Survival data for 648 patients with osteosarcoma treated at one institution

A Retrospective Cohort Analysis of Limb Salvage Surgery Using Mega Prosthesis in Bone Tumours at a Tertiary Care Centre in Eastern India

Background

The method known as "limb salvage surgery" (LSS) aids in the removal of extremity tumours, and reconstruction is completed with satisfactory oncologic, functional, and cosmetic outcomes. Oncologic clearance is given first priority, followed by functional outcomes. Worldwide, the trend has already shifted away from amputations and toward limb salvage surgery for eligible patients due to efficient chemotherapy regimens, improved imaging techniques, precise administration of enhanced radiation, better reconstructive choices, and developments in bio-engineering. The purpose of the present study was to determine the clinicopathological characteristics, surgical techniques, functional outcome, and prognostic factors of limb salvage surgery performed using mega prosthesis in primary malignant or benign resectable tumours.

Methods

Our retrospective cohort study was carried out over a period of two years and included 28 patients who received care for bone tumours. The data gathered comprised the demographic profile, clinical characteristics, histological characteristics, treatments given, functional results, and survival. LSS was performed on all patients by orthopaedics oncologists trained in the surgical oncology department. Following surgery, during the first two years, patients were examined at every three-month interval, then every six months until the fifth year, and then once a year after that. The Kaplan-Meier method was utilized to determine the median follow-up and recurrence-free survival (RFS).

Results

In our study, the mean age of study subjects was 30.0±10.9 years. Almost all of the subjects included in the study had lower limb bone tumours (96.4%). The most common site for the tumour was the distal femur (57.1%) followed by the proximal femur (32.2%). The most common type of benign tumour was giant cell tumour (GCT) (53.6%), including recurrences of giant cell tumour (GCT), and among malignant tumours, osteosarcoma was the most common (25.0%). The mean surgical resection of bone in limb salvage surgery was 125.2±24.2 mm. The most common post-operative complication was leg length discrepancy (LLD) among 25.0% of subjects, which was managed by shoe raise. The overall mean musculoskeletal tumour society (MTSS) score after LSS was 25.0±4.3. Using the Kaplan-Meier method analysis, we found that relapse-free survival was 83.7% among enrolled subjects at a median follow-up period of 80 months.

Conclusion

It can be difficult to surgically treat patients who have malignant bone tumours. In limb-sparing surgery for bone tumours, the modular segmental-replacement system prosthesis that we preferred produced satisfactory results in terms of tumour control and limb function. To get good long-term results, the case selection must be appropriate.

CD44 In Sarcomas: A Comprehensive Review and Future Perspectives

It is widely accepted that the tumor microenvironment, particularly the extracellular matrix, plays an essential role in the development of tumors through the interaction with specific protein-membrane receptors. One of the most relevant proteins in this context is the transmembrane protein CD44. The role of CD44 in tumor progression, invasion, and metastasis has been well established in many cancers, although a comprehensive review concerning its role in sarcomas has not been published. CD44 is overexpressed in most sarcomas and several in vitro and in vivo experiments have shown a direct effect on tumor progression, dissemination, and drug resistance. Moreover, CD44 has been revealed as a useful marker for prognostic and diagnostic (CD44v6 isoform) in osteosarcoma. Besides, some innovative treatments such as HA-functionalized liposomes therapy have become an excellent CD44-mediated intracellular delivery system for osteosarcoma. Unfortunately, the reduced number of studies deciphering the prognostic/diagnostic value of CD44 in other sarcoma subgroups, neither than osteosarcoma, in addition to the low number of patients involved in those studies, have produced inconclusive results. In this review, we have gone through the information available on the role of CD44 in the development, maintenance, and progression of sarcomas, analyzing their implications at the prognostic, therapeutic, and mechanistic levels. Moreover, we illustrate how research involving the specific role of CD44 in the different sarcoma subgroups could suppose a chance to advance towards a more innovative perspective for novel therapies and future clinical trials.

Development of a Simple Risk Model to Predict Mortality in Patients With Osteosarcoma of the Extremity

Background

Osteosarcoma (OS) is the most prevalent primary malignant bone cancer with poor prognosis. The aim of this study was to explore the prognostic factors that influence survival, and build up and validate a simple risk model to predict mortality in OS patients.

Materials and Methods

This was a single-center retrospective cohort study. A total of 153 patients with newly diagnosed OS were enrolled as the training group. We analyzed the clinical data and outcomes of the OS patients. Prognostic risk factors were identified and evaluated by a logistic regression model with Markov Chain Monte Carlo simulation. The risk score was constructed based on the training group and was further validated using each patient.

Results

Among the 153 patients, the mean (standard deviation) age was 21.6 (14.2) years, and 62 (40.5%) patients were females. The rate of in-hospital mortality of patients was 41.2% (95% CI, 31.6–50.7%). The candidate prognostic factors were selected and evaluated in relation to patient age, sex, tumor site (lower/upper extremity), tumor volume, intramedullary length of lesion, serum levels of alkaline phosphatase (ALP) and primary metastasis. However, only tumor size and primary metastasis were identified as independent prognostic indicators for patients with osteosarcoma. The risk model had a C-statistic of 0.7308 with a predictive range of 21.05–68.42%. Based on the distribution of the risk score, 24.8, 49.7 and 25.5% of patients were stratified into the high-, average- and low-risk groups for in-hospital mortality, with corresponding probabilities of 0.684, 0.329, and 0.210, respectively.

Conclusion

A simple risk model was developed and validated to predict the prognosis for patients with osteosarcoma of the extremity at primary diagnosis. The simple risk score system could be used to stratify patients into different risk groups of in-hospital mortality and may help clinicians judge the outcomes of prognosis and establish appropriate surveillance strategies.

Intralesional margin after excision of a high-grade osteosarcoma: Is it a catastrophe?

BACKGROUND AND OBJECTIVES

Treatment of high-grade osteosarcoma (OS) relies on a combination of systemic chemotherapy and radical surgical excision of the tumor. Little is known on what happens in case of an irrefutably inadequate (intralesional) margin. We aimed to describe the outcome of patients with high-grade OSs of the trunk and the extremities where planned wide resection resulted in an intralesional margin.

METHODS

A retrospective study from the Scandinavian Sarcoma Group registry and the Royal Orthopaedic Hospital databases including data from 53 patients surgically treated between the years 1990 and 2017.

RESULTS

Local recurrence was observed in 13/53 patients. All patients with local recurrence where the neoadjuvant chemotherapy response could be retrieved (n = 9) were shown to be poor responders. None of the patients with good response to chemotherapy relapsed. Postoperative radiotherapy was not associated with improved local control of the disease. Re-excision surgery was performed in only seven patients, and two of them had tumor relapse.

CONCLUSIONS

Good response to chemotherapy salvages the outcome of surgical excision with a poor margin in patients with high-grade OSs and a watchful waiting strategy may be justified in these cases. Poor responders have a higher recurrence risk and their approach should be individualized.

Characteristics, Management, and Outcomes of Patients With Osteosarcoma: An Analysis of Outcomes From the National Cancer Database

Introduction:

Previous studies about osteosarcoma patient characteristics, management, and outcomes have limited patient numbers, combine varied tumor types, and/or are older studies.

Methods:

Patients with osteosarcoma from the 2004 to 2015 National Cancer Database data sets were separated into axial, appendicular, and other. Demographic and treatment data as well as 1-, 5-, and 10-year survival were determined for each group. A multivariate Cox analysis of patient variables with the likelihood of death was performed, and the Kaplan Meier survival curves were generated.

Results:

Four thousand four hundred thirty patients with osteosarcoma (3,435 appendicular, 810 axial, and 185 other) showed survival at 1-year, 5-year, and 10-year and was highest among the appendicular cohort (91.17%, 64.43%, and 58.58%, respectively). No change in survival was seen over the periods studied. The likelihood of death was greater with increasing age category, distant metastases, and treatment with radiation alone but less with appendicular primary site, treatment with surgery alone, or surgery plus chemotherapy.

Discussion:

Despite advances in tumor management, surgical excision remains the best predictor of survival for osteosarcomas. No difference was observed in patient survival from 2004 to 2015 and, as would be expected, distant metastases were a poor prognostic sign, as was increasing age, male sex, and axial location.

Diagnosis and staging of malignant bone tumours in children: what is due and what is new?

PURPOSE

Although malignant bone tumours in children are infrequent, it is important to know how to properly diagnose and stage them, in order to establish an adequate treatment.

METHODS

We present a review of the diagnostic workflow of malignant bone tumours in children, including history and clinical examination, imaging, laboratory tests and biopsy techniques. Moreover, the two most commonly used staging systems are reviewed.

RESULTS

History, clinical examination and laboratory tests are nonspecific for diagnosing malignant bone tumours in children. Radiographs remain the mainstay for initial diagnosis, with MRI the modality of choice for local assessment and staging. Fluorine-18 labelled fluoro-deoxy-glucose-positron emission tomography scans provide a noninvasive method to assess the aggressiveness of the tumour and to rule out metastasis and is replacing the use of the bone scintigraphy. Biopsy must be always performed under the direction of the surgeon who is to perform the surgical treatment and after all diagnostic evaluation has been done. Staging systems are useful to study the extent of the tumour and its prognosis. They are expected to evolve as we better understand new molecular and genetic findings.

CONCLUSION

When a malignant bone tumour is suspected in a child, it is essential to make a correct diagnosis and referral to an experienced centre. Following an appropriate workflow for diagnosis and staging facilitates, prompt access to treatment improves outcomes.

LEVEL OF EVIDENCE

Level V Expert opinion.

Complex joint-preserving bone tumor resection and reconstruction using computer navigation and 3D-printed patient-specific guides: A technical note of three cases

In selected extremity bone sarcomas, joint-preserving surgery retains the natural joints and nearby ligaments with a better function than in traditional joint-sacrificing surgery. Geometric multiplanar osteotomies around bone sarcomas were reported with the advantage of preserving more host bone. However, the complex surgical planning translation to the operating room is challenging.

Using both Computer Navigation and Patient-Specific Guide may combine each technique's key advantage in assisting complex bone tumor resections. Computer Navigation provides the visual image feedback of the pathological information and validates the correct placement of Patient-Specific Guide that enables accurate, guided bone resections. We first described the digital workflow and the use of both computer navigation and patient-specific guides (NAVIG) to assist the multiplanar osteotomies in three extremity bone sarcoma patients who underwent joint-preserving bone tumor resections and reconstruction with patient-specific implants. The NAVIG technique verified the correct placement of patient-specific guides that enabled precise osteotomies and well-fitted patient-specific implants. The mean maximum deviation errors of the nine achieved bone resections were 1.64 ​± ​0.35 ​mm (95% CI 1.29 to 1.99). The histological examination of the tumor specimens showed negative resection margin. At the mean follow-up of 55 months (40–67), no local recurrence was noted. There was no implant loosening that needed revision. The mean MSTS score was 29 (28–30) out of 30 with the mean knee flexion of 140° (130°–150°).

The excellent surgical accuracy and limb function suggested that the NAVIG technique might replicate the surgical planning of complex bone sarcoma resections by combining the strength of both Computer Navigation and Patient-Specific Guide. The patient-specific approach may translate into clinical benefits. The translational potential of this article:

The newly described technique enhances surgeons’ capability in performing complex joint-preserving surgery in bone sarcoma that is difficult to be achieved by the traditional method. The high precision and accuracy may translate into superior clinical outcomes.

Prognostic factors of chondroblastic osteosarcoma and nomogram development for prediction: A population-based, STROBE-compliant study

The present study aimed to develop nomograms to predict survival in patients with chondroblastic osteosarcoma (COS).An analysis was conducted of 320 cases of COS collected from the surveillance, epidemiology, and end results (SEER) database between 2004 and 2015. Independent prognostic factors were screened using univariate and multivariate Cox analyses. Subsequently, nomograms were established to predict the patients' cancer-specific survival (CSS) and overall survival (OS) rates. The prediction accuracy and discriminative ability of the nomograms were examined using calibration curves and the concordance index (C-index).As revealed in the univariate and multivariate Cox regression analysis, age, tumor size, the primary site, the presence of metastasis, a history of having undergone surgery, and a history of having received radiotherapy were found to be independent prognostic factors associated with survival in patients with COS (all P < .05). Furthermore, age >39 years, the presence of distant metastasis, no history of having undergone any surgery, and tumor size >103 mm were found to be associated with poor prognosis in patients, while the primary site of the mandible and no history of having undergone radiotherapy showed associations with a more favorable prognosis in patients. Next, nomograms were constructed to predict the OS and CSS in patients with COS.We constructed nomograms that can provide accurate survival predictions in patients with chondroblastic osteosarcoma. These nomograms can help surgeons customize the treatment strategies for patients with chondroblastic osteosarcoma.

Effect assessment of methotrexate in combination with other chemotherapeutic agents for osteosarcoma in children: A protocol for systematic review and meta-analysis

BACKGROUND

Osteosarcoma is a primary form of malignant bone tumor. It is commonly prevalent among children. Treating osteosarcoma with chemotherapy has had limited clinical outcomes due to side effects and the formation of drug resistance. Presently, a mixture of doxorubicin, cisplatin, ifosfamide, epirubicin methrotrexate, and other supplementary medications are used in osteosarcoma chemotherapy. Therefore, this study aims to investigate the clinical therapeutic effects of combining methotrexate with other chemotherapeutic agents to treat osteosarcoma in children.

METHODS

The search of several electronic databases will lead to source related published studies. The electronic databases include both English (PubMed, EMBASE, Web of Science, and the Cochrane Library) and Chinese (China National Knowledge Infrastructure, WanFang, and China Biomedical Database) databases. All studies published from inception to November 19, 2020 are searched. Study selection, extraction of data, and evaluation of the bias risk in included studies are carried out by two authors independently. The software, RevMan 5.3, is used to analyze the data.

RESULTS

This study provides evidence of substantial quality for the clinical therapeutic effects of methotrexate combined with other chemotherapeutic agents for treating osteosarcoma in children.

CONCLUSION

The results of this study provide conclusive evidence with regards to the clinical application of methotrexate combined with other chemotherapeutic agents for treating osteosarcoma in children.

ETHICS AND DISSEMINATION

Since this study will use published data, ethical approval is not required.

SYSTEMATIC REVIEW REGISTRATION NUMBER

This protocol has been registered on INPLASY202110024.

Osteosarcoma, chondrosarcoma and Ewing sarcoma: Clinical aspects, biomarker discovery and liquid biopsy

Bone sarcomas, although rare, are associated with significant morbidity and mortality. The most frequent primary bone cancers include osteosarcoma, chondrosarcoma and Ewing sarcoma. The treatment approaches are heterogeneous and mainly chosen based on precise tumour staging. Unfortunately, clinical outcome has not changed significantly in over 30 years and tumour grade is still the best prognosticator of metastatic disease and survival. An option to improve this scenario is to identify molecular biomarkers in the early stage of the disease, or even before the disease onset. Blood-based liquid biopsies are a promising, non-invasive way to achieve this goal and there are an increasing number of studies which investigate their potential application in bone cancer diagnosis, prognosis and personalised therapy. This review summarises the interplay between clinical and molecular aspects of the three main bone sarcomas, alongside biomarker discovery and promising applications of liquid biopsy in each tumour context.

Survival Analysis of 3 Different Age Groups and Prognostic Factors among 402 Patients with Skeletal High-Grade Osteosarcoma. Real World Data from a Single Tertiary Sarcoma Center

Age is a known prognostic factor for many sarcoma subtypes, however in the literature there are limited data on the different risk profiles of different age groups for osteosarcoma survival. This study aims to provide an overview of survival in patients with high-grade osteosarcoma in different age groups and prognostic variables for survival and local control among the entire cohort. In this single center retrospective cohort study, 402 patients with skeletal high-grade osteosarcoma were diagnosed and treated with curative intent between 1978 and 2017 at the Leiden University Medical Center (LUMC). Prognostic factors for survival were analyzed using a Cox proportional hazard model. In this study poor overall survival (OS) and event-free survival (EFS) were associated with increasing age. Age groups, tumor size, poor histopathological response, distant metastasis (DM) at presentation and local recurrence (LR) were important independent prognostic factors influencing OS and EFS. Differences in outcome among different age groups can be partially explained by patient and treatment characteristics.

Advances in the Functional Assessment of Patients with Sarcoma

Functional assessment of patients with osteosarcoma may yield unique insights into the guide and advance treatment. A range of patient-reported outcomes has been validated, including general health and condition-specific measures as well as computer adaptive testing. Health state utility measures, which facilitate comparative-effectiveness research, are also available. Beyond these surveys, and laboratory-dependent gait analyses, is the potential for real-world evaluation through research-oriented and consumer-oriented accelerometers. Initial studies have shown promising validity of these activity trackers and may also have implications for traditional oncologic outcomes.

Long Non-Coding RNA OIP5-AS1 Knockdown Enhances CDDP Sensitivity in Osteosarcoma via miR-377-3p/FOSL2 Axis

Background

Drug resistance is one of big obstacles for the treatment of tumor. Long non-coding RNA Opa-interacting protein 5-antisense RNA 1 (OIP5-AS1) was identified to involve in drug resistance. In this research, the effects of OIP5-AS1 on cisplatin (CDDP) resistance in osteosarcoma (OS) were mainly investigated.

Methods

The levels of OIP5-AS1, microRNA-377-3p (miR-377-3p), and FOS like 2 (FOSL2) were measured by quantitative real-time polymerase chain reaction. The inhibitory concentration 50 (IC₅₀) value of CDDP, cell viability and apoptotic rate was evaluated through Cell Counting Kit-8 and flow cytometry assays, respectively. The levels of multidrug resistance-associated protein 1 (MRP1), P-glycoprotein, B-cell lymphoma 2, Bcl2-associated X, cleaved-caspase-3, and FOSL2 were detected by Western blot assay. The interaction between miR-377-3p and OIP5-AS1 or FOSL2 was verified by Dual-Luciferase Reporter and RNA Immunoprecipitation assays. The function of OIP5-AS1 was detected by a xenograft tumor model in vivo.

Results

OIP5-AS1 and FOSL2 were up-regulated, while miR-377-3p was down-regulated in CDDP-resistant OS tissues and cells. OIP5-AS1 silencing inhibited cell viability and the IC₅₀ value of CDDP, and promoted apoptotic rate in CDDP-resistant OS cells. Mechanically, OIP5-AS1 was verified as a sponge to miR-377-3p and FOSL2 was a target of miR-377-3p. Moreover, OIP5-AS1 knockdown repressed OS tumor growth and enhanced CDDP sensitivity of OS in vivo.

Conclusion

OIP5-AS1 positively modulated FOSL2 expression to decrease CDDP sensitivity in OS by sponging miR-377-3p.

Age and Tumor Location Predict Survival in Nonmetastatic Osteosarcoma in Upper Egypt

AIM

The aims of this study were to assess survival outcome of pediatric patients with localized osteosarcoma of the extremities in Upper Egypt, identify factors of prognostic significance for survival, and to determine factors predictive of surgical methods used in these patients, as well as developing a clinical model for risk prediction.

PATIENTS AND METHODS

A retrospective analysis of data assembled from medical records of 30 pediatric patients with a histologically verified nonmetastatic osteosarcoma of the extremities treated at South Egypt Cancer Institute with a unified chemotherapy protocol between January 2001 and December 2015 was carried out. Prognostic factors were determined using univariable and multivariable methods. A model for surgical outcomes in these patients based on the baseline clinical factors, and the parameters predictive of their tumor response to chemotherapy, was developed.

RESULTS

With a median follow-up of 63 months for the study population, the estimates for event-free survival and overall survival (OS) at 3 and 5 years were 69.5% and 79% and 65.2% and 65.3%, respectively. Age 16 years or above was independently associated with both worse metastasis-free survival (hazard ratio [HR]=6.05, 95% confidence interval [CI]: 1.43-25.6, P=0.015) and OS (HR=7.9, 95% CI: 1.71-36.2, P=0.008). In the multivariable analysis, a proximal location within the limb gained a statistical significance to be independently associated with worse OS (HR=2.4, 95% CI: 1.13-22.1, P=0.003). Poor response to chemotherapy was marginally associated with worse metastasis-free survival (HR=4.9, 95% CI: 1.02-23.8, P=0.047) only in the univariable analysis. The patients found to be more likely to undergo an amputation surgery (odds ratio=14.1, 95% CI: 1.34-149.4, P=0.028) were those in whom a tumor was poorly responding to chemotherapy.

CONCLUSION

In Upper Egypt, despite the reasonable survival outcomes in nonmetastatic osteosarcoma, a relatively high limb amputation rate has been encountered. The development of a clinical prediction model for future planning of possible outcome improvement in these patients, however, is still feasible.

Alpha-Particle Therapy for Multifocal Osteosarcoma: A Hypothesis

Osteosarcoma (OST) is the most common bone tumor in children and adolescents with a second peak of incidence in elderly adults usually diagnosed as secondary tumors in Paget's disease or irradiated bone. Subjects with metastatic disease or whose disease relapses after the initial therapy have a poor prognosis. Moreover, multifocal OST contains tumor-initiating cells that are resistant to chemotherapy. The use of aggressive therapies in an attempt to eradicate these cells can have long-term negative consequences in these vulnerable patient populations. ²²⁷Th-labeled molecular probes based on ligands to OST-associated receptors such as IGF-1R (insulin-like growth factor receptor 1), HER2 (human epidermal growth factor receptor 2), and PSMA (prostate-specific membrane antigen) are expected to detect and treat osseous and nonosseous sites of multifocal OST. Published reports indicate that ²²⁷Th has limited myelotoxicity, can be stably chelated to its carriers and, as it decays at targeted sites, ²²⁷Th produces ²²³Ra that is subsequently incorporated into the areas of increased osteoblastic activity, that is, osseous metastatic lesions. Linear energy transfer of α particles emitted by ²²⁷Th and its daughter ²²³Ra is within the range of the optimum relative biological effectiveness. The radiotoxicity of α particles is virtually independent of the phase in the cell cycle, oxygenation, and the dose rate. For these reasons, even resistant OST cells remain susceptible to killing by high-energy α particles, which can also kill adjacent quiescent OST cells or cells with low expression of targeted receptors. Systemic side effects are minimized by the limited range of these intense radiations. Quantitative single-photon emission computed tomography of ²²⁷Th and ²²³Ra is feasible. Additionally, the availability of radionuclide pairs, for example, ⁸⁹Zr for positron emission tomography and ²²⁷Th for therapy, establish a strong basis for the theranostic use of ²²⁷Th in the individualized treatment of multifocal OST.

Establishment and characterization of a novel human osteosarcoma cell line for spontaneous pulmonary metastasis research in vivo

Background

A large number of osteosarcoma patients are dying of pulmonary metastasis in spite of the recent progress achieved in treatment research. Therefore, there is an urgent need for an in vivo experiment, whose purpose is to investigate the growth and metastasis of human osteosarcoma tumor. In this study, a novel human osteosarcoma cell line was established and characterized for osteosarcoma metastatic research in vivo.

Methods

Small pieces of parental primary osteosarcoma samples from a 16-year-old boy were xeno-transplanted into NOD/SCID mice. Then, osteosarcoma cells from the xeno-grafts were isolated and further passaged in vitro. Expression profiling was confirmed using HE staining and immunohistochemistry. The tumorigenic and metastatic ability of the established cell line was analyzed by cell scratch and CCK8 assay in vitro, and tumor transplantation in NOD/SCID mice.

Results

Parental cells were pleomorphic and positive with ALP, SSEA-4, and CD44. Osteosarcoma cells, named Well5 cells, were successfully isolated and had the ability of adipogenesis and osteogenesis. Well5 cells were mostly positive for SSEA-4 protein, and possessed morphological characteristics such as osteoblastic nature during the cultivation and hetero transplantation. Cell scratch and CCK8 assay indicated Well5 cells obtained a better capacity for migration and proliferation than the MG63 cell line. In NOD/SCID mice, orthotopic tumors were established at the primary site, and spontaneous pulmonary metastases were developed.

Conclusions

A novel human osteosarcoma cell line was successfully established, which may be helpful for spontaneous pulmonary metastasis research in vivo.

Treatment outcome of patients with chondroblastic osteosarcoma of the limbs and pelvis

AIMS

The aim of this study was to identify factors that determine outcomes of treatment for patients with chondroblastic osteosarcomas (COS) of the limbs and pelvis.

PATIENTS AND METHODS

The authors carried out a retrospective review of prospectively collected data from 256 patients diagnosed between 1979 and 2015. Of the 256 patients diagnosed with COS of the pelvis and the limbs, 147 patients (57%) were male and 109 patients (43%) were female. The mean age at presentation was 20 years (0 to 90).

RESULTS

In all, 82% of the patients had a poor response to chemotherapy, which was associated with the presence of a predominantly chondroblastic component (more than 50% of tumour volume). The incidence of local recurrence was 15%. Synchronous or metachronous metastasis was diagnosed in 60% of patients. Overall survival was 51% and 42% after five and ten years, respectively. Limb localization and wide surgical margins were associated with a lower risk of local recurrence after multivariable analysis, while the response to chemotherapy was not. Local recurrence, advanced patient age, pelvic tumours, and large volume negatively influenced survival. Resection of pulmonary metastases was associated with a survival benefit in the limited number of patients in whom this was undertaken.

CONCLUSION

COS demonstrates a poor response to chemotherapy and a high incidence of metastases. Wide resection is associated with improved local control and overall survival, while excision of pulmonary metastases is associated with improved survival in selected patients. Cite this article: Bone Joint J 2019;101-B:739-744.

Treatment-Related Prognostic Factors in Managing Osteosarcoma around the Knee with Limb Salvage Surgery: A Lesson from a Long-Term Follow-Up Study

Purpose

The aim of this study was to assess the treatment-related factors associated with local recurrence and overall survival of patients with osteosarcoma treated with limb-salvage surgery.

Patients and Methods

Treatment-related factors were analyzed to evaluate their effects on local recurrence-free survival (LRFS) and overall survival (OS) in 182 patients from 2004 to 2013.

Results

The mean length of follow-up was 73.4 ± 34.7 months (median, 68 months; range, 12-173 months), and 63 patients died by the end of the follow-up. The 5-year and 10-year overall survival rates were 68.6 ± 6.6% and 59.4 ± 10.6%, respectively. Univariate analysis showed that treatment-related prognostic factors for overall survival were prolonged symptom intervals >=60 days, biopsy/tumor resection performed by different centers, previous medical history, incomplete preoperative chemotherapy (<8 weeks), and prolonged postoperative interval >21 days. In the multivariate analysis, biopsy/tumor resection performed by different centers, incomplete implementation of planned new adjuvant chemotherapy, and delayed resumption of postoperative chemotherapy (>21 days) were risk factors for poor prognosis; biopsy/tumor resection performed by different centers and tumor necrosis <90% were independent predictors of local recurrence.

Conclusion

For localized osteosarcoma treated with limb-salvage surgery, it is necessary to optimize timely standard chemotherapy and to resume postoperative chemotherapy to improve survival rates. Biopsies should be performed at experienced institutions in cases of developing local recurrence.

Osteosarcoma after the age of fifty: A clinicopathological study

INTRODUCTION

Osteosarcoma, a primary malignant bone tumor, has a well-recognised double peak of incidence in early adolescence and after 50 years. This study investigates the clinical features and prognostic factors of patients older than 50 years with osteosarcoma.

MATERIEL AND METHODS

From January 2000 to December 2012, in one bone tumor reference center, 32 patients aged more than 50 years at the diagnosis (mean age: 62.4 years (50-85), sex ratio: 13 males, 19 females) diagnosed with osteosarcoma were included. Patients younger than 50 years at diagnosis or with a non-histologically proved osteosarcoma were excluded. For each patient, we registered medical history, tumor location, systemic and local extension, treatment, and survival.

RESULTS

62% were located in the extremities and 28% in the axial skeleton. 6 were secondary sarcomas. Mean delay between first symptoms and biopsy was 7.4 months (range from 0 to 28 months). Ten patients had a systemic osteosarcoma with one or more pulmonary metastases. Six patients were treated with palliative care (18.8%). Eighteen patients received neodajuvant chemotherapy, sixteen of them received postoperative chemotherapy. Twenty-five patients had surgery. Postoperative complications were reported in eight cases (25%). Overall survival for all 31 patients was 25% at 5 years and 6.2% at 10 years. Survival without metastases was 15.6% at 5 years and nil at 10 years. Median survival time for the 22 localised osteosarcoma patients was 4 years (0.9-12.6) versus 1.2 years (0.3-12.3) for the 10 systemic osteosarcoma patients (p = 0.01).

CONCLUSION

Metastases at diagnosis, age, axial location are worse prognostic for survival.

Cytokine Expression in Canine Lymphoma, Osteosarcoma, Mammary Gland Tumour and Melanoma: Comparative Aspects

Cytokines released in the tumour microenvironment play a major role in cancer pathogenesis. In human cancers and corresponding animal models, cytokine expression contributes to tumour growth and progression, as well as regulation of the host anti-tumour response. The elucidation of the function and importance of cytokines in canine cancers is still in an early stage, although relevant data have been obtained in classical examples of comparative models of human cancers, such as osteosarcoma, melanoma, mammary tumour and lymphoma. A deeper understanding of the cytokine signature may advance diagnosis, prevention and treatment of canine cancers.

Clinicopathological and prognostic value of hypoxia-inducible factor-1α in patients with bone tumor: a systematic review and meta-analysis

Background

Recently, many studies have shown the role of hypoxia-inducible factor-1α (HIF-1α) expression in the outcome of bone tumor. However, the results remain inconclusive. It is necessary to carry out a meta-analysis of all the current available data to clarify the relationship between HIF-1α and survival or clinicopathological features of bone tumor.

Methods

PubMed, Cochrane Library, Web of Science, China National Knowledge Internet, and Wanfang databases were used to search the relationship between HIF-1α and bone tumor. Articles investigating clinicopathological and prognostic value of HIF-1α in bone tumor patients were enrolled in this meta-analysis. Overlapping articles, duplicate data, reviews, case reports, and letters without original data were excluded. The pooled risk ratios (RRs) and hazard ratios (HRs) were used to evaluate the clinicopathological and prognostic value of HIF-1α on bone tumor patients, respectively.

Results

A total of 28 studies including 1443 patients were included in this meta-analysis, which were involved in three different types of bone tumor including 3 chondrosarcomas, 2 giant cell tumors of bone, and 23 osteosarcomas. Our results showed that high expression levels of HIF-1α were associated with poorer OS (overall survival) (HR = 2.61, 95% CI 2.11–3.23, P <  0.001) and shorter DFS (disease-free survival) (HR = 2.02, 95% CI 1.41–2.89, P <  0.001) in bone tumor. In addition, this study also analyzed the role of HIF-1α expression in clinicopathological features, which were closely related with the severity of bone tumor, including differentiation, clinical stage, metastasis, and microvessel density. Our results indicated that HIF-1α overexpression was significantly associated with differentiation (RR = 1.56, 95% CI 1.00–2.43, P = 0.049), clinical stage (RR = 1.75, 95% CI 1.25–2.45, P = 0.001), metastasis (RR = 1.78, 95% CI 1.58–2.00, P <  0.001), and microvessel density (SMD = 2.34, 95% CI 1.35–3.34, P <  0.001) of bone tumor.

Conclusions

HIF-1α overexpression indicated an unfavorable factor for OS and DFS in bone tumor, suggesting that HIF-1α may serve as a potential prognostic marker for bone tumor.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1101-5) contains supplementary material, which is available to authorized users.

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.

Peroxiredoxin 1 (PRDX1) Suppresses Progressions and Metastasis of Osteosarcoma and Fibrosarcoma of Bone

BACKGROUND Osteosarcoma and fibrosarcoma are malignant tumors with poor prognosis. Peroxiredoxin 1 (PRDX1) is considered to prevent tumors in many malignances. However, few studies have focused on the functions of PRDX1 in osteosarcoma and fibrosarcoma. MATERIAL AND METHODS PRDX1 mRNA in tumors and adjacent tissues of 32 osteosarcoma patients and 16 fibrosarcoma patients was extracted and measured. Proliferation and invasion of MG63 and HT1080 cell lines after silencing or overexpressing PRDX1 were used to detect the role of PRDX1 in metastasis of osteosarcoma and fibrosarcoma. RESULTS PRDX1 mRNA level was lower in tumor tissues than in adjacent tissues of osteosarcoma (F=50.105) and fibrosarcoma (F=28.472) patients, both significantly (P<0.05). Silencing PRDX1 promoted proliferation of MG63 and HT1080 cells, while overexpressing PRDX1 suppressed proliferation after 24 h, 48 h, and 72 h, compared to the control group, both significantly (P<0.05). Silencing PRDX1 increased invasive cells of MG63 (F=246.218) and HT1080 (F=245.602), while overexpressing PRDX1 decreased invasive cells of both, compared to the control, and the difference was significant (P<0.05). CONCLUSIONS PRDX1 expression is low in osteosarcoma and fibrosarcoma tumors. PRDX1 suppressed the progression and metastasis of osteosarcoma and fibrosarcoma cells.

Surgical and Functional Outcomes After Limb-Preservation Surgery for Tumor in Pediatric Patients: A Systematic Review

BACKGROUND

Limb-salvage surgery and segmental reconstruction for the treatment of lower extremity osseous tumors in the pediatric population have been described in the literature, but there is little consensus regarding the optimal surgical treatment for this patient population.

METHODS

A systematic review of the literature was performed to identify studies focusing on limb-salvage procedures in pediatric patients who were managed with one of three reconstructions with use of a metallic endoprosthesis, allograft, or allograft-prosthesis composite. Data were segregated according to the excised and reconstructed anatomical location (proximal part of the femur, total femur, distal part of the femur, proximal part of the tibia) and were collated to assess modes of failure and functional outcomes of each reconstruction type for each anatomic location.

RESULTS

Sixty articles met the inclusion criteria; all were Level-IV evidence, primarily consisting of small, retrospective case series. Infection was a primary mode of failure across all reconstruction types and locations, whereas allograft reconstructions were susceptible to structural failure as well. The rate of failure in the pediatric population correlated well with previously published results for adults. The incidence of subsequent amputation was lower in the pediatric population (5.2%) than has been reported in adults (9.5%) (p = 0.013). Meaningful growth of expandable metallic endoprostheses was reported in the literature, with an overall rate of leg-length discrepancy of 13.4% being noted at the time of the latest follow-up. The Musculoskeletal Tumor Society (MSTS) questionnaire was the most consistently used outcome measure in the literature, with average scores ranging from 71.0% to 86.8%, depending on reconstruction type and anatomic location.

CONCLUSIONS

The current state of the literature detailing the surgical and functional outcomes of segmental reconstruction for the treatment of pediatric bone tumors is limited to Level-IV evidence and is complicated by under-segregation of the data by age and anatomical location of the reconstruction. Despite these limitations, pediatric limb-salvage surgery demonstrates satisfactory initial surgical and functional outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of low- and high-linear energy transfer radiation on in vitro and orthotopic in vivo models of osteosarcoma by activation of caspase-3 and -9

Osteosarcoma (OS) is a malignant tumor of the bone derived from primitive transformed cells of the mesenchymal origin. Local low-linear energy transfer (LET) radiotherapy has limited benefits on OS owing to its radioresistance. Thus, this study aimed to investigate the effects of high-LET radiation on human OS. Therefore, the human OS cell lines, U2O2 and KHOS/NP, were examined in vitro, or an orthotopic mouse xenograft model was studied in vivo after treatment with low-LET (gamma-ray) and high-LET (neutron) radiation. Notably, OS cells were significantly more sensitive to high-LET radiation in vitro and in the orthotopic xenograft tumor model. Specifically, neutron radiation treatment increased the relative percentage of apoptotic sub-G1 phase cells via caspase-3/9 activation; increased intracellular reactive oxygen species, autophagy, and DNA damage; and decreased invasion and migration. Similarly, the mean size of gamma-irradiated (8 Gy) orthotopic KHOS/NP OS was 195 mm³ at 6 weeks after gamma-irradiation (8 Gy), but it was only 150 mm³ in mice treated with high-LET neutron radiotherapy. Significantly, our results provide a rationale for the use of high-LET radiotherapy to treat patients with OS.

Clinicopathological significance of glucose transporter protein-1 overexpression in human osteosarcoma

Although previous studies have demonstrated that Glut-1 is the predominant glucose transporter, is significantly overexpressed in various types of tumor and is correlated with poor prognosis, the potential function and clinical value of Glut-1 expression in osteosarcoma remains largely unclear. In particular, the prospective associations between Glut-1 expression levels and clinicopathological factors remains to be elucidated. In the present study, immunohistochemistry was performed to detect Glut-1 protein expression in 51 paired osteosarcoma specimens and adjacent non-cancerous tissues, and reverse transcription-quantitative polymerase chain reaction analysis was performed to examine Glut-1 mRNA expression levels in 6 pairs of these tissues. Statistical analyses were conducted to determine the associations between Glut-1 expression and various clinicopathological parameters. Glut-1 protein was revealed to be overexpressed in 38 (74.5%) osteosarcoma tissues, but only in 6 (11.8%) adjacent non-cancerous tissues. Glut-1 mRNA levels were also upregulated in osteosarcoma tissues compared with adjacent non-cancerous tissues. While there were no clear statistical relationships between Glut-1 expression and patient sex, resection, tumor location, size, T stage and adjuvant treatment, Glut-1 expression levels were significantly associated with age, tumor-node-metastasis stage, lymph node metastasis and survival. The median survival time in patients with low Glut-1 expression levels was longer than in patients with a high expression level. Glut-1 was significantly overexpressed in osteosarcoma tissues, and Glut-1 expression was associated with clinicopathological factors which upregulate the invasion and metastasis of osteosarcoma, and may be a potential predictor of survival in patients with osteosarcoma.

Role of RANK and Akt1 activation in human osteosarcoma progression: A clinicopathological study

The receptor activator of nuclear factor κB (RANK) axis is the fundamental signaling pathway in bone formation as well as bone tumor pathophysiology. The aim of the present study was to evaluate the impact of the expression of RANK and its downstream signaling molecule Akt1 on tumor progression in patients with osteosarcoma. Expression of RANK and Akt1 was examined in 78 human osteosarcoma samples by immunohistochemistry using formalin-fixed samples. Following this, each graded immunohistochemistry result was correlated with clinicopathological parameters and patient survival. In total, 60 osteosarcomas (76.9%) expressed RANK and 58 cases (74.4%) showed expression of Akt1. In addition, expression of RANK was negatively correlated with disease-free survival by Kaplan-Meier analysis. A resistance was observed to chemotherapy in RANK-expressing cases, which was statistically significant (P<0.05). In addition, chemotherapy and staging of the tumor were found to independent factors that have an effect on patient survival (P<0.05). Thus, RANK was identified as a negative prognostic factor of osteosarcoma survival.

Can a Bayesian Belief Network Be Used to Estimate 1-year Survival in Patients With Bone Sarcomas?

BACKGROUND

Extremity sarcoma has a preponderance to present late with advanced stage at diagnosis. It is important to know why these patients die early from sarcoma and to predict those at high risk. Currently we have mid- to long-term outcome data on which to counsel patients and support treatment decisions, but in contrast to other cancer groups, very little on short-term mortality. Bayesian belief network modeling has been used to develop decision-support tools in various oncologic diagnoses, but to our knowledge, this approach has not been applied to patients with extremity sarcoma.

QUESTIONS/PURPOSES

We sought to (1) determine whether a Bayesian belief network could be used to estimate the likelihood of 1-year mortality using receiver operator characteristic analysis; (2) describe the hierarchal relationships between prognostic and outcome variables; and (3) determine whether the model was suitable for clinical use using decision curve analysis.

METHODS

We considered all patients treated for primary bone sarcoma between 1970 and 2012, and excluded secondary metastasis, presentation with local recurrence, and benign tumors. The institution's database yielded 3499 patients, of which six (0.2%) were excluded. Data extracted for analysis focused on patient demographics (age, sex), tumor characteristics at diagnosis (size, metastasis, pathologic fracture), survival, and cause of death. A Bayesian belief network generated conditional probabilities of variables and survival outcome at 1 year. A lift analysis determined the hierarchal relationship of variables. Internal validation of 699 test patients (20% dataset) determined model accuracy. Decision curve analysis was performed comparing net benefit (capped at 85.5%) for all threshold probabilities (survival output from model).

RESULTS

We successfully generated a Bayesian belief network with five first-degree associates and describe their conditional relationship with survival after the diagnosis of primary bone sarcoma. On internal validation, the resultant model showed good predictive accuracy (area under the curve [AUC] = 0.767; 95% CI, 0.72-0.83). The factors that predict the outcome of interest, 1-year mortality, in order of relative importance are synchronous metastasis (6.4), patient's age (3), tumor size (2.1), histologic grade (1.8), and presentation with a pathologic fracture (1). Patient's sex, tumor location, and inadvertent excision were second-degree associates and not directly related to the outcome of interest. Decision curve analysis shows that clinicians can accurately base treatment decisions on the 1-year model rather than assuming all patients, or no patients, will survive greater than 1 year. For threshold probabilities less than approximately 0.5, the model is no better or no worse than assuming all patients will survive.

CONCLUSIONS

We showed that a Bayesian belief network can be used to predict 1-year mortality in patients presenting with a primary malignancy of bone and quantified the primary factors responsible for an increased risk of death. Synchronous metastasis, patient's age, and the size of the tumor had the largest prognostic effect. We believe models such as these can be useful as clinical decision-support tools and, when properly externally validated, provide clinicians and patients with information germane to the treatment of bone sarcomas.

CLINICAL RELEVANCE

Bone sarcomas are difficult to treat requiring multidisciplinary input to strategize management. An evidence-based survival prediction can be a powerful adjunctive to clinicians in this scenario. We believe the short-term predictions can be used to evaluate services, with 1-year mortality already being a quality indicator. Mortality predictors also can be incorporated in clinical trials, for example, to identify patients who are least likely to experience the side effects of experimental toxic chemotherapeutic agents.

Chemotherapy in primary osteogenic sarcoma in patients over the age of forty

OBJECTIVE

In this study, we sought to review the clinical and histopathological features and the chemotherapy regimens in osteogenic sarcoma in patients over 40 years of age, and we aimed at identifying the possible prognostic factors in this particular group of patients.

METHODS

We reviewed 287 patients with osteosarcoma treated between the year 1986 and 2010. Patients from this group who met the following criteria were considered eligible for our study; presence of primary OS, had typical histological and radiographic features of OS, no prior history of cancer or any treatment elsewhere and no prior history of preexisting bone abnormalities.

RESULTS

The Kaplan-Meier survival curve for the entire group, with a 95% confidence interval, at two and five years showed the survival rates as 76.2% and 72.8% respectively. The surgical margin was a significant factor affecting the survival. Presence of a pathological fracture also had a significant effect on the survival rate.

CONCLUSION

Osteogenic sarcoma remains a challenging disease to treat. Despite the expectation that elderly patients may not tolerate aggressive modern chemotherapy as the younger patients, we believe that patients with primary OS over the age of 40 should be treated aggressively with effective chemotherapy and complete surgical excision whenever possible.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Knockdown of DDX46 Inhibits the Invasion and Tumorigenesis in Osteosarcoma Cells

DDX46, a member of the DEAD-box (DDX) helicase family, is involved in the development of several tumors. However, the exact role of DDX46 in osteosarcoma and the underlying mechanisms in tumorigenesis remain poorly understood. Thus, in the present study, we explored the role of DDX46 in osteosarcoma and the underlying mechanisms. Our results demonstrated that the expression levels of DDX46 in both mRNA and protein were greatly elevated in human osteosarcoma tissues and cell lines. Knockdown of DDX46 obviously inhibited osteosarcoma cell proliferation and tumor growth in vivo. In addition, knockdown of DDX46 also significantly suppressed migration and invasion in osteosarcoma cells. Furthermore, knockdown of DDX46 substantially downregulated the phosphorylation levels of PI3K and Akt in SaOS2 cells. In summary, the present results have revealed that DDX46 plays an important role in osteosarcoma growth and metastasis. Knockdown of DDX46 inhibited osteosarcoma cell proliferation, migration, and invasion in vitro and tumor growth in vivo. Therefore, DDX46 may be a potential therapeutic target for the treatment of osteosarcoma.

Role of Long Noncoding RNA HOTAIR in the Growth and Apoptosis of Osteosarcoma Cell MG-63

This study investigated the function of HOTAIR in the growth and apoptosis of OS MG-63 cell line in vitro and further clarified its mechanism. The expression levels of HOTAIR in OS MG-63 cell line and normal osteoblast hFOB1.19 cell line were determined by RT-PCR, respectively. The growth and apoptosis of MG-63 cells in vitro were investigated by MTT assay and flow cytometry assay after HOTAIR was knocked down with retroviral vector construction. And the expression levels of cell growth and apoptosis related factors TGF-β, p53, Bcl-2, and TNF-α were determined to clarify the mechanism. We found that HOTAIR was highly expressed in osteosarcoma MG-63 cell line compared with normal osteoblast hFOB1.19 cell line. The proliferation rate was lower and the apoptosis rate was higher significantly in shHOTAIR MG-63 cells than those in EV MG-63 cells. TGF-β and Bcl-2 were downregulated significantly when HOTAIR was knocked down. p53 and TNF-α were upregulated significantly when HOTAIR was knocked down. These results indicated that HOTAIR functioned as a carcinogenic lncRNA, which could promote the proliferation and inhibit the apoptosis of MG-63 cells in vitro. HOTAIR could be a potential target for the treatment of osteosarcoma.

Characterization of the metastatic phenotype of a panel of established osteosarcoma cells

Osteosarcoma (OS) is the most common bone tumor in pediatric patients. Metastasis is a major cause of mortality and morbidity. The rarity of this disease coupled with the challenges of drug development for metastatic cancers have slowed the delivery of improvements in long-term outcomes for these patients. In this study, we collected 18 OS cell lines, confirmed their expression of bone markers and complex karyotypes, and characterized their in vivo tumorgenicity and metastatic potential. Since prior reports included conflicting descriptions of the metastatic and in vivo phenotypes of these models, there was a need for a comparative assessment of metastatic phenotypes using identical procedures in the hands of a single investigative group. We expect that this single characterization will accelerate the study of this metastatic cancer. Using these models we evaluated the expression of six previously reported metastasis-related OS genes. Ezrin was the only gene consistently differentially expressed in all the pairs of high/low metatstatic OS cells. We then used a subtractive gene expression approach of the high and low human metastatic cells to identify novel genes that may be involved in OS metastasis. PHLDA1 (pleckstrin homology-like domain, family A) was identified as one of the genes more highly expressed in the high metastatic compared to low metastatic cells. Knocking down PHLDA1 with siRNA or shRNA resulted in down regulation of the activities of MAPKs (ERK1/2), c-Jun N-terminal kinases (JNK), and p38 mitogen-activated protein kinases (MAPKs). Reducing the expression of PHLDA1 also delayed OS metastasis progression in mouse xenograft models.

En bloc resection of a C-1 lateral mass osteosarcoma: technical note

Osteosarcoma is an aggressive primary bone tumor. It is currently treated with multimodality therapy including en bloc resection, which has been demonstrated to confer a survival benefit over intralesional resection. The authors present the case of an 8-year-old girl with a C-1 lateral mass osteosarcoma, which was treated with a 4-stage en bloc resection and spinal reconstruction. While technically complex, the feasibility of en bloc resection for spinal osteosarcoma should be explored in the pediatric population.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

MicroRNA-184 Modulates Doxorubicin Resistance in Osteosarcoma Cells by Targeting BCL2L1

Background

Early metastasis of osteosarcoma (OS) is highly lethal and responds poorly to drug and radiation therapies. MicroRNAs (miRNAs) are a class of small noncoding RNAs that modulate gene expression at the post-transcriptional level. However, the detailed functions of specific miRNAs are not entirely understood. The aim of the present study was to investigate the role of miR-184 as a mediator of drug resistance in human osteosarcoma.

Material/Methods

qRT-PCR was used to analyze the expression level of miR-184 in OS cell line U-2 OS and MG-63 treated with doxorubicin. MiR-184 agomir or miR-184 antagomir was transferred into cells to regulated miR-184. The target of miR-184 was predicted by TargetScan and confirmed by luciferase reporter assay. Bcl-2-like protein 1 (BCL2L1) expression was detected by Western blot. Cell apoptosis was determined by Annexin V staining and analysis by flow cytometry.

Results

Doxorubicin induced time-dependent expression of miR-184 in OS cell line U-2 OS and MG-63. Luciferase reporter assay identified BCL2L1 as the direct target gene of miR-184. Furthermore, doxorubicin reduced BCL2L1 expression, which was reversed by miR-184 overexpression and further decreased by miR-184 inhibition in OS cells. In addition, miR-184 agomir reduced doxorubicin-induced cell apoptosis, whereas miR-184 antagomir enhanced apoptosis in OS cells, suggesting that up-regulation of miR-184 contributes to chemoresistance of the OS cell line.

Conclusions

Our data show that miR-184 was up-regulated in OS patients treated with doxorubicin therapy and leads to poor response to drug therapy by targeting BCL2L1.

MicroRNA-144 suppresses osteosarcoma growth and metastasis by targeting ROCK1 and ROCK2

Osteosarcoma (OS) is the most common primary tumor of bone. MicroRNAs (miRNAs) are a class of endogenously expressed small non-coding RNAs that are strongly implicated in cancerous processes. However, our current understanding of the biological role of miRNAs in OS remains incomplete. In the present study, miR-144 was markedly downregulated in OS cell lines and clinical specimens. Low-level expression of miR-144 was significantly associated with distant metastasis and poor prognosis. Functional studies demonstrated that ectopic expression of miR-144 suppresses tumor cell proliferation and metastasis in vitro as well as in vivo. Furthermore, we identified Rho-associated kinases 1 and 2 (ROCK1 and ROCK2) as direct targets for miR-144 binding, resulting in suppression of their expression. Exogenous expression of ROCK1 or ROCK2 in 143B-miR-144 cells partially restored miR-144-inhibited cell proliferation and invasion. In clinical OS specimens, ROCK1 and ROCK2 levels were elevated, relative to that in paired normal bone tissues, and inversely correlated with miR-144 expression. Taken together, miR-144 suppresses OS progression by directly downregulating ROCK1 and ROCK2 expression, and may be a promising therapeutic target for OS.

Reconstruction After Tumor Resection in the Growing Child

Limb preservation surgery has gained acceptance as a viable alternative to amputation for the treatment of extremity bone tumors in the growing child. There are several options for reconstructing the potential loss of a physis and the defect created by tumor excision. Metallic endoprosthesis, massive allograft, and allograft-prosthesis composites have been described in the skeletally immature population. With the development of expandable prostheses, even those far from skeletal maturity may be candidates for limb salvage. However, improvements in the literature are needed, including reporting surgical and functional outcomes in a rigorous manner, specific to age, anatomic location, and reconstruction.

Survival rate and prognostic factors of conventional osteosarcoma in Northern Thailand: A series from Chiang Mai University Hospital

BACKGROUND

Osteosarcoma is a common and aggressive primary malignant bone tumor occurring in children and adolescents. It is one of the most aggressive human cancers and the most common cause of cancer-associated limb loss. As treatment in Thailand has produced a lower survival rate than in developed countries; therefore, this study identified survival rate and the poor prognostic factors of osteosarcoma in Northern Thailand.

METHODS

The retrospective cases of osteosarcoma, diagnosis between 1 January 1996 and 31 December 2013, were evaluated. Five and ten year overall survival rates were analyzed using time-to-event analysis. Potential prognostic factors were identified by multivariate regression analysis.

RESULTS

There were 208 newly diagnosed osteosarcomas during that period, and 144 cases met the criteria for analysis. The majority of the osteosarcoma cases (78.5%) were aged 0-24 years. The overall 5- and 10-year survival rates were 37.9% and 33.6%, respectively. Presence of metastasis at initial examination, delayed and against treatment co-operation, and axial skeletal location were identified as independent prognostic factors for survival, with hazard ratios of 4.3, 2.5 and 3.8, and 3.1, respectively.

CONCLUSIONS

This osteosarcoma cohort had a relatively poor overall survival rate. The prognostic factors identified would play a critical role in modifying survival rates of osteosarcoma patients; as rapid disease recognition, a better treatment counselling, as well as improving of chemotherapeutic regimens were found to be important in improving the overall survival rate in Thailand.

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.

AMD3100 reduces CXCR4-mediated survival and metastasis of osteosarcoma by inhibiting JNK and Akt, but not p38 or Erk1/2, pathways in in vitro and mouse experiments

Osteosarcoma (OS) has an unfavorable prognosis and tends to metastasize to lung tissue. Although the CXCL12-CXCR4 axis appears to affect progression and metastasis in numerous tumors, its mechanism and downstream pathways in OS remain unclear. We used western blotting and flow cytometry to detect CXCR4 and CXCR7 expression in two OS cell lines (LM8 and Dunn). An MTT assay was used to evaluate the effects of CXCL12 and AMD3100, a specific CXCR4 antagonist, on cell viability. Flow cytometry was utilized to analyze changes in apoptosis induced by serum deprivation following treatment with CXCL12 and AMD3100. A Transwell assay was used to assess cell migration in response to CXCL12 and AMD3100. Western blotting was performed to identify the phosphorylation of signaling molecules (JNK, c-Jun, Akt, p38 and Erk1/2) and expression of caspase-3 and -8, and PARP. Mouse models were employed to evaluate AMD3100 inhibition of primary OS growth and lung metastasis in vivo. CXCR4 expression was detected in LM8 but not Dunn cells, and neither cell line expressed CXCR7. The addition of CXCL12 induced the survival and migration of serum-starved CXCR4⁺ LM8 cells activating JNK and Akt pathways, which were abrogated by adding AMD3100. However, similar results were not observed in CXCR4⁻ Dunn cells. CXCL12 protected LM8, but not Dunn cells, from apoptosis induced by serum deprivation by suppressing PARP cleavage, which was partly reversed by AMD3100. In a mouse model, AMD3100 reduced primary tumor growth and lung metastasis compared with the controls. Thus, the CXCL12-CXCR4 axis regulated OS survival and metastasis through the JNK and Akt pathways, and blocking them with AMD3100 was found to be a potential OS treatment.

CD8+/FOXP3+-ratio in osteosarcoma microenvironment separates survivors from non-survivors: a multicenter validated retrospective study

Osteosarcoma is the most common primary bone tumor characterized by juvenile onset, tumor heterogeneity, and early pulmonary metastasis. Therapeutic improvement stagnates since more than two decades. Unlike major malignancies, biomarkers as prognostic factors at time of diagnosis are missing. Disease rareness hampers study recruitment of patient numbers sufficient to outweigh tumor heterogeneity. Here, we analyzed in a multicenter cohort the osteosarcoma microenvironment to reduce effects of tumor cell heterogeneity. We hypothesized that quantitative ratios of intratumoral CD8⁺T-cells to FOXP3⁺T-cells (CD8⁺/FOXP3⁺-ratios) provide strong prognostic information when analyzed by whole-slide imaging in diagnostic biopsies. We followed recommendations-for-tumor-marker-prognostic-studies (REMARK). From 150 included cases, patients with complete treatment were identified and assigned to the discovery (diagnosis before 2004) or the validation cohort (diagnosis 2004-2012). Highly standardized immunohistochemistry of CD8⁺ and FOXP3⁺, which was validated by methylation-specific gene analysis, was performed followed by whole-slide analysis and clinical outcome correlations. We observed improved estimated survival in patients with CD8⁺/FOXP3⁺-ratios above the median (3.08) compared to patients with lower CD8⁺/FOXP3⁺-ratios (p = 0.000001). No patients with a CD8⁺/FOXP3⁺-ratio above the third quartile died within the observation period (median follow-up 69 mo). Multivariate analysis demonstrated independence from current prognostic factors including metastasis and response to neoadjuvant chemotherapy. Data from an independent validation cohort confirmed improved survival (p = 0.001) in patients with CD8⁺/FOXP3⁺-ratios above 3.08. Multivariate analysis proofed that this observation was also independent from prognostic factors at diagnosis within the validation cohort. Intratumoral CD8⁺/FOXP3⁺-ratio in pretreatment biopsies separates patients with prolonged survival from non-survivors in osteosarcoma.

Impact of RANK signalling on survival and chemotherapy response in osteosarcoma

The receptor activator of NF-κB (RANK) signalling pathway represents a promising target for the therapy of bone-related tumours. In the present study we evaluated the impact of the expression of RANK and its ligand (RANKL) on survival and response to chemotherapy in osteosarcoma patients.Expression of RANK and RANKL was examined in 91 human osteosarcomas by immunohistochemistry using formalin fixed, paraffin embedded (FFPE) tumour samples. Results of the stainings were correlated with clinicopathological parameters and patient survival.Sixty-three osteosarcomas (69.2%) expressed RANK, whereas only eight cases (8.8%) showed expression of RANKL. Expression of RANK was significantly associated with shorter disease-free survival by Kaplan-Meier analysis (p=0.031). We further observed worse response to chemotherapy in RANK expressing tumours, which was statistically not significant (p=0.099). RANKL expression was significantly more frequent in osteosarcoma of the lower extremity than in any other location. Analysis of RANKL expression did not reveal any statistically significant correlation with disease-free or osteosarcoma-specific survival.In our study, we identified RANK expression as a negative prognostic factor regarding disease-free survival in osteosarcoma. Moreover, RANK might modulate response of human osteosarcoma to chemotherapy. Therefore, RANK signalling cascade is likely to provide a novel alternative to targeted therapy of osteosarcoma and deserves further investigation.

A novel long non-coding RNA, hypoxia-inducible factor-2α promoter upstream transcript, functions as an inhibitor of osteosarcoma stem cells in vitro

Long non-coding RNAs (lncRNAs) have recently been identified as novel modulators of malignant tumors. However, the function of lncRNAs in cancer stem cells (CSCs) remains to be elucidated. The present study aimed to investigate the regulating role of a novel lncRNA, hypoxia-inducible factor-2α (HIF-2α) promoter upstream transcript (HIF2PUT), in osteosarcoma stem cells. The expression levels of HIF2PUT were assessed by quantitative polymerase chain reaction in 17 osteosarcoma tissue specimens, and the correlation between the expression of HIF2PUT and its host transcript-HIF-2α was determined. In functional experiments, HIF2PUT expression was knocked down by small interfering RNAs, or overexpressed by transfection with pcDNA-HIF2PUT, in order to evaluate the effects of HIF2PUT on cell proliferation, migration, expression rate of osteosarcoma stem cell marker CD133, and stem sphere-forming ability in MG63 cells. HIF2PUT expression levels were positively correlated with HIF-2α in osteosarcoma tissues. Overexpression of HIF2PUT markedly inhibited cell proliferation and migration, decreased the percentage of CD133 expressing cells, and impaired the osteosarcoma stem sphere-forming ability of the MG63 cells. Whereas, knockdown of HIF2PUT expression had the opposite effect. Furthermore, altering the expression of HIF2PUT resulted in a concomitant change to HIF-2α mRNA expression. These results indicate that the lncRNA HIF2PUT may be a novel regulatory factor of osteosarcoma stem cells, which may exert its function partly by controlling HIF-2α expression. Further studies regarding HIF2PUT may provide a novel therapeutic target of osteosarcoma in the future.

A case of radiation-induced osteosarcoma treated effectively by boron neutron capture therapy

We treated a 54-year-old Japanese female with a recurrent radiation-induced osteosarcoma arising from left occipital skull, by reactor-based boron neutron capture therapy (BNCT). Her tumor grew rapidly with subcutaneous and epidural extension. She eventually could not walk because of cerebellar ataxia. The tumor was inoperable and radioresistant. BNCT showed a marked initial therapeutic effect: the subcutaneous/epidural tumor reduced without radiation damage of the scalp except hair loss and the patient could walk again only 3 weeks after BNCT. BNCT seems to be a safe and very effective modality in the management of radiation-induced osteosarcomas that are not eligible for operation and other treatment modalities.

Postoperative nomogram to predict the probability of metastasis in Enneking stage IIB extremity osteosarcoma

BACKGROUND

Metastasis is the most crucial prognostic factor in osteosarcoma. The goal of this study was to develop a new nomogram to predict the probability of metastasis in Enneking stage IIB extremity osteosarcoma after neoadjuvant chemotherapy and limb salvage surgery.

METHODS

We examined medical records of 91 patients who had undergone surgery between March 1994 and March 2007. A nomogram was developed using multivariate logistic regression. The nomogram was validated internally by bootstrapping-method (200 repetitions) and externally in independent validation set (n = 34). A Youden-derived cutoff value was assigned to the nomogram to predict dichotomous outcomes for metastasis.

RESULTS

The nomogram was built from four predictors of tumor site, serum alkaline phosphatase, intracapsular extension, and Huvos grade, and an additional clause that the cutoff value should be added to the total points in the cases of incomplete surgical resection. P-value of Hosmer and Lemshow Goodness-of-fit test of this model was 0.649. Area under receiver operating curve values of 0.83 (95% confidence interval [CI], 0.75 to 0.92) in the training set and 0.80 (95% CI, 0.63 to 0.96) in the validation set were obtained. The accuracy of dichotomous outcomes was 79.1% (95% CI, 0.69 to 0.86) and 82.4% (95% CI, 0.63 to 0.92) in the training and validation sets.

CONCLUSIONS

We have developed a new high-performance nomogram to predict the probability of metastasis in Enneking stage IIB extremity osteosarcoma after limb salvage surgery.