Outcome in dedifferentiated chondrosarcoma for patients treated with multimodal therapy: Results from the EUROpean Bone Over 40 Sarcoma Study

INTRODUCTION

The role of chemotherapy for patients with dedifferentiated chondrosarcoma (DDCS) is still under discussion. Here, we present the outcome in patients with DDCS treated with intensive chemotherapy from the EUROpean Bone Over 40 Sarcoma Study.

MATERIALS AND METHODS

The chemotherapy regimen included doxorubicin, ifosfamide and cisplatin. Postoperative methotrexate was added in case of poor histological response. Toxicity was graded based on the National Cancer Institute expanded common toxicity criteria, version 2.0, and survival was analysed using Kaplan-Meier curves, log-rank tests and univariate Cox regression models.

RESULTS

Fifty-seven patients with DDCS (localised, 34 [60%]; metastatic, 23 [40%]) aged 42-65 years were included. Surgical complete remission (SCR) was achieved in 36 (63%) patients. The median overall survival (OS) was 24 months (95% confidence interval, 22-25), and the 5-year OS was 39%. Patients with extremity localisation had a 5-year OS of 49% compared with 29% in patients with a central tumour (P = 0.08). Patients with localised disease had a 5-year OS of 46%, whereas patients with metastatic disease had a 5-year OS of 29% (P = 0.12). Patients in SCR had a 5-year OS of 49%, whereas patients not in SCR had a 5-year OS of 23% (P = 0.004). Chemotherapy toxicity was considerable but manageable. There was no treatment-related death, and 39 (70%) patients received ≥6 cycles of the planned nine chemotherapy cycles.

CONCLUSIONS

Adding intensive chemotherapy to surgery for treatment of DDCS is feasible and shows favourable survival data compared with previous reports. With the limitations of data from a non-controlled trial, we conclude that chemotherapy could be considered in the management of patients aged >40 years.

Targeting cancer stem cells by disulfiram and copper sensitizes radioresistant chondrosarcoma to radiation

Overcoming the radiosensitivity of chondrosarcoma (CS), the second most common primary bone tumor, is needed. Radioresistance is attributed to cancer stem cells (CSCs) in many malignancies. Disulfiram (DSF), an FDA-approved anti-alcoholism drug, complexed with Cu (DSF/Cu) can radiosensitize epithelial CSCs. This prompted us to investigate the radiosensitizing effect of DSF/Cu on CS CSCs (CCSCs). The radiosensitizing effects of DSF/Cu on CCSCs were investigated in vitro using cell lines SW1353 and CS-1. Stemness was identified independently by flow cytometry for CCSCs (ALDH⁺CD133⁺), sphere-forming ability, and Western blot analysis of stemness gene protein expression. The radiosensitizing effect of DSF/Cu was studied in an orthotopic CS xenograft mouse model by analyzing xenograft growth and residual xenografts for stemness. CCSCs were found to be resistant to single-dose (IR) and fractionated irradiation (FIR). IR and FIR increased CS stemness. Combined with DSF/Cu in vitro and in vivo, IR and FIR eliminated CS stemness. RT + DSF/Cu was safer and more effective than either RT ± DSF in inhibiting growth of orthotopic CS xenografts. In conclusion, DSF/Cu radiosensitizes CCSCs. These results can be translated into clinical trials for CS patients requiring RT for improved outcomes.

Primary chest wall sarcoma; a single institution experience of 3 years

INTRODUCTION

Primary chest wall sarcoma is a rare entity. It can be classified based on its origin, as bone sarcomas or soft tissue sarcomas. Various prognostic factors have been studied in different case series like age, sex, tumor histology, grade, resection margin status, adjuvant treatment, and others. The present study aimed to analyze common histological types, their management by resection and reconstruction and prognosis, in cases presenting at a regional cancer center in western India.

MATERIAL AND METHOD

This was an observational study from a prospectively maintained database. 57 patients with chest wall sarcoma treated with curative intent between January 2016 till January 2019 with a minimum follow-up of 3 months were included in the study. The goals of surgical treatment were to obtain a wide resection margin of 3-4 cm, preserve the function of the chest wall and provide stability and rigidity to protect intrathoracic organs.

RESULTS

The median follow-up of the present patient's cohort was for 20.2 months. Overall two-year survival was 74.7%. Two-year OS and DFS of bone sarcoma were 62.3% and 35% and soft tissue sarcomas were 91% and 71.3%. Ewing's sarcoma had the worst two-year overall survival of 50.6% and chondrosarcoma and fibromatosis had 100% two-year overall survival.

CONCLUSION

Chest wall sarcoma forms a heterogeneous group of tumors. In the present study, Ewing's sarcoma was the most common histology with the worst survival, since they presented in advanced stages. Management should be multidisciplinary and surgical resection should be aggressive to achieve an R0 resection. Reconstruction of chest wall should aim to provide structural and functional stability with minimal morbidity. Frozen section assessment should be utilized whenever in doubt.

Prognostic factors and survival in conventional chondrosarcoma: A single institution review

BACKGROUND

Chondrosarcoma is the second most common primary sarcoma of the bone. Surgery remains the gold standard for treatment due to chemotherapy and radiotherapy resistance in chondrosarcoma. The main aim of our study was to analyze patients with primary chondrosarcoma of the bone who were treated in a single tumor center. Our study team identified the prognostic factors for overall survival, metastasis-free survival, and recurrence-free survival.

METHODS

From 1998 to 2012, 55 consecutive patients were treated surgically. All patients were followed for local recurrence or distant metastasis. Uni- and multivariate analyses were performed for overall, metastasis-free, and recurrence-free survival.

RESULTS

Local recurrence developed in 29 of the 55 patients (52.7%). Recurrence-free survival in the multivariate analysis showed a significant association with the surgical margin, and high-grade lesions were an independent factor for local recurrence. In total, 11 patients died of the disease in the study, and the 5- and 10-year survival rates were 84.4% and 78.1%, respectively. The tumor grade and local recurrence were significant factors in the univariate analysis but were insignificant in the Cox regression with time-dependent covariates (p = 0.327 and p = 0.82, respectively). The development of distant metastasis was a significant poor prognostic factor in both the uni- and multivariate analyses.

CONCLUSION

Chondrosarcoma of the bone is a disease with surgery-dependent outcomes; but, however, patients often develop subsequent recurrence of the disease. The surgical margins were statistically associated with the risk of subsequent local recurrence but did not predict survival. The development of distant metastases was an independent prognostic factor for poor survival.

Survival, Tumor Recurrence, and Function Following Shoulder Girdle Limb Salvage at 24 to 35 Years of Follow-up

Limb salvage is the treatment of choice for malignant shoulder girdle tumors; however, there is a paucity of data examining the long-term outcome. The authors have previously reported on a cohort of patients at short- and mid-term follow-up. The purpose of this study was to report the long-term outcome of shoulder reconstruction in terms of oncological and functional outcome. The authors reviewed 53 patients who underwent a limb salvage procedure for treatment of a tumor of the shoulder girdle. At a mean of 28 years following the resection, 76% of surviving patients were contacted and administered functional outcome scores using the Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage (TESS). The 20-year survival and recurrence-free survival were 79% and 80%, respectively. Likewise, the 20-year revision survival was 75%, with a limb salvage rate of 94%. At last follow-up, the mean MSTS rating and TESS score were 75% and 85%, respectively, with 9 patients having improvement in their MSTS rating from the previous findings. Limb salvage following resection of shoulder girdle tumor resulted in acceptable means of oncological outcome and function. Some patients continued to experience improvements in functional outcome even at late (>20 years) follow-up. [Orthopedics. 2019; 42(6):e514-e520.].

Clinical features and prognostic analysis of patients with chest wall chondrosarcoma

Chest wall chondrosarcoma is a rare malignant tumor of the bone. This study is aimed to identify the prognostic determinants of chest wall chondrosarcoma. We used the Surveillance, Epidemiology, and End Results (SEER) database to identify patients with chest wall chondrosarcoma from 1973 to 2015. Statistical analyses were performed using Kaplan-Meier method and Cox regression proportional hazards. A total of 779 patients were identified from the SEER database. The overall survival (OS) and cancer-specific survival (CSS) rates of the entire group at 10 years were 66.2% and 77.2%, respectively. On multivariate Cox regression, age ≤40 years, localized tumor stage, low tumor grade, surgery, and no radiotherapy were significantly associated with improved both OS and CSS. This study may help clinicians to predict survival of patients with chest wall chondrosarcoma and to provide appropriate treatment recommendations.

Intralesional treatment versus wide resection for central low-grade chondrosarcoma of the long bones

BACKGROUND

Grade I or low-grade chondrosarcoma (LGCS) is a primary bone tumour with low malignant potential. Historically, it was treated by wide resection, since accurate pre-operative exclusion of more aggressive cancers can be challenging and under-treatment of a more aggressive cancer could negatively influence oncological outcomes. Intralesional surgery for LGCS has been advocated more often in the literature over the past few years. The potential advantages of less aggressive treatment are better functional outcome and lower complication rates although these need to be weighed against the potential for compromising survival outcomes.

OBJECTIVES

To assess the benefits and harms of intralesional treatment by curettage compared to wide resection for central low-grade chondrosarcoma (LGCS) of the long bones.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE and Embase up to April 2018. We extended the search to include trials registries, reference lists of relevant articles and review articles. We also searched 'related articles' of included studies suggested by PubMed.

SELECTION CRITERIA

In the absence of prospective randomised controlled trials (RCTs), we included retrospective comparative studies and case series that evaluated outcome of treatment of central LGCS of the long bones. The primary outcome was recurrence-free survival after a minimal follow-up of 24 months. Secondary outcomes were upgrading of tumour; functional outcome, as assessed by the Musculoskeletal Tumor Society (MSTS) score; and occurrence of complications.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recognised by Cochrane. We conducted a systematic literature search using several databases and contacted corresponding authors, appraised the evidence using the ROBINS-I risk of bias tool and GRADE, and performed a meta-analysis. If data extraction was not possible, we included studies in a narrative summary.

MAIN RESULTS

We included 18 studies, although we were only able to extract participant data from 14 studies that included a total of 511 participants; 419 participants were managed by intralesional treatment and 92 underwent a wide resection. We were not able to extract participant data from four studies, including 270 participants, and so we included them as a narrative summary only. The evidence was at high risk of performance, detection and reporting bias.Meta-analysis of data from 238 participants across seven studies demonstrated little or no difference in recurrence-free survival after intralesional treatment versus wide resection for central LGCS in the long bones (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.92 to 1.04; very low-certainty evidence). MSTS scores were probably better after intralesional surgery (mean score 93%) versus resection (mean score 78%) with a mean difference of 12.69 (95% CI 2.82 to 22.55; P value < 0.001; 3 studies; 72 participants; low-certainty evidence). Major complications across six studies (203 participants) were lower in cases treated by intralesional treatment (5/125 cases) compared to those treated by wide resection (18/78 cases), with RR 0.23 (95% CI 0.10 to 0.55; low-certainty evidence). In four people (0.5% of total participants) a high-grade (grade 2 or dedifferentiated) tumour was found after a local recurrence. Two participants were treated with second surgery with no evidence of disease at their final follow-up and two participants (0.26% of total participants) died due to disease. Kaplan-Meier analysis of data from 115 individual participants across four studies demonstrated 96% recurrence-free survival after a maximum follow-up of 300 months after resection versus 94% recurrence-free survival after a maximum follow-up of 251 months after intralesional treatment (P value = 0.58; very low-certainty evidence). Local recurrence or metastases were not reported after 41 months in either treatment group.

AUTHORS' CONCLUSIONS

Only evidence of low- and very low-certainty was available for this review according to the GRADE system. Included studies were all retrospective in nature and at high risk of selection and attrition bias. Therefore, we could not determine whether wide resection is superior to intralesional treatment in terms of event-free survival and recurrence rates. However, functional outcome and complication rates are probably better after intralesional surgery compared to wide resection, although this is low-certainty evidence, considering the large effect size. Nevertheless, recurrence-free survival was excellent in both groups and a prospective RCT comparing intralesional treatment versus wide resection may be challenging for both practical and ethical reasons. Future research could instead focus on less invasive treatment strategies for these tumours by identifying predictors that help to stratify participants for surgical intervention or close observation.

Surgery and protontherapy in Grade I and II skull base chondrosarcoma: A comparative retrospective study

Objective

Skull base chondrosarcoma is a rare tumour usually treated by surgery and proton therapy. However, as mortality rate is very low and treatment complications are frequent, a less aggressive therapeutic strategy could be considered. The objective of this study was to compare the results of surgery only vs surgery and adjuvant proton therapy, in terms of survival and treatment adverse effects, based on a retrospective series.

Methods

Monocentric retrospective study at a tertiary care centre. All patients treated for a skull base grade I and II chondrosarcoma were included. We collected data concerning surgical and proton therapy treatment and up-to-date follow-up, including Common Terminology Criteria for Adverse Events (CTCAE) scores.

Results

47 patients (23M/24F) were operated on between 2002 and 2015; mean age at diagnosis was 47 years-old (10–85). Petroclival and anterior skull base locations were found in 34 and 13 patients, respectively. Gross total resection was achieved in 17 cases (36%) and partial in 30 (64%). Adjuvant proton therapy (mean total dose 70 GyRBE,1.8 GyRBE/day) was administered in 23 cases. Overall mean follow-up was 91 months (7–182). Of the patients treated by surgery only, 8 (34%) experienced residual tumour progression (mean delay 51 months) and 5 received second-line proton therapy. Adjuvant proton therapy was associated with a significantly lower rate of relapse (11%; p = 0.01). There was no significant difference in 10-year disease specific survival between patients initially treated with or without adjuvant proton therapy (100% vs 89.8%, p = 0.14). Difference in high-grade toxicity was not statistically significant between patients in both groups (25% (7) vs 11% (5), p = 0.10). The most frequent adverse effect of proton therapy was sensorineural hearing loss (39%).

Conclusion

Long-term disease specific survival was not significantly lower in patients without adjuvant proton therapy, but they experienced less adverse effects. We believe a surgery only strategy could be discussed, delaying as much as possible proton therapy in cases of relapse. Further prospective studies are needed to validate this more conservative strategy in skull base chondrosarcoma.

[Bone chondrosarcomas: clinical features and surgical outcomes in five years]

BACKGROUND

Biological and clinical behavior of chondrosarcoma, and its prognosis, are broadly related to histological grade, location and treatment. Surgery plays the most important role in local control and preservation of the limb. Given its low incidence, there are few cancer surgical centers in our country that report their experience concerning the treatment of this pathology.

OBJECTIVE

To describe the management, clinical features, and outcomes of surgical treatment in patients diagnosed with bone chondrosarcoma.

METHODS

Descriptive study which included 25 patients diagnosed with bone chondrosarcoma who received surgical treatment. We assessed their clinical features, localization, stage, treatment and surgical outcomes.

RESULTS

Mean age was 43.4 ± 14.7 years and the most frequently affected site was the pelvis (44%). The most frequently performed surgery was wide resection and immediate reconstruction with implants in 10 patients (40%). Local recurrence was observed in six patients (24%). During follow up, two patients died from metastatic disease (8%).

CONCLUSIONS

Due to the characteristics of chondrosarcoma, the treatment is multidisciplinary. Local surgery plays the most important role in control, limb preservation and function.

Can Machine-learning Techniques Be Used for 5-year Survival Prediction of Patients With Chondrosarcoma?

BACKGROUND

Several studies have identified prognostic factors for patients with chondrosarcoma, but there are few studies investigating the accuracy of computationally intensive methods such as machine learning. Machine learning is a type of artificial intelligence that enables computers to learn from data. Studies using machine learning are potentially appealing, because of its possibility to explore complex patterns in data and to improve its models over time.

QUESTIONS/PURPOSES

The purposes of this study were (1) to develop machine-learning algorithms for the prediction of 5-year survival in patients with chondrosarcoma; and (2) to deploy the best algorithm as an accessible web-based app for clinical use.

METHODS

All patients with a microscopically confirmed diagnosis of conventional or dedifferentiated chondrosarcoma were extracted from the Surveillance, Epidemiology, and End Results (SEER) Registry from 2000 to 2010. SEER covers approximately 30% of the US population and consists of demographic, tumor characteristic, treatment, and outcome data. In total, 1554 patients met the inclusion criteria. Mean age at diagnosis was 52 years (SD 17), ranging from 7 to 102 years; 813 of the 1554 patients were men (55%); and mean tumor size was 8 cm (SD 6), ranging from 0.1 cm to 50 cm. Exact size was missing in 340 of 1544 patients (22%), grade in 88 of 1544 (6%), tumor extension in 41 of 1544 (3%), and race in 16 of 1544 (1%). Data for 1-, 3-, 5-, and 10-year overall survival were available for 1533 (99%), 1512 (98%), 1487 (96%), and 977 (63%) patients, respectively. One-year survival was 92%, 3-year survival was 82%, 5-year survival was 76%, and 10-year survival was 54%. Missing data were imputed using the nonparametric missForest method. Boosted decision tree, support vector machine, Bayes point machine, and neural network models were developed for 5-year survival. These models were chosen as a result of their capability of predicting two outcomes based on prior work on machine-learning models for binary classification. The models were assessed by discrimination, calibration, and overall performance. The c-statistic is a measure of discrimination. It ranges from 0.5 to 1.0 with 1.0 being perfect discrimination and 0.5 that the model is no better than chance at making a prediction. The Brier score measures the squared difference between the predicted probability and the actual outcome. A Brier score of 0 indicates perfect prediction, whereas a Brier score of 1 indicates the poorest prediction. The Brier scores of the models are compared with the null model, which is calculated by assigning each patient a probability equal to the prevalence of the outcome.

RESULTS

Four models for 5-year survival were developed with c-statistics ranging from 0.846 to 0.868 and Brier scores ranging from 0.117 to 0.135 with a null model Brier score of 0.182. The Bayes point machine was incorporated into a freely available web-based application. This application can be accessed through https://sorg-apps.shinyapps.io/chondrosarcoma/.

CONCLUSIONS

Although caution is warranted, because the prediction model has not been validated yet, healthcare providers could use the online prediction tool in daily practice when survival prediction of patients with chondrosarcoma is desired. Future studies should seek to validate the developed prediction model.

LEVEL OF EVIDENCE

Level III, prognostic study.

Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine

BACKGROUND

Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment.

METHODS

A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision.

RESULTS

In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001).

CONCLUSIONS

CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.

Can a Nomogram Help to Predict the Overall and Cancer-specific Survival of Patients With Chondrosarcoma?

BACKGROUND

Many factors have been reported to be associated with the prognosis of patients with chondrosarcoma, but clinicians have few tools to estimate precisely an individual patient's likelihood of surviving the illness. We therefore sought to develop effective nomograms to better estimate the survival of patients with chondrosarcoma.

QUESTIONS/PURPOSES

(1) Which clinicopathologic features are independent prognostic factors for patients with chondrosarcoma? (2) Can we develop a nomogram to predict 3- and 5-year overall and cancer-specific survival of individual patients with chondrosarcoma based on personalized information?

METHODS

We collected information on patients diagnosed with chondrosarcoma between 1988 and 2011 from the Surveillance, Epidemiology, and End Results (SEER) database. The SEER database consists of 18 cancer registries and covers approximately 30% of the total United States population. One thousand thirty-four adult patients with grade II or III chondrosarcoma were included in the cohort (patients with grade I chondrosarcoma were not evaluated in this study), while 327 patients were excluded from the study owing to missing data regarding tumor size or metastasis. Nine hundred nineteen patients (89%) in the cohort had complete followup for at least 1 year. The X-tile program was used to determine optimal cutoff points. Univariate and multivariate analyses were applied to identify independent factors that were further included in the nomograms predicting 3- and 5-year overall survival and cancer-specific survival. Records of 1034 patients were collected and randomly divided into training (n = 517) and validation (n = 517) cohorts. The nomograms were developed based on training cohort. Data for the training cohort were obtained for internal validation of the nomograms, whereas data for the validation cohort were obtained for external validation of the nomograms. Bootstrapped validation, which used a resample with 500 iterations, was applied to validate the nomograms internally and externally.

RESULTS

Six independent prognostic factors for overall survival and six for cancer-specific survival were identified and incorporated to construct nomograms for 3- and 5-year overall and cancer-specific survival. These nomograms can easily be used by providers in the office to estimate a patient's prognosis; the only clinical details a provider needs to use these nomograms effectively are age, histologic subtype, tumor grade, whether surgery was performed, tumor size, and the presence or absence of metastases. Internal and external calibration plots for the probability of 3- and 5-year overall survival and cancer-specific survival showed good agreement between nomogram prediction and observed outcomes. The concordance indices (C-indices) for internal validation of overall survival and cancer-specific survival prediction were 0.803 and 0.829, respectively, whereas the C-indices for external validation were 0.753 and 0.759, respectively.

CONCLUSIONS

We were able to develop effective nomograms to predict overall survival and cancer-specific survival for patients with chondrosarcoma; these nomograms require only basic information, which should be available to all providers in the office setting. If these observations can be validated in different registries or databases, the nomograms can assist clinicians in counseling patients regarding therapeutic choices.

LEVEL OF EVIDENCE

Level III, prognostic study.

Digital PCR analysis of circulating tumor DNA: a biomarker for chondrosarcoma diagnosis, prognostication, and residual disease detection

Conventional chondrosarcoma is the most common primary bone tumor in adults. Prognosis corresponds with tumor grade but remains variable, especially for individuals with grade (G) II disease. There are currently no biomarkers available for monitoring or prognostication of chondrosarcoma. Circulating tumor DNA (ctDNA) has recently emerged as a promising biomarker for a broad range of tumor types. To date, little has been done to study the presence of ctDNA and its potential utility in the management of sarcomas, including chondrosarcoma. In this study, we have assessed ctDNA levels in a cohort of 71 patients, 32 with sarcoma, including 29 individuals with central chondrosarcoma (CS) and 39 with locally aggressive and benign bone and soft tissue tumors, using digital PCR. In patients with CS, ctDNA was detected in pretreatment samples in 14/29 patients, which showed clear correlation with tumor grade as demonstrated by the detection of ctDNA in all patients with GIII and dedifferentiated disease (n = 6) and in 8/17 patients with GII disease, but never associated with GI CS. Notably detection of ctDNA preoperatively in GII disease was associated with a poor outcome. A total of 14 patients with CS had ctDNA levels assessed at multiple time points and in most patients there was a clear reduction following surgical removal. This research lays the foundation for larger studies to assess the utility of ctDNA for chondrosarcoma diagnosis, prognostication, early detection of residual disease and monitoring disease progression.

Clinical benefit of antiangiogenic therapy in advanced and metastatic chondrosarcoma

Chondrosarcoma is the most common bone sarcoma in adults. Conventional chondrosarcoma, the commonest histological subtype, is largely resistant to anthracycline-based chemotherapy. There have been anecdotal reports of durable clinical benefit with antiangiogenic agents in this disease. A retrospective search of patients treated at three sarcoma referral centers was performed to identify patients with advanced chondrosarcoma treated with antiangiogenic agents. The aim of this study was to evaluate the efficacy and safety of antiangiogenic agents in advanced chondrosarcoma. Ten patients were identified; seven with conventional, one each with clear cell, extraskeletal mesenchymal chondrosarcoma and extraskeletal myxoid chondrosarcoma. The median progression-free survival for patients with conventional and clear cell sarcoma was 22.6 months. Median overall survival has not been met. Antiangiogenic therapy was well tolerated in this series of patients. Our retrospective data suggest that antiangiogenic therapy can provide prolonged clinical benefit in advanced chondrosarcoma patients. Further prospective trials are required to precisely define the role of this class of agent in advanced chondrosarcoma.

Functional and oncological outcome after surgical resection of the scapula and clavicle for primary chondrosarcoma

PURPOSE

The scapula is a relatively common site for chondrosarcoma to develop in contrary to the clavicle, which is rarely affected by these tumors. The aim of this study is to determine the functional and oncological outcome for patients treated operatively for scapular or clavicular chondrosarcoma.

METHODS

In this single-center retrospective study, we included a sample of 20 patients that received the diagnosis of a primary chondrosarcoma of the scapula or clavicle. Of the surviving patients, the functional function was assessed using the DASH and the PROMIS Physical Function-Upper Extremity. Patients were longitudinally tracked for their oncological outcome.

RESULTS

All patients were followed for at least 2 years or until death. The mean age of the cohort was 47 years. Eighteen patients suffered from a chondrosarcoma of the scapula, and in 2 patients, the tumor was located in the clavicle. Metastasis, local recurrence and a higher tumor grade were all associated with a decreased overall survival. For the patients with a chondrosarcoma of the scapula, the average DASH score was 16 ± 16 and the mean PROMIS Physical Function-Upper Extremity score was 48 ± 10. Patients with both an intact rotator cuff and glenoid had a better physical function.

CONCLUSIONS

Upper extremity function after (partial) scapulectomy varied depending on whether the glenoid was spared and whether a functioning shoulder abductor remained. When the resection spared these structures, then excellent functional outcomes were reported. Oncologic outcomes depended upon the grade of the tumor and whether local recurrence and metastases occurred.

[Demographic Analysis of Patients with Osteosarcoma, Chonddrosarcoma, Ewing's Sarcoma from one Sarcoma Center in Switzerland]

Retrospective analysis of presentation, diagnosis and outcome of patients with osteosarcoma, chondrosarcoma and Ewing's sarcoma was performed for a single Sarcoma Center in Zurich at the University Hospital Balgrist. 201 patients were included. Overall survival at five and ten years were 74 ± 6%, 69 ± 7% for osteosarcoma (n = 85, since 2000), 85 ± 7%, 80 ± 9% for Ewing's sarcoma (n = 43, since 1990) and 86 ± 5%, 78 ± 9% for chondrosarcoma (n = 73, since 2000). The here presented overall survival rates from a single Sarcoma Center in Switzerland appear to be equivalent to other large international monocenter studies. The presentation and epidemiology of these patients are in accordance with large multicenter epidemiological studies. A nationwide sarcoma database (SwissSARCOS; www.sarcoma.ch) seems indispensable for more detailed analysis and quality management in such rare diseases.

Management and prognostic significance of pathological fractures through chondrosarcoma of the femur

PURPOSE

The aim of the study was to report overall survival, local recurrence and development of metastasis in a group of patients with femur chondrosarcoma that presented with or without a pathological fracture.

METHODS

A retrospective review was performed, and 182 patients (39 pathological fractures) that had been treated by oncologic surgery for femoral chondrosarcoma were included. The mean age of the series was 50 years (range, eight to 90) and 114 patients were male (63%). Mean follow-up was 113 months (range, three to 216). Cancer-specific overall survival, development of metastasis and local recurrence were analysed, grouping patients by grade (grade I / grade 2-3 / dedifferentiated).

RESULTS

Disease-specific survival in the entire group of chondrosarcoma of the femur was 69% (CI95% 63-76) at 5 years. Five-year disease-specific survival in the fracture group was 49% lower than in the control group 75% (p = 0.0001). Survival of patients with grade 1 chondrosarcoma with fracture was significantly less than those without fracture (p = 0.02) but there was no difference in those with grade 2-3 (p = 0.49) and dedifferentiated tumours (p = 0.09). The local recurrence rate of the entire series was 27%. Only dedifferentiated chondrosarcomas with an associated pathological fracture had a significantly higher rate of local recurrence. There was no relationship between development of metastases and fracture.

CONCLUSION

A pathological fracture of the femur has a negative prognostic influence in grade 1 chondrosarcoma and increases the risk of local recurrence in dedifferentiated femur chondrosarcomas.

The Danish experience with trabectedin treatment for metastatic sarcoma: Importance of hyponatremia

BACKGROUND

Trabectedin was in Europe approved for treatment of metastatic soft tissue sarcoma (STS) in 2007 based on results of a phase II study with relatively few patients. The purpose of this nationwide retrospective study was to assess efficacy and safety of using trabectedin in the entire unselected cohort of patients with metastatic sarcoma and to test known, as well as new prognostic factors that may affect overall survival (OS).

PATIENTS AND METHODS

Between January 2008 and April 2013, 117 patients were treated with trabectedin for metastatic sarcoma in the three specialized sarcoma centers in Denmark. Known prognostic factors such as age, gender and performance status, the histopathology as well as other new factors such as response to previous chemotherapy and hyponatremia were tested.

RESULTS

Median age was 59 years. Lipo- and leiomysosarcomas (L-sarcomas) represented 43% of the cases and 18% had hyponatremia before the start of trabectedin. The median number of previous lines of chemotherapy was two (range 0-6) and the median number of chemotherapy cycles given before trabectedin was nine (range 0-85). The median number of trabectedin cycles was three (range 1-17). The median OS for the whole cohort was seven months. Poor performance status, non-L-sarcomas, and hyponatremia were statistically significant adverse prognostic factors with median survival of: 4, 5, and 2 months compared to 9, 12 and 13 months, respectively. Moreover, having achieved clinical benefit [complete response (CR), partial response (PR) or stable disease (SD)] from previous chemotherapy was a favorable prognostic factor for response to trabectedin. In multivariate analysis hyponatremia was the only independent significant poor prognostic factor affecting OS.

CONCLUSIONS

This retrospective study confirmed the previously published safety and efficacy of trabectedin in patients with metastatic sarcoma and showed hyponatremia to be a strong independent statistically significant poor prognostic factor.

Extraskeletal myxoid chondrosarcoma with non-EWSR1-NR4A3 variant fusions correlate with rhabdoid phenotype and high-grade morphology

Extraskeletal myxoid chondrosarcomas (EMC) are rare soft tissue sarcomas with distinctive histology and uncertain histogenesis, characterized by Ewing sarcoma breakpoint region 1-nuclear receptor subfamily 4, group A, member 3 (EWSR1-NR4A3) fusion in 75% of the cases. A smaller proportion of cases show NR4A3 fused to other gene partners including TATA binding protein-associated factor 15 (TAF15), transcription factor 12 (TCF12), and TRK-fused gene (TFG). The impact of various gene fusions on morphology and outcome has not been previously evaluated. We investigated 26 consecutive EMCs and correlated the genetic findings with morphology and clinical outcome. There were 5 females and 21 males (median age, 49.5 years). Mean size of the tumors was 11 cm. Fluorescence in situ hybridization analysis showed EWSR1-NR4A3 gene fusion in 16 cases (62%), TAF15-NR4A3 gene fusion in 7 cases (27%), and TCF12-NR4A3 gene fusion in 1 case (4%). Two cases showed only NR4A3 gene rearrangements. Morphologically, most EWSR1-rearranged tumors (10/16) showed low cellularity, minimal cytologic atypia, and low mitotic counts. In contrast, 80% of EMCs with variant (non-EWSR1) NR4A3 gene fusions (TAF15, TCF12) had high-grade morphology with increased cellularity, proliferation, and cytologic atypia, showing a plasmacytoid/rhabdoid morphology in half the cases. Follow-up showed that only 1 of 16 patients with EWSR1-rearranged tumors died of disease, in contrast to 3 (43%) of 7 TAF15-rearranged tumors. In conclusion, EMCs with variant NR4A3 gene fusions show a higher incidence of rhabdoid phenotype, high-grade morphology, and a more aggressive outcome compared with the EWSR1-NR4A3 positive tumors. Furthermore, fluorescence in situ hybridization assay for NR4A3, along with EWSR1, may be an additional ancillary test to confirm diagnosis of EMCs.

[Bipolar prosthetic replacement for proximal femoral tumors]

OBJECTIVE

To evaluate the effectiveness of bipolar prosthetic replacement for proximal femoral tumors from the perspectives of patient survival, prosthesis survival, functional outcomes, and complication rates.

METHODS

Between July 2001 and July 2010, 96 patients with proximal femoral tumors underwent wide resection and bipolar prosthetic replacement, including 83 cases of primary femoral tumors and 13 cases of soft tissue sarcomas involving the proximal femur. There were 50 male and 46 female patients with a mean age of 43.2 years (range, 15-69 years). Prosthetic replacement for proximal femoral tumors was used in 85 patients and deactivated bone-prosthetic complex was used in 11 patients. According to Enneking staging, the patients were divided into 3 groups: group A, 24 patients at stages IA, IB, and benign lesion; group B, 56 patients at stages IIA and IIB; and group C, 16 patients at stage III, myeloma, and lymphoma. The American Musculoskeletal Tumor Society 1993 version (MSTS93) functional score was used to evaluate the lower limb function.

RESULTS

Primary healing of incision was obtained in 93 patients; 3 patients had poor healing, which was cured after debridement. Of the patients, 89 were followed up 6.5 years on average (range, 1-10 years). During follow-up, 28 patients died of tumor. The 5- and 10-year survival rates of patients were 100% in group A, and were 56.5% and 41.5% in group B respectively, and the 5-year survival rate was 18.4% in group C; there was significant difference among 3 groups (P < 0.01). The 5- and 10-year survival rates of prosthesis were 74.4% and 62.5%, which were significantly higher than those of patients in groups B and C (P < 0.01). Sixty-one patients were followed up 1-10 years (mean, 4.7 years) for functional evaluation. The mean MSTS93 score of the survival patients was 79% (range, 63%-95%) at last follow-up. Complications were observed in 15 patients (16.9%): hip dislocation in 2, delayed infection in 2, aseptic loosening in 8, severe acetabulum wear in 1, and hip pain in 2.

CONCLUSION

Bipolar proximal femoral prosthetic replacement for proximal femoral tumors can provide a satisfactory functional outcome, especially for tumors at stage II or III and myeloma and lymphorma patients. Revision is needed because of main late complications of aseptic loosening, hip pain, and acetabulum wear.

Chondrosarcoma of the larynx

BACKGROUND

Chondrosarcoma of the larynx is a rare tumor. The most common symptom is hoarseness. Treatment is controversial.

OBJECTIVES

To describe six patients with laryngeal chondrosarcoma from a single center.

METHODS

The medical records of a major tertiary hospital were reviewed for all patients with laryngeal chondrosarcoma diagnosed and treated from 1959 to 2010. Data on background, clinical treatment and outcome were collected.

RESULTS

Six patients, all males with a mean age of 53.3 years, were identified. Partial laryngectomy was performed in three patients, and total laryngectomy, local excision, and partial cricoidectomy in one patient each. Four patients had a permanent tracheostomy after surgery. One patient required postoperative chemotherapy and one radiotherapy. Follow-up time was 12-216 months (mean 102 months). Recurrence developed in two patients 2 and 8 years after initial treatment and was treated by salvage surgery in both patients. One patient died during the follow-up from an unrelated cause. The others are currently alive.

CONCLUSIONS

This study supports earlier reports recommending initial treatment with partial or total laryngectomy for laryngeal chondrosarcoma. Long-term follow-up for recurrence is advised. We recommend preserving the larynx, if possible, even if a permanent tracheostomy is necessary.

Dedifferentiated chondrosarcoma revisited

This article reviews recent molecular, biologic, therapeutic, and clinical findings in dedifferentiated chondrosarcoma. Dedifferentiated chondrosarcoma is one of the most malignant primary bone tumors characterized by two distinct histopathologic components: a well-differentiated chondral lesion sharply juxtaposed with a high-grade noncartilaginous component. Wide or radical surgical resection is mandatory. High-dose radiation therapy is confined to inaccessible sites and palliation. Chemotherapy is administered whenever the dedifferentiated component is chemosensitive and the patient is in good general condition. Despite this approach, metastases will result in poor survival of these patients.

Chondrosarcoma of the spine: a series of 16 cases and a review of the literature

Only a few major studies of chondrosarcoma of the mobile spine have been reported. These studies have shown that spinal chondrosarcomas require complete surgical resection and are notoriously resistant to chemotherapy and radiation. We present 16 cases of chondrosarcoma of the mobile spine diagnosed at a median age of 54.5 (range 20 - 79) years. Diagnosis and treatment studies were based on both CT scans and MRI. Fifteen of our 16 patients had low-grade (grade 1-2) chondrosarcomas. All patients were treated with surgical resection. Fourteen patients had total resection while two patients had subtotal resection. The two patients who had subtotal resection died of their disease. Five of the fourteen patients who had total resection also died. The mean interval to death was 3.6 years. This study confirms that although chondrosarcomas of the spine are low grade, they are dangerous neoplasms. Even with complete resection, they have a high rate of recurrence and metastasis.

The Friedman-Eilber resection arthroplasty of the pelvis

It has been argued that internal hemipelvectomy without reconstruction of the pelvic ring leads to poor ambulation and inferior patient acceptance. To determine the accuracy of this contention, we posed the following questions: First, how effectively does a typical patient ambulate following this procedure? Second, what is the typical functional capacity of a patient following internal hemipelvectomy? In the spring of 2006, we obtained video documentation of eight patients who had undergone resection arthroplasty of the hemipelvis seen in our clinic during routine clinical followup. The minimum followup in 2006 was 1.1 years (mean, 8.2 years; range, 1.1-22.7 years); at the time of last followup in 2008 the minimum followup was 2.9 years (mean, 9.8 years; range, 2.9-24.5 years). At last followup seven of the eight patients were without pain, and were able to walk without supports. The remaining patient used narcotic medication and a cane or crutch only occasionally. The mean MSTS score at the time of most recent followup was 73.3% of normal (range 53.3-80.0%; mean raw score was 22.0; range 16-24). All eight patients ultimately returned to gainful employment. These observations demonstrate independent painless ambulation and acceptable function is possible following resection arthroplasty of the hemipelvis.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Surgical management of conventional grade I chondrosarcoma of long bones

We retrospectively reviewed 70 patients with low-grade (Grade I) chondrosarcoma of the appendicular skeleton treated at the Mayo Clinic from 1980 to 2001. Fifty-four patients underwent wide resections and three patients underwent marginal excision for radiographically aggressive lesions. Thirteen patients were treated with intralesional curettage for more indolent lesions. The mean age of the patients was 43 years (range, 5-85 years) and the minimum followup was 0.2 year (mean, 8.5 years; range, 0.2-22.8 years). Of the patients who had wide resection, one experienced local recurrence and one had metastasis develop. One patient in the group treated with intralesional curettage had local recurrence and metastasis. We observed no difference in overall survival rate between the intralesional curettage group and the wide resection group. Although there was no difference in the treatment outcome between the two groups, patients with more radiographically aggressive lesions underwent more extensive surgery. The data suggest in selected patients less radiographically aggressive Grade I chondrosarcoma can be safely treated with intralesional curettage without compromising patient outcome.

Does local recurrence impact survival in low-grade chondrosarcoma of the long bones?

We hypothesized local recurrence of Grade 1 chondrosarcoma in the long bones of the extremity negatively influences survival. To explore that notion, we retrospectively reviewed 164 patients treated surgically for Grade 1 chondrosarcoma of the long bones. Local recurrence occurred in 21 (13%) patients. Four patients had progression of tumor grade on recurrence, and six patients had more than one local recurrence. Seven of the 21 patients with local recurrences had metastasis. Six of the 21 patients with local recurrences died secondary to chondrosarcoma. Local recurrence, progression of grade at recurrence, and distant metastases all were associated with a decrease in overall survival. The difference in survival was not apparent until after 5 years and was more pronounced after 10 years. Recurrence may be regarded as a declaration of an aggressive phenotype and should be treated as such.

Dedifferentiated chondrosarcoma: prognostic factors and outcome from a European group

BACKGROUND

Dedifferentiated chondrosarcoma has a very poor prognosis. Because of its rarity, there are few large studies of outcome which might identify potential prognostic factors. In particular there remains uncertainty about the value of chemotherapy for this condition.

METHOD

A retrospective study was done using data supplied by members of the European Musculo Skeletal Oncology Society (EMSOS). We obtained data on 337 patients from nine European centres with this rare condition, with details on patients, treatment and outcome which were then analysed in an attempt to identify prognostic features.

RESULTS

The median age was 59 years and there was a slight predominance of males (53%). The most common sites were the femur and pelvis. Twenty-nine percent of patients with a long bone tumour had a pathological fracture. 71 patients (21%) had metastases at the time of diagnosis and these patients had a median survival of 5 months with a 10% chance of survival at 2 years. For the 266 patients without metastases at diagnosis, 254 underwent surgery with 79% having limb salvage. Thirty-one percent of these 266 patients had chemotherapy with 47% of those under 60 receiving it. In this group of 266 patients, overall survival was 28% at 10 years and poor prognostic factors were the presence of a pathological fracture at diagnosis, a pelvic location and increasing age. Local recurrence and overall survival were related to inadequate margins of excision. We did not find that the histological subtype, size of the tumour or the use of chemotherapy significantly affected outcome. For all patients the overall survival was 24% at 5 years.

CONCLUSIONS

The prognosis for patients with dedifferentiated chondrosarcoma remains dismal. Surgery with clear margins remains the principal treatment for this condition. Further use of chemotherapy should be within a trial or treatment protocol.

Do pathological fractures influence survival and local recurrence rate in bony sarcomas?

The influence of pathological fracture on surgical management, local recurrence and survival was established in patients with high grade, localised, extremity osteosarcoma (n=484), chondrosarcoma (n=130) and Ewing's sarcoma (n=156). Limb salvage was possible in 79% of patients with a fracture compared to 84% of patients without a fracture (p=0.17). No difference in local recurrence was found between fracture and control groups. In univariate analysis, survival in the fracture group was lower than in the control group for osteosarcoma (34% versus 58%, p<0.01) and chondrosarcoma (35% versus 63%, p=0.04), but not for Ewing's sarcoma (75% versus 64%, p=0.80). In multivariate analysis, fracture remained a significant predictor of survival for osteosarcoma, but not for chondrosarcoma, where dedifferentiated subtype appeared to be decisive. Pathological fracture independently predicts worse survival in osteosarcoma, but not chondrosarcoma and Ewing's sarcoma. Limb saving surgery seems safe, if adequate resection margins are achieved.

Treatment of proximal humeral chondrosarcoma with resection and allograft

Chondrosarcoma of the proximal humerus is an uncommon malignant bone tumor, and limited information is available about treatment. We retrospectively reviewed 31 patients treated by resection and replacement with allograft implants during the past 24 years. The patients were followed up for an average of more than 16 years. Despite some allograft complications, the overall success rate for the grafts was 77%, and patient survival was 96%. Only 1 patient died. Two patients required amputation for local recurrences, and the remainder did reasonably well despite some functional problems. On the basis of this study and by comparison data, we believe that proximal humeral chondrosarcomas are less malignant than chondrosarcomas in other sites. In comparing them against 26 metallic implants, we believe that resection and allograft implantation remains a generally successful treatment, although the improvement of the metallic devices over the years has made this technique more available and acceptable.

[Total spondylectomy and reconstruction for thoracolumbar spinal tumors with neurological deficit]

OBJECTIVE

To elucidate the surgical indications and treatment outcome of total spondylectomy and reconstruction for thoracolumbar spinal tumors with neurological deficit.

METHODS

From January 1999 to December 2005, 16 patients with thoracolumbar spinal tumors with neurological deficit were treated with total spondylectomy and reconstruction. There were 10 males and 6 females, with an average age of 31.5 years (16-62 years). There were 10 cases of primary tumors of spine (4 giant cell tumor of bone, 3 chondrosarcoma, 2 recurrent aneurysmal bone cyst, and 1 osteosarcoma), and 6 cases of solitary metastasis of thoracic or lumbar spine. Tomita's surgical classification was as follows: 9 cases of type 4, 6 of type 5, and 1 of type 6. Frankel's neurological classification was as follows: grade A in 1 case, B in 4, C in 7, and D in 4. All patients were treated with total spondylectomy and reconstruction through combined anterior and posterior approach.

RESULTS

All patients were followed up from 10 to 63 months with an average of 27.5 months. Pain was relieved completely in all patients. The neurological function returned to grade D in 5 cases, to grade E in 11 cases. Among the 10 patients with primary spinal tumor, nine patients survived with tumor-free, and one with osteosarcoma died because of lung metastases 18 months after surgery. Among the 6 patients with spinal metastasis, three patients survived with tumor-free, and lung metastasis occurred in 1 case 10 months after surgery, two died because of multiple metastases of internal organs 10 months and 32 months after surgery.

CONCLUSION

Total spondylectomy and reconstruction is a safe and effective surgery for thoracolumbar spinal tumors with neurological deficit, with pain relief, neurological improvement and minimum tumor recurrence. It will be an optimal choice for patients with primary malignant, aggressive benign, or solitary metastatic bone tumors of the thoracolumbar spine with Tomita surgical classification type 3 to 5.

Dedifferentiated chondrosarcomas arising in preexisting osteochondromas

BACKGROUND

Dedifferentiated chondrosarcomas that arise in osteochondromas are extremely rare lesions for which very little information on treatment and outcome is available in the literature. The purpose of the present study was to describe the specific clinical, radiographic, and histologic features of this lesion and to evaluate the oncologic outcome after different treatment strategies.

METHODS

We reviewed the files of the Rizzoli Institute between 1970 and 2002 and identified eighteen patients for whom adequate records and histologic images were available and in whom a high-grade sarcoma had been diagnosed at the same location as a preexisting osteochondroma. Radiographic studies, histologic slides, and clinical records were reviewed, the features of those studies were tabulated, and prognostic features and the results of treatment were identified.

RESULTS

The patients included twelve men and six women with an average age of forty-six years (range, twenty-two to seventy-four years). Eight lesions occurred in patients with multiple osteochondromas, and ten occurred in patients with solitary lesions. The most common locations were the pelvis (six lesions) and the femur (five lesions). Symptoms included pain, swelling, and a growing mass; the average duration of symptoms was eighteen months. Radiographically, ten lesions appeared as a conventional secondary chondrosarcoma arising in an exostosis, whereas eight showed typical signs of dedifferentiation. Histologic evaluation of the cartilage component demonstrated thirteen grade-1 and two grade-2 chondrosarcomas. In three cases, no cartilage component was recognized. The dedifferentiated component was considered to be an osteosarcoma in nine cases (including six cases in which it was osteoblastic and three in which it was fibroblastic), a malignant fibrous histiocytoma in eight, and a fibrosarcoma in one. The dedifferentiated component represented an average of 59% (range, 20% to 100%) of the lesion. For the fifteen patients who were managed at the authors' institution, the two and five-year survival rates were 47% and 29%, respectively; the median survival time was fourteen months. Patients who were managed with a combination of surgery and chemotherapy had a better overall survival rate than did those who were managed with surgery alone (p = 0.03).

CONCLUSIONS

Dedifferentiated chondrosarcoma arising in a preexisting osteochondroma is an extremely rare lesion with a poor prognosis. In the present small series, overall survival was better when wide surgical resection was combined with adjuvant chemotherapy.

Carbon ion radiotherapy of skull base chondrosarcomas

PURPOSE

To evaluate the effectiveness and toxicity of carbon ion radiotherapy in chondrosarcomas of the skull base.

PATIENTS AND METHODS

Between November 1998 and September 2005, 54 patients with low-grade and intermediate-grade chondrosarcomas of the skull base have been treated with carbon ion radiation therapy (RT) using the raster scan technique at the Gesellschaft für Schwerionenforschung in Darmstadt, Germany. All patients had gross residual tumors after surgery. Median total dose was 60 CGE (weekly fractionation 7 x 3.0 CGE). All patients were followed prospectively in regular intervals after treatment. Local control and overall survival rates were calculated using the Kaplan-Meier method. Toxicity was assessed according to the Common Terminology Criteria (CTCAE v.3.0) and the Radiation Therapy Oncology Group (RTOG)/European Organization for Research and Treatment of Cancer (EORTC) score.

RESULTS

Median follow-up was 33 months (range, 3-84 months). Only 2 patients developed local recurrences. The actuarial local control rates were 96.2% and 89.8% at 3 and 4 years; overall survival was 98.2%at 5 years. Only 1 patient developed a mucositis CTCAE Grade 3; the remaining patients did not develop any acute toxicities >CTCAE Grade 2. Five patients developed minor late toxicities (RTOG/EORTC Grades 1-2), including bilateral cataract (n = 1), sensory hearing loss (n = 1), a reduction of growth hormone (n = 1), and asymptomatic radiation-induced white matter changes of the adjacent temporal lobe (n = 2). Grade 3 late toxicity occurred in 1 patient (1.9%) only.

CONCLUSIONS

Carbon ion RT is an effective treatment for low- and intermediate-grade chondrosarcomas of the skull base offering high local control rates with low toxicity.

Diagnostic Relevance of the Immunohistochemical Detection of Growth Factors in Benign and Malignant Cartilaginous Tumors

The goal of this study was to evaluate the diagnostic relevance of the expression of growth factors in cartilaginous tumors and to investigate on the possible correlation with grade, local recurrence, metastatic potential, and survival. Expression of VEGF, PDGF, FGF1, TFGbeta2, TNFalpha, Ki-67, and p53 was analyzed in 21 cases of benign and malignant cartilaginous tumors using immunohistochemistry. Immunohistochemical staining was performed on sections from paraffin-embedded tissue. The correlation of these markers' expression and grading or clinical outcome was also evaluated. Immunohistochemistry revealed a high correlation between grading and VEGF-positive staining (P=0.001). In addition, a correlation with local recurrence was found in cases with a positive expression of Ki-67 (P=0.035), TGFbeta (P=0.007), PDGF (P=0.007), and p53 (P=0.0455), with a time-related association. These data suggest a progressive modification in the biologic behavior of malignant cartilaginous tumors. VEGF could be used as a marker in the preoperative surgical assessment of chondrosarcoma. New therapeutic strategies could be considered for VEGF-positive cases. Positive expression of TGFbeta and PDGF seems to be a predictor of clinical outcome.

Survivorship analysis in patients with periosteal chondrosarcoma

To investigate outcome and identify prognostic factors, we retrospectively reviewed 24 consecutive patients with periosteal chondrosarcomas. There were 17 males and seven females with a mean age of 37.6 years (range, 15-73 years). The femur was involved in 12 patients, the proximal humerus in five, the tibia in two, and the distal fibula, ilium, pubis, metatarsal, and rib in one patient each. The mean greatest dimension of the lesions was 8.1 cm (range, 1.5-27 cm). Based on the histologic pattern, there were 18 Grade 1 tumors and six Grade 2 tumors. All patients were treated surgically. Two patients had intralesional excisions, five patients had marginal excisions, and 17 patients had wide resections. With a mean followup of 17 years (range, 28 months-47 years), seven of 24 patients (29%) had one or more local recurrences. The 5-year local recurrence-free survival was less in patients treated with intralesional or marginal excisions (25%) than for patients treated with wide resections (93%). At the latest followup, six of 24 patients (25%) had died of pulmonary metastases. The overall 5-year metastasis-free survival was 83%. The 5-year metastasis-free survival was less for patients with Grade 2 tumors (50%) than for patients with Grade 1 tumors (94%).

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Skull base chondrosarcoma originating from the petroclival junction

OBJECTIVE

To define the presentation of patients with skull base chondrosarcoma, to elucidate surgical strategies, and to identify the role of postoperative radiotherapy.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

All patients (n = 33) with skull base chondrosarcoma managed at our institution. The average follow-up time was 7.7 years (range, 0-20 years).

MAIN OUTCOME MEASURES

Tumor location, presenting symptoms, presence of residual or recurrent tumor, and mortality.

RESULTS

The most common tumor location was the petroclival junction (n = 29). Common presenting symptoms were diplopia (48%) and headache (45%). Surgical approaches included retrosigmoid, transtemporal, transfacial, and frontotemporal craniotomies. Biopsy only was performed in four patients, subtotal resection in 19 patients, and total resection in nine patients. Most patients received postoperative radiotherapy (82%). Follow-up revealed residual, stable disease in 28% of patients and recurrent disease in 24% of patients. The mean time to recurrence was 3.0 +/- 2.8 years. The lack of postoperative radiation was significantly correlated with an increased risk of recurrence (odds ratio, 28; p = 0.007) but incomplete tumor resection was not (p = 0.6). Life-table analysis revealed that the 5-year survival rate was 85% and the 10-year survival rate was 77%. Five patients died; four of the deaths attributable to recurrent disease.

CONCLUSION

The characteristic growth pattern of skull base chondrosarcoma is tumor eroding the petroclival junction. Current therapeutic strategy is resection through an extradural subtemporal craniotomy with removal of the petrous apex and clivus. Radical resection of uninvolved structures is often not necessary. Nonetheless, gross total removal is often achievable. Postoperative radiotherapy reduces the chance of tumor recurrence.

Transbasal approach to skull base tumors: evaluation and proposal of classification

A clinical study of the TBA was performed in 22 patients harboring tumors of the skull base. The follow-up ranged from 3 to 89 months (average, 30.5 months). The main complications were intracerebral hematoma, ptosis, and infection. One patient died (4.5%) because of an extradural hematoma. Eight patients died during the follow-up because of tumor complications. Among the survivals, the median of the Karnofsky index was 96.4. Based on this study, we propose a classification for the TBA, according to its extension.

Pelvic reconstruction techniques

Partial resection of the pelvis or sacrum is an uncommon procedure, typically performed in the setting of tumors, severe infections, or trauma. The resultant defects, depending on the size and location, may cause significant postoperative morbidity or functional impairment. It is therefore essential that the surgeon be aware of all reconstructive options available and implement the most appropriate option for each individual patient. The purpose of this article is to review the functional consequences of the various pelvic resections and discuss the options available for reconstruction.

An institutional review of clear cell chondrosarcoma

Clear cell chondrosarcoma is a rare bone neoplasm with a slow progressive clinical course and infrequent metastasis, but with a high local recurrence rate. We sought to ascertain the long-term outcome of patients with this neoplasm and to identify possible factors predicting survival. Sixteen patients with clear cell chondrosarcomas treated at one institution and who had long-term clinical followup were identified. All patients were treated by surgical resection of the tumor, which was classified as clear (> 2 mm) in 10 patients and marginal or intralesional in six patients. Three patients had local recurrence after a median of 1.7 years. Metastatic disease developed in four patients with a median time to diagnosis of 8.1 years. Ten-year overall survival of patients with clear cell chondrosarcomas was 89%, and disease-free survival was 68%. Patients with surgical resections comprising clear margins had longer disease-free survival compared with patients with marginal and intralesional tumors. Inadequate surgical resection of clear cell chondrosarcoma leads to risk of local recurrence and metastatic disease. The malignancy has a tendency to metastasize relatively late, therefore, followup of patients is necessary after the generally accepted 5-year period.

LEVEL OF EVIDENCE

Prognostic study, Level III (case control study). See the Guidelines for Authors for a complete description of levels of evidence.

Radiosurgery for Cranial Base Chordomas and Chondrosarcomas

OBJECTIVE:

To evaluate the efficacy and toxicity of radiosurgery in the treatment of cranial base chordoma and chondrosarcoma.

METHODS:

We reviewed 29 patients with cranial base chordoma (n = 25) or chondrosarcoma (n = 4) who underwent stereotactic radiosurgery between September 1990 and December 2002. The median patient age was 45 years (range, 10–81 yr). Nineteen patients also had radiation therapy before or in conjunction with radiosurgery (median dose, 50.4 Gy). The median tumor volume was 14.4 cm3 (range, 0.6–65.1 cm3). The median tumor margin dose was 15 Gy (range, 10–20 Gy); the median maximum radiation dose was 30 Gy (range, 20–40 Gy). Median clinical and imaging follow-up periods were 4.8 and 4.5 years, respectively.

RESULTS:

Seven chordoma patients (28%) had tumor progression (in-field, n = 3; out-of-field, n = 4), whereas 18 had stable disease or tumor shrinkage. No patient with a chondroid chordoma had tumor enlargement. The actuarial tumor control rates were 89 and 32% at 2 and 5 years, respectively. All 4 patients with chondrosarcoma had tumor control. Clinically, 7 patients (24%) had improvement of pretreatment symptoms, 16 (55%) remained stable, and 6 (21%) worsened. Three patients with tumor progression died. Ten patients (34%) had radiation-related complications. Complications included cranial nerve deficits (n = 6), radiation necrosis (n = 5), and pituitary dysfunction (n = 3). Patients having radiosurgery alone had no toxicity.

CONCLUSION:

Cranial base chordomas and chondrosarcomas remain a formidable management challenge. Radiosurgery as an adjunct to surgical resection provides in-field tumor control for some patients, but radiation-related complications are relatively high, especially when radiosurgery is combined with fractionated radiation therapy.

Dedifferentiated chondrosarcoma--a fatal disease

BACKGROUND

We report on 13 patients with dedifferentiated chondrosarcomas. The mean age of the patients at diagnosis was 59.8 years. Nine patients were classified as stage IIB and four as stage III.

METHODS

In 11/13 cases surgery was performed. Mostly, limb salvage with tumour resection and implantation of a megaprosthesis was done; three patients needed amputation or disarticulation. In one out of three patients with a pelvic tumour resection was followed by implantation of a pelvic replacement; the other two patients received tumour resection with autologous stabilisation of the pelvis. Surgical margins were wide in six patients, marginal in two and intralesional in three. Adjuvant chemotherapy was given to five patients.

RESULTS

Recurrence was detected in 5/11 of the patients operated on: in two with wide, in one with marginal, and in two with intralesional resection. No recurrence was seen in 5/11 patients: in four after wide and in one after marginal resection. In one patient the stage was unknown. At follow-up 11 patients were dead of disease (DOD), one dead of unknown reason (DOU) and one alive with disease (AWD). The mean survival time was 9.7 months. Metastasis to different anatomical sites was evident after a period of 10 months.

CONCLUSIONS

Our results resemble those reported in the literature. DDCS is rare and is the primary malignant bone tumour with the worst prognosis. Surgery is the most important procedure, although it is unclear whether a radical resection improves the long-term results. Information regarding neoadjuvant and/or adjuvant therapy with chemotherapy is very limited.

Minichromosome maintenance protein (MCM6) in low-grade chondrosarcoma: distinction from enchondroma and identification of progressive tumors

The distinction between chondrosarcoma and enchondroma is difficult, and no reliable immunohistochemical or molecular methods are available. Differentiation is important because the therapeutic consequences range from radiologic followup to radical operation. We studied 17 chondrosarcomas (12 grade 1) and compared them with 14 enchondromas immunohistochemically by using the monoclonal antibodies Ki-MCM6 (minichromosome maintenance protein 6), Ki-S5 (Ki-67), and Ki-S2 (repp86), in addition to the established clinical criteria. In comparison with the other markers, Ki-MCM6 proved more effective at identifying proliferative activity in grade 1 chondrosarcomas. The MCM6 labeling index correlated with tumor grade and was significantly increased in grade 1 chondrosarcomas compared with enchondromas. The 5 cases of progressive chondrosarcoma also had a significantly higher MCM6 labeling index than the nonprogressive cases. Furthermore, by means of the MCM6 labeling index, many cases of progressive disease were recognized among those of uncertain malignant potential, justifying their classification as low-grade chondrosarcomas.

Chondrosarcoma of the scapula

BACKGROUND

Chondrosarcoma is the second most common primary sarcoma of bone. It often develops within flat bones, such as the pelvis, ribs, and scapula. In the current study, the authors reviewed the surgical experience and long-term oncologic outcomes of patients with chondrosarcoma arising in the scapula.

METHODS

The medical records of 29 consecutive patients with chondrosarcoma of the scapula were reviewed. The patients were treated between 1954 and 1994. All patients had localized disease at the time of presentation. The tumors were classified histologically as Grade 1 (10 patients), Grade 2 (10 patients), Grade 3 (7 patients), dedifferentiated (1 patient), and mesenchymal (1 patient) (using the criteria of Evans et al.). The mean maximal dimension of the tumors was 11 cm. Twenty-five patients underwent limb-sparing surgical resection and 4 patients underwent forequarter amputations. The median follow-up was 13 years (range, 1-35 years).

RESULTS

At last follow-up, 22 patients (76%) were free of disease and 7 patients (24%) had died of their disease. Local recurrence occurred in 4 patients at 7 months, 16 months, 40 months, and 43 months, respectively. The local recurrence-free survival rate was 86% at 5 years, 10 years, and 20 years. Disease-specific survival was 83% at 5 years, 74% at 10 years, and 74% at 20 years. Patients who had low-grade chondrosarcomas had better survival compared with patients who had high-grade chondrosarcomas (P = 0.07).

CONCLUSIONS

Patients who had localized chondrosarcoma of the scapula had a favorable long-term outcome, most likely due to the unique anatomic features that improved the likelihood of achieving wide surgical margins with limb-sparing surgery, despite the frequent presentation of locally advanced disease.

Carbon ion radiation therapy for chordomas and low grade chondrosarcomas - current status of the clinical trials at GSI-

Carbon ion radiation therapy (RT) is available at the German Ion Research Center (GSI) in Darmstadt, Germany, since December 1997. Patient treatments within the pilot project are carried out by radiation oncologists of the University of Heidelberg in cooperation with the Department of Biophysics of GSI, the Division of Medical Physics of the German Cancer Research Center Heidelberg and the Research Center Rossendorf. Patients are treated within three beam time blocks of 20 days per year at the basic physics research center at GSI, the overall capacity per year being 45 to 50 patients. Main purpose of the pilot project was to investigate carbon ion radiation therapy for different tumor entities within clinical phase I/II trials. This manuscript updates the results of the clinical phase I/II trial of carbon ion RT in chordomas and low grade chondrosarcomas of the skull base and summarizes the current status of the ongoing phase I/II trial for extracranial chordomas and low grade chondrosarcomas.

Dedifferentiated chondrosarcoma: the role of chemotherapy with updated outcomes

BACKGROUND

There are very few published data on the survival of patients with dedifferentiated chondrosarcoma, or, more specifically, on the efficacy and role of chemotherapy, especially in the era of modern diagnostic and treatment modalities. The current study examines the influence of advancements in imaging and chemotherapy on outcome and serves as an extension to a previous study published in 1986.

METHODS

Forty-two patients with dedifferentiated chondrosarcoma who had presented to our institution between 1986 and 2000 were identified, and a retrospective chart review was performed. The study group included twenty-four men and eighteen women with an average age of sixty-six years. The diagnosis of dedifferentiated chondrosarcoma was verified histologically, and data on treatment, adjuvant therapy, and survival were obtained from the medical records of all patients. All patients had been followed for a minimum of twenty-four months.

RESULTS

The tumors were classified, according to the system of the Musculoskeletal Tumor Society, as grade IIA (five), grade IIB (twenty-six), and grade III (eleven). Three patients underwent biopsy only, eighteen had a limb-sacrificing procedure, and twenty-one had a limb-sparing procedure. In the group of patients who underwent resection, the surgical margins were classified as intralesional in three, marginal in two, wide in nineteen, and radical in fifteen. Twenty-seven patients received neoadjuvant therapy; of these, twenty-three received chemotherapy only, two received radiotherapy only, and two received combined therapy. The median survival time was 7.5 months, and the five-year rate of disease-free survival was 7.1%. With the numbers available, there was no significant difference in the rate of disease-free survival with respect to the use of chemotherapy (p = 0.54), the location of surgical margins (p = 0.14), the histological subtype (p = 0.87), the tumor stage at the time of diagnosis (p = 0.43), the tumor size (p = 0.79), or the performance of limb-sparing as opposed to limb-sacrificing procedures (p = 0.42).

CONCLUSIONS

Despite advances in diagnostic modalities and adjuvant therapies, dedifferentiated chondrosarcoma continues to carry a poor prognosis. While local control is achieved in the majority of cases, distant disease remains the greatest clinical challenge, developing in 90% of patients. Efforts are needed to continue to encourage earlier diagnosis and to develop effective adjuvant therapies for the control of distant disease. The routine use of current adjuvant chemotherapy and its inherent risks in this population should be reconsidered.

Chondrosarcoma of the chest wall: a retrospective clinical analysis

Primary chondrosarcoma of the chest wall is uncommon, and reports of treatment from one institution are limited. Treatment of this lesion is difficult because of the anatomic location, which is in close proximity to surrounding neurovascular and visceral structures. The purpose of this study was to review the outcome of surgical resection of chondrosarcoma of the chest wall, and to delineate the prognostic factors related to local recurrence and survival. Twenty-four patients with chondrosarcoma of the chest wall were treated at our institution between 1986 and 2000. There were 14 males and 10 females, with an average age of 54 years (range, 11-76 years). Patients were observed for a minimum of 3 years or until death. The median followup was 71 months. The anatomic locations of chondrosarcoma of the chest wall were the rib in 16 patients, the ribs and sternum in two patients, the ribs and spine in three patients, and the sternum only in three patients. Histologically, 17 patients had Grade 1 disease and seven patients had Grade 2 disease. At followup, 17 patients were alive without disease, two were alive with disease, two died without disease, and three died secondary to progressive disease. The overall survival estimate at 5 years was 92%. The recurrence rate for patients with adequate surgical margins was 10%, compared with 75% for patients with inadequate margins. The 5-year survival rate for patients with adequate surgical margins was 100%, compared with 50% in patients with inadequate surgical margins. An inadequate margin of resection was associated with a significantly worse overall survival and a higher chance of having local recurrence develop.

Limb salvage in aggressive and malignant tumours of the fibula

We treated 25 patients with aggressive and malignant fibular tumours between April 1989 and May 2001. There were 11 osteosarcomas, seven Ewing's sarcoma and five chondrosarcomas. The tumours predominantly involved the upper one third; 16 were of Stage IIB. Neo-adjuvant and adjuvant chemotherapy were given to all patients with osteosarcoma and Ewing's sarcoma. In 20 patients, surgical margins were wide and in three radical. Mean follow-up was 71 (26-168) months. Local recurrences were met with in three patients requiring amputation. Three patients died of disease and one was lost to follow-up. Functional outcome was excellent in 12 patients and good in seven. The 5- and 10-year survival rates of patient and limb are reported based on Kaplan-Meier survival analysis.

Scapular chondrosarcomas have high rates of local recurrence and metastasis

This is the first report of a large series of patients with scapular chondrosarcomas. The grade distributions, locations of the tumors in the scapula, surgical techniques, status of margins, chondrosarcoma subtypes, Enneking stages, adjuvant therapies, local recurrence rates, metastasis rates, and survival prognoses of patients with scapular chondrosarcoma were evaluated. Forty-seven patients treated between 1921 and 1999 were analyzed retrospectively. Grade 3 disease was significantly associated with a poorer survival prognosis when compared with Grades 1 or 2 disease. Patients with tumors smaller than 5 cm were treated mainly with partial scapulectomy, and patients with tumors larger than 5 cm often were treated with total scapulectomy. The survival prognoses of patients with intralesional resections at initial surgery showed a tendency toward poorer survival when compared with patients with wide resections at initial surgery. Metastasis and local recurrence (21.3% and 40.4%) were higher in scapular chondrosarcomas than rates reported for patients with general chondrosarcomas, and local recurrence or metastasis was associated with limited survival. The 5- and 15-year survival probabilities subsequent to diagnosis were 79% and 53%, respectively. The high rates of local recurrence and metastasis likely were caused by the difficult anatomic relationships encountered during scapular resections. This study shows the importance of wide margins which must be achieved to provide local disease control.

FDG PET imaging for grading and prediction of outcome in chondrosarcoma patients

The aims of this study were to assess the potential of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) for tumor grading in chondrosarcoma patients and to evaluate the role of standardized uptake value (SUV) as a parameter for prediction of patient outcome. FDG PET imaging was performed in 31 patients with chondrosarcoma prior to therapy. SUV was calculated for each tumor and correlated to tumor grade and size, and to patient outcome in terms of local relapse or metastatic disease with a mean follow-up period of 48 months. Chondrosarcomas were detectable in all patients. Tumor SUV was 3.38 +/- 1.61 for grade I (n = 15), 5.44 +/- 3.06 for grade II (n = 13), and 7.10 +/- 2.61 for grade III (n =3). Significant differences were found between patients with and without disease progression: SUV was 6.42 +/- 2.70 (n = 10) in patients developing recurrent or metastatic disease compared with 3.74 +/- 2.22 in patients without relapse (P = 0.015). Using a cut-off of 4 for SUV, sensitivity, specificity, and positive and negative predictive values for a relapse were 90%, 76%, 64%, and 94%, respectively. Combining tumor grade and SUV, these parameters improved to 90%, 95%, 90%, and 95%, respectively. Pretherapeutic tumor SUV obtained by FDG PET imaging was a useful parameter for tumor grading and prediction of outcome in chondrosarcoma patients. The combination of SUV and histopathologic tumor grade further improved prediction of outcome substantially, allowing identification of patients at high risk for local relapse or metastatic disease.