Effects of neoadjuvant chemotherapy on image-directed planning of surgical resection for distal femoral osteosarcoma

Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis

» The proximal humerus is a common location for primary bone tumors, and the goal of surgical care is to obtain a negative margin resection and subsequent reconstruction of the proximal humerus to allow for shoulder function.» The current evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty when reconstructing the proximal humerus after resection of a bone sarcoma if the axillary nerve can be preserved.» There is a lack of high-quality data comparing allograft prosthetic composite (APC) with endoprosthetic reconstruction of the proximal humerus.» Reverse APC should be performed using an allograft with donor rotator cuff to allow for soft-tissue repair of the donor and host rotator cuff, leading to improvements in shoulder motion compared with an endoprosthesis.

Surgical Margins in Musculoskeletal Sarcoma

» Negative margin resection of musculoskeletal sarcomas is associated with reduced risk of local recurrence.» There is limited evidence to support an absolute margin width of soft tissue or bone that correlates with reduced risk of local recurrence.» Factors intrinsic to the tumor, including histologic subtype, grade, growth pattern and neurovascular involvement impact margin status and local recurrence, and should be considered when evaluating a patient's individual risk after positive margins.» Appropriate use of adjuvant therapy, critical analysis of preoperative advanced cross-sectional imaging, and the involvement of a multidisciplinary team are essential to obtain negative margins when resecting sarcomas.

Identification of mitochondrial-related signature and molecular subtype for the prognosis of osteosarcoma

Mitochondria play a vital role in osteosarcoma. Therefore, the purpose of this study was to investigate the potential role of mitochondrial-related genes (MRGs) in osteosarcoma. Based on 92 differentially expressed MRGs, osteosarcoma samples were divided into two subtypes using the nonnegative matrix factorization (NMF). Ultimately, a univariate, least absolute shrinkage and selection operator (LASSO), and multivariate Cox analysis were performed to construct a prognostic risk model. The single-sample gene set enrichment analysis assessed the immune infiltration characteristics of osteosarcoma patients. Finally, we identified an osteosarcoma biomarker, malonyl-CoA decarboxylase (MLYCD), which showed downregulation. Osteosarcoma cells proliferation, migration, and invasion were effectively inhibited by the overexpression of MLYCD. Our findings will help us to further understand the molecular mechanisms of osteosarcoma and contribute to the discovery of new diagnostic biomarkers and therapeutic targets.

Rotationplasty with Tibial Nerve Coaptation: A Case Report

CASE

We present the case of a 14-year-old adolescent boy with a distal femoral osteosarcoma partially encasing the tibial nerve. He underwent rotationplasty with resection and coaptation (end-to-end repair) of the tibial nerve. By 1 year postoperatively, he had recovered sensation on the plantar aspect of his foot and Medical Research Council scale 4+/5 gastro-soleus contraction that powered extension of the new knee.

CONCLUSION

Tibial nerve resection is not an absolute contraindication for rotationplasty, even in an adolescent. Nerve coaptation allows for well-functioning rotationplasty as an alternative to endoprosthetic reconstruction or above-knee amputation.

[Research on three-dimensional printing technology based on three-dimensional multimodality imaging to assist the operation of malignant bone tumors of limbs]

OBJECTIVE

To explore the role and effectiveness of three-dimensional (3D) printing technology based on 3D multimodality imaging in surgical treatment of malignant bone tumors of limbs.

METHODS

The clinical data of 15 patients with malignant bone tumors of the limbs who met the selection criteria between January 2016 and January 2019 were retrospectively analyzed. There were 6 males and 9 females, with a median age of 34 years (range, 17-73 years). There were 5 cases of osteosarcoma, 3 cases of chondrosarcoma, 2 cases of Ewing sarcoma, 1 case of hemangiosarcoma, 1 case of ameloblastoma, and 3 cases of metastatic carcinoma. The tumors were located in the humerus in 5 cases, ulna in 2 cases, femur in 3 cases, and tibia in 5 cases. The disease duration was 2-8 months (median, 4 months). Preoperative 3D multimodality imaging was administered first, based on which computer-assisted preoperative planning was performed, 3D printed personalized special instruments and prostheses were designed, and in vitro simulation of surgery was conducted, successively. Two cases underwent knee arthroplasty, 2 had semi-shoulder arthroplasty, 2 had proximal ulna arthroplasty, and 9 had joint-preserving surgery. Surgical margins, operation time, intraoperative blood loss, surgical complications, Musculoskeletal Tumor Society (MSTS) score, and oncological outcome were collected and analyzed.

RESULTS

All 15 patients completed the operation according to the preoperative plan, and the surgical margins were all obtained wide resection margins. The operation time was 80-240 minutes, with a median of 150 minutes. The intraoperative blood loss was 100-400 mL, with a median of 200 mL. There was no significant limitation of limb function due to important blood vessels or nerves injury during operation. One case of superficial infection of the incision was cured after dressing change, and the incisions of the other patients healed by first intention. All patients were followed up 6-48 months, with a median of 24 months. Two of the patients died of lung metastasis at 6 and 24 months after operation, respectively. No local recurrence, prosthesis dislocation, or prosthesis loosening occurred during follow-up. At last follow-up, the MSTS score ranged from 23 to 30, with an average of 25.

CONCLUSION

3D printing tecnology, based on 3D multimodality imaging, facilitates precise resection and reconstruction for malignant bone tumors of limbs, resulting in improved oncological and functional outcome.

Diagnosis of joint invasion in patients with malignant bone tumors: value and reproducibility of direct and indirect signs on MR imaging

OBJECTIVES

To evaluate the performance and reproducibility of MR imaging features in the diagnosis of joint invasion (JI) by malignant bone tumors.

METHODS

MR images of patients with and without JI (n = 24 each), who underwent surgical resection at our institution, were read by three radiologists. Direct (intrasynovial tumor tissue (ITT), intraarticular destruction of cartilage/bone, invasion of capsular/ligamentous insertions) and indirect (tumor size, signal alterations of epiphyseal/transarticular bone (bone marrow replacement/edema-like), synovial contrast enhancement, joint effusion) signs of JI were assessed. Odds ratios, sensitivity, specificity, PPV, NPV, and reproducibilities (Cohen's and Fleiss' κ) were calculated for each feature. Moreover, the diagnostic performance of combinations of direct features was assessed.

RESULTS

Forty-eight patients (28.7 ± 21.4 years, 26 men) were evaluated. All readers reliably assessed the presence of JI (sensitivity = 92-100 %; specificity = 88-100%, respectively). Best predictors for JI were direct visualization of ITT (OR = 186-229, p < 0.001) and destruction of intraarticular bone (69-324, p < 0.001). Direct visualization of ITT was also highly reliable in assessing JI (sensitivity, specificity, PPV, NPV = 92-100 %), with excellent reproducibility (κ = 0.83). Epiphyseal bone marrow replacement and synovial contrast enhancement were the most sensitive indirect signs, but lacked specificity (29-54%). By combining direct signs with high specificity, sensitivity was increased (96 %) and specificity (100 %) was maintained.

CONCLUSION

JI by malignant bone tumors can reliably be assessed on preoperative MR images with high sensitivity, specificity, and reproducibility. Particularly direct visualization of ITT, destruction of intraarticular bone, and a combination of highly specific direct signs were valuable, while indirect signs were less predictive and specific.

KEY POINTS

• Direct visualization of intrasynovial tumor was the single most sensitive and specific (92-100%) MR imaging sign of joint invasion. • Indirect signs of joint invasion, such as joint effusion or synovial enhancement, were less sensitive and specific compared to direct signs. • A combination of the most specific direct signs of joint invasion showed best results with perfect specificity and PPV (both 100%) and excellent sensitivity and NPV (both 96 %).

Knockdown of HCG18 Inhibits Cell Viability, Migration and Invasion in Pediatric Osteosarcoma by Targeting miR-188-5p/FOXC1 Axis

Understanding the underlying mechanisms of pediatric osteosarcoma (OS) migration and invasion is important for prognosis and treatment. We tried to measure the expression of long non-coding RNA HLA complex group 18 (HCG18) in OS and reveal its function in the malignant behaviors of OS cells. This study detected the expression of HCG18, miR-188-5p and forkhead box C1 (FOXC1) in OS tissues and cell lines by quantitative real-time PCR (qRT-PCR). The relevance between miR-188-5p and HCG18 or FOXC1 was affirmed by dual-luciferase reporter (DLR) assay. Cell viability was analyzed by MTT assay. Transwell assay was utilized to test cell invasion and migration. FOXC1 protein expression was detected by western blot. HCG18 expression was elevated in OS tissues, and enhanced HCG18 expression was related to metastasis. HCG18 silencing repressed the viability, migration and invasion of OS cells. Moreover, HCG18 interacted with miR-188-5p. MiR-188-5p up-regulation repressed cell viability, invasion and migration in OS cells. FOXC1, a known target of miR-188-5p, was negatively modulated by miR-188-5p. Furthermore, miR-188-5p inhibition or FOXC1 over-expression partially abolished the reduced of cell viability, invasion and migration mediated by HCG18 silencing in OS cell lines. This study revealed that HCG18 knockdown repressed the viability, invasion and migration of OS cells by targeting miR-188-5p and regulating FOXC1 expression. Thus, HCG18/ miR-188-5p/FOX may be a hopeful target for OS therapy.

Circ_WWC3 overexpression decelerates the progression of osteosarcoma by regulating miR-421/PDE7B axis

Background

Emerging evidence has shown that circular RNAs (circRNAs) are vital regulators in osteosarcoma (OS) progression. However, the effects of circ_WWC3 in OS have not been explored. In this research, the functions and mechanisms of circ_WWC3 in OS were investigated.

Methods

Quantitative reverse trancription polymerase chain reaction (qRT-PCR) was adopted to determine the levels of circ_WWC3, WW and WWC3 mRNA, miR-421, and phosphodiesterase 7B (PDE7B) mRNA. RNase R assay was used to determine the characteristic of circ_WWC3. Colony formation assay and 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) assay were applied for cell growth. Transwell assay was performed for cell migration and invasion. Flow cytometry analysis was utilized for cell apoptosis. Western blot assay was conducted for the levels of apoptosis-related proteins and PDE7B protein. Dual-luciferase reporter assay was carried out to analyze the targeting relationship between miR-421 and circ_WWC3 or PDE7B. The murine xenograft model was established to explore the effect of circ_WWC3 in vivo.

Results

Compared to normal tissues and cells, circ_WWC3 and PDE7B were downregulated in OS tissues and cells. Overexpression of circ_WWC3 or PDE7B suppressed OS cell growth, migration, and invasion and promoted apoptosis in vitro. Regarding the mechanism analysis, circ_WWC3 positively modulated PDE7B expression by targeting miR-421. MiR-421 overexpression restored the impacts of circ_WWC3 on OS cell growth, metastasis, and apoptosis. Inhibition of miR-421 repressed the malignant behaviors of OS cells by targeting PDE7B. In addition, circ_WWC3 inhibited the tumorigenicity of OS in vivo.

Conclusion

Circ_WWC3 overexpression slowed the development of OS by elevating PDE7B via sponging miR-421.

Radiological Assessment and Outcome of Local Disease Progression after Neoadjuvant Chemotherapy in Children and Adolescents with Localized Osteosarcoma

Objective: We examined the interobserver reliability of local progressive disease (L-PD) determination using two major radiological response evaluation criteria systems (Response evaluation Criteria in Solid Tumors (RECIST) and the European and American Osteosarcoma Study (EURAMOS)) in patients diagnosed with localized osteosarcoma (OS). Additionally, we describe the outcomes of patients determined to experience L-PD. Materials and Methods: Forty-seven patients diagnosed with localized OS between 2000 and 2012 at our institution were identified. Paired magnetic resonance imaging of the primary tumor from diagnosis and post-neoadjuvant chemotherapy were blindly assessed by two experienced radiologists and determined L-PD as per RECIST and EURAMOS radiological criteria. Interobserver reliability was measured using the kappa statistic (κ). The Kaplan Meier method and log-rank test was used to assess differences between groups. Results: Of 47 patients (median age at diagnosis 12.9 years), 16 (34%) had L-PD (by RECIST or EURAMOS radiological definition). There was less agreement between the radiologists using EURAMOS radiological criteria for L-PD (80.9%, κ = 0.48) than with RECIST criteria (97.9%, κ = 0.87). Patients with radiologically defined L-PD had a 5-year progression-free survival (PFS) of 55.6%, compared to a 5 year-PFS of 82.7% in the group of patients without L-PD (n = 31) (Log rank p = 0.0185). Conclusions: The interobserver reliability of L-PD determination is higher using RECIST than EURAMOS. RECIST can be considered for response assessment in OS clinical trials. The presence of L-PD was associated with worse outcomes.

The current status of MRI in the pre-operative assessment of intramedullary conventional appendicular osteosarcoma

Osteosarcoma is the commonest primary malignant bone tumour in children and adolescents, the majority of cases being conventional intra-medullary high-grade tumours affecting the appendicular skeleton. Treatment is typically with a combination of neo-adjuvant chemotherapy, tumour resection with limb reconstruction and post-operative chemotherapy. The current article reviews the role of magnetic resonance imaging (MRI) in the pre-operative assessment of high-grade central conventional osteosarcoma.

Downregulation of miR-136 promotes the progression of osteosarcoma and is associated with the prognosis of patients with osteosarcoma

Osteosarcoma (OS) is the most common bone tumor in children and young adults, and is an aggressive tumor with poor prognosis. MicroRNAs (miRNAs) are aberrantly expressed in various types of cancer, and contribute to cancer tumorigenesis and progression. In the present study, the potential prognostic value and biological function of miRNA-136 (miR-136) in OS was investigated. Reverse transcription-quantitative polymerase chain reaction analysis was used to evaluate the expression of miR-136 in OS tissues and cell lines. Kaplan-Meier survival analysis and Cox regression analysis were conducted to investigate the prognostic significance of miR-136. Various in vitro cell based assays were used to evaluate the effects of miR-136 on the biological behavior of OS cells. A luciferase assay was performed to determine the key miR-136 targets associated with OS. The expression of miR-136 was significantly downregulated in osteosarcoma tissues and cells compared with the normal controls (all P<0.05). Decreased miR-136 expression was significantly associated with Enneking staging (P=0.030) and distant metastasis (P=0.016). Decreased miR-136 expression in patients was associated with shorter overall survival compared with patients with increased expression levels (log-rank test; P<0.05). The expression of miR-136 was indicated as an independent prognostic factor for the patients (hazard ratio=0.496; 95% confidence interval=0.250-0.987; P=0.046). MTT, transwell and Matrigel assays demonstrated that upregulation of miR-136 decreased proliferation, migration and invasion of OS cells. Bioinformatics and luciferase assays demonstrated that migration and invasion enhancer 1 (MIEN1) is a direct target of miR-136. Together, the results suggested that miR-136 functions as a tumor suppressor gene to regulate proliferation, migration and invasion of OS cells. MIEN1 was a potential target of miR-136. Additionally, miR-136 may serve as a prognostic biomarker for OS.

MALAT1 induces osteosarcoma progression by targeting miR-206/CDK9 axis

Long noncoding RNAs (LncRNAs) have been reported to participate in cancer development, including osteosarcoma. Here, in our study, we observed that lncRNA metastasis-associated lung adenocarcinoma transcription 1 (MALAT1) was remarkably overexpressed in osteosarcoma. However, the role it plays in osteosarcoma proliferation mediated by miR-206/cyclin-dependent kinase 9 (CDK9) axis remains uninvestigated. It was found that miR-206 was decreased and CDK9 was elevated in human osteosarcoma cells including MG63, Saos-2, U2OS, and KHOS compared with human osteoblast cell line hFOB 1.19. In addition, it was exhibited that knockdown of MALAT1 was able to inhibit osteosarcoma cell proliferation, which suggested that MALAT1 played an oncogenic role in osteosarcoma development. Bioinformatics analysis indicated that MALAT1 can function as a competing endogenous RNA by sponging miR-206. Because miR-206 has been identified as a significant tumor suppressive gene in multiple cancers, we validated that mimics of miR-206 can restrain osteosarcoma progression. Furthermore, dual-luciferase reporter assay, RNA binding protein immunoprecipitation, and RNA pull-down assay demonstrated the correlation between miR-206 and MALAT1. Besides these, CDK9 was predicted as a downstream gene of miR-206, and we observed that MALAT1 can regulate osteosarcoma progress by modulating CDK9 expression via sponging miR-206. In conclusion, our study implied that MALAT1/miR-206/CDK9 axis can provide novel insights into the biological mechanism of osteosarcoma progression.

Osteosarcoma: a comprehensive review

Osteosarcoma (OS) is a relatively rare tumor of bone with a worldwide incidence of 3.4 cases per million people per year. For most of the twentieth century, five-year survival rates for classic OS were very low. In the 1970s, the introduction of adjuvant chemotherapy in the treatment of OS increased survival rates dramatically. The current article reviews the various types of OS and analyzes the clinical and histological features. We also examine historical and current literature to present a succinct review of methods for diagnosis and staging, as well as treatment, and we also discuss some of the future directions of treatment.

Planning for Bone Excision in Ewing Sarcoma: Post-Chemotherapy MRI More Accurate Than Pre-Chemotherapy MRI Assessment

BACKGROUND

In determining the level of bone resection in Ewing sarcoma, the most suitable time at which to perform magnetic resonance imaging (MRI) remains controversial. Current guidelines recommend that surgical planning be based on MRI performed prior to neoadjuvant chemotherapy. The goal of this study was to determine whether pre-chemotherapy or post-chemotherapy MRI provides greater accuracy of tumor limits for planning bone excision in the management of Ewing sarcoma.

METHODS

This was a single-center, retrospective study. MRI was performed using 3 sequences: T1-weighted, T1-weighted with contrast enhancement by gadolinium injection, and a fluid-sensitive sequence (STIR [short tau inversion recovery] or proton-density-weighted with fat saturation). The tumor extent as assessed on pre-chemotherapy and post-chemotherapy MRI was compared with histological measurement of the resected specimen.

RESULTS

Twenty patients with Ewing sarcoma of a long bone were included. In 6 cases, the tumor was located on the femur, in 5, the tibia; in 5, the fibula; and in 4, the humerus. The median patient age at diagnosis was 9.7 years. We found greater accuracy of measurements from MRI scans acquired after chemotherapy than from those acquired before chemotherapy. For both pre-chemotherapy and post-chemotherapy MRI, the greatest accuracy was achieved with the nonenhanced T1 sequence. There was no benefit to gadolinium enhancement. The median difference between T1 MRI and histological measurements was 19.0 mm (interquartile range [IQR], 4.3 to 32.8 mm) before chemotherapy and 5.0 mm (IQR, 2.0 to 13.0 mm) after chemotherapy. Adding a minimum margin of 20 mm to the limit of the tumor on post-chemotherapy T1 MRI always led to safe histological margin.

CONCLUSIONS

Post-chemotherapy MRI provided a more accurate assessment of the limits of Ewing sarcoma. Surgical planning can therefore be based on post-chemotherapy MRI. Surgical cuts can be, at minimum, 20 mm from the limits as seen on MRI.

Chondromodulin‑I suppresses tumorigenesis of human osteosarcoma cells

Osteosarcoma is the most common type of bone cancer, and accounts for ~3% of cancers that occurring in children. Chondromodulin‑I (ChM-I) is a 25 kDa glycoprotein that is expressed mainly in cartilage. ChM-I demonstrates anti‑angiogenic activity and has been suggested to inhibit endothelial cells from invading cartilage, and then has been shown to be an inhibitor of tumorigenesis. However, it remains unclear if ChM‑I has any direct anti‑tumorigenesis role on osteosarcoma. Therefore, the present study aimed to identify whether ChM‑I has any direct inhibit effect on human osteosarcoma cells. A bromodeoxyuridine incorporation assay was performed on the Saos‑2 human osteosarcoma cell line treated with or without recombinant human ChM‑I, to evaluate its impact on DNA synthesis. An adenovirus carrier for the expression of ChM‑I was constructed and transfected into tumor cells in vitro to evaluate the effect of ChM‑I on tumor cells. Additionally, ChM‑I was knocked down by using small interfering RNA to downregulate the expression of ChM‑I. Cell invasion, migration and cell‑colony formation assays, and xenograft tumor experiments were performed to evaluate the effects of ChM‑I on tumor cells in vitro and in vivo. The results demonstrated that ChM‑I could suppress DNA synthesis of human osteosarcoma cells, and it also exerted an inhibitory effect on the proliferation and colony formation abilities of human osteosarcoma cells. In addition, ChM‑I inhibited cell invasion and migration in vitro and suppressed osteosarcoma cell growth significantly in vivo. In conclusion, ChM‑I directly suppressed the proliferation and growth of osteosarcoma cells in an anchorage‑independent manner, and may therefore be a promising drug for the treatment of osteosarcoma.

Long non-coding RNA MALAT1 for promoting metastasis and proliferation by acting as a ceRNA of miR-144-3p in osteosarcoma cells

Long non-coding RNAs (lncRNAs) are involved in various biological processes and diseases including osteosarcoma. Long non-coding RNA metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) is overly expressed in osteosarcoma. But the function and mechanism it works on in osteosarcoma proliferation and metastasis mediated by Rho associated coiled-coil containing protein kinase 1 (ROCK1) and Rho associated coiled-coil containing protein kinase 2 (ROCK2) remain unclear. In the present study, an elevated MALAT1 was found in osteosarcoma tissues and cell lines, and the elevated MALAT1 was correlated with a poor prognosis in osteosarcoma patients. The functional experiments show that a decreased MALAT1 could remarkably inhibit osteosarcoma cell metastasis and proliferation but induce cell cycle arrest, indicating that MALAT1 functioned as an oncogene in osteosarcoma. Furthermore, we confirmed that MALAT1 and ROCK1/ROCK2 which were targeted by microRNA-144-3p (miR-144-3p) shared the same miR-144-3p combining site. Furthermore, the constructed luciferase assay verified that MALAT1 was a target of miR-144-3p. Additionally, the results of a qRT-PCR demonstrated that MALAT1 and miR-144-3p repressed each other's expression in a reciprocal manner. Finally, we affirmed that an overexpression of MALAT1 inhibited ROCK1/ROCK2 expression and its mediated metastasis and proliferation by working as a competitive endogenous RNA (ceRNA) via miR-144-3p.

In summary, the findings of this study based on the ceRNA theory, combining the research foundation of miR-144-3p, ROCK1 and ROCK2, taking MALAT1 as a new point of study, provided new insights into molecular level proliferation reversal and metastasis of osteosarcoma.

Data errors in the National Hip Fracture Database

Aims

We present an audit comparing our level I major trauma centre’s data for a cohort of patients with hip fractures in the National Hip Fracture Database (NHFD) with locally held data on these patients.

Patients and Methods

A total of 2036 records for episodes between July 2009 and June 2014 were reviewed.

Results

The demographics of nine patients were recorded incorrectly. The rate of incorrect data in operation codes was most significant with overall accuracy of 0.637 (95% CI 0.615 to 0.658). The sensitivity of NHFD coding ranged from 0.250 to 1.000 and the specificity 0.879 to 0.999. The recording of cementation had a sensitivity of 0.932 and specificity of 0.713. The recording of total hip arthroplasty had a sensitivity of 0.739 and specificity of 0.983. The overall accuracy of mortality data was 0.942 (95% CI 0.931 to 0.952), with sensitivity of 0.967 and specificity of 0.419.

Conclusion

This paper highlights the need for local audit of the integrity of data uploaded to the NHFD. Cite this article: Bone Joint J 2016;98-B:1406–9.

Influence of bony resection margins and surgicopathological factors on outcomes in limb-sparing surgery for extremity osteosarcoma

BACKGROUND

Limb-sparing surgery for osteosarcoma requires taking wide bony resection margins while maximizing preservation of native bone and joint. However, the optimal bony margin and factors associated with recurrence and survival outcomes in these patients are not well established.

PROCEDURE

We conducted a retrospective review of outcomes in children and adolescents with newly diagnosed osteosarcoma from 1986 to 2012, where bony resection margins for limb-sparing surgeries were decreased serially from 5 to 1.5 cm. The association between bony margins and other surgicopathological factors with survival and recurrence outcomes was determined.

RESULTS

In 181 limb-sparing surgeries in 173 patients, planned and actual bony resection margins were not significantly associated with local recurrence-free survival (LRFS), event-free survival (EFS), and overall survival (OS)-at median 5.8 years follow-up, decreasing planned bony resection margins from 5 to 1.5 cm did not significantly decrease survival outcomes. Multivariable analysis showed that the presence of distant metastases at diagnosis was associated with decreased LRFS, EFS, and OS (P = 0.002, 0.005, and <0.0001, respectively). Post-chemotherapy tumor necrosis ≤90% was associated with decreased EFS and OS (P = 0.001 and 0.022, respectively). Earlier years of treatment and pathologic fractures were associated with decreased OS only (P = 0.018 and 0.008, respectively); previous cancer history and male gender were associated with decreased EFS only (P = 0.043 and 0.023, respectively).

CONCLUSION

We did not observe significant increase in adverse survival outcomes with reduction of longitudinal bony resection margins to 1.5 cm. Established prognostic factors, particularly histologic response to chemotherapy and metastases at diagnosis, remain relevant in limb-sparing patients. Pediatr Blood Cancer 2015;62:246-251. © 2014 Wiley Periodicals, Inc.