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Palmerini E, Meazza C, Tamburini A, Bisogno G, Ferraresi V, Asaftei SD, Milano GM, Coccoli L, Manzitti C, Luksch R, Serra M, Gambarotti M, Donati DM, Scotlandi K, Bertulli R, Favre C, Longhi A, Abate ME, Perrotta S, Mascarin M, D'Angelo P, Cesari M, Staals EL, Marchesi E, Carretta E, Ibrahim T, Casali PG, Picci P, Fagioli F, Ferrari S. Phase 2 study for nonmetastatic extremity high-grade osteosarcoma in pediatric and adolescent and young adult patients with a risk-adapted strategy based on ABCB1/P-glycoprotein expression: An Italian Sarcoma Group trial (ISG/OS-2). Cancer 2022; 128:1958-1966. [PMID: 35201621 PMCID: PMC9305236 DOI: 10.1002/cncr.34131] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/27/2021] [Accepted: 01/07/2022] [Indexed: 12/02/2022]
Abstract
Background According to retrospective osteosarcoma series, ABCB1/P‐glycoprotein (Pgp) overexpression predicts for poor outcomes. A prospective trial to assess a risk‐adapted treatment strategy using mifamurtide in Pgp+ patients was performed. Methods This was a phase 2, multicenter, uncontrolled trial including patients 40 years old or younger with nonmetastatic extremity high‐grade osteosarcoma stratified according to Pgp expression. All patients received high‐dose methotrexate, doxorubicin, and cisplatin (MAP) preoperatively. In Pgp+ patients, mifamurtide was added postoperatively and combined with MAP for a good histologic response (necrosis ≥ 90%; good responders [GRs]) or with high‐dose ifosfamide (HDIFO) at 3 g/m2/d on days 1 to 5 for a histologic response < 90% (poor responders [PRs]). Pgp– patients received MAP postoperatively. After an amendment, the cumulative dose of methotrexate was increased from 60 to 120 g/m2 (from 5 to 10 courses). The primary end point was event‐free survival (EFS). A postamendment analysis was performed. Results In all, 279 patients were recruited, and 194 were included in the postamendment analysis: 70 (36%) were Pgp–, and 124 (64%) were Pgp+. The median follow‐up was 51 months. For Pgp+ patients, 5‐year EFS after definitive surgery (null hypothesis, 40%) was 69.8% (90% confidence interval [CI], 62.2%‐76.2%): 59.8% in PRs and 83.7% in GRs. For Pgp– patients, the 5‐year EFS rate was 66.4% (90% CI, 55.6%‐75.1%). Conclusions This study showed that adjuvant mifamurtide, combined with HDIFO for a poor response to induction chemotherapy, could improve EFS in Pgp+ patients. Overall, the outcomes compared favorably with previous series. Mifamurtide and HDIFO as salvage chemotherapy are worth further study. The expression of ABCB1/P‐glycoprotein (Pgp) at diagnosis has been used to stratify patients with high‐grade osteosarcoma. Adjuvant mifamurtide, combined with high‐dose ifosfamide for a poor response to induction chemotherapy, can improve event‐free survival in Pgp+ patients.
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Affiliation(s)
- Emanuela Palmerini
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristina Meazza
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Gianni Bisogno
- Hematology Oncology Division, Department of Women's and Children's Health, University of Padova, Padua, Italy
| | | | | | - Giuseppe M Milano
- Pediatric Oncology Department, Regina Margherita Children's Hospital, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Coccoli
- IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Carla Manzitti
- IRCCS Istituto G. Gaslini-Ospedale Pediatrico, Genoa, Italy
| | - Roberto Luksch
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Massimo Serra
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Gambarotti
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide M Donati
- Third Orthopedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Katia Scotlandi
- Laboratory of Experimental Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rossella Bertulli
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudio Favre
- Azienda Ospedaliera Universitaria A. Meyer, Florence, Italy
| | - Alessandra Longhi
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Massimo E Abate
- Pediatric Oncology, National Medical Specialization Center Santobono-Pausilipon, Napoli, Italy
| | - Silverio Perrotta
- Ematologia ed Oncologia Pediatrica, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Maurizio Mascarin
- AYA Oncology and Pediatric Radiotherapy Unit, IRCCS Centro di Riferimento Oncologico, Aviano, Italy
| | | | - Marilena Cesari
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eric L Staals
- Third Orthopedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | | | - Elisa Carretta
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Toni Ibrahim
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Paolo G Casali
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Franca Fagioli
- Azienda Ospedaliero Universitaria Pisana, Pisa, Italy.,Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Stefano Ferrari
- Osteoncology, Bone and Soft Tissue Sarcomas, and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Palmerini E, Setola E, Grignani G, D’Ambrosio L, Comandone A, Righi A, Longhi A, Cesari M, Paioli A, Hakim R, Pierini M, Marchesi E, Vanel D, Pignochino Y, Donati DM, Picci P, Ferrari S. High Dose Ifosfamide in Relapsed and Unresectable High-Grade Osteosarcoma Patients: A Retrospective Series. Cells 2020; 9:E2389. [PMID: 33142760 PMCID: PMC7692098 DOI: 10.3390/cells9112389] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 01/20/2023] Open
Abstract
Background: The evidence on high-dose ifosfamide (HD-IFO) use in patients with relapsed osteosarcoma is limited. We performed a retrospective study to analyze HD-IFO activity. Methods: Patients with osteosarcoma relapsed after standard treatment [methotrexate, doxorubicin, cisplatin +/- ifosfamide (MAP+/-I)] with measurable disease according to RECIST1.1 were eligible to ifosfamide (3 g/m2/day) continuous infusion (c.i.) days 1-5 q21d. RECIST1.1 overall response rate (ORR) (complete response (CR) + partial response (PR)), progression-free survival at 6-month (6m-PFS), duration of response (DOR), and 2-year overall survival (2y-OS) were assessed. PARP1 expression and gene mutations were tested by immunohistochemistry and next-generation sequencing. Results: 51 patients were included. ORR was 20% (1 CR + 9 PR). Median DOR was 5 months (95%CI 2-7). Median PFS, 6m-PFS, OS, and 2y-OS were 6 months (95%CI 4-9), 51%, 15 months (10-19), and 30%, respectively. A second surgical complete remission (CR2) was achieved in 26 (51%) patients. After multivariate analysis, previous use of ifosfamide (HR 2.007, p = 0.034) and CR2 (HR 0.126, p < 0.001) showed a significant correlation with PFS and OS, respectively. No significant correlation was found between outcomes and PARP1 or gene mutations. Conclusions: HD-IFO should be considered as the standard first-line treatment option in relapsed osteosarcoma and control arm of future trial in this setting.
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Affiliation(s)
- Emanuela Palmerini
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
| | - Elisabetta Setola
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
| | - Giovanni Grignani
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS. St. Provinciale 142, Km 3.95, 10060 Candiolo, Torino, Italy; (G.G.); (Y.P.)
| | - Lorenzo D’Ambrosio
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS. St. Provinciale 142, Km 3.95, 10060 Candiolo, Torino, Italy; (G.G.); (Y.P.)
| | | | - Alberto Righi
- Pathology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.R.); (D.V.)
| | - Alessandra Longhi
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
| | - Marilena Cesari
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
| | - Anna Paioli
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
| | - Rossella Hakim
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
| | - Michela Pierini
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
| | - Emanuela Marchesi
- Italian Sarcoma Group, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.M.); (P.P.)
| | - Daniel Vanel
- Pathology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.R.); (D.V.)
| | - Ymera Pignochino
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS. St. Provinciale 142, Km 3.95, 10060 Candiolo, Torino, Italy; (G.G.); (Y.P.)
| | - Davide Maria Donati
- Orthopedic Oncology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Piero Picci
- Italian Sarcoma Group, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.M.); (P.P.)
| | - Stefano Ferrari
- Chemotherapy Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (E.P.); (E.S.); (A.L.); (M.C.); (A.P.); (R.H.); (M.P.); (S.F.)
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