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

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

A Planned Multidisciplinary Surgical Approach to Treat Primary Pelvic Malignancies

The pelvic anatomy poses great challenges to orthopedic surgeons. Sarcomas are often large in size and typically enclosed in the narrow confines of the pelvis with the close proximity of vital structures. The aim of this study is to report a systematic planned multidisciplinary surgical approach to treat pelvic sarcomas. Seventeen patients affected by bone and soft tissue sarcomas of the pelvis, treated using a planned multidisciplinary surgical approach, combining the expertise of orthopedic oncology and other surgeons (colleagues from urology, vascular surgery, abdominal surgery, gynecology and plastic surgery), were included. Seven patients were treated with hindquarter amputation; 10 patients underwent excision of the tumor. Reconstruction of bone defects was conducted in six patients with a custom-made 3D-printed pelvic prosthesis. Thirteen patients experienced at least one complication. Well-organized multidisciplinary collaborations between each subspecialty are the cornerstone for the management of patients affected by pelvic sarcomas, which should be conducted in specialized centers. A multidisciplinary surgical approach is of paramount importance in order to obtain the best successful surgical results and adequate margins for achieving acceptable outcomes.

Management of Unresectable Localized Pelvic Bone Sarcomas: Current Practice and Future Perspectives

Simple Summary

Some locally advanced pelvic bone tumors are deemed unresectable and, as such, not suitable for curative surgery. In this setting, treatment options are generally limited and not unanimous, with decisions being made on an individual basis after multidisciplinary discussion. Ultimately, and notwithstanding the bright prospects raised by novel therapeutic approaches, treatment should be patient-tailored, weighing a panoply of patient- and tumor-related factors.

Abstract

Bone sarcomas (BS) are rare mesenchymal tumors usually located in the extremities and pelvis. While surgical resection is the cornerstone of curative treatment, some locally advanced tumors are deemed unresectable and hence not suitable for curative intent. This is often true for pelvic sarcoma due to anatomic complexity and proximity to vital structures, making treatment options for these tumors generally limited and not unanimous, with decisions being made on an individual basis after multidisciplinary discussion. Several studies have been published in recent years focusing on innovative treatment options for patients with locally advanced sarcoma not amenable to local surgery. The present article reviews the evidence regarding the treatment of patients with locally advanced and unresectable pelvic BS, with the goal of providing an overview of treatment options for the main BS histologic subtypes involving this anatomic area and exploring future therapeutic perspectives. The management of unresectable localized pelvic BS represents a major challenge and is hampered by the lack of comprehensive and standardized guidelines. As such, the optimal treatment needs to be individually tailored, weighing a panoply of patient- and tumor-related factors. Despite the bright prospects raised by novel therapeutic approaches, the role of each treatment option in the therapeutic armamentarium of these patients requires solid clinical evidence before becoming fully established.

Venous Tumor Thrombus in Primary Bone Sarcomas in the Pelvis: A Clinical and Radiographic Study of 451 Cases

BACKGROUND

Few investigations of venous tumor thrombus (VTT) in primary pelvic bone sarcomas are available. We aimed to identify the prevalence, associated factors, and prognosis of VTT across different types of pelvic sarcomas and to propose an algorithm for management.

METHODS

We included 451 consecutive cases of primary, bone-derived, treatment-naive, pelvic sarcomas in this study. Demographic data and the results of initial laboratory tests, imaging examinations, and oncological evaluations were extracted and analyzed. Forty-four cases of VTT were diagnosed with radiographic examinations, and 18 of them were verified histologically.

RESULTS

The cohort consisted of chondrosarcomas (41.2%), osteosarcomas (30.4%), Ewing sarcomas (15.5%), bone-derived undifferentiated pleomorphic sarcomas (5.8%), and other bone sarcomas (7.1%). The prevalence of VTT was 9.8% in the whole group, and associated factors included a lactate dehydrogenase (LDH) level of ≥230.5 U/L and invasion of the L5-S1 intervertebral foramen. Patients with pelvic osteosarcoma had a high prevalence of VTT (22.6%), and the associated factors in this group included a chondroblastic subtype, an LDH level of ≥187 U/L, and invasion of the obturator foramen and the L5-S1 intervertebral foramen. Patients with VTT had a poor prognosis with a median overall survival time of 14 months. Subgroup analyses of localized pelvic osteosarcoma indicated that the presence of VTT decreased the median overall survival time (21.5 versus 54.0 months for those without VTT, p = 0.003), median recurrence-free survival time (18.6 versus 32.4 months, p = 0.020), and median metastasis-free survival time (11.2 versus 41.0 months, p < 0.001).

CONCLUSIONS

VTT is most common in patients with pelvic osteosarcoma as compared with patients with other primary bone sarcomas, and it is associated with several factors. It is a negative prognostic factor. An algorithm for management of pelvic sarcomas with VTT stratified by the classification of the VTT might be beneficial, but further validation is necessary.

LEVEL OF EVIDENCE

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

Impact of Surgical Resection and Reasons for Poor Prognosis of Pelvic Osteosarcoma Based on the Bone Tumor Registry in Japan

Simple Summary

Pelvic osteosarcoma has a poor prognosis compared to osteosarcomas in other locations, and the reasons for this remains unknown. Surgical resection of pelvic osteosarcoma is technically demanding and often results in dysfunction and complications. In this study, we investigated the reasons underlying the poor prognosis of pelvic osteosarcoma by comparing it to femoral osteosarcoma using data from the Bone Tumor Registry in Japan. We used propensity score analysis to determine whether surgical resection of pelvic osteosarcoma improved its prognosis. We demonstrated that pelvic osteosarcoma had a poor prognosis because it occurred more often in the elderly, often had a larger tumor size, and had metastasis at presentation more often in comparison to femoral osteosarcoma. These three factors were also associated with the non-surgical treatment of pelvic osteosarcoma, which also led to a poor outcome. The overall survival rate was only comparable in pelvic osteosarcoma and femoral osteosarcoma in cases treated with surgical resection. Propensity score analysis revealed that surgical treatment improved the prognosis of pelvic osteosarcoma. As such, we propose that surgical resection should be considered based on tumor stage and patient age in order to improve the prognosis of pelvic osteosarcoma.

Abstract

Pelvic osteosarcoma has a poor prognosis compared to osteosarcomas in other locations, and the reasons for this remain unknown. Surgical resection of pelvic osteosarcoma is technically demanding and often results in dysfunction and complications. In this study, we investigated the reasons underlying the poor prognosis of pelvic osteosarcoma by comparing it to femoral osteosarcoma using data from the Bone Tumor Registry in Japan. We used propensity score analysis to determine whether surgical resection of pelvic osteosarcoma improved its prognosis. We demonstrated that pelvic osteosarcoma had a poor prognosis because it occurred more often in the elderly, often had larger tumor size, and had metastasis at presentation more often in comparison to femoral osteosarcoma. These three factors were also associated with the non-surgical treatment of pelvic osteosarcoma, which also led to a poor outcome. The overall survival rate was only comparable in pelvic osteosarcoma and femoral osteosarcoma in cases treated with surgical resection. Propensity score analysis revealed that surgical treatment improved the prognosis of pelvic osteosarcoma. As such, we propose that surgical resection should be considered based on tumor stage and patient age in order to improve the prognosis of pelvic osteosarcoma.

Managing axial bone sarcomas in childhood

Introduction: Axial osteosarcoma and Ewing sarcoma are rare, aggressive neoplasms with a worse prognosis than with tumors involving the extremities because they are more likely to be associated with larger tumor volumes, older age, primary metastases, and a poor histological response to chemotherapy. The 5-year OS rates are reportedly in the range of 18-41% for axial osteosarcoma, and 46-64% for Ewing sarcoma.Area covered: The treatment of axial bone tumors is the same as for extremity bone tumors, and includes chemotherapy, surgery and/or radiotherapy.Expert opinion: Local treatment of axial tumors is particularly difficult due to their proximity to neurological and vascular structures, which often makes extensive and en bloc resections impossible without causing significant morbidity. The incidence of local relapse is consequently high, and this is the main issue in the treatment of these tumors. Radiotherapy is an option in the case of surgical resections with close or positive margins, as well as for inoperable tumors. Delivering high doses of RT to the spinal cord can be dangerous. Given the complexity and rarity of these tumors, it is essential for this subset of patients to be treated at selected reference institutions with specific expertise and multidisciplinary skills.

Complication rate, functional outcomes, and risk factors associated with carbon ion radiotherapy for patients with unresectable pelvic bone sarcoma

BACKGROUND

To the authors' knowledge, carbon ion radiotherapy (CIRT) is one of the few curative treatments for unresectable pelvic bone sarcoma. The current study investigated the complications, functional outcomes, and risk factors of CIRT.

METHODS

Of 112 patients who were treated with CIRT for unresectable pelvic bone sarcoma, the authors enrolled 29 patients who were without local disease recurrence or distant metastasis. The mean follow-up was 93 months. Complications, functional outcomes, and quality of life scores were assessed. Risk factors were analyzed, including the dose-volume histogram of the femoral head.

RESULTS

Femoral head necrosis occurred in approximately 37% of patients, pelvic fractures were reported in 48% of patients, and neurological deficits were noted in 52% of patients. Femoral head necrosis was found to be significantly more prevalent among patients with periacetabular tumors (P = .018). The dose-volume histogram of the femoral head indicated tolerable volume percentages of the femoral head to be <33% for 40 grays (relative biological effectiveness) and 16% for 60 grays ( relative biological effectiveness). The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score were 53% and 64%, respectively, and the mean EuroQol 5 dimensions questionnaire index was 0.587. Patients aged >50 years and those with periacetabular tumors were found to have significantly lower Toronto Extremity Salvage Scores.

CONCLUSIONS

Femoral head necrosis, pelvic fracture, and nerve damage are common complications with the use of CIRT for pelvic bone sarcoma. To prevent femoral head necrosis, the radiation dose to the femoral head should be kept below the estimated tolerance curve presented in the current study. The functional outcome is nearly equivalent to that of surgery. CIRT may be a promising alternative to surgery for patients with unresectable pelvic bone sarcoma.

Neoadjuvant Chemotherapy Followed by Delayed Surgery: Is it Necessary for All Patients With Nonmetastatic High-Grade Pelvic Osteosarcoma?

BACKGROUND

Neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy is the most-frequently employed strategy for patients with high-grade osteosarcoma. However, the contribution of neoadjuvant chemotherapy compared with postoperative adjuvant chemotherapy has not been tested rigorously in patients with nonmetastatic high-grade pelvic osteosarcoma.

QUESTIONS/PURPOSES

(1) Does neoadjuvant chemotherapy followed by delayed surgery offer a survival benefit to patients with nonmetastatic high-grade pelvic osteosarcoma compared with immediate surgery and adjuvant chemotherapy? (2) Is the timing of chemotherapy and surgery associated with a difference in the survivorship free from local recurrence and the risk of complications? (3) Is the threshold of 90% necrosis after neoadjuvant chemotherapy appropriate to distinguish responders from nonresponders in patients with pelvic osteosarcoma?

METHODS

Between 2000 and 2015, our center treated 112 patients with nonmetastatic high-grade primary pelvic osteosarcoma, of whom 93 underwent tumor resection with chemotherapy. Four patients (4%) were lost to followup before 24 months but were not known to have died; the remaining 89 patients were included in this retrospective study. Based on the timing of surgery and chemotherapy, patients were analyzed in two groups: (1) neoadjuvant chemotherapy followed by delayed surgery and adjuvant chemotherapy (n = 56; mean followup of 61 months, range 27-137 months), and (2) immediate surgery followed by adjuvant chemotherapy (n = 33; mean followup of 77 months, range 25-193 months). The total duration and intensity of chemotherapy was similar in both groups. During the period in question, we generally used neoadjuvant therapy followed by delayed surgery and adjuvant chemotherapy when patients received their biopsies in our center. We typically used immediate surgery with adjuvant chemotherapy when patients initially refused chemotherapy or when they had severe pain or poor walking function. Patients in the neoadjuvant chemotherapy group had a higher proportion of sacral infiltration; other factors such as sex, age and tumor size were well balanced between groups. We compared overall survival and local recurrence-free survival rates between the two groups. We completed univariate log-rank tests and multivariate Cox analyses in all patients to identify factors associated with survival and local recurrence using the Kaplan-Meier method.

RESULTS

No survival benefit was found in the patients treated with neoadjuvant chemotherapy followed by delayed surgery compared with the group treated with immediate surgery and adjuvant chemotherapy. At 5 years, the overall survival (OS) was 42% (95% CI, 33-52) for all patients in this study, 43% (95% CI, 30-56) for the neoadjuvant group, and 40% (95% CI, 25-55) for the immediate surgery group; p = 0.709. With the numbers available, there was no difference in the likelihood of successful limb salvage (five of 56 patients [89%] in the neoadjuvant chemotherapy group versus three of 33 patients [91%] in the immediate surgery group; p = 0.557). The 5-year local recurrence-free survival was 67% (95% CI, 59-76) with no difference between the two groups (68%; 95% CI, 57-78% versus 67%; 95% CI, 52-81; p = 0.595). With the numbers available, there was no difference in survival between patients whose tumors demonstrated more than 90% necrosis; however, only four of 56 patients in the neoadjuvant chemotherapy group demonstrated 90% necrosis.

CONCLUSIONS

We found no survival advantage with chemotherapy before surgery compared with immediate surgery in patients with nonmetastatic high-grade pelvic osteosarcoma. The decision on chemotherapy timing should be made for reasons other than survival. A prospective trial is needed to confirm this conclusion.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Radiological characteristics and predisposing factors of venous tumor thrombus in pelvic osteosarcoma: A mono-institutional retrospective study of 115 cases

BACKGROUND

Venous tumor thrombus (VTT) in pelvic osteosarcoma has been regarded as a rare oncological condition and few literatures investigated this issue.

METHODS

We retrospectively reviewed 115 cases of pelvic osteosarcoma treated in our center from 2006 to 2016. Diagnosis of VTTs was made based on histo-pathological findings. We summarized the radiological manifestations of VTTs on CT, MRI, and PET/CT. We also compared the demographical, oncological, and radiological data between cases with or without VTTs to identify its predisposing factors.

RESULTS

Seventeen cases (14.8%) were diagnosed with VTT. Manifestations of VTTs on CT included increased caliber (64.7%), calcification (47.1%), low density on plain scan (100%), filling defect (100%), and streak-like enhancement (35.7%) on contrast enhancement. On MRI, the VTTs could be hypo- or iso-intense on T1WI (100%), hyperintense on T2WI (100%), and filling defect on contrast enhancement (100%). PET/CT showed high metabolic activity of the VTTs. The ranges of the VTTs included unilateral external iliac vein (EIV) (two cases), unilateral internal iliac vein (IIV) (one case), unilateral common iliac vein (CIV) and IIV (five cases), unilateral CIV + EIV (two cases), inferior vena cava (IVC) and unilateral CIV + EIV (one case), IVC and unilateral CIV + IIV (four cases), IVC and bilateral CIVs + IIVs (two cases). Multivariate analysis indicated that chondroblastic subtype and involvement of L5/S1 intervertebral foramen might predispose to VTTs.

CONCLUSION

The incidence of VTTs in pelvic osteosarcoma was 14.8%. Comprehensive radiological studies help preoperative diagnosis of VTTs. Predisposing factors included chondroblasic subtype and involvement of L5/S1 intervertebral foramen.

EURO-B.O.S.S.: A European study on chemotherapy in bone-sarcoma patients aged over 40: Outcome in primary high-grade osteosarcoma

INTRODUCTION

The EUROpean Bone Over 40 Sarcoma Study (EURO-B.O.S.S.) was the first prospective international study for patients 41-65 years old with high-grade bone sarcoma treated with an intensive chemotherapy regimen derived from protocols for younger patients with high-grade skeletal osteosarcoma.

METHODS

Chemotherapy based on doxorubicin, cisplatin, ifosfamide, and methotrexate was suggested, but patients treated with other regimens at the investigators' choice were also eligible for the study.

RESULTS

The present report focuses on the subgroup of 218 patients with primary high-grade osteosarcoma. With a median follow-up of 47 months, the 5-year probability of overall survival (OS) was 66% in patients with localized disease and 22% in case of synchronous metastases. The 5-year OS in patients with localized disease was 29% in pelvic tumors, and 70% and 73% for extremity or craniofacial locations, respectively. In primary chemotherapy, tumor necrosis ≥90% was reported in 21% of the patients. There were no toxic deaths; however, hematological toxicity was considerable with 32% of patients experiencing 1 or more episodes of neutropenic fever. The incidence of nephrotoxicity and neurotoxicity (mainly peripheral) was 28% and 24%, respectively. After methotrexate, 23% of patients experienced delayed excretion, in 4 cases with nephrotoxicity.

CONCLUSIONS

In patients over 40 years of age with primary high-grade osteosarcoma, an aggressive approach with chemotherapy and surgery can offer the probability of survival similar to that achieved in younger patients. Chemotherapy-related toxicity is significant and generally higher than that reported in younger cohorts of osteosarcoma patients treated with more intensive regimens.

An update on chemotherapy for osteosarcoma

INTRODUCTION

In the early seventies chemotherapy significantly improved survival in osteosarcoma. Since then minor innovations have occurred although recent years have offered insights of clinical and scientific relevance.

AREAS COVERED

This review focuses on the most recent results of phase 3 and 2 studies. Published data or presentations at International meetings are discussed. A specific section discusses recent insights from studies supporting the hypothesis of a possible personalized chemotherapy approach.

EXPERT OPINION

Osteosarcoma is a rare tumor and any effort should be made to improve the level of International collaboration. The MAP (methotrexate, doxorubicin and cisplatin) regimen has become the treatment of choice. Poor pathological response to primary chemotherapy is confirmed as a predictive factor of survival and, presently with the available drugs, it is not recommended to intensify or change post-operative treatment on the basis of pathological response to primary chemotherapy. The genomic complexity and the heterogeneity of osteosarcoma makes active and effective molecularly targeted therapies unlikely to be available in the near future. A relation between pharmacogenetic profile and chemotherapy toxicity and prognosis has been reported. The new frontier for clinical research in osteosarcoma is to optimize the use of the active drugs available by personalizing chemotherapy treatment.

Curcumin-loaded nanoparticles enhance apoptotic cell death of U2OS human osteosarcoma cells through the Akt-Bad signaling pathway

Curcumin has potential anticancer activity and has been shown to be involved in several signaling pathways including differentiation and apoptosis. Our previous study showed that water-soluble PLGA curcumin nanoparticles (Cur-NPs) triggered apoptotic cell death through regulation of the function of MDR1 and the production of reactive oxygen species (ROS) in cisplatin-resistant human oral cancer CAR cells. In this study, we investigated the anti-proliferative effects of Cur-NPs on human osteosarcoma U2OS cells. The morphology of Cur-NPs showed spherical shape by TEM analysis. The encapsulation efficiency of curcumin in Cur-NPs prepared by single emulsion was 90.5 ± 3.0%. Our results demonstrated that the curcumin fragments on the mass spectrum of Cur-NPs and the peaks of curcumin standard could be found on the Cur-NPs spectrum by 1H-NMR spectra analysis. Cur-NPs induced anti-proliferative effects and apoptosis in U2OS cells. Compared to the untreated U2OS cells, more detectable amount of Cur-NPs was found inside the treated U2OS cells. Cur-NPs induced DNA fragmentation and apoptotic bodies in U2OS cells. Both the activity and the expression levels of caspases-3/-7 and caspase-9 were elevated in the treated U2OS cells. Cur-NPs upregulated the protein expression levels of cleaved caspase-3/caspase-9, cytochrome c, Apaf-1 and Bad and downregulated the protein expression level of p-Akt in U2OS cells. These results suggest Cur-NPs are effective in enhancing apoptosis in human osteosarcoma cells and thus could provide potential for cancer therapeutics.