Twenty years of follow-up of survivors of childhood osteosarcoma: a report from the Childhood Cancer Survivor Study

Osseointegration reduces aseptic loosening of primary distal femoral implants in pediatric and adolescent osteosarcoma patients: a retrospective clinical and radiographic study

AIM

The challenge of distal femoral replacement (DFR) longevity remains a priority for orthopaedic oncologists as the overall survival and activity level of young patients with osteosarcoma continues to improve. This study hypothesized that increased extracortical osseointegration at the bone-implant shoulder (i.e., where the metal implant shaft abuts the femur) will improve stress transfer adjacent to the implant, as evidenced by reduced cortical bone loss, radiolucent line progression and implant failure in young patients (< 20 years) following DFR surgery.

METHODS

Twenty-nine patients of mean age 13.09 ± 0.56 years received a primary DFR. The clinical outcome of 11 CPS®, 10 GMRS®, 5 Stanmore® and 3 Repiphysis® implants was evaluated over a mean follow-up period of 4.25 ± 0.55 years. The osseous response to a bone-implant shoulder composed of either a hydroxyapatite-coated grooved ingrowth collar (Stanmore®), a porous metal coating (GMRS®) or a polished metal surface (Repiphysis®) was quantified radiographically.

RESULTS

All (100.0%) of the Stanmore® implants, 90.0% of GMRS®, 81.8% of CPS® and 33.3% of the Repiphysis® implants survived. Significantly increased extracortical bone and osseointegration were measured adjacent to the Stanmore® bone-implant shoulder when compared with the GMRS® and Repiphysis® implants (p < 0.0001 in both cases). Significantly decreased cortical loss was identified in the Stanmore® group (p = 0.005, GMRS® and p < 0.0001, Repiphysis®) and at 3 years, the progression of radiolucent lines adjacent to the intramedullarly stem was reduced when compared with the GMRS® and Repiphysis® implants (p = 0.012 and 0.026, respectively).

CONCLUSIONS

Implants designed to augment osseointegration at the bone-implant shoulder may be critical in reducing short- (≤ 2 years) to mid- (≤ 5 years) term aseptic loosening in this vulnerable DFR patient group. Further longer-term studies are required to confirm these preliminary findings.

Functional role of MicroRNA/PI3K/AKT axis in osteosarcoma

Osteosarcoma (OS) is a primary malignant bone tumor that occurs in children and adolescents, and the PI3K/AKT pathway is overactivated in most OS patients. MicroRNAs (miRNAs) are highly conserved endogenous non-protein-coding RNAs that can regulate gene expression by repressing mRNA translation or degrading mRNA. MiRNAs are enriched in the PI3K/AKT pathway, and aberrant PI3K/AKT pathway activation is involved in the development of osteosarcoma. There is increasing evidence that miRNAs can regulate the biological functions of cells by regulating the PI3K/AKT pathway. MiRNA/PI3K/AKT axis can regulate the expression of osteosarcoma-related genes and then regulate cancer progression. MiRNA expression associated with PI3K/AKT pathway is also clearly associated with many clinical features. In addition, PI3K/AKT pathway-associated miRNAs are potential biomarkers for osteosarcoma diagnosis, treatment and prognostic assessment. This article reviews recent research advances on the role and clinical application of PI3K/AKT pathway and miRNA/PI3K/AKT axis in the development of osteosarcoma.

What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report

BACKGROUND

Although pediatric lower extremity sarcoma once was routinely treated with amputation, multiagent chemotherapy as well as the evolution of tumor resection and reconstruction techniques have enabled the wide adoption of limb salvage surgery (LSS). Even though infection and tumor recurrence are established risk factors for early amputation (< 5 years) after LSS, the frequency of and factors associated with late amputation (≥ 5 years from diagnosis) in children with sarcomas are not known. Additionally, the resulting psychosocial and physical outcomes of these patients compared with those treated with primary amputation or LSS that was not complicated by subsequent amputation are not well studied. Studying these outcomes is critical to enhancing the quality of life of patients with sarcomas.

QUESTIONS/PURPOSES

(1) How have treatments changed over time in patients with lower extremity sarcoma who are included in the Childhood Cancer Survivor Study (CCSS), and did primary treatment with amputation or LSS affect overall survival at 25 years among patients who had survived at least 5 years from diagnosis? (2) What is the cumulative incidence of amputation after LSS for patients diagnosed with pediatric lower extremity sarcomas 25 years after diagnosis? (3) What are the factors associated with time to late amputation (≥ 5 years after diagnosis) in patients initially treated with LSS for lower extremity sarcomas in the CCSS? (4) What are the comparative social, physical, and emotional health-related quality of life (HRQOL) outcomes among patients with sarcoma treated with primary amputation, LSS without amputation, or LSS complicated by late amputation, as assessed by CCSS follow-up questionnaires, the SF-36, and the Brief Symptom Inventory-18 at 20 years after cancer diagnosis?

METHODS

The CCSS is a long-term follow-up study that began in 1994 and is coordinated through St. Jude Children's Research Hospital. It is a retrospective study with longitudinal follow-up of more than 38,000 participants treated for childhood cancer when younger than 21 years at one of 31 collaborating institutions between 1970 and 1999 in the United States and Canada. Participants were eligible for enrollment in the CCSS after they had survived 5 years from diagnosis. Within the CCSS cohort, we included participants who had a diagnosis of lower extremity sarcoma treated with primary amputation (547 patients with a mean age at diagnosis of 13 ± 4 years) or primary LSS (510 patients with a mean age 14 ± 4 years). The LSS cohort was subdivided into LSS without amputation, defined as primary LSS without amputation at the time of latest follow-up; LSS with early amputation, defined as LSS complicated by amputation occurring less than 5 years from diagnosis; or LSS with late amputation, defined as primary LSS in study patients who subsequently underwent amputation 5 years or more from cancer diagnosis. The cumulative incidence of late amputation after primary LSS was estimated. Cox proportional hazards regression with time-varying covariates identified factors associated with late amputation. Modified Poisson regression models were used to compare psychosocial, physical, and HRQOL outcomes among patients treated with primary amputation, LSS without amputation, or LSS complicated by late amputation using validated surveys.

RESULTS

More study participants were treated with LSS than with primary amputation in more recent decades. The overall survival at 25 years in this population who survived 5 years from diagnosis was not different between those treated with primary amputation (87% [95% confidence interval [CI] 82% to 91%]) compared with LSS (88% [95% CI 85% to 91%]; p = 0.31). The cumulative incidence of amputation at 25 years after cancer diagnosis and primary LSS was 18% (95% CI 14% to 21%). With the numbers available, the cumulative incidence of late amputation was not different among study patients treated in the 1970s (27% [95% CI 15% to 38%]) versus the 1980s and 1990s (19% [95% CI 13% to 25%] and 15% [95% CI 10% to 19%], respectively; p = 0.15). After controlling for gender, medical and surgical treatment variables, cancer recurrence, and chronic health conditions, gender (hazard ratio [HR] 2.02 [95% CI 1.07 to 3.82]; p = 0.03) and history of prosthetic joint reconstruction (HR 2.58 [95% CI 1.37 to 4.84]; p = 0.003) were associated with an increased likelihood of late amputation. Study patients treated with a primary amputation (relative risk [RR] 2.04 [95% CI 1.15 to 3.64]) and LSS complicated by late amputation (relative risk [RR] 3.85 [95% CI 1.66 to 8.92]) were more likely to be unemployed or unable to attend school than patients treated with LSS without amputation to date. The CCSS cohort treated with primary amputation and those with LSS complicated by late amputation reported worse physical health scores than those without amputation to date, although mental and emotional health outcomes did not differ between the groups.

CONCLUSION

There is a substantial risk of late amputation after LSS, and both primary and late amputation status are associated with decreased physical HRQOL outcomes. Children treated for sarcoma who survive into adulthood after primary amputation and those who undergo late amputation after LSS may benefit from interventions focused on improving physical function and reaching educational and employment milestones. Efforts to improve the physical function of people who have undergone amputation either through prosthetic design or integration into the residuum should be supported. Understanding factors associated with late amputation in the setting of more modern surgical approaches and implants will help surgeons more effectively manage patient expectations and adjust practice to mitigate these risks over the life of the patient.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Skeletal Muscle Measurements in Pediatric Hematology and Oncology: Essential Components to a Comprehensive Assessment

Children with hematologic and oncologic health conditions are at risk of impaired skeletal muscle strength, size, and neuromuscular activation that may limit gross motor performance. A comprehensive assessment of neuromuscular function of these children is essential to identify the trajectory of changes in skeletal muscle and to prescribe therapeutic exercise and monitor its impact. Therefore, this review aims to (a) define fundamental properties of skeletal muscle; (b) highlight methods to quantify muscle strength, size, and neuromuscular activation; (c) describe mechanisms that contribute to muscle strength and gross motor performance in children; (d) recommend clinical assessment measures; and (e) illustrate comprehensive muscle assessment in children using examples of sickle cell disease and musculoskeletal sarcoma.

Quantifying muscle strength, size, and neuromuscular activation in adolescent and young adult survivors of musculoskeletal sarcoma: Identifying correlates and responses to functional strengthening

BACKGROUND

Medical and surgical treatment for musculoskeletal sarcoma (MSS) place survivors at risk for impairments in muscle properties including muscle strength, muscle size, and neuromuscular activation. The purpose of this study was to explore muscle properties, gross motor performance, and quality of life (QoL) and the changes in response to a 6-week functional strengthening intervention (PT-STRONG) in MSS survivors of childhood cancer (CCS).

METHODS

Eight lower extremity MSS CCS (13-23 years old) performed baseline testing and three completed PT-STRONG. Participants completed measurements of knee extension strength using handheld dynamometry, vastus lateralis (VL) and rectus femoris (RF) muscle thickness using ultrasonography at rest, and neuromuscular activation using electromyography during strength testing and a step-up task. Participants also completed gross motor and QoL assessments.

RESULTS

Compared with the non-surgical limb, MSS CCS had lower surgical limb knee extension strength, VL muscle thickness, and RF step-up muscle rate of activation (RoA). Compared with normative values, MSS CCS had decreased bilateral knee extension strength, gross motor performance, and physical QoL. Positive correlations among muscle strength, muscle thickness, and gross motor performance were identified. After PT-STRONG, MSS CCS had improvements in VL muscle thickness, VL and RF RoA duing step-up, gross motor performance, and physical QoL.

CONCLUSIONS

Positive association between larger muscle thickness with greater knee extension strength, and higher knee extension strength with better gross motor performance indicate that comprehensive physical therapy assessment and interventions that identify and target impairments in muscle properties to guide clinical decision making should be considered for MSS CCS into survivorship.

Resource-appropriate selection of osteosarcoma treatment protocols in low- and middle-income countries

Osteosarcoma is a rare malignancy; however, it is still the most common primary bone tumor in adolescents and young adults. Chemotherapy improves survival indubitably in osteosarcoma; nevertheless, the concern is the stagnant progress since the last several decades. There are a handful of active agents and unresolved issues, especially in choosing the ideal chemotherapy regimen. The oncology community is in equipoise regarding the position of high-dose methotrexate (HDMTX), mandatory or adjunct. The choice of therapy becomes widely relevant, including in low- and middle-income countries (LMIC), where HDMTX administration brings additional complexities. Research into novel non-HDMTX-based protocols adapted to the available resources is pivotal in improving disease outcomes, especially in LMIC. The current review focuses on real-world challenges in decision-making and provides a comprehensive overview of the evolution of treatment protocols in LMIC.

Hsa_circ_0087302, a circular RNA, affects the progression of osteosarcoma via the Wnt/β-catenin signaling pathway

Osteosarcoma is the most common malignant tumor in adolescent bone malignancies. It has the characteristics of a high metastasis rate, high mortality and poor prognosis. As a subclass of endogenous noncoding RNAs, circRNAs have been identified to be related to the occurrence, development and prognosis of different kinds of cancers, but the mechanism of their effect on osteosarcoma is not clear. In the present study, we identified a novel circRNA, hsa_circ_0087302, by RNA-seq, and we found that it was expressed at low levels in osteosarcoma. Using RT-PCR, we confirmed that the expression of hsa_circ_0087302 in osteosarcoma cells was lower than that in osteoblasts. Functional validation experiments revealed that hsa_circ_0087302 overexpression inhibited proliferation, cell cycle, migration, and invasion in osteosarcoma cells. Furthermore, Western blotting experiments demonstrated that hsa_circ_0087302 affected the expression of cell cycle- and Wnt/β-catenin signaling pathway-related proteins. For the first time, we identified that hsa_circ_0087302 may affect the malignant biological behavior of osteosarcoma cells through the Wnt/β-catenin signaling pathway. In summary, hsa_circ_0087302 may provide a new direction for the diagnosis and treatment of osteosarcoma.

Late effects and survival of children with malignant solid tumours in northern Finland: a single-centre cohort study

The global survival rates for childhood cancers are high: approximately 80% of affected children will survive. Nevertheless, the burden of treatment for survivors is also high as three-quarters experience late effects of varying severity following cancer treatment. The aims of this study were to evaluate the treatment-related late effects of patients with childhood solid tumour in northern Finland and to report their survival rates. Our study included 104 patients treated for malignant solid tumours, excluding central nervous system tumours and lymphomas, between 1990 and 2015. Information regarding the type of late effects as well as other clinical data were obtained from the patients' medical records. Late effects were observed in 65 (63%) patients, and almost half (40%) of the patients displayed more than one late effect. The most common late effect was hearing loss (n = 20). The 5-year survival rate in our study was 75%.   Conclusion: Our results highlight the importance of long-term follow-up for childhood cancer survivors. As survivors age and survival rates improve, late effects and their impact on patient health as well as the value of surveillance must be considered. What is Known: • Up to three-quarters of childhood cancer survivors experience treatment-related late effects. What is New: • The 5-year survival rate and the prevalence of late effects amongst childhood solid tumour patients treated in northern Finland are in line with findings from previous studies.

Identification of key genes in osteosarcoma - before and after CDK7 treatment

BACKGROUND

Osteosarcoma is one of the most common bone tumors, with a high degree of malignancy and a poor prognosis. Recent studies have shown that THZ2, a cyclin-dependent kinase 7 inhibitor, can exhibit strong antibone tumor effects in vivo and in vitro by inhibiting transcriptional activity. In this study, by screening the differentially expressed genes (DEGs) of osteosarcoma cells before and after THZ2 treatment, it provides new possible targets for the future targeted therapy of osteosarcoma.

METHODS

Download the gene expression profile of GSE134603 from the Gene Expression Omnibus database, and use the R software package "limma Geoquery" to screen DEGs. DAVID database was used for gene ontology analysis of DEGs. Use search tool for the retrieval of interacting genes online database and Cytoscape software to construct protein-protein interaction network. Use the "MCODE" plugin in Cytoscape to analyze key molecular complexes (module) of DEGs, and use the "Cluego" plugin to perform Kyoto Encyclopedia of Genes and Genomes enrichment analysis on module genes. The Hub gene is selected from the genes in DEGs that coexist in the top 30 Degree and the Kyoto Encyclopedia of Genes and Genomes pathway.

RESULTS

A total of 1033 DEGs were screened, including 800 up-regulated genes and 233 down-regulated genes. Gene ontology analysis showed that cell component is the main enrichment area of DEGs, mainly in the nucleus, cytoplasm, and nucleoplasm. In addition, in molecular function analysis, DEGs are mainly enriched in the process of protein binding. In biological process analysis, changes in DEGs can also be observed in transcription and regulation using DNA as a template. Twenty-nine module genes are enriched in the Ribosome biogenesis in eukaryotes pathway. Finally, 4 key genes are drawn: essential for mitotic growth 1, U3 SnoRNP protein 3 homolog, U3 small nucleolar RNA-associated protein 15 homolog, and WD repeat domain 3.

CONCLUSION

This study found that the 4 genes essential for mitotic growth 1, U3 SnoRNP protein 3 homolog, U3 small nucleolar RNA-associated protein 15 homolog, WD repeat domain 3, and the ribosome biogenesis in eukaryotes pathway play a very important role in the occurrence and development of osteosarcoma, and can become a new target for molecular targeted therapy of osteosarcoma in the future.

Socioeconomic factors associated with limb salvage versus amputation for adult extremity bone sarcomas in patients with insurance coverage

BACKGROUND

Limb salvage (LS) has become the preferred treatment for adult patients with bone sarcoma of the extremities. The decision to perform LS versus an amputation is often dictated by tumor characteristics, however there may be socioeconomic factors associated with LS. Previously this has been linked to insurance status, however currently there is a paucity of data examining socioeconomic factors in patients with medical insurance at the time of sarcoma diagnosis. Therefore, the purpose of the current study was to examine socioeconomic factors which could be associated with the decision to perform LS versus amputation for adult bone sarcoma patients.

METHODS

Data from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Bivariate regression was used to identify factors associated with LS versus amputation.

RESULTS

Of 1,390 (743 males, 647 female) patients, 252 (18%) under amputation while 1,138 (82%) underwent LS. Lower extremity tumors (OR 4.72, p < 0.001), income <$75,000 (OR 1.85, p = 0.03), being treated a public hospital (OR 1.41, p = 0.04) and a hospital with <200 beds (OR 1.90, p = 0.006) were associated with amputation. Income ≥$125,000 (OR 0.62, 0.04) were associated with LS.

CONCLUSION

In adult patients with medical insurance at the time of diagnosis, socioeconomic and hospital factors were associated with an amputation for bone sarcoma, with poorer patients, and those treated at smaller, and public hospitals more likely to undergo amputation.

Somatic Disease in Survivors of Childhood Malignant Bone Tumors in the Nordic Countries

Simple Summary

The treatment of osteosarcoma and Ewing sarcoma, the two major types of malignant bone tumors in children, has progressed considerably during the last decades, with more patients becoming long-term survivors. This improvement has resulted in an increasing number of patients with long-term adverse health consequences from the life-saving treatment. The aim of this study was to provide a detailed, comprehensive overview of somatic diseases that require hospitalization in long-term survivors of osteosarcoma and Ewing sarcoma. This study contributes new insights into the risk of somatic late effects in survivors of osteosarcoma and Ewing sarcoma which are urgently requested by pediatric oncologists, researchers, and by survivors and their families. The study provides an essential basis for the development of preventive intervention strategies and for optimal patient counseling and follow-up care, which all contribute to improving the health and quality of life in survivors.

Abstract

Survivors of malignant bone tumors in childhood are at risk of long-term adverse health effects. We comprehensively reviewed cases of somatic diseases that required a hospital contact in survivors of osteosarcoma and Ewing sarcoma. In a population-based cohort study, 620 five-year survivors of osteosarcoma (n = 440) or Ewing sarcoma (n = 180), diagnosed before the age of 20 years in Denmark, Finland, Iceland, and Sweden during 1943–2008, were followed in the national hospital registers. Overall rates of hospital contacts for any somatic disease and for 12 main diagnostic groups and 120 specific disease categories were compared with those in a matched comparison cohort (n = 3049) randomly selected from the national population registers. The rate of hospital contact for any somatic disease was 80% higher in survivors of malignant bone tumors than in comparisons and remained elevated up to 30 years after diagnosis. The rate of hospital contacts was higher after Ewing sarcoma (rate ratio (RR) 2.24; 95% confidence interval (CI) 1.76–2.85) than after osteosarcoma (RR 1.67; 95% CI 1.41–1.98). Elevated rates were observed for 11 main diagnostic groups, including infections, second malignant neoplasms, and diseases of the skin, bones, and circulatory, digestive, endocrine, and urinary systems. Survivors of malignant bone tumors in childhood are at increased risk of somatic diseases many years after diagnosis. This comprehensive study contributes new insight into the risk of late effects in survivors of osteosarcoma and Ewing sarcoma, which is an essential basis for optimal patient counseling and follow-up care.

Identification of potential gene signatures associated with osteosarcoma by integrated bioinformatics analysis

Background

Osteosarcoma (OS) is the most primary malignant bone cancer in children and adolescents with a high mortality rate. This work aims to screen novel potential gene signatures associated with OS by integrated microarray analysis of the Gene Expression Omnibus (GEO) database.

Material and Methods

The OS microarray datasets were searched and downloaded from GEO database to identify differentially expressed genes (DEGs) between OS and normal samples. Afterwards, the functional enrichment analysis, protein–protein interaction (PPI) network analysis and transcription factor (TF)-target gene regulatory network were applied to uncover the biological function of DEGs. Finally, two published OS datasets (GSE39262 and GSE126209) were obtained from GEO database for evaluating the expression level and diagnostic values of key genes.

Results

 In total 1,059 DEGs (569 up-regulated DEGs and 490 down-regulated DEGs) between OS and normal samples were screened. Functional analysis showed that these DEGs were markedly enriched in 214 GO terms and 54 KEGG pathways such as pathways in cancer. Five genes (CAMP, METTL7A, TCN1, LTF and CXCL12) acted as hub genes in PPI network. Besides, METTL7A, CYP4F3, TCN1, LTF and NETO2 were key genes in TF-gene network. Moreover, Pax-6 regulated four key genes (TCN1, CYP4F3, NETO2 and CXCL12). The expression levels of four genes (METTL7A, TCN1, CXCL12 and NETO2) in GSE39262 set were consistent with our integration analysis. The expression levels of two genes (CXCL12 and NETO2) in GSE126209 set were consistent with our integration analysis. ROC analysis of GSE39262 set revealed that CYP4F3, CXCL12, METTL7A, TCN1 and NETO2 had good diagnostic values for OS patients. ROC analysis of GSE126209 set revealed that CXCL12, METTL7A, TCN1 and NETO2 had good diagnostic values for OS patients.

A Comparative Oncology Drug Discovery Pipeline to Identify and Validate New Treatments for Osteosarcoma

Simple Summary

Osteosarcoma is a rare bone cancer that occurs primarily in children. The discovery of new treatments for osteosarcoma and other rare cancer types has been severely limited by access to patient samples to study these often-complex diseases. Here we capitalize on naturally-occurring cancers in pet dogs to study the biology of these rare cancers. Using living cells from canine and human patients to test thousands of drugs simultaneously, we identify a unique combination of drugs that disrupts protein degradation and protein trafficking in cancer cells. This drug combination represents a promising new treatment to treat both dogs and people with osteosarcoma.

Abstract

Background: Osteosarcoma is a rare but aggressive bone cancer that occurs primarily in children. Like other rare cancers, treatment advances for osteosarcoma have stagnated, with little improvement in survival for the past several decades. Developing new treatments has been hampered by extensive genomic heterogeneity and limited access to patient samples to study the biology of this complex disease. Methods: To overcome these barriers, we combined the power of comparative oncology with patient-derived models of cancer and high-throughput chemical screens in a cross-species drug discovery pipeline. Results: Coupling in vitro high-throughput drug screens on low-passage and established cell lines with in vivo validation in patient-derived xenografts we identify the proteasome and CRM1 nuclear export pathways as therapeutic sensitivities in osteosarcoma, with dual inhibition of these pathways inducing synergistic cytotoxicity. Conclusions: These collective efforts provide an experimental framework and set of new tools for osteosarcoma and other rare cancers to identify and study new therapeutic vulnerabilities.

Large variation in assessment and outcome definitions to describe the burden of long-term morbidity in childhood cancer survivors: A systematic review

We systematically reviewed outcome assessment methods, outcome classification, and severity grading of reported outcomes in studies investigating the burden of physical long-term morbidity in childhood cancer survivors (CCS). A MEDLINE and EMBASE search identified 56 studies reporting on three or more types of health conditions in 5-year CCS, for which information was extracted on outcome types and classification, methods of outcome ascertainment, and severity grading. There was substantial variability in classification and types of health conditions reported and in methods of outcome ascertainment. Only 59% of the included studies applied severity grading, mainly the common terminology criteria of adverse events. This large variation in assessment and definition of the burden of physical long-term morbidity in CCS challenges interpretation, comparison, and pooling data across studies. Global collaboration is needed to standardize assessments and harmonize definitions of long-term physical morbidity and associated outcomes in childhood cancer survivorship research.

LncRNA LINC00210 regulated radiosensitivity of osteosarcoma cells via miR-342-3p/GFRA1 axis

BACKGROUND

Radiotherapy is an effective strategy for preventing cancer metastasis, including osteosarcoma. However, cancer radioresistance limits the efficiency of radiotherapy. Therefore, it is essential to investigate the mechanism of osteosarcoma radioresistance.

METHODS

The osteosarcoma tissues and adjacent healthy tissues were collected from 53 osteosarcoma patients. The expression of LINC00210, miR-342-3p, and GFRA1 mRNA were determined using qRT-PCR. Cell viability, cell apoptosis, and cell surviving fraction were determined by MTT assay, flow cytometry, and colony formation assay, respectively. Western blot was performed to detect the protein levels. Luciferase assay was conducted to verify the relationship between LINC00210, miR-342-3p, and GFRA1.

RESULTS

LINC00210 and GFRA1 were up-regulated, and miR-342-3p was down-regulated in osteosarcoma tissues and cells. The expression of LINC00210 in osteosarcoma was negatively related to miR-342-3p expression and positively associated with GFRA1. Besides, there was a negative correlation between LINC00210 and GFRA1 expression in osteosarcoma. Also, LINC00210 and GFRA1 were up-regulated, and miR-342-3p was down-regulated in osteosarcoma cells exposed to 4 Gy irradiation treatment. Furthermore, either LINC00210 knockdown or miR-342-3p overexpression enhanced the radiosensitivity of osteosarcoma cells. Moreover, LINC00210 increased GFRA1 expression via sponging miR-342-3p. Additionally, LINC00210 knockdown improved the radiosensitivity of osteosarcoma cells by regulating GFRA1 expression via sponging miR-342-3p.

CONCLUSION

LINC00210 modulated the radiosensitivity of osteosarcoma cells via the miR-342-3p/GFRA1 axis, making LINC00210 a novel target for improving radiotherapy efficiency in osteosarcoma.

Cumulative Burden of Chronic Health Conditions in Adult Survivors of Osteosarcoma and Ewing Sarcoma: A Report from the St. Jude Lifetime Cohort Study

BACKGROUND

Adult survivors of childhood osteosarcoma and Ewing sarcoma are at risk of developing therapy-related chronic health conditions. We characterized the cumulative burden of chronic conditions and health status of survivors of childhood bone sarcomas.

METHODS

Survivors (n = 207) treated between 1964 and 2002 underwent comprehensive clinical assessments (history/physical examination, laboratory analysis, and physical and neurocognitive testing) and were compared with community controls (n = 272). Health conditions were defined and graded according to a modified version of the NCI's Common Terminology Criteria for Adverse Events and the cumulative burden estimated.

RESULTS

Osteosarcoma and Ewing sarcoma survivors [median age 13.6 years at diagnosis (range 1.7-24.8); age at evaluation 36.6 years (20.7-66.4)] demonstrated an increased prevalence of cardiomyopathy (14.5%; P < 0.005) compared with controls. Nearly 30% of osteosarcoma survivors had evidence of hypertension. By age 35 years, osteosarcoma and Ewing sarcoma survivors had, on average, 12.0 (95% confidence interval, 10.2-14.2) and 10.6 (8.9-12.6) grade 1-4 conditions and 4.0 (3.2-5.1) and 3.5 (2.7-4.5) grade 3-4 conditions, respectively, compared with controls [3.3 (2.9-3.7) grade 1-4 and 0.9 (0.7-1.0) grade 3-4]. Both survivor cohorts exhibited impaired 6-minute walk test, walking efficiency, mobility, strength, and endurance (P < 0.0001). Accumulation of ≥4 grade 3-4 chronic conditions was associated with deficits in executive function [RR: osteosarcoma 1.6 (1.0-2.4), P = 0.049; Ewing sarcoma 2.0 (1.2-3.3), P = 0.01] and attention [RR: osteosarcoma 2.3 (1.2-4.2); P = 0.008].

CONCLUSIONS

Survivors of osteosarcoma and Ewing sarcoma experience a high cumulative burden of chronic health conditions, with impairments of physical function and neurocognition.

IMPACT

Early intervention strategies may ameliorate the risk of comorbidities in bone sarcoma survivors.

Preclinical Testing of a Novel Niclosamide Stearate Prodrug Therapeutic (NSPT) Shows Efficacy Against Osteosarcoma

Therapeutic advances for osteosarcoma have stagnated over the past several decades, leading to an unmet clinical need for patients. The purpose of this study was to develop a novel therapy for osteosarcoma by reformulating and validating niclosamide, an established anthelminthic agent, as a niclosamide stearate prodrug therapeutic (NSPT). We sought to improve the low and inefficient clinical bioavailability of oral dosing, especially for the relatively hydrophobic classes of anticancer drugs. Nanoparticles were fabricated by rapid solvent shifting and verified using dynamic light scattering and UV-vis spectrophotometry. NSPT efficacy was then studied in vitro for cell viability, cell proliferation, and intracellular signaling by Western blot analysis; ex vivo pulmonary metastatic assay model; and in vivo pharmacokinetic and lung mouse metastatic model of osteosarcoma. NSPT formulation stabilizes niclosamide stearate against hydrolysis and delays enzymolysis; increases circulation in vivo with t _1/2 approximately 5 hours; reduces cell viability and cell proliferation in human and canine osteosarcoma cells in vitro at 0.2-2 μmol/L IC₅₀; inhibits recognized growth pathways and induces apoptosis at 20 μmol/L; eliminates metastatic lesions in the ex vivo lung metastatic model; and when injected intravenously at 50 mg/kg weekly, it prevents metastatic spread in the lungs in a mouse model of osteosarcoma over 30 days. In conclusion, niclosamide was optimized for preclinical drug delivery as a unique prodrug nanoparticle injected intravenously at 50 mg/kg (1.9 mmol/L). This increased bioavailability of niclosamide in the blood stream prevented metastatic disease in the mouse. This chemotherapeutic strategy is now ready for canine trials, and if successful, will be targeted for human trials in patients with osteosarcoma.

The Dutch LATER physical outcomes set for self-reported data in survivors of childhood cancer

Purposes

Studies investigating self-reported long-term morbidity in childhood cancer survivors (CCS) are using heterogeneous outcome definitions, which compromises comparability and include (un)treated asymptomatic and symptomatic outcomes. We generated a Dutch LATER core set of clinically relevant physical outcomes, based on self-reported data. Clinically relevant outcomes were defined as outcomes associated with clinical symptoms or requiring medical treatment.

Methods

First, we generated a draft outcome set based on existing questionnaires embedded in the Childhood Cancer Survivor Study, British Childhood Cancer Survivor Study, and Dutch LATER study. We added specific outcomes reported by survivors in the Dutch LATER questionnaire. Second, we selected a list of clinical relevant outcomes by agreement among a Dutch LATER experts team. Third, we compared the proposed clinically relevant outcomes to the severity grading of the Common Terminology Criteria for Adverse Events (CTCAE).

Results

A core set of 74 self-reported long-term clinically relevant physical morbidity outcomes was established. Comparison to the CTCAE showed that 36% of these clinically relevant outcomes were missing in the CTCAE.

Implications for Cancer Survivors

This proposed core outcome set of clinical relevant outcomes for self-reported data will be used to investigate the self-reported morbidity in the Dutch LATER study. Furthermore, this Dutch LATER outcome set can be used as a starting point for international harmonization for long-term outcomes in survivors of childhood cancer.

Electronic supplementary material

The online version of this article (10.1007/s11764-020-00880-0) contains supplementary material, which is available to authorized users.

Longitudinal pain and pain interference in long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

The objective of this study was to characterize the prevalence and risk of pain, pain interference, and recurrent pain in adult survivors of childhood cancer in comparison with siblings.

METHODS

This study analyzed longitudinal data from survivors (n = 10,012; 48.7% female; median age, 31 years [range, 17-57 years]; median time since diagnosis, 23 years) and siblings (n = 3173) from the Childhood Cancer Survivor Study. Survivors were diagnosed between 1970 and 1986 at 1 of 26 participating sites. Associations between risk factors (demographics, cancer-related factors, and psychological symptoms) and pain, pain interference, and recurrent pain (5 years apart) were assessed with multinomial logistic regression. Path analyses examined cross-sectional associations between risk factors and pain outcomes.

RESULTS

Twenty-nine percent of survivors reported moderate to severe pain, 20% reported moderate to extreme pain interference, and 9% reported moderate to severe recurrent pain. Female sex, a sarcoma/bone tumor diagnosis, and severe/life-threatening chronic medical conditions were associated with recurrent pain. Depression and anxiety were associated with increased risk for all pain outcomes. Poor vitality mediated the effects of anxiety on high pain and pain interference (root mean square error of approximation, 0.002).

CONCLUSIONS

A large proportion of adult survivors report moderate to severe pain and pain interference more than 20 years after their diagnosis. Increased screening and early intervention for pain interference and recurrent pain are warranted.

Progress toward liquid biopsies in pediatric solid tumors

Pediatric solid tumors have long been known to shed tumor cells, DNA, RNA, and proteins into the blood. Recent technological advances have allowed for improved capture and analysis of these typically scant circulating materials. Efforts are ongoing to develop "liquid biopsy" assays as minimally invasive tools to address diagnostic, prognostic, and disease monitoring needs in childhood cancer care. Applying these highly sensitive technologies to serial liquid biopsies is expected to advance understanding of tumor biology, heterogeneity, and evolution over the course of therapy, thus opening new avenues for personalized therapy. In this review, we outline the latest technologies available for liquid biopsies and describe the methods, pitfalls, and benefits of the assays that are being developed for children with extracranial solid tumors. We discuss what has been learned in several of the most common pediatric solid tumors including neuroblastoma, sarcoma, Wilms tumor, and hepatoblastoma and highlight promising future directions for the field.

Use of a simple form to facilitate communication on long-term consequences of treatment in sarcoma survivors

Background

To report on our experience using a simple optional form to facilitate communication on late effects between the patients and the oncologists during outpatient follow-up and to detail on the spectrum of challenges reported by sarcoma survivors.

Methods

The form was presented for the patients to complete before their consultation and covered topics related to late effects and unmet needs that the patient wished to discuss with the medical personnel. Logistic regression analysis examined how the distribution of the topics varied with age, gender, diagnosis and type of treatment received.

Results

The form was manageable in a busy outpatient clinic. Of the 265 patients that received the form, 236 (89%) returned it. Patients in a palliative setting and those with other diagnosis than bone sarcoma (BS) and soft-tissue sarcoma (STS) were excluded for subsequent analyses. The final study-cohort comprised 160 patients, 54 (34%) with BS and 106 (66%) with STS. Among these, 140 (88%) had late-effect topics they wanted to discuss with their oncologist. Fatigue was raised by 39% of the patients, pain by 29% and impaired mobility by 23%. BS patients raised fatigue more often (P < 0.005) than those with STS. Patients who had undergone multimodal treatment with chemotherapy raised fatigue more frequently (P < 0.001) than those who had only undergone surgery, radiotherapy or both.

Conclusions

A simple form on the long-term consequences of sarcoma treatment achieved a high response rate, was feasible to use in an outpatient clinic and facilitated communication on these issues. Fatigue was the most frequent topic raised and it was raised significantly more often in patients who had undergone chemotherapy.

Alterations in Muscle Architecture: A Review of the Relevance to Individuals After Limb Salvage Surgery for Bone Sarcoma

Osteosarcoma and Ewing's sarcoma are the most common primary bone malignancies affecting children and adolescents. Optimal treatment requires a combination of chemotherapy and/or radiation along with surgical removal when feasible. Advances in multiple aspects of surgical management have allowed limb salvage surgery (LSS) to supplant amputation as the most common procedure for these tumors. However, individuals may experience significant impairment after LSS, including deficits in range of motion and strength that limit function and impact participation in work, school, and the community, ultimately affecting quality of life. Muscle force and speed of contraction are important contributors to normal function during activities such as gait, stairs, and other functional tasks. Muscle architecture is the primary contributor to muscle function and adapts to various stimuli, including periods of immobilization-protected weightbearing after surgery. The impacts of LSS on muscle architecture and how adaptations may impact deficits within the rehabilitation period and into long-term survivorship is not well-studied. The purpose of this paper is to [1] provide relevant background on bone sarcomas and LSS, [2] highlight the importance of muscle architecture, its measurement, and alterations as seen in other relevant populations and [3] discuss the clinical relevance of muscle architectural changes and the impact on muscle dysfunction in this population. Understanding the changes that occur in muscle architecture and its impact on long-term impairments in bone sarcoma survivors is important in developing new rehabilitation treatments that optimize functional outcomes.

Exercise and Physical Activity in Patients with Osteosarcoma and Survivors

Exercise has the potential to positively affect patients with osteosarcoma by improvement of function, mitigation of disability, and maintenance of independence and quality of life. Exercise may also directly impact cancer treatment efficacy. This chapter examines the feasibility and use of exercise or physical activity as therapy in the treatment of osteosarcoma and its survivors. It additionally presents the benefits of physical activity as treatment and rehabilitation both preoperatively (prehabilitation) and postoperatively. This chapter will also discuss barriers to exercise and physical activity for patients with osteosarcoma and its survivors, emphasizing the need for a comprehensive and cohesive support system to promote its incorporation into patient treatment plans and ensure compliance.

Right ventricular 2D speckle-tracking echocardiography in children with osteosarcoma under chemotherapy

Background

Cardiotoxicity from anthracyclin chemotherapy is a leading cause of death in patients with cancer. Therefore, left ventricular (LV) function is routinely assessed during protocol to detect cardiotoxicity; however, animal studies suggest that right ventricular (RV) function may be also impaired. So, our objective was to investigate the incidence of RV dysfunction in children with osteosarcoma receiving anthracyclines and to highlight the role of 2D STE in early detection of RV dysfunction.

Results

RV function was affected by anthacyclines through direct cardiotoxic effect on RV myocardium without simultaneous derangement of LV function. Furthermore, there is a direct proportion between the incidence of RV dysfunction and the cumulative dose of anthracyclines. At the first echo follow-up at 10th week, 7 patients had impaired RV GLS in comparison to baseline study. At 20th week, the number of patients with impaired RV strain increased to 10. At 29th week, it reaches 12 patients. This effect was early detected by RV 2DSTE before adversely affecting TAPSE and FAC. The incidence of RV dysfunction from anthracyclines was around 12%, and the recovery rate was around 8% in 3 months after completion of chemotherapy.

Conclusion

RV 2DSTE is the best modality to detect early affection of RV function in comparison with other modalities. RV function decreases early even before derangement of LV function. Accordingly, it should be assessed separately in all patients who received anthracyclines even without evident LV affection.

The Roles of Circular RNAs in Osteosarcoma

Osteosarcoma is a malignant tumor that occurs most commonly in the metaphysis of the long bones in the limbs in children and adolescents. Even with surgery and neoadjuvant chemotherapy, the therapeutic effect has reached a peak with 60-70% survival rates. Therefore, new biological targets or molecular mechanisms that enhance the efficacy of osteosarcoma treatments are needed. Circular RNAs (circRNAs) are useful biomarkers that have recently been recognized clinically and in medical research and have been of interest due to the use of next-generation sequencing and bioinformatics analysis. CircRNAs are involved in many diseases, including cancer. Therefore, this review aims to summarize the roles of circRNA in the diagnosis, progression, and prognosis of osteosarcoma.

Miscorrelation of Functional Outcome and Sociooccupational Status of Childhood, Adolescent, and Young Adult Generation With Bone and Soft Tissue Sarcoma Patients

Few studies have examined the relationship between functional outcome and sociooccupational or psychological status in adolescent and young adults (AYA) generation and childhood sarcoma patients. We retrospectively analyzed clinical (prognostic and functional) and sociooccupational outcomes in 50 patients; 22 children aged under 14 years and 28 AYAs generation (15 to 29 y). There were 35 cases of bone sarcomas and 15 of soft tissue sarcomas. Limb-sparing surgery was performed in 30 of 37 extremity cases. The most prevalent problems among patients were as follows: limited activities; drop-out or delayed studies among high school and college students; limitation in job searching; and changes in social relationships. These problems were unaffected by limb-sparing. Regression analysis between functional and sociooccupational disability showed that the correlation coefficient was significant (P=0.005) in all limb-salvaged patients, but there was no significant correlation among osteosarcoma patients (P=0.07). These findings suggest that quality of life is a multidimensional measure: it depends on physical status, spiritual health, and social well-being of both patients and family members. To overcome the disadvantages of this type of disease, it is essential to provide comprehensive care at the earliest convenience using multidimensional approaches.

A Critical Review of the Impact of Sarcoma on Psychosocial Wellbeing

Background

Previous reviews of outcomes in specific sarcoma populations suggest patients have poor quality of life. In most of these reviews, there is a predominant focus on physical function rather than psychosocial outcome. The aim of this review was to describe the psychosocial impact of diagnosis and treatment on patients with all types of sarcoma.

Methods

Searches were conducted through six electronic databases for publications of any study design using a validated patient-reported outcome measure reporting the psychosocial impact in this population.

Results

Eighty-two studies fulfilled the inclusion criteria. Most (65%) were assessed of being of reasonable quality. The most common aspect of psychosocial wellbeing measured was quality of life (80%). Due to the heterogeneity of methods, outcomes, and populations, it was not possible to make definitive conclusions. It seems there is an improvement in the physical aspects of quality of life over time but not in psychosocial function or mental health. There was no change in mental health scores, but patients reported an improvement in adjusting to normal life. There are no differences according to the type of surgery patients receive, and psychosocial outcomes tend to be poorer than the general population. There is no consistency in identifying the factors that predict/influence psychosocial wellbeing.

Conclusion

The published literature does not provide a clear understanding of the impact of sarcoma diagnosis and treatment on psychosocial wellbeing. Instead, the review demonstrates a need for well-designed studies in this area and a more consistent approach to the measurement of patient-reported outcomes, which include psychosocial domains. Recommendations for future research have been proposed.

Inhibitory effect of MSH6 gene silencing in combination with cisplatin on cell proliferation of human osteosarcoma cell line MG63

Osteosarcoma (OS) is one of the most common primary bone malignancies, with the survival rate of patients with OS remaining low. Therefore, we conducted this study to identify the potential role combination of both MSH6 gene silencing and cisplatin (DDP) plays in OS cell proliferation and apoptosis. Microarray-based gene expression profiling was used to identify the differentially expressed genes (DEGs) in patients with OS, as well as microRNAs (miRNAs) that regulate the candidate gene. OS tissues from 67 patients with OS along with normal tissues from 24 amputee patients were collected for detection of the positive expression of mutS homolog 6 (MSH6) protein, mRNA, and protein expressions of c-myc, cyclin D1, l-2, B-cell lymphoma 2 (Bcl-2), Stathmin, proliferating cell nuclear antigen (PCNA), and Bcl-2-associated X (Bax). Moreover, after MSH6 silencing and DDP were treated on the selected human OS cell line MG63 with the highest expression of MSH6, cell viability, cell cycle distribution, and apoptosis were detected. The microarray analysis showed that MSH6 was upregulated in OS chip data. Furthermore, silencing MSH6 combined with DDP reduced expressions of c-myc, cyclin D1, Bcl-2, Stathmin, and PCNA, and elevated Bax expression, whereas inhibiting OS cell viability, impeding cell cycle distribution, and inducing apoptosis. In conclusion, our preliminary results indicated that the combination of MSH6 gene silencing coupled with DDP may have a better effect on the inhibition of OS cell proliferation and promote apoptosis, potentially providing targets for the OS treatment.

Surviving childhood cancer: a systematic review of studies on risk and determinants of adverse socioeconomic outcomes

Substantial improvements in childhood cancer survival have resulted in a steadily increasing population of childhood cancer survivors. Whereas somatic late effects have been assessed in many studies, less is known about the impact of childhood cancer on socioeconomic outcomes in survivors. The aim of this article was to evaluate and summarise the evidence on the socioeconomic conditions of childhood cancer survivors and to identify survivors at particular risk of adverse socioeconomic outcomes. An extensive literature search of three electronic databases was conducted. Of 419 articles identified, 52 met the inclusion criteria. All the selected articles were appraised for quality, and findings were summarised in a narrative synthesis. Childhood cancer survivors were at higher risk of adverse socioeconomic outcomes with regard to educational achievement, income and social security benefits than the general population or a sibling comparison group. The risks for unemployment and a lower occupational position were significantly increased only for survivors of a central nervous system tumour. Notably, survivors of central nervous system tumours, survivors treated with cranial radiotherapy and those diagnosed at younger age independent of cancer type were determinants of particular adverse socioeconomic outcomes. Given the increasing population of childhood cancer survivors, targeted follow-up interventions and support strategies addressing not only the somatic and psychiatric late effects but also the socioeconomic difficulties that some childhood cancer survivors face is of high importance to reduce social inequity, and ensure a high quality of life after childhood cancer.

PYGB siRNA inhibits the cell proliferation of human osteosarcoma cell lines

Osteosarcoma is the most common malignant bone carcinoma that primarily occurs between childhood to adolescence. It was suggested by recent research that the Brain type glycogen phosphorylase (PYGB) gene may serve an important role in various types of cancer. In the present study, the PYGB gene was knocked down in order to evaluate the cell viability, invasion and migration of the human osteosarcoma cell lines MG63 and HOS. The expression levels of PYGB in osteosarcoma and bone cyst tissue samples, as well as in the osteosarcoma cell lines were identified using reverse transcription-quantitative polymerase chain reaction and western blot assay. Subsequently, a Cell Counting kit 8 assay was employed to evaluate cell proliferation. Cell apoptosis rate and cell cycle distribution were measured by flow cytometry. In addition, cell invasion and migration were evaluated through a Transwell assay. The expression levels of the cell apoptosis and tumor metastasis associated proteins B-cell lymphoma 2 (Bcl-2), Bcl-2-associated X protein, E-cadherin, Twist, matrix metalloproteinase (MMP)-9 and MMP2 were measured via western blotting. PYGB exhibited a higher expression level in the osteosarcoma tissue samples, particularly in the human osteosarcoma cell lines MG63 and HOS. Knockdown of PYGB resulted in a decline in cell proliferation, invasion and migration, which was coupled with induced cell apoptosis and cell cycle arrest in MG63 and HOS cells. Furthermore, alterations in the expression of apoptosis and metastasis associated proteins indicated that small interfering (si)PYGB may have regulated cell viability by targeting the Bcl/Caspase and cyclin dependent kinase (CDK)-1 signaling pathway. In conclusion, PYGB siRNA exerted an inhibitory effect on the cell viability of the human osteosarcoma cells MG63 and HOS by blocking the Caspase/Bcl and CDK1 signaling pathway, highlighting novel potential therapeutic methods for treating osteosarcoma.

Triple primary malignancies of surface osteosarcoma of jaw, myelodysplastic syndrome and colorectal cancer as a second primary cancer detected by PET2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography: A case report

Second primary malignancy (SPM) is a severe issue for cancer survivors, particularly for osteosarcoma (OS) survivors. To date, the associations between subsequent SPM and OS have been well reported. Hematogenic and solid malignancies tend to occur following OS treatment. Reportedly, 2-[¹⁸F]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) is mainly used in OS patients for initial cancer staging, to evaluate the response of neoadjuvant chemotherapy, and when recurrence or metastasis is clinically suspected. The present case report describes a 70-year-old man diagnosed with three primary malignancies: jaw OS, myelodysplastic syndrome and colorectal adenocarcinoma. To the best of our knowledge, this combination of malignancies has not been reported previously. Until now, there is no specific protocol of postoperative FDG-PET for OS patients. Few studies have described OS follow-up methods; therefore, there is no consensus on proper follow-up methods. In the present case report, the colorectal early-stage SPM was observed, without any symptoms, by FDG-PET/computed tomography. To avoid overlooking solid SPMs, it is suggested that FDG-PET should be performed in the long-term follow-up of OS patients.

Methotrexate Free Chemotherapy and Limb Salvage Surgery for Paediatric Osteosarcoma in India

BACKGROUND

Osteosarcoma (OS) is the most common primary malignant tumor of bone. The survival of OS patients has steadily improved from <20% in the early 20th century to around 70% with current treatment. There are very few studies in pediatric OS from India analyzing various aspects of the disease. This study focuses on the clinical profile, treatment options, and their complications and survival outcomes in pediatric osteosarcoma (OS) patients.

MATERIALS AND METHODS

This was a retrospective observational study which included pediatric patients <14 years of age, with newly diagnosed OS confirmed by histological diagnosis. Medical records of all patients were reviewed for clinical profile, treatment data, surgical management, and treatment complications. Patients alive at the end of treatment were followed up and overall (OAS) and disease-free survival (DFS) were analyzed.

RESULTS

Sixty-two patients were diagnosed with OS during the study of whom 55 opted for treatment. Cisplatin, adriamycin, and ifosfamide (PAI) was offered as chemotherapy and was completed as planned in the majority of patients. Limb salvage surgery was performed in most patients (87%, n = 40). The local recurrence occurred in 7 patients. The 3 years overall survival for the cohort was 54.6% ± 7.8% and DFS was 43.4% ± 7.9%, with females and those with the localized disease having a significantly better DFS.

CONCLUSIONS

High dose methotrexate free chemotherapy can give good OAS in localized disease and LSS is feasible in most of the pediatric OS patients. However the modest DFS even for localized disease with PAI chemotherapy and extremely poor outcomes in the metastatic OS, demand further research and innovations in systemic therapy to improve outcomes.

Considerations for the Long Term Treatment of Pediatric Sarcoma Survivors

Sarcomas are primary malignancies of the connective tissues. They are exceedingly rare in adults, but much more common in children. The historically recent advent of cytotoxic chemotherapy for pediatric sarcomas has revolutionized the treatment of these diseases and dramatically improved their prognoses. There is thus a population of pediatric sarcoma survivors that are "coming of age" as adults. However, this progress is not without consequences. Due to aggressive treatment protocols that include various combinations of surgery, chemotherapy, and radiation therapy, pediatric sarcoma survivors are at risk of myriad physical, medical, and psychological difficulties as they enter adulthood. These include but are not limited to physical disabilities, chemotherapy-induced cardiac issues, second malignancies, and anxiety. These patients pose unique challenges to their adult primary care physicians. One possible solution to these challenges is multidisciplinary sarcoma survivorship clinics. By paying greater attention to the unique issues of pediatric sarcoma survivors, involved physicians can maximize the physical and emotional health of pediatric sarcoma survivors.

Fertility, Cardiac, and Orthopedic Challenges in Survivors of Adult and Childhood Sarcoma

The combination of cisplatin, doxorubicin, and methotrexate was established as the standard backbone of contemporary osteosarcoma therapy in 1986. Since then, however, further improving the survival of patients with osteosarcoma has been challenging-30% to 40% of patients with osteosarcoma still die of this disease. In addition, these patients often experience loss of fertility at a young age, short- and long-term treatment-related cardiotoxicity, and adverse orthopedic effects from surgical resection of the tumor or endoprosthetic reconstructions. Cancer treatment often markedly increases the risk of infertility later in life, causing many patients substantial distress and regret. Sperm banking and oocyte cryopreservation are standard of care and should be available to all at-risk patients. Newer techniques, such as autologous gonadal tissue transplant for prepubertal children, are being developed, and newer systemic agents have infertility risk profiles that remain undefined and warrant further study. Cost and access remain barriers to these options. The late effects of anthracycline-induced cardiotoxicity are also increasingly a problem for these patients. These effects are often progressive and can be disabling. Adding dexrazoxane to doxorubicin therapy significantly reduces the risk for most adverse cardiac outcomes without compromising the efficacy of induction chemotherapy. Limb salvage surgery remains the standard of care for treatment in the majority of patients with extremity sarcomas. Modular metal prostheses and allograft reconstructions comprised the majority of surgical procedures for limb salvage surgery. The most common mechanism of failure of these implants is infection and mechanical failure of the implant.

TUG1 promotes osteosarcoma tumorigenesis by upregulating EZH2 expression via miR-144-3p

lncRNA-TUG1 (Taurine upregulated 1) is up regulated and highly correlated with poor prognosis and disease status in osteosarcoma. TUG1 knockdown inhibits osteosarcoma cell proliferation, migration and invasion, and promotes apoptosis. However, its mechanism of action has not been well addressed. Growing evidence documented that lncRNA works as competing endogenous (ce)RNAs to modulate the expression and biological functions of miRNA. As a putative combining target of TUG1, miR-144-3p has been associated with the progress of osteosarcoma. To verify whether TUG1 functions through regulating miR-144-3p, the expression levels of TUG1 and miR-144-3p in osteosarcoma tissues and cell lines were determined. TUG1 was upregulated in osteosarcoma tissues and cell lines, and negatively correlated with miR-144-3p. TUG1 knockdown induced miR-144-3p expression in MG63 and U2OS cell lines. Results from dual luciferase reporter assay, RNA-binding protein immuno precipitation (RIP) and applied biotin-avidin pull-down system confirmed TUG1 regulated miR-144-3p expression through direct binding. EZH2, a verified target of miR-144-3p was upregulated in osteosarcoma tissues and negatively correlated with miR-144-3p. EZH2 was negatively regulated by miR-144-3p and positively regulated by TUG1. Gain-and loss-of-function experiments were performed to analyze the role of TUG1, miR-144-3p and EZH2 in the migration and EMT of osteosarcoma cells. EZH2 overexpression partly abolished TUG1 knockdown or miR-144-3p overexpression induced inhibition of migration and EMT in osteosarcoma cells. In addition, TUG1 knockdown represses the activation of Wnt/β-catenin pathway, which was reversed by EZH2 over expression. The activator of Wnt/β-catenin pathway LiCl could partially block the TUG1-knockdown induced osteosarcoma cell migration and EMT inhibition. In conclusion, our results showed that TUG1 plays an important role in osteosarcoma development through miRNA-144-3p/EZH2/Wnt/β-catenin pathway.

Long-term functional outcomes and quality of life in adult survivors of childhood extremity sarcomas: a report from the St. Jude Lifetime Cohort Study

PURPOSE

This study compared measured physical performance, health-related quality of life (HRQOL), and social role attainment between extremity sarcoma survivors and controls, and evaluated associations between disease and treatment exposures, health conditions, and performance measures.

METHODS

Survivors of extremity sarcoma from the St. Jude Lifetime cohort and controls frequency matched by age-, sex-, and race completed physical performance testing and questionnaires. Survivors with Z-scores on outcome measures ≤ -2.0 SD (compared to controls) were categorized with severe impairment/limitation.

RESULTS

Among 206 survivors (52.4 % male median age 36 years (range 19-65)), 37 % had low relative lean mass, 9.7 % had an ejection fraction <50 %, 51.5 % had diffusion capacity for carbon monoxide <75 %, 27.7 % had sensory and 25.2 % motor neuropathy, and 78.2 % had musculoskeletal complications. Severe impairments/limitations were present among ≥25 % of survivors on fitness, balance, and physical HRQOL measures, and among ≥15 % on strength and activity of daily living measures. Lower extremity tumor location (OR 8.23, 95 % CI 2.54-26.67, P value 0.0004) and amputation (OR 8.07, 95 % CI 3.06-21.27, P value <0.0001) were associated with poor fitness. Poor fitness was associated with increased odds of scoring <40 on the SF-36 physical component summary (OR 4.83, 95 % CI 1.95-11.99, P value 0.001) and role-physical subscale (OR 3.34, 95 % CI 1.33-8.43, P value 0.01). Survivors and controls had similar rates of marriage, independent living, employment, and college attendance.

CONCLUSIONS

Extremity sarcoma survivors experience high rates of physical impairment and report lower than expected physical HRQOL. However, they are as likely as peers to be married, live independently, be employed, and attend college.

IMPLICATIONS FOR CANCER SURVIVORS

Follow-up for extremity sarcoma survivors should include assessment of need for further orthopedic care and rehabilitation to address cardiopulmonary and musculoskeletal health.

Pediatric Osteosarcoma: An Updated Review

Osteosarcoma (OS), the most common type of primary malignant bone tumor, is defined by the presence of malignant mesenchymal cells producing osteoid or immature bone. The peak incidence of the most frequent type of OS, i.e., high-grade central OS, occurs in the second decade of life during the adolescent growth spurt. Most patients suffer from the pain and swelling in the involved region and, usually, seek medical attention. Diagnosis is carried out by conventional radiographs, computed tomography, and magnetic resonance image (MRI). In addition, three-phase bone scans, thallium scintigraphy, dynamic MRI, and positron emission spectroscopy are new innovative promising tools. OS can be treated with surgery, radiotherapy, and chemotherapy. There is a clear need for newer effective agents for patients with OS, especially for patients who afflicted with metastatic and recurrence tumor. Monoclonal antibodies directed against OS may prove useful as treatment, either for drug delivery or for radiopharmaceuticals.

IAP antagonists sensitize murine osteosarcoma cells to killing by TNFα

Outcomes for patients diagnosed with the bone cancer osteosarcoma have not improved significantly in the last four decades. Only around 60% of patients and about a quarter of those with metastatic disease survive for more than five years. Although DNA-damaging chemotherapy drugs can be effective, they can provoke serious or fatal adverse effects including cardiotoxicity and therapy-related cancers. Better and safer treatments are therefore needed. We investigated the anti-osteosarcoma activity of IAP antagonists (also known as Smac mimetics) using cells from primary and metastatic osteosarcomas that arose spontaneously in mice engineered to lack p53 and Rb expression in osteoblast-derived cells. The IAP antagonists SM-164, GDC-0152 and LCL161, which efficiently target XIAP and cIAPs, sensitized cells from most osteosarcomas to killing by low levels of TNFα but not TRAIL. RIPK1 expression levels and activity correlated with sensitivity. RIPK3 levels varied considerably between tumors and RIPK3 was not required for IAP antagonism to sensitize osteosarcoma cells to TNFα. IAP antagonists, including SM-164, lacked mutagenic activity. These data suggest that drugs targeting XIAP and cIAP1/2 may be effective for osteosarcoma patients whose tumors express abundant RIPK1 and contain high levels of TNFα, and would be unlikely to provoke therapy-induced cancers in osteosarcoma survivors.

The University of Michigan Sarcoma Survivorship Clinic: Preventing, Diagnosing, and Treating Chronic Illness for Improved Survival and Long-Term Health

The Children's Cancer Survivorship Study reports more chronic illnesses in sarcoma survivors than other pediatric cancers. Chemotherapy and radiation put survivors at risk for developing chronic illnesses, including heart disease, diabetes, hypertension, and kidney failure. Sarcoma survivors may have a reduced life expectancy and signs of heart disease in their 30s and 40s. Since these medical problems occur much later in the general population, they often go undetected or misdiagnosed in sarcoma survivors, creating delays in intervention and treatment. The good news is that these chronic illnesses can often be prevented or minimized. The most common adverse effect of chemotherapy and radiation is coronary artery disease (CAD). CAD has a number of risk factors, including hypertension, diabetes, obesity, and dyslipidemia. These risk factors are modifiable with lifestyle changes, including diet and exercise, and/or pharmacological intervention. By identifying and managing risk factors like hypertension early, we in turn reduce the risk for CAD and prolong survival. This is well established in the general population; there is no reason a priori not to apply it to sarcoma survivors. Sarcoma survivors should be followed by physicians who understand the late effects and outcomes of sarcoma treatment. The University of Michigan Sarcoma Survivorship Clinic provides long-term care for sarcoma survivors by preventing, diagnosing, and treating the adverse long-term physical and psychological effects associated with sarcoma survivorship.

Upregulation of long non-coding RNA TUG1 correlates with poor prognosis and disease status in osteosarcoma

The pathogenesis of osteosarcoma involves complex genetic and epigenetic factors. This study was to explore the impact and clinical relevance of long non-coding RNA (lncRNA), Taurine up-regulated gene 1 (TUG1) on patients with osteosarcoma. Seventy-six osteosarcoma tissues and matched adjacent normal tissues were included for analysis. The plasma samples were obtained from 29 patients with osteosarcoma at pre-operation and post-operation, 42 at newly diagnosed, 18 who experienced disease progression or relapse, 45 post-treatment, 36 patients with benign bone tumor, and 20 healthy donors. Quantitative real-time reverse transcript polymerase chain reactions were used to assess the correlation of the expression levels of TUG1 with clinical parameters of osteosarcoma patients. TUG1 was significantly overexpressed in the osteosarcoma tissues compared with matched adjacent normal tissues (P < 0.01) and was closely correlated with tumor size, post-operative chemotherapy, and Enneking surgical stage. Upregulation of TUG1 strongly correlated with poor prognosis and was an independent prognostic indicator for overall survival (HR = 2.78, 95% CI = 1.29-6.00, P = 0.009) and progression-free survival (HR = 1.81, 95% CI = 1.01-3.54, P = 0.037). Our constructed nomogram containing TUG1 had more predictive accuracy than that without TUG1 (c-index 0.807 versus 0.776, respectively). In addition, for plasma samples, TUG1 expression levels were obviously decreased in post-operative patients (mean ΔCT -4.98 ± 0.22) compared with pre-operation patients (mean ΔCT -6.09 ± 0.74), and the changes of TUG1 expression levels were significantly associated with disease status. Receiver operating characteristic (ROC) curve analysis demonstrated that TUG1 could distinguish patients with osteosarcoma from healthy individuals compared with alkaline phosphatase (ALP) (the area under curve 0.849 versus 0.544). TUG1 was overexpressed in patients with osteosarcoma and strongly correlated with disease status. In addition, TUG1 may serve as a molecular indicator in maintaining surveillance and forecasting prognosis.

Identifying Predictors of Longitudinal Decline in the Level of Medical Care Received by Adult Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study

OBJECTIVES

Characterize longitudinal changes in the use of medical care in adult survivors of childhood cancer.

DATA SOURCES

The Childhood Cancer Survivor Study, a retrospective cohort study of 5+ year survivors of childhood cancer.

STUDY DESIGN

Medical care was assessed at entry into the cohort (baseline) and at most recent questionnaire completion. Care at each time point was classified as no care, general care, or survivor-focused care.

DATA COLLECTION

There were 6,176 eligible survivors. Multivariable models evaluated risk factors for reporting survivor-focused care or general medical care at baseline and no care at follow-up; and survivor-focused care at baseline and general care at follow-up.

PRINCIPAL FINDINGS

Males (RR, 2.3; 95 percent CI 1.8-2.9), earning <$20,000/year (RR, 1.6; 95 percent CI 1.2-2.3) or ≤ high school education (RR, 2.5; 95 percent CI 1.6-3.8 and RR 2.0; 95 percent CI 1.5-2.7 for

CONCLUSIONS

While the incidence of late effects increases over time for survivors, the likelihood of receiving survivor-focused care decreases for vulnerable populations.

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Key Words

• Childhood cancer survivors
• delivery of health care
• health care access
• health insurance
• survivorship

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MESH Headings

• Adolescent
• Adult
• Age Factors
• Female
• Health Services/statistics & numerical data
• Health Status
• Humans
• Longitudinal Studies
• Male
• Middle Aged
• Neoplasms/epidemiology
• Neoplasms/therapy
• Retrospective Studies
• Sex Factors
• Socioeconomic Factors
• Survivors/statistics & numerical data
• Young Adult

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Grants

• U24 CA055727 NCI NIH HHS
• CA21765 NCI NIH HHS
• P30 CA008748 NCI NIH HHS
• P30 CA021765 NCI NIH HHS
• CA55727 NCI NIH HHS

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Affiliation(s)

Jacqueline Casillas Address correspondence to Jacqueline Casillas, M.D., M.S.H.S., Department of Pediatrics, University of California, 10833 Le Conte Ave. Room A2-312 MDCC, Los Angeles, CA 90095; e-mail:
Kevin C Oeffinger Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Melissa M Hudson Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Mark L Greenberg Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Mark W Yeazel Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Kirsten K Ness Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Tara O Henderson Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Leslie L Robison Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Gregory T Armstrong Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Qi Liu Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Wendy Leisenring Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Yutaka Yasui Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Paul C Nathan Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA

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Long-term adverse outcomes in survivors of childhood bone sarcoma: the British Childhood Cancer Survivor Study

Background:

With improved survival, more bone sarcoma survivors are approaching middle age making it crucial to investigate the late effects of their cancer and its treatment. We investigated the long-term risks of adverse outcomes among 5-year bone sarcoma survivors within the British Childhood Cancer Survivor Study.

Methods:

Cause-specific mortality and risk of subsequent primary neoplasms (SPNs) were investigated for 664 bone sarcoma survivors. Use of health services, health and marital status, alcohol and smoking habits, and educational qualifications were investigated for survivors who completed a questionnaire.

Results:

Survivors were seven times more likely to experience all-cause mortality than expected, and there were substantial differences in risk depending on tumour type. Beyond 25 years follow-up the risk of dying from all-causes was comparable to the general population. This is in contrast to dying before 25 years where the risk was 12.7-fold that expected. Survivors were also four times more likely to develop a SPN than expected, where the excess was restricted to 5–24 years post diagnosis. Increased health-care usage and poor health status were also found. Nonetheless, for some psychosocial outcomes survivors were better off than expected.

Conclusions:

Up to 25 years after 5-year survival, bone sarcoma survivors are at substantial risk of death and SPNs, but this is greatly reduced thereafter. As 95% of all excess deaths before 25 years follow-up were due to recurrences and SPNs, increased monitoring of survivors could prevent mortality. Furthermore, bone and breast SPNs should be a particular concern. Since there are variations in the magnitude of excess risk depending on the specific adverse outcome under investigation and whether the survivors were initially diagnosed with osteosarcoma or Ewing sarcoma, risks need to be assessed in relation to these factors. These findings should provide useful evidence for risk stratification and updating clinical follow-up guidelines.