Osteosarcoma of the extremities: chemotherapy experience at Memorial Sloan-Kettering

Operative Treatment and Outcomes of Pediatric Patients with an Extremity Bone Tumor: A Secondary Analysis of the PARITY Trial Data

BACKGROUND

Osteosarcoma and Ewing sarcoma are the 2 most common primary bone sarcomas, occurring predominantly in pediatric patients, with the incidence of osteosarcoma correlating with periods of peak bone-growth velocity. Although survival outcomes have plateaued over the past several decades, ongoing treatment advances have improved function, decreased infection rates, and improved other clinical outcomes in patients with bone tumors. Recently, the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial addressed the serious problem of surgical site infection (SSI) and the lack of consensus regarding the appropriate prophylactic postoperative antibiotic regimen. The objective of the present secondary analysis of the PARITY trial was to characterize the modern treatment and surgical and oncologic outcomes of pediatric patients with bone tumors at 1 year postoperatively.

METHODS

The PARITY trial included patients ≥12 years old with a bone tumor or soft-tissue sarcoma that was invading the femur or tibia, necessitating osseous resection and endoprosthetic reconstruction. This pediatric subanalysis of the PARITY trial data included all PARITY patients ≤18 years old. As in the main PARITY study, patients were randomized to either a 5-day or 1-day course of postoperative antibiotic prophylaxis. The primary outcome measure was the development of an SSI within 1 year, and secondary outcomes included antibiotic-related adverse events, unplanned additional operations, local recurrence, metastasis, and death.

RESULTS

A total of 151 patients were included. An adjudicated SSI occurred in 27 patients (17.9%). There was no difference in the rate of any SSI between the 5-day and 1-day antibiotic groups (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.4 to 1.9; p = 0.82). Antibiotic-related complications occurred in 13 patients (8.6%), with no difference noted between groups (HR, 0.46; 95% CI, 0.2 to 1.4; p = 0.18). A total of 45 patients (29.8%) required a return to the operating room within the first postoperative year, which corresponded with a 68.8% reoperation-free rate of survival at 1 year when accounting for competing risks. The most common reason for reoperation was infection (29 of 45; 64.4%). A total of 7 patients (4.6%) required subsequent amputation of the operative extremity, and an additional 6 patients (4.0%) required implant revision within 12 months. A total of 36 patients (23.8%) developed metastases, and 6 patients (4.0%) developed a local recurrence during the first postoperative year. A total of 11 patients (7.3%) died during the study period. There were no significant differences in oncologic outcomes between the 5-day and 1-day antibiotic groups (HR, 0.97; 95% CI, 0.5-1.8; p = 0.92).

CONCLUSIONS

There were no significant differences in surgical or oncologic outcomes between pediatric patients who underwent a 1-day versus 5-day antibiotic regimen following endoprosthetic reconstruction in the PARITY trial. Surgeons should be aware of and counsel patients and caregivers regarding the 30% rate of reoperation and the risks of infection (17.9%), death (7.3%), amputation (4.6%), and implant revision (4%) within the first postoperative year.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Survival after pulmonary metastasectomy for relapsed osteosarcoma

OBJECTIVES

The purpose of this study was to evaluate the postrelapse survival of relapsed osteosarcoma with pulmonary metastases in patients who received pulmonary metastasectomy using intent to treat and propensity score analysis.

METHODS

Patients with osteosarcoma who relapsed with pulmonary metastases between 2004 and 2018 who were treated in a hospital affiliated with a medical school were included. All the enrolled patients were evaluated as operable with assessment algorithm at the time of diagnosis of pulmonary relapse and intent to treat analysis was done. Multiple propensity score methods (eg, matching, stratification, covariate adjustment, and inverse probability of treatment weighting) were performed to balance confounding bias. Cox proportional hazards regression and the Kaplan-Meier method were used to evaluate patient survival.

RESULTS

A total of 125 patients met the study criteria. Of these, 59 (47.2%) patients received pulmonary metastasectomy combined with chemotherapy and 66 (52.8%) received chemotherapy alone. The 2-year and 5-year postrelapse survival rate of metastasectomy group and nonmetastasectomy group were 68.4% versus 25.0% and 41.0% versus 0%, respectively. The median postrelapse survival was 24.9 versus 13.5 months, respectively. Pulmonary metastasectomy was independently associated with improved survival (hazard ratio, 0.185; 95% confidence interval, 0.103-0.330; P < .001). These results were confirmed by multiple propensity score analyses. Further stratified analysis revealed that the survival advantage associated with metastasectomy was not significant in patients with metastases involving ≥3 lung lobes and patients with very high pretreatment serum alkaline phosphatase (more than twice the upper limit).

CONCLUSIONS

Pulmonary metastasectomy is associated with improved survival in patients with recurrent osteosarcoma.

Prognostic Significance of Serum Lactate Dehydrogenase in Osteosarcoma of the Extremity: Experience at Rizzoli on 1421 Patients Treated over the Last 30 Years

Aims

The study evaluated the correlation between pretreatment serum lactate dehydrogenase (LDH) levels with the stage of disease and its clinical prognostic value.

Methods

Pretreatment serum LDH of 1421 patients with osteosarcoma of the extremity were assessed to investigate whether the enzyme correlates with the stage of the tumor. In 860 assessable patients with localized disease, treated according to 10 different protocols of adjuvant (four) and neoadjuvant chemotherapy (six), we also evaluated the correlation between the serum levels of LDH and outcome.

Results

According to the stage of disease, the rate of high serum level of LDH was significantly higher in 199 patients with metastatic disease at presentation than in 1222 patients with localized disease (36.6% vs 18.8%; P <0.0001). In these patients, the 5-year disease-free survival was 39.5% for patients with high LDH levels and 60% for those with normal values. The 5-year disease-free survival correlated with serum level of LDH at univariate and multivariate analysis, although it lost its significance when histologic response to chemotherapy was also considered in the multivarite analysis.

Conclusions

Serum LDH has a prognostic value and it should be considered in evaluating the results of therapeutic trials of chemotherapy, as well as defining a category of patients at high-risk of relapse to be treated with a more aggressive regimen.

What are the functional outcomes of endoprosthestic reconstructions after tumor resection?

BACKGROUND

The majority of published functional outcome data for tumor megaprostheses comes in the form of subjective functional outcome scores. Sparse objective data exist demonstrating functional results, activity levels, and efficiency of gait after endoprosthetic reconstruction in patients treated for orthopaedic tumors. Patients embarking on massive surgical operations, often in the setting of debilitating medical therapies, face mortality and a myriad of unknowns. Objective functional outcomes provide patients with reasonable expectations and a means to envision life after treatment. Objective outcomes also provide a means for surgeons to compare techniques, rehabilitation protocols, and implants.

QUESTIONS/PURPOSES

We asked the following questions: (1) What is the efficiency of gait (ie, oxygen consumption) at final recovery from endoprosthetic reconstruction for oncologic resections? (2) What is the knee strength after lower extremity endoprosthetic reconstruction as compared with the contralateral limb? (3) How active are patients with tumor megaprostheses at home and in the community?

METHODS

Sixty-nine patients with endoprosthetic reconstructions for primary lower extremity bone sarcoma met inclusion criteria and were invited by mailing to undergo oxygen cost study and strength testing. Twenty-four patients (seven proximal femoral replacements, nine distal femoral replacements, and eight proximal tibia replacements) underwent evaluation in the gait laboratory at a mean of 13.2 years after their reconstruction. All patients were then asked to wear step activity monitors at home and in the community for 7 consecutive days.

RESULTS

Median O2 consumption (in mL/kg/m) among the endoprothesis groups was not different from the control patients with the numbers available (proximal femoral replacement 0.17, distal femoral replacement 0.16, proximal tibia replacement 0.18, control 0.15, p = 0.21). With the numbers available, there was no difference in walking speed as compared with the control group (proximal femoral replacement 1.20 m/s, distal femoral replacement 1.27 m/s, proximal tibia replacement 1.12 m/s, control 1.27 m/s, p = 0.08). Patients with proximal tibia replacements had reduced knee extension and flexion strength compared with patients in other reconstruction groups (84% reduction in extension versus those with proximal femoral replacements, 35%, and distal femoral replacement, 53%, p = 0.001, and 43% reduction in flexion versus proximal femoral replacement, 11%, distal femoral replacement, 2%, p = 0.006). With the numbers available, mean strides per day were not different among the reconstruction groups (proximal femoral replacement = 4709 strides/day [3094-6696], distal femoral replacement = 2854 [2461-6015], and proximal tibia replacement = 4411 [3093-6215], p = 0.53).

CONCLUSIONS

Although knee strength was reduced in patients with proximal tibia replacements compared with femoral reconstructions, all groups had an efficient gait and were active at home and in the community at a mean of 13.2 years after surgery. Despite the magnitude of these surgeries, these patients are similarly active as patients after standard total hip arthroplasty. These findings provide objective data from which patients undergoing tumor megaprosthesis reconstructions of the lower extremity can reasonably base expectations of efficient gait and active lifestyles outside of the hospital setting. These data may provide hope and long-term goals for patients facing the uncertainty of chemotherapy and surgical treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The role of chemotherapy for metastatic, relapsed and refractory osteosarcoma

Despite a large number of publications on outcomes of second-line chemotherapy for osteosarcoma, there is little consensus on efficacy of the therapy.

OBJECTIVE

Our objective was to systematically categorize published evidence for chemotherapy for metastatic, relapsed and refractory osteosarcoma in order to provide an updated and comprehensive analysis of the clinical outcomes.

METHODS

We performed a search of PubMed and EMBASE to identify published articles reporting on validated clinical outcomes measures (the rate of complete response [CR] and partial response [PR], the rate of stable disease [SD] and progressive disease [PD] and the 5-year overall survival) after chemotherapy in patients with metastatic, relapsed and refractory osteosarcoma. A total of 20 articles were identified and stratified by different regimens. Finally, six regimens that have at least two drugs were reviewed. Weighted averages of each outcome were computed.

RESULTS

The weighted average overall response rate (CR + PR) for the combination of ifosfamide, etoposide and high-dose methotrexate therapy was 62 %, and the tumor control rate (CR + PR + SD) was 92.3 %; the highest of all six regimens. The weighted average overall response rate and tumor control rate of ifosfamide-etoposide therapy (41.7 and 77.9 %, respectively) were the highest of the two-drug regimens. Weighted average overall response rate and tumor control rate for the remaining regimens were 20.5 and 56.8 %, respectively, for cyclophosphamide-etoposide; 30.0 and 73.5 % for ifosfamide, carboplatin, and etoposide; 12.0 and 40.0 % for cyclophosphamide-topotecan; and 14.5 and 36.4 % for gemcitabine-docetaxel.

CONCLUSION

A chemotherapy regimen comprising both a cell cycle-specific drug and a cell cycle-nonspecific drug could increase response rates. The combination of ifosfamide and etoposide therapy is our first choice in two-drug regimens. Regarding three-drug regimens, adding a cell cycle-specific drug to ifosfamide-etoposide therapy may result in a better response rate than adding a cell cycle-nonspecific drug, or any other two-drug regimens in current studies. Hence, we recommend the use of second-line chemotherapy based on the combination ifosfamide-etoposide regimen in patients with metastatic, relapsed and refractory osteosarcoma.

Local and systemic control after ablative and limb sparing surgery in patients with osteosarcoma

Limb salvage surgery in patients with osteosarcoma is reported to cause a higher rate of local recurrences with a poorer chance of survival. It was the aim of the study to analyze differences between ablative and limb sparing surgery in patients with osteosarcoma who are treated with chemotherapy with respect to local and systemic tumor control and to determine independent prognostic factors. One hundred thirty consecutive patients younger than the age of 21 years who were operated on at the authors' institution for osteosarcoma of the extremities were reviewed. Histologic evaluations of surgical margins according to Enneking and coworkers revealed mostly wide (n = 109) and radical (n = 10) resection margins. The 5-year disease free survival rate was 60% for those patients treated by amputation and 71% for those treated by limb salvage. The overall local recurrence rate was 2.3%; 4.3% for ablation but only 1.2% for limb sparing surgeries. Multivariate analysis showed an independent effect of tumor volume, response to chemotherapy, and as expected, metastases at the time of diagnosis on overall survival. These data indicate that in patients where wide or radical tumor resection can be achieved, no difference in the outcome between ablative and limb sparing surgery occurred in local and systemic tumor control.

The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society

In 1982, members of the Musculoskeletal Tumor Society, representing sixteen centers for the treatment of bone and soft-tissue cancer, compiled data regarding the hazards associated with 329 biopsies of primary malignant musculoskeletal sarcomas. The investigation showed troubling rates of error in diagnosis and technique, which resulted in complications and also adversely affected the care of the patients. These data were quite different when the biopsy had been carried out in a treatment center rather than in a referring institution. On the basis of these observations, the Society made a series of recommendations about the technical aspects of the biopsy and stated that, whenever possible, the procedure should be done in a treatment center rather than in a referring institution. In 1992, the Musculoskeletal Tumor Society decided to perform a similar study to determine whether the rates of complications, errors, and deleterious effects related to biopsy had changed. Twenty-five surgeons from twenty-one institutions submitted the cases of 597 patients. The results were essentially the same as those in the earlier study. The rate of diagnostic error for the total series (in which cases from referring institutions and treatment centers were combined) was 17.8 percent. There was no significant difference in the rate of patients for whom a problem with the biopsy forced the surgeon to carry out a different and often more complex operation or to use adjunctive irradiation or chemotherapy (19.3 percent in the current study, compared with 18 percent in the previous one). There was also no significant differences in the percentage of patients who had a change in the outcome, such as the need for a more complex resection that resulted in disability, loss of function, local recurrence, or death, attributable to problems related to the biopsy (10.1 percent in the current study, compared with 8.5 percent in the 1982 study). Eighteen patients in the current study had an unnecessary amputation as a result of the biopsy, compared with fifteen in the previous study. Errors, complications, and changes in the course and outcome were two to twelve times greater (p < 0.001) when the biopsy was done in a referring institution instead of in a treatment center.