Pulmonary metastases from osteogenic sarcoma: Complete resection and effective chemotherapy contributing to improved prognosis

Second and subsequent recurrences of osteosarcoma: presentation, treatment, and outcomes of 249 consecutive cooperative osteosarcoma study group patients

PURPOSE

To evaluate patient and tumor characteristics, treatment, and outcomes in a large cohort of unselected patients with second and subsequent recurrences of osteosarcoma.

PATIENTS AND METHODS

Two hundred forty-nine consecutive patients who had originally received combined-modality therapy on neoadjuvant Cooperative Osteosarcoma Study Group protocols and went on to develop a total of 409 second and subsequent osteosarcoma recurrences were analyzed for patient-, tumor-, and treatment-related factors and outcomes.

RESULTS

Five-year overall and event-free survival rates were 16% and 9% for 249 second, 14% and 0% for 93 third, 13% and 6% for 38 fourth, and 18% and 0% for 14 fifth recurrences, respectively. The proportion of recurrences confined to the lungs decreased and the proportion of those with chest wall involvement increased with increasing numbers of recurrences. The duration of relapse-free intervals and the number of lesions at recurrence correlated with outcomes. While only one of 205 patients with rerecurrence survived past 5 years without surgical remission, 5-year overall and event-free survival rates were 32% and 18% for 119 second, 26% and 0% for 45 third, 28% and 13% for 20 fourth, and 53% and 0% for five fifth recurrences, respectively, in which a renewed surgical remission was achieved. The use of chemotherapy correlated with longer survival in patients without surgical remissions.

CONCLUSION

To our knowledge, this is the first report of survival estimates derived from large cohorts of unselected patients with second and subsequent osteosarcoma recurrences. It confirms the overwhelming importance of surgical clearance. Prognostic indicators after rerecurrences resemble those known from first recurrence. The exact role of re-treatment with chemotherapy, particularly in the adjuvant situation, remains to be defined.

Osteosarcoma relapse after combined modality therapy: an analysis of unselected patients in the Cooperative Osteosarcoma Study Group (COSS)

PURPOSE

To evaluate the impact of patient, tumor, and treatment-related factors on outcome in unselected patients with recurrent osteosarcoma.

PATIENTS AND METHODS

Five hundred seventy-six consecutive patients who had achieved a first complete surgical remission (CR) during combined-modality therapy on neoadjuvant Cooperative Osteosarcoma Study Group (COSS) protocols and then developed recurrent osteosarcoma were analyzed (median time from biopsy to relapse, 1.6 years; range, 0.1 to 14.3 years). There were 501 patients with metastases, 44 with local recurrences, and 31 with both. Metastases involved lungs (469 patients), bones (90 patients), and/or other sites (54 patients).

RESULTS

After a median follow-up of 1.2 years for all patients and 4.2 years for survivors, actuarial overall survival (OS) rates at 2, 5, and 10 years were 0.38, 0.23, and 0.18, respectively. Five-year OS was 0.39 for 339 patients with and 0.00 for 229 patients without a second surgical CR (P < .0001). A long time to relapse, a solitary lesion, and, in the case of pulmonary metastases, unilateral disease and the absence of pleural disruption, were of positive prognostic value in uni- and multivariate analyses, as were a second surgical CR and the use of second-line chemotherapy. Radiotherapy was associated with moderately prolonged survival in patients without a second CR. The very limited prognostic differences associated with the use of second-line chemotherapy appeared to be more pronounced with polychemotherapy.

CONCLUSION

Time to relapse and tumor burden correlate with postrelapse outcome in osteosarcoma. Complete surgery is an essential component of curative second-line therapy. Chemotherapy, particularly chemotherapy with more than one agent, may contribute to limited improvements in outcome.

Long-term survival in high-grade axial osteosarcoma with bone and lung metastases treated with chemotherapy only

A boy, age 2 years 10 months, with high-grade malignant osteosarcoma of the fifth lumbar vertebra with secondary bilateral pulmonary lesions and bone metastasis at the fifth thoracic vertebra is described. The primary site of disease was inoperable and the patient was treated with chemotherapy only. At present, 83 months from diagnosis and 64 from the end of therapy, he is in very good general condition. Although a surgical approach on the primary and secondary sites is fundamental, this case may be considered an indication of the efficacy of aggressive chemotherapy in treating osteosarcoma.

FR901228 induces tumor regression associated with induction of Fas ligand and activation of Fas signaling in human osteosarcoma cells

We investigated the antitumor effects of FR901228, a HDAC inhibitor, on human osteosarcoma cells, in vitro and in vivo to explore its possible utility in the treatment of pediatric bone cancers. FR901228 caused marked growth inhibition with a 50% inhibitory concentration of 1.2-7.3 nM and induction of apoptosis in all eight osteosarcoma cell lines tested. These effects of FR901228 were also observed in vivo xenograft models on BALB/c nude mice, and treatment with 5.6 mg/kg/day resulting in a >70% reduction in the mean final tumor volume compared with the mean initial tumor volume. TUNEL assays demonstrated extensive apoptosis in tumor sections of mice treated with FR901228. Induction of apoptosis was preceded by increased expression of Fas ligand (FasL) mRNA, resulting in expression of membrane-bound FasL, which was followed by sequential activation of caspase-8 and -3. The level of apoptosis induction was reduced using a neutralizing anti-FasL antibody and overexpression of either the dominant-negative FADD or the viral FLICE inhibitory protein. Furthermore, treatment with a suboptimal dose of FR901228 greatly sensitized osteosarcoma cells to agonistic anti-Fas antibody-mediated apoptosis. These findings suggest that FR901228 is a highly promising antitumor agent against osteosarcoma, inducing apoptosis by the activation of the Fas/FasL system.

Postrelapse survival in osteosarcoma of the extremities: prognostic factors for long-term survival

PURPOSE

To identify factors that influence postrelapse survival (PRS) in patients with nonmetastatic osteosarcoma of the extremity.

PATIENTS AND METHODS

One hundred sixty-two patients with recurrent osteosarcoma of the extremity were retrospectively reviewed. The first-line treatment included surgery of the primary lesion and chemotherapy with methotrexate, doxorubicin, cisplatin, and ifosfamide.

RESULTS

The projected 5-year PRS rate was 28%. Patients who had complete surgery of recurrence had a 5-year PRS of 39%, whereas for those who did not have complete surgery, PRS was 0% at 3 years (P <.0001). In the latter group, PRS was not influenced by site of recurrence and relapse-free interval (RFI), although it was influenced (P =.006) by the use of second-line chemotherapy (PRS, 53% at 12 months for patients who received chemotherapy v 12% for those who did not). In patients who had complete surgery, PRS was influenced by site of relapse (5-year PRS, lung 44%, other 19%; P <.06), RFI (5-year PRS at < or = 24 months, 20%; at > 24 months, 60%; P <.0001), and number of lung metastases (5-year PRS, two or fewer nodules, 59%; more than two nodules, 14%; P <.0001) but not by the use of a second-line chemotherapy treatment.

CONCLUSION

RFI, site of metastases, and number of pulmonary nodules are the main prognostic factors for PRS in osteosarcoma. Complete surgery of recurrence is pivotal in the strategy of treatment. Patients with unresectable recurrence benefit from second-line chemotherapy, whereas our data do not support a generalized use of chemotherapy after complete surgery of first recurrence.

A pilot study of short-course intensive multiagent chemotherapy in metastatic and axial skeletal osteosarcoma

BACKGROUND

This pilot study was undertaken to assess the feasibility, toxicity and response to short-course multiagent chemotherapy followed by high-dose chemotherapy (HDC) in patients with poor prognosis osteosarcoma.

PATIENTS AND METHODS

A total of 30 patients entered the study. Chemotherapy consisted of four blocks of multiagent chemotherapy administered sequentially over a short period in a dose-intensive manner. This therapy was followed by HDC which consisted of carboplatin at an AUC8 x 3 days, etoposide 400 mg/m(2) x 3 days and cyclophosphamide 60 mg/kg x 2 days.

RESULTS

A total of 227 cycles of chemotherapy were administered. The main toxicity (for blocks 1-4) was haematological. There were two treatment-related deaths: one post HDC due to sepsis and one during surgery. High-dose chemotherapy was administered to 11 patients (10 with extremity tumours and only one with a pelvic tumour). Twenty-seven patients underwent surgery to the primary. Histological response was assessed in 23 patients. Seven patients (30%) had >90% necrosis. Eight patients underwent pulmonary metastatectomy. The median survival time for the whole group was 16 months. The 2- and 3-year survival rates were 50% and 21% for those with extremity tumours and 19% and 13% for those with axial skeletal tumours.

CONCLUSIONS

Dose-intensive multiagent chemotherapy though feasible in the group of patients with extremity tumours did not significantly improve the treatment outcome compared with conventional relapse therapy. Inferior survival rates in the axial skeletal group are attributed to less intensive treatment and poor local tumour control.

Osteosarcoma of the extremities with synchronous lung metastases: long-term results in 44 patients treated with neoadjuvant chemotherapy

Between September 1986 and September 1991, 44 patients with lung metastases originating from an osteosarcoma of an extremity were treated with: primary chemotherapy, simultaneous resection of primary and metastatic lesions (when feasible), and then further chemotherapy. After primary chemotherapy, lung metastases disappeared in 5 patients, whereas in 11 patients they remained surgically unresectable. All 16 patients received local treatment of the primary tumor only. In the remaining 28 patients simultaneous surgical treatment of the primary and the metastatic tumor was performed. The removal of metastatic lesions was complete in 25 and incomplete in 3 patients. With a median follow-up of 8 years (5.5-10.8) all 14 patients who never achieved a tumor-free status died. Of the 30 patients who achieved remission 5 (17%) remained continuously free of disease and 25 developed new metastases, associated with local recurrence in 4 cases. The 5-year overall survival for all 44 patients of the study was 14%, and the 5-year disease-free survival for the 30 patients who reached remission was 17%. These results are significantly worse than those achieved with the same chemotherapy protocol in 144 contemporary patients with localized disease at presentation (73% disease-free and 79% overall survival). We conclude that, despite aggressive chemotherapy which is successful in patients with localized disease, the prognosis remains very poor for patients with osteosarcoma of the extremities with lung metastases at presentation, and justifies the use of novel therapies.

Lung volumes following resection of pulmonary metastases in paediatric patients--a retrospective study

Pulmonary function was evaluated before and after 15 operations for resection of pulmonary metastases from osteogenic sarcoma. In the whole study group (ten patients, aged 13-18 years) preoperative vital capacity (VC) ranged from 62% to 122% (mean 83%) of predicted normal values for height. The operations were performed via median sternotomy. One-28 metastases were removed per session. Six months after the operations VC averaged nearly 95% of the preoperative values. Signs of bronchial obstruction or persistent pulmonary hyperinflation were only present in one patient with repeated operations. We conclude that resection of pulmonary metastases with limited loss of parenchyma leads to an almost complete recovery of preoperative pulmonary function parameters.