Osteosarcoma of the spine: dismal past, any hope for the future?

Primary Sarcomas of the Spine: A Systematic Review and Pooled Data Analysis

STUDY DESIGN

A systematic review of the literature and pooled data analysis of treatment outcomes of primary sarcomas of the spine.

OBJECTIVE

To examine the current literature and treatment options for primary sarcomas of the spine.

SUMMARY OF BACKGROUND DATA

A paucity of literature exists on treatment outcomes of primary sarcomas of the spine.

MATERIALS AND METHODS

Two authors searched PubMed to identify articles for review, and a pooled data analysis was performed to determine overall survival for each type of surgical resection on spine sarcomas.

RESULTS

In total, 1776 articles were identified, and 11 met our inclusion criteria for review. In chondrosarcoma, overall survival was significantly higher with en bloc excision when compared with piecemeal resection (HR for piecemeal resection: 4.11; 95% CI: 2.08-8.15). Subgroup analysis showed that the addition of radiation therapy after piecemeal excision increased overall survival to 60 months from 48 months with piecemeal excision alone. In osteosarcoma, there was no significant difference in overall survival between en bloc and piecemeal resection (HR for piecemeal resection: 1.76; 95% CI: 0.776-3.99). In Ewing's sarcoma, overall survival was significantly higher when a successful en bloc resection was achieved and coupled with chemotherapy and radiation therapy for local control (HR for piecemeal resection: 7.96; 95% CI: 2.12-20.1). Interestingly, when a successful en bloc resection could not be achieved, chemotherapy and radiation therapy alone had significantly higher survival than piecemeal resection (HR for piecemeal resection: 2.63; 95% CI: 1.01-6.84). A significantly higher number of local recurrences were associated with the piecemeal resection group in all types of spine sarcomas.

CONCLUSION

This review and pooled data seem to favor en bloc excision for local control as the treatment of choice in primary sarcomas of the spine.

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.

Suicide and accidental deaths among patients with primary malignant bone tumors

Background

It has been recognized that cancer is associated with a higher risk of suicide or accidental death. Earlier studies have evidenced that patients with malignant bone tumors usually experience psychological dysfunction and physical disability following surgery, which are shared risk factors between suicidal and accidental deaths. To our knowledge, there is no large population-based study on the risk of suicide or accidental death among patients with malignant bone tumors.

Questions/purposes

This study aimed to determine whether patients with primary malignant bone tumors are at a higher risk of suicide and accidental death than the general population and to identify the demographic and tumour-related characteristics and type of surgery associated with a higher risk of suicide and accidental death among these patients.

Methods

Overall, 50,817 patients diagnosed with primary malignant bone tumors between 1973 and 1975 were identified from the Surveillance, Epidemiology, and End Results database. The standardised mortality ratio (SMR) was calculated based on the general population's mortality data, gathered by the National Center for Health Statistics. The Cox regression model was developed to determine risk factors associated with a higher risk of suicide and accidental death.

Results

Patients with primary malignant bone tumors had a higher risk of suicide and accidental death than the general population in the United States (US) (SMR = 2.17; 95% confidence interval (CI) [1.80-2.62] and SMR = 1.73; 95% CI [1.54-1.95]). Compared with limb salvage, amputation significantly increased the risk of suicide (SMR = 3.99; 95% CI [2.52-6.34], hazard ratio (HR) = 2.32; 95% CI [1.31-4.09]; P < 0.01) but did not increase the risk of accidental death (SMR = 1.61; 95% CI [1.07-2.42], HR = 1.11; 95% CI [0.71-1.74]; P = 0.65). Higher suicide risk was observed among older patients whose age at diagnosis was more than 60 years (HR = 4.04; 95% CI [1.98-8.26]; P < 0.001), males (HR = 3.48; 95% CI [2.16-5.62]; P < 0.001), and whites (HR = 3.71; 95% CI [1.17-11.73]; P < 0.001). The risk of suicide and accidental death was highest in the first year after diagnosis (SMR = 2.95; 95% CI [1.86-4.69] and SMR = 2.02; 95% CI [1.48-2.74]).

Conclusion

We first reported that patients with primary malignant bone tumors had a higher risk of suicide and accidental death than the general US population. Therefore, clinicians should pay more attention to the psychological status, physical function, and cognitive level of these survivors.

Clinical effectiveness of Enneking appropriate versus Enneking inappropriate procedure in patients with primary osteosarcoma of the spine: a systematic review with meta-analysis

PURPOSE

Primary osteosarcoma of the spine is a rare osseous tumour. En bloc resection, in contrast to intralesional resection, is the only procedure able to provide Enneking appropriate (EA) margins, which has improved local control and survival of patients with primary osteosarcoma of the spine. The objective of this study is to compare the risk of local recurrence, metastases development and survival in patients with primary osteosarcoma of the spine submitted to Enneking appropriate (EA) and Enneking inappropriate (EI) procedures.

METHODS

A systematic search was performed on EBSCO, PubMed and Web of Science, between 1966 and 2018, to identify studies evaluating patients submitted to resection of primary osteosarcoma of the spine. Two reviewers independently assessed all reports. The outcomes were local recurrence, metastases development and survival at 12, 24 and 60 months.

RESULTS

Five studies (108 patients) were included for systematic review. These studies support the conclusion that EA procedure has a lower local recurrence rate (RR 0.33, 95% CI 0.17-0.66), a lower metastases development rate (RR 0.39, 95% CI 0.17-0.89) and a higher survival rate at 24 months (RR 1.78, 95% CI 1.24-2.55) and 60 months (RR 1.97, 95% CI 1.14-3.42) of follow-up; however, at 12 months, there is a non-significant difference.

CONCLUSIONS

EA procedure increases the ratio of remission and survival after 24 months of follow-up. Multidisciplinary oncologic groups should weigh the morbidity of an en bloc resection, knowing that in the first year the probability of survival is the same for EA and EI procedures. These slides can be retrieved under Electronic Supplementary Material.

Spinal sarcomas and immunity: An undervalued relationship

Sarcomas, especially spine sarcomas, are rare yet debilitating and are underestimated types of cancer. Treatment options for spine sarcomas are limited to chemotherapy, radiotherapy and surgical intervention. Accumulating evidence suggests a complex course associated with the treatment of spine sarcomas as compared to other soft tissue sarcomas in the extremities since adjuvant therapy adds limited success to the oncological outcome. Likewise, the limitations of surgical interventions imposed by the proximity and high sensitivity of the spinal cord, leads to an increased recurrence and mortality rates associated with spine sarcomas. Finding novel treatment options to spine sarcomas as such is inevitable, necessitating a more thorough understanding of the different mechanisms of the underlying etiologies of these tumors. In this review, we discuss the most recent studies tackling the involvement of the immune system; a key player in the emergence of the different types of spine sarcomas and the promising immune-mediated targeted therapy that can be applied in these kind of rare cancers.

What is the Incidence of Suicide in Patients with Bone and Soft Tissue Cancer? : Suicide and Sarcoma

BACKGROUND

Patients with cancer in the United States are estimated to have a suicide incidence that is approximately twice that of the general population. Patients with bone and soft tissue cancer often have physical impairments and activity limitations develop that reduce their quality of life, which may put them at high risk for depression, anxiety, and suicidal ideation. To our knowledge, there have been no large studies determining incidence of suicide among patients with bone and soft tissue cancer; this information might allow screening of certain high-risk groups.

QUESTIONS/PURPOSES

To determine (1) the incidence of suicide in patients with bone and soft tissue cancer, (2) whether the incidence of suicide is greater in patients with bone and soft tissue cancer than it is in the general US population, and (3) any demographic and tumor characteristics associated with increased suicide incidence.

METHODS

A retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) program was performed. A total of 23,620 patients with primary bone and soft tissue cancer were identified in this database from 1973 and 2013. Patients with a cause of death listed as "suicide and self-inflicted injury" were considered to have committed suicide and suicide incidences were determined for different demographic and tumor characteristics in this subset of patients. Patient data for age, gender, race, marital status, year of diagnosis, primary cancer site, cancer stage, course of treatment, and survival time were collected and analyzed. The incidence of suicide in patients with bone and soft tissue sarcoma was compared with the age-, gender-, and race-adjusted incidence of suicide in the general US population from 1970 to 2013 available from the National Center for Health Statistics through the SEER Program.

RESULTS

The overall suicide incidence in this population was 32 per 100,000 person-years, which was higher than the age-, race-, and gender-adjusted US general population suicide incidence of 13 per 100,000 person-years. When compared with the incidence of suicide in matched subgroups of the general US population, a higher suicide incidence was observed in men (standardized mortality ratio [SMR], 2.49; 95% CI, 1.92-3.22; p < 0.001), patients of white race (SMR, 2.68; 95% CI, 1.94-3.56; p < 0.001), patients 21 to 30 years old (SMR, 4.40; 95% CI, 3.44-5.54; p < 0.001) and 61 to 70 years old (SMR, 3.27; 95% CI, 2.54-4.18; p < 0.001), patients with cancer of the vertebral column (SMR, 2.88; 95% CI, 2.13-3.83; p < 0.001) and pelvic bones (SMR, 2.75; 95% CI, 2.00-3.65; p < 0.001), and patients within the first 5 years of cancer diagnosis (SMR, 10.8; 95% CI, 9.19-12.61; p < 0.001).

CONCLUSIONS

With identification of these characteristics that are associated with higher incidence of suicide, physicians should consider screening patients possessing these traits. By identifying at-risk patients, we can hope to reduce the incidence of suicide in this population by providing the treatment that these patients need. Further research must be done to determine how best to screen these patients and to identify the best interventions to reduce suicide incidence.

LEVEL OF EVIDENCE

Level III, prognostic study.