Prognostic factors in the survival of patients diagnosed with primary non-metastatic osteosarcoma with a poor response to neoadjuvant chemotherapy

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

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

Meta-analysis of the prognosis after surgical treatment of osteosarcoma complicated by pathologic fracture

AIM

To evaluate the prognosis of surgical treatment of osteosarcoma complicated by pathologic fracture.

MATERIALS AND METHODS

We searched articles in PubMed, Web of Science, and Embase for studies published up to January 1, 2022, that reported the surgical prognosis of osteosarcoma patients complicated with/without pathologic fracture. The specific outcome indicators used in the meta-analysis included the local recurrence rate (LRR), distant metastasis rate (DMR), overall survival (OS) rate and disease-free survival (DFS) rate after surgical treatment such as amputation or limb salvage in the pathologic fracture group and non-pathologic fracture group. Crude and adjusted Odds Ratio (OR) with 95% confidence intervals were used to compare data between the case group and control group. Fifteen studies and 3839 patients were included in the final meta-analysis.

RESULTS

The difference between the pathologic fractures group and the non-pathologic fracture group was not statistically significance in LRR analysis (OR = 1.27, 95% CI: 0.88-1.84, P > 0.05); however, a statistically significant difference was found between two groups in DMR (OR = 1.42, 95% CI: 1.03-1.95, P < 0.05). For survival rates, the following ORs were found: 3-year OS (OR = 1.71, 95% CI: 1.25-2.35, P < 0.05); 5-year OS (OR = 1.41, 95% CI: 1.06-1.87, P < 0.05); 3-year DFS (OR = 1.88, 95% CI: 1.20-2.94, P < 0.05); and 5-year DFS (OR = 1.49, 95% CI: 1.10-2.03, P < 0.05). The pooled estimate of OR is 1.48 (95% CI: 0.72-3.04, P > 0.05) for local recurrence and 1.82 (95% CI: 0.92-3.60, P > 0.05) for distant metastasis in the amputation group and the limb salvage group for osteosarcoma patients with pathologic fractures, respectively. Our analysis indicated that patients with a pathologic fracture have a higher risk of DMR after surgery, but there is no significant difference in LRR between patients with a pathologic fracture and without. Additionally, in osteosarcoma patients with a pathologic fracture, there was no difference in LDR or DMR between limb-salvage surgery and amputation.

CONCLUSION

Complicated with pathologic fracture is a negative prognostic indicator of osteosarcoma, and its poor survival rates (both OS and DFS) may be associated with a higher DMR. For osteosarcoma patients with pathologic fractures treated with standard treatment, LRR and DMR exhibit no significant difference between amputation and limb-salvage surgery.

Loading and Releasing Behavior of Selenium and Doxorubicin Hydrochloride in Hydroxyapatite with Different Morphologies

Doxorubicin (Dox)-loaded or selenium-substituted hydroxyapatite (HA) has been developed to achieve anti-osteosarcoma or bone regeneration in a number of studies. However, currently, there is a lack of studies on the combination of Dox and selenium loading in/on HA and comparative research studies on which form and size of HA are more suitable for drug loading and release in the treatment osteogenesis after osteosarcoma resection. Herein, selenium-doped rod-shaped nano-HA (n-HA) and spherical mesoporous HA (m-HA) were successfully prepared. The doping efficiency of selenium and the Dox loading capacity of selenium-doped HA with different morphologies were studied. The release kinetics of Dox and the selenium element in phosphate-buffered saline with different pH values was also comparatively investigated. The drug loading results showed that n-HA exhibited 3 times higher selenium doping amount than m-HA, and the Dox entrapment efficiency of selenium-doped n-HA (0.1Se-n-HA) presented 20% higher than that of selenium-doped m-HA (0.1Se-m-HA). The Dox release behaviors of HA in two different morphologies showed similar release kinetics, with almost the same Dox releasing ratio but slightly more Dox releasing amount in selenium-doped HA than in HA without selenium. The selenium release from selenium-doped n-HA-D (0.1Se-n-HA-D) particles was 2 times as much as that of selenium-doped m-HA-D (0.1Se-m-HA) particles. Our study indicated that n-HA loaded with Dox and selenium may be a promising drug delivery strategy for inhibition of osteosarcoma recurrence and promoting osteogenesis simultaneously.

Radiologic Assessment of Osteosarcoma Lung Metastases: State of the Art and Recent Advances

The lung is the most frequent site of osteosarcoma (OS) metastases, which are a critical point in defining a patient’s prognosis. Chest computed tomography (CT) represents the gold standard for the detection of lung metastases even if its sensitivity widely ranges in the literature since lung localizations are often atypical. ESMO guidelines represent one of the major references for the follow-up program of OS patients. The development of new reconstruction techniques, such as the iterative method and the deep learning-based image reconstruction (DLIR), has led to a significant reduction of the radiation dose with the low-dose CT. The improvement of these techniques has great importance considering the young-onset of the disease and the strict chest surveillance during follow-up programs. The use of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is still controversial, while volume doubling time (VDT) and computer-aided diagnosis (CAD) systems are recent diagnostic tools that could support radiologists for lung nodules evaluation. Their use, well-established for other malignancies, needs to be further evaluated, focusing on OS patients.

Transepiphyseal resection for osteosarcoma in patients with open physes using MRI assessment

AIMS

For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy.

METHODS

We retrospectively reviewed 16 patients (seven male and nine female, mean age 12.2 years (7 to 16)) with osteosarcoma of the knee who had been treated by TER. We evaluated the MRI scans before and after neoadjuvant chemotherapy for all patients to assess the extent of the disease and the response to treatment.

RESULTS

The mean follow-up period was 64.3 months (25 to 148) after surgery and no patients were lost to follow-up. On MRI evaluation, 13 tumours were near but not in contact with the physes and three tumours were partially in contact with the physes before neoadjuvant chemotherapy. Bone oedema in the epiphysis was observed in eight patients. After neoadjuvant chemotherapy, bone oedema in the epiphysis disappeared in all patients. In total, 11 tumours were not in contact and five tumours were in partial contact with the physes. The postoperative pathological margin was negative in all patients. At the last follow-up, 12 patients were continuously disease-free and three had no evidence of disease. One patient died due to the disease. Functionally, the patients with retained allograft or recycled autograft had a mean knee range of flexion of 126° (90° to 150°). The mean Musculoskeletal Tumor Society functional score was 27.6 (23 to 30).

CONCLUSION

TER is an effective limb-salvage technique for treating malignant metaphyseal bone tumours in paediatric and young osteosarcoma patients with open physes when a good response to chemotherapy and no progression of the tumour to the epiphysis have been confirmed by MRI. Cite this article: Bone Joint J 2020;102-B(6):772-778.

Fibroblastic Subtype has a Favourable Prognosis in Appendicular Osteosarcoma of Dogs

Osteosarcoma (OS) is an aggressive malignant bone neoplasm that occurs mostly in the appendicular skeleton of dogs and people. OS is classified based on the presence of malignant stroma and the formation of extracellular matrix into osteoblastic, chondroblastic and fibroblastic forms. This study investigated the correlation between the three histological subtypes of canine OS and clinical outcome. Additionally, we examined whether there was any difference in the immunolabelling of desmin, S100 and neuron-specific enolase (NSE) between the three histological subtypes. Formalin-fixed and paraffin wax-embedded tissues from 87 dogs with primary OS were available for this study. The survival times were correlated with appendicular OS subtypes in dogs that were treated surgically, received adjuvant chemotherapy and had no pulmonary metastasis at the time of diagnosis. Dogs with an appendicular fibroblastic OS had significantly prolonged mean average survival times (546 ± 105 days) in comparison with dogs having appendicular osteoblastic (257 ± 48 days) or appendicular chondroblastic (170 ± 28 days) OS (P = 0.003, Log Rank). The results also revealed that the appendicular chondroblastic subtype is a significant indicator for poor prognosis in dogs compared with the fibroblastic or osteoblastic subtypes (P = 0.006, Cox regression). Moreover, the findings indicated that there was no significant correlation between the localization of desmin, NSE or S100 and histological subtypes. Importantly, dogs with appendicular fibroblastic OS were found to have a better prognosis when compared with dogs with other subtypes. This may suggest that histological subtypes of appendicular OS have diverse behaviour and could be used to categorize patients for risk-based assessment.

Clinical Significance of the Radiological Relationship between the Tumor and the main blood vessels in Enneking IIB Osteosarcoma of the extremities

Aim: Osteosarcoma is one of the most prevalent primary bone malignancies in children and adolescents. Magnetic resonance imaging (MRI) has been considered a very critical tool to provide anatomical information of tumor and surrounding main blood vessels. To evaluate the prognostic significance of the radiological vascular involvement according to the pre-treatment MRI in patients with Enneking IIB osteosarcoma. Methods: In this retrospective study, we included 482 patients younger than 50 years old with Enneking IIB primary osteosarcoma of the extremities with complete clinical records from 2005 to 2015.Univariate and multivariable analyses were conducted to identify the risk factors for OS (Overall survival) and EFS (Event-free survival). The correlations between the risk factors was performed using Spearman analysis. The Kaplan-Meier method was used to calculate survival curves. Based on the radiological relationship between the tumor lesion and the surrounding reactive area with the main blood vessels as shown on pretreatment MRI findings. Results: Radiological vascular involvement assessed via pretreatment MRI is an important risk factor for Enneking IIB primary patients with osteosarcoma (HR_OS=2.32/HR_EFS=1.81 P<0.01) according to the univariate and multivariable analyses. Enneking IIB patients with osteosarcoma were assigned to three subtypes based on the radiological relationship between the main blood vessels and the lesion or reactive area. The 5-year cumulative OS of patients classified by the three types were 81.6% (type I), 67.1% (type II) and 44.8% (type III)(P<0.01). The 5-year cumulative EFS of the three types were 60.2% (type I), 46.7% (type II) and 30.2% (type III)(P<0.05). The total 5-year cumulative OS and EFS for all patients were 68.3% and 48.3%, respectively. Conclusion: Vascular involvement according to radiological findings from pretreatment MRI is an independent risk factor for cumulative OS and EFS in patients with Enneking IIB primary osteosarcoma of the extremities. The new subtyping based on the relationship between the tumors and surrounding reactive area with the main blood vessels based on pretreatment MRI can predict the prognosis of patients with osteosarcoma and provide certain directive information for selecting the appropriate surgical procedure for individual patients.

Prognostic Factors for Development of Subsequent Metastases in Localized Osteosarcoma: A Systematic Review and Identification of Literature Gaps

Aim

To investigate prognostic factors in pediatric and young adult patients with localized osteosarcoma that could predict the development of subsequent pulmonary metastases and lead to an ability to risk-stratify therapy. We performed a systematic review of the literature published since January 1990 to establish common evidence-based prognostic factors.

Methods

PubMed and Embase searches (Jan 1990–Aug 2018) were performed. Two reviewers independently selected papers for patients with localized osteosarcoma with subsequent metastatic development and then reviewed for quality of methods and prognostic factors.

Results

Database searches yielded 216 unique results. After screening, 27 full-text articles were studied in depth, with 9 items fulfilling predetermined inclusion and exclusion criteria. Age, tumor location, tumor size/volume, and histologic response carried independent prognostic value in the majority of the studies.

Conclusions

Several prognostic factors seemed to be consistent amongst the studies, but the heterogeneity and smaller sizes of the study populations made pooling of results difficult. Standardization of larger patient populations and consistent definitions/cutoffs for prognostic factors are needed to further assess for consistent prognostic factors and potential predictive models to be developed.

Subcutaneous extraskeletal osteosarcoma of foot: A case report

•

Subcutaneous extraskeletal osteosarcoma is a rare high grade mesenchymal sarcoma.

•

The exact diagnosis can be established with histologic study.

•

Wide marginal resection is associated with a decreased risk of local recurrence and metastasis.

Introduction

Subcutaneous extraskeletal osteosarcoma (ESO) is a rare high grade malignant mesenchymal neoplasm consistent of approximately 1% of soft tissue sarcoma. Less than 10% of ESOs are superficial, originating in subcutis.

Presentation of case

We reported a 72 years old male with chief complain of a painless slowly growing soft tissue mass in his plantar aspect of right foot in the last 9 months before admission. The plain radiography showed a large subcutaneous soft tissue mass in plantar area and heel, Magnetic resonance images displayed an irregular subcutaneous soft tissue mass extending from posterior lower leg to ankle and involving calcaneus inferiorly. A percutaneous core biopsy of the mass, obtained. The histopathology examination confirmed an soft tissue osteosarcoma. Subsequent wide local excision of the mass performed. Final histopathological result was subcutaneous extraskeletal osteosarcoma.

Discussion

The patient has had no evidence of recurrence or/and distant metastasis at 25 months followed up. However, excising subcutaneous ESOs with a safe surgical margin is paramount for achieving the best outcome.

Conclusion

A subcutaneous ESO is a rare malignant tumor. We recommended that along with clinicohistological findings, radiological correlation is necessary for ruling out other diagnoses.

Treatment-Related Prognostic Factors in Managing Osteosarcoma around the Knee with Limb Salvage Surgery: A Lesson from a Long-Term Follow-Up Study

Purpose

The aim of this study was to assess the treatment-related factors associated with local recurrence and overall survival of patients with osteosarcoma treated with limb-salvage surgery.

Patients and Methods

Treatment-related factors were analyzed to evaluate their effects on local recurrence-free survival (LRFS) and overall survival (OS) in 182 patients from 2004 to 2013.

Results

The mean length of follow-up was 73.4 ± 34.7 months (median, 68 months; range, 12-173 months), and 63 patients died by the end of the follow-up. The 5-year and 10-year overall survival rates were 68.6 ± 6.6% and 59.4 ± 10.6%, respectively. Univariate analysis showed that treatment-related prognostic factors for overall survival were prolonged symptom intervals >=60 days, biopsy/tumor resection performed by different centers, previous medical history, incomplete preoperative chemotherapy (<8 weeks), and prolonged postoperative interval >21 days. In the multivariate analysis, biopsy/tumor resection performed by different centers, incomplete implementation of planned new adjuvant chemotherapy, and delayed resumption of postoperative chemotherapy (>21 days) were risk factors for poor prognosis; biopsy/tumor resection performed by different centers and tumor necrosis <90% were independent predictors of local recurrence.

Conclusion

For localized osteosarcoma treated with limb-salvage surgery, it is necessary to optimize timely standard chemotherapy and to resume postoperative chemotherapy to improve survival rates. Biopsies should be performed at experienced institutions in cases of developing local recurrence.

CEP55 promotes the proliferation and invasion of tumour cells via the AKT signalling pathway in osteosarcoma

The molecular mechanisms underlying the development of osteosarcoma (OS) are not fully understood. In this study, we investigated for the first time the clinical significance and biological activity of centrosomal protein 55 (CEP55) in OS. We found that CEP55 was overexpressed in OS, and the CEP55 expression level in OS was correlated with metastasis and poor prognosis. Through in vitro experiments, we confirmed that CEP55 knockdown significantly induced cell cycle arrest at G1 phase and suppressed OS cell proliferation, migration and invasion. In addition, CEP55 knockdown suppressed OS tumour growth in nude mice. Global gene expression profiling of CEP55-silenced MNNG/HOS cells showed that the AKT pathway might be involved in the regulation of OS cell activity. Two downstream factors of AKT signalling, CCND1 and FN1, were found to have significantly higher expression in tumour tissues, and their mRNA expression levels were strongly correlated with CEP55 expression. To conclude, our data suggest that CEP55 can be used as a prognostic marker for OS, highlighting the significance of CEP55 signalling as a putative therapeutic target.

Prognostic factors to survival of patients with chondroblastic osteosarcoma

This study was aimed to reveal the changes in survival rates and prognostic factors to survival of chondroblastic osteosarcoma (COS).Patients from the Surveillance, Epidemiology, and End Results (SEER) database were retrieved. Kaplan-Meier survival analysis and Cox proportional hazard model were used during analysis.There were significant differences on overall survival between subtypes of osteosarcoma (P < .001*). Overall survival of COS did not change significantly during last forty years (P = .610), and cancer-specific survival increased to a plateau in 1980s and then remained stable (P = .058). Younger onset age, patients of white race, well and moderately differentiated tumors, and surgery independently predicted better overall (Hazard ratio [HR]: 1.034, P < .001*; HR: 0.538, P = .004*; HR: 0.240, P = .020* and HR: 0.350, P < .001*, respectively) and cancer-specific (HR: 1.031, P = .002*; HR: 0.592, P = .036*; HR: 0.098, P = .027* and HR: 0.253, P < .001*, respectively) survival. Metastasis at diagnosis independently predicted worse overall (HR: 3.108, P < .001*) and cancer-specific (HR: 4.26, P < .001*) survival compared to no metastasis.Younger onset age, white race, well and moderately differentiated tumors, no metastasis at diagnosis and surgical resection can independently predict better overall and cancer-specific survival of COS.

MRI Identification of the Osseous Extent of Pediatric Bone Sarcomas

BACKGROUND

The quantitative accuracy of MRI in predicting the intraosseous extent of primary sarcoma of bone has not been definitively confirmed, although MRI is widely accepted as an accurate tool to plan limb salvage resections. Because inaccuracies in MRI determination of tumor extent could affect the ability of a tumor surgeon to achieve negative margins and avoid local recurrence, we thought it important to assess the accuracy of MR-determined tumor extent to the actual extent observed pathologically from resected specimens in pediatric patients treated for primary sarcomas of bone.

QUESTIONS/PURPOSES

(1) Does the quantitative pathologic bony margin correlate with that measured on preoperative MRI? (2) Are T1- or T2-weighted MRIs most accurate in determining a margin? (3) Is there a difference in predicting tumor extent between MRI obtained before or after neoadjuvant chemotherapy and which is most accurate?

METHODS

We retrospectively studied a population of 211 potentially eligible patients who were treated with limb salvage surgery between August 1999 and July 2015 by a single surgeon at a single institution for primary sarcoma of bone. Of 131 patients (62%) with disease involving the femur or tibia, 107 (51%) were classified with Ewing's sarcoma or osteosarcoma. Records were available for review in our online database for 79 eligible patients (37%). Twenty-six patients (12%) were excluded because of insufficient or unavailable clinical or pathology data and 17 patients (8%) were excluded as a result of inadequate or incomplete MR imaging, leaving 55 eligible participants (26%) in the final cohort. The length of the resected specimen was superimposed on preresection MRI sequences to compare the margin measured by MRI with the margin measured by histopathology. Arithmetic mean differences and Pearson r correlations were used to assess quantitative accuracy (size of the margin).

RESULTS

All MR imaging types were positively associated with final histopathologic margin. T1-weighted MRI after neoadjuvant chemotherapy and final histopathologic margin had the strongest positive correlation of all MR imaging and time point comparisons (r = 0.846, p < 0.001). Mean differences existed between the normal marrow margin on T1-weighted MRI before neoadjuvant chemotherapy (t = 8.363; mean, 18.883 mm; 95% confidence interval [CI], 14.327-23.441; p < 0.001), T2-weighted MRI before neoadjuvant chemotherapy (t = 8.194; mean, 17.204 mm; 95% CI, 12.970-21.439; p < 0.001), T1-weighted after neoadjuvant chemotherapy (t = 10.808; mean, 22.178 mm; 95% CI, 18.042-26.313; p < 0.001), T2-weighted after neoadjuvant chemotherapy (t = 10.702; mean, 20.778 mm; 95% CI, 16.865-24.691; p < 0.001), and the final histopathologic margin. T1-weighted MRI after neoadjuvant chemotherapy compared with the final histopathologic margin had the smallest mean difference in MRI-measured versus histopathologic margin size (mean, 5.9 mm; SD = 4.5 mm).

CONCLUSIONS

T1 MRI after neoadjuvant chemotherapy exhibited the strongest positive correlation and smallest mean difference compared with histopathologic margin. When planning surgical resections based on MRI obtained after neoadjuvant chemotherapy, for safety, one should account for a potential difference between the apparent margin of a tumor on an MRI and the actual pathologic margin of that tumor of up to 1 cm.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Factors associated with local recurrence in operated osteosarcomas: A retrospective evaluation of 95 cases from a tertiary care center in a resource challenged environment

BACKGROUND AND OBJECTIVES

Local control of disease is one of the main goals of osteosarcoma management. We conducted a retrospective evaluation of 95 operated cases of osteosarcoma over 7 years to know about the factors associated with local recurrence in resource-challenged environment of the developing world.

METHODS

The factors which were evaluated and compared between local recurrence and non-local recurrence groups included demographic profile, site of tumor, whether biopsy done outside, type of surgery (limb salvage or amputation), presence of pathological fracture, vicinity of neurovascular bundle, tumor volume, histological subtype, chemotherapy induced necrosis, surgical margins, and delay in surgery. The time to local recurrence after surgery was also noted in the local recurrence group.

RESULTS

At a mean follow-up of 2.8 years, biopsy done from outside the treating center and delay in surgery after completion of neo-adjuvant chemotherapy emerged as significant risk factors for local recurrence. Most of the local recurrences (80%) occurred within 12 months of the primary surgery.

CONCLUSIONS

Lack of financial resources and availability of few tertiary care centers dealing with musculoskeletal oncology in the developing countries, lead to overburden with a long waiting list for tumor surgery making the scenario different from the Western world.

Staged lengthening and reconstruction for children with a leg-length discrepancy after excision of an osteosarcoma around the knee

AIMS

Children treated for osteosarcoma around the knee often have a substantial leg-length discrepancy at skeletal maturity. The aim of this study was to investigate the results of staged skeletal reconstruction after a leg lengthening procedure using an external fixator in these patients.

PATIENTS AND METHODS

We reviewed 11 patients who underwent staged reconstruction with either an arthroplasty (n = 6) or an arthrodesis (n = 5). A control group of 11 patients who had undergone wide excision and concurrent reconstruction with an arthroplasty were matched for gender, location, and size of tumour. We investigated the change in leg-length discrepancy, function as assessed by the Musculoskeletal Tumor Society Scale (MSTS) score and complications.

RESULTS

A mean 5.2 cm (1.7 to 8.9) of lengthening was achieved. The mean MSTS scores significantly improved after staged reconstruction (p = 0.003) but were still worse than those of the control group (p = 0.049). However, the MSTS scores of the arthroplasty subgroup were comparable with those of the controls, although the extensor lag was greater and the range of movement was less. The patient group experienced more complications, but all of these resolved.

CONCLUSION

Approximately 5 cm of lengthening and significant functional improvement can be achieved by staged reconstruction and lengthening, without major complications. Although it has limitations, this method of treatment seems to be a satisfactory surgical option for growing children with a significant leg-length discrepancy after excision of an osteosarcoma around the knee. Cite this article: Bone Joint J 2017;99-B:401-8.

A Novel System for the Surgical Staging of Primary High-grade Osteosarcoma: The Birmingham Classification

BACKGROUND

Chemotherapy response and surgical margins have been shown to be associated with the risk of local recurrence in patients with osteosarcoma. However, existing surgical staging systems fail to reflect the response to chemotherapy or define an appropriate safe metric distance from the tumor that will allow complete excision and closely predict the chance of disease recurrence. We therefore sought to review a group of patients with primary high-grade osteosarcoma treated with neoadjuvant chemotherapy and surgical resection and analyzed margins and chemotherapy response in terms of local recurrence.

QUESTIONS/PURPOSES

(1) What predictor or combination of predictors available to the clinician can be assessed that more reliably predict the likelihood of local recurrence? (2) Can we determine a better predictor of local recurrence-free survival than the currently applied system of surgical margins? (3) Can we determine a better predictor of overall survival than the currently applied system of surgical margins?

METHODS

This retrospective study included all patients with high-grade conventional osteosarcomas without metastasis at diagnosis treated at one center between 1997 and 2012 with preoperative chemotherapy followed by resection or amputation of the primary tumor who were younger than age 50 years with minimum 24-month followup for those still alive. A total of 389 participants matched the inclusion criteria. Univariate log-rank test and multivariate Cox analyses were undertaken to identify predictors of local recurrence-free survival (LRFS). The Birmingham classification was devised on the basis of two stems: the response to chemotherapy (good response = ≥ 90% necrosis; poor response = < 90% necrosis) and margins (< 2 mm or ≥ 2 mm). The 5-year overall survival rate was 67% (95% confidence interval [CI], 61%-71%) and 47 patients developed local recurrence (12%).

RESULTS

Intralesional margins (hazard ratio [HR], 9.9; 95% CI, 1.2-82; p = 0.03 versus radical margin HR, 1) and a poor response to neoadjuvant chemotherapy (HR, 3.8; 95% CI, 1.7-8.4; p = 0.001 versus good response HR, 1) were independent risk factors for local recurrence (LR). The best predictor of LR, however, was a combination of margins ≤ 2 mm and a less than 90% necrosis response to chemotherapy (Birmingham 2b HR, 19.6; 95% CI, 2.6-144; p = 0.003 versus Birmingham 1a; margin >2 mm and more than 90% necrosis HR, 1). Two-stage Cox regression model and higher Harrell's C statistic demonstrate that the Birmingham classification was superior to the Musculoskeletal Tumor Society (MSTS) margin classification for predicting LR (Harrell's C statistic Birmingham classification 0.68, MSTS criteria 0.59). A difference in overall survival was seen between groups of the Birmingham classification (log-rank test p < 0.0001), whereas the MSTS margin system was not discriminatory (log-rank test p = 0.14).

CONCLUSIONS

Based on these observations, we believe that a combination of the recording of surgical margins in millimeters and the response to neoadjuvant chemotherapy can more accurately predict the risk of local recurrence than the current MSTS system. A multicenter collaboration study initiated by the International Society of Limb Salvage is recommended to test the validity of the proposed classification and if these findings are confirmed, this classification system might be considered the standard practice in oncology centers treating patients with osteosarcomas and allow more effective communication of margin status for research.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Do Surgical Margins Affect Local Recurrence and Survival in Extremity, Nonmetastatic, High-grade Osteosarcoma?

BACKGROUND

Long-term survival for all patients with osteosarcoma using current aggressive adjuvant chemotherapy and surgical resection is between 60% and 70%. In patients who present with nonmetastatic, high-grade extremity osteosarcoma of bone, limb salvage surgery is favored, when appropriate, over amputation to preserve the limb, because limb salvage may lead to a superior quality of life compared with amputation. However, concern remains that in the attempt to preserve the limb, close or microscopically positive surgical margins may have an adverse effect on event-free survival.

QUESTIONS/PURPOSES

(1) Does a positive or close surgical margin increase the likelihood of a local recurrence? (2) Does a positive or close surgical margin adversely affect the development of metastatic disease? (3) What is the relationship of surgical margin on overall survival?

METHODS

With institutional review board approval, we retrospectively evaluated 241 patients treated at our institution between 1999 and 2011. Exclusion criteria included nonextremity locations, metastatic disease at initial presentation, low- or intermediate-grade osteosarcoma, treatment regimens that did not follow National Comprehensive Cancer Network (NCCN) guidelines, incomplete medical records, and any part of treatment performed outside of Moffitt Cancer Center or All Children's Hospital. Fifty-one patients were included in the final analysis, of whom 31 (61%) had followup data at a minimum of 2 years or whose clinical status was known but had died before 2 years of followup. Margin status was defined as (1) microscopically positive; (2) negative ≤ 1 mm; and (3) negative > 1 mm. Margin status, histologic response (tumor percent necrosis), type of osteosarcoma, type of surgery, presence of local recurrence, metastatic disease, and overall survival were recorded for each patient. The mean age was 22 years (range, 12-74 years) and the mean followup was 3 years (range, 0.1-14 years). Margin status was positive in 10% (five of 51), negative ≤ 1 mm 26% (13 of 51), and negative > 1 mm 65% (33 of 51).

RESULTS

Local recurrence was noted to be 14% (seven of 51) at 3.4 years. After controlling for relevant confounding variables, the presence of a positive margin compared with a negative margin > 1 mm was the only independent predictor of local recurrence (hazard ratio [HR], 8.006; 95% confidence interval [CI], 1.314-48.781; p = 0.0241). At a mean of 3.4 years, 29% (15 of 51) of the patients developed metastatic disease with no difference with the numbers available in the probability of developing metastatic disease among the three margin groups (p = 0.614). Overall survival at 3.8 years was 75% (38 of 51). After controlling for relevant confounding variables, we found that patients with positive margins were more likely to die from disease than those with negative margins (HR, 6.26; 95% CI, 1.50-26.14; p = 0.0119); no other independent predictors of survival were identified.

CONCLUSIONS

With the numbers of patients we had, we observed that patients with extremity, nonmetastatic, high-grade osteosarcoma who had positive margins showed a higher probability of local recurrence in comparison to those with negative surgical margins. Given that positive margins appear to be associated with poorer survival in patients with high-grade osteosarcoma of the extremities, surgeons should strive to achieve negative margins, but larger studies are needed to confirm these findings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Forkhead box protein M1 predicts outcome in human osteosarcoma

PURPOSE

In the present study, we examined both FOXM1 mRNA and protein expression by Real-time quantitative PCR (qRT-PCR) and Western blot and investigate the expression of the human FOXM1 by Immunohistochemistry (IHC), and identify their potential roles in prognosis for patients with osteosarcoma.

METHODS

FOXM1 mRNA and protein expression levels were detected by RT-PCR and Western blot assays, respectively. Then, IHC was performed to analyze the association of FOXM1 expression in 83 osteosarcoma tissues with clinicopathological factors and survival of patients.

RESULTS

The expression levels of FOXM1 mRNA were found to be significantly increased in osteosarcoma tissues compared to noncancerous bone tissues (P = 0.0313). Simultaneously, western blot analysis showed that the protein level of FOXM1 in osteosarcoma tissues was significantly higher than that in noncancerous bone tissues. Kaplan-Meier analysis with the log-rank test indicated that high FOXM1 expression had a significant impact on overall survival (P = 0.0001).

CONCLUSIONS

Our data showed that FoxM1 was upregulated in osteosarcoma tissues, and high expression of FoxM1 was correlated with a poor prognosis of patients with osteosarcoma. FoxM1 may function as a valuable prognostic biomarker for osteosarcoma.

The importance of standardized treatment in high-grade osteosarcoma: 30 years of experience from a hospital-based database

BACKGROUND

Treatment of high-grade osteosarcoma remains a major challenge in orthopedic oncology as no major breakthrough in overall survival has occurred in the past 20 years. Due to the rarity of the disease, comparing the results of a single institution to best standard practice needs the establishment of clinical databases. The aim of this study was to report the cumulative 30-years' experience of a single institution and to assess the incidence, survival and prognostic factors of high-grade osteosarcoma using a recently validated, hospital-based database, representing all citizens living in western Denmark, the Aarhus Sarcoma Registry.

MATERIAL AND METHODS

Between 1979 and 2008, 169 patients were treated at the Sarcoma Centre of Aarhus University Hospital for high-grade osteosarcoma. The incidence was calculated as a WHO age-standardized incidence per million per year. The endpoint was overall survival, analyzed by the Kaplan-Meier method and log-rank. Possible prognostic factors were analyzed by the uni- and multivariate Cox proportional hazard method.

RESULTS

The incidence of high-grade osteosarcoma in western Denmark from 1979 to 2008 was 2.7/million inhabitants/year. The five-year overall survival was 42% (95% CI 34; 49) for the whole cohort of patients with high-grade osteosarcoma and 54% (95% CI 43; 64) for patients with localized disease treated with wide excision and chemotherapy. For patients treated with curative intent, no soft tissue extension, treatment with sufficient surgical margin and standard chemotherapy, as well as a high degree of necrosis after chemotherapy were all independent prognostic factors for overall survival.

CONCLUSION

The data from this hospital-based, validated database confirms the relevance of the known prognostic factors of high-grade osteosarcoma and emphasizes the importance of adequate surgical margins and chemotherapy.

High expression of MACC1 predicts poor prognosis in patients with osteosarcoma

Increasing evidence has demonstrated that high metastasis-associated in colon cancer-1 (MACC1) level is tightly associated with the development, progression, and poor prognosis of a variety of tumors. However, the relationship between MACC1 and the occurrence, development, and progression of osteosarcoma (OS) remains to be clarified. To facilitate and deepen the understanding of the associations of MACC1 with the development and progression of OS, in the current study, we detected the expressions of MACC1 mRNA and protein, and investigated the relationship between MACC1 expression and prognosis of the patients with OS. Our findings demonstrated that expressions of MACC1 mRNA and protein in OS tissues were significantly higher than those in paired normal bone tissues (P < 0.05). Additionally, the level of MACC1 mRNA in the patients with higher clinical stage and distant metastasis was markedly higher than those with lower clinical stage and without metastasis (P < 0.05). Furthermore, high MACC1 level was closely correlated with clinical stage and distant metastasis (P < 0.05), but not related to the patients' age, gender, tumor size, and anatomical location (P > 0.05). Stepwise investigation revealed that survival time of the patients with high MACC1 level was obviously lower than that with low MACC1 level (P < 0.05). Collectively, our data suggest that MACC1 may play important roles in the development and progression of OS, and thus may be considered as a novel molecular target for therapy of the patients with OS.

Increased expression of insulin-like growth factor-1 receptor is correlated with tumor metastasis and prognosis in patients with osteosarcoma

BACKGROUND

The aim of this study was to investigate the association of insulin-like growth factor-1 receptor (IGF-1R) with metastasis and prognosis of osteosarcoma patients.

METHODS

RT-PCR and Western blot assays were performed to detect IGF-1R mRNA and protein expression in 26 osteosarcoma and noncancerous bone tissues. Immunohistochemistry was performed to analyze the correlation of IGF-1R expression in 84 osteosarcoma tissues with clinicopathological factors or survival of patients. Lentivirus-mediated RNA interference system was employed to downregulate IGF-1R expression and analyze the effects of IGF-1R downregulation on invasion and metastasis of osteosarcoma cells.

RESULTS

The relative levels of IGF-1R mRNA and protein expression were significantly higher in osteosarcoma tissues than in corresponding noncancerous bone tissues. The expression of IGF-1R protein was closely associated with surgical stage and distant metastasis of osteosarcoma patients. Osteosarcoma patients with high IGF-1R expression had poorer survival, and multivariate Cox analyses showed that high IGF-1R expression was an independent prognostic maker. Lentivirus-mediated targeting IGF-1R could significantly inhibit adhesion, migration, invasion, and metastasis of osteosarcoma cells, which might be correlated with of inactivation of Akt signaling pathway.

CONCLUSIONS

IGF-1R is an independent prognostic marker for osteosarcoma patients and increased expression of this molecular is correlated with metastasis of osteosarcoma.

IS THERE ANY DIFFERENCE IN THE PROGNOSIS FOR PATIENTS WITH PRIMARY OSTEOSARCOMA WITH A POOR RESPONSE TO NEOADJUVANT CHEMOTHERAPY BETWEEN HUVOS GRADES I AND II?

Would there be any difference in the prognosis for patients who presented, for example, 8% or 88% tumor necrosis induced by chemotherapy, even though both individuals were considered to be poor responders? The aim of this study was to compare the prognoses for different histological grades (Huvos grade I versus grade II), consequent to chemotherapy, among patients with primary osteosarcoma that was not metastatic at diagnosis.

METHODS

Twenty-four patients admitted to a referral center between 2000 and 2004 were selected for the study. The accumulated chances of survival were calculated using the Kaplan-Meier technique. Huvos grades I and II for necrosis consequent to chemotherapy were evaluated as variables in order to determine their prognostic value, in relation to local recurrence-free survival, metastasis-free survival and overall survival, using the log-rank test.

RESULTS

Comparing Huvos grades I and II, the following P values for survival were attained: local recurrence-free survival (P = 0.731), metastasis-free survival (P = 0.596) and overall survival (P = 0.669).

CONCLUSION

In this series, Huvos grades I and II did not have any comparative prognostic value and had similar behavior.

Estudo de publicações em periódicos gerais de artigos sobre ortopedia e aparelho locomotor

Os autores estudam o perfil de publicação de artigos sobre ortopedia e área de interesse em aparelho locomotor em revistas gerais, não específicas de ortopedia, com registro no PUBMED, em um período de dois anos. Selecionados 67 artigos com distribuição heterogênea entre as revistas estudadas foi constatada presença de 26,47% de artigos com desenho de intervenção e 38% com desenho observacional. Os dados são comentados.

Impact of close surgical margin on local recurrence and survival in osteosarcoma

PURPOSE

Whether neoadjuvant chemotherapy safely allows close margins in osteosarcoma patients is still unknown. This study investigates the impact of close margins on local recurrence (LR) and overall survival (OS) for osteosarcoma patients treated with neoadjuvant chemotherapy.

METHODS

We retrospectively reviewed 47 cases of conventional osteosarcoma who were treated at our institution. Patient and treatment factors such as age, gender, MSTS stage, tumour site, surgery type, pathological type, tumour size, surgical margin, tumour necrosis rate, chemotherapy regimens and cycles were recorded. A close margin was defined as tumour present less than 5 mm from the closest resection margin. The average followup was 87.6 months (range, 25-135 months).

RESULTS

Twenty-five patients were alive, 22 patients had died, and eight had LR. Twenty-eight patients had wide margins, seven had positive margins and 12 had close margins. Positive margins had a greater risk of LR (57.1%) than wide margins and close margins. There was no difference in LR (8.3% vs 10.7%) between close margins and wide margins. Margin status was not correlated with OS.

CONCLUSION

Compared with wide margins, close margins did not lead to increased local recurrence in our study group. Whether close margins, as defined in our study, are just as acceptable as wide margins in terms of patient outcomes for osteosarcoma patients with neoadjuvant chemotherapy needs to be further confirmed in the future.