How Are Indeterminate Pulmonary Nodules at Diagnosis Associated with Survival in Patients with High-Grade Osteosarcoma?

The clinical significance of indeterminate pulmonary nodules in patients with primary bone sarcoma: a systematic review

OBJECTIVE

To report the incidence of indeterminate pulmonary nodules (IPN) and the rate of progression of IPNs to metastasis in patients with primary bone cancers. We also aimed to evaluate clinical or radiological parameters that may identify IPNs more likely to progress to metastatic disease and their effect on overall or event-free survival in patients with primary bone sarcoma.

METHODS

A systematic search of the electronic databases Medline, Embase, and Cochrane Library was undertaken for eligible articles on IPNs in patients with primary bone sarcomas, published in the English language from inception of the databases to 2023. The Newcastle-Ottawa Quality Assessment Form for Cohort Studies was utilized to evaluate risk of bias in included studies.

RESULTS

Six studies, involving 1667 patients, were included in this systematic review. Pooled quantitative analysis found the rate of incidence of IPN to be 18.1% (302 out of 1667) and the rate of progression to metastasis to be 45.0% (136 out of 302). Nodule size (more than 5 mm diameter), number (more than or equal to 4), distribution (bilaterally distributed), incomplete calcification, and lobulated margins were associated with an increased likelihood of IPNs progressing to metastasis, however, their impact on overall or event-free survival remains unclear.

CONCLUSION

The risk of IPNs progressing to metastasis in patients with primary bone sarcoma is non-negligible. Large IPNs have a high risk to be an actual metastasis. We suggest that IPNs in these patients be followed up for a minimum of 2 years with CT imaging at 3, 6, and 12 month intervals, particularly for nodules measuring >5 mm in average diameter.

ADVANCES IN KNOWLEDGE

This is the first systematic review on IPNs in patients with primary bone sarcomas only and proposes viable management strategies for such patients.

What Is the Significance of Indeterminate Pulmonary Nodules in High-Grade Soft Tissue Sarcomas? A Retrospective Cohort Study

BACKGROUND

Sarcomas are rare, aggressive cancers which frequently metastasise to the lungs. Following diagnosis, patients typically undergo staging by means of a CT scan of their chest. This often identifies indeterminate pulmonary nodules (IPNs), but the significance of these in high-grade soft tissue sarcoma (STS) is unclear. Identifying whether these are benign or malignant is important for clinical decision making. This study analyses the clinical relevance of IPNs in high-grade STS.

METHODS

All patients treated at our centre for high-grade soft tissue sarcoma between 2010 and 2020 were identified from a prospective database. CT scans and their reports were reviewed, and survival data were collected from patient records.

RESULTS

389 suitable patients were identified; 34.4% had IPNs on their CT staging scan and 20.1% progressed into lung metastases. Progression was more likely with IPNs ≥ 5 mm in diameter (p = 0.006), multiple IPNs (p = 0.013) or bilateral IPNs (p = 0.022), as well as in patients with primaries ≥ 5 cm (p = 0.014), grade 3 primaries (p = 0.009) or primaries arising deep to the fascia (p = 0.041). The median time to progression was 143 days. IPNs at diagnosis were associated with an increased risk of developing lung metastases and decreased OS in patients with grade 3 STS (p = 0.0019 and p = 0.0016, respectively); this was not observed in grade 2 patients.

CONCLUSIONS

IPNs at diagnosis are associated with significantly worse OS in patients with grade 3 STS. It is crucial to consider the primary tumour as well as the IPNs when considering the risk of progression. Surveillance CT scans should be carried out within 6 months.

Incidence, survival, and associated factors estimation in osteosarcoma patients with lung metastasis: a single-center experience of 11 years in Tianjin, China

BACKGROUND

Osteosarcoma is the most common primary malignant bone tumor. The current study was conducted to describe the general condition of patients with primary osteosarcoma in a single cancer center in Tianjin, China and to investigate the associated factors in osteosarcoma patients with lung metastasis.

METHODS

From February 2009 to October 2020, patients from Tianjin Medical University Cancer Institute and Hospital, China were retrospectively analyzed. The Kaplan-Meier method was used to evaluate the overall survival of osteosarcoma patients. The Cox proportional hazard regression analysis was performed to analyze the prognostic factors of all osteosarcoma patients and those patients with lung metastasis, respectively. Furthermore, risk factors for developing lung metastasis were identified in synchronous lung metastasis (SLM) and metachronous lung metastasis (MLM) patients.

RESULTS

A total of 203 patients were involved and 150 patients were successfully followed up for survival status. The 5-year survival rate of osteosarcoma was 70.0% and the survival months for patients with SLM and MLM were 33.3 ± 12.6 and 45.8 ± 7.4 months, respectively. The presence of lung metastasis was one of the independent prognostic factors for prognosis of osteosarcoma. In patients with lung metastasis, twenty-one (10.3%) showed lung metastasis at the diagnosis of osteosarcoma and 67 (33%) were diagnosed with lung metastases during the later course. T3 stage (OR = 11.415, 95%CI 1.362-95.677, P = 0.025) and bone metastasis (OR = 6.437, 95%CI 1.69-24.51, P = 0.006) were risk factors of SLM occurrence. Bone metastasis (OR = 1.842, 95%CI 1.053-3.224, P = 0.032), good necrosis (≥ 90%, OR = 0.032, 95%CI 0.050-0.412, P < 0.001), elevated Ki-67 (OR = 2.958, 95%CI 1.098-7.969, P = 0.032) and elevated LDH (OR = 1.791, 95%CI 1.020-3.146, P = 0.043) were proved to be independent risk factors for developing MLM.

CONCLUSION

The overall survival, prognostic factors and risk factors for lung metastasis in this single center provided insight about osteosarcoma management.

Prognostic Impact of Pulmonary Metastasectomy in Bone Sarcoma Patients: A Retrospective, Single-Centre Study

This retrospective study aimed at analyzing the impact of metastasectomy on post-metastasis survival (PMS) in bone sarcoma patients with lung metastases. Altogether, 47 bone sarcoma patients (24 males, median age at diagnosis of lung metastases: 21.8 (IQR: 15.6–47.3) years) with primary (n = 8) or secondary (n = 39) lung metastases treated at a single university hospital were retrospectively included. Based on a propensity score, inverse probability of treatment weight (IPTW) was calculated to account for selection bias whether patients had undergone metastasectomy or not. The most common underlying histology was osteosarcoma (n = 37; 78.7%). Metastasectomy was performed in 39 patients (83.0%). Younger patients (p = 0.025) with singular (p = 0.043) and unilateral lesions (p = 0.024), as well as those with an interval ≥ 9 months from primary diagnosis to development of lung metastases (p = 0.024) were more likely to undergo metastasectomy. Weighted 1- and 3-year PMS after metastasectomy was 80.8% and 58.3%, compared to 88.5% and 9.1% for patients who did not undergo metastasectomy. Naive Cox-regression analysis demonstrated a significantly prolonged PMS for patients with metastasectomy (HR: 0.142; 95%CI: 0.045–0.450; p = 0.001), which was confirmed after IPTW-weighting (HR: 0.279; 95%CI: 0.118–0.662; p = 0.004), irrespective of age, time to metastasis, and the number of lesions. In conclusion, metastasectomy should be considered in bone sarcoma patients with lung metastases, after carefully considering the individual risks, to possibly improve PMS.

The Role of a Multidisciplinary Team in the Diagnosis and Treatment of Bone and Soft Tissue Sarcomas: A Single-Center Experience

Bone and soft tissue sarcomas with complex and varied clinical, imaging, and pathological characteristics cannot be diagnosed and treated by a single discipline, as each discipline has some limitations. This study aimed to explore the role of a multidisciplinary team (MDT) in the diagnosis and treatment of bone and soft tissue sarcomas over the past four consecutive years. The subjects were 269 patients discussed during MDT meetings at a Bone and Soft Tissue Sarcomas Center in South China. The diagnosis, relapse diagnosis, unplanned resection, management of pulmonary nodules, and treatment of refractory and advanced tumors were compared to similar data provided in the literature to (i) determine whether the MDT significantly affected the diagnosis and treatment of bone and soft tissue sarcomas, and (ii) explore trends in the types of patients with bone and soft tissue sarcomas and treatment decision-making since the establishment of the MDT. Results revealed that the MDT significantly improved preoperative diagnostic accuracy for patients with bone and soft tissue sarcomas; the accuracy of diagnosis and relapse diagnosis by the MDT reached 95.42% and 100%, respectively. After an MDT discussion, the positive pathology rate for extended resection after unplanned resection was 81.2%. The overall accuracy of the MDT in determining the nature of pulmonary nodules was 87.1-91.9%. For patients presenting with pulmonary nodules in osteosarcoma, no statistically significant difference in survival was shown between cases discussed by the MDT and those without an MDT discussion (p = 0.5751). Collectively, the MDT can play a positive role in accurate preoperative diagnosis, relapse diagnosis, the decision to extend resection after an unplanned resection, and the diagnostic accuracy of pulmonary nodules.

How to confront the high prevalence of pulmonary micro nodules (PMNs) in osteosarcoma patients?

PURPOSE

Pulmonary metastasis was a negative factor of osteosarcoma prognosis. However, there is no universal criteria to confirm pulmonary metastasis at pulmonary micro nodule (PMN, Dmax ≤ 5 mm) stage other than pathology. We aimed to identify prevalence of PMNs, determine prognosis of osteosarcoma with PMNs, and analyze risk factors related to PMN progression.

METHODS

We retrospectively reviewed 425 consecutive osteosarcoma patients. According to dynamic change in size and number of PMNs, patients were divided into PMN progression and non-progression group. Demographic data, initial laboratory data, radiological features, and oncological evaluations were analyzed. Cox regression was used to identify risk factors for PMN progression. Overall survival rate was measured and analyzed with Kaplan-Meier method. Differences with p < 0.05 were considered significant.

RESULTS

PMNs were found in 74% (315/425) osteosarcoma patients, half of whom (157/315) suffering PMN progression. Overall survival rate was 70.2%, while survival rates for PMN progression group and non-progression group were 53.40% and 87.40%, respectively. Clinical risk factors for PMN progression in certain patients included blood vessel invasion, extrapulmonary metastases, low tumour cell necrosis rate, and large tumour size. Radiologic risk factors included greatest diameter, distance to pleura, CT value, solid components, and smooth border.

CONCLUSION

PMN is quite common in osteosarcoma patients. PMN progression is related to both certain clinical and radiological factors, which could assist surgeons to determine its possibility to progress at an early stage.

Osteosarcoma immune prognostic index can indicate the nature of indeterminate pulmonary nodules and predict the metachronous metastasis in osteosarcoma patients

Purpose

The relationship between indeterminate pulmonary nodules (IPNs) and metastasis is difficult to determine. We expect to explore a predictive model that can assist in indicating the nature of IPNs, as well as predicting the probability of metachronous metastasis in osteosarcoma patients.

Patients and methods

We conducted a retrospective study including 184 osteosarcoma patients at West China Hospital from January 2016 to January 2021. Hematological markers and clinical features of osteosarcoma patients were collected and analyzed.

Results

In this study, we constructed an osteosarcoma immune prognostic index (OIPI) based on the lung immune prognostic index (LIPI). Compared to other hematological markers and clinical features, OIPI had a better ability to predict metastasis. OIPI divided 184 patients into four groups, with the no-OIPI group (34 patients), the light-OIPI group (35 patients), the moderate-OIPI group (75 patients), and the severe-OIPI group (40 patients) (P < 0.0001). Subgroup analysis showed that the OIPI could have a stable predictive effect in both the no-nodule group and the IPN group. Spearman’s rank correlation test and Kruskal–Wallis test demonstrated that the OIPI was related to metastatic site and metastatic time, respectively. In addition, patients with IPNs in high-OIPI (moderate and severe) groups were more likely to develop metastasis than those in low-OIPI (none and light) groups. Furthermore, the combination of OIPI with IPNs can more accurately identify patients with metastasis, in which the high-OIPI group had a higher metastasis rate, and the severe-OIPI group tended to develop metastasis earlier than the no-OIPI group. Finally, we constructed an OIPI-based nomogram to predict 3- and 5-year metastasis rates. This nomogram could bring net benefits for more patients according to the decision curve analysis and clinical impact curve.

Conclusion

This study is the first to assist chest CT in diagnosing the nature of IPNs in osteosarcoma based on hematological markers. Our findings suggested that the OIPI was superior to other hematological markers and that OIPI can act as an auxiliary tool to determine the malignant transformation tendency of IPNs. The combination of OIPI with IPNs can further improve the metastatic predictive ability in osteosarcoma patients.

Lung Immune Prognostic Index Could Predict Metastasis in Patients With Osteosarcoma

Background

The lung immune prognostic index (LIPI), composed of serum lactate dehydrogenase (LDH) and the derived neutrophil to lymphocyte ratio (dNLR), is a novel prognostic factor of lung cancer. The prognostic effect of the LIPI has never been verified in osteosarcoma.

Methods

We retrospectively reviewed the osteosarcoma patients with metachronous metastasis from January 2016 to January 2021 in West China Hospital. We collected and analyzed the clinical data and constructed the LIPI for osteosarcoma. The correlation between the LIPI and metastasis was analyzed according to the Kaplan–Meier method and Cox regression analysis with hazard ratios (HRs) and 95% confidence intervals (CIs). Univariate analysis and multivariate analysis were conducted to clarify the independent risk factors of metastasis. The nomogram model was established by R software, version 4.1.0.

Results

The area under the curve (AUC) and best cutoff value were 0.535 and 91, 0.519, and 5.02, 0.594 and 2.77, 0.569 and 227.14, 0.59 and 158, and 0.607 and 2.05 for ALP, LMR, NLR, PLR, LDH, and dNLR, respectively. The LIPI was composed of LDH and dNLR and showed a larger AUC than other hematological factors in the time-dependent operator curve (t-ROC). In total, 184 patients, 42 (22.8%), 96 (52.2%), and 46 (25.0%) patients had LIPIs of good, moderate, and poor, respectively (P &lt; 0.0001). Univariate analysis revealed that pathological fracture, the initial CT report of suspicious nodule, and the NLR, PLR, ALP, and the LIPI were significantly associated with metastasis, and multivariate analysis showed that the initial CT report of suspicious nodule and the PLR, ALP, and LIPI were dependent risk factors for metastasis. Metastatic predictive factors were selected and incorporated into the nomogram construction, including the LIPI, ALP, PLR, initial CT report, and pathological fracture. The C-index of our model was 0.71. According to the calibration plot, this predictive nomogram could accurately predict 3- and 5-year metachronous metastasis. Based on the result of decision curve and clinical impact curve, this predictive nomogram could also help patients obtain significant net benefits.

Conclusion

We first demonstrated the metastatic predictive effect of the LIPI on osteosarcoma. This LIPI-based model is useful for clinicians to predict metastasis in osteosarcoma patients and could help conduct timely intervention and facilitate personalized management of osteosarcoma patients.

Biomineralization-inspired synthesis of amorphous manganese phosphates for GLUT5-targeted drug-free catalytic therapy of osteosarcoma

Osteosarcoma, occurring most frequently in children, teens, and young adults, is a lethal bone cancer with a high incidence of distant metastases and drug resistance. Developing a therapeutic platform that integrates targeting, curing and imaging is highly desirable for enhanced osteosarcoma therapy, yet quite challenging. In this work, we demonstrate a novel biomineralization-inspired strategy for the synthesis of a fructose incorporated manganese phosphate (Fru-MnP) nanoplatform for tumour targeting, drug-free therapy, and MRI imaging. Benefitting from the glucose transporter 5 (GLUT5)-mediated endocytosis, our Fru-MnP nanoplatform produces a high level of reactive oxygen species (ROS) via the Mn²⁺-driven Fenton reaction within osteosarcoma cells, leading to efficient cancer cell killing due to caspase-mediated apoptosis. By virtue of the T1 signal enhancement of Mn²⁺, our Fru-MnP nanoplatform also acts as an effective tumour-specific MRI contrast agent, realizing the MRI-monitored chemodynamic therapy. The proposed synergistic therapeutic platform opens new possibilities for high efficacy therapy for osteosarcoma.

Indeterminate pulmonary nodules are not associated with worse overall survival in Ewing Sarcoma

AIM

Lung metastases are a negative prognostic factor in Ewing sarcoma, however, the incidence and significance of sub-centimetre pulmonary nodules at diagnosis is unclear. The aims of this study were to (1): determine the incidence of indeterminate pulmonary nodules (IPNs) in patients diagnosed with Ewing sarcoma (2); establish the impact of IPNs on overall and metastasis-free survival and (3) identify patient, oncological and radiological factors that correlate with poorer prognosis in patients that present with IPNs on their staging chest CT.

MATERIALS & METHODS

Between 2008 and 2016, 173 patients with a first presentation of Ewing sarcoma of bone were retrospectively identified from an institutional database. Staging and follow-up chest CTs for all patients with IPN were reviewed by a senior radiologist. Clinical and radiologic course were examined to determine overall- and metastasis-free survival for IPN patients and to identify demographic, oncological or nodule-specific features that predict which IPN represent true lung metastases.

RESULTS

Following radiologic re-review, IPN were found in 8.7% of patients. Overall survival for IPN patients was comparable to those with a normal staging chest CT (2-year overall survival of 73.3% [95% CI 43.6-89] and 89.4% [95% CI 81.6-94], respectively; p = 0.34) and was significantly better than for patients with clear metastases (46.0% [95% CI 31.9-59]; p < 0.0001). Similarly, there was no difference in metastasis-free survival between 'No Metastases' and 'IPN' patients (p = 0.16). Lung metastases developed in 40% of IPN patients at a median 9.6 months. Reduction of nodule size on neoadjuvant chemotherapy was associated with worse overall survival in IPN patients (p = 0.0084).

CONCLUSION

IPN are not uncommon in patients diagnosed with Ewing sarcoma. In this study, we were unable to detect a difference in overall- or metastasis-free survival between patients with IPN at diagnosis and patients with normal staging chest CTs.