Osteosarcoma of the pelvis: experience of the Cooperative Osteosarcoma Study Group

Cross-Cultural Adaptation and Validation of the Romanian Musculoskeletal Tumor Society Scoring System for Patients with Extremity Bone Sarcomas

Background and Objectives: Primary malignant bone tumors are rare lesions, and their complex treatment can lead to functional impairment. It is important to have a postoperative assessment tool for patients' functional outcomes to be evaluated and to consequently adapt future treatments in the pursuit of a continuous improvement of their quality of life. The Musculoskeletal Tumor Society Score (MSTS) is a validated specific system score that is used frequently in the follow-up of these patients. We found no information about a valid translated Romanian version of this score neither for the upper limb nor for the lower limb. We proposed in this study to translate the original version of the MSTS Score into Romanian and to perform validation analysis of the Romanian-language MSTS Score. Materials and Methods: We selected 48 patients who underwent limb-salvage surgery after resection of bone sarcomas. Patients were interrogated twice according to the translated Romanian version of the MSTS Score during their follow-up. The translation was performed according to the recommended guidelines. A total number of 96 questionnaires were valid for statistical analysis. Results: Internal consistency and reliability were good for both sets of questionnaires' analytic measurements, with Cronbach's alpha values of 0.848 (test) and 0.802 (retest). The test-retest evaluation proved to be statistically strong for reproducibility and validity with Spearman's rho = 0.9 (p < 0.01, 95% CI). Conclusions: This study permitted the translation of this score and the validation of psychometric data. Our results showed that the Romanian version of the MSTS is a reliable means of assessment of the functional outcome of patients who received limb-salvage surgery for the upper and lower extremities.

Sacral-Nerve-Sparing Planning Strategy in Pelvic Sarcomas/Chordomas Treated with Carbon-Ion Radiotherapy

To minimize radiation-induced lumbosacral neuropathy (RILSN), we employed sacral-nerve-sparing optimized carbon-ion therapy strategy (SNSo-CIRT) in treating 35 patients with pelvic sarcomas/chordomas. Plans were optimized using Local Effect Model-I (LEM-I), prescribed DRBE|LEM-I|D50% (median dose to HD-PTV) = 73.6 (70.4-76.8) Gy (RBE)/16 fractions. Sacral nerves were contoured between L5-S3 levels. DRBE|LEM-I to 5% of sacral nerves-to-spare (outside HD-CTV) (DRBE|LEM-I|D5%) were restricted to <69 Gy (RBE). The median follow-up was 25 months (range of 2-53). Three patients (9%) developed late RILSN (≥G3) after an average period of 8 months post-CIRT. The RILSN-free survival at 2 years was 91% (CI, 81-100). With SNSo-CIRT, DRBE|LEM-I|D5% for sacral nerves-to-spare = 66.9 ± 1.9 Gy (RBE), maintaining DRBE|LEM-I to 98% of HD-CTV (DRBE|LEM-I|D98%) = 70 ± 3.6 Gy (RBE). Two-year OS and LC were 100% and 93% (CI, 84-100), respectively. LETd and DRBE with modified-microdosimetric kinetic model (mMKM) were recomputed retrospectively. DRBE|LEM-I and DRBE|mMKM were similar, but DRBE-filtered-LETd was higher in sacral nerves-to-spare in patients with RILSN than those without. At DRBE|LEM-I cutoff = 64 Gy (RBE), 2-year RILSN-free survival was 100% in patients with <12% of sacral nerves-to-spare voxels receiving LETd > 55 keV/µm than 75% (CI, 54-100) in those with ≥12% of voxels (p < 0.05). DRBE-filtered-LETd holds promise for the SNSo-CIRT strategy but requires longer follow-up for validation.

Graphene Oxide (GO) for the Treatment of Bone Cancer: A Systematic Review and Bibliometric Analysis

Cancer is a severe disease that, in 2022, caused more than 9.89 million deaths worldwide. One worrisome type of cancer is bone cancer, such as osteosarcoma and Ewing tumors, which occur more frequently in infants. This study shows an active interest in the use of graphene oxide and its derivatives in therapy against bone cancer. We present a systematic review analyzing the current state of the art related to the use of GO in treating osteosarcoma, through evaluating the existing literature. In this sense, studies focused on GO-based nanomaterials for potential applications against osteosarcoma were reviewed, which has revealed that there is an excellent trend toward the use of GO-based nanomaterials, based on their thermal and anti-cancer activities, for the treatment of osteosarcoma through various therapeutic approaches. However, more research is needed to develop highly efficient localized therapies. It is suggested, therefore, that photodynamic therapy, photothermal therapy, and the use of nanocarriers should be considered as non-invasive, more specific, and efficient alternatives in the treatment of osteosarcoma. These options present promising approaches to enhance the effectiveness of therapy while also seeking to reduce side effects and minimize the damage to surrounding healthy tissues. The bibliometric analysis of photothermal and photochemical treatments of graphene oxide and reduced graphene oxide from January 2004 to December 2022 extracted 948 documents with its search strategy, mainly related to research papers, review papers, and conference papers, demonstrating a high-impact field supported by the need for more selective and efficient bone cancer therapies. The central countries leading the research are the United States, Iran, Italy, Germany, China, South Korea, and Australia, with strong collaborations worldwide. At the same time, the most-cited papers were published in journals with impact factors of more than 6.0 (2021), with more than 290 citations. Additionally, the journals that published the most on the topic are high impact factor journals, according to the analysis performed, demonstrating the high impact of the research field.

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.

Tumors and infections of the growing spine

The growing spine differs from the adult spine in several ways. Although tumors and infections cause only a small percentage of pediatric back pain incidences, delayed proper diagnosis and treatment may be disastrous. Benign lesions, such as osteoid osteoma, osteoblastoma, and aneurysmal bone cyst in the spine, are predominant during the first two decades of life, whereas malignant bony spinal tumors are rare. In the pediatric population, malignant spine tumors include osteosarcoma, Ewing's sarcoma, lymphoma, and metastatic neuroblastoma. Infections of the growing spine are rare, with the incidence of discitis peaking in patients under the age of 5 years and that of vertebral osteomyelitis peaking in older children. Spondylodiscitis is often a benign, self-limiting condition with low potential for bone destruction. Conservative treatments, including bedrest, immobilization, and antibiotics, are usually sufficient. Spinal tuberculosis is a frequently observed form of skeletal tuberculosis, especially in developing countries. Indications for surgical treatment include neurologic deficit, spinal instability, progressive kyphosis, late-onset paraplegia, and advanced disease unresponsive to nonoperative treatment. Spinal tumors and infections should be considered potential diagnoses in cases with spinal pain unrelated to the child's activity, accompanied by fever, malaise, and weight loss. In spinal tumors, early diagnosis, fast and adequate multidisciplinary management, appropriate en bloc resection, and reconstruction improve local control, survival, and quality of life. Pyogenic, hematogenous spondylodiscitis is the most common spinal infection; however, tuberculosis-induced spondylodiscitis should also be considered. Level of evidence: level 4.

Advances in Virtual Cutting Guide and Stereotactic Navigation for Complex Tumor Resections of the Sacrum and Pelvis: Case Series with Short-Term Follow-Up

Primary malignancies of the sacrum and pelvis are aggressive in nature, and achieving negative margins is essential for preventing recurrence and improving survival after en bloc resections. However, these are particularly challenging interventions due to the complex anatomy and proximity to vital structures. Using virtual cutting guides to perform navigated osteotomies may be a reliable method for safely obtaining negative margins in complex tumor resections of the sacrum and pelvis. This study details the technique and presents short-term outcomes. Patients who underwent an en bloc tumor resection of the sacrum and/or pelvis using virtual cutting guides with a minimum follow-up of two years were retrospectively analyzed and included in this study. Preoperative computer-assisted design (CAD) was used to design osteotomies in each case. Segmentation, delineating the tumor from normal tissue, was performed by the senior author using preoperative CT scans and MRI. Working with a team of biomedical engineers, virtual surgical planning was performed to create osteotomy lines on the preoperative CT and overlaid onto the intraoperative CT. The pre-planned osteotomy lines were visualized as "virtual cutting guides" providing real-time stereotactic navigation. A precision ultrasound-powered cutting tool was then integrated into the navigation system and used to perform the osteotomies in each case. Six patients (mean age 52.2 ± 17.7 years, 2 males, 4 females) were included in this study. Negative margins were achieved in all patients with no intraoperative complications. Mean follow-up was 38.0 ± 6.5 months (range, 24.8-42.2). Mean operative time was 1229 min (range, 522-2063). Mean length of stay (LOS) was 18.7 ± 14.5 days. There were no cases of 30-day readmissions, 30-day reoperations, or 2-year mortality. One patient was complicated by flap necrosis, which was successfully treated with irrigation and debridement and primary closure. One patient had local tumor recurrence at final follow-up and two patients are currently undergoing treatment for metastatic disease. Using virtual cutting guides to perform navigated osteotomies is a safe technique that can facilitate complex tumor resections of the sacrum and pelvis.

Planning Strategy to Optimize the Dose-Averaged LET Distribution in Large Pelvic Sarcomas/Chordomas Treated with Carbon-Ion Radiotherapy

To improve outcomes in large sarcomas/chordomas treated with CIRT, there has been recent interest in LET optimization. We evaluated 22 pelvic sarcoma/chordoma patients treated with CIRT [large: HD-CTV ≥ 250 cm3 (n = 9), small: HD-CTV < 250 cm3 (n = 13)], DRBE|LEM-I = 73.6 (70.4-73.6) Gy (RBE)/16 fractions, using the local effect model-I (LEM-I) optimization and modified-microdosimetric kinetic model (mMKM) recomputation. We observed that to improve high-LETd distribution in large tumors, at least 27 cm3 (low-LETd region) of HD-CTV should receive LETd of ≥33 keV/µm (p < 0.05). Hence, LETd optimization using 'distal patching' was explored in a treatment planning setting (not implemented clinically yet). Distal-patching structures were created to stop beams 1-2 cm beyond the HD-PTV-midplane. These plans were reoptimized and DRBE|LEM-I, DRBE|mMKM, and LETd were recomputed. Distal patching increased (a) LETd50% in HD-CTV (from 38 ± 3.4 keV/µm to 47 ± 8.1 keV/µm), (b) LETdmin in low-LETd regions of the HD-CTV (from 32 ± 2.3 keV/µm to 36.2 ± 3.6 keV/µm), (c) the GTV fraction receiving LETd of ≥50 keV/µm, (from <10% to >50%) and (d) the high-LETd component in the central region of the GTV, without significant compromise in DRBE distribution. However, distal patching is sensitive to setup/range uncertainties, and efforts to ascertain robustness are underway, before routine clinical implementation.

A semiautomatic segmentation method framework for pelvic bone tumors based on CT-MR multimodal images

The pelvic structure is complex and the tumor is poorly defined from the surrounding tissues. Finding the exact tumor resection margin based on the surgeon's clinical experience alone is a time-consuming and difficult task, which is a major factor leading to surgical failure. An accurate method for segmenting pelvic bone tumors is needed. In this paper, a semiautomatic segmentation method for pelvic bone tumors based on CT-MR multimodal images is presented. The method combines multiple medical prior knowledge and image segmentation algorithms. Finally, the segmentation results are visualized in three dimensions. We tested the proposed method on a collection of 10 cases (97 tumor MR images in total). The segmentation results were compared with the manual annotation of the physicians. On average, our method has an accuracy of 0.9358, a recall of 0.9278, an IOU value of 0.8697, a Dice value of 0.9280, and an AUC value of 0.9632. The average error of the 3D model was within the allowable range of the surgery. The proposed algorithm can accurately segment bone tumors in pelvic MR images regardless of tumor location, size, and other factors. It provides the possibility to assist pelvic bone tumor preservation surgery.

Pelvic bone sarcomas, prognostic factors, and treatment: A narrative review of the literature

Primary sarcomas of bone are rare malignant mesenchymal tumors. The most common bone sarcomas are osteosarcoma, Ewing's sarcoma, and chondrosarcoma. The prognosis has improved over the years, but bone sarcomas are still life-threatening tumors that need a multidisciplinary approach for diagnosis and treatment. Bone sarcomas arising in the pelvis present a unique challenge to orthopedic oncologists due to the absence of natural anatomical barriers, the close proximity of vital neurovascular structures, and the high mechanical demands placed on any pelvic reconstruction following the excision of the tumor. While radiotherapy has an important role especially in Ewing's sarcoma and chemotherapy for both Ewing's sarcoma and osteosarcoma, surgery remains the main choice of treatment for all three entities. While external hemipelvectomy has remained one option, the main aim of surgery is limb salvage. After complete tumor resection, the bone defect needs to be reconstructed. Possibilities to reconstruct the defect include prosthetic or biological reconstruction. The method of reconstruction is dependent on the location of tumor and the surgery required for its removal. The aim of this article is to give an insight into pelvic bone sarcomas, their oncological and surgical outcomes, and the options for treatment based on the authors' experiences.

The Role of 3D Printing in Treatment Planning of Spine and Sacral Tumors

Three-dimensional (3D) printing technology has proven to have many advantages in spine and sacrum surgery. 3D printing allows the manufacturing of life-size patient-specific anatomic and pathologic models to improve preoperative understanding of patient anatomy and pathology. Additionally, virtual surgical planning using medical computer-aided design software has enabled surgeons to create patient-specific surgical plans and simulate procedures in a virtual environment. This has resulted in reduced operative times, decreased complications, and improved patient outcomes. Combined with new surgical techniques, 3D-printed custom medical devices and instruments using titanium and biocompatible resins and polyamides have allowed innovative reconstructions.

Development and Validation of a Prognostic Model for Overall Survival in Patients with Primary Pelvis and Spine Osteosarcoma: A Population-Based Study and External Validation

Background: Primary pelvis and spine osteosarcoma (PSOS) is a specific type of osteosarcoma that is difficult to treat and has a poor prognosis. In recent years, the research on osteosarcoma has been increasing, but there have been few studies on PSOS; in particular, there have been a lack of analyses with a large sample size. This study aimed to construct and validate a model to predict the overall survival (OS) of PSOS patients, as currently there are no tools available for assessing their prognosis. Methods: Data including demographic information, clinical characteristics, and follow-up information on patients with PSOS were collected from the Surveillance, Epidemiology, and End Results (SEER) database, as well as from the Spine Tumor Center of Changzheng Hospital. Variable selection was achieved through a backward procedure based on the Akaike Information Criterion (AIC). Prognostic factors were identified by univariate and multivariate Cox analysis. A nomogram was further constructed for the estimation of 1-, 3-, and 5-year OS. Calibration plots, the concordance index (C-index), and the receiver operating characteristic (ROC) were used to evaluate the prediction model. Results: In total, 83 PSOS patients and 90 PSOS patients were separately collected from the SEER database and Changzheng Hospital. In the SEER cohort, liver metastasis, lung metastasis, and chemotherapy were recognized as independent prognostic factors for OS (p < 0.05) and were incorporated to construct the initial nomogram. However, the initial nomogram showed poor predictive accuracy in internal and external validation. Then, we shifted our focus to the Changzheng data. Lung metastasis involving segments, Eastern Cooperative Oncology Group (ECOG) performance score, alkaline phosphatase (ALP) level, and en bloc resection were ultimately identified as independent prognostic factors for OS (p < 0.05) and were further incorporated to construct the current nomogram, of which the bias-corrected C-index was 0.834 (0.824–0.856). The areas under the ROC curves (AUCs) of the current nomogram regarding 1-, 3-, and 5-year OS probabilities were 0.93, 0.96, and 0.92, respectively. Conclusion: We have developed a predictive model with satisfactory performance and clinical practicability, enabling effective prediction of the OS of PSOS patients and aiding clinicians in decision-making.

Primary osteosarcoma of the ribs: A report from the Cooperative Osteosarcoma Study Group

PURPOSE

Primary rib osteosarcoma has not been investigated extensively, and clinical characteristics and optimal therapeutic strategies have not been defined. The authors used the database of the Cooperative Osteosarcoma Study Group (COSS) to analyze this tumor-site in depth.

METHODS

The COSS database was searched for treatment-naive, high-grade osteosarcomas of the rib. Affected patients were analyzed for demographic and tumor-related factors, treatments, and outcomes.

RESULTS

A total of 44 patients (23 males, 21 females; median age, 23 years [range, 6-59]) were identified. Primary metastases were detected in six of 44 (14%) patients. Surgery was performed in 40 of 44 (91%) patients and rendered 35 of 44 (80%) patients macroscopically disease-free. Chemotherapy was known to have been administered in 43 of 44 (98%) patients and radiotherapy in seven of 42 (17%) (no data for two patients). A good response to chemotherapy was only noted in five (33%) of those 15 evaluable patients who had received any preoperative chemotherapy. After a median follow-up of 2.49 (0.22-40.35) years for all patients and 6.61 (0.25-40.35) years for 26 survivors (21 of these in first complete remission), 5-year actuarial overall and event-free survival were 53.0% (8.5%) and 42.2% (8.1%), respectively. Incomplete tumor surgery was the most notable negative prognostic factor. Osteoblastic histology and a poor response to chemotherapy may have contributed.

CONCLUSION

This large series provides evidence that patients with costal primaries are older than the average osteosarcoma patient, but appear to share the similar tumor biology and-if treated according to standard protocols-prognostic factors with tumors of other sites. Early, preoperative diagnosis and permanent, definitive local control remain major challenges and should contribute to improved outcomes.

Pragmatic, Prospective Comparative Effectiveness Trial of Carbon Ion Therapy, Surgery, and Proton Therapy for the Management of Pelvic Sarcomas (Soft Tissue/Bone) Involving the Bone: The PROSPER Study Rationale and Design

Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.

Establishment, Maintenance, and Performance of the Cooperative Osteosarcoma Study Group (COSS)

INTRODUCTION

Osteosarcoma treatment has benefitted greatly from collaborative research. This paper describes the history and accomplishments of the Cooperative Osteosarcoma Study Group (COSS), mainly dedicated to clinical questions, as well as remaining challenges.

MATERIALS AND METHODS

Narrative review of over four decades of uninterrupted collaboration within the multi-national German-Austrian-Swiss COSS group.

RESULTS

Since its very first prospective osteosarcoma trial starting in 1977, COSS has continuously been able to provide high-level evidence on various tumor- and treatment-related questions. This includes both the cohort of patients enrolled into prospective trials as well as those patients excluded from them for various reasons, followed in a prospective registry. Well over one hundred disease-related publications attest to the group's impact on the field. Despite these accomplishments, challenging problems remain.

DISCUSSION

Collaborative research within a multi-national study group resulted in better definitions of important aspects of the most common bone tumor, osteosarcoma, and its treatments. Important challenges continue to persist.

Development of nomogram and discussion of radiotherapy effect for osteosarcoma survival

This study aimed to develop a predictive system for prognostic evaluation of osteosarcoma patients. We obtained osteosarcoma sample data from 1998 to 2016 using SEER*Stat software version 8.3.8, and established a multivariable Cox regression model using R-4.0.3 software. Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The diagnosis of the model was completed through influential cases, proportionality, and multicollinearity. The predictive ability of the model was tested using area under the curve (AUC), calibration curves, and Brier scores. Finally, the bootstrap method was used to internally verify the model. In total, data from 3566 patients with osteosarcoma were included in this study. The multivariate Cox regression model was used to determine the independent prognostic variables. A nomogram and Kaplan-Meier survival curve were established. The AUC and Brier scores indicated that the model had a good predictive calibration. In addition, we found that the radiotherapy appears to be a risk factor of patients with osteosarcoma and made a discussion. We developed a prognostic evaluation system for patients with osteosarcoma for 1-, 3-, and 5-year overall survival with good predictive ability using sample data extracted from the SEER database. This has important clinical significance for the early identification and treatment of high-risk groups of osteosarcoma patients.

Osteosarcoma and Its Advancement

Cancer with its high mortality rate is really hard to treat even in this era. Extensive research work is still required to overcome the threat caused by the disease. Currently, the treatment modality is based on the combination therapy, and diagnostics is dependent upon biopsy results. Once the stage of cancer is clear, the treatment is prescribed. To bring a successful treatment approach of patients with osteosarcoma, it requires multidisciplinary team approach including pediatric, medical and surgical oncologist, surgeons, pathologists, pain management, orthopedic oncologist, endocrinologist, and radiologists. Therefore, cancer treatment is to be performed in specialized hospitals able to provide access to all approaches with multidisciplinary team care.

The safety and efficiency of photodynamic therapy for the treatment of osteosarcoma: A systematic review of in vitro experiment and animal model reports

BACKGROUND

Osteosarcoma (OS) is an aggressive malignant bone tumour with high mortality. A poor prognosis is noted in patients with distal metastases or multidrug resistance. As an emerging antitumor strategy, photodynamic therapy (PDT) mediated by visible and near infrared light has attracted intensive attention given its target selectivity, remote controllability, minimal or non-invasive features. However, PDT also has obvious limitations. Specifically, due to the limited penetration of light, it is mainly used in the clinical treatment of superficial malignant tumours, such as musculoskeletal sarcomas and melanoma, but it has not been applied to the clinical treatment of deep malignant bone tumours except for a very small number of experiments on deep canine OS models.

MATERIALS AND METHODS

We searched for studies that focused on the effectiveness and safety of PDT for OS based on in vitro experiments and animal models in the last decade. A systematic search was conducted using electronic databases, including PubMed, ClinicalTrials.gov, and the Cochrane Library.

INCLUSION CRITERIA

(1) original research articles about PDT for OS; (2) articles in English; (3) in vitro or animal model research; and (4) detailed information, including cell name, fluence, irradiation wavelength, time of incubation with PS, duration between PS treatment and irradiation, and duration between irradiation and viability assays.

EXCLUSION CRITERIA

(1) study was a review/systemic review article, patent, letter, or conference abstract/paper; (2) articles were not published in English; (3) studies containing overlapping or insufficient data.

RESULTS

We identified 201 publications, and 44 articles met the inclusion criteria and were included in the synthesis. Unfortunately, there are no relevant clinical reports of the use of PDT in the treatment of human OS. In these studies, 8 studies only employed in vivo experiments to evaluate the efficiency of PDT in an OS animal model, 19 studies exclusively performed in vitro viability assays of cells treated with PDT under different conditions, and 17 studies included in vitro cell experiments and in vivo animal OS models to evaluate the effect of PDT on OS in vivo and in vitro. All studies have shown that PDT is cytotoxic to OS cells or can inhibit the growth of OS in heterologous or homologous animal OS models but exhibits minimal cytotoxicity at a certain range of dosages.

CONCLUSION

Based on this systematic review, PDT can eradicate OS cells in cell culture and there is some evidence for efficacy in animal models. However, the ability for PDT to control human OS is unclear, the animal and human reports do not show evidence of human OS control, they just do show feasibility. The major issues concerning the potential for treatment of osteosarcoma with PDT are that adequate light should be transmitted to tumor loci and if the disease is caught before metastasis and irradiation of tumor sites is feasible, curative potential is there. Otherwise, PDT may be mainly palliative. To determine whether PDT can safely and efficiently be used in the clinical treatment of OS, many preclinical orthotopic animal OS models and OS models of multiple systemic metastases must be performed and interstitial PDT or intraoperative PDT may be a good and potential candidate for human OS treatment. If these problems can be well solved, PDT may be a potentially effective strategy for the treatment of OS patients.

Controversies and Challenges in the Management of Osteosarcoma-an Indian Perspective

Osteosarcoma (OGS) is the most common primary bone tumor in children and adolescents which requires a multidisciplinary approach to management. Although chemotherapy and surgery can cure more than half of localized OGS cases, the unique challenges faced by resource-limited countries like India make this outcome difficult to achieve. Various questions in the management of OGS including role of high-dose methotrexate (HDMTX) in neoadjuvant setting, triplet vs doublet chemotherapy, intensification of chemotherapy based on response in setting of doublet, and indigenous prosthesis in setting of limb salvage need to be defined. Similarly, in the metastatic and recurrent setting, questions regarding intent of treatment, indications of chemotherapy, timing of surgery, and role of targeted therapies need clarification. Lack of randomized trials from India makes definite conclusions difficult, but an attempt can be made to define the best approach in the Indian scenario from available evidence. Hence, a critical review of literature from India and the West was done to define possible management approaches and highlight the lacuna for future research.

Internal Hemipelvectomy for primary bone sarcomas using intraoperative patient specific instruments- the next step in limb salvage concept

BACKGROUND

During pelvic Sarcoma resections, Surgeons often struggle to obtain negative margins while minimizing collateral damage and maintaining limb function. These complications are usually due to the complex anatomy of the pelvis. Here we present an accurate 3D surgical approach, including pre-operative printing of models and intraoperative patient-specific instruments (PSIs) for optimizing pelvic sarcoma resections.

METHODS

This single-center retrospective study (N = 11) presents surgical, functional, and oncological outcomes of patients (average age 14.6 +/- 7.6 years, 4 males) who underwent pelvic sarcoma resections using a 3D surgical approach between 2016 and 2021. All patients were followed up for at least 24 months (mean = 38.9 +/- 30.1 months).

RESULTS

Our results show promising surgical, oncological, and functional outcomes. Using a 3D approach, 90.9% had negative margins, and 63.6% did not require reconstruction surgery. The average estimated blood loss was 895.45 ± 540.12 cc, and the average surgery time was 3:38 ± 0.05 hours. Our results revealed no long-term complications. Three patients suffered from short-term complications of superficial wound infections. At 24 month follow up 72.7% of patients displayed no evidence of disease. The average Musculoskeletal Tumor Society (MSTS) score at 12 months was 22.81.

CONCLUSION

3D technology enables improved accuracy in tumor resections, allowing for less invasive procedures and tailored reconstruction surgeries, potentially leading to better outcomes in function and morbidity. We believe that this approach will enhance treatments and ease prognosis for patients diagnosed with pelvic sarcoma and will become the standard of care in the future.

Efficacy and safety of carbon ion radiotherapy for bone sarcomas: a systematic review and meta-analysis

Objective

This study aimed to systematically evaluate and conduct a meta-analysis of the efficacy and safety of carbon ion radiotherapy for bone sarcomas.

Methods

We searched for articles using the PubMed, Embase, Cochrane Library, and the Web of Science databases from their inception to January 12, 2022. Two researchers independently screened the literature and extracted data based on the inclusion and exclusion criteria. Statistical analyses were performed using STATA version 14.0.

Results

We searched for 4378 candidate articles, of which 12 studies were included in our study according to the inclusion and exclusion criteria. Of the 897 BSs patients who received carbon ion radiotherapy in the studies, 526 patients had chordoma, 255 patients had chondrosarcoma, 112 patients had osteosarcoma, and 4 patients had other sarcomas. The local control rate at 1, 2, 3, 4, 5, and 10 years in these studies were 98.5% (95% confidence interval [CI] = 0.961–1.009, I² = 0%), 85.8% (95% CI = 0.687–1.030, I² = 91%), 86% (95% CI = 0.763–0.957, I² = 85.3%), 91.1% (95% CI = 0.849–0.974), 74.3% (95% CI = 0.666–0.820, I² = 85.2%), and 64.7% (95% CI = 0.451–0.843, I² = 95.3%), respectively. The overall survival rate at 1, 2, 3, 4, 5, and 10 years in these studies were 99.9% (95% CI = 0.995–1.004, I² = 0%), 89.6% (95% CI = 0.811–0.980, I² = 96.6%), 85% (95% CI = 0.750–0.950, I² = 89.4%), 92.4% (95% CI = 0.866–0.982), 72.7% (95% CI = 0.609–0.844, I² = 95.3%), and 72.1% (95% CI = 0.661–0.781, I² = 46.5%), respectively. Across all studies, the incidence of acute and late toxicities was mainly grade 1 to grade 2, and grade 1 to grade 3, respectively.

Conclusion

As an advanced radiotherapy, carbon ion radiotherapy is promising for patients with bone sarcomas that are unresectable or residual after incomplete surgery. The data indicated that carbon ion radiotherapy was safe and effective for bone sarcomas, showing promising results for local control, overall survival, and lower acute and late toxicity.

PROSPERO registration number

CRD42021258480.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-022-02089-0.

Fifty years of bone tumors

There have been enormous advances in the treatment of bone tumors over the past half-century. The most notable of these has been the transition from amputation as the standard of care to limb salvage surgery. This transition is the result of advances in imaging techniques, accurate diagnosis, systemic therapies (including chemotherapy), and prosthetic design for the reconstruction of musculoskeletal defects. Advances have also been made in the management of benign and metastatic bone tumors.

Management of pelvic sarcoma

Pelvic sarcomas are a rare and heterogenous group of tumors divided into two groups: soft tissue sarcomas and bone sarcomas. Soft tissue sarcomas of the pelvis include most commonly liposarcoma, leiomyosarcoma, gastrointestinal stromal tumors, malignant peripheral nerve sheath tumors, and solitary fibrous tumors. Bone sarcomas of the pelvis most commonly include osteosarcoma and chondrosarcoma. Multidisciplinary treatment at a center experienced in the treatment of sarcoma is essential. Management is dictated by histologic type and grade. Surgical resection with wide margins is the cornerstone of treatment for pelvic sarcomas, although this is often challenging due to anatomic constraints of the pelvis. Multimodal treatment is critical due to the high risk of local recurrence in the pelvis.

Research hotspots and trends of chordoma: A bibliometric analysis

Background

Chordoma is a type of mesenchymal malignancy with a high recurrence rate and poor prognosis. Due to its rarity, the tumorigenic mechanism and optimal therapeutic strategy are not well known.

Methods

All relevant articles of chordoma research from 1 January 2000 to 26 April 2022 were obtained from Web of Science Core Collection database. Blibliometrix was used to acquire basic publication data. Visualization and data table of collaboration network, dynamic analysis, trend topics, thematic map, and factorial analysis were acquired using Blibliometrix package. VOSviewer was used to generate a visualization map of co-citation analysis and co-occurrence.

Results

A total of 2,285 articles related to chordoma were identified. The most influential and productive country/region was the United States, and Capital Medical University has published the most articles. Among all high-impact authors, Adrienne M. Flanagan had the highest average citation rate. Neurosurgery was the important periodical for chordoma research with the highest total/average citation rate. We focused on four hotspots in recent chordoma research. The research on surgical treatment and radiotherapy was relatively mature. The molecular signaling pathway, targeted therapy and immunotherapy for chordoma are not yet mature, which will be the future trends of chordoma research.

Conclusion

This study indicates that chordoma studies are increasing. Surgery and radiotherapy are well reported and always play fundamental roles in chordoma treatment. The molecular signaling pathway, targeted therapy, and immunotherapy of chordoma are the latest research hotspots.

Timing of treatment in osteosarcoma: challenges and perspectives - a scoping review

BACKGROUND

The timing of events in the management of osteosarcoma may be critical for patient survivorship; however, the prognostic value of factors such as onset of symptoms or initiation of therapy in these patients has not been studied. This study sought to review the literature reporting treatment of osteosarcoma to determine the utility of event timing as a prognostic indicator. Due to significant heterogeneity in the literature, this study was conducted as a scoping review to assess the current state of the literature, identify strengths and weaknesses in current reporting practices, and to propose avenues for future improvement.

MAIN BODY

This review screened 312 peer-reviewed studies of osteosarcoma in any anatomic location published in an English journal for reporting of an event timing metric of any kind in a population of 6 or more. Thirty-seven studies met inclusion/exclusion criteria and were assessed for level of evidence, quality, and event timing metric. Reviewers also collated: publication year, population size, population age, tumor site, tumor type, surgical treatment, and adjuvant medical treatment. Extracted event timing data were further characterized using nine standardized categories to enable systematic analysis. The reporting of event timing in the treatment of osteosarcoma was incomplete and heterogenous. Only 37 of 312 (11.9%) screened studies reported event timing in any capacity. The period between patient-reported symptom initiation and definitive diagnosis was the most reported (17/37, 45.9%). Symptom duration was the second most reported period (10/37, 27.0%). Event timing was typically reported incidentally and was never rigorously incorporated into data analysis or discussion. No studies considered the impact of event timing on a primary outcome. The six largest studies were assessed in detail to identify pearls for future researchers. Notable shortcomings included the inadequate reporting of the definition of an event timing period and the pooling of patients into poorly defined timing groups.

CONCLUSIONS

Inconsistent reporting of event timing in osteosarcoma treatment prevents the development of clinically useful conclusions despite evidence to suggest event timing is a useful prognostic indicator. Consensus guidelines are necessary to improve uniformity and utility in the reporting of event timing.

Predictive value of the systemic immune-inflammation index for cancer-specific survival of osteosarcoma in children

Background

Osteosarcoma (OS) is the primary malignant bone tumor that most commonly affects children and adolescents. Recent years effective chemotherapy have improved the 5-year survival in osteosarcoma patients to up to 60%-70%. Still, there is a lack of novel therapeutic strategies to enhance further survival. Our study aimed to evaluate the clinical significance of pretreatment inflammatory-based parameters, including PLT, NLR, and SII, as prognostic indicators of survival in pediatric osteosarcoma patients.

Methods

A total of 86 pediatric osteosarcoma patients between 2012 and 2021 in the Department of Orthopedics or tumor Surgery of Children's Hospital affiliated to Chongqing Medical University were retrospectively analyzed. The clinicopathological variables and systematic inflammatory biomarkers, including NLR, PLR and SII, was performed by the A Receiver operating characteristic (ROC) curve and Cox proportional risk regression model. According to the results of multivariate analysis, a prognostic nomogram was generated, and the concordance index (C-index) was calculated to predict the performance of the established nomogram. The survival curve was plotted by the Kaplan-Meier method.

Results

Univariate analysis showed that TNM stage, tumor size, NLR value, PLR value, SII value, neutrophil count and platelet count were related to CSS (p < 0.05). According to multivariate analysis, only TNM stage (p = 0.006) and SII values (p = 0.015) were associated with poor prognosis.To further predict survival in pediatric osteosarcoma patients, multivariate Cox regression analysis was used to predict cancer-specific survival at 1, 3 and 5 years. And constructed a nomogram model to predict children's CSS. The C-index of the nomogram is 0.776 (95%CI, 0.776–0.910), indicating that the model has good accuracy.

Conclusion

Preoperative SII and TNM staging are independent prognostic markers for pediatric osteosarcoma patients. SII may be used in conjunction with TNM staging for individualized treatment of pediatric osteosarcoma patients in future clinical work.

Long-term survival of two patients with inoperable post-irradiation osteosarcoma treated with carbon-ion radiotherapy: a case report

BACKGROUND

Curative treatment of inoperable post-irradiation sarcoma is often challenging, especially using radiotherapy, wherein curative dose administration is difficult because the organs around the tumor have already been irradiated during the first cancer treatment. Carbon-ion radiotherapy (C-ion RT) might be useful in the treatment of post-irradiation sarcomas because it allows re-irradiation with high-dose localization properties and also demonstrates higher cytotoxic effects on radioresistant tumors compared with X-rays. This study presents the long-term survival of two patients with inoperable post-irradiation pelvic osteosarcoma treated with C-ion RT after uterine cervical cancer treatment.

CASE PRESENTATION

The durations from prior radiotherapy to the diagnosis of post-irradiation osteosarcoma were 112.8 and 172.2 months, respectively. Both patients received 70.4 Gy (relative biological effectiveness) in 16 fractions of C-ion RT, and chemotherapy was performed before and after C-ion RT. Both patients achieved a complete response 1 year after the initiation of C-ion RT. However, one patient developed single lung metastasis 12.6 months after the initiation of C-ion RT and underwent thoracoscopic lobectomy. After 63.7 and 89.0 months from the initiation of C-ion RT, respectively, the patients were alive with no evidence of local recurrence, other distant metastasis, or fatal toxicities.

CONCLUSIONS

The study findings suggest that C-ion RT is a suitable treatment option for inoperable post-irradiation osteosarcoma.

[Update on 3D printing in the surgery of musculoskeletal tumors]

The importance of 3D printing applications in the surgery of musculoskeletal tumors has increased in recent years. Even prior to the era of 3D printing, computer-assisted techniques, such as navigation, have proved their utility. Due to the variable appearance of bone tumors, there is a need for individual solutions. The 3D printing can be used for the development of anatomical demonstration models, the construction of patient-specific instruments and custom-made implants. For these three applications, different regulatory hurdles exist. Especially for the resection of pelvic tumors, 3D printing technologies seem to provide advantages due to the complicated anatomy and the proximity to relevant neurovascular structures. With the introduction of titanium printing, construction of individualized implants that fit exactly into the defect became feasible.

Pain and Analgesia in Children with Cancer after Hemipelvectomy: A Retrospective Analysis

A paucity of data exists centering on the pain experience of children following hemipelvectomy performed for primary bone and soft tissue sarcomas. In this study, we aimed to describe the incidence, severity, and evolution of perioperative pain and function in pediatric oncology patients undergoing hemipelvectomy, and, additionally, we sought to detail the analgesic regimens used for these patients perioperatively. A retrospective chart review was conducted, studying cancer patients, aged 21 years and under, who underwent hemipelvectomy at MD Anderson Cancer Center (MDACC) from 2018 to 2021. Primary outcomes included the evolution of pain throughout the perioperative course, as well as the route, type, dose, and duration of analgesic regimens. Eight patients were included in the analysis. The mean age at operation was 13 ± 2.93 years. All patients received opioids and acetaminophen. The mean pain scores were highest on post-operative day (POD)0, POD5, and POD 30. The mean opioid use was highest on POD5. A total of 75% of patients were noted to be ambulating after hemipelvectomy. The mean time to ambulation was 5.33 ± 2.94 days. The combination of acetaminophen with opioids, as well as adjunctive regional analgesia, non-steroidal anti-inflammatory drugs, gabapentin, and/or ketamine in select patients, appeared to be an effective analgesic regimen, and functional outcomes were excellent in 75% of patients.

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

Introduction:

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

Methods:

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

Results:

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

Discussion:

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

Leaving half the acetabulum in pelvic resections improves hip function. Is there a need to revisit conventional pelvic resections?

BACKGROUND

Conventional periacetabular pelvic resections are associated with poor functional outcomes. Resections through surgical corridors beyond the conventional margins may be helpful in retaining greater function without compromising the oncological margins.

METHODS

The study included a retrospective review of 82 cases of pelvic resections for pelvic tumors. Outcomes of acetabulum preservation (Group A) were compared with complete acetabular resection (Group B). Also, we compared outcomes of Type I + half resections (Group 1) with Type I + II resections (Group 2), and Type III + half resections (Group 3) with Type II + III resections (Group 4).

RESULTS

Group A (n = 44) had significantly better functional outcome than Group B (n = 38) with average MSTS93 score 22.3 versus 20.1 and average HHS 91.3 versus 82.5 (p < 0.001). Group 1 (n = 14) and Group 2 (n = 12) had similar functional outcomes (mean MSTS93 score 22.07 vs. 21.58 [p = 0.597] and mean HHS 90.37 vs. 86.51 [p = 0.205]). Group 3 (n = 11) had significantly better functional outcome than Group 4 (n = 17), with mean MSTS93 score 22.8 versus 19.7 (p < 0.001) and mean HHS 92.3 versus 80.1 (p < 0.001). Oncological outcomes were similar among the groups.

CONCLUSION

Transacetabular pelvic resections provide functional benefit over conventional resections without compromising oncological margins. There is a need to revisit and revise the pelvic resection planes.

Development and Validation of Nomograms to Assess Risk Factors and Overall Survival Prediction for Lung Metastasis in Young Patients with Osteosarcoma: A SEER-Based Study

BACKGROUND

To establish two nomograms to quantify the diagnostic factors of lung metastasis (LM) and their role in assessing prognosis in young patients with LM osteosarcoma.

METHODS

A total of 618 osteosarcoma young patients from 2010 to 2015 were included from the Surveillance, Epidemiology, and End Results (SEER) database. Another 131 patients with osteosarcoma from local hospitals were also collected as an external validation set. Patients were randomized into training sets (n = 434) and validation sets (n = 184) with a ratio of 7:3. Univariate and multivariate logistic regression analyses were used to identify the risk factor for LM and were used to construct the nomogram. Risk variables for the overall survival rate of patients with LM were evaluated by Cox regression. Another nomogram was also constructed to predict survival rates. The results were validated using bootstrap resampling and retrospective research on 131 osteosarcoma young patients from 2010 to 2019 at three local hospitals.

RESULTS

There were 114 (18.45%) patients diagnosed as LM at initial diagnosis. The multivariate logistic regression analysis suggested that T stage, N stage, and bone metastasis were independent risk factors for LM in newly diagnosed young osteosarcoma patients (P < 0.001). The ROC analysis revealed that area under the curve (AUC) values were 0.751, 0.821, and 0.735 in the training set, internal validation set, and external validation set, respectively, indicating good predictive discrimination. The multivariate Cox proportional hazard regression analysis suggested that age, surgery, chemotherapy, primary site, and bone metastasis were prognostic factors for young osteosarcoma patients with LM. The time-dependent ROC curves showed that the AUCs for predicting 1-year, 2-year, and 3-year survival rates were 0.817, 0.792, and 0.815 in the training set and 0.772, 0.807, and 0.804 in the internal validation set, respectively. As for the external validation set, the AUCs for predicting 1-year, 2-year, and 3-year survival rates were 0.787, 0.818, and 0.717.

CONCLUSIONS

The nomograms can help clinicians strengthen their personal decision-making and can improve the prognosis of osteosarcoma patients.

Osteosarcoma of the Pelvis: Clinical Presentation and Overall Survival

Introduction

Osteosarcoma is the most common sarcoma of bone. Pelvic osteosarcoma presents a significant therapeutic challenge due to potential late symptom onset, metastatic dissemination at diagnosis, and inherent difficulties of wide surgical resection secondary to the complex and critical anatomy of the pelvis. The rates of survival are well reported for osteosarcoma of the appendicular skeleton, but specific details regarding presentation and survival are less known for osteosarcoma of the pelvis.

Methods

The Surveillance, Epidemiology, and End Results (SEER) program was queried for primary osteosarcoma of the bony pelvis from 2004 to 2015. Cases with Collaborative Staging variables (available after 2004) were analyzed by grade, histologic subtype, surgical intervention, tumor size, tumor extension, and presence of metastasis at diagnosis. The 2-, 5-, and 10-year survival rates were assessed with respect to these variables. The SEER database was then queried for age, tumor size, surgical intervention, metastasis at time of presentation, and survivorship data for patients with primary osteosarcoma of the upper extremity, lower extremity, vertebrae, thorax, and face/skull, and rates for all anatomic locations were then compared to patients with primary pelvic osteosarcoma.

Results

A total of 292 cases of pelvic osteosarcoma were identified from 2004 to 2015 within the database, representing 9.8% of cases among all surveyed primary sites. The most common histologic subtype was osteoblastic osteosarcoma (69.9%), followed by chondroblastic osteosarcoma (22.3%). The majority of cases were high-grade tumors (94.3%), of size >8 cm (72.0%), and with extension beyond the originating bone (74.0%). For the entire pelvic osteosarcoma group, the 2-, 5-, 10-year survival rates were 45.6%, 26.5%, and 21.4%, respectively, which were the poorest among surveyed anatomic sites. The 5-year overall survival was an abysmal 5.3% for patients with metastatic disease at diagnosis, and 37.0% for non-metastatic pelvic osteosarcoma treated with surgery and chemotherapy. When compared to other locations, pelvic osteosarcoma had higher rates of metastatic disease at presentation (33.5%), larger median tumor size (11.0 cm), and older median age at diagnosis (47.5 years). While over 85% of patients with tumors at the extremities received surgery, only 47.4% of pelvic osteosarcomas in this cohort received surgical resection—likely influenced by larger tumor size, sacral involvement, frequency of metastasis, older age, or delayed referral to a sarcoma center.

Conclusion

This study clarifies presenting features and clinical outcomes of pelvic osteosarcomas, which often present with large, high-grade tumors with extracompartmental extension, high likelihood of metastatic disease at diagnosis, and a potential limited ability to be addressed surgically. The survival rates of primary osteosarcoma of the pelvis are poor and are lower than osteosarcomas from other anatomic locations. While acknowledging the influence of metastasis, tumor characteristics, and advanced age on the decision to undergo surgical excision of a pelvic osteosarcoma, the rates of surgical resection are low and highlight the importance of understanding appropriate conditions for oncologic resection of pelvic sarcomas.

Outcomes of osteosarcoma, chondrosarcoma and chordoma treated with image guided-intensity modulated radiation therapy

BACKGROUND & PURPOSE

To evaluate the efficacy and toxicity of dose-escalated image guided-intensity modulated radiation therapy (IG-IMRT) in osteosarcoma (OGS), chondrosarcoma (CS) and chordoma (CH) of head and neck (H&N) and pelvis.

METHODS AND MATERIALS

In this prospective non-randomized study, 65 patients of H&N or pelvic OGS (24), CS (7) and CH (34) mandating definitive or post-operative radiotherapy from May 2013 to December 2018 were included. Radiotherapy doses in definitive setting were 72.0 Gy for CH and 70.2 Gy for OGS and CS; while in post-operative setting it was 66.6 Gy and 64.8 Gy respectively (at 1.8 Gy per fraction).

RESULTS

Planned doses of radiotherapy could be completed in 61 (93.8%) patients; with grade III or higher acute and late toxicities of 3% and 0% respectively. With a median follow-up of 52 (range 6-92) months, the five-year actuarial local control (LC) rates were 66% in OGS, 38.1% in CS and 75.9% in CH; while cause-specific survival (CSS) rates were 54.7%, 64.3% and 92.2% respectively. There was no statistically significant difference in outcomes for patients receiving definitive and post-operative radiotherapy. Locally controlled disease at first follow-up after radiotherapy was associated with improved CSS and OS in CS (p = 0.014) and CH (p < 0.001). Radiotherapy resulted in significant and sustained improvement in Musculoskeletal tumour society (MSTS) score and reduction in pain score. Salvage re-irradiation was feasible in local progression after radiotherapy, with good outcomes and tolerability.

CONCLUSION

Dose-escalated IG-IMRT results in good LC & functional improvement with minimal toxicity in OGS, CS and CH.

Partial replacement of pelvis with the hip joint in osteosarcoma treatment: A case report

Introduction

and importance: Pelvic osteosarcoma is quite rare and is a challenging task for orthopedic surgeons. This aim of this study is to present the first case report using customized 3D-printed prosthesis in Vietnam.

Case presentation

57-year-old male was diagnosed with pelvic osteosarcoma. After neoadjuvant chemotherapy, we did limb-salvage surgery after partial pelvic resection. He had to undergo another surgery due to an infection complication that exposed part of the prosthesis. At 6 months follow-up, the patient's overall status was stable. VAS score when moving is 2/10. He can walk with one crutch. Patient is still being followed up and treated.

Clinincal discussion

Management of pelvic osteosarcoma remains a challenging task for orthopedic surgeons. Advancements in customized 3D-printed prosthesis have been applied in treatment of pelvic osteosarcoma. Despite the complications, the results are promising. We believe that this is a new and innovative route in surgery of pelvic osteosarcoma.

Conclusion

Using customized 3D-printed prosthesis is a good way for management of pelvic osteosarcoma.

•

Osteosarcoma of pelvis is not common, account for 4–10% of all bone cancer.

•

Pelvis connect the lower limb with body by hip joint and support the intraabdominal organ.

•

It is very difficult to preserve the pelvis after wide resection.

•

Custom made 3D printed implant give us a chance to restore the pelvis anatomically and functionally.

Primary malignant bone tumours of spine and pelvis in children

PURPOSE

Axial malignant bone tumours are rare in children and adolescents, and their prognosis is still relatively poor due to non-specific symptoms, such as back or groin pain, which may result in late hospital presentation. Therefore, it is very important to raise awareness regarding this pathology.

METHODS

We performed a narrative review, including scientific publications published in English. We searched Medline and Google Scholar databases for information on the incidence and prognosis of axial malignant bone tumours in children and adolescents (< 18 years). Outcomes of different surgical management strategies and reconstruction options were assessed.

RESULTS

The incidence of primary malignant bone tumours before the age of 18 years is approximately five per one million population; around 25% of these tumours are located in the axial skeleton. With a five-year survival rate of 50%, tumours in an axial location (chest cage, spine, pelvis) are associated with a poorer prognosis than tumours in more peripheral locations. En bloc excision with clear margins has been shown to improve local control and overall survival, even though obtaining adequate surgical margins is difficult due to the close location of large neurovascular structures and other major organs. Spinal reconstruction options include instrumented fusion with allograft or expandable cage. Pelvic reconstruction is needed in internal hemipelvectomy, and the options include biological, endoprosthetic reconstructions, hip transposition, arthrodesis or creation of pseudoarthrosis and lumbopelvic instrumentation.

CONCLUSION

Early diagnosis, a timely adequate multidisciplinary management, appropriate en bloc excision, and reconstruction improve survival and quality of life in these patients.

LEVEL OF EVIDENCE

V.

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.

Chondrosarcoma Arising from the Posterior Iliac Crest Extending into the Spinal Canal

Chondrosarcoma is a malignant tumor characterized by the production of a cartilage matrix. Extension into the spinal canal from the extracannular space is seen mainly for neurogenic tumors, but it is rare in nonneurogenic tumors. A 75-year-old woman suffered from sciatic pain and numbness in her lower left extremity. The diagnosis was of a low-grade conventional chondrosarcoma, which originated from the posterior ilium with an intraspinal extension at the level of the sacrum, compressing the cauda equina. The tumor extended further into the S1 sacral anterior foramen, in the shape of a dumbbell. The tumor was resected in several blocks posteriorly, and the dumbbell-shaped tumor in the S1 foramen was resected by widening the S1 foramen from behind. The posterior extension of the iliac tumor seemed prevented by the posterior sacroiliac ligament, and the tumor extended into the canal. Here, we report that the iliac chondrosarcoma extending into the spinal canal is rare for this tumor type. An understating of the tumor extension is important for planning the surgical strategy.

Successful pregnancy after limb-sparing hemipelvectomy for Ewing sarcoma: Case report and literature review

OBJECTIVE

We present a case of successful pregnancy in a patient who underwent limb-sparing hemipelvectomy combined with multi-agent chemotherapy and radiotherapy for Ewing sarcoma.

CASE REPORT

A 17-year-old girl was diagnosed with Ewing sarcoma of the left pelvis at the age of 17 and received limb-sparing hemipelvectomy combined with multi-agent chemotherapy and radiotherapy. The patient received oral contraceptives as hormone replacement therapy after completion of treatment. A normal menstruation cycle restored after the withdrawal of oral contraceptives. The patient spontaneously conceived at the age of 25. The patient complained of difficulty walking due to pelvic distortion during pregnancy and delivered a healthy neonate at term by cesarean section.

CONCLUSION

Successful pregnancy and delivery can be achieved after limb-sparing hemipelvectomy combined with chemotherapy and radiotherapy for Ewing sarcoma. Our report provides important information on perinatal management, given the low incidence of pregnancy following treatment of Ewing sarcoma in the pelvis.

The effect of preoperative radiotherapy on local control and prognosis in high-grade non-metastatic intramedullary osteosarcoma of the extremities

INTRODUCTION

This study aimed to analyse the effect of preoperative radiotherapy on survival, recurrence and necrosis rates in osteosarcoma patients treated with neoadjuvant chemotherapy and limb-salvage surgery.

MATERIALS AND METHODS

Osteosarcoma patients who referred to our clinic from 1998 to 2015 were investigated retrospectively. 141 patients with non-metastatic osteosarcoma of the limb who received neoadjuvant chemotherapy and underwent limb-sparing surgery with or without preoperative radiotherapy were included in the study. 73 patients had neoadjuvant chemotherapy only (CT group), while 68 patients had additional preoperative radiotherapy (CT + RT group). 5-year survival, disease-free survival, limb survival, local recurrence, metastasis, complication and necrosis rates were compared between the two groups.

RESULTS

Overall 5-year survival, 5-year disease-free survival, 5-year limb survival rates were 68.5, 64.3, 65.7 for CT group and 72.1, 67.6, 64.7 for CT + RT group, respectively. Preoperative radiotherapy gave similar survival and disease-free survival rates. Limb survival, recurrence and metastasis rates were similar between the groups. The necrosis rate of the lesions was significantly higher in the CT + RT group compared to the CT group.

CONCLUSION

Preoperative radiotherapy can provide a higher necrosis rate and may allow the resection of unresectable lesions in the treatment of osteosarcoma. CT + RT provided similar 5-year survival despite the larger tumour size compared to CT group. Due to the higher wound complication rate (8.2% in CT, 23.5% in CT + RT group, p = 0.01), CT + RT should be restricted to the lesions with large size or close proximity to neurovascular structures.

LEVEL OF EVIDENCE

Level III; Therapeutic, Retrospective comparative study.

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.

Pelvic Ring Reconstruction After Iliac or Iliosacral Resection of Pediatric Pelvic Ewing Sarcoma: Use of a Double-Barreled Free Vascularized Fibular Graft and Minimal Spinal Instrumentation

BACKGROUND

In patients undergoing iliosacral resections, pelvic ring reconstruction can maintain stability of the pelvis and spinal column, which is expected to achieve good functional outcomes. However, no optimal reconstruction method has been established. We aimed to analyze the outcome of pelvic ring reconstruction using double-barreled free vascularized fibular graft (FVFG) and internal fixation after iliosacral resections in children.

METHODS

We retrospectively reviewed 16 children with pelvic Ewing sarcoma who underwent pelvic ring reconstruction using double-barreled FVFG after iliosacral resection. The fibular graft was placed between the supraacetabular region distally and the remaining ilium or sacrum proximally. The stability of the remaining pelvis and spinal column was provided by minimal spinal instrumentation.

RESULTS

Eleven Type-I and 5 Type-I+IV resections were performed for 10 boys and 6 girls, who had a mean age of 13.4 years (range, 10 to 18 years). The mean follow-up was 49.8 months (range, 28 to 96 months). At the time of the final follow-up, 14 patients were alive and 2 patients had died of disease. The mean time for bone union was 9 months (range, 6 to 12 months). Graft hypertrophy was evident in all patients at 12 months. The median Musculoskeletal Tumor Society (MSTS) score at the time of the final follow-up was 80% (range, 60% to 96.6%). Seven patients had complications. Three complications required reoperation: 1 deep infection, 1 hematoma, and 1 wound dehiscence. Three patients had disease relapse in terms of lung metastases.

CONCLUSIONS

This reconstruction method can achieve a high rate of bone union and can provide good functional outcomes following resection of pediatric pelvic Ewing sarcomas with iliosacral involvement. Complications are usually manageable without a need for revision surgical procedures.

LEVEL OF EVIDENCE

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

Childhood Cancer: Occurrence, Treatment and Risk of Second Primary Malignancies

Cancer represents the leading cause of disease-related death and treatment-associated morbidity in children with an increasing trend in recent decades worldwide. Nevertheless, the 5-year survival of childhood cancer patients has been raised impressively to more than 80% during the past decades, primarily attributed to improved diagnostic technologies and multiagent cytotoxic regimens. This strong benefit of more efficient tumor control and prolonged survival is compromised by an increased risk of adverse and fatal late sequelae. Long-term survivors of pediatric tumors are at the utmost risk for non-carcinogenic late effects such as cardiomyopathies, neurotoxicity, or pneumopathies, as well as the development of secondary primary malignancies as the most detrimental consequence of genotoxic chemo- and radiotherapy. Promising approaches to reducing the risk of adverse late effects in childhood cancer survivors include high precision irradiation techniques like proton radiotherapy or non-genotoxic targeted therapies and immune-based treatments. However, to date, these therapies are rarely used to treat pediatric cancer patients and survival rates, as well as incidences of late effects, have changed little over the past two decades in this population. Here we provide an overview of the epidemiology and etiology of childhood cancers, current developments for their treatment, and therapy-related adverse late health consequences with a special focus on second primary malignancies.

Curcumin in Osteosarcoma Therapy: Combining With Immunotherapy, Chemotherapeutics, Bone Tissue Engineering Materials and Potential Synergism With Photodynamic Therapy

Osteosarcoma is a dominating malignant bone tumor with high mortality due to pulmonary metastases. Furthermore, because of the cancer cell erosion and surgery resection, osteosarcoma always causes bone defects, which means dysfunction and disfigurement are seldom inevitable. Although various advanced treatments (e.g. chemotherapy, immunotherapy, radiotherapy) are coming up, the 5-year survival rate for osteosarcoma with metastases is still dismal. In line with this, the more potent treatments for osteosarcoma are in high demand. Curcumin, a perennial herb, has been reportedly applied in the therapy of various types of tumors via different mechanisms. In vitro, it has also been reported that curcumin can inhibit the proliferation of osteosarcoma cell lines and can be used to repair bone defects. This seems curcumin is a promising candidate in osteosarcoma treatment. However, due to its congenital property like hydrophobicity, and low bioavailability, affecting its anticancer effect, clinical applications of curcumin are highly limited. To enhance its performance in cancer therapies, some synergist approaches with curcumin have emerged. The present review presents some prospective ones (i.e. combinations with immunotherapy, chemotherapeutics, bone tissue engineering, and biomaterials) applied in osteosarcoma treatment. Additionally, with the advancements of photodynamic therapy in cancer therapy, this review also prospects the combination of curcumin with photodynamic therapy in osteosarcoma treatment.

Osteosarcoma

Osteosarcoma is a rare tumor that requires complex multidisciplinary management. This paper reviews the general management and standard radiotherapy guidelines for osteosarcoma in both North America and Europe in a joined effort between the Children's Oncology Group and International Society of Pediatric Oncology. Standard treatment involves multiagent induction chemotherapy followed by surgical resection for local tumor control and consolidation local control to metastatic sites. Radiotherapy is reserved for cases with a marginal or incomplete resection or for definitive treatment in the case of unresectable disease. We present supporting data for the role of chemotherapy, surgery, and radiation therapy.

Pelvic Reconstruction With a Novel Three-Dimensional-Printed, Multimodality Imaging Based Endoprosthesis Following Enneking Type I + IV Resection

BACKGROUND AND PURPOSE

Pelvic tumor involving Type I + IV resections are technically challenging, along with various reconstructions methods presenting unsatisfactory outcomes and high complication rates. Since predominating studies preferred adopting pedicle screw-rod system (PRSS) to address this issue, we designed a novel three-dimensional-printed, multimodality imaging (3DMMI) based endoprosthesis with patient-specific instrument (PSI) assistance to facilitate the surgical reconstruction of pelvic tumor involving Enneking Type I + IV resection. We aimed to investigate the clinical effectiveness of this novel endoprosthesis and compare it with PRSS in Type I + IV reconstruction.

METHODS

We retrospective studied 28 patients for a median follow-up of 47 months (range, 10 to 128 months) in this study with either 3D-printed endoprosthesis reconstruction (n = 10) or PRSS reconstruction (n = 18) between January 2000 and December 2017. Preoperative 3DMMI technique was used for tumor evaluation, PSI design, virtual surgery, and endoprosthesis fabrication. Clinical, oncological outcomes, functional assessments, and complications were analyzed between the two groups.

RESULTS

Minor surgical trauma with mean operative duration of 251 ± 52.16 minutes (p = 0.034) and median intraoperative hemorrhage of 2000ml (range, 1600, 4000ml) (p = 0.032) was observed in endoprosthesis group. Wide margins were achieved in 9 patients of the endoprosthesis group compared with 10 in the PRSS group (p = 0.09). The 1993 version of the Musculoskeletal Tumor Society score (MSTS-93) was 23.9 ± 3.76 in endoprosthesis group, which was higher than PRSS group (p = 0.012). No statistical significance was found in relapse between two groups (p = 0.36). Complications were observed in two patients in endoprosthesis group compared with 12 patients in PRSS group (p = 0.046).

CONCLUSION

The novel design of this 3D-printed endoprosthesis, together with 3DMMI and PSI assisted, is technically accessible with favorable clinical outcomes compared with PRSS. Further study is essential to identify its long-term outcomes.

Limb-salvage reconstruction following resection of pelvic bone sarcomas involving the acetabulum

AIMS

Limb salvage for pelvic sarcomas involving the acetabulum is a major surgical challenge. There remains no consensus about what is the optimum type of reconstruction after resection of the tumour. The aim of this study was to evaluate the surgical outcomes in these patients according to the methods of periacetabular reconstruction.

METHODS

The study involved a consecutive series of 122 patients with a periacetabular bone sarcoma who underwent limb-salvage surgery involving a custom-made prosthesis in 65 (53%), an ice-cream cone prosthesis in 21 (17%), an extracorporeal irradiated autograft in 18 (15%), and nonskeletal reconstruction in 18 (15%).

RESULTS

The rates of major complications necessitating further surgery were 62%, 24%, 56%, and 17% for custom-made prostheses, ice-cream cone prostheses, irradiated autografts and nonskeletal reconstructions, respectively (p = 0.001). The ten-year cumulative incidence of failure of the reconstruction was 19%, 9%, 33%, and 0%, respectively. The major cause of failure was deep infection (11%), followed by local recurrence (6%). The mean functional Musculoskeletal Tumour Society (MSTS) scores were 59%, 74%, 64%, and 72%, respectively. The scores were significantly lower in patients with major complications than in those without complications (mean 52% (SD 20%) vs 74% (SD 19%); p < 0.001). For periacetabular resections involving the ilium, the mean score was the highest with custom-made prostheses (82% (SD 10%)) in patients without any major complication; however, nonskeletal reconstruction resulted in the highest mean scores (78% (SD 12%)) in patients who had major complications. For periacetabular resections not involving the ilium, significantly higher mean scores were obtained with ice-cream cone prostheses (79% (SD 17%); p = 0.031).

CONCLUSION

Functional outcome following periacetabular reconstruction is closely associated with the occurrence of complications requiring further surgery. For tumours treated with periacetabular and iliac resection, skeletal reconstruction may result in the best outcomes in the absence of complications, whereas nonskeletal reconstruction is a reasonable option if the risk of complications is high. For tumours requiring periacetabular resection without the ilium, reconstruction using an ice-cream cone prosthesis supported by antibiotic-laden cement is a reliable option. Cite this article: Bone Joint J 2021;103-B(4):795-803.

Delay in diagnosis of primary osteosarcoma of bone in children: Have we improved in the last 15 years and what is the impact of delay on diagnosis?

Aims

Examine: (1) If length of symptoms (LS) of children with osteosarcoma has improved in the last 15 years (2) Is delay in diagnosis related to the presence of metastases at presentation? (3) The impact of delay in diagnosis on prognosis.

Methods

250 consecutive patients with a diagnosis of osteosarcoma of bone treated at a national bone tumor treatment center between 2004 and 2018 were studied retrospectively. Three groups comprising those diagnosed over a five-year period (Group 1: 2004-2008, Group 2: 2009-2013; Group 3: 2014-2018) were studied.

Results

There were 126 males and 124 females with a mean age 12.2 years. The median LS for all patients was eight weeks. The median LS for Group 3 was significantly shorter than that for other groups. Development of metastasis during follow-up period was significantly less in Group 3 compared to the other groups. Overall survival gradually improved over the whole study period. There was no difference in the proportion presenting with metastases at diagnosis between the three groups. The survival rates in patients with LS shorter than 4 weeks was better than those with LS longer than 4 weeks, irrespective of the study time period.

Conclusions

There has been an improvement in the LS in patients diagnosed with osteosarcoma over the last 15 years. The development of metastasis during follow-up has reduced and the overall survival in the last 15 years has improved. LS longer than 4 weeks is associated with a poorer prognosis.

Impact of Carbon Ion Radiotherapy on Inoperable Bone Sarcoma

Simple Summary

The standard treatment for bone sarcoma is surgery with or without additional chemotherapy; however, complete resection of the tumor might not be possible in patients with locally advanced lesions. Management of patients with bone sarcoma who are unsuitable for surgery is challenging. Carbon ion radiotherapy (C-ion RT) was initiated in 1994 for treating various cancers in Japan and is being considered to be an effective treatment for unresectable bone sarcoma. However, there is a limited number of reports on the clinical outcomes of C-ion RT for bone sarcoma. Here, we aimed to analyze the clinical outcomes and prognostic factors among patients with unresectable bone sarcoma who were treated with C-ion RT. We found that C-ion RT had favorable overall survival and local control with low toxicity rates compared to surgery. Therefore, our results suggest a potential role for C-ion RT in the radical treatment of inoperable bone sarcoma.

Abstract

Management of patients with bone sarcoma who are unsuitable for surgery is challenging. We aimed to analyze the clinical outcomes among such patients who were treated with carbon ion radiotherapy (C-ion RT). We reviewed the medical records of the patients treated with C-ion RT between April 2011 and February 2019 and analyzed the data of 53 patients. Toxicities were classified using the National Cancer Institute’s Common Terminology Criteria for Adverse Events (Version 4.0). The median follow-up duration for all patients was 36.9 months. Histologically, 32 patients had chordoma, 9 had chondrosarcoma, 8 had osteosarcoma, 3 had undifferentiated pleomorphic sarcoma, and 1 had sclerosing epithelioid fibrosarcoma. The estimated 3-year overall survival (OS), local control (LC), and progression-free survival (PFS) rates were 79.7%, 88.6%, and 68.9%, respectively. No patients developed grade 3 or higher acute toxicities. Three patients developed both grade 3 radiation dermatitis and osteomyelitis, one developed both grade 3 radiation dermatitis and soft tissue infection, and one developed rectum-sacrum-cutaneous fistula. C-ion RT showed favorable clinical outcomes in terms of OS, LC, and PFS and low rates of toxicity in bone sarcoma patients. These results suggest a potential role for C-ion RT in the management of this population.

The role of imaging in computer assisted tumor surgery of the sacrum and pelvis

The use of a navigation system allows precise resection of a tumor and accurate reconstruction of the resultant defect thereby sparing important anatomical structures and preserving function. It is an "image-based" system where the imaging (computed tomography and magnetic resonance imaging) is required to supply the software with data. The fusion of the preoperative imaging provides pre-operative information about local anatomy and extent of the tumor, so that it allows an accurate preoperative planning. Accurate pre-operative imaging is mandatory in order to minimize CATS errors, thus performing accurate tumor resections.

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.