Osteosarcoma in Pediatric and Adult Populations: Are Adults Just Big Kids?

Malignant bone tumors are commonly classified as pediatric or adolescent malignancies, and clinical trials for these diseases have generally focused on these populations. Of primary bone cancers, osteosarcoma is among the most common. Osteosarcoma has a bimodal age distribution, with the first peak occurring in patients from 10 to 14 years old, and the second peak occurring in patients older than 65, with about 25% of cases occurring in adults between 20 and 59 years old. Notably, adult osteosarcoma patients have worse outcomes than their pediatric counterparts. It remains unclear whether age itself is a poor prognostic factor, or if inherent differences in tumor biology exist between age groups. Despite these unknowns, current treatment strategies for adults are largely extrapolated from pediatric studies since the majority of clinical trials for osteosarcoma treatments are based on younger patient populations. In light of the different prognoses observed in pediatric and adult osteosarcoma, we summarize the current understanding of the molecular etiology of osteosarcoma and how it may differ between age groups, hypothesizing why adult patients have worse outcomes compared to children.

Characteristics and prognostic factors of adult patients with osteosarcoma from the SEER database

Osteosarcoma is the most common bone malignancy. There are many studies on the prognostic factors of children and adolescents, but the characteristics and prognostic factors of adult osteosarcoma are rarely studied. The aim of this study was to construct a nomogram for predicting the prognosis of adult osteosarcoma. Information on all osteosarcoma patients aged ≥ 18 years from 2004 to 2015 was downloaded from the surveillance, epidemiology and end results database. A total of 70% of the patients were included in the training set and 30% of the patients were included in the validation set. Univariate log-rank analysis and multivariate cox regression analysis were used to screen independent risk factors affecting the prognosis of adult osteosarcoma. These risk factors were used to construct a nomogram to predict 3-year and 5-year prognosis in adult osteosarcoma. Multivariate cox regression analysis yielded 6 clinicopathological features (age, primary site, tumor size, grade, American Joint Committee on Cancer stage, and surgery) for the prognosis of adult osteosarcoma patients in the training cohort. A nomogram was constructed based on these predictors to assess the prognosis of adult patients with osteosarcoma. Concordance index, receiver operating characteristic and calibration curves analyses also showed satisfactory performance of the nomogram in predicting prognosis. The constructed nomogram is a helpful tool for exactly predicting the prognosis of adult patients with osteosarcoma, which could enable patients to be more accurately managed in clinical practice.

Survival benefits and challenges of adjuvant chemotherapy for high-grade osteosarcoma: a population-based study

BACKGROUND

Osteosarcoma is the most prevalent primary malignant bone tumor. The primary treatment for osteosarcoma is a combination of chemotherapy and surgery. However, there has been no recent progress in the role of chemotherapy in improving the long-term survival of osteosarcoma patients. This study aims to analyze the factors that affect chemotherapy in patients with osteosarcoma and explore the challenges and survival benefits of chemotherapy.

METHODS

Patient data were downloaded from The Surveillance, Epidemiology, and End Results database. Univariable and multivariable logistic regressions were used to analyze the factors affecting patients receiving chemotherapy. Kaplan-Meier (K-M) curve was used to analyze the survival benefit of chemotherapy in patients with osteosarcoma. Finally, we used annual percentage change (APC) to evaluate the annual changes in chemotherapy treatment rates and trends in 5-year survival rates in osteosarcoma patients.

RESULTS

A total of 2157 osteosarcoma patients were included, of which 1887 patients received chemotherapy. Factors affecting patients receiving chemotherapy included age, primary tumor site, tumor size, N stage, M stage, and surgery. The K-M curve showed that older patients could benefit significantly from chemotherapy. The APC results showed no significant change in the chemotherapy treatment rate and 5-year overall survival rate of osteosarcoma patients.

CONCLUSION

Chemotherapy is an irreplaceable treatment for patients with osteosarcoma. However, in recent years, there has been no significant progress in chemotherapy for osteosarcoma, and the long-term survival of patients has not improved significantly. New chemotherapeutic drugs or drug delivery systems are urgently needed to improve the prognosis of patients with osteosarcoma.

Osteosarcomas in older adults: A report from the Cooperative Osteosarcoma Study Group

INTRODUCTION

Osteosarcoma is typically a disease of the young, but may affect any age. Little is known about the disease in older patients beyond retirement age. We aim to describe the characteristics, treatment, and outcomes of older adult patients registered with our cooperative group.

MATERIALS AND METHODS

The database of the Cooperative Osteosarcoma Study Group (COSS) was searched for osteosarcoma patients diagnosed from 1980 to 2020 who were aged 65 years or older at diagnosis. Affected individuals were analyzed for presenting factors, treatments employed, and outcomes.

RESULTS

Fifty-five eligible patients were detected (median age 68 [range: 65-84] years; male:female = 25:30). Among these patients, 15/55 (27%) tumors were secondary malignancies, 41/55 (75%) were high-grade central, 4/55 (7%) surface, and 10/55 (18%) extraosseous malignancies, and all but three high-grade. Primary metastases were present in 15/55 (27%) patients. Surgery was reported for 46/55 (84%) patients, radiotherapy for 6/54 (11%, 1 unknown), chemotherapy for 42/50 (84%, 5 unknown). A complete surgical remission was achieved in 31/55 (56%). There were two toxic deaths. With a median follow-up of 1.7 (range: 0.1-18.0) years for all 55 patients and 2.2 (0.1-12.4) years for 24 survivors, event-free and overall survival at 2/5 years were 39.6% (standard error: 6.8%) / 24.5% (6.5%) and 62.0% (7.1%) / 32.7% (7.5%), respectively. Tumor site, metastatic status, surgery, and a complete surgical remission were prognostic for event-free and/or overall survival.

DISCUSSION

Osteosarcomas can occur in older individuals. It is more often secondary, axially located, or extraosseous than in younger patients. However, the same treatment principles seem to apply, and selected patients may be cured. Multi-center cooperation is encouraged, thereby gathering expertise for such a rare disease presentation.

Profilin 1 deficiency drives mitotic defects and reduces genome stability

Profilin 1-encoded by PFN1-is a small actin-binding protein with a tumour suppressive role in various adenocarcinomas and pagetic osteosarcomas. However, its contribution to tumour development is not fully understood. Using fix and live cell imaging, we report that Profilin 1 inactivation results in multiple mitotic defects, manifested prominently by anaphase bridges, multipolar spindles, misaligned and lagging chromosomes, and cytokinesis failures. Accordingly, next-generation sequencing technologies highlighted that Profilin 1 knock-out cells display extensive copy-number alterations, which are associated with complex genome rearrangements and chromothripsis events in primary pagetic osteosarcomas with Profilin 1 inactivation. Mechanistically, we show that Profilin 1 is recruited to the spindle midzone at anaphase, and its deficiency reduces the supply of actin filaments to the cleavage furrow during cytokinesis. The mitotic defects are also observed in mouse embryonic fibroblasts and mesenchymal cells deriving from a newly generated knock-in mouse model harbouring a Pfn1 loss-of-function mutation. Furthermore, nuclear atypia is also detected in histological sections of mutant femurs. Thus, our results indicate that Profilin 1 has a role in regulating cell division, and its inactivation triggers mitotic defects, one of the major mechanisms through which tumour cells acquire chromosomal instability.

The Combination of Separation Surgery and Intensity Modulated Radiation Therapy (IMRT) for a Primary Osteosarcoma of the Spine: A Case Report and Literature Review

Background

Primary spinal osteosarcoma is a rare and intractable disease. Although en bloc resection is favorable for longer survival, it is not always achievable. Separation surgery, a partial resection with circumferential separation to safely deliver high-dose irradiation including intensity-modulated radiation therapy (IMRT), has been recently indicated for patients with spinal cord compression secondary to solid tumor metastases. However, little evidence regarding this combination approach to spinal osteosarcoma exists.

Case presentation

We report a 55-year-old male patient with a T1 tumor who underwent urgent decompression surgery for epidural spinal cord compression. Pathological findings revealed primary osteosarcoma. Separation surgery, IMRT, and adjuvant chemotherapy were applied to reduce the symptoms of epidural spinal cord compression. The patient was alive without local recurrence at the 5-year follow-up.

Conclusions

Separation surgery with IMRT can be a relatively safe and effective treatment option in patients with osteosarcoma adjacent to spinal cord when en-bloc resection is challenging.

Do frailty scores predict outcome after proximal femoral replacement for musculoskeletal tumours: a case series?

PURPOSE

Frailty has a negative independent relationship with morbidity and mortality. A frail individual has low resilience and adaptive capacity to stressors with unfavourable consequences. The relationship between musculoskeletal tumour patients undergoing surgery and frailty is underrepresented in literature. This study's questions are; what is the prevalence of frailty in patients undergoing surgery for musculoskeletal tumours; what is the correlation between frailty and survival plus secondary outcome measures including length of hospital stay (LOS); can clinicians use frailty scoring to support preoperative decision-making?

METHODS

Patients over 60 years of age undergoing proximal femoral replacement for musculoskeletal tumours were included and classified as fit, vulnerable or frail using the modified frailty index (mFI), Rockwood and American Society of Anaesthesiologist's physical status classification (ASA) grading systems. Correlation with outcomes including survival and (LOS) was determined.

RESULTS

85 patients were identified of mean age 72.6 years. Median follow-up was 18.9 months. The prevalence of frailty ranged between 55 to 76% and the overall median survival in frail groups were 19.8 months with all scoring systems used. Frail patients classified by the Rockwood score had a greater LOS and a trend to reduced survival.

CONCLUSIONS

There is a high prevalence of frailty in this cohort and frailty scores should be considered when planning surgery as part of holistic care. Moreover, a median survival greater than 18 months in frail patients supports the decision to offer surgery which may positively impact quality of life. Further research to identify the relationship between frailty and outcomes in musculoskeletal tumour patients is needed.

LEVEL OF EVIDENCE

IV, Retrospective Case Series.

A Novel Tool to Predict the Overall Survival of High-Grade Osteosarcoma Patients after Neoadjuvant Chemotherapy: A Large Population-Based Cohort Study

Background. The goal of this study was to discover clinical factors linked to overall survival in patients with high-grade osteosarcoma who had received neoadjuvant therapy and to develop a prognostic nomogram and risk classification system. Methods. A total of 762 patients with high-grade osteosarcoma were included in this study. In the training cohort, Cox regression analysis models were used to find prognostic variables that were independently linked with overall survival. To predict overall survival at 3, 5, and 8 years, a nomogram is created. In addition, in both the internal and external validation cohorts, receiver operating characteristic curves, calibration curves, and decision curve analysis (DCA) were utilized to assess the prediction model’s performance. Results. The age, size of the tumor, and the stage of the disease are all important predictive variables for overall survival. The training and validation cohorts have C-indexes of 0.699 and 0.669, respectively. At the same time, the area under the curve values for both cohorts also showed that the nomogram had good discriminatory power. The calibration curve demonstrated the good performance and predictive accuracy of the model. The DCA results suggest that the nomogram has a wide range of therapeutic applications. Furthermore, a new risk classification system based on the nomogram was established, which allows all patients to be classified into three subgroups as high, middle, and low risk of death. Conclusion. The prognostic nomogram constructed in this study may provide a better precise prognostic prediction for patients with high-grade osteosarcoma after neoadjuvant chemotherapy.

Development and Validation of Nomogram-Based Prognosis Tools for Patients with Extremity Osteosarcoma: A SEER Population Study

Objective

Osteosarcoma, usually occurring in the extremities, is the most common malignant bone tumour. The purpose of this study is to develop and validate nomogram-based prognosis tools for survival (OS) and cancer special survival (CSS) of patients with osteosarcoma of the extremities via the application of survival analysis.

Materials and Methods

A total of 1427 patients diagnosed with osteosarcoma of the extremities during 2004–2015 were selected from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results- (SEER-) Medicare database. The samples were randomly assigned to either the training set (n = 856) or the validation cohort (n = 571). Kaplan–Meier (K–M) survival analysis was conducted to calculate patients' 1-, 3-, and 5-year OS and CSS rates. Cox proportional hazard ratio (HR) regression models were employed to identify and examine the factors that have a significant impact on OS and CSS with data from the training cohort.

Results

The results of univariate and multivariate analyses performed in the training cohort indicated that older age, increased tumour size, higher grade, distant tumour extension, amputation, or no surgery (all HR > 1, P < 0.05) were risk predictors of poor OS and CSS. Subsequently, the independent prognosis signatures were utilised to construct nomograms. The concordance index (C-index), calibration plot, and decision curve analysis (DCA) were simultaneously used to validate the nomograms. The internally validated C-index values of the OS and CSS prediction models for the training set were 0.752 (95% confidence interval [CI]: 0.738–0.765) and 0.754 [95% CI: 0.740–0.768], respectively. Then, the models were validated in the validation cohort population, which also demonstrated the models had good reliability for prognostication.

Conclusions

The SEER cohort of patients with osteosarcoma of the extremities can be employed to produce effective tools that can assist in prognosis modelling.

Management of elderly patients with bone and soft tissue sarcomas: JCOG Bone and Soft Tissue Tumor Study Group

Approximately, 40% of bone sarcomas and 60% of soft tissue sarcoma arise in patients aged ≥65 years. However, because sarcoma is very rare, there is little evidence regarding the management of elderly patients with sarcoma. Age has been reported as a prognostic factor in patients with sarcomas. The standard therapy for all localized bone and soft tissue sarcomas is surgical resection, even in elderly patients. Radiation or ion-beam therapy can be considered for unresectable sarcomas. Although adjuvant chemotherapy is standard for osteosarcoma, the usefulness of adjuvant chemotherapy for elderly patients has not been verified; therefore, it may not be recommended for elderly patients with osteosarcoma. For elderly patients with advanced osteosarcoma, if general conditions permit, doxorubicin- and/or ifosfamide-based regimens as well as molecular-targeted therapies, including sorafenib, regorafenib and everolimus, may be considered, although these drugs have not been approved for sarcoma in Japan. Adjuvant chemotherapy with doxorubicin plus ifosfamide is recommended for patients with high-risk localized soft tissue sarcoma if they are aged ≤70 years. For first-line treatment of advanced soft tissue sarcoma in elderly patients, doxorubicin monotherapy is considered to be the standard regimen, and pazopanib can be an alternative. For second-line treatment, gemcitabine-based regimens, pazopanib, trabectedin and eribulin may be options for elderly patients with advanced soft tissue sarcoma.

Osteosarcoma: a Surveillance, Epidemiology, and End Results program-based analysis from 1975 to 2017

BACKGROUND

Osteosarcoma is the most common primary bone malignancy. As a rare cancer, population-based studies remain small with limited information on finer demographic categories. Recent studies have reported important genetic differences based on age and ethnicity, and more detailed studies are needed to better understand potentially important osteosarcoma risk groups.

METHODS

Incidence and survival rates for 5016 patients with osteosarcoma from the Surveillance, Epidemiology, and End Results (SEER) program (1975-2017) were analyzed by age (0-9, 10-24, 25-59, and >60 years old), race/ethnicity, histologic subtype, stage, and tumor location using SEER*Stat software.

RESULTS

For cases 0 to 9 years old, incidence of primary osteosarcoma was similar between the sexes, increased significantly throughout the study period (P < .05), and the 5-year relative survival has steadily increased over time. Blacks had the highest incidence in all aged cases combined and a significant increase in incidence throughout the study period (P < .05). Overall, survival rates for all cases have remained relatively unchanged over recent decades, with worse survival observed in males, American Indian/Alaska Native cases, older patients, metastatic disease, axial tumors, and subsequent osteosarcoma cases. For cases 0 to 24 years old, the incidence of subsequent osteosarcoma increased 3-fold since the 2000s.

CONCLUSION

Important differences in osteosarcoma incidence and survival, particularly for the youngest children, ethnic minorities, and subsequent osteosarcoma, are identified. A genetic risk factor may be associated with observed ancestry-specific incidence differences and illustrates the importance of analyzing osteosarcoma by specific age groups and ethnicities to better understand their unique epidemiology and underlying biology.

LAY SUMMARY

Osteosarcoma is the most common bone cancer, but still a relatively rare disease, and previous studies have had limited information on finer demographics. Using a large database, osteosarcoma incidence and survival patterns are thoroughly evaluated and important differences, especially for the youngest children, ethnic minorities, and subsequent osteosarcoma cases, are identified.

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.

Bone Infarct Associated Osteosarcoma: Epidemiologic and Survival Trends

Background Bone tumors are not a frequent occurrence and bone-infarct-associated sarcomas are even rarer. The prognosis of this disease is poor and its treatment remains a challenge. Nevertheless, hardly any analyses in literature report on secondary osteosarcoma (SO) on bone infarct and most of the data available do not provide sufficient details. We evaluated whether this condition could be further characterized and if prognosis could be influenced by the chemotherapy treatment. In particular, we sought to determine (1) the main features of this rare disease; (2) the overall survival (OS) rate; (3) the OS rate associated to chemotherapy treatment; (4) the correspondence between our results and published data in terms of survival. Methods We retrospectively reviewed patients admitted at Rizzoli Orthopedic Institute of Bologna between 1992 and 2018 (1465 total cases of osteosarcoma). We identified a list of 11 cases of SO on bone infarct (cohort 1). We conferred about the epidemiology, surgical and chemotherapy (ChT) treatment and surveillance of infarct-associated osteosarcoma showing the correlation to data present in literature, corresponding to 15 case reports published within 1962-2018 (cohort 2). Results (1) cohort 1 was made of 11 patients: six females and five males, median age was 55 years. Nine (81%) were grade 4, two (19%) grade 3. Tumor predominantly arise on distal femur (64%). Most of patients had localized osteosarcoma at the diagnosis (81%); resection surgery was the elective treatment (73%) followed by amputation (18%). Of 11 patients, seven received also ChT (64%). (2) Five-years OS was 62% (95% CI: 28-84). Median OS was 74 months (95% CI: 12-not reached). The cumulative incidence of cancer-related deaths (CICRD) was 37.7% (95% CI: 11.4-64.5) at 120 months. (3) In the group treated with only surgery OS was 50% at 5 years. For patients treated with any form of ChT, OS was 71% at 5 years (p=0.4773) and hazard ratio (HR) 0.56. The CICRD was 29% (at 2 years of follow-up. Instead, it was of 50% for patients treated only with surgery. (4) Median survival was 74 months and 19 months for cohort 1 and cohort 2 respectively (p=0.09). Data analysis showed a decreased HR for cohort 1 compared to cohort 2 (HR 0.378). Results confirmed also stratifying for age and ChT administration (HR 0.355). Conclusions Based on this work, our opinion is that the choice to undergo the patients to ChT combined to surgery could improve their prognosis.

SRPK1 promotes cell proliferation and tumor growth of osteosarcoma through activation of the NF-κB signaling pathway

To explore the expression and the functions of SRPK1 in osteosarcoma, we retrieved transcription profiling dataset by array of human bone specimens from patients with osteosarcoma from ArrayExpress (accession E-MEXP-3628) and from Gene Expression Omnibus (accession GSE16102) and analyzed expression level of SRPK1 and prognostic value in human osteosarcoma. Then we examined the effect of differential SRPK1 expression levels on the progression of osteosarcoma, including cell proliferation, cell cycle, apoptosis, and investigated its underlying molecular mechanism using in vitro osteosarcoma cell lines and in vivo nude mouse xenograft models. High expression level of SRPK1 was found in human osteosarcoma tissues and cell lines as compared to the normal bone tissues and osteoblast cells, and predicted poor prognosis of human osteosarcoma. Overexpression of SRPK1 in osteosarcoma U2OS cells led to cell proliferation but inhibition of apoptosis. In contrast, knockdown of SRPK1 in HOS cells impeded cell viability and induction of apoptosis. Moreover, silencing SRPK1 inhibited osteosarcoma tumor growth in nude mice. Mechanistic studies revealed that SRPK1 promoted cell cycle transition in osteosarcoma cells and activation of NF-κB is required for SRPK1 expression and its pro-survival signaling. SRPK1 promoted human osteosarcoma cell proliferation and tumor growth by regulating NF-κB signaling pathway.

The Role of Chemotherapy in the Survival Benefits of Patients Aged Older Than 40 Years With Osteosarcoma

Objectives: The value of chemotherapy in the survival benefits of patients aged > 40 years with osteosarcoma is controversial. We aimed to explore the impact of chemotherapy on the survival benefits of patients aged >40 years with osteosarcoma. Methods: The Surveillance, Epidemiology, and End Results database was used to select eligible patients. The selected patients were divided into the chemotherapy and non-chemotherapy groups. Logistic regression analysis was performed to investigate the potential factors contributing to the selection of chemotherapy. The overall survival (OS) and cancer-specific survival (CSS) of the two groups were compared using the Kaplan–Meier method with a log-rank test. Cox proportional risk models were used to determine the prognostic factors for OS and CSS. Stratified analysis was performed according to tumour grade and stage. Results: A total of 1032 eligible patients were included in our analysis. Of these, 586 and 446 patients were in the chemotherapy and nonchemotherapy groups, respectively. Multivariate logistic analysis indicated that grade III/IV and distant stage were associated with chemotherapy. Kaplan–Meier plots showed that patients did not achieve an improved OS or CSS after receiving chemotherapy. Cox regression analysis indicated that age > 60 years, axial, grade III/IV, and regional and distant stage were independent risk factors for poor prognosis in both OS and CSS. Stratified analysis revealed a survival benefit from chemotherapy in patients with grade III/IV and distant stage. Conclusions: Chemotherapy did not significantly improve OS and CSS in patients aged > 40 years with osteosarcoma. In this age group, survival benefit from chemotherapy was observed in patients with high-grade tumours (grade III/IV) and metastasis (distant stage).

A Retrospective Comparative Analysis of Outcomes and Prognostic Factors in Adult and Pediatric Patients with Osteosarcoma

Osteosarcoma is the most common primary bone malignancy in both children and adults. Despite introduction of intensive multimodal treatment with chemotherapy and surgery, outcomes are still poor, especially for patients with metastatic disease and adults. Hence, there is an ongoing need for better prognostic markers and outcome data to inform management decisions in both the adult and pediatric setting. Here, we retrospectively analyzed 112 patients with bone osteosarcoma treated at two large adult and pediatric tertiary academic centers between 1989 and 2019. Patients were divided into an adult (≥18 years) and pediatric (<18 years) cohort for comparison. Our aim was to evaluate predictors of outcomes in pediatric and adult patients, with a specific focus on the role of methotrexate when added to a combination of doxorubicin-cisplatin; the prognostic value of tumor necrosis after neoadjuvant chemotherapy; and outlining any differences in outcomes between adults and pediatric patients that could inform clinical management. Adult patients treated with methotrexate-doxorubicin-cisplatin and those treated with doxorubicin-cisplatin had similar 5-year PFS (26%, 95%CI: 45.5%–10% vs. 50%, 95%CI: 69.6%–26.2%, p = 0.1) and 5-year OS (63%, 95%CI: 82%–34%, vs. 78%, 95%CI: 90.6%–52.6%, p = 0.5). In the adult cohort, there was no difference between patients with ≥90% necrosis and <90% necrosis in either 5-year PFS (42%, 95%CI: 71.1%–11.3% vs. 38%, 95%CI: 57.7%–18.2%, p = 0.4) or 5-year OS (85%, 95%CI: 97.8%–33.4% vs. 56%, 95%CI: 76.8%–27.6%, p = 0.4). In the pediatric cohort, compared to patients with <90% necrosis, those with ≥90% necrosis had significantly better 5-year PFS (30%, 95%CI: 49.3%–14.1% vs. 55%, 95%CI: 73.9%–38.5%, p = 0.003) and 5-year OS (64%, 95%CI: 80.8%–41.1% vs. 78%, 95%CI: 92%–60.9%, p = 0.04). Adult and pediatric patients had similar 5-year OS (69%, 95%CI: 83.2%–49.8% vs. 73%, 95%CI: 83.2%–59.3%, p = 0.8) and 5-year PFS (37%, 95%CI: 52.4%–22.9% vs. 43%, 95%CI: 56.2%–30.4% p = 0.3) even though the proportion of patients with ≥90% necrosis after neoadjuvant chemotherapy was higher for children compared to adults (60.3% vs. 30%, OR: 3.54, 95%CI: 1.38–8.46, p = 0.006). In conclusion, in adult patients, the addition of methotrexate to doxorubicin and cisplatin did not correlate with a significant survival benefit, questioning the therapeutic value of methotrexate overall. Our study confirms the prognostic utility of percent tumor necrosis after neoadjuvant chemotherapy in pediatric patients but not in adult patients. Lastly, this is one of the few reported studies where patients with osteosarcoma younger and older than 18 years had similar PFS and OS.

Long-term survival following radiofrequency ablation of lung metastases in an elderly patient with calcaneal osteosarcoma: A case report and review of the literature

RATIONALE

Recently, the number of osteosarcomas has been increasing in elderly patients due to human longevity. Lung metastases are the primary cause of death from osteosarcomas. Complete resection of lung metastases can prolong the survival. However, complete resection in elderly patients is often difficult due to high risk of operative complications. Computed tomography (CT) guided radiofrequency ablation (RFA) is a minimally invasive technique to destroy tumor nodules using heat. In this report, we present the first case older than 65 years applying RFA for lung metastases due to osteosarcoma.

PATIENT CONCERNS

A 74-year-old male presented with 1-year history of heel pain. A conventional high-grade osteosarcoma in his calcaneus was diagnosed. Below-knee amputation was performed. However, lung metastases were found in both lungs 1 year after amputation. CT-guided lung RFA was chosen since surgical intervention for lung metastases was abandoned because of tumor multiplicity and medical comorbidities. A total of 18 lung metastases were treated by CT-guided RFA. The most frequent complication was pneumothoraxes in 4 of 8 (50%) procedures and chest tube drainage was required in 2 of these (2 of 8 (25%) procedures).

DIAGNOSES

Six lung metastases of osteosaroma were found in both lungs at 1 year after surgery.

INTERVENTIONS

CT-guided lung RFA was performed. A total of 18 lung metastases were treated in 8 lung RF procedures.

OUTCOMES

The patient has been alive with disease for 5.5 years after the initial surgery.

LESSONS

CT-guided lung RFA is effective for elderly patients with osteosarcoma lung metastases in spite of discouragement of lung metastasectomy due to multiplicity of metastases and medical-comorbidities.

State-of-the-art, approved therapeutics for the pharmacological management of osteosarcoma

Introduction: Advances in the treatment of osteosarcoma (OS) came in the mid-1970s, when adding chemotherapy to surgery significantly improved patient survival. OS outcomes have since plateaued, however, despite exhaustive clinical investigations.Area covered: This review focuses on the most significant recent results of trials (in phases II and III) on localized and metastatic/relapsing OS and offers an overview of new targeted drugs.Expert opinion: Recent findings confirm the MAP (methotrexate, doxorubicin, and cisplatin) regimen as the gold standard for OS patients, also in metastatic cases, and the inefficacy of augmenting or modifying chemotherapy in poor responder patients. Immunotherapy and several tyrosine kinase inhibitors seem to be effective and promising in the treatment of OS. Optimizing the use of active drugs available by personalizing chemotherapies might prove important in the future. We urgently need bench-to-bedside research on OS. This will need to involve the extensive sequencing and immunoprofiling of all resected tumor tissue to find new therapeutic agents, especially for relapsing/metastatic patients. The low incidence of OS, its genomic complexity, and differences within and between tumors combine to complicate efforts to elucidate the biology of this disease. This means that we need to pool the resources of different groups studying OS and support translational research.

International trends in incidence of osteosarcoma (1988-2012)

Osteosarcoma (OS) is the most common primary bone tumor in children and adolescents. The etiology of OS is largely unknown but may be informed by comparisons of incidence and trends between geographic regions. Using the Cancer Incidence in Five Continents (CI5) data from 1988 to 2012, we present OS age-standardized incidence rates (ASRs; cases/million) and average annual percent change (AAPC) and 95% confidence interval (CI) by geographic region among the age groups 0-9, 10-19, 20-29, 30-59, 60-79, 0-79. Among the 10-19 age group, we also used the most recent data (2008-2012) to present the ASRs for each country. We observed little variation in OS incidence between geographic regions in 2008-2012 across all age groups. Overall, the ASR for 0-79 ranged from 2 cases per million in Southern Asia to 4.2 in Sub-Saharan Africa. A bimodal distribution in incidence was observed with peaks in the 10-19 and 60-79 age groups across all regions over time. Overall, OS incidence was relatively stable across 1988-2012 with the only statistically significant increases in the 0-79 age group observed in Eastern Asia (AAPC: 1.8; 95% CI: 0.6, 1.9) and Sub-Saharan Africa (AAPC: 3.1; 95% CI: 0.5, 5.8). The small variation in incidence between regions and the stability in incidence over time suggests that OS carcinogenesis is not influenced by environmental or time-varying exposures.

New drug candidates for osteosarcoma: Drug repurposing based on gene expression signature

Osteosarcoma (OS) is an aggressive bone malignancy and the third most common cancer in adolescence. Since the late 1970s, OS therapy and prognosis had only modest improvements, making it appealing to explore new tools that could help ameliorate the treatment. We present a meta-analysis of the gene expression signature of primary OS, and propose small molecules that could reverse this signature. The meta-analysis was performed using GEO microarray series. We first compared gene expression from eleven primary OS against osteoblasts to obtain the differentially expressed genes (DEGs). We later filtered those DEGs by verifying which ones had a concordant direction of differential expression in a validation group of 82 OS samples versus 30 bone marrow mesenchymal stem cells (BM-MSC) samples. A final gene expression signature of 266 genes (98 up and 168 down regulated) was obtained. The L1000CDS² engine was used for drug repurposing. The top molecules predicted to reverse the signature were afatinib (PubChem CID 10184653), BRD-K95196255 (PubChem CID 3242434), DG-041 (PubChem CID 11296282) and CA-074 Me (PubChem CID 23760717). Afatinib (Gilotrif™) is currently used for metastatic non-small-cell lung cancer with EGFR mutations, and in vitro evidence shows antineoplastic potential in OS cells. The other three molecules have reports of antineoplastic effects, but are not currently FDA-approved. Further studies are necessary to establish the potential of these drugs in OS treatment. We believe our results can be an important contribution for the investigation of new therapeutic genetic targets and for selecting new drugs to be tested for OS.

A Pharmacological Analysis of the Activity and Failure of the Medical Treatment of High-Grade Osteosarcoma

Osteosarcomas (OSs) are a group of neoplasms originating from bone cells, usually presenting in three specific age groups: children, young adults, and the elderly. High-grade OS is an extremely malignant tumor mainly due to evolution into metastatic disease, usually in the lungs. Survival of these patients has improved since the 1980s thanks to close cooperation between oncologists, oncological surgeons and orthopedic surgeons. Unfortunately, no progress has been made in the last 30 years and new, more effective drugs are needed. This article reviews the biological and pharmacological basis of the treatment of OS. Models of clinical pharmacology of the active drugs, toxic effects and reasons for primary and secondary resistance to old and new drugs are discussed.

Factors associated with 30-day soft tissue complications following upper extremity sarcoma surgery

BACKGROUND AND OBJECTIVES

The incidence of soft tissue complications following sarcoma surgery in the upper extremity is reportedly high. Therefore, this study assessed the National Surgical Quality Improvement Program (NSQIP) database to identify independent risk factors, while also reporting the incidence of soft tissue complications in the first 30 days after surgery.

METHODS

A total of 620 patients that underwent surgical treatment for upper extremity sarcoma were included from the NSQIP database. Soft tissue complications were defined as surgical site infection, wound dehiscence, or soft-tissue related reoperations. Clinically relevant patient and treatment characteristics were selected and analyzed.

RESULTS

The 30-day soft tissue complication rate was 4.7%. In the multivariable analysis, higher body mass index (p = .047) and longer operative times (p = .002) were independently associated with soft tissue complications.

CONCLUSIONS

Higher body mass index and longer operative times are risk factors for soft tissue complications following upper extremity sarcoma surgery. The soft-tissue complication rate following resection of upper extremity tumors is low in this national cohort, possibly due to the relatively small tumor size and low prevalence of radiotherapy.

Nomograms for predicting overall survival and cancer-specific survival of chondroblastic osteosarcoma patients

BACKGROUND

The establishment of precise and personalized prediction systems for chondroblastic osteosarcoma patients is important for guiding the treatment.

METHODS

The univariate logrank test and multivariate Cox regression analysis were performed to identify independent prognostic factors for overall survival (OS) and cancer-specific survival (CSS). Nomograms were constructed to estimate the OS and CSS based on these factors. Internal and external validation was performed. The predictive power of the nomograms was determined by C-index and calibration plots.

RESULTS

A total of 401 chondroblastic osteosarcoma cases were identified. Univariate and multivariate analysis revealed that age at diagnosis, histological grade, tumor size, Surveillance, Epidemiology, and End Results stage, and surgical resection were independent prognostic factors for OS and CSS. The five factors were incorporated to construct the nomograms for estimating the 3- and 5-year OS and CSS. The C-index values for the internal validation of the OS and CSS nomogram were 0.732 and 0.746, respectively, and for the external validation were 0.780 and 0.808, respectively. The calibration curves revealed that the predicted OS and CSS could well match the actual survival rate.

CONCLUSIONS

The nomograms for predicting 3- and 5-year OS and CSS were constructed and were proved to be accurate and reliable by the internal and external validation.

What are the predictors of emergency department utilization and readmission following extremity bone sarcoma resection?

INTRODUCTION

Treatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery.

METHODS

Data from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions.

RESULTS

Of 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001).

CONCLUSION

One in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow-up to minimize readmission.

The Real-Life Journey of Elderly Patients in Soft Tissue and Bone Sarcomas: A Retrospective Analysis from a Sarcoma Referral Center

The high complexity of multimodality treatment frequently results in undertreatment of elderly sarcoma patients, and this may be one of the factors that influence their prognosis. We describe the real-life approach to a population of patients aged over 70 with both soft tissue (STS) and bone sarcomas (BS) followed by our Sarcoma Disease Management Team from 2012 to 2017. One-hundred and twenty-three patients with a median age of 77 years (range: 70–92) were identified. STS were the most common histological subtypes (94%) and the grade was high in 79/123 patients (64%). At diagnosis, 88% of patients had localized disease (LD) and 12% were metastatic (MD). Overall, 96% of patients with LD underwent surgery, 46/54 (85%) with high grade STS patients underwent complementary radiotherapy, and 10/54 (19%) received adjuvant treatments. Twelve out of 33 patients who relapsed (36%) underwent local therapies. Seventeen (52%) and eight (24%) patients were treated with first-line and second-line medical treatments, respectively. Tolerability to systemic treatments was fairly good. Overall, 21% of the patients with advanced disease were candidates for best supportive care alone. Our case series of elderly patients with both STS and BS shows that personalized multidisciplinary treatment can nevertheless be offered to this frail population in order to control the evolution of disease.

Characteristics and Prognostic Factors of Patients With Osteosarcoma Older Than 60 Years From the SEER Database

Osteosarcoma is predominant in the adolescent and the elderly population, but few studies have described the characteristics and prognostic factors of patients older than 60 years. In this study, the Surveillance, Epidemiology, and End Results registry database was used to identify all patients diagnosed with primary osteosarcoma from 1973 to 2014. We utilized Cox proportional hazards regression analysis to evaluate the association between patient overall survival and relevant characteristics, including gender, race, disease stage, treatment methods, primary tumor site, differentiation grade, and histologic subtype. In the data set, a total of 1139 patients with osteosarcoma older than 60 years old were identified. The overall rate of distant metastatic cases was 28.6%. Osteosarcoma occurred equally in men and women (49.5% vs 50.5%). Of all, 41.3% of tumors were located in axial location (pelvis, spine, and ribs), 34.1% of tumors were located in extremity (long or short bones of the upper or lower extremity), and 24.6% in other location (mandible, skull, and other atypical locations). Male (hazard ratio [HR] = 1.201; 95% confidence interval [CI]: 1.056-1.366), axial location (HR = 1.342; 95% CI: 1.157-1.556), distant metastasis (HR = 2.369; 95% CI: 2.015-2.785), non-surgery perform (HR = 2.108; 95% CI: 1.814-2.451) were independent risk factors for 5-year overall survival. This study revealed distinct clinicopathological features of patients with osteosarcoma older than 60 years. Male gender, tumor in axial site, nonsurgery perform, and distant metastasis indicated worse prognosis survival. Performing surgery is still an effective and reliable treatment method for patients older than 60 years.

Osteosarcoma in patients over 50 years of age: Multi-institutional retrospective analysis of 104 patients

BACKGROUND

Primary osteosarcoma in elderly patients are rare malignant tumors. Its optimal treatment has not yet been determined.

METHODS

This retrospective study included 104 patients aged >50 years with resectable, non-metastatic osteosarcoma treated by the members of the Bone and Soft Tissue Tumor Study Group of the Japan Clinical Oncology Group. The effects of adjuvant chemotherapy were estimated by comparing outcomes in patients who received surgery plus chemotherapy with those who underwent surgery alone.

RESULTS

Median age at presentation was 59 years. Neoadjuvant and adjuvant chemotherapy was administered to 83 (79.8%) patients. Patients who underwent surgery plus chemotherapy and those who underwent surgery alone had 5-year overall survival (OS) rates of 68.6% and 71.7%, respectively (p = 0.780), and 5-year relapse free survival (RFS) rates of 48.2% and 43.6%, respectively (p = 0.64). Univariate analysis showed that resection with wide margins was significantly correlated with better prognosis.

CONCLUSIONS

The addition of chemotherapy to surgery did not improve OS or RFS in patients aged >50 years with resectable, non-metastatic osteosarcoma. Surgery with wide margins was only significantly prognostic of improved survival. The effect of chemotherapy in elderly osteosarcoma patients was unclear.

Results of API-AI based regimen in osteosarcoma adult patients included in the French OS2006/Sarcome-09 study

In the OS2006 study, patients younger than 18 years were treated with a methotrexate-based regimen (MTX), patients older than 25 years with a doxorubicin-cisplatin-ifosfamide-based regimen (API-AI), whereas patients aged 18-25 years received either API-AI or MTX. We herein report the prespecified subgroup analysis of the outcome of 106 patients treated with API-AI. Preoperative chemotherapy combined three doxorubicin-ifosfamide-cisplatin (API) and two doxorubicin-ifosfamide (AI) courses. Postoperative chemotherapy was assigned by risk group: localised patients with a good histological response (<10% viable cells) received two AI and two cisplatin-ifosfamide (PI) courses; patients with synchronous metastases, poor histological response or unresectable primary received five cycles of etoposide-ifosfamide (EI). Of the 106 patients, 61 were randomised to receive or not zoledronate. Median age was 30 years (range 18-67), 66 (62%) patients were >25 years. The primary tumours were axial in 28 patients (26%), and 28 (26%) presented with metastases. Ninety-six patients (91%) had surgery, conservative in 82 (85%); 36 patients (38%, 95% CI 28-48%) were good responders. Toxicity was manageable, with no significant difference in severe acute toxicity between patients aged >25 years and those younger. With a median follow-up of 4.8 years, the 5-year event-free survival and overall survival rates were 46% (95% CI 36-56) and 57% (95% CI 47-67), respectively. The primary tumour size and initial metastases correlated with a higher risk of event. In these 106 osteosarcoma adult patients, API-AI proved feasible with no excess of toxicity, and favourable activity despite poor-prognosis factors.

Survival analysis of elderly patients with osteosarcoma

BACKGROUND

Few studies have described the characteristics and prognostic factors of elderly patients with osteosarcoma. We retrospectively investigated clinico-pathological features and prognostic factors in osteosarcoma patients > 40 years old.

METHODS

Patients with high-grade osteosarcoma > 40 years old who were treated at our institutions from 2000 to 2016 were recruited for this study. Information on patient, tumour, and treatment-related factors was collected and statistically analyzed. The median follow-up was 26.5 months (range, 5-139 months) for all patients.

RESULTS

Fifty patients (30 males and 20 females) were included. The median age at diagnosis was 59.5 years (range, 41-81 years). The primary lesions were found in the limbs in 32 patients, trunk in 12, and craniofacial bones in six. Primary and secondary osteosarcoma occurred in 41 and 9 patients, respectively. Eight patients exhibited initial distant metastasis. Definitive surgery and chemotherapy were performed in 39 patients each. The rate of good responders after neoadjuvant chemotherapy was 38%. The five year overall survival (OS) rates for all patients and those without distant metastasis at diagnosis were 44.5% and 51.1%, respectively. Multivariate analysis showed that definitive surgery was the only significant prognostic factor in non-metastatic patients. The five year OS and disease-free survival (DFS) rates for non-metastatic patients who received definitive surgery were 64.3% and 60%, respectively. Among these patients, neoadjuvant and/or adjuvant chemotherapy significantly improved both OS and DFS.

CONCLUSIONS

Complete surgical resection and intensive chemotherapy should be performed for osteosarcoma patients > 40 years old despite distinct clinicopathological characteristics from those of younger patients.

Prognosis of Primary Osteosarcoma in Elderly Patients: A Comparison between Young and Elderly Patients

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.

Prognostic nomograms for predicting overall and cancer-specific survival of high-grade osteosarcoma patients

Aim

The present study aimed to develop nomograms estimating survival for patients with high-grade osteosarcoma.

Methods

1990 patients with high-grade osteosarcoma between 1994 and 2013 were retrospectively retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Data from 12 cancer registries (n = 1460) were used to conduct multivariate Cox analysis to identify independent prognostic factors. Nomograms which estimate 3- and 5-year overall survival (OS) and cancer-specific survival (CSS) were constructed. The nomograms were internally validated for calibration and were also externally validated with an independent patient cohort from 1 cancer registry (n = 530).

Results

Age, primary site, tumor size, use of surgery, and extent of disease were found to be independently associated with OS and CSS (p < 0.05). The nomograms estimating 3- and 5-year OS and CSS were developed based on these prognostic factors. The concordance indices were high in internal validation (0.726 for OS and 0.731 for CSS) and external validation (0.716 for OS and 0.724 for CSS). Internal and external calibration plots demonstrated a good agreement between nomogram prediction and actual observation.

Conclusions

We constructed nomograms that accurately predict OS and CSS of high-grade osteosarcoma patients. The nomograms can be used for counseling patients and establishing risk stratification.

The outcomes and prognostic factors in patients with osteosarcoma according to age: a Japanese nationwide study with focusing on the age differences

Background

Few reports have described clinical features, prognosis and prognostic factors of osteosarcoma patients according to age.

Methods

Using the Bone and Soft Tissue Tumor Registry in Japan, we identified 1043 osteosarcoma patients including 760 who were younger than 40 years, 173 aged between 41 and 64 years, and 110 patients older than 65 years. We extracted data on patient demographics and prognosis. Prognostic factors for patients older than 65 years or other age groups were analyzed.

Results

Patients older than 65 years showed a significantly higher proportion of tumors arising in the trunk and with metastasis at diagnosis, and their 5-year disease-specific survival (DSS) rate was 32.7%. Multivariate analysis showed that the presence of metastasis at diagnosis [hazard ratio (HR): 3.04; 95% confidence interval (CI), 1.63–5.69; P < 0.001] and tumors > 16 cm in size (HR: 2.84 compared with < 8 cm; 95% CI, 1.16–6.97; P = 0.023) were significantly associated with worse DSS. The 5-year DSS was 39.1% in 80 patients older than 65 years without metastasis at diagnosis. Methotrexate was used in only 5.0% of these patients. Adjuvant chemotherapy was not significantly associated with better DSS (P = 0.323) in this generation and aged between 41 and 64 years (P = 0.566), although adjuvant chemotherapy yielded significantly better survival in patients younger than 40 years (P < 0.001).

Conclusions

Analysis of this cohort of osteosarcoma patients revealed some unique clinical, therapeutic and prognostic features according to age groups in the largest cohort. Adjuvant chemotherapy was not associated with a better DSS in the group of patients aged between 41 and 64 years or older than 65 years.

Primary Osteosarcoma in the Elderly Revisited: Current Concepts in Diagnosis and Treatment

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.

Primary bone sarcomas in patients over 40 years of age: A retrospective study using data from the Bone Tumor Registry of Japan

BACKGROUND

Optimal treatments of patients aged >40 years with osteosarcoma and Ewing sarcoma and of patients with other types of bone sarcoma have not yet been established.

METHODS

The clinical characteristics of 746 patients with primary bone sarcomas aged >40 years listed in the nationwide tumor registry (Bone and Soft Tissue Tumor Registry of Japan) were investigated. Patients with Ewing sarcoma, conventional chondrosarcoma, multiple myeloma, and malignant lymphoma were excluded. The effects of adjuvant chemotherapy were determined by comparing outcomes in patients aged 40-70 years with non-metastatic high grade bone tumors who received surgery plus chemotherapy with those who underwent surgery alone.

RESULTS

Axial site tumors (38.6%) and distant metastasis at presentation (21.4%) were frequent in patients aged >40 years with primary bone sarcomas. Chemotherapy was administered to 407 (54.6%) patients. Their 5-year overall survival (OS) and progression free survival (PFS) rates were 47.6% and 39.8%, respectively. Multivariate analysis showed that distant metastases at presentation, histological high grade, and radiation therapy were significantly correlated with both OS and PFS. Age and tumor size were also significantly correlated with OS. Patients aged 40-70 years who underwent surgery plus chemotherapy and those who underwent surgery alone had 5-year OS rates of 69.3% and 63.2%, respectively (p = 0.092), and 5-year PFS rates of 55.4% and 50.7%, respectively (p = 0.63).

CONCLUSIONS

Bone sarcoma patients aged >40 years had distinct clinical features and a poor prognosis. Chemotherapy did not improve OS or PFS in patients aged 40-70 years.

Chemotherapy for Bone Sarcoma in Adults

The largest studies of chemotherapy for bone sarcomas are in the pediatric population. Although increasing age is often found to be an adverse prognostic factor in these clinical trials, few studies are aimed at assessing regimens specifically in the adult population. Osteosarcoma and Ewing sarcoma have peak incidences in the pediatric and young adult population but also occur in adults. Chondrosarcoma and giant cell tumor of bone are generally found in adults. In this review, we describe the current status of our knowledge about treating adults with cancers of bone origin. We also describe our experience treating patients in the adult Sarcoma Medical Oncology group at The University of Texas MD Anderson Cancer Center.

Prevalence of Metastasis at Diagnosis of Osteosarcoma: An International Comparison

BACKGROUND

Osteosarcoma (OS) is the most common primary malignant bone tumor in many countries, with metastatic disease responsible for most patient deaths. This study compares the prevalence of metastatic OS at diagnosis across countries to inform the critical question of whether diagnostic delay or tumor biology drives metastases development prior to diagnosis.

PROCEDURE

A literature search of the PubMed database was conducted to compare the prevalence of metastatic disease at the time of OS diagnosis between countries. A pooled prevalence with 95% confidence intervals was calculated for each study meeting inclusion criteria. Studies were grouped for analysis based on human development index (HDI) scores.

RESULTS

Our analysis found an 18% (95% confidence interval [CI]: 15%, 20%) average global pooled proportion of metastasis at OS diagnosis. The average prevalence of metastasis at diagnosis increased as HDI groupings decreased, with very high HDI, high HDI, and medium/low HDI groups found to be 15% (95% CI: 13%, 17%), 20% (95% CI: 14%, 28%), and 31% (95% CI: 15%, 52%), respectively.

CONCLUSIONS

Our evidence suggests there is a biological baseline for metastatic OS at diagnosis, which is observed in countries with very high HDI. In countries with medium/low HDI, where there are more barriers to accessing healthcare, the higher prevalence of metastasis may result from treatment delay or an artificial prevalence inflation due to patients with less severe symptoms not presenting to clinic. Additional research in countries with medium/low HDI may reveal that earlier detection and treatment could improve patient outcomes in those countries.

Chemotherapy for bone sarcomas in adults: the MD anderson experience

Increasing age is an adverse prognostic factor in the treatment of primary bone tumors. There are few published data on treatment of primary bone tumors in adults. This paper presents data from the Department of Sarcoma Medical Oncology at The University of Texas MD Anderson Cancer Center, summarizing our treatment results. To treat primary osteosarcoma, we used 90 mg/m2 of doxorubicin as a continuous intravenous infusion over 48 to 96 hours and 120 to 160 mg/m2 of cisplatin intravenously or intra-arterially. Initially, we found a marked difference in postoperative continuous disease-free survival (CDFS) between those with 90% or greater (i.e., good response) tumor necrosis and those with less than 90% (i.e., poor response) tumor necrosis. The sequential addition of high-dose methotrexate and ifosfamide to patients with poorly responding disease improved their CDFS to that of patients with good response. Older patients and those who have tumors with variant histology have inferior outcomes. Evaluation of subsequent patients revealed similar outcomes for those with good or poor response to induction therapy, supporting our practice of adaptation of postoperative chemotherapy to the results of preoperative chemotherapy. PET-CT is the best imaging modality to screen for a response with tumors inside bone. To treat Ewing sarcoma, we have employed 2 mg of vincristine, 75 to 90 mg/m2 of doxorubicin as a 72-hour infusion, and 2.5 g/m2 of ifosfamide over 3 hours daily for 4 doses (i.e., vincristine, doxorubicin, and ifosfamide [VAI]). Preliminary analysis indicates a higher CDFS when adjusted for patient age than seen with the standard alternating regimen used in pediatrics. A screening MRI of the pelvis and spine can detect subtle metastatic disease in bone or bone marrow that is missed by other imaging modalities or blind biopsy. Chondrosarcoma is treated surgically or on investigational protocols. Giant cell tumor of bone is usually managed surgically, but multiple options exist for medical treatment, and therapy is individualized with embolization, denosumab, and interferon.

Update on Survival in Osteosarcoma

Osteosarcoma is the most common primary bone malignancy in children. Treatment has evolved to include systemic chemotherapy and local control surgery. Although survival improved initially in a drastic fashion with this approach, recent decades have seen little to no further gains in this area. Limb salvage surgery evolved with effective chemotherapy and advances in imaging, and continues to improve in the recent era. This article serves as a review of survival in high-grade osteosarcoma: prognostic factors, advances in chemotherapy and surgery, late effects of chemotherapy and surgery in survivors, and future directions.

Current status of publicly available sarcoma cell lines for use in proteomic studies

Cell lines are valuable resources for proteomic studies and can be used as tools to verify the significance of proteomic findings. Here, the authors overview the current status of the publicly available sarcoma cell lines. The authors surveyed seven major cell banks and found that the diversity observed in the sarcoma cell banks was largely insufficient; sarcoma cell lines are available for only a limited histological subtype. They also observed a number of issues with the pathological diagnosis of the cell lines, limitations in their behavioral diversity, and various unmet needs. Well characterized cell lines with accurate diagnosis based on modern diagnosis criteria should be available from public cell banks. The authors conclude that additional cell lines, along with detailed genetic and pathological analyses, should be prepared and deposited in order to promote sarcoma-specific proteomic research. The authors focused on sarcoma cell lines, but their discussion can be applied to the other cancers.

An update on chemotherapy for osteosarcoma

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Perioperative chemotherapy in the treatment of osteosarcoma: a 26-year single institution review

Background

Chemotherapy in the multimodality treatment of osteosarcoma has improved survival. Reported outcomes on adult patients are limited. Poor necrosis rates post neoadjuvant chemotherapy (NAC) is considered an adverse prognostic factor and attempts have been made to improve survival in this group.

Patients and methods

Adult and young adult patients diagnosed with osteosarcoma between January 1986 and August 2012 were retrospectively reviewed. Patients identified were stratified according to stage (localised or metastatic) and age (≤40 and >40 years). Event free survival (EFS) and overall survival (OS) outcomes were determined. In patients with localised disease ≤40 years, survival was assessed according to necrosis rates post NAC (<90 and ≥90%). NAC consisted of two cycles of methotrexate alternating with doxorubicin/cisplatin (MAP) followed by definitive surgery. Those with ≥90% tumour necrosis continued on MAP. Patients with <90% necrosis received ifosfamide and etoposide (IE) post operatively.

Results

A total of 108 patients were reviewed and 97 were included. Median age was 23 years (range 16–75) and 70% of patients were male. Five year EFS and OS across all groups was 57% and 63% respectively. Of the patients with localised disease (N = 81), 5-year overall survival (OS), with a median follow up of 7 years (2–26) was 70% (p < 0.0001). Patients aged 16–40 (N = 68) with localised osteosarcoma had a significantly improved 5-year OS (74%) compared to those >40 years (N = 13) (42%) (p = 0.004). Of the 68 patients with localised osteosarcoma ≤40 years, 62 were evaluated according to necrosis rates post MAP. In 33 patients who achieved ≥90% necrosis and continued MAP, 5-year OS was 82%. In 29 patients who had <90% tumour necrosis and received adjuvant IE, 5-year OS was 68% (p = 0.15). Multivariate analysis confirmed age and stage as prognostic factors but not poor necrosis rates in our treated population.

Conclusions

Long-term survival outcomes in a predominantly adult Irish population are similar to large reported trials. Age and stage at diagnosis are prognostic. Postoperative ifosfamide/etoposide alone in patients with poor necrosis rates is a feasible regimen, but its role in the adjuvant setting remains uncertain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13569-015-0032-0) contains supplementary material, which is available to authorized users.

Osteosarcoma in Asian Populations Over the Age of 40 Years: A Multicenter Study

BACKGROUND

Elderly patients with osteosarcoma (OSA) are no longer uncommon; however, many questions remain regarding this population. We investigated the clinicopathological characteristics and prognostic factors of OSA in an Asian population over the age of 40 years.

METHODS

This was a multi-national, multi-institutional study by the Eastern Asian Musculoskeletal Oncology Group (EAMOG).

RESULTS

A total of 232 patients were enrolled (116 males and 116 females), with a median age of 50 years at diagnosis; 25 (10.8 %) patients exhibited initial metastasis. Median follow-up was 52 months for survivors. We observed 102 osteolytic and mixed radiographic findings for 173 lesions. Histological subtypes other than osteoblastic type were frequent. Radiation-associated OSA was seen in seven patients, with a 5-year overall survival (OS) of 16.7 %. No Paget's OSA was observed. High-grade spinopelvic OSA was seen in 29 (12.5 %) patients. The 5-year OS was 59.4 % in patients without initial metastasis and 45.2 % in patients with spinopelvic OSA. While surgery and initial metastasis were common prognostic factors for OS, chemotherapy was not. Histologic response to neoadjuvant chemotherapy was poor in 61 of 83 patients.

CONCLUSION

This study revealed distinct clinicopathological features of OSA patients over 40 years of age compared with younger patients, such as the high incidence of axial tumors, common osteolytic and mixed radiographic findings, the high frequency of unusual histologic subtypes, and poor prognosis. Contrary to Western elderly patients with OSA, there was no Paget's OSA in this study, which may result in a lower incidence of secondary OSA. Prognostic factor analyses demonstrated chemotherapy did not influence OS.

Clinical characteristics and evolution of giant cell tumor occurring in Paget's disease of bone

Patients with Paget's bone disease (PDB) have an increased risk of developing giant cell tumor (GCT). This study was performed to evaluate the clinical characteristics and evolution of GCT complicating PDB and to compare these clinical characteristics to those observed in two large PDB cohorts, the PDB Italian Registry and the United Kingdom's Multi-Centre Randomised Controlled Trial of Symptomatic Versus Intensive Bisphosphonate Therapy for Paget's Disease (PRISM) study. A systematic literature review identified 117 cases of PDB complicated by GCT (PDB-GCT), which involved the skeletal sites affected by PDB (110 patients) or the extraskeletal tissues adjacent to affected bones (7 patients). In contrast to what previously reported for GCT patients without GCT patients (83.2%) were white and one-fourth of them (24.8%) had multifocal GCTs. Compared to PDB patients without GCT, PDB-GCT patients showed a higher male/female ratio (2.1 versus 1.2) and more severe disease (age at PDB onset 52.1 ± 12.1 versus 63.3 ± 10.6 years; number of affected sites 6.1 ± 2.9 versus 2.34 ± 1.6; prevalence of polyostotic PDB 93.3% versus 60.6%). The mortality rate of PDB-GCT patients was higher than those occurring in GCT patients without PDB (about 50% versus 0% to 5% at 5 years) or in PDB patients without GCT (log rank = 29.002). Moreover, up to 98% of PDB-GCT cases had elevated total alkaline phosphatase levels at neoplasm diagnosis, suggestive of active PDB. Importantly, PDB-GCT patients from Southern Italy (45.6% of all GCT patients) showed a higher prevalence of multifocal GCT (51.7%) and of positive familial history for PDB (70.8%) and GCT (65.0%). Finally, indirect evidence suggests a decline in the incidence of GCT in PDB patients. The occurrence of GCT in PDB patients is associated with severe disease and reduced life expectancy of affected patients. The increased prevalence of familial diseases in PDB-GCT patients from Southern Italy suggests a founder effect. The observed changes over time in the incidence of GCT in PDB patients could be related to improved clinical management and/or living conditions of patients.

Diaphyseal osteosarcomas have distinct clinical features from metaphyseal osteosarcomas

AIMS

The aim of this study was to clarify the clinical features and outcomes of diaphyseal osteosarcoma.

METHODS

Patients with newly-diagnosed high-grade osteosarcoma occurring in the long bone were eligible for this retrospective study. Clinicopathological information was collected from our database and compared with 36 diaphyseal, 405 proximal and 519 distal metaphyseal, and 14 whole bone osteosarcoma patients. Additionally, case-control study matching by age, gender, site, and metastatic status at diagnosis with 1:3 ratio of 36 diaphyseal to 108 metaphyseal osteosarcomas patients was also conducted.

RESULTS

Five-year overall survival and metastasis-free survival of the three groups including diaphyseal, metaphyseal, and whole bone osteosarcoma patients showed significant difference (P = .029 and P = .013, respectively), although there is no difference for the survivals between proximal and distal metaphyseal osteosarcoma patients. Case-control study showed that patients with diaphyseal osteosarcomas had a significantly larger tumour (mean 13.5 cm vs 10 cm, P = .026), and demonstrated higher pathologic fracture rate (28% vs 12%, P = .033), superior 5-year metastasis-free survival (74% vs 40%, P = .0068), and slightly better 5-year overall survival (68% vs 46%, P = .074). Prognostic factor analysis showed that a pathologic fracture significantly decreased the survival of the patients with diaphyseal osteosarcoma.

CONCLUSIONS

The current study showed that diaphyseal osteosarcoma has distinct clinical features from metaphyseal osteosarcoma having an increased risk of pathologic fractures but with favorable survival outcome.

Single institution retrospective review of perioperative chemotherapy in adult and adolescent patients with operable osteosarcoma

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.