate the clinical significance of pretreatment inflammatory-based parameters, including PLT, NLR, and SII, as prognostic indicators of survival in pediatric osteosarcoma patients.

Methods

A total of 86 pediatric osteosarcoma patients between 2012 and 2021 in the Department of Orthopedics or tumor Surgery of Children's Hospital affiliated to Chongqing Medical University were retrospectively analyzed. The clinicopathological variables and systematic inflammatory biomarkers, including NLR, PLR and SII, was performed by the A Receiver operating characteristic (ROC) curve and Cox proportional risk regression model. According to the results of multivariate analysis, a prognostic nomogram was generated, and the concordance index (C-index) was calculated to predict the performance of the established nomogram. The survival curve was plotted by the Kaplan-Meier method.

Results

Univariate analysis showed that TNM stage, tumor size, NLR value, PLR value, SII value, neutrophil count and platelet count were related to CSS (p < 0.05). According to multivariate analysis, only TNM stage (p = 0.006) and SII values (p = 0.015) were associated with poor prognosis.To further predict survival in pediatric osteosarcoma patients, multivariate Cox regression analysis was used to predict cancer-specific survival at 1, 3 and 5 years. And constructed a nomogram model to predict children's CSS. The C-index of the nomogram is 0.776 (95%CI, 0.776–0.910), indicating that the model has good accuracy.

Conclusion

Preoperative SII and TNM staging are independent prognostic markers for pediatric osteosarcoma patients. SII may be used in conjunction with TNM staging for individualized treatment of pediatric osteosarcoma patients in future clinical work.

Total femur replacement with 18 years of follow-up: A case report

BACKGROUND

Osteosarcoma is one of the most common primary malignant bone tumors and is more common in adolescents. The femur is the most common site of osteosarcoma, and many patients require total femur replacement. We reviewed the relevant literature and case findings, summarized and analyzed this case in combination with relevant literature, and in doing so improved the understanding of the technology.

CASE SUMMARY

The case we report was a 15-year-old patient who was admitted to the hospital 15 days after the discovery of a right thigh mass. The diagnosis was osteosarcoma of the right femoral shaft. After completion of neoadjuvant chemotherapy and preoperative preparation, total right femoral resection + artificial total femoral replacement was performed. Then, chemotherapy was continued after surgery. The patient recovered well after treatment, and the function of the affected limb was good. No recurrence, metastasis, prosthesis loosening, dislocation, fracture or other complications were found during 18 years of follow-up. At present, the patient can still work and lives normally. The results of the medium- and long-term follow-up were satisfactory.

CONCLUSION

Artificial total femur replacement is a feasible limb salvage operation for patients with femoral malignant tumors, and the results of medium- and long-term follow-up are satisfactory.

Osteosarcoma: a Surveillance, Epidemiology, and End Results program-based analysis from 1975 to 2017

BACKGROUND

Osteosarcoma is the most common primary bone malignancy. As a rare cancer, population-based studies remain small with limited information on finer demographic categories. Recent studies have reported important genetic differences based on age and ethnicity, and more detailed studies are needed to better understand potentially important osteosarcoma risk groups.

METHODS

Incidence and survival rates for 5016 patients with osteosarcoma from the Surveillance, Epidemiology, and End Results (SEER) program (1975-2017) were analyzed by age (0-9, 10-24, 25-59, and >60 years old), race/ethnicity, histologic subtype, stage, and tumor location using SEER*Stat software.

RESULTS

For cases 0 to 9 years old, incidence of primary osteosarcoma was similar between the sexes, increased significantly throughout the study period (P < .05), and the 5-year relative survival has steadily increased over time. Blacks had the highest incidence in all aged cases combined and a significant increase in incidence throughout the study period (P < .05). Overall, survival rates for all cases have remained relatively unchanged over recent decades, with worse survival observed in males, American Indian/Alaska Native cases, older patients, metastatic disease, axial tumors, and subsequent osteosarcoma cases. For cases 0 to 24 years old, the incidence of subsequent osteosarcoma increased 3-fold since the 2000s.

CONCLUSION

Important differences in osteosarcoma incidence and survival, particularly for the youngest children, ethnic minorities, and subsequent osteosarcoma, are identified. A genetic risk factor may be associated with observed ancestry-specific incidence differences and illustrates the importance of analyzing osteosarcoma by specific age groups and ethnicities to better understand their unique epidemiology and underlying biology.

LAY SUMMARY

Osteosarcoma is the most common bone cancer, but still a relatively rare disease, and previous studies have had limited information on finer demographics. Using a large database, osteosarcoma incidence and survival patterns are thoroughly evaluated and important differences, especially for the youngest children, ethnic minorities, and subsequent osteosarcoma cases, are identified.

Development and comparison of 1-year survival models in patients with primary bone sarcomas: External validation of a Bayesian belief network model and creation and external validation of a new gradient boosting machine model

Background:

Bone sarcomas often present late with advanced stage at diagnosis and an according, varying short-term survival. In 2016, Nandra et al. generated a Bayesian belief network model for 1-year survival in patients with bone sarcomas. The purpose of this study is: (1) to externally validate the prior 1-year Bayesian belief network prediction model for survival in patients with bone sarcomas and (2) to develop a gradient boosting machine model using Nandra et al.’s cohort and evaluate whether the gradient boosting machine model outperforms the Bayesian belief network model when externally validated in an independent Danish population cohort.

Material and Methods:

The training cohort comprised 3493 patients newly diagnosed with bone sarcoma from the institutional prospectively maintained database at the Royal Orthopaedic Hospital, Birmingham, UK. The validation cohort comprised 771 patients with newly diagnosed bone sarcoma included from the Danish Sarcoma Registry during January 1, 2000–June 22, 2016. We performed area under receiver operator characteristic curve analysis, Brier score and decision curve analysis to evaluate the predictive performance of the models.

Results:

External validation of the Bayesian belief network 1-year prediction model demonstrated an area under receiver operator characteristic curve of 68% (95% confidence interval, 62%-73%). Area under receiver operator characteristic curve of the gradient boosting machine model demonstrated: 75% (95% confidence interval: 70%-80%), overall model performance by the Brier score was 0.09 (95% confidence interval: 0.077–0.11) and decision curve analysis demonstrated a positive net benefit for threshold probabilities above 0.5. External validation of the developed gradient boosting machine model demonstrated an area under receiver operator characteristic curve of 63% (95% confidence interval: 57%-68%), and the Brier score was 0.14 (95% confidence interval: 0.12–0.16).

Conclusion:

External validation of the 1-year Bayesian belief network survival model yielded a poor outcome based on a Danish population cohort validation. We successfully developed a gradient boosting machine 1-year survival model. The gradient boosting machine did not outperform the Bayesian belief network model based on external validation in a Danish population-based cohort.

Early immunohistochemical detection of pulmonary micrometastases in dogs with osteosarcoma

Background

Despite decades of research, the early phases of metastatic development are still not fully understood. Canine osteosarcoma (OS) is a highly aggressive cancer, with a high metastatic rate (> 90%), despite a low overt metastatic prevalence at initial diagnosis (< 15%). Canine OS is generally regarded as a good clinically relevant model for human OS. The aim of this hypothesis-generating study was to evaluate a method to detect pulmonary micrometastases and study their prevalence in dogs with OS without macroscopic metastases. We prospectively enrolled dogs with OS that received no cancer-specific treatment (n = 12) and control dogs without cancer (n = 2). Dogs were necropsied and sampled immediately after euthanasia. The OS dogs were classified as having macroscopic metastases (n = 2) or not (n = 10). We immunohistochemically stained one tissue sample from each of the seven lung lobes from each dog with a monoclonal antibody (TP-3) to identify micrometastases (defined as clusters of 5–50 tumour cells), microscopic metastases (> 50 tumour cells) and TP-3 positive single cells (< 5 tumour cells).

Results

We showed that pulmonary micrometastases easily overseen on routine histology could be detected with TP-3. Pulmonary micrometastases and microscopic metastases were present in two dogs with OS without macroscopic metastases (20%). Micrometastases were visualised in three (43%) and four (57%) of seven samples from these two dogs, with a mean of 0.6 and 1.7 micrometastases per sample. Microscopic metastases were present in one (14%) and four (57%) of seven samples from the same two dogs, with a mean of 0.14 and 1.0 microscopic metastases per sample. There were four (57%) and two (29%) samples with neither microscopic metastases nor micrometastases for each of these two dogs. The prevalence of pulmonary micrometastases (20%) was significantly lower than expected (> 90%) based on commonly expected metastatic rates after amputation (P < 0.0001). There was no statistically significant difference in the number of TP-3 positive single cells in between groups (P = 0.85).

Conclusions

Pulmonary micrometastases could be detected with TP-3 immunohistochemistry in a subset of dogs with OS before macroscopic metastases had developed. We propose that dogs with spontaneous OS represent clinically relevant models to study early micrometastatic disease.

Assessing a Novel 3D Assay System for Drug Screening against OS Metastasis

Osteosarcoma (OS) is an aggressive mesenchymal cell tumor that carries a poor long-term prognosis. Despite definitive surgery for the primary tumor and adjuvant chemotherapy, pulmonary metastasis is common and is the primary cause of morbidity. To improve outcomes for patients, we have developed and optimized a phenotypic screen for drugs that may target OS disseminated tumor cells (DTCs) and inhibit their metastatic outbreak rather than merely screening for cytotoxic activity against proliferating cells, as is commonly conducted in conventional drug discovery approaches. We report on the validation of a previously described 3D reconstituted basement membrane extract (3D BME) model system for tumor dormancy and metastatic outgrowth adapted to clonal pairs of high and low metastatic OS cells. A post-hoc validation of the assay was possible by comparing the activity of a drug in our assay with early evidence of activity in human OS clinical trials (regorafenib and saracatinib). In this validation, we found concordance between our assay and human clinical trial experience We then explored an approved veterinary small molecule inhibitor of Janus kinase-1 (oclacitinib) as a potential drug candidate to take advantage of the high prevalence of OS in pet dogs and its translational value to humans. Despite the biological rationale, we found no evidence to support the use of oclacitinib as an antimetastatic agent in OS. The findings support our 3D BME assay as a highly efficient method to examine drugs for activity in targeting OS DTCs.

CircPRDM2 Contributes to Doxorubicin Resistance of Osteosarcoma by Elevating EZH2 via Sponging miR-760

Background

Circular RNAs (circRNAs) are implicated in the chemoresistance of human cancers. However, the functions of circRNA PR/SET domain 2 (circPRDM2) in the resistance of osteosarcoma (OS) to doxorubicin (DXR) are unknown.

Methods

Quantitative real-time polymerase chain reaction (qRT-PCR) assay was conducted to determine the levels of circPRDM2, microRNA-760 (miR-760) and enhancer of zeste homolog 2 (EZH2). RNase R assay was used to analyze the characteristics of circPRDM2. IC50 of DXR was estimated by Cell Counting Kit-8 (CCK-8) assay. Colony formation assay was performed for cell colony formation ability. Wound-healing assay and transwell assay were utilized for cell migration and invasion. Flow cytometry analysis was conducted for cell apoptosis. Western blot assay was employed for protein levels. Dual-luciferase reporter assay, RNA immunoprecipitation (RIP) assay and RNA pull-down assay were adopted to analyze the relationships among circPRDM2, miR-760 and EZH2. Murine xenograft model assay was utilized to explore DXR resistance in vivo.

Results

CircPRDM2 level was enhanced in DXR-resistant OS tissues and cells. CircPRDM2 deficiency inhibited IC50 of DXR, colony formation, migration and invasion and facilitated apoptosis in DXR-resistant OS cells in vitro. CircPRDM2 was identified as the sponge for miR-760. MiR-760 inhibition reversed the inhibitory effects of circPRDM2 knockdown on DXR resistance and cell progression in DXR-resistant OS cells. Moreover, EZH2 was identified as the target gene of miR-760 and EZH2 overexpression abolished miR-760-mediated impacts on DXR sensitivity and malignant behaviors in DXR-resistant OS cells. Also, circPRDM2 silencing improved DXR sensitivity in vivo.

Conclusion

Our study demonstrated the role of circPRDM2/miR-760/EZH2 axis in enhancing DXR resistance.

Advances in the Management of Pediatric Sarcomas

PURPOSE OF REVIEW

The prognosis of pediatric patients who present with metastatic or recurrent sarcomas remains poor. In this review, we summarize the advances in the management of metastatic and relapsed pediatric sarcoma by highlighting recent and future clinical trials.

RECENT FINDINGS

Research into the identification of novel therapies for refractory pediatric sarcomas continues to advance. Outcomes have not improved in several decades underlying a need for improved understanding of the biology behind these tumors and the identification of novel therapeutic molecular targets that can be exploited pharmacologically. Multiple challenges remain for novel therapy in sarcomas such as the selection of effective targets, management of toxicities, and the tumor microenvironment. Many unique challenges remain in the treatment of patients with refractory pediatric sarcomas. Multiple strategies and targets are under investigation that hold promise.

Adoptive transfer of TILs plus anti-PD1 therapy: An alternative combination therapy for treating metastatic osteosarcoma

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Anti-PD1 therapy for metastatic osteosarcoma patients is limited and the identification of new strategies for these patients is urgently needed.

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TILs plus anti-PD1 therapy significantly increases ORR, mPFS and mOS of patients.

•

More infusion of TIL numbers and CD8⁺TIL percentage and less infusion of CD8⁺PD1⁺ TIL percentage and CD4⁺FoxP3⁺ TIL percentage may be potential prognostic factors which can predict clinical response to combined TILs and anti-PD1 therapy.

•

PD1^hi in fresh TILs is another good prognostic factor that predict PFS and OS.

Aim

We sought to investigate the efficacy of adoptive transfer of TILs plus anti-PD1 therapy in metastatic osteosarcoma patients.

Materials and methods

A total of 30 patients received anti-PD1 therapy (Group 1) while 30 patients were subjected to TILs plus anti-PD1 therapy (Group 2). Progression-free survival time (PFS) and overall survival time (OS) were analyzed using Kaplan-Meier analysis. Potential prognostic factors were analyzed using univariate and multivariate analyses.

Results

The ORR in Group 2 is 33.3%, which is significantly higher than Group1 (6.67%). In addition, we found significantly prolonged mPFS (5.4 months) and mOS (15.2 months) in Group 2 compared to those in Group 1, which recorded mPFS and mOS of 3.8 and 6.6 months, respectively. Univariate and multivariate analyses indicate that patients with more infusions of TIL numbers and CD8⁺TILs or less infusions of CD8⁺ PD1⁺TILs and CD4⁺FoxP3⁺ TILs show increased PFS and OS. Moreover, PD1^hi is another good prognostic factor that predict PFS and OS.

Conclusion

Overall, these findings indicated that TILs plus anti-PD1 therapy has significant clinical outcomes in metastatic osteosarcoma patients. However, further studies are essential to validate and characterize the therapeutic activity of TILs plus anti-PD1.

Delayed Diagnosis Is the Primary Cause of Sarcoma Litigation: Analysis of Malpractice Claims in the United States

BACKGROUND

Sarcoma care is highly litigated in medical malpractice claims. Understanding the reasons for litigation and legal outcomes in sarcoma care may help physicians deliver more effective and satisfying care to patients while limiting their legal exposure. However, few studies have described malpractice litigation in sarcoma care.

QUESTIONS/PURPOSES

(1) What percentage of sarcoma malpractice cases result in a defendant verdict? (2) What is the median indemnity payment for cases that result in a plaintiff verdict or settlement? (3) What are the most common reasons for litigation, injuries sustained, and medical specialties of the defendant physicians? (4) What are the factors associated with plaintiff verdicts or settlements and higher indemnity payments?

METHODS

The national medicolegal database Westlaw was queried for medical malpractice cases pertaining to sarcomas that reached verdicts or settlements. Cases from 1982 to 2018 in the United States were included in the study to evaluate for trends in sarcoma litigation. Demographic and clinical data, tumor characteristics, reasons for litigation, injuries, and legal outcomes were recorded for each case. A univariate analysis was performed to identify factors associated with plaintiff verdicts or settlements and higher indemnity payments, such as tumor characteristics, defendant's medical or surgical specialty, reason for litigation, and injuries sustained. A total of 92 cases related to sarcomas were included in the study, of which 40 were related to bone sarcomas and 52 were related to soft-tissue sarcomas. Eighty-five percent (78 of 92) of cases involved adult patients (mean age ± SD: 40 ± 15 years) while 15% (14 of 92) of cases involved pediatric patients (mean age ± SD: 12.5 ± 5 years).

RESULTS

Thirty-eight percent (35 of 92) of the included cases resulted in a defendant verdict, 30% (28 of 92) resulted in a plaintiff verdict, and 32% (29 of 92) resulted in a settlement. The median (interquartile range [IQR]) indemnity payment for plaintiff verdicts and settlements was USD 1.9 million (USD 0.5 to USD 3.5 million). Median (IQR) indemnity payments were higher for cases resulting in a plaintiff verdict than for cases that resulted in a settlement (USD 3.3 million [1.1 to 5.7 million] versus USD 1.2 million [0.4 to 2.4 million]; difference of medians = USD 2.2 million; p = 0.008). The most common reason for litigation was delayed diagnosis of sarcoma (91%; 84 of 92) while the most common injuries cited were progression to metastatic disease (51%; 47 of 92) and wrongful death (41%; 38 of 92). Malpractice claims were most commonly filed against primary care physicians (26%; 28 of 109 defendants), nononcology-trained orthopaedic surgeons (23%; 25 of 109), and radiologists (15%; 16 of 109). Cases were more likely to result in a ruling in favor of the plaintiff or settlement if a delay in diagnosis occurred despite suspicious findings on imaging or pathologic findings (80% versus 51%; odds ratio 3.84 [95% CI 1.34 to 11.03]; p = 0.02). There were no differences in indemnity payments with the numbers available in terms of tumor type, tumor location, defendant specialty, reason for litigation, and resulting injuries.

CONCLUSIONS

Many lawsuits were made against primary care physicians, nononcology-trained orthopaedic surgeons, or radiologists for a delayed diagnosis of sarcoma despite the presence of imaging or histologic findings suspicious for malignancy. Although previous studies of bone and soft-tissue sarcomas have not shown a consistent association between time to diagnosis and decreased survival, our study suggests that physicians are still likely to lose these lawsuits because of the perceived benefits of an early diagnosis.

CLINICAL RELEVANCE

Physicians can mitigate their malpractice risk while reducing delays in diagnosis of sarcomas by carefully reviewing all existing diagnostic studies, establishing closed-loop communication protocols to communicate critical findings from diagnostic studies, and developing policies to facilitate second-opinion consultation, particularly for imaging studies, with an experienced sarcoma specialist. Musculoskeletal oncologists may be able to help further reduce the rates of malpractice litigation in sarcoma care by helping patients understand that delays in diagnosis do not necessarily constitute medical malpractice.

Osteosarcoma of the frontal bone: a study of a rare case in a 17-year-old female

Head and neck osteosarcomas are infrequent and usually present in the third-fourth decades of life. However, they are extremely rare in the pediatric population. Primary involvement of the cranial vault, excluding the mandible and maxilla, is an exceedingly rare phenomenon; thus, the number of clinical studies published in the literature is limited. Because of the anatomy of the head, complete resection may be difficult to achieve. Furthermore, an aggressive surgical approach can cause a significant functional impairment or cosmetic defect. We report the case of a 17-year-old patient with an aggressive recurrence of multiple tumors in the left side of the skull accompanied with a severe headache and complete left-sided vision loss with no metastases at presentation. The recurrence of the tumor was preceded by pregnancy and delivery, which raised the question of whether pregnancy hormones were a provoking factor in the recurrence of the tumor or not.

Long non-coding RNA LINC00426 contributes to doxorubicin resistance by sponging miR-4319 in osteosarcoma

Background

LINC00426 is a newly identified long non-coding RNA (lncRNA) with unacknowledged biological roles. Here we set out to characterize the expression status of LINC00426 in osteosarcoma and understand its mechanistic involvement in incidence of doxorubicin (Dox) resistance.

Methods

The relative expression of LINC00426 and miR-4319 was determined by real-time PCR. Cell viability and proliferation in response to LINC00426 silencing or miR-4319 over-expression was measured with CCK-8 kit and colony formation assay, respectively. The direct association between LINC00426 and miR-4319 was analyzed by pulldown assay with biotin-labelled probes.

Results

LINC00426 was significantly up-regulated in Dox-resistant osteosarcoma (OS) both in vitro and in vivo, which intimately associated with unfavorable prognosis. SiRNA-mediated knockdown of LINC00426 remarkably compromised cell viability and proliferation in Dox-resistant OS cells, which accompanied with decrease of IC50 and activation of caspase-3. We further predicted and validated the regulatory effects of miR-4319 on LINC00426 expression. Simultaneously, we provided evidences in support of direct binding between LINC00426 and miR-4319 by pulldown assay. Reciprocally negative regulation was observed between LINC00426 and miR-4319 each other.

Conclusion

Ectopic introduction of miR-4319 significantly surmounted the Dox resistance in OS cells, while miR-4319 inhibition in LINC00426-deficient cells greatly restore this phenotype. We uncovered the important contribution of LINC00426/miR-4319 to Dox resistance in osteosarcoma.

Reviewers

This article was reviewed by Bo Liang and Sinan Zhu.

Analysis of long-term outcome of image-guided volumetric modulated arc therapy (VMAT) for primary malignant tumor of the cervical spine

OBJECTIVE

Retrospective analysis of the long-term clinical outcome and acute toxicity of the primary malignant tumor of cervical spine receiving CBCT image-guided VMAT.

METHODS

Thirty patients with primary malignant tumor of the cervical spine included in our center, from December 2013 to January 2016, 28 patients were retrospectively studied. The prescription dosage 95% PTV volume dose was 44 Gy, 2.0 Gy/fraction, and a total of 22 times. The median PGTV synchronized volume dose was 60 Gy (45-62.1 Gy), median 2.5 Gy (2-2.7 Gy)/fraction. In volumetric modulated, two arc volumetric modulated arc therapy (VMAT) was used, with spinal cord dosage D_MAX< 45 Gy. Early response rate and acute toxicities were analyzed.

RESULT

The follow-up duration was 6-76 months (median 53 months). At the end of follow-up of June 1, 2019, 78.6% (22/28) patients were still alive. 3 and 5-y local control rates were 67.3% and 56.5% while 3 and 5-y OS were both 78.6% in the whole group of patients, respectively. Fourteen patients with chordoma 5-y local control rates and OS were 57.1% and 85.7%, respectively. Nine patients with giant-cell tumor of bone had a 5-y local control rate and OS were 77.8% and 85.7%, respectively. The response rate for moderate pain or above was 80% (8/10). Eleven patients (39.3%) suffered from grade 1 acute skin toxicity. Twenty-four patients (85.7%) had grade 1/2 mucositis. No radiation-induced spinal cord injury was found.

CONCLUSION

The image-guided VMAT for primary malignant tumor of the cervical spine provided a satisfactory long-term local control rate.

National Comprehensive Cancer Network guidelines compliance of a sarcoma service: A retrospective review

BACKGROUND

Clinical workup and treatment guidelines have been published by the National Comprehensive Cancer Network (NCCN) to ensure patients are treated uniformly and appropriately. This study sought to retrospectively review patients with a new diagnosis of sarcoma who were treated in a National Cancer Institute (NCI) designated center and determine compliance rates with guidelines for sarcoma.

AIM

To evaluate our compliance of NCCN sarcoma guidelines at a major NCI designated center and to report instances of deviation that could be used for future studies to improve patient care.

METHODS

Data was collected retrospectively as an internal review and quality assessment of 35 newly diagnosed and treated patients. Demographic data were recorded and information concerning whether patients had appropriate imaging, biopsy and management. Variables of interest were expressed as raw numbers and percentages.

RESULTS

Primary site imaging was obtained in 100% of cases. Chest and full-body imaging were obtained in 97% and 100% of indicated cases, respectively. Tissue was obtained preoperatively in 97% of cases. Imaging was reviewed at multidisciplinary Treatment Planning Conference (TPC) in 97% of cases. Pathology was reviewed in 94% of cases in TPC. Both tumor, node, metastasis staging and plan of care were reviewed in 100% of cases in TPC. Treatment guidelines were followed in 94% of cases reviewed.

CONCLUSION

This study evaluated the workup and treatment provided by a single NCI designated sarcoma service to a series of patients with pathologies defined with the NCCN sarcoma treatment guidelines. Although adherence to NCCN was reported to be very high future prospective studies are required to investigate whether NCCN guidelines impact patient outcomes.

Multifunctional Pt(iv) complexes containing a glutathione S-transferase inhibitor lead to enhancing anticancer activity and preventing metastasis of osteosarcoma cells

Cisplatin has been clinically applied in the treatment of osteosarcoma (OS), but its efficacy is severely limited due to drug resistance and metastasis. One of the chief culprits is the overexpression of glutathione S-transferases (GSTs) in cancer cells, which can accelerate the interaction of glutathione (GSH) with cisplatin, reducing its biological effects. In this study, three Pt(iv) complexes derived from cisplatin conjugated with a GST inhibitor (NBDHEX) were designed and synthesized. The stabilities and releasing capabilities of these complexes, as well as their abilities to inhibit GSTs, were investigated together with their in vitro anticancer activities toward osteosarcoma cells. Among them, complex 2, bearing one NBDHEX derivative and a hydroxyl group at the axial positions, could markedly kill human OS cells due to its suitable stability and prominent ability to inhibit GSTs. Meanwhile, it can prevent the metastasis of OS via down-regulating Akt. Thus, complex 2 has the potential for further research for the treatment of OS.

Evaluation of factors affecting survival rate in primary bone sarcomas with extremity and pelvis involvement

OBJECTIVE

This study is an evaluation of the overall survival rate and factors affecting survival in patients with osteosarcoma, chondrosarcoma, or Ewing's sarcoma. This study aimed to determine the effect of factors related to the preoperative period, patient, tumor, treatment, and postoperative period on survival.

METHODS

A total of 114 patients (64 male and 50 female) with osteosarcoma, chondrosarcoma, or Ewing's sarcoma treated between 2005 and 2013 were included in this study. All the patients received standard treatment and were followed up regularly. In all, 44 cases of (conventional and telangiectatic) osteosarcoma, 30 cases of Ewing's sarcoma, and 40 cases of high-grade chondrosarcoma were identified using the Bone and Soft Tissue Tumor Registry. Gender, age, tumor size and localization, pathological fractures, histopathological type, grade, surgical treatment, adjuvant treatments, relapse of the disease, and postoperative complication data were obtained from follow-up forms. The learning curve of institutional expertise was also evaluated. The patient survival rate was calculated using the Kaplan-Meier method, and log-rank statistical methods were used to compare survival rates.

RESULTS

The mean length of survival of the patients was 72 months. There was a 56% 5-year survival rate, and the event-free survival rate was 53%. The survival of patients with Ewing's sarcoma whose prodromal period was less than 12 weeks was significantly higher than that of the other groups (p=0.031). The survival of patients with tumor size greater than 150 cc, with local recurrence and distant metastases was low for all groups. Survival rates were significantly lower in osteosarcoma and Ewing's sarcoma patients with stage III tumor or metastasis at diagnosis. The survival of patients with osteosarcoma diagnosed between 2010 and 2013 was significantly higher than that of the earlier group (p=0.02).

CONCLUSION

Decreasing the prodromal period (early diagnosis) can improve survival by preventing the local and systemic spread of the tumor. Increase in the surgical experience is likely to have a positive effect on survival rates, especially for patients with osteosarcoma. The relapse of the disease is a poor prognostic factor for survival despite aggressive surgery and adjuvant therapies.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Malignant distal femur tumors management in children, low cost innovations with affordable care in a tertiary care hospital, a cross sectional study

Introduction

Malignant musculoskeletal tumors in children are mostly comprised of Osteosarcoma and Ewing's sarcoma and distal femur is the most common site for primary bone tumors. This study examined the surgical management outcomes of pediatric patients (<18 years) presented in our setup with malignant distal femur tumors.

Methodology

We retrospectively reviewed the medical records of patients diagnosed with malignant sarcomas of distal femur and younger than 18 years of age who underwent limb salvage surgery during June 2009–June2017.

Results

There were 31 pediatric patients who had distal femur malignant tumors and out of them 20 patients were selected who underwent limb salvage as a primary surgery. The mean age (range) of patients was 11.90 (6–17) years. Seventeen had osteosarcoma and three had Ewing's sarcoma. In surgery all patients were offered reconstruction. Post-operative complications were observed in (50%) patients while other 50% patients had no complications. Wound infection, flap necrosis, broken plates with non-union and recurrence of disease were the reported complications. Revision surgery was performed in 10 patients out of 20 patients.

Conclusion

Salvage was the primary option in our surgery and revision surgery was performed in the cases due to complications. Small sample size was the limitation of the study.

•

Distal femur tumors in pediatric population can be managed with low cost.

•

The innovations discussed in study include fibular grafting, autoclaved tumor bone and parental fibula.

•

In resource retrained countries, multiple reconstruction options are available with  good outcome for the children.

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.

[Radiotherapy after tumour prostheses-status, indication, coordination]

BACKGROUND

Patients with complex tumour prostheses often require radiotherapy or radiochemotherapy.

OBJECTIVES

Possible tumour diagnoses, indications, planning and therapy procedures, and prognosis of radiotherapy in the context of an interdisciplinary treatment for bone sarcomas are reviewed, including interactions of metal prostheses with radiation and possible subsequent complications.

METHODS

Literature search, summary of personal experience.

RESULTS

Complex prosthetic procedures are usually applied to patients suffering from Ewing sarcoma or osteosarcoma. In patients with Ewing sarcoma, radiotherapy is an integral part of multimodal treatment, while in patients with osteosarcoma radiotherapy is indicated in special situations. Planning and implementation of radiotherapy treatment can be impaired by metal implants within the target volume (artefacts in the planning computerized tomography, interaction of metal with the therapeutic beam). However, it is-to our knowledge-a point of debate whether radiotherapy after implantation of a prosthesis could impair healing or prosthesis fixation to bone. The data available in the literature suggest that prostheses implanted after radiotherapy entail a higher rate of complications. Multidisciplinary treatment improves the prognosis for these patients markedly.

CONCLUSIONS

Patients with sarcomas of the bone undergoing interdisciplinary treatment consisting of surgery, radiotherapy and chemotherapy have a favourable prognosis and an acceptable functionality of the limb can be expected.

Phase II trial of VEGFR2 inhibitor apatinib for metastatic sarcoma: focus on efficacy and safety

Apatinib (YN968D1) is a novel tyrosine kinase inhibitor targeting vascular endothelial growth factor receptor 2 (VEGFR-2). We conducted a single-arm, nonrandomized phase II study (NCT03121846) to assess the efficacy and safety of apatinib in patients with stage IV sarcoma. We recruited 64 patients with stage IV sarcoma who had failed chemotherapy. The primary endpoint was progression-free survival (PFS), and the secondary endpoints were progression-free survival rate (PFR), objective response rate (ORR), and disease control rate (DCR) at week 12. Treatment-related adverse effects (AEs) were evaluated. Fifty-nine patients were assessed for efficacy and 64 patients for AEs. The median PFS was 7.93 months. At 12 weeks, the PFR was 74%, the ORR was 16.95% (10/59), and the DCR was 86.44% (51/59). The final ORR was 15.25% (9/59) and the DCR was 57.63% (34/59). Notably, 22 patients (34.38%) who developed hypertension, hand-foot-skin reaction, or proteinuria had significantly longer OS than those without these AEs (18.20 vs. 10.73 months; P = 0.002). We conclude that apatinib is effective and well tolerated in patients with advanced sarcoma. The development of hypertension, hand-foot-skin reaction, or proteinuria may indicate a favorable prognosis, representing a novel finding in sarcoma patients.

A drug that inhibits blood vessel growth offers a potentially promising treatment for a class of tumors with a poor prognosis. Sarcomas form in bone and connective tissue, and patients with advanced disease have a five-year survival rate of less than 10%. Researchers led by Jilong Yang of the Tainjin Medical University Cancer Institute & Hospital in China tested apatanib, a drug that starves tumors by preventing blood vessel development, in late-stage sarcoma patients. Strikingly, 15% of the patients experienced tumor reduction after treatment, and more than half overall achieved at least partial disease control. Adverse events were generally mild, but Yang and colleagues observed that patients who experienced certain side-effects achieved a greater survival benefit from treatment. These results support further investigation of this drug, and offer hints of possible biomarkers to predict response.

Long Non-Coding RNA Metastasis-Associated Lung Adenocarcinoma Transcript 1 (MALAT1) Promotes Proliferation and Metastasis of Osteosarcoma Cells by Targeting c-Met and SOX4 via miR-34a/c-5p and miR-449a/b

BACKGROUND Metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) is a functional long non-coding RNA involved in many biologic processes. The study was aimed to explore the functional roles of MALAT1 in osteosarcoma progression. MATERIAL AND METHODS A total of 76 osteosarcoma tissues and paired adjacent non-tumor tissues were collected from surgical resection. MALAT1, miRNAs, and genes mRNA expression levels were detected using quantitative real-time PCR (qRT-PCR). Protein expression level, cell proliferation, migration, and invasion were assessed using western blot, Cell Counting Kit-8 (CCK-8), wound-healing assay, and Matrigel invasion assay respectively. The target relationships among miRNAs, MALAT1, and mRNA were detected via dual-luciferase reporter assay. RESULTS We found that MALAT1 was frequently upregulated in osteosarcoma samples and cell lines and a high level of MALAT1 predicted poor overall survival in osteosarcoma patients. Knockdown of MALAT1 inhibited proliferation, migration, and invasion of osteosarcoma cells. Further study showed a positive correlation between MALAT1 and c-Met or SOX4 expression. Mechanistic investigations demonstrated that MALAT1, as a competing endogenous RNA (ceRNA), regulated osteosarcoma proliferation and metastasis through competitively binding to miR-34a/c-5p and miR-449a/b. CONCLUSIONS Taken together, our study illustrates a new regulatory mechanism for MALAT1 and may provide a novel therapeutic strategy for the treatment of osteosarcoma.

Mitochondrial genome and functional defects in osteosarcoma are associated with their aggressive phenotype

Osteosarcoma (OSA) is an aggressive mesenchymal tumor of the bone that affects children and occurs spontaneously in dogs. Human and canine OSA share similar clinical, biological and genetic features, which make dogs an excellent comparative model to investigate the etiology and pathogenesis of OSA. Mitochondrial (mt) defects have been reported in many different cancers including OSA, although it is not known whether these defects contribute to OSA progression and metastasis. Taking a comparative approach using canine OSA cell lines and tumor tissues we investigated the effects of mtDNA content and dysfunction on OSA biology. OSA tumor tissues had low mtDNA contents compared to the matched non-tumor tissues. We observed mitochondrial heterogeneity among the OSA cell lines and the most invasive cells expressing increased levels of OSA metastasis genes contained the highest amount of mitochondrial defects (reduced mtDNA copies, mt respiration, and expression of electron transport chain proteins). While mitochondria maintain a filamentous network in healthy cells, the mitochondrial morphology in OSA cells were mostly "donut shaped", typical of "stressed" mitochondria. Moreover the expression levels of mitochondrial retrograde signaling proteins Akt1, IGF1R, hnRNPA2 and NFkB correlated with the invasiveness of the OSA cells. Furthermore, we demonstrate the causal role of mitochondrial defects in inducing the invasive phenotype by Ethidium Bromide induced-mtDNA depletion in OSA cells. Our data suggest that defects in mitochondrial genome and function are prevalent in OSA and that lower mtDNA content is associated with higher tumor cell invasiveness. We propose that mt defects in OSA might serve as a prognostic biomarker and a target for therapeutic intervention in OSA patients.

Novel molecular insights and new therapeutic strategies in osteosarcoma

Osteosarcoma (OS) is one of the most prevalent malignant cancers with lower survival and poor overall prognosis mainly in children and adolescents. Identifying the molecular mechanisms and OS stem cells (OSCs) as new concepts involved in disease pathogenesis and progression may potentially lead to new therapeutic targets. Therefore, therapeutic targeting of OSCs can be one of the most important and effective strategies for the treatment of OS. This review describes the new molecular targets of OS as well as novel therapeutic approaches in the design of future investigations and treatment.

Complex Reconstruction After Sarcoma Resection and the Role of the Plastic Surgeon: A Case Series of 298 Patients Treated at a Single Center

BACKGROUND

More than 1000 new patients present to the London Sarcoma Unit each year and between 5% and 10% require plastic surgery intervention. Advancements in radiotherapy and chemotherapy protocols combined with higher expectations for limb preservation has led to increased reconstructive challenges. Frequently, primary closure is achievable; however, larger tumors often require specialist reconstruction.

STUDY DESIGN

A retrospective chart review of all referred patients from the London Sarcoma Unit requiring reconstruction between February 2006 and January 2015 was performed. Patients who underwent primary amputation were excluded.

RESULTS

The total number of operations performed was 298 and the mean follow-up was 16 months (12-46 months). 51% of patients had major comorbidities. Patients could be separated into early (0-1 week postoperatively, n = 167) and late reconstructions (>1 week postoperatively, n = 131). 32 patients were reconstructed with skin grafts, 137 patients were managed with regional flaps and 129 patients were treated with free flaps.

CONCLUSIONS

A patient with 3 or more major comorbidities resulted in a significantly increased risk of reconstructive failure (P < 0.05). Our experience has lead us to adhere to the following guidelines: (1) All patients should be reviewed in a multidisciplinary team meeting. (2) After primary excision, patients should be managed with a vacuum dressing until margins are clear. (3) Definitive reconstruction should be performed by a specialist reconstructive surgeon.

Efficacy and safety of apatinib in advance osteosarcoma with pulmonary metastases: A single-center observational study

This study was designed to evaluate the efficacy and safety of apatinib in patients with advanced osteosarcoma and pulmonary metastases following failed first-line chemotherapy.There were 10 patients with osteosarcoma pulmonary metastases, whose first-line chemotherapy had failed, had received apatinib treatment as a single agent. All patients had at least 1 measurable lung tumor. Progression free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR), and treatment-related adverse effects (AEs) were reviewed and evaluated. Tumor response was assessed by response evaluation criteria in solid tumor criteria (RECIST). The 10 patients in this study received apatinib treatment for 2 to 16 months with a median of 7.5 months. The median PFS was 7.5 months. The 6-month, 8-month, and 10-month PFS rates were 60%, 40% and 26.6%, respectively. The median OS was 14 months. After 6-month apatinib treatment, 2 patients achieved partial response and 5 patients achieved stable disease, while 3 patients were evaluated as progression of the disease. At the 6-month follow-up, the ORR was 20.0% and the DCR was 70.0%. Hand-foot syndrome with grade 1/2 was the most common treatment-related AE. No drug-related severe AEs occurred.After failed first-line chemotherapy, apatinib as a single agent exhibited efficacy and acceptable safety in patients with advanced osteosarcoma and pulmonary metastases.

Recombined humanized endostatin (Endostar) combined with chemotherapy for advanced bone and soft tissue sarcomas in stage IV

PURPOSE

This retrospective case-series study evaluated efficacy and safety of Endostar combined with chemotherapy in the treatment of advanced bone and soft tissue sarcomas in stage IV.

MATERIALS AND METHODS

Forty-seven patients diagnosed with stage IV bone and soft tissue sarcomas and treated with chemotherapy in Tianjin Medical University Cancer Institute & Hospital were reviewed. Of these patients, 23 patients were treated with Endostar plus chemotherapy (designated as combined group), and 24 patients received only chemotherapy (designated as control group). Progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and clinical benefit response (CBR) were analyzed to find the difference between these two groups with the purpose to investigate the role of Endostar in metastatic sarcomas.

RESULTS

Endostar combined with chemotherapy had significantly increased PFS. In the combined group and control groups, the median PFS (8.6 months versus 4.4 months) and the CBR (47.8% versus 16.7%) showed significant difference (P = 0.032), while the median overall survival (11.7 months versus 10.6 months, P = 0.658) and the ORR (17.4% versus 8.3%, P = 0.167) showed no significant difference. The common grade 3-4 side effects for both groups were myelosuppression and transient elevation of transaminases.

CONCLUSION

Endostar combined with chemotherapy had significant activity to increase the PFS and improve CBR in patients with advanced sarcomas, with tolerable side effects.

Inhibition of NADPH oxidase 2 induces apoptosis in osteosarcoma: The role of reactive oxygen species in cell proliferation

Osteosarcomas (OS) are aggressive tumors that are characterized by dysregulated growth and resistance to apoptosis. Reactive oxygen species (ROS) are thought to be important signal transduction molecules in the regulation of cell growth. ROS-generating nicotinamide adenine dinucleotide phosphate oxidase (NOX) family enzymes have previously been suggested to be involved in neoplastic proliferation. To examine whether NOX-mediated generation of intracellular ROS confers anti-apoptotic activity, and thus a growth advantage, the current study first analyzed the mRNA expression of NOX family members by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) in five human OS cell lines. RT-PCR analysis revealed that NOX2 and NOX4 mRNAs were expressed in all the OS cell lines examined, whereas little or no NOX1 and NOX3 mRNAs were detected. By RT-qPCR, NOX2 mRNA expression levels were demonstrated to be higher than NOX4 mRNA expression levels. The viability of OS cells decreased in a dose-dependent manner with treatment of diphenylene iodonium (DPI), an inhibitor of flavoprotein-dependent oxidase. DPI treatment was observed to reduce intracellular ROS levels by ~50%, and increase the frequency of apoptosis by 30%. Notably, small interfering RNAs (siRNAs) targeting NOX2 significantly suppressed ROS generation; ROS depletion by DPI or NOX2 siRNAs induced apoptosis in OS cells. Together, the results of the present study indicate that NOX2-mediated ROS generation promotes cell survival and ROS depletion leads to apoptosis, thus highlighting the NOX2-ROS signaling pathway as a potential therapeutic target for OS treatment.

Primary osteosarcoma of frontal bone: A case report and review of literature

RATIONALE

Primary osteosarcomas of the skull and skull base are rare, comprising <2% of all skull tumors. Primary osteosarcomas of the skull are aggressive neoplasms composed of spindle cells producing osteoid which have poor outcome.

PATIENT CONCERNS

A 33-year-old woman was admitted to our hospital with a major complaint of a growing mass on her left frontal region of the skull for 10 months. Prior to the accurate diagnosis, the mass on her skull was considered to be eosinophilic granuloma.

DIAGNOSES

Computerized tomogram (CT) scan of skull revealed a lytic lesion causing destruction of left frontal bone with surrounding soft tissue mass. The histological examination of the lesion showed typical features of osteosarcoma.

INTERVENTIONS

The patient received 3 surgeries and adjuvant chemotherapy and radiotherapy for the frontal bone lesion.

OUTCOMES

At the last follow-up, after 4 years, the patient was free of disease both clinically and on imaging by magnetic resonance imaging (MRI) scan after 4 years.

LESSONS

Because osteosarcoma of skull is a rare disease, the early recognition and correct diagnosis are very important for a better prognosis. It is therefore imperative that clinicians recognize osteosarcoma early to make an accurate diagnosis and complete surgical resection followed by combined chemo-radiation is proved to be one of the most optimal treatment regimens.

Establishing musculoskeletal oncology service in resource constrained country: challenges and solutions

The burden of orthopedic tumor surgery in Pakistan is not known. Similarly the number of procedures being performed for bone and soft tissue surgery are not known. This is even becoming more challenging where the existence of rules and regulations in health care are next to minimal. Furthermore data recording in our country and case registries hardly exist. Despite the lack of information and resources, with high disease burden on community, various providers provide surgical interventions every day in our settings. A lot of tumor surgery is still being done by general surgeons and general orthopedic surgeons who have little knowledge and update about musculoskeletal oncology principles. Lack of subspecialized centers and the high cost of such centers force the patients to visit these surgeons for a highly sophisticated problem like a bone tumor which is the disease of young bones. In this article we will emphasize on the difficulty in establishing an orthopedic tumor service in our part of the world and the consequences including delay in diagnosis, faulty course of management and later decline in functionality, disease progression and increased mortality. We will highlight the principles and stepwise approach of orthopedic tumor surgery and explain the difficulty encountered if these principles are not followed.

Therapeutic potential of the metabolic modulator Metformin on osteosarcoma cancer stem-like cells

PURPOSE

Osteosarcoma is the most common primary bone tumour appearing in children and adolescents. Recent studies demonstrate that osteosarcoma possesses a stem-like cell subset, so-called cancer stem-like cells, refractory to conventional chemotherapeutics and pointed out as responsible for relapses frequently observed in osteosarcoma patients. Here, we explored the therapeutic potential of Metformin on osteosarcoma stem-like cells, alone and as a chemosensitizer of doxorubicin.

METHODS

Stem-like cells were isolated from human osteosarcoma cell lines, MNNG/HOS and MG-63, using the sphere-forming assay. Metformin cytotoxicity alone and combined with doxorubicin were evaluated using MTT/BrdU assays. Protein levels of AMPK and AKT were evaluated by Western Blot. Cellular metabolic status was assessed based on [¹⁸F]-FDG uptake and lactate production measurements. Sphere-forming efficiency and expression of pluripotency transcription factors analysed by qRT-PCR were tested as readout of Metformin effects on stemness features.

RESULTS

Metformin induced a concentration-dependent decrease in the metabolic activity and proliferation of sphere-forming cells and improved doxorubicin-induced cytotoxicity. This drug also down-regulated the expression of master regulators of pluripotency (OCT4, SOX2, NANOG), and decreased spheres' self-renewal ability. Metformin effects on mitochondria led to the activation and phosphorylation of the energetic sensor AMPK along with an upregulation of the pro-survival AKT pathway in both cell populations. Furthermore, Metformin-induced mitochondrial stress increased [¹⁸F]-FDG uptake and lactate production in parental cells but not in the quiescent stem-like cells, suggesting the inability of the latter to cope with the energy crisis induced by metformin.

CONCLUSIONS

This preclinical study suggests that Metformin may be a potentially useful therapeutic agent and chemosensitizer of osteosarcoma stem-like cells to doxorubicin.

Effectiveness of mifamurtide in addition to standard chemotherapy for high-grade osteosarcoma: a systematic review

BACKGROUND

Osteosarcoma mostly occurs during the period of rapid bone growth in children and adolescents as high-grade osteosarcomas. Current treatment recommended for high-grade non-metastatic and metastatic and/or relapsed osteosarcoma involves neoadjuvant multiagent conventional chemotherapy, followed by surgical resection of macroscopically detected tumor and postoperative adjuvant chemotherapy. However, residual micrometastatic deposits that develop following surgery have shown resistance to postoperative/adjuvant chemotherapy. Therefore, there is a critical need for more effective and innovative therapeutic approaches such as immune stimulatory agents. The most extensively studied immune stimulatory agent in the treatment of osteosarcoma is mifamurtide. The aim of this systematic review was to identify and synthesize the evidence on the effectiveness of mifamurtide in addition to standard chemotherapy on survival outcomes.

OBJECTIVES

To present the best available evidence on the treatment of high-grade non-metastatic and metastatic osteosarcoma with mifamurtide in addition to standard chemotherapy.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

All populations of patients regardless of age, gender or ethnicity with high-grade, resectable, non-metastatic and metastatic osteosarcoma based on histological diagnosis.

TYPES OF INTERVENTIONS AND COMPARATORS

This review focused on intravenous infusion of either of the pharmaceutical formulations of mifamurtide (MTP-PE or L-MTP-PE) in addition to standard chemotherapy, and the comparator was chemotherapy alone.

TYPES OF STUDIES

This review considered any experimental study design including randomized controlled trials, non-randomized trials and quasi-experimental studies.

OUTCOMES

The primary outcomes of interest were event-free survival, overall survival and recurrence of osteosarcoma. Secondary outcomes that were considered included health-related quality of life and any mifamurtide-related adverse events.

SEARCH STRATEGY

A search for published and unpublished literature in English was undertaken (seven published literature databases, four unpublished literature databases, and three government agency and organizational websites were searched). Studies published between 1990 to June 2016 were considered. A three-step strategy was developed using MeSH terminology and keywords to ensure that all relevant studies were included related to this review.

METHODOLOGICAL QUALITY

The methodological quality of included studies was assessed by two reviewers, who appraised each study independently, using a standardized Joanna Briggs Institute (JBI) critical appraisal tool.

DATA EXTRACTION

Data was extracted from the studies that were identified as meeting the criteria for methodological quality using the standard JBI data extraction tool.

DATA SYNTHESIS

Due to the heterogeneity of populations and interventions in available studies, meta-analysis was not possible and results are presented in narrative form.

RESULTS

Three papers outlining two studies involving 802 patients evaluated the effectiveness of mifamurtide in addition of chemotherapy. Results indicated no significant difference in event-free survival between the addition of mifamurtide to standard chemotherapy regimen and chemotherapy alone, both in non-metastatic and metastatic osteosarcoma patients. There was a significant difference in progression-free survival favoring the addition of mifamurtide in pulmonary metastatic and/or relapsed osteosarcoma. There was no significant difference in overall survival between the addition of mifamurtide and chemotherapy alone in metastatic osteosarcoma; however there was a significant difference favoring the addition of mifamurtide in non-metastatic osteosarcoma patients. The addition of mifamurtide resulted in a significant difference in survival after relapse in pulmonary metastatic and/or relapsed osteosarcoma patients. Both studies reported on mifamurtide-related adverse events - the first was reported as toxicity which included haematological, hepatic, renal, gastrointestinal disorders, cardiac, rhythm and nervous system disorders, ear disorders and others (infection, fever; and performance status) in metastatic osteosarcoma patients. Results were similar across all combined treatment regimens. Although no statistical analysis was undertaken, the figures suggest there were no significant differences between the treatment regimens. In the other study, mifamurtide-related adverse events were reported as clinical toxic effects of mifamurtide in relapsed osteosarcoma, which included chills, fever and headache for the initial dose of mifamurtide, while for the subsequent doses of mifamurtide all patients reported toxicity as delayed fatigue.

CONCLUSIONS

The available evidence on the effectiveness of mifamurtide in addition to a standard chemotherapy regimen for the treatment of high-grade osteosarcoma is limited and therefore no definitive conclusions can be made.

Cucurbitacin B inhibits cell proliferation and induces apoptosis in human osteosarcoma cells via modulation of the JAK2/STAT3 and MAPK pathways

Osteosarcoma (OS) is the most commonly diagnosed tumor of the bones in children and young adults. Even with conventional therapies the 5-year survival rate is ~65% in patients with OS. Considering the side effects and aggressiveness of malignant bone tumors, research is focussing on multi-targeted strategies in treatment. Cucurbitacin B, a triterpenoid compound has been demonstrated to induce apoptosis in various cancer cell types. The Janus kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) signalling cascades and mitogen activated protein kinases (MAPK) signalling cascades are critical regulators of tumorigenesis. The present study assessed the influence of cucurbitacin B on the viability and expression of MAPKs and proteins of the JAK2/STAT3 cascades in human OS cells (U-2 OS). Cucurbitacin B (20-100 µM) significantly reduced cell viability (P<0.05) and induced apoptosis, as assessed by MTT and Annexin V/propidium iodide staining, along with inhibiting cell migration. Gelatin zymography revealed supressed activities of matrix metalloproteinase (MMP-)2 and 9. Furthermore, cucurbitacin B effectively upregulated the apoptotic pathway and caused the effective inhibition of MAPK signalling and JAK2/STAT3 cascades. Multifold suppression of vascular endothelial growth factor by cucurbitacin B was also observed, indicating inhibition of angiogenesis. Thus, by downregulating major pathways-MAPK and JAK2/STAT3 and MMPs, cucurbitacin B has potent anti-proliferative and anti-metastatic effects that require further investigation with regards to cancer treatment.

Efficacy and safety of Apatinib in stage IV sarcomas: experience of a major sarcoma center in China

Purpose

This study was conducted to review the efficacy and safety of Apatinib in stage IV sarcoma patients who failed previous chemotherapy.

Materials and Methods

The clinical information on 16 patients with stage IV sarcomas who failed in prior chemotherapy and subsequently received Apatinib treatment was collected. Apatinib was given 500mg/daily and 4 weeks as a cycle. All patients had at least one measurable extracranial tumor according to Response Evaluation Criteria In Solid Tumors 1.0 criteria. Progression free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR) and treatment-related adverse effects (AEs) were reviewed and evaluated.

Results

Patients was administered Apatinib for 0 to 9 cycles with the median of 3.2 cycles. Median follow-up time was 8.4 months (1 to 12 months). Ten of 16 patients received at least 1 complete cycle of Apatinib treatment were eligible for the efficacy analysis. The median PFS was 8.84 months. Two patients achieved partial response (PR) and 6 patients achieved stable disease (SD). Two patients were evaluated as progression disease (PD) and one patient died of disease progression. The ORR was 20.0% (2/10) and the DCR was 80.0% (8/10). The most common grade 3/4 treatment-related AEs were hypertension (18.7%), hand-foot syndrome (12.5%) and proteinuria (6.3%). No drug-related severe AEs occurred.

Conclusion

CApatinib treatment in this exploratory study exhibited objective efficacy and manageable toxicity in stage IV sarcoma patients who failed in chemotherapy. This result supports future random controlled trial to further define Apatinib activity in stage IV sarcomas.

Pathological fractures in predicting clinical outcomes for patients with osteosarcoma

Background

Studies reported contradictory results for the prognostic significance of a pathological fracture in osteosarcoma patients. The aim of this study is to report the outcomes for a cohort of patients with osteosarcoma who presented with and without pathological fractures and to identify the prognostic importance of pathological fracture in predicting outcomes and influences on survival.

Methods

Data of patients with osteosarcoma were retrospectively reviewed. Between March 1992 and June 2014, a total of 268 patients with osteosarcoma were included in this analysis, of whom 34 (12.7%) with fractures at diagnosis or sustained after chemotherapy and 234 (87.3%) without fracture. All patients were treated with approaches that integrated chemotherapy and surgical resections to maximal extent of all sites whenever feasible. The association between potential prognostic factors and survival for these patients were analyzed and compared.

Results

No significant difference was observed in overall survival, progression free survival, and disease free survival between osteosarcoma patients with pathological fractures and without fracture. The patients without fracture had a 5-year survival of 50% and 10-year survival of 21%, in contrast to 37% (5-year) and 22% (10-year) in patients with fractures. Lung metastasis was the significant predictor for the presence of fractures. Advanced stage (III) of tumor, lung metastasis, poor response to chemotherapy, and local recurrence were associated increased risk for death in all osteosarcoma patients.

Conclusion

Pathological fracture is not a predictor of worse survival in this study. Further studies with matched cases are needed to confirm our observations.

Diagnostic accuracy of CD44V6 for osteosarcoma: a meta-analysis

Background

Recently, more and more evidences have revealed the association between CD44V6 and osteosarcoma (OS), but whether it can be used as a clinical biomarker is still unknown. The purpose of this study is to assess the diagnostic value of CD44V6 in OS by conducting a meta-analysis.

Methods

All relevant electronic literatures were collected from seven international databases together with three Chinese databases up to April 23, 2016. Eligible studies were selected through multiple search strategies and the quality was assessed by QUADAS. Data was extracted from studies according to the key statistics index. All analyses were performed using STATA 12 and Meta-DiSc 1.4 statistical software.

Results

According to the exclusion and inclusion criteria, 8 literatures were retrieved, accounting for 463 cases and 188 controls. For discriminating OS from benign bone tumor or healthy controls, the area under the receiver operating characteristic curve (AUC) was 0.91 (95 % CI 0.88–0.93). Overall, the results showed pooled sensitivity of 0.743 (95 % CI 0.606–0.844) and specificity of 0.897 (95 % CI 0.818–0.945), respectively. Substantial heterogeneity was detected in this study (I² = 90 %). The publication bias was assessed by using Deeks’ asymmetry test (p = 0.795). No evidence of heterogeneity from threshold effects was detected by the Spearman correlation coefficient (−0.506, p = 0.201). Meta-regression was performed to mining the source of heterogeneity, and subgroup analysis showed that neither the cut-off values nor the control groups were the source of heterogeneity.

Conclusions

The present results suggest that promoted CD44V6 expression levels are associated with OS and CD44V6 may be used as a diagnostic marker for OS.

Corosolic acid inhibits the proliferation of osteosarcoma cells by inducing apoptosis

Corosolic acid (CRA), a pentacyclic triterpene isolated from medicinal herbs, has been reported to exhibit anticancer properties in several cancers. However, the anticancer activity of CRA in osteosarcoma cells is still unclear. In the present study, the inhibitory effect of CRA in osteosarcoma MG-63 cells was investigated, and the results revealed that CRA significantly inhibited the viability of MG-63 cells in a dose- and time-dependent manner. A typical apoptotic hallmark such as DNA ladder was detected by agarose gel electrophoresis following treatment with CRA. Further experiments demonstrated that CRA induced apoptosis of MG-63 cells by flow cytometry using propidium iodide and annexin V staining. In addition, it was observed that the apoptosis of MG-63 cells induced by CRA was closely associated with activation of caspase-3 and caspase-9, loss of mitochondrial membrane potential, and release of cytochrome c from mitochondria, suggesting that CRA may trigger the activation of the mitochondria-mediated apoptosis pathway. In addition, the inhibition of caspase activity attenuated the CRA-induced apoptosis of MG-63 cells, which further confirmed the role of the mitochondrial pathway in CRA-induced apoptosis. These results indicated that CRA could induce the apoptosis of osteosarcoma cells through activating the mitochondrial pathway, which provides an evidence that CRA may be a useful chemotherapeutic agent for osteosarcoma.

Fibulin-4 is a novel Wnt/β-Catenin pathway activator in human osteosarcoma

Fibulin-4, an extracellular glycoprotein implicated in connective tissue development and elastic fiber formation, draws increasing focuses in cancer research. However, little is known about the underlying oncogenic roles of Fibulin-4 in human osteosarcoma (OS). In this study, by immunohistochemical analysis, upregulated expression of Fibulin-4 was found in the OS clinical specimens and cell lines compared to their normal counterparts. Fibulin-4 was positively correlated with the T stage of OS patients, and the proliferation index Ki67. Based on informatics analysis and functional verification, microRNA-137 was identified as a potential upstream regulator of Fibulin-4. Knockdown of Fibulin-4 or introduction of microRNA-137 inhibited cell proliferation and promoted cell apoptosis, and adverse effects were observed by overexpression of Fibulin-4. Furthermore, the tumor-suppressive functions of microRNA-137 were markedly abolished by restoration of Fibulin-4 expression in OS cells. Mechanistically, Fibulin-4 activated Wnt/β-Catenin pathway and promoted the expression of its downstream targets, including CCND2, c-Myc and VEGF. Taken together, Fibulin-4 plays critical neoplastic roles in tumor growth of human OS by activating Wnt/β-Catenin signaling and may represent a potential therapeutic target.

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.

miRNA-223 is a potential diagnostic and prognostic marker for osteosarcoma

Background

MicroRNA-223 (miR-223) has been shown to be a potential diagnostic and prognostic marker for several cancers. In addition, miR-223 has been reported to suppress osteosarcoma cell proliferation in vitro. However, the clinical value of miR-223 is still unknown.

Methods

We detected the expression of miR-223 expression in the serum of osteosarcoma patients and in osteosarcoma cancer cells using RT-PCR. We compared the serum expression of miR-223 with the clinicopathological characteristics and survival of osteosarcoma patients. Finally, we explored the role of miR-223 on the invasion of osteosarcoma cancer cells using cell migration and invasion assays.

Results

We observed that the expression of miR-223 was significantly decreased in the serum of osteosarcoma patients and osteosarcoma cancer cells compared to healthy controls (P<0.01). Moreover, a receiver operating characteristic (ROC) curve analysis indicated that serum miR-223 is a potential diagnostic marker of osteosarcoma with an area under the ROC curve (AUC) of 0.956. Importantly, the patients with a lower expression of miR-223 tended to have distant metastasis (P<0.001) and a more advanced clinical stage (P<0.001). In addition, the survival time of patients with low miR-223 expression was significantly shorter compared to patients with high miR-223 expression (P<0.001). Furthermore, we found that miR-223 could inhibit the migration and invasion of osteosarcoma cells.

Conclusions

miR-223 might be related to the metastasis of osteosarcoma and could be used as a potential diagnostic and prognostic biomarker in osteosarcoma.

Diagnostic value of circulating microRNAs for osteosarcoma in Asian populations: a meta-analysis

A large number of studies have provided new insights into the diagnostic value of circulating microRNAs (miRNA) for osteosarcoma (OS), one of the most common primary malignancies in adolescents. However, inconsistent conclusions on the diagnostic performance of various kinds of miRNAs have been made. To assess the true diagnostic value of circulating miRNA for the early detection of OS in this meta-analysis, multiple databases, including PubMed, EMBASE, Web of Science, Chinese National Knowledge Infrastructure (CNKI), and Technology of Chongqing (VIP), were carefully searched for available studies up to October 30, 2015. The quality of each study was scored using the quality assessment of diagnostic accuracy studies-2 (QUADAS-2). Sensitivity and specificity was pooled using a random-effects model. Positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the curve (AUC) were used to measure the diagnostic values. Subgroup and meta-regression analyses were used to find potential sources of heterogeneity. Publication bias was tested with the Deeks' funnel plot asymmetry test. Eight articles with 741 OS patients and 479 healthy controls were finally included in this meta-analysis. The pooled estimations indicated circulating miRNAs has a high accuracy for diagnosing OS, with sensitivity of 0.94, specificity of 0.80, PLR of 4.75, NLR of 0.07, DOR of 69, and AUC of 0.94. In addition, subgroup and meta-regression analyses revealed that the expression patterns of miRNAs obtained from plasma are more credible diagnostic biomarkers than those from serum. In conclusion, as noninvasive biomarkers, circulating miRNAs have a promising future for the diagnosis of OS in Asian populations.

Primary Hepatic Osteosarcoma: A Rare Cause of Primary Liver Tumor

INTRODUCTION

Extraosseous osteosarcomas are rare, accounting for approximately 4% of all osteosarcomas. A literature review yields very few cases of osteosarcoma primarily arising from the hepatic parenchyma.

CASE REPORT

This report describes a case of a man in his 50s with a history of hepatitis C and cirrhosis who presented with 5 days of progressive right upper quadrant pain. Magnetic resonance imaging of the abdomen and pelvis demonstrated a 4.4 cm × 4.8 cm × 4.8 cm right hepatic lobe mass with a large area of necrosis and peripheral enhancement. The subsequent liver biopsy showed few cores of tumor composed of fibroblastic malignant cells producing lace-like osteoid matrix. Osteosarcomatous foci in other parts of the body were excluded by performing extensive physical examination, radiologic imaging, and biopsy. Hence, a primary osteosarcoma was diagnosed. The patient underwent portal vein embolization in preparation for a surgical resection of the right liver lobe. He was admitted six weeks after the embolization for dyspnea and abdominal distension and expired due to abdominal hematoma and pulmonary embolism.

CONCLUSION

Based on the rarity, lack of consensus in treatment, and dismal prognosis, extraosseous osteosarcoma should be considered a separate entity from osseous osteosarcoma. More data and research are needed in this rare and understudied malignancy.