The Prognostic Value of Serum Biomarkers for Survival of Children with Osteosarcoma of the Extremities

Clinical and Pathological Profile of Children and Adolescents with Osteosarcoma

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

Exploiting biochemical data to improve osteosarcoma diagnosis with deep learning

Early and accurate diagnosis of osteosarcomas (OS) is of great clinical significance, and machine learning (ML) based methods are increasingly adopted. However, current ML-based methods for osteosarcoma diagnosis consider only X-ray images, usually fail to generalize to new cases, and lack explainability. In this paper, we seek to explore the capability of deep learning models in diagnosing primary OS, with higher accuracy, explainability, and generality. Concretely, we analyze the added value of integrating the biochemical data, i.e., alkaline phosphatase (ALP) and lactate dehydrogenase (LDH), and design a model that incorporates the numerical features of ALP and LDH and the visual features of X-ray imaging through a late fusion approach in the feature space. We evaluate this model on real-world clinic data with 848 patients aged from 4 to 81. The experimental results reveal the effectiveness of incorporating ALP and LDH simultaneously in a late fusion approach, with the accuracy of the considered 2608 cases increased to 97.17%, compared to 94.35% in the baseline. Grad-CAM visualizations consistent with orthopedic specialists further justified the model's explainability.

Diagnostic and Prognostic Role of Neutrophil/Lymphocyte Ratio, Platelet/Lymphocyte Ratio and Lymphocyte/Monocyte Ratio in Pediatric Sarcomas

AIM

The correlation between the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) with prognosis has been observed in different types of adult sarcomas. However, there is insufficient evidence in pediatric tumors. Our study aimed to examine if alterations in these characteristics serve as prognostic indicators in juvenile sarcomas.

METHODS

A cohort group of 138 patients including Ewing sarcoma (n = 62), osteosarcoma (n = 52), and rhabdomyosarcoma (n = 24), the most common pediatric sarcomas diagnosed and treated in our institute between January 2006 and December 2022, were retrospectively evaluated. Pre-treatment values of NLR, PLR, and LMR were calculated for all patients. These values were then evaluated about overall survival (OS) and disease-free survival (DFS), along with other established prognostic variables.

RESULTS

In terms of area under the ROC curve (AUC) values, NLR and LMR in osteosarcoma, NLR and PLR in Ewing sarcoma, and NLR in rhabdomyosarcoma were statistically significant. In patients with osteosarcoma (OS), NLR ≥ 3 and LMR < 5.3 were found to be an independent prognostic factor for overall survival in multivariate analysis (HR, 2, 95% [CI], 1.1-8; P = 0.049 and HR, 2.1, 95% [CI], 1.3-8.3; P = 0.046, respectively). Furthermore, positive surgical margins were found to be an independent prognostic factor in OS patients (HR, 2.7, 95% CI, 1-9.2; P = 0.045). In multivariate analysis, cut-off values of NLR ≥ 2.1 and PLR ≥ 194 were determined as prognostic factors for overall survival in patients with Ewing sarcoma (ES) (HR, 2.2, 95% [CI], 1-6.8; P = 0.048, HR, 3.2, 95% [CI], 1.1-9; P = 0.035, respectively). Metastatic disease was found to be correlated with poorer overall and disease-free survival rates in patients with ES. The hazard ratio for overall survival was 4 (95% confidence interval: 2.1-17.4; P = 0.03), while the hazard ratio for disease-free survival was 2.3 (95% confidence interval: 2-4.9; P = 0.024). In the rhabdomyosarcoma (RMS) group, surgical margin positivity and NLR ≥ 4.6 were associated with worse overall survival rates in univariate analysis (HR, 4, 95% CI, 1.6-27.2; P = 0.029 and HR, 2.2, 95% CI, 1.05-6.9; P = 0.046, respectively).

CONCLUSION

Our study revealed that elevated NLR hurt OS and DFS in patients with osteosarcoma and Ewing sarcoma. Low LMR and high PLR were also associated with poor prognosis in these diseases, even in the presence of heterogeneity. In the rhabdomyosarcoma group, however, none of the markers provided a significant prognostic contribution.

Primary Multi-Systemic Metastases in Osteosarcoma: Presentation, Treatment, and Survival of 83 Patients of the Cooperative Osteosarcoma Study Group

BACKGROUND

To evaluate patient and tumour characteristics, treatment, and their impact on survival in patients with multi-systemic metastases at initial diagnosis of high-grade osteosarcoma. Precedure: Eighty-three consecutive patients who presented with multi-systemic metastases at initial diagnosis of high-grade osteosarcoma were retrospectively reviewed. In cases of curative intent, the Cooperative Osteosarcoma Study Group recommended surgical removal of all detectable metastases in addition to complete resection of the primary tumour and chemotherapy.

RESULTS

Eighty-three eligible patients (1.8%) were identified among a total of 4605 individuals with high-grade osteosarcoma. Nine (10.8%) of these achieved complete surgical remission, of whom seven later had recurrences. The median follow-up time was 12 (range, 1-165) months for all patients. Actuarial event-free survival after 1, 2, and 5 years was 9.6 ± 3.2%, 1.4 ± 1.4%, and 1.4 ± 1.4%, and overall survival was 54.0 ± 5.6%, 23.2 ± 4.9%, and 8.7 ± 3.3%. In univariate analyses, elevated alkaline phosphatase before chemotherapy, pleural effusion, distant bones as metastatic sites, and more than one bone metastasis were negative prognostic factors. Among treatment-related factors, the microscopically complete resection of the primary tumour, a good response to first-line chemotherapy, the macroscopically complete resection of all affected tumour sites, and local treatment (surgery ± radiotherapy) of all bone metastases were associated with better outcomes. Tumour progression under first-line treatment significantly correlated with shorter survival times.

CONCLUSION

The outlook for patients with multi-systemic primary metastases from osteosarcoma remains very poor. The utmost importance of surgical resection of all tumour sites was confirmed. For unresectable bone metastases, radiotherapy might be considered. In the patient group studied, standard chemotherapy was often insufficiently effective. In the case of such advanced disease, alternative treatment options are urgently required.