Prognostic implication of adjuvant/neoadjuvant chemotherapy consisting of doxorubicin and ifosfamide in patients with extraskeletal osteosarcoma

BACKGROUND

Extraskeletal osteosarcoma (ESOS) is an extremely rare soft tissue sarcoma. Their prognosis remains poor. Our purposes were to identify the effective chemotherapeutic regimen for ESOS.

METHODS

We retrospectively reviewed 16 patients with ESOS treated at the Osaka University Orthopaedic Oncology Group between 1992 and 2012. We extracted the clinical data on patients. Kaplan-Meier method and the log-rank test were used for survival analyses.

RESULTS

Median age of the patients was 61.5 years (range 25-79 years). Wide local excision was performed for 11 patients and 9 patients were treated combined with chemotherapy. The 5-year disease-specific survival (DSS) rate was 53.9%. The 5-year DSS rates for patients treated with adjuvant/neoadjuvant chemotherapy or not were 66.7% or 25%, respectively (p = 0.0215). Furthermore, the 5-year DSS rates for patients treated with adjuvant/neoadjuvant chemotherapy consisting of doxorubicin and ifosfamide and those treated with other regimens were 100% or 40%, respectively (p = 0.0327).

CONCLUSION

The present study demonstrated that adjuvant/neoadjuvant chemotherapy, especially consisting of doxorubicin and ifosfamide, was potentially efficacious for ESOS. Further prospective study using this multimodality treatment approach to patients with ESOS should be strongly warranted.

Favorable outcomes of localized synovial sarcoma patients with a high utilization rate of neoadjuvant and/or adjuvant chemotherapy

Synovial sarcoma (SS) is considered to be a chemosensitive, soft tissue sarcoma. Therefore, neoadjuvant and/or adjuvant chemotherapy (N/AC) is used for the treatment of high-risk SS patients. However, the role of N/AC remains controversial. The present study aimed to review the clinical outcomes of surgically treated localized SS and investigate the effects of N/AC with long-term observation. The clinical outcomes of 54 patients with surgically treated localized SS were retrospectively analyzed. The median patient age was 42 years (range, 8-81 years), and the median follow-up period was 94 months for survivors (range, 7-220 months). A total of 38 patients (70%) received chemotherapy. Of these, 32 (59%) patients received neoadjuvant chemotherapy, 33 (61%) received adjuvant chemotherapy, and 27 (50%) received neoadjuvant and adjuvant chemotherapy. Fourteen patients (26%) received adjuvant radiotherapy. Three patients (6%) had local recurrence and 13 patients (24%) developed distant metastasis. The overall survival (OS) rates at 5 and 10 years were 87 and 84%, respectively. N/AC did not improve survival. In conclusion, we found satisfactory long-term OS among patients with a high utilization rate of N/AC. Further study should be necessary to evaluate which population of SS would benefit from N/AC.

Survival analysis of elderly patients with osteosarcoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of clinical and functional outcome between surgical treatment and carbon ion radiotherapy for pelvic chondrosarcoma

BACKGROUND

As there are no reports of studies in patients with pelvic chondrosarcoma treated with carbon ion radiotherapy (CIRT), the aim of this study was to evaluate the applicability of CIRT for patients with chondrosarcoma of the pelvis.

METHODS

The medical records of 31 patients with chondrosarcoma of the pelvis treated either by surgical resection or by CIRT between 1983 and 2014 were reviewed. There were 22 males and 9 females with a median age of 43 years (range 16-77 years). The median duration of follow-up was 66 months (range 5-289 months). Twenty-four patients underwent surgery, and 7 patients received CIRT (70.4 GyE in 16 fractions over 4 weeks).

RESULTS

The overall local recurrence rate was 32 %, and the estimated overall 5- and 10-year survival rates were 72 and 57 %, respectively. The mean Musculoskeletal Tumor Society functional score was 59 %. The treatment procedures (surgery or CIRT) did not affect overall survival (P = 0.347). However, the patients who underwent surgery had impaired function compared with those who received CIRT (P = 0.03).

CONCLUSION

Although more patients need to be monitored to assess the clinical and functional outcomes of CIRT for patients with chondrosarcoma of the pelvis, this treatment might offer an acceptable alternative.

Choroid Plexus Metastasis of Follicular Thyroid Carcinoma Diagnosed due to Intraventricular Hemorrhage

Choroid plexus metastasis (CPM) is extremely rare and originates most frequently from renal cell carcinoma (RCC). We herein report the case of a 58-year-old man who developed a solitary CPM lesion derived from follicular thyroid carcinoma in addition to intraventricular hemorrhage. Computed tomography revealed acute hydrocephalus as a result of the hemorrhage, and we planned endoscopic hematoma evacuation. Since it was too difficult to reach the hematoma, we considered the possibility of a neoplasm and performed a biopsy of the lesion, the results of which led to an accurate diagnosis of CPM in this case. We also review previous reports of CPM originating from thyroid carcinoma compared with RCC.

Knee reconstruction with endoprosthesis after extra-articular and intra-articular resection of osteosarcoma

OBJECTIVE

Extra-articular resection is necessary to obtain a wide margin for primary osteosarcomas invading the knee joint, and the limb is often reconstructed using a prosthesis. Here, outcomes of extra-articular and intra-articular procedures were compared.

METHODS

Between 1999 and 2012, 14 patients with osteosarcoma underwent extra-articular excision (n = 6; ages 23-65 years; mean follow-up 82.8 months) or intra-articular excision (n = 8; ages 8-58 years; mean follow-up 96.4 months). In the extra-articular group, there was one Enneking Stage IIA case and five Enneking Stage IIB cases. No local recurrences were noted in either group.

RESULTS

Patient outcomes were as follows (extra-articular cases vs. intra-articular cases): continuous disease-free (2 vs. 7), alive with disease (2 vs. 0) and death from disease (1 vs. 1). Average Musculoskeletal Tumor Society functional scores were 69.4% (range 63.3-83.3%) and 88.3% (range 70.0-96.7%) in the extra-articular and intra-articular groups, respectively, constituting a significant difference (P < 0.05). The 5-year oncological overall survival exceeded 80% in both groups. Amputation was necessary for one patient in the extra-articular group. The 5-year event-free prosthesis survival rates in the extra-articular and intra-articular groups were 33.3 and 75.0%, respectively (P < 0.05).

CONCLUSION

The extra-articular excision group developed more complications than the intra-articular excision group, as a result of extensive bone and muscle excision. The limb survival rates were similar in both groups. Our results suggest that extra-articular resection was a necessary and clinically acceptable procedure.

Primary amyloidoma in epidural and paravertebral space of the lumbar spine

BACKGROUND CONTEXT

Localized amyloid deposits result in a mass, that is, so-called amyloidoma; it has been reported in every anatomic site, although systemic amyloid deposition is much more common. However, primary lumbar epidural amyloidoma without bony involvement is extremely rare. To the best of our knowledge, only one case has been reported previously.

PURPOSE

To report and review the clinical presentations, imaging studies, and treatment of epidural and paravertebral amyloidoma.

STUDY DESIGN

A case report and review of the literature.

METHODS

Lumbar epidural and paravertebral amyloidoma in a 75-year-old man with neurologic compromise is presented. Laminectomy with mass resection was performed.

RESULTS

After surgery, almost complete neurologic improvement was observed. Histologically, definite diagnosis was obtained only after the specific staining of tissue. No sign of local recurrence was evident 1 year after surgery.

CONCLUSIONS

Primary amyloidoma, although rare, should be included in the differential diagnosis of epidural mass of the spine. Diagnosis before surgery is difficult as there were no characteristic findings in clinical and imaging studies. Special histologic technique and stains are useful to make a definite diagnosis.

Neoadjuvant and adjuvant chemotherapy with high-dose ifosfamide, doxorubicin, cisplatin and high-dose methotrexate in non-metastatic osteosarcoma of the extremities: a phase II trial in Japan

From 1997 to 2003, 40 patients (all <40 years of age) with non-metastatic osteosarcoma of the extremities were treated with OOS-D and definitive surgery. Two cycles of doxorubicin 90 mg/m(2) plus cisplatin 120 mg/m(2) and ifosfamide 15 g/m(2) were given as neoadjuvant chemotherapy, and two cycles of doxorubicin/cisplatin and ifosfamide, and two cycles of high-dose methotrexate (10-12 g/m(2)) were given post-operatively. All patients underwent limb salvage surgeries, and 66% showed good response to neoadjuvant chemotherapy. With a median follow-up period of 117 months, 31 of the evaluable 40 patients were continuously disease-free, 7 were currently alive with no evidence of disease, and 2 died of disease. There was no local recurrence. The 5-year event-free and overall survival rates were 83 and 98%, respectively. The 10-year event-free and overall survival rates were 80 and 95%, respectively. The major form of toxicity was haematological one.

[Effect of transarterial chemoembolization for recurrent desmoid tumor - a case report]

Desmoid fibromatosis is classified as a benign soft tissue tumor regardless of its local invasive behavior and its, local recurrence rate is 57-85% after local resection. A 19 y/o male patient with post-operative recurrence of a desmoid tumor in the shoulder was initially treated by arterial embolization; however, no improvement of symptoms was obtained. As second-line treatment, 20 mg of epirubicin, 50 mg of cisplatin and 250 mg of 5-FU were infused to tumor-related arteries and embolization was performed with a super absorbent polymer microsphere. After a single session of treatment, reduction of tumor size and improvement of symptoms were achieved. The same treatment was repeated three times without major complications. Considerable reduction of tumor was obtained after treatment. Chemo-embolization should be considered for the postoperative recurrence of desmoid fibromatosis, in order to prevent loss of function and maintain a high QOL for the patient.

Surgical treatment for skeletal metastases from soft tissue sarcomas: experience with 23 lesions in 20 patients

Purpose. This paper reports the procedures and the clinical results of a series of surgical treatments for skeletal metastases from soft tissue sarcomas.Subjects and methods. Surgical treatment of metastatic bony lesions from soft tissue sarcomas has been carried out over a 20 year period (1975-1996). Thirty-two patients developed skeletal metastases from soft tissue sarcomas, and 20 of these cases received surgical treatment. The 23 metastatic bony lesions in these 20 patients were treated using the following surgical approaches: wide resection with prosthetic replacement in five lesions, wide or marginal resection without reconstruction in four lesions, intramedullarly nailing with curettage and methylmethacrylate cementation in four lesions, marginal resection of vertebral body with replacement by a ceramic prosthesis in three lesions, laminectomy in three lesions, intramedullarly nailing in two lesions, and curettage in two lesions.Results. Relief of pain was achieved in 17 of the 20 patients. The ambulatory status of the patients with metastasis in the lower extremity or periacetabular region was significantly improved in nine of 10 cases. Seventeen patients died of disease, with a mean survival period of 17.9 months after surgery for metastasis.Discussion. Although surgical treatment for skeletal metastases from soft tissue sarcomas cannot save the life of the patient, it can be of value in improving their well-being and overall quality of life. In these cases, surgical intervention may be more frequently indicated than in tumors with an osteoblastic or mixed pattern.

Expression of smooth muscle calponin in synovial sarcoma

Purpose. Histogenesis of synovial sarcoma remains controversial and reliable molecular markers for diagnosis are necessary. Expression of basic calponin, a smooth muscle differentiation-specific actin-binding protein, was studied in synovial sarcoma.Subjects and Methods. The basic calponin gene and the gene product were analyzed by reverse transcription PCR analysis (RT-PCR) and immunohistochemistry in 14 synovial sarcomas and a human synovial sarcoma cell line (HS-SY-II).Results and Discussion. Immunoreactivity for basic calponin was detected in the cytoplasm of 6 synovial sarcomas (43% positive). In the basic calponin-positive tumors and the HS-SY-II cells, expression for smooth muscle-specific genes, including basic calponin and SM22alpha , was detected by RT-PCR, suggesting a lineage relationship between synovial sarcoma cells and smooth muscle-like mesenchymal cells.Conclusions. A subset of synovial sarcomas expressing the basic calponin gene and the gene product were identified. The basic calponin may have potential utility as a novel molecular marker identifying certain synovial sarcomas.

Novel fully interconnected porous hydroxyapatite ceramic in surgical treatment of benign bone tumor

BACKGROUND

Large bone defects remaining after curettage of benign bone tumors should be filled with a substitute to restore mechanical strength. In 2000, we developed a fully interconnected porous calcium hydroxyapatite ceramic (IPCHA, NEOBONE) and have utilized it as a bone substitute. IP-CHA has a finely organized, three-dimensional interconnecting pore structure. The large interconnecting channels (average diameter 40 microm) permit easy penetration of tissue into the deep pores, so IP-CHA can itself induce local bone repair processes. The purpose of this study was to evaluate the clinical outcomes with the use of IP-CHA as bone substitute after curettage of benign bone tumors.

METHODS

We reviewed the results of 71 patients with benign bone tumors sequentially treated by curettage followed by implantation of IP-CHA between 2000 and 2006. There were 29 women and 42 men, with a mean age of 28 years. Assessment was based on radiography at each time point during the follow-up. Radiographic findings were classified into five stages: stage 0, no change; stage 1, slight bone formation; stage 2, moderate bone formation; stage 3, consolidation; stage 4, absorption.

RESULTS

In 70 of 74 operated lesions, radiographs showed that implanted IP-CHA proceeded to stage 2 or more within an average of 8 months after the surgery. In addition, 17 lesions proceeded to stage 4 within 35 months after surgery, on average. However, there were 10 local recurrences, which is similar to the recurrence rate for such tumors treated with or without implantation of CHAs and reflects the biological nature of each tumor.

CONCLUSIONS

In this study, we utilized IP-CHA as a bone substitute after curettage of benign bone tumors and demonstrated its usefulness in the clinical situation. IP-CHA comparatively exhibited excellent bone formation at an early stage although the problem of recurrence of the tumor remained. We conclude that IP-CHA is a useful bone substitute for the treatment of benign bone tumors.

Orphan receptor tyrosine kinase ROR2 as a potential therapeutic target for osteosarcoma

Osteosarcoma is the most prevalent bone malignant tumor in children and adolescents, and displays heterogeneous histology and high propensity for distant metastasis. Although adjuvant chemotherapy remarkably improved treatment outcome over the past few decades, prognosis for osteosarcoma patients with pulmonary metastasis is still unsatisfactory. To identify novel therapeutic targets for osteosarcoma, we investigated the gene expression profile of osteosarcomas by cDNA microarray analysis and found transactivation of receptor tyrosine kinase-like orphan receptor 2 (ROR2) expression in the majority of osteosarcoma samples. Treatment of osteosarcoma cell lines with siRNA against ROR2 significantly inhibited cell proliferation and migration. We also identified wingless-type MMTV integration site family, member 5B (WNT5B) as a putative ROR2 ligand and that the physiological interaction of WNT5B and ROR2 could enhance cell migration, indicating the possible roles of ROR2 and WNT5B in the metastatic property of osteosarcoma cells. Taken together, our findings revealed that the WNT5B/ROR2 signaling pathway is a promising therapeutic target for osteosarcoma.

Validation of radiographic response evaluation criteria of preoperative chemotherapy for bone and soft tissue sarcomas: Japanese Orthopaedic Association Committee on Musculoskeletal Tumors Cooperative Study

BACKGROUND

The radiographic evaluation of the response to preoperative chemotherapy for bone and soft tissue sarcomas is based mostly on the change in primary tumor size before and after chemotherapy, as is done for many solid cancers. Its prognostic correlation, however, has hardly been validated.

METHODS

We conducted a retrospective validation study of the Japanese Orthopaedic Association (JOA) radiographic response evaluation criteria of preoperative chemotherapy for bone and soft tissue sarcomas as a JOA Committee on Musculoskeletal Tumors cooperative study. A total of 125 consecutive patients with high-grade bone (n = 77) and soft tissue (n = 48) sarcomas treated with neoadjuvant chemotherapy and definitive surgery in 25 tertiary referral hospitals were selected for the study. We investigated the correlation between the tumor size-based radiographic response evaluation criteria of preoperative chemotherapy for bone and soft tissue sarcomas provided by the JOA Committee on Musculoskeletal Tumors (hereafter called the JOA criteria) and the patients' overall survival using the Kaplan-Meier method and the log-rank test.

RESULTS

The JOA criteria correlated relatively well with survival for malignant bone tumors (mostly comprising osteosarcoma and Ewing's sarcoma) but not for soft tissue sarcomas, suggesting that the tumor size-based radiographic evaluation criteria for the response to preoperative chemotherapy in patients with soft tissue sarcomas is invalid.

CONCLUSIONS

The JOA criteria, based on the change in primary tumor size, is valid for malignant bone tumors but invalid for soft tissue sarcomas. Other new evaluation modalities of the response to preoperative chemotherapy using innovative functional imaging techniques are needed for soft tissue sarcomas.

Prognostic implication of SYT-SSX fusion type in synovial sarcoma: a multi-institutional retrospective analysis in Japan

The prognostic implication of SYT-SSX fusion type in synovial sarcomas is still controversial. The aim of this study is to clarify the prognostic impact of fusion type, in association with other clinical factors, in patients with synovial sarcoma in Japan. Data on 108 SYT-SSX fusion transcript-positive patients with synovial sarcoma, treated in 11 tertiary referral cancer centers in Japan, were retrospectively analyzed. The following parameters were examined for their potential prognostic impact: SYT-SSX fusion type, patient age at presentation, sex, primary tumor location, tumor size, histological subtype, histological grade, treatment modalities and disease stage at presentation. Among the patients with localized disease at presentation, 5-year overall survival (OS) for SYT-SSX1 and -2 subgroups were 84.4 and 74.9%, respectively (P=0.244). Five-year metastasis-free survival (MFS) rates were 67.8% for SYT-SSX1 and 68.5% for SYT-SSX2 (P=0.949). Univariate survival analyses for 91 patients with localized disease at presentation showed that tumor size was the only significant prognostic factor for OS (P=0.0033) and MFS (P=0.0029) and the histological grade was marginally significant for MFS (P=0.0785), whereas the SYT-SSX fusion type and other variables were not. Multivariate survival analyses further indicated that tumor size was the most significant independent prognostic factor for OS and MFS and the histological grade was also significant for MFS. In conclusion, the SYT-SSX fusion type is not a significant prognostic factor unlike tumor size, followed by histological grade for patients with localized synovial sarcoma in Japan.

Analysis of germline and tumor mutations of p53 gene in familial occurrence of soft tissue sarcomas

BACKGROUND

Familial soft tissue sarcomas are extremely rare. There is little information available on the clinical features and molecular findings of the hereditary occurrence of mesenchymal tumor.

PATIENTS AND METHODS

A woman and her younger brother had malignant fibrous histiocytoma (pleomorphic type) and liposarcoma (pleomorphic type) in the lower limbs, respectively. Analysis of p53 mutations in exons 5-9 of the tumor and in germ-line was done.

RESULTS

A guanine to adenine substitution occurred in CGC, codon 175 of exon 5 in p53 gene, to CAC in the tumor sample of Case 1. Likewise, a thymine to cytosine substitution occurred in TTT, codon 270 of exon 8 in p53 gene, to TCT in tumor sample of Case 2. Germline mutations were not seen in the either patients.

CONCLUSIONS

Different missense mutations of p53 were detected in each tumor, however no germline mutations of p53 were found. The alteration of codon 175 in Case 1 is relatively common mutation. On the contrary, the mutation in codon 270 in Case 2 was extremely rare in cancers. Further molecular investigation is needed to understand the mechanism in familial occurrence of sarcomas.

Reassessment of the 1993 Osaka grading system for localized soft tissue sarcoma in Japan

BACKGROUND

The Osaka system for soft-tissue sarcoma grading was proposed through an analysis of soft-tissue sarcoma (STS), treated from 1964 to 1989. The present study was conducted to evaluate the utility of the Osaka system under recent therapeutic regimens.

PATIENTS AND METHODS

One hundred and eleven patients with localized STSs arising in the trunk and extremities (66 males and 45 females; median age 57) were selected. Histological factors, argyrophilic nucleolar organizer region (AgNOR) count and Ki-67 labeling index (LI) were evaluated for prognostic significance.

RESULTS

Univariate analysis revealed that histological classification, mitotic count, cellularity, AgNOR count, and Ki-67 LI were prognostically significant for survival. Multivariate analysis revealed Ki-67 LI as an independent prognostic factor. The five-year survival rate for low-, intermediate-, and high-grade STSs in Osaka grading was 94.6%, 75.2%, and 68.4%, respectively.

CONCLUSION

Osaka grading is a useful system for the decision-making of therapeutic modalities for STS.

Prognostic significance of activated AKT expression in soft-tissue sarcoma

PURPOSE

AKT is a serine/threonine kinase which is important in tumorigenesis. Several molecules involved in AKT pathway are dysregulated in various kinds of human cancers.

PATIENTS AND METHODS

Ninety-three patients (53 males and 40 females), ages ranging from 19 to 77 years (median, 57 years), with localized soft-tissue sarcomas arising in the trunk and extremities, were analyzed. Immunoperoxidase procedure (avidin-biotin complex method) was done on paraffin-embedded sections with anti-phosphorylated AKT (Thr308), anti-phosphorylated p44/42 extracellular signal-regulated kinase 1 and 2 (ERK1/2) (Thr202/Tyr204), anti-phosphorylated forkhead in rhabdomyosarcoma (FKHR) (Ser256), and anti-Ki 67 antibodies. Expression levels of phosphorylated AKT (p-AKT), phosphorylated ERK1/2 (p-ERK1/2), and phosphorylated FKHR (p-FKHR) were categorized as either weaker (level 1) or equal to or stronger (level 2) compared with those in the endothelial cells of the same specimens. Percentage of cells showing intranuclear staining with Ki-67 was shown as the Ki-67 labeling index (LI). Cases were divided into two groups: level 1, Ki-67 LI < 20%; level 2, Ki-67 LI > or = 20%.

RESULTS

Twenty-six (28.0%), 6 (6.5%), and 46 (44.1%) of the tumors showed level 2 expression for p-AKT, p-ERK1/2, and Ki-67 LI, respectively. Tumors with level 2 p-AKT expression showed a higher ratio of level 2 p-FKHR expression (P < 0.01). Multivariate analysis revealed p-AKT expression and Ki-67 LI to be independent prognosticators for overall survival, and p-AKT expression for disease-free survival.

CONCLUSION

p-AKT expression level is a significant prognosticator in soft-tissue sarcoma.

Quality of life in children with osteosarcoma after limb salvage operation

19501

Background: There are several options for the surgical management of osteosarcoma (OS) especially in the skeletally immature patients. We evaluate the clinical results and quality of life (QOL) of OS patients with limb salvage operations. Methods: From 1996 to 2005, ten children with newly diagnosed previously untreated nonmetastatic (stage IIB) OS of extremities were reviewed. There were 5 females and 5 males. The median age was 12 years (range, 8 to 14). Tumor locations: proximal humerus in 2, proximal femur in 1, distal femur in 2, proximal tibia in 3, distal tibia in 1, and tibial shaft in 1. Patients received neoadjuvant and adjuvant chemotherapy, and local wide resection of tumor. Limb salvage procedures: intraoperative extracorporeal autogenous irradiated bone graft (IORBG) in 4 and prosthetic replacement in 6. The functional results were measured for the patients accordance with the Musculoskeletal Tumor Society rating score. Results: With a median follow up of 4 years (range, 1 to 9), 7 were continuously disease free, 2 died of disease and in one there was no evidence of disease. No local recurrence was seen. Mean functional rating scores of patients with IORBG and prosthetic replacement were 82% (range 77 to 90) and 82% (range 57 to 93), respectively. Functional results were not different between these study groups and relatively good. There was one infection in patients with prosthetic replacement. There were subchondral collapse in 2 (50%), fracture in 1 (25%) and infection in 1 (25%) with IORBG. Conclusions: Limb salvage operation with neoadjuvant chemotherapy is the optimum treatment. However there remain several problems of function after limb salvage operations, with improvement of survival of pediatric osteosarcoma patient. We should select the most suitable surgical procedure to achieve the good function of limbs as well as local control.

No significant financial relationships to disclose.

Synovial chondromatosis of the acromioclavicular joint

A 53-year-old woman presented with swelling of 3 years' duration on the right anterior chest wall. A radiograph showed coarse calcifications around the subclavicular region and erosion of the ipsilateral acromioclavicular joint. Computed tomography also showed calcifications in soft tissue. Magnetic resonance imaging revealed a tumor around the clavicle extending to the anterior aspect of chest wall, which had low signal intensity on T1-weighted imaging and high signal intensity on T2-weighted imaging. The histologic findings were of a hyaline cartilage-like mass consisting of mature chondrocytes and an extracellular matrix. The histologic diagnosis of synovial chondromatosis was made. The present case is unusual in respect of the location and size of the tumor.

Bilateral achilles tendon ruptures in a patient with ochronosis: a case report

We report the case of a 67-year-old man with ochronosis who had bilateral Achilles tendon ruptures. We reconstructed the Achilles tendon using pull-out wiring for the right side and an anchoring system for the left side, and reinforced the repair site using the peroneus brevis tendon for both sides. He could walk without a cane at 3 months postoperatively. Tendon ruptures in patients with ochronosis should be treated as pathologic ruptures because histologic examination reveals that both ends of the ruptured tendon and the insertion site at the calcaneus have extensive black pigment depositions where homogentisic acid and its metabolites have accumulated, and there are no normal collagen bundles present. Even if an Achilles tendon rupture is clinically diagnosed as an acute injury, the ruptured Achilles tendon should be primarily repaired and reinforced with autologous tissue because there are a few viable cells at the ruptured site, and because the tendon ruptures mainly at the insertion site of the calcaneus. Although this is a preliminary report, the short-term result is good and the reconstructed sites have showed no rerupture.

New cell lines with chondrocytic phenotypes from human chondrosarcoma

In the present study, we investigated chondrocytic characterization for newly established human chondrosarcoma cell lines. A chondrosarcoma cell line, HCS-TG, was established by the implantation of grade-2 human chondrosarcoma into athymic mice. Cloning of HCS-TG cells from passage 17 was performed. After cell cloning, two clonal-cell lines (HCS-TG C3 and E2) with good proliferative activities were obtained. These cell lines in monolayer culture retained a polygonal morphology. Their doubling times were 68 h and 45 h, respectively. mRNA expressions of type-I, -II, -X, and -XI collagens and aggrecan core protein were detected on reverse-transcription polymerase chain reaction. Protein expression of type-II collagen was confirmed in each cell line using Western blotting. However, there was no expression of type-I collagen. Moreover, gelatin zymography revealed that both cell lines produced extracellular matrices with matrix metalloproteinases 2 and 9. The parental HCS-TG cells had tumorigenicity in athymic mice; however, C3 and E2 were not tumorigenic. New clonal-cell lines HCS-TG C3 and E2 derived from human chondrosarcoma are morphologically chondrocytic in serial monolayer cultures and express chondrocytic phenotypes.

Prediction of response to neoadjuvant chemotherapy for osteosarcoma by gene-expression profiles

To establish a method for predicting the response to chemotherapy for osteosarcoma (OS), we performed expression profile analysis using cDNA microarray consisting of 23,040 genes. Hierarchical clustering based on the expression profiles of 19 biopsy samples of OS demonstrated two major clusters, one of which consisted exclusively of typical OS, i.e. conventional central OS in long bone of patients in the second decade. A set of genes was identified to characterize this subgroup, some of which have previously indicated some relation to carcinogenesis. Thirteen of the 19 patients were treated with an identical protocol of chemotherapy containing doxorubicin, cis-platinum and ifosfamide, and histological examination of resected specimens after operation classified 6 cases as responder and 7 as non-responder. A comparison of expression profiles of these two groups identified 60 genes whose expression levels were likely to be correlated with the response to chemotherapy (P<0.008). A drug response scoring (DRS) system was developed based on the expression levels of these genes, which proved to be applicable to predict the response to chemotherapy irrespective for the subclassification of OS. The reliability of the DRS system was further confirmed by testing additional 5 OS cases. These results indicated that scoring system based on gene-expression profiles might be useful to predict the response to chemotherapy for OS.

Synovial sarcoma after chemotherapy for osteosarcoma: a case report

A 23-year-old man had eight cycles of adjuvant chemotherapy including doxorubicin, cisplatin, methotrexate, and ifosfamide and radical surgery for biopsy-proved osteosarcoma of the right fibular shaft. Two years after the initial diagnosis, he noticed a mass in the medial aspect of his right knee. Magnetic resonance imaging scans revealed a soft tissue tumor measuring 2 x 2 cm in the pericapsular region of the right knee. Histologically, this soft tissue tumor was composed of spindle cells with occasional atypical mitoses and without matrix formation. Immunohistochemically, the tumor cells were positive for vimentin, cytokeratin, and epithelial membrane antigen, and negative for alpha smooth muscle actin. A fusion gene, SYT-SSX was detected with reverse transcription-polymerase chain reaction. From the results, the secondary tumor was diagnosed as a synovial sarcoma. The current case of double sarcomas is rare. Both sarcomas were diagnosed accurately using immunohistochemical and molecular procedures. This case suggests a positive association between a second tumor and chemotherapy including intraarterial perfusion of doxorubicin.

Cystic synovial sarcomas: imaging features with clinical and histopathologic correlation

OBJECTIVE

To characterize the radiological and clinicopathologic features of cystic synovial sarcoma.

DESIGN AND PATIENTS

Seven patients with primary cystic synovial sarcoma were evaluated. Computed tomography (CT) and magnetic resonance (MR) imaging were undertaken at the first presentation. The diagnosis of synovial sarcoma was made on the basis of histological examinations followed by molecular analysis. Radiological and clinicopathologic findings were reviewed.

RESULTS

CT showed well-defined soft tissue mass without cortical bone erosion and invasion. Calcification was seen at the periphery of the mass in three cases. T2-weighted MR images showed multilocular inhomogeneous intensity mass in all cases, five of which showed fluid-fluid levels. On gross appearance, old and/or fresh hematomas were detected in six cases. In the one remaining case, microscopic hemorrhage in the cystic lumen was proven. Four cases had poorly differentiated areas. In five cases prominent hemangiopericytomatous vasculature was observed. Histologic grade was intermediate in one tumor and high in six. One case had a history of misdiagnosis for tarsal tunnel syndrome, one for lymphadenopathy, two for sciatica and two for hematoma.

CONCLUSION

All cystic synovial sarcomas demonstrated multilocularity with well-circumscribed walls and internal septae. Synovial sarcoma should be taken into consideration in patients with deeply situated multicystic mass with triple signal intensity on T2-weighted MR imaging.

Frequent expression of smooth muscle markers in malignant fibrous histiocytoma of bone

BACKGROUND/AIMS

Malignant fibrous histiocytoma (MFH) of bone, a relatively rare primary malignant bone tumour, is a distinct clinicopathological entity as opposed to MFH derived from soft tissue. Although the true histogenesis of this condition is still controversial, a considerable number of cases of MFH in soft tissue show positive immunohistochemical reactivity for muscle markers such as desmin, common muscle actin (HHF35), and alpha smooth muscle actin (SMA), suggesting that MFH cells are myofibroblastic in nature.

METHODS

This study investigated immunoreactivity for several different muscle markers in 19 cases of MFH of bone together with reverse transcription polymerase chain reaction (RT-PCR) analysis on frozen tissue samples that were available in four cases, and compared the data with those found in 11 cases of osteosarcoma and 11 cases of soft tissue MFH treated over the same period.

RESULTS

Immunohistochemistry revealed that MFH of bone showed relatively frequent expression of smooth muscle markers, including calponin (nine cases), alpha-SMA (nine cases), and SM22alpha (18 cases), and this was confirmed by RT-PCR analysis. However, only one, two, and three cases of MFH of bone showed positive staining for desmin, MyoD1, and HHF35, respectively. Similarly, 11 osteosarcoma cases were relatively frequently positive for alpha-SMA (five cases), calponin (four cases), and SM22alpha (seven cases), and less frequently positive for desmin (one case), MyoD1 (none), and HHF35 (none). In contrast, very few MFH of soft tissue cases (n = 11) showed positive reactivity for all of these muscle markers. It has recently been reported that human bone marrow stromal cells also express various kinds of smooth muscle markers including alpha-SMA and calponin.

CONCLUSIONS

These results suggested that MFH of bone may derive from mesenchymal stromal cells in bone marrow and has a more myofibroblastic differentiation than soft tissue MFH.

Inhibition of murine osteosarcoma cell proliferation by glucocorticoid

The effects of glucocorticoid (GC) on the proliferation of Dunn Osteosarcoma (OS) cells were examined under in vitro culture conditions. Dexamethasone (Dex) inhibited the proliferation of Dunn OS cells in a dose-dependent manner, while the addition of anti-GC, RU486, to the culture medium in part recovered Dex-induced growth inhibition. The number of maximum binding sites (Bmax) and the dissociation constant (Kd) value of glucocorticoid receptor (GR) in Dunn OS cells were 19,560 sites/cell and 5.2 +/- 0.8 nM, respectively. RU486 competed with labeled Dex against GR at a concentration of 10(-6) M. Western blot analysis of [3H]Dex-mesylate-labeled cell homogenate and immunohistochemical staining against GR further confirmed the presence of GR. Dex treatment of Dunn OS cells resulted in apoptosis with the characteristic internucleosomal DNA cleavage shown by the DNA ladder pattern in agarose gel electrophoresis. These data demonstrate that GC inhibits the proliferation of Dunn OS cells via GR, for which one possible mechanism in vitro is induction of apoptosis.

Clinical implications of serum C-reactive protein levels in malignant fibrous histiocytoma

Paraneoplastic syndromes (PNSs) associated with mesenchymal tumors are uncommon. Previous reports sporadically described inflammatory PNSs with elevated serum C-reactive protein (CRP) levels and leukocytosis in patients with inflammatory malignant fibrous histiocytoma (MFH) of soft tissue; however, the relationship between other subtypes of MFH and PNS has not been extensively investigated. Forty-six patients with primary MFH of soft tissues who underwent radical surgery were retrospectively analyzed. These patients were divided into 2 groups according to preoperative serum CRP level: normal (<1.0 mg/dl) and elevated (> or = 1.0 mg/dl). The correlation between serum CRP level and several clinicopathologic factors was analyzed. Correlation between preoperative serum CRP level and metastasis-free and overall survival was also investigated by univariate and multivariate analyses. Elevated preoperative serum CRP levels were found in 65% of patients with a mean of 3.7 mg/dl. There were statistically significant relationships regarding tumor size, depth, histologic subtypes, grade, stage and metastatic rate among normal and elevated CRP groups (p < 0.001, p < 0.02, p < 0.005, p < 0.001, p < 0.001 and p < 0.05, respectively). When the tumor was removed, the elevated CRP level subsided into the normal range and other abnormal laboratory findings diminished in all cases. In 11/14 relapsed cases that showed elevated CRP preoperatively, the serum CRP level re-elevated with tumor relapse. The normal CRP group showed significantly more favorable prognosis than the elevated CRP group in metastasis-free and overall survival on univariate analysis (p < 0.02, p < 0.05, respectively). Patients with MFH frequently present with an inflammatory PNS, such as elevated serum CRP level, which can be a useful marker of disease activity and a valuable prognostic indicator.

Malignant mesenchymoma of the lower leg

A 24 year old man had a two year history of a painless mass on his right popliteal region. Magnetic resonance imaging demonstrated a 6 x 8 cm tumour mass in the lateral gastrocnemius. Histological examination of the tumour resected by radical surgery revealed that it consisted of myoblastic sarcoma and chondrosarcoma. Immunohistochemical studies were positive for Ki-67 and p53 throughout the area and for S-100 protein in the chondrosarcomatous area; in addition, they showed partial positivity for muscle common actin (HHF-35), smooth muscle actin, and myoglobin in the spindle cells. The percentages of Ki-67, p53, and p21/WAF1 positive cells in the spindle cell component were 34%, 65.7%, and < 0.1%, respectively. In addition, staining was negative for pancytokeratin, desmin, and glial fibrillary acidic protein. The SYT-SSX, TLS-CHOP, and EWS-FLI1 fusion genes were not detected using the reverse transcription polymerase chain reaction. Given the results, the definitive histological diagnosis is malignant mesenchymoma. This is the first report of malignant mesenchymoma of the lower leg with immunohistochemical and molecular studies.

In vivo inhibition of tumour growth by dexamethasone in murine osteosarcomas

This study was performed to determine whether glucocorticoid (GC) is an effective inhibitor of tumour growth in murine osteosarcoma (OS) in vivo. The effects of dexamethasone (DEX) on the growth of this tumour were studied in male C3H/He mice. The animals received a dose of 1.25 or 5 microg/g of DEX in 0.1 ml of steroid solution daily intraperitoneally (i.p.) for 14 days. In each DEX-treated group, significant inhibition of the tumour growth curve was seen in a dose- dependent manner compared with the control group (P<0.0001). The percentage of proliferative cell nuclear antigen (PCNA)-positive cells was 22.7% in the 5 microg/g DEX treatment group compared with 67.6% in the control group (P=0.009). Furthermore, mifepristone, a GC receptor antagonist, blocked the inhibition of tumour growth induced by DEX. In the control group, tumour cells showed positive reactivity for nuclear glucocorticoid receptors (GR) by immunohistochemistry. The results of this study indicate that tumour growth inhibition by DEX in murine osteosarcoma may be via GR.

Intramuscular haemangioma adjacent to the bone surface with periosteal reaction. Report of three cases and review of the literature

We present three cases of intramuscular haemangioma adjacent to bone in the lower limb. All patients had local pain during the third decade. Plain radiographs showed an irregular or hypertrophic periosteal reaction on the shaft of the fibula and an intramuscular mass adjacent to the bone with inhomogeneous high signal intensity on MRI. These lesions mimic periosteal or parosteal tumours.

Intramuscular haemangioma adjacent to the bone surface with periosteal reaction

We present three cases of intramuscular haemangioma adjacent to bone in the lower limb. All patients had local pain during the third decade. Plain radiographs showed an irregular or hypertrophic periosteal reaction on the shaft of the fibula and an intramuscular mass adjacent to the bone with inhomogenous high signal intensity on MRI. These lesions mimic periosteal or parosteal tumours.

Bone Metastases from Soft Tissue Sarcomas

The incidence, distribution, time of appearance, and radiologic findings of bone metastases from soft tissue sarcomas, exclusive of lymphomas, were evaluated in 320 patients with soft tissue sarcomas. Thirty patients (9.4%) had evidence of 58 bone metastases. Five of 30 patients presented with metastases, and 25 of 30 patients developed metastases up to 66 months after presentation with a mean time interval of 21.3 months. The incidence of skeletal metastases differed among histologic subtypes of sarcomas; alveolar soft part sarcoma (5 of 8), dedifferentiated liposarcoma (2 of 4), angiosarcoma (2 of 4), and rhabdomyosarcoma (5 of 16) tended to show a higher incidence of bone metastases. The sarcomas metastasized to the regional bones close to the primary tumor in 16 (53%) of 30 patients and to the axial bones in 18 (60%). On conventional radiographs, the osseous metastases demonstrated predominantly osteolytic changes, and evidence of pathological fracture was observed in 31% of 58 metastases.

Malignant hemangiopericytoma of the breast

A55-year-old woman presented with 1-year history of mass in the right breast. Incisional biopsy showed the tumor to be malignant hemangiopericytoma from its histology. The tumor showed low--intermediate density and peripheral contrast enhancement on CT, and inhomogeneous mixed-signal intensity both on T1W and T2W images, and peripheral enhancement with Gd-DTPA on MRI with no invasion of the duct.

Plexiform schwannoma of the foot

The present report describes a plexiform schwannoma involving the subcutis of the foot in an 8-year-old boy. Gross findings revealed thin fibrous septa in a multilobulated tumor that was partly separated into free body-like nodules in the subcutis. Preoperative CT and MRI failed to delineate this multinodular architecture or free bodies. This is a case presentation including the CT and MR findings associated with plexiform schwannoma.