Prognostic stratification of patients with non-metastatic osteosarcoma may improve the clinical management and the design of clinical trials.

Data from 773 patients [median age 15 years (3-40)] treated at our Institute from 1983 to 2000 with high-dose methotrexate, cisplatin, doxorubicin and ifosfamide (neoadjuvant chemotherapy) were analyzed. After multivariate analysis including age, site, tumour volume (cut-off 200 mL), serum LDH and Alkaline Phosphatase (SAP), histology (osteoblastic and chondroblastic vs others), high LDH and SAP, osteoblastic and chondroblastic histotypes resulted independent prognostic factors of DFS.

Patients were grouped according to a score from 0 (absence) to 3 (one to 3 adverse factors). The scoring system was implemented by the addition of PgP expression and grade of chemotherapy-induced necrosis.

A score of 0, 1, 2, 3 was given to 14%, 38%, 32% and 16% of patients respectively.10-year DFS was 80% (95%CI 72-89) for score of 0, 58% (95%CI 52-64) for 1, 53% (95%CI 46-59) for 2 and 40% (95%CI 32-50) for 3 (p= 0.001). PgP expression (168 patients) identified patients with 100% probability of DFS (score of 0 and negative PgP) and patients with 18% (95%CI 52-64) DFS (score of 3 and positive PgP).

Good (GR) and poor responder (PR) patients had the same probability of DFS in case of score of 0 [GR82% (95% CI 72-91), PR79% (95% CI 65-93)] and score of 3 [GR43% (95% CI 32-55) PR36% (95% CI 21-51)]. Different probability of DFS in case of score of 1 [GR64% (95% CI 57-72) PR47% (95% CI 36-59)] and score of 2 [GR63% (95% CI 55-71) PR36% (95% CI 21-51)].

It is possible to stratify outcomes of patients with non metastatic osteosarcoma of the extremity by means of a simple score based on easily available clinical parameters. This scoring system is worth to be validated on larger series.

Aim

Purpose of this study was to review a single Institution experience and results of management of extraskeletal osteosarcoma (OGS), with emphasis on the role of combined treatment consisting of surgery and adjuvant chemotherapy.

Aim

To report late development of sarcomas on sites of previously curetted and grafted benign tumours. Rare cases of development of sarcomas in sites of previous benign lesions are documented, and the development is generally considered secondary to progression of benign lesions, even without radiotherapy.

Introduction: Extraskeletal osteosarcoma is a rare malignant tumor of the soft tissues. Overall, this malignancy has been associated with worse local control and overall survival rates than its skeletal counterpart despite multimodal approach. Purpose of this study was to review a single Institution experience and analyse results of management to identify factors affecting the outcome.

Methods: Retrospective study of 48 patients observed between 1966 and 2007 was undertaken. Of the total, 36 patients were admitted and managed at our Institution while 12 patients were sent for consultation and therefore not included in this study. Clinico-pathologic features and details of treatment of all 36 patients were reviewed and correlated with outcome. Updated follow-up was available in all patients.

Results: There were 21 males and 15 females, mean age was 53.6+/−19.3 years (range 14–84 yrs); 23 patients (63.9%) presented with localised disease while distant metastases were present in 13 patients (36.1%). Surgery consisted of a limb-salvage procedure in 25 patients (69.4%), amputation in 9 patients (25%) and 2 patients were considered inoperable (5.6%). Postoperative radiation therapy was given to 6 patients (16.7%) and multiagent chemotherapy administered to 19 patients (52.8%). At mean follow-up of 5.8 years, 23 patients had died of disease, expected 5 and 10 year overall survival rates were 41% and 31%. Tumor size and age at presentation were the most important predictors of survival while chemotherapy showed a trend towards improved survival in patients with localised disease.

Discussion and Conclusion: Extraskeletal osteosarcoma was associated with substantially worse prognosis than skeletal osteosarcoma despite multimodal management.

Purpose: GSD, also known as massive osteolysis or disappearing bone disease, is rare, characterized by proliferation of vascular channels of hematic and lymphatic origin resulting in progressive distruction of bone. This study about Gorham-Stout disease is a retrospective review of the Rizzoli files with special attention given to treatment and outcome.

Materials and Methods: This study is based on a retrospective analysis of a single institution experience. In the Rizzoli files we found 15 cases of GSD from 1968 to 2008. Two were excluded for insufficient documentation. For 13 cases clinical data, imaging and histology were analysed. Histopatologically benign vascular proliferation of thin-walled endothelial capillaries surrounded by a fibrous stroma is present. Adipose involution of the bone marrow and extreme thinning of bony trabeculae represent other histopatologic features. A final diagnosis was established based on clinical, radiological and histopathologic features, as recommended in the literature. Imaging included X-rays in 11 cases and CT or MRI in 5. All lesions were lytic, with an associated sclerosis in two cases. There was one lesion in four cases, several lesions in the same bone in one, and multiple bones involved in six patients. Primary sites were proximal femur in 7 cases, pelvis in 2, hip and knee, calcaneus, humerus and cervical spine in 1 case each.

Results: Two patients had no treatment, 2 conservative treatment (cast or brace), 5 surgery, 6 medical treatment (byphosphonates, calcitonin, zoledronic acid, interferon, steroids), 1 radiotherapy, 2 selective arterial embolization. Surgery consisted of internal fixation of 4 pathologic fractures and reconstruction of the entire humerus with a double composite allograf in 1. Overall, surgery only in 2 patients, medical treatment only in 4 (1 also embolization), surgery and medical treatment in 2 (1 also embolization), radiotherapy only in 1, conservative treatment in 2. Four patients were lost at follow up. In the remaining 9 patients mean follow up was 17 ys.(min 2, max 30). These 9 patients had the following results: 2 dead, 3 healed, 3 with stable disease, 1 alive with asymptomatic disease at 24 ys.

Conclusions: No clear treatment recommendations were desumed. Surgery is indicated in pathologic fractures or reconstruction of massively destroyed bones, medical treatment and selective embolization are helpful. In the literature prostheses are mostly recommended for reconstructions due to the risk of allografts resorption.

Short intense electrical pulses transiently increase the permeability of the cell membrane, an effect known as electroporation. This can be combined with antiblastic drugs for ablation of tumours of the skin and subcutaneous tissue. The aim of this study was to test the efficacy of electroporation when applied to bone and to understand whether the presence of mineralised trabeculae would affect the capability of the electric field to porate the membrane of bone cells.

Different levels of electrical field were applied to the femoral bone of rabbits. The field distribution and modelling were simulated by computer. Specimens of bone from treated and control rabbits were obtained for histology, histomorphometry and biomechanical testing.

After seven days, the area of ablation had increased in line with the number of pulses and/or with the amplitude of the electrical field applied. The osteogenic activity in the ablated area had recovered by 30 days. Biomechanical testing showed structural integrity of the bone at both times.

Electroporation using the appropriate combination of voltage and pulses induced ablation of bone cells without affecting the recovery of osteogenic activity. It can be an effective treatment in bone and when used in combination with drugs, an option for the treatment of metastases.

Gorham-Stout disease (GSD) is rare, characterized by proliferation of vascular channels resulting in progressive distruction of bone. In the Rizzoli files we found 15 cases of GSD from 1968 to 2008. Two were excluded for insufficient documentation. For 13 cases clinical data, imaging and histology were analysed. Histopathologic features included benign vascular proliferation, vascular pattern of osteolytic angioma, fibro-connective tissue component and bony destruction. A final diagnosis was established based on clinical, radiological and histopathologic features.

Imaging included X-rays in 11 cases and CT or MRI in 5. All lesions were lytic, with associated sclerosis in two cases. There was one lesion only in 4 cases, multiple lesions in the same bone in 1 and multiple bones involved in 6. Primary sites were proximal femur in 7 cases, pelvis in 2, hip and knee, calcaneus, humerus and cervical spine in 1 case each. Two patients had no treatment, 2 conservative treatment (cast or brace), 5 surgery, 6 medical treatment (byphosphonates, calcitonin, zoledronic acid, interferon, steroids), 1 radiotherapy, 2 selective arterial embolization. Surgery consisted of internal fixation of pathologic fractures in 4 patients and reconstruction of the entire humerus with a double composite allograft in 1. Treatment was surgery only in 2 patients, medical treatment in 4 (1 also embolization), surgery and medical treatment in 2 (1 also embolization), radiotherapy only in 1, conservative treatment in 2. Four patients were lost at follow up. Mean follow up was 17 ys.(min 2, max 30) in 9 patients: 2 dead, 3 healed, 3 with stable disease, 1 alive with disease at 24 ys.

No conclusive treatment recommendations are possible; surgery is indicated in pathologic fractures or reconstruction of massively destroyed bones, medical treatment and selective embolization are helpful. In literature prosthetic reconstruction is preferred due to the risk of allografts resorption.

Solitary fibrous tumour (SFT) is a relatively uncommon mesenchymal neoplasm that most frequently arises in the pleura, but is also known to affect extrathoracic sites. About 15 % of SFT’s behave in an aggressive way, giving rise to local recurrence and/or distant metastasis. However, the behaviour of SFT remains unpredictable and due to the rarity of this tumour, it is difficult to define prognostic factors. The purpose of this study was to describe our experience with SFT, trying to define the pathologic features of this rare entity and better understand its clinical behaviour.

We performed a clinicopathologic review of all cases treated for a SFT at the Istituto Ortopedico Rizzoli in Bologna, between 1996 and 2008. We included 24 patients, nine males and fifteen females, ranging in age from 22 to 82 years (median 43.5 years). The anatomical sites involved were: the thigh (12 cases), shoulder region (four cases), gluteus (three cases), foot (two cases), extrapleural thoracic wall (two cases), and the lower leg (one case).

The tumour was > 5 cm in 15 cases, ranging in diameter from 2.5 cm to 18 cm (median 7.5 cm). Pain and swelling were the most frequently reported symptoms at presentation, with a mean duration of symptoms of 10 months. All patients were treated by excisional surgery (wide margins in 11, marginal margins in 13). Three patients had undergone pre-operative radiotherapy (44Gy) and one of these had also adjuvant radiotherapy after marginal excision of the tumour. Six tumours showed at least one atypical histologic feature (moderate to marked cytological atypia, extensive tumor necrosis, ≥ four mitoses per ten high-power fields, or infiltrative margins). On immunohistochemistry, 21 cases were positive for CD-34, 10 for CD-99, 17 for vimentin, three for CD-31, four for actin and one for S-100. Subsequent follow-up (average 33 months, range 5 to 112 months) revealed tumour relapse in only one case: a bone metastasis after 36 months of follow-up. The initial lesion was considered a large, deep, malignant SFT of the thigh, treated with wide surgical excision.

In the current review, including 24 extrathoracic solitary fibrous tumours, all lesions but one had a benign course. Nevertheless, this entity has a potential to recur or metastasize, and therefore careful long-term follow-up is necessary for all patients, even after wide excisional surgery. Although specific prognostic factors are yet to be defined, a high degree of suspicion for malignant behaviour is warranted for those cases in which atypical histologic features are present, particularly in the context of a deep tumor > 5cm in diameter.

Giant cell tumour of bone (GCTB) is a primary tumour of bone characterised by a proliferation of mononuclear stromal cells and infiltrating macrophages and osteoclast-like giant cells. GCTB has a variable and unpredictable course and can produce metastatic lesions, mostly in the lungs, in up to 3% of cases. Whether these represent tumour implants rather than true neoplastic secondaries is uncertain. In this study, we analysed morphological and immunophenotypic features of primary GCTBs which metastasised to the lung as well as the metastatic lesions themselves in order to determine if these would provide a clue as to the mechanism of lung metastasis in GCTB.

17 cases of primary GCTB which metastasised to the lung and the lung metastases in these cases were obtained from IOR, Bologna. Morphologically, primary tumours showed variable features, often containing both giant cell-rich and mononuclear stromal cell-rich areas. Mononuclear cells showed frequent mitotic activity and a degree of nuclear pleomorphism; none of the tumours showed cytological features of malignancy. The tumours were highly vascular and frequently contained dilated thin-walled blood vessels and large areas of haemorrhage. GCTB lung metastases were generally small and contained osteoclast-like giant cells and mononuclear stromal cells which showed typical mitotic activity; cytologically, the metastatic tumours were relatively bland and showed little nuclear pleomorphism. Expression of HLA-DR (an allele of which has been associated with a more aggressive GCTB phenotype) and smooth muscle actin (SMA) was noted in stromal cells in primary and secondary GCTBs; frequently, the same pattern of SMA expression was seen in both primary and secondary lesions. Osteoclasts were vitronectin receptor+, CD14-HLA-DR- in both primary and secondary GCTBs.

Our findings indicate that mononuclear stromal cells in lung metastases of GCTB often recapitulate the immunophenotype of the primary tumours from which they derive. Taken with the morphological finding that many primary GCTBs are highly vascular and contain areas of haemorrhage, it is possible that the lung “secondaries” of GCTB more likely represent tumour implants than true neoplastic metastases.

Forty-six hemangioendotheliomas (HE) of bone treated at Rizzoli from 1985 to 2004 were studied with minimum follow up of 4 years: 19 females and 27 males, mean age 37 years, mean follow-up 9 years, 35 cases unifocal at diagnosis (10 spine – 1 with lung metastasis also- 11 lower limb, 8 upper limb, 6 pelvis) and 11 with multifocal involvement. In 10 patients intralesional surgery was previously performed elsewhere. In 27 patients primarily treated at Rizzoli with unifocal localization, surgery was used in 15 cases, surgery and radiotherapy in 7, surgery with radio/chemotherapy in 1 and no surgery in 4 (2 radiotherapy, 1 radio/chemotherapy and 1 embolization). Eight unifocal patients already treated elsewhere had surgery in 3 cases, surgery and radiotherapy in 3, surgery with radio/chemotherapy in 1 and surgery plus chemotherapy in 1. Three of the unifocal cases had further bone involvement subsequently. Nine multifocal patients primarily treated at Rizzoli had surgery in 4 cases, surgery and radiotherapy in 4, surgery with radio/chemotherapy in 1. The 2 previously treated multifocal HE had 1 surgery and 1 radiotherapy.

Six patients died: 3 of disease, 1 of radio-induced osteosarcoma, 2 of different disease. Two patients are AWD. Of remaining 40 patients, 26 are NED (mean follow up 9 years), 11 NED after treatment of recurrence, 1 NED after treatment of radio-induced sarcoma. No lung metastases were diagnosed after treatment. All 10 cases previously treated intralesionally had recurrence. Two of 15 unifocal cases treated with surgery recurred (13%). None of 9 resected unifocal cases previously untreated recurred. Two of 21 pts. with radiotherapy (9.5%) had radio-induced sarcoma.

Surgery is recommended, resection when feasible. Radiotherapy, implying risk of induced sarcoma, should be reserved to multifocal or unresectable cases. Adverse prognostic factor was previous intralesional surgery.

Despite local treatment with systemic chemotherapy in Ewing’s sarcoma family tumours (ESFT), patients with detectable metastases at presentation have a markedly worse prognosis than those with apparently localised disease. We investigated the clinical, pathological and laboratory differences in 888 patients with ESFT, 702 with localised disease and 186 with overt metastases at presentation, seen at our institution between 1983 and 2006.

Multivariate analyses showed that location in the pelvis, a high level of serum lactic dehydrogenase, the presence of fever and a short interval between the onset of symptoms and diagnosis were indicative of metastatic disease. The rate of overt metastases at presentation was 10% without these four risk factors, 22.7% with one, 31.4% with two, and 50% for those with three or four factors. We concluded that in ESFT the site, the serum level of lactic dehydrogenase, fever, and the interval between the onset of symptoms and diagnosis are indicators of tumours having a particularly aggressive metastatic behaviour.