Challenges and opportunities for sarcoma care and research in Latin America: a position paper from the LACOG sarcoma group

As a developing region, Latin America faces unique cancer control and prevention challenges, which are intensified when considering rare cancers, including sarcomas. Sarcomas are a group of malignancies that arise in the connective tissues of the body-such as muscle, fat, nerves, blood vessels, and bones-accounting for a diverse range of tumours that, although rare, require specialized attention. Sarcoma care and research in Latin America require a comprehensive approach that includes deeper epidemiologic knowledge, diagnostic capacity building, access to innovative treatments, increased patient advocacy, and strengthening of clinical research capacity. This article will review current challenges and opportunities for treating patients with sarcoma in Latin America and outline a pathway toward improvement for regional collaborative groups.

Disruption of the HIF-1 pathway in individuals with Ollier disease and Maffucci syndrome

Ollier disease (OD) and Maffucci Syndrome (MS) are rare disorders characterized by multiple enchondromas, commonly causing bone deformities, limb length discrepancies, and pathological fractures. MS is distinguished from OD by the development of vascular anomalies. Both disorders are cancer predisposition syndromes with malignancies developing in ~50% of the individuals with OD or MS. Somatic gain-of-function variants in IDH1 and IDH2 have been described in the enchondromas, vascular anomalies and chondrosarcomas of approximately 80% of the individuals with OD and MS. To date, however, no investigation of germline causative variants for these diseases has been comprehensively performed. To search for germline causative variants, we performed whole exome sequencing or whole genome sequencing of blood or saliva DNA in 94 unrelated probands (68 trios). We found that 7 had rare germline missense variants in HIF1A, 6 had rare germline missense variants in VHL, and 3 had IDH1 variants including 2 with mosaic IDH1-p.Arg132His variant. A burden analysis using 94 probands assigned as cases and 2,054 unrelated individuals presenting no OD- or MS-related features as controls, found that variants in HIF1A, VHL, and IDH1 were all significantly enriched in cases compared to controls. To further investigate the role of HIF-1 pathway in the pathogenesis of OD and MS, we performed RNA sequencing of fibroblasts from 4 probands with OD or MS at normoxia and at hypoxia. When cultured in hypoxic conditions, both proband and control cells showed altered expression of a subset of HIF-1 regulated genes. However, the set of differentially expressed genes in proband fibroblasts included a significantly reduced number of HIF-1 regulated genes compared to controls. Our findings suggest that germline or early post-zygotic variants identified in HIF1A, VHL, and IDH1 in probands with OD and MS underlie the development of the phenotypic abnormalities in a subset of individuals with OD and MS, but extensive functional studies are needed to further confirm it.

Leiomyosarcoma of the great saphenous vein (vena saphena magna) with granular cell change: Report of a superficial neoplasm

The great saphenous vein (GSV) corresponds to the main superficial large-caliber vessel affected by leiomyosarcoma (LMS). Given its superficial location and because signs of vascular origin may not be clinically apparent, LMS of the GSV may be misinterpreted clinically as superficial nonvascular soft tissue mass. Herein, we report a case on the distal portion of the right GSV of a 57-year-old man. The histopathological recognition of a large-caliber vein-associated LMS (with granular cell change) in an incisional biopsy specimen was crucial to guide radiological evaluation and confirmation of a superficial vascular LMS before surgical treatment. Recognizing this entity in small biopsies is important as its surgical treatment and prognosis differ substantially from nonvascular superficial (ie, subcutaneous and dermal) LMSs. In addition, because vascular LMSs can involve long vessel segments, underestimation of extent of disease is a risk. To the best of our knowledge, granular cell change has not been documented in LMS of the GSV.

Is PET-CT an accurate method for the differential diagnosis between chondroma and chondrosarcoma?

The differential diagnosis between chondroma and intraosseous chondrosarcoma is based on imaging and clinical exams, but only a biopsy can confirm diagnosis. The aim of this study was to evaluate the value of PET–CT in differentially diagnosing chondroma and chondrosarcoma. From October 2009 to May 2015, 36 patients with cartilaginous bone lesions in the extremities, 12 (33.3 %) men and 24 (66.6 %) women, were prospectively included in the study. Patients ranged in age from 21 to 68 years, with a mean age of 44 years. Lesions were located in the long bones: in the proximal humerus in 26 (72.2 %) patients, in the femoral shaft in 1 (2.7 %), in the distal femur in 7 (19.4 %), and in the proximal tibia in 2 (5.5 %). The SUVmax value of 2.0 was used to separate between patients submitted to surgery and patients submitted to observation. Among the 36 patients studied, 17 (47.2 %) had SUVmax ≤ 2.0, and they were diagnosed as chondroma and they were treated conservatively. Follow-up ranged from 14 to 76 months, averaging 38 months. Nineteen (52.7 %) patients with SUVmax >2.0 were diagnosed as chondrosarcoma and underwent surgery. The area of the curve, calculated considering the SUV variable as numeric, is estimated in 0.966, with a 95 % confidence interval from 0.906 to 1.000. To evaluate the sensitivity, specificity and positive/negative predictive values, it was built a 2 × 2 table. Significance was set at p < 0.05. According the criteria of maximum sensitivity and specificity, the cut point suggested to SUVmax was 2.2. If we consider this point, it is possible to identify 19 of 36 positive cases to chondroma (52.8 %), it means, all chondrosarcomas of the series. We concluded that PET–CT can be used as an objective and quantitative method of differentiating between chondromas and chondrosarcomas located within the long bones. It represents a complementary examination to standard imaging (X-ray, scintigraphy, CT and MRI) and pathological exams. The SUVmax between 2.0 and 2.2 would be a range area between chondroma and chondrosarcoma and this range can be of value, among others exams, in decide the best treatment for patients with cartilaginous lesions in long bones.

Level of evidence Level I—diagnostic study—prospectively investigating a diagnostic test using a universally applied “gold” standard.

Predictive factors of overall quality of life in advanced cancer patients using EORTC QLQ-C30

OBJECTIVE

To identify which domains/symptoms from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) were predictive of overall quality of life (QoL) in advanced cancer patients.

METHODS

Four hundred and forty seven patients with brain metastases or bone metastases from seven countries were enrolled with regression analysis to determine the predictive value of the QLQ-C30 functional/symptom scores for patient reported overall QoL (question 30), overall health (question 29) and the global health status domain (questions 29 and 30).

RESULTS

Worse role functioning, social functioning, fatigue and financial problems were the most significant predictive factors for worse QoL. In the bone metastases subgroup (n = 400), role functioning, fatigue and financial problems were the most significant predictors. In patients with brain metastases (n = 47), none of the EORTC domains significantly predicted worse QOL.

CONCLUSION

Deterioration of certain QLQ-C30 functional/symptom scores significantly contributes to worse QoL, overall health and global health status.

Determinants of quality of life in advanced cancer patients with bone metastases undergoing palliative radiation treatment

PURPOSE

Assessment of health-related quality of life (HRQOL) is critical to effective delivery of palliative care in patients with advanced cancer. The current study analyzes relationships between baseline social determinants of health and medical factors, and self-reported HRQOL in patients with bone metastases receiving palliative radiotherapy.

METHODS AND MATERIALS

Advanced cancer patients referred for radiotherapy treatment of bone metastases completed the EORTC QLQ-C30 questionnaire in multiple outpatient clinics internationally. Demographics and social determinants were collected as baseline information. Univariate and Bonferroni-adjusted multivariate linear regression analyses were used to detect significant correlations between baseline determinants and different HRQOL domains.

RESULTS

Karnofsky Performance Status (KPS) was correlated with better physical (p = 0.0002), role (p < 0.0001), emotional (p < 0.0001), and social (p < 0.0001) functioning, and global health scores (p = 0.0015) and predicted lower symptom scores for fatigue (p < 0.0001), pain (p < 0.0001), appetite loss (p < 0.0001), and constipation (p < 0.0001). Increased age was predictive of better social functioning (p < 0.0001) and less insomnia (p = 0.0036), higher education correlated with better global health status (p = 0.0043), and patients who were employed or retired had improved physical functioning (p = 0.0004 and p = 0.0030, respectively) and less financial challenges compared to patients who were unemployed (p = 0.0005).

CONCLUSIONS

Baseline KPS had the greatest influence on EORTC QLQ-C30 domain scores. Age, education level, and employment status had significant impacts, although on fewer domains. Further studies that investigate baseline determinants are worthwhile to clarify relationships in order to care for patients more effectively at the end of life.

An international prospective study establishing minimal clinically important differences in the EORTC QLQ-BM22 and QLQ-C30 in cancer patients with bone metastases

PURPOSE

Quality of life (QOL) is frequently an endpoint in clinical trials involving patients with advanced cancer. Statistical significance of minimal differences can be achieved with sufficient sample size, yet the actual clinical relevance is unknown. The purpose of this study was to establish the minimal clinically important difference (MCID) for the European Organisation for Research and Treatment of Cancer (EORTC) bone metastases module (EORTC QLQ-BM22).

METHODS

Patients with bone metastases across seven countries were prospectively enrolled in a trial validating the EORTC QLQ-BM22 and completed the QLQ-BM22 and core measure (QLQ-C30) at baseline and 1-month follow-up. MCIDs were calculated for each QOL scale for both improvement and deterioration using both an anchor- (performance status) and distribution-based approach.

RESULTS

A total of 93 patients completed both baseline and follow-up QOL and had recorded performance status at both intervals. Statistically significant meaningful differences were seen in seven scales. There were improvements of 30.5 (95 % confidence interval, 9.0 to 52.0), 20.1 (7.1 to 33.2), 30.5 (13.8 to 47.3) and 19.6 (5.0 to 34.3) in the pain, painful site, painful characteristic and functional interference scales, respectively, demonstrated clinical relevance. Decreases of 12.4 (0.3 to 24.6), 22.4 (11.8 to 32.9) and 13.5 (1.9 to 25.1) were required to represent clinically relevant deterioration in emotional functioning, global health status and financial issues, respectively. Minimal differences for improvement were closest to 0.5 standard deviations (SD) while for deterioration, closer to 0.3 SD on the QLQ-BM22.

CONCLUSION

Identification of requirements for clinical significance can assist in determining the relevance of QOL changes after treatment and in sample size determination in future trials. Our study is limited by the small sample size. Future studies should continue to determine MCID and confirm our findings using a variety of appropriate anchors and in a larger sample.

Large and round tumor nuclei in osteosarcoma: good clinical outcome

Osteosarcoma is the most frequent primary malignant bone tumor. Distinct histological features are distinguishable based on the morphology of the tumor. Differences in nuclei size and shape are often observed in osteosarcoma reflecting its broad histopathological heterogeneity. This study explores the relevance of two nuclear parameters in osteosarcoma: large area and round shape. Computerized nuclear morphometry was performed in 56 conventional osteosarcoma preoperative biopsies. The mean patient follow-up time was 35.1 months. Based on the nuclear area, no significant difference (P = 0.09) in overall survival between patients with large (> 42.5 μm(2)) and small (< 42.5 μm(2)) tumor nuclei was found. However, when cases with large and round nuclei were analyzed jointly (> 42.5 μm(2) and coefficient of nuclear roundness > 0.7), these two parameters together were likely to be a predictive factor (P = 0.05). Osteosarcoma patients with large and round tumor nuclei had a better outcome than patients with small and polymorphic (ovoid or spindle-shaped) nuclei. In this study, nuclear morphometry proved to be a useful tool to shed light on the biology of osteosarcoma showing that some morphometric parameters can be easily applied to help identifying patients with a good prognosis.

O uso de espaçadores com antibiótico no tratamento das infecções em endopróteses de joelho

OBJETIVO: O objetivo do estudo é avaliar a utilização dos espaçadores de cimento acrílico com antibiótico no tratamento das infecções em endopróteses não convencionais de joelho. MÉTODO: Desde de 2004 foram tratados sete pacientes (seis pacientes operados no nosso serviço e um paciente que havia sido submetido a cirurgia primária do tumor em outro serviço) com infecção peri-endoprótese não convencional de joelho. Todos pacientes foram submetidos a retirada da endoprótese e reconstrução com espaçador com cimento acrílico com antibiótico. Todos os pacientes foram monitorados clínica e laboratorialmente quanto ao controle da evolução, sendo considerados aptos para a revisão e recolocação de endoprótese após 06 (seis) meses sem sinais infecciosos RESULTADOS: Notamos um discreto predomínio do do processo infeccioso nas próteses realizadas na tíbia proximal em comparação com o fêmur distal (57,1% x 42,9%). O seguimento médio dos pacientes foi 68,2 meses. Durante o seguimento, um paciente faleceu devido a doença de base. Dos sete pacientes, 6 foram considerados curados e um persistiu com sinais e sintomas de infecção. CONCLUSÃO: Os resultados obtidos até o momento tem motivado a continuidade deste método de tratamento.

Results of the Brazilian Osteosarcoma Treatment Group Studies III and IV: prognostic factors and impact on survival

PURPOSE

To evaluate the impact of chemotherapy and surgery on the outcome of osteosarcoma (OS) of the extremities and to identify prognostic factors in Brazilian patients.

PATIENTS AND METHODS

A total of 225 patients with metastatic and nonmetastatic OS of the extremities were enrolled and assessed in two consecutive studies designed and implemented by the Brazilian Osteosarcoma Treatment Group.

RESULTS

The 5-year survival and event-free survival rates for the 209 assessable patients were 50.1% and 39%, respectively; for the 178 patients with nonmetastatic disease at diagnosis, the rates were 60.5% and 45.5%, respectively. The multivariate analysis showed that the following variables were associated with a shorter survival: metastases at diagnosis (P < .001), necrosis grades 1 and 2 (P = .046), and tumor size (P = .0071).

CONCLUSION

The overall 5- and 10-year survival rates were lower than the rates reported in North American and European trials. A pattern of advanced disease at diagnosis was often present, with a high proportion of patients having metastases (20.8%) and large tumor size (42.9%). However, these features were not necessarily associated with longer duration of prediagnostic symptoms. These findings were considered in the strategic planning of the current Brazilian cooperative study, with the aim of improving survival and quality of life of a large number of patients with OS.

Use of the Ilizarov external fixator in the treatment of patients with Ollier's disease

The authors present the results of treatment of 10 patients with Ollier's disease using the Ilizarov technique. The Ilizarov device was used to treat leg length discrepancy and to enhance the conversion of chondroma cartilage into normal mature bone, with no curettage and bone grafting. The mean duration of treatment was 9.4 months. This technique was highly efficient in treating the disease. It led to conversion of the abnormal cartilage into histologically mature bone in all patients. Some complications were seen, such as decreased knee mobility, which required prolonged use of the device. The Ilizarov technique is successful in treating patients with Ollier's disease despite some complications and the difficulty in using the technique.

Epiphyseal plate involvement in osteosarcoma

Fourteen boys (56%) and 11 girls (44%) 4 to 17 years of age (mean, 12.2 years) who had osteosarcoma and open epiphyseal plates were studied. A possible correlation between transepiphyseal spread of osteosarcoma and radiologic and histopathologic findings was investigated. Epiphyseal plate invasion was detected radiologically in only 11 patients (44%), whereas histopathologic examination showed transepiphyseal extension in 21 patients (84%). The authors conclude that the epiphyseal plate is not a barrier against tumor growth and strongly recommend that limb salvage surgery preserving the epiphysis be planned carefully.