Neoadjuvant chemotherapy for patients with synchronous multifocal osteosarcoma: results in eleven cases

Comparative Analysis of Skip Metastasis in Pediatric Osteosarcoma: Clinical Features and Outcomes

BACKGROUND

Skip metastasis (SM) is a synchronous regional bone metastasis. Using new imaging modalities, the detection of SM is easier and possibly more common. We reviewed patients with SM and compared their characteristics and outcomes to other patients with osteosarcoma treated at our center.

METHODS

We reviewed retrospectively children (<18 years) with newly diagnosed osteosarcoma who presented from June 2006 to March 2022. Patients' characteristics, treatment modalities, and outcomes were analyzed. All cases were discussed in a multidisciplinary clinic that included 2 experienced radiologists.

RESULTS

We identified 155 patients with osteosarcoma, among which 13 (8.3%) patients had SM detected by MRI. Patients with SM had a median age at diagnosis of 11.2 years (range 7 to 17). Three patients had lung metastasis at diagnosis. Bone scan was positive for the SM in 8 patients (62%). All patients underwent primary tumor resection after neoadjuvant chemotherapy (amputation in 5, limb salvage surgery in 8). Five had postchemotherapy necrosis ≥90% in primary tumor. Seven patients relapsed/progressed (1 local and 6 in the lung), all relapsed patients died of disease. Compared to the rest of the patients, those with SM had similar clinical features to patients without SM; outcomes were similar with no significant differences in event-free survival and overall survival ( P =0.7 and 0.3, respectively).

CONCLUSION

In this study, we observed a percentage of patients with SM comparable to previous reports. Patients with SM exhibited clinical features akin to the rest of our patients. Thorough evaluation of imaging studies and multidisciplinary care, coupled with meticulous surgical planning, are crucial for achieving a cure, which remained unjeopardized in our patients with SM.

A 3D Collagen-Based Bioprinted Model to Study Osteosarcoma Invasiveness and Drug Response

The biological and therapeutic limits of traditional 2D culture models, which only partially mimic the complexity of cancer, have recently emerged. In this study, we used a 3D bioprinting platform to process a collagen-based hydrogel with embedded osteosarcoma (OS) cells. The human OS U-2 OS cell line and its resistant variant (U-2OS/CDDP 1 μg) were considered. The fabrication parameters were optimized to obtain 3D printed constructs with overall morphology and internal microarchitecture that accurately match the theoretical design, in a reproducible and stable process. The biocompatibility of the 3D bioprinting process and the chosen collagen bioink in supporting OS cell viability and metabolism was confirmed through multiple assays at short- (day 3) and long- (day 10) term follow-ups. In addition, we tested how the 3D collagen-based bioink affects the tumor cell invasive capabilities and chemosensitivity to cisplatin (CDDP). Overall, we developed a new 3D culture model of OS cells that is easy to set up, allows reproducible results, and better mirrors malignant features of OS than flat conditions, thus representing a promising tool for drug screening and OS cell biology research.

Metastatic Progression of Osteosarcomas: A Review of Current Knowledge of Environmental versus Oncogenic Drivers

Simple Summary

Osteosarcomas are heterogeneous bone tumors with complex genetic and chromosomic alterations. The numerous patients with metastatic osteosarcoma have a very poor prognosis, and only those who can have full surgical resection of the primary tumor and of all the macro metastasis can survive. Despite the recent improvements in prediction and early detection of metastasis, big efforts are still required to understand the specific mechanisms of osteosarcoma metastatic progression, in order to reveal novel therapeutic targets.

Abstract

Metastases of osteosarcomas are heterogeneous. They may grow simultaneously with the primary tumor, during treatment or shortly after, or a long time after the end of the treatment. They occur mainly in lungs but also in bone and various soft tissues. They can have the same histology as the primary tumor or show a shift towards a different differentiation path. However, the metastatic capacities of osteosarcoma cells can be predicted by gene and microRNA signatures. Despite the identification of numerous metastasis-promoting/predicting factors, there is no efficient therapeutic strategy to reduce the number of patients developing a metastatic disease or to cure these metastatic patients, except surgery. Indeed, these patients are generally resistant to the classical chemo- and to immuno-therapy. Hence, the knowledge of specific mechanisms should be extended to reveal novel therapeutic approaches. Recent studies that used DNA and RNA sequencing technologies highlighted complex relations between primary and secondary tumors. The reported results also supported a hierarchical organization of the tumor cell clones, suggesting that cancer stem cells are involved. Because of their chemoresistance, their plasticity, and their ability to modulate the immune environment, the osteosarcoma stem cells could be important players in the metastatic process.

Osteosarcoma Cell Growth Inhibition by Isoxanthanol-Nanoparticles through Histone H3 Lysine 27 Trimethylation Downregulation and AMPK Activation

The present study was aimed to investigate the effect of isoxanthanol-nanoparticles (IXNP) on proliferation of osteosarcoma cells and evaluate the underlying mechanism. In MG-63 and U2-OS cells proliferative potential was reduced significantly (p < 0.05) in dose-dependent manner by IXNP treatment. The IXNP treatment at 15 mg/mL suppressed MG-63 cell viability to 39% and that U2-OS cells to 43% at 48 h. Treatment with IXNP led to a prominent up-regulation of caspases-3 and -9 cleavage compared to untreated cells. Moreover, PARP and Bax levels in the cells showed a remarkable increase on IXNP-treatment in comparison to the control cells. Phosphorylation of AMPKα, expression of p21 and replication of mtDNA was also promoted in MG-63 and U2-OS cells on treatment with IXNP. In MG-63 and U2-OS cells, IXNP-treatment elevated expression of PGC-1α and TFAM while as EED, EZH2, and SUZ12 expression was down-regulated. Thus, IXNP suppress proliferation of osteosarcoma cells through activates AMPK activation and elevation of Histone H3 lysine 27 trimethylation. Therefore, IXNP has therapeutic potential to be developed for treatment of osteosarcoma.

Reconstruction using a frozen autograft for a skull and humeral lesion of synchronous multicentric osteosarcoma after undergoing successful neoadjuvant chemotherapy: a case report and review of the literature

Background

Synchronous multicentric osteosarcoma (SMOS) is a rare disease characterized by simultaneous multicentricity of intraosseous osteosarcoma without visceral involvement. SMOS, including a skull lesion, which occurs relatively rarely, and reconstruction using a frozen autograft after the excision of a lesion of SMOS has been infrequently reported previously.

Case presentation

We report an 18-year-old girl with SMOS, with lesions located in the left distal femur, right proximal humerus, and left occipital bone. Her major complaint was pain and swelling around the left knee joint. Asymptomatic lesions of the humerus and skull bone were detected on a systemic bone scan. No visceral organ metastasis was observed. A biopsy of the distal femoral lesion revealed osteosarcoma. Based on the histological findings, multiple bone lesions, and absence of visceral lesion, the clinical diagnosis of SMOS was made. After five courses of neoadjuvant chemotherapy with a regimen of doxorubicin and cisplatin, reconstruction using a tumor prosthesis following wide excision of the left distal femur was performed, and total necrosis was histologically observed in the retracted specimen. Following three cycles of adjuvant chemotherapy, tumor excision and reconstruction with a frozen autograft treated with liquid nitrogen was conducted for both lesions of the humerus and skull, rather than tumor prosthesis or synthetics, in order to retain a normal shoulder function, and to obtain a good cosmetic and functional outcome after treatment of the skull lesion. Further adjuvant chemotherapy could not be administered after the completion of the surgical treatment for all lesions because the adverse events due to chemotherapy were observed. At over 5 years after the diagnosis, she remains clinically disease-free.

Conclusions

An early correct diagnosis, the proper management of chemotherapy, and surgical treatment for all lesions are essential for achieving a good clinical outcome, even in SMOS including a skull lesion. By performing reconstruction using a frozen autograft for a proximal humeral lesion and a skull lesion after confirming the good histological efficacy of neoadjuvant chemotherapy for the primary lesion, the excellent function of the shoulder joint and a good cosmetic outcome at the site of the skull lesion was acquired without complications or recurrence.

Clinical Prognostic Factors and Outcome in Pediatric Osteosarcoma: Effect of Delay in Local Control and Degree of Necrosis in a Multidisciplinary Setting in Lebanon

PURPOSE

Outcomes in pediatric osteosarcoma have dramatically improved over the past few decades, with overall survival rates of 70% and 30% for patients with localized and metastatic disease, respectively.

PATIENTS AND METHODS

We retrospectively reviewed clinical characteristics and outcomes of 38 patients treated between 2001 and 2012 at a single institution in Lebanon. All patients received a uniform three-drug chemotherapy regimen consisting of cisplatin, doxorubicin, and methotrexate. Ifosfamide and etoposide were added to the adjuvant treatment regimen in case of metastatic disease and/or poor degree of tumor necrosis (< 90%).

RESULTS

After a median follow-up of 61 months (range, 8 to 142 months), patients with localized disease had 5-year overall and event-free survival rates of approximately 81% and 68%, respectively, whereas for metastatic disease, they were approximately 42%. The most common primary site was the long bones around the knee (n = 34; 89.5%). Six patients (15.8%) had metastatic disease to lungs, and three (7.9%) had synchronous multifocal bone disease with lung metastases. Adverse prognostic factors included nonlower extremity sites, metastasis, poor degree of necrosis, and delay of more than 4 weeks in local control. In bivariable analysis, only degree of necrosis was a prognostic predictor for survival and disease recurrence.

CONCLUSION

Treatment of pediatric osteosarcoma in a multidisciplinary cancer center in Lebanon resulted in survival similar to that in developed countries. Delay in local control was associated with worse outcome. The only statistically significant inferior outcome predictor was poor degree of necrosis at the time of local control.

What is the best clinical approach to recurrent/refractory osteosarcoma?

Introduction: Osteosarcoma is the most common malignant bone tumor. It is currently treated with pre-and postoperative chemotherapy, associated with surgical resection of the tumor.Area covered: Relapses occur in about one in three patients presenting with localized disease, and three in four of those with metastases at diagnosis. Relapsing disease carries a very poor prognosis, with 5-year survival rates ranging between 13% and 40%.Expert opinion: Patients with unilateral lung involvement or solitary lung metastases and a recurrence-free interval (RFI) longer than 24 months have a better prognosis, and could be managed with surgical resection and close observation. Complete surgical resection of all sites of disease remains essential to survival: patients unable to achieve complete remission have a catastrophic overall survival rate. The role of second-line chemotherapy is not at all clear, and no controlled studies are available on this topic. It is worth considering for patients unable to achieve complete surgical remission, and those with multiple metastases and/or a RFI <24 months. Given their dismal prognosis, patients with multiple sites of disease not amenable to complete surgical resection should also be considered for innovative therapeutic approaches.

Long noncoding RNA OR3A4 promotes the proliferation and invasion of osteosarcoma cells by sponging miR-1227-5p

Background

Long noncoding RNAs (lncRNAs) have been identified as key players in promoting tumourigenesis in osteosarcoma. LncRNA OR3A4 (OR3A4) has been reported as an oncogene in a number of tumours. However, the clinical value of OR3A4 in osteosarcoma and the role of OR3A4 in osteosarcoma progression are still unknown.

Methods

The expression levels of OR3A4 in the tumour tissue of osteosarcoma patients and osteosarcoma cell lines were detected by RT-PCR. Kaplan-Meier analysis and log-rank test were performed to evaluate the relationship between the level of OR3A4 expression and the prognosis of osteosarcoma patients. We investigated the association between the tissue expression levels of OR3A4 and different clinicopathological characteristics of osteosarcoma patients by χ² tests. Bioinformatic databases and luciferase reporter assays were used to predict and validate the target microRNA of OR3A4. Finally, the role of OR3A4 in the proliferation and invasion of osteosarcoma cells was tested by MTT and Transwell assays, respectively.

Results

We observed that the expression level of OR3A4 was upregulated in the tumour tissue of osteosarcoma patients (p < 0.001) and osteosarcoma cell lines (p < 0.01) compared with the normal adjacent tissue and a normal human foetal osteoblastic cell line, respectively. The survival curve revealed that patients with high expression levels of OR3A4 had lower overall survival. Increased OR3A4 expression in osteosarcoma patients was associated with distant metastasis (p = 0.02) and advanced clinical stage (p < 0.001). In addition, bioinformatics analysis and luciferase reporter assays verified the complementary binding between OR3A4 and miR-1227-5p. Furthermore, we found that OR3A4 acted as a miR-1227-5p “sponge” to modulate osteosarcoma cell proliferation and invasion via downregulation of miR-1227-5p.

Conclusion

OR3A4 promotes osteosarcoma cell proliferation and invasion by sponging miR-1227-5p, which might be related to the metastasis of osteosarcoma and could be used as a potential prognostic biomarker and therapeutic target in osteosarcoma.

Case Report of Synchronous Multicentric Osteosarcoma and Review of the Literature: The Importance of Autopsy for Diagnosis

Synchronous multicentric osteosarcoma is a rare entity with fewer than 100 well documented cases in the medical literature. The disease usually progresses rapidly in young patients and slightly slower in adults. We present a case of synchronous multicentric osteosarcoma with some peculiarities in a 73-year-old woman. The diagnosis was made after postmortem examination, which underlines the importance of this procedure. This case report is accompanied by a review of the literature.

Myokines related to leukocyte recruitment are down-regulated in osteosarcoma

Myokines are cytokines that are secreted by muscle cells during exercises, muscle development and pathology. Studies have shown that expression of some individual myokines was altered in tumors. However, comprehensive analyses of myokines' expression in osteosarcoma (OS), the most common malignant tumor in musculoskeletal system, have not been performed. In this study, we analyzed the expression of 35 myokines in osteosarcoma, peritumoral skeletal muscle, and cancellous bone by qRT-PCR. Heatmap analysis based on the expression pattern of these myokines revealed that OS is more likely derived from cancellous bone than peritumoral skeletal muscle. Thus, we compared the expression of myokines between OS and cancellous bone to reveal a potential role of myokines in OS development. Our results showed that expression of 19 myokines in OS was significantly lower than that in cancellous bone. KEGG signaling pathway analysis showed that these 19 myokines are involved in several important signaling pathways, one of which was associated with leukocyte recruitment in TNF-α signaling. We verified that expression of these leukocyte recruitment-related myokines were down-regulated in OS cell line MNNG compared to those in human BMSC. Downregulation of the myokines related to leukocyte recruitment suggests that escaping from host immune system may help the occurrence of osteosarcoma.

Plant flavonoid taxifolin inhibits the growth, migration and invasion of human osteosarcoma cells

The aim of the present study was to investigate the anti-cancer effects of the natural plant flavonoid, taxifolin, on human osteosarcoma cancer cells. Taxifolin was demonstrated to exhibit anti‑cancer effects on U2OS and Saos‑2 osteosarcoma cell lines. Treatment of cells with taxifolin inhibited proliferation and diminished colony formation in soft agar in a dose‑dependent manner. In vivo, intraperitoneal administration of taxifolin in nude mice bearing U2OS xenograft tumors, significantly inhibited tumor growth. In addition, taxifolin treatment was demonstrated to promote G1 cell cycle arrest and cell apoptosis in U2OS and Saos‑2 cell lines, as demonstrated by flow cytometry analysis. Western blot analysis demonstrated that taxifolin treatment was associated with a reduction in the expression levels of AKT serine/threonine kinase 1 (AKT), phosphorylated (p‑Ser473) AKT, v‑myc avian myelocytomatosis viral oncogene homolog (c‑myc) and S‑phase kinase associated protein 2 (SKP‑2) in U2OS and Saos‑2 cell lines. Overexpression of AKT considerably reversed the taxifolin‑induced decrease in AKT, c‑myc and SKP‑2 protein expression and the decrease in AKT phosphorylation, suggesting that inactivation of AKT was a mediator of taxifolin‑induced inhibition of c‑myc and SKP‑2. Furthermore, overexpression of SKP‑2 in U2OS cells partially reversed the growth inhibition mediated by taxifolin. Finally, taxifolin treatment repressed cell migration and invasion in U2OS cells and this effect was markedly reversed by SKP‑2 overexpression. The results of the present study indicate that taxifolin may present a potential novel therapeutic agent for osteosarcoma treatment.

Preliminary Application of Precision Genomic Medicine Detecting Gene Variation in Patients with Multifocal Osteosarcoma

OBJECTIVES

The purpose of this study was to present our clinical experience of treating multifocal osteosarcoma (MFOS) in our center and gain more insight into the biology of this rare condition; in particular, to address with the help of precision genomic medicine the issue of whether the multiple osteosarcoma (OS) lesions in such patients are multi-centric or originate from one primary lesion and metastasize to other sites. Finally, we aimed to identify particular gene phenotypes and mutations that differentiate MFOS from OS with only one tumor.

METHODS

Clinical data of patients with MFOS treated at our center between June 2007 and October 2014 were collected and analyzed retrospectively. High throughput sequencing of the whole exome of normal tissue and multiple lesions had been performed on samples from two patients (HJF and JZ) diagnosed in 2014. To explore the particular gene phenotype and clinical significance of MFOS, these sequencing results were analyzed and compared with those from patients with osteosarcoma in a single site. Seven patients with MFOS (three male and four female; average age 19.71 ± 3.35 years were enrolled in this study. Two of these patients declined treatment and died after 4 and 6 months, respectively. The remaining patients received standard treatment comprising neoadjuvant chemotherapy, surgery and chemotherapy. The chemotherapy regimen was lobaplatin (45 mg/m(2) ), doxorubicin (60 mg/m(2) ) and ifosfamide (12 g/m(2) ). Patients were followed up every 3 months after completing treatment and evaluated by the Enneking and Response Evaluation Criteria in Solid Tumors scoring systems.

RESULTS

Up to the last follow-up on 1 December 2015, three patients were still alive. The event-free survival ranged from 4 to 144 weeks (median, 50.14 weeks), the mean (±SD) being 55.45 ± 45.47 weeks. Overall survival ranged from 16 to 388 weeks (median, 89 weeks; mean ± SD, 118.7 ± 147.7 weeks). The rates of mutation of the targeted drug-related genes were 133.5% ± 3.0% in the proximal tibia lesion and 113.1% ± 1.9% in the distal femur of patient HJF (P < 0.01) and 136.1% ± 10.8% in the proximal tibial lesion and 122.3% ± 5.5% in the proximal humerus of patient JZ (P = 0.0335). Furthermore, there were several anti-oncogenes in the somatic copy number variation lists analyzed from the two patients, especially TP53. However, no kataegis was found.

CONCLUSIONS

Early and radical surgery accompanied by appropriate chemotherapy is the optimal means of treating MFOS. These patients may benefit from precision genomic medicine.

miRNA-223 is a potential diagnostic and prognostic marker for osteosarcoma

Background

MicroRNA-223 (miR-223) has been shown to be a potential diagnostic and prognostic marker for several cancers. In addition, miR-223 has been reported to suppress osteosarcoma cell proliferation in vitro. However, the clinical value of miR-223 is still unknown.

Methods

We detected the expression of miR-223 expression in the serum of osteosarcoma patients and in osteosarcoma cancer cells using RT-PCR. We compared the serum expression of miR-223 with the clinicopathological characteristics and survival of osteosarcoma patients. Finally, we explored the role of miR-223 on the invasion of osteosarcoma cancer cells using cell migration and invasion assays.

Results

We observed that the expression of miR-223 was significantly decreased in the serum of osteosarcoma patients and osteosarcoma cancer cells compared to healthy controls (P<0.01). Moreover, a receiver operating characteristic (ROC) curve analysis indicated that serum miR-223 is a potential diagnostic marker of osteosarcoma with an area under the ROC curve (AUC) of 0.956. Importantly, the patients with a lower expression of miR-223 tended to have distant metastasis (P<0.001) and a more advanced clinical stage (P<0.001). In addition, the survival time of patients with low miR-223 expression was significantly shorter compared to patients with high miR-223 expression (P<0.001). Furthermore, we found that miR-223 could inhibit the migration and invasion of osteosarcoma cells.

Conclusions

miR-223 might be related to the metastasis of osteosarcoma and could be used as a potential diagnostic and prognostic biomarker in osteosarcoma.

Metastatic osteosarcoma: a challenging multidisciplinary treatment

Osteosarcoma is the most common malignant bone tumor, currently treated with pre-and postoperative chemotherapy in association with the surgical removal of the tumor. About 15-20% of patients have evidence of metastases at diagnosis, mostly in the lungs. Patients with metastatic disease still have a very poor prognosis, with approximately 20-30% of long-term survivors, as compared with 65-70% of patients with localized disease. The optimum management of these patients has not been standardized yet due to several patterns of metastatic disease harboring different prognosis. Complete surgical resection of all sites of disease is mandatory and predictive of survival. Patients with multiple sites of disease not amenable to complete surgery removal should be considered for innovative therapeutic approaches because of poor prognosis.

Combined elevation of microRNA-196a and microRNA-196b in sera predicts unfavorable prognosis in patients with osteosarcomas

AIM

To investigate whether the aberrant expression of microRNA (miR)-196a and miR-196b can be used as potential prognostic markers of human osteosarcoma.

METHODS

Quantitative real-time reverse transcriptase-polymerase chain reaction (qRT-PCR) analysis was performed to detect the expression levels of miR-196a and miR-196b in osteosarcoma tissues and patients' sera.

RESULTS

Expression levels of miR-196a and miR-196b in osteosarcoma tissues were both significantly higher than those in noncancerous bone tissues (both p<0.001), in line with which, the serum levels of the two miRNAs were also markedly upregulated in patients with osteosarcomas compared with healthy controls (both p<0.001). Then, the elevation of serum miR-196a and miR-196b levels both more frequently occurred in osteosarcoma patients with high tumor grade (p=0.008 and 0.01, respectively), positive metastasis (p=0.001 and 0.006, respectively) and recurrence (p=0.001 and 0.006, respectively). Moreover, high serum miR-196a, high serum miR-196b and conjoined expression of miR-196a/miR-196b were all independent prognostic factors for OS (overall survival) and DFS (disease-free survival) of osteosarcoma patients.

CONCLUSION

Our present data indicate the involvement of miR-196a and miR-196b upregulation in the pathogenesis of osteosarcoma. More importantly, the altered levels of circulating miR-196a and miR-196b might have great potential to serve as novel and non-invasive prognostic factors for this malignancy.

Osteosarcoma of jaws

Tumors of jaw bones are among the most uncommon of all types of neoplasms. Osteosarcoma of jaw bones represents a distinct group of lesions from the conventional type commonly occurring in long bones. Nonetheless, our present knowledge of the tumor allows us to affirm that its clinical behavior and pathologic features differ markedly from those of its homolog in the long bones. The maxillary tumors show predilection for posterior portion of the alveolar process and the antrum, whereas the body is most commonly involved in the mandible followed, by angle, symphysis, and ascending ramus. We have reviewed around 300 cases of osteosarcoma of varied racial origin from PubMed indexed journals spanning from 1967 to 2010 and present their etiology, pathogenesis, features and treatment modalities.

Radiation-induced osteosarcoma 17 years after mediastinal irradiation following surgical removal of thymoma

Radiation-induced osteosarcoma is a rare complication after irradiation of primary malignancies. In the chest wall, it is usually secondary to radiotherapy for breast cancer or lymphoma. We report a rare case of radiation-induced osteosarcoma of the sternum after mediastinal irradiation of a thymoma. A 49-year-old woman presented with a sternal tumor 17 years after surgery plus mediastinal irradiation (50 Gy) for a stage III thymoma. On biopsy, this second tumor was diagnosed as a radiation-induced osteosarcoma. Systemic survey revealed additional metastatic spread to vertebrae and pelvis. Despite intensive combination chemotherapy that initially stabilized her disease, the patient died 2 years after the diagnosis was made. Because thymoma patients receiving mediastinal irradiation are thus at additional risk of radiation-induced secondary malignancy, long-term follow-up is advisable.

Synchronous multicentric osteosarcoma involving mandible and maxillas

Synchronous multicentric osteosarcoma (SMO) is rare with fewer than 100 well-documented cases in the medical literature. SMO affecting the jaw is even rarer with only three cases involving the mandible having been reported. SMO in the maxilla has not been previously reported. The authors report the first case of SMO involving both mandible and maxilla in an 18-year-old girl. The clinical course, radiological and histological appearance of the lesion indicated it was an SMO rather than metastasis arising from a single osteosarcoma. This case could be regarded as powerful evidence to support the multicentric theory related to SMO.

Poor prognosis osteosarcoma: new therapeutic approach

Over the past 30 years, a significant improvement in the prognosis of localized osteosarcoma of the extremities has been observed. Despite these results, approximately 30-40% of patients will relapse, mostly within the first 3 years from diagnosis. The prognosis of patients with recurrent disease or metastases at diagnosis is poor. To improve the survival in this patient population, several attempts have been made. An increased dose intensity of chemotherapy induces short lasting remission but does not increase the survival. In the era of targeted therapy, few drugs have been tested with dismal results. The use of biological agents endowed with immunomodulant activity (that is IL-2) or reduced-intensity allogeneic hemopoietic SCT has produced intriguing results that need further confirmation. In this context, an ongoing study explores the antitumor activity of specific T-cytotoxic lymphocytes.

Hypocalcemia as a presentation for multifocal osteosarcoma

We report the case of a 16-year-old male with multifocal osteosarcoma presented with symptomatic hypocalcemia. The patient presented signs of hypocalcemia accompanied by generalized bone pain and a femoral mass. Further evaluation revealed secondary hyperparathyroidism, highly elevated alkaline phosphatase levels, and generalized sclerotic and lytic lesions. Biopsy confirmed osteosarcomatosis. Despite aggressive chemotherapy, he died from progressive disease 2 months after diagnosis. The course of disease in this patient suggests that hypocalcemia reflects a poor prognosis.

Upfront window trial of topotecan in previously untreated children and adolescents with poor prognosis metastatic osteosarcoma: children's Cancer Group (CCG) 7943

BACKGROUND

Patients with metastatic osteosarcoma have a poor prognosis. The objectives of the study were to determine the antitumor activity and toxicity of topotecan (daily x5) in newly diagnosed patients with metastatic osteosarcoma followed by chemotherapy (ifosfamide, carboplatin, etoposide [ICE], alternating with cisplatin and doxorubicin [CD]).

METHODS

Newly diagnosed patients (< or =30 years of age) with extensive metastatic disease (primary and > or =5 pulmonary nodules and/or bone metastases) with normal hepatic, renal, and cardiac function were eligible. Patients were eligible to receive further topotecan after standard chemotherapy if they exhibited a response. Twenty-eight patients were enrolled. Seventeen had metastases to the lung only and 11 had metastases to the bone or multiple sites. Of 28 patients enrolled, 27 could be evaluated for response. A limited dose escalation was incorporated.

RESULTS

No responses were seen in the 11 patients treated at 3 mg/m(2)/day. One partial response (PR) and 1 clinical response (CLR) were reported among 15 patients who received topotecan at 3.5 mg/m(2)/day. No dose-limiting toxicity was observed. Principal nondose-limiting toxicities were hematologic and gastrointestinal. The 2- and 5-year event-free survival rates were low, 7% and 4%, respectively, but the 2- and 5-year overall survival rates were 44% and 22%, respectively.

CONCLUSIONS

Topotecan at dose of 3.5 mg/m(2)/day can be safely administered upfront to newly diagnosed patients without excessive toxicity. Insufficient activity was seen with topotecan in this schedule to warrant further studies in osteosarcoma. The combination of ICE and CD was tolerable when delivered after initial topotecan therapy.

Diffuse calcification of metastases after intensive multiagent chemotherapy in widespread osteosarcoma leading to death in a 18-year-old male: report of a case and literature review

Multifocal osteosarcoma represents a rare and aggressive type of osteosarcoma in which multiple bone lesions are detected simultaneously in the absence of pulmonary or any other visceral organ involvement. Despite a multidisciplinary approach, overall survival remains poor and disease progresses, leading to death within 1 yr of diagnosis. Here we report a case of an 18-yr-old patient with extensively metastatic osteosarcoma developing diffuse calcification in lung, pleural, diaphragm, pericardial, subcutaneous metastases, and mediastinal lymph nodes after intensive multiagent chemotherapy. We provide an extensive review of the literature together with presentation of different aspects regarding the debate on the multicentric versus metastatic hypotheses for multifocal osteosarcoma. An update on the current understanding of the molecular features of this disease is also included.

Intra-arterial chemotherapy for limb preservation in patients with osteosarcoma: nursing implications

Osteosarcoma is an aggressive tumor found in children and young adults, originating primarily in the legs or arms. The high-grade tumor grows in a circular, ball-like mass in the bone tissue. Before the 1970s and the advent of chemotherapy use in osteosarcoma, treatment consisted solely of amputation. More recently, a preoperative regimen of intra-arterial (IA) cisplatin and infusional doxorubicin with limb-sparing procedures has provided an effective treatment option and improved survival for many patients with osteosarcoma. IA chemotherapy is administered through a small, temporary, external catheter that rests in the arterial vessel that supplies the tumor. The primary advantage of IA chemotherapy administration is the delivery of a higher chemotherapy concentration directly to the tumor site, Nursing management of patients with IA chemotherapy requires knowledge of treatment side effects and procedure-related assessments. Further implications for practice include instructing patients and families before and after the insertion of the IA line and giving discharge and long-term follow-up education. Oncology nurses are well positioned to assist children and young adult patients through difficulties with adjustment after treatment is completed and a response has been achieved, owing to advanced communication skills and knowledge of developmental stages and survivorship issues,

Primary bone osteosarcoma in the pediatric age: State of the art

The current combination treatment, chemotherapy and surgery, has significantly improved the cure rate and the survival rate of primary bone osteosarcoma. The 5-year survival rate has increased in the last 30 years from 10% to 70%. Even in patients with poor prognosis, such as those with metastases at diagnosis, the 5-year survival rate has reached 20-30% due to chemotherapy and the surgical removal of metastases and primary tumor. However, the most effective drugs are still the same as those employed over the last 20 years as front line neoadjuvant or adjuvant chemotherapy: Doxorubicin, Cisplatin, Methotrexate, Ifosfamide. No standard, second line therapy exists for those who relapse. At relapse, due to the lack of new non-cross-resistant drugs, surgery is still the main option when feasible. Other drugs have been employed in relapsed patients with poor results. This article reviews the state of the art of treatment for bone osteosarcoma in the pediatric age.

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.

Anti-tumor efficacy of a transcriptional replication-competent adenovirus, Ad-OC-E1a, for osteosarcoma pulmonary metastasis

BACKGROUND

Osteosarcoma (OSA) is the most frequent type of primary malignant bone tumor and is apt to occur in children and young adults. Pulmonary metastasis (OSPM) is the major reason for its fatal outcome. Osteocalcin (OC) is a major noncollagenous bone protein whose expression is limited almost exclusively to bone marrow and osteotropic tumors. OC is also known to express in cell lines with bone metastasis feathers. Gene therapy strategies with the OC promoter directing the replication of adenovirus in a tumor-specific manner are a potential modality for OSPM therapy.

METHODS

We detected OC mRNA expression by RNA in situ hybridization in OSA and OSPM samples from patients, and tested OC promoter transcriptional activity in OSA and non-OSA cell lines. Then we used a transcriptional replication-competent adenovirus, Ad-OC-E1a, to treat OSPM, and evaluated its tumor-specific replication and killing activities in vitro as well as anti-OSPM efficacy in vivo via systemic delivery.

RESULTS

OC mRNA was detected in all types of OSA tissues, including OSPM tissues. The transcriptional activity of the OC promoter was much higher in a OSPM cell line SAOS-2LM7 and primary OSA cell line MG63 than in non-OSA cell lines, including cell lines from breast cancer, colon cancer, and liver cancer. Ad-OC-E1a expressed E1a protein only in MG63 and SAOS-2LM7, which indicated that adenovirus E1a was under strict control by the OC promoter. Ad-OC-E1a demonstrated killing and viral replication activity close to wild-type adenovirus levels in MG63 and SAOS-2LM7, but the killing and viral replication activities were attenuated significantly in cells expressing low OC transcriptional activity. To test whether Ad-OC-E1a could be used to target human OSPM in vivo, SAOS-2LM7 pulmonary metastasis models in nude mice were induced and treated by tail-vein injection with Ad-OC-E1a. Compared to tumor nodules in the lung in groups treated with PBS or control virus, the quantity of metastasized tumor nodules decreased significantly. Adenovirus-infected cells were stained immunohistochemically only inside and around the OSPM nodules but spared normal lung tissue and other organs.

CONCLUSIONS

These data demonstrated that OC promoter could direct adenovirus replication by controlling the E1a gene to target human OSPM in a tumor-specific manner, providing an efficient tool to develop a feasible therapeutic modality for OSPM.

Skip metastases in osteosarcoma: experience of the Cooperative Osteosarcoma Study Group

PURPOSE

The outlook for patients with osteosarcoma who present with synchronous regional bone metastases (skip metastases), either in the primary bone site or transarticular, is considered to be extremely poor. This study was conducted to further investigate the prognostic implication of skip metastases in osteosarcoma.

PATIENTS AND METHODS

The authors retrospectively analyzed the collected data of 1,765 consecutive patients with newly diagnosed high-grade osteosarcoma of bone who were registered in the neoadjuvant Cooperative Osteosarcoma Study Group studies and identified 24 patients (1.4%) with unequivocally proven skip metastases. All 24 patients were treated by an aggressive surgical approach coupled with polychemotherapy. Demographic, diagnostic, tumor, and treatment-related variables and response and survival data were analyzed.

RESULTS

Skip metastases were identified preoperatively in 11 of 24 patients by bone scan, eight of 22 patients by plain x-ray, 15 of 18 patients by magnetic resonance imaging, and five of 10 patients by computed tomography. A complete surgical remission (CSR) of all clinically detectable tumor sites was achieved in 22 of 24 patients during front-line therapy. With a median follow-up time of 4.4 years (8 years for survivors) from diagnosis, 12 patients were alive, all of whom were in continuous CSR. Survival did correlate with location of skip metastases and histologic response to neoadjuvant chemotherapy.

CONCLUSION

Synchronous regional bone metastases are rare in osteosarcoma, and preoperative detection relies on appropriate diagnostic imaging. Aggressive multimodal therapy holds the promise to achieve prolonged survival, especially in patients in whom these metastases occur within the same bone as the primary lesion and whose tumors respond well to chemotherapy.

Conditionally Replicative Adenovirus with Tropism Expanded towards Integrins Inhibits Osteosarcoma Tumor Growth in Vitro and in Vivo

PURPOSE

The clinical course of osteosarcoma (OS) demands the development of new therapeutic options. Conditionally replicative adenoviruses (CRAds) represent promising agents for the treatment of solid tumors, because CRAds have an intrinsic replication capacity that allows in situ amplification and extensive tumor infection through lateral spread. The CRAd AdDelta24 has been developed to replicate selectively in cells with a defective retinoblastoma (Rb) pathway. Because genetic alterations in the Rb pathway are frequently observed in OS, AdDelta24 might be useful in the treatment of this cancer.

EXPERIMENTAL DESIGN

Because the lack of Coxsackie adenovirus receptor on OS cells limits the efficacy of CRAd treatment, we explored alternative target molecules on OS. Insertion of an Arg-Gly-Asp (RGD-4C) integrin-targeting motif into the adenovirus fiber knob expanded tropism toward the alpha(nu)beta(3) and alpha(nu)beta(5) integrins. The oncolytic capacity of the CRAd Ad5-Delta24RGD was tested on primary OS cells in vitro and in vivo.

RESULTS

The alpha(nu)beta(3)and alpha(nu)beta(5) integrins are abundantly expressed on OS cells. RGD-mediated infection augmented adenovirus infection of primary OS cells by two orders of magnitude. Ad5-Delta24RGD was shown to be highly active in killing human OS cell lines, as well as primary cell cultures. Furthermore, intratumoral injections with Ad5-Delta24RGD into established human OS xenografts that were derived directly from a patient with OS refractory for chemotherapeutic treatment caused a significant tumor-growth delay. Furthermore, adenoviral particles could be detected in tumor cells 25 days posttumor injection.

CONCLUSIONS

Targeting adenovirus toward integrins rendered OS cells more sensitive to killing by Ad5-Delta24RGD. These findings suggest that Ad5-Delta24RGD has potential for use in OS treatment.

Primary metastatic osteosarcoma: presentation and outcome of patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols

PURPOSE

To determine demographic data and define prognostic factors for long-term outcome in patients presenting with high-grade osteosarcoma of bone with clinically detectable metastases at initial presentation.

PATIENTS AND METHODS

Of 1,765 patients with newly diagnosed, previously untreated high-grade osteosarcomas of bone registered in the neoadjuvant Cooperative Osteosarcoma Study Group studies before 1999, 202 patients (11.4%) had proven metastases at diagnosis and therefore were enrolled onto an analysis of demographic-, tumor-, and treatment-related variables, response, and survival. The intended therapeutic strategy included pre- and postoperative multiagent chemotherapy as well as aggressive surgery of all resectable lesions.

RESULTS

With a median follow-up of 1.9 years (5.5 years for survivors), 60 patients were alive, 37 of whom were in continuously complete surgical remission. Actuarial overall survival rates at 5 and 10 (same value for 15) years were 29% (SE = 3%) and 24% (SE = 4%), respectively. In univariate analysis, survival was significantly correlated with patient age, site of the primary tumor, number and location of metastases, number of involved organ systems, histologic response of the primary tumor to preoperative chemotherapy, and completeness and time point of surgical resection of all tumor sites. However, after multivariate Cox regression analysis, only multiple metastases at diagnosis (relative hazard rate [RHR] = 2.3) and macroscopically incomplete surgical resection (RHR = 2.4) remained significantly associated with inferior outcomes.

CONCLUSION

The number of metastases at diagnosis and the completeness of surgical resection of all clinically detected tumor sites are of independent prognostic value in patients with proven primary metastatic osteosarcoma.