Preoperative surgical risk stratification in osteosarcoma based on the proximity to the major vessels

Prognostic factors of the synovial sarcoma of the extremities: imaging does matter

OBJECTIVES

Synovial sarcomas (SS) of the extremities are rare soft tissue sarcomas that are more common in young adults. We deciphered the imaging phenotype of SS with the aim to determine if imaging could provide an incremental value to currently known prognostic factors (PF)-age and histological grade-to predict long-term overall survival (OS).

METHODS

This retrospective multicenter study included consecutive pediatric and adult patients with synovial sarcomas of the extremities from December 2002 to August 2020. Inclusion criteria were (i) a follow-up greater than 5 years and (ii) available pre-therapeutic MRI. A subset analysis included MRI and CT-scan. Clinical, pathological, and imaging variables were collected in all patients. The primary endpoint was to evaluate the association of these variables with OS using univariate and multivariate Cox regressions.

RESULTS

Out of 428 patients screened for eligibility, 98 patients (mean age: 37.1 ± 15.2 years) were included (MRI: n = 98/98, CT scan: n = 34/98; 35%). The median OS was 75.25 months (IQR = 55.50-109.12) and thirty-six patients (n = 36/98;37%) died during follow-up. The recurrence rate was 12.2% (n =12/98). SS lesions were mostly grade 2 (57/98; 58%). On MRI, SS had a mean long-axis diameter of 67.5 ± 38.3 mm. On CT scan, 44% (15/34) were calcified. Grade (hazard ratio [HR] = 2.71; 95%CI = 1.30-5.66; p = 0.008), size of the lesions evaluated on MRI (HR = 1.02; 95% CI = 1.01-1.03; p < 0.001), and calcifications on CT scan (HR = 0.10; 95% CI = 0.02-0.50; p = 0.005) were independent PF of OS.

CONCLUSIONS

This study demonstrated that imaging biomarkers can be used to predict long-term outcome in patients with SS. Strikingly, the presence of calcifications on CT scan is associated with favorable outcome and provides an incremental value over existing PF such as age, grade, and size.

KEY POINTS

• Beyond its diagnostic value, MRI is a pre-operative prognostic tool in synovial sarcomas of the extremities since the size of the lesion is an important prognostic factor. • Calcifications on CT scans are independently and significantly associated with prolonged overall survival.

A classification system of joint-salvage tumor resection in osteosarcoma of the knee: A retrospective cohort study

BACKGROUND

Joint-preserving surgery is possible for patients with juxta-articular osteosarcoma of the knee, even when the tumor invades the epiphysis. Oncologic and functional outcomes may vary due to the extent of tumor invasion, the amount of epiphysis preservation, and reconstruction methods. We aimed to introduce a novel classification facilitating clinical evaluation of different surgical treatments.

METHODS

We identified 52 patients with osteosarcoma of the knee undergoing joint-preserving tumor resection and intercalary reconstruction. We classified procedures into two types and six subtypes based on the tumor location and adjuvant treatment employed. Oncologic outcomes, limb function and complications were compared among different types.

RESULTS

None of the patients had a local recurrence in the preserved epiphysis apart from three (5.7 %) who had local recurrence in soft tissue. Overall survival rate of the patients was 82.7 % at 5 and 10 years. There was no difference in survival rate (P = 0.909), local recurrence (P = 0.642) between type I (tumor not invading epiphysis) and type II (tumor invading epiphysis). In addition to one skin necrosis in the 3D-printed prosthesis reconstruction and one infection in Capanna reconstruction, all complications necessitating additional surgery occurred in allograft. The Musculoskeletal Tumor Society (MSTS) scores ranged from 21 to 30 with a median of 26. There were differences in the MSTS scores among six subgroups (P = 0.015), with the highest in type Ia and the lowest in type IIc. The less of the viable epiphysis retained, the worse the knee function was at long-term follow up.

CONCLUSIONS

The suggested classification can guide surgical strategy and is convenient for comparison of the functional results.

A Planned Multidisciplinary Surgical Approach to Treat Primary Pelvic Malignancies

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

Mediating effect assessment of ifosfamide on limb salvage rate in osteosarcoma: A study from a single center in China

Osteosarcoma is one of the most prevalent primary bone malignancies in children and adolescents. Surgery and chemotherapy are the standard treatment methods of osteosarcoma. Methotrexate, adriamycin, and cisplatin, and methotrexate, adriamycin, cisplatin, and ifosfamide regimens are both first-line neoadjuvant chemotherapy regimens for osteosarcoma. Moreover, the use of ifosfamide is highly controversial. Most studies of ifosfamide focused on the overall survival rate and event-free survival rate; few studies concentrated on surgical options. We conducted this retrospective study to compare the baseline characteristic of amputation and limb salvage osteosarcoma patients. Furthermore, we analyzed the direct and indirect roles in surgical decision-making and found that ifosfamide may play a partial mediating role in the surgery option choice by mediating tumor mass volume change, tumor response, and the shortest distance from the center of main blood vessels to the margin of the tumor lesion.

Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity

BACKGROUND/PURPOSE

Limb preserving surgery for the treatment of patients with osteosarcoma younger than 10 years old is challenging and some authors have advocated amputation to reduce the risk of complications. The aim of this study was to compare the clinical outcomes and surgical complications of patients with osteosarcoma of the extremity aged <10 years old who were treated with limb salvage and amputation.

PATIENTS AND METHODS

Retrospective review of patients aged <10 years old who were treated for primary osteosarcoma of bone between 2000 and 2018.

RESULTS

We analyzed 82 consecutive patients (32 males, 50 females; median age 8, range 3-9 yrs). Limb-salvage surgery (LSS; n = 65, 79%) and amputation (n = 17, 21%) were performed. Fourteen patients had metastasis at surgery. In patients without metastasis at surgery, the metastasis-free and overall survival rates at 5 years following LSS vs. amputation were 75% vs. 58% (p = 0.162) and 71% vs. 55% (p = 0.516), respectively. The 2-year and 5-year OS rates of the LSS and amputation groups of patients with metastasis at surgery were 88% versus 83% and 50% versus 0%, respectively (p = 0.180). The overall complication rates were 46% post-LSS with 31% requiring re-operation versus 12% post-amputation, with 6% requiring re-operation (p = 0.010).

CONCLUSION

The prognosis of patients with localized osteosarcoma aged <10 years undergoing LSS is similar to those treated with amputation, but LSS is associated with a higher risk of complications and subsequent re-operation.

LEVEL OF EVIDENCE

Level III.

Pediatric Osteosarcoma: Correlation of Imaging Findings with Histopathologic Features, Treatment, and Outcome

Osteosarcoma is the most common primary bone sarcoma in children. Imaging plays a pivotal role in diagnostic workup, surgical planning, and follow-up monitoring for possible disease relapse. Survival depends on multiple factors, including presence or absence of metastatic disease, chemotherapy response, and surgical margins. At diagnosis, radiography and anatomic MRI are used to characterize the primary site of disease, whereas chest CT and whole-body bone scintigraphy and/or PET are used to identify additional sites of disease. Treatment starts with neoadjuvant chemotherapy, followed by en bloc tumor resection and limb reconstruction, and finally, adjuvant chemotherapy. Preoperative planning requires precise tumor delineation, which traditionally has been based on high-spatial-resolution anatomic MRI to identify tumor margins (medullary and extraosseous), skip lesions, neurovascular involvement, and joint invasion. These findings direct the surgical approach and affect the options for reconstruction. For skeletally immature children, the risk of cumulative limb-length discrepancy and need for superior longevity of the reconstruction have led to the advent and preferential use of several pediatric-specific surgical techniques, including rotationplasty, joint preservation surgery, autograft or allograft reconstruction, and extendible endoprostheses. A better understanding of the clinically impactful imaging features can directly and positively influence patient care. Online supplemental material is available for this article. ^©RSNA, 2022.

Prevalence, Risk Factors, and Prognostic Factors of Primary Malignant Bone Neoplasms with Bone Metastasis at Initial Diagnosis: A Population-Based Study

Background. Bone metastasis (BM) has been proven to be responsible for the poor prognosis of primary malignant bone neoplasms (PMBNs). We aimed to identify the prevalence, risk factors, and prognostic factors for PMBNs patients with BM based on the Surveillance, Epidemiology, and End Results (SEER) database. Methods. 4,758 patients diagnosed with PMBNs from 2010 to 2018 were selected from the SEER database. All patients were divided into two groups: the BM group or the non-BM group. Pearson’s chi-square test and Fisher’s exact method were used to assess baseline characteristics, and logistic regression analysis was applied to assess risk factors. In addition, a nomogram was constructed based on the results of Cox regression analysis among 227 patients with BM. The good performance and clinical applicability of the nomogram were tested by the concordance index, operating characteristic curve, area under the curve, calibration curves, and decision curve analysis. Results. 227 (4.8%) patients had metastasis to bone at diagnosis. Primary site outside the extremities (axial: odds ratio, $\text{OR}=1.770$ ; others: $\text{OR}=1.951$ ), Ewing sarcoma ( $\text{OR}=2.845$ ), larger tumor size (5–8 cm: $\text{OR}=3.403$ ; >8 cm: $\text{OR}=5.562$ ), tumor extension beyond the periosteum ( $\text{OR}=2.477$ ), and regional lymph node metastasis ( $\text{OR}=2.900$ ) were associated with a higher risk of BM at the initial diagnosis of PMBNs. Five independent prognostic factors were found in the survival analysis: pathological type (chondrosarcoma vs. osteosarcoma: hazard ratio, $\text{HR}=0.342$ ; Ewing sarcoma vs. osteosarcoma: $\text{HR}=0.592$ ; and chordoma vs. osteosarcoma: $\text{HR}=0.015$ ), marital status ( $\text{HR}=2.457$ ), pulmonary metastasis ( $\text{HR}=1.934$ ), surgery at the primary site ( $\text{HR}=0.164$ ), and chemotherapy ( $\text{HR}=0.084$ ). A nomogram based on these prognostic factors could be a good predictor of cancer-specific survival. Conclusions. We identified the prevalence, risk factors, and prognostic factors correlated with BM in PMBNs patients. The related nomogram could be a practical tool for therapeutic decision-making and individual counseling.

A meta-analysis comparing efficiency of limb-salvage surgery vs amputation on patients with osteosarcoma treated with neoadjuvant chemotherapy

Osteogenic sarcoma is the central malignant bone neoplasm affecting the bones of arms and legs and rarely the soft tissues outside the bones. Historically, amputation was the chief surgical technique; currently, the popular standard is limb salvage surgery (LSS), although both procedures' effect on 5‐year‐event survival, 5‐year disease‐free survival rates (DFS) and the local recurrence is uncertain. Therefore, this meta‐study aimed to establish the relationship between the effect of LSS and amputation in subjects with osteogenic carcinoma. A systematic survey till January 2021 to know the effect of LLS vs amputation with subjects treated with neoadjuvant chemotherapy was conducted. Clinical studies were identified with 9760 subjects with osteosarcoma of the extremities at the beginning of the trial; 7095 of them were managed with limb salvage surgery and 2611 with amputation. This study tried to compare the effects of LSS vs amputation in subjects with osteogenic sarcoma in the extremities. The dichotomous method in statistical analysis was used as a tool for establishing odds ratio (OR) at a confidence interval of 95% (CI) to assess the efficiency of LSS and amputees with osteosarcoma of the extremities with a fixed or random‐effect model. Although patients with osteosarcoma of the extremities managed with LSS were significantly related to a higher local recurrence rate than those treated with amputation, they were also associated with higher 5‐year overall survival (OS) than amputation. Patients showed no significant difference in a 5‐year DFS rate between LSS vs amputation. The subjects who have undergone LSS for osteosarcoma of the extremities may have a higher risk of local recurrence than amputees. However, LSS may increase 5‐year OS compared to amputees. These results depict that local recurrence of osteosarcoma does not influence survival rate. However, more studies are needed to validate this finding.

Current approaches to management of bone sarcoma in adolescent and young adult patients

Bone tumors are a group of histologically diverse diseases that occur across all ages. Two of the commonest, osteosarcoma (OS) and Ewing sarcoma (ES), are regarded as characteristic adolescent and young adult (AYA) cancers with an incidence peak in AYAs. They are curable for some but associated with unacceptably high rates of treatment failure and morbidity. The introduction of effective new therapeutics for bone sarcomas is slow, and to date, complex biology has been insufficiently characterized to allow more rapid therapeutic exploitation. This review focuses on current standards of care, recent advances that have or may soon change that standard of care and challenges to the expert clinical research community that we suggest must be met.

Vascular Proximity Increases the Risk of Local Recurrence in Soft-Tissue Sarcomas of the Thigh-A Retrospective MRI Study

Simple Summary

Proximity to major vessels increases risk of local recurrence in soft tissue sarcomas of the thigh. When major vessels were observed to be surrounded by the tumor on preoperative MRI, vascular resection and by-pass reconstruction offered a better local control.

Abstract

The aim of this study was to establish the prognostic effects of the proximity of the tumor to the main vessels in patients affected by soft tissue sarcomas (STS) of the thigh. A total of 529 adult patients with deeply seated STS of the thigh and popliteal fossa were included. Vascular proximity was defined on MRI: type 1 > 5 mm; type 2 ≤ 5 mm and >0 mm; type 3 close to the tumor; type 4 enclosed by the tumor. Proximity to major vessels type 1–2 had a local recurrence (LR) rate lower than type 3–4 (p < 0.001). In type 4, vascular by-pass reduced LR risk. On multivariate analysis infiltrative histotypes, high FNLCC grade, radiotherapy administration, and type 3–4 of proximity to major vessels were found to be independent prognostic factors for LR. We observed an augmented risk of recurrence, but not of survival as the tumor was near to the major vessels. When major vessels were found to be surrounded by the tumor on preoperative MRI, vascular resection and bypass reconstruction offered a better local control.

Cryoablation-aided joint retention surgery for epiphysis involvement in osteosarcoma compared with endoprosthetic replacement

AIMS

We have previously reported cryoablation-assisted joint-sparing surgery for osteosarcoma with epiphyseal involvement. However, it is not clear whether this is a comparable alternative to conventional joint arthroplasty in terms of oncological and functional outcomes.

METHODS

A total of 22 patients who had localized osteosarcoma with epiphyseal involvement around the knee and underwent limb salvage surgery were allocated to joint preservation (JP) group and joint arthroplasty (JA) group. Subjects were followed with radiographs, Musculoskeletal Tumor Society (MSTS) score, and clinical evaluations at one, three, and five years postoperatively.

RESULTS

Patients in both groups (ten in JP and 12 in JA) did not differ in local recurrence (p ≥ 0.999) and occurrence of metastases (p ≥ 0.999). Overall survival was similar in both groups (p = 0.858). Patients in the JP group had less range of motion (ROM) of the knee (p < 0.001) and lower MSTS scores (p = 0.010) compared with those of the JA group only at one year postoperatively. There was no difference between groups either at three years for ROM (p = 0.185) and MSTS score (p = 0.678) or at five years for ROM (p = 0.687) and MSTS score (p = 0.536), postoperatively. Patients in the JA group tended to have more complications (p = 0.074). Survival of primary reconstruction in the JP group was better than that of the JA group (p = 0.030).

CONCLUSION

Cryoablation-aided joint-sparing surgery offers native joint preservation with comparable functional recovery and more durable reconstruction without jeopardizing oncological outcomes compared with conventional limb salvage surgery. Cite this article: Bone Joint J 2021;103-B(8):1421-1427.

Limb-salvage surgery offers better five-year survival rate than amputation in patients with limb osteosarcoma treated with neoadjuvant chemotherapy. A systematic review and meta-analysis

Background

Osteosarcoma is the most common primary bone sarcoma. Currently, the main treatment option for high-grade osteosarcomas is neoadjuvant chemotherapy, followed by surgical resection of the lesion and adjuvant chemotherapy. Limb salvage surgery (LSS) and amputation are the main surgical techniques; however, controversy still exists concerning the best surgical method. Our meta-analysis compared the effectiveness of LSS and amputation combined with neoadjuvant chemotherapy in patients with limb osteosarcoma, in terms of 5-year overall survival (OS), 5-year disease-free survival (DFS) and local recurrence rate.

Methods

Following the established methodology of PRISMA guidelines, a literature search was conducted in PubMed, Cochrane, Google Scholar from 1975 until January 2020. Two independent reviewers evaluated the study quality based on the Newcastle-Ottawa scale. Odds ratio and 95% confidence interval of the OS, DFS and local recurrence rate were calculated.

Results

Thirteen studies were finally included with a total of 2884 patients; 1986 patients undergone LSS and 898 amputations. Five-year overall survival was almost 2-fold in patients treated with LSS than those treated with amputation (OR: 1.99; 95% CI: 1.35-2.93; I² = 74%, p < 0.001). No difference was found in 5-year DFS between LSS patients and amputees (OR: 1.24; 95% CI: 0.55-2.79; I² = 67%, p = 0.01). The odds of local recurrence was numerically higher in LSS compared to amputation but not statistically significant (OR: 2.29; 95% CI: 0.95-5.53; I² = 47%, p = 0.05). However, the included studies did not clearly define differences in the stages of patients of the two groups.

Conclusion

Our study demonstrated that in patients with limb osteosarcoma treated with neoadjuvant chemotherapy, LSS is associated with a higher 5-year overall survival and the odds of local recurrence may be increased but these results should be interpreted with caution due to high heterogeneity.

Impact of chemotherapy-induced necrosis on event-free and overall survival after preoperative MAP chemotherapy in patients with primary high-grade localized osteosarcoma

AIMS

To assess the correlation between the histological response to preoperative chemotherapy and event-free survival (EFS) or overall survival (OS) in patients with high-grade localized osteosarcoma.

METHODS

Out of 625 patients aged ≤ 40 years treated for primary high-grade osteosarcoma between 1997 and 2016, 232 patients without clinically detectable metastases at the time of diagnosis and treated with preoperative high-dose methotrexate, adriamycin and cisplatin (MAP) chemotherapy and surgery were included. Associations of chemotherapy-induced necrosis in the resected specimen and EFS or OS were assessed using Cox model and the Pearson's correlation coefficients (r). Time-dependent receiver operating characteristic analysis was applied to determine the optimal cut-off value of chemotherapy-induced necrosis for EFS and OS.

RESULTS

OS was 74% (95% confidence interval (CI) 67 to 79) at five years. Median chemotherapy-induced necrosis was 85% (interquartile range (IQR) 50% to 97%). In multivariate Cox model, chemotherapy-induced necrosis was significantly associated with EFS and OS (hazard ratio (HR) = 0.99 (95% CI 0.98 to 0.99); p < 0.001 and HR = 0.98 (95% CI 0.97 to 0.99); p < 0.001, respectively). Positive correlation was observed between chemotherapy-induced necrosis and five-year EFS and five-year OS (r = 0.91; p < 0.001, and r = 0.85; p < 0.001, respectively). The optimal cut-off value of chemotherapy-induced necrosis for five-year EFS and five-year OS was 85% and 72%, respectively.

CONCLUSION

Chemotherapy-induced necrosis in the resected specimen showed positive correlation with EFS and OS in patients with high-grade localized osteosarcoma after MAP chemotherapy. In our analysis, optimal cut-off values of MAP chemotherapy-induced necrosis in EFS and OS were lower than the commonly used 90%, suggesting the need for re-evaluation of the optimal cut-off value through larger, international collaborative research. Cite this article: Bone Joint J 2020;102-B(6):795-803.

Intraoperative considerations in a patient with chondroblastic osteosarcoma and saddle pulmonary embolism undergoing amputation

In patients presenting to the operating room with a saddle pulmonary embolism for noncardiac surgery, it is best to take a multidisciplinary approach and involve the cardiac and vascular surgeons.

Clinical features and outcomes of primary bone and soft tissue sarcomas in adolescents and young adults

The aim of the present study was to investigate the clinical outcomes of adolescents and young adults with bone and soft tissue sarcomas. Records of seven male and six female patients aged 17-39 years with bone or soft tissue sarcomas were reviewed retrospectively; data on histology, size, location, grade/stage, treatment, recurrence, presence of metastasis, and prognosis were retrieved. Five-year survival rates were estimated using the Kaplan-Meier method and were compared according to age, sarcoma type, histological grade, and location. Seven and six patients had bone and soft tissue sarcomas, respectively. In terms of histology, patients with bone sarcomas included four with osteosarcoma, two with chondrosarcoma, and one with Ewing sarcoma of the bone. Of those with soft tissue sarcomas, three had liposarcomas, two had synovial sarcomas, and one each had Ewing sarcoma and leiomyosarcoma. The five-year survival rate of the cohort was 57.1%. Younger patients with sarcoma had poorer survival than older patients. Patients with high-grade sarcomas also had poorer survival than those with low-grade tumors. In addition, patients with trunk-located tumors had poorer survival than those with tumors in the extremities. These findings suggest that, younger adolescents and young adults with high-grade or trunk-located sarcomas require more aggressive treatment.