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Wu X, Wang J, He D. Establishment and validation of a competitive risk model for predicting cancer-specific survival in patients with osteosarcoma: a population-based study. J Cancer Res Clin Oncol 2023; 149:15383-15394. [PMID: 37639006 DOI: 10.1007/s00432-023-05320-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Osteosarcoma is the most common primary bone tumor with a poor prognosis. The aim of this study was to establish a competitive risk model nomogram to predict cancer-specific survival in patients with osteosarcoma. METHODS Patient data was obtained from the Surveillance, Epidemiology, and End Results database in the United States. A sub-distribution proportional hazards model was used to analyze independent risk factors affecting cancer-specific mortality (CSM) in osteosarcoma patients. Based on these risk factors, a competitive risk model was constructed to predict 1-year, 3-year, and 5-year cancer-specific survival (CSS) in osteosarcoma patients. The reliability and accuracy of the nomogram were evaluated using the concordance index (C-index), the area under the receiver operating characteristic curve (AUC), and calibration curves. RESULTS A total of 2900 osteosarcoma patients were included. The analysis showed that age, primary tumor site, M stage, surgery, chemotherapy, and median household income were independent risk factors influencing CSM in patients. The competitive risk model was constructed to predict CSS in osteosarcoma patients. In the training and validation sets, the C-index of the model was 0.756 (95% CI 0.725-0.787) and 0.737 (95% CI 0.717-0.757), respectively, and the AUC was greater than 0.7 for both. The calibration curves also demonstrated a high consistency between the predicted survival rates and the actual survival rates, confirming the accuracy and reliability of the model. CONCLUSION We established a competitive risk model to predict 1-year, 3-year, and 5-year CSS in osteosarcoma patients. The model demonstrated good predictive performance and can assist clinicians and patients in making clinical decisions and formulating follow-up strategies.
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Affiliation(s)
- Xin Wu
- Department of Urology, Children's Hospital of Chongqing Medical University, 2 ZhongShan Rd, Chongqing, 400013, Chongqing, China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jinkui Wang
- Department of Urology, Children's Hospital of Chongqing Medical University, 2 ZhongShan Rd, Chongqing, 400013, Chongqing, China
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Dawei He
- Department of Urology, Children's Hospital of Chongqing Medical University, 2 ZhongShan Rd, Chongqing, 400013, Chongqing, China.
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.
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Bientinesi E, Lulli M, Becatti M, Ristori S, Margheri F, Monti D. Doxorubicin-induced senescence in normal fibroblasts promotes in vitro tumour cell growth and invasiveness: the role of Quercetin in modulating these processes. Mech Ageing Dev 2022; 206:111689. [PMID: 35728630 DOI: 10.1016/j.mad.2022.111689] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 01/10/2023]
Abstract
Ageing is a complex biological phenomenon representing the major risk factor for developing age-related diseases, such as cardiovascular pathologies, neurodegenerative diseases, and cancer. Geroscience, the new vision of gerontology, identifies cellular senescence as an interconnected biological process that characterises ageing and age-related diseases. Therefore, many strategies have been employed in the last years to reduce the harmful effects of senescence, and among these, the most intriguing ones use nutraceutical compounds. Here we show that a pre-treatment with Quercetin, a bioactive flavonoid present in many fruits and vegetables, increasing cellular antioxidant defence, can alleviate Doxorubicin (Doxo)-induced cellular senescence in human normal WI-38 fibroblasts. Furthermore, our work demonstrates that Quercetin pre-treatment, reducing the number of senescent cells and the production of the senescence-associated secretory phenotype (SASP) factors, can decrease the pro-tumour effects of conditioned medium from Doxo-induced senescent fibroblasts on osteosarcoma cells. Overall, our findings are consistent with the hypothesis that targeting senescent cells can be an emerging strategy for cancer treatment, especially in elderly patients, in which senescent cells are already abundant in several tissues and organs.
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Affiliation(s)
- Elisa Bientinesi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy 50134
| | - Matteo Lulli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy 50134.
| | - Matteo Becatti
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy 50134.
| | - Sara Ristori
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy 50134.
| | - Francesca Margheri
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy 50134.
| | - Daniela Monti
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy 50134.
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Xin S, Wei G. Correlation of vascular endothelial growth factor with survival and pathological characteristics of patients with osteosarcoma: A systematic review and meta-analysis. Eur J Cancer Care (Engl) 2022; 31:e13629. [PMID: 35707976 DOI: 10.1111/ecc.13629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/24/2021] [Accepted: 03/18/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study aimed to assess the prognostic role of vascular endothelial growth factor (VEGF) expression in osteosarcoma. METHODS Systematic searches of PubMed, Embase, CINAHL, Cochrane Library, ScienceDirect, and Web of Science were conducted. The correlation between VEGF expression and patients' survival was our primary endpoint. The secondary endpoints were the associations between VEGF level and patients' sociodemographic and pathological characteristics. The pooled hazard ratio (HR) or odd ratio (OR) and corresponding 95% confidence intervals (CIs) were obtained to assess the associations between VEGF expression and the target factors. Subgroup and meta-regression analyses were conducted to explore potential factors that associated with VEGF efficacy. RESULTS The combined HR suggested that a positive VEGF status has a negative impact on overall survival (OS) (HR = 2.58; 95% CI, 2.09-3.19; P < 0.0001) and disease-free survival (DFS) (HR = 2.54; 95% CI, 1.84-3.50; P < 0.0001) in patients with osteosarcoma. Meta-regression analysis ruled out the influence of cut-off value, disease stage, histological subtype, disease grade, tumour location, geographic area, publication year, and method of HR acquisition on heterogeneity. Results showed that VEGF expression was closely correlated with tumour staging, chemotherapy response, and metastasis. CONCLUSION Based on the study results, VEGF could serve as an effective biomarker of prognosis in patients with osteosarcoma. Besides, VEGF was related to increased tumour malignancy, which might help guide clinical decision-making regarding therapy and outcomes.
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Affiliation(s)
- Sun Xin
- Orthopedic Oncology, Peking University People's Hospital, Beijing, China
| | - Guo Wei
- Orthopedic Oncology, Peking University People's Hospital, Beijing, China
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Aznab M, Khajevand Ahmady M, Jamshidi K, Madani SH, Khazaei S, Shoushtaryzadeh T, Bagheri A. Investigating the Relationship between of Vascular Endothelial Growth Factor and HER-2neu in IHC Staining with Metastasis and Mortality in Patients with Osteosarcoma. Asian Pac J Cancer Prev 2020; 21:3005-3009. [PMID: 33112560 PMCID: PMC7798143 DOI: 10.31557/apjcp.2020.21.10.3005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Indexed: 11/29/2022] Open
Abstract
Background: The expression of HER-2neu and vascular endothelial growth factor (VEGF) in patients with osteosarcoma may determine the response to treatment. These two factors are likely to be effective in cancer progression. This study aimed at investigating the prevalence of these two factors in the pathological samples. Methods: Pathological samples of patients with osteosarcoma collected at a cancer surgery center between 2017 and 2018 were evaluated, of which 37 samples were included. The samples were evaluated using the IHC technique by two pathologists. Results: 12 women and 25 men with an average age of 26.7 years were studied. 21 patients (56.8%) developed metastases from the beginning or during follow-up, whereas 16 patients (43.2%) have not yet developed metastases. Regarding HER-2neu, 21 patients (56.8%) scored 0, 9 patients (24.3%) scored 1, 3 patients (8.1%) scored +2, and 4 patients (10.8%) scored +3. The VEGF intensity scores of 0, 1+, 2+, +3, +4 and were found in 7 (18.9%), 2 (5.4%), 18 (48.6%), 8 (21.6%), and 2 (5.4%) patients, respectively. The results of the study did not show a significant relationship between age, gender, metastasis, and positive expression rates of HER-2neu and VEGF. Conclusion: The high expression of VEGF (75.7%) in the studied samples should be considered and further studies on this biomarker in cases with osteosarcoma are recommended from different aspects. To achieve validated results and prove the results of this study, similar studies with a larger sample size should be performed, and using targeted therapy for angiogenesis in large scale trials should be considered.
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Affiliation(s)
- Mozaffar Aznab
- Internal Medicine Department, Talaghani Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Khodamrad Jamshidi
- Department of Orthopedic Surgery, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Madani
- Department of Pathology, Molecular Pathology Research Center, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Sdigheh Khazaei
- Molecular Pathology Research Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Tina Shoushtaryzadeh
- Oncopathology Research Center and Hasheminejad Clinical Research Developing Center (HCRDC), Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Abolfazl Bagheri
- Department of Orthopedic Surgery, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
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Xu Q, Gao T, Zhang B, Zeng J, Dai M. Primary osteosarcoma in elderly patients: A report of three cases. Oncol Lett 2019; 18:990-996. [PMID: 31423158 PMCID: PMC6607338 DOI: 10.3892/ol.2019.10446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 03/07/2019] [Indexed: 02/04/2023] Open
Abstract
Osteosarcoma is the most common type of primary malignant bone tumor in children and young adults. However, primary osteosarcoma in elderly patients is rare. The present study reports 3 cases of advanced osteosarcoma in elderly patients. The pathological findings in all 3 cases confirmed the diagnosis of primary osteosarcoma. Notably, each patient received different treatment options. Chemoradiotherapy was recommended in case 1 due to the age of the patient. However, the patient requested to be discharged and was lost to follow-up. Conversely, in case 2, the 62-year-old female patient underwent systemic chemotherapy, but no surgical treatment, and in case 3, the 51-year-old male patient underwent complete tumor resection and received systemic chemotherapy for late tumor recurrence. Early diagnosis of osteosarcoma in elderly patients is difficult, and misdiagnosis or a missed diagnosis is common. In clinical practice, bone tumors in elderly patients should be investigated carefully. Imaging examinations are essential for diagnosis, and biopsy is required for confirmation. However, the efficacy of chemotherapy for elderly patients with primary osteosarcoma remains uncertain. Collectively, due to the small number of reports of osteosarcoma in the elderly population, the 3 cases in the present study raise awareness of this rare condition.
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Affiliation(s)
- Qiang Xu
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, Jiangxi 330006, P.R. China
| | - Tian Gao
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, Jiangxi 330006, P.R. China
| | - Bin Zhang
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, Jiangxi 330006, P.R. China
| | - Jin Zeng
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, Jiangxi 330006, P.R. China
| | - Min Dai
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, Nanchang, Jiangxi 330006, P.R. China
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Tsuchie H, Emori M, Nagasawa H, Miyakoshi N, Murahashi Y, Shimizu J, Mizushima E, Yamashita T, Shimada Y. Prognosis of Primary Osteosarcoma in Elderly Patients: A Comparison between Young and Elderly Patients. Med Princ Pract 2019; 28:425-431. [PMID: 30991396 PMCID: PMC6771043 DOI: 10.1159/000500404] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 04/16/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Osteosarcoma is the most common malignant bone tumor in childhood. Although a poorer prognosis has been described in older patients, few reports have focused solely on primary osteosarcoma. We evaluated the clinical features of elderly patients with primary osteosarcoma. MATERIALS AND METHODS Ninety-four patients were included in this retrospective study, and we divided them into 2 groups (older patients and younger patients) based on a cut-off age of 40 years. The patients' information, including age, tumor type, location, presence of metastasis, American Joint Committee on Cancer (AJCC) stage, treatment-related factors, local and distant relapse, and outcome, was collected. We compared the clinical courses between the 2 groups in all and only deceased patients. RESULTS In all patients, the frequency of chemotherapy in the older group was significantly lower than in the younger group (p < 0.001), and tumors were more frequent in axial bone in the older patients (p = 0.041). Only in patients with surgical treatment, histological effectiveness after chemotherapy in the older group was lower than in the younger group (p = 0.041). The older patients showed a poorer prognosis (p = 0.031). However, the 5-year overall survival rate in the older patients was more favorable than that in the younger patients only among deceased patients (p =0.032). Only the existence of metastasis affected the prognosis in older patients (p = 0.012). CONCLUSION Primary osteosarcoma in elderly patients showed a high incidence of axial bone involvement, a low rate of chemotherapy, and resistance to chemotherapy. Although the final life prognosis is poor, survival may be relatively prolonged.
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Affiliation(s)
- Hiroyuki Tsuchie
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan,
| | - Makoto Emori
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroyuki Nagasawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Yasutaka Murahashi
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Junya Shimizu
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Emi Mizushima
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshihiko Yamashita
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
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Zheng W, Huang Y, Chen H, Wang N, Xiao W, Liang Y, Jiang X, Su W, Wen S. Nomogram application to predict overall and cancer-specific survival in osteosarcoma. Cancer Manag Res 2018; 10:5439-5450. [PMID: 30519092 PMCID: PMC6235004 DOI: 10.2147/cmar.s177945] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose A prognostic nomogram was applied to predict survival in osteosarcoma patients. Patients and methods Data collected from 2,195 osteosarcoma patients in the Surveillance, Epidemiology, and End Results (SEER) database between 1983 and 2014 were analyzed. Independent prognostic factors were identified via univariate and multivariate Cox analyses. These were incorporated into a nomogram to predict 3- and 5-year overall survival (OS) and cancer-specific survival (CSS) rates. Internal and external data were used for validation. Concordance indices (C-indices) were used to estimate nomogram accuracy. Results Patients were randomly assigned into a training cohort (n=1,098) or validation cohort (n=1,097). Age at diagnosis, tumor site, histology, tumor size, tumor stage, use of surgery, and tumor grade were identified as independent prognostic factors via univariate and multivariate Cox analyses (all P<0.05) and then included in the prognostic nomogram. C-indices for OS and CSS prediction in the training cohort were 0.763 (95% CI 0.761–0.764) and 0.764 (95% CI 0.762–0.765), respectively. C-indices for OS and CSS prediction in the external validation cohort were 0.739 (95% CI 0.737–0.740) and 0.740 (95% CI, 0.738–0.741), respectively. Calibration plots revealed excellent consistency between actual survival and nomogram prediction. Conclusion Nomograms were constructed to predict OS and CSS for osteosarcoma patients in the SEER database. They provide accurate and individualized survival prediction.
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Affiliation(s)
- Weipeng Zheng
- Department of Orthopedics, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong 510180, People's Republic of China
| | - Yuanping Huang
- Department of Orthopedics, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong 510180, People's Republic of China
| | - Haoyi Chen
- Department of Orthopedics, Guangzhou Chest Hospital, Guangzhou, Guangdong 510180, People's Republic of China
| | - Ning Wang
- Department of Orthopedics, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong 510180, People's Republic of China
| | - Wende Xiao
- Department of Orthopedics, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong 510180, People's Republic of China
| | - YingJie Liang
- Department of Orthopedics, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong 510180, People's Republic of China
| | - Xin Jiang
- Department of Orthopedics, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong 510180, People's Republic of China
| | - Wenzhou Su
- Department of Orthopedics, Guangzhou First People's Hospital, Guangzhou Medical University, School of Medicine, South China University of Technology, Guangzhou, Guangdong 510180, People's Republic of China,
| | - Shifeng Wen
- Department of Orthopedics, Guangzhou First People's Hospital, Guangzhou Medical University, School of Medicine, South China University of Technology, Guangzhou, Guangdong 510180, People's Republic of China,
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Chindaprasirt P, Promsorn J, Ungareewittaya P, Twinprai N, Chindaprasirt J. Bone metastasis from cholangiocarcinoma mimicking osteosarcoma: A case report and review literature. Mol Clin Oncol 2018; 9:532-534. [PMID: 30402235 PMCID: PMC6200975 DOI: 10.3892/mco.2018.1720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/17/2018] [Indexed: 01/01/2023] Open
Abstract
Cholangiocarcinoma is an aggressive tumor of the hepatic biliary system and it commonly spreads to the regional lymph nodes, liver and lungs. However, bone metastasis from cholangiocarcinoma is rare compared with other tumors. We herein present the case of a 61-year-old Asian woman who presented with pain in the right scapular area. Magnetic resonance imaging revealed bone destruction and an adjacent soft tissue mass at the right scapula. The findings on computed tomography imaging were compatible with cholangiocarcinoma. Bone biopsy was performed and the diagnosis of cholangiocarcinoma with bone metastasis was confirmed. The survival time was 10 months, despite administration of palliative radiotherapy and chemotherapy. Therefore, bone metastasis from cholangiocarcinoma should be considered as a differential diagnosis in patients who present with an osteolytic bone lesion and a liver mass.
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Affiliation(s)
- Prin Chindaprasirt
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Julaluck Promsorn
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Piti Ungareewittaya
- Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Nattaphon Twinprai
- Department of Orthopedic Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Jarin Chindaprasirt
- Division of Oncology, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
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Xiong Q, Wang X, Wang L, Huang Y, Tian X, Fan Y, Lin CY. BMP-2 inhibits lung metastasis of osteosarcoma: an early investigation using an orthotopic model. Onco Targets Ther 2018; 11:7543-7553. [PMID: 30464502 PMCID: PMC6214601 DOI: 10.2147/ott.s176724] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Bone morphogenetic proteins (BMPs), members of the TGF-β superfamily, are known to regulate cell proliferation, differentiation, apoptosis, chemotaxis, and angiogenesis. BMPs also participate in the development of most tissues and organs in vertebrates. Recombinant human (rh) BMPs, such as rhBMP-2, rhBMP-4, and rhBMP-7, have been recently approved to augment spinal fusion and recalcitrant long-bone non-unions because of their equivalent or superior efficacy to autogenous bone graft in enhancing bony fusion. Nonetheless, the use of BMPs is contraindicated in surgery for bone tumors because of concerns that this anabolic growth factor may cause tumor proliferation. However, we have repeatedly reported that BMP-2 is effective in inducing osteogenic differentiation of a subpopulation of osteosarcoma (OSA) cells that acquire stem cell attributes and are capable of reconstituting tumor masses, which in turn suppress the malignancy of the bone tumor. Methods 3×105/20 µL human OSA 143B cells were inoculated into 5–6 weeks old BABL/c nude mice to establish orthotopic OSA. X-ray device was used to monitor the developed tumors in animals. Necropsy was performed and the pathology of lung metastasis were tested by Haemotoxylin and Eosin. Moreover, bone formation induced by rhBMP-2 was investigated through micro-computed tomography. In addition, immunohistochemistry staining was used to evaluate the tumorigenicity and growth of OSA cells after rhBMP-2 treatment. Results In the present study, we established an orthotopic model of OSA by inoculating 143B cells into BABL/c mice, which resulted in a tumor occurrence rate of 100%. Following the treatment with rhBMP-2, lung metastasis, which contributes to poor prognosis, was significantly restricted, indicating an additional aspect of rhBMP-2 to suppress expansion of OSA. Concurrently, our micro-computed tomography and radiographic analyses showed that rhBMP-2 reduced the invasion of tumor cells into adjacent bone tissue, which in turn helped to preserve the integrity of the affected bone tissue. Finally, the growth of Ki-67-positive cells and those cells that express high levels of aldehyde dehydrogenase (ALDHbr) was found to be inhibited in the developed tumors. Conclusion On the basis of these results, we conclude that rhBMP-2 can impede the malignancy of OSA by reducing lung metastasis of the tumor. Induction of the tumor cells by rhBMP-2 also helps to preserve the impaired skeleton. These results imply that BMP-2 or BMP-2-mimetic drugs, if properly combined with traditional therapies, may provide a new therapeutic option for the treatment of OSA.
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Affiliation(s)
- Qisheng Xiong
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China, .,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China,
| | - Xuesong Wang
- Spine Department, The No 2 Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lizhen Wang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China, .,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China,
| | - Yan Huang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China, .,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China,
| | - Xiaodong Tian
- Spine Department, The No 2 Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yubo Fan
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China, .,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China,
| | - Chia-Ying Lin
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China, .,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China, .,Department of Orthopaedic Surgery, University of Cincinnati Academic Health Center, Cincinnati, OH, USA, .,Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, USA,
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Kumar R, Kumar M, Malhotra K, Patel S. Primary Osteosarcoma in the Elderly Revisited: Current Concepts in Diagnosis and Treatment. Curr Oncol Rep 2018; 20:13. [PMID: 29492676 DOI: 10.1007/s11912-018-0658-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Osteosarcoma is mostly seen in bones of children and young adults. When it occurs in older persons, the tumor is considered secondary usually complicating Paget disease or irradiated bone. However, there is a second incidence peak of primary osteosarcoma later in life when these tumors occur de novo. This article describes the clinical, imaging, and treatment of POS in older patients, including demographic data of patients from our institution. FINDINGS We present our experience with 920 cases of osteosarcoma that were seen between 1984 and 2003 at the University of Texas MD Anderson Cancer Center in Houston, TX, USA. Among the 868 primary osteosarcoma of bones, there were 100 (11.52%), which comprised 69% of the tumors in patients over the age of 50 years. Older patients with primary osteosarcoma tend to have relatively more common axial skeleton involvement, have more distant disease, and are difficult to treat because of concomitant comorbidities. Despite that, most adult patients treated with chemotherapy have shown good results with longer disease-free survival. A lytic bone lesion seen in radiographs of elderly patients should include primary osteosarcoma among differential diagnoses. Radical surgery and chemotherapy seem to ensure long-term disease-free survival in most cases. The elderly patients with POS in pelvis, spine, and upper extremities and those with distant disease (metastases) have worse prognosis.
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Affiliation(s)
- Rajendra Kumar
- Department of Diagnostic Imaging, UT MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1475, Houston, TX, 77030, USA.
| | - Meena Kumar
- Department of Diagnostic Imaging, Section of Nuclear Medicine, Veterans Administration Hospital, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - Kavin Malhotra
- Victoria Radiology Associates, 2701 Hospital Drive, Victoria, TX, 77901, USA
| | - Shreyaskumar Patel
- Victoria Radiology Associates, 2701 Hospital Drive, Victoria, TX, 77901, USA
- Department of Sarcoma Medical Oncology, UT MD Anderson Cancer Center, 1400 - Holcombe Blvd., Unit # 450, Houston, TX, 77030, USA
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Boss DS, Glen H, Beijnen JH, de Jong D, Wanders J, Evans TRJ, Schellens JHM. Serum β-HCG and CA-125 as Tumor Markers in a Patient with Osteosarcoma: Case Report. TUMORI JOURNAL 2018; 97:109-14. [DOI: 10.1177/030089161109700119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Elevated β-HCG serum levels are usually an indication of pregnancy or pregnancy-related disorders, but β-HCG can also be elevated in testis and germ cell tumors. HCG expression by osteosarcoma is a rare phenomenon, with a few documented cases. CA-125 is commonly used to monitor disease progression and treatment response in ovarian cancer. CA-125 expression in patients with osteosarcoma has not previously been documented. Case report Elevated β-HCG and CA-125 serum levels were observed in a female patient of 57 years of age with metastatic osteosarcoma during screening investigations prior to participation in a phase I clinical trial. Pregnancy was excluded. Immunohistochemical studies revealed the tumor to be the source of the elevated β-HCG serum levels. We found no CA-125 expression in tumor tissue. The patient was treated with E7080, a novel oral multi-targeted tyrosine kinase inhibitor. We measured serum β-HCG and CA-125 to monitor treatment response. She had a significant clinical and radiological response after two cycles of treatment, but developed progressive disease after the third cycle. The β-HCG serum levels seemed to better reflect her disease status than those of the other tumor marker, CA-125. Conclusions When elevated, β-HCG serum levels in patients with osteosarcoma might be used to monitor treatment. Treatment of advanced osteosarcoma with tyrosine kinase inhibitors, including E7080, warrants further investigation. Free full text available at www.tumorionline.it
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Affiliation(s)
- David S Boss
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilary Glen
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, Slotervaart Hospital, Amsterdam, The Netherlands
- Science Faculty, Department of Pharmaceutical Sciences, Division of Biomedical Analysis, Utrecht University, Utrecht, The Netherlands
| | - Daphne de Jong
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - TR Jeffry Evans
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Jan HM Schellens
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Science Faculty, Department of Pharmaceutical Sciences, Division of Biomedical Analysis, Utrecht University, Utrecht, The Netherlands
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12
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Miller BJ, Gao Y, Duchman KR. Socioeconomic measures influence survival in osteosarcoma: an analysis of the National Cancer Data Base. Cancer Epidemiol 2017; 49:112-117. [DOI: 10.1016/j.canep.2017.05.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 04/29/2017] [Accepted: 05/31/2017] [Indexed: 01/12/2023]
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Zhang M, Zhang X. Association of MMP-2 expression and prognosis in osteosarcoma patients. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2015; 8:14965-14970. [PMID: 26823829 PMCID: PMC4713615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 06/23/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Our aim was to investigate the MMP-2 expression and its prognostic value in osteosarcoma patients. METHODS We performed RT-qPCR to detect the expression of MMP-2 in 45 paired osteosarcoma tissues and adjacent noncancerous tissues. Immunohistochemical staining assay was used to verify the expression of MMP-2 protein in osteosarcoma patients. Independent-sample T test was used to analyze the difference of MMP-2 expression level between osteosarcoma and control groups. The relationship between clinicopathologic factors and MMP-2 expression was analyzed by chi-square test. Kaplan-Meier was performed to analyze the association of MMP-2 expression and overall survival rate. The prognostic value of clinicopathologic factors and MMP-2 was estimated via Cox regression analysis. RESULTS RT-qPCR revealed that the expression of MMP-2 was up-regulated in osteosarcoma group compared with the control group. Besides MMP-2 expression was influenced by pulmonary metastasis (P<0.05) while gender, age, tumor site and Enneking stage showed no obvious impact (P>0.05). Kaplan-Meier curve revealed that patients with positive MMP-2 expression had a shorter survival time than those with negative MMP-2 expression, and the survival rates were 18.5% (5/27) and 44.4% (8/18), respectively. Cox regression analysis indicated that pulmonary metastasis and expression of MMP-2 gene were important factors in the prognosis of osteosarcoma. CONCLUSION The expression of MMP-2 was associated with pulmonary metastasis, and was related to the prognosis of osteosarcoma. MMP-2 could act as an independent prognostic marker in osteosarcoma patients.
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Duchman KR, Gao Y, Miller BJ. Prognostic factors for survival in patients with high-grade osteosarcoma using the Surveillance, Epidemiology, and End Results (SEER) Program database. Cancer Epidemiol 2015; 39:593-9. [DOI: 10.1016/j.canep.2015.05.001] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/30/2015] [Accepted: 05/05/2015] [Indexed: 12/13/2022]
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15
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Baptista AM, Camargo AFDF, Filippi RZ, Oliveira CRGCMD, Azevedo Neto RSD, Camargo OPD. Correlation between the expression of vegf and survival in osteosarcoma. ACTA ORTOPEDICA BRASILEIRA 2014; 22:250-5. [PMID: 25328432 PMCID: PMC4199641 DOI: 10.1590/1413-78522014220500978] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/30/2014] [Indexed: 11/30/2022]
Abstract
Objective: To present a series of 50 consecutive patients with non-metastatic extremity osteosarcoma, and attempt to correlate expression of the vascular endothelial growth factor (VEGF) protein in biopsy tissue to their prognosis regarding overall survival, disease-free survival and local recurrence. Methods: Fifty cases of non-metastatic osteosarcoma of the extremities treated between 1986 and 2006 at Instituto de Ortopedia e Traumatologia da Universidade de São Paulo, São Paulo, Brasil, were evaluated regarding expression of the VEGF protein. There were 19 females and 31 males. The mean age was 16 years old (range 5-28 years old) and the mean follow-up was 60.6 months (range 25-167 months). The variables studied were age, gender, anatomic location, type of surgery, surgical margins, tumor size, post chemotherapy necrosis, local recurrence, pulmonary metastasis and death. Results: Thirty-six patients showed VEGF expression on 30% or less cells (low), and the remaining 14 cases had VEGF expression above 30% (high). Among the 36 patients with low VEGF expression, nine developed pulmonary metastasis and four died (11.1%). Among the 14 patients with high VEGF expression, six developed pulmonary metastasis and three died (21.4%). Conclusion: There was no statistically significant correlation between the expression of VEGF and any of the variables studied. Level of Evidence IV, Therapeutic Study.
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Kunz P, Fellenberg J, Moskovszky L, Sápi Z, Krenacs T, Machado I, Poeschl J, Lehner B, Szendrõi M, Ruef P, Bohlmann M, Bosch AL, Ewerbeck V, Kinscherf R, Fritzsching B. Improved survival in osteosarcoma patients with atypical low vascularization. Ann Surg Oncol 2014; 22:489-96. [PMID: 25155396 DOI: 10.1245/s10434-014-4001-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Osteosarcoma is considered a highly vascularized bone tumor with early metastatic dissemination through intratumoral blood vessels mostly into the lung. Novel targets for therapy such as tumor vascularization are highly warranted since little progress has been achieved in the last 30 years. However, proof of relevance for vascularization as a major prognostic parameter has been hampered by tumor heterogeneity, difficulty in detecting microvessels by immunohistochemistry, and small study cohorts. Most recently, we demonstrated that highly standardized whole-slide imaging could overcome these limitations (Kunz et al., PloS One 9(3):e90727, 2014). In this study, we applied this method to a multicenter cohort of 131 osteosarcoma patients to test osteosarcoma vascularization as a prognostic determinant. METHODS Computer-assisted whole-slide analysis, together with enzymatic epitope retrieval, was used for CD31-based microvessel quantification in 131 pretreatment formalin-fixed and paraffin-embedded biopsies from three bone tumor centers. Kaplan-Meier-estimated survival and chemoresponse were determined and multivariate analysis was performed. Conventional hot-spot-based microvessel density (MVD) determination was compared with whole-slide imaging. RESULTS We detected high estimated overall (p ≤ 0.008) and relapse-free (p ≤ 0.004) survival in 25 % of osteosarcoma patients with low osteosarcoma vascularization in contrast to other patient groups. Furthermore, all patients with low osteosarcoma vascularization showed a good response to neoadjuvant chemotherapy. Comparison of conventional MVD determination with whole-slide imaging suggests false high quantification or even exclusion of samples with low osteosarcoma vascularization due to difficult CD31 detection in previous studies. CONCLUSION Low intratumoral vascularization at the time of diagnosis is a strong predictor for prolonged survival and good response to neoadjuvant chemotherapy in osteosarcoma.
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Affiliation(s)
- Pierre Kunz
- Department of Orthopedics and Traumatology, University Hospital Heidelberg, Heidelberg, Germany,
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17
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Fatimi SH, Khawaja RDA, Majid Z. Giant osteosarcoma of chest wall requiring resection and pneumonectomy. Asian Cardiovasc Thorac Ann 2014; 22:875-7. [PMID: 24887861 DOI: 10.1177/0218492313498089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We present the case of a 13-year-old girl who had a large swelling in her left breast with a history of weight loss, low-grade fever, and cold sweats. Computed tomography showed a large mass encroaching on the mediastinum and heart, with erosion of the adjacent ribs. Resection of the mass along with a pneumonectomy were performed. Postoperative tests showed no sign of metastases.
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Affiliation(s)
- Saulat Hasnain Fatimi
- Section of Cardiothoracic Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Ranish Deedar Ali Khawaja
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Medical College, Aga Khan University, Karachi, Pakistan
| | - Zain Majid
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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18
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Osteosarcoma microenvironment: whole-slide imaging and optimized antigen detection overcome major limitations in immunohistochemical quantification. PLoS One 2014; 9:e90727. [PMID: 24594971 PMCID: PMC3940945 DOI: 10.1371/journal.pone.0090727] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 02/03/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In osteosarcoma survival rates could not be improved over the last 30 years. Novel biomarkers are warranted to allow risk stratification of patients for more individual treatment following initial diagnosis. Although previous studies of the tumor microenvironment have identified promising candidates, novel biomarkers have not been translated into routine histopathology. Substantial difficulties regarding immunohistochemical detection and quantification of antigens in decalcified and heterogeneous osteosarcoma might largely explain this translational short-coming. Furthermore, we hypothesized that conventional hot spot analysis is often not representative for the whole section when applied to heterogeneous tissues like osteosarcoma. We aimed to overcome these difficulties for major biomarkers of the immunovascular microenvironment. METHODS Immunohistochemistry was systematically optimized for cell surface (CD31, CD8) and intracellular antigens (FOXP3) including evaluation of 200 different antigen retrieval conditions. Distribution patterns of these antigens were analyzed in formalin-fixed and paraffin-embedded samples from 120 high-grade central osteosarcoma biopsies and computer-assisted whole-slide analysis was compared with conventional quantification methods including hot spot analysis. RESULTS More than 96% of osteosarcoma samples were positive for all antigens after optimization of immunohistochemistry. In contrast, standard immunohistochemistry retrieved false negative results in 35-65% of decalcified osteosarcoma specimens. Standard hot spot analysis was applicable for homogeneous distributed FOXP3+ and CD8+ cells. However, heterogeneous distribution of vascular CD31 did not allow reliable quantification with hot spot analysis in 85% of all samples. Computer-assisted whole-slide analysis of total CD31- immunoreactive area proved as the most appropriate quantification method. CONCLUSION Standard staining and quantification procedures are not applicable in decalcified formalin-fixed and paraffin-embedded samples for major parameters of the immunovascular microenvironment in osteosarcoma. Whole-slide imaging and optimized antigen retrieval overcome these limitations.
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Hansen AR, Hughes BG, Paul S, Steadman P, Sommerville S, Dickinson IC, Walpole ET, Thomson DB, Mar Fan HG, Joubert WL. Single institution retrospective review of perioperative chemotherapy in adult and adolescent patients with operable osteosarcoma. Asia Pac J Clin Oncol 2014; 12:e222-8. [PMID: 24571381 DOI: 10.1111/ajco.12167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2013] [Indexed: 11/29/2022]
Abstract
AIMS Perioperative chemotherapy has improved the prognosis for patients with operable osteosarcoma. The literature is conflicting about which regimen is optimal. The aim of this study was to evaluate the survival outcomes of two cohorts of patients with operable osteosarcoma treated with different perioperative chemotherapy regimens. METHODS This was a retrospective review of patients diagnosed with operable osteosarcoma treated at the Princess Alexandra Hospital from 1986 to 2009. The standard perioperative chemotherapy regimen changed from the modified T10 Rosen protocol to cisplatin/doxorubicin in 1997. Using the Kaplan-Meier method, overall survival (OS) and disease-free survival (DFS) curves were generated for the cisplatin/doxorubicin and the modified T10 Rosen cohorts. RESULTS Seventy-one patients were identified of whom 63 had potentially curable disease. Of these, 24 received the modified T10 Rosen regimen and 39 received cisplatin/doxorubicin. There was a non-significant trend toward better OS and DFS in the patients who received the modified T10 Rosen protocol. CONCLUSION The trend toward poorer survival in the cisplatin/doxorubicin cohort, in combination with current evidence, has prompted our institution to change its practice.
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Affiliation(s)
- Aaron R Hansen
- Division of Cancer Services, Princess Alexandra Hospital, Queensland, Australia
| | - Brett Gm Hughes
- Cancer Care Services, The Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Sanjoy Paul
- Queensland Clinical Trials and Biostatistics Centre, School of Population Health, The University of Queensland, Princess Alexandra Hospital, Queensland, Australia
| | - Peter Steadman
- Department of Orthopaedics, Princess Alexandra Hospital, Queensland, Australia
| | - Scott Sommerville
- Department of Orthopaedics, Princess Alexandra Hospital, Queensland, Australia
| | - Ian C Dickinson
- Department of Orthopaedics, Princess Alexandra Hospital, Queensland, Australia
| | - Euan T Walpole
- Division of Cancer Services, Princess Alexandra Hospital, Queensland, Australia
| | - Damien B Thomson
- Division of Cancer Services, Princess Alexandra Hospital, Queensland, Australia
| | - Helen G Mar Fan
- Division of Cancer Services, Princess Alexandra Hospital, Queensland, Australia.,University of Queensland School of Medicine, Brisbane, Queensland, Australia
| | - Warren L Joubert
- Division of Cancer Services, Princess Alexandra Hospital, Queensland, Australia
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20
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Miller BJ, Lynch CF, Buckwalter JA. Conditional survival is greater than overall survival at diagnosis in patients with osteosarcoma and Ewing's sarcoma. Clin Orthop Relat Res 2013; 471:3398-404. [PMID: 23821136 PMCID: PMC3792244 DOI: 10.1007/s11999-013-3147-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 06/25/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Conditional survival is a measure of the risk of mortality given that a patient has survived a defined period of time. These estimates are clinically helpful, but have not been reported previously for osteosarcoma or Ewing's sarcoma. QUESTIONS/PURPOSES We determined the conditional survival of patients with osteosarcoma and Ewing's sarcoma given survival of 1 or more years. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) Program database to investigate cases of osteosarcoma and Ewing's sarcoma in patients younger than 40 years from 1973 to 2009. The SEER Program is managed by the National Cancer Institute and provides survival data gathered from population-based cancer registries. We used an actuarial life table analysis to determine any cancer cause-specific 5-year survival estimates conditional on 1 to 5 years of survival after diagnosis. We performed a similar analysis to determine 20-year survival from the time of diagnosis. RESULTS The estimated 5-year survival improved each year after diagnosis. For local/regional osteosarcoma, the 5-year survival improved from 74.8% at baseline to 91.4% at 5 years-meaning that if a patient with localized osteosarcoma lives for 5 years, the chance of living for another 5 years is 91.4%. Similarly, the 5-year survivals for local/regional Ewing's sarcoma improved from 72.9% at baseline to 92.5% at 5 years, for metastatic osteosarcoma 35.5% at baseline to 85.4% at 5 years, and for metastatic Ewing's sarcoma 31.7% at baseline to 83.6% at 5 years. The likelihood of 20-year cause-specific survival from the time of diagnosis in osteosarcoma and Ewing's sarcoma was almost 90% or greater after 10 years of survival, suggesting that while most patients will remain disease-free indefinitely, some experience cancer-related complications years after presumed eradication. CONCLUSIONS The 5-year survival estimates of osteosarcoma and Ewing's sarcoma improve with each additional year of patient survival. Knowledge of a changing risk profile is useful in counseling patients with time. The presence of cause-specific mortality decades after treatment supports lifelong monitoring in this population. LEVEL OF EVIDENCE Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin J. Miller
- Department of Orthopaedics and Rehabilitation, University of Iowa, 200 Hawkins Dr., 01015 JPP, Iowa City, IA 52246 USA
| | - Charles F. Lynch
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA USA
| | - Joseph A. Buckwalter
- Department of Orthopaedics and Rehabilitation, University of Iowa, 200 Hawkins Dr., 01015 JPP, Iowa City, IA 52246 USA
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Miller BJ, Cram P, Lynch CF, Buckwalter JA. Risk factors for metastatic disease at presentation with osteosarcoma: an analysis of the SEER database. J Bone Joint Surg Am 2013; 95:e89. [PMID: 23824394 PMCID: PMC3689260 DOI: 10.2106/jbjs.l.01189] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Osteosarcoma is the most common primary bone sarcoma and affects all ages. There are substantial differences in management and outcomes for patients who have localized disease compared with distant spread at the time of diagnosis. Our goal was to examine potential risk factors predictive of metastatic disease at presentation. METHODS The Surveillance, Epidemiology, and End Results (SEER) Program database was used to identify all patients diagnosed with osteosarcoma from 2000 to 2008 and to classify each patient as having metastatic or localized disease at the time of diagnosis. Patient-based characteristics, tumor characteristics, and county-level socioeconomic measures were analyzed to determine which factors were predictive of an increased rate of distant metastatic disease at presentation. These factors were analyzed as univariate characteristics as well as in a multivariate logistic regression model. RESULTS We identified 2017 cases of high-grade osteosarcoma, and 464 (23.0%) of the patients presented with metastatic disease. In the unadjusted logistic regression analysis, patients had increased odds of metastatic disease at presentation if they had an age of sixty years or more (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.71 to 2.89), had a tumor located in the axial skeleton (OR = 2.47; 95% CI, 1.88 to 3.26), and lived in a county with low socioeconomic status (OR = 1.59; 95% CI, 1.08 to 2.35). These factors remained significant when combined in multivariate models controlling for age, location, and socioeconomic status. For patients with recorded tumor size information (n = 1398), the odds of metastasis at presentation increased by 10% with each additional centimeter of tumor size (OR = 1.10; 95% CI, 1.08 to 1.13). When the patients with missing tumor size information were excluded, socioeconomic status was no longer a significant risk factor for metastasis at presentation in the multivariate model. CONCLUSIONS Osteosarcoma patients with advanced age, a tumor in the axial skeleton, a larger tumor size, and a residence in a less affluent county were more likely to have metastatic disease at presentation.
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Affiliation(s)
- Benjamin J. Miller
- Departments of Orthopaedics and Rehabilitation (B.J.M., J.A.B.), Internal Medicine (P.C.), and Epidemiology (C.F.L.), University of Iowa, 200 Hawkins Drive, 01015 JPP, Iowa City, Iowa 52242. E-mail address for B.J. Miller:
| | - Peter Cram
- Departments of Orthopaedics and Rehabilitation (B.J.M., J.A.B.), Internal Medicine (P.C.), and Epidemiology (C.F.L.), University of Iowa, 200 Hawkins Drive, 01015 JPP, Iowa City, Iowa 52242. E-mail address for B.J. Miller:
| | - Charles F. Lynch
- Departments of Orthopaedics and Rehabilitation (B.J.M., J.A.B.), Internal Medicine (P.C.), and Epidemiology (C.F.L.), University of Iowa, 200 Hawkins Drive, 01015 JPP, Iowa City, Iowa 52242. E-mail address for B.J. Miller:
| | - Joseph A. Buckwalter
- Departments of Orthopaedics and Rehabilitation (B.J.M., J.A.B.), Internal Medicine (P.C.), and Epidemiology (C.F.L.), University of Iowa, 200 Hawkins Drive, 01015 JPP, Iowa City, Iowa 52242. E-mail address for B.J. Miller:
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Kubo T, Shimose S, Fujimori J, Arihiro K, Ochi M. Diversity of angiogenesis among malignant bone tumors. Mol Clin Oncol 2012; 1:131-136. [PMID: 24649135 DOI: 10.3892/mco.2012.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 07/11/2012] [Indexed: 11/06/2022] Open
Abstract
Several studies have demonstrated that angiogenesis assessed by microvessel density (MVD) correlates with patient prognosis in various types of cancer, whereas data regarding the relevance of angiogenesis and prognosis in malignant bone tumors are scarce and controversial. The aim of this study was to examine MVD in representative malignant bone tumors, such as osteosarcoma, chondrosarcoma and Ewing's sarcoma, in order to clarify the role of angiogenesis in prognosis. A total of 69 patients with malignant bone tumors, including 44 osteosarcomas, 20 chondrosarcomas and 5 Ewing's sarcomas, were reviewed retrospectively and treated at our hospital between 1980 and 2007. Biopsy or pre-chemotherapy surgical specimens were immunohistochemically stained with anti-CD34 antibody. The MVD values of osteosarcomas and Ewing's sarcomas were significantly higher compared to chondrosarcoma. In osteosarcomas with high MVD, American Joint Committee on Cancer stage IIA, good histological response to chemotherapy was significantly correlated with better disease-free survival, while MVD was closely associated with age and chemotherapy response. In chondrosarcomas, the surgical margin (marginal and intralesional), MVD (high), tumor size (≥8) and histological grade (grades 2 and 3) significantly correlated with a shorter disease-free survival, while MVD was closely associated with age and histological grade. These findings showed that osteosarcomas and Ewing's sarcomas were hypervascular, compared to chondrosarcomas. In osteosarcomas, hypervascularity induced good chemotherapy response, leading to better prognosis, while in chondrosarcomas, high MVD was associated with histological grade and predicted poor prognosis.
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Affiliation(s)
- Tadahiko Kubo
- Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University
| | - Shoji Shimose
- Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University
| | - Jun Fujimori
- Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Minami-ku, Hiroshima 734-8551, Japan
| | - Mitsuo Ochi
- Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University
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Ługowska I, Woźniak W, Klepacka T, Michalak E, Szamotulska K. A prognostic evaluation of vascular endothelial growth factor in children and young adults with osteosarcoma. Pediatr Blood Cancer 2011; 57:63-8. [PMID: 21416580 DOI: 10.1002/pbc.23021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Accepted: 12/10/2010] [Indexed: 11/09/2022]
Abstract
BACKGROUND The potential role of VEGF in osteosarcoma has been evaluated in several studies. The majority of them included heterogeneous and limited series of patients, giving conflicting results. The aim of presented study is to evaluate the prognostic role of VEGF-A in biopsy samples of clinically homogeneous group of osteosarcoma patients with at least 5 years of follow up. MATERIALS AND METHODS VEGF-A was assessed immunohistochemically in the pre-treatment biopsy samples of 91 patients (mean age 14 years; range, 4-23 years) with primary, high-grade, non-metastatic osteosarcoma localized in extremities. The survival of each patient was assessed after at least 5-year follow-up period. RESULTS VEGF-A over 50% of positive tumor cells was observed in 39% of cases and was linked to patients age below 14-year old (P = 0.025) and tumor size more than 8 cm (P = 0.054). VEGF-A was associated with a significantly decreased both overall survival (P = 0.006) and progression-free survival (P = 0.011). In the Cox proportional hazard model it was confirmed that VEGF-A expression in the biopsy samples was an independent prognostic factor of unfavorable survival in osteosarcoma (HR 2.51; 95% CI: 1.12-5.66). CONCLUSION The expression of VEGF-A in the biopsy sample is the potential marker for predicting the course and outcome of osteosarcoma.
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Affiliation(s)
- Iwona Ługowska
- Institute of Mother and Child, Department of Pediatrics and Adolescent Oncological Surgery, Warsaw, Poland.
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VanCleave TT, Moore JH, Benford ML, Brock GN, Kalbfleisch T, Baumgartner RN, Lillard JW, Kittles RA, Kidd LCR. Interaction among variant vascular endothelial growth factor (VEGF) and its receptor in relation to prostate cancer risk. Prostate 2010; 70:341-52. [PMID: 19908237 PMCID: PMC4433472 DOI: 10.1002/pros.21067] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prostate cancer (PCa) incidence and mortality are disproportionately high among African-American (AA) men. Its detection and perhaps its disparities could be improved through the identification of genetic susceptibility biomarkers within essential biological pathways. Interactions among highly variant genes, central to angiogenesis, may modulate susceptibility for prostate cancer, as previous demonstrated. This study evaluates the interplay among three highly variant genes (i.e., IL-10, TGFbetaR-1, VEGF), their receptors and their influence on PCa within a case-control study consisting of an under-served population. METHODS This study evaluated single gene and joint modifying effects on PCa risk in a case-control study comprised of 859 AA men (193 cases and 666 controls) using TaqMan qPCR. Interaction among polymorphic IL-10, TGFbetaR-1 and VEGF was analyzed using conventional logistic regression analysis (LR) models, multi-dimensionality reduction (MDR) and interaction entropy graphs. Symbolic modeling allowed validation of gene-gene interaction findings identified by MDR. RESULTS No significant single gene effects were demonstrated in relation to PCa risk. However, carriers of the VEGF 2482T allele had a threefold increase in the risk of developing aggressive PCa. The presence of VEGF 2482T combined with VEGFR IVS6 + 54 loci were highly significant for the risk of PCa based on MDR and symbolic modeling analyses. These findings were substantiated by 1,000-fold cross validation permutation testing (P = 0.04), respectively. CONCLUSION These findings suggest the inheritance of VEGF and VEGFR IVS6 + 54 sequence variants may jointly modify PCa susceptibility through their influence on angiogenesis. Larger sub-population studies are needed to validate these findings and evaluate whether the VEGF-VEGR axis may serve as predictors of disease prognosis and ultimately clinical response to available treatment strategies.
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Affiliation(s)
- Tiva T. VanCleave
- Department of Pharmacology & Toxicology, University of Louisville (UofL), Louisville, Kentucky
- Cancer Prevention & Control Program, James Graham Brown Cancer Center, University of Louisville (UofL), Louisville, Kentucky
| | - Jason H. Moore
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Marnita L. Benford
- Department of Pharmacology & Toxicology, University of Louisville (UofL), Louisville, Kentucky
- Cancer Prevention & Control Program, James Graham Brown Cancer Center, University of Louisville (UofL), Louisville, Kentucky
| | - Guy N. Brock
- Department of Bioinformatics & Biostatistics, School of Public Health and Information Science (SPHIS), University of Louisville (UofL), Louisville, Kentucky
| | - Ted Kalbfleisch
- Department of Biochemistry and Molecular Biology, University of Louisville (UofL), Louisville, Kentucky
| | - Richard N. Baumgartner
- Department of Epidemiology, SPHIS, University of Louisville (UofL), Louisville, Kentucky
| | - James W. Lillard
- Department of Pharmacology & Toxicology, University of Louisville (UofL), Louisville, Kentucky
- Department of Microbiology and Immunology, University of Louisville (UofL), Louisville, Kentucky
| | - Rick A. Kittles
- Department of Medicine, Section of Genetic Medicine, University of Chicago, Chicago, Illinois
| | - La Creis R. Kidd
- Department of Pharmacology & Toxicology, University of Louisville (UofL), Louisville, Kentucky
- Cancer Prevention & Control Program, James Graham Brown Cancer Center, University of Louisville (UofL), Louisville, Kentucky
- Department of Epidemiology, SPHIS, University of Louisville (UofL), Louisville, Kentucky
- Correspondence to: La Creis R. Kidd, PhD, MPH, 580 South Preston Street, 304A Delia Baxter II Research Building, Louisville, KY 40202.
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25
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Rossi B, Schinzari G, Maccauro G, Scaramuzzo L, Signorelli D, Rosa MA, Fabbriciani C, Carlo B. Neoadjuvant multidrug chemotherapy including high-dose methotrexate modifies VEGF expression in osteosarcoma: an immunohistochemical analysis. BMC Musculoskelet Disord 2010; 11:34. [PMID: 20158913 PMCID: PMC2835659 DOI: 10.1186/1471-2474-11-34] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 02/16/2010] [Indexed: 11/21/2022] Open
Abstract
Background Angiogenesis plays a role in the progression of osteosarcoma, as well as in other mesenchymal tumors and carcinomas, and it is most commonly assessed by vascular endothelial growth factor (VEGF) expression or tumor CD31-positive microvessel density (MVD). Tumor VEGF expression is predictive of poor prognosis, and chemotherapy can affect the selection of angiogenic pattern. The aim of the study was to investigate the clinical and prognostic significance of VEGF and CD31 in osteosarcoma, both at diagnosis and after neoadjuvant chemotherapy, in order to identify a potential role of chemotherapy in angiogenic phenotype. Methods A retrospective analysis was performed on 16 patients with high grade osteosarcoma. In each case archival pre-treatment biopsy tissue and post-chemotherapy tumor specimens were immunohistochemically stained against CD31 and VEGF, as markers of angiogenic proliferation both in newly diagnosed primary osteosarcoma and after multidrug chemotherapy including high-dose methotrexate (HDMTX). The correlation between clinicopathological parameters and the degree of tumor VEGF and CD31 expression was statistically assessed using the χ2 test verified with Yates' test for comparison of two groups. Significance was set at p < 0,05. Results Expression of VEGF was positive in 11 cases/16 of cases at diagnosis. Moreover, 8 cases/16 untreated osteosarcomas were CD31-negative, but the other 8 showed an high expression of CD31. VEGF expression in viable tumor cells after neoadjuvant chemotherapy was observed in all cases; in particular, there was an increased VEGF expression (post-chemotherapy VEGF - biopsy VEGF) in 11 cases/16. CD31 expression increased in 11 cases/16 and decreased in 3 cases after chemotherapy. The data relating to the change in staining following chemotherapy appear statistically significant for VEGF expression (p < 0,05), but not for CD31 (p > 0,05). Conclusions Even if the study included few patients, these results confirm that VEGF and CD31 expression is affected by multidrug chemotherapy including HDMTX. The expression of angiogenic factors that increase microvessel density (MVD) can contribute to the penetration of chemotherapeutic drugs into the tumor in the adjuvant stage of treatment. So VEGF could have a paradoxical effect: it is associated with a poor outcome but it could be a potential target for anti-angiogenic therapy.
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Affiliation(s)
- Barbara Rossi
- Department of Orthopaedics and Traumatology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
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26
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Zhou Q, Deng Z, Zhu Y, Long H, Zhang S, Zhao J. mTOR/p70S6K signal transduction pathway contributes to osteosarcoma progression and patients' prognosis. Med Oncol 2009; 27:1239-45. [PMID: 19936974 DOI: 10.1007/s12032-009-9365-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 11/09/2009] [Indexed: 12/21/2022]
Abstract
The mTOR/p70S6K signal transduction pathway plays a key role in the regulation of cancer cells' survival and proliferation. However, its roles in osteosarcoma, which is one of the most rapidly growing sarcomas, remain unknown. This study investigated for the first time the correlation between the mTOR/p70S6K signal transduction pathway in human osteosarcoma and patients' prognosis. The expression patterns of mTOR and p70S6K in paraffin-embedded specimens gathered from 65 patients with primary osteosarcoma were detected by the method of immunohistochemistry using antibodies against mTOR and p70S6K. Kaplan-Meier survival and Cox regression analyses were performed to evaluate the prognosis of patients. Immunostaining revealed that the mTOR/p70S6K signal transduction pathway is activated in human osteosarcoma. Additionally, positive expression of mTOR and p70S6K proteins was significantly correlated with surgical stage, metastasis pattern and percentage of dead cells of osteosarcoma. Moreover, in univariate analysis, surgical stage, metastasis pattern and percentage of dead cells, mTOR and p70S6K expression showed significant influence on overall survival (OS) and disease-free survival (DFS). In multivariate analysis, surgical stage (IIA vs. IIB/III), metastasis pattern (without vs. with), percentage of dead cells (≥90 vs. <90%), mTOR expression pattern (negative vs. positive) and p70S6K expression pattern (negative vs. positive) were significant for DFS and OS. Our results demonstrate the correlation of mTOR and p70S6K expression patterns with the oncological progression of osteosarcoma patients, suggesting the prognostic significance of the mTOR/p70S6K signal transduction pathway in osteosarcoma patients, which may lay a foundation for making further investigations on the mTOR/p70S6K signal transduction pathway as a potential target for osteosarcoma therapy.
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Affiliation(s)
- Quan Zhou
- Department of Orthopaedics, Huai'an Hospital, Xuzhou Medical College, Huai'an, People's Republic of China
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27
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Longhi A, Errani C, Gonzales-Arabio D, Ferrari C, Mercuri M. Osteosarcoma in Patients Older Than 65 Years. J Clin Oncol 2008; 26:5368-73. [DOI: 10.1200/jco.2007.14.9104] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose We reviewed the outcome of osteosarcoma patients older than 65 years, an age group usually excluded from protocols, to determine the different clinical features and prognostic factors in this age group compared with younger patients. Patients and Methods Patients treated at our institute who had high-grade osteosarcoma and were older than 65 years were observed. Results Forty-three patients were eligible to be enrolled onto this study; of these, 22 were male and 21 were female. The median age of this group was 69 years (range, 65 to 80 years). Of the 43 patients, 29 patients had localized disease, and 14 patients had metastatic disease. Localizations were appendicular in 33 patients, and axial in 10 patients. Twenty-nine patients had a primary osteosarcoma, 13 patients (30%) had a sarcoma in Paget's disease, and one patient had postradiotherapy (RT) osteosarcoma. The median interval from onset of symptoms to diagnosis was 4 months (range, 0 to 73 months).Thirty-two of 43 patients received surgery for a primary tumor. Of these, 18 patients had limb salvage, 13 patients had an amputation, and one patient had palliative surgery; the remaining 11 patients received palliative RT. Fourteen patients received chemotherapy; two deaths related to chemotherapy were observed. Median overall survival (OS) for all 43 patients was 19 months (range, 3 to 229 months); 5-year OS was 22% (SE = 3%) for the whole group, and 45% OS for those patients with localized primary osteosarcoma. Multivariate analysis demonstrated that stage, volume, and surgery were significant prognostic factors. Insignificant prognostic factors were sex, type of surgery, chemotherapy, and Paget's disease. Conclusion Patients older than 65 years with osteosarcoma have a worse prognosis compared with younger patients. This older age group is characterized by a longer time lapse from the onset of symptoms to diagnosis, more metastatic cases at diagnosis, less use of limb salvage, fewer patients receiving chemotherapy, and more patients excluded from clinical trials than a younger age group.
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Affiliation(s)
- Alessandra Longhi
- From the Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Costantino Errani
- From the Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Daniel Gonzales-Arabio
- From the Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristina Ferrari
- From the Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Mario Mercuri
- From the Department of Musculoskeletal Oncology, Istituto Ortopedico Rizzoli, Bologna, Italy
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28
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Honorati MC, Cattini L, Facchini A. Possible prognostic role of IL-17R in osteosarcoma. J Cancer Res Clin Oncol 2007; 133:1017-21. [PMID: 17690908 DOI: 10.1007/s00432-007-0296-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Accepted: 07/25/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE An intense vascularization of primary tumor mass is associated with a fatal outcome in various types of invasive solid tumors. Interleukin 17 (IL-17), a CD4+ T-cell-derived cytokine, stimulates some tumor cells to secrete angiogenic factors, among which venous endothelial growth factor (VEGF). We assessed whether the expression of IL-17 receptor (IL-17R) represents a marker for the metastasizing ability of osteosarcoma (OS), a very malignant bone tumor. METHODS We immunoassayed the amount of VEGF secreted by three OS cell lines expressing IL-17R in differing amounts: HOS, MG63 and U-2 OS, and their sensitivity to IL-17 stimulation to secrete VEGF. RESULTS U-2 OS, which best expresses IL-17R, secreted the highest amounts of VEGF and was the most sensitive to IL-17, whereas MG63 expressed the lowest level of IL-17R, secreted the lowest amount of VEGF and was not sensitive to IL-17. IL-17R expression correlated with VEGF secretion and IL-17 sensitivity. U-2 OS expressed the most dedifferentiated phenotype, which is associated with tumor malignancy. CONCLUSIONS These results suggest that IL-17R in OS might represent a marker of tumor metastasis potential.
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Affiliation(s)
- Maria Cristina Honorati
- Dipartimento di Medicina Interna e Gastroenterologia, Università di Bologna, Via Massarenti 9, 40136 Bologna, Italy.
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