Scandinavian Sarcoma Group Osteosarcoma Study SSG VIII: prognostic factors for outcome and the role of replacement salvage chemotherapy for poor histological responders

Effect of chemotherapy and surgery timing on mortality in upper and lower extremity osteosarcoma

BACKGROUND

Surgery with neoadjuvant and adjuvant chemotherapy represents the standard of care for extremity osteosarcoma despite a lack of high-quality evidence for its use, and trial evidence that suggests upfront surgery may result in better outcomes. This study estimated the difference in overall survival for the standard of care (neoadjuvant first) vs upfront surgery first followed by adjuvant chemotherapy (surgery first).

METHODS

Using Surveillance, Epidemiology, and End Results data, we identified patients aged 5-29 years diagnosed with a primary cancer of upper or lower extremity osteosarcoma between 2007 and 2019 who received surgery and chemotherapy. Our primary endpoint was the 5-year survival difference between the surgery first and neoadjuvant first groups.

RESULTS

Adjusted 5-year survival was 74% for surgery first patients and 67% for neoadjuvant first patients, with a survival difference of 6.9% (95% confidence interval [CI] = -4.2% to 16.1%). In sensitivity analyses of 5-year survival, the results were consistent, showing a 6.8%-13.7% higher 5-year survival in surgery first patients. Statistically significant mortality risk factors included older age, larger tumor size, the type of resection (salvage vs amputation), and stage III-IV disease (vs stage I-II disease).

CONCLUSION

The evidence supporting neoadjuvant therapy in osteosarcoma care is weak. However, there is evidence that pausing chemotherapy in the perisurgical period might affect outcomes. Consequently, this study, and its consistency with the results from the only randomized trial to address this question, suggests that there is reason to revisit a prospective, randomized trial of osteosarcoma treatment regarding the timing of surgery and chemotherapy.

Tumor necrosis drives prognosis in osteosarcoma: No difference in chemotherapy response and survival between chondroblastic and osteoblastic osteosarcoma

INTRODUCTION

The percentage of tumor necrosis is a crucial prognostic factor in osteosarcoma. Many studies adopt a 90 % cutoff based on osteoblastic osteosarcoma, but these findings are generalized to all conventional subtypes, including chondroblastic osteosarcoma. We sought to answer these questions: (1) Is tumor necrosis ≥90 % associated with better overall survival (OS) and disease-free survival (DFS) in osteoblastic and chondroblastic osteosarcoma? (2) Does the osteosarcoma subtype impact tumor necrosis? (3) Does the osteosarcoma subtype in "good" responders (tumor necrosis ≥90 %) affect OS and DFS?.

MATERIALS AND METHODS

We conducted a retrospective study of 156 patients with osteoblastic and chondroblastic osteosarcoma treated at our institution. All patients received a standardized chemotherapy protocol and underwent surgery with the goal of achieving negative margins (R0 resection). Propensity-score matching was performed to adjust for potential confounders. Kaplan-Meier survival analysis and Cox proportional hazards modeling were performed.

RESULTS

Patients with osteoblastic osteosarcoma and tumor necrosis ≥90 % had higher 5- and 10-year OS and DFS compared to those with necrosis <90 %. In chondroblastic osteosarcoma, a trend towards higher OS and DFS was seen in patients with tumor necrosis ≥90 %; this, however, was not significant. Chondroblastic osteosarcoma was not a risk factor for either tumor necrosis <90 % (p = 0.89) or tumor necrosis <70 % (p = 0.57). Patients with osteoblastic or chondroblastic osteosarcoma that were deemed "good" responders (tumor necrosis ≥90 %) had similar OS and DFS at the 5- and 10-year marks.

CONCLUSION

Conventional osteosarcoma subtype was not a risk factor for "poor" response. Survival outcomes (OS and DFS) were similar for osteoblastic and chondroblastic osteosarcoma with good response to chemotherapy.

Long-term outcomes among survivors of childhood osteosarcoma: A report from the Childhood Cancer Survivor Study (CCSS)

PURPOSE

Treatment strategies for osteosarcoma evolving between 1970 and 1999 improved 5-year survival and continue as standard of care today. This report evaluates the impact of these evolving therapies on long-term health outcomes.

METHODS

Five-year survivors of childhood osteosarcoma in CCSS treated from 1970 to 1999 were evaluated for late (>5 years from diagnosis) mortality, chronic health conditions (CHCs), and health status using piecewise-exponential and logistical models. Comparisons were made between survivors and siblings without cancer, and among survivors examining historical and current standard chemotherapies (e.g., methotrexate/doxorubicin/cisplatin [MAP] vs. others), specific chemotherapy agents and surgical approaches (amputation vs. limb salvage [LS]). Models were evaluated adjusting for attained age, sex, race, ethnicity, and age at diagnosis.

RESULTS

A total of 1257 survivors of osteosarcoma were followed on average for 24.4 years. Twenty-year all-cause late mortality was 13.3% (95% confidence interval [CI]: 11.7%-14.9%) overall and 11.7% (95% CI: 6.9%-16.5%) for the subset treated with MAP plus LS. Survivors were at higher risk of CHCs (rate ratio [RR] 3.7, 95% CI: 3.2-4.3) than the sibling cohort, most notably having more serious cardiac, musculoskeletal, and hearing CHCs. Within the survivor cohort, the risk of severe CHCs was twice as high with MAP versus no chemotherapy (RR 2.1, 95% CI: 1.3-3.4). Compared with primary amputation, serious musculoskeletal CHCs were higher after LS (RR 6.6, 95% CI: 3.6-13.4), without discernable differences in health status.

CONCLUSION

Contemporary osteosarcoma therapy with MAP plus LS, while improving 5-year disease-free survival, continues to be associated with a high burden of late mortality, CHCs, and health status limitations.

Osteosarcoma in Pediatric and Adult Populations: Are Adults Just Big Kids?

Malignant bone tumors are commonly classified as pediatric or adolescent malignancies, and clinical trials for these diseases have generally focused on these populations. Of primary bone cancers, osteosarcoma is among the most common. Osteosarcoma has a bimodal age distribution, with the first peak occurring in patients from 10 to 14 years old, and the second peak occurring in patients older than 65, with about 25% of cases occurring in adults between 20 and 59 years old. Notably, adult osteosarcoma patients have worse outcomes than their pediatric counterparts. It remains unclear whether age itself is a poor prognostic factor, or if inherent differences in tumor biology exist between age groups. Despite these unknowns, current treatment strategies for adults are largely extrapolated from pediatric studies since the majority of clinical trials for osteosarcoma treatments are based on younger patient populations. In light of the different prognoses observed in pediatric and adult osteosarcoma, we summarize the current understanding of the molecular etiology of osteosarcoma and how it may differ between age groups, hypothesizing why adult patients have worse outcomes compared to children.

Chemotherapy Regimens for Non-Metastatic Conventional Appendicular Osteosarcoma: A Literature Review Based on the Outcomes

Osteosarcoma is a rare condition with a complex treatment. Most protocols include neoadjuvant chemotherapy, surgery, and consolidation chemotherapy as the standard of treatment. However, the use of neoadjuvant chemotherapy lacks scientific evidence proving superiority in opposition to the use of isolated chemotherapy in an adjuvant regimen after surgery. We conducted a review for studies published in English between 1980 and 2020, using the MEDLINE/PubMed and Scopus electronic databases, to evaluate the outcomes when using neoadjuvant chemotherapy or adjuvant chemotherapy strategies in the treatment of non-metastatic appendicular osteosarcoma, as well as the toxicity associated with different chemotherapeutic regimens. Patients were divided into a neoadjuvant chemotherapy group (NAC) and adjuvant chemotherapy group (ACT), depending on the chemotherapy regimen used in association with surgery. A total of 1254 articles in English were screened by title and abstract, and 146 were pre-selected for full reading and analysis. A total of 24 assays matching the inclusion criteria were selected: 10 prospective and 14 retrospective studies. This review points to an absence of significative differences in outcomes, namely overall survival, disease-free survival/event-free survival rates, or toxicity, regarding neoadjuvant or single adjuvant chemotherapy strategies used in the treatment of appendicular non-metastatic osteosarcomas. However, there is a significative difference in population dimensions between the NAC and the ACT groups. Additionally, clinical presentation, tumor localization, tumor volume, or histological type were not considered, with these variables presenting the potential to influence these results. Despite these limitations, our findings should allow a re-thinking of our current practice and promote new opportunities to optimize treatment, always looking towards better survival and lower complications rates.

High-dose chemotherapy followed by autologous stem cell transplantation in pediatric patients with relapsed osteosarcoma

BACKGROUND

Patients with relapsed osteosarcoma have poor treatment outcomes. High-dose chemotherapy with autologous stem cell transplantation (HDCT/ASCT) has been used in several high-risk malignant solid tumors; however, few studies have evaluated their role in treating osteosarcoma. We evaluated the effectiveness of HDCT/ASCT in relapsed pediatric osteosarcoma cases.

PROCEDURE

We retrospectively reviewed the medical records of 40 patients diagnosed with and treated for relapsed osteosarcoma at Asan Medical Center and Samsung Medical Center from January 1996 to July 2019.

RESULTS

The median age of this cohort was 13.4 years (range: 6.1-18.2). The cohort's 5-year overall survival (OS) was 51.0% ± 0.1% during a median follow-up period of 67.5 months. Twenty-five patients (62.5%) achieved complete remission (CR) with salvage treatment, and the 5-year OS was 82.4% ± 0.1%, whereas none of the remaining 15 patients who did not achieve CR survived (p < .0001). Of the 25 CR cases, 15 underwent subsequent HDCT/ASCT. We compared the effect of HDCT/ASCT among patients who achieved CR. There were no significant differences in the 5-year OS outcomes between patients who did and did not receive HDCT/ASCT (83.9% ± 0.1%, 13/15 vs. 80.0% ± 0.1%, 8/10, respectively; p = .923).

CONCLUSION

To our knowledge, we report the first comparative cohort study that proved HDCT/ASCT does not significantly improve survival outcomes in relapsed osteosarcoma. Achievement of CR remains the most crucial factor for good survival outcomes.

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.

CircSRSF4 Enhances Proliferation, Invasion, and Migration to Promote the Progression of Osteosarcoma via Rac1

(1) Background: At present, cancer cell metastasis is the main cause of death in patients with malignant tumors, and up to 23% of osteosarcoma patients have died due to lung and lymph node metastasis. Therefore, finding new molecules involved in tumor development can provide new strategies for the diagnosis and treatment of osteosarcoma patients. Circular RNAs (circRNAs) are a type of RNA molecule that are connected head-to-tail to form a closed ring. There is increasing evidence that circRNAs are RNA molecules with many biological functions in various diseases. However, the role and mechanism of circRNAs in osteosarcoma have rarely been reported. (2) Methods: The expression of circSRSF4 in osteosarcoma tissues and cell lines was detected by quantitative real-time PCR (RT-qPCR), and the result of high-throughput sequencing was verified. In order to explore the effect of circSRSF4 on tumor proliferation, invasion, and migration, a dual-luciferase reporter assay, RNA binding protein immunoprecipitation assay, cell counting kit-8 (CCK-8), transwell assay, scratch wound healing assay, Western blot analysis, and other experiments were carried out in vitro. Rescue experiments and a xenograft model confirmed that circSRSF4 directly acted on miR-224 to regulate Rac1 expression. (3) Results: The expression of circSRSF4 was significantly higher in osteosarcoma tissues and cell lines. Down-regulating the expression of circSRSF4 in vitro significantly inhibited the proliferation, invasion, and migration of cells, and also reduced the expression of Rac1, while the overexpression of Rac1 and miR-224 inhibition could reverse these effects. The inhibition of circSRSF4 expression in vivo also attenuated tumor growth. A mechanistic study showed that circSRSF4 can be used as an miR-224 sponge to up-regulate the expression of Rac1, thereby promoting the development of osteosarcoma. (4) Conclusions: CircSRSF4 acting as a ceRNA promotes the malignant behavior of osteosarcoma through the circSRSF4/miR-224/Rac1 axis, which provides a new theoretical basis for the clinical prevention and treatment of osteosarcoma and the study of related markers and intervention targets.

Management of Primary Aggressive Tumors of the Knee

Primary bone sarcomas and aggressive benign bone tumors are relatively rare. It is essential to recognize features that are concerning for these aggressive tumors based on a patient's history, physical exam, and radiographs. Physicians and other health care providers should have a high suspicion for these tumors and promptly refer these patients to orthopaedic oncologists. A multidisciplinary, team-based approach is required to obtain an accurate diagnosis and provide comprehensive care. This review discussed the appropriate work-up, biopsy principles, relevant peri-operative medical management, and surgical treatment options for patients with aggressive primary bone tumors around the knee. Primary bone sarcomas (osteosarcoma and chondrosarcoma) and aggressive benign bone tumors (giant cell tumor, chondroblastoma, and chondromyxoid fibroma) that have a predilection to the distal femur and proximal tibia are the focus of this review.

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.

Advancing therapy for osteosarcoma

Improving the survival of patients with osteosarcoma has long proved challenging, although the treatment of this disease is on the precipice of advancement. The increasing feasibility of molecular profiling together with the creation of both robust model systems and large, well-annotated tissue banks has led to an increased understanding of osteosarcoma biology. The historical invariability of survival outcomes and the limited number of agents known to be active in the treatment of this disease facilitate clinical trials designed to identify efficacious novel therapies using small cohorts of patients. In addition, trial designs will increasingly consider the genetic background of the tumour through biomarker-based patient selection, thereby enriching for clinical activity. Indeed, osteosarcoma cells are known to express a number of surface proteins that might be of therapeutic relevance, including B7-H3, GD2 and HER2, which can be targeted using antibody-drug conjugates and/or adoptive cell therapies. In addition, immune-checkpoint inhibition might augment the latter approach by helping to overcome the immunosuppressive tumour microenvironment. In this Review, we provide a brief overview of current osteosarcoma therapy before focusing on the biological insights from the molecular profiling and preclinical modelling studies that have opened new therapeutic opportunities in this disease.

State-of-the-art, approved therapeutics for the pharmacological management of osteosarcoma

Introduction: Advances in the treatment of osteosarcoma (OS) came in the mid-1970s, when adding chemotherapy to surgery significantly improved patient survival. OS outcomes have since plateaued, however, despite exhaustive clinical investigations.Area covered: This review focuses on the most significant recent results of trials (in phases II and III) on localized and metastatic/relapsing OS and offers an overview of new targeted drugs.Expert opinion: Recent findings confirm the MAP (methotrexate, doxorubicin, and cisplatin) regimen as the gold standard for OS patients, also in metastatic cases, and the inefficacy of augmenting or modifying chemotherapy in poor responder patients. Immunotherapy and several tyrosine kinase inhibitors seem to be effective and promising in the treatment of OS. Optimizing the use of active drugs available by personalizing chemotherapies might prove important in the future. We urgently need bench-to-bedside research on OS. This will need to involve the extensive sequencing and immunoprofiling of all resected tumor tissue to find new therapeutic agents, especially for relapsing/metastatic patients. The low incidence of OS, its genomic complexity, and differences within and between tumors combine to complicate efforts to elucidate the biology of this disease. This means that we need to pool the resources of different groups studying OS and support translational research.

Survival analysis of osteosarcoma patients: A 15-year experience

INTRODUCTION

Management of osteosarcoma has evolved considerably for the past two decades and there have been changes of practices especially pertaining to chemotherapy regime. This is a review of our cases in the past 15 years.

METHOD

This is a retrospective survival analysis study of 128 patients treated at University Malaya Medical Centre (UMMC) from 1997 to 2011.

RESULTS

There were 80 (62.5%) male and 48 (37.5%) female patients with the median age being 15 (5-59). Majority had osteosarcoma of extremities (94.5%). More than 60% patients developed metastasis throughout the course of treatment with 39% presenting with lung metastasis. Osteoblastic osteosarcoma was the commonest subtype (65.6%). Of the 109 patients treated surgically, 84 patients (65.6%) underwent limb salvage surgery while the rest underwent amputation. Seventy-one per cent of patients completed treatment with local recurrence rate of 22.7%. The 5-year and 10-year survival rates were 56.31% (95% CI: 46.20, 65.24) and 22.33% (95% CI: 14.86, 30.76), respectively. The 5-year event-free survival was 52.94% (95% CI: 41.83, 62.87). In multivariate analysis, the independent prognostic factors were presence of metastasis and completion of treatment for both 5-year and 10-year overall survival. Good histological response was only significant for multivariate analysis at 5 years. Patients with metastasis had a hazard ratio of 20.4 at 5 years and 3.26 at 10 years.

CONCLUSION

Overall survival rate for osteosarcoma patients at our centre was comparably higher than other centres in the region. Two independent risk factors for survival are metastatic status and completion of treatment. A standardized chemotherapy regime is essential for long-term survival.

Chitosan applications in studying and managing osteosarcoma

Osteosarcoma has a high prevalence among children and adolescents. Common treatments of this disease are not promising enough. Molecular processes involved in the pathogenesis of osteosarcoma are not fully understood. Besides, the remnants of tumor cells after surgery can cause bone destruction and recurrence of the disease. Thus, there is a need to develop novel drugs or enhancing the currently-used drugs as well as identifying bone-repairing methods. Chitosan is a natural compound produced by the deacetylation of chitin. Research has shown that chitosan can be used in various fields due to its beneficial effects, such as biodegradability and biocompatibility. Regarding cancer, chitosan exerts several anti-tumor activities. Moreover, it can be used in diagnostic techniques, drug delivery systems, and cell culture methods. Herein, we aim to discuss the potential roles of chitosan in studying and treating osteosarcoma. We review the literature on chitosan's applications as a drug delivery system and how it can be combined with other substances to improve its ability of local drug delivery. We take a look into the studies concerning the possible benefits of chitosan in the field of bone tissue engineering and 3D culturing. Furthermore, anti-cancer activities of different compounds of chitosan are reviewed.

Clinical factors affecting prognosis of limb osteosarcoma in China: a multicenter retrospective analysis

Objective

This study was performed to explore the relationship between various clinical factors and the prognosis of limb osteosarcoma.

Methods

We retrospectively analyzed the clinical data of 336 patients with limb osteosarcoma treated from June 2000 to August 2016 at 7 Chinese cancer centers. Data on the patients’ clinical condition, treatment method, complications, recurrences, metastasis, and prognosis were collected and analyzed. Kaplan–Meier analysis and Cox regression models were used to analyze the data.

Results

The patients comprised 204 males and 132 females ranging in age from 6 to 74 years (average, 21.1 years). The overall 3- and 5-year survival rates were 65.0% and 55.0%, respectively. The 5-year overall survival rate was 64.0% with standard chemotherapy and 45.6% with non-standard chemotherapy. Cox regression analysis demonstrated that standard chemotherapy, surgery, recurrence, and metastasis were independent factors associated with the prognosis of limb osteosarcoma.

Conclusion

The survival of patients with limb osteosarcoma can be significantly improved by combining standard chemotherapy and surgery. The overall survival rate can also be improved by adding methotrexate to doxorubicin–cisplatin–ifosfamide triple chemotherapy.

Characteristics and Prognostic Factors of Patients With Osteosarcoma Older Than 60 Years From the SEER Database

Osteosarcoma is predominant in the adolescent and the elderly population, but few studies have described the characteristics and prognostic factors of patients older than 60 years. In this study, the Surveillance, Epidemiology, and End Results registry database was used to identify all patients diagnosed with primary osteosarcoma from 1973 to 2014. We utilized Cox proportional hazards regression analysis to evaluate the association between patient overall survival and relevant characteristics, including gender, race, disease stage, treatment methods, primary tumor site, differentiation grade, and histologic subtype. In the data set, a total of 1139 patients with osteosarcoma older than 60 years old were identified. The overall rate of distant metastatic cases was 28.6%. Osteosarcoma occurred equally in men and women (49.5% vs 50.5%). Of all, 41.3% of tumors were located in axial location (pelvis, spine, and ribs), 34.1% of tumors were located in extremity (long or short bones of the upper or lower extremity), and 24.6% in other location (mandible, skull, and other atypical locations). Male (hazard ratio [HR] = 1.201; 95% confidence interval [CI]: 1.056-1.366), axial location (HR = 1.342; 95% CI: 1.157-1.556), distant metastasis (HR = 2.369; 95% CI: 2.015-2.785), non-surgery perform (HR = 2.108; 95% CI: 1.814-2.451) were independent risk factors for 5-year overall survival. This study revealed distinct clinicopathological features of patients with osteosarcoma older than 60 years. Male gender, tumor in axial site, nonsurgery perform, and distant metastasis indicated worse prognosis survival. Performing surgery is still an effective and reliable treatment method for patients older than 60 years.

Retrospective analysis of high-dose chemotherapy followed by autologous stem cell transplantation for high-risk pediatric osteosarcoma

The outcomes of osteosarcoma with poor prognostic factors, such as poor responders, metastatic disease at diagnosis, and relapsed or refractory disease, are poor. We reviewed the clinical records of the patients diagnosed with osteosarcoma at our institute between 2004 and 2018 who received high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) in our institute. Ten patients of osteosarcoma with poor responder, refractory status, and metastatic disease at diagnosis received high-dose chemotherapy followed by ASCT. Four patients underwent high-dose chemotherapy followed by ASCT with the conditioning regimen consisted of thiotepa and melphalan (MEL). Five patients underwent high-dose chemotherapy followed by ASCT with the conditioning regimen consisted of intravenous busulfan (BU) and MEL. One patient underwent tandem high-dose chemotherapy followed by ASCT with BU and MEL followed by carboplatin and etoposide. None of the ten patients died of regimen related toxicities. None of the five patients with poor responders who underwent high-dose chemotherapy followed by ASCT as part of consolidation therapy died of disease after ASCT. High-dose chemotherapy followed by ASCT might be effective for poor responders in osteosarcoma.

Histologic Response and Toxicity following Interval-Compressed Four-Drug Therapy Given Preoperatively in Children and Young Adults with Osteosarcoma: A Retrospective Study

OBJECTIVES

The histologic response to chemotherapy is an important prognostic factor in osteosarcoma. Thus, we attempted to develop an effective neoadjuvant regimen to achieve an improvement in histologic response.

METHODS

Twenty-nine patients with a high-grade osteosarcoma received 2 courses of neoadjuvant chemotherapy non-randomly with either the MAP regimen (methotrexate 12 g/m2, cisplatin 120 mg/m2, and doxorubicin 75 mg/m2) or MAPI regimen (MAP plus ifosfamide 9 g/m2). We applied interval compression to MAPI by shortening the preoperative period to be aligned with that of MAP. Adjuvant chemotherapy was tailored according to the necrosis rate of resected tumor specimens. Necrosis rate, toxicity, and survival outcome were compared retrospectively between the 2 groups.

RESULTS

The median interval between the beginning of neoadjuvant chemotherapy and surgery was 97.0 days in the MAPI group (17 patients) and 90.5 days in the MAP group (12 patients; p = 0.19). The good histologic response (>90% of necrosis) was observed in 71% of MAPI and in 42% of MAP (p = 0.12). Major toxicities of grade 3 or worse were not different between the 2 groups. The probability of 5-year progression-free survival and overall survival of the MAPI group were 74 and 83%, and those in the MAP group were 50 and 75%, showing no difference.

CONCLUSIONS

Interval-compressed MAPI therapy given in a similar duration of the preoperative phase to that of conventional MAP therapy showed a marginal trend toward a better histologic response without a significant increase in major toxicities. Regarding the proportion of good histologic response, 71% is one of the highest values ever reported in the literature. The results warrant further testing in a prospective way in a larger cohort.

Osteosarcoma journey over two decades in India: Small steps, big changes

BACKGROUND

The management of osteosarcoma is challenging especially in lower-income and middle-income countries, and there is an unmet need to evolve efficient and sustainable chemotherapy regimens.

METHODS

We compared the outcomes in nonmetastatic osteosarcoma patients treated with three sequential non-high-dose methotrexate-based combination chemotherapy protocols at a single tertiary care center over two decades. The first protocol, OGS-99, involved dose-intense, alternating dyads of three drugs: doxorubicin (Dox), cisplatin (CDDP), and ifosfamide (Ifo). The second protocol, OGS-99 enhanced, included OGS-99 drugs with etoposide and enhanced supportive care. The OGS-12 protocol involved dose-dense administration of eight sequential dyads of Dox, CDDP and Ifo, universal growth factor prophylaxis and targeted nutritional support. Event-free survival (EFS), overall survival (OS), and toxicity were reported using a retrospective chart review in the OGS-99 and OGS-99 enhanced protocols and prospectively in the OGS-12 protocol.

RESULTS

A total of 41, 94, and 385 treatment-naïve, consecutive, nonmetastatic patients with extremity osteosarcoma were treated with the OGS-99 (2000-2005), OGS-99 enhanced (2010), and OGS-12 (2011-2016), respectively. At a median follow-up of 19, 86, and 39 months, the five-year EFS rates were 38%, 50%, and 62% in the OGS-99, OGS-99 enhanced, and OGS-12, respectively. The corresponding rates of five-year OS were nonevaluable, 60% and 77%, respectively, with acceptable rates of grade 3-4 toxicities: febrile neutropenia (40%), thrombocytopenia (36%), anemia (51%), and 1% deaths related to toxicity.

CONCLUSIONS

Sequential selection of an intelligent, dose-dense chemotherapy regimen together with enhanced supportive care resulted in marked improvement in outcomes of nonmetastatic osteosarcoma and this "small steps-big changes" model deserves wider recognition and usage.

Predictors of the Survival of Primary and Secondary Older Osteosarcoma Patients

Purpose: Older osteosarcoma patients have a very poor prognosis and treatment for them remains a challenge. The outcomes and potential prognostic factors of primary or secondary older osteosarcoma patients are rarely documented. Therefore, we examined the prognosis of the two special cohorts to identify possible prognostic factors, and provide optimal treatment strategy for them.

Methods: The Surveillance, Epidemiology, and End Results (SEER) program database was used to identify osteosarcoma patients aged over 40 years from 1973 to 2015. The prognostic analysis was performed using the Kaplan-Meier method and a Cox proportional hazards regression model.

Results: In total, 1162 primary older osteosarcoma patients and 444 secondary older osteosarcoma patients were eligible for this study. The OS and CSS rates of the primary older osteosarcoma patients at 5-year were 38.5% and 37.1%, respectively. The 3- and 5-year OS rates of the secondary older osteosarcoma patients were 22.8% and 14.6%, respectively. On multivariate analysis of the primary older osteosarcoma patients, age > 60, male, axial site, high grade, metastasis, tumor size>10 cm, no surgery, and radiation treatment were negatively associated with OS. In terms of CSS, age, gender, decade of diagnosis, tumor site, tumor grade, tumor stage, tumor size, and surgery were independent prognostic factors. A multivariate Cox regression model showed that secondary older osteosarcoma patients of high grade, metastasis, tumor size > 10 cm, no surgery, and no chemotherapy were independent predictors of decreased OS.

Conclusions: Surgery in combination with chemotherapy should be recommended for the treatment of the secondary older osteosarcoma patients, while for the primary older osteosarcoma patients, only surgery should be recommended.

Preoperative surgical risk stratification in osteosarcoma based on the proximity to the major vessels

Aims

The aim of this study was to determine the risk of local recurrence and survival in patients with osteosarcoma based on the proximity of the tumour to the major vessels.

Patients and Methods

A total of 226 patients with high-grade non-metastatic osteosarcoma in the limbs were investigated. Median age at diagnosis was 15 years (4 to 67) with the ratio of male to female patients being 1.5:1. The most common site of the tumour was the femur (n = 103) followed by tibia (n = 66). The vascular proximity was categorized based on the preoperative MRI after neoadjuvant chemotherapy into four types: type 1 > 5 mm; type 2 ≤ 5 mm, > 0 mm; type 3 attached; type 4 surrounded.

Results

Limb salvage rate based on the proximity type was 92%, 88%, 51%, and 0% for types 1 to 4, respectively, and the overall survival at five years was 82%, 77%, 57%, and 67%, respectively (p < 0.001). Local recurrence rate in patients with limb-salvage surgery was 7%, 8%, and 22% for the types 1 to 3, respectively (p = 0.041), and local recurrence at the perivascular area was observed in 1% and 4% for type 2 and 3, respectively. The mean microscopic margin to the major vessels was 6.9 mm, 3.0 mm, and 1.4 mm for types 1 to 3, respectively. In type 3, local recurrence-free survival with limb salvage was significantly poorer compared with amputation (p = 0.025), while the latter offered no overall survival benefit. In this group of patients, factors such as good response to chemotherapy or limited vascular attachment to less than half circumference or longitudinal 10 mm reduced the risk of local recurrence.

Conclusion

The proximity of osteosarcoma to major blood vessels is a poor prognostic factor for local control and survival. Amputation offers better local control for tumours attached to the blood vessels but does not improve survival. Limb salvage surgery offers similar local control if the tumour attachment to blood vessels is limited. Cite this article: Bone Joint J 2019;101-B:1024–1031.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Method to measure the mismatch between target and achieved received dose intensity of chemotherapy in cancer trials: a retrospective analysis of the MRC BO06 trial in osteosarcoma

OBJECTIVES

In cancer studies, the target received dose intensity (tRDI) for any regimen, the intended dose and time for the regimen, is commonly taken as a proxy for achieved RDI (aRDI), the actual individual dose and time for the regimen. Evaluating tRDI/aRDI mismatches is crucial to assess study results whenever patients are stratified on allocated regimen. The manuscript develops a novel methodology to highlight and evaluate tRDI/aRDI mismatches.

DESIGN

Retrospective analysis of a randomised controlled trial, MRC BO06 (EORTC 80931).

SETTING

Population-based study but proposed methodology can be applied to other trial designs.

PARTICIPANTS

A total of 497 patients with resectable high-grade osteosarcoma, of which 19 were excluded because chemotherapy was not started or the estimated dose was abnormally high (>1.25 × prescribed dose).

INTERVENTIONS

Two regimens with the same anticipated cumulative dose (doxorubicin 6×75 mg/m²/week; cisplatin 6×100 mg/m²/week) over different time schedules: every 3 weeks in regimen-C and every 2 weeks in regimen-DI. PRIMARY AND SECONDARY OUTCOME MEASURES: tRDI distribution was measured across groups of patients derived from k-means clustering of treatment data. K-means creates groups of patients who are aRDI-homogeneous. The main outcome is the proportion of tRDI values in groups of homogeneous aRDI.

RESULTS

For nearly half of the patients, there is a mismatch between tRDI and aRDI; for 21%, aRDI was closer to the tRDI of the other regimen.

CONCLUSIONS

For MRC BO06, tRDI did not predict well aRDI. The manuscript offers an original procedure to highlight the presence of and quantify tRDI/aRDI mismatches. Caution is required to interpret the effect of chemotherapy-regimen intensification on survival outcome at an individual level where such a mismatch is present.The study relevance lies in the use of individual realisation of the intended treatment, which depends on individual delays and/or dose reductions reported throughout the treatment.

TRIAL REGISTRATION NUMBER

ISRCTN86294690.

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

Background

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

Methods

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

Results

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

Conclusions

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

•

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

•

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

•

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

•

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

•

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

Clinical epidemiology and treatment outcomes of spindle cell non-osteogenic bone sarcomas - A nationwide population-based study

Purpose

To describe epidemiological and clinical characteristics, as well as long-term treatment outcomes of spindle cell non-osteogenic bone sarcomas (SCS), comprising leiomyosarcoma, fibrosarcoma and undifferentiated pleomorphic sarcoma in bone.

Method

We have analysed a nationwide cohort of 104 patients with histologically verified SCS diagnosed between 1975 and 2009, based on registry sources supplemented with clinical records from Norwegian hospitals involved in sarcoma management.

Results

In this unselected cohort, a stable annual incidence for SCS patients of slightly below 0.6 per million was observed, with a dominant peak among elderly patients. SCS is mostly a high-grade malignancy (92%) with a male to female ratio of 1.6 for all patients. The axial to appendicular ratio was 0.7, seemingly independent of age. More than one fourth of the patients (29%) had primary metastatic disease. Another 32 patients (46%) developed metastases during follow-up and 12 (17%) experienced local relapses. The five-year sarcoma-specific survival rate was 37%, with no documented improvement over time. Primary metastatic disease was an adverse prognostic factor for survival. Predisposing factors were documented in 19 patients (18%). Negative prognostic factors for overall survival were tumour size >9 cm, age > 40 years, axial tumour localization, FS as subtype and pathologic fracture at time of diagnoses. As expected, patients who received both surgery and chemotherapy as their primary treatment for high-grade SCS (25%) significantly had best sarcoma specific five years survival (62%).

Conclusion

We confirm SCS as a rare high-grade bone sarcoma entity, mostly among elderly patients and with a poor overall outcome. The combined treatment of surgery and chemotherapy is essential to achieve optimal long-term survival of SCS.

Surgical and Functional Outcome after Endoprosthetic Reconstruction in Patients with Osteosarcoma of the Humerus

Endoprosthetic reconstruction (EPR) is the most widely used reconstruction technique after humeral osteosarcoma (OSA). Complications are common and function is often compromised due to the premise of wide resection. In the current study we evaluated (1) the risk of complications after resection and EPR; (2) the functional outcome and how it is influenced by the preservation/resection of deltoid muscle (DM), rotator cuff (RC), axillary nerve or the type of resection (intra-/extraarticular) and (3) if the preservation/resection of DM, RC, axillary nerve or the type of resection has a negative influence on the oncological outcome. We retrospectively evaluated data of 49 patients with humeral OSA. All patients underwent resection and EPR. Complication-free survival according to the ISOLS classification was estimated by a competing risk model. Functional outcome was evaluated by range of motion (ROM) in abduction and the MSTS score. Eleven patients (22%) had at least one complication. The estimated cumulative incidence for the first complication was 18% at one year, 23% at five years, and 28% at ten years, respectively. Soft tissue failure was the most common complication. ROM and MSTS scores were significantly higher in patients where DM and RC (p = 0.043/p = 0.046) and axillary nerve (p = 0.014/p = 0.021) could be preserved. Preservation of these structures had no negative influence on the surgical margins. In conclusion, EPR is a good treatment method with an acceptable complication rate. Preservation of the abductor mechanism, when possible in the setting of obtaining negative margins, provides superior functional outcome.

Osteosarcoma in patients below 25 years of age: An observational study of incidence, metastasis, treatment and outcomes

Only few systematic and comprehensive studies have focused on osteosarcoma in children and adolescents. In the present study, 3,085 patients with osteosarcoma were identified in the Surveillance, Epidemiology and End Results Program database. The patients were <25 years of age and diagnosed between 1973 to 2012. A retrospective study was performed to investigate the factors associated with tumor incidence, metastasis, treatment and survival. The results indicated that the incidence of osteosarcoma was higher in male patients compared with female patients. In addition, the incidence rate of osteosarcoma was higher among male and female patients between the ages of 10 and 19. Osteosarcoma located in the chest and pelvic bones was associated with metastatic disease; however, metastasis in two histological types, parosteal and periosteal, was infrequent. Survival analysis revealed the following were associated with poor outcomes: Sex, patients diagnosed between 1973 and 1982, distant metastasis, treatment without surgery or with radiation, a tumor with a poorly differentiated or undifferentiated grade, tumor size ≥100 mm, and a tumor in the pelvic bones. Patient's whose histologic type was parosteal osteosarcoma and whose tumor was located in one of the limbs, or who underwent local or radical excision, exhibited a good survival outcome. Survival outcomes were ranked according to the type of surgery, from best to worst, as follows: Local excision, radical excision, amputation and no surgery. In summary, the incidence of osteosarcoma is higher in male patients compared with female patients. Furthermore, individuals between the ages of 10 and 19 have a higher risk of osteosarcoma. Osteosarcoma located in the chest and pelvic bones has a high risk of metastasis. Limb-salvage surgery may be the optimal treatment approach for non-metastatic osteosarcoma.

Gender differences in doxorubicin pharmacology for subjects with chemosensitive cancers of young adulthood

PURPOSE

For many cancers, adolescents and young adults (AYA) have worse outcomes than for children and adults. Many factors may contribute to the AYA survival gap, including differences in biology, therapeutic intent, and adherence to therapy. It has been observed that male AYAs have poorer outcomes than females. The purpose of this work was to test the proposition that gender-related pharmacologic factors may account for a component of the AYA survival gap.

PATIENTS AND METHODS

A prospective, multi-institutional pharmacologic study of 79 patients in total with chemosensitive cancers (Ewing sarcoma, osteosarcoma and Hodgkin lymphoma) was conducted, with conventional doxorubicin treatment. Pharmacokinetic data of 13 children, 40 AYAs and 13 adults were valid for analysis. Population pharmacokinetics models were developed for doxorubicin and its metabolite doxorubicinol based on the data created in this study. Consequently, model-based analysis was conducted to investigate the relevant topics.

RESULTS

The clearance of doxorubicinol (normalized to body surface area), the main active metabolite of doxorubicin, appears faster in male AYAs than female (p = 0.04, 95% CI 0.1-3.9 L/h). The exposure of doxorubicinol (normalized to dose) is lower in male AYA than female (p = 0.03, 95% CI - 0.005 to - 0.0002 h/L). These might be correlated to the observed difference on nadir neutrophil count between male AYA and female (p = 0.027, 95% CI 0.09-1.4).

CONCLUSION

Gender-related differences in doxorubicin pharmacology may account for worse outcomes for male AYAs with chemosensitive cancers compared to females. These findings may reduce the AYA survival gap compared to other age groups.

Implant and limb survival after resection of primary bone tumors of the lower extremities and reconstruction with mega-prostheses fifty patients followed for a mean of forteen years

PURPOSE

Previous studies reported variable outcome and failure rates after mega-prosthetic reconstructions in the lower extremities. The purpose of this study was to make a long-term single-center evaluation of patients treated with limb-sparing surgery and reconstruction with mega-prostheses in the lower extremities.

METHODS

We identified 50 patients (osteosarcoma (n = 30), chondrosarcoma (n = 9), osteoclastoma (n = 6), Ewing sarcoma (n = 4), angiosarcoma (n = 1)), who underwent limb-sparing reconstruction of the lower extremities (proximal femur (n = 9), distal femur (n = 29), proximal tibia (n = 9), and the entire femur (n = 3)) between 1985 and 2005. Surviving patients not lost to follow-up were evaluated using the MSTS score. Causes of failure were classified according to the Henderson classification. Kaplan-Meier survival analysis was used for evaluation of patient, prosthesis, and limb survival.

RESULTS

Twenty-eight patients were alive at follow-up. Fifty-four percent had revision surgery (n = 27). The ten year patient survival was 60% (95%CI 46-74%); the ten year implant survival was 24% (95%CI 9-41%), and the ten year limb survival rate was 83% (95%CI 65-96%). Type 1 failure occurred in 9%, type 2 in 16%, type 3 in 28%, type 4 in 18%, and type 5 in 3%. Mean MSTS score was 21 (range, 6-30), representing a median score of 71%.

CONCLUSIONS

Our long-term results with mega-prostheses justify the use of limb-salvage surgery and prosthetic reconstruction. Our results are fully comparable with other findings, with regard to limb and prosthesis survival, but also with regard to functional outcome.

Tumor histopathological response to neoadjuvant chemotherapy in childhood solid malignancies: is it still impressive?

The management of oncological malignancies has significantly improved over the last decades. In modern medicine, new concepts and trends have emerged paving the way for the era of personalized and evidence-based strategies adapted to the patients’ prognostic variables and requirements. Several challenges do exist that are encountered during the management, including the difficulty to assess chemotherapy response with certainty. Having known that neoadjuvant chemotherapy might be the only solution for a proportion of patients with tumors that are unresectable at diagnosis, emergence of strategies that use risk group-directed therapy became an integral part in the management of oncological malignancies. Tumor histopathological change post neoadjuvant chemotherapy is one of the most important predictors of management outcome and is being used in many chemotherapy protocols as an essential determinant of the most suitable postoperative chemotherapy regimen. Bone tumors are the classic models of this approach; however, other childhood solid tumors show significant variations in outcome as a result of tumor histopathological response to neoadjuvant chemotherapy. The aim of this review is therefore to summarize the significance of histopathological responses seen after neoadjuvant chemotherapy in childhood solid tumors. Moreover, it suggests that the effect on tumor histopathology through modifying neoadjuvant chemotherapy and, on the other hand, toxicities from intensifying adjuvant chemotherapy might either necessitate the change of a number of arm groups in different protocol regimens or include newer chemotherapeutic agents adjuvantly for better outcome and lesser toxicities in poor tumor histopathological responders.

Long non-coding RNA XIST regulates PDCD4 expression by interacting with miR-21-5p and inhibits osteosarcoma cell growth and metastasis

lncRNA-X-inactive specific transcript (lncRNA XIST) has been demonstrated to be a tumor suppressor involved in the pathogenesis and development of various cancers. However, the function of XIST and its working mechanism in osteosarcoma (OS) remain enigmatic. Firstly, we determined the expression of XIST in OS tissues and cell lines by quantitative reverse transcription-PCR (qRT-PCR) and explored whether aberrant XIST expression was associated with recurrence and short overall survival. Furthermore, the effects of XIST on osteosarcoma cells were studied by lentivirus mediated overexpression approach in vitro and in vivo. Detection of a set of epithelial-mesenchymal transition (EMT) markers was performed to explore whether XIST is involved in EMT. Finally, we investigated the regulatory mechanism of XIST acting as a competitive endogenous RNA (ceRNA) of miR-21-5p in OS progression and metastasis. lncRNA XIST was significantly downregulated in osteosarcoma tissues and osteosarcoma cells, and associated with recurrence and short overall survival in OS patients. XIST overexpression remarkably inhibited the proliferation of OS cells as well as the xenograft tumor formation in vivo. Both cell invasion and migration were inhibited by XIST overexpression via suppressing the EMT process. These results indicated that XIST functioned as a tumor suppressor in OS. Moreover, we found that miR-21-5p interacted with XIST by directly targeting the miRNA-binding site in the XIST sequence, and qRT-PCR results showed XIST and miR-21-5p could affect each other's expression, respectively. The following assays verified that the tumor suppressor, PDCD4 was a functional target of miR-21-5p in OS cells. Finally, we affirmed that XIST regulated PDCD4 expression by competitively binding to miR-21-5p. XIST inhibited cell proliferation and cell mobility by competitively binding to miR-21-5p and upregulating PDCD4 in OS. Our study demonstrated that lncRNA-XIST, which acts as a miRNA sponge, impedes miR-21-5p to maintain the expression of PDCD4, which contributes to the progression of OS. Our findings suggest that the newly identified XIST/miR-21-5p/PDCD4 axis could be a potential biomarker or therapeutic target for OS.

Using decision modeling to guide drug allocation during a shortage

BACKGROUND

Drug shortages require clinical teams to decide how to allocate drugs in limited supply among their patients. Ethical frameworks are invaluable for promoting rational approaches to drug distribution, but gaps remain between ethical theory and clinical application. The goal of this work was to explore how decision modeling could supplement ethical frameworks to inform drug distribution from the perspective of a clinical team.

PROCEDURE

We created a hypothetical pediatric oncology clinic with a limited supply of 50,000 mg of methotrexate (MTX) and 21 patients due for treatment on one of six regimens. We constructed a simple decision analytic model to compare the effectiveness of MTX in milligrams per life year saved for each regimen. The robustness of the model was tested under various conditions including alternative drug effectiveness and time horizons. Effects on outcomes and distribution by substituting alternative dosing were explored for each regimen.

RESULTS

Prescribed therapy for this group of patients required 108,791 mg MTX. Two regimens for three patients required ≥20,000 mg/m² . If distributed in order of arrival, only seven patients could receive full treatment. If distributed in order of efficiency, 19 patients could receive treatment. If less effective regimens were substituted, 20 patients could receive treatment. The primary driver of efficiency was dose per square meter.

CONCLUSIONS

In this hypothetical drug shortage, no allocation scenario exists that does not result in a worse outcome for some patients. Evidence of drug efficacy affected the decisions to substitute alternative treatments. First-come-first-served allocation resulted in fewer patients receiving treatment than allocation based on efficiency.

Associations between inflammatory gene polymorphisms (TNF-α 308G/A, TNF-α 238G/A, TNF-β 252A/G, TGF-β1 29T/C, IL-6 174G/C and IL-10 1082A/G) and susceptibility to osteosarcoma: a meta-analysis and literature review

Associations between inflammatory gene polymorphisms (TNF-α 308G/A, TNF-α 238G/A, TNF-β 252A/G, TGF-β1 29T/C, IL-6 174G/C and IL-10 1082A/G) and osteosarcoma (OS) risk remain unclear. We conducted a systematic search to retrieve studies that investigated associations between inflammatory gene polymorphisms and OS risk. Nine studies that met the inclusion criteria were finally recruited in this meta-analysis. Overall, there was a significant association between TNF-α 308G/A, IL-10 1082A/G and OS risk, while there was no significant association between TNF-α 238G/A, TNF-β 252A/G and IL-6 174G/C and OS risk. Our subgroup analysis showed a significant association between IL-6 174G/C and IL-10 1082A/G and OS risk in Asians, while no such significant correlation was observed with TNF-α 308G/A, TNF-α 238G/A, TNF-β 252A/G and TGF-β1 29T/C polymorphisms. In Caucasians, there was a significant association between TNF-α 238G/A and the decreased incidence of OS. In conclusion, inflammatory gene polymorphisms play a key role in the occurrence and progression of OS. IL-6 174G/C polymorphism was obviously associated with OS risk in Asians, while TNF-α 238G/A polymorphism seemed to be associated with the decreased susceptibility to OS in Caucasians as Altman and Bland test indicated. Although controversial results were observed between IL-10 1082A/G and OS risk in Asians and Caucasians, it is difficult to make a definite conclusion about the role of IL-10 1082A/G polymorphism in the etiology of OS because our Altman and Bland test showed no good evidence to support a different effect in Asians and Caucasians.

Functional outcome after surgery in patients with bone sarcoma around the knee; results from a long-term prospective study

Background and Objectives

In a previous conducted study functional outcome of young patients with bone sarcoma located around the knee was longitudinally evaluated during the first 2 years postoperatively. Functional outcome improved significantly over the first 2 years. The purpose of this descriptive study was to evaluate the functional outcome of these patients at long‐term follow‐up of 7 years.

Methods

Functional outcome was assessed with the TESS, MSTS, Baecke questionnaire, and three functional performance tests: time up and down stairs (TUDS), various walking activities (VWA), and the 6‐min walking test (6MWT). Linear Mixed Model has been employed for the repeated measurements.

Results

Twenty patients of the original study (n = 44) participated in the current study. Fifteen limb‐salvage and five ablative surgery patients, median follow‐up 7.4 years (6.8‐8.0) (CI 95%), mean age 22.3 years (18.2‐31.6). Between 2 and 7 years after surgery, 8 limb‐salvage patients (53%) encountered surgery related complications. Questionnaires and functional performance tests showed no significant difference in functional outcome between 2 years and 7 years after surgery (P < 0.05).

Conclusions

Between 2 years and follow‐up at average 7 years after surgery no further improvements were noticed at young patients with a bone sarcoma located around the knee.

Osteosarcoma Overview

Osteosarcoma (OS) is the most common primary malignancy of bone and patients with metastatic disease or recurrences continue to have very poor outcomes. Unfortunately, little prognostic improvement has been generated from the last 20 years of research and a new perspective is warranted. OS is extremely heterogeneous in both its origins and manifestations. Although multiple associations have been made between the development of osteosarcoma and race, gender, age, various genomic alterations, and exposure situations among others, the etiology remains unclear and controversial. Noninvasive diagnostic methods include serum markers like alkaline phosphatase and a growing variety of imaging techniques including X-ray, computed tomography, magnetic resonance imaging, and positron emission as well as combinations thereof. Still, biopsy and microscopic examination are required to confirm the diagnosis and carry additional prognostic implications such as subtype classification and histological response to neoadjuvant chemotherapy. The current standard of care combines surgical and chemotherapeutic techniques, with a multitude of experimental biologics and small molecules currently in development and some in clinical trial phases. In this review, in addition to summarizing the current understanding of OS etiology, diagnostic methods, and the current standard of care, our group describes various experimental therapeutics and provides evidence to encourage a potential paradigm shift toward the introduction of immunomodulation, which may offer a more comprehensive approach to battling cancer pleomorphism.

Telangiectatic osteosarcoma: a review of 87 cases

PURPOSES

Telangiectatic osteosarcoma (TOS) is a rare subtype of osteosarcoma. We analyzed (1) oncologic outcome in a large homogeneous series and (2) the role of prognostic factors on prognosis, local recurrence and metastasis.

METHODS

Eighty-seven patients (47 males, 54 %) were retrospectively analyzed. All except 4 had extracompartmental disease, and ten patients had lung metastasis at diagnosis. Pathologic fracture was present in 27 cases (31 %). Seventy-eight patients were treated with neoadjuvant chemotherapy; nine had surgery as first treatment. Limb-salvage surgery was performed in 71 cases, amputation in 14, and rotationplasty in one. One patient died before surgery. Possible prognostic factors were statistically evaluated.

RESULTS

Overall survival was 60.7 % at 10 years of follow-up. Fifty-one patients were disease-free (58.6 %), 2 were alive with disease (2.3 %), 31 died with disease (35.6 %), and 3 died of other causes (3.4 %). Ten local recurrences were observed (11 %). Twenty-five patients (29 %) developed lung (22) or bone (3) metastases. No statistical difference was found considering age, metastases at diagnosis, gender, pathologic fracture, tumor volume, compartmental status, number of neoadjuvant chemotherapy agents and treatment. Induced necrosis was significant at both univariate and multivariate analysis (p < 0.0001).

CONCLUSIONS

TOS does not have a poor prognosis as previously reported in literature, with a survival of about 60 % at 10 years. Most of patients can be cured with neoadjuvant chemotherapy plus surgery (limb sparing surgery is possible and safe). Tumor response to chemotherapy as induced necrosis was the only significant prognostic factors on survival, even if small tumor volume at diagnosis correlates with better prognosis at univariate analysis.

LEVEL OF EVIDENCE

IV.

Prognostic Value of Vascular Invasion in Pediatric Osteosarcomas

Metastatic status, histologic response, and quality of surgical resection are prognostic factors for osteosarcomas. Pathology reports sometimes describe peritumoral vascular invasion on surgical specimens after neoadjuvant chemotherapy but their prognostic significance as an independent parameter has never been reported. The aim of this study was to evaluate how the presence of this peritumoral vascular invasion could influence survival. We retrospectively analyzed histology, demographics, and outcomes of pediatric patients treated for osteosarcoma in our institutions between January 2007 and December 2012. A single pathologist analyzed the resection specimens after neoadjuvant chemotherapy. Fifty-one osteosarcomas were diagnosed over a 6-year period; nine had metastatic disease at diagnosis. Surgery was performed after neoadjuvant chemotherapy in all cases. We identified peritumoral vascular invasion in the surgical specimens in 15 cases. Two-year event-free survival (EFS) was 78 % (CI95%[64;93]) for patients without vascular invasion versus 48 % (CI95% [21;75]) in patients with vascular invasion, and 2-year overall survival (OS) was 94 % (CI95%[86;100]) for those without vascular invasion versus 79 % (CI95%[57;100]) for others. Multivariate analysis demonstrated correlation of metastatic status and presence of vascular invasion with survival. The histopathological description of peritumoral vascular invasion in surgical specimens of osteosarcoma after neoadjuvant chemotherapy can be considered a prognostic factor and could indicate modification of the postoperative therapeutic strategy.

TRIM59 is upregulated and promotes cell proliferation and migration in human osteosarcoma

Osteosarcoma is a prevalent type of cancer and has a high metastatic ability, particularly for metastasis to the lungs. Effective treatment strategies have improved, however, the detailed molecular mechanism underlying the onset of this malignancy remains to be fully elucidated. The current study investigated the role of the tripartite motif (TRIM) family protein TRIM59 in osteosarcoma growth and metastasis. It was identified that TRIM59 was overexpressed in clinical osteosarcoma tissues and cultured osteosarcoma cell lines. In addition, the MTT assay demonstrated that in U2OS and MG63 cells, knockdown of TRIM59 by specific siRNA inhibited proliferation, whereas overexpression of TRIM59 promoted cell proliferation. Furthermore, overexpression of TRIM59 significantly increased the U2OS cell migrative and invasive abilities in a Transwell chamber assay. In addition, TRIM59 was able to negatively regulate the protein levels of P53 without significantly affecting the mRNA levels in U2OS and MG63 cells. These data suggest the oncogenic abilities of TRIM59 in osteosarcoma, which promote osteosarcoma cell proliferation, migration and invasion.

Chondroblastic osteosarcoma secondary to fibrosarcoma: A case report and literature review

Osteosarcoma, which is most common in non-blood systemic tumors, accounts for 20% of primary bone malignancies. Primary osteosarcoma usually occurs in young individuals aged 10-20 years, while secondary osteosarcoma is more common in the elderly. It had been reported that secondary osteosarcoma may be associated with osteofibrous dysplasia, bone infarction, chondrosarcoma or osteogenesis imperfecta. However, osteosarcoma secondary to fibrosarcoma has rarely been reported. The current study presents the rare case of a female with chondroblastic osteosarcoma secondary to fibrosarcoma. The patient was relatively young and suffered from more than one type of cancer. The course of the disease lasted for >20 years. This case study provides general knowledge of osteosarcoma, and discusses its clinical presentation, diagnosis, treatment and prognosis.

Prognostic Significance of Serum Alkaline Phosphatase Level in Osteosarcoma: A Meta-Analysis of Published Data

Background. Serum alkaline phosphatase (SALP) is commonly elevated in osteosarcoma patients. A number of studies have investigated the prognostic role of SALP level in patients with osteosarcoma but yielded inconsistent results. Method. Systematic computerized searches were performed in PubMed, Embase, and Web of Science databases for relevant original articles. The pooled hazard ratios (HRs) and relative risks (RRs) with corresponding confidence intervals (CIs) were calculated to assess the prognostic value of SALP level. Results. Finally, 21 studies comprising 3228 patients were included. Overall, the pooled HRs of SALP suggested that elevated level had an unfavorable impact on osteosarcoma patients' overall survival (OS) (HR = 1.82; 95% CI: 1.61–2.06; p < 0.001) and event-free survival (EFS) (HR = 1.97; 95% CI: 1.61–2.42; p < 0.001). Combined RRs of SALP indicated that elevated level was associated with presence of metastasis at diagnosis (RR = 5.55; 95% CI: 1.61–9.49; p = 0.006). No significantly different results were obtained after stratified by variables of age range, cancer stage, sample size, and geographic region. Conclusion. This meta-analysis demonstrated that high SALP level is significantly associated with poor OS or EFS rate and presence of metastasis at diagnosis. SALP level is a convenient and effective biomarker of prognosis for osteosarcoma.

Developing a prognostic model for patients with localized osteosarcoma treated with uniform chemotherapy protocol without high dose methotrexate: A single‐center experience of 237 patients

Background

Studies of baseline prognostic factors in patients with localized osteosarcoma treated without high dose methotrexate are limited.

Methods

This is single‐institutional review of localized osteosarcoma patients treated without high dose methotrexate between June 2003–December 2012. A multivariate analysis of impact of baseline and treatment characteristics on outcome was performed and a prognostic model was developed based solely on baseline factors for predicting event‐free survival (EFS) and overall survival (OS).

Results

Of 237 patients with median age of 17 years (range 2–66 yrs), neoadjuvant chemotherapy (NACT) was administered in 220 (92.82%) patients. Post NACT, 200/237 (84.38%) patients underwent surgery. At 30 months median follow‐up, 5‐year EFS and OS were 36.60 ± 0.03%, and 50.33 ± 0.04%, respectively. In multivariate analysis, baseline factors including duration of symptom >4 months (P < 0.001) and good performance status (PS) (P < 0.001) predicted better EFS whereas good PS (P = 0.01) and normal serum alkaline phosphatase (SAP) (P = 0.03) predicted better OS. The 5‐year EFS without any risk factor (symptom duration <4 months, PS>1) was 58.7 ± 0.1%, with either one factor 31.5 ± 0.1% and with both factors 21.9 ± 0.1%. The 5‐year OS without any risk factor (PS>1, elevated SAP) was 66.9 ± 0.1%, with either one factor 57.9 ± 0.1% and with both factors 25.6 ± 0.1%

Conclusions

This prognostic model assists in categorizing risk‐groups within localized osteosarcoma. J. Surg. Oncol. 2015;112:662–668. © 2015 Wiley Periodicals, Inc.

Referral patterns, treatment and outcome of high-grade malignant bone sarcoma in Scandinavia--SSG Central Register 25 years' experience

AIMS

The objectives of this study were to present changes in referral patterns, treatment and survival in patients with high-grade malignant bone sarcoma in Sweden and Norway based on data in the Scandinavian Sarcoma Group (SSG) Central Register.

METHOD

Data on 1,437 patients with diagnosis 1986-2010 was analyzed.

RESULTS

Osteosarcoma was the most frequentl diagnosis (45%), followed by Ewing sarcoma (21%) and chondrosarcoma (17%). Thirty-one percent of Swedish and 41% of Norwegian patients had tumors in the axial skeleton. Eighty-six percent of extremity tumors and 66% of axial tumors were referred to a sarcoma center prior to unplanned surgery or biopsy. During the past decade, limb salvage surgery has risen from under 50% to over 80%. Five-year overall survival in non-metastatic osteosarcoma was 70% for extremity tumors, and 35% for axial tumors. No improvement in osteosarcoma survival was observed during the last decade. Five-year survival in Ewing sarcoma improved from 50% to 69%.

CONCLUSION

Referral patterns in bone sarcomas have improved. However, greater efforts should be dedicated to improving referral of patients with possible tumors in the axial skeleton to multidisciplinary teams (MDTs). Overall survival of patients with high-grade malignant bone sarcomas in Sweden and Norway is in line with other reports.

Perioperative chemotherapy in the treatment of osteosarcoma: a 26-year single institution review

Background

Chemotherapy in the multimodality treatment of osteosarcoma has improved survival. Reported outcomes on adult patients are limited. Poor necrosis rates post neoadjuvant chemotherapy (NAC) is considered an adverse prognostic factor and attempts have been made to improve survival in this group.

Patients and methods

Adult and young adult patients diagnosed with osteosarcoma between January 1986 and August 2012 were retrospectively reviewed. Patients identified were stratified according to stage (localised or metastatic) and age (≤40 and >40 years). Event free survival (EFS) and overall survival (OS) outcomes were determined. In patients with localised disease ≤40 years, survival was assessed according to necrosis rates post NAC (<90 and ≥90%). NAC consisted of two cycles of methotrexate alternating with doxorubicin/cisplatin (MAP) followed by definitive surgery. Those with ≥90% tumour necrosis continued on MAP. Patients with <90% necrosis received ifosfamide and etoposide (IE) post operatively.

Results

A total of 108 patients were reviewed and 97 were included. Median age was 23 years (range 16–75) and 70% of patients were male. Five year EFS and OS across all groups was 57% and 63% respectively. Of the patients with localised disease (N = 81), 5-year overall survival (OS), with a median follow up of 7 years (2–26) was 70% (p < 0.0001). Patients aged 16–40 (N = 68) with localised osteosarcoma had a significantly improved 5-year OS (74%) compared to those >40 years (N = 13) (42%) (p = 0.004). Of the 68 patients with localised osteosarcoma ≤40 years, 62 were evaluated according to necrosis rates post MAP. In 33 patients who achieved ≥90% necrosis and continued MAP, 5-year OS was 82%. In 29 patients who had <90% tumour necrosis and received adjuvant IE, 5-year OS was 68% (p = 0.15). Multivariate analysis confirmed age and stage as prognostic factors but not poor necrosis rates in our treated population.

Conclusions

Long-term survival outcomes in a predominantly adult Irish population are similar to large reported trials. Age and stage at diagnosis are prognostic. Postoperative ifosfamide/etoposide alone in patients with poor necrosis rates is a feasible regimen, but its role in the adjuvant setting remains uncertain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13569-015-0032-0) contains supplementary material, which is available to authorized users.