Osteosarcoma of the spine: experience in 26 patients treated at the Massachusetts General Hospital

The Role of En Bloc Resection in the Modern Era for Primary Spine Tumors

STUDY DESIGN

A literature review.

OBJECTIVE

The aim of this review is to provide an overview of benign and malignant primary spine tumors and a balanced analysis of the benefits and limitations of (and alternatives to) surgical treatment with en bloc resection.

SUMMARY OF BACKGROUND DATA

Primary spine tumors are rare but have the potential to cause severe morbidity, either from the disease itself or as a result of treatment. The prognosis, goals, and treatment options vary significantly with the specific disease entity. Appropriate initial management is critical; inappropriate surgery before definitive treatment can lead to recurrence and may render the patient incurable, as salvage options are often inferior.

METHODS

We performed a comprehensive search of the PubMed database for articles relevant to primary spine neoplasms and en bloc spine surgery. Institutional review board approval was not needed.

RESULTS

Although Enneking-appropriate en bloc surgery can be highly morbid, it often provides the greatest chance for local control and/or patient survival. However, there is growing data to support modern radiotherapy as a feasible and less morbid approach to certain primary neoplasms that historically were considered radioresistant.

CONCLUSIONS

Choosing the optimal approach to primary spine tumors is complex. A comprehensive and up-to-date assessment of the evidence is required to guide patient care and to balance the often-competing goals of prolonging life and preserving quality of life.

Development and Validation of a Prognostic Model for Overall Survival in Patients with Primary Pelvis and Spine Osteosarcoma: A Population-Based Study and External Validation

Background: Primary pelvis and spine osteosarcoma (PSOS) is a specific type of osteosarcoma that is difficult to treat and has a poor prognosis. In recent years, the research on osteosarcoma has been increasing, but there have been few studies on PSOS; in particular, there have been a lack of analyses with a large sample size. This study aimed to construct and validate a model to predict the overall survival (OS) of PSOS patients, as currently there are no tools available for assessing their prognosis. Methods: Data including demographic information, clinical characteristics, and follow-up information on patients with PSOS were collected from the Surveillance, Epidemiology, and End Results (SEER) database, as well as from the Spine Tumor Center of Changzheng Hospital. Variable selection was achieved through a backward procedure based on the Akaike Information Criterion (AIC). Prognostic factors were identified by univariate and multivariate Cox analysis. A nomogram was further constructed for the estimation of 1-, 3-, and 5-year OS. Calibration plots, the concordance index (C-index), and the receiver operating characteristic (ROC) were used to evaluate the prediction model. Results: In total, 83 PSOS patients and 90 PSOS patients were separately collected from the SEER database and Changzheng Hospital. In the SEER cohort, liver metastasis, lung metastasis, and chemotherapy were recognized as independent prognostic factors for OS (p < 0.05) and were incorporated to construct the initial nomogram. However, the initial nomogram showed poor predictive accuracy in internal and external validation. Then, we shifted our focus to the Changzheng data. Lung metastasis involving segments, Eastern Cooperative Oncology Group (ECOG) performance score, alkaline phosphatase (ALP) level, and en bloc resection were ultimately identified as independent prognostic factors for OS (p < 0.05) and were further incorporated to construct the current nomogram, of which the bias-corrected C-index was 0.834 (0.824–0.856). The areas under the ROC curves (AUCs) of the current nomogram regarding 1-, 3-, and 5-year OS probabilities were 0.93, 0.96, and 0.92, respectively. Conclusion: We have developed a predictive model with satisfactory performance and clinical practicability, enabling effective prediction of the OS of PSOS patients and aiding clinicians in decision-making.

Prognostic factors and treatment outcomes of spinal osteosarcoma: Surveillance, epidemiology, and end results database analysis

Objective

Spinal osteosarcoma is a rare osseous neoplasm. The aim of this study is to make a comprehensive analysis of the demographic features, clinicopathologic characteristics and factors affecting prognosis of spinal osteosarcoma using the Surveillance, Epidemiology and End Results (SEER) database.

Methods

SEER data were reviewed to identify patients diagnosed with spinal osteosarcoma between 1975 and 2016 and determine their overall survival (OS) and disease-specifc survival (DSS). Univariate and multivariate analyses were performed using the Cox-regression proportional hazards model and Kaplan-Meier method.

Results

A total of 668 patients (53.1% males) with spinal osteosarcoma were identified. The mean age at diagnosis was 45.2 years, including 67.5% patients younger than 60 years. The median OS of these patients was 15 months, and the 5-year OS was 16.8%. Multivariate analysis showed that age ≥60 year (HR=2.271, p = 0.008), high grade (HR=1.323, p = 0.008), regional stage (HR=1.658, p = 0.017), metastasis stage (HR=3.045, p < 0.001) and no-surgery treatment (HR=1.761, p < 0.001) were adversely associated with OS; gender (HR=0.657, p = 0.044), tumor grade (HR=1.616, p = 0.006), tumor stage (HR=3.329, p = 0.011; HR=7.983, p < 0.001) and radiotherapy (HR=0.606, p = 0.031) were independent prognostic factors affecting DSS.

Conclusion

Based on SEER data analysis, male, high tumor grade, regional stage, metastasis stage and radiotherapy are independent predictors of poor survival of patients with spinal osteosarcoma. The clinical treatment of spinal osteosarcoma still faces serious challenges. Future research should focus on the clinical impact and survival outcomes of the emerging targeted and immune therapies for the sake of improving the survival stalemate of spinal osteosarcoma.

Does Primary Tumor Resection in Patients with Metastatic Primary Mobile Vertebral Column Sarcoma Improve Survival?

BACKGROUND

Primary mobile vertebral column sarcoma is an exceedingly rare malignancy. Although primary tumor resection has been reported to prolong survival in patients with metastatic bone sarcoma, whether primary tumor resection in patients with advanced primary mobile vertebral column sarcoma is associated with survival remains unclear owing to the rarity of this pathological entity.

METHODS

Using the Surveillance, Epidemiology, and End Results database, 182 patients with metastatic primary mobile vertebral column sarcoma were identified between 1983 and 2015. Of the 182 patients enrolled, 101 patients (55%) underwent primary tumor resection (Surgery group) and 81 patients (45%) did not undergo resection (No Surgery group). To account for imbalances in the basic characteristics of patients between groups, propensity score matching was performed. Survival analysis was performed by weighted Cox proportional hazards modeling to calculate hazard ratios.

RESULTS

After adjusting for patient background characteristics, 138 patients were included for the analysis (Surgery group: 69 patients; No Surgery group: 69 patients). The Surgery group did not show improved cancer-specific survival (hazard ratio = 0.73, 95% CI 0.49-1.10). Similarly, the Surgery group did not show improved overall survival compared with the No Surgery group (hazard ratio = 0.80, 95% CI 0.55-1.16).

CONCLUSIONS

To our knowledge, this is the first study to indicate that surgical resection for advanced primary mobile vertebral column sarcoma does not have a positive impact on survival.

Application of additively manufactured 3D scaffolds for bone cancer treatment: a review

Bone cancer is a critical health problem on a global scale, and the associated huge clinical and economic burdens are still rising. Although many clinical approaches are currently used for bone cancer treatment, these methods usually affect the normal body functions and thus present significant limitations. Meanwhile, advanced materials and additive manufacturing have opened up promising avenues for the development of new strategies targeting both bone cancer treatment and post-treatment bone regeneration. This paper presents a comprehensive review of bone cancer and its current treatment methods, particularly focusing on a number of advanced strategies such as scaffolds based on advanced functional materials, drug-loaded scaffolds, and scaffolds for photothermal/magnetothermal therapy. Finally, the main research challenges and future perspectives are elaborated.

Long-term survival following resection of extracompartmental osteosarcoma of the spine - A case report and literature review

Background:

Osteosarcoma, representing 3% of sarcomas, rarely involves the axial skeleton. The overall 5-year survival is just 18%. Here, we present a 15-year-old female with an extracompartmental osteosarcoma, who following radical spine surgery, chemotherapy, and intensive radiotherapy remained disease-free 15.5 years later.

Case Description:

A 15-year-old female presented with an acute right lower extremity monoparesis and T4 relative sensory level attributed to a T4 extracompartmental Osteosarcoma. Following circumferential spine surgery, chemotherapy, and radiotherapy, her tumor did not recur over the 15.5-year follow-up period.

Conclusion:

Osteosarcoma rarely presents focally in the spine. When it originates in the spine, there are typically few long-term survivors. Here, we report a 15-year-old female who presented with an acute monoparesis attributed to an extracompartmental T4 spinal osteosarcoma. Following circumferential tumor resection, adjuvant chemotherapy, and radiotherapy, the patient remains disease-free 15.5 years later.

Primary mobile vertebral column sarcomas: Prognostic factors vary by histologic subtypes

BACKGROUND

Primary sarcomas originating from the mobile spine portends a particularly sinister outcome. Rarity of the disease process has resulted in inconsistent data due to small sample size and heterogeneity in patient selection and analytics.

METHODS

Surveillance, Epidemiology and End Result (SEER) database from 1975 to 2017 was queried to report incidence and survival data in 712 patients in the United States. Kaplan-Meier and Cox Regression were used to determine the prognostic factors affecting survival.

RESULTS

Incidence of spinal sarcoma was 0.019 per 100,000 persons in 2017 and has not significantly changed since 2000 (p > 0.05). Disease-specific 5-year survival for the entire cohort was 57%. Osteosarcoma has the worst 5-year survival (39%) and chondrosarcoma has the best 5-year survival (69%). Independent predictors of survival for the entire cohort included age, grade, and stage. Stage was an independent predictor of survival for every histologic subtype. Additional predictors of survival for spinal osteosarcoma, Ewing sarcoma, and chondrosarcoma included age, size, and grade, respectively.

CONCLUSIONS

The current study is an analysis of a population-based registry reporting incidence survival data for patients with sarcoma of mobile vertebral column. Survival and prognostic factors vary by histologic subtypes. There is lack of improvement in survival over the last three decades.

Henry J. Mankin: A Trailblazer in Skeletal Pathology Research

: Dr. Henry Mankin has made a profound impact in the fields of skeletal surgery and orthopedics. In a career spanning over 50 years, Dr. Mankin conducted extensive research on and provided treatment for numerous patients with Gaucher disease and spinal tumors such as sacral chordomas. Dr. Mankin's prolific career includes many leadership positions in the field of skeletal surgery, including Chief of Orthopaedics at the Hospital for Joint Diseases and at Massachusetts General Hospital. He has touched the lives of over 19,000 patients with bone and soft tissue tumors and undoubtedly shaped the future of skeletal surgery.

Non-operative management of spinal metastases: A prognostic model for failure

OBJECTIVES

To describe patient-specific characteristics associated with non-operative failure leading to surgery.

PATIENTS AND METHODS

We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications.

RESULTS

We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004).

CONCLUSION

We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.

Clinical effectiveness of Enneking appropriate versus Enneking inappropriate procedure in patients with primary osteosarcoma of the spine: a systematic review with meta-analysis

PURPOSE

Primary osteosarcoma of the spine is a rare osseous tumour. En bloc resection, in contrast to intralesional resection, is the only procedure able to provide Enneking appropriate (EA) margins, which has improved local control and survival of patients with primary osteosarcoma of the spine. The objective of this study is to compare the risk of local recurrence, metastases development and survival in patients with primary osteosarcoma of the spine submitted to Enneking appropriate (EA) and Enneking inappropriate (EI) procedures.

METHODS

A systematic search was performed on EBSCO, PubMed and Web of Science, between 1966 and 2018, to identify studies evaluating patients submitted to resection of primary osteosarcoma of the spine. Two reviewers independently assessed all reports. The outcomes were local recurrence, metastases development and survival at 12, 24 and 60 months.

RESULTS

Five studies (108 patients) were included for systematic review. These studies support the conclusion that EA procedure has a lower local recurrence rate (RR 0.33, 95% CI 0.17-0.66), a lower metastases development rate (RR 0.39, 95% CI 0.17-0.89) and a higher survival rate at 24 months (RR 1.78, 95% CI 1.24-2.55) and 60 months (RR 1.97, 95% CI 1.14-3.42) of follow-up; however, at 12 months, there is a non-significant difference.

CONCLUSIONS

EA procedure increases the ratio of remission and survival after 24 months of follow-up. Multidisciplinary oncologic groups should weigh the morbidity of an en bloc resection, knowing that in the first year the probability of survival is the same for EA and EI procedures. These slides can be retrieved under Electronic Supplementary Material.

Prognostic significance of human telomerase reverse transcriptase promoter region mutations C228T and C250T for overall survival in spinal chordomas

BACKGROUND

Spinal chordomas, a subtype of primary spinal column malignancies (PSCM), are rare tumors with poor prognosis, and we have limited understanding of the molecular drivers of neoplasia.

METHODS

Study design was a retrospective review of prospectively collected data with cross-sectional survival. Archived paraffin embedded pathologic specimens were collected for 133 patients from 6 centers within Europe and North America between 1987 and 2012. Tumor DNA was extracted and the human telomerase reverse transcriptase (hTERT) promoter was sequenced. The hTERT mutational status was correlated with overall survival (OS) and time to first local recurrence.

RESULTS

Ninety-two chordomas, 26 chondrosarcomas, 7 osteosarcomas, 3 Ewing's sarcomas, and 5 other malignant spinal tumors were analyzed. Median OS following surgery was 5.8 years (95% CI: 4.6 to 6.9) and median time to first local recurrence was 3.9 years (95% CI: 2.5 to 6.7). Eight chordomas, 2 chondrosarcomas, 1 Ewing's sarcoma, and 1 other malignant spinal tumor harbored either a C228T or C250T mutation in the hTERT promoter. In the overall cohort, all patients with hTERT mutation were alive at 10 years postoperative with a median OS of 5.1 years (95% CI: 4.5 to 6.6) (P = 0.03). hTERT promoter mutation was observed in 8.7% of spinal chordomas, and 100% of chordoma patients harboring the mutation were alive at 10 years postoperative compared with 67% patients without the mutation (P = 0.05).

CONCLUSIONS

We report for the first time that hTERT promoter mutations C228T and C250T are present in approximately 8.7% of spinal chordomas. The presence of hTERT mutations conferred a survival benefit and could potentially be a valuable positive prognostic molecular marker in spinal chordomas.

Spinal sarcomas and immunity: An undervalued relationship

Sarcomas, especially spine sarcomas, are rare yet debilitating and are underestimated types of cancer. Treatment options for spine sarcomas are limited to chemotherapy, radiotherapy and surgical intervention. Accumulating evidence suggests a complex course associated with the treatment of spine sarcomas as compared to other soft tissue sarcomas in the extremities since adjuvant therapy adds limited success to the oncological outcome. Likewise, the limitations of surgical interventions imposed by the proximity and high sensitivity of the spinal cord, leads to an increased recurrence and mortality rates associated with spine sarcomas. Finding novel treatment options to spine sarcomas as such is inevitable, necessitating a more thorough understanding of the different mechanisms of the underlying etiologies of these tumors. In this review, we discuss the most recent studies tackling the involvement of the immune system; a key player in the emergence of the different types of spine sarcomas and the promising immune-mediated targeted therapy that can be applied in these kind of rare cancers.

Novel therapeutic strategies for spinal osteosarcomas

At the dawn of the third millennium, cancer has become the bane of twenty-first century man, and remains a predominant public health burden, affecting welfare and life expectancy globally. Spinal osteogenic sarcoma, a primary spinal malignant tumor, is a rare and challenging neoplastic disease to treat. After the conventional therapeutic modalities of chemotherapy, radiation and surgery have been exhausted, there is currently no available alternative therapy in managing cases of spinal osteosarcoma. The defining signatures of tumor survival are characterised by cancer cell ability to stonewall immunogenic attrition and apoptosis by various means. Some of these biomarkers, namely immune-checkpoints, have recently been exploited as druggable targets in osteosarcoma and many other different cancers. These promising strides made by the use of reinvigorated immunotherapeutic approaches may lead to significant reduction in spinal osteosarcoma disease burden and corresponding reciprocity in increase of survival rates. In this review, we provide the background to spinal osteosarcoma, and proceed to elaborate on contribution of the complex ecology within tumor microenvironment giving arise to cancerous immune escape, which is currently receiving considerable attention. We follow this section on the tumor microenvironment by a brief history of cancer immunity. Also, we draw on the current knowledge of treatment gained from incidences of osteosarcoma at other locations of the skeleton (long bones of the extremities in close proximity to the metaphyseal growth plates) to make a case for application of immunity-based tools, such as immune-checkpoint inhibitors and vaccines, and draw attention to adverse upshots of immune-checkpoint blockers as well. Finally, we describe the novel biotechnique of CRISPR/Cas9 that will assist in treatment approaches for personalized medication.

Changes to the American Joint Committee on Cancer staging system for spine tumors-practice update

The American Joint Committee on Cancer recently released the 8th edition staging manual; this provides the staging system used at nearly all American cancer centers and many international centers. For the first time, this system separates out spine and pelvic tumors with a separate and distinct TNM classification. This practice update reviews these changes along with the rationale and data behind this change.

Molecular foundations of primary spinal tumors-implications for surgical management

Primary spinal tumors are rare lesions that require careful clinical management due to their intimate relationship with critical neurovascular structures and the significant associated risk of morbidity. While the advent of molecular and genomic profiling is beginning to impact the management of the cranial counterparts, translation for spinal tumors has lagged behind. Maximal safe surgical resection remains the mainstay of patients with primary spinal tumors, with extent of resection and histology the only consistently identified independent predictors of survival. Adjuvant therapy has had limited impact. To develop targeted neoadjuvant and adjuvant therapies, improve prognostication, and enhance patient selection in spinal oncology, a thorough understanding of the current molecular and genomic landscape of spinal tumors is required. In this review, we detail the epidemiology, current standard-of-care, and molecular features of the most commonly encountered intramedullary spinal cord tumors (IMSCT), intradural extramedullary (IDEM) tumors, and primary spinal column malignancies (PSCM). We further discuss current efforts and future opportunities for integrating molecular advances in spinal oncology with clinical management.

Spinal osteosarcoma in the paediatric age group: case series and literature review

INTRODUCTION AND OBJECTIVE

Osteosarcoma is the most frequent malignant spinal tumour in the paediatric age group. Diagnosis and early treatment of this pathology is essential for a good prognosis. The aim of this study was to present the results of treatment of paediatric patients with lumbar osteosarcoma and conduct a literature review.

MATERIAL AND METHODS

All the patients with lumbar osteosarcoma who were operated between 2012 and 2014 in the same centre were included. Demographic and radiological data (Enneking, WBB and Tomita classification), as well as anatomopathological (Broders classification) variables were analysed. All the patients were treated by surgical resection associated with adjuvant therapies (chemotherapy and radiotherapy); according to consensus with the tumour committee. The average follow-up was 62.53 months (47-70 months).

RESULTS

A total of 3 patients were studied, two girls of 9 and 11, with L5 osteosarcoma, and a 15-year-old boy with L4 osteosarcoma. Two of the cases were initially treated as an osteoblastoma, supported by radiological and anatomopathological images. None of the patients had local recurrences or metastases during follow-up.

CONCLUSIONS

Due to a lack of long series of cases of osteosarcoma in the mobile spine during childhood, the optimal treatment and prognosis in these patients is uncertain. Block resection improves local control of the disease, without demonstrating improvement in overall survival. Intralesional resection is associated with a higher rate of local recurrence. Oncological treatment is essential in the treatment of this pathology. A correct differential diagnosis of the tumour (osteosarcoma vs. osteoblastoma) is vital for its correct treatment.

Prognostic determinants and treatment outcomes analysis of osteosarcoma and Ewing sarcoma of the spine

BACKGROUND CONTEXT

Osteosarcoma (OGS) and Ewing sarcoma (EWS) are the two classic primary malignant bone tumors. Due to the rarity of these tumors, evidence on demographics, survival determinants, and treatment outcomes for primary disease of the spine are limited and derived from small case series.

PURPOSE

To use population-level data to determine the epidemiology and prognostic indicators in patients with OGS and EWS of the osseous spine.

STUDY DESIGN/SETTING

Large-scale retrospective study.

PATIENT SAMPLE

Patients diagnosed with OGS and EWS of the spine in the Surveillance, Epidemiology, and End Results (SEER) registry from 1973 to 2012.

OUTCOME MEASURES

Overall survival (OS) and disease-specific survival (DSS).

METHODS

Two separate queries of the SEER registry were performed to identify patients with OGS and EWS of the osseous spine from 1973-2012. Study variables included age, sex, race, year of diagnosis, tumor size, extent of disease (EOD), and treatment with surgery and/or radiation therapy. Primary outcome was defined as OS and DSS in months. Univariate survival analysis was performed using the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed using Cox proportional hazards regression models.

RESULTS

The search identified 648 patients with primary OGS and 736 patients with primary EWS of the spine from 1973 to 2012. Mean age at diagnosis was 48.1 and 19.9 years for OGS and EWS, respectively, with OGS showing a bimodal distribution. The median OS and DSS were 1.3 and 1.7 years, respectively, for OGS, with OGS in Paget's disease having worse OS (0.7 years) relative to the mean (log-rank p=.006). The median OS and DSS for EWS were 3.9 and 4.3 years, respectively. Multivariate cox regression analysis showed that age (OS p<.001, DSS p<.001), decade of diagnosis (OS p=.049), surgical resection (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent positive prognostic indicators for spinal OGS; radiation therapy predicted worse OS (hazard ratio [HR] 1.48, confidence interval [CI] 1.05-2.10, p=.027) and DSS (HR 1.74, CI 1.13-2.66, p=.012) for OGS. For EWS, age (OS p<.001, DSS p<.001), surgical resection (OS p=.030, DSS p=.046), tumor size (OS p<.001, DSS p<.001), and EOD (OS p<.001, DSS p<.001) were independent determinants of improved survival; radiation therapy trended toward improved survival but did not achieve statistical significance for both OS (HR 0.76, CI 0.54-1.07, p=.113) and DSS (0.76, CI 0.54, 1.08, p=.126).

CONCLUSIONS

Age, surgical resection, and EOD are key survival determinants for both OGS and EWS of the spine. Radiation therapy may be associated with worse outcomes in patients with OGS, and is of potential benefit in EWS. Overall prognosis has improved in patients with OGS of the spine over the last four decades.

The role of revision surgery and adjuvant therapy following subtotal resection of osteosarcoma of the spine: a systematic review with meta-analysis

OBJECTIVE Primary osteosarcoma of the spine is a rare osseous neoplasm. While previously reported retrospective studies have demonstrated that overall patient survival is impacted mostly by en bloc resection and chemotherapy, the continued management of residual disease remains to be elucidated. This systematic review was designed to address the role of revision surgery and multimodal adjuvant therapy in cases in which en bloc excision is not initially achieved. METHODS A systematic literature search spanning the years 1966 to 2015 was performed on PubMed, Medline, EMBASE, and Web of Science to identify reports describing outcomes of patients who underwent biopsy alone, neurological decompression, or intralesional resection for osteosarcoma of the spine. Studies were reviewed qualitatively, and the clinical course of individual patients was aggregated for quantitative meta-analysis. RESULTS A total of 16 studies were identified for inclusion in the systematic review, of which 8 case reports were summarized qualitatively. These studies strongly support the role of chemotherapy for overall survival and moderately support adjuvant radiation therapy for local control. The meta-analysis revealed a statistically significant benefit in overall survival for performing revision tumor debulking (p = 0.01) and also for chemotherapy at relapse (p < 0.01). Adjuvant radiation therapy was associated with longer survival, although this did not reach statistical significance (p = 0.06). CONCLUSIONS While the initial therapeutic goal in the management of osteosarcoma of the spine is neoadjuvant chemotherapy followed by en bloc marginal resection, this objective is not always achievable given anatomical constraints and other limitations at the time of initial clinical presentation. This systematic review supports the continued aggressive use of revision surgery and multimodal adjuvant therapy when possible to improve outcomes in patients who initially undergo subtotal debulking of osteosarcoma. A limitation of this systematic review is that lesions amenable to subsequent resection or tumors inherently more sensitive to adjuvants would exaggerate a therapeutic effect of these interventions when studied in a retrospective fashion.

Management of Bone Sarcoma

Treatment of bone sarcoma requires careful planning and involvement of an experienced multidisciplinary team. Significant advancements in systemic therapy, radiation, and surgery in recent years have contributed to improved functional and survival outcomes for patients with these difficult tumors, and emerging technologies hold promise for further advancement.

Primary osseous tumors of the pediatric spinal column: review of pathology and surgical decision making

Spinal column tumors are rare in children and young adults, accounting for only 1% of all spine and spinal cord tumors combined. They often present diagnostic and therapeutic challenges. In this article, the authors review the current management of primary osseous tumors of the pediatric spinal column and highlight diagnosis, management, and surgical decision making.

Osteosarcoma of the spine: prognostic variables for local recurrence and overall survival, a multicenter ambispective study

OBJECTIVE

Primary spinal osteosarcomas are rare and aggressive neoplasms. Poor outcomes can occur, as obtaining marginal margins is technically demanding; further Enneking-appropriate en bloc resection can have significant morbidity. The goal of this study is to identify prognostic variables for local recurrence and mortality in surgically treated patients diagnosed with a primary osteosarcoma of the spine.

METHODS

A multicenter ambispective database of surgically treated patients with primary spine osteosarcomas was developed by AOSpine Knowledge Forum Tumor. Patient demographic, diagnosis, treatment, perioperative morbidity, local recurrence, and cross-sectional survival data were collected. Tumors were classified in 2 cohorts: Enneking appropriate (EA) and Enneking inappropriate (EI), as defined by pathology margin matching Enneking-recommended surgical margins. Prognostic variables were analyzed in reference to local recurrence and survival.

RESULTS

Between 1987 and 2012, 58 patients (32 female patients) underwent surgical treatment for primary spinal osteosarcoma. Patients were followed for a mean period of 3.5 ± 3.5 years (range 0.5 days to 14.3 years). The median survival for the entire cohort was 6.7 years postoperative. Twenty-four (41%) patients died, and 17 (30%) patients suffered a local recurrence, 10 (59%) of whom died. Twenty-nine (53%) patients underwent EA resection while 26 (47%) patients underwent EI resection with a postoperative median survival of 6.8 and 3.7 years, respectively (p = 0.048). EI patients had a higher rate of local recurrence than EA patients (p = 0.001). Patient age, previous surgery, biopsy type, tumor size, spine level, and chemotherapy timing did not significantly influence recurrence and survival.

CONCLUSIONS

Osteosarcoma of the spine presents a significant challenge, and most patients die in spite of aggressive surgery. There is a significant decrease in recurrence and an increase in survival with en bloc resection (EA) when compared with intralesional resection (EI). The effect of adjuvant and neoadjuvant chemotherapeutics, as well as method of biopsy, requires further exploration.

Imaging of presacral masses--a multidisciplinary approach

Our objective is to describe an approach for retrorectal/presacral mass evaluation on imaging with attention to imaging features, allowing for refinement of the differential diagnosis of these masses. Elaborate on clinically relevant features that may affect biopsy or surgical approach, of which the radiologist should be aware. A review of current literature regarding the diagnosis and treatment of retrorectal/presacral masses was performed with attention to specific findings, which may lend refinement to the differential diagnosis of these masses. Cases were obtained by searching through a radiology database at a single institution after Institutional Review Board approval. Recent advances in imaging and treatment methods have led to the increased role of radiology in both imaging and tissue diagnosis of retrorectal masses. Surgical philosophies surrounding the treatment of these masses have not significantly changed in recent years, but there are a few key factors of which the radiologist must be aware. The radiologist can offer refinement of the differential diagnosis of retrorectal masses and can elaborate on salient findings which could alter the need for neoadjuvant chemoradiation therapy, pre-surgical tissue diagnosis and surgical approach. This article presents an imaging approach to retrorectal/presacral masses with emphasis on findings which can dictate the ultimate need for neoadjuvant therapy and pre-surgical tissue diagnosis and alter the preferred surgical approach. This article consolidates key findings, so radiologists can become more clinically relevant in the evaluation of these masses.

Modeling 1-year survival after surgery on the metastatic spine

BACKGROUND CONTEXT

Choosing appropriate surgical patients in the setting of spinal metastases can be challenging. Existing scoring systems focus primarily on patient selection or operative techniques. These scores are limited in their capacity to predict postoperative survival.

PURPOSE

The aim was to model survival after spine surgery for metastastic disease.

STUDY DESIGN

This was a retrospective multicenter study.

PATIENT SAMPLE

All patients who had undergone surgery for the treatment of metastatic spinal disease at one of four tertiary care centers between 2007 and 2013 were included.

OUTCOME MEASURE

The outcome measure was 1-year survival after surgery.

METHODS

Demographic, medical, oncologic, surgical, and survival data were abstracted from medical records. The effect of predictor variables on survival was evaluated alone and in combination using stepwise logistic regression. Multivariable logistic regression was subsequently used to adjust for confounders. A predictive score was then developed and compared against that of the modified Bauer score alone in terms of prognosticating 1-year survival after surgery.

RESULTS

In the time period under investigation, 318 patients underwent surgical intervention for metastastic disease involving the spine, with 307 having data available for analysis. The survival rate at 1 year was 48% (n=142), with a median survival of 10 months. In final adjusted analysis, preoperative modified Bauer score (odds ratio [OR] 3.00; 95% confidence interval [CI] 1.80-5.01; p<.001), ambulatory status (OR 2.47; 95% CI 1.48-4.14; p=.001), and serum albumin (OR 2.80; 95% CI 1.66-4.72; p<.001) were all independent predictors of 1-year survival. The most parsimonious model weighted the modified Bauer score with 2 points and intact ambulatory status and normal serum albumin level with 1 point each, with a ceiling score of 3. The final model using the predictive score was able to explain 74% of the variation in 1-year survival. In contrast, the modified Bauer score alone was only able to explain 64% of the variation in 1-year survival.

CONCLUSIONS

This study demonstrates the importance of including factors related to the overall health of a patient, in addition to parameters surrounding their cancer diagnosis, to better prognosticate survival. Our predictive score performed better than the modified Bauer alone and may be used to predict survival after surgical intervention for metastatic disease.

LEVEL OF EVIDENCE

III.

RANK ligand blockade with denosumab in combination with sorafenib in chemorefractory osteosarcoma: a possible step forward?

BACKGROUND

There is no established systemic treatment option for unresectable osteosarcoma progressing after standard chemotherapy. A recently published clinical trial has demonstrated some activity of sorafenib in this situation. Preclinical research suggests a role for the inhibition of the receptor activator of nuclear factor-ĸB ligand (RANKL), but no clinical data have been reported so far.

CASE REPORT

A 37-year-old man was diagnosed with unresectable osteoblastic, osteoblastoma-like osteosarcoma in the C7/Th1 vertebra. The tumour progressed locally despite two lines of chemotherapy and stereotactic radiotherapy. On treatment with sorafenib and denosumab, a complete metabolic remission was achieved and is ongoing for over 18 months. Immunohistochemistry revealed an overexpression of RANK and RANKL in the patient's primary tumour.

DISCUSSION

This is the first report of activity achieved by the combination of the tyrosine kinase inhibitor sorafenib and the RANKL inhibitor denosumab in a patient with osteosarcoma. It confirms preclinical data on RANK/RANKL inhibition in osteosarcoma and could serve as a hypothesis-generating approach for clinical trials in this patient population.

Osteosarcoma of the spine: dismal past, any hope for the future?

PURPOSE

The purpose of this study was to analyse all cases of spinal osteosarcoma (OS) treated in a regional bone tumour unit over the last 27 years. We were primarily interested in overall survival following tumour surgery, and if there is a difference in the survival of patients undergoing en bloc resection versus non-en bloc surgery.

METHODS

Prospectively maintained tumour databases were searched in a regional bone tumour unit. All cases of surgically managed spinal OS were extracted and inpatient notes, imaging (including staging), histological margin status, and outcomes (neurological deficit and survival curves) were reviewed.

RESULTS

Twenty-six patients were identified between 1985 and 2012. The median age was 26.5 years (range 6-78 y). Overall Kaplan-Meier survival was 69.5% (95% CI: 46.3-84.2%) and 10.8% (95% CI: 1.8-29.0%) at 1 and 5 years, respectively. There appears to be improved survival associated with primary spinal OS compared to that of metastatic disease, but this does not reach statistical significance (p = 0.29, Cox proportional hazards analysis). En bloc resection results in a significantly improved survival time compared to non-en bloc (biopsy and debulking): 44.1% alive at 2 years compared to 9.4%, respectively, p = 0.009.

CONCLUSIONS

En bloc resection for primary spinal OS is associated with improved survival; there have been major changes in both surgical treatment and chemo/radiotherapy regimens over the period studied, potentially confounding the interpretation.

Spinal osteosarcoma

Although osteosarcoma represents the second most common primary bone tumor, spinal involvement is rare, accounting for 3%–5% of all osteosarcomas. The most frequent symptom of osteosarcoma is pain, which appears in almost all patients, whereas more than 70% exhibit neurologic deficit. At a molecular level, it is a tumor of great genetic complexity and several genetic disorders have been associated with its appearance. Early diagnosis and careful surgical staging are the most important factors in accomplishing sufficient management. Even though overall prognosis remains poor, en-block tumor removal combined with adjuvant radiotherapy and chemotherapy is currently the treatment of choice. This paper outlines histopathological classification, epidemiology, diagnostic procedures, and current concepts of management of spinal osteosarcoma.

Survival and recurrence rate after treatment for primary spinal sarcomas

Objective

We have limited understanding on the presentation and survival of primary spinal sarcomas. The survival, recurrence rate, and related prognostic factors were investigated after treatment for primary sarcomas of the spine.

Methods

Retrospective analysis of medical records and radiological data was done for 29 patients in whom treatment was performed due to primary sarcoma of the spine from 2000 to 2010. As for treatment method, non-radical operation, radiation therapy, and chemotherapy were simultaneously or sequentially combined. Overall survival (OS), progression free survival (PFS), ambulatory function, and pain status were analyzed. In addition, factors affecting survival and recurrence were analyzed : age (≤42 or ≥43), gender, tumor histologic type, lesion location (mobile spine or rigid spine), weakness at diagnosis, pain at diagnosis, ambulation at diagnosis, initial treatment, radiation therapy, kind of irradiation, surgery, chemotherapy and distant metastasis.

Results

Median OS was 60 months, the recurrence rate was 79.3% and median PFS was 26 months. Patients with distant metastasis showed significantly shorter survival than those without metastasis. No factors were found to be significant relating to recurrence. Prognostic factor associated with walking ability was the presence of weakness at diagnosis.

Conclusion

Primary spinal sarcomas are difficult to cure and show high recurrence rate. However, the development of new treatment methods is improving survival.

A review of update clinical results of carbon ion radiotherapy

Among various types of ion species, carbon ions are considered to have the most balanced, optimal properties in terms of possessing physically and biologically effective dose localization in the body. This is due to the fact that when compared with photon beams, carbon ion beams offer improved dose distribution, leading to the concentration of the sufficient dose within a target volume while minimizing the dose in the surrounding normal tissues. In addition, carbon ions, being heavier than protons, provide a higher biological effectiveness, which increases with depth, reaching the maximum at the end of the beam's range. This is practically an ideal property from the standpoint of cancer radiotherapy. Clinical studies have been carried out in the world to confirm the efficacy of carbon ions against a variety of tumors as well as to develop effective techniques for delivering an efficient dose to the tumor. Through clinical experiences of carbon ion radiotherapy at the National Institute of Radiological Sciences and Gesellschaft für Schwerionenforschung, a significant reduction in the overall treatment time with acceptable toxicities has been obtained in almost all types of tumors. This means that carbon ion radiotherapy has meanwhile achieved for itself a solid place in general practice. This review describes clinical results of carbon ion radiotherapy together with physical, biological and technological aspects of carbon ions.

Osteosarcoma of the mobile spine

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Our goal was to assess whether en bloc resection had an impact on survival.

SUMMARY OF BACKGROUND DATA

Osteogenic sarcoma occurs rarely in the mobile spine, but when it does, the prognosis is poor. Wide resection is recommended for osteogenic sarcoma of the extremities, but wide resection is difficult and often dangerous in the spine. The goal of this study was to examine whether en bloc removal of osteogenic sarcomas in the mobile spine improves survival.

METHODS

We performed a retrospective review of all cases of high-grade, osteogenic sarcoma of the mobile spine treated with high-dose methotrexate and adrimaycin-based chemotherapy between 1985 through 2005. There were 9 male patients and 8 female patients. Patients were followed for a median of 38 months or until death, and surviving patients were followed for a minimum of 6.4 years. Patients were grouped on the basis of whether they underwent en bloc spondylectomy. The Enneking stage and Weinstein, Boriani, and Biagini stage, as well as the pre- and postoperative Frankel grades, were collected on all patients. Local recurrence and metastasis data were collected for all patients. Overall survival was calculated using Kaplan-Meier methods with the log rank test utilized to evaluate the effect of en bloc resection on survival.

RESULTS

Twelve (71%) of 17 patients with osteogenic sarcoma of the mobile spine died. Median disease-specific survival for the entire cohort was 38.1 months (standard error 29.6; 95% confidence interval 0-96). Nine patients underwent en bloc resection. Median overall survival for patients after en bloc resection was 77.3 months (standard error 62; 95% confidence interval 96) versus 17 months (standard error 6.5; 95% confidence interval 4-29.6) (P = 0.09). Eleven (65%) of 17 patients developed pulmonary metastasis, and 9 of those 11 died from their disease (P = 0.04). Six (35%) patients developed a local recurrence, and all 6 died from their disease (P = 0.07).

CONCLUSION

Osteogenic sarcoma of the mobile spine presents a significant challenge, and most patients die from their disease in spite of aggressive surgery and chemotherapy. Metastastic disease is associated with a worse prognosis. There is a trend toward improved survival with en bloc resection when compared with intralesional resection. Osteogenic sarcoma of the mobile spine is rare and historically has a very poor prognosis. We reviewed our cases of osteogenic sarcoma of the mobile spine to assess whether modern en bloc resection improved survival. Survival remains poor, but there is a trend toward improved survival with en bloc resection.