Results of treatment for metastatic osteosarcoma with neoadjuvant chemotherapy and surgery

Osteosarcoma in a Teenage Athlete With a Swollen Knee Joint

Osteosarcoma is a malignant mesenchymal tumour. This primarily manifests in the formation of immature osteoid cells by tumour cells. Osteosarcoma is the most common primary bone tumour in children and adolescents. It tends to occur in the metaphysis of long shafts, shows osteoblastic differentiation, and produces malignant osteoid material. We present the case of a 17-year-old male who presented to our clinic who had left knee pain for a few days. An initial radiograph of the knee joint revealed a lytic lesion in the proximal tibia and further imaging was advised. During a follow-up visit, the patient had worsening pain and had a computerized tomography scan of the left knee, confirming osteosarcoma on the lateral side of the left tibia. He was referred to the orthopaedic department, where a biopsy was performed, to confirm the diagnosis of osteosarcoma. The patient was commenced on chemotherapy due to metastatic disease and has so far tolerated therapy well.

Psoralen-loaded polymeric lipid nanoparticles combined with paclitaxel for the treatment of triple-negative breast cancer

Background: Chemotherapeutic drugs are associated with toxic effects. Metastasis is the leading cause of death in breast cancer patients. Aim: To evaluate the antitumor effect of paclitaxel (PTX) combined with psoralen-loaded polymeric lipid nanoparticles (PSO-PLNs) in triple-negative breast cancer. Methods: After treatment of samples, cell viability, apoptosis, migration, invasion, expression of proteins in the IRAK1/NF-κB/FAK signal pathway, biodistribution and pathological characteristics were detected. Results: Compared with the control group, the PTX + PSO-PLNs group showed increased apoptosis and reduced migration, invasion and expression of phosphorylated IRAK1 and NF-κB, with significant inhibition of tumor growth and lung metastases and no obvious toxicity. Conclusion: Combined administration of PTX and PSO-PLNs exerted a synergistic effect and significantly inhibited the growth and metastasis of triple-negative breast cancer.

Roles of programmed cell death protein 5 in inflammation and cancer (Review)

PDCD5 (programmed cell death 5) is an apoptosis related gene cloned in 1999 from a human leukemic cell line. PDCD5 protein containing 125 amino acid (aa) residues sharing significant homology to the corresponding proteins of species. Decreased expression of PDCD5 has been found in many human tumors, including breast, gastric cancer, astrocytic glioma, chronic myelogenous leukemia and hepatocellular carcinoma. In recent years, increased number of studies have shown the functions and mechanisms of PDCD5 protein in cancer cells, such as paraptosis, cell cycle and immunoregulation. In the present review, we provide a comprehensive review on the role of PDCD5 in cancer tissues and cells. This review summarizes the recent studies of the roles of PDCD5 in inflammation and cancer. We mainly focus on discoveries related to molecular mechanisms of PDCD5 protein. We also discuss some discrepancies between the current studies. Overall, the current available data will open new perspectives for a better understanding of PDCD5 in cancer.

Depression of focal adhesion kinase induces apoptosis in rat osteosarcoma OSR-6 cells in a caspase-dependent pathway

Focal adhesion kinase (FAK), a nonreceptor tyrosine kinase protein, acts as an early modulator of integrin signaling cascade, regulating basic cellular functions. In transformed cells, unopposed FAK signaling has been considered to promote tumor growth, progression, and metastasis. The aim of this study was to assess the role of FAK in rat osteosarcoma OSR-6 cells. OSR-6 cells were transfected with PGPU6/GFP/shNC (shNC), and PGPU6/GFP/FAK-2434 (shRNA-2434), separately. Expression of FAK was detected by Real-time PCR and Western blots. MTT assay was used to examine changes in cell proliferation. Cell apoptosis was analyzed by flow cytometry. The expression of caspase-3,-7,-9 was measured by Western blots. The expression of FAK in OSR-6 cells significantly decreased in shRNA-2434 group in contrast to the control group (P < 0.01). Cell proliferation was inhibited by shRNA-2434 and shRNA-2434+ cisplatin, and the effects were clearly enhanced when cells were treated with anticancer agents. The level of cell apoptosis in shRNA-2434 and shRNA-2434+ cisplatin group was higher than that in the control group (P < 0.01). The current data support evidence that down-regulation of FAK could induce rat osteosarcoma cells (OSR-6) apoptosis through the caspase-dependent cell death pathway. Inhibition of the kinases may be important for therapies designed to enhance the apoptosis in osteosarcoma.

Survival, recurrence, and function after epiphyseal preservation and allograft reconstruction in osteosarcoma of the knee

BACKGROUND

Bone tumor resections for limb salvage have become the standard treatment. Recently, intercalary tumor resection with epiphyseal sparing has been used as an alternative in patients with osteosarcoma. The procedure maintains normal joint function and obviates some complications associated with osteoarticular allografts or endoprostheses; however, long-term studies analyzing oncologic outcomes are scarce, and to our knowledge, the concern that a higher local recurrence rate may be an issue has not been addressed.

QUESTIONS/PURPOSES

We wanted to assess (1) the overall survival in patients treated with this surgical technique; (2) the percentage of local recurrence and limb survival, specifically the incidence of recurrence in the remaining epiphysis; (3) the frequency of orthopaedic complications, and, (4) the functional outcomes in patients who have undergone intercalary tumor resection.

METHODS

We analyzed all 35 patients with osteosarcomas about the knee (distal femur and proximal tibia) treated at our center between 1991 and 2008 who had resection preserving the epiphysis and reconstruction with intercalary allografts. Minimum followup was 5 years, unless death occurred earlier (mean, 9 years; range, 1-16 years), and no patients were lost to followup. During the study period, our indications for this approach included patients without metastases, with clinical and imaging response to neoadjuvant chemotherapy, that a residual epiphysis of at least 1 cm thickness could be available after a surgical margin width in bone of 10 mm was planned, and 16% of patients (35 of 223) meeting these indications were treated using this approach. Using a chart review, we ascertained overall survival of patients, oncologic complications such as local recurrence and tumor progression, limb survival, and orthopaedic complications including infection, fracture, and nonunion. Survival rates were estimated using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system.

RESULTS

Overall survival rate of the patients was 86% (95% CI, 73%-99%) at 5 and 10 years. Five patients died of disease. No patient had a local recurrence in the remaining bony epiphysis, but three patients (9%; 95% CI, 0%-19%) had local recurrence in the soft tissue. The limb survival rate was 97% (95% CI, 89%-100%) at 5 and 10 years. Complications treated with additional surgical procedures were recorded for 19 patients (54%), including three local recurrences, two infections, 11 fractures, and three nonunions. In 10 of these 19 patients, the allograft was removed. Only five of the total 35 study patients (14%) lost the originally preserved epiphysis owing to complications. The mean functional score was 26 points (range, 10-30 points, with a higher score representing a better result) at final followup.

CONCLUSIONS

Although the recurrence rate was high in this series, the small sample size means that even one or two fewer recurrences might have resulted in a much more favorable percentage. Because of this, future, larger studies will need to determine whether this is a safe approach, and perhaps should compare epiphyseal preservation with other possible approaches, including endoprosthetic reconstruction and/or osteoarticular allografts.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Bufalin inhibited the growth of human osteosarcoma MG-63 cells via down-regulation of Bcl-2/Bax and triggering of the mitochondrial pathway

Cinobufacini (Huachansu), a Chinese medicine prepared from the skin of Bufo bufo gargarizans Cantor (Bufonidae), has potent anti-tumor activity in vitro and in vivo. However, the molecular mechanism of cell apoptosis induced by Bufalin remains elusive. Here, we investigated the apoptosis in Bufalin-treated human osteosarcoma MG-63 cells. The results showed that Bufalin could inhibit cell proliferation and induce apoptosis in a dose- and time-dependent manner. Further investigation revealed that a disruption of mitochondrial transmembrane potential (MMP) and an up-regulation of reactive oxygen species (ROS) in Bufalin-treated cells. By western blot analysis, we found that the up-regulation of Apaf-1, cleaved PARP, cleaved caspase-3, cleaved caspase-9, and Bax/Bcl-2, varies with different concentration of Bufalin. These protein interactions may play a pivotal role in the regulation of apoptosis. Taken together, these results overall indicate that Bufalin could be used as an effective anti-tumor agent in therapy of osteosarcoma targets the mitochondrial-dependent signaling pathway.

Bufalin-inhibited migration and invasion in human osteosarcoma U-2 OS cells is carried out by suppression of the matrix metalloproteinase-2, ERK, and JNK signaling pathways

Bufalin has been shown to exhibit multiple pharmacological activities, including induction of apoptosis in many types of cancer cell lines. Osteosarcoma is a type of cancer which is difficult to treat and the purpose of this study was to investigate the effects of bufalin on the migration and invasion of human osteosarcoma U-2 OS cells. The wound healing assay and Boyden chamber transwell assay were used for examining the migration of U-2 OS cells. Western blotting and gelatin zymography assays were used for theexpression and activities of metalloproteinase (MMP)-2, MMP-7 or MMP-9 levels. Western blotting analysis also was used for measuring the levels of growth factor receptor-bound protein 2 (GRB2), son of sevenless homolog 1 (SOS1), c-Jun N-terminal kinases 1/2 (JNK1/2), extracellular signal-regulated kinase 1/2 (ERK1/2), and p38 in bufalin-treated U-2 OS cells. Bufalin inhibited the cell migration and invasion of U-2 OS cells in vitro. Moreover, bufalin reduced MMP-2 and MMP-9 enzyme activities of U-2 OS cells. Bufalin also suppressed the protein level of MMP-2 and reduced the levels of mitogen-activated protein kinases (MAPKs) such as JNK1/2 and ERK1/2 signals in U-2 OS cells. Our results suggest that signaling pathways for bufalin-inhibited migration and invasion of U-2 OS cells might be mediated through blocking MAPK signaling and resulting in the inhibition of MMP-2. Bufalin could be a useful agent to develop as a novel antitumor agent by virtue of its ability to inhibit tumor cell migration and invasion.

Review of management issues in relapsed osteosarcoma

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. With combined modality treatment long-term survival rate for localized disease is near 70%. Thirty percent of patients relapse with lung as the commonest site. Surgery is the treatment of choice for relapsed patients whenever possible. Addition of chemotherapy to surgery provides survival benefit in patients not achieving second surgical remission. Even patients with multiple lung recurrences can be cured with repeated thoracotomies. Disease-free interval and complete surgical resection are the main prognostic factor for post-relapse survival.

Inhibition of focal adhesion kinase induces apoptosis in human osteosarcoma SAOS-2 cells

Focal adhesion kinase (FAK), a non-receptor tyrosine kinase protein, acts as an early modulator of integrin signaling cascade, regulating basic cellular functions. In transformed cells, unopposed FAK signaling has been considered to promote tumor growth, progression, and metastasis. The aim of this study was to assess the role of focal adhesion kinase in human osteosarcoma SAOS-2 cells. SAOS-2 cells were transfected with PGPU6/GFP/shNC, and PGPU6/GFP/FAK-334 (shRNA-334), respectively. Expression of FAK was detected by real-time PCR and western blots. MTT assay was used to examine changes in cell proliferation. Cell apoptosis was analyzed by flow cytometry. The expression of caspase-3,-7,-9 was measured by Western blots. The expression of FAK in SAOS-2 cells significantly decreased in shRNA-334 group contrast to the control group (P < 0.01). Cells proliferation was inhibited by shRNA-334 and shRNA-334 + cisplatin, and the effects were clearly enhanced when cells treated with the anticancer agents. The level of cell apoptosis in shRNA-334 and shRNA-334 + cisplatin group was higher than in the control group (P < 0.01). The current data support evidence that down-regulation of FAK could induce SAOS-2 apoptosis through the caspase-dependent cell death pathway. Inhibition of the kinases may be important for therapies designed to enhance the apoptosis in osteosarcoma.

Induction of cell cycle arrest and apoptosis in human osteosarcoma U-2 OS cells by Solanum lyratum extracts

This research focused on a Chinese herb medicine, Solanum lyratum Thunb (Solanaceae) by ethanol extracts (SLE) for investigating the molecular anticancer mechanism in vitro for exploring the means of cell death through the effects on mitochondrial function. We found that SLE induced cytotoxic effects in human osteosacroma U-2 OS cells, and these effects include cell morphological changes, a decrease of the percentage of viable cells and induction of apoptosis. The results suggest that cell death induced by SLE is closely related to apoptosis based on the observations of DAPI staining and sub-G1 phase in U-2 OS cells. Flow cytometric assays also showed that SLE promoted the production of reactive oxygen species and nitric oxide but decreased the levels of mitochondrial membrane potential and promoted the activations of caspase-8 and -9 in U-2 OS cells. SLE inhibited the level of Bcl-2 but promoted the Bax level, and both proteins led to the release of cytochrome c from mitochondria to cytosol and activation of caspase-9 and -3, resulting in the apoptotic death which is mediated through the mitochondrial pathway. Taken together, SLE was demonstrated to be effective in killing U-2 OS osteosacroma cells via the ROS-promoted and mitochondria- and caspase-dependent apoptotic pathways.

Matrine inhibited the growth of rat osteosarcoma UMR-108 cells by inducing apoptosis in a mitochondrial-caspase-dependent pathway

Matrine, one of the main active components of the extracts from the dry roots of Sophora flavescens, has a potent antitumor activity in vitro and in vivo. However, the molecular mechanism of cell apoptosis induced by matrine remains elusive. Here, we investigated the apoptosis in matrine-treated rat osteosarcoma UMR-108 cells. The results showed that matrine could inhibit cell proliferation and induce apoptosis in a dose- and time-dependent manner. Further investigation revealed a disruption of mitochondrial transmembrane potential and an upregulation of reactive oxygen species in matrine-treated cells. By western blot analysis, we found the upregulation of cleaved poly(ADP-ribose) polymerase, cleaved caspase-3, and cleaved caspase-9 and the downregulation of Bax/Bcl-2 with different concentrations of matrine. These protein interactions may play a pivotal role in the regulation of apoptosis. Taken together, these results overall indicate that matrine could be used as an effective antitumor agent in therapy of osteosarcoma targets the caspase-dependent signaling pathway.

The anti-tumor role and mechanism of integrated and truncated PDCD5 proteins in osteosarcoma cells

Osteosarcoma (OS) is a high-grade malignant bone tumor. In these studies, the cell apoptosis-related gene, programmed cell death 5 gene (PDCD5), and various fragments of it, were overexpressed in the OS cell line, MG-63. The effects of PDCD5 on MG-63 cells both in vivo and in vitro were then identified. Our results indicate that PDCD5 can induce apoptosis and G(2) phase arrest in MG-63 cells. Moreover, expression of PDCD5 in established xenografted tumors was associated with a decrease in tumor size and weight. Accordingly, the survival rate of these mice was significantly higher than that of mice bearing tumors that did not express PDCD5. To analyze the signaling pathway involved, western blotting was performed. In these assays, PDCD5 was found to inhibit the Ras/Raf/MEK/ERK signaling pathway, leading to inhibition of cyclin B and CDK1. In addition, down-regulation of ERK resulted in activation of caspase 3 and caspase 9. These results are consistent with the G(2) phase arrest observed with overexpression of PDCD5. However, a G(1) phase arrest was not observed. Therefore, proteins associated with the G(1) phase of the cell cycle were overexpressed in combination with PDCD5 overexpression. Overall, these studies demonstrate the anti-tumor activity of PDCD5 in the OS cell line, MG-63, and provide insight into relevant mechanisms that may lead to novel treatments for OS.

Gallic acid inhibits migration and invasion in human osteosarcoma U-2 OS cells through suppressing the matrix metalloproteinase-2/-9, protein kinase B (PKB) and PKC signaling pathways

Advanced cancer is a multifactorial disease which complicates treatment if the cancer cells have metastasized calling for the targeting of multiple cellular pathways. Gallic acid (GA) is known to possess multiple pharmacological activity including antitumor effects. This study investigated the mechanisms for the anticancer properties of GA on migration and invasion of human osteosarcoma U-2 OS cells. The migration and invasion in U-2 OS cells were determined by a Boyden chamber transwell assay. The expression levels and activities of MMP-2 and MMP-9 were measured by Western blotting, real-time PCR and gelatin zymography assays. All examined proteins levels from Western blotting indicated that GA decreased the protein levels of GRB2, PI3K, AKT/PKB, PKC, p38, ERK1/2, JNK, NF-κB p65 in U-2 OS cells. GA also inhibited the activities of AKT, IKK and PKC by in vitro kinase assay. GA suppressed the migration and invasive ability of U-2 OS cells, and it decreased MMP-2 and MMP-9 protein and mRNA levels and secreted enzyme activities in vitro. These results suggest that potential signaling pathways of GA-inhibited migration and invasion in U-2 OS cells may be due to down-regulation of PKC, inhibition of mitogen-activated protein kinase (MAPK) and PI3K/AKT, resulting in inhibition of MMP-2 and MMP-9 expressions.

Benzyl isothiocyanate (BITC) and phenethyl isothiocyanate (PEITC)-mediated generation of reactive oxygen species causes cell cycle arrest and induces apoptosis via activation of caspase-3, mitochondria dysfunction and nitric oxide (NO) in human osteogenic sarcoma U-2 OS cells

Benzyl isothiocyanate (BITC) and phenethyl isothiocyanate (PEITC), a member of the isothiocyanate family, have been shown to exhibit antineoplastic ability against many human cancer cells. In this study, we found that exposure of human osteogenic sarcoma U-2 OS cells to BITC and PEITC led to induce morphological changes and to decrease the percentage of viable cells in a time- and dose-dependent manner. BITC and PEITC induced cell cycle arrest at G2/M phase at 48 h treatment and inhibited the levels of cell cycle regulatory proteins such as cyclin A and B1 in U-2 OS cells but promoted the level of Chk1 and p53 that led to G2/M arrest. BITC and PEITC induced a marked increase in apoptosis (DNA fragmentation) and poly(ADP-ribose)polymerase (PARP) cleavage, which was associated with mitochondrial dysfunction and the activation of caspase-9 and -3. BITC and PEITC also promoted the ROS production in U-2 OS cells and the N-acetylcysteine (NAC, an antoxidant agent) was pretreated and then treated with both compounds which led to decrease the levels of ROS and increase the cell viability. Interestingly, BITC and PEITC promoted the levels of NO production and increased the iNOS enzyme. Confocal laser microscope also demonstrated that BITC and PEITC promoted the release of cytochrome c and AIF, suggesting that both compounds induced apoptosis through ROS, caspase-3 and mitochondrial, and NO signaling pathways. Taken together, these molecular alterations and signaling pathways offer an insight into BITC and PEITC-caused growth inhibition, G2/M arrest, and apoptotic death of U-2 OS cells.

Prognostic factors in pulmonary metastasized high-grade osteosarcoma

INTRODUCTION

Resection of pulmonary metastases has previously been reported to improve outcome in high-grade osteosarcoma (OS) patients. Factors influencing survival in OS patients with pulmonary metastases are important for clinical decision making.

METHODS

All 88 OS patients with pulmonary metastases either at diagnosis or during follow-up treated at the Leiden University Medical Center between January 1, 1990 and January 1, 2008 under the age of 40 were included in this study, including 79 cases of conventional, 8 cases of telangiectatic and 1 case of small cell OS.

RESULTS

In total, 56 of 88 patients with pulmonary metastases were treated by metastasectomy. Resectability of pulmonary metastases was the main prognostic factor. In patients with primary non-metastatic OS, a longer relapse free interval to pulmonary metastases was significantly associated with better survival (P = 0.02). Independent risk factors determining worse survival after metastasectomy in multivariate analysis were male sex (P = 0.05), higher number of pulmonary nodules (P = 0.03), and non-necrotic metastases (P = 0.04). Whether surgery for recurrent pulmonary metastases was performed did not influence survival. Histological subtype of the primary tumor, histological response in the primary tumor after neo-adjuvant chemotherapy, occurrence of local relapse, local resection or amputation of the primary tumor and age at diagnosis did not influence outcome.

CONCLUSION

This cohort of patients with detailed follow-up data enabled us to identify important risk factors determining survival in OS patients with pulmonary metastases. We demonstrate that after repeated metastasectomies, a subset of patients can be cured.

Palliative limb salvage using a retrograde nail-cement composite after intercalary resection of a distal femoral osteosarcoma: a case report

Malignant lower-limb metaphyseal and diaphyseal bone tumours that have not yet invaded the epiphysis can usually be managed with limb-sparing surgery. Reconstructions using intercalary allografts, autoclaved autografts, extracorporeally irradiated autografts, vascularised autografts, and distraction osteogenesis have all achieved favourable results. In patients with metastatic disease and a short life expectancy, reconstruction with allografts or autografts should be carefully considered because a long recovery period is needed. An intercalary endoprosthesis provides immediate stability, a short recovery period and a low implant failure rate. Nonetheless, it may be expensive when there is inadequate space for stem insertion, necessitating a custom-made endoprosthesis. We present a 12-year-old boy with stage-III osteosarcoma of the metaphysis and diaphysis of the femur who underwent knee joint salvage and reconstruction with a retrograde, locked, intramedullary nail surrounded with methylmethacrylate. At the one-month follow-up, the patient could walk unassisted. At the 2-year follow-up, his Musculoskeletal Tumor Society score was 83%. The patient died from lung metastases at 31 months. He had not experienced any complications with the reconstruction.

The metastasectomy and timing of pulmonary metastases on the outcome of osteosarcoma patients

Background:

The author intended to clarify the therapeutic effect and prognostic factors of metastasectomy and timing of pulmonary metastases in osteosarcoma patents.

Methods:

Data was obtained retrospectively on all consecutive osteosarcoma patients from 1985 to 2005 in author’s institute. Fifty-two patients with pulmonary nodules were identified, including 24 patients undergoing pulmonary metastasectomy treatment. These patients were categorized into four groups: group 1, patients with lung metastases at the initial presentation; group 2, lung metastases identified during the period of pre-operative chemotherapy; group 3, lung metastases identified during period of the post-operative che motherapy; group 4, lung metastases identified after therapy for the primary osteosarcoma completed.

Results:

In our study, the 2-, 3-, and 5-year overall survival rates for 52 patients were 49%, 39% and 20%. The 2-year overall survival rates were 18% for group 1, 32% for group 3, and 70% for group 4 (p < 0.001). The 5-year overall survival rate was 34% for group 4. Patients who underwent metastesectomy showed a better survival outcome as compared with the patients not undergoing metastasectomy (p = 0.003). The 2-year and 5-year overall survival rates of only one lung metastatic nodule were 62% and 50%, and for initially multiple lung metastatic nodules, 45% and 5%, respectively. In addition, the patients presented with lung metastases had a worse prognosis as compared with those without initial lung metastases (p = 0.0001).

Conclusions:

The patients having single metastatic nodule showed a better prognosis than those with multiple lung nodules. Furthermore, those patients who underwent metastasectomy survived longer than those not undergoing metastasectomy. Patients who had late metastases after complete chemotherapy had a better prognosis; whereas those who had metastases identified at the initial presentation predicted a poor prognosis.

Risedronate inhibits human osteosarcoma cell invasion

BACKGROUND

Osteosarcoma is a highly malignant bone tumor and is the most commonly encountered malignant bone tumor in children and adolescents. Furthermore, significant numbers of patients eventually develop pulmonary metastases and succumb to the disease even after conventional multi-agent chemotherapy and surgical excision. Several solid tumors display enhanced expression of matrix metalloproteinases (MMPs), and recently clinical trials have been initiated on MMP-inhibitors. On the other hand, bisphosphonates (BPs), which have a profound effect on bone resorption, are widely used to treat osteoclast-mediated bone diseases. BPs are also known to inhibit tumor growths and metastases in some tumors such as breast cancer, renal cell carcinoma, and prostate cancer.

METHODS

Two osteosarcoma cell lines (SaOS-2 and U2OS) were treated with risedronate (0, 0.1, 1, 10 microM) for 48 hours. Cell viabilities were determined using MTT assay, the mRNA levels of MMP-2 and MMP-9 were analyzed by reverse-transcription polymerase chain reaction, the amount of MMP-2 and MMP-9 protein were analyzed by Westernblot, the activities of MMP-2 and MMP-9 were observed by Gelatin zymography, and Matrigel invasion assays were used to investigate the invasive potential of osteosarcoma cell lines before and after risedronate treatment.

RESULTS

The invasiveness of osteosarcoma cell lines (SaOS-2, U2OS) were reduced in a dose dependent manner follow 48 hour treatment of up to 10 microM of the risedronate at which concentration no cytotoxicity occurred. Furthermore, the gelatinolytic activities and protein and mRNA levels of MMP-2 and MMP-9 were also suppressed by increasing risedronate concentrations.

CONCLUSION

Given that MMP-2 and MMP-9 are instrumental in tumor cell invasion, our results suggest the risedronate could reduce osteosarcoma cell invasion.

The multidisciplinary management of osteosarcoma

Patients with suspected or confirmed osteosarcoma should be evaluated and treated at a comprehensive cancer center within a multidisciplinary sarcoma program that includes pediatric, medical and radiation oncologists, orthopedic and surgical oncologists, musculoskeletal pathologists, and radiologists. Successful treatment involves proper diagnosis, neoadjuvant and adjuvant multi-agent chemotherapy, and aggressive surgery with an emphasis toward limb-preserving procedures. Treatment of osteosarcoma should be undertaken within the framework of large cooperative group clinical trials for children, adolescents, and adults. Patients treated with osteosarcoma should be followed closely both for recurrence of disease and for development of late effects of the treatment of their cancer. The treatment of metastatic, recurrent and/or refractory disease is more controversial. Despite advances in systemic treatment, surgical technique, and supportive care, the overall outcome is still poor.

High grade osteosarcoma of the extremities with lung metastases at presentation: treatment with neoadjuvant chemotherapy and simultaneous resection of primary and metastatic lesions

BACKGROUND AND METHODS

Between 1986 and 2001, 162 patients with extremity osteosarcoma and lung metastases at presentation, were treated by neoadjuvant chemotherapy, simultaneous resection of primary and, when feasible, secondary lesions followed by chemotherapy.

RESULTS

After neoadjuvant chemotherapy, metastases disappeared in 14 patients, 16 were judged unresectable by both our thoracic surgeons, 132 had primary tumors and lung metastases removed simultaneously. Removal of lung metastases was complete in 123 and incomplete in 9. Histologically lesions were benign in 32 patients. For the 100 patients simultaneously operated with histologically proven lung metastases, 5-year event-free survival (EFS) was 18.9%; 27.4% for the 91 who had a complete resection of pulmonary lesions and entered remission as opposed to none for 9 patients who had incomplete removal of lung nodules. Among these 91, 5-year EFS was significantly higher for patients with monolateral compared to bilateral lesions (27.1% vs. 7.9%, P < 0.02) and when only one to three metastatic nodules were present (40.0% vs. 13.3%, P < 0.0001).

CONCLUSIONS

These different results, demonstrate that our treatment had a reasonable survival outcome whereas other groups continue to have dismal prognosis. More efforts should be made to improve survival by identifying new active agents or novel approaches with cellular molecular targets.

Effect of erroneous surgical procedures on recurrence and survival rates for patients with osteosarcoma

To determine whether inappropriate surgical procedures based on an initial misdiagnosis affected recurrence and survival rates, we retrospectively reviewed the surgical treatment and results of 117 patients with high-grade osteosarcomas treated from January 1, 1990 to December 31, 2000. Nine patients had intralesional curettage performed at other institutions based on an erroneous diagnosis of a benign lesion. Two of the nine patients had amputations and seven patients had limb-salvage procedures. Of the 108 patients who were not misdiagnosed, six patients had amputations and 102 patients had limb-salvage procedures. All patients received neoadjuvant therapy. Fifteen of the 117 patients had local recurrences. Patients who had erroneous surgical procedures based on the initial misdiagnosis of osteosarcoma had an increased risk of local recurrence and decreased 10-year survival rate. Response to adjuvant therapy and the amount of previous violation of natural tumor barriers should be evaluated carefully before deciding surgical treatment.

Treatment and prognosis for synchronous multifocal osteosarcoma in 42 patients

Between 1986 and 2002, 42 patients with synchronous multifocal osteosarcoma were treated with two different protocols of neoadjuvant chemotherapy. When feasible, the primary and secondary tumours were excised as a combined procedure.

After initial chemotherapy 26 patients were excluded from simultaneous excision of all their secondary bone lesions as their disease was too advanced. In 12 patients only isolated excision of the primary lesion was possible. For 16 patients simultaneous operations were conducted to excise the primary and secondary lesions. This involved two supplementary sites in 15 patients and four additional sites in one patient. Of these, 15 attained remission but 12 relapsed and died (11 within two years). Three patients remained disease-free at five, six and 17 years. The histological response to pre-operative chemotherapy of the primary and secondary lesions was concordant in 13 of the 16 patients who underwent simultaneous operations at more than one site.

The prognosis for synchronous multifocal osteosarcoma remains poor despite combined chemotherapy and surgery. The homogeneous histological responses in a large proportion of the primary and secondary lesions implies that synchronous multifocal osteosarcoma tumours are not multicentric in origin, but probably represent bone-to-bone metastases from a single tumour.

Resection of recurrent pulmonary metastases in patients with osteosarcoma

BACKGROUND

Surgical resection of lung metastases is widely accepted in osteosarcoma patients. Few data exist on treatment of recurrent pulmonary metastases. The authors of the current study retrospectively analyzed patients with osteosarcoma who received surgery for recurrent lung metastases.

METHODS

From 1980 to 2001, 127 metastasectomies were performed on 94 patients. Criteria of eligibility were no metastases beyond the lung, no local recurrence, possibility of achieving complete resection of metastases without causing respiratory insufficiency, acceptable operative risk. Data were statistically elaborated with survival analysis according to Kaplan-Meier method of univariate analysis, life tables and Gehan statistic model, and multivariate analysis using Cox regression test. Results were considered in terms of time from first (DFI1) and second (DFI2) metastasectomy.

RESULTS

Of 94 patients operated upon twice, 59 (62.7%) died. Thirty-five (37.3%) are alive; 31 (32.9%) of these are continuously disease-free. The 3- and 5-year event-free actuarial survival curve from first metastasectomy was 45%, and 38%, respectively, whereas from the second metastasectomy, it was 33% and 32%, respectively. According to a Cox regression model, DFI1 has a risk of death of 0.974 times and DFI2 of 0.972 times for every additional month of survival. In multivariate analysis, Cox regression test showed the best predictive model of local recurrence and number of metastases (P = 0.0014).

CONCLUSIONS

The authors concluded that patients persistently free of the primary osteosarcoma who developed recurrent resectable metastatic disease of the lung should be considered for reoperation a second, third, or fourth time, as these patients had similar DFI curves after five-years.

Influence of local recurrence on survival in patients with extremity osteosarcoma treated with neoadjuvant chemotherapy

BACKGROUND

Risk factors for local recurrence (LR) after osteosarcoma, such as surgical margins and histologic response to preoperative treatment, have been well documented, whereas the outcome for patients who locally recur has not been well established yet.

METHODS

Retrospective analysis of the management and outcome of 44 patients who developed LR after treatment of osteosarcoma of the extremities with neoadjuvant chemotherapy was performed in a single institution between 1983 and 1999.

RESULTS

In 24 patients (54.5%), LR was the first sign of recurrence; in 8 patients (18.2%) LR followed systemic recurrence and in 12 patients (27.3%), the 2 events, local and systemic recurrence, were concurrent. Of the 44 patients, 26 with local recurrences were free of disease, but only 5 were long-term event-free survivors, and 39 patients developed further recurrences: 37 died of the tumor and 2 were alive with uncontrolled disease at the time of last follow-up. The 5-year disease-free survival rate after the last recurrence was 15.9%; it was 25.9% for patients who achieved remission and 0% for the others. The only prognostic factor identified for post-LR disease-free survival was the presence of systemic recurrence at the time of diagnosis of LR or before (5-year postrecurrence event-free survival rate of 29.1% for patients without metastases at the time of local recurrence vs. 0% for those with metastases; P = .02).

CONCLUSIONS

These results confirm that patients with osteosarcoma of the extremities who develop LR are at a very significantly high risk of developing metastatic disease and dying of the tumor.

Partial epiphyseal preservation and intercalary allograft reconstruction in high-grade metaphyseal osteosarcoma of the knee

BACKGROUND

The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of the knee who had been treated with a transepiphyseal resection, with preservation of the distal femoral and the proximal tibial (articular) portions of the epiphysis, and an intercalary allograft reconstruction.

METHODS

The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had transepiphyseal resection and reconstruction with an intercalary allograft were retrospectively reviewed at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring system were documented at the time of the latest follow-up.

RESULTS

At the final follow-up examination, eleven of the thirteen patients continued to be disease-free. One patient died of bone and pulmonary metastases with no evidence of local recurrence, and the remaining patient had no evidence of disease after resection of a local recurrence of the tumor in the soft tissues. No patient had a local recurrence in the remaining epiphysis. Seven patients had complications that included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and a local recurrence in the soft tissues (one). The allograft was removed in only four of these patients. At the latest follow-up examination, twelve patients were alive with preserved limbs. In one patient, the epiphysis, which originally had been preserved, was resected because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The patients with a preserved epiphysis had an average functional score of 27 points (maximum, 30 points).

CONCLUSIONS

Preservation of the epiphysis in high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected patients. Crucial factors needed to obtain local tumor control and achieve an acceptable functional result are a positive response to chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and appropriate fixation techniques for intercalary allografts.

Case report: A rare case of Ewing's sarcoma and osteosarcoma at different sites 10 years apart

Ewing's sarcoma of bone and osteosarcoma are rare tumors. A combination of high-grade osteosarcoma and Ewing's sarcoma of bone in anatomically unrelated sites is unique, especially in the absence of previous radiation or retinoblastoma. We present a patient with a rare case of Ewing's sarcoma of the scapula that showed no evidence of recurrence (after 10 years of continued followup) and who subsequently presented with a primary osteosarcoma of the femur.

Matrix metalloproteinases participate in osteosarcoma invasion

BACKGROUND

Osteosarcoma (OS) is a highly malignant bone tumor and is the most frequent malignant bone tumor in children and adolescents. Metastases are the major cause of death, and patients with relapse have poor prognosis. Several solid tumors display enhanced expression of matrix metalloproteinases (MMPs), and recently MMP-inhibitors have entered clinical trials. A disturbance of the MMP system in favor of enhanced proteolytic activity may be suspected in OS because OS growth is accompanied by both enhanced local bone destruction and bone formation, two processes that are dependant on proteolytic enzymes. Thus, the aim of the present study was to evaluate the involvement of MMPs in a panel of human OS cell lines, xenografts and biopsies.

MATERIAL AND METHODS

Expression of MMPs and their endogenous inhibitors were studied by zymography and Northern blot analyses. In vitro invasion of OS cell lines and effects of MMP-inhibitors (Marimastat and doxycycline) were assessed in the transwell chamber assay.

RESULTS

In vitro invasiveness was compared with gelatinase activity, and the most invasive cell line secreted the highest amounts of MMP-2 and MMP-9. Two different MMP-inhibitors significantly reduced OS cell invasion. The majority of the OS xenografts expressed both the inactive and active form of MMP-2 and in some cases also MMP-9. The biopsies from primary and metastatic OS also expressed MMP-2 mRNA. However, MMP-9 levels were higher in the biopsies than in the xenografts.

CONCLUSION

The obtained results support the hypothesis that MMPs and their endogenous inhibitors participate in the invasive process of human OS.

Osteosarcoma relapse after combined modality therapy: an analysis of unselected patients in the Cooperative Osteosarcoma Study Group (COSS)

PURPOSE

To evaluate the impact of patient, tumor, and treatment-related factors on outcome in unselected patients with recurrent osteosarcoma.

PATIENTS AND METHODS

Five hundred seventy-six consecutive patients who had achieved a first complete surgical remission (CR) during combined-modality therapy on neoadjuvant Cooperative Osteosarcoma Study Group (COSS) protocols and then developed recurrent osteosarcoma were analyzed (median time from biopsy to relapse, 1.6 years; range, 0.1 to 14.3 years). There were 501 patients with metastases, 44 with local recurrences, and 31 with both. Metastases involved lungs (469 patients), bones (90 patients), and/or other sites (54 patients).

RESULTS

After a median follow-up of 1.2 years for all patients and 4.2 years for survivors, actuarial overall survival (OS) rates at 2, 5, and 10 years were 0.38, 0.23, and 0.18, respectively. Five-year OS was 0.39 for 339 patients with and 0.00 for 229 patients without a second surgical CR (P < .0001). A long time to relapse, a solitary lesion, and, in the case of pulmonary metastases, unilateral disease and the absence of pleural disruption, were of positive prognostic value in uni- and multivariate analyses, as were a second surgical CR and the use of second-line chemotherapy. Radiotherapy was associated with moderately prolonged survival in patients without a second CR. The very limited prognostic differences associated with the use of second-line chemotherapy appeared to be more pronounced with polychemotherapy.

CONCLUSION

Time to relapse and tumor burden correlate with postrelapse outcome in osteosarcoma. Complete surgery is an essential component of curative second-line therapy. Chemotherapy, particularly chemotherapy with more than one agent, may contribute to limited improvements in outcome.

TP-3 immunotoxins improve antitumor activity in mice with osteosarcoma

We measured the antitumor activity of two types of TP-3 immunotoxins that target an antigen expressed in tumors associated with osteosarcoma. Development of novel agents for treatment of patients with osteosarcoma is important. We previously described a monovalent-disulfide-stabilized recombinant immunotoxin made from the TP-3 antibody. This agent is called TP-3(dsFv)-PE38 and is cytotoxic to human osteosarcoma cells in vitro. To improve antigen binding, we designed and produced a bivalent immunotoxin, TP-3(dsFv)2-PE38. We evaluated the activity of both molecules in vitro and in vivo using tumor-bearing mice. Compared with the monovalent TP-3 immunotoxin, the bivalent TP-3 immunotoxin showed an approximately sevenfold increase in cytotoxic activity against three osteosarcoma cell lines which react with the TP-3 monoclonal antibody. The apparent affinity of the bivalent TP-3 immunotoxin was 12-fold greater than that of the monovalent TP-3 immunotoxin. The antitumor activities of both TP-3 immunotoxins were measured using severe combined immunodeficient mice bearing osteosarcoma cell line OHS-M1 tumors. The dose at which the bivalent TP-3 immunotoxin produces complete regressions of tumors is (1/2) that of the monovalent TP-3 immunotoxin. Increasing the avidity of TP-3(dsFv)-PE38 significantly improves its cytotoxic activity in vitro and results in a twofold increase in antitumor activity in vivo. Because TP-3-based immunotoxins have good antitumor activity in mice, these molecules merit additional development for possible treatment of osteosarcoma in humans.

Survival data for 648 patients with osteosarcoma treated at one institution

During the past 30 years, the orthopaedic oncology group at the Massachusetts General Hospital has treated 648 patients with osteosarcoma centrally located in the bone. Using records maintained in a specifically designed computer system, a study was done to assess the factors that seemed to influence the survival outcome. The overall survival for the entire series was 68% at an average followup of 6 +/- 4 years. Death occurred at a mean of 3 +/- 3 years. Patient gender had no effect, but age of the patient was correlated with survival data, with the poorest survival for the older patients. Surgical treatment had no effect on outcome, but the Musculoskeletal Tumor Society stage of the lesion, the presence of metastases or local recurrence, and the chemotherapeutic treatment (very dependent on the drugs available and adjuvant versus neoadjuvant administration at various decades) all had a profound effect. In addition, anatomic location, size of the tumor, and percentage of tumor cells killed after neoadjuvant chemotherapy all had an effect on outcome.

Partial epiphyseal preservation and intercalary allograft reconstruction in high-grade metaphyseal osteosarcoma of the knee

BACKGROUND

The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of the knee who had been treated with a transepiphyseal resection, with preservation of the distal femoral and the proximal tibial (articular) portions of the epiphysis, and an intercalary allograft reconstruction.

METHODS

The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had transepiphyseal resection and reconstruction with an intercalary allograft were retrospectively reviewed at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring system were documented at the time of the latest follow-up.

RESULTS

At the final follow-up examination, eleven of the thirteen patients continued to be disease-free. One patient died of bone and pulmonary metastases with no evidence of local recurrence, and the remaining patient had no evidence of disease after resection of a local recurrence of the tumor in the soft tissues. No patient had a local recurrence in the remaining epiphysis. Seven patients had complications that included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and a local recurrence in the soft tissues (one). The allograft was removed in only four of these patients. At the latest follow-up examination, twelve patients were alive with preserved limbs. In one patient, the epiphysis, which originally had been preserved, was resected because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The patients with a preserved epiphysis had an average functional score of 27 points (maximum, 30 points).

CONCLUSIONS

Preservation of the epiphysis in high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected patients. Crucial factors needed to obtain local tumor control and achieve an acceptable functional result are a positive response to chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and appropriate fixation techniques for intercalary allografts.

LEVEL OF EVIDENCE

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

Surgical management and outcome of osteosarcoma patients with unilateral pulmonary metastases

PURPOSE

The surgical management of osteosarcoma patients with unilateral pulmonary nodules is controversial. The authors reviewed their institutional experience to evaluate the incidence of occult contralateral metastases.

METHODS

Data were obtained retrospectively on all consecutive osteosarcoma patients from 1980 to 2002. Eighty-four patients with pulmonary nodules were identified. Forty-one had bilateral disease, and 43 had unilateral involvement by computed tomography (CT) scan.

RESULTS

All 43 patients with unilateral nodules underwent ipsilateral thoracotomies. Fifteen patients had negative exploration findings, and only 1 had pulmonary relapse. Of the 28 patients with metastases confirmed at initial thoracotomies, 14 had extensive pleural or extrapulmonary disease at initial thoracotomy followed by disease progression. The other 14 are separated into early versus late metastases, using 2 years from diagnosis as the cutoff point. Seven of the 9 (78%) patients with early metastases had or subsequently had contralateral disease; 6 were identified at staged contralateral thoracotomy and 1 had relapsed in the unexplored lung a year later. Only 1 of the 5 patients with late unilateral metastases had relapse in the contralateral side.

CONCLUSIONS

Our data indicate that there is a high rate of contralateral involvement in osteosarcoma patients with unilateral nodules diagnosed by CT scan. Staged bilateral thoracotomies should be considered in osteosarcoma patients presenting with unilateral pulmonary disease on imaging studies within 2 years of diagnosis.

Neoadjuvant chemotherapy for osteosarcoma of the extremities with metastases at presentation: recent experience at the Rizzoli Institute in 57 patients treated with cisplatin, doxorubicin, and a high dose of methotrexate and ifosfamide

BACKGROUND

Effective adjuvant or neoadjuvant regimens of chemotherapy have dramatically improved the prognosis of patients with high-grade osteosarcoma of the extremity, localized at diagnosis. Currently, little is known about patients with metastatic disease at presentation.

PATIENTS AND METHODS

From May 1995 to May 2000, 57 patients with osteosarcoma of the extremity, metastatic at presentation, were treated according to the following scheme: primary chemotherapy, restaging, simultaneous resection of primary tumor and metastatic lesions, and maintenance chemotherapy.

RESULTS

Thirty-five patients achieved remission. At a follow-up ranging from 2 to 7 years, seven remained continuously free of disease, one died of chemotherapy-related toxicity and 27 patients relapsed. Twenty-one of the 22 patients who never achieved remission died as a result of the tumor, as well as 20 of the 27 who achieved remission but then relapsed. Of the remaining seven relapsing patients, six are alive with uncontrolled disease, while one is alive and free of disease 24 months after the last post-relapse treatment. Two-year event-free survival (EFS) and overall survival (OS) were 21% and 55%, respectively. These results are significantly poorer than those achieved in 128 contemporary patients with non-metastatic disease at presentation, treated with the same chemotherapy protocol (2-year EFS and OS of 75% and 94%, respectively).

CONCLUSIONS

The results of our study confirm that the prognosis of patients with osteosarcoma of the extremity, metastatic at presentation, remains poor, despite the use of aggressive treatments.