Long-term follow-up and post-relapse survival in patients with non-metastatic osteosarcoma of the extremity treated with neoadjuvant chemotherapy

Analysis of clinical factors impacting recurrence in myxofibrosarcoma

Myxofibrosarcoma (MFS) is a malignant fibroblastic/myofibroblastic neoplasm with a prominent myxoid area. It has the clinical features of frequent local recurrence (LR) and occasional distant metastasis. Robust epidemiological data on MFS in China are lacking. The aim of this retrospective analysis was to determine the natural history of MFS, identify prognostic factors for recurrence and describe the real-life outcomes of MFS. We reviewed 52 patients with primary MFS from the First Affiliated Hospital of Nanjing Medical University diagnosed between 2016 and 2020. All tumors were subjected to retrospective univariate analysis for prognostic factors of the disease, including tumor size, grade, location and sex; patient age; planned operation; surgical margin; and laboratory results. The significant factors identified by univariate analysis were subsequently analyzed via multivariate analysis. Overall survival (OS), post-treatment LR and metastatic-free survival were assessed as outcomes. The median age was 61 years (range, 13-93). Fourteen (26.92%) patients exhibited low grade disease, and 38 (73.08%) exhibited high grade disease. Among the 29 males, and 23 females, 15 (28.85%) had tumors in the trunk, 37 (71.15%) had tumors in the extremities, 26 had undergone planned surgery, and 26 had unexpected unplanned operation. The margin was negative in 39 (75%) patients and positive in 13 patients (25%). The serum creatine kinase (CK) concentration was high level in 33 (63.46%) patients and low level in 19 (36.54%) patients. The serum lactate dehydrogenase (LDH) levels were low in 23 (44.23%) patients and high in 29 (55.77%) patients. LR was observed in 25 patients (48.08%), and 4 patients developed metastasis. A worse LR rate was found for patients with a low CK level (84.21%) than for those with a high CK level (27.27%) at 5 years (p < 0.05). The LR rate of patients who underwent planned surgery was lower than that of patients who underwent unplanned surgery (p < 0.05). There were significantly more patients with positive margins than patients with negative margins (92.30%, and 33.33%, respectively; p < 0.05). Moreover, superficial tumors were also associated with greater recurrence rate (2/20 [10%]) than deep tumors, (23/32 [71.86%]) [p < 0.05]. The probability of LR in patients with MFS was significantly greater in association with unplanned operations, positive margins, low serum CK levels or superficial tumor depth. These data could help identify high-risk patients; thus, more careful follow-up should be performed for higher-risk patients. Diagnosis and treatment at qualified regular medical centers can reduce the local recurrence rate of MFS.

The landscape of drug sensitivity and resistance in sarcoma

Sarcomas are a family of rare malignancies composed of over 100 distinct histological subtypes. The rarity of sarcoma poses significant challenges in conducting clinical trials to identify effective therapies, to the point that many rarer subtypes of sarcoma do not have standard-of-care treatment. Even for established regimens, there can be substantial heterogeneity in responses. Overall, novel, personalized approaches for identifying effective treatments are needed to improve patient out-comes. Patient-derived tumor organoids (PDTOs) are clinically relevant models representative of the physiological behavior of tumors across an array of malignancies. Here, we use PDTOs as a tool to better understand the biology of individual tumors and characterize the landscape of drug resistance and sensitivity in sarcoma. We collected n=194 specimens from n=126 sarcoma patients, spanning 24 distinct subtypes. We characterized PDTOs established from over 120 biopsy, resection, and metastasectomy samples. We leveraged our organoid high-throughput drug screening pipeline to test the efficacy of chemotherapeutics, targeted agents, and combination therapies, with results available within a week from tissue collection. Sarcoma PDTOs showed patient-specific growth characteristics and subtype-specific histopathology. Organoid sensitivity correlated with diagnostic subtype, patient age at diagnosis, lesion type, prior treatment history, and disease trajectory for a subset of the compounds screened. We found 90 biological pathways that were implicated in response to treatment of bone and soft tissue sarcoma organoids. By comparing functional responses of organoids and genetic features of the tumors, we show how PDTO drug screening can provide an orthogonal set of information to facilitate optimal drug selection, avoid ineffective therapies, and mirror patient outcomes in sarcoma. In aggregate, we were able to identify at least one effective FDA-approved or NCCN-recommended regimen for 59% of the specimens tested, providing an estimate of the proportion of immediately actionable information identified through our pipeline.

Highlights

Standardized organoid culture preserve unique sarcoma histopathological featuresDrug screening on patient-derived sarcoma organoids provides sensitivity information that correlates with clinical features and yields actionable information for treatment guidanceHigh-throughput screenings provide orthogonal information to genetic sequencingSarcoma organoid response to treatment correlates with patient response to therapyLarge scale, functional precision medicine programs for rare cancers are feasible within a single institution.

Three-Dimensional CT and 3D MRI of Hip- Important Aids to Hip Preservation Surgery

Common hip internal derangements include femoroacetabular impingement (FAI), developmental dysplasia of hip (DDH) dysplasia, and avascular necrosis (AVN) of the femoral head. These are initially screened by radiographs. For preoperative planning of hip preservation, 3-dimensional (3D) CT is commonly performed to assess bony anatomy and its alterations. Magnetic resonance imaging (MRI) is used to evaluate labrum, hyaline cartilage, tendons, synovium, and loose bodies, and provides vital information for surgical decision-making. However, conventional 2D MRI techniques are limited by lack of isotropic multiplanar reconstructions and partial volume artifacts. With advancements in hardware and software, novel isotropic 3D MR Proton Density images are acquired with acceptable acquisition times leading to improved visualization of soft tissue and osseous structures for various hip conditions. Three-Dimensional MRI allows multiplanar non-gap reconstructions along the structures of interest. It results in detection of small, otherwise inconspicuous labral tears without the need for MR arthrogram, which can be subsequently measured. In addition, radial reconstructions of the femoral head can be performed from original 3D volume MR imaging and CT imaging without the need for individual different plane acquisitions. Three-Dimensional MRI thus impacts surgical decision-making for the important common hip derangement conditions. For example, femoral head hyaline cartilage loss may make hip preservation difficult or impossible. In this review, we discuss the advantages and technical details of 3D CT and MRI and their significant role in aiding hip preservation surgery for common hip conditions. The conditions discussed in this article include FAI, DDH, AVN, synovial disorders, cartilaginous tumors, and hip fractures.

Ninety Percent or Greater Tumor Necrosis Is Associated With Survival and Social Determinants of Health in Patients With Osteosarcoma in the National Cancer Database

BACKGROUND

The histologic response of osteosarcoma to chemotherapy is commonly cited as a prognostic factor and typically graded as the percent necrosis of the tumor at the time of surgical resection. Few studies, to our knowledge, have examined the relationship of tumor necrosis relative to other factors. Existing studies are limited by prolonged enrollment periods or analysis of patient subsets without the strongest predictor of mortality: metastasis at diagnosis. Additionally, the definitive threshold value for a good histologic response is commonly set at more than 90% tumor necrosis with little evidence; some authors advocate other values.

QUESTION/PURPOSES

(1) Are there alternative cutoff values for a good response to chemotherapy in a large, national cohort of contemporarily treated patients with osteosarcoma? (2) How does the association of histologic response to survival in osteosarcoma compare with other clinicopathologic factors? (3) What patient and clinical factors are associated with the histologic response?

METHODS

We identified 2006 patients with osteosarcoma diagnosed between 2010 and 2015 in the National Cancer Database (NCDB), a registry that includes 70% of all new cancers diagnosed in the United States with 90% follow-up. Patients were excluded for missing documentation of percent tumor necrosis (21% [425 of 2006]) or if definitive resection was not performed (< 1% [1 of 2006]). A total of 1580 patients were included in the analysis, with a mean follow-up duration of 37 ± 22 months. A Kaplan-Meier survival analysis, stratified by the percent tumor necrosis after chemotherapy, was performed for the 5-year period. Other covariates examined were sex, race, socioeconomic score composite, insurance type, Charlson/Deyo score, distance from the hospital, and location (metropolitan, urban, or rural). Clinical and sociodemographic data including patient-identified race from the patient's medical record is input into the NCDB by certified registrars. The NCDB only allows coding of one primary race for each patient; thus, most of our patients were grouped as White or Black race and the remaining were grouped as Other for our analysis. A multiple Cox regression analysis was performed to evaluate the effect of percent necrosis compared with other demographic, clinicopathologic, and treatment effects on survival. Finally, a multiple logistic regression analysis was performed to assess demographic and clinicopathologic characteristics associated with percent necrosis.

RESULTS

Five-year overall survival for patients with histologic gradings of 90% to 94% necrosis (70% [95% confidence interval (CI) 60.6% to 79.7%) and 95% to 100% necrosis (74% [95% CI 68% to 80.3%) was not different between groups (p = 0.47). A comparison of histologic responses below 90% necrosis found no difference in survival between patients with decreasing histologic response (p > 0.05). Necrosis of less than 90% was associated with worse survival (HR 2.00 [95% CI 1.58 to 2.52]; p < 0.001 compared with more than 90% necrosis), and factors most associated with poor survival were metastasis (HR 2.85 [95% CI 2.27 to 3.59]; p < 0.001) and skip metastasis at the time of diagnosis (HR 2.52 [95% CI 1.64 to 3.88]; p < 0.001). On multivariate analysis, adjusting for demographic, clinicopathologic, and treatment factors, social determinants of health were negatively associated with percent necrosis of 90% or more, including uninsured status (OR 0.46 [95% CI 0.23 to 0.92]; p = 0.02 compared with private insurance) and lower socioeconomic status composite (OR for the lowest first and second quartiles were 0.63 [95% CI 0.44 to 0.90]; p = 0.01 and 0.70 [95% CI 0.50 to 0.96]; p = 0.03, respectively). Race other than White or Black (OR 0.61 [95% CI 0.40 to 0.94]; p = 0.02 compared with White race) was also negatively associated with percent necrosis of more than 90% after controlling for available covariates.

CONCLUSION

This study suggests that a cutoff of 90% necrosis provides the best prognostic value for patients with osteosarcoma undergoing chemotherapy. Other threshold values did not show different survival benefits. Sociodemographic factors were associated with histologic response less than 90%. These associations must be carefully understood not as cause and effect but likely demonstrating the effects of health disparities and access to care. Although we controlled for multiple variables in our analysis, broad variables such as race may have been associated with histologic response due to unaccounted confounders. Medical providers should be aware of these associations to ensure equitable access and delivery of care because access to care may be responsible for these associations. Future studies should examine potential drivers of this observation, such as a delay in presentation or deviation from standard of care practices.

LEVEL OF EVIDENCE

Level III, therapeutic study.

T2-weighted MRI radiomics in high-grade intramedullary osteosarcoma: predictive accuracy in assessing histologic response to chemotherapy, overall survival, and disease-free survival

OBJECTIVE

To analyze radiomic features obtained from pre-treatment T2-weighted MRI acquisitions in patients with histologically proven intramedullary high-grade osteosarcomas and assess the accuracy of radiomic modelling as predictive biomarker of tumor necrosis following neoadjuvant chemotherapy (NAC), overall survival (OS), and disease-free survival (DFS).

MATERIALS AND METHODS

Pre-treatment MRI exams in 105 consecutive patients who underwent NAC and resection of high-grade intramedullary osteosarcoma were evaluated. Histologic necrosis following NAC, and clinical outcome-survival data was collected for each case. Radiomic features were extracted from segmentations performed by two readers, with poorly reproducible features excluded from further analysis. Cox proportional hazard model and Spearman correlation with multivariable modelling were used for assessing relationships of radiomics features with OS, DFS, and histologic tumor necrosis.

RESULTS

Study included 74 males, 31 females (mean 32.5yrs, range 15-77 years). Histologic assessment of tumor necrosis following NAC was available in 104 cases, with good response (≥ 90% necrosis) in 41, and poor response in 63. Fifty-three of 105 patients were alive at follow-up (median 40 months, range: 2-213 months). Median OS was 89 months. Excluding 14 patients with metastases at presentation, median DFS was 19 months. Eleven radiomics features were employed in final radiomics model predicting histologic tumor necrosis (mean AUC 0.708 ± 0.046). Thirteen radiomic features were used in model predicting OS (mean concordance index 0.741 ± 0.011), and 12 features retained in predicting DFS (mean concordance index 0.745 ± 0.010).

CONCLUSIONS

T2-weighted MRI radiomic models demonstrate promising results as potential prognostic biomarkers of prospective tumor response to neoadjuvant chemotherapy and prediction of clinical outcomes in conventional osteosarcoma.

Multifunctional inorganic biomaterials: New weapons targeting osteosarcoma

Osteosarcoma is the malignant tumor with the highest incidence rate among primary bone tumors and with a high mortality rate. The anti-osteosarcoma materials are the cross field between material science and medicine, having a wide range of application prospects. Among them, biological materials, such as compounds from black phosphorous, magnesium, zinc, copper, silver, etc., becoming highly valued in the biological materials field as well as in orthopedics due to their good biocompatibility, similar mechanical properties with biological bones, good biodegradation effect, and active antibacterial and anti-tumor effects. This article gives a comprehensive review of the research progress of anti-osteosarcoma biomaterials.

Serum lactate dehydrogenase levels predict the prognosis of patients with soft tissue sarcoma

Several studies have reported the prognostic factors for soft tissue sarcoma. Although serum lactate dehydrogenase (LDH) levels are associated with poor prognosis in several types of cancer, their role in soft tissue sarcomas remains unclear. Therefore, the present study evaluated the association between serum LDH levels and the clinical characteristics and prognosis of soft tissue sarcoma. A total of 103 patients diagnosed with primary soft tissue sarcoma between 2003 and 2019 were retrospectively examined, and the association between serum LDH levels at the first visit and clinical characteristics were analysed. In high-grade soft tissue sarcoma, the association between survival and clinical characteristics, including stratified LDH levels, was also analysed. Serum LDH levels were stratified (>253 and ≤253 IU/l) according to the standard values used at our institution. High serum LDH levels were significantly associated with the presence of metastasis and histological grade (P<0.001 and 0.040, respectively). In both the univariate and multivariate analyses, disease-specific survival (DSS) was significantly worse in patients with high-grade soft tissue sarcoma and high serum LDH levels than in patients with normal serum LDH levels (univariate analysis: P=0.025; multivariate analysis: Hazard ratio, 4.60; 95% confidence interval, 1.16-18.2; P=0.030). In conclusion, high serum LDH levels at the first visit predicted the presence of distant metastasis, high histological grade and worse DSS in patients with high-grade soft tissue sarcoma. Therefore, in patients with high serum LDH levels at the first visit, these risks should be considered during pretreatment examinations and post-treatment follow-up.

Chemotherapy in the management of periosteal osteosarcoma: A narrative review

Periosteal osteosarcoma (PO), an intermediate-grade chondroblastic osteosarcoma (OST) arising from the surface of the bones, is a rare histological subtype among primary bone sarcomas, most commonly diagnosed in young patients. It is characterized by distinct specific radiological and pathological features. The current management strategy is based on several case reports and series, without any solid international recommendations. Most sarcoma experts agree on the crucial role of an optimal complete surgical approach. However, with the paucity of available reports, the role of systemic treatment and its timing remains debatable. With this paper, we will review the available data on the actual impact of chemotherapy in PO patients with emphasis on the radiological, pathological, and therapeutic characteristics of this rare entity.

Assessment of Risk of Bias in Osteosarcoma and Ewing's Sarcoma Randomized Controlled Trials: A Systematic Review

Aim: The aim of this study was to systematically assess the risk of bias in osteosarcoma and Ewing’s sarcoma (ES) randomized controlled trials (RCT) and to examine the relationships between bias and conflict of interest/industry sponsorship. Methods: An OVID-MEDLINE search was performed (1976–2019). Using the Cochrane Collaboration guidelines, two reviewers independently assessed the prevalence of risk of bias in different RCT design domains. The relationship between conflicts of interest and industry funding with the frequency of bias was examined. Results: 73 RCTs met inclusion criteria. Prevalence of low-risk bias domains was 47.3%, unclear-risk domains 47.8%, and 4.9% of the domains had a high-risk of bias. Domains with the highest risk of bias were blinding of participants/personnel and outcome assessors, followed by randomization and allocation concealment. Overtime, frequency of unclear-risk of bias domains decreased (χ² = 5.32, p = 0.02), whilst low and high-risk domains increased (χ² = 8.13, p = 0.004). Studies with conflicts of interest and industry sponsorships were 4.2 and 3.1 times more likely to have design domains with a high-risk of bias (p < 0.05). Conclusion: This study demonstrates that sources of potential bias are prevalent in both osteosarcoma and ES RCTs. Studies with financial conflicts of interest and industry sponsors were significantly more likely to have domains with a high-risk of bias. Improvements in reporting and adherence to proper methodology will reduce the risk of bias and improve the validity of the results of RCTs in osteosarcoma and ES.

OLIE, ITCC-082: a Phase II trial of lenvatinib plus ifosfamide and etoposide in relapsed/refractory osteosarcoma

While survival rates for patients with relapsed/refractory osteosarcoma are low, kinase inhibitors have shown efficacy in its treatment. The multikinase inhibitor lenvatinib, plus ifosfamide and etoposide, showed antitumor activity in a Phase II study in patients with relapsed/refractory osteosarcoma. This Phase II randomized controlled trial (OLIE) will assess whether the combination of lenvatinib + ifosfamide + etoposide is superior to ifosfamide + etoposide alone in children, adolescents and young adults with relapsed/refractory osteosarcoma. The primary end point is progression-free survival; secondary and exploratory end points include, but are not limited to, overall survival, objective response rate, safety and tolerability, pharmacokinetic characterization of lenvatinib in the combination treatment, quality of life and quantification of baseline unresectable lesions that are converted to resectable.

Correlation between Prognostic Factors and the Histopathological Response to Neoadjuvant Chemotherapy in Osteosarcoma: A Retrospective Study

Background

Multimodality treatment, incorporating neoadjuvant chemotherapy and adjuvant chemotherapy, is the standard management plan for osteosarcoma that increases the overall survival (OS) rate. However, data regarding prognostic factors affecting the histopathological response following neoadjuvant chemotherapy is limited. Patients and Methods. We retrospectively reviewed patients diagnosed with osteosarcoma in our center between 2008 and 2018. We classified patient characteristics according to gender, age, tumor size, site and stage at diagnosis, site of metastasis, type of surgery, necrosis rate based on the Huvos grading system, and the number of neoadjuvant chemotherapy cycles. We divided response to neoadjuvant chemotherapy into poor responder for patients with Huvos grades 1 and 2 and good responder for patients with Huvos grades 3 and 4. We also documented patients' survival and follow-up information.

Results

We reviewed 64 patients within 5–65 years of age, dominated by men (62.5%). The distal femur (53.1%) was the most common site of osteosarcoma. Fifteen (23.4%) patients had a good response while 49 (76.6%) patients were poor responders to neoadjuvant chemotherapy based on the Huvos grading system. Based on multivariate analysis, gender (p = 0.012), age (p = 0.029), symptom duration (p = 0.004), and tumor enlargement after neoadjuvant chemotherapy (p < 0.001) were significantly associated with histopathological response. A scoring system was proposed integrating these significant variables (age > 20 years = 1 point, female gender = 1 point, symptom duration > 12 weeks = 1 point, and increased tumor size after neoadjuvant chemotherapy = 2 points). This scoring system divides patients into two groups with a total score of more than two predicting a poor responder to neoadjuvant chemotherapy.

Conclusions

Age, gender, symptoms duration, and tumor size after neoadjuvant chemotherapy are the prognostic features that affect the histopathological response to neoadjuvant chemotherapy in patients with osteosarcoma.

PET with 18F-Fluorodeoxyglucose/Computed Tomography in the Management of Pediatric Sarcoma

The role for PET with fludeoxyglucose F 18 (¹⁸F-FDG PET)/computed tomography (CT) in the management of pediatric sarcomas continues to be controversial. The literature supports a role for PET/CT in the staging and surveillance of certain specific pediatric sarcoma subtypes; however, the data are less clear regarding whether PET/CT can be used as a biomarker for prognostication. Despite the interest in using this imaging modality in the management of pediatric sarcomas, most studies are limited by retrospective design and small sample size. Additional data are necessary to fully understand how best to use ¹⁸F-FDG PET/CT in pediatric sarcoma management.

Alkaline phosphatase, lactic dehidrogenase, inflammatory variables and apparent diffusion coefficients from MRI for prediction of chemotherapy response in osteosarcoma. A cross sectional study

BACKGROUND

This present study aimed to assess if clinical, laboratory and MRI were an accurate benchmark in assessing the effectiveness of neoadjuvant chemotherapy in osteosarcoma patients.

METHODS

This was an observational analytic study with a cross-sectional design. We correlated among clinical, laboratory and magnetic resonance imaging (MRI) data before and after neoadjuvant chemotherapy; and percentage of tumor necroses from osteosarcoma patients during the period between January 2017-July 2019.

RESULTS

Of the 58 patients included in this study, 38 were male and 20 were female aged 5 - 67 years (mean: 16-year-old. 37(63.8%) patients underwent neoadjuvant chemotherapy with CAI regimens and 13 (36.2%) with CA regiments. The tumors were classified as stage IIB in 43 (74.1%) patients and stage III in 15 (25.9%) patients. Wilcoxon test showed significant differences between alkaline phosphatase (ALP), erythrocyte sedimentation rate (ESR), and neutrophil to lymphocyte ratio (NLR) before and after neoadjuvant chemotherapy in the poor-response group. We found no significant difference between lactic dehydrogenase (LDH) and lymphocyte-to-monocyte ratio (LMR) before and after neoadjuvant chemotherapy in the good-response group. MRI revealed decreased tumor volume in patients in the good-response to chemotherapy.

CONCLUSION

We demonstrated that ALP level was statistically significant in the poor-response group. We also found that LDH value before neoadjuvant chemotherapy had a strong correlation with degree of necrosis and could be used as a predictive indicator. MRI plays an important role in evaluating tumor volumes and preoperative radiological changes to predict histological necrosis.

What Effect Do Pulmonary Micronodules Detected at Presentation in Patients with Osteosarcoma Have on 5-Year Overall Survival?

For osteosarcoma, staging criteria, prognosis estimates, and surgical recommendations have not yet changed to reflect increasingly sensitive computed tomography (CT) imaging. However, the frequent identification of micronodules (<5 mm) on presentation leaves clinicians in a difficult position regarding the need to biopsy, resect, or follow the lesions and whether to consider the patient metastatic or non-metastatic. Our objective was to compare the 5-year overall survival rates of patients with osteosarcoma with non-surgically resected lung micronodules on presentation to patients without micronodules to guide community oncologists faced with this common dilemma. We collected data retrospectively on all newly diagnosed osteosarcoma patients, aged less than 50, treated at Rush University Hospital over 25 years without pulmonary nodules >10 mm or pulmonary surgical intervention. Kaplan–Meier curves showed there was no difference in 5-year overall survival in patients with any size nodule <5 mm compared to patients with no nodules. Additionally, our study showed a survival advantage for those who presented with 0 or 1 nodule (90%) compared to ≥2 nodules (53%). Our data suggest surgery may not be necessary for singular nodules <5 mm identified on presentation, and that these patients behave more like “localized” patients than metastatic patients.

What is the best clinical approach to recurrent/refractory osteosarcoma?

Introduction: Osteosarcoma is the most common malignant bone tumor. It is currently treated with pre-and postoperative chemotherapy, associated with surgical resection of the tumor.Area covered: Relapses occur in about one in three patients presenting with localized disease, and three in four of those with metastases at diagnosis. Relapsing disease carries a very poor prognosis, with 5-year survival rates ranging between 13% and 40%.Expert opinion: Patients with unilateral lung involvement or solitary lung metastases and a recurrence-free interval (RFI) longer than 24 months have a better prognosis, and could be managed with surgical resection and close observation. Complete surgical resection of all sites of disease remains essential to survival: patients unable to achieve complete remission have a catastrophic overall survival rate. The role of second-line chemotherapy is not at all clear, and no controlled studies are available on this topic. It is worth considering for patients unable to achieve complete surgical remission, and those with multiple metastases and/or a RFI <24 months. Given their dismal prognosis, patients with multiple sites of disease not amenable to complete surgical resection should also be considered for innovative therapeutic approaches.

Prognostic Factors for Development of Subsequent Metastases in Localized Osteosarcoma: A Systematic Review and Identification of Literature Gaps

Aim

To investigate prognostic factors in pediatric and young adult patients with localized osteosarcoma that could predict the development of subsequent pulmonary metastases and lead to an ability to risk-stratify therapy. We performed a systematic review of the literature published since January 1990 to establish common evidence-based prognostic factors.

Methods

PubMed and Embase searches (Jan 1990–Aug 2018) were performed. Two reviewers independently selected papers for patients with localized osteosarcoma with subsequent metastatic development and then reviewed for quality of methods and prognostic factors.

Results

Database searches yielded 216 unique results. After screening, 27 full-text articles were studied in depth, with 9 items fulfilling predetermined inclusion and exclusion criteria. Age, tumor location, tumor size/volume, and histologic response carried independent prognostic value in the majority of the studies.

Conclusions

Several prognostic factors seemed to be consistent amongst the studies, but the heterogeneity and smaller sizes of the study populations made pooling of results difficult. Standardization of larger patient populations and consistent definitions/cutoffs for prognostic factors are needed to further assess for consistent prognostic factors and potential predictive models to be developed.

Outcomes in Treatment-Naïve Patients With Metastatic Extremity Osteosarcoma Treated With OGS-12, a Novel Non-High-Dose Methotrexate-Based, Dose-Dense Combination Chemotherapy, in a Tertiary Care Cancer Center

Purpose

Metastatic osteosarcoma is largely treated with high-dose methotrexate (HDMTX)–based therapy, especially in the pediatric population. This mandates complex pharmacokinetic monitoring in a costly inpatient setting to mitigate unpredictable serious toxicities. Hence, a non-HDMTX–based regimen is worth exploring, especially in India and low- and middle-income countries.

Materials and Methods

All consecutive treatment-naïve patients with metastatic osteosarcoma were prospectively treated on the novel OGS-12 protocol consisting of sequential doublets of doxorubicin, cisplatin, and ifosfamide. Four cycles were administered as neoadjuvant therapy followed by planned curative intent surgery and metastasectomy when feasible, followed by four cycles of adjuvant chemotherapy. Baseline characteristics, histologic response, event-free survival (EFS), overall survival (OS), and toxicity data were prospectively collected.

Results

Three hundred seventeen patients were enrolled onto the OGS-12 protocol from 2011 to 2014, of whom 80 (25%) had metastatic disease; median age was 17 years. The majority of patients were nutritionally challenged with high-risk features. At presentation, 83% of patients (66 patients) had lung metastases. After neoadjuvant chemotherapy, 57% of patients were histologically good responders. Four-year EFS and OS rates were 24% and 27%, respectively, in the intent-to-treat population and 27% and 29%, respectively, in the per-protocol analysis. Significant grade 3 or 4 toxicities were febrile neutropenia (51%), thrombocytopenia (36%), and anemia (54%). Histologic response was an independent predictor for EFS and OS in patients who underwent surgery. Surgical intervention was found to be significant for survival in univariable analysis.

Conclusion

The novel, low-cost, non-HDMTX–based, dose-dense OGS-12 regimen has shown comparable outcomes to international standards in metastatic osteosarcomas and is worthy of wider clinical application. An aggressive multimodality approach may result in long-term survival in a select group of patients and, hence, is worth considering.

Current and future therapeutic approaches for osteosarcoma

INTRODUCTION

Current treatment of osteosarcoma includes surgical resection of all gross disease in conjunction with systemic chemotherapy to control micro-metastatic disease. This yields a 5-year event free survival (EFS) of approximately 70% for patients with localized osteosarcoma while patients with metastatic or recurrent disease fare poorly with overall survival rates of less than 20%. Areas covered: This review outlines the current and future approach towards the treatment of osteosarcoma. A literature search was performed utilizing PubMed. Several recent clinical trials are reviewed in detail, as is innovative research evaluating novel agents and surgical techniques which hold promise. Expert commentary: The outcome for patients with osteosarcoma has not changed in several decades. This plateau in survival rates highlights the need for a novel approach towards research. There remains a great deal of interest in utilizing the very high risk population of recurrent osteosarcoma patients to rapidly and sequentially evaluate novel agents to determine if any of these agents hold promise. Several phase II studies are ongoing or in development that offer hope based on intriguing preclinical data. Furthermore, initiatives in obtaining specimens to further explore the genetic and immunological profile behind osteosarcoma will be essential towards identifying novel pathways and targets to exploit.

A Novel System for the Surgical Staging of Primary High-grade Osteosarcoma: The Birmingham Classification

BACKGROUND

Chemotherapy response and surgical margins have been shown to be associated with the risk of local recurrence in patients with osteosarcoma. However, existing surgical staging systems fail to reflect the response to chemotherapy or define an appropriate safe metric distance from the tumor that will allow complete excision and closely predict the chance of disease recurrence. We therefore sought to review a group of patients with primary high-grade osteosarcoma treated with neoadjuvant chemotherapy and surgical resection and analyzed margins and chemotherapy response in terms of local recurrence.

QUESTIONS/PURPOSES

(1) What predictor or combination of predictors available to the clinician can be assessed that more reliably predict the likelihood of local recurrence? (2) Can we determine a better predictor of local recurrence-free survival than the currently applied system of surgical margins? (3) Can we determine a better predictor of overall survival than the currently applied system of surgical margins?

METHODS

This retrospective study included all patients with high-grade conventional osteosarcomas without metastasis at diagnosis treated at one center between 1997 and 2012 with preoperative chemotherapy followed by resection or amputation of the primary tumor who were younger than age 50 years with minimum 24-month followup for those still alive. A total of 389 participants matched the inclusion criteria. Univariate log-rank test and multivariate Cox analyses were undertaken to identify predictors of local recurrence-free survival (LRFS). The Birmingham classification was devised on the basis of two stems: the response to chemotherapy (good response = ≥ 90% necrosis; poor response = < 90% necrosis) and margins (< 2 mm or ≥ 2 mm). The 5-year overall survival rate was 67% (95% confidence interval [CI], 61%-71%) and 47 patients developed local recurrence (12%).

RESULTS

Intralesional margins (hazard ratio [HR], 9.9; 95% CI, 1.2-82; p = 0.03 versus radical margin HR, 1) and a poor response to neoadjuvant chemotherapy (HR, 3.8; 95% CI, 1.7-8.4; p = 0.001 versus good response HR, 1) were independent risk factors for local recurrence (LR). The best predictor of LR, however, was a combination of margins ≤ 2 mm and a less than 90% necrosis response to chemotherapy (Birmingham 2b HR, 19.6; 95% CI, 2.6-144; p = 0.003 versus Birmingham 1a; margin >2 mm and more than 90% necrosis HR, 1). Two-stage Cox regression model and higher Harrell's C statistic demonstrate that the Birmingham classification was superior to the Musculoskeletal Tumor Society (MSTS) margin classification for predicting LR (Harrell's C statistic Birmingham classification 0.68, MSTS criteria 0.59). A difference in overall survival was seen between groups of the Birmingham classification (log-rank test p < 0.0001), whereas the MSTS margin system was not discriminatory (log-rank test p = 0.14).

CONCLUSIONS

Based on these observations, we believe that a combination of the recording of surgical margins in millimeters and the response to neoadjuvant chemotherapy can more accurately predict the risk of local recurrence than the current MSTS system. A multicenter collaboration study initiated by the International Society of Limb Salvage is recommended to test the validity of the proposed classification and if these findings are confirmed, this classification system might be considered the standard practice in oncology centers treating patients with osteosarcomas and allow more effective communication of margin status for research.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Osteosarcoma follow-up: chest X-ray or computed tomography?

Background

In patients with relapsed osteosarcoma, the surgical excision of all metastases, defined as second complete remission (CR-2), is the factor that mainly influences post-relapse survival (PRS). Currently a validated follow-up policy for osteosarcoma is not available, both chest X-ray and computed tomography (CT) are suggested for lung surveillance. The purpose of this study is to evaluate whether the type of imaging technique used for chest surveillance, chest X-ray or CT, influenced the rate of CR-2 and prognosis in patients with recurrent osteosarcoma.

Methods

Patients up to 40 years with extremity osteosarcoma enrolled in consecutive clinical trials and treated at the Rizzoli Institute from 1986 to 2009 were identified. Only patients who had lung metastases alone as first pattern of recurrence were considered for the analysis. The rate of CR-2, overall survival (OS) and PRS were the end-points of the study.

Results

The median follow-up was 47 months (1–300), 215 patients were eligible. Lung metastases were detected by chest X-ray in 100 (47%) patients, by CT in 112 (52%) and by symptoms in 3 (1%). CR-2 rate was 60% for patients followed by X-rays and 88% for those followed by CT (p < .0001). 5-year PRS was 30% (95% CI 21–39) in the X-ray group and 49% (95% CI 39–59) in the CT group (p = .0004). 5-year OS was 35% (95% CI 26–44) in the X-ray group and 60% (95% CI 51–70) in the CT group (p = .004).

Conclusions

A follow-up strategy with chest CT leads to a higher rate of CR-2 and significantly improves PRS and OS in osteosarcoma, compared to chest X-ray.

The Role of 18F-FDG-PET/CT in Pediatric Sarcoma

Considerable debate remains regarding how best to incorporate ¹⁸F-FDG-PET/CT into clinical practice for pediatric sarcomas. Although there is a clear role for ¹⁸F-FDG-PET/CT in staging pediatric sarcoma, the value of ¹⁸F-FDG-PET/CT in prognostication for pediatric sarcomas remains unclear. In osteosarcoma, Ewing sarcoma, and rhabdomyosarcoma, ¹⁸F-FDG-PET/CT may be most useful in the identification of skeletal metastases, where the literature consistently suggests that it has improved sensitivity and specificity as compared to bone scintigraphy. The role of the imaging modality in the identification of pulmonary metastatic disease is less clear. Further controversy exists regarding the use of ¹⁸F-FDG-PET/CT in predicting outcome. Several studies, particularly in osteosarcoma, suggest changes in the maximal standardized uptake value (SUV_max) that can predict histologic response following neoadjuvant chemotherapy as well as overall outcome. Conversely, studies are conflicting regarding the use of ¹⁸F-FDG-PET/CT as a prognostic tool in Ewing sarcoma and rhabdomyosarcoma. The role of ¹⁸F-FDG-PET/CT in pediatric nonrhabdomyosarcoma soft tissue sarcomas is unknown at this time. Although most studies have been small and retrospective, in certain histologic subtypes, there is a clear role for the use of this imaging modality. Additional prospective and larger studies are needed to fully determine how best to incorporate ¹⁸F-FDG-PET/CT into treatment regimens for pediatric sarcomas in the future.

[Treatment Outcomes and Prognostic Factors of Pulmonary Metastasectomy for Bone and Soft Tissue Sarcoma: a High Volume Academic Institution Experience]

背景与目的

肺是骨与软组织肉瘤最常见的远隔转移脏器，肺转移严重影响患者长期生存。肺转移瘤切除术有助于改善预后，然而对其临床地位、适应证及预后影响因素的认识目前仍存在争议。由于发病率较低难以开展随机对照研究，同时国际单中心大宗病例回顾研究也极为罕见，国内尚无类似报道。本研究旨在回顾本组单中心大样本肺转移性骨与软组织肉瘤的外科治疗结果，并且对预后影响因素进行分析。

方法

2007年1月-2015年12月期间，经病理确诊为骨与软组织肉瘤，已在多学科综合治疗框架下完成原发病灶根治性切除，并且至少经过1次肺转移瘤切除术的所有患者均纳入分析。收集相关临床变量，运用Cox风险比例回归法进行单因素及多因素分析寻找与预后影响因素。

结果

144例骨与软组织肉瘤患者符合纳入标准，总共行155次肺转移瘤切除术。多因素分析结果提示非R0切除、无病间期 < 1年、肺转移灶数目≥3枚、肺转移灶的长径总和≥45 mm均是预后的独立危险因素。

结论

积极行肺转移瘤外科治疗有助于改善转移性骨与软组织肉瘤患者的长期预后。R0切除，无病间期时间较长，转移瘤数目较少及长径总和较小是本组患者良好的预后因素。

Mesenchymal stem cells increase proliferation but do not change quiescent state of osteosarcoma cells: Potential implications according to the tumor resection status

Conventional therapy of primary bone tumors includes surgical excision with wide resection, which leads to physical and aesthetic defects. For reconstruction of bone and joints, allografts can be supplemented with mesenchymal stem cells (MSCs). Similarly, adipose tissue transfer (ATT) is supplemented with adipose-derived stem cells (ADSCs) to improve the efficient grafting in the correction of soft tissue defects. MSC-like cells may also be used in tumor-targeted cell therapy. However, MSC may have adverse effects on sarcoma development. In the present study, human ADSCs, MSCs and pre-osteoclasts were co-injected with human MNNG-HOS osteosarcoma cells in immunodeficient mice. ADSCs and MSCs, but not the osteoclast precursors, accelerated the local proliferation of MNNG-HOS osteosarcoma cells. However, the osteolysis and the metastasis process were not exacerbated by ADSCs, MSCs, or pre-osteoclasts. In vitro proliferation of MNNG-HOS and Saos-2 osteosarcoma cells was increased up to 2-fold in the presence of ADSC-conditioned medium. In contrast, ADSC-conditioned medium did not change the dormant, quiescent state of osteosarcoma cells cultured in oncospheres. Due to the enhancing effect of ADSCs/MSCs on in vivo/in vitro proliferation of osteosarcoma cells, MSCs may not be good candidates for osteosarcoma-targeted cell therapy. Although conditioned medium of ADSCs accelerated the cell cycle of proliferating osteosarcoma cells, it did not change the quiescent state of dormant osteosarcoma cells, indicating that ADSC-secreted factors may not be involved in the risk of local recurrence.

Analysis of the coincidence rate between imaging and pathological findings of pulmonary metastasis in 45 cases with invasive bone and soft tissue sarcoma

Background

It is not uncommon for imaging examinations of invasive bone and soft tissue sarcoma patients during initial treatment or postoperative follow-up to detect pulmonary nodules. This has important significance in determining the nature of nodules either for tumor staging and therapeutic regimen selection or for prognosis evaluation.

Methods

A review was carried out of invasive bone and soft tissue sarcoma patients diagnosed and treated in the department of orthopedic oncology of Beijing Jishuitan Hospital from June 2002 to June 2012. Data from patients who developed pulmonary metastases, diagnosed by imaging and treated surgically, were analyzed for consistency between imaging and postoperative pathological diagnoses.

Results

A total of 45 patients with pulmonary metastasis diagnosed by imaging and treated with resection of pulmonary lesions were included in the study. Thirty-eight cases with pulmonary metastases (84.4%) and seven cases without pulmonary metastases (15.6%) were confirmed by postoperative pathological examination. The most common pathological type in the latter patients was tuberculosis, with a total of four cases (57.1%).

Conclusion

There is a certain degree of misdiagnosis when using imaging for diagnosis of pulmonary metastasis, and attention should be paid to the pathological diagnosis of pulmonary metastasis in order to avoid overtreatment. Tuberculosis is most common in invasive bone and soft tissue sarcoma patients with pulmonary benign lesions, and it should be distinguished.

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

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

Late recurrence of osteosarcoma: a report of two cases

We report 2 cases of late recurrence of osteosarcoma after 6 and 7 years. One patient had pulmonary metastasis, and the other had soft tissue recurrence. Both patients underwent complete resection and chemotherapy. The first patient achieved complete remission and remained disease-free 47 months later and had no limitation in his daily life. The second patient had a re-recurrence and underwent further resection and chemotherapy. He remained disease-free 35 months later and could walk using a T-handled walking cane.

Review of management issues in relapsed osteosarcoma

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. With combined modality treatment long-term survival rate for localized disease is near 70%. Thirty percent of patients relapse with lung as the commonest site. Surgery is the treatment of choice for relapsed patients whenever possible. Addition of chemotherapy to surgery provides survival benefit in patients not achieving second surgical remission. Even patients with multiple lung recurrences can be cured with repeated thoracotomies. Disease-free interval and complete surgical resection are the main prognostic factor for post-relapse survival.

Synthesis, characterization and anti-proliferative activity of Cd(II) complexes with NNN type pyrazole-based ligand and pseudohalide ligands as coligand

Cd(II) complexes of tridentate nitrogen donor ligand, 2,6-bis(3,4,5-trimethylpyrazolyl)pyridine (btmpp), Cd(btmpp)X2 (X:Cl, ONO or N(CN)2) have been synthesized and characterized by elemental and spectral (FT-IR, (1)H NMR, (13)C NMR, UV-Vis) analyses, differential thermal analysis and single crystal X-ray diffraction studies. The molecular structure of reported complex 1, revealed distorted square-pyramidal geometry around Cadmium. Complexes 1-3 and corresponding ligand were tested for cytotoxic activity against the human carcinoma cell lines HEP3B (hepatocellular carcinoma), PC3 (prostate adenocarcinoma), MCF7 (breast adenocarcinoma) and Saos2 (osteosarcoma). The results show that, complexes are more cytotoxic than the free ligand and complex 2 is the most cytotoxic complex for PC3.

Prognostic value of histological response to chemotherapy in osteosarcoma patients receiving tumor-bearing frozen autograft

Background

A variety of surgical procedures are now available for tissue reconstruction after osteosarcoma excision, and an important prognostic factor is the evaluation of response to chemotherapy using histology. Although tumor-bearing autografts are useful tools for reconstruction, re-use of the primary tumor may make it difficult to assess the histological response to chemotherapy, since the entire tumor cannot be analyzed. Here, we analyzed the prognostic value of the histological response in the patients who received frozen tumor-bearing autografts for reconstruction.

Method

Retrospective analysis of the medical records of 51 patients with high-grade osteosarcoma of the extremities was performed. All patients received reconstruction using frozen tumor-bearing autografts. Tumor necrosis was evaluated in extraskeletal masses and cancellous bone.

Results

Five-year overall survival of patients with good and poor response to chemotherapy was 82.9% and 46.4%, respectively (P = 0.044), and 5-year event-free survival was 57.7% and 36.0%, respectively (P = 0.329). Multivariate analysis revealed that a poor histological response to chemotherapy was a significant prognostic factor for overall survival (P = 0.033).

Conclusion

Histological response is an important and reliable prognostic factor in patients undergoing reconstruction using frozen tumor-bearing autografts.

Prognostic factors for teenage and adult patients with high-grade osteosarcoma: an analysis of 240 patients

The aim of this retrospective, multicenter study was to evaluate clinicopathological characteristics, prognostic factors and treatment outcomes of teenage and adult patients with high-grade osteosarcoma. A total of 240 osteosarcoma patients who were diagnosed and treated from March 1995 to September 2011 were analyzed. Median age was 20 years (range 13-74 years), and 153 patients (63.8%) were male. Primary tumor localization was extremity in 204 patients (85.4 %), trunk in 21 patients (8.8%) and head and neck region in 14 patients (5.9%). According to American Joint Committee on Cancer staging system, 186 patients (77.5%) were stage II, 3 (1.3%) were stage III and 48 (20.0%) were stage IV. Median overall survival (OS) was 55 months (95 % CI 36.8-73.1 months). OS after 2, 5 and 10 years were 67, 49 and 42%, respectively. Univariable analysis for OS showed that male gender (p = 0.032), high baseline lactate dehydrogenase (LDH) level (p < 0.001), high baseline serum alkaline phosphatase level (p = 0.002), telangiectatic subtype (p = 0.023), presence of metastasis at diagnosis (p < 0.001), presence of tumor positive margins after primary surgery (p = 0.015), poor pathological response to preoperative chemotherapy (p = 0.006) and presence of recurrent disease during follow-up period (p < 0.001) were significantly associated with poor survival. Patients who received postoperative methotrexate plus doxorubicin plus cisplatin (M + A + P) combination regimen (p = 0.019), underwent surgery for recurrent disease (p < 0.001) and received chemotherapy for recurrent disease (p < 0.001) had longer OS. In multivariable analysis for OS, only high LDH level (p = 0.002) and the presence of metastasis at diagnosis (p = 0.011) were associated with poor OS, whereas the patients who received chemotherapy for recurrent disease had a longer OS (p = 0.009).

Surgical resection of relapse may improve postrelapse survival of patients with localized osteosarcoma

BACKGROUND

Despite neoadjuvant chemotherapy and wide surgical ablation, 15% to 25% of patients with primary osteosarcoma will relapse (local recurrence or metastases). Neither chemotherapy nor radiation therapy alone will render a patient disease-free without concomitant surgical ablation of relapse. We prefer excision of relapse when possible. However, it is unclear whether excision enhances survival.

QUESTIONS/PURPOSES

We therefore determined (1) onset, location, and treatments for relapse; (2) postrelapse disease-free survival of patients who underwent surgical ablation and those who did not; and (3) relapse-free interval between initial diagnosis and first relapse in survivors and in those who died of their disease.

METHODS

We retrospectively reviewed 15 children who initially presented with localized, nonmetastatic extremity osteosarcoma and attained initial complete remission after neoadjuvant chemotherapy, wide local resection, postoperative chemotherapy, and subsequently developed disease relapse. Relapse occurred at a median of 28 months, although late relapse after 5 years occurred in three. We resected the recurrent tumor in nine patients and treated six nonoperatively.

RESULTS

Seven of nine surgically treated patients had a postrelapse disease-free survival ranging from 3 to 14 years and an overall survival ranging from 7 to 16 years. Patients not surgically treated all died within 40 months of their relapse. The median relapse-free interval in patients who survived was longer 34 months (range, 17-152 months) as compared with 17 months (range, 7-40 months) in those who died of their disease.

CONCLUSIONS

Our data confirm the importance of surgery in patients with relapsed osteosarcoma. Disease-free survival in patients with relapsed osteosarcoma is only possible if complete remission is attained. Patients with late relapse may have a better chance of survival.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Incidence, epidemiology and treatment results of osteosarcoma in Finland - a nationwide population-based study

BACKGROUND

Patients diagnosed with osteosarcoma in Finland during 1991-2005 were retrospectively analyzed in a nationwide, population-based study. We focused on the incidence, treatment and outcome of osteosarcoma patients. We also evaluated the value of known prognostic parameters.

MATERIAL AND METHODS

Osteosarcomas were retrieved from the files of the national Finnish Cancer Registry. Only patients with histologically confirmed osteosarcoma were included in the analysis. Histological review was performed.

RESULTS

The study consists of 144 osteosarcoma patients with a mean follow-up of 9.8 years for survivors. Mean annual incidence of histologically confirmed osteosarcoma was 1.8 new osteosarcomas per million. The 10-year sarcoma-specific survival for the whole population was 63% and 73% for patients with local disease at presentation. Overall limb-salvage rate was 73% and local control was 84% for patients with a peripheral tumor. Development of local recurrence and major deviation from the chemotherapy protocol were significant adverse factors for sarcoma-specific survival in multivariate analysis.

CONCLUSION

The present nationwide and population-based study is our second report of treatment and prognosis of osteosarcoma in Finland. With modern chemotherapy the prognosis of local osteosarcoma has improved in Finland from 47% during 1971-1980 and 65% during 1981-1990 at five years to the present 73% during 1991-2005 at 10 years. The 10-year sarcoma-specific survival of 73% is excellent and comparable to results reported with contemporary treatment protocols in high-volume centers. However, improvement in limb-salvage rate and local control probably requires centralization of treatment of this rare disease.

Intensive induction chemotherapy without methotrexate in adult patients with localized osteosarcoma: results of the Institut Gustave-Roussy phase II trial

PURPOSE

To improve outcomes in localized osteosarcoma and to reduce the duration of preoperative chemotherapy, we conducted a phase ii trial assessing the efficacy of an intensive protracted regimen without methotrexate (api-ai regimen) in adolescent and adult patients with newly diagnosed disease.

PATIENTS AND METHODS

Induction chemotherapy consisted of 2 cycles (4 courses) of doxorubicin 60 mg/m(2) (days 1 and 15), cisplatin 100 mg/m(2) (day 1), and ifosfamide 5 g/m(2) (days 2 and 15). The primary endpoint was good histologic response [ghr (≤5% identifiable tumour cells)].

RESULTS

From March 1993 to March 2000, 32 patients [median age: 21 years (range: 15-49 years)] were administered 126 induction courses. The median time between chemotherapy courses was 15 days (range: 12-32 days). All but 3 patients underwent conservative surgery. Toxicity was mainly hematologic, with febrile neutropenia occurring in 35% of patients and grades 3-4 thrombocytopenia in 35%. The ghr rate was 47%. The median follow-up was 64 months (range: 30-115 months). The 5-year event-free and overall survivals were 65% [95% confidence interval (ci): 48%-79%] and 69% (95% ci: 50%-83%) respectively. Two secondary hematologic malignancies occurred: 1 acute myelocytic leukemia (M5) in a poor responder with concomitant relapse, and 1 myelodysplastic syndrome in a patient achieving ghr.

CONCLUSIONS

Despite hematologic toxicity, the results observed with the api-ai regimen compare favourably with those observed during previous induction chemotherapy containing methotrexate in adult patients and the pediatric population treated at our institution. These promising results have to be validated by an ongoing national multicentre trial coordinated by the French Sarcoma Group.

Chemotherapeutic adjuvant treatment for osteosarcoma: where do we stand?

AIM

Since the introduction of chemotherapy, survival in localised high-grade osteosarcoma has improved considerably. However, there is still no worldwide consensus on a standard chemotherapy approach. In this systematic review evidence for effectiveness of each single drug and the role of response guided salvage treatment of adjuvant chemotherapy are addressed, whereas in a meta-analysis the number of drugs in current protocols is considered.

METHODS

A systematic literature search for clinical studies in localised high-grade osteosarcoma was undertaken, including both randomised and non-randomised trials. Historical clinical studies from the pre-chemotherapy era were included for comparison purposes.

RESULTS

Nine historical studies showed a long-term survival of 16% after only local treatment. Fifty single agent phase II studies showed high response rates for adriamycin (A, 43%), ifosfamide (Ifo, 33%), methotrexate (M, 32%), cisplatin (P, 26%) but only 4% for etposide (E). In 19 neo-adjuvant studies the mean 5-year event free survival (EFS) was 48% for 2-drug regimens and 58% for ⩾3 drug regimens, with a 5-year overall survival (OAS) of 62% and 70%, respectively. Meta-analysis showed that ⩾3 drug regimens including methotrexate plus adriamycin plus cisplatin (plus ifosfamide) (MAP(Ifo)) had significant better outcome (EFS: HR=0.701 (95% confidence interval [95% CI]: 0.615-0.799); OAS: HR=0.792 (95% CI: 0.677-0.926) than 2-drug regimens, but there was no significant difference between MAP and MAPIfo (or plus etoposide). Salvage of poor responders by changing drugs, or intensifying treatment postoperatively has not proven to be useful in this analysis.

CONCLUSION

Meta-analysis in patients with localised high-grade osteosarcoma shows that 3-drug regimens, for example MAP are the most efficacious drug regimens.

Impact of close surgical margin on local recurrence and survival in osteosarcoma

PURPOSE

Whether neoadjuvant chemotherapy safely allows close margins in osteosarcoma patients is still unknown. This study investigates the impact of close margins on local recurrence (LR) and overall survival (OS) for osteosarcoma patients treated with neoadjuvant chemotherapy.

METHODS

We retrospectively reviewed 47 cases of conventional osteosarcoma who were treated at our institution. Patient and treatment factors such as age, gender, MSTS stage, tumour site, surgery type, pathological type, tumour size, surgical margin, tumour necrosis rate, chemotherapy regimens and cycles were recorded. A close margin was defined as tumour present less than 5 mm from the closest resection margin. The average followup was 87.6 months (range, 25-135 months).

RESULTS

Twenty-five patients were alive, 22 patients had died, and eight had LR. Twenty-eight patients had wide margins, seven had positive margins and 12 had close margins. Positive margins had a greater risk of LR (57.1%) than wide margins and close margins. There was no difference in LR (8.3% vs 10.7%) between close margins and wide margins. Margin status was not correlated with OS.

CONCLUSION

Compared with wide margins, close margins did not lead to increased local recurrence in our study group. Whether close margins, as defined in our study, are just as acceptable as wide margins in terms of patient outcomes for osteosarcoma patients with neoadjuvant chemotherapy needs to be further confirmed in the future.

The relation of tumour necrosis and survival in patients with osteosarcoma

PURPOSE

We investigated whether tumour necrosis was associated with disease-free survival (DFS) and overall survival (OS) of osteosarcoma patients treated in our institution.

METHODS

We retrospectively studied the predictive value of percentage of necrosis in 40 cases of IIB osteosarcoma treated from 1999 to 2008 in our institution. Patient and treatment factors such as age, gender, tumour site, surgery type, pathological type, tumour size, margin status, percentage of tumour necrosis, chemotherapy regimens and cycles were recorded. The average follow-up was 85.9 months (range, 25-135 months).

RESULTS

Two patients had local recurrence (LR) alone, five patients had both LR and metastasis, 14 patients had metastasis alone. Twenty-four patients were alive and 16 had died. The five-year DFS and OS were 47.8% and 65.9%, respectively. Tumour necrosis grouped by 90% was not associated with DFS and OS. Patients with greater than 70% necrosis rate had a significantly higher DFS than those with less than 70%.

CONCLUSION

We found no survival advantage at 90% tumour necrosis in our study. Further study with more patients should be performed to evaluate the predictive value of necrosis rate at the cutoff of 70%.

Safety concern between autologous fat graft, mesenchymal stem cell and osteosarcoma recurrence

BACKGROUND

Osteosarcoma is the most common malignant primary bone tumour in young adult treated by neo adjuvant chemotherapy, surgical tumor removal and adjuvant multidrug chemotherapy. For correction of soft tissue defect consecutive to surgery and/or tumor treatment, autologous fat graft has been proposed in plastic and reconstructive surgery.

PRINCIPAL FINDINGS

We report here a case of a late local recurrence of osteosarcoma which occurred 13 years after the initial pathology and 18 months after a lipofilling procedure. Because such recurrence was highly unexpected, we investigated the possible relationship of tumor growth with fat injections and with mesenchymal stem/stromal cell like cells which are largely found in fatty tissue. Results obtained in osteosarcoma pre-clinical models show that fat grafts or progenitor cells promoted tumor growth.

SIGNIFICANCE

These observations and results raise the question of whether autologous fat grafting is a safe reconstructive procedure in a known post neoplasic context.

The multidisciplinary management of osteosarcoma

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

The treatment of nonmetastatic high grade osteosarcoma of the extremity: review of the Italian Rizzoli experience. Impact on the future

The Bone Tumor Center of the "Istituto Ortopedico Rizzoli" was established in 1955 with the aim of studying and treating the musculoskeletal tumors. Between 1959 and 2006, 1245 patients with high grade nonmetastatic osteosarcoma of the extremity were treated at our Institute. Most of them were enrolled in study protocols. In the "prechemotherapy era", the cure rate was 11%, with an amputation rate of 90%. Our first experience with adjuvant chemotherapy was in 1972. A total of 223 patients received adjuvant chemotherapy, with a disease-free survival (DFS) ranging from 45% to 53%, according to the chemotherapy protocol used. With the introduction of neoadjuvant chemotherapy, the resection rate increased and reached 94%, when high dose fosfamide was added to standard doses of methotrexate, cisplatin, and adriamycin. In the last few years, the results of treatment of nonmetastatic osteosarcoma of the extremity have reached a plateau (64% five-year DFS), and strategies of dose intensification are not able to improve the prognosis. Not only new active drugs, but also different approaches to the disease, are needed. In this regard, we are now investigating tumor microenvironment-targeted agents and chemotherapy protocols based on prospective biological stratification of patients. Collaborative projects with international groups and institutions are crucial for this rare disease.

Intraarterial chemotherapy for extremity osteosarcoma and MFH in adults

The neoadjuvant treatment of osteosarcoma using intravenous agents has resulted in survival rates of 55% to 77% [3, 5, 6, 20, 22, 35]. We designed a neoadjuvant chemotherapy protocol using combined intraarterial and intravenous agents to treat high-grade osteosarcoma and malignant fibrous histiocytoma of bone in an attempt to improve survival. We report the results of treating 53 adults (age 18-77 years) diagnosed with nonmetastatic extremity osteosarcoma or malignant fibrous histiocytoma. Preoperative chemotherapy consisted of intravenous doxorubicin followed by intraarterial cisplatinum administered repetitively every 3 weeks for three to five cycles, depending on tumor response assessed by serial arteriography. Dose and duration of cisplatin were adjusted for tumor size. After resection, good responders (90% or greater necrosis) underwent treatment with the same agents and poor responders were treated with alternative agents for longer duration. Minimum followup was 24 months (mean, 111 months; range, 24-235 months). Estimated Kaplan-Meier survival at 10 years was 82% and event-free survival was 79%. Forty-one patients (77%) had a good histologic response and 92% (49 of 53) underwent limb-sparing procedures. Local recurrence occurred in two patients (4%). These results compared favorably with those reported in the current literature.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Late recurrence in primary region of parosteal osteosarcoma: a case report

Recurrence in patients with osteosarcoma after 5 years is a rare condition and has been infrequently reported. Here, the authors present a case of conventional parosteal osteosarcoma that had relapsed 17 years after diagnosis. To their knowledge, this is one of the latest recurrence times in the primary region of osteosarcoma.