Patterns of care and survival for patients aged under 40 years with bone sarcoma in Britain, 1980-1994

Clinical and Pathological Profile of Children and Adolescents with Osteosarcoma

Introduction: Osteosarcoma (OS) is the most common type of primary malignant bone and cartilage tumour. Because of the remarkable developments in technology, remarkable progress has been made in the medical field regarding the diagnosis and management of OS patients. The aim of the study is to describe the clinical and pathological profile of paediatric patients with osteosarcoma and to identify potential prognostic factors for an unfavourable outcome in our country. Methods: We conducted a retrospective study of all children and adolescents with musculoskeletal tumours diagnosed and treated at our tertiary Orthopaedic Department for a period of 10 years. Results: A group of 65 children and adolescents with osteosarcoma who benefited from diagnosis, neoadjuvant, adjuvant and surgical treatment in the Emergency Clinical Hospital for Children "Sfânta Maria" Iasi, România, was analysed. The average age at the time of diagnosis was 12.9 years. The analysis revealed a higher frequency for male patients in the case of femur and tibia locations and a significantly higher frequency of osteosarcoma in the scapula and clavicle in female patients, while OS in the humerus was found only in male patients (χ2 = 19.46, p = 0.0149). The most frequent histopathological subtype was osteoblastic osteosarcoma, but there was no significant correlation with the gender or the age of the patients (χ2 = 0.73, p = 0.863 and χ2 = 0.843, p = 0.839). The results indicated instead a significantly (p = 0.0185) lower age values of patients with undifferentiated osteosarcomas, the average age being 9.4 years ± 2.1 SD. After performing a multivariate logistic regression analysis for the risk of death based on clinical parameters, we found that high tumoural grading increases the risk of death 2.8 times, pleomorphic histological subtype increases the risk of death 3.5 times, and stage IV TNM increases this risk 5.9 times. Conclusions: For the north-eastern geographical part of Romania, the epidemiological and clinical profile of a child with osteosarcoma is a 13-year-old boy with a femoral or tibia tumour or a 12-year-old girl with a femoral, tibia, scapula or clavicle tumour, both coming from a rural area. The tumour has around 12 cm diameter and is a differentiated osteoblastic osteosarcoma. The survival rate at 10 years is 63%. Tumour grading, histological subtype and TNM staging significantly influence the probability of death and could be important prognostic parameters for patients with osteosarcoma.

Malignant bone tumors around the knee: A single-center experience

Aim: This study aimed to determine the frequency of malignant bone tumors (primary and metastatic) seen around the knee in our region, the patients’ type and demographic characteristics, and the treatments’ outcomes. Material and Method: A retrospective analysis of the patients who were diagnosed and treated with histopathologically malignant tumors in the knee region in our hospital between 2004-2021 was performed from the hospital database. Patients’ complaints, demographic information, and diagnostic and imaging findings were examined. In addition, tumor types, tumor localization, and treatments applied were analyzed. Results: Malignant bone tumor was detected in 88 (35.7%) of 246 patients included in the study. The patients were 48 women and 40 men, with a mean age of 39.72±21.8 (6-76 years). A total of 88 patients were divided into the pediatric group (<18 years; n=39) and the adult group (≥18 years; n=49). The most common tumors were osteosarcoma in 54 (61.3%) and metastatic tumors in 22 (25%) patients. The most common localization of tumors was the distal femur with a rate of 75%. Metastasis was detected in 12 (18.2%) of 66 patients treated and followed up for primary malignant bone tumors. Limb sparing surgery was performed in 70 (79.5%), and various levels of amputation were performed in 14 (15.9%). Palliative radiotherapy was applied to two patients with metastatic lesions, while two patients who were in the neoadjuvant chemotherapy period died. The 5-year overall survival was 63.7%. Pediatric and adult age groups did not differ significantly in terms of survival (p=0.74), gender (p=0.585), and metastasis development (p=0.53). Conclusion: The knee is a region that requires attention regarding bone tumors around it. As malignant bone tumors are rarely seen around the knee, a misdiagnosis may be made, and appropriate treatment may be delayed. Although the first diagnosis to come to mind for patients presenting with knee pain is trauma and growing pains, it must not be forgotten that a tumor could be the cause.

An Efficient Nomogram to Predict Overall Survival of Patients with Pediatric Ewing's Sarcoma: A Population-Based Study

Background

The objective of our study was to develop and validate a nomogram to predict the overall survival (OS) of patients with pediatric Ewing’s sarcoma (PES).

Methods

Age, gender, race, tumor stage, tumor size, tumor site, treatment method, and survival time were collected from patients diagnosed with PES between 2004 and 2016 from the Surveillance, Epidemiology, and End Results (SEER) database. A total of 772 patients were randomly allocated to a training dataset (n = 579) and a validation dataset (n = 193). Then, univariate and multivariate analyses were performed to determine the prognostic effect of the selected variables. A nomogram was constructed to estimate the OS and it was further assessed using the concordance index (C-index), calibration curves, and receiver operating characteristic (ROC).

Results

Age, race, tumor size, and tumor stage were included in the nomogram. The C-index was 0.77 in the OS for the training dataset. The C-index for the validation dataset of the OS prediction was 0.75. Calibration plots and ROC curves showed excellent predictive accuracy.

Conclusion

Age, race, tumor stage, and tumor size were independent prognostic factors for patients with PES. The nomogram showed an accurate and reliable prognostic performance for PES patients.

Age as a Prognostic Factor in Patients with Ewing Sarcoma-The Polish Sarcoma Group Experience

Ewing sarcoma (ES) is a rare and aggressive disease that requires multidisciplinary treatment with the use of chemotherapy, radiotherapy, and surgery. Our retrospective study aimed to analyze the prognostic factors and treatment results in different age groups of patients. Between 1998 and 2018, 569 patients with ES were treated in two referral centers. The patients were divided into four age groups (≤10 years; 11–18 years; 19–25, and >25). The treatment results and prognostic factors were assessed for each group. For statistical analyses, we used the Chi2 test, the Kaplan–Meier estimator with a log-rank test, and the multivariate Cox model. Five-year overall survival (OS) rate was 56%. In the age subgroups: ≤10 years, 11–18 years, 19–25 years, and >25 years, the 5-year OS rates were 75%, 58%, 41%, and 52%, respectively. Favorable prognostic factors: female gender (p = 0.024), non-axial localization (p = 0.005), VIDE regimen (p < 0.001), and surgery as a local treatment (p < 0.001) dominated in the group ≤10 years. In multivariate analysis, male (HR = 1.53), axial localization (HR = 1.46), M1 status at presentation (HR = 2.64), and age > 10 years (HR = 2.29) were associated with shorter OS. The treatment results in ES are significantly better in children aged ≤10 years; the challenge is to provide therapy for adolescents and young adults. The diagnostics and treatment of ES patients must be provided in referral centers.

Organization of Bone Sarcoma Care: A Cross-Sectional European Study

Objective

To assess organization of care in several bone sarcoma centers in Europe affiliated with the European Musculoskeletal Oncology Society (EMSOS) for comparison and to identify potential improvements in organization of care.

Methods

Data for this observational cross‐sectional study was obtained through healthcare professionals affiliated to EMSOS. The authors formulated 10 questions regarding organization of care. The questions were focused on guidance, multidisciplinary decision‐making, and data storage. A digital questionnaire was synthesized and included quality control. The digital questionnaire was sent to 54 representative members of EMSOS. We did not receive responses from 29 representative countries (53.7%) after one digital invitation and two digital reminders.

Results

We received data from 25 representatives of bone sarcoma centers from 17 countries across Europe (46.3%). Authorization to perform oncological care in a bone sarcoma center was government issued in 41.2% of cases and based on expertise without governmental influence in 52.9% of cases. In 64.7% of the countries, a national bone tumor guideline regarding for diagnosis and treatment is used in oncological care. A national bone tumor board for extensive case evaluation including classification and advice for treatment is available for 47.1% of the countries. All participating bone sarcoma centers have a mandatory local multidisciplinary meeting before the start of treatment; in 84.0% this meeting takes place once a week. During this multidisciplinary meeting a median of 15 cases (range, 4–40 cases) are discussed. In terms of storage of oncological data, a local registry is used in eight countries (47.1%). A national registry is used in eight countries (47.1%).

Conclusions

A national bone tumor board gives bone sarcoma centers with little adherence the opportunity to gain knowledge from a more experienced team. Centralization of care in a bone sarcoma center is important to lower incidences. The optimal size for a bone sarcoma center in terms of patient adherence is not known at present.

[DKG certification of paediatric cancer centres - a wide field …]

Die Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH) und die Deutsche Krebsgesellschaft (DKG) haben Kriterien für die DKG-Zertifizierung der Kinderonkologie erarbeitet, nach denen 2017 in Deutschland erstmals pädiatrisch-onkologische Abteilungen zertifiziert wurden. Das Ziel der DKG-Zertifizierung ist „die Vereinheitlichung und die transparente Darstellung der Versorgungsqualität für pädiatrische Patientinnen und Patienten mit hämato-onkologischen Erkrankungen“, wie 2018 in einer Veröffentlichung von Mensah et al. dargestellt. Die Auswahl der Zertifizierungskriterien hat innerhalb der GPOH zu einer intensiven Diskussion darüber geführt, inwieweit die Kriterien für sich genommen einer wissenschaftlichen Überprüfbarkeit standhalten und damit valide Parameter für die Bestimmung der Versorgungsqualität in der Kinderonkologie in Deutschland darstellen.

Wir haben untersucht, ob aus der Arbeit von Mensah et al. valide Folgerungen für das deutsche Gesundheitssystem ableitbar sind. Dabei zeigt sich, dass die momentan definierten DKG-Zertifizierungskriterien für die Kinderonkologie in Deutschland in kritischen Bereichen einer fundierten wissenschaftlichen Grundlage entbehren.

Diese Arbeit stellt Fallzahlen als Maß für Qualität in der Kinderonkologie infrage und regt die Entwicklung alternativer Kriterien für die Überprüfbarkeit von Qualität in der deutschen Kinderonkologie an.

Management of Sarcoma in Adolescents and Young Adults: An Australian Population-Based Study

Background: While overall survival (OS) for cancer in adolescents and young adults (AYA) has improved, there has been little change in AYA survival for several types of sarcomas. Using national data for Australia we describe (1) the treatment centers caring for AYA sarcoma, (2) treatments provided, and (3) survival outcomes. Procedure: National population-based study assessing treatment of 15-24 year-olds diagnosed with soft tissue sarcoma (STS), bone sarcoma (BS), and Ewing family tumors (ET) between 2007 and 2012. Treatment details were abstracted from hospital medical records. Treatment centers were classified as pediatric or adult specialist AYA/sarcoma center, or other adult. Cox proportional hazard regression analyses examined associations between type of treatment center and OS. Results: Sixty-one hospitals delivered treatment to 318 patients (135 STS; 91 BS, 92 ET), with 9%, 22%, and 17% of STS, BS, and ET, respectively, treated at pediatric and 62%, 59%, and 71% at adult specialist hospitals. Of 18-24 year-olds, 82% of BS, 90% of ET, and 73% of rhabdomyosarcomas at adult specialist centers were on a trial or standard protocol, compared with 42%, 89%, and 100%, respectively, at nonspecialist adult hospitals. After adjusting for disease and patient characteristics, survival was not associated with treatment center type for any disease type. However, ET survival was poorer for patients not receiving a standard chemotherapy protocol. Conclusions: Around 10% of AYA sarcoma patients attending adult hospitals were not on a standard protocol. Poorer survival for ET patients not on a standard protocol highlights the importance of ensuring all patients receive optimal care.

Socio-economic patterning in early mortality of patients aged 0-49 years diagnosed with primary bone cancer in Great Britain, 1985-2008

BACKGROUND

Studies have shown marked improvements in survival between 1981 and 2000 for Ewing sarcoma patients but not for osteosarcoma. This study aimed to explore socio-economic patterning in early mortality rates for both tumours.

PROCEDURE

The study analysed all 2432 osteosarcoma and 1619 Ewing sarcoma cases, aged 0-49 years, diagnosed in Great Britain 1985-2008 and followed to 31/12/2009. Logistic regression models were used to calculate risk of dying within three months, six months, one year, three years and five years after diagnosis. Associations with Townsend deprivation score and its components were examined at small-area level. Urban/rural status was studied at larger regional level.

RESULTS

For osteosarcoma, after age adjustment, mortality at three months, six months and one year was associated with higher area unemployment, OR = 1.05 (95% CI 1.00, 1.10), OR = 1.04 (95% CI 1.01, 1.08) and OR = 1.04 (95% CI 1.02, 1.06) respectively per 1% increase in unemployment. Mortality at six months was associated with greater household non-car ownership, OR = 1.02 (95% CI 1.00, 1.03). For Ewing sarcoma, there were no significant associations between mortality and overall Townsend score, nor its components for any time period. For both tumours increasing mortality was associated with less urban and more remote rural areas.

CONCLUSIONS

This study found that for osteosarcoma, early mortality was associated with residence at diagnosis in areas of higher unemployment, suggesting risk of early death may be socio-economically determined. For both tumours, distance from urban centres may lead to greater risk of early death.

Survival patterns in teenagers and young adults with cancer in the United Kingdom: Comparisons with younger and older age groups

AIMS

We aimed to describe and compare survival in teenagers and young adults (TYAs) with cancer to that of younger children and older adults, to identify sub-populations at greater or lesser risk of death.

METHODS

We compared survival in cancer patients diagnosed in the United Kingdom aged 13-24 years (TYAs) to those aged 0-12 (children) and 25-49 years (adults) using the National Cancer Data Repository. All cases had a first cancer diagnosis between 1st January 2001 and 31st December 2005 with censor date 31st December 2010 or death if earlier.

RESULTS

We found six distinct statistically significant survival patterns. In pattern 1, the younger the age-group the better the 1- and 5-year survival (acute lymphoid leukaemia, carcinoma of ovary and melanoma). In pattern 2, TYAs had a worse 5-year survival than both children and young adults (bone and soft tissues sarcomas). In pattern 3, TYAs had a worse 1-year survival but no difference at 5-years (carcinoma of cervix and female breast). In pattern 4, TYAs had better 1-year survival than adults, but no difference at 5 years (carcinoma of liver and intrahepatic bile ducts, germ cell tumours of extra-gonadal sites). In pattern 5, the younger the age-group the better the 5-year survival, but the difference developed after 1-year (acute myeloid leukaemia, carcinoma of colon and rectum). In pattern 6, there was no difference in 1- and 5-year survival between TYAs and adults (testicular germ cell tumours, ovarian germ cell tumours and carcinoma of thyroid).

CONCLUSION

TYAs with specific cancer diagnoses can be grouped according to 1- and 5-year survival patterns compared to children and young adults. To further improve survival for TYAs, age-specific biology, pharmacology, proteomics, genomics, clinician and patient behaviour studies embedded within clinical trials are required.

Incidence, treatment and survival of paediatric patients with bone sarcomas in Finland from 1991 to 2005

AIM

Our aims were to establish the 10-year overall and event-free survival rates among children and adolescents with bone sarcomas in Finland, estimate their respective incidences, evaluate the treatment given and describe the key prognostic factors.

METHODS

We included 88 patients of <18 years of age diagnosed with a bone sarcoma during 1991-2005 in this retrospective, nationwide and population-based study. Median follow-up time was 12.2 years (range 5.8-20.3 years) for surviving patients.

RESULTS

The overall incidence among children and adolescents was 5.1 per million: 3.6 for osteosarcoma, 1.2 for Ewing's sarcoma and 0.3 for chondrosarcoma. The 10-year event-free and overall survival of those with a localised disease at diagnosis was 69% and 82%, respectively. The overall 10-year survival of those with a metastatic disease at diagnosis was 47%. Prognostic factors for localised disease included an axial versus peripheral primary tumour site in Ewing's sarcoma (p = 0.022) and age at diagnosis in osteosarcoma (p = 0.027).

CONCLUSION

The 10-year overall survival of children and adolescents diagnosed with a bone sarcoma in Finland during 1991 to 2005 was very good, at 82% if the disease was localised at diagnosis and 47% if it was metastatic at diagnosis.

Prognostic factors and treatment results of high-grade osteosarcoma in norway: a scope beyond the "classical" patient

Purpose. A retrospective study of prognostic factors and treatment outcome of osteosarcoma (OS) during modern chemotherapy era with focus on patients with primary metastatic disease, nonextremity localisation, or age >40 years (nonclassical OS). Methods. A nationwide cohort, comprising 424 high-grade Norwegian bone OS patients, was based on registry sources supplemented with clinical records from hospitals involved in sarcoma management between 1975 and 2009. Results. Only 48% were younger patients with tumour in the extremities and without metastasis at diagnosis (classical OS). A considerable discrepancy in survival between classical and nonclassical OS was observed: 61% versus 26% 10-year sarcoma specific survival. Twice as many of the former received both adequate surgery and chemotherapy compared to the latter. This could only partly explain the differences in survival due to inherent chemoresistance in primary metastatic disease and a higher rate of local relapse among patients with axial tumours. Metastasis at diagnosis, increased lactate dehydrogenase, age > 40 years, and tumour size above median value were all adverse prognostic factors for overall survival. Conclusion. We confirm a dramatic difference in outcome between classical and nonclassical high-grade OS patients, but treatment variables could only partly explain the dismal outcome of the latter.

Time-trends on incidence and survival in a nationwide and unselected cohort of patients with skeletal osteosarcoma

Background

This study describes time-trends on epidemiology, subtypes and histopathological entities of osteosarcoma (OS) in a nationwide and unselected cohort of OS patients in Norway between 1975 and 2009. Few nationwide studies are published, and we still have particularly limited knowledge regarding patients not included in clinical trials comprising about half of the OS population.

Method

Histologically verified skeletal OS for all subgroups were included, resulting in 473 eligible cases from a total of 702 evaluated patients. To ensure completeness, the present cohort was based on all cases reported to the Norwegian Cancer Registry, complemented with data from all Norwegian hospitals involved in sarcoma management. Survival analyses were performed with overall and sarcoma-specific survival as endpoints.

Results

Mean annual age-standard incidence amounted to about 3.8 per million in male and 2.8 per million in female with no clear time-trends. The male to female ratio was 1.4. Peak incidence was observed in the second decade for both genders. Conventional OS comprised 71.2% of all cases, while low grade OS represented 10.4% and telangiectatic OS only 1.3%. The most common primary site of OS was femur and tibia, respectively. The axial to appendicular ratio increased with the age. The overall 10-year survival did increase from about 30% during the late 1970s to around 50% 20 years later, with no subsequent improvement during the last two decades. Axial tumours, age above 40 years and overt metastatic disease at time of diagnosis were all negative prognostic factors.

Conclusion

No improvement in the overall survival for OS since the 1990s was documented. The survival rates are still poor for elderly people, patients with axial disease and in the primary metastatic setting. The average incidence rate of skeletal OS in Norway was in line with international figures.

The volume effect in paediatric oncology: a systematic review

BACKGROUND

For several adult cancer types, there is evidence that treatment in high volume hospitals, high case volume providers, or in specialised hospitals leads to a better outcome. The aim of this study is to give an overview of the existing evidence regarding the volume effect in paediatric oncology related to the quality of care or survival.

MATERIALS AND METHODS

An extensive search was carried out for studies on the effect of provider case volume on the quality of care or survival in childhood cancer. Information about study characteristics, comparisons, results, and quality assessment were abstracted.

RESULTS

In total, 14 studies were included in this systematic review. Studies with a low risk of bias provide evidence that treatment of children with brain tumours, acute lymphoblastic leukaemia, osteosarcoma, Ewing's sarcoma, or children receiving treatment with allogenic bone marrow transplantation in higher volume hospitals, specialised hospitals, or by high case volume providers, is related with a better outcome.

CONCLUSIONS

This systematic review provides support for the statement that higher volume hospitals, higher case volume providers, and specialised hospitals are related to the better outcome in paediatric oncology. No studies reported a negative effect of a higher volume.

Descriptive epidemiology of sarcomas in Europe: report from the RARECARE project

Sarcomas are a heterogeneous group of malignant neoplasms arising from mesenchymal cells which encompass dozens of histological types and can occur in virtually any anatomic site. They form one of the principal groups of rare cancers in Europe as defined in the RARECARE project. We analysed 45,568 incident cases diagnosed during 1995-2002 and registered by 76 population-based cancer registries. Total crude incidence was 5.6 per 100,000 per year with an estimated 27,908 new cases per year in the EU27 countries, of which 84% were soft tissue sarcomas and 14% were bone sarcomas. Gastrointestinal stromal tumours (GIST) were only widely recognised as an entity in the late 1990s and consequently were under-registered. Their true incidence is believed to be about 1.5 per 100,000. Age-standardised incidence of soft tissue sarcomas ranged from 3.3 per 100,000 in Eastern Europe to 4.7 per 100,000 in Northern Europe. About 280,000 persons were estimated to be alive at the beginning of 2003 with a past diagnosis of sarcoma, of which 83% were soft tissue sarcomas and 16% were bone sarcomas. Five-year relative survival for 2000-2002 by the period was 58% for soft tissue sarcomas and 62% for bone sarcomas. The diversity and rarity of sarcomas combined with the quite large number of people affected by them mean that they provide a classic example of the importance of networking in diagnosis, therapy and research for rare cancers.

Population survival from childhood cancer in Britain during 1978-2005 by eras of entry to clinical trials

BACKGROUND

Inclusion in clinical trials is generally viewed as best practice for most newly diagnosed childhood cancers, but the impact on population-based survival has rarely been examined.

PATIENTS AND METHODS

The population-based data were analysed for 25 853 children (66% of all registered childhood cancers) diagnosed in Britain during 1978-2005 with acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), Hodgkin lymphoma, non-Hodgkin lymphoma, medulloblastoma, neuroblastoma, Wilms tumour, hepatoblastoma, osteosarcoma, Ewing sarcoma, rhabdomyosarcoma and germ-cell tumours. The Kaplan-Meier survival curves were compared by log-rank tests. Time trends were analysed by Cox regression. Separate analyses were done for children with ALL, medulloblastoma and neuroblastoma according to clinically relevant age thresholds.

RESULTS

Survival increased significantly during 1978-2005 for every diagnostic category; the annual reduction in risk of death ranged from 2.7% (rhabdomyosarcoma) to 12.0% (gonadal germ-cell tumours). Survival increased steadily between trial eras for ALL (age 1-14 years) and neuroblastoma (age 1-14 years), but changed little since the mid-1980s for medulloblastoma (age 0-2 years), osteosarcoma or Ewing sarcoma.

CONCLUSIONS

Changes in survival between trial eras parallel those reported by the relevant clinical trials. The increasing level of participation in trials, facilitated by the organisation of specialist care, has underpinned the substantial improvements in survival seen at the population level.

Incidence and survival of malignant bone sarcomas in England 1979-2007

Primary malignant bone sarcomas (MBS) are rare and there are few studies examining their incidence and outcome. Here, the incidence and survival of all subtypes of MBS registered in England between 1979 and 2007 were analysed from patient registry data held by the National Cancer Intelligence Network (NCIN). Over 11,002 new cases of MBS were registered, an average of 379 per year. There was no change in incidence demonstrated over the study period (p = 0.08). Although a peak incidence is observed in adolescence, approximately half of MBS are diagnosed in patients over 50 years. An improvement in outcome of MBS was observed between those patients registered from 1979 to 1983 and 1983 to 1987 (p < 0.0001), but there has been no improvement since. In the most recent period studied (patients diagnosed 1998-2002) 5-year survival was 55% in Ewing sarcoma, 70% in chondrosarcoma, 56% in chordoma and 43% in osteosarcoma. Patients diagnosed with osteosarcoma over the age of 40 years or with a non-extremity tumour have a significantly inferior outcome; 22% 5-year survival >40 years compared with 53% <40 years (p < 0.0001) and 16% non-extremity tumour compared to 48% extremity tumour (p < 0.0001). This population-based study has allowed us to confidently define the English incidence and survival rates of both the commoner bone tumours such as osteosarcoma, and rarer entities such as chordoma as well as groups with inferior outcome. The lack of significant improvement over recent decades for these diseases is cause for concern and further research.

Incidence, epidemiology and treatment results of osteosarcoma in Finland - a nationwide population-based study

BACKGROUND

Patients diagnosed with osteosarcoma in Finland during 1991-2005 were retrospectively analyzed in a nationwide, population-based study. We focused on the incidence, treatment and outcome of osteosarcoma patients. We also evaluated the value of known prognostic parameters.

MATERIAL AND METHODS

Osteosarcomas were retrieved from the files of the national Finnish Cancer Registry. Only patients with histologically confirmed osteosarcoma were included in the analysis. Histological review was performed.

RESULTS

The study consists of 144 osteosarcoma patients with a mean follow-up of 9.8 years for survivors. Mean annual incidence of histologically confirmed osteosarcoma was 1.8 new osteosarcomas per million. The 10-year sarcoma-specific survival for the whole population was 63% and 73% for patients with local disease at presentation. Overall limb-salvage rate was 73% and local control was 84% for patients with a peripheral tumor. Development of local recurrence and major deviation from the chemotherapy protocol were significant adverse factors for sarcoma-specific survival in multivariate analysis.

CONCLUSION

The present nationwide and population-based study is our second report of treatment and prognosis of osteosarcoma in Finland. With modern chemotherapy the prognosis of local osteosarcoma has improved in Finland from 47% during 1971-1980 and 65% during 1981-1990 at five years to the present 73% during 1991-2005 at 10 years. The 10-year sarcoma-specific survival of 73% is excellent and comparable to results reported with contemporary treatment protocols in high-volume centers. However, improvement in limb-salvage rate and local control probably requires centralization of treatment of this rare disease.

Chemotherapeutic adjuvant treatment for osteosarcoma: where do we stand?

AIM

Since the introduction of chemotherapy, survival in localised high-grade osteosarcoma has improved considerably. However, there is still no worldwide consensus on a standard chemotherapy approach. In this systematic review evidence for effectiveness of each single drug and the role of response guided salvage treatment of adjuvant chemotherapy are addressed, whereas in a meta-analysis the number of drugs in current protocols is considered.

METHODS

A systematic literature search for clinical studies in localised high-grade osteosarcoma was undertaken, including both randomised and non-randomised trials. Historical clinical studies from the pre-chemotherapy era were included for comparison purposes.

RESULTS

Nine historical studies showed a long-term survival of 16% after only local treatment. Fifty single agent phase II studies showed high response rates for adriamycin (A, 43%), ifosfamide (Ifo, 33%), methotrexate (M, 32%), cisplatin (P, 26%) but only 4% for etposide (E). In 19 neo-adjuvant studies the mean 5-year event free survival (EFS) was 48% for 2-drug regimens and 58% for ⩾3 drug regimens, with a 5-year overall survival (OAS) of 62% and 70%, respectively. Meta-analysis showed that ⩾3 drug regimens including methotrexate plus adriamycin plus cisplatin (plus ifosfamide) (MAP(Ifo)) had significant better outcome (EFS: HR=0.701 (95% confidence interval [95% CI]: 0.615-0.799); OAS: HR=0.792 (95% CI: 0.677-0.926) than 2-drug regimens, but there was no significant difference between MAP and MAPIfo (or plus etoposide). Salvage of poor responders by changing drugs, or intensifying treatment postoperatively has not proven to be useful in this analysis.

CONCLUSION

Meta-analysis in patients with localised high-grade osteosarcoma shows that 3-drug regimens, for example MAP are the most efficacious drug regimens.

Oncological outcomes of patients with Ewing's sarcoma: is there a difference between skeletal and extra-skeletal Ewing's sarcoma?

The aim of this study was to identify whether there was any difference in patient, tumour, treatment or outcome characteristics between patients with skeletal or extra-skeletal Ewing's sarcoma. We identified 300 patients with new primary Ewing's sarcoma diagnosed between 1980 and 2005 from the centres' local database. There were 253 (84%) with skeletal and 47 (16%) with extra-skeletal Ewing's sarcomas. Although patients with skeletal Ewing's were younger (mean age 16.8 years) than those with extra-skeletal Ewing's sarcoma (mean age 27.5 years), there was little difference between the groups in terms of tumour stage or treatment. Nearly all the patients were treated with chemotherapy and most had surgery. There was no difference in the overall survival of patients with skeletal (64%) and extra-skeletal Ewing's sarcoma (61%) (p = 0.85), and this was also the case when both groups were split by whether they had metastases or not. This large series has shown that the oncological outcomes of Ewing's sarcoma are related to tumour characteristics and patient age, and not determined by whether they arise in bone or soft tissue.

Optimising the management of soft tissue tumours

The Royal College of Pathologists of Australasia is developing a series of protocols as an educational tool to assist pathologists in the reporting of relevant information for specific cancer specimens. The protocol for the management of soft tissue tumour resections has recently been released, and this document elaborates the relevant literature on which that protocol drew. Sarcoma is uncommon but is associated with significant morbidity and mortality, and its management is complex. Diagnostic errors are not uncommon and these can have disastrous effects on patient outcome. Sophisticated ancillary testing is often an important adjunct to diagnosis and prognostication. Referral to a specialist sarcoma unit is indicated for both adult and paediatric sarcoma.

Using epidemiology and genomics to understand osteosarcoma etiology

Osteosarcoma is a primary bone malignancy that typically occurs during adolescence but also has a second incidence peak in the elderly. It occurs most commonly in the long bones, although there is variability in location between age groups. The etiology of osteosarcoma is not well understood; it occurs at increased rates in individuals with Paget disease of bone, after therapeutic radiation, and in certain cancer predisposition syndromes. It also occurs more commonly in taller individuals, but a strong environmental component to osteosarcoma risk has not been identified. Several studies suggest that osteosarcoma may be associated with single nucleotide polymorphisms in genes important in growth and tumor suppression but the studies are limited by sample size. Herein, we review the epidemiology of osteosarcoma as well as its known and suspected risk factors in an effort to gain insight into its etiology.

UK Guidelines for the Management of Bone Sarcomas

These guidelines have been developed in order to provide an overview and a set of broad-based key recommendations for the management of patients with bone sarcomas in the UK. They have taken into consideration the most up-to-date scientific literature along with the recent recommendations by the European Society of Medical Oncology. The principles of the NICE guidance on both "improving outcomes for patients with sarcomas" and "improving outcomes with children and young people with cancer" have been incorporated. As care evolves, it is acknowledged that these guidelines will need updating. The key recommendations are that bone pain or a palpable mass should always lead to further investigation and patients with clinicoradiological findings suggestive of a primary bone tumour should be sent to a reference centre. Patients should then have their care managed at such a specialist centre by a fully accredited multidisciplinary team.

Fifty years of paediatric malignant bone tumours in the West Midlands, UK, 1957-2006: incidence, treatment and outcome

Malignant bone tumours in the paediatric age group (0-14 years) are uncommon; various aetiological theories exist and few reports of incidence, age and sex distributions have been published. We examined the incidence of childhood malignant bone tumours in one large single region of the UK over an extended period of 50 years. The West Midlands specialist regional children's tumour registry holds data on all malignancies and benign brain tumours in children under 15 years in the West Midlands region, which has a population of around 1 million children. Demographic and clinical data have been abstracted and diagnoses reviewed by a panel of expert pathologists. During the period 1957-2006, 259 cases of malignant paediatric bone tumours were diagnosed. There were 153 osteosarcomas, 78 Ewing sarcomas and 28 other primary bone tumours. The overall age standardised rate was 4.66, with no increase over time, although there was a significant increase in the incidence of Ewing sarcomas in the period 1965-92. Sixty-eight per cent of tumours were in patients over 10 years, whereas the incidence in patients under 10 years showed a non-significant increase. Survival rates increased dramatically post-chemotherapy introduction, with Ewing sarcoma demonstrating better survival overall. This is a large study giving an overview of malignant bone tumours in the childhood population of a single region over an extended period, showing results consistent with national reports. It also examines late effects, which were mostly mobility/orthopaedic, although almost one-fifth of patients had cardiac problems and five went on to develop second malignancies.

Emerging drugs for high-grade osteosarcoma

IMPORTANCE OF THE FIELD

Osteosarcoma (OS) is the most common primary malignant bone tumour in children and adolescents. This review focuses on the most promising therapeutic markers and drugs which may potentially be considered for innovative high-grade OS treatments.

AREAS COVERED IN THIS REVIEW

The list of drugs and compounds reviewed has been generated by taking into account those which target markers of potential clinical interest for high-grade OS and have been included in Phase I, II or III clinical trials. The literature search covers the last 40 years, starting from the first OS chemotherapy reports of the early 1970s. Particular relevance was given to reports and reviews on new targeted therapies of possible clinical usefulness for high-grade OS.

WHAT THE READER WILL GAIN

This review gives an updated overview of novel therapeutic approaches which have been or are going to be evaluated in Phase I/II/III clinical studies for high-grade OS.

TAKE HOME MESSAGE

On the basis of the information that has emerged so far, it can be predicted that in the next 5 - 10 years, new agents to be included in innovative treatment strategies for selected subgroups of high-grade OS patients may become available.

The epidemiology of bone cancer in 0 - 39 year olds in northern England, 1981 - 2002

BACKGROUND

There is a paucity of recent epidemiological data on bone cancers. The aim of this study was to describe incidence and survival patterns for bone cancers diagnosed during 1981 - 2002.

METHODS

Cases aged 0 - 39 years (236 osteosarcomas, 166 Ewing sarcomas and 73 chondrosarcomas) were analysed using Poisson and Cox regressions.

RESULTS

Incidence rates (per million persons per year) for osteosarcoma were 2.5 at age 0 - 14 years; 4.5 at age 15 - 29 years and 1.0 at age 30 - 39 years. Similarly, for Ewing sarcoma the incidence rates were 2.2; 2.9; 0.4 and for chondrosarcoma rates were 0.1; 1.2; 1.8 respectively. Incidence of osteosarcoma increased at an average annual rate of 2.5% (95% CI 0.4 - 4.7; P = 0.02), but there was no change in incidence of Ewing sarcoma or chondrosarcoma. There was a marginally statistically significant improvement in survival for Ewing sarcoma (hazard ratio (HR) per annum = 0.97; 95% CI 0.94 - 1.00; P = 0.06), although patients aged 15 - 39 years (n = 93) had worse overall survival than those aged 0 - 14 (n = 73; HR = 1.46; 95% CI 0.98 - 2.17; P = 0.06). There was no significant improvement in osteosarcoma survival (HR per annum = 0.98; 95% CI 0.95 - 1.01; P = 0.18).

CONCLUSIONS

Reasons for poorer survival in Ewing sarcoma patients aged 15 - 39 years and failure to significantly improve survival for osteosarcoma patients requires further investigation.

Incidence and survival of childhood bone cancer in northern England and the West Midlands, 1981-2002

There is a paucity of population-based studies examining incidence and survival trends in childhood bone tumours. We used high quality data from four population-based registries in England. Incidence patterns and trends were described using Poisson regression. Survival trends were analysed using Cox regression. There were 374 cases of childhood (ages 0-14 years) bone tumours (206 osteosarcomas, 144 Ewing sarcomas, 16 chondrosarcomas, 8 other bone tumours) registered in the period 1981-2002. Overall incidence (per million person years) rates were 2.63 (95% confidence interval (CI) 2.27-2.99) for osteosarcoma, 1.90 (1.58-2.21) for Ewing sarcoma and 0.21 (0.11-0.31) for chondrosarcoma. Incidence of Ewing sarcoma declined at an average rate of 3.1% (95% CI 0.6-5.6) per annum (P=0.04), which may be due to tumour reclassification, but there was no change in osteosarcoma incidence. Survival showed marked improvement over the 20 years (1981-2000) for Ewing sarcoma (hazard ratio (HR) per annum=0.95 95% CI 0.91-0.99; P=0.02). However, no improvement was seen for osteosarcoma patients (HR per annum=1.02 95% CI 0.98-1.05; P=0.35) over this time period. Reasons for failure to improve survival including potential delays in diagnosis, accrual to trials, adherence to therapy and lack of improvement in treatment strategies all need to be considered.

Osteosarcoma in Finland from 1971 through 1990: a nationwide study of epidemiology and outcome

BACKGROUND AND PURPOSE

There have only been a few nationwide studies on the epidemiology and outcome of osteosarcoma. We report the clinical features, treatment, and prognosis of osteosarcoma in Finland for the period 1971-1990.

METHODS

The study material was derived from population-based data from the national Finnish Cancer Registry. 302 osteosarcomas were reported during the study period. Histological slides could be retrieved for 199 cases and from histological re-examination, 139 (83%) of these cases were confirmed as osteosarcoma and were included in the analysis. The mean length of follow-up was 8 (0.1-28) years.

RESULTS

The overall 5-year survival for the whole study population was 58%, with an improvement in survival during 1981-1990 (65%) compared to the period 1971-1980 (47%) (p=0.01). More chemotherapy was administered in the later time period. For metastasis-free survival, diagnosis in the 1970s as opposed to the 1980s (p=0.01) and large tumor size worsened outcome in univariate analysis. Patients who developed metastatic relapse within 10 months of the diagnosis had worse sarcoma-specific survival than those who developed metastases later. Limb-salvage surgery increased from 12% to 23% for patients with a peripheral tumor, with no increase in local relapses.

INTERPRETATION

We recommend aggressive approach to treat recurrent disease, with a view to further improving survival. In a small country such as Finland it is necessary to concentrate treatment to only a few centers, to ensure a high quality of treatment.

Changes in incidence and survival of Ewing sarcoma patients over the past 3 decades: Surveillance Epidemiology and End Results data

PURPOSE

The US population-based cancer registry Surveillance, Epidemiology, and End Results (SEER) database provides an opportunity to evaluate the incidence and survival rates of Ewing sarcoma (ES) for the past 3 decades. This analysis reflects trends for the diagnosis of localized versus metastatic disease and changes in ES survival in a setting of wide-ranging cancer care institutions across the United States, which is expected to be different from clinical trials published to date.

MATERIALS/METHODS

Data from the SEER public-access database were reviewed for the diagnosis of ES of the bone among patients of 1 to 19 years of age between 1973 and 2004. Age-adjusted incidence was analyzed for the entire group and for localized and metastatic disease separately over the past 3 decades. Actuarial survival rates were examined for 3 intervals: 1973 to 1982, 1983 to 1992, and 1993 to 2004.

RESULTS

The overall incidence of ES seemed to remain unchanged with an average of 2.93 cases/1,000,000 reported annually between 1973 and 2004. The proportion of patients with distant metastasis among all ES cases remained in the 26% to 28% range, whereas the percent of localized cases slightly increased from 57% in 1973 to 1982 to 67% in 1993 to 2004 and the proportion of unstaged cases decreased from 17% to 5%. The 5-year survival of localized disease increased from 44% in the first study decade to 68% in the period after 1993, whereas 5-year survival of metastatic disease increased from 16% to 39%. The corresponding 10-year survival increased from 39% to 63% for localized disease and from 16% to 32% for metastatic ES.

CONCLUSIONS

The incidence of ES has not increased appreciably over the last 30 years. A marked decrease in the proportion of unstaged cases may be reflective of diagnostic improvement or changes in reporting. There is a clear improvement in survival for both localized and metastatic disease. Poorer outcome of metastatic patients still warrants intensification of therapy, which is currently being tested in several ongoing trials.

Ewing tumors in infants

BACKGROUND

Malignancies in infancy are extremely rare. Ewing tumors are hardly ever noted in these children. Since it is generally assumed that malignancies in infancy have an extremely poor outcome, we wanted to investigate whether this was also the case in Ewing tumors.

PROCEDURE

We identified in the Munster data bases of CESS81, CESS86, EICESS92 and EuroEwing99 14 children <12 months of age with a tumor of the Ewing family. Numbers of girls and boys were equal.

RESULTS

All infants had axial tumors, including pelvic primaries; 80% of the tumors were <200 ml. An uncommon pathology distribution was noted; the majority were peripheral neuroectodermal tumors, only two atypical Ewing, one classical Ewing, and one unspecified PAS positive small round blue cell soft tissue sarcoma was found. Three patients had metastatic disease at initial diagnosis. Treatment modalities were comparable with patients of older age. The number of cytostatic courses ranged from 6 to 15. Dose reductions were limited, ranged from 73% to 90%. Outcome results were similar to those in patients of older ages (5-year EFS 65%, OS 72%).

CONCLUSIONS

Infants with Ewing family tumors are in the majority of cases PNETs and are predominantly axial tumors. Outcome is similar to patients with Ewing tumors at older ages. Generally accepted adverse prognostic factors did not influence outcome.

Management of tumors of the chest wall in childhood: a review

Chest wall tumors in childhood are major challenges with respect to diagnostic workup and treatment. Incidence rate is less than 1 per 1,000,000 and various benign and malignant diseases are noted. From the malignant diseases, Ewing tumors and rhabdomyosarcoma tumors are most often seen. Depending on diagnosis, staging, and age, therapy has to be tailored for each patient, which should be discussed in a multidisciplinary team setting. Radical resection is in most cases the major component of treatment. Use of chemotherapy depends on the diagnosis. In soft-tissue tumors, previously considered to be chemotherapy insensitive, favorable results are currently reported. The role of radiotherapy is debated owing to its pronounced late sequelae in children, but should be added when adequate margins cannot be achieved by surgery.

Bone tumours in European children and adolescents, 1978-1997. Report from the Automated Childhood Cancer Information System project

Data on 5572 children and adolescents diagnosed with malignant bone tumours (International Classification of Childhood Cancer, Group VIII) before the age of 20 years during 1978-1997 in Europe were extracted from the Automated Childhood Cancer Information System (ACCIS) database. Age-standardised incidence among children during the period 1988-1997 was similar for boys and girls aged 0-14 years (5.5-5.6 per million). Among adolescents aged 15-19 years, males had higher incidence (19.3 per million) than females (10.7 per million). Among children, osteosarcoma accounted for 51% of registrations and Ewing's sarcoma for 41%. Among adolescents, 55% of registrations were osteosarcoma and 28% Ewing's sarcoma. Both tumours had their highest incidence in late childhood or early adolescence. There were no significant time trends in incidence during 1978-1997. Five-year survival estimates for patients diagnosed during 1988-1997 were, respectively, 59% and 51% among children and adolescents with osteosarcoma and 62% and 30% among children and adolescents with Ewing's sarcoma. Between 1978-1982 and 1993-1997, survival increased for both children and adolescents with osteosarcoma, and for children with Ewing's sarcoma.