Osteosarcoma is the most commonly occurring bone cancer in children and adolescents. Unfortunately, treatment failures are common due to the development of chemoresistance, for which the underlying molecular mechanisms remain unclear. In this study the investigators implicate the DNA binding protein HMGB1, which also exerts immuno-regulatory effects in its secreted form, in the development of drug resistance in osteosarcoma. Anti-cancer agents including doxorubicin, cisplatin, and methotrexate each induced HMGB1 upregulation in human osteosarcoma cells and RNAi-mediated knockdown of HMGB1 restored the chemosensitivity of osteosarcoma cells in vivo and in vitro. Mechanistic investigation revealed that HMGB1 increased drug resistance by inducing autophagy, an intracellular self-defense mechanism known to confer drug resistance. They found that HMGB1 bound to the autophagy regulator Beclin1 and regulated the formation of the Beclin1-PI3KC3 complex that facilitates autophagic progression. Additionally, they found that interaction between HMGB1 and Beclin1 relied upon the autophagic complex ULK1-mAtg13-FIP200. Therefore, through its role as a regulator of autophagy, HMGB1 is a critical factor in the development of chemoresistance, and it offers a novel target for improving osteosarcoma therapy.

Stereotactic Body Radiotherapy for Pulmonary Metastases From Soft-Tissue Sarcomas: Excellent Local Lesion Control and Improved Patient Survival

Patients with pulmonary metastases (PM) from soft-tissue sarcomas (STS) have historically been treated with surgery and/or chemotherapy. Since 2001, the authors of this paper have treated PM with stereotactic body radiation therapy (SBRT). They postulated that SBRT for PM from STS would yield excellent local control (LC) and overall survival (OS). Fifty-two patients with PM from STS, diagnosed between 1990 and 2006 at the University of Rochester, were retrospectively reviewed. Most patients received multimodality treatment comprising of surgery, chemotherapy, and/or radiation. SBRT used the Novalis ExacTrac patient positioning platform, vacuum bag immobilization, and relaxed end-expiratory breath hold techniques. Results were as follows: Leiomyosarcoma (23%), malignant fibrous histiocytoma (19%), and synovial sarcoma (15%) were the most common histologies. Forty-eight percent initially presented with PM, whereas 52% developed PM at a median of 0.7 (0.3–7.3) years after initial diagnosis. Median follow-up from diagnosis of PM was 0.9 (0.3–7.3) years. Fifteen patients underwent SBRT to 74 lesions. Median number of lesions treated was 4 (1–16) per patient and 3.5 (1–6) per session. Preferred dose and fractionation was 50 Gy in 5 Gy fractions. Three-year LC was 82%. No patients experienced Grade ≥3 toxicity. Median OS was 2.1 (0.8–11.5) years for patients treated with SBRT, and 0.6 (0.1–7.8) years for those who never received SBRT (p = 0.002). Conclusions: SBRT provides excellent LC of PM and may extend OS. SBRT should be considered for all patients with PM from STS, particularly those who are not surgical candidates. Further investigation is warranted to establish criteria for the use of SBRT for STS patients with PM.

A functional, new short isoform of Death Receptor 4 in Ewing's sarcoma cell lines may be involved in TRAIL sensitivity/resistance mechanisms

Ewing's sarcoma (ES) is a high-grade neoplasm arising in bones of children and adolescents. Survival rate decreases from greater than 50% to only 20% after 5 years for patients not responding to treatment or presenting metastases at diagnosis. TNF-related apoptosis-inducing ligand (TRAIL), which has strong antitumoral activity, is a promising therapeutic candidate. In this study to address TRAIL sensitivity, 7 human ES cell lines were used. Cell viability experiments (XTT assay) showed that 4 out of the 7 ES cell lines were resistant to TRAIL. Western-blotting and flow cytometry analyses revealed that DR5 was uniformly expressed by all ES cell lines whereas DR4 levels were higher in sensitive cell lines. In TRAIL-sensitive TC71 cells, knockdown of TNFRSF10A /DR4 by shRNA was associated with a loss of sensitivity to TRAIL in spite of DR5 presence. Interestingly, the investigators identified a new transcript variant that results from an alternative splicing and encodes a 310 amino acid protein which corresponds to the 468 aa of DR4 original isoform but truncated of aa 11-168 within the extracellular TRAIL-binding domain. According to modeling studies, the contact of this new DR4 isoform (bDR4) with TRAIL appeared largely preserved. The overexpression of bDR4 in a TRAIL-resistant cell line restored TRAIL sensitivity. TRAIL re-sensitization was also observed after c-FLIP knockdown by shRNA in two TRAIL-resistant cell lines as shown by XTT assay and caspase-3 assay. The results presented in this study demonstrated that DR4, both as the complete form or as its new short isoform, is involved in TRAIL sensitivity in ES.

Intragenic DNA methylation: implications of this epigenetic mechanism for cancer research

Epigenetics is the study of all mechanisms that regulate gene transcription and genome stability that are maintained throughout the cell division, but do not include the DNA sequence itself. The best-studied epigenetic mechanism to date is DNA methylation, where methyl groups are added to the cytosine base within cytosine–guanine dinucleotides (CpG sites). CpGs are frequently clustered in high density (CpG islands (CGIs)) at the promoter of over half of all genes. Current knowledge of transcriptional regulation by DNA methylation centres on its role at the promoter where unmethylated CGIs are present at most actively transcribed genes, whereas hypermethylation of the promoter results in gene repression. Over the last 5 years, research has gradually incorporated a broader understanding that methylation patterns across the gene (so-called intragenic or gene body methylation) may have a role in transcriptional regulation and efficiency. Numerous genome-wide DNA methylation profiling studies now support this notion, although whether DNA methylation patterns are a cause or consequence of other regulatory mechanisms is not yet clear. This review article examines the evidence for the function of intragenic methylation in gene transcription, and discusses the significance of this in carcinogenesis and for the future use of therapies targeted against DNA methylation.

Prognosis for primary retroperitoneal sarcoma survivors - A conditional survival analysis

The AJCC staging system and post-operative nomograms use patient and tumor characteristics to provide prognostic estimates after resection of retroperitoneal sarcoma (RPS). While these variables help to predict survival at the time of diagnosis and resection, the applicability of these prognostic factors to survivors of RPS remains unknown. The investigators in this study hypothesized that the variables evaluated in the current staging system and post-operative nomograms would have limited ability to predict conditional survival in patients surgically treated for RPS. A retrospective study was conducted using National Cancer Institute-sponsored tumor registries. They identified 1,199 patients who underwent surgical resection for non-metastatic RPS from 1988 to 2007. Conditional survival was defined as time-specific estimates conditioned on living a certain number of years post-diagnosis. Cox proportional hazards regression was used to assess the impact of various factors on sarcoma-specific survival (SSS) at baseline and up to 5 years after diagnosis. Results were as follows: Older age, male gender, histologic subtype, and high tumor grade predicted worse SSS at the time of diagnosis. After 1 year of survival, older age, male gender, and histologic subtype were no longer significant predictors of conditional survival. Only high grade tumors remained a significant predictor of worse prognosis after 5 years of survival (HR 1.95). Conclusions: This population-based study demonstrates that the factors which are predictive of survival at baseline lose significance after one year of survival. Conditional survival estimates allow clinicians to provide survivors with more meaningful prognostic estimates that may impact surveillance schedules and streamline adjuvant therapy decisions and design of future clinical trials.

Impact of Postoperative Radiation on Survival for High-grade Soft Tissue Sarcoma of the Extremities After Limb Sparing Radical Resection

The purpose of this study was to use the Surveillance, Epidemiology, and End Results (SEER) Database to analyze the impact of postoperative radiation after limb sparing surgery for high-grade extremity soft tissue sarcomas (STS). The authors identified patients, aged 20 to 79, who were diagnosed between 1988 and 2006 with high-grade STS of the extremities and underwent radical limb sparing surgery with or without postoperative external beam radiation. Kaplan-Meier and Cox regression analyses were performed to evaluate the effect of postoperative external beam radiation therapy on overall survival (OS) and disease-specific survival (DSS). Results were as follow: A total of 983 patients met the selection criteria: 788 (80.2%) received postoperative radiation and 195 (19.8%) underwent surgery alone. For the whole cohort, there were no differences between the groups in OS (P=0.06) or DSS (P=0.20). On subgroup analysis, for tumors ≤5 cm there remained no significant differences in OS (P=0.8) or DSS (P=0.93). However, for tumors >5 cm the 3-year OS improved with the addition of postoperative radiation from 55.6% to 73.4% (P<0.001). Similarly, the 3-year DSS improved from 68.1% to 80.6% (P=0.005). Conclusions: Because of the retrospective nature of this study and inherent limitations of the SEER database, a large prospective study is needed to further elucidate the relationship between postoperative radiation and survival. However, these data do support the use of adjuvant radiation for patients with high-grade extremity STS measuring >5 cm.

Cancer Genomics: Technology, Discovery, and Translation

In recent years, the increasing awareness that somatic mutations and other genetic aberrations drive human malignancies has led us within reach of personalized cancer medicine (PCM). The implementation of PCM is based on the following premises: genetic aberrations exist in human malignancies; a subset of these aberrations drive oncogenesis and tumor biology; these aberrations are actionable (defined as having the potential to affect management recommendations based on diagnostic, prognostic, and/or predictive implications); and there are highly specific anticancer agents available that effectively modulate these targets. This article highlights the technology underlying cancer genomics and examines the early results of genome sequencing and the challenges met in the discovery of new genetic aberrations. Finally, drawing from experiences gained in a feasibility study of somatic mutation genotyping and targeted exome sequencing led by Princess Margaret Hospital–University Health Network and the Ontario Institute for Cancer Research, the processes, challenges, and issues involved in the translation of cancer genomics to the clinic are discussed.

Cancer immunotherapy comes of age

Activating the immune system for therapeutic benefit in cancer has long been a goal in immunology and oncology. After decades of disappointment, the tide has finally changed due to the success of recent proof-of-concept clinical trials. Most notable has been the ability of the anti-CTLA4 antibody, ipilimumab, to achieve a significant increase in survival for patients with metastatic melanoma. In the context of advances in the understanding of how tolerance, immunity and immunosuppression regulate antitumour immune responses together with the advent of targeted therapies, these successes suggest that active immunotherapy represents a path to obtain a durable and long-lasting response in cancer patients. This review article summarizes what must happen to elicit a protective immune response to cancer, and why overcoming these barriers has been so difficult.

Oncogene Mutation Profiling of Pediatric Solid Tumors Reveals Significant Subsets of Embryonal Rhabdomyosarcoma and Neuroblastoma with Mutated Genes in Growth Signaling Pathways

In contrast to the numerous broad screens for oncogene mutations in adult cancers, few such screens have been conducted in pediatric solid tumors. To identify novel mutations and potential therapeutic targets in pediatric cancers, the investigators of this study conducted a high-throughput Sequenom-based analysis in large sets of several major pediatric solid cancers, including neuroblastoma, Ewing sarcoma, rhabdomyosarcoma (RMS), and desmoplastic small round cell tumor (DSRCT). They designed a highly multiplexed Sequenom-based assay to interrogate 275 recurrent mutations across 29 genes. Genomic DNA was extracted from 192 neuroblastoma, 75 Ewing sarcoma, 89 RMS, and 24 DSRCT samples. All mutations were verified by Sanger sequencing. Results were as follows: Mutations were identified in 13% of neuroblastoma samples, 4% of Ewing sarcoma samples, 21.1% of RMS samples, and no DSRCT samples. ALK mutations were present in 10.4% of neuroblastoma samples. The remainder of neuroblastoma mutations involved the BRAF, RAS, and MAP2K1 genes and were absent in samples harboring ALK mutations. Mutations were more common in embryonal RMS (ERMS) samples (28.3%) than alveolar RMS (3.5%). In addition to previously identified RAS and FGFR4 mutations, the investigators report for the first time PIK3CA and CTNNB1 (β-catenin) mutations in 5% and 3.3% of ERMS, respectively. Conclusions: In ERMS, Ewing sarcoma, and neuroblastoma, the investigators identified novel occurrences of several oncogene mutations recognized as drivers in other cancers. Overall, neuroblastoma and ERMS contain significant subsets of cases with nonoverlapping mutated genes in growth signaling pathways. Tumor profiling can identify a subset of pediatric solid tumor patients as candidates for kinase inhibitors or RAS-targeted therapies.

PARP-1 inhibition as a targeted strategy to treat Ewing's sarcoma

Ewing's sarcoma family tumors (ESFTs) are aggressive malignancies which frequently harbor characteristic EWS-FLI1 or EWS-ERG genomic fusions. In this study, the investigators report that these fusion products interact with the DNA damage response protein and transcriptional co-regulator PARP-1. ESFT cells, primary tumor xenografts and tumor metastases were all highly sensitive to PARP1 inhibition. Addition of a PARP1 inhibitor to the second-line chemotherapeutic agent temozolamide resulted in complete responses of all treated tumors in an EWS-FLI1-driven mouse xenograft model of ESFT. Mechanistic investigations revealed that DNA damage induced by expression of EWS-FLI1 or EWS-ERG fusion genes was potentiated by PARP1 inhibition in ESFT cell lines. Notably, EWS-FLI1 fusion genes acted in a positive feedback loop to maintain the expression of PARP1, which was required for EWS-FLI-mediated transcription, thereby enforcing oncogene-dependent sensitivity to PARP-1 inhibition. Together, these findings offer a strong preclinical rationale to target the EWS-FLI1: PARP1 intersection as a therapeutic strategy to improve the treatment of Ewing's sarcoma family tumors.

ACCELERATING PROGRESS AGAINST CANCER -
ASCO’s Blueprint for Transforming Clinical and Translational Cancer Research

This report from the American Society of Clinical Oncology — which represents over 30,000 physicians and other professionals who treat people with cancer and conduct clinical research — provides a high-level blueprint for transforming the translational and clinical cancer research system in the United States. It addresses three main areas in which changes are urgently needed:

1. Establishing a new approach to therapeutic development, driven by our more thorough understanding of cancer biology;

2. Designing smarter, faster clinical trials that are appropriate for the era of molecularly-targeted therapies;

3. Harnessing information technology to seamlessly integrate clinical and translational research and patient care, ensuring that every patient’s experience can inform research and improve care

In each area, the report describes the vision that ASCO believes can become a reality within the next decade and provide an initial blueprint for action. It also outlines the steps ASCO plans to take to achieve this vision, and it invites stakeholders in the cancer research community to join them.

With respect to (1) above, ASCO recommends that the following actions be implemented over the next three years to accelerate therapeutic development and make this vision a reality: (1) Establish clear priorities for therapeutic and prevention strategies and biomarker development; and (2) Incentivize collaboration in therapeutic development.

With respect to (2) above, ASCO recommends: (1) Prioritize trials with the greatest potential benefits for patients; (2) Select study populations based on molecular characteristics; (3) Employ flexible, efficient trial designs; (4) Streamline data requirements for new uses of existing treatments; (5) Train health care providers in clinical research; (6) Improve prioritization of NCI-sponsored trials; (7) Revitalize the NCI Cooperative Group program.

With respect to (3) above, ASCO recommends (1) Standardize oncology Electronic Health Records; (2) Build ASCO’s Rapid Learning System for Cancer Care; (3) Develop industry standards for working with biospecimens; (4) Ensure that advances in Health Information Technology protect patients and researchers.

Survival and prognostic factors in chondrosarcoma - Results in 115 patients with long-term follow-up

There have been few long-term studies on the outcome of chondrosarcoma and the findings regarding prognostic factors are controversial. The authors of this paper examined a homogeneous group of patients with primary central chondrosarcoma of bone who were treated according to a uniform surgical protocol at our institution, in order to determine the factors that influence survival and identify potential improvements to our therapeutic algorithm. They performed a retrospective analysis of 115 patients with primary central chondrosarcoma of bone who presented with localized disease and who had a minimum follow-up of 5 years after diagnosis. 68 tumors were localized in the extremities and 47 in the axial skeleton or pelvis. 59 patients had a high-grade (II and III) and 56 a low-grade (I) tumor. 94 patients underwent surgical resection with adequate (wide or radical) margins, while 21 patients had inadequate (marginal or intralesional) margins. Results were as follows: Tumor grade and localization were found to be statistically significant independent predictors of disease-related deaths in multivariate analysis. The quality of surgical margins did not influence survival. The AJCC staging system was able to predict prognosis in patients with chondrosarcoma of the extremities, but not in those with tumors of the axial skeleton and pelvis. Long-term survival after secondary metastatic disease was only observed when metastases were resected with wide margins. Patients with metastases who received further treatment with conventional chemotherapy, radiotherapy, and/or further surgery had significantly better survival compared to those who received best supportive care. Interpretation: The outcome in patients with primary central chondrosarcoma of bone who present with localized disease is mostly affected by tumor-related parameters.

Sarcoma metastases to the skin - A clinicopathologic study of 65 patients

Sarcoma metastases to the skin are relatively rare, because most involve the lung, liver, or deep soft tissues. The authors of this report examined the distribution and clinical significance of cutaneous and superficial subcutaneous sarcoma metastases. Sixty-five patients with histologically confirmed dermal and superficial subcutaneous sarcoma metastases were identified in pathology files from more than 25,000 patients with sarcoma who were evaluated at The University of Texas M. D. Anderson Cancer Center from 1989 to 2009. Pathology slides and clinical and radiological information were evaluated. Results were as follows: Cutaneous metastases were documented histologically in <0.25% of patients. The mean patient age was 49 years (range, 16-79 years), and there was an equivalent ratio of men to women. The most common source of metastasis was leiomyosarcoma (28 of 65 patients; 43%). The most common region of first skin metastasis was head and neck (33 patients; 51%), and the scalp predominated (25 patients; 38%). The mean time from primary tumor diagnosis to skin metastasis was 48 months (range, 0-166 months). Fifty-three patients (81%) had multiple metastases (skin and other). Among the patients who had complete clinical information available, 31 patients (62%) had other metastases diagnosed before skin involvement, 17 patients (34%) had skin metastases diagnosed first, and 2 patients (4%) had simultaneous presentation. The following clinical outcomes were documented: Twenty-nine patients (45%) died of disease, 24 patients (37%) remained alive with disease, and 12 patients were lost to follow-up. The mean time to death was 80 months (range, 9-224 months) after primary diagnosis, 45 months (range, 5-94 months) after the first metastasis to any site, and 27 months (range, 5-65 months) after the first skin metastasis. Conclusions: Sarcoma metastases to the skin are rare. In this large study, leiomyosarcoma was the most common source, and the scalp was the most frequent site. The majority of patient with skin metastases harbored metastases elsewhere. However, skin was the initial site of metastasis in approximately 1 in 3 patients. Thus, clinical correlation is needed before establishing a diagnosis of primary cutaneous sarcoma, particularly leiomyosarcoma of scalp. Finally, the current results indicated that skin metastasis usually is a late event in sarcoma clinical progression and heralds a poor prognosis.

Post-radiation sarcomas. Clinical outcome of 52 Patients

Previous studies reported on post-radiation sarcomas. However, the incidence, latency from radiation therapy, treatment, and survival has been difficult to evaluate. The authors of this study performed a retrospective, single-institutional study to determine these factors for post-radiation sarcomas. They retrospectively studied 52 patients with post-radiation sarcomas diagnosed and treated from 1985 to 2011. The mean age was 49 years; 45 patients had bone and 7 soft tissue sarcoma. The mean follow-up was 45 months. Survival was analyzed with respect to age at diagnosis, type (bone vs. soft tissue), histology, location (trunk vs. extremities), size, and surgical treatment (resection vs. amputation). Results were as follows: The risk of post-radiation sarcoma was 0.06% at a mean latency of 15 years (3–50 years) after radiation therapy. The most common histology was osteosarcoma followed by malignant fibrous histiocytoma and fibrosarcoma; all sarcomas were high grade. Survival of the patients with post-radiation sarcomas was 85% at 1 year, 51% at 2 years, 48% at 3 years, and 45% at 5 years. Univariate predictor of survival was only the type of the sarcoma. No variable was significant in multivariate analysis. Conclusions: Prognosis of post-radiation sarcomas is poor; the type of the sarcomas is the only significant variable for survival.

Immunotherapeutic Intervention against Sarcomas

Advances in systemic therapy for sarcoma have produced, over the last two decades, relatively short-term benefits for the majority of patient. Among the novel biologic therapeutics that will likely increase our ability to cure human cancer in the years to come, immunotherapy is one of the most promising approaches. While past attempts to use immunotherapy have failed to dramatically shift the paradigm of care for the treatment of patients with sarcoma, major advances in basic and translational research have resulted, in more recent years, in clinical trial activity that is now beginning to generate promising results. This review article argues, however, that in order to move from “proof of principle” to large scale clinical applicability, we need well-designed, multi-institutional clinical trials, along with continuous laboratory research to explore further the immunological characteristics of individual sarcoma subtypes and the consequent tailoring of therapy.

Somatic mosaic IDH1 and IDH2 mutations are associated with enchondroma and spindle cell hemangioma in Ollier disease and Maffucci syndrome

Ollier disease and Maffucci syndrome are non-hereditary skeletal disorders characterized by multiple enchondromas (Ollier disease) combined with spindle cell hemangiomas (Maffucci syndrome). In this paper, the investigators report somatic heterozygous mutations in IDH1 (c.394C>T encoding an R132C substitution and c.395G>A encoding an R132H substitution) or IDH2 (c.516G>C encoding R172S) in 87% of enchondromas (benign cartilage tumors) and in 70% of spindle cell hemangiomas (benign vascular lesions). In total, 35 of 43 (81%) subjects with Ollier disease and 10 of 13 (77%) with Maffucci syndrome carried IDH1 (98%) or IDH2 (2%) mutations in their tumors. Fourteen of 16 subjects had identical mutations in separate lesions. Immunohistochemistry to detect mutant IDH1 R132H protein suggested intraneoplastic and somatic mosaicism. IDH1 mutations in cartilage tumors were associated with hypermethylation and downregulated expression of several genes. Mutations were also found in 40% of solitary central cartilaginous tumors and in four chondrosarcoma cell lines, which will enable functional studies to assess the role of IDH1 and IDH2 mutations in tumor formation.

Comparison of doxorubicin and weekly paclitaxel efficacy in metastatic angiosarcomas

Data regarding the role of anthracyclines and taxanes as first-line treatments of metastatic angiosarcoma are limited. In this study, the records of 117 metastatic angiosarcoma patients who were treated with either doxorubicin or weekly paclitaxel were reviewed. Results were as follows: Seventy-five patients (64%) were treated with weekly paclitaxel and 42 (36%) with single-agent doxorubicin. Patients in the weekly paclitaxel group were older and more frequently had angiosarcomas arising from the skin. In the doxorubicin group, 34 patients were evaluable for response: 2 (6%) had complete response, 8 (23.5%) had partial response, 10 (29.5%) had stable disease, and 14 (41%) had progressive disease. In the weekly paclitaxel group, 68 patients were evaluable for response: 9 (13%) had complete response, 27 (40%) had partial response, 20 (29.5%) had stable disease, and 12 (17.5%) had progressive disease. Objective responses to weekly paclitaxel were more frequent in cutaneous angiosarcomas, whereas tumor location did not impact response to doxorubicin. Median progression-free survival (PFS) was 4.9 months (95% confidence interval [95% CI], 3.9-6.0 months). Median overall survival (OS) was 8.5 months (95% CI, 6.4-10.7 months). On multivariate analysis, ECOG performance status (PS) was the sole independent factor associated with PFS and OS. Conclusions: First-line single-agent doxorubicin and weekly paclitaxel seem to have similar efficacy in metastatic angiosarcomas. Cutaneous angiosarcomas respond favorably to weekly paclitaxel. Best supportive care should be considered in patients with poor PS.

The clinical and functional outcome for patients with radiation-induced soft tissue sarcoma

Radiation-induced soft tissue sarcomas (RI-STS) are rare, and it is believed that they are associated with a poor prognosis. The authors of this report compared the clinical and functional outcomes of adults who had extremity RI-STS with the outcomes of adults with sporadic STS. Forty-four patients who were diagnosed with RI-STS from 1989 to 2009 were identified from 4 prospectively collected databases. Patient demographics, surgical and adjuvant treatment parameters, and oncologic and functional outcomes were evaluated. Results were as follows: The median latent period from irradiation of the primary condition to RI-STS diagnosis was 16 years. The median radiotherapy dose used for the index condition was 45 gray. The median age at RI-STS diagnosis was 56 years. The most common primary diagnoses were breast cancer (36.4%) and lymphoma (34.1%). The most common RI-STS histologies were malignant fibrous histiocytoma (36.4%) and angiosarcoma (18.2%). Forty-two patients underwent surgery, 13 patients received adjuvant radiotherapy, and 8 patients received adjuvant chemotherapy. Systemic metastases occurred in 50% of treated patients (n = 21), and 26% (n = 11) developed local recurrence, the risk of which was lower among patients who received reirradiation (P = .043). The 5-year disease-free interval (DFI) and overall survival (OS) rates for patients with RI-STS who presented without metastasis were 36% and 44%, respectively. Patients who had International Union Against Cancer TNM stage III RI-STS had a significantly worse DFI compared with patients who had stage III sporadic STS (multivariate analysis, P = .051). Eighteen patients with RI-STS underwent functional assessment after surgery, and their results were comparable to those of patients with sporadic STS. Conclusions: Despite aggressive surgical treatment, patients who have RI-STS remain at greater risk of both local and systemic recurrence compared with patients who have sporadic STS, but they can anticipate similar functional outcomes. Reirradiation can be relatively safe and effective if used properly.

Cancer research: past, present and future

Research into cancer over the past 10 years has diverged enormously, partly based on the large number of new technologies that are now at our finger tips. With areas of cancer research so disparate, it is not always easy to identify where the next new findings and therapies might come from. With this in mind, the editors of Nature Reviews Caner asked four leading cancer researchers (Ya Cao, Ronald A. DePinho, Matthias Ernst, and Karen Vousden) from around the world what, in their opinion, we have learnt over the past 10 years and how we should progress in the next 10 years.

A decade of exploring the cancer epigenome — biological and translational implications

This article discusses how the past decade has highlighted the central role of epigenetic processes in cancer causation, progression and treatment. Next-generation sequencing is providing a window for visualizing the human epigenome and how it is altered in cancer. Epigenetic alterations are leading candidates for the development of specific markers for cancer detection, diagnosis and prognosis. The enzymatic processes that control the epigenome present new opportunities for deriving therapeutic strategies designed to reverse transcriptional abnormalities that are inherent to the cancer epigenome. The field is now ripe for the elucidation of the topography of these epigenomes with respect to the precise cellular origins of cancer and how to use epigenetic classifications to better define cancer subcategories. Epigenetic therapies, although clearly now a reality, must be markedly refined and we must better understand how currently available agents are actually producing their clinical efficacies. As the article discusses, we still have much to learn about the best strategies for maximally using such drugs in terms of what combinations to use, how to synchronize them with other treatment modalities and especially whether they can sensitize patients to other agents or be used to overcome the paramount issue of drug resistance. Finally, the many new epigenetic therapeutic targets that are emerging must be intensely and creatively pursued. The future is exciting in terms of the benefits that may emerge for the prevention and management of all types of cancer.

Clinical Trial Participation and Time to Treatment Among Adolescents and Young Adults With Cancer: Does Age at Diagnosis or Insurance Make a Difference?

Because adolescent and young adult (AYA) patients with cancer have experienced variable improvement in survival over the past two decades, enhancing the quality and timeliness of cancer care in this population has emerged as a priority area. To identify current trends in AYA care, the investigators of this study examined patterns of clinical trial participation, time to treatment, and provider characteristics in a population-based sample of AYA patients with cancer. Using the National Cancer Institute Patterns of Care Study, we used multivariate logistic regression to evaluate demographic and provider characteristics associated with clinical trial enrollment and time to treatment among 1,358 AYA patients with cancer (age 15 to 39 years) identified through the Surveillance, Epidemiology, and End Results Program. The results were as follows: 14% of patients age 15 to 39 years had enrolled onto a clinical trial; participation varied by type of cancer, with the highest participation in those diagnosed with acute lymphoblastic leukemia (37%) and sarcoma (32%). Multivariate analyses demonstrated that uninsured, older patients and those treated by nonpediatric oncologists were less likely to enroll onto clinical trials. Median time from pathologic confirmation to first treatment was 3 days, but this varied by race/ethnicity and cancer site. In multivariate analyses, advanced cancer stage and outpatient treatment alone were associated with longer time from pathologic confirmation to treatment. The investigators conclude: The study identified factors associated with low clinical trial participation in AYA patients with cancer. These findings support the continued need to improve access to clinical trials and innovative treatments for this population, which may ultimately translate into improved survival.

Cancer-testis antigens expressed in osteosarcoma identified by gene microarray correlate with a poor patient prognosis

Between 30% to 40% patients with osteosarcoma eventually experience medical failure; and few biomarkers of prognostic significance have been established. High-throughput methods like gene microarray analysis can help to identify molecular biomarkers that are useful for diagnosing osteosarcoma and targeting its treatment. In this study, oligonucleotide microarrays were used to compare expression profiles of osteosarcoma cell lines and osteoblasts. Differentially expressed genes were confirmed by real-time polymerase chain reaction (PCR) analysis. Corresponding proteins were evaluated by flow cytometry and Western blot analysis in osteosarcoma cell lines and by immunohistochemistry in osteosarcoma tissues. The association between staining intensity and clinical outcome was analyzed further. The results were as follows: Cancer-testis antigens, including melanoma antigen family A (MAGEA), chondrosarcoma-associated gene family, member 2 (CSAG2), and preferentially expressed antigen in melanoma (PRAME), were increased significantly in all osteosarcoma cell lines that were analyzed. Real-time PCR examinations indicated that cancer-testis antigen expression was frequent and coordinated in patients with osteosarcoma. The expression of MAGEA was confirmed by Western blot and flow cytometry analyses in osteosarcoma cell lines. Furthermore, immunohistochemical staining analysis suggested that MAGEA expression may be used to predict distant metastasis and poor survival. The adjusted relative risk for lung metastasis was 2.79 (95% confidence interval, 1.12-6.93; P = .028) for MAGEA-positive patients. Five-year survival rates for patients with and without MAGEA expression were 39.6% ± 8.4% and 80% ± 8.9%, respectively (log-rank test; P = .01). The study concludes: The combined use of an oligonucleotide microarray, a clinical database, and a tissue bank was useful for identifying molecular tumor markers. The frequent expression of MAGEA and other cancer-testis antigens in osteosarcoma indicates that they may be useful as diagnostic markers and targets of immunotherapy that warrant further investigation.

Pretreatment and routine echocardiogram monitoring during chemotherapy for anthracycline-induced cardiotoxicity rarely identifies significant cardiac dysfunction or alters treatment decisions

The widespread use of anthracycline chemotherapy has contributed to improved outcomes in children with cancer. The most feared complication of the anthracyclines is cardiotoxicity. Routine echocardiographic monitoring typically is used before, during, and after treatment to minimize cardiotoxicity. The ideal use of screening before and during chemotherapy remains uncertain. This was a retrospective review of children who were treated at a single cancer treatment center over 5 years. The results of all echocardiograms and related clinical decisions were reviewed. The results were as follows: In 356 patients who were identified for review (age range, 3 months to 22 years; mean age, 10 years; median age, 11 years), 991 echocardiograms were reviewed (average, 2.78 echocardiograms per patient; median, 2 echocardiograms per patient; mode, 1; maximum, 11 echocardiograms per patient). Nine abnormal echocardiograms were identified (2.5% of patients and 0.9% of echocardiograms performed). Four echocardiograms were performed during episodes of septic shock, 2 echocardiograms represented false-positive studies after repeat evaluation, and 1 echocardiogram demonstrated mild abnormality of function on the day of surgical resection of a large Wilms tumor. None of the 356 pretreatment echocardiograms altered treatment decisions. In 635 follow-up echocardiograms during treatment, cardiac defects were detected in 2 patients (0.5%). The study concludes: The routine use of echocardiograms to screen for anthracycline-induced cardiac damage before and during chemotherapy rarely identified significant cardiac damage to impact treatment decisions. Improved screening techniques with better discrimination and predictability are needed. Pediatric Oncology cooperative groups should consider a revision of standard monitoring protocols before and during treatment.

Benefit of Surgical Treatment of Lung Metastasis in Soft Tissue Sarcoma

This retrospective study of medical records tested the hypothesis that patients with pulmonary metastatic soft tissue sarcoma benefit from resection, with long-term cure possible. The study used data from an academic tertiary care center - University Hospital, Hamburg-Eppendorf, Germany. Between January 1, 1991, and December 31, 2002, 61 patients (33 men and 28 women; median age at initial diagnosis, 42 years [age range, 18-74 years]) were surgically treated for pulmonary metastases of soft tissue sarcoma. Sternotomy or anterior lateral thoracotomy was performed for metastasectomy, including wedge resection or lobectomy. The effects of clinical and pathologic factors on disease-specific survival were analyzed using the log rank test and a multivariate Cox proportional hazards model. The results were as follows: Primary tumor size was pT1 in 13 patients and pT2 in 48 patients. The differentiation was high in 7 patients, intermediate in 19 patients, and low in 35 patients. The mean number of resected pulmonary metastatic lesions was 5 (range, 1-48). An anterolateral thoracotomy was performed in 39 patients, and sternotomy in 22 patients. There were no significant postoperative complications that required surgical revision. The perioperative mortality was 0%. At a mean follow-up of 60 months, the mean survival time after metastasectomy was 33 months (range, 2-125 months). The 5-year survival was 25%. The number of resected lung metastatic lesions had no prognostic relevance (P=.37). The study concludes: Patients with lung metastasis from soft tissue sarcomas benefit from surgical excision. This treatment has low complication rates and has a favorable influence on the course of the disease. Long-term survival is possible even when recurrent pulmonary disease is resected.

Development of a novel tumor-targeted vascular disrupting agent activated by MT-MMPs

Vascular disrupting agents (VDA) offer a strategy to starve solid tumors of nutrients and oxygen concomitant with tumor shrinkage. Several VDAs have progressed into early clinical trials but their therapeutic value seems to be compromised by systemic toxicity. In this report, the investigators describe the design and characterization of a novel VDA, ICT2588, that is non-toxic until activated specifically in the tumor by membrane-type-1 matrix metalloproteinase (MT1-MMP). HT1080 cancer cells expressing MT1-MMP were selectively chemosensitive to ICT2588, whereas MCF7 cells that did not express MT1-MMP were non-responsive. Preferential hydrolysis of ICT2588 to its active metabolite (ICT2552) was observed in tumor homogenates of HT1080 relative to MCF7 homogenates, mouse plasma and liver homogenate. ICT2588 activation was inhibited by the MMP inhibitor Ilomastat. In HT1080 tumor-bearing mice, ICT2588 administration resulted in formation of the active metabolite, diminution of tumor vasculature and hemorrhagic necrosis of the tumor. The antitumor activity of ICT2588 was superior to its active metabolite, exhibiting reduced toxicity, improved therapeutic index, enhanced pharmacodynamic effect and greater efficacy. Co-administration of ICT2588 with doxorubicin resulted in a significant antitumor response (22.6 day growth delay), which was superior to administration of ICT2588 or doxorubicin as a single agent, including complete tumor regressions. The investigators state that their findings support the clinical development of ICT2588 which achieves selective VDA targeting based on MT-MMP activation in the tumor microenvironment.

Shared Mind: Communication, Decision Making, and Autonomy in Serious Illness

In the context of serious illness, individuals usually rely on others to help them think and feel their way through difficult decisions. To help us to understand why, when, and how individuals involve trusted others in sharing information, deliberation, and decision making, the authors of this paper offer the concept of shared mind—ways in which new ideas and perspectives can emerge through the sharing of thoughts, feelings, perceptions, meanings, and intentions among 2 or more people. They consider how shared mind manifests in relationships and organizations in general, building on studies of collaborative cognition, attunement, and sense making. Then, they explore how shared mind might be promoted through communication, when appropriate, and the implications of shared mind for decision making and patient autonomy. Next, they consider a continuum of patient-centered approaches to patient-clinician interactions. At one end of the continuum, an interactional approach promotes knowing the patient as a person, tailoring information, constructing preferences, achieving consensus, and promoting relational autonomy. At the other end, a transactional approach focuses on knowledge about the patient, information-as-commodity, negotiation, consent, and individual autonomy. Finally, they propose that autonomy and decision making should consider not only the individual perspectives of patients, their families, and members of the health care team, but also the perspectives that emerge from the interactions among them. By drawing attention to shared mind, clinicians can observe in what ways they can promote it through bidirectional sharing of information and engaging in shared deliberation.

Automated Volumetric Growth Plate Measurement Using Magnetic Resonance Imaging for Monitoring Skeletal Toxicity in Children Treated on Investigational Drug Trials

Targeted anticancer agents have been reported to have side effects on the skeletal system such as thickening of the epiphyseal growth plate in preclinical models of juvenile, but not mature, animals. Careful evaluation of skeletal toxicity in the clinical development of targeted therapies for children is required. The authors of this study validated a novel method to measure the growth plate volume using MRI. A semiautomated method of volumetric growth plate measurement was developed on the basis of the differences of pixel intensity of the growth plate from surrounding bone on T1 sagittal MRI. Two observers measured the femoral growth plate volume and thickness on three different days using 20 pediatric knee MRIs obtained at the NIH. Five subjects had two knee MRIs obtained on the same day to evaluate intrasubject reproducibility. The results were as follows: Volumetric analysis showed low intraobserver variability, with the coefficient of variation for the two observers ranging from 0.2% to 6.1%. Interobserver correlation was 0.99, and good concordance was shown with a mean volume difference of −1.8 mm3. One-dimensional measurements had poorer intra and interobserver consistency. No statistically significant differences in volumetric measurements were observed between the two scans done on the same day in five subjects (P = 0.5). The authors conclude: MRI volumetric growth plate measurement is a reproducible and sensitive method to evaluate meaningful growth plate volume changes over time. This tool, along with close monitoring of height and laboratory evaluations for bone metabolism, may be used to evaluate potential bone and growth toxicities of children enrolled in trials of investigational drugs.

Germline genetic polymorphisms may influence chemotherapy response and disease outcome in osteosarcoma

Osteosarcoma is the most common malignant bone tumor in children and young people. Efficacy of multiagent MAP (methotrexate, doxorubicin [Adriamycin], cisplatin) chemotherapy may be influenced by multiple cellular pathways. This pilot study aimed to investigate the association of 36 candidate genetic polymorphisms in MAP pathway genes with histological response, survival, and grade 3-4 chemotherapy toxicity in osteosarcoma. Blood samples were obtained from 60 patients who had completed MAP chemotherapy. All patients were manually genotyped for 5 polymorphisms. The remaining 31 polymorphisms were genotyped in 50 patients using the Illumina 610-Quad microarray. Associations between candidate polymorphisms and histological response, progression-free survival, and toxicity were estimated using Pearson chi-square and Fisher exact tests, the Kaplan-Meier method, the log-rank test, and the Cox proportional hazards model. The results were as follows: Poor histological response was increased in variants of ABCC2 c.24C>T (P = .011) and GSTP1 c.313A>G p.Ile105Val (P = .009), whereas MTHFD1 c.1958G>A p.Arg653Gln was protective (P = .03). Methotrexate toxicity was increased in variants of MTHFR c.1298A>C p.Glu429Ala (P = .038), ABCB1 c.3435T>C Ile145Ile (P = .027), and ABCC2 c.3563T>A p.Val1188Glu (P = .028). Variants of GSTP1 c.313A>G p.Ile105Val were at increased risk of myelosuppression (P = .024) and cardiac damage (P = .008). Conclusions: This pilot study represents the most comprehensive study to date examining the role of genetic polymorphisms in osteosarcoma. Although small and retrospective, it shows that several polymorphisms appear to significantly influence toxicity and clinical outcome. These deserve prospective validation in the hope of optimizing treatment for resistant disease and reducing the late effects burden.

Malignant Peripheral Nerve Sheath Tumors (MPNST): The Mayo Clinic Experience

Malignant peripheral nerve sheath tumors (MPNST) are a rare form of soft tissue sarcoma with few studies reporting on patient outcomes and prognostic variables. This paper is a retrospective review of 175 patients diagnosed with MPNST from 1985 to 2010. Patient, tumor, and treatment characteristics were evaluated to identify prognostic variables. The results were as follows: The median age of our study population was 44 years, and 51% were female. Median tumor size was 6 cm, and 61% of patients had high-grade tumors. Tumors were most commonly located on the extremities (45%), then trunk (34%) and head/neck (19%). The majority of patients underwent surgical resection (95%) and adjuvant treatment with chemotherapy (6%), radiation (42%) or both (22%). Margin status was R0 in 69%, R1 in 2%, R2 in 9%, and unknown in 20%. The local recurrence rate was 22%, and 5- and 10-year disease-specific survival (DSS) were 60% and 45%, respectively. On univariate analysis, no predictors for local recurrence were identified. Tumor size ≥5 cm, high tumor grade, tumor location, presence of neurofibromatosis type 1, local recurrence, and adjuvant chemotherapy were all associated with DSS. On multivariate analysis, size ≥5 cm [hazard ratio (HR) = 6.1, 95% confidence interval (CI) 1.5–25.0], local recurrence (HR = 4.4, 95% CI 1.7–11.4), high tumor grade (HR = 3.8, 95% CI 1.1–13.2), and truncal location (HR = 3.7, 95% CI 1.1–12.7) were poor prognostic indicators for DSS. The paper concludes: High tumor grade and tumor size ≥5 cm predict adverse DSS for MPNST. In the context of a multidisciplinary treatment regimen, local recurrence and survival outcomes at 5 and 10 years were better than previously reported for MPNST.

Pharmacogenomic Prediction of Anthracycline-Induced Cardiotoxicity in Children

Anthracycline-induced cardiotoxicity (ACT) is a serious adverse drug reaction limiting anthracycline use and causing substantial morbidity and mortality. The aim of this study was to identify genetic variants associated with ACT in patients treated for childhood cancer. The investigators carried out a study of 2,977 single-nucleotide polymorphisms (SNPs) in 220 key drug biotransformation genes in a discovery cohort of 156 anthracycline-treated children from British Columbia, with replication in a second cohort of 188 children from across Canada and further replication of the top SNP in a third cohort of 96 patients from Amsterdam, the Netherlands. The results were as follows: The investigators identified a highly significant association of a synonymous coding variant rs7853758 (L461L) within the SLC28A3 gene with ACT (odds ratio, 0.35; P = 1.8 × 10−5 for all cohorts combined). Additional associations (P < .01) with risk and protective variants in other genes including SLC28A1 and several adenosine triphosphate–binding cassette transporters (ABCB1, ABCB4, and ABCC1) were present. They further explored combining multiple variants into a single-prediction model together with clinical risk factors and classification of patients into three risk groups. In the high-risk group, 75% of patients were accurately predicted to develop ACT, with 36% developing this within the first year alone, whereas in the low-risk group, 96% of patients were accurately predicted not to develop ACT. Conclusions: The investigators identified multiple genetic variants in SLC28A3 and other genes associated with ACT. Combined with clinical risk factors, genetic risk profiling might be used to identify high-risk patients who can then be provided with safer treatment options.

Antitumor Activity of Ridaforolimus and Potential Cell-Cycle Determinants of Sensitivity in Sarcoma and Endometrial Cancer Models

Ridaforolimus is a nonprodrug rapamycin analogue that potently inhibits mTOR and has shown significant activity in patients with metastatic sarcoma and endometrial cancer, two diseases where high unmet need remains. In this study the investigators evaluated the activity of ridaforolimus in preclinical models of these tumor types and used these models to explore molecular correlates of sensitivity. The in vitro sensitivity of a panel of sarcoma and endometrial cancer cell lines was established by measuring the effect of ridaforolimus on cell proliferation rate, revealing broad inhibition at low nanomolar concentrations. Additional benefit was found when ridaforolimus was combined with agents used to treat sarcoma and endometrial cancer patients. In vivo, potent antitumor activity of ridaforolimus associated with inhibition of mTOR signaling was observed in sarcoma and endometrial xenograft models. Immunoblot analysis was conducted to assess the expression and activation state of multiple signaling proteins in the phosphoinositide-3-kinase/AKT/mTOR and cell-cycle pathways. In endometrial but not sarcoma cell lines, the absence of PTEN or elevated levels of phosphorylated or total AKT was associated with greater sensitivity. However, in both tumor types, the proportion of cells in the G0–G1 phase before treatment correlated significantly with ridaforolimus sensitivity. Consistent with this, expression of several G1 phase cell-cycle proteins, notably p21 and p27, was higher in more sensitive lines. These results underscore the promise of ridaforolimus as a single agent or combination treatment of these tumor types and suggest novel potential predictive biomarkers of sensitivity to an mTOR inhibitor based on cell-cycle status.

ASPS-1, A Novel Cell Line Manifesting Key Features of Alveolar Soft Part Sarcoma

In vitro growth of alveolar soft part sarcoma (ASPS) and establishment of an ASPS cell line, ASPS-1, are described in this study. Using a recently developed xenograft model of ASPS derived from a lymph node metastasis, organoid nests consisting of 15 to 25 ASPS cells were isolated from ASPS xenograft tumors by capture on 70 μm filters and plated in vitro. After attachment to the substratum, these nests deposited small aggregates of ASPS cells. These cells grew slowly and were expanded over a period of 3 years and have maintained characteristics consistent with those of both the original ASPS tumor from the patient and the xenograft tumor including (1) presence of the alveolar soft part locus-transcription factor E3 type 1 fusion transcript and nuclear expression of the alveolar soft part locus-transcription factor E3 type 1 fusion protein; (2) maintenance of the t(X;17)(p11;q25) translocation characteristic of ASPS; and (3) expression of upregulated ASPS transcripts involved in angiogenesis (ANGPTL2, HIF-1-α, MDK, c-MET, VEGF, and TIMP-2), cell proliferation (PRL, PCSK1), metastasis (ADAM9), as well as the transcription factor BHLHB3 and the muscle-specific transcripts TRIM63 and ITGβ1BP3. This ASPS cell line forms colonies in soft agar and retains the ability to produce highly vascularized ASPS tumors in NOD.SCID/NCr mice. Immunohistochemistry of selected ASPS markers on these tumors indicated similarity to those of the original patient tumor as well as to the xenografted ASPS tumor. The investigators anticipate that this ASPS cell line will accelerate investigations into the biology of ASPS including identification of new therapeutic approaches for treatment of this slow growing soft tissue sarcoma.

Breast sarcomas: Current and future perspectives

Breast sarcomas are rare neoplasms of the breast which, this article sets forth, need to be clearly distinguished from the very common breast carcinomas and treated in a multidisciplinary manner modelled after treatment paradigms in other sarcoma locations. An increasing need to differentiate sarcoma sub-types based on molecular characteristics that will also be depicted in differential treatment sensitivities and development of specifically targeted therapies are equally valid in sarcomas in general and in breast sarcomas in particular. This article also discusses sarcomas developing after breast irradiation for a previous breast carcinoma, a scenario that is increasingly common, given the increasing trends of breast conservation in the surgical treatment of breast carcinoma that necessitates the adjuvant use of radiotherapy.

The Bone Niche of Chondrosarcoma: A Sanctuary for Drug Resistance, Tumour Growth and also a Source of New Therapeutic Targets

Chondrosarcomas are malignant cartilage-forming tumors representing around 20% of malignant primary tumors of bone and affect mainly adults in the third to sixth decade of life. Unfortunately, the molecular pathways controlling the genesis and the growth of chondrosarcoma cells are still not fully defined. It is well admitted that the invasion of bone by tumor cells affects the balance between early bone resorption and formation and induces an “inflammatory-like” environment which establishes a dialogue between tumor cells and their environment. The bone tumor microenvironment is then described as a sanctuary that contributes to the drug resistance patterns and may control at least in part the tumor growth. The concept of “niche” defined as a specialized microenvironment that can promote the emergence of tumor stem cells and provide all the required factors for their development recently emerges in the literature. This paper summarizes the main evidence sustaining the existence of a specific bone niche in the pathogenesis of chondrosarcomas.

Combining EGFR and mTOR blockade for the treatment of epithelioid sarcoma

Molecular deregulations underlying epithelioid sarcoma (ES) progression are poorly understood yet critically needed to develop new therapies. EGFR is overexpressed in ES. Using preclinical models, the investigators of this study examined the ES EGFR role and assessed anti-ES EGFR blockade effects, alone and with mTOR inhibition. EGFR and mTOR expression/activation was examined via tissue microarray (n=27 human ES specimens; IHC) and in human ES cell lines (WB and qRTPCR). Cell proliferation, survival, migration, and invasion effects of EGFR and mTOR activation and erlotinib (anti-EGFR small molecule inhibitor) alone and combined with rapamycin were assessed in cell culture assays. In vivo growth effects of erlotinib alone or with rapamycin, were evaluated using SCID mouse ES xenograft models. The results were as follows: EGFR was expressed and activated in ES specimens and cell lines. EGFR activation increased ES cell proliferation, motility, and invasion, and induced cyclin D1, MMP2, and MMP9 expression. EGFR blockade inhibited these processes and caused significant cytostatic ES growth inhibition in vivo. mTOR pathway activation at varying levels was identified in all TMA-evaluable ES tissues; 88% of samples had no or reduced PTEN expression. Similarly, both ES cell lines demonstrated enhanced mTOR activity; VAESBJ cells exhibited constitutive mTOR activation uncoupled from EGFR signaling. Most importantly, combined erlotinib/rapamycin resulted in synergistic anti-ES effects in vitro and induced superior tumor growth inhibition in vivo versus single agent administration. The authors conclude: EGFR- and mTOR-signaling pathways are deregulated in ES. Preclinical ES model-derived insights suggest that combined inhibition of these targets might be beneficial, supporting evaluations in clinical trials.

Dipeptidyl Peptidases as Survival Factors in Ewing Sarcoma Family of Tumors Implication for Tumor Biology and Therapy

Ewing sarcoma family of tumors (ESFT) is a group of aggressive pediatric malignancies driven by the EWS-FLI1 fusion protein, an aberrant transcription factor up-regulating specific target genes, such as neuropeptide Y (NPY) and its Y1 and Y5 receptors (Y5Rs). Previously, the investigators have shown that both exogenous NPY and endogenous NPY stimulate ESFT cell death via its Y1 and Y5Rs. Here in this study, the investigators demonstrate that this effect is prevented by dipeptidyl peptidases (DPPs), which cleave NPY to its shorter form, NPY3–36, not active at Y1Rs. They have shown that NPY-induced cell death can be abolished by overexpression of DPPs and enhanced by their down-regulation. Both NPY treatment and DPP blockade activated the same cell death pathway mediated by poly(ADP-ribose) polymerase (PARP-1) and apoptosis-inducing factor (AIF). Moreover, the decrease in cell survival induced by DPP inhibition was blocked by Y1 and Y5R antagonists, confirming its dependence on endogenous NPY. Interestingly, similar levels of NPY-driven cell death were achieved by blocking membrane DPPIV and cytosolic DPP8 and DPP9. Thus, this is the first evidence of these intracellular DPPs cleaving releasable peptides, such as NPY, in live cells. In contrast, another membrane DPP, fibroblast activation protein (FAP), did not affect NPY actions. In conclusion, DPPs act as survival factors for ESFT cells and protect them from cell death induced by endogenous NPY. This is the first demonstration that intracellular DPPs are involved in regulation of ESFT growth and may become potential therapeutic targets for these tumors.

Chemotherapeutic adjuvant treatment for osteosarcoma: Where do we stand?

Since the introduction of chemotherapy, survival in localized high-grade osteosarcoma has improved considerably. However, there is still no worldwide consensus on a standard chemotherapy approach. In this systematic review article, evidence for effectiveness of each single drug and the role of response guided salvage treatment of adjuvant chemotherapy are addressed. In addition, in a meta-analysis the number of drugs in current protocols is considered. A systematic literature search for clinical studies in localized high-grade osteosarcoma was undertaken, including both randomized and non-randomized trials. Historical clinical studies from the pre-chemotherapy era were included for comparison purposes. The results: Nine historical studies showed a long-term survival of 16% after only local treatment. Fifty single agent phase II studies showed high response rates for adriamycin (A, 43%), ifosfamide (Ifo, 33%), methotrexate (M, 32%), cisplatin (P, 26%) but only 4% for etposide (E). In 19 neo-adjuvant studies the mean 5-year event free survival (EFS) was 48% for 2-drug regimens and 58% for 3 drug regimens, with a 5-year overall survival (OAS) of 62% and 70%, respectively. Meta-analysis showed that 3 drug regimens including methotrexate plus adriamycin plus cisplatin (plus ifosfamide) (MAP(Ifo)) had significant better outcome (EFS: HR = 0.701 (95% confidence interval [95% CI]: 0.615–0.799); OAS: HR = 0.792 (95% CI: 0.677–0.926) than 2-drug regimens, but there was no significant difference between MAP and MAPIfo (or plus etoposide). Salvage of poor responders by changing drugs, or intensifying treatment postoperatively has not proven to be useful in this analysis. The article concludes: Meta-analysis in patients with localized high-grade osteosarcoma shows that 3-drug regimens, for example MAP are the most efficacious drug regimens.

Genetic amplification of the vascular endothelial growth factor (VEGF) pathway genes, including VEGFA, in human osteosarcoma

Osteosarcoma is the most common primary tumor of bone. It is a highly vascular and extremely destructive malignancy that mainly affects children and young adults. The authors of this paper conducted microarray-based comparative genomic hybridization (aCGH) and pathway analyses to gain a systemic view of pathway alterations in the genetically altered genes. Recurrent amplified and deleted genes that were detected by aCGH were subjected to an analysis based on the Kyoto Encyclopedia of Genes and Genomes to identify the altered pathways. Among the enriched pathways, vascular endothelial growth factor (VEGF) pathway genes collectively were amplified, and alterations of this pathway were validated by fluorescence in situ hybridization (FISH) and immunohistochemistry analyses in 58 formalin-fixed, paraffin-embedded osteosarcoma archival tissues that had clinical follow-up information. The results were as follows: The pathway enrichment analyses of the aCGH data revealed that VEGF pathway genes, including the VEGFA gene itself, were amplified significantly in osteosarcoma. Genetic amplification of the VEGFA gene, both focally and in larger fragment, was validated by FISH analysis. It is noteworthy that amplification of the VEGFA gene and elevated expression of the VEGFA protein were associated significantly with microvascular density and adverse tumor-free survival in patients with osteosarcoma. The authors conclude: VEGF pathway genes, including the VEGFA gene, are amplified in osteosarcoma. Amplification of the VEGFA gene is not only an important mechanism for elevated VEGFA protein expression but also is a poor prognostic factor for tumor-free survival. Combined classification of VEGFA gene amplification and positive VEGFA protein expression may provide a more accurate stratification method of selecting anti-VEGF therapy for patients with osteosarcoma.

Significance of Microscopic Margin Status in Completely Resected Retroperitoneal Sarcoma

The investigators of this study determined whether microscopic margin status was an independent prognosticator in patients who underwent complete resection of retroperitoneal sarcoma. A total of 99 patients with a median age of 55.4 years (range 26.0 to 81.9) underwent complete surgical resection for primary (79) or recurrent (20) retroperitoneal sarcoma between September 1990 and January 2010. Median follow-up was 36.0 months (range 1.0 to 221.1). The results were as follows: Microscopic involvement of the margins was detected in 24 patients and local recurrence developed in 69 (69.7%). Univariate analysis showed that pain, recurrent disease and higher Fédération Nationale des Centres de Lutte Contre le Cancer grade were associated with an increased risk of local recurrence. On multivariate Cox analysis presenting symptoms and grade were significantly associated with local recurrence-free survival, including pain vs. other symptoms (HR 1.7, p = 0.035) and grade 3 vs. 1 (HR 2.4, p = 0.028). A total of 25 patients (25.3%) died of retroperitoneal sarcoma. Histological subtype, grade and tumor margin status were prognostic for disease specific survival. Cox regression analysis revealed that certain factors were significantly associated with disease specific survival, including other sarcomas vs. liposarcoma (HR 2.8, p = 0.030) and positive vs. negative margins (HR 3.4, p = 0.005). The investigators conclude: Although complete surgical resection is possible in patients with retroperitoneal sarcoma, the procedure is associated with a high recurrence rate even in patients with negative margins. Microscopically clear margins reliably predict disease specific survival but not local control.

Frontline extended surgery is associated with improved survival in retroperitoneal low- to intermediate-grade soft tissue sarcomas

The purpose of this study was to retrospectively reassess at a longer follow-up the value of a systematic attempt to carry out wide resections in retroperitoneal soft tissue sarcoma at the Istituto Nazionale Tumori, Milan, Italy. Three hundred and thirty-one consecutive patients surgically treated were analyzed. Since a shift toward a systematic more extended surgical approach took place starting from 2002, patients were divided in two groups according to the time of surgery. Overall survival (OS), crude cumulative incidence of local recurrence (LR) and distant metastases (DMs) were estimated. Cox model multivariate analysis was carried out. The results were as follows: Five-year OS of patients operated in the recent period was 66%, compared with 48% for those operated in the previous period. This was associated with less LR (28% versus 49%), while the number of DMs was higher in the recent group (25% versus 12%). Beside the treatment period, the only independent determinant for survival was histological grade. The study concludes: The adoption of a policy of more liberal visceral en bloc resections was associated with a higher local control and OS. This benefit was evident in patients with grade I–II tumors, while DMs were a limiting factor in high-grade ones. New therapies are needed to control systemic disease as local surgery may improve local control.

Brain, the last fortress of sarcoma: Similar dismal outcome but discrepancy of timing of brain metastasis in bone and soft tissue sarcoma

Brain metastasis is a rare but dismal event in sarcomas. However, the pattern of occurrence and the prognostic factors associated with post-brain metastasis survival (PBMS) are not yet well-characterized. In this paper, sarcoma patients treated at one institute within a 10-year period were retrospectively reviewed and those with brain metastasis were identified. The incidence of brain metastasis was demonstrated by case per person-years and cumulative incidence curves. Univariate factors associated with PBMS were analyzed. The results were as follows: Among 611 sarcoma patients, 20 (3.3%) developed brain metastasis. Alveolar soft part sarcoma (ASPS) and osteosarcoma were the most common subtypes. Overall, the cumulative incidence was 3.9% at 5 years and 8.4% at 10 years. However, the incidence in STS patients continued to rise up to 10 years after primary diagnosis, whereas it reached a plateau in bone sarcoma patients at 3 years. Median PBMS was 1.67 months. Univariate factors associated with better PBMS included ASPS histology, initial surgical treatment, and brain irradiation for non-surgically treated patients. Conclusion: The study revealed a discrepancy in the timing of occurrence of brain metastasis between STS and bone sarcoma. However, patients with brain metastasis had a poor prognosis, implicating the brain as the last fortress of sarcoma.

Long-term Risks of Subsequent Primary Neoplasms Among Survivors of Childhood Cancer

Survivors of childhood cancer are at excess risk of developing subsequent primary neoplasms but the long-term risks are uncertain. The purpose of this study was to investigate long-term risks of subsequent primary neoplasms in survivors of childhood cancer, to identify the types that contribute most to long-term excess risk, and to identify subgroups of survivors at substantially increased risk of particular subsequent primary neoplasms that may require specific interventions. The study involved a population-based cohort of 17,981 5-year survivors of childhood cancer diagnosed with cancer at younger than 15 years between 1940 and 1991 in Great Britain, followed up through December 2006. The main outcome measures were standardized incidence ratios (SIRs), absolute excess risks (AERs), and cumulative incidence of subsequent primary neoplasms. The results were as follows: After a median follow-up time of 24.3 years (mean = 25.6 years), 1354 subsequent primary neoplasms were ascertained; the most frequently observed being central nervous system (n = 344), nonmelanoma skin cancer (n = 278), digestive (n = 105), genitourinary (n = 100), breast (n = 97), and bone (n = 94). The overall SIR was 4 times more than expected (SIR, 3.9; 95% confidence interval [CI], 3.6-4.2; AER, 16.8 per 10 000 person-years). The AER at older than 40 years was highest for digestive and genitourinary subsequent primary neoplasms (AER, 5.9 [95% CI, 2.5-9.3]; and AER, 6.0 [95%CI, 2.3-9.6] per 10 000 person-years, respectively); 36% of the total AER was attributable to these 2 subsequent primary neoplasm sites. The cumulative incidence of colorectal cancer for survivors treated with direct abdominopelvic irradiation was 1.4% (95% CI, 0.7%-2.6%) by age 50 years, comparable with the 1.2% risk in individuals with at least 2 first-degree relatives affected by colorectal cancer. The study concludes: Among a cohort of British childhood cancer survivors, the greatest excess risk associated with subsequent primary neoplasms at older than 40 years was for digestive and genitourinary neoplasms.

Advances in sarcoma genomics and new therapeutic targets

Increasingly, human mesenchymal malignancies are being classified by the abnormalities that drive their pathogenesis. Although many of these aberrations are highly prevalent within particular sarcoma subtypes, few are currently targeted therapeutically. Indeed, most subtypes of sarcoma are still treated with traditional therapeutic modalities, and in many cases sarcomas are resistant to adjuvant therapies. In this Review article, the authors discuss the core molecular determinants of sarcomagenesis and emphasize the emerging genomic and functional genetic approaches that, coupled with novel therapeutic strategies, have the potential to transform the care of patients with sarcoma.

FUS-CREB3L2/L1–Positive Sarcomas Show a Specific Gene Expression Profile with Upregulation of CD24 and FOXL1

Low-grade fibromyxoid sarcoma (LGFMS) is typically characterized by the specific translocation t(7;16)(q33;p11) and the corresponding fusion gene FUS-CREB3L2. This study aimed to extract LGFMS-specific, and putatively FUS-CREB3L2–dependent, gene expression patterns to learn more about the pathogenesis of this tumor. The investigators carried out single nucleotide polymorphism (SNP) and global gene expression array analyses, and/or immunohistochemical (IHC) analyses on 24 LGFMS tumor biopsies. Tumor types that are important differential diagnoses to LGFMS were included as comparison in the gene and protein expression analyses. In addition, cells that stably expressed FUS-CREB3L2 were analyzed with gene expression array and the influence of FUS-CREB3L2 on gene expression was investigated in vitro. The results were as follows: The SNP array analysis detected recurrent microdeletions in association with the t(7;16) chromosomal breakpoints and gain of 7q in cases with ring chromosomes. Gene expression analysis clearly distinguished LGFMS from morphologically similar tumors and MUC4 was identified as a potential diagnostic marker for LGFMS by gene expression and IHC analysis. FOXL1 was identified as the top upregulated gene in LGFMS and CD24 was upregulated in both LGFMS tumors and FUS-CREB3L2 expressing cells. FUS-CREB3L2 was capable of activating transcription from CD24 regulatory sequences in luciferase assays, suggesting an important role for the upregulation of this gene in LGFMS. The investigators conclude: The gene expression profile of LGFMS is distinct from that of soft tissue tumors with similar morphology. The data could be used to identify a potential diagnostic marker for LGFMS and to identify possible FUS-CREB3L2 regulated genes.

Oncological outcomes of patients with Ewing’s sarcoma

The aim of this study was to identify whether there was any difference in patient, tumor, treatment or outcome characteristics between patients with skeletal or extra-skeletal Ewing’s sarcoma. The authors identified 300 patients with new primary Ewing’s sarcoma diagnosed between 1980 and 2005 from the centers’ local database. There were 253 (84%) with skeletal and 47 (16%) with extra-skeletal Ewing’s sarcomas. Although patients with skeletal Ewing’s were younger (mean age 16.8 years) than those with extra-skeletal Ewing’s sarcoma (mean age 27.5 years), there was little difference between the groups in terms of tumor stage or treatment. Nearly all the patients were treated with chemotherapy and most had surgery. There was no difference in the overall survival of patients with skeletal (64%) and extra-skeletal Ewing’s sarcoma (61%) (p = 0.85), and this was also the case when both groups were split by whether they had metastases or not. Thus the authors conclude: This large series has shown that the oncological outcomes of Ewing’s sarcoma are related to tumor characteristics and patient age, and not determined by whether they arise in bone or soft tissue.

Epithelioid Sarcoma and Unclassified Sarcoma with Epithelioid Features: Clinicopathological Variables, Molecular Markers, and a New Experimental Model

Epithelioid sarcoma (ES) and unclassified sarcoma with epithelioid features (USEF) are clinically and therapeutically unresolved. The investigators of this study compared ES and USEF patients' clinical behavior, treatment, outcome, and molecular marker expression. Furthermore, preclinical ES study models were developed to enable comprehensive benchside investigations. A database of ES and USEF patients (n = 116) treated since 1992 was created. A clinically annotated ES–USEF tissue microarray (TMA) was assayed for tumor-related markers. Newly established human and commercially available ES cell lines were characterized and tested in vivo. The results were as follows: ES and USEF patients presenting with localized disease exhibited 22% and 25% local recurrence rates, 35% and 19% nodal metastasis rates, and 41% and 53% distant metastasis rates (median follow-up, 54 months and 39 months, respectively). The 5- and 10-year disease-specific survival rates were 88% and 43% and 52% and 42% (ES and USEF, respectively). TMA immunohistochemistry identified integrase interactor (INI)-1 loss, cancer antigen 125, and p53 nuclear expression as significantly more common in ES than USEF cases. Both cell lines preserved ES morphological and biochemical characteristics in vitro and in vivo; loss of INI-1 was shown to occur in both lines. The investigators conclude: Enhanced knowledge of ES and USEF clinical behavior, marker expression, and molecular determinants, extended via experimental models, will hopefully accelerate development of urgently needed effective targeted therapies for ES and USEF.

Atypical Intradermal Smooth Muscle Neoplasms: Clinicopathologic Analysis of 84 Cases and a Reappraisal of Cutaneous “Leiomyosarcoma”

Atypical or mitotically active dermal smooth muscle neoplasms are uncommon lesions, which are most often termed “cutaneous leiomyosarcoma,” although preexisting—mostly small—series suggest a low risk of aggressive behavior. In this report, the authors studied 84 cases from consultation and institutional files which were analyzed for pathologic and clinical characteristics. There was a striking male-to-female preponderance (4.3:1), with a mean age of 56 years (range, 6 to 82y). Nine patients had a history of malignancies (6 of the skin). Tumors measured 1.3 cm on average and were predominantly located on the trunk (32) and lower extremities (30). Histologically, all tumors were confined to the dermis or showed only very superficial, focal subcutaneous extension. The majority showed an infiltrative growth pattern with fascicles of atypical eosinophilic spindle cells ramifying between dermal collagen fibers. Primary tumors showed a mean mitotic rate of 4.7/10 high-power fields. By the Fédération Nationale des Centres de Lutte Contre le Cancer grading system, 97% of primary tumors were grade I lesions, with only 3% showing necrosis. All tumors were immunopositive for smooth muscle actin; 98% expressed desmin, 90% caldesmon, and 45% pankeratin (usually focal). Follow-up in 52 cases (mean, 51 mo) showed no metastases or tumor-related deaths. Eighteen tumors showed local recurrence at a mean interval of 43 months; 12 of the recurrent lesions showed positive margins in the primary excision and 1 showed margins <0.2 cm. Margin status was not available for the other 5 cases, which recurred locally. Recurrent tumors showed, on average, 13.7 mitoses/10 high-power fields. Of recurrences, 47% were grade I lesions, 35% were grade II, and 18% were grade III, and 28% showed necrosis. The primary excision of tumors, which later recurred, showed no difference in grade, presence of necrosis, or mitotic rate, compared with those that did not recur; there were no discernible clinical differences either. In summary, these tumors, when confined to the dermis or showing only minimal subcutaneous involvement, seem to carry no evident risk of metastasis; hence, the designation “sarcoma” is inappropriate. Margin status is the most important predictor of recurrence. On excision with clear margins, the risk of local recurrence is very low. Hence, the authors propose the term “atypical intradermal smooth muscle neoplasm” as being more appropriate.

Cryoimmunology for malignant bone and soft-tissue tumors

Several new methods have recently been developed for the treatment of malignant bone and soft-tissue tumors, and many of these targeted therapies have yielded promising initial results in clinical settings. As more sarcomas become amenable to effective molecular-targeting therapy, the need to evaluate the synergistic effects of combination therapies with anticancer drugs will grow. Other immunologic therapies have also been reported, such as exogenous cytokines, dendritic cell (DC) therapy and peptide vaccines. Cryoimmunology has shown promising results in some malignant tumors after cryosurgery and is expected to influence the next generation of tumor immunotherapy. In this report, the authors describe the induction of a systemic antitumor immune response following liquid nitrogen cryotreatment of a destructive murine osteosarcoma. Combining tumor cryotreatment with DCs to promote tumor-specific immune responses enhanced systemic immune responses and inhibited metastatic tumor growth. They also describe the induction of a systemic antitumor immune response following reconstruction for malignant bone tumors using frozen autografts treated with liquid nitrogen.

IL-4R Drives Dedifferentiation, Mitogenesis, and Metastasis in Rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in childhood. The alveolar subtype of rhabdomyosarcoma (ARMS) is a paradigm for refractory and incurable solid tumors because more than half of the children at diagnosis have either regional lymph node or distant metastases. This study follows the investigators previous observation that Interleukin-4 receptor α (IL-4Rα) is upregulated in both human and murine ARMS, and that the IL-4R signaling pathway may be a target for abrogating tumor progression. By in vitro biochemical and cell biology studies as well as preclinical studies using a genetically engineered mouse model, the investigators evaluated the role of IL-4 and IL-13 in IL-4R–mediated mitogenesis, myodifferentiation, and tumor progression. The results were as follows: IL-4 and IL-13 ligands accelerated tumor cell growth and activated STAT6, Akt, or MAPK signaling pathways in the human RMS cell lines, RD and Rh30, as well as in mouse primary ARMS cell cultures. IL-4 and IL-13 treatment also decreased protein expression of myogenic differentiation factors MyoD and Myogenin, indicating a loss of muscle differentiation. Using a genetically engineered mouse model of ARMS, they showed that inhibition of IL-4R signaling pathway with a neutralizing antibody has a profound effect on the frequency of lymph node and pulmonary metastases, resulting in significant survival extension in vivo. The investigators conclude: Results indicate that an IL-4R-dependent signaling pathway regulates tumor cell progression in RMS, and inhibition of this pathway could be a promising adjuvant therapeutic approach.

Excellent Prognosis in a Subset of Patients with Ewing Sarcoma Identified at Diagnosis by CD56 Using Flow Cytometry

Ewing sarcoma (ES) is considered a systemic disease with the majority of patients harboring micrometastases at diagnosis. In this study, multiparameter flow cytometry (MPFC) was used to detect ES cells in bone marrow (BM) of ES patients at diagnosis and to evaluate the prognostic significance of CD56 expression in BM samples. BM samples from 46 ES patients, 6 tumor aspirates, 2 ES cell lines, and 10 control BM samples were analyzed by MPFC. ES cells were identified by the combination of CD45−/CD90+/CD99+. CD56 was evaluated on these cells by a cutoff of 22%. The results were as follows: BM samples obtained from all patients at diagnosis were found to be positive for micrometastatic tumor cells assessed by CD99+/CD90+/CD45− expression. A total of 60% of the BM samples harbored high CD56 expression. There was a highly significant correlation between CD56 expression and progression-free survival (PFS; 69% in low/negative expression versus 30% in high expression groups, P = 0.024). In patients with localized nonpelvic disease, those expressing low/negative CD56 had 100% PFS versus 40% in the high expressing group (P = 0.02). By Cox regression analysis, CD56 was found to be an independent prognostic marker with an 11-fold increased risk for relapse in patients with localized disease (P = 0.006). The study concludes: All samples contained cells that are positive for the CD99+/CD90+/CD45− combination at diagnosis, indicating that ES is a systemic disease. CD56 expression could be used to reveal ES patients with excellent prognosis or patients predisposed to relapse, thus improving treatment stratification and implementation of personalized therapy.

Pronociceptive Pain Modulation in Patients with Painful Chemotherapy-Induced Polyneuropathy

Several chemotherapy agents induce polyneuropathy that is painful for some patients, but not for others. The investigators of this study assumed that these differences might be attributable to varying patterns of pain modulation. The aim of the present study was to evaluate pain modulation in such patients. Twenty-seven patients with chemotherapy-induced polyneuropathy were tested for detection thresholds (cold, warm, and mechanical) in both the forearm and foot, as well as for heat pain threshold, mechanical temporal summation (TS), and conditioned pain modulation (CPM; also known as the diffuse noxious inhibitory control-like effect), which were tested in the upper limbs. The results were as follows: Positive correlations were found between clinical pain levels and both TS (r = 0.52, P = 0.005) and CPM (r = 0.40, P = 0.050) for all patients. In addition, higher TS was associated with less efficient CPM (r = 0.56, P = 0.004). The group of patients with painful polyneuropathy (n = 12) showed a significantly higher warm detection threshold in the foot (P = 0.03), higher TS (P < 0.01), and less efficient CPM (P = 0.03) in comparison to the group with nonpainful polyneuropathy. The investigators conclude: The painfulness of polyneuropathy is associated with a “pronociceptive” modulation pattern, which may be primary to the development of pain. The higher warm sensory thresholds in the painful polyneuropathy group suggest that the severity of polyneuropathy may be another factor in determining its painfulness.

Breast sarcomas: Current and future perspectives

Sarcomas of the breast are heterogeneous neoplasms derived from non-epithelial elements of the gland. Although they represent comparatively rare neoplasms, comprising less than 1% of breast cancers and less than 5% of all location sarcomas, their incidence may increase in the years to come as a result of increasing use of breast radiation after breast-conserving treatment of breast cancer. In addition, sarcomas are very important to differentiate from breast carcinomas because treatment of the two entities differs. In this review article, data on specific sub-types of breast sarcomas will be reviewed and implications for treatment will be discussed.

MDM2 antagonist Nutlin-3a potentiates antitumour activity of cytotoxic drugs in sarcoma cell lines

Frequent failure and severe side effects of current sarcoma therapy warrants new therapeutic approaches. The small-molecule MDM2 antagonist Nutlin-3a activates the p53 pathway and efficiently induces apoptosis in tumors with amplified MDM2 gene and overexpression of MDM2 protein. However, the majority of human sarcomas have normal level of MDM2 and the therapeutic potential of MDM2 antagonists in this group is still unclear. This study investigated if Nutlin-3a could be employed to augment the response to traditional therapy and/or reduce the genotoxic burden of chemotherapy. A panel of sarcoma cell lines with different TP53 and MDM2 status were treated with Nutlin-3a combined with Doxorubicin, Methotrexate or Cisplatin, and their combination index determined. The results were as follows: Clear synergism was observed when Doxorubicin and Nutlin-3a were combined in cell lines with wild- typeTP53 and amplified MDM2, or with Methotrexate in both MDM2 normal and amplified sarcoma cell lines, allowing for up to tenfold reduction of cytotoxic drug dose. Interestingly, Nutlin-3a seemed to potentiate the effect of classical drugs as Doxorubicin and Cisplatin in cell lines with mutated TP53, but inhibited the effect of Methotrexate. The study concludes: The use of Nutlin in combination with classical sarcoma chemotherapy shows promising preclinical potential, but since clear biomarkers are still lacking, clinical trials should be followed up with detailed tumor profiling.

Atypical Intradermal Smooth Muscle Neoplasms: Clinicopathologic Analysis of 84 Cases and a Reappraisal of Cutaneous Leiomyosarcoma

Atypical or mitotically active dermal smooth muscle neoplasms are uncommon lesions, which are most often termed "cutaneous leiomyosarcoma," although preexisting—mostly small—series suggest a low risk of aggressive behavior. In this study, to further investigate these tumors, 84 cases from consultation and institutional files were analyzed for pathologic and clinical characteristics. There was a striking male-to-female preponderance (4.3:1), with a mean age of 56 years (range, 6 to 82y). Nine patients had a history of malignancies (6 of the skin). Tumors measured 1.3 cm on average and were predominantly located on the trunk (32) and lower extremities (30). Histologically, all tumors were confined to the dermis or showed only very superficial, focal subcutaneous extension. The majority showed an infiltrative growth pattern with fascicles of atypical eosinophilic spindle cells ramifying between dermal collagen fibers. Primary tumors showed a mean mitotic rate of 4.7/10 high-power fields. By the Fédération Nationale des Centres de Lutte Contre le Cancer grading system, 97% of primary tumors were grade I lesions, with only 3% showing necrosis. All tumors were immunopositive for smooth muscle actin; 98% expressed desmin, 90% caldesmon, and 45% pankeratin (usually focal). Follow-up in 52 cases (mean, 51 mo) showed no metastases or tumor-related deaths. Eighteen tumors showed local recurrence at a mean interval of 43 months; 12 of the recurrent lesions showed positive margins in the primary excision and 1 showed margins <0.2 cm. Margin status was not available for the other 5 cases, which recurred locally. Recurrent tumors showed, on average, 13.7 mitoses/10 high-power fields. Of recurrences, 47% were grade I lesions, 35% were grade II, and 18% were grade III, and 28% showed necrosis. The primary excision of tumors, which later recurred, showed no difference in grade, presence of necrosis, or mitotic rate, compared with those that did not recur; there were no discernible clinical differences either. In summary, these tumors, when confined to the dermis or showing only minimal subcutaneous involvement, seem to carry no evident risk of metastasis; hence, the designation "sarcoma" is inappropriate. Margin status is the most important predictor of recurrence. On excision with clear margins, the risk of local recurrence is very low. Hence, the investigators propose the term "atypical intradermal smooth muscle neoplasm" as being more appropriate.

Prognostic value of PAX–FKHR fusion status in alveolar rhabdomyosarcoma: A report from the cooperative soft tissue sarcoma study group (CWS)

Alveolar Rhabdomyosarcomas (RMA) are characterized by chromosomal translocations, fusing the PAX3 or PAX7 gene with FKHR in about 85%. Previous studies have suggested that the fusion type is associated with prognosis. In order to investigate the predictive value of the PAX–FKHR fusion status on disease outcome of patients with RMA treated in the CWS trials, the authors of this study performed a retrospective analysis. Between 1986 and 2004, out of 446 patients with RMA treated in four consecutive CWS trials, tumor samples from 126 patients were available for RT-PCR analysis. Survival depending on fusion status in context with known clinical risk-factors was analyzed. The results were as follows: Out of 126 samples, 121 had adequate quality for PAX–FKHR fusion status analysis. PAX–FKHR fusions were detected in 101 samples: 60% PAX3–FKHR and 24% PAX7–FKHR fusions, 17% were fusion-negative. There was no significant difference in survival between patients with PAX3–FKHR versus PAX7–FKHR positive tumors. The fusion transcript negative cohort showed a more favorable outcome than the fusion transcript positive cohort among patients with metastatic disease. From the established clinical risk-factors none was associated with a significantly higher risk of failure or death in a multivariate analysis. The authors conclude: PAX–FKHR fusion type was not a significant predictor for survival in our analysis. More extensive molecular analyses are needed to identify features with prognostic relevance and useful therapeutic impact.

Health related quality of life in adolescent and young adult survivors of lower extremity bone tumors

Dramatic increases in survival rates have led to increased interest regarding the health related quality of life (HRQOL) of adolescent and young adult survivors of bone tumors. This study investigated HRQOL and physical disability in adolescent and young adult survivors of lower extremity bone tumors as a function of type of surgical intervention, gender, and age at assessment. Twenty-eight participants (age range 18–32 years) completed three generic and one disease-specific measures of HRQOL and a measure of physical disability. For analysis, surgical intervention was grouped into limb sparing surgeries (LS; allograft fusion and endoprosthesis) and ablative surgeries (AMP; amputation or Van Nes rotationplasty). Age at study was grouped into ≤25 years of age and ≥26 years of age. The MOS-SF-36, HUI2, HUI3, and EORTC-QLQ-C30 were used to measure HRQOL and the TESS was used to assess physical disability. The results were as follows: Survivors reported HRQOL equivalent to the general population, with the exception of physical functioning. LS reported poorer HRQOL than AMP participants for emotional functioning and fatigue. Males reported better HRQOL compared with females for overall HRQOL, general health, physical functioning, and social functioning. Finally, younger participants generally reported better HRQOL than older participants for overall HRQOL and physical functioning. The authors conclude: This study identifies LS surgical intervention, female gender and older age as risk factors for reduced HRQOL in adolescent and young adult survivors of lower extremity bone tumors. This study also provides information about what instrument may be most useful in identifying these specific difficulties and subgroups.

Late effects in survivors of teenage and young adult cancer: does age matter?

Late effects (LEs) after cancer treatment are increasing. After childhood cancer, substantial risks include physical, psychological and social LE and vary with age. Teenagers and young adults (TYA) present with particular cancers; their risk of LE may relate to cancer site, treatment or their age itself. In this study, the LEs after TYA-onset cancers are described in relation to age at diagnosis of primary tumor. Data were extracted from Medline English language articles, 1999–2009. Keywords were late effect/s, late toxicity and survivor and the frequent TYA cancer sites. Only those articles that reported the relation between LEs risks with age at diagnosis were included. The results were as follows: The majority of known LEs are described after TYA cancer. No study primarily aimed to relate TYA age to LEs. Many studies did not report LE by age. TYA-specific risks are seen in cardiac toxicity, second malignancies, pulmonary complications and psychosocial difficulties when compared with older or younger cancer survivors. The authors conclude: TYA age brings specific LE risks after cancer. Prospective population-based collection of LE data after TYA cancer will inform the development of appropriate services to effectively manage LE.

Ecteinascidin 743 Interferes with the Activity of EWS-FLI1 in Ewing Sarcoma Cells

ET-743 (trabectedin; Yondelis) is approved in Europe for the treatment of soft tissue sarcomas. Emerging phase 1 and 2 clinical data have shown high response rates in myxoid liposarcoma in part owing to the inhibition of the FUS-CHOP transcription factor. In this report, the investigators show that modulation of specific oncogenic transcription factors by ET-743 may extend to other tumor types. They demonstrate that, among a panel of pediatric sarcomas, Ewing sarcoma family of tumors (ESFTs) cell lines bearing the EWS-FLI1 transcription factor are the most sensitive to treatment with ET-743 compared with osteosarcoma, rhabdomyosarcoma, and synovial sarcoma. They show that ET-743 reverses a gene signature of induced downstream targets of EWS-FLI1 in two different ESFT cell lines (P = .001). In addition, ET-743 directly suppresses the promoter activity of a known EWS-FLI1 downstream target NR0B1 luciferase reporter construct without changing the activity of a constitutively active control in ESFT cells. Furthermore, the effect is specific to EWS-FLI1, as forced expression of EWS-FLI1 in a cell type that normally lacks this fusion protein, HT1080 cells, induces the same NR0B1 promoter, but this activation is completely blocked by ET-743 treatment. Finally, they used gene set enrichment analysis to confirm that other mechanisms of ET-743 are active in ESFT cells. These results suggest a particular role for ET-743 in the treatment of translocation-positive tumors. In addition, the modulation of EWS-FLI1 makes it a novel targeting agent for ESFT and suggests that further development of this compound for the treatment of ESFT is warranted.

Array-based comparative genomic hybridization identifies CDK4 and FOXM1 alterations as independent predictors of survival in malignant peripheral nerve sheath tumor

Malignant peripheral nerve sheath tumors (MPNSTs) are highly aggressive sarcomas with variable patient survival and few known prognostically relevant genomic biomarkers. In order to identify survival-associated genomic biomarkers, the investigators of this study performed high resolution array-based comparative genomic hybridization (aCGH) on a large set of MPNSTs. Candidate gene alterations identified by aCGH in 38 MPNSTs were validated at the DNA, RNA, and protein levels on these same tumors and an independent set of 87 MPNST specimens. The rResults were as follows: aCGH revealed highly complex copy-number alterations, including both previously reported and completely novel loci. Four regions of copy-number gain were associated with poor patient survival. Candidate genes in these regions include SOX5 (12p12.1), NOL1 and MLF2 (12p13.31), FOXM1 and FKBP1 (12p13.33), and CDK4 and TSPAN31 (12q14.1). Alterations of these candidate genes and several others of interest (ERBB2, MYC and TP53) were confirmed by at least one complementary methodology, including DNA and mRNA quantitative PCR, mRNA expression profiling, and tissue microarray-based fluorescence in situ hybridization and immunohistochemistry. Multivariate analysis showed that CDK4 gain/amplification and increased FOXM1 protein expression were the most significant independent predictors for poor survival in MPNST patients (p<0.05). The investigators conclude: Their study provides new and independently confirmed candidate genes that could serve as genomic biomarkers for overall survival in MPNST patients.

Association of Elevated HIF-2α Levels with Low Beclin 1 Expression and Poor Prognosis in Patients with Chondrosarcoma

Hypoxia inducible factor (HIF)-2α is an important transcription factor that contributes to tumor proliferation and progression. Beclin 1 is a key mediator of autophagy, and dysfunction of Beclin 1 is implicated in tumorigenicity. This study was designed to investigate the expression patterns of HIF-2α and Beclin 1 and to clarify their clinical significance in chondrosarcoma. The mRNA and protein levels of HIF-2α and Beclin 1 in chondrosarcoma and the corresponding nontumor tissues were analyzed by real-time polymerase chain reaction and Western blot, respectively. The protein expression of HIF-2α and Beclin 1 was investigated by immunohistochemistry, and their associations with clinicopathological factors and overall survival were evaluated. The results were as follows: HIF-2α was remarkably elevated, whereas Beclin 1 was significantly reduced in chondrosarcoma compared with the corresponding nontumor tissues. High HIF-2α level and negative Beclin 1 expression were 52.9% and 58.8% in chondrosarcoma specimens, respectively. HIF-2α and Beclin 1 were associated with histological grade and Musculoskeletal Tumor Society stage. There was a significant inverse relationship between HIF-2α and Beclin 1. HIF-2α and Beclin 1 had significant impacts on the prognosis of chondrosarcoma patients. Multivariate analysis revealed that Beclin 1 was an independent prognostic factor for overall survival of patients with chondrosarcoma. The investigators conclude: Elevated HIF-2α levels associated with low Beclin 1 expression play a role in the development of chondrosarcoma. Beclin 1 can serve as a novel biomarker to predict survival of chondrosarcoma patients, and may represent a potential therapeutic target.

Either Called "Chemobrain" or "Chemofog," the Long-Term Chemotherapy-Induced Cognitive Decline in Cancer Survivors Is Real

In recent years, there is growing evidence in the medical literature to support an association between administration of commonly used chemotherapeutic agents and an increased risk for cognitive impairment. The authors of this paper critically summarize data relating to the pathophysiological mechanisms by which chemotherapy may induce cognitive impairment in patients surviving from solid tumors. The clinical and epidemiological characteristics and the proposed management strategies to counter chemotherapy-induced cognitive impairment (CICI) also are presented. References for this review were identified by searches of PubMed from 1995 until December 2009 with related terms. The results were as follows: Both the pathogenetic mechanisms and the overall clinical nature of CICI remain vaguely defined. Findings indicate that CICI is a relatively common event that, in most of the cases, remains underdiagnosed, thereby adversely affecting the quality of life of patients with cancer. Effective pharmacological interventions toward the symptomatic or prophylactic management of CICI also are lacking. The authors conclude: Either called "chemobrain" or "chemofog," the long-term CICI in cancer survivors is real. The need for multidisciplinary care interventions toward a timely diagnosis and management of CICI is clearly warranted.

Evidence for an Unanticipated Relationship between Undifferentiated Pleomorphic Sarcoma and Embryonal Rhabdomyosarcoma

Embryonal rhabdomyosarcoma (eRMS) shows the most myodifferentiation among sarcomas, yet the precise cell of origin remains undefined. In this study, the investigators used Ptch1, p53 and/or Rb1 conditional mouse models and controlling prenatal or postnatal myogenic cell of origin to demonstrate that eRMS and undifferentiated pleomorphic sarcoma (UPS) lie in a continuum, with satellite cells predisposed to giving rise to UPS. Conversely, p53 loss in maturing myoblasts gives rise to eRMS, which have the highest myodifferentiation potential. Regardless of origin, Rb1 loss modifies tumor phenotype to mimic UPS. In human sarcomas that lack pathognomic chromosomal translocations, p53 loss of function is prevalent, whereas Shh or Rb1 alterations likely act primarily as modifiers. Thus, the investigators conclude sarcoma phenotype is strongly influenced by cell of origin and mutational profile.

Preclinical Evaluation of Telomerase-Specific Oncolytic Virotherapy for Human Bone and Soft Tissue Sarcomas

Tumor-specific replication-selective oncolytic virotherapy is a promising antitumor therapy for induction of cell death in tumor cells but not of normal cells. The investigators previously developed an oncolytic adenovirus, OBP-301, that kills human epithelial malignant cells in a telomerase-dependent manner. Recent evidence suggests that nonepithelial malignant cells, which have low telomerase activity, maintain telomere length through alternative lengthening of telomeres (ALT). However, it remains unclear whether OBP-301 is cytopathic for nonepithelial malignant cells. In this study, the investigators evaluated the antitumor effect of OBP-301 on human bone and soft tissue sarcoma cells. The cytopathic activity of OBP-301, coxsackie and adenovirus receptor (CAR) expression, and telomerase activity were examined in 10 bone (OST, U2OS, HOS, HuO9, MNNG/HOS, SaOS-2, NOS-2, NOS-10, NDCS-1, and OUMS-27) and in 4 soft tissue (CCS, NMS-2, SYO-1, and NMFH-1) sarcoma cell lines. OBP-301 antitumor effects were assessed using orthotopic tumor xenograft models. The fiber-modified OBP-301 (termed OBP-405) was used to confirm an antitumor effect on OBP-301–resistant sarcomas. The results were as follows: OBP-301 was cytopathic for 12 sarcoma cell lines but not for the non–CAR-expressing OUMS-27 and NMFH-1 cells. Sensitivity to OBP-301 was dependent on CAR expression and not on telomerase activity. ALT-type sarcomas were also sensitive to OBP-301 because of upregulation of human telomerase reverse transcriptase (hTERT) mRNA following virus infection. Intratumoral injection of OBP-301 significantly suppressed the growth of OST and SYO-1 tumors. Furthermore, fiber-modified OBP-405 showed antitumor effects on OBP-301–resistant OUMS-27 and NMFH-1 cells. The investigators conclude: A telomerase-specific oncolytic adenovirus is a promising antitumor reagent for the treatment of bone and soft tissue sarcomas.

Circulating Natural IgM Antibodies Against Angiogenin in the Peripheral Blood Sera of Patients with Osteosarcoma as Candidate Biomarkers and Reporters of Tumorigenesis

Tumor immunology research has led to the identification of a number of tumor-associated self antigens, suggesting that most tumors trigger an immunogenic response, as is the case in osteosarcoma, where the detection of natural serum IgM antibodies might achieve the diagnosis of osteosarcoma. Natural IgM antibodies to tumor-associated proteins may expand the number of available tumor biomarkers for osteosarcoma and may be used together in a serum profile to enhance test sensitivity and specificity. Natural IgM antibodies can be consistently detected in the peripheral blood sera months to years before the tumor is diagnosed clinically. The study of the level of a potential biomarker many months (or years) prior to diagnosis is fundamentally important. Integrated circulating and imaging markers in clinical practice treating osteosarcoma have potential applications for controlling tumor angiogenesis. The objectives of this paper were to study the expression of natural IgM antibodies to the tumor antigens of angiogenesis in the peripheral blood sera of osteosarcoma patients and healthy individuals, and to develop serum-based predictive biomarkers. Peripheral venous blood samples were collected from 117 osteosarcoma patients and 117 patients with other tumors. All diagnosis was histologically confirmed. Staging of patients was performed according to the Enneking Surgical Staging System. The control group consisted of 117 age- and sex- matched healthy individuals. In this study, novel immunoconjugates were designed, synthesized and then used to develop a rapid, specific and sensitive enzyme-linked immunosorbent assay (ELISA) method to detect angiogenin (ANG)–IgM directly in the peripheral blood sera of humans. The Results were as follows: Serum ANG–IgM levels are significantly higher in osteosarcoma patients than in healthy individuals (P < 0.005). Serum ANG–IgM levels varied widely, but were highly dependent on the concentration of IgM (r = 0.85; P < 0.0005). They found ANG–IgM in the sera of 85% of newly diagnosed osteosarcoma patients and ANG–IgM levels were significantly higher in osteosarcoma patients compared to any other tumors (P < 0.001). The authors Conclude: These results demonstrated that the combined biomarker ANG–IgM has greater sensitivity and specificity in early diagnosis of osteosarcoma patients than the traditional biomarkers (ANG and vascular endothelial growth factor). Circulating ANG–IgM immune complexes can potentially serve as a biomarker for increased risk of osteosarcoma, because relatively high serum levels were also detected in otherwise healthy individuals with a first degree family history of osteosarcoma and in patients with a diagnosis of benign conditions. Immunological aspects of angiogenesis for managing osteosarcoma will have a practical value in early diagnosis, prognosis and monitoring response to antiangiogenic therapy.

February 2011

Clinical features and outcomes in patients with extraskeletal ewing sarcoma

The purpose of this study was to investigate whether patient characteristics, treatment strategies, and outcomes differ between skeletal Ewing sarcoma and extraskeletal Ewing sarcoma (EES). Patients less than 40 years of age with Ewing sarcoma or peripheral primitive neuroectodermal tumor reported to the United States Surveillance, Epidemiology, and End Results Program database from 1973 to 2007 were evaluated based on skeletal (n = 1519) versus extraskeletal (n = 683) site of origin. Patient characteristics were compared using Fisher exact tests. Overall survival was estimated via the Kaplan-Meier method and compared using log-rank tests and Cox proportional hazard models. The results were as follows: Patients with EES had a higher mean age (19.5 vs. 16.3 years; P < .001) and were less likely to be male (53.4% vs. 63.3%; P < .001) or white (84.8% vs. 92.5%; P < .001) compared with patients with skeletal tumors. Extraskeletal tumors were more likely to arise in axial locations (72.9% vs. 54.2%; P = .001) but were less likely to arise specifically in the pelvis (19.8% vs. 26.6%; P < .001). Metastatic status or tumor size did not differ by group. Five-year overall survival was superior for localized EES compared with localized skeletal tumors (69.7% vs. 62.6%; P = .02). The hazard ratio for death in patients with localized skeletal tumors compared with localized EES was 2.36 (95% confidence interval, 1.61-3.44) beyond 24 months from initial diagnosis. The study concludes: Patient characteristics and outcomes differ among patients with EES compared with patients with skeletal Ewing sarcoma. These findings may have important implications for patient care.

Nutlin-3a Is a Potential Therapeutic for Ewing Sarcoma

Although mutations in the TP53 gene occur in half of all cancers, approximately 90% of Ewing sarcomas retain a functional wild-type p53. The low frequency of TP53 alterations in Ewing sarcoma makes this tumor type an ideal candidate for p53-targeted therapies. In this study, the investigators examined the molecular and cellular responses of cultured Ewing sarcoma cell lines following exposure to Nutlin-3a, a recently developed MDM2 antagonist. The ability of Nutlin-3a to impart apoptosis or cell cycle arrest in a p53-dependent manner was determined in a comprehensive panel of Ewing sarcoma cell lines. The capacity of Nutlin-3a to augment the antitumor activity of MDM4 antagonists and cytotoxic agents currently used in the clinical treatment of Ewing sarcoma was also investigated. The results were as follows: Apoptosis was the primary response of wild-type p53 expressing Ewing sarcoma cell lines. The cytotoxicity of Nultin-3a was also synergistic with the chemotherapeutic agents, vincristine, actinomycin D, doxorubicin, and etoposide in a concentration-dependent manner. Significant MDM4 protein overexpression was observed in Ewing sarcoma cell lines of wild-type p53 status, providing a mechanism through which Ewing sarcomas can develop in the absence of TP53 alterations. This study provides the first evidence of synergism between targeted inhibition of MDM2 and MDM4. The investigators conclude: Findings suggest that p53-dependent apoptosis is the primary cellular response of Ewing sarcoma cell lines following exposure to Nutlin-3a. Furthermore, Nutlin-3a can synergize with the current Ewing sarcoma chemotherapy protocols, suggesting p53 activation as a novel systemic therapeutic approach for this disease.

Pediatric Cutaneous Angiosarcomas: A Clinicopathologic Study of 10 Cases

Cutaneous angiosarcomas are rare tumors, which predominantly arise in the sun-exposed skin of the head and neck of adult and elderly patients. Rarely, these tumors can be seen in children. The authors of this paper identified cutaneous angiosarcomas in 10 children and assessed clinical (patient age, tumor site, tumor size, and tumor focality) and histologic features including growth pattern (vasoformative vs. solid), mitotic rate (mitotic figures per 10 high power field), necrosis (present vs. absent), and cell shape (epithelioid vs. nonepithelioid). Tumors predominated in the lower extremities (6 of 10) of female patients (2 male and 8 female); age at diagnosis ranged from 1.5 months to 15 years. Four patients had preexisting conditions: congenital hemihypertrophy of the contralateral limb, the Aicardi syndrome, congenital lymphedema, and congenital hemangioma treated with radiation therapy. Tumors were located in the lower extremity (6), flank (1), elbow (1), and buccal mucosa (1), and ranged in size from 0.6 to 6.5 cm. Eight cases showed predominantly epithelioid morphology, 1 case showed mixed epithelioid and spindled morphology and 1 case was entirely spindled. Mitotic activity ranged from 1 to 55 mitotic figures per 10 high power field. Necrosis was seen in 5 cases. Clinical follow-up was obtained for 9 patients: 4 died of disease (range, 12 to 49 mo; mean, 25 mo) and 5 patients were alive without disease (18 mo to 28 y). Five patients had metastatic disease; sites of involvement included the lung, soft tissue, lymph node, pleura, liver, and bone. Cutaneous angiosarcomas in children are rare tumors, which are commonly associated with a preexisting condition, suggesting a greater role for genetics as opposed to environmental factors in the pathogenesis of these tumors.

The role of epidermal growth factor receptor in chordoma pathogenesis: a potential therapeutic target

Chordoma, the molecular hallmark of which is T (brachyury), is a rare malignant bone tumor with a high risk of local recurrence and a tumor from which metastatic disease is a common late event. Currently, there is no effective drug therapy for treating chordomas, although there is evidence that some patients respond to the empirical use of epidermal growth factor receptor (EGFR) antagonists. The aim of this study was to determine the role of EGFR in the pathogenesis of chordoma. Paraffin-embedded material from 173 chordomas from 160 patients [sacro-coccygeal (n = 94), skull-based (n = 50), and mobile spine (n = 16)] was analyzed by immunohistochemistry and revealed total EGFR expression in 69% of cases analyzed. Of 147 informative chordomas analyzed by FISH, 38% revealed high-level EGFR polysomy, 4% high-level polysomy with focal amplification, 18% low-level polysomy, and 39% disomy. Phospho-receptor tyrosine kinase array membranes showed EGFR activation in the chordoma cell line U-CH1 and all of the three chordomas analyzed. Direct sequencing of EGFR (exons 18–21), KRAS, NRAS, HRAS (exons 2, 3), and BRAF (exons 11, 15) using DNA from 62 chordomas failed to reveal mutations. PTEN expression was absent by immunohistochemistry in 19 of 147 (13%) analyzed chordomas, only one of which revealed high-level polysomy of EGFR. The EGFR inhibitor tyrphostin (AG 1478) markedly inhibited proliferation of the chordoma cell line U-CH1 in vitro and diminished EGFR phosphorylation in a dose-dependant manner, a finding supported by inhibition of phosphorylated Erk1/2. p-Akt was suppressed to a much lesser degree in these experiments. There was no reduction of T as assessed by western blotting. These data implicate aberrant EGFR signaling in the pathogenesis of chordoma. This study provides a strategy for patient stratification for treatment with EGFR antagonists.

Primary leiomyosarcoma of the inferior vena cava: A 2-institution analysis of outcomes

Approximately 300 cases of leiomyosarcoma of the inferior vena cava (IVC) have been reported in the literature to date. In this study, the authors combined the experience from 2 institutions to provide additional clinical outcomes data. They performed a retrospective analysis from 1984 to 2009 that included 17 patients treated between the 2 institutions. Clinicopathologic data, surgical and adjuvant therapy, and survival outcomes were obtained. The results were as follows: The median age of patients in the study was 48 years. The tumor location was infrarenal in 8 patients, juxtarenal in 6, and suprahepatic in 2 patients; 7 patients had high-grade tumors. All patients underwent complete resection; the IVC was repaired primarily in 5 patients, ligated in 5, and reconstructed with a prosthetic tube graft in 7 patients. There was no perioperative mortality; 6 patients had complications. Median follow-up was 49 months; median survival had not been reached when this paper was written. The 5-year overall and disease -free survival were 56% and 37%, respectively. Of the 17 patients, 10 experienced disease recurrence and underwent numerous treatment modalities for these recurrences. The authors conclude: Aggressive resection of primary leiomyosarcoma of the IVC can be performed safely and result in long-term survival, irrespective of IVC management. Despite high recurrence rates, no consensus yet exists regarding adjuvant treatment.

Oleanane triterpenoid CDDO-Me induces apoptosis in multidrug resistant osteosarcoma cells through inhibition of Stat3 pathway

The activation of signal transducer and activator of transcription 3 (Stat3) pathway correlates with tumor growth, survival, drug resistance and poor prognosis in osteosarcoma. To explore the potential therapeutic values of this pathway, this study assessed both the expression and the activation of Stat3 pathway in several pairs of multidrug resistant (MDR) osteosarcoma cell lines, and tissues. To explore the potential therapeutic values of this pathway, the study analyzed the ability of the synthetic oleanane triterpenoid, C-28 methyl ester of 2-cyano-3,12-dioxoolen-1,9-dien-28-oic acid (CDDO-Me), to inhibit Stat3 expression and activation as well as its effects on doxorubicin sensitivity in osteosarcoma cells. Expression of Stat3, phosphorylated Stat3 (pStat3) and Stat3 targeted proteins, including Bcl-XL, Survivin and MCL-1 were determined in drug sensitive and MDR osteosarcoma cell lines and tissues by Western blot analysis. The effect of CDDO-Me on osteosarcoma cell growth was evaluated by MTT and apoptosis by PARP cleavage assay and caspase-3/7 activity. The Results were as follows: Stat3 pathway was activated in osteosarcoma tissues and in MDR cell lines. CDDO-Me inhibited growth and induced apoptosis in osteosarcoma cell lines. Treatment with CDDO-Me significantly decreased the level of nuclear translocation and phosphorylation of Stat3. The inhibition of Stat3 pathway correlated with the suppression of the anti-apoptotic Stat3 targeted genes Bcl-XL, survivin, and MCL-1. Furthermore, CDDO-Me increased the cytotoxic effects of doxorubicin in the MDR osteosarcoma cell lines. The study concludes: Stat3 pathway is overexpressed in MDR osteosarcoma cells. CDDO-Me significantly inhibited Stat3 phosphorylation, Stat3 nuclear translocation and induced apoptosis in osteosarcoma. This study provides the framework for the clinical evaluation of CDDO-Me, either as monotherapy or perhaps even more effectively in combination with doxorubicin to treat osteosarcoma and overcome drug resistance.

Solitary skeletal osteosarcoma recurrence. Findings from the Cooperative Osteosarcoma Study Group

Solitary skeletal osteosarcoma (OS) manifestations distant from the site of the primary tumor rarely arise as the only sign of disease recurrence. This report reviews 38 patients with high-grade central OS of the limbs or axial skeleton and initial complete surgical remission (CR) who developed first recurrences as solitary osseous lesions distant from the primary tumor. The Cooperative Osteosarcoma Study Group (COSS) database was used to evaluate patient-, tumor-, and treatment-related variables and outcomes. The Results were as follows: Thirty-eight patients (27 males and 11 females; 36 limb and 2 axial primaries) developed solitary osseous recurrences a median of 2.1 years (range: 0.5–14.3) from primary diagnosis. Relapses involved axial (24), extremity (10), or craniofacial bones (4). Treatment for recurrence included surgery (28), radiotherapy (10), and chemotherapy (27). After a median follow-up of 1.9 years (range: 0.1–21.2) from first recurrence for all 38 patients and 5.5 years (0.3–21.2) for 16 survivors (10 in continuous second CR), 2- and 5-year overall and event-free survival (EFS) probabilities were 55% and 34% and 34% and 27%, respectively. A long interval to recurrence (>1.5 years) predicted for better overall (P < 0.001) and EFS (P = 0.005). For 21 patients achieving a second CR, 2- and 5-year overall and EFS probabilities were 81% and 61% and 52% and 49%, respectively, while only 1/17 others survived beyond 5 years (P < 0.001). Survivors (14/16) had also received second-line chemotherapy. The report concludes: First solitary skeletal recurrences of OS should be treated with curative intent. Some presumed bone metastases may represent second primary Oss.

Prognosticators in Thigh Soft Tissue Sarcomas

In sarcoma patients the roles of smoking history, family cancer history, and leukoreduced blood transfusions have not been studied and the effect of preoperative radiation on blood loss has not been examined. In this study seventy-seven patients with non-metastatic and non-recurrent thigh sarcomas surgically treated at the Cleveland Clinic were identified. Among patient variables studied were: close family history of cancer, perioperative transfusion history, smoking history, and radiation history. Median follow-up for the survivors was 3.2 years. The results were as follows: The investigators found that tumor grade, transfusion >3U (P¼0.022), and pre- or post-operative radiation therapy (P¼0.041) were risk factors for distant metastasis. Tumor grade (P¼0.008), positive smoking history (P¼0.039), and >3U of non-leukoreduced blood transfused (P¼0.037) were risk factors for death of any-cause. Close family history of cancer correlated with having a grade 3 sarcoma (P¼0.044). Neoadjuvant radiotherapy correlated with >3U of blood transfused (P¼0.001) and biopsy performed at the treating institution led to a significant decrease in rate of recurrence (P¼0.016). The investigators conclude: they present novel findings in terms of transfusions, family history of cancer and site of initial biopsy in sarcoma patients.

Non-metastatic unresected paediatric non-rhabdomyosarcoma soft tissue sarcomas: Results of a pooled analysis from United States and European groups

Non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) with initially unresected tumors represent a particular subset of patients with a poor outcome. Various international research groups pooled their data in a joint study in order to investigate prognostic variables and treatment modalities. The study population consisted of 304 patients less than 21 years old treated between 1980 and 2005 using a multimodality therapeutic strategy. The Results were as follows: Synovial sarcoma and malignant peripheral nerve sheath tumor (MPNST) were the most frequent histotypes. Most patients received initial chemotherapy: major responses were recorded in 41% and minor in 16% of cases. Overall survival (OS) was 60.0% and 51.5% at 5 and 10 years, respectively, and it was significantly associated with patient’s age, histological subtype, tumor site and size, quality of delayed surgical resection, radiotherapy administration and response to induction chemotherapy. MPNST associated to neurofibromatosis type 1 was the tumor type with the worst rate of response to chemotherapy and the worst outcome. The study concludes: In unresected NRSTS patients, radiotherapy and delayed surgery are of crucial importance. Patients who respond to chemotherapy have better chance of survival. However, given the relatively poor prognosis, research on intensive multimodal treatment approaches and novel strategies is warranted.

Massive Genomic Rearrangement Acquired in a Single Catastrophic Event during Cancer Development

Cancer is driven by somatically acquired point mutations and chromosomal rearrangements, conventionally thought to accumulate gradually over time. Using next-generation sequencing, the investigators of this study characterize a phenomenon, which they term chromothripsis, whereby tens to hundreds of genomic rearrangements occur in a one-off cellular crisis. Rearrangements involving one or a few chromosomes crisscross back and forth across involved regions, generating frequent oscillations between two copy number states. These genomic hallmarks are highly improbable if rearrangements accumulate over time and instead imply that nearly all occur during a single cellular catastrophe. The stamp of chromothripsis can be seen in at least 2%–3% of all cancers, across many subtypes, and is present in 25% of bone cancers. They found that one, or indeed more than one, cancer-causing lesion can emerge out of the genomic crisis. They conclude that this phenomenon has important implications for the origins of genomic remodeling and temporal emergence of cancer.

Efficacy of Exercise Interventions in Modulating Cancer-Related Fatigue among Adult Cancer Survivors: A Meta-Analysis

The purpose of this meta-analysis was to explore the efficacy of exercise as a non-pharmacological intervention to reduce cancer-related fatigue (CRF) among adult cancer survivors. The authors also investigated how different components of the exercise prescription (Ex Rx), methodological considerations, and subject characteristics modulate CRF. A systematic search for randomized controlled trials was conducted using words related to cancer, exercise, and fatigue. The results were as follows: In total 44 studies with 48 interventions qualified, including 3,254 participants of varying cancer types, stages of diagnosis, treatments, and exercise interventions. Cancer survivors in exercise interventions reduced their CRF levels to a greater extent than usual care controls, d+ = 0.31 (95% confidence interval = 0.22 to 0.40; random-effects assumptions), an effect that appeared to generalize across several types of cancer. CRF levels improved in direct proportion to the intensity of resistance exercise (β = 0.60, p = .01), a pattern that was stronger in higher quality studies (β = 0.23, p < .05). CRF levels also reduced to a greater extent when interventions were theoretically-driven (β = 0.48, p < .001) or cancer survivors were older (β = 0.24, p = .04). The authors conclude: results indicate exercise interventions for adult cancer survivors should be multi-dimensional and individualized according to health outcome and cancer type. Results indicate exercise interventions for adult cancer survivors should be multi-dimensional and individualized according to health outcome and cancer type.

December 2010

Soft tissue sarcoma: from molecular diagnosis to selection of treatment

Pathological diagnosis of soft tissue sarcoma amid molecular biology and targeted therapies: During the past few years, differential diagnosis of soft tissue tumors has improved due to novel molecular diagnostic tools. Besides a better differentiation between different tumor entities the recognition of specific molecular aberrations may also help to identify novel therapeutic targets. One of the most promising examples of effective molecularly driven treatment is the gastrointestinal stromal tumor. Shortly after the detection of gain-of-function mutations in the type III receptor tyrosine kinases KIT and PDGFRα a targeted treatment with the tyrosine kinase inhibitor imatinib was introduced and became the gold standard in advanced GIST disease. The success of this therapy with response rates of >80% stable disease and partial remission is still unmatched. Since then, many groups aim to identify other potential molecular targets. Genomic and proteomic signatures may pinpoint potential areas of interest for diagnostic tools, prediction of clinical outcome and potential response to therapeutic targets. This article gives an overview of the most important genomic aberrations in sarcomas, their differential diagnosis and the relevance of molecular biology for treatment strategies.

Disease State Awareness in Sarcoma

Dr. George Demetri of the Dana-Farber Cancer Institute answers questions from the editors of Clinical Advances in Hematology & Oncology on what is new in the field of sarcoma research and outlines some emerging treatment approaches.

Advances in Drug Development – New Treatments for Sarcoma

Dr. Ian Judson from the Royal Marsden Hospital/Institute of Cancer Research answers questions from the editors of Clinical Advances in Hematology & Oncology on new agents currently being investigated in sarcoma treatment.

Compartment surgery in treatment strategies for retroperitoneal sarcomas: a single-center experience

Retroperitoneal sarcomas (RPS) are rare tumors and radical surgery is still the only curative treatment. The investigators of this study sought to estimate postoperative morbidity and mortality and identify significant prognostic factors for survival of patients with RPS and then evaluate the effect of en bloc resection on survival. This was a retrospective follow-up study of 91 patients with RPS who underwent surgery at the Section of Abdominopelvic Surgery of the National Cancer Institute-Brazil (INCA) between June 1992 and January 2008. Overall and 2-, 5-, and 10-year disease-free survival rates were calculated and univariate and Cox multivariate analyses were performed. The Results were as follows: The most common complaints were abdominal pain and mass. Resection was possible in 83.5% and curative resection in 55.3%. Six patients died within the postoperative period (mortality = 6.6%) and 28 had complications (30.8%). Leiomyosarcomas and liposarcomas predominated, as well as G3. The median tumor diameter was 20.5 cm. There were 124 organs resected in association, with only 42 proven invaded. The 5-year overall survival and disease-free survival rates were 32.0 and 36.8%, respectively. Cell differentiation, curative or palliative resection, blood transfusion, and re-resection were significant variables. Compartment surgery had no impact on survival, but it increased the duration of surgery, the need for blood transfusion, and overall morbidity. The investigators conclude: This study suggests that early diagnosis and curative resection of retroperitoneal sarcomas can improve long-term survival. Adjacent organs with evidence of direct invasion must be removed en bloc; others should be spared.

MicroRNA miR-183 Functions as an Oncogene by Targeting the Transcription Factor EGR1 and Promoting Tumor Cell Migration

The transcription factor EGR1 is a tumor suppressor gene that is downregulated in many cancer types. Clinically, loss of EGR1 translates to increased tumor transformation and subsequent patient morbidity and mortality. In synovial sarcoma, the SS18-SSX fusion protein represses EGR1 expression through a direct association with the EGR1 promoter. However, the mechanism through which EGR1 becomes downregulated in other tumor types is unclear. In this article, the authors report that EGR1 is regulated by microRNA (miR)-183 in multiple tumor types including synovial sarcoma, rhabdomyosarcoma (RMS), and colon cancer. Using an integrative network analysis, they identified that miR-183 is significantly overexpressed in these tumor types as well as in corresponding tumor cell lines. Bioinformatic analyses suggested that miR-183 could target EGR1 mRNA and this specific interaction was validated in vitro. miR-183 knockdown in synovial sarcoma, RMS, and colon cancer cell lines revealed deregulation of a miRNA network composed of miR-183–EGR1–PTEN in these tumors. Integrated miRNA- and mRNA-based genomic analyses indicated that miR-183 is an important contributor to cell migration in these tumor types and this result was functionally validated to be occurring via an EGR1-based mechanism. The authors conclude that their findings have significant implications in the mechanisms underlying EGR1 regulation in cancers. miR-183 has a potential oncogenic role through the regulation of 2 tumor suppressor genes, EGR1 and PTEN, and the deregulation of this fundamental miRNA regulatory network may be central to many tumor types.

Embryonal rhabdomyosarcoma with metastases confined to the lungs: Report from the CWS study group

Embryonal rhabdomyosarcoma [RME] is the most common pediatric soft tissue sarcoma. Whereas the prognosis of localized rhabdomyosarcoma has improved, it remains poor for metastatic disease. This study analyzed RME-patients with isolated pulmonary metastases [PRME] treated in four consecutive CWS-trials. Treatment included multiagent chemotherapy and local treatment of the primary tumor. Therapy of lung metastases after induction chemotherapy depended on response and individual decisions. The results were as follows: Twenty-nine patients <21 years had PRME. Their median age was six years, the median follow-up nine years. Twenty-eight children had their primary tumor located in an unfavorable site and 22 of the primaries were >5 cm. In addition to conventional chemotherapy, seven patients received high-dose treatment and eight patients oral metronomic chemotherapy. The lung metastases were in remission after induction chemotherapy in 22 individuals. 19 patients received no local treatment of metastases; 3 patients had pulmonary metastasectomy and lung radiation was administered to 9 individuals. In total, 24/29 patients achieved a complete remission [CR]. Actuarial 5-year event-free and overall survival for all patients was 37.9 ± 18% and 48.7 ± 18%, respectively; it was 45.8 ± 20% and 58.3 ± 20% for the 24 patients who achieved a CR. Local treatment of metastases had no impact on the failure pattern. Younger age, good response, achievement of CR and maintenance-treatment were favorable prognostic factors in univariate analysis. The authors conclude: Children with PRME have a fair prognosis. Local treatment of metastases did not improve outcome in our sample. Metronomic treatment may be an attractive option for PREM-patients.

Preoperative versus Postoperative Radiotherapy in Soft-tissue Sarcoma: Multi-institutional Analysis of 821 Patients

The purpose of this study was to assess the impact of radiotherapy (RT) sequencing with surgery on overall survival (OS), cause-specific survival (CSS), local failure, and distant failure in soft-tissue sarcoma (STS). A retrospective analysis was conducted using the National Oncology Database, a proprietary database of aggregated tumor registries owned by IMPAC Medical Systems (Sunnyvale, CA). Patients with STS of all major anatomic sites who received definitive surgery and either preoperative (preop) or postoperative (postop) RT were included. Patients were also required to have known stage and grade. Prognostic factors for survival were identified using multivariate techniques. Survival was calculated using the Kaplan-Meier method, and compared for statistical significance (p < 0.05) using the log-rank test. The results were as follows: A total of 821 patients met inclusion criteria. The median follow-up time was 63 months. Age, stage, histology, gender, tumor size, and RT sequence were independent predictors for OS (p < 0.05). Preop RT was associated with significantly improved OS and CSS compared with postop RT (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.56–0.91, p < 0.01, and HR = 0.64, 95% CI 0.46–0.88, p < 0.01, respectively). The 5-year CSS was 79% and 74%, in favor of preop RT (log–rank, p < 0.05). Preop RT was also significantly associated with a reduced risk for local and distant relapse compared with postop RT. The authors conclude: Preoperative RT is associated with a reduced cancer-specific mortality compared with postoperative RT in STS. The results of this study may serve as motivation to conduct future prospective studies with larger patient numbers.

Myeloid sarcomas: a histologic, immunohistochemical, and cytogenetic study

Myeloid sarcoma (MS) is a neoplasm of immature granulocytes, monocytes, or both involving any extramedullary site. The correct diagnosis of MS is important for adequate therapy, which is often delayed because of a high misdiagnosis rate. The objective of this study was to evaluate the lineage differentiation of neoplastic cells in MS by immunohistochemistry, and to correlate the results with clinicopathologic findings and cytogenetic studies. Histologic and immunohistochemical examinations were performed on formalin-fixed paraffin-embedded tissue samples from 13 cases of MS. They were classified according to the World Health Organization criteria. Chromosomal analysis data were available in 11 cases. Clinical, pathological, and cytogenetic findings were analyzed. The results were as follows: The study included six male and seven female patients with an age range of 25 to 72 years (mean, 49.3 years) and a male to female ratio of 1:1.2. MS de novo occurred in 4/13 (31%) of cases examined. The most sensitive immunohistochemical markers were CD43 and lysozyme present in all cases with MS (13/13, 100%). All de novo MS showed a normal karyotype, monoblastic differentiation, and lack of CD34. The most common chromosomal abnormalities in MS associated with a hematopoietic disorder were trisomy 8 and inv(16) (2/11, 18%). The authors Conclude: An immunohistochemical panel including CD43, lysozyme, myeloperoxidase (MPO), CD68 (or CD163), CD117, CD3 and CD20 can successfully identify the vast majority of MS variants in formalin-fixed paraffin-embedded tissue sections. The present report expands the spectrum of our knowledge showing that de novo MS has frequent monoblastic differentiation and frequently carries a normal karyotype.

Myxoid Liposarcoma with EWS–CHOP Type 1 Fusion Gene

In myxoid liposarcoma (MLS), the t(12;16)(q13;p11) chromosomal translocation and its resultant fusion transcript, the human translocation liposarcoma (TLS)–CCAAT/enhancer binding protein (C/EBP) homologous protein (CHOP), are found in the majority of cases. On the other hand, the variant translocation, t(12;22)(q13;q12) creating the Ewing sarcoma (EWS)–CHOP fusion transcript, is detectable in a limited number of cases. In this study, tissue from MLS arising in the left thigh of a 19-year-old female was analyzed for possible detection of chromosome translocation and fusion transcript. Fluorescent in situ hybridization (FISH) and reverse transcription-polymerase chain reaction (RT-PCR) methods were used. The results were as follows: FISH analysis demonstrated a rearrangement in the CHOP gene. RT-PCR analysis confirmed the presence of EWS–CHOP chimeric transcript type 1, in which exon 7 of EWS was in-frame fused to exon 2 of CHOP with a serine (AGT) to methionine (ATG) transition at the junction. The patient underwent a radical segmental resection including a left vastus medialis musclectomy. Sixty months following the surgical resection, the patient was alive with no evidence of disease. The authors conclude: Analysis of MLS with EWS–CHOP variant transcripts, type 1 through type 4, including this case together with 15 cases in the literature, indicated that MLS with type 1 fusion transcript may show a more favorable clinical behavior than MLS with other types of fusion transcript.

Benign Mesenchymal Stromal Cells in Human Sarcomas

Recent evidence suggests that at least some sarcomas arise through aberrant differentiation of mesenchymal stromal cells (MSCs), but MSCs have never been isolated directly from human sarcoma specimens. In this study, the investigators examined human sarcoma cell lines and primary adherent cultures derived from human sarcoma surgical samples for features of MSCs. They further characterized primary cultures as either benign or malignant by the presence of tumor-defining genetic lesions and tumor formation in immunocompromised mice. The Results were as follows: They showed that a dedifferentiated liposarcoma cell line DDLS8817 posesses fat, bone, and cartilage trilineage differentiation potential characteristic of MSCs. Primary sarcoma cultures have the morphology, surface immunophenotype, and differentiation potential characteristic of MSCs. Surprisingly, many of these cultures are benign, as they do not form tumors in mice and lack sarcoma-defining genetic lesions. Consistent with the recently proposed pericyte origin of MSCs in normal human tissues, sarcoma-derived benign MSCs (SDBMSCs) express markers of pericytes and cooperate with endothelial cells in tube formation assays. In human sarcoma specimens, a subset of CD146-positive microvascular pericytes expresses CD105, an MSC marker, whereas malignant cells largely do not. In an in vitro coculture model, SDBMSCs as well as normal human pericytes markedly stimulate the growth of sarcoma cell lines. The investigators conclude: DBMSCs/pericytes represent a previously undescribed stromal cell type in sarcoma that may contribute to tumor formation.

Caveolin-1 Modulates the Ability of Ewing's Sarcoma to Metastasize

Metastasis is the final stage of tumor progression and is thought to be responsible for up to 90% of deaths associated with solid tumors. Caveolin-1 (CAV1) regulates multiple cancer-associated processes related to malignant tumor progression. In this study, the investigators tested the hypothesis that CAV1 modulates the metastatic ability of cells from the Ewing's sarcoma family of tumors (ESFT). First, they analyzed the expression of CAV1 by immunostaining a tissue microarray containing 43 paraffin-embedded ESFT tumors with known EWS translocations. Even though no evidence was found for a significant association between CAV1 expression and stage, size or tumor site, all metastatic samples (10 of 10) had significantly high CAV1 expression, suggesting that high CAV1 content could positively contribute to enhance ESFT metastasis. To determine the effect of CAV1 on the migratory and invasive capabilities of ESFT cells, they knocked down CAV1 expression in TC252 and A673 cells by stably transfecting a previously validated shRNA construct. In vitro, migration and invasion assays showed that for both cell lines, CAV1 knocked-down cells migrated and invaded significantly less (P ≤ 0.01) than control cells. Moreover, control A673 cells introduced into BALB/c nude mice by tail vein injection strongly colonized the lungs. In contrast, animals injected with CAV1 knocked-down cells showed either no incidence of metastasis or developed lung metastases after a significant delay (P < 0.0001). Finally, they showed that the molecular mechanisms by which CAV1 carries out its key role in regulating ESFT metastasis involve matrix metalloproteinase production and activation as well as the control of the expression of SPARC, a known determinant of lung colonization.

Nutlin-3a is a potential therapeutic for Ewing Sarcoma

Although mutations in the TP53 gene occur in half of all cancers, approximately 90% of Ewing Sarcomas retain a functional wild type p53. The low frequency of TP53 alterations in Ewing Sarcoma makes this tumor type an ideal candidate for p53-targeted therapies. In this study, the investigators examined the molecular and cellular responses of cultured Ewing Sarcoma cell lines following exposure to Nutlin-3a, a recently developed MDM2 antagonist. The ability of Nutlin-3a to impart apoptosis or cell cycle arrest in a p53-dependent manner was determined in a comprehensive panel of Ewing Sarcoma cell lines. The capacity of Nutlin-3a to augment the antitumor activity of MDM4 antagonists and cytotoxic agents currently used in the clinical treatment of Ewing Sarcoma was also investigated. The results were as follows: Apoptosis was the primary response of wild type p53 expressing Ewing Sarcoma cell lines. The cytotoxicity of Nultin-3a was also synergistic with the chemotherapeutic agents, Vincristine, Actinomycin D, Doxorubicin, and Etoposide in a concentration-dependent manner. Significant MDM4 protein overexpression was observed in Ewing Sarcoma cell lines of wild type p53 status, providing a mechanism through which Ewing Sarcomas can develop in the absence of TP53 alterations. This study provides the first evidence of synergism between targeted inhibition of MDM2 and MDM4. The investigators conclude: findings suggest that p53-dependent apoptosis is the primary cellular response of Ewing Sarcoma cell lines following exposure to Nutlin-3a. Furthermore, Nutlin-3a can synergize with the current Ewing sarcoma chemotherapy protocols, suggesting p53 activation as a novel systemic therapeutic approach for this disease.

Sox9 Expression Is Not Limited to Chondroid Neoplasms: Variable Occurrence in Other Soft Tissue and Bone Tumors With Frequent Expression by Synovial Sarcomas

The transcription factor Sox9 is known to play a crucial role in normal chondrogenesis, and antibodies against Sox9 have been proposed as a diagnostic tool for neoplasms with chondroid differentiation. However, the pattern of Sox9 immunohistochemical expression by other bone and soft tissue neoplasms, as well as its diagnostic specificity, remain unexplored. The authors of this article have performed immunohistochemistry with antibodies against Sox9 in 106 chondroid and nonchondroid bone and soft tissue neoplasms. Moderate to intense Sox9 nuclear staining was observed in 14/20 chondrosarcomas (70%), and in 24/81 (29.6%) cases from a multitumor tissue microarray, which included 16/18 synovial sarcomas, 4/15 osteosarcomas, 2/5 peripheral primitive neuroectodermal tumor (PNET)/Ewing sarcomas, 1/1 mesenchymal chondrosarcoma, and 1/1 chondroblastoma. The results suggest that Sox9 usefulness in the diagnosis of chondroid tumors may be limited because of low sensitivity and specificity. The finding of Sox9 expression by 88.9% of synovial sarcomas represents a novel and striking observation, which deserves further investigation.

Liposarcoma: Molecular Genetics and Therapeutics

Sarcomas are a group of heterogeneous tumors with varying genetic basis. Cytogenetic abnormalities range from distinct genomic rearrangements such as pathognomonic translocation events and common chromosomal amplification or loss, to more complex rearrangements involving multiple chromosomes. The different subtypes of liposarcoma are spread across this spectrum and constitute an interesting tumor type for molecular review. This paper outlines the molecular pathogenesis of the three main subtypes of liposarcoma: well-¬‐differentiated/de-¬differentiated, myxoid/round cell and pleomorphic liposarcoma. Both the molecular basis and future avenues for therapeutic intervention are discussed.

Angiosarcoma: State of the art and perspectives

The authors conducted a literature review of available data on angiosarcoma (AS) which revealed as follows. AS account for 1% of adult soft tissue sarcoma. Two risk factors are well-establish chronic lymhoedema, previous radiotherapy. Clinical presentations of AS are heterogeneous. Large resection followed, if possible, by adjuvant radiotherapy is the cornerstone of curative intent treatment of localized forms. There are no convincing data supporting the administration of adjuvant chemotherapy. For metastatic or locally advanced AS, doxorubicin and weekly paclitaxel seem to provide the longer progression-free survival. Three phase II or parts of phase II trials have been published in the last 2 years, investigating weekly paclitaxel, sorafenib and imatinib, demonstrating that clinical trials are feasible for such rare diseases. Biological evidences for the key role of angiogentic factors have been accumulated during the last years and support the further investigation of anti-angiogenetic agents alone and almost combination with chemotherapy in such disease.

Radiotherapy for Soft Tissue Sarcoma of the Proximal Lower Extremity

Soft-tissue sarcoma (STS) is a histopathologically diverse group of tumors accounting for approximately 10,000 new malignancies in the US each year. The proximal lower extremity is the most common site for STS, accounting for approximately one-third of all cases. Coordinated multimodality management in the form of surgery and radiation is often critical to local control, limb preservation, and functional outcome. This review article provides an overview of the treatment of STS of the lower extremity with a particular focus on the modern role of radiotherapy. The article concludes that preoperative radiation may provide a functional benefit in long-term survivors without compromising local control, and in select circumstances, adjuvant chemotherapy may augment local management.

October 2010

Influx of funding impels collaborative explorations to study sarcoma as behavior model for other cancers

by Fran Lowry, Oncology NEWS International. Vol. 19 No. 9. September 1, 2010

In this Oncology NEWS International article, Fran Lowry reports that sarcoma research is producing valuable information not only on the behavior of sarcomas but other types of cancers as well. Citing comments from experts, Lowry states, "This orphan disease is finding a home in the cancer care continuum," and "experts told Oncology News International that there has never been a better time to be engaged in sarcoma research."

Who are these experts and what did they say?

Gary K Schwartz, MD is the chief of Memorial Sloan-Kettering Cancer Center (MSKCC)’s Melanoma & Sarcoma Service in New York. Schwarz is one of several researchers heavily involved in the study of the molecular pathways associated with sarcoma. According to Schwartz, "The U.S. government has identified sarcoma as one of the diseases they are going to help, over the next several years, to find ways to treat and ways, hopefully, to cure." Schwartz’s labs have received grants from both NCI and the ARAA (Recovery & Reinvestment Act) to further this work.

Lee Cranmer, MD, PhD, Associate Professor of Clinical Medicine at the Arizona Cancer Center in Tucson, echoes this positive trend, saying "I would say there is a great deal of hope". He goes on to say, "Sarcomas are very tough nuts to crack, but we are making progress. Future generations—and I don't mean many generations, I mean the next generation—will not have the same burden of this problem as we experience now."

Jonathan Trent, MD of The University of Texas M.D. Anderson Cancer Center in Houston, TX is also involved in research aimed at understanding the molecular pathways that contribute to cancer cell growth. Mapping of the human genome has greatly facilitated his work. He describes the significance of understanding how the genes work, saying "We are finding now that each different sarcoma is caused by a specific genetic event, and treatment of those specific tumors has to be individualized to the specific histology. This highlights the importance of getting a sarcoma patient's genetic blueprint." He continued, "If there is one gene that is causing this cancer, surely we can develop therapies to target these genes. We can develop a therapy to target the gene that causes the cancer and then we stand a good chance of helping a lot of people. That is a very attractive prospect to me," he added. Indeed, that is attractive to a lot of people.

Robert Maki, MD, PhD, also of MSKCC, discusses the need to coordinate among multiple institutions, internationally, in order to launch the clinical trials needed before new drugs can reach actual patients.

Some of the groups that are involved in coordination efforts include:

SARC: Sarcoma Alliance for Research through Collaboration
CTOS: Connective Tissue Oncology Society
EORTC: The European Organization for Research and Treatment of Cancer
GEIS: The Spanish Sarcoma Group
RTOG: Radiation Therapy Oncology Group

Maki says of SARC, "SARC is a stand-alone group that coordinates centers to perform clinical trials together. It's led by Denise Reinke, MS, NP, and a board of scientific directors, and is an excellent example of a successful collaborative sarcoma clinical trials effort."

Maki adds, "More and more we are trying to coordinate these groups to perform clinical trials worldwide, which is the only way we will be able to move the field forward efficiently," Dr. Maki said. These collaborative groups are filling a gap left by bigger collaborative cancer trial groups, he added. "Sarcoma subgroups have been cut out of the research budgets of the cooperative trials groups. The RTOG is presently the only cooperative group that still has a dedicated sarcoma committee," he said.

CTEP has also been an important player in testing combinations of different drugs. Maki says, "CTEP makes it possible to combine drugs in research studies, which is exceptionally difficult to do as an investigator-initiated study or as an industrial study because it is hard to get two industrial concerns together on one study." He further explains that "CTEP is able to put out requests for proposals for research studies, and researchers can submit applications to test a given combination." Dr Maki’s trials using the combination of the IGF-1R inhibitor and the mTOR inhibitor was made possible by CTEP. "Kudos to CTEP for allowing us to put together this study," he said. "They have access to different companies' drugs and it does allow us to put them together for the first time. Everybody, including pharma, recognizes that this is a win-win situation."

Dr Maki and George Demetri, MD (director of Boston’s Ludwig Center and the Sarcoma Center at the Dana-Farber Cancer Institute and Harvard Medical School) serve on the board of directors of an important clinical trial of the targeted agent palifosfamide, produced by Ziopharm Oncology.

This trial endeavors to improve on current chemotherapy combinations to make them not just more effective, but more tolerable for patients. Anyone familiar with current sarcoma treatments knows about ifosfamide and its many side effects. Demetri says that ifosfamide "has been used in sarcomas since the 1980s." He goes on to say "It is a pro drug that the body has to metabolize to the active form. Different people metabolize it differently, so there is not a lot of reliability. Also, one of the metabolites of ifosfamide is toxic itself and causes bladder bleeding. Palifosfamide does not have this toxic metabolite; that is a huge advantage." The combination of palifosfamide and doxorubicin has proven to be both more effective and more tolerable.

Research into the following sarcoma growth factors has potential benefits for treatment of lung, breast, ovarian and renal cancers: Vascular endothelial growth factor (VEGF), Mammalian target of rapamycin (mTOR), Insulin-like growth factor (IGF-1R), Receptor Activator for Nuclear Factor κ B Ligand (RANK ligand) and KIT or C-kit receptor (CD117)

"Sarcomas are telling us just how darn complicated all cancers are going to be. That's the message of sarcomas. They really are the canary in the coal mine," says Demetri.

Elevated expression of CXC chemokines in pediatric osteosarcoma patients

Despite the advent of chemotherapy, the survival of osteosarcoma patients has not been significantly improved recently. Chemokines are a group of signaling molecules that have been implicated in tumorigenesis and metastasis. The authors of this study used an antibody microarray to identify chemokines that were elevated in the plasma samples of osteosarcoma patients. The tumor expressions of 3 chemokines were examined in 2 sets of osteosarcoma tissue arrays. The authors also evaluated the proliferative effect of the chemokines in 4 osteosarcoma cell lines. The authors found that the plasma levels of CXCL4, CXCL6, and CXCL12 in the osteosarcoma patients were significantly higher than those in the controls, and the results were validated by an independent osteosarcoma cohort (P < .05). However, CXCL4 (100%) and CXCL6 (91%) were frequently expressed in osteosarcoma, whereas CXCL12 was only expressed in 4%. Survival analysis further showed that higher circulating levels of CXCL4 and CXCL6, but not CXCL12, were associated with a poorer outcome of osteosarcoma patients. Addition of exogenous chemokines significantly promoted the growth of different osteosarcoma cells (P < .05). The authors conclude that their results demonstrate that CXCL4 and CXCL6 are frequently expressed in osteosarcoma, and that the plasma levels of these 2 chemokines are associated with patient outcomes. Further study of these circulating chemokines may provide a promising approach for prognostication of osteosarcoma. Targeting these chemokines or their receptors may also lead to a novel therapeutic invention.

Oncolytic virotherapy reaches adolescence

Lytic viruses kill cells as a consequence of their normal replication life cycle. The idea of harnessing viruses to kill cancer cells arose over a century ago, before viruses were even discovered, from medical case reports of infections associated with cancer remissions. Since then, there has been no shortage of hype, hope, or fear regarding the prospect of oncolytic virotherapy for cancer. Early developments in the field included encouraging antitumor efficacy both in animal studies in the 1920s–1940s and in human clinical trials in the 1950s–1970s. Despite its long-standing history, oncolytic virotherapy was an idea ahead of its time. Without needed advances in molecular biology, virology, immunology, and clinical research ethics, early clinical trials resulted in infectious complications and were fraught with controversial research conduct, so that enthusiasm in the medical community waned. Oncolytic virotherapy is now experiencing a major growth spurt, having sustained numerous laboratory advances and undergone multiple encouraging adult clinical trials, and is now witnessing the emergence of pediatric trials. This article reviews the history and salient biology of the field, including preclinical and clinical data, with a special emphasis on those agents now being tested in pediatric cancer patients.

Early Treatment Failure in Intermediate-Risk Rhabdomyosarcoma: Results From IRS-IV and D9803—A Report From the Children's Oncology Group

The goal of this study was to determine the frequency and clinical features of early treatment failure during induction chemotherapy before protocol radiation therapy for children with intermediate-risk rhabdomyosarcoma (RMS). Patients with intermediate-risk RMS enrolled onto the Intergroup Rhabdomyosarcoma Study-IV and the Children's Oncology Group D9803 study were reviewed for an early treatment failure. Early failure was defined as failure caused by progressive disease, death as a result of progressive disease, or death as a result of other causes occurring fewer than 120 days from study entry. Patients with parameningeal site RMS with high-risk features who received radiation therapy at week 1 were excluded from analysis. Overall survival (OS) was estimated using the Kaplan-Meier method. Fisher's exact test was used to compare differences between groups. Cumulative incidence of progression was estimated. The results were as follows: Of 916 patients, 20 (2.2%) were found to have an early disease progression and did not receive planned protocol radiotherapy. Three additional early failures resulted from treatment-related death without progression. Median time to failure was 48 days (range, 7 to 106 days). Nineteen (95%) of the 20 patients experienced progression at their primary site. Five-year OS was 32% (95% CI, 12% to 54%) for patients experiencing an early progression. The investigators conclude: A small proportion of patients with intermediate-risk RMS suffer an early failure as a result of early progression (2.2%) or treatment-related mortality (0.3%). The majority of patients with early progression had a local failure. Earlier radiotherapy could potentially improve outcome by preventing early local progression.

Histologic Type Predicts Survival in Patients with Retroperitoneal Soft Tissue Sarcoma

Histologic grade, completeness of resection, and presence of metastases are traditionally regarded as the primary factors in predicting survival for retroperitoneal soft tissue sarcoma (RPSTS). The investigators of this study sought to examine the importance of histologic type as a prognostic factor among patients with RPSTS. They identified 2337 cases of RPSTS in the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2004. After excluding 273 cases of age <18, identification by autopsy only, or absence of histologic confirmation, they arrived at a final study cohort of 2064 patients. Overall survival (OS) and disease-specific survival (DSS) were estimated using the Kaplan-Meier method. Multivariate analysis was performed using a Cox proportional hazards model, adjusting for age, gender, race, histologic type, histologic grade, tumor size, extent of resection, and SEER summary stage. The Results were as follows: Among 33 histologic types, leiomyosarcoma (28.7%), well-differentiated/dedifferentiated liposarcoma (20.3%), liposarcoma not otherwise specified (NOS) (11.9%), malignant fibrous histiocytoma (MFH–11.0%), and sarcoma NOS (10.7%) were the most prevalent. Grade distribution was low, 24.2%; intermediate, 16%; high 34.3%, and unknown, 25.5%. Surgery was performed in 85.8%, and radiotherapy was administered to 22.8%. With a median follow-up of 38 mo, median OS was 78, 35, 25, 18, and 10 mo for liposarcoma, leiomyosarcoma, other histologies, MFH, and sarcoma NOS, respectively (P < 0.0001). Median DSS was 120, 53, not reached, 30, and 13 mo for liposarcoma, leiomyosarcoma, other histologies, MFH, and sarcoma NOS, respectively (P < 0.0001). On multivariate analysis, histologic type was associated with statistically significant differences in both OS and DSS. The investigators conclude: Histologic type is an important predictor of survival in RPSTS.

EWSR1-POU5F1 fusion in soft tissue myoepithelial tumors. A molecular analysis of sixty-six cases, including soft tissue, bone, and visceral lesions, showing common involvement of the EWSR1 gene

The diagnosis of myoepithelial (ME) tumors outside salivary glands remains challenging, especially in unusual clinical presentations, such as bone or visceral locations. A few reports have indicated EWSR1 gene rearrangement in soft tissue ME tumors, and, in one case each, the fusion partner was identified as either PBX1 or ZNF444. However, larger studies to investigate whether these genetic abnormalities are recurrent or restricted to tumors in soft tissue locations are lacking. In this study, sixty-six ME tumors mainly from soft tissue (71%), but also from skin, bone, and visceral locations, characterized by classic morphological features and supporting immunoprofile were studied. Gene rearrangements in EWSR1, FUS, PBX1, and ZNF444 were investigated by fluorescence in situ hybridization. EWSR1 gene rearrangement was detected in 45% of the cases. A EWSR1-POU5F1 fusion was identified in a pediatric soft tissue tumor by 3′Rapid Amplification of cDNA Euds (RACE) and subsequently confirmed in four additional soft tissue tumors in children and young adults. An EWSR1-PBX1 fusion was seen in five cases, whereas EWSR1-ZNF444 and FUS gene rearrangement was noted in one pulmonary tumor each. In conclusion, EWSR1 gene rearrangement is a common event in ME tumors arising outside salivary glands, irrespective of anatomical location. EWSR1-negative tumors were more often benign, superficially located, and showed ductal differentiation, suggesting the possibility of genetically distinct groups. A subset of soft tissue ME tumors with clear cell morphology harbor an EWSR1-POU5F1 fusion, which can be used as a molecular diagnostic test in difficult cases. These findings do not support a pathogenetic relationship between soft tissue ME tumors and their salivary gland counterparts.

Enhancement of Radiation Response in Osteosarcoma and Rhabomyosarcoma Cell Lines by Histone Deacetylase Inhibition

Histone deacetylase inhibitors (HDACIs) can enhance the sensitivity of cells to photon radiation treatment (XRT) by altering numerous molecular pathways. The investigators of this study investigated the effect of pan-HDACIs such as suberoylanilide hydroxamic acid (SAHA) on radiation response in two osteosarcoma (OS) and two rhabdomyosarcoma (RMS) cell lines. Clonogenic survival, cell cycle analysis, and apoptosis were examined in OS (KHOS-24OS, SAOS2) and RMS (A-204, RD) cell lines treated with HDACI and HDACI plus XRT, respectively. Protein expression was investigated via immunoblot analysis, and cell cycle analysis and measurement of apoptosis were performed using flow cytometry. The results were as follows: SAHA induced an inhibition of cell proliferation and clonogenic survival in OS and RMS cell lines and led to a significant radiosensitization of all tumor cell lines. Other HDACI such as M344 and valproate showed similar effects as investigated in one OS cell line. Furthermore, SAHA significantly increased radiation-induced apoptosis in the OS cell lines, whereas in the RMS cell lines radiation-induced apoptosis was insignificant with and without SAHA. In all investigated sarcoma cell lines, SAHA attenuated radiation-induced DNA repair protein expression (Rad51, Ku80). The investigators conclude: results show that HDACIs enhance radiation action in OS and RMS cell lines. Inhibition of DNA repair, as well as increased apoptosis induction after exposure to HDACIs, can be mechanisms of radiosensitization by HDACIs.

Small deletions but not methylation underlie CDKN2A/p16 loss of expression in conventional osteosarcoma

Conventional osteosarcoma is characterized by rapid growth, high local aggressiveness, and metastasizing potential. Patients developing lung metastases experience poor prognosis despite extensive chemotherapy regimens and surgical interventions. Previously the investigators of this study identified a subgroup of osteosarcoma patients with loss of CDKN2A/p16 protein expression in the primary tumor biopsies which was significantly predictive of a very poor prognosis. Here they aimed to identify the underlying mechanism(s) of this protein loss in relation to osteosarcoma behavior. The CDKN2A locus was analyzed in osteosarcoma cases with total loss of CDKN2A/p16 expression and in cases with high protein expression using melting curve analysis-methylation assay (MCA-Meth), fluorescent in situ hybridization (FISH), multiplex ligation-dependent probe amplification (MLPA), and mutation analysis. All cases with complete CDKN2A/p16 protein loss showed homozygous deletions at the CDKN2A locus. In none of the cases hyper methylation of the promoter region was seen which was confirmed by sequencing this region. Taken together the investigators show that large or smaller deletions of the CDKN2A locus are evident in patient samples and underlie the CDKN2A/p16 protein expression loss while promoter methylation does not appear to be a mechanism of this expression loss. Genomic loss of CDKN2A instead of promoter methylation might be a plausible explanation for the rapid proliferation and high aggressiveness of osteosarcoma by simultaneous impairment CDKN2A/p14ARF function.

August 2010

Subtype-specific genomic alterations define new targets for soft-tissue sarcoma therapy

Soft-tissue sarcomas show remarkable histologic diversity, with more than 50 recognized subtypes. However, knowledge of their genomic alterations is limited. The authors of this paper describe an integrative analysis of DNA sequence, copy number and mRNA expression in 207 samples encompassing seven major subtypes. Frequently mutated genes included TP53 (17% of pleomorphic liposarcomas), NF1 (10.5% of myxofibrosarcomas and 8% of pleomorphic liposarcomas) and PIK3CA (18% of myxoid/round-cell liposarcomas, or MRCs). PIK3CA mutations in MRCs were associated with Akt activation and poor clinical outcomes. In myxofibrosarcomas and pleomorphic liposarcomas, they found both point mutations and genomic deletions affecting the tumor suppressor NF1. Finally, they found that short hairpin RNA (shRNA)-based knockdown of several genes amplified in dedifferentiated liposarcoma, including CDK4 and YEATS4, decreased cell proliferation. Their study yields a detailed map of molecular alterations across diverse sarcoma subtypes and suggests potential subtype-specific targets for therapy.

Oncogenesis and classification of mixed-type liposarcoma: A radiological, histopathological and molecular biological analysis

Liposarcomas are separated into clinicopathological entities with a characteristic morphological spectrum and mutually exclusive genetic alterations. Therefore, the rare occurrence of cases with combined patterns of well-differentiated liposarcoma and myxoid liposarcoma designated as mixed-type liposarcoma pose a conceptual problem. Moreover, this feature may have consequences for treatment choice and prognosis. In this study, the investigators dissected the molecular relation of tumor components in cases of mixed-type liposarcoma. On the basis of heterogeneous preoperative magnetic resonance image (MRI) features, eight cases of mixed-type liposarcoma were selected. Preoperative biopsy samples and resection specimens were analyzed including molecular and immunohistochemical analysis on all components. As controls, cases with homogeneous MRI features and uniform aspects of myxoid liposarcoma (n = 5), round cell liposarcoma (n = 5) and well-differentiated liposarcoma (n = 5) were studied. All patients with heterogeneous MRI features showed morphological components of myxoid liposarcoma and well-differentiated liposarcoma. Real-time polymerase chain reaction showed FUS-DDIT3 fusion in both components in five of eight cases in the absence (zero of five) of MDM2 and CDK4 amplification. In three of eight patients, MDM2 and/or CDK4 were overexpressed, and amplification was shown by multiplex ligation-dependent probe amplification (MLPA) in the absence of myxoid liposarcoma translocations. All control patients showed a molecular pattern consistent with their morphological features. Therefore, the investigators conclude that mixed-type liposarcomas should not be regarded as collision tumors, but as an extreme variant of the morphological spectrum within a single biological entity, explaining the biological contradiction of mixed-type liposarcoma. For treatment stratification, detailed classification including molecular support should be performed in tumors with heterogeneous MRI features.

CD117 and Stro-1 Identify Osteosarcoma Tumor-Initiating Cells Associated with Metastasis and Drug Resistance

Emerging evidence indicates the presence of tumor-initiating cells (TIC) or cancer stem cells in osteosarcoma. However, no study has shown specific markers to identify osteosarcoma TICs with in vivo tumor formation ability. Additionally, there has been a lack of investigations gauging the contribution of osteosarcoma TICs to metastatic and drug-resistant properties. In this study, the investigators have identified mouse and human osteosarcoma TICs using mesenchymal stem cell markers CD117 and Stro-1. These markers were preferentially expressed in spheres and doxorubicin-resistant cells. Both mouse and human cells expressing these markers were sorted and analyzed for their abilities of tumor formation with as few as 200 cells, self-renewability, multipotency, drug resistance, metastatic potential, and enrichment of a metastasis-associated marker (CXCR4) and a drug resistance marker (ABCG2). CD117+Stro-1+ cells efficiently formed serially transplantable tumors, whereas CD117–Stro-1– cells rarely initiated tumors. On orthotopic injections, CD117+Stro-1+ cell-derived tumors metastasized at a high frequency. Further, CD117+Stro-1+ cells showed high invasive and drug-resistant properties and were efficiently enriched for CXCR4 (20–90%) and ABCG2 (60–90%). The investigators conclude: These results suggest possible mechanisms for the high metastatic and drug-resistant properties of osteosarcoma TICs. In summary, CD117 and Stro-1 identify osteosarcoma TICs associated with the most lethal characteristics of the disease—metastasis and drug resistance—and these markers offer candidates for TIC-targeted drug delivery aimed at eradicating osteosarcoma.

Molecular Characterization of Commonly Used Cell Lines for Bone Tumor Research: A Trans-European EuroBoNet Effort

Usage of cancer cell lines has repeatedly generated conflicting results provoked by differences among subclones or contamination with mycoplasm or other immortal mammalian cells. To overcome these limitations, the investigators of this study decided within the EuroBoNeT consortium to characterize a common set of cell lines including osteosarcomas (OS), Ewing sarcomas (ES), and chondrosarcomas (CS). DNA fingerprinting was used to guarantee the identity of all of the cell lines and to distinguish subclones of osteosarcoma cell line HOS. Screening for homozygous loss of 38 tumor suppressor genes by MLPA revealed deletion of CDKN2A as the most common event (15/36), strictly associated with absence of the CDKN2A (p16) protein. Ten cell lines showed missense mutations of the TP53 gene while another set of nine cell lines showed mutations resulting in truncation of the TP53 protein. Cells harboring missense mutations expressed high levels of nuclear TP53, while cell lines with nonsense mutations showed weak/absent staining for TP53. TP53wt cell lines usually expressed the protein in 2–10% of the cells. However, seven TP53wt osteosarcomas were negative for both mRNA and protein expression. Their analyses shed light on the correlation between immunohistochemical and genetic data for CDKN2A and TP53, and confirm the importance of these signaling pathways. The characterization of a substantial number of cell lines represents an important step to supply research groups with proven models for further advanced studies on tumor biology and may help to make results from different laboratories more comparable.

Cytotoxicity of Activated Natural Killer Cells against Pediatric Solid Tumors

In order to develop new therapies for children with solid tumors, the investigators of this study tested the cytotoxicity of natural killer (NK) cells expanded by coculture with K562-mb15-41BBL cells. They sought to identify the most sensitive tumor subtypes, clarify the molecular interactions regulating cytotoxicity, and determine NK antitumor potential in vivo. They tested in vitro cytotoxicity of expanded NK cells against cell lines representative of Ewing sarcoma (EWS; n = 5), rhabdomyosarcoma (n = 4), neuroblastoma (n = 3), and osteosarcoma (n = 3), and correlated the results with expression of inhibitory and activating NK receptor ligands. They also compared expanded and primary NK cells, determined the effects of activating receptor ligation and of chemotherapeutic drugs, and assessed the therapeutic effect of NK cell infusions in xenografts. The results were as follows: In 45 experiments, EWS and rhabdomyosarcoma cell lines were remarkably sensitive to expanded NK cells, with median cytotoxicities at 1:1 effector/target ratio of 87.2% and 79.1%, respectively. Cytotoxicity was not related to levels of expression of NK receptor ligands, nor was it affected by pretreatment of target cells with daunorubicin or vincristine, but was markedly inhibited by preincubation of NK cells with a combination of antibodies against the NK-activating receptors NKGD2 and DNAM-1. Expanded NK cells were considerably more cytototoxic than unstimulated NK cells, and eradicated EWS cells engrafted in nonobese diabetic/severe combined immunodeficient Il2rgnull mice. The investigators conclude: Among pediatric solid tumors, EWS and rhabdomyosarcoma are exquisitely sensitive to expanded NK cells. The NK expansion method described here has been adapted to large-scale conditions and supports a phase I clinical study including patients with these malignancies.

A Differentiation-Based MicroRNA Signature Identifies Leiomyosarcoma as a Mesenchymal Stem Cell-Related Malignancy

Smooth muscle (SM) is a spontaneously contractile tissue that provides physical support and function to organs such as the uterus. Uterine smooth muscle–related neoplasia comprise common well-differentiated benign lesions called leiomyomas (ULM), and rare, highly aggressive and pleomorphic tumors named leiomyosarcomas (ULMS). MicroRNAs (miRNAs) are small non-coding RNAs that play essential roles in normal cellular development and tissue homeostasis that can be used to accurately subclassify different tumor types. In this study, the investigators demonstrate that miRNAs are required for full smooth muscle cell (SMC) differentiation of bone marrow–derived human mesenchymal stem cells (hMSCs). They also report a miRNA signature associated with this process. Moreover, they show that this signature, along with miRNA profiles for ULMS and ULM, are able to subclassify tumors of smooth muscle origin along SM differentiation. Using multiple computational analyses, they determined that ULMS are more similar to hMSCs as opposed to ULM, which are linked with more mature SMCs and myometrium. Furthermore, a comparison of the SM differentiation and ULMS miRNA signatures identified miRNAs strictly associated with SM maturation or transformation, as well as those modulated in both processes indicating a possible dual role. These results support separate origins and/or divergent transformation pathways for ULM and ULMS, resulting in drastically different states of differentiation. In summary, this work expands on our knowledge of the regulation of SM differentiation and sarcoma pathogenesis.

Targeting Wild-Type and Mutant p53 with Small Molecule CP-31398 Blocks the Growth of Rhabdomyosarcoma by Inducing Reactive Oxygen Species–Dependent Apoptosis

Rhabdomyosarcoma (RMS) is a common soft-tissue sarcoma of childhood in need of more effective therapeutic options. The expression of p53 in RMS is heterogeneous such that some tumors are wild-type whereas others are p53 mutant. The small molecule CP-31398 modulates both the wild-type and the mutant p53 proteins. In this study, the investigators show that CP-31398 blocks the growth of RMS cells that have either wild-type or mutant p53 status. In wild-type A204 cells, CP-31398 increased the expression of p53 and its downstream transcriptional targets, p21 and mdm2; enhanced the expression of apoptosis-related proteins; and reduced proliferation biomarkers. Flow profiling of CP-31398–treated cells indicated an enhancement in sub-G0 and G1 populations. CP-31398 inhibited proliferation in a manner associated with co-induction of SOX9 and p21. Apoptosis induced by CP-31398 occurred with translocation of p53 to mitochondria, leading to altered mitochondrial membrane potential, cytochrome c release, and reactive oxygen species release. In vivo, CP-31398 decreased the growth of tumor xenografts composed of wild-type or mutant p53 tumor cells, increasing tumor-free host survival. The investigators thus state that their findings indicate that the ability of CP-31398 to modulate wild-type and mutant p53 results in the inhibition of RMS growth and invasiveness.

Subsequent Neoplasms in 5-Year Survivors of Childhood Cancer: The Childhood Cancer Survivor Study

The occurrence of subsequent neoplasms has direct impact on the quantity and quality of life in cancer survivors. This study sought a better understanding of the occurrence of these events as the survivor population ages. The incidence of and risk for subsequent neoplasms occurring 5 years or more after the childhood cancer diagnosis were determined among 14 359 5-year survivors in the Childhood Cancer Survivor Study (CSS) who were treated from 1970 through 1986 and who were at a median age of 30 years (range = 5–56 years) for this analysis. At 30 years after childhood cancer diagnosis, the investigators calculated cumulative incidence at 30 years of subsequent neoplasms and calculated standardized incidence ratios (SIRs), excess absolute risks (EARs) for invasive second malignant neoplasms, and relative risks for subsequent neoplasms by use of multivariable Poisson regression. The results were as follows: Among 14 359 5-year survivors, 1402 subsequently developed 2703 neoplasms. Cumulative incidence at 30 years after the childhood cancer diagnosis was 20.5% (95% confidence interval [CI] = 19.1% to 21.8%) for all subsequent neoplasms, 7.9% (95% CI = 7.2% to 8.5%) for second malignant neoplasms (excluding nonmelanoma skin cancer), 9.1% (95% CI = 8.1% to 10.1%) for nonmelanoma skin cancer, and 3.1% (95% CI = 2.5% to 3.8%) for meningioma. Excess risk was evident for all primary diagnoses (EAR = 2.6 per 1000 person-years, 95% CI = 2.4 to 2.9 per 1000 person-years; SIR = 6.0, 95% CI = 5.5 to 6.4), with the highest being for Hodgkin lymphoma (SIR = 8.7, 95% CI = 7.7 to 9.8) and Ewing sarcoma (SIR = 8.5, 95% CI = 6.2 to 11.7). In the Poisson multivariable analysis, female sex, older age at diagnosis, earlier treatment era, diagnosis of Hodgkin lymphoma, and treatment with radiation therapy were associated with increased risk of subsequent neoplasm. The investigators Conclude: As childhood cancer survivors progress through adulthood, risk of subsequent neoplasms increases. Patients surviving Hodgkin lymphoma are at greatest risk. There is no evidence of risk reduction with increasing duration of follow-up.

Osteosarcoma in very young children

This study was conducted to investigate presentation, treatment, and outcome in very young children with osteosarcoma. The authors retrospectively analyzed the data of 2706 consecutive COSS patients with newly diagnosed osteosarcoma and identified 28 (1.0%) patients aged younger than 5 years at diagnosis. Demographic, diagnostic, tumor, treatment-related variables, response, and survival data were analyzed. The results were as follows: Of the 28 preschoolers, 27 presented with high-grade central osteosarcoma of an extremity, and 1 had a secondary osteosarcoma of the orbit. This analysis focused on the 27 patients with extremity tumors. The size of the primary was large (≥one-third of the involved bone) in 20 of 27 patients. Primary metastases were detected in 4 of 27 children. All patients received multiagent chemotherapy, and 11 of 18 analyzed tumors responded well (>90% necrosis) to neoadjuvant chemotherapy. Limb-sparing surgery was performed in 9 cases, ablative procedures were performed in 15, and, in 3 cases, no local surgery was performed. With a median follow-up of 4 years (6.2 years for survivors), 13 patients were alive. Four patients never achieved a complete remission, and 11 developed recurrences; 14 of these 15 patients died. Five-year overall and event-free survival probabilities were 51% (standard error of the mean [SE], 10%) and 48% (SE, 10%). Better survival was correlated with good response to chemotherapy and later time period of diagnosis. The authors conclude: Osteosarcoma is extremely rare in preschool children. These patients often have large tumors that may require mutilating resections. Prognosis is in the range of that reported for older patients.

Local Recurrence After Initial Multidisciplinary Management of Soft Tissue Sarcoma: Is there a Way Out?

Multimodality treatment of primary soft tissue sarcoma by expert teams reportedly affords a low incidence of local recurrence. Despite advances, treatment of local recurrence remains difficult and is not standardized. In this study, the authors: (1) determined the incidence of local recurrence from soft tissue sarcoma; (2) compared characteristics of the recurrent tumors with those of the primary ones; (3) evaluated local recurrences, metastases and death according to treatments; and (4) explored the relationship between the diagnosis of local recurrence and the occurrence of metastases. From their prospective database, they identified 618 soft tissue sarcomas. Thirty-seven of the 618 patients (6%) had local recurrence. Leiomyosarcoma was the most frequent diagnosis (eight of 37). The mean delay from original surgery was 22 months (range, 2–75 months). Mean size was 4.8 cm (range, 0.4–28.0 cm). Median follow-up after local recurrence was 16 months (range, 0–98 months). The results were as follows: Recurrent tumors had a tendency toward becoming deeper seated and higher graded. Nineteen of the 37 patients with recurrence underwent limb salvage (nine free flaps) and six had an amputation. Twenty-two (59%) had metastases, including 10 occurring after the local recurrence event at an average delay of 21 months (range, 1–34 months). Six patients developed additional local recurrences, with no apparent difference in risk between amputation (two of six) and limb salvage (four of 19). The authors conclude: Patients with a local recurrence of a soft tissue sarcoma have a poor prognosis. Limb salvage and additional radiotherapy remain possible but with substantial complications. Amputation did not prevent additional local recurrence or death.

Updating progress in sarcoma therapy with mTOR inhibitors

Sarcomas are a diverse group of difficult-to-treat connective tissue neoplasms. The mammalian target of rapamycin (mTOR) pathway has been identified as a therapeutic target in many sarcomas. This article reviews the role of this pathway and updates clinical data for the available mTOR inhibitors. The article concludes that the PI3K–Akt–mTOR pathway is an exciting target for therapy in many types of solid malignancies and its blockade represents an opportunity to improve outcomes in poor-prognosis sarcoma.

Diagnosis and management of primary breast sarcoma

Primary sarcoma of the breast is an extremely rare and heterogeneous disease. The rarity of this tumor limits most studies to small retrospective case reviews and case reports and has made clinicopathological study difficult. This article reviews the current literature on the diagnosis and management of breast sarcoma, and states the following. The optimal treatment of breast sarcoma involves a multidisciplinary team prior to the initiation of treatment. Patients with tumors less than 5 cm that are easily resectable should undergo complete resection to the extent required to provide negative surgical margins. Negative surgical margins are more important for local recurrence and overall survival than the extent of surgical resection. Thus, neoadjuvant chemotherapy should be considered in order to shrink the tumor and help obtain negative surgical margins. Whether chemotherapy is indicated is primarily determined by tumor size. There is evidence that tumors larger than 5 cm are associated with an elevated risk of systemic failure and a poor prognosis. After surgical resection, patients with chemosensitive tumors should undergo additional adjuvant chemotherapy to treat micrometastatic disease. Radiation therapy should be used to improve local control in cases in which the tumor is larger than 5 cm and in cases with positive surgical margins. The authors propose to treat the patients according to the clinical practice guidelines in use for soft tissue sarcomas and address them to a reference centre for sarcoma. The appropriate treatment of breast sarcoma requires a multidisciplinary team approach necessitating experienced sarcoma surgeons, pathologists, radiotherapists and medical oncologists. Treating rare tumors in the same place should permit standardization of pathological data and to include patients into multicentric radiotherapy or chemotherapy protocols to improve overall survival.

Gene Therapy for Sarcoma

Exciting progress in genetic profiling of sarcomas and molecular identification of constituent oncogenes and protein products has recently occurred, which will ultimately enable the development of sarcoma targeted therapies. In this chapter of their book Gene-Based Therapies for Cancer, authors Keila E. Torres and Raphael E. Pollock discuss the major advances in cytogenetics and the importance of genetic and molecular signatures in sarcoma diagnosis and treatment. In an attempt to create better treatments for cancers several strategies have evolved to administer therapeutic genes that inactivate oncogenes, restore tumor-suppressor genes, and enhance the native immune response. The authors explore some promising initial data regarding these novel gene delivery systems, such as isolated limb perfusion which may be a useful promising technique in delivering growth-suppressing constructs into soft tissue sarcomas.

June 2010

Long-term results after resection for bone sarcoma pulmonary metastases

European Journal of Cardio-thoracic Surgery 37 (2010) 1205—1208

About 40% of bone sarcoma patients are found to have metastases to the lungs. Pulmonary metastases are treated using a combination of radiation and chemotherapy. The authors of this study "aim to study the influence of different prognostic factors on long-term survival". Data was collected for 52 patients that had received treatment at the Universidad de Navarra in Pamplona, Spain during the 10 year interval between 1996 and 2005. Each had received chemotherapy and removal of pulmonary metastases. The selected patients had been treated for the following types of tumors: Osteosarcoma, Ewing’s Sarcoma, Chondrosarcoma, Undifferentiated sarcoma, Fibrosarcoma, Neuroectodermic tumor, Leiomyosarcoma, Adamantinoma and Fusocellular tumor.

According to the study, the following patient characteristics were taken into consideration,

age
gender
primary site
histopathologic type
disease-free interval between treatment of the primary bone tumour and first lung metastasectomy (DFI)
disease-free interval between first and second lung surgery (DFI2)
thoracic approach and type of lung resection
number of lung metastases
complete resection of lung metastases and
re-do surgery for oncological purposes.

Regarding repeated lung surgeries, it is interesting to note that the authors find that repeat surgeries are beneficial. The authors state, "Lung metastasectomies have low morbidity and mortality rates. This is basically because (1) patients with bone sarcoma lung metastases usually have normal cardiopulmonary function tests and (2) lung resections are conservative operations, being re-do lung surgery for recurrent disease, quite frequent in these patients (31% of patients in our series). Various studies have demonstrated that repeated pulmonary resections enable controlling the disease for an extended period [16, 18].

Following extensive analysis, the authors conclude, "Long-term survival is encouraging after bone sarcoma lung metastasectomy, with a 5-year survival rate of 31%. In our series, DFI and DF2 showed to be prognostic factors, none of the other variables studied had an influence on survival. Redo surgery, although not found to be a key prognostic factor, was highly significant in long-term survivors."

References
[16] McCarville MB, Kaste SC, Cain AM, Gouloubeva O, Rao BN, Pratt CB. Prognostic factors and imaging patterns of recurrent pulmonary nodules after thoracotomy in children with osteosarcoma. Cancer 2001;91: 1170—6.

[18] Bricolli A, Ferrari S, Picci P, Mercuri M, Bacci G, Guernelli N. Surgical treatment of pulmonary metastases of osteosarcoma. Apropos of 206 operated cases. Ann Chir 1999;53:207—14.

Sarcomas Across the Age Spectrum

In this paper, researchers Suzanne Wolden and Kaled Alektiar of the MSK Cancer Center in New York discuss the incidence of sarcoma at different patient ages. They begin by noting that sarcoma is known for occurring in infants, the elderly and all ages in between. Treatment for sarcomas differs based on the whether they primarily affect children vs. adults. The authors state, "In general, the pediatric-type sarcomas tend to be relatively sensitive to chemotherapy and radiotherapy, whereas the adult sarcomas are less so. These distinctions have led to different treatment algorithms for pediatric and adult sarcomas. In addition, the long-term risk to benefit ratio of different treatment modalities differs between children and adults. This also influences our approach to treating sarcomas across the age spectrum."

They go on to note that, despite the histological differences between sarcomas, scientific advances made through research into one type of sarcoma can result in findings that relate to other sarcomas. "For example", the authors state, "advances at the molecular level in Ewing sarcoma, a disease that affects predominantly children, helped spearhead the uncovering of several signature translocations in adult sarcomas, such as synovial sarcoma and myxoid liposarcomas.

The success of chemotherapy in pediatric sarcomas continues to be a benchmark for adult sarcomas to emulate." Advances in treatment of adult sarcomas have also enhanced pediatric treatments. For example, limb-sparing surgery in combination with radiation therapy was pioneered with adult patients having extremity sarcomas, but is now used more frequently for pediatric sarcomas as well.

The authors define their approach to this discussion, saying, "To illustrate some of these concepts and to enhance our understanding of sarcomas across the age spectrum, 4 types of sarcoma are discussed. The first 2 are Ewing sarcoma and rhabdomyosarcoma seen mainly, but not exclusively, in children. The other 2 are synovial sarcoma, which can be looked at as a bridge between pediatric and adult sarcomas as it affects mainly young adults, and liposarcoma that is almost exclusively an adult sarcoma."

Some interesting snippets from the discussion of treatment therapies for these 4 sarcomas and findings based on age:

Regarding RMS, "A recent article confirms that adults with RMS have significantly worse outcomes than children. Part of the difference may be attributed to a higher percentage of adult patients having poor prognostic features, such as unfavorable site or histology (Table 1). However, the explanation for this is not known ..... Regional and distant metastases were not more common in adults. Given the dramatic difference in 5-year survival for localized disease, ~7% for adults versus 82% for children (P < 0.0001), it is clear that age itself is a strong prognostic factor."

Regarding Ewing's sarcoma, "When deciding whether to use radiotherapy for a child with ES, one must consider a variety of potential late effects that may not be a significant consideration in the older adult patient. Growth of bone and soft tissue can be severely impaired when treating young patients. This problem is much less of concern for a mature teen than for the younger child, but even muscle development seems more impaired in teens than in adults."

Following extensive analysis of the data, the authors summarize their findings, saying, "Much progress has been made treating pediatric sarcomas in children and adult sarcomas in adults, but we do not yet understand how to optimally treat these tumors when they occur at uncharacteristic ages. The COG is currently conducting a trial (ARST 0332) for non-RMS soft-tissue sarcomas in an effort to meet this clinical challenge. Likewise, additional work is needed in adult oncology to understand and potentially narrow the gap in survival for adults with pediatric-type tumors, such as RMS. Our hope for future progress will depend on collaboration of pediatric and adult oncologists to study sarcomas across the age spectrum."

CD117 and Stro-1 Identify Osteosarcoma Tumor-Initiating Cells Associated with Metastasis and Drug Resistance

Improved Survival With Radiation Therapy in High-Grade Soft Tissue Sarcomas of the Extremities: A SEER Analysis

The benefit of radiation therapy in extremity soft tissue sarcomas remains controversial. The purpose of this study was to determine the effect of radiation therapy on overall survival among patients with primary soft tissue sarcomas of the extremity who underwent limb-sparing surgery. This was a retrospective study from the Surveillance, Epidemiology, and End Results (SEER) database that included data from January 1, 1988, to December 31, 2005. A total of 6,960 patients constituted the study population. Overall survival curves were constructed using the Kaplan-Meir method and for patients with low- and high-grade tumors. Hazard ratios were calculated based on multivariable Cox proportional hazards models. The results were as follows: Of the cohort, 47% received radiation therapy. There was no significant difference in overall survival among patients with low-grade tumors by radiation therapy. In high-grade tumors, the 3-year overall survival was 73% in patients who received radiation therapy vs. 63% for those who did not receive radiation therapy (p < 0.001). On multivariate analysis, patients with high-grade tumors who received radiation therapy had an improved overall survival (hazard ratio 0.67, 95% confidence interval 0.57-0.79). In patients receiving radiation therapy, 13.5% received it in a neoadjuvant setting. The incidence of patients receiving neoadjuvant radiation did not change significantly between 1988 and 2005. The authors conclude: To our knowledge, this is the largest population-based study reported in patients undergoing limb-sparing surgery for soft tissue sarcomas of the extremities. It reports that radiation was associated with improved survival in patients with high-grade tumors.

Abdominal soft tissue sarcoma: a multicenter retrospective study

Soft tissue sarcomas (STS) are rare mesenchymal neoplasms with a variety of histological subtypes. However, in Japan, data on the clinical characteristics and prognostic profiles of these tumors are lacking. The purpose of this study was to clarify the clinical features and outcomes of Japanese patients with retroperitoneal and abdominal STS. The authors reviewed and analyzed retrospectively the data for 82 patients who underwent surgery for retroperitoneal and abdominal STS at Osaka University and affiliated hospitals from 2000 to 2007. The factors analyzed included patient demographics and clinical features. The results were as follows: The histological subtypes included leiomyosarcoma in 32 patients (39.0%), liposarcoma in 30 (36.6%), malignant fibrous histiocytoma in 10 (12.2%), and other miscellaneous subtypes in 10 (12.2%). The overall survivals were 92, 69, and 62%, respectively, at 1, 3, and 5 years after primary surgery. The overall survival of patients with low-grade sarcoma was significantly better than that of patients with high-grade sarcoma. Complete resection was done in 63 patients (77%) and their recurrence-free survivals were 73, 34, and 23%, respectively, at 1, 3, and 5 years after the surgery. Subgroup analysis of differences between leiomyosarcoma and liposarcoma revealed that liposarcomas were mainly located in the retroperitoneum and leiomyosarcomas were located equally in the retroperitoneum and abdominal cavity. The tumor size of liposarcomas was larger than that of leiomyosarcomas; however, the recurrence-free survival was better in patients with liposarcoma than in those with leiomyosarcoma. The authors conclude: Results showed the clinical features and prognoses of retroperitoneal and abdominal STS in Japan. Further large-scale nationwide studies are required to clarify the detailed clinical behavior of retroperitoneal and abdominal STS in Japan.

Clinical outcome of children and adults with localized Ewing sarcoma

Ewing’s sarcoma (EWS) can affect children and adults. Patients can be treated at either a pediatric or an adult institution. This study investigated whether differences in therapeutic strategy undertaken in pediatric and adult specialty sarcoma centers correlated with clinical outcome. Data from patients with localized EWS treated between 1990 and 2005 at tertiary care pediatric and adult institutions were reviewed. The results were as follows: Fifty-three patients (24 adult and 29 pediatric) were treated. Pediatric patients received a median of 16 cycles of chemotherapy comprised of doxorubicin, vincristine, cyclophosphamide, ifosfamide, and etoposide. Adult patients received a median of 10 cycles of treatment, and a significantly lower total cumulative dose of ifosfamide and cyclophosphamide (P < .0001). There was no difference noted with regard to the total dose of doxorubicin, or in the type of local therapy offered (surgery or radiotherapy, vs. both). However, local therapy occurred earlier in pediatric patients compared with adults (3.7 months vs. 7.4 months; P = .0003). The 3-year event-free survival (EFS) rate in pediatric and adult patients was 70% ± 9% and 43% ± 13% (P = 0.1), respectively. The 3-year overall survival rate was 81% ± 7.7% and 59% ± 12% (P = .02) for pediatric and adult patients, respectively. Factors found to be significantly associated with EFS on univariate analysis included pelvic site, cyclophosphamide dose, and time to local therapy. On multivariate analysis, only pelvic disease (hazard ratio [HR] 4.26; P = .018) and time to local therapy (HR, 1.19; P = .002) were found to be significant. The authors conclude: Adults with localized EWS have an inferior outcome compared with pediatric patients. This difference may be related to lower doses of alkylating agents and the timing of local therapy.

Histone deacetylase inhibitor (HDACI) PCI-24781 potentiates cytotoxic effects of doxorubicin in bone sarcoma cells

The purpose of this study was to better understand the mechanisms of cytotoxicity and cell death induced by HDACI PCI-24781 in bone sarcoma cells. Four bone sarcoma cell lines were treated with PCI-24781, and the cytotoxicity was investigated. Further, accumulation of acetylated histones, p21, and PARP cleavage were evaluated in PCI-24781-treated cells. The synergistic effect of PCI-24781 to doxorubicin and its mechanism was investigated in bone sarcoma cells. The results were as follows: MTT assay demonstrated that the growth of bone sarcoma cells was inhibited after treatment with PCI-24781. Accumulation of acetylated histones, p21, and PARP cleavage were found in PCI-24781-treated cells. Expression of DNA repair protein RAD51 was inhibited, and the expression of apoptosis protein GADD45α was induced by PCI-24781 in bone sarcoma cells. Bone sarcoma cells treated with PCI-24781 become more sensitive to doxorubicin. The caspase-3/7 activity was increased with doxorubicin and PCI-24781 treatment in these cells. The investigators conclude: HDACI PCI-24781 has a synergistic effect on doxorubicin-induced apoptosis in bone sarcoma cells.

Sox9 Expression Is Not Limited to Chondroid Neoplasms: Variable Occurrence in Other Soft Tissue and Bone Tumors With Frequent Expression by Synovial Sarcomas

The transcription factor Sox9 is known to play a crucial role in normal chondrogenesis, and antibodies against Sox9 have been proposed as a diagnostic tool for neoplasms with chondroid differentiation. However, the pattern of Sox9 immunohistochemical expression by other bone and soft tissue neoplasms, as well as its diagnostic specificity, remain unexplored. The authors in this study have performed immunohistochemistry with antibodies against Sox9 in 106 chondroid and nonchondroid bone and soft tissue neoplasms. Moderate to intense Sox9 nuclear staining was observed in 14/20 chondrosarcomas (70%), and in 24/81 (29.6%) cases from a multitumor tissue microarray, which included 16/18 synovial sarcomas, 4/15 osteosarcomas, 2/5 peripheral primitive neuroectodermal tumor (PNET)/Ewing sarcomas, 1/1 mesenchymal chondrosarcoma, and 1/1 chondroblastoma. The results suggest that Sox9 usefulness in the diagnosis of chondroid tumors may be limited because of low sensitivity and specificity. The finding of Sox9 expression by 88.9% of synovial sarcomas represents a novel and striking observation, which deserves further investigation.

Distinct roles for miR-1 and miR-133a in the proliferation and differentiation of rhambomyosarcoma cells

Rhabdomyosarcoma is the most common soft tissue sarcoma in the pediatric population. As this tumor has an undifferentiated myogenic phenotype, agents that promote differentiation hold particular promise as part of a novel therapeutic approach to combat this type of cancer. In this report, the investigators focus on the contribution of two microRNAs (miRNAs) in rhabdomyosarcomas. Levels of miR-1 and miR-133a are drastically reduced in representative cell lines from each major rhabdomyosarcoma subtype (embryonal and alveolar). Introduction of miR-1 and miR-133a into an embryonal rhabdomyosarcoma-derived cell line is cytostatic, thereby suggesting a tumor suppressor-like role for these myogenic miRNAs. Transcriptional profiling of cells after miR-1 and miR-133a expression reveals that miR-1 (but not miR-133a) exerts a strong promyogenic influence on these poorly differentiated tumor cells. They identify mRNAs that are down-regulated by these miRNAs and propose roles for miR-1 and miR-133a in repressing isoforms of genes that are normally not expressed in muscle. Finally, they show that mRNA targets of miR-1 and miR-133a are up-regulated in rhabdomyosarcomas, suggesting a causative role for these miRNAs in the development of rhabdomyosarcomas. More important, these results point to the promise of enhancing rhabdomyosarcoma therapy using miRNAs as agents that mediate cytostasis and promote muscle differentiation.

Surgery and Radiotherapy for Retroperitoneal and Abdominal Sarcoma

The purpose of this study was to evaluate the effect of surgical resection and radiotherapy (RT) in retroperitoneal or abdominal sarcoma. It was a retrospective study of patients 18 years or older with initial diagnosis of primary retroperitoneal and nonvisceral abdominal sarcoma between 1988-2005. Main outcome measures were survival for 2 years after diagnosis. Kaplan-Meier survival was stratified based on surgery and RT status. Cox proportional hazards model was used to assess adjusted effects of surgery and RT on survival in patients with locoregional disease. The results were as follows: Of 1901 patients with locoregional disease, 1547 (81.8%) underwent resection; 447 (23.5%) received RT. Overall, patients who received both surgery and RT demonstrated improved survival compared with patients who underwent either therapy alone; patients undergoing monotherapy in turn had more favorable survival compared with patients who received neither therapy (P < .001, log rank). Cox analysis demonstrated that surgical resection (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.21-0.29; P < .001) and RT (0.78; 0.63-0.95; P = .01) independently predicted improved survival in locoregional disease only. In adjusted analyses stratified for American Joint Commission on Cancer (AJCC) stage, for stage I disease (n = 694), RT provided an additional benefit (HR, 0.49; 95% CI, 0.25-0.96; P = .04) independent of that from resection (0.35; 0.21-0.58; P < .001). For stage II/III (n = 552), resection remained protective (HR, 0.24; 95% CI, 0.18-0.32; P < .001); however, RT was no longer associated with a significant benefit (0.78; 0.58-1.06; P = .11). The authors conclude: Surgical resection was associated with significant survival benefits for AJCC disease stages I to III. Radiotherapy provided additional benefit for patients with stage I disease. Resection should be offered to reasonable surgical candidates with nonmetastatic retroperitoneal/abdominal sarcomas; radiotherapy may most benefit patients with early-stage disease.

Primary Bone Malignancy: Effective Treatment with High-Intensity Focused Ultrasound Ablation

The purpose of this study was to evaluate the long-term follow-up results of ultrasonographically (US)-guided high-intensity focused ultrasound ablation in patients with primary bone malignancy. From December 1997 to November 2004, 80 patients with a primary bone malignancy—60 with stage IIb disease and 20 with stage III disease (Enneking staging system)—were treated with US-guided high-intensity focused ultrasound ablation. High-intensity focused ultrasound ablation combined with chemotherapy was performed in 62 patients with osteosarcoma, one patient with periosteal osteosarcoma, and three patients with Ewing sarcoma. The remaining 14 patients had chondrosarcoma, giant cell bone cancer, periosteal sarcoma, or an unknown malignancy and were treated with high-intensity focused ultrasound ablation only. Magnetic resonance (MR) imaging or computed tomography (CT), and single photon emission computed tomography (SPECT) were used to assess tumor response. Cumulative survival rates were calculated by using the Kaplan-Meier method. Adverse effects were recorded. The results were as follows: High-intensity focused ultrasound ablation guided by real-time US was performed. Follow-up images demonstrated completely ablated malignant bone tumors in 69 patients and greater than 50% tumor ablation in the remaining 11 patients. Overall survival rates at 1, 2, 3, 4, and 5 years were 89.8%, 72.3%, 60.5%, 50.5%, and 50.5%, respectively. Survival rates at 1, 2, 3, 4, and 5 years were 93.3%, 82.4%, 75.0%, 63.7%, and 63.7%, respectively, in the patients with stage IIb cancer and 79.2%, 42.2%, 21.1%, 15.8%, and 15.8%, respectively, in those with stage III disease. Among the patients with stage IIb disease, long-term survival rates were substantially improved in the 30 patients who received the full treatment—that is, complete high-intensity focused ultrasound and full cycles of chemotherapy—compared with the survival rates for the 24 patients who did not finish the chemotherapy cycles and the six patients who underwent partial ablation only. Only five (7%) of the 69 patients who underwent complete ablation had local cancer recurrence during the follow-up period. Forty adverse events were recorded, with 14 patients requiring surgical intervention. The investigators conclude: US-guided high-intensity focused ultrasound ablation of malignant bone tumors is feasible and effective and eventually may be a component of limb-sparing techniques for patients with these cancers.

April 2010

Antitumor and Anti-inflammatory Effects of Trabectedin on Human Myxoid Liposarcoma Cells

Inflammatory mediators present in the tumor milieu may promote cancer progression and are considered promising targets of novel biological therapies. The authors previously reported that the marine antitumor agent trabectedin, approved in Europe in 2007 for soft tissue sarcomas and in 2009 for ovarian cancer, was able to downmodulate the production of selected cytokines/chemokines in immune cells. Patients with myxoid liposarcoma (MLS), a subtype characterized by the expression of the oncogenic transcript FUS-CHOP, are highly responsive to trabectedin. The drug had marked antiproliferative effects on MLS cell lines at low nanomolar concentrations. The authors tested the hypothesis that trabectedin could also affect the inflammatory mediators produced by cancer cells. In this study they show that MLS express several cytokines, chemokines, and growth factors (CCL2, CCL3, CCL5, CXCL8, CXCL12, MIF, VEGF, SPARC) and the inflammatory and matrix-binder protein pentraxin 3 (PTX3), which build up a prominent inflammatory environment. In vitro treatment with noncytotoxic concentrations of trabectedin selectively inhibited the production of CCL2, CXCL8, IL-6, VEGF, and PTX3 by MLS primary tumor cultures and/or cell lines. A xenograft mouse model of human MLS showed marked reduction of CCL2, CXCL8, CD68+ infiltrating macrophages, CD31+ tumor vessels, and partial decrease of PTX3 after trabectedin treatment. Similar findings were observed in a patient tumor sample excised after several cycles of therapy, indicating that the results observed in vitro might have in vivo relevance. The author concludes: trabectedin has dual effects in liposarcoma: in addition to direct growth inhibition, it affects the tumor microenvironment by reducing the production of key inflammatory mediators.

ABT-869 Inhibits the Proliferation of Ewing Sarcoma Cells and Suppresses Platelet-Derived Growth Factor Receptor β and c-KIT Signaling Pathways

The Ewing Sarcoma (EWS) family of tumors is one of the most common tumors diagnosed in children and adolescents and is characterized by a translocation involving the EWS gene. Despite advances in chemotherapy, the prognosis of metastatic EWS is poor with an overall survival of <30% after 5 years. EWS tumor cells express the receptor tyrosine kinases, platelet-derived growth factor receptor (PDGFR) and c-KIT. ABT-869 is a multitargeted small-molecule inhibitor that targets Fms-like tyrosine kinase-3, c-KIT, vascular endothelial growth receptors, and PDGFRs. To determine the potential therapeutic benefit of ABT-869 in EWS cells, the investigators of this study examined the effects of ABT-869 on EWS cell lines and xenograft mouse models. ABT-869 inhibited the proliferation of two EWS cell lines, A4573 and TC71, at an IC50 of 1.25 and 2 μmol/L after 72 h of treatment, respectively. The phosphorylation of PDGFRβ, c-KIT, and extracellular signal-regulated kinases was also inhibited. To examine the effects of ABT-869 in vivo, the drug was given to mice injected with EWS cells. They observed inhibition of growth of EWS tumor cells in a xenograft mouse model and prolonged survival in a metastatic mouse model of EWS. Therefore, they conclude that their in vitro and in vivo studies show that ABT-869 inhibits proliferation of EWS cells through inhibition of PDGFRβ and c-KIT pathways.

The EWS/FLI1 oncogenic protein inhibits expression of the Wnt inhibitor DICKKOPF-1 gene and antagonizes β-catenin/TCF-mediated transcription

Tumors of the Ewing family, which comprise Ewing's sarcoma and peripheral primitive neuroectodermal tumors, are highly aggressive and mostly affect children and adolescents. They are characterized by chromosomal translocations leading to the generation of fusion proteins between EWS (or very rarely FUS) and members of the E-twenty-six (ETS) family of transcription factors that are capable of transforming cells. EWS/FLI1, the most frequent fusion, is thought to cause transformation through activation or repression of specific target genes. The investigators of this study present evidence demonstrating that the Wnt inhibitor and β-catenin/T-cell factor (TCF)-responsive gene DICKKOPF-1 (DKK-1) is a transcriptional target of EWS/FLI1, which can inhibit both basal and β-catenin-induced transactivation of the DKK-1 promoter. Moreover, their data indicate that EWS/FLI1 has a more general effect on β-catenin/TCF-mediated transcription since it can block transactivation of a consensus β-catenin/TCF reporter construct. Consistently, Ewing tumor cells expressing different EWS/ETS translocations cannot engage β-catenin/TCF-dependent transcription, whereas silencing of EWS/FLI1 restores β-catenin responsiveness in A673 and RD-ES Ewing tumor cells. Accordingly, gene set enrichment analysis shows that β-catenin/TCF target genes are significantly enriched among genes downregulated by EWS/FLI1 in the Ewing cell line A673. Mechanistically, the inhibitory effect of EWS/FLI1 can be overcome by a constitutively active TCF4 protein (TCF4-VP16). Moreover, EWS/FLI1 binds lymphoid enhancer factor 1, a TCF family member, and interferes with its binding to β-catenin, which could explain its negative effect on β-catenin/TCF-mediated transcription. Their results show that EWS/FLI1 inhibits both DKK-1 expression as well as β-catenin/TCF-dependent transcription, which could contribute to progression of tumors of the Ewing family.

Gene Expression Profiling for Survival Prediction in Pediatric Rhabdomyosarcomas: A Report From the Children's Oncology Group

The authors of this study investigated whether tumors from diagnostic biopsies of primary rhabdomyosarcoma (RMS) contain relevant prognostic information in the form of gene expression signatures that can be used to model and predict outcome of patients. A 22,000-probe set microarray was used to evaluate 120 RMS specimens and correlate gene expression patterns to survival. Multivariate gene expression models or metagenes were developed using cross-validated Cox regression proportional hazards modeling and were evaluated using Kaplan-Meier analysis. The results were as follows: A 34-metagene, based on expression patterns of 34 genes, was highly predictive of outcome. It was not highly correlated with individual clinical risk factors such as patient age, stage, tumor size, or histology. However, it was correlated with a risk classification used by the Children's Oncology Group and the biologic subsets of alveolar histology tumors. The authors conclude: These data support further evaluation of RMS metagenes to discriminate patients with good prognosis from those with poor prognosis, with the potential to direct risk-adapted therapy.

Clinical outcome of leiomyosarcomas of vascular origin: comparison with leiomyosarcomas of other origin

There was previously no data about the natural history of leiomyosarcoma of vascular origin (vLMS) in comparison with leiomyosarcoma (LMS) of other origin and about the management of advanced disease. This study sought to provide some data on the issue. Among 1472 patients diagnosed with sarcoma from January 1980 to December 2008 at the authors’ institution, 195 patients (13%) had LMS. LMS had a vascular origin in 14 cases (7%). The results were as follows: Patients with vLMS had a significantly worse median metastasis-free survival (MFS) (0.25 versus 9.6 years, P = 0.001) and overall survival (OS; 2.1 versus 7 years, P < 0.0001) than patients with LMS of other origin. On multivariate analysis, grade and vascular origin were the sole independent adverse prognostic factors for OS. Eight metastatic patients with vLMS received a first-line anthracycline chemotherapy regimen. Two patients had partial response, four had stable disease and two had progressive disease. OS of patients with metastatic vLMS was not significantly different from that observed in patients with metastatic LMS of other origin (22.1 versus 16.5 months, P = 0.84). The authors conclude: Vascular origin is an independent adverse prognostic factor for MFS and OS in patients with LMS. Patients with metastatic vLMS had a similar outcome than patients with metastatic LMS of other origin.

Extraskeletal myxoid chondrosarcoma: a case report of complete remission by chemotherapy and review of the literature

Extraskeletal myxoid chondrosarcoma is a rare soft tissue sarcoma. Surgery is the cornerstone of the management of this tumor. The response rate to chemotherapy has been very poor; overall results are disappointing because no significant radiologic or clinical responses have been noted with chemotherapy. Here the authors present a case report of a 15-year-old girl who presented with extraskeletal myxoid chondrosarcoma in the sacrococcygeal region which was regarded as unresectable. After four cycles of chemotherapy the mass showed complete remission which has lasted greater than 6 months. The authors also review the literature.

TLE1 is a robust diagnostic biomarker for synovial sarcomas and correlates with t(X;18): Analysis of 319 cases

Genomewide expression profiling has identified a number of genes expressed at higher levels in synovial sarcoma than in other sarcomas. The objectives of this study were (1) to test whether the differentially expressed gene, Transducin-Like Enhancer of split (TLE1) belonging to the groucho/TLE family, is also distinct on the protein level; (2) to evaluate this biomarker in a series of well-characterized synovial sarcomas on standard, full-sized tissue sections and (3) to correlate the expression of TLE1 with t(X;18) and other established biomarkers. Three-hundred and eighty four spindle cell sarcomas from the German consultation and reference centre of soft tissue tumors initially suspected for synovial sarcoma were revisited. Three-hundred and nineteen of these specimens were analyzed immunohistochemically using a monoclonal antibody TLE1 and standard, full-sized tissue sections. The nuclear staining was scored semiquantitatively as −, negative; +, weak; ++, moderate and +++, strong positive. Furthermore, 118 specimens among these were further analyzed using FISH and/or PCR to detect t(X;18). They authors correlated the TLE1 expression with the t(X;18) translocation and other established biomarkers (EMA, PanCK, CK7, CD34 and BCL2). The results were as follows: TLE1 expression was observed in 96% of the synovial sarcomas (score+, 249/259) and discriminates them from other soft tissue tumors (p<0.001). Multivariate analysis showed that positive TLE1 staining was a statistically independent diagnostic marker. Furthermore molecular analysis showed that t(X;18) was clearly correlated with TLE1 protein expression (p<0.001). The authors conclude: Expression of TLE1 is significantly correlated with t(X;18) and may serve as a new robust diagnostic biomarker in synovial sarcomas and potential therapeutic target.

Impact of adjuvant treatment modalities on the management of patients with stages I–II endometrial stromal sarcoma

The purpose of this study was to explore whether adjuvant treatment options may impact on the prognosis in localized endometrial stromal sarcomas (ESSs; stages I and II). The historical options usually discussed in addition to hysterectomy and bilateral salpingoophorectomy (BSO) are active surveillance, pelvic radiotherapy, chemotherapy and hormonal therapy, alone or in combination. Among 84 consecutive patients treated for ESS at a single referral center, 54 with localized stage disease were identified. Recurrence-free survival and overall survival were estimated and patterns of recurrences described. Univariate and multivariate analyses were carried out. The results were as follows: With a median follow-up of 58 months, only one patient had died. None of the 23 patients who had received adjuvant therapy relapsed compared with 13 of 31 patients who had not received any adjuvant therapy. Adjuvant treatments were hormonal therapy (n = 10) and brachytherapy with/without pelvic radiotherapy (n = 13). Almost the majority of relapses were local (92%) and extra-pelvic metastasis was observed in nearly half of the patients (46%). In the multivariate analysis, the major determinants of relapse-free survival were adjuvant treatment, myometrial invasion (P = 0.005) and no BSO (P = 0.005). The authors conclude: In this series, adjuvant treatment of localized ESSs was associated with the absence of recurrence.

Function of EWS-POU5F1 in Sarcomagenesis and Tumor Cell Maintenance

POU5F1 is a transcription factor essential for the self-renewal activity and pluripotency of embryonic stem cells and germ cells. The investigators have previously reported that POU5F1 is fused to EWSR1 in a case of undifferentiated sarcoma with chromosomal translocation t(6;22)(p21;q12). In addition, the EWS-POU5F1 chimeras have been recently identified in human neoplasms of the skin and salivary glands. To clarify the roles of the EWS-POU5F1 chimera in tumorigenesis and tumor cell maintenance, the investigators used small-interfering RNA-mediated gene silencing. Knockdown of EWS-POU5F1 in the t(6;22) sarcoma-derived GBS6 cell line resulted in a significant decrease of cell proliferation because of G1 cell cycle arrest associated with p27Kip1 up-regulation. Moreover, senescence-like morphological changes accompanied by actin polymerization were observed. In contrast, EWS-POU5F1 down-regulation markedly increased the cell migration and invasion as well as activation of metalloproteinase 2 and metalloproteinase 14. The results indicate that the proliferative activity of cancer cells and cell motility are discrete processes in multistep carcinogenesis. These findings reveal the functional role of the sarcoma-related chimeric protein as well as POU5F1 in the development and progression of human neoplasms.

Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?

With the coming investment in electronic health records, questions are arising as to how to best design such records to enhance clinicians’ workflow and the quality of care. The most fundamental concern of such records should of course be geared towards getting the diagnosis right. But a concern is the possibility of a problem of having too much information as opposed to too little. This article from the New England Journal of Medicine proposes several ways in which electronic health records can be designed so as to diminish diagnostic errors.

Translating Gene Expression Into Clinical Care: Sarcomas As a Paradigm

Whereas most solid tumors are characterized by considerable genetic instability and molecular heterogeneity, sarcomas include many subtypes with very specific underlying molecular events driving oncogenesis. Gene expression profiling and other modern techniques have consequently had particular success in identifying the critical biologic pathways active in specific sarcomas, yielding insights which can be translated into useful diagnostic biomarkers. Public availability of data sets and new sequencing-based technologies will accelerate this process. Molecular studies have also identified oncogenic pathways of particular importance in sarcomas which can be targeted by investigational drugs. Examples include histone deacetylases in translocation-associated sarcomas of young adults, Akt/mammalian target of rapamycin in pleomorphic sarcomas, and macrophage colony-stimulating factor in tenosynovial giant cell tumor. This article argues that despite challenges in organization and accrual, future clinical trials of sarcomas need to be designed that take into account specific molecular subtypes as distinct diseases.

A Video Game Improves Behavioral Outcomes in Adolescents and Young Adults With Cancer: A Randomized Trial

Adherence to self-administered medications is a common problem. The purpose of this study was to determine the effectiveness of a video-game intervention for improving adherence and other behavioral outcomes for adolescents and young adults with malignancies including acute leukemia, lymphoma, and soft-tissue sarcoma. A randomized trial with baseline and 1- and 3-month assessments was conducted from 2004 to 2005 at 34 medical centers in the United States, Canada, and Australia. A total of 375 male and female patients who were 13 to 29 years old, had an initial or relapse diagnosis of a malignancy, and currently undergoing treatment and expected to continue treatment for at least 4 months from baseline assessment were randomly assigned to the intervention or control group. The intervention was a video game that addressed issues of cancer treatment and care for teenagers and young adults. Outcome measures included adherence, self-efficacy, knowledge, control, stress, and quality of life. For patients who were prescribed prophylactic antibiotics, adherence to trimethoprim-sulfamethoxazole was tracked by electronic pill-monitoring devices (n = 200). Adherence to 6-mercaptopurine was assessed through serum metabolite assays (n = 54). The results were as follows: Adherence to trimethoprim-sulfamethoxazole and 6-mercaptopurine was greater in the intervention group. Self-efficacy and knowledge also increased in the intervention group compared with the control group. The intervention did not affect self-report measures of adherence, stress, control, or quality of life. The authors conclude: The video-game intervention significantly improved treatment adherence and indicators of cancer-related self-efficacy and knowledge in adolescents and young adults who were undergoing cancer therapy. The findings support current efforts to develop effective video-game interventions for education and training in health care.

Untangling the Web — Patients, Doctors, and the Internet

Medical information has traditionally flowed from doctor to patient. But the abundance of medical information on the Web has upended this tradition. Patients now have access to the same information that doctors do. This perspective article from the New England Journal of Medicine argues that information and knowledge do not equal wisdom, and that physicians are still in the best position to weigh information and advise patients, drawing on their understanding of the available evidence as well as their training and experience.

S-MED: Sarcoma microRNA Expression Database

Human sarcomas are a heterogeneous group of over 50 different malignant tumors for which very few diagnostic markers currently exist. MicroRNA (miRNA) transcript levels have been proposed for use in the diagnosis, classification and prognosis of tumors. Over 700 miRNAs are identified in humans and miRNA are considered attractive candidates for developing novel biomarkers in sarcomas. However, miRNA expression patterns found in sarcomas are poorly understood and no central resource exists to contain this information. To systematically address the gap in both biological knowledge and bioinformatics infrastructure, the authors of this article generated miRNA expression profiles for over 300 tumor tissue samples representing 22 different sarcoma types and developed a web-accessible database to enable facile access to the data. Sarcoma microRNA Expression Database (S-MED) is a repository that describes the patterns of miRNA expression in various human sarcoma types. S-MED provides both basic and advanced data search options for exploration of the data in heat map and text/numerical formats. The database also provides statistical details such as fold changes and P-values for differentially expressed miRNAs in each sarcoma type and corresponding normal tissue. Further, the authors have experimentally validated differentially expressed miRNAs in angiosarcoma and other sarcoma types. This comprehensive database is the first of its kind specifically devoted to miRNA expression patterns in sarcomas.

Immunoglobulin G is present in a wide variety of soft tissue tumors and correlates well with proliferation markers and tumor grades

The traditional view that immunoglobulin (Ig) is produced only by B lymphocytes has been challenged, because it has been demonstrated that Ig genes and proteins are expressed in epithelial cancer cells. However, whether Ig expression in nonlymphoid cells is limited to epithelial cells is unclear. Because sarcomas differ distinctly from carcinomas in their biologic and clinical features, the authors of this study investigated the question of nonlymphoid IgG expression in soft tissue lesions.

Immunohistochemistry, in situ hybridization, and polymerase chain reaction (PCR) were used to demonstrate IgG expression in 80 soft tissue lesions. The correlation between Ig expression and proliferation markers (proliferating cell nuclear antigen [PCNA], Ki-67, and cyclin D1) in sarcomas was investigated by immunohistochemical and statistical analyses. The results were as follows: Ig was identified in 97.4% of sarcomas and in 31.7% of benign lesions by immunohistochemistry. The difference was statistically significant (P < .01). Messenger RNA from the IgG1 heavy-chain constant region was also detected by in situ hybridization. Variable-diversity-joining recombination sequences of both heavy and light chains were obtained by PCR and sequencing. Moreover, the labeling index of PCNA, Ki-67, and cyclin D1 was much higher in sarcomas with high Ig expression than in sarcomas with low Ig expression (P < .01 for PCNA and cyclin D1; P < .001 for Ki-67). There were more grade 3 sarcomas with high Ig expression compared with grade 1 and 2 sarcomas (P < .05). The authors conclude: IgG was identified in a wide variety of soft tissue tumors and correlated well with proliferation markers and tumor grades. IgG may be a useful marker for cell proliferation in sarcomas.

Surgery alone is adequate treatment for early stage soft tissue sarcoma of the extremity

Evolving evidence suggests that, in selected patients with tumor category 1 (T1) extremity soft tissue sarcoma (ESTS), surgery alone offers satisfactory results without decreasing survival. This study assessed the effect of sarcoma treatments on survival outcomes of T1 ESTS in a population-based data set. Using the Surveillance, Epidemiology, and End Results database, 1618 patients with primary ESTS underwent limb-sparing surgery. Multivariable analysis was used to assess the impact of radiotherapy on overall survival (OS) and sarcoma-specific survival (SSS), adjusting for co-variables. The results were as follows: Some 803 patients (49·6 per cent) underwent surgery alone for T1 ESTS. Radiotherapy in patients with low- and high-grade tumors did not result in any significant difference in OS or SSS. When stratified by grade, multivariable analysis showed that adjuvant radiotherapy was not an independent predictor of SSS (hazard ratio (HR) 1·05; P = 0·906) or OS (HR 0·89; P = 0·695) in low-grade tumors. Neither was radiotherapy a significant predictor of SSS (HR 0·87; P = 0·608) or OS (HR 0·67; P = 0·071) in high-grade tumors. The authors conclude: This population-based appraisal validated previous evidence supporting a role for surgery alone in the treatment of T1 ESTS. Future policies should be tailored to offer patients minimal yet effective therapy, rather than maximum tolerated therapy.

Is There a Predisposition Gene for Ewing's Sarcoma?

The molecular mechanisms that underlie Ewing's Sarcoma development are beginning to be understood. For example, most cases of this disease harbor somatic chromosomal translocations that fuse the EWSR1 gene on chromosome 22 with members of the ETS family. While some cooperative genetic events have been identified, such as mutations in TP53 or deletions of the CDKN2A locus, these appear to be absent in the vast majority of cases. It is therefore uncertain whether EWS/ETS translocations are the only consistently present alteration in this tumor, or whether there are other recurrent abnormalities yet to be discovered. One method to discover such mutations is to identify familial cases of Ewing's sarcoma and to then map the susceptibility locus using traditional genetic mapping techniques. Although cases of sibling pairs with Ewing's sarcoma exist, familial cases of Ewing's sarcoma have not been reported. While Ewing's sarcoma has been reported as a 2nd malignancy after retinoblastoma, significant associations of Ewing's sarcoma with classic tumor susceptibility syndromes have not been identified. This article reviews the current evidence, or lack thereof, regarding the potential of a heritable condition predisposing to Ewing's sarcoma. The authors come to the conclusion that the epidemiological evidence supports a slight but possible genetic contribution to the risk of developing Ewing’s sarcoma. However, due to its rarity, many of these studies lack statistical power to definitely prove or disprove a genetic susceptibility to this sarcoma. They state there is no "smoking gun" to suggest an underlying cancer predisposition in the majority of cases of Ewing’s sarcoma, and large-scale studies investigating the genetic epidemiology of Ewing’s sarcoma are sorely needed to answer the question of genetic disease risk. This will only be accomplished through group consortia and multi-institutional collaborations.

Do Radiation-Associated Soft Tissue Sarcomas Have the Same Prognosis As Sporadic Soft Tissue Sarcomas?

The purpose of this study was to determine the prognostic significance of histologic type in radiation-associated soft tissue sarcomas (RASs) and determine whether RASs are associated with an inferior prognosis compared with sporadic soft tissue sarcomas (STSs). One hundred thirty primary RASs were identified from 7,649 STS patients from 1982 to 2007. Multivariate analysis of clinicopathologic factors for disease-specific survival (DSS) was performed for RASs, and a multivariate analysis of radiation exposure was also performed for RASs and sporadic sarcomas. A matched-cohort analysis was performed for radiation-associated and sporadic malignant fibrous histiocytoma (MFH). The results were as follows: Most RASs were high grade (83%), deep (87%), and truncal (61.5%). The median interval between radiation therapy and RAS development was 10 years (range, 1.3 to 74 years), which varied significantly by histologic type (P = .003). The 5-year DSS was 58%, and independent predictors were size > 5 cm, margin positivity, and histologic type. Multivariate analysis of histologic types of primary, high-grade radiation-associated and sporadic STSs showed that RAS was associated with a worse DSS (hazard ratio, 1.7; range, 1.1 to 2.4; P = .007). For pleomorphic MFH—the most common RAS type—the 5-year DSS was 44% versus 66% in a matched cohort of sporadic MFH patients (P = .07). DSS was significantly worse in primary RAS malignant peripheral nerve sheath tumors (MPNSTs) compared with unmatched sporadic MPNSTs (P = .001). The authors Conclude: Histologic type, margin status, and tumor size are the most important independent predictors of DSS in patients with RASs. DSS in patients with primary RAS is significantly worse compared with sporadic STS independent of sarcoma histologic type.

February 2010

Identification of the Receptor Tyrosine Kinase c-Met and Its Ligand, Hepatocyte Growth Factor, as Therapeutic Targets in Clear Cell Sarcoma

Clear cell sarcoma (CCS), a childhood tumor of the tendons and aponeuroses, is uniformly fatal once it has metastasized because of its profound therapeutic resistance. CCS is characterized by production of a chimeric transcription factor, EWS-ATF1, which is formed as the result of a disease-specific chromosomal translocation. EWS-ATF1 activates the melanocyte transcription factor MITF, which in turn activates transcription of c-Met, an oncogenic receptor tyrosine kinase recently shown to be activated in CCS. Based on this connection, the investigators of this study hypothesized that c-Met inhibition may offer a strategy to treat CCS, as an indirect tactic to defeat a transforming pathway downstream of EWS-ATF1. They show that primary CCS and CCS-derived cell lines express c-Met, which is activated in an autocrine fashion by its ligand hepatocyte growth factor (HGF)/scatter factor in some CCS cell lines. c-Met expression is critical for CCS invasion, chemotaxis, and survival. Blocking c-Met activity with a small-molecule inhibitor (SU11274) or a neutralizing antibody to its ligand HGF (AMG 102) significantly reduced CCS cell growth in culture. Similarly, AMG 102 significantly suppressed in vivo tumor growth in an autocrine xenograft model of CCS. Collectively, the investigators believe these findings suggest the HGF:c-Met signaling axis as a candidate therapeutic target to improve clinical management of CCS.

Antiangiogenesis agents in the treatment of soft tissue sarcomas

Tumor angiogenesis has been an intense focus in cancer therapy over the past decade. Several of numerous antiangiogenesis agents have been developed, and many already have been approved for the treatment of both solid and liquid tumors. Certain soft tissue sarcomas are highly vascular tumors that often demonstrate angiogenesis markers. The objective of this review article was to evaluate these angiogenesis markers in defining the role of angiogenesis in the treatment of patients with Soft tissue sarcoma. In addition, the authors conducted an in-depth review of the results from using key antiangiogenesis agents in the treatment of soft tissue sarcoma.

Angiogenesis and vascular targeting in Ewing sarcoma

In recent years, the mechanisms by which Ewing’s sarcoma tumors develop and maintain their vascular supply have been elucidated. Additional work has demonstrated that inhibition of angiogenic pathways or disruption of established vasculature can attenuate the growth of Ewing’s sarcoma mouse xenografts. Early clinical data suggest that these results also may extend to patients with Ewing’s sarcoma who are treated with antiangiogenic or antivascular therapies. In this review article, the authors summarized the available data supporting this approach.

Co-detection of members of the urokinase plasminogen activator system in tumor tissue and serum correlates with a poor prognosis for soft-tissue sarcoma patients

The urokinase plasminogen activator (uPA) system is one of the best-investigated protease systems, both under physiological and pathological conditions, including various types of cancer. However, effects of co-expression of members of the uPA system in soft-tissue sarcoma (STS) patients at the protein level in both tumor tissue and serum have not been investigated yet. In this study, the investigators examined 82 STS patients for protein levels of uPA, PAI-1and uPAR in tumor tissue and serum by ELISA. The results were as follows: A significant correlation between high antigen levels of uPA, PAI-1 or uPAR in tumor tissue, and of uPAR in serum, with poor outcome of STS patients was found for the first time. Most strikingly, they observed an additive effect of combined uPA, PAI-1 or uPAR levels in tumor tissue extracts with uPAR levels in serum on patients’ prognosis. High uPA/uPAR, PAI-1/uPAR and uPAR/uPAR antigen levels in tumor tissue/serum were associated with a 5.9-fold, 5.8-fold and 6.2-fold increased risk of tumor-related death (P=0.003, 0.001 and 0.002, respectively) compared with those patients who displayed low levels of the respective marker combination. The investigators conclude: As expression of members of the uPA system in tumor tissue and serum is additively correlated with prognosis of STS patients, results suggest that combinations of these biomarkers can identify STS patients with a higher risk of tumor-related death.

Prognostic and predictive factors for outcome to first-line ifosfamide-containing chemotherapy for adult patients with advanced soft tissue sarcomas: An exploratory, retrospective analysis on large series from the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group (EORTC-STBSG)

Adult patients with advanced soft tissue sarcomas (STS) are generally treated similarly, regardless of great differences between STS subtypes, disease presentation and patients’ characteristics. As ifosfamide is frequently applied in first line systemic therapy, the investigators of this study aimed to establish prognostic and predictive factors for outcome to ifosfamide-based therapy. A retrospective, exploratory analysis was performed on data from 1337 advanced STS patients who received first-line ifosfamide-containing chemotherapy. For predictive factor analysis, 660 patients treated with doxorubicin monotherapy served as comparators. The results were as follows: Independent favorable prognostic factors for overall survival (OS) were good performance status, female gender, low histological grade, extremity primary tumor site and locally advanced disease; for progression-free survival (PFS), the combination of doxorubicin and ifosfamide, locally advanced disease, and tumor entity with a lower risk to progress for synovial sarcoma patients compared to leiomyosarcoma. For response, independent favorable prognostic factors were doxorubicin combined with ifosfamide, higher histological grade, and histology with synovial sarcoma patients having the highest chance to respond. Predictive factor analysis showed that compared to doxorubicin monotherapy, patients who benefited less from ifosfamide-based therapies were leiomyosarcoma patients in terms of OS, and patients with liposarcoma for response. No predictive factors were found for PFS. The investigators conclude: that they established an independent set of prognostic and predictive factors for outcome to ifosfamide-based chemotherapy in advanced STS patients. This study provides important information for the interpretation and design of clinical trials for specific STS entities and may contribute to further treatment individualization of advanced STS patients.

Interaction of Histologic Subtype and Histologic Grade in Predicting Survival for Soft-Tissue Sarcomas

Histologic grade is considered the paramount prognostic factor in predicting survival for soft-tissue sarcomas (STS). Increasing data suggest that histologic type substantially impacts STS behavior. In this study, The Surveillance, Epidemiology, and End Results program was used to identify 17,364 cases of STS diagnosed between 1988 and 2004. Using death from STS as 1 of the outcomes variables, histologic types were grouped into 3 categories: favorable (survival ≥ 20% above the mean), neutral (survival within 20% of the mean), and unfavorable (survival ≥ 20% below the mean). The effect of histology on survival was analyzed stratified by tumor grade. Five-year survival was calculated using Kaplan-Meier analysis. The Results were as follows: Among 73 histologic types, malignant fibrous histiocytoma (24.1%); leiomyosarcoma, not otherwise specified (14.8%); sarcoma, not otherwise specified (12.8%); and myxoid liposarcoma (5.9%) were the most prevalent. Grade distribution was as follows: low, 12.6%; intermediate, 14.9%; high, 37.1%; and unknown, 35.4%. Risk of death from STS increased with increasing grade: 8.0% for low, 25.9% for intermediate, and 38.3% for high. Among low-grade tumors, risk of death from STS ranged from 4.3% for favorable types to 15.3% for unfavorable types. Among intermediate-grade tumors, risk of death from STS ranged from 6.0% for favorable types to 45.4% for unfavorable types. Among high-grade tumors, risk of death from STS ranged from 24.3% for favorable types to 58.9% for unfavorable types. The authors conclude: that within categories of STS grade, there are substantial differences in survival, depending on histologic type. Histologic type is an important predictor of biologic behavior in STS.

Increased vulnerability of the spinal cord to radiation or intrathecal chemotherapy during adolescence: A report from the Children's Oncology Group

The purpose of this study was to assess the rate of spinal cord toxicity in adolescents resulting from chemoradiotherapy of parameningeal sarcoma. Of 152 patients with parameningeal sarcoma treated per the Intergroup Rhabdomyosarcoma Study Group protocol from 1977 through 1989, eight developed paralyzing ascending myelitis after intrathecal chemotherapy with cytosine arabinoside, methotrexate, and hydrocortisone administered during and after radiation therapy to volumes that included part of the spinal cord. The eight cases include three not previously published. Of the eight patients who developed CNS toxicity after intrathecal chemotherapy and radiotherapy for parameningeal rhabdomyosarcoma, all but one were between 13 and 18 years of age when treated. This severe toxicity occurred in one quarter of 28 adolescents treated with the regimen in comparison with one of 123 children 12 years of age or less (P < 0.0001), a rate that was as much as 30 times higher in the adolescents. Lengthening of the spinal cord during the pubertal growth spurt may account for the apparent increased vulnerability. The authors conclude: Chemoradiotoxicity-associated spinal cord injury appears to be more likely to occur in adolescents than in younger or older ages. This observation appears to reverse a conventional wisdom in which the central nervous system is thought to become more resistant to the neurotoxic effects of chemoradiotherapy as it matures.

Tumor response to sunitinib malate observed in clear-cell sarcoma

This letter to the editor of Annals of Oncology reports on a tumor response to sunitinib malate (SM) in a 46-year-old female patient with metastatic clear-cell sarcoma (CCS). The tumor appeared in December 2008, with two close lesions located to the soft tissues of the left knee. It was initially treated elsewhere with a marginal excision plus local–regional lymph node dissection, followed by radiation therapy on the primary tumor site. The presence of the tumor-specific EWSR1 chromosomal rearrangement was assessed by FISH analysis and confirmed the diagnosis. In June 2009, the disease relapsed at multiple sites. The patient was treated with chemotherapy with anthracycline plus ifosfamide for two cycles, with progression. Meanwhile, the analysis of a series of naive CCS preliminarily showed evidence of platelet-derived growth factor receptor beta (PDGFRB) immunohistochemical expression and biochemical expression/activation in seven of nine cases. On this basis, and lacking any conventional alternative for this patient, the doctors biopsied one of her recurrent lesions, which proved positive for PDGFRB on immunohistochemistry. Therefore, in September 2009, the patient was treated with sunitinib malate 37.5 mg/day on a continuous dosing regimen. Treatment was provided within a compassionate use program. Sunitinib malate is a multitargeted tyrosine kinase inhibitor and antiangiogenic drug with activity against VEGFR, PDGFRA/B, KIT, FLT3, RET, and M-CSFR approved for the treatment of gastrointestinal stromal tumor and renal cancer. The disease was extended to the left laterocervical nodes, soft tissues (multiple lesions to the trunk and buttocks), breast, and left thigh. Concomitant palliative radiotherapy to the left thigh was done. Decrease in size of most lesions was evident on clinical examination after few days of treatment. Interestingly, a hemorrhagic effusion to the skin above each lesion was observed as well. Computed tomography scan after 2 months of sunitinib malate treatment confirmed a dimensional response to all lesions, with the exception of the breast one. Indeed, the latter increased in size, but with a clearcut concomitant decrease in tumor density. The patient was still on treatment and responsive after 3 months.

Biomarkers of angiogenesis and their role in the development of VEGF inhibitors

Vascular endothelial growth factor (VEGF) has been confirmed as an important therapeutic target in randomized clinical trials in multiple disease settings. However, the extent to which individual patients benefit from VEGF inhibitors is unclear. If we are to optimize the use of these drugs or develop combination regimens that build on this efficacy, it is critical to identify those patients who are likely to benefit, particularly as these agents can be toxic and are expensive. To this end, this article reviews biomarkers that have been evaluated in tissue, in circulation and by imaging. Consistent drug-induced increases in plasma VEGF-A and blood pressure, as well as reductions in soluble VEGF-R2 and dynamic contrast-enhanced MRI parameters are particularly noted. In some clinical trials, biomarker changes were statistically significant and associated with clinical end points, but there is considerable heterogeneity between studies that are to some extent attributable to methodological issues. The authors state that on the basis of observations with these biomarkers, it is now appropriate to conduct detailed prospective studies to define a suite of predictive, pharmacodynamic and surrogate response biomarkers that identify those patients most likely to benefit from and monitor their response to this novel class of drugs.

How Children With Cancer Communicate and Think About Symptoms

Journal of Pediatric Oncology Nursing 2010; 27; 24 originally published online Oct 15, 2009; Torun M. Vatne, Laura Slaugther and Cornelia M. Ruland.

This Journal of Pediatric Oncology Nursing study, presented by Vatne Torun, Laura Slaughter and Cornelia Ruland of Oslo, Norway, explores the communication between children with cancer and clinicians. Clinicians rely on patients to report symptoms that are not discoverable as part of a physical exam. Under-reporting of symptoms, or a breakdown in communication between doctors and patients because they don’t use the same language in talking about their symptoms, can cause important signs of disease or side effects of medication to go untreated.

When children don’t recognize changes in their bodies as symptoms of their illness, they don’t tell their nurses and doctors. This study represents an effort to bridge this gap between child patients and their caregivers. The authors focus on the terms used by children when talking about the causes, cures and consequences of symptoms. The authors select 44 symptom terms, aiming "to evaluate how well children comprehend these symptom terms, to ascertain their thoughts about symptoms, and to learn what other terms children may use to express symptoms. Another goal was to explore if there were any differences in understanding and thoughts about symptoms between children who had the experience of cancer and those who did not."

A fascinating communication tool named SiSom1 was used to collect information from the children. According to researchers at the Rikshospitalet University Hospital, "SiSom is an interactive assessment and communication tool for children with cancer, with the purpose of giving them a 'voice' in their own care. SiSom helps children with cancer report their symptoms / problems in a child-friendly, age-adjusted manner, and clinicians to improve patient-provider communication and patient-centered care. Healthy children and children with cancer participated actively in all stages of the design process. SiSom uses spoken text, sound, animations and intuitively meaningful metaphors and pictures to depict symptoms and problems that even younger children who cannot read can respond to."

After the child completes the program, a report is printed that is easily understood by children. This report is designed to be useful to both the child and clinicians. It helps the children recognize important information that they need to tell their parents and doctors, and it helps the clinicians to become familiar with the child’s manner of expressing symptom-related information.

The study found that children did understand medical terms. In their own speech, however, they did not use these terms, or child-like equivalents. Instead, they spoke in the lingo of the day for their age group. One example of a child’s expression of dry mouth caused by medication was "need something to drink". Another child described stomach symptoms as "Feel like I have eaten too much." On this point, the authors conclude that clinicians should use "normal" language with children to elicit more complete information from them.

Another finding was that children did not associate changes in their lifestyles with their symptoms. Restrictions in activities and diet were not perceived as direct consequences of their illness. The author’s speculate that parents of seriously ill children often make great efforts to keep the child from feeling deprived. If the prognosis is poor, they want to keep the child distracted and happy, making sure that they experience life as fully as possible in the time that they have.

The authors summarize their results, stating, "Children demonstrated a good understanding of symptom terms, yet were not always able to explain the symptoms. They had a rich vocabulary to talk about symptoms but did not use childish terms. Children with cancer had a more varied vocabulary for symptoms, but they did not use more medical terms. This study contributes to knowledge about children’s understanding of symptoms that can be helpful to clinicians when communicating with children about their illness."

"1. SiSom is the Norwegian acronym for Si det Som det er, meaning "Tell it as it is," or Selvrapportering Innen Symptomer Og Mestring, meaning "self-reporting on symptoms and management."

Targeted Therapies: The Rare Cancer Paradigm

This review articles analyzes the state of the art of targeted therapies for several tumors, starting from the paradigmatic example of Imatinib treatment in chronic myelogenous leukemia (CML). The authors discuss how rare tumors can be models for various mechanisms of receptor tyrosine kinase (RTK) activation, and provide the opportunity to develop new therapies also for more common cancer types. They discuss the activation of the downstream RTK effectors as further targets for therapies in colorectal cancer. Finally, they highlight how a novel multidimensional approach which adds an in silico dimension to the in vitro and in vivo approach, can predict clinical results.

Combining Targeted Therapies: Practical Issues to Consider at the Bench and Bedside

Numerous practical issues must be considered when combining targeted therapies in early clinical drug development. These include tumor resistance mechanisms, the existence of multiple, redundant signaling pathways, and the failure of single-agent therapies to achieve cures. The strategies adopted to examine combinatorial therapy include the goal of hitting more than one target by specifically inhibiting signal transduction cascades and suppressing specific mechanisms of action with the use of multitargeted kinase inhibitors made possible by high-throughput screening techniques, combinatorial chemistry, and chemoinformatics. Two complex considerations are: which agents to combine given the heterogeneity of tumors and their various underlying perturbations, including secondary mutations and feedback loops, and how to translate findings from the bench to the bedside or directly from the bedside. Another consideration is: When is there enough information to provide a rationale for instituting a phase I trial? Various strategies have been used in combining molecules, including targeting diverse pathways, inhibiting upstream and downstream signals, and adopting a synthetic lethality paradigm. Other issues are: determining appropriate target populations for treatment, how to combine therapeutics with diagnostics, and the frequency of targets in patients referred to clinical trials. The authors of this article review these issues and propose various novel trial designs that are logical for determining the efficacy of a drug or drug combination for personalized treatment. A difficult issue that must be answered is how many and which drugs to combine. Recent technologies, such as multiplexed assay platforms and bioinformatics, will shape the future of clinical trials and help answer these questions surrounding combinatorial treatment.

Phantom Limb Phenomena in Cancer Amputees

The objective of this study was to determine the prevalence of phantom pain and correlated conditions such as phantom sensations and stump pain in a population of cancer patients who had undergone limb amputation. A cross-sectional study was carried out in adult patients submitted to limb amputation, who were being followed up at the Physiotherapy Department between April 3 and November 30, 2006. The presence of phantom pain and associated conditions was quantified using a verbal numerical scale. The data obtained were analyzed for means, medians, and proportions with their respective confidence intervals, as appropriate. The results were as follows: Seventy-five patients participated in this study, 50 men (66.7%) and 25 women (33.3%). Mean age was 54.4 years (SD ± 18.5); range 19 to 88 years. The prevalence of phantom pain was 46.7% (95%CI: 35.1 to 58.6), phantom sensation 90.7% (95%CI: 81.7 to 96.2), and surgical stump pain 32.0% (95%CI: 21.7 to 43.8). The authors conclude: Phantom pain and phantom sensations are highly prevalent among cancer patients, and further studies should be carried out to determine the main factors associated with their onset.

United Kingdom Agrees to Cost-reducing Scheme For New Cancer Drug Trabectedin

United Kingdom patients with advanced soft tissue sarcoma could now benefit from a new drug called trabectedin, after the National Institute for Health and Clinical Excellence (NICE) approved the drug for National Health Service (NHS) use. Trabectedin works by damaging the DNA in cancer cells, preventing them from growing and spreading to other parts of the body.

Research suggests that the drug may extend life by at least three months more than other NHS treatments and that it may therefore be beneficial for some of the 500 to 600 people in England and Wales with advanced soft tissue sarcoma.

In its preliminary draft guidance, NICE had argued that trabectedin would not be a cost-effective use of NHS resources, but it has since changed its mind thanks to a cost-sharing scheme agreed with manufacturer PharmaMar. The drug has now been recommended in the institute's final draft guidance, with the NHS paying for each patient's first five treatment cycles and PharmaMar funding any cycles beyond this. Under the latest guidance, the drug is recommended as a treatment for people with advanced soft tissue sarcoma who have previously failed to respond to treatment with anthracyclines and ifosfamide, or who are unable to tolerate those treatments.

Dr. Carole Longson, director at the NICE Health Technology Evaluation Centre, said: "We are delighted the Independent Appraisal Committee has been able to recommend trabectedin in its draft guidance. It has certainly not been an easy decision to make; soft tissue sarcoma is a rare cancer and the evidence was limited. However, treatment options for this type of cancer are limited and in the last 20 years there have been no major developments to treat the advanced stages of this disease. Being able to recommend trabectedin for use on the NHS represents a step forward in the care of this group of patients who may have very few treatment options left."

The decision has been welcomed by Sarcoma UK, an organization that disseminates information about the disease and develops support services for patients.

Director Roger Wilson commented: "I am delighted that trabectedin has been approved. This drug benefits a large proportion of the small number of patients who receive it." Hilary Tovey, Cancer Research UK's policy manager, said that the decision is, "great news for people with advanced soft tissue sarcoma. We are delighted with this decision and pleased to see manufacturers responding to opportunities to make their drugs available on the NHS."

Fine-needle aspiration diagnosis of a metastatic adult sclerosing rhabdomyosarcoma in a lymph node

Adult sclerosing rhabdomyosarcoma (ASRMS) is a rare variant of rhabdomyosarcoma with a characteristic histological appearance of small, round cells in a dense, hyalinized stroma. Although nodal metastases of soft-tissue sarcomas are considered uncommon, up to 5% overall are associated with lymph node metastases. Nonetheless, there is little literature on the cytologic characteristics of metastatic soft-tissue sarcomas in lymph nodes, and there are no reports of nodal metastasis of ASRMS diagnosed by fine-needle aspiration (FNA) cytology. This article reports on a 55-year-old woman who presented with a right thigh mass and associated ipsilateral inguinal lymphadenopathy. Biopsy of the mass revealed a uniform population of small, round cells in a dense, sclerotic background. A diagnosis of ASRMS was rendered. Subsequently, the patient underwent FNA of an enlarged inguinal lymph node, which revealed an identical population of small, round cells in a dense, myxoid background. This case highlights the cytologic features of a rare form of rhabdomyosarcoma, and emphasizes the utility of FNA in the assessment of lymphadenopathy in the setting of a soft-tissue sarcoma.

Intracerebroventricular Morphine for Refractory Cancer Pain: Transitioning to the Home Setting

Refractory cancer pain may be effectively controlled by titrating intracerebroventricular (ICV) preservative-free opioid. This case report describes a continuous infusion of ICV morphine to a patient with lung cancer and painful spinal metastases who was discharged to home hospice with family. The approach exploited the high potency of morphine injected into cerebrospinal fluid (CSF). Sterile, injectable, preservative-free morphine was directly infused into CSF through a subcutaneous Ommaya reservoir placed under the scalp by a neurosurgeon, with an attached catheter passed through a burr hole in the skull with its tip in a cerebral ventricle. Although investigators have described home care of patients receiving intraspinal analgesics, no report describes the process of transitioning the patient receiving continuous ICV morphine infusion to the home setting.

Proteasome inhibition with bortezomib suppresses growth and induces apoptosis in osteosarcoma

Osteosarcomas are primary bone tumors of osteoblastic origin that mostly affect adolescent patients. These tumors are highly aggressive and metastatic. Previous reports indicate that gain of function of a key osteoblastic differentiation factor, Runx2, leads to growth inhibition in osteosarcoma. The authors of this study previously established that Runx2 transcriptionally regulates expression of a major proapoptotic factor, Bax. Runx2 is regulated via proteasomal degradation, and proteasome inhibition has a stimulatory effect on Runx2. In this study, they hypothesized that proteasome inhibition will induce Runx2 and Runx2-dependent Bax expression sensitizing osteosarcoma cells to apoptosis. Their data showed that a proteasome inhibitor, bortezomib, increased Runx2 and Bax in osteosarcoma cells. In vitro, bortezomib suppressed growth and induced apoptosis in osteosarcoma cells but not in nonmalignant osteoblasts. Experiments involving intratibial tumor xenografts in nude mice demonstrated significant tumor regression in bortezomib-treated animals. Immunohistochemical studies revealed that bortezomib inhibited cell proliferation and induced apoptosis in osteosarcoma xenografts. These effects correlated with increased immunoreactivity for Runx2 and Bax. In summary, their results indicate that bortezomib suppresses growth and induces apoptosis in osteosarcoma in vitro and in vivo suggesting that proteasome inhibition may be effective as an adjuvant to current treatment regimens for these tumors.

Nonreferral of Possible Soft Tissue Sarcomas in Adults: A Dangerous Omission in Policy

The purpose of this study was to compare outcomes in three groups of Soft Tissue Sarcoma (STS) patients treated at the University of Navarra, Spain: patients referred immediately after an inadequate initial treatment, patients referred after a local recurrence, and patients referred directly, prior to any treatment. The authors reviewed all their nonmetastatic extremity-STS patients with a minimum follow-up of 2 years. They compared three patient groups: those referred directly to our centre (group A), those referred after an inadequate initial excision (group B), and patients with local recurrence (group C). The results were as follows: The study included 174 patients. Disease-free survival was 73%, 76%, and 28% in groups A, B, and C, respectively (P<.001). Depth, size, and histologic grade influenced the outcome in groups A and B, but not in C. The authors conclude: Initial wide surgical treatment is the main factor that determines local control, being even more important than the known intrinsic prognostic factors of tumor size, depth, and histologic grade. The influence on outcome of initial wide local excision (WLE), which is made possible by referral to a specialist centre, is paramount.

December 2009

A REQUEST TO THE NATIONAL CANCER INSTITUTE FROM THE SARCOMA RARE CANCER COMMUNITY

November 19, 2009

John Niederhuber, M.D.
Director, National Cancer Institute
Building 31, Room 10A24
9000 Rockville Pike
Bethesda, MD 20892

Subj: EXPANSION OF NCI CANCER GENOME ATLAS PROJECT TO INCLUDE SARCOMA

Dear Dr. Niederhuber:

The undersigned represent cancer patients and their families, health care providers, as well as patient advocacy, patient support and scientific research organizations interested in and affected by rare cancers known as "sarcoma."

As you know, in President Obama's first "Address to Congress" he announced the bold goal of curing cancer in our lifetimes. Regarding our community, the President specifically addressed the needs of people with rare cancers in the 2008 Obama/Biden Plan to Combat Cancer. We are sure you would agree that sarcoma certainly qualifies for this distinction.

Recently, we noted the visit that President Obama made to the NIH to highlight the increased funding that his administration had made available to the NCI to accelerate progress against cancer. Subsequent to the gathering, it was announced that specific new funds were to be aimed at the NCI Cancer Genome Atlas Project (TCGA), and that upwards of twenty new cancer types would be added to TCGA.

We would like to take this opportunity to encourage you to consider the following information regarding sarcoma as you decide the specific cancer types to be added to the project:

1) Unlike several cancer types, sarcoma is prevalent in all ages of the U.S. population, and is especially prevalent in children. Thus each child saved from death by sarcoma adds 60-70 years of value and contribution to society.

2) There are very limited treatment options for sarcoma, with the sole FDA approved agent being approved over 20 years ago.

3) Though sarcoma is an uncommon cancer, research discoveries in sarcoma have been shown to go on and provide enormous insight into more prevalent tumors. For example, work to elucidate the role of the P53 gene played in explaining heritable cancers, prediction of the RB gene leading to the multiple "hit" hypothesis in carcinogenesis, research of the src gene leading to the viral genetic relationship with cancer, and the more recent work of the importance of the ews fusion gene in prostate cancer, all have their origin in research based in studying sarcomas. Thus there would be a synergistic efficiency to data obtained by uncovering genomic abnormalities in sarcomas as a result of being a part of TCGA.

4) The sarcoma community, including academic centers and patient advocacy groups, is an extraordinarily tight knit, engaged and cooperative community. We appreciate that one of the key elements driving the tumor choices is the availability of large numbers of frozen tumors with matched normal blood or tissue, either prospective or retrospective, obtained with proper consents. As a result of our community's unity, it can be anticipated that participation in an endeavor such as TCGA would result in rapid and robust collection of high quality tissue samples and completion of other requirements of participation in the program.

The rare cancer community, and specifically the sarcoma community, has been energized by the recent increases in funding allocated to the NCI. We hope that by addressing the needs of this relatively neglected group of cancer patients, we will accomplish the original intent of President Obama's concern for patients with rare cancers.

If we may be of assistance, please do not hesitate to call upon our union of organizations as a resource. Thank you again for your diligent work on behalf of cancer patients.

Sincerely,

Sarcoma Alliance for Research Consortium	BeatSarcoma
Connective Tissue Cancer Network	Connective Tissue Oncology Society
Desmoid Tumor Research Foundation	Ewings Sarcoma Alliance
Foster Foundation	GIST Cancer Research Fund
GIST Support International	Hope Fund for Sarcoma Research
Kristen Ann Carr Fund	Liddy Shriver Sarcoma Initiative
Life Raft Group	National Leiomyosarcoma Foundation
Northwest Sarcoma Foundation	Polish Sarcoma Patient Advocacy
Sarcoma Alliance	Sarcoma Foundation of America
The Alliance Against ASP Sarcoma	The sPECial Fund
The Swing Away Foundation	WWWW Foundation, Inc. (QuadW)

The Claudia Cohen Research Foundation Announces Annual Prize for Outstanding Gynecologic Cancer Researcher

The Claudia Cohen Research Foundation in association with the Gynecologic Cancer Foundation (GCF) announced today that it will award an annual $50,000 prize to an individual in recognition of his or her outstanding contributions to research improving the care of women with gynecologic cancer. The awardees will have made important contributions that improve gynecologic cancer patient care, including early detection. The award will be made to the individual rather than his/her institution. The prize named is being funded by the Claudia Cohen Research Foundation (CCRF) in honor of Claudia Cohen who lost her battle with uterine leiomyosarcoma in 2007. Ms. Cohen was a highly respected journalist and philanthropist. Individuals can apply for this prize or nominators can propose potential candidates by filling out the application form which is downloadable on the GCF Web site. The deadline for applications is January 8, 2010. The GCF Award's Committee will select the awardee with the first prize to be announced at the 2010 SGO Annual Meeting on Women's Cancer in San Francisco, California. The Claudia Cohen Research Foundation was founded by Ms. Cohen's daughter, Samantha, and her sisters Caleigh and Debra Perelman, to foster research aimed at reducing the burden of gynecologic cancer.

Prognostic factors in pulmonary metastasized high-grade osteosarcoma

The resection of pulmonary metastases has previously been reported to improve outcome in high-grade osteosarcoma (OS) patients. This study sought to validate these results. In the study there were 88 OS patients with pulmonary metastases either at diagnosis or during follow-up. All were treated at Leiden University Medical Center between January 1, 1990 and January 1, 2008. All were under the age of 40; there were 79 conventional cases, 8 cases of telangiectatic and 1 case of small cell OS. The results were as follows: In total, 56 of 88 patients with pulmonary metastases were treated by metastasectomy. Resectability of pulmonary metastases was the main prognostic factor. In patients with primary non-metastatic OS, a longer relapse free interval to pulmonary metastases was significantly associated with better survival (P = 0.02). Independent risk factors determining worse survival after metastasectomy in multivariate analysis were male sex (P = 0.05), higher number of pulmonary nodules (P = 0.03), and non-necrotic metastases (P = 0.04). Whether surgery for recurrent pulmonary metastases was performed did not influence survival. Histological subtype of the primary tumor, histological response in the primary tumor after neo-adjuvant chemotherapy, occurrence of local relapse, local resection or amputation of the primary tumor and age at diagnosis did not influence outcome. The investigators conclude: This cohort of patients with detailed follow-up data enabled identification of important risk factors determining survival in OS patients with pulmonary metastases. They demonstrate that after repeated metastasectomies, a subset of patients can be cured.

Learn about Novel Targets to Treat Osteosarcoma Lung Metastases in the Research Center.

Noninvasive Imaging Surrogate of Angiogenesis in Osteosarcoma

Measurement of tumor angiogenesis by qualitative analysis of dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI), and its association with diffusion-weighted (DW)-MRI and glucose metabolism using positron emission tomography-computerized tomography (PET-CT) scan has not been explored in osteosarcoma. This study was aimed to evaluate the potential of these surrogates. Thirty-one treatment naive patients with osteosarcoma underwent MRI and PET-CT preceding and following three cycles of neoadjuvant chemotherapy (NACT) and surgery. Time intensity curves (TICs) representing low microvascular permeability is persistent type while that of high permeability are plateau and washout types. Vascular endothelial growth factor (VEGF) expression was assessed in biopsy and resected specimens by immunohistochemistry. The sample was considered VEGF positive when intensive positive staining of VEGF was observed in >10% of the tumor cells in biopsy or resection specimens. The results were as follows: TIC could correctly identify all 28 VEGF positive samples at baseline and 24/25 (96%) of VEGF positive samples and 5/6 (83%) of VEGF negative samples after NACT. The change in curve pattern from washout/plateau to persistent type was in agreement with corresponding decrease in microvascular permeability, that is, VEGF expression. For persistent type of TIC, mean change in VEGF was 73.3 ± 43.2% and for plateau and washout type of TIC it was 19.54 ± 45% and 16.66 ± 28.86%, respectively (P 0.04). VEGF expression did not correlate with DW-MRI and PET-CT parameters. The investigators conclude: This study suggests an important role of DCE-MRI as a noninvasive imaging surrogate of tumor angiogenesis in osteosarcoma based on visual inspection of TIC.

Deletion of the WWOX gene and frequent loss of its protein expression in human osteosarcoma

The purpose of this study was to evaluate the role of WWOX gene in human osteosarcoma. An array comparative genomic hybridization on 10 frozen osteosarcoma specimens and immunohistochemical staining of 55 formalin-fixed and paraffin-embedded tissues for WWOX was performed. Deletion of the WWOX gene was observed in 3 of 10 samples and the WWOX protein was undetectable in 34 of 55 osteosarcomas. This is the first investigation of the role of WWOX gene in human osteosarcoma. The WWOX gene deletion, loss of its protein expression, and lack of correlation of WWOX expression with patient survival suggest loss of WWOX expression is an early event in the pathogenesis of osteosarcoma and the phenotypic results of its deletion do not imminently result in patient death.

This study was funded by a grant from the Liddy Shriver Sarcoma Initiative. The initial study proposal and results were published in previous ESUN issues.

Molecular prognosticators of complex karyotype soft tissue sarcoma outcome: a tissue microarray-based study

Molecular markers are currently being utilized as sensitive prognosticators of cancer patient outcome. The investigators of this study sought to identify prognostic biomarkers for complex karyotype soft tissue sarcoma (STS). A large (n = 205) clinically annotated tissue microarray (TMA) was constructed and immunostained for several tumor-related markers. Staining was scored via an automated Ariol image analysis system; data were statistically analyzed to evaluate the correlation of clinicopathological and molecular variables with overall survival (OS) and local recurrence. The results were as follows: Multivariable analysis identified older age [hazard ratio (HR) 1.62, P < 0.0001], nonextremity location (HR 2.95, P = 0.001), high tumor grade (HR 2.5, P = 0.02), and increased matrix metalloproteinase (MMP) 2 expression (HR 1.74, P = 0.04) as predictors for poor OS. Similarly, older age (HR 1.51, P = 0.008), nonextremity location (HR 4.09, P = 0.001), and increased MMP2 expression (HR 6.28, P = 0.006) were all found to correlate with shorter local recurrence-free interval. High nuclear p53 expression was associated with shorter STS local recurrence-free interval, with a trend toward significance. The investigators conclude: Data presented indicate that a clinically annotated TMA can be utilized to identify STS-related prognostic markers. Specifically, MMP2 and nuclear p53 should be further evaluated for their potential inclusion in complex karyotype STS staging systems.

Treatment of Relapsed/Refractory Pediatric Sarcomas With Gemcitabine and Docetaxel

This report describes experience with gemcitabine-docetaxel in pediatric patients with relapsed or refractory sarcomas. Ten relapsed/refractory pediatric sarcoma patients including 6 Ewing sarcoma, 2 synovial sarcoma, 1 osteosarcoma, and 1 undifferentiated sarcoma, were treated prospectively, in an outpatient setting, with gemcitabine 1000 mg/m2 over 90 minutes on day 1 and 8, and docetaxel 100 mg/m2 over 2 to 4 hours on day 8 of a 21-day cycle, as an investigational rescue therapy. The results were as follows: The patients (ages 4 to 18) received a total of 70 cycles of therapy (median 6 cycles; range: 4 to 10 y). All symptomatic patients responded clinically to the new regimen. By Response Evaluation Criteria in Solid Tumors criteria, 4 (40%) patients had a complete response (CR), 1 (10%) had a partial response (PR), 3 (30%) had stable disease (SD), and 2 (20%) had a progressive disease (PD), which provides an objective response rate (CR+PR) of 50%. Median duration of response (CR+PR+SD) was 10 months (range: 6 to 32+ mo). Five out of the 10 patients (50%) are alive, with a median follow-up of 48 months from diagnosis. Mild toxicities (no grades 3 to 4) were encountered and managed in the ambulatory setting. The investigators conclude: The gemcitabine-docetaxel regimen demonstrated antitumor activity against advanced pediatric (mainly Ewing) sarcomas, allowing for good quality of life. Evaluation in a large, formal phase 2 trials for Ewing patients is ongoing.

Profiling of high-grade central osteosarcoma and its putative progenitor cells identifies tumourigenic pathways

Osteosarcoma is the most prevalent primary malignant bone tumor in children and young adults, with poor survival in 40% of patients. To identify the signaling pathways involved in tumourigenesis, the investigators of this study compared gene expression in osteosarcoma with that in its presumed normal counterparts. Genome-wide expression profiles were generated from 25 high-grade central osteosarcoma prechemotherapy biopsies, 5 osteoblastomas, 5 mesenchymal stem cell (MSC) populations and these same MSCs differentiated into osteoblasts. Genes that were differentially expressed were analyzed in the context of the pathways in which they function using the GenMAPP programme. The results were as follows: MSCs, osteoblasts, osteoblastomas and osteosarcomas clustered separately and thousands of differentially expressed genes were identified. The most significantly altered pathways are involved in cell cycle regulation and DNA replication. Several upstream components of the Wnt signaling pathway are downregulated in osteosarcoma. Two genes involved in degradation of -catenin protein, the key effectors of Wnt signaling, Axin and GSK3-, show decreased expression, suggesting that Wnt signaling is no longer under the control of regular signals. Comparing benign osteoblastomas with osteosarcomas identified cell cycle regulation as the most prominently changed pathway. The investigators conclude: These results show that upregulation of the cell cycle and downregulation of Wnt signaling have an important role in osteosarcoma genesis. Gene expression differences between highly malignant osteosarcoma and benign osteoblastoma involve cell cycle regulation.

Randomized Trial and Pharmacokinetic Study of Pegfilgrastim versus Filgrastim after Dose-Intensive Chemotherapy in Young Adults and Children with Sarcomas

The purpose of this study was to compare the effectiveness, tolerance, and pharmacokinetics of a single dose of pegfilgrastim to daily filgrastim in children and young adults with sarcomas treated with dose-intensive combination chemotherapy. Patients were randomized to receive a single dose of 100 mcg/kg of pegfilgrastim s.c. or 5 mcg/kg/day of filgrastim s.c., daily until neutrophil recovery after two treatment cycles with vincristine, doxorubicin, and cyclophosphamide (VDC) and two cycles of etoposide and ifosfamide (IE). The duration of severe neutropenia (absolute neutrophil count, ≤500/mcL) during cycles 1 to 4 and cycle duration for all cycles were compared. Pharmacokinetics of pegfilgrastim and filgrastim and CD34+ stem cell mobilization were studied on cycle 1. Growth factor–related toxicity, transfusions, and episodes of fever and neutropenia and infections were collected for cycles 1 to 4. The results were as follows: Thirty-four patients (median age, 20 years; range 3.8-25.8) were enrolled, and 32 completed cycles 1 to 4. The median (range) duration of absolute neutrophil count of <500/mcL was 5.5 (3-8) days for pegfilgrastim and 6 (0-9) days for filgrastim (P = 0.76) after VDC, and 1.5 (0-4) days for pegfilgrastim and 3.75 (0-6.5) days for filgrastim (P = 0.11) after IE. More episodes of febrile neutropenia and documented infections occurred on the filgrastim arm. Serum pegfilgrastim concentrations were highly variable. Pegfilgrastim apparent clearance (11 mL/h/kg) was similar to that reported in adults. The investigators conclude: A single dose per cycle of pegfilgrastim was well tolerated and may be as effective as daily filgrastim based on the duration of severe neutropenia and number of episodes of febrile neutropenia and documented infections after dose-intensive treatment with VDC and IE.

Phase I, Pharmacokinetic, and Pharmacodynamic Study of AMG 479, a Fully Human Monoclonal Antibody to Insulin-Like Growth Factor Receptor 1

The purpose of this study was to determine the maximum-tolerated dose (MTD) and to assess the safety, pharmacokinetics, and evidence of antitumor activity of AMG 479, a fully human monoclonal antibody to insulin-like growth factor receptor 1 (IGF-1R). Patients with advanced solid malignancies or non-Hodgkin's lymphoma received escalating doses of AMG 479 intravenously (IV) every 2 weeks (Q2W). Blood samples were assayed to determine pharmacokinetic parameters and IGF-1R occupancy on neutrophils; fluorodeoxyglucose–positron emission tomography scans were used to assess tumor metabolic effects. The results were as follows: Fifty-three patients received 312 infusions of AMG 479 Q2W. Overall, the most common grades 1 to 2 toxicities were fatigue, thrombocytopenia, fever, rash, chills, and anorexia. One dose-limiting toxicity (i.e., grade 3 thrombocytopenia) occurred in a patient at 20 mg/kg during course 1; grade 3 thrombocytopenia (n = 8) and grade 3 transaminitis elevations (n = 1) also were reported but not in the escalation phase. The maximum-planned dose of 20 mg/kg was safely administered; thus, an MTD was not reached. High levels of neutrophil IGF-1R binding and increases from baseline in serum IGF-1 levels were observed in the 12- and 20-mg/kg cohorts. Tumor responses included one durable complete response (CR) and one unconfirmed partial response (PR) in two patients with Ewing/primitive neuroectodermal tumors and included one PR and one minor response in two patients with neuroendocrine tumors. The patients with Ewing/PNET who had a CR have remained disease free on therapy after 28 months. The investigators conclude: AMG 479 can be administered safely at 20 mg/kg IV Q2W. The absence of severe toxicities, attainment of serum concentrations associated with high levels of IGF-1R binding on neutrophils, and provocative antitumor activity warrant additional studies of this agent.

Late Recurrence in Pediatric Cancer: A Report From the Childhood Cancer Survivor Study

An increasing percentage of childhood cancer patients are surviving their disease, but there is limited research on late recurrence. The investigators of this study sought to estimate late recurrence rates for the most common pediatric cancers and to determine risk factors for late recurrence. The incidence of late recurrences, or first recurrences that occurred more than 5 years after diagnosis, was analyzed for the most common pediatric cancers using data from the Childhood Cancer Survivor Study, a retrospective cohort of 5-year survivors of childhood and adolescent cancers who were diagnosed between 1970 and 1986. A total of 12,795 survivors with no history of recurrence within 5 years after their original cancer diagnosis were included in the analysis, with a total of 217 127 person-years of follow-up. Cumulative incidence of late recurrence at 5, 10, 15, and 20 years after diagnosis was calculated using death as a competing risk. Adjusted relative rates of late recurrence were obtained using multivariable Poisson regression. All statistical tests were two-sided. Results were as follows: Overall, 5-year survivors of pediatric cancers experienced a cumulative incidence of recurrent disease of 4.4%, 5.6%, and 6.2% at 10, 15, and 20 years, respectively. Cumulative incidence varied by diagnosis: Survivors of Ewing sarcoma and astrocytoma had the highest 20-year cumulative incidences at 13.0% (95% confidence interval [CI] = 9.4 to 16.5) and 14.4% (95% CI = 12.3 to 16.6), respectively. In multivariable analysis, the greatest risk factors for late recurrence included diagnosis, combination treatment with chemotherapy and radiation, earlier treatment era, and fewer years since diagnosis (P < .001 for all). The investigators conclude: Late recurrence is a risk for some pediatric cancers. By understanding diagnosis-specific risks, patients, families, and their medical providers can be better informed of the probability of cure.

Small interfering RNA library screen of human kinases and phosphatases identifies polo-like kinase 1 as a promising new target for the treatment of pediatric rhabdomyosarcomas

Rhabdomyosarcoma, consisting of alveolar (aRMS) and embryonal (eRMS) subtypes, is the most common type of sarcoma in children. Currently, there are no targeted drug therapies available for rhabdomyosarcoma. In searching for new molecular therapeutic targets, the authors of this paper carried out genome-wide small interfering RNA (siRNA) library screens targeting human phosphatases (n = 206) and kinases (n = 691) initially against an aRMS cell line, RH30. Sixteen phosphatases and 50 kinases were identified based on growth inhibition after 72 hours. Inhibiting polo-like kinase 1 (PLK1) had the most remarkable impact on growth inhibition (∼80%) and apoptosis on all three rhabdomyosarcoma cell lines tested, namely, RH30, CW9019 (aRMS), and RD (eRMS), whereas there was no effect on normal muscle cells. The loss of PLK1 expression and subsequent growth inhibition correlated with decreased p-CDC25C and Cyclin B1. Increased expression of WEE 1 was also noted. The induction of apoptosis after PLK1 silencing was confirmed by increased p-H2AX, propidium iodide uptake, and chromatin condensation, as well as caspase-3 and poly(ADP-ribose) polymerase cleavage. Pediatric Ewing's sarcoma (TC-32), neuroblastoma (IMR32 and KCNR), and glioblastoma (SF188) models were also highly sensitive to PLK1 inhibition. Finally, based on cDNA microarray analyses, PLK1 mRNA was overexpressed (>1.5 fold) in 10 of 10 rhabdomyosarcoma cell lines and in 47% and 51% of primary aRMS (17 of 36 samples) and eRMS (21 of 41 samples) tumors, respectively, compared with normal muscles. Similarly, pediatric Ewing's sarcoma, neuroblastoma, and osteosarcoma tumors expressed high PLK1. The authors conclude: PLK1 could be a promising therapeutic target for the treatment of a wide range of pediatric solid tumors including rhabdomyosarcoma.

Current Approach to Pediatric Soft Tissue Sarcomas

This article, authored by Melinda Merchant and Crystal Mackall (Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA), describes the current standard of care for pediatric soft tissue sarcomas. Pediatric STS are generally defined as those that occur in the first 20 years of life. The types of sarcomas discussed includes (refer to acronyms list below) RMS, ERMS, ARMS, ESFT, undifferentiated or poorly differentiated sarcomas, DSRCT, SS, MPNST, ASPS and IFS. It also touches on adult-type sarcomas such as liposarcoma, leiomyosarcoma, fibrosarcoma, myxoid chondrosarcoma and clear cell sarcoma. The following type of information is provided, by tumor type:

Diagnostic methods (stains, biopsy type, molecular/ imaging evaluations)
Chromosome translocation information, where applicable
Most common tumor sites
Risk factors
Prognostic factors
Method of metastasis
Treatment approaches that have a proven record of success or are under study
Current recommended protocols
Special considerations or controversies for specific disease characteristics
General information on current trials
Survival rates

The authors emphasis the need for a multidisciplinary approach in treating these sarcomas. They state, "Radiologists, oncologists, surgeons, and radiation oncologists treating children and young adults with sarcomas ought to be aware of the national and international study options that will provide quality of care and also continue to move the field forward."

Loss Of Tumor Suppressor Gene Essential To Transforming Benign Nerve Tumors Into Malignant Peripheral Nerve Sheath Tumors

Researchers at UCLA's Jonsson Comprehensive Cancer Center have demonstrated that the loss or decreased expression of the tumor suppressor gene PTEN plays a central role in the malignant transformation of benign nerve tumors called neurofibromas into the deadly form of sarcoma know as malignant peripheral nerve sheath tumors. The work, a collaboration between the Institute for Molecular Medicine, the Department of Molecular and Medical Pharmacology and the cancer center's Sarcoma Program, could lead to the development of new therapies that target the cell signaling pathway regulated by PTEN. A novel mouse model of neurofibromatosis type 1 (NF1) developed at UCLA first illustrated the importance of PTEN tumor suppressor in malignant transformation and this finding was validated in malignant peripheral nerve sheath tumors.

"The loss of expression of PTEN in the human sarcomas we studied mirrored the loss of PTEN in mice, and we anticipate being able to target this pathway abnormality for the development of new methods of diagnosis and treatment" said Dr. Fritz Eilber, director of the Sarcoma Program and an assistant professor of surgical oncology. "Within the sarcoma world, malignant peripheral nerve sheath tumors are one of the most lethal sub-types, so this is a significant finding and may lead to new and more effective treatments."

NF1 is one of the most common genetically inherited disorders, with an incidence of about 1 in every 2,500 births, said, Dr. Hong Wu, associate director of the molecular medicine institute, a Jonsson Cancer Center researcher and senior author of the study. "Patients with NF1 have an about 10 percent lifetime risk of developing this lethal sarcoma sub-type," Wu said.

The study also showed that Positron Emission Tomography (PET) scanning with the glucose analogue FDG - both in the mice and in humans - is a highly accurate way to distinguish between the benign tumors and the malignant ones, indicating that this non-invasive imaging technology is valuable in assessing therapeutic response to new treatments.

The mouse model was created by altering two cell signaling pathways that are commonly activated in peripheral and central nervous system cancers, the RAS/RAF/MAPK & PTEN/P13K/AKT pathways, known to regulate cell proliferation, survival and differentiation.

"When we began to generate mouse models to mimic different human cancers, we usually did gene-based analysis to see the relevance of a specific gene in the development of the cancer," Wu said. "But we realize that sometimes targeting the cell signaling pathways that organize and instruct cells to function, both for normal functions of our body and also in abnormal ways in disease, are more important and informative than the individual gene."

The mouse model developed benign neurofibromas, but then progressed to the deadly sub-type of sarcoma. The neurofibromas had half the normal levels of PTEN and the sarcomas had a complete loss of PTEN. Since PTEN is an important factor in suppressing cells from becoming malignant, this could provide an explanation for the sequence of the normal cells transforming into benign neurofibromas that could then transform into cancer.

Wondering if this was also the case in people, Dr. Wu collaborated with Eilber and pathologist Dr. Sarah Dry, director of the Institute of Molecular Medicine's Pathway Pathology Center, and a multidisciplinary team of physician-scientists to determine if people with this sarcoma sub-type also had little or no PTEN.

Currently, there are no effective treatments to prevent the benign NF1 tumors from transforming into cancer. The genetically engineered mouse model will be used to screen drugs that may be able to target the signaling pathway regulated by PTEN, to block signals that instruct the cells to change from a benign state to a malignant one, providing treatment options for patients with the deadly form of cancer.

"I think these findings will help us provide a better diagnosis that can determine if the neurofibroma is becoming a malignant tumor or not," Eilber said. "But more importantly, the loss of the PTEN and its associated signaling pathways gives us targets for therapy and it may lay the foundation for treatment in other sarcomas as well."

Practice and Effectiveness of Outpatient Psycho-Oncological Counseling for Cancer Patients

Because of various types of psychological distress, cancer patients are encouraged to attend outpatient psycho-oncological and psychosocial counseling. The aim of this prospective study was an analysis of the impact and success of existing counseling resources. All cancer patients who had applied at a central counseling center were given a standardized questionnaire (FBK-R23), designed to assess the type and degree of cancer patients' difficulties prior to their first counseling session. Additionally, the psychological condition of the patients was assessed psycho-oncologically by a third party (PO-Bado). After at least 2 and no more than 5 sessions, patients underwent both self-evaluation and third-party assessment, using the same instruments. The Results were as follows: During the period from September 2008 and August 2009, the authors looked at a total of 447 people seeking counseling, including 186 family members (42%), 33 professional caregivers (7%), and 228 patients (51%). Out of the 228 patients, 48 attended counseling sessions personally and 20 of these additionally completed the second questionnaire. Counseling led to only a tendency toward improvement, on average, of total psychological distress (p=0.08). In individual areas - for example, "Social Distress" and "Everyday Limitations"- no change could be measured. Only the problem area identified as "Information Deficit" was improved, on average, after 3 counseling sessions (p=0.008). The authors Conclude: Results indicate that while short-term counseling has no concrete effect on the improvement of a patient's psychological well-being, these support sessions do serve to decrease the patient's so-called "Information Deficit", thereby bringing about an indirect improvement in the sufferer's psychological state. The course of treatment offered should be determined according to the patient's needs. In order to ensure that even the very sickest of the tumor patient group seek outreach groups, we must target this particular group with additional evaluative questions. Further studies must determine whether short-term counseling or other counseling strategies are most effective.

October 2009

Trail-induced apoptosis and interaction with cytotoxic agents in soft tissue sarcoma cell lines

In this study, five human soft tissue sarcoma (STS) cell lines (HTB-82 rhabdomyosarcoma, HTB-91 fibrosarcoma, HTB-92 liposarcoma, HTB-93 synovial sarcoma and HTB-94 chondrosarcoma) were analyzed for their sensitivity to tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) and the function of the TRAIL apoptotic pathway in these cells. The study found that TRAIL induced significant apoptosis (>90%) in HTB-92 and HTB-93 cells, whereas no effect was observed in HTB-82, HTB-91 and HTB-94 cells. TRAIL-Receptor 1 (TRAIL-R1) was expressed in TRAIL-sensitive HTB-92 and HTB-93 cell lines, but not in TRAIL-resistant HTB-91 and HTB-94 cells. HTB-82 cells, which expressed the long (c-FLIP(L)) and short (c-FLIP(S)) splice variants of the FLICE-like inhibitory protein (FLIP), were resistant to TRAIL in spite of the presence of TRAIL-R1. TRAIL-R2,-R3,-R4 and osteoprotegerin (OPG) expression did not correlate with TRAIL sensitivity. Coincubation of TRAIL and doxorubicin led to the overexpression of TRAIL-R2 resulting in a synergistic effect of doxorubicin and TRAIL in TRAIL-sensitive cell lines and in the overcoming of TRAIL-resistance in all of the TRAIL-resistant cell lines, except HTB-91, which lacked caspase 8 expression. The investigators thus believe this data suggests that TRAIL, either as a single agent or in combination with cytotoxic agents, might represent a new treatment option for advanced STS, which constitutes a largely chemotherapy-resistant disease.

Learn more about TRAIL at SarcomaHelp.org.

Advances in Ewing's Sarcoma Research: Where Are We Now and What Lies Ahead?

Research into the molecular biology of Ewing’s sarcoma (ES) has increased enormously over the last few years, and a large body of knowledge is now available. Despite these efforts, understanding of the mechanisms responsible for the disease is only advancing slowly. This article reviews the most recent insights into the origins of ES pathogenesis, focusing on the critical points that may be hindering the progress in the field, namely: the basis of gene and protein regulation networks initiated by the chimeric protein, the proposed direct and indirect targets, and the pathways they are involved in; sarcomagenesis, with the clarification of the cell of origin, and its extrapolation to the construction of animal models absent in ES research; the future promises of investigation in tumor immunology; and finally the translation of such a large volume of information from research contributed developments into the preclinical field of drug assays.

Bone sarcomas arising in patients with neurofibromatosis type 1

This study identified eight patients of 2900 with a primary malignant bone tumor who had coexisting neurofibromatosis type 1. This is a much higher incidence than would be expected by chance. The patients had a mean age of 22.4 years (9 to 54): five were male. Two patients subsequently developed a second bone sarcoma, one of which was radiation induced. Four of the primary tumors were osteosarcomas, four were spindle-cell sarcomas and one a Ewing's sarcoma. All the patients were treated with chemotherapy and surgery: six of the eight appear to be cured. The authors thus suggest a possible relationship between neurofibromatosis type 1 and the development of a bone sarcoma, the increased risk being estimated at eight times that of the normal population. They recommend that further research into this possible link should be considered.

Learn more about Neurofibromatosis Type 1 as well as Cancer Predisposition Syndromes at SarcomaHelp.org

The Insulin-like Growth Factor-1 Receptor–Targeting Antibody, CP-751,871, Suppresses Tumor-Derived VEGF and Synergizes with Rapamycin in Models of Childhood Sarcoma

Signaling through the type 1 insulin-like growth factor receptor (IGF-1R) occurs in many human cancers, including childhood sarcomas. As a consequence, targeting the IGF-1R has become a focus for cancer drug development. The investigators of this study examined the antitumor activity of CP-751,871, a human antibody that blocks IGF-1R ligand binding, alone and in combination with rapamycin against sarcoma cell lines in vitro and xenograft models in vivo. The results were as follows: In Ewing sarcoma (EWS) cell lines, CP751,871 inhibited growth poorly (<50%), but prevented rapamycin-induced hyperphosphorylation of AKT(Ser473) and induced greater than additive apoptosis. Rapamycin treatment also increased secretion of IGF-1 resulting in phosphorylation of IGF-1R (Tyr1131) that was blocked by CP751,871. In vivo CP-751,871, rapamycin, or the combination were evaluated against EWS, osteosarcoma, and rhabdomyosarcoma xenografts. CP751871 induced significant growth inhibition [EFS(T/C) >2] in four models. Rapamycin induced significant growth inhibition [EFS(T/C) >2] in nine models. Although neither agent given alone caused tumor regressions, in combination, these agents had greater than additive activity against 5 of 13 xenografts and induced complete remissions in one model each of rhabdomyosarcoma and EWS, and in three of four osteosarcoma models. CP751,871 caused complete IGF-1R down-regulation, suppression of AKT phosphorylation, and dramatically suppressed tumor-derived vascular endothelial growth factor (VEGF) in some sarcoma xenografts. Rapamycin treatment did not markedly suppress VEGF in tumors and synergized only in tumor lines where VEGF was dramatically inhibited by CP751,871. The investigators thus conclude: These data suggest a model in which blockade of IGF-1R suppresses tumor-derived VEGF to a level where rapamycin can effectively suppress the response in vascular endothelial cells.

Learn more about Anti-IGF1R therapies at SarcomaHelp.org

Small Round Cell Sarcomas

Small round cell sarcomas are the most aggressive of the tumors morphologically and clinically encountered in children and adults. They are in some ways the most leukemia- or lymphoma-like of sarcomas. Small round cell sarcomas often are associated with chromosomal translocations, like hematologic malignancies, and are usually more sensitive to chemotherapy than other sarcoma subtypes. They have a high risk of mortality, but chemotherapy (in addition to surgery and often radiation therapy) provides a good cure rate, although treatment is often long and intensive. The biology of these tumors is very telling in terms of some of the mechanisms of cancer cell survival and proliferation. This article highlights some of the key issues with these sarcomas with some ideas that may bear fruit both in terms of the management of these, other sarcomas, and other cancers alike.

Editor's Note: The Liddy Shriver Sarcoma Initiative is acknowledged in this article.

The TET Family of Proteins: Functions and Roles in Disease

Translocated in liposarcoma, Ewing's sarcoma and TATA-binding protein-associated factor 15 constitute an interesting and important family of proteins known as the TET proteins. The proteins function in several aspects of cell growth control, including multiple different steps in gene expression, and they are also found mutated in a number of specific diseases. For example, all contain domains for binding nucleic acids and have been shown to function in both RNA polymerase II-mediated transcription and pre-mRNA splicing, possibly connecting these two processes. Chromosomal translocations in human sarcomas result in a fusion of the amino terminus of these proteins, which contains a transcription activation domain, to the DNA-binding domain of a transcription factor. Although the fusion proteins have been characterized in a clinical environment, the function of the cognate full-length protein in normal cells is a more recent topic of study. The first part of this review article describes the TET proteins, followed by detailed descriptions of their multiple roles in cells. The final sections examine changes that occur in gene regulation in cells expressing the fusion proteins. The clinical implications and treatment of sarcomas are not addressed in the article.

Vincristine, Actinomycin, and Cyclophosphamide Compared With Vincristine, Actinomycin, and Cyclophosphamide Alternating With Vincristine, Topotecan, and Cyclophosphamide for Intermediate-Risk Rhabdomyosarcoma: Children's Oncology Group Study D9803

The purpose of this study was to compare the outcome of patients with intermediate-risk rhabdomyosarcoma (RMS) treated with standard VAC (vincristine, dactinomycin, and cyclophosphamide) chemotherapy to that of patients treated with VAC alternating with vincristine, topotecan, and cyclophosphamide (VAC/VTC). Patients were randomly assigned to 39 weeks of VAC versus VAC/VTC; local therapy began after week 12. Patients with parameningeal RMS with intracranial extension (PME) were treated with VAC and immediate x-ray therapy. The primary study end point was failure-free survival (FFS). The study was designed with 80% power (5% two-sided level) to detect an increase in 5-year FFS from 64% to 75% with VAC/VTC. The results were as follows: A total of 617 eligible patients were entered onto the study: 264 were randomly assigned to VAC and 252 to VAC/VTC; 101 PME patients were nonrandomly treated with VAC. Treatment strata were embryonal RMS, stage 2/3, group III (33%); embryonal RMS, group IV, less than age 10 years (7%); alveolar RMS or undifferentiated sarcoma (UDS), stage 1 or group I (17%); alveolar RMS/UDS (27%); and PME (16%). At a median follow-up of 4.3 years, 4-year FFS was 73% with VAC and 68% with VAC/VTC (P = .3). There was no difference in effect of VAC versus VAC/VTC across risk groups. The frequency of second malignancies was similar between the two treatment groups. The authors thus conclude: For intermediate-risk RMS, VAC/VTC does not significantly improve FFS compared with VAC.

Tyrosine Kinase Inhibitor Enhances the Bioavailability of Oral Irinotecan in Pediatric Patients With Refractory Solid Tumors

The purpose of this study was to assess the maximum-tolerated dosages (MTDs), and dose-limiting toxicities (DLTs) of the epidermal growth factor receptor inhibitor gefitinib and of intravenous (IV) irinotecan when administered together in children with refractory solid tumors. In addition, the study also sought to assess the effect of gefitinib on the pharmacokinetics of IV irinotecan and on the bioavailability of a single oral dose of irinotecan. IV irinotecan (15 or 20 mg/m2) was given daily for 5 days of 2 consecutive weeks. Oral gefitinib (150 or 112.5 mg/m2) was concomitantly given daily for 12 or 21 days. A single oral dose of irinotecan was given on day 9 of course 2 to allow pharmacokinetic analysis. The results were as follows: The study enrolled 29 patients with recurrent solid tumors. The 21-day regimen of oral gefitinib with irinotecan was not tolerated. Diarrhea was the most common DLT. The MTD of the combination regimen was 15 mg/m2/d of IV irinotecan for 5 days of 2 consecutive weeks and 112.5 mg/m2/d of gefitinib given for 12 days. Gefitinib increased the bioavailability of oral irinotecan by four-fold over that observed in historical controls (median, 0.09 v 0.42; P < .000001), reducing the apparent clearance (an inverse measure of exposure) of irinotecan and SN-38 by 37% and 38%, respectively (P < .0001). A partial response was observed in a patient with refractory Ewing sarcoma. The investigators conclude: IV irinotecan given with 12 days of oral gefitinib is well tolerated in children. We observed one partial response. Gefitinib significantly enhances the bioavailability of oral irinotecan. This combination warrants further investigation, particularly with orally administered irinotecan.

GSTM4 is a microsatellite-containing EWS/FLI target involved in Ewing's sarcoma oncogenesis and therapeutic resistance

Ewing's sarcoma is a malignant bone-associated tumor of children and young adults. Most cases of Ewing's sarcoma express the EWS/FLI fusion protein. EWS/FLI functions as an aberrant ETS-type transcription factor and serves as the master regulator of Ewing's sarcoma-transformed phenotype. The investigators recently showed that EWS/FLI regulates one of its key targets, NR0B1, through a GGAA-microsatellite in its promoter. Whether other critical EWS/FLI targets are also regulated by GGAA-microsatellites was unknown. In this study, the investigators combined transcriptional analysis, whole genome localization data, and RNA interference knockdown to identify glutathione S-transferase M4 (GSTM4) as a critical EWS/FLI target gene in Ewing's sarcoma. They found that EWS/FLI directly binds the GSTM4 promoter, and regulates GSTM4 expression through a GGAA-microsatellite in its promoter. Reduction of GSTM4 levels caused a loss of oncogenic transformation. Furthermore, reduction of GSTM4 resulted in an increased sensitivity of Ewing's sarcoma cells to chemotherapeutic agents, suggesting a role for this protein in drug resistance. Consistent with this hypothesis, patients with Ewing's sarcoma whose tumors had higher levels of GSTM4 expression had worse outcomes than those with lower expression levels. The investigators thus conclude: These data show that GSTM4 contributes to the cancerous behavior of Ewing's sarcoma and define a wider role for GGAA-microsatellites in EWS/FLI function than previously appreciated. These data also suggest a novel therapeutic resistance mechanism, in which the central oncogenic abnormality directly regulates a resistance gene.

Learn more about EWS/FLI in the following articles: "Small Molecules That Can Inhibit EWS-FLI1 May Represent Novel and Specific Therapy for ESFT Patients," "EWS/FLI and its targets in Ewing’s sarcoma: a progress report and future directions," and "Targeting EWS-FLI1 with Small Molecule Inhibitors: A Progress Report."

Adaptor Protein Crk Induces Src-Dependent Activation of p38 MAPK in Regulation of Synovial Sarcoma Cell Proliferation

The adaptor protein Crk mediates intracellular signaling related to cell motility and proliferation and is implicated in human tumorigenesis. The role of Crk in the growth of human sarcoma has remained unclear, however. This study shows that Crk-induced activation of Src and subsequent signaling by p38 mitogen-activated protein kinase (MAPK) contribute to the enhanced proliferation of human synovial sarcoma cells. Depletion of Crk by RNA interference markedly inhibited proliferation of the synovial sarcoma cell lines HS-SYII, SYO-1, and Fuji as well as prevented anchorage-independent growth. Conversely, reconstitution with CrkII by authentic small interfering RNA–resistant Crk gene restored proliferation in Crk-silenced SYO-1 cells. Crk-depleted synovial sarcoma cells manifested enhanced transcriptional activity and expression of the p16INK4A gene, resulting in their accumulation in G1 phase of the cell cycle. In response to hepatocyte growth factor stimulation, Crk prominently induced the tyrosine phosphorylation of Grb2-associated binder 1 through activation of Src and focal adhesion kinase, and the Src family kinase inhibitor PP2 almost completely inhibited the proliferation of SYO-1 cells. Crk also induced the phosphorylation of p38 MAPK, and SB203580, a p38 MAPK–specific inhibitor, increased expression of p16INK4A gene in SYO-1 cells. Furthermore, SB203580 or depletion of p38 MAPK by small interfering RNA suppressed both the phosphorylation of Akt triggered by hepatocyte growth factor and the proliferation of SYO-1 cells. The investigators believe these results suggest that Crk promotes proliferation of human synovial sarcoma cells through activation of Src and its downstream signaling by a novel p38 MAPK-Akt pathway, with these signaling molecules providing potent new targets for molecular therapeutics.

KDR Activating Mutations in Human Angiosarcomas Are Sensitive to Specific Kinase Inhibitors

Angiosarcomas (AS) represent a heterogeneous group of malignant vascular tumors occurring not only in different anatomic locations but also in distinct clinical settings, such as radiation or associated chronic lymphedema. Although representing only 1% to 2% of soft tissue sarcomas, vascular sarcomas provide unique insight into the general process of tumor angiogenesis. However, no molecular candidates have been identified to guide a specific therapeutic intervention. In this study by expression profiling, AS showed distinct up-regulation of vascular-specific receptor tyrosine kinases, including TIE1, KDR, SNRK, TEK, and FLT1. Full sequencing of these five candidate genes identified 10% of patients harboring KDR mutations. A KDR-positive genotype was associated with strong KDR protein expression and was restricted to the breast anatomic site with or without prior exposure to radiation. Transient transfection of KDR mutants into COS-7 cells showed ligand-independent activation of the kinase, which was inhibited by specific KDR inhibitors. The investigators conclude: These data provide a basis for the activity of vascular endothelial growth factor receptor–directed therapy in the treatment of primary and radiation-induced AS.

Innovative Trident Fixation Technique for Allograft Knee Arthrodesis for High-grade Osteosarcoma around the Knee

Reconstruction for osteosarcoma around the knee after wide resection faces the challenge of great bone defect and future limb length discrepancy in the skeletally immature patients. Modern prosthetic reconstruction may provide good results, but the longevity may be of concern and may not be affordable in certain communities. Allograft knee arthrodesis still has its role in light of bone stock preservation and cost-effectiveness. Here the investigators developed an innovative trident fixation technique utilizing three Steinmann pins to minimize limb length inequality without jeopardizing knee fusion stability. Twelve patients were enrolled. The mean age was 11.5 (10–13) years. Two had high-grade osteosarcoma in proximal tibia and others in distal femur. The results were as follows: Two patients died of oncological disease. The median follow-up of the disease-free 10 patients was 47 (41–60) months. All allograft-host bone junctions healed uneventfully without major complications except one allograft fracture. The average limb length discrepancy was 1.45 (1.0–2.1) cm at latest follow-up. The investigators conclude: This straightforward technique was successful in knee arthrodesis with minimized limb length inequality. Accordingly, in light of bone stock preservation and longevity for the young children, it may be a surgical alternative for malignant bone tumors around the knee.

August 2009

Osteosarcoma, Chondrosarcoma, and Ewing's Sarcoma: National Cancer Data Base Report

This report from 2007 summarizes descriptive epidemiologic and survival data from the National Cancer Data Base of the American College of Surgeons for 26,437 cases of osteosarcoma (n = 11,961), chondrosarcoma (n = 9606), and Ewing's sarcoma (n = 4870) from 1985 to 2003. Survival data are reported on cases with a minimum 5-year follow-up from 1985 to 1998 (8,104 osteosarcomas, 6,476 chondrosarcomas, and 3,225 Ewing's sarcomas). The relative 5-year survival rate was 53.9% for osteosarcoma, 75.2% for chondrosarcoma, and 50.6% for Ewing's sarcoma. Survival rates did not change notably over the collection period. Within osteosarcomas, the relative 5-year survival rates were 52.6% for high grade, 85.9% for parosteal, and 17.8% for Paget's subtypes. For osteosarcoma patients, the relative 5-year survival rate was 60% for those younger than 30 years, 50% for those aged 30 to 49 years, and 30% for those aged 50 years or older. Within chondrosarcomas, the relative 5-year survival rate was 76% for conventional, 71% for myxoid, 87% for juxtacortical, and 52% for mesenchymal. While the National Cancer Data Base has limitations, the survival data and demographics for bone sarcomas are unprecedented in numbers and duration.

Efficacy and Safety of Trabectedin in Patients With Advanced or Metastatic Liposarcoma or Leiomyosarcoma After Failure of Prior Anthracyclines and Ifosfamide: Results of a Randomized Phase II Study of Two Different Schedules

The purpose of this Phase II trial was to evaluate the safety and efficacy of trabectedin in adult patients with unresectable/metastatic liposarcoma or leiomyosarcoma after failure of prior conventional chemotherapy including anthracyclines and ifosfamide. Patients were randomly assigned to one of two trabectedin regimens (via central venous access): 1.5 mg/m2 24-hour intravenous infusion once every 3 weeks (q3 weeks 24-hour) versus 0.58 mg/m2 3-hour IV infusion every week for 3 weeks of a 4-week cycle (qwk 3-hour). Time to progression (TTP) was the primary efficacy end point, based on confirmed independent review of images. The results were as follows: Two hundred seventy patients were randomly assigned; 136 (q3 weeks 24-hour) versus 134 (qwk 3-hour). Median TTP was 3.7 months versus 2.3 months (hazard ratio [HR], 0.734; 95% CI, 0.554 to 0.974; P = .0302), favoring the q3 weeks 24-hour arm. Median progression-free survival was 3.3 months versus 2.3 months (HR, 0.755; 95% CI, 0.574 to 0.992; P = .0418). Median overall survival (n = 235 events) was 13.9 months versus 11.8 months (HR, 0.843; 95% CI, 0.653 to 1.090; P = .1920). Although somewhat more neutropenia, elevations in AST/ALT, emesis, and fatigue occurred in the q3 weeks 24-hour, this regimen was reasonably well tolerated. Febrile neutropenia was rare (0.8%). No cumulative toxicities were noted. The investigators conclude: Prior studies showed clinical benefit with trabectedin in patients with sarcomas after failure of standard chemotherapy. This trial documents superior disease control with the q3 weeks 24-hour trabectedin regimen in liposarcomas and leiomyosarcomas, although the qwk 3-hour regimen also demonstrated activity relative to historical comparisons. Trabectedin may now be considered an important new option to control advanced sarcomas.

Prognostic significance of c-Myc expression in soft tissue leiomyosarcoma

The biological potential of soft tissue leiomyosarcoma is difficult to predict using current standard prognostic parameters, and control of systemic disease is challenging with current chemotherapeutic protocols. Additional prognostic markers and alternative treatment options are very much required. Previous studies implicate upregulation of the oncogenic nuclear transcription factor c-Myc with aggressive behavior of many solid tumors. Therefore, in this study this oncoprotein was evaluated as a prognostic marker for overall and metastasis-free survival in leiomyosarcoma. Immunohistochemical stains for c-Myc were performed on 28 cases of leiomyosarcoma occurring in the deep somatic soft tissues. Comparisons of Kaplan–Meier survival curves stratified by c-Myc status and conventional prognostic factors (histological grade, tumor size, and tumor stage) were evaluated using standard univariate statistical methods. A subsequent multivariate survival analysis was carried out according to the Cox proportional hazards regression model adjusting for potential confounding prognostic factors. The results were as follows: A total of 15 cases (54%) were positive for nuclear c-Myc expression. Patients with c-Myc-positive tumors had significantly shorter metastasis-free survival intervals compared with those with c-Myc-negative tumors (median, 9 months vs. >94 months; P=0.014). c-Myc positivity also correlated with decreased overall survival (median, 23 months vs. >94 months; P=0.017). Histological grade was the only other prognostic marker predictive of poor outcome in the univariate analyses. In the multivariate survival analysis, only c-Myc status reached statistical significance, suggesting that it is an important and independent predictor of prognosis in leiomyosarcoma. Detection of nuclear c-Myc in leiomyosarcoma predicts decreased overall and metastasis-free survival, independent of standard prognostic variables, tumor size, histological grade, and TNM stage. The investigators conclude: The expression of the c-Myc oncoprotein may represent a useful prognostic marker and potential therapeutic target in leiomyosarcoma.

Targeted mutation of p53 and Rb in mesenchymal cells of the limb bud produces sarcomas in mice

Mice bearing germline mutations of p53 develop sarcomas at a significant rate. Since they are susceptible to a variety of other malignancies, they are not ideally suited to the study of sarcomas. The purpose of this study was to test the possibility that targeted mutation of tumor suppressor genes in early mesenchymal cells would induce formation of sarcomas. Thus, the Prx1-cre transgenic mouse was crossed to mice bearing floxed alleles of p53 and Rb. The study found that mice with homozygous deletion of p53 (Prx1-cre p53lox/lox) developed sarcomas in the extremities at a mean time of 50 weeks. Osteosarcomas were the most common type of sarcoma (56%) followed by poorly differentiated soft tissue sarcomas (26%). Homozygous deletion of p53 produced sarcomas significantly more rapidly than heterozygous deletion, which resulted in sarcoma formation after a mean of 96 weeks. Mice with homozygous Rb mutation (Prx1-cre Rblox/lox) developed normally and had no ostensible defects in the limbs. In contrast to p53, targeted deletion of Rb did not produce sarcomas in the limbs. However, simultaneous deletion of Rb and p53 accelerated the time to sarcoma formation, and a greater percentage of poorly differentiated soft tissue sarcomas were found. Deletion of p53 in committed osteoblasts by the Col1a1-cre transgenic mouse bearing an osteoblast-specific enhancer resulted in a high percentage of osteosarcomas. The investigators thus believe these findings suggest that deletion of p53 in mesenchymal cells that give rise to osteoblasts is a powerful initiator of osteosarcomas. And deletion of Rb does not initiate sarcoma formation in mice, but it accelerates formation of both soft tissue sarcomas and osteosarcomas.

MicroRNA miR-29 Modulates Expression of Immunoinhibitory Molecule B7-H3: Potential Implications for Immune Based Therapy of Human Solid Tumors

B7-H3, a surface immunomodulatory glycoprotein, inhibits natural killer cells and T cells. The monoclonal antibody (mAb) 8H9 is specific for 4Ig-B7-H3, the long and principal form of B7-H3. Early results from radioimmunotherapy using 8H9 have shown promise in patients with metastatic solid tumors to the central nervous system. Whereas B7-H3 transcript was ubiquitously expressed in a wide spectrum of human solid tumors as well as human normal tissues, B7-H3 protein was preferentially expressed only in tumor tissues. By quantitative reverse transcription-PCR, all three isoforms of microRNA miR-29 (a, b, and c) were highly expressed in normal tissues. However, they were down-regulated in a broad spectrum of solid tumors, including neuroblastoma, sarcomas, brain tumors, and tumor cell lines. B7-H3 protein expression was inversely correlated with miR-29 levels in both cell lines and tumor tissues tested. Using luciferase reporter assay, miR-29a was shown to directly target B7-H3 3' untranslated region, and knock-in and knockdown of miR-29a led to down-regulation and up-regulation, respectively, of B7-H3 protein expression. The ability of miR-29 to control B7-H3 protein expression has implications in immune escape by solid tumors. Differential modulation of this key immunoinhibitory molecule in tumor versus normal tissues may advance both cell-mediated immunotherapy and antibody-based targeted strategies using the B7-H3–specific mAb 8H9.

Response to Imatinib Plus Sirolimus in Advanced Chordoma

Imatinib (IM) is active in advanced chordoma. The evidence of upstream and/or downstream mammalian target of rapamycin (mTOR) pathway activation prompted the investigators of this study to combine an mTOR inhibitor, sirolimus, to IM in IM-resistant advanced chordoma. Beginning in July 2007, 10 progressive advanced chordoma patients with secondary resistance to IM, and biochemical and/or immunohistochemical evidence of upstream and/or downstream mTOR effector activation, started IM (400 mg/day) plus sirolimus (2 mg/day) on a named basis. The results were as follows: The mean treatment duration was 9 months. Of nine patients assessable for response, at 3 months, we had one RECIST partial response (PR), seven stable disease (SD) and one progressive disease (PD). According to Choi criteria applied even to magnetic resonance imaging, there were seven PR (10% decrease in size in four cases), one SD and one PD. Seven patients had a positron emission tomography response. The clinical benefit [RECIST complete response + PR + SD 6 months] was 89%. Pretreatment mTOR effectors analysis carried out in nine cases was positive in all patients (AKT activation in six patients, S6Sp6 expression/activation in seven). Post-treatment biopsy in one responsive patient confirmed S6 switch off. The investigators conclude: In addition to PDGFRB, mTOR pathway can be activated in chordomas and the combination of IM plus rapalogs may be effective in IM-resistant chordomas.

Primary Osteogenic Sarcoma with Pulmonary Metastasis: Clinical Results and Prognostic Factors in 91 Patients

The long-term outcome for Osteosarcoma patients with metastatic disease is poor. This study looked at the results of 91 patients with pulmonary metastasis at a single institution. From June 1989 to January 2008, 202 patients (128 males and 74 females) with high-grade osteosarcoma of the extremities were treated at the study’s institution. Patients were divided into three groups depending on the time of identification of pulmonary metastasis: group A, identified with primary tumor diagnosis; group B, during whole treatment course; and group C, after completion of treatment. Long-term survival was calculated and factors related to metastases were analyzed. The results were as follows: Ninety-one patients developed pulmonary metastases; 21 in group A, 18 in group B and 52 in group C. The mean period from initial diagnosis to lung metastases in groups B and C was 22.2 months (±20.6). Five-year survival rates were 82.0% and 38.3% in the non-metastasis group and metastasis group, respectively (P < 0.001). The 5-year survival rate was significantly worse in group A than in group B or C (0%, 7.4%, 59.5%, P < 0.001), in patient with more than one lobe involved (27.0%, P = 0.006) and more than three pulmonary nodule metastases (21.3%, P = 0.002). Factors related to the pulmonary metastasis were: old age (65.5% in older than 27.5 years old and 41.6% in younger, P = 0.017), large tumor volume (54.4% in larger than 202.5 ml and 33.7% in smaller, P = 0.005) and elevated lactodehydrogenase (LDH; 55.1% vs.31.0% in normal, P = 0.001). The authors conclude: The prognosis of osteosarcoma with pulmonary metastases is dismal, especially for patients who have primary pulmonary metastases, more than three pulmonary metastatic nodules or involvement of more than one lobe. Factors such as older age, larger tumor volume and elevated LDH may reflect high metastatic rate.

Long-term results after resection for soft tissue sarcoma pulmonary metastases

Isolated pulmonary metastases from soft tissue sarcomas (STS) occur in approximately 20% of the cases. Chemotherapy and surgical resection are the current standard treatment options for these patients. The goal of this study was to identify any prognostic factors for these patients as well as to estimate their long-term survival rate. The authors examined a series of twenty-two consecutive patients with pulmonary metastases from STS, treated in their institution from 1996 to 2006. Univariate (log-rank and Cox-regression) analysis was performed to identify any significant prognostic factor. Five-year survival rates were estimated by using Kaplan–Meier methods. The results were as follows: Four patients (18.2%) were alive without any disease, twelve patients (54.5%) died of disease and we lost all track of six patients (27.3%). Follow-up period ranged from 7 to 75 months. Median follow-up: 14 months, median survival: 19 months. Disease-free interval (DFI) (P=0.005), number of lung nodules (P=0.04) and histology type (P=0.01) were significant prognostic factors at univariate analysis. The overall five-year survival rate was 23.1%. DFI, number of lung nodules at surgery and metastatic histology are significant prognostic factors for patients with resected pulmonary metastases from STS.

Post-imatinib surgery in advanced/metastatic GIST: is it worthwhile in all patients?

Surgical indication for metastatic gastrointestinal stromal tumor (GIST) treated with imatinib is not yet established. In this study, the investigators analyzed 80 patients who underwent surgery for metastatic GIST after imatinib therapy from July 2002 to October 2007. Patients were divided into those with surgery at best clinical response (group A, n = 49) and those with surgery at focal progression (group B, n = 31). Primary end points were progression-free survival (PFS) and disease-specific survival (DSS). The results were as follows: Two-year postoperative PFS was 64.4% in group A and 9.7% in group B (P < 0.01). In group A, median PFS was not reached; in group B, it was 8 months. Median DSS from the time of imatinib onset was not reached in either group. Five-year DSS was 82.9% in group A and 67.6% in group B (P < 0.01). Multivariate analysis confirmed a significantly shorter PFS and DSS in group B. Surgical morbidity occurred in 13 patients (16.3%). The investigators conclude: Surgery for focal progressive lesions could be considered as part of the second-line/third-line armamentarium in selected cases. Surgery of residual disease upon best clinical response seems associated with survival benefit compared with historical controls in similar patient collectives treated with imatinib alone. However, evidence from prospective randomized trials is needed to make definite recommendations.

The Management of Cancer Pain in the Elderly

Cancer pain in the elderly population is an increasingly common clinical situation which physicians are challenged with managing. Physiological changes occur with ageing affecting the patients’ perception of pain, their ability to describe pain and also their metabolism of drugs. This article discusses the evaluation of pain in the elderly, physiologic changes in the elderly, the causes and patho-physiology of pain, and the management of cancer pain. The article reaches the following conclusions. As a general rule, the elderly should be treated according to their physiological age rather than their chronological age. This also applies to decisions regarding anti-tumor treatments such as chemotherapy. Analgesics should also be used with care in the elderly as the elderly are generally more susceptible to larger changes in doses and to drug side effects. However, this should not deter the use of analgesics, in particular opioids, in the treatment of elderly patients who suffer from cancer related pain.

June 2009

Combining PCI-24781, a Novel Histone Deacetylase Inhibitor, with Chemotherapy for the Treatment of Soft Tissue Sarcoma

Histone deactylase inhibitors (HDACi) are a promising new class of anticancer therapeutics. However, little is known about HDACi activity in soft tissue sarcomas (STS). The investigators of this study investigated the novel HDACi PCI-24781, alone/in combination with conventional chemotherapy, to determine its potential anti-STS–related effects and the underlying mechanisms involved. Immunoblotting was used to evaluate the effects of PCI-24781 on histone and nonhistone protein acetylation and expression of potential downstream targets. Cell culture–based assays were utilized to assess the effects of PCI-24781 on STS cell growth, cell cycle progression, apoptosis, and chemosensitivity. Quantitative reverse transcription-PCR, chromatin immunoprecipitation, and reporter assays helped elucidate molecular mechanisms resulting in PCI-24781–induced Rad51 repression. The effect of PCI-24781, alone or with chemotherapy, on tumor and metastatic growth was tested in vivo using human STS xenograft models. The results were as follows: PCI-24781 exhibited significant anti-STS proliferative activity in vitro, inducing S phase depletion, G2/M cell cycle arrest, and increasing apoptosis. Superior effects were seen when combined with chemotherapy. A PCI-24781–induced reduction in Rad51, a major mediator of DNA double-strand break homologous recombination repair, was shown and may be a mechanism underlying PCI-24781 chemosensitization. The investigators showed that PCI-24781 transcriptionally represses Rad51 through an E2F binding-site on the Rad51 proximal promoter. Although single-agent PCI-24781 had modest effects on STS growth and metastasis, marked inhibition was observed when combined with chemotherapy. The investigators conclude: In light of these findings, this novel molecular-based combination may be applicable to multiple STS histologic subtypes, and potentially merits rigorous evaluation in human STS clinical trials.

Prognostic Significance of Tumor Response at the End of Therapy in Group III Rhabdomyosarcoma: A Report From the Children's Oncology Group

Some patients with rhabdomyosarcoma (RMS) achieve less than a complete response (CR) despite receiving all planned therapy. The investigators of this study assessed the impact of best response at the completion of all therapy on patient outcome. They studied 419 clinical group III participants who completed all protocol therapy without developing progressive disease for Intergroup Rhabdomyosarcoma Study (IRS) IV. Response (complete resolution [CR], partial response [PR; 50% decrease], or no response [NR; < 50% decrease and < 25% increase]) was determined by radiographic measurement and categorized by the best response. The results were as follows: At the end of therapy, 341 participants (81%) achieved a best response of CR and 78 (19%) had a best response of PR/NR. Five-year failure-free survival was similar for participants achieving CR (80%) and PR/NR (78%). After adjustment for age, nodal status, primary site, and histology, there was no significant indication of lower risk of failure (hazard ratio [HR], 0.77; 95% CI, 0.46 to 1.27; P = .3) nor death (HR, 0.63; 95% CI, 0.36 to 1.09; P = .1) for CR versus PR/NR participants. Seventeen participants with a best response of PR/NR had surgical procedures; eight (50%) of 16 with available pathology reports had residual viable tumor and only three achieved a complete resection. Resection of residual masses was not associated with improved outcome. The investigators conclude: CR status at the end of protocol therapy in clinical group III participants was not associated with a reduction of disease recurrence and death. Aggressive alternative therapy may not be warranted for RMS patients with a residual mass at the end of planned therapy.

Molecular classification of solid tumours: towards pathway-driven therapeutics

The last decade has witnessed unprecedented developments in the genetic and epigenetic analyses of solid tumors. Transcriptional and DNA copy-number studies have improved understanding and classification of solid tumors and highlighted the patterns of genomic aberrations associated with outcome. The identification of altered transcriptional and translational silencing by microRNAs and epigenetic modification by methylation in tumors has showed a layer of additional intricacy to the regulation of gene expression in different tumor types. The advent of massive parallel sequencing has allowed whole cancer genomes to be sequenced with extraordinary speed and accuracy providing insight into the complexity of gene mutations present in solid tumors. Functional genomic studies using RNA interference-screening tools promises to improve the classification of solid tumors by probing the relevance of each gene to tumor phenotype. In this review article, the authors discuss how these studies have contributed to solid tumor classification and why such studies are central to the future of oncology. They suggest that these developments are gradually leading to a change in emphasis of early clinical trials to a therapeutic model guided by the molecular classification of tumors. The investigation of drug efficacy later in development is beginning to rely on patient selection defined by predictive molecular criteria that complement solid tumor classification based on anatomic site.

A high proportion of bone marrow T cells with regulatory phenotype (CD4+CD25hiFoxP3+) in Ewing sarcoma patients is associated with metastatic disease

Immunosuppressive CD4+CD25hiFoxP3+ T cells (Treg cells) have been found at increased densities within the tumor microenvironment in many malignancies and interfere with protective antitumor immune responses. Osseous Ewing sarcomas (ESs) are thought to derive from a bone marrow (BM) mesenchymal cell of origin, and microscopic marrow involvement defines a subpopulation of patients at a high risk of relapse. The investigators of this study hypothesized that BM-resident T cells may contribute to a permissive milieu for immune escape of ESs. Using 6-color-flow cytometry, they investigated the pattern of immune cell subset distribution including NK cells, T cells, central and effector memory CD8+ and CD4+ T cells as well as T cells with regulatory phenotype (Treg cells) in BM obtained at diagnosis from 45 primary or relapsed ES patients treated within standardized protocols. Although patients at relapse had an inverted CD4:CD8 T-cell ratio, neither CD8+ effector/memory T-cell subsets nor Treg cells significantly differed from patients at diagnosis. No significant associations of innate and effector/memory T-cell subpopulations with known risk factors were found, including age, gender, tumor site, primary metastases and histological tumor response. By contrast, Treg cells were found at significantly higher frequencies in patients with primary metastatic disease compared with localized ESs (5.0 vs. 3.3%, p = 0.01). Thus, the investigators believe increased BM Treg cells in patients with metastasized ES may reflect an immune escape mechanism that contributes to the development of metastatic disease. Immunotherapeutic strategies will have to adequately consider the regulatory milieu within areas of Ewing tumor-immune interactions.

Trabectedin in myxoid liposarcomas (MLS): a long-term analysis of a single-institution series

Trabectedin has been approved in Europe as second-line therapy for advanced soft tissue sarcomas. A previous analysis showed that myxoid liposarcomas (MLS) are particularly sensitive to the drug. This study reports on the long-term efficacy of trabectedin in a subgroup of that series. Since September 2002, 32 advanced pretreated MLS patients received trabectedin at the study’s center. Data were reviewed focusing on their long-term outcome. The results were as follows: Trabectedin was given as a 24-h continuous infusion every 21 days. A total of 376 and a median of 12 courses per patient (range 2–26; interquartiles range (IQR) 8–15) were delivered. Response rate per RECIST was 50% [95% confidence interval (CI) 32% to 68%], median progression-free survival (PFS) was 17 months (95% CI 13.5–30.1) and median overall survival is still not reached. In 10 patients, therapy was stopped in the absence of any evident disease, mostly after complete surgery of residual lesions. In these 10 patients, at a median follow-up of 25 months, PFS was 28.1 months (95% CI 25.6–36.4) from treatment start. The investigators conclude: These data indicate that the high response rate of MLS to trabectedin translates into prolonged PFS. Surgery of residual metastatic disease is already used quite extensively in metastatic MLS. Trabectedin may give further significance to this kind of surgery.

View clinical trials for sarcoma involving Trabectedin.

Targeting the mTOR Signaling Network for Cancer Therapy

The serine-threonine kinase mammalian target of rapamycin (mTOR) plays a major role in the regulation of protein translation, cell growth, and metabolism. Alterations of the mTOR signaling pathway are common in cancer, and thus mTOR is being actively pursued as a therapeutic target. Rapamycin and its analogs (rapalogs) have proven effective as anticancer agents in a broad range of preclinical models. Clinical trials using rapalogs have demonstrated important clinical benefits in several cancer types; however, objective response rates achieved with single-agent therapy have been modest. Rapalogs may be more effective in combination with other anticancer agents, including chemotherapy and targeted therapies. It is increasingly apparent that the mTOR signaling network is quite complex, and rapamycin treatment leads to different signaling responses in different cell types. A better understanding of mTOR signaling, the mechanism of action of rapamycin, and the identification of biomarkers of response will lead to more optimal targeting of this pathway for cancer therapy.

Optimizing the Treatment of Gastrointestinal Stromal Tumors: The Roles of Tumor Genotyping, Imatinib Blood-level Testing, and New Therapeutic Strategies

Gastrointestinal stromal tumors (GISTs) are the most common soft tissue sarcoma of the gastrointestinal tract. Formerly untreatable, except by surgery, the management of these tumors has been revolutionized by the use of small molecule kinase inhibitors that target the underlying pathogenetic mutant kinases found in the vast majority of cases. Recent studies have suggested that future improvements in therapy may be possible using improved diagnostic testing strategies (tumor mutation testing, imatinib blood-level testing) and development of new drugs that target aberrant signal transduction in GIST cells. In this review article, the authors discuss how the treatment of patients with GIST might be further optimized.

The prognostic value of DNA ploidy in a total population of uterine sarcomas

The diagnosis of uterine sarcoma is associated with poor outcome for the patient and there is a need for reliable prognostic markers. Most previous studies on the prognostic value of DNA ploidy include few uterine sarcomas and report conflicting results. The investigators of this study examined the prognostic value of DNA ploidy and its association with clinicopathological parameters and crude survival in a total population of 354 sarcoma. The results were as follows: In univariate analyses, they observed significantly better crude survival for endometrial stromal sarcomas (ESS) and adenosarcoma (AS) patients with diploid as compared with nondiploid tumors, but not for patients with leiomyosarcomas (LMS). In Cox multivariate analyses, DNA ploidy was the only significant predictor of survival for patients with AS. In LMS, mitotic index (MI), tumor size, tumor extent and tumor margins, whereas for ESS, MI, tumor extent and tumor necrosis obtained independent significance of survival. DNA ploidy was a significant predictor of survival for LMS patients in Cox regression analyses when excluding MI. The investigators conclude: DNA ploidy might be useful as a prognostic marker in patients with LMS and AS.

Gamma Knife Radiosurgery as a Therapeutic Strategy for Intracranial Sarcomatous Metastases

The purpose of this study was to determine the indication and outcomes for Gamma Knife stereotactic radiosurgery (GKSRS) in the care of patients with intracranial sarcomatous metastases. Data from 21 patients who underwent radiosurgery for 60 sarcomatous intracranial metastases (54 parenchymal and 6 dural-based) were studied. Nine patients had radiosurgery for solitary tumors and 12 for multiple tumors. The primary pathology was metastatic leiomyosarcoma (4 patients), osteosarcoma (3 patients), soft-tissue sarcoma (5 patients), chondrosarcoma (2 patients), alveolar soft part sarcoma (2 patients), and rhabdomyosarcoma, Ewing's sarcoma, liposarcoma, neurofibrosarcoma, and synovial sarcoma (1 patient each). Twenty patients received multimodality management for their primary tumor, and 1 patient had no evidence of systemic disease. The mean tumor volume was 6.2 cm(3) (range, 0.07-40.9 cm(3)), and a median margin dose of 16 Gy was administered. Three patients had progressive intracranial disease despite fractionated whole-brain radiotherapy before SRS. The results were as follows: A local tumor control rate of 88% was achieved (including patients receiving boost, up-front, and salvage SRS). New remote brain metastases developed in 7 patients (33%). The median survival after diagnosis of intracranial metastasis was 16 months, and the 1-year survival rate was 61%. The investigators conclude: Gamma Knife radiosurgery was a well-tolerated and initially effective therapy in the management of patients with sarcomatous intracranial metastases. However, many patients, including those who also received fractionated whole-brain radiotherapy, developed progressive new brain disease.

Ewing Sarcoma Fusion Protein EWSR1/FLI1 Interacts with EWSR1 Leading to Mitotic Defects in Zebrafish Embryos and Human Cell Lines

The mechanism whereby the fusion of EWSR1 with the ETS transcription factor FLI1 contributes to malignant transformation in Ewing sarcoma remains unclear. The investigators of this study show that injection of human or zebrafish EWSR1/FLI1 mRNA into developing zebrafish embryos leads to mitotic defects with multipolar and disorganized mitotic spindles. Expression of human EWSR1/FLI1 in HeLa cells also results in mitotic defects, along with mislocalization of Aurora kinase B, a key regulator of mitotic progression. Because these mitotic abnormalities mimic those observed with the knockdown of EWSR1 in zebrafish embryos and HeLa cells, they investigated whether EWSR1/FLI1 interacts with EWSR1 and interferes with its function. EWSR1 coimmunoprecipitates with EWSR1/FLI1, and overexpression of EWSR1 rescues the mitotic defects in EWSR1/FLI1-transfected HeLa cells. This interaction between EWSR1/FLI1 and EWSR1 in Ewing sarcoma may induce mitotic defects leading to genomic instability and subsequent malignant transformation.

Therapeutic Guidelines for the Treatment of Bone Metastasis: A Report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology

Bone metastases remain a therapeutic challenge because of the diversity of the problems they cause, the relative paucity of data regarding their treatment, and the necessity for management by a multidisciplinary palliative care team. The American College of Radiology convened an Appropriateness Criteria Expert Panel on Radiation Oncology for the treatment of bone metastasis to create representative clinical case scenarios and then rank the appropriate use of treatment modalities as well as the most reasonable radiotherapy dose schema and treatment planning methods. This report presents both the resulting Appropriateness Criteria and the rationale for making these decisions. The treatment recommendations are placed within the larger framework of the role of radiation in palliative care by discussing the efficiency of palliative radiotherapy schedules, cost effectiveness issues, and the need for additional research regarding the proper multidisciplinary care of patients with symptomatic bone metastasis.

Expression of insulin-like growth factor 2 in mesenchymal neoplasms

This article discusses the link between the insulin-like growth factor (IGF) and tumor formation and growth. While the number of specimens studied has been low, there is evidence of "high expression of IGF2, encoding the activating ligand for this system, in gastrointestinal stromal tumors (GISTs) and in synovial sarcomas." The authors refer to known reports of GIST patients suffering from hypoglycemia, as a result of raised IGF2. Clinical trials are now underway, using drugs that target the "signaling system" of IGF. The authors state their purpose as "to survey IGF2 expression at the protein level on a broad number of mesenchymal tumors representing all major diagnostic classes."

The researchers examined tissue microarrays from 1288 cases, using antibody-based staining methods. From this they found data regarding 51 categories for diagnosing tumors of bone and soft-tissue. The samples were assessed for "membranous and/or cytoplasmic IFG2 immunoreactivity." The study reports that high expression of IGF2 was found in "solitary fibrous tumors". High expressions were also found in:

synovial sarcomas
myxoid liposarcomas
GISTs
malignant peripheral nerve sheath tumors
chondrosarcomas
undifferentiated pleomorphic sarcomas (MFH)
Ewing’s sarcomas
tenosynovial giant cell tumors

This knowledge opens another pathway for researchers to investigate as they work towards a therapy directed towards the IGF signaling pathways. On a sobering note, the authors point out that "Of the 445 GIST cases with clinical information, those with high expression of IGF2 had a significantly worse outcome than those with low or no expression."

April 2009

Osteosarcoma incidence and survival rates from 1973 to 2004

Osteosarcoma occurs most frequently in adolescents. But there is a second incidence peak among individuals aged >60 years. Most osteosarcoma epidemiology studies have been embedded in large analyses of all bone tumors or focused on cases occurring in adolescence. Detailed descriptions of osteosarcoma incidence and survival with direct comparisons among patients of all ages and ethnicities are not available. In this study the frequency, incidence, and survival rates for 3482 patients with osteosarcoma from the National Cancer Institute's population-based Surveillance, Epidemiology, and End Results (SEER) Program between 1973 and 2004 were investigated by age (ages 0-24 years, 25-59 years, and 60 to 85 years), race, sex, pathology subtype, stage, and anatomic site. The Results were as follows: There were large differences in incidence and survival rates by age. There was a high percentage of osteosarcoma with Paget disease and osteosarcoma as a second or later cancer among the elderly. There was a high percentage of osteosarcoma among patients with Paget disease and osteosarcoma as a second or later cancer among the elderly. Tumor site differences among age groups were noted. Survival rates varied by anatomic site and disease stage and did not improve significantly from 1984 to 2004. The authors Conclude: This comprehensive, population-based description of osteosarcoma, identified important differences in incidence, survival, pathologic subtype, and anatomic site among age groups, and quantified the impact of osteosarcoma in patients with Paget disease or as a second cancer on incidence and mortality rates. These findings may have implications in understanding osteosarcoma biology and epidemiology.

Adjuvant imatinib mesylate after resection of localised, primary gastrointestinal stromal tumour: a randomised, double-blind, placebo-controlled trial

Gastrointestinal stromal tumor is the most common sarcoma of the intestinal tract. Imatinib mesylate is a small molecule that inhibits activation of the KIT and platelet-derived growth factor receptor α proteins, and is effective in first-line treatment of metastatic gastrointestinal stromal tumor. The investigators of this trial postulated that adjuvant treatment with imatinib would improve recurrence-free survival compared with placebo after resection of localized, primary gastrointestinal stromal tumor.

They undertook a randomized phase III, double-blind, placebo-controlled, multicentre trial. Eligible patients had complete gross resection of a primary gastrointestinal stromal tumor at least 3 cm in size and positive for the KIT protein by immunohistochemistry. Patients were randomly assigned, by a stratified biased coin design, to imatinib 400 mg (n=359) or to placebo (n=354) daily for 1 year after surgical resection. Patients and investigators were blinded to the treatment group. Patients assigned to placebo were eligible to crossover to imatinib treatment in the event of tumor recurrence. The primary endpoint was recurrence-free survival, and analysis was by intention to treat. Accrual was stopped early because the trial results crossed the interim analysis efficacy boundary for recurrence-free survival. This study is registered with ClinicalTrials.gov, number NCT00041197.

The Results were as follows: All randomized patients were included in the analysis. At median follow-up of 19·7 months (minimum—maximum 0—56·4), 30 (8%) patients in the imatinib group and 70 (20%) in the placebo group had had tumor recurrence or had died. Imatinib significantly improved recurrence-free survival compared with placebo (98% [95% CI 96—100] vs. 83% [78—88] at 1 year; hazard ratio [HR] 0·35 [0·22—0·53]; one-sided p<0·0001). Adjuvant imatinib was well tolerated, with the most common serious events being dermatitis (11 [3%] vs. 0), abdominal pain (12 [3%] vs. six [1%]), and diarrhea (ten [2%] vs. five [1%]) in the imatinib group and hyperglycemia (two [<1%] vs. seven [2%]) in the placebo group.
The investigators thus believe adjuvant imatinib therapy is safe and seems to improve recurrence-free survival compared with placebo after the resection of primary gastrointestinal stromal tumor.

The NFATc2 Gene Is Involved in a Novel Cloned Translocation in a Ewing Sarcoma Variant That Couples Its Function in Immunology to Oncology

In Ewing’s sarcoma disease-specific t(11;22) (85-90%), t(21;22) (5-10%), or rarer variant translocations with the involvement of chromosome 22 (5%) are present. At the gene level, the EWSR1 gene fuses with FLI1, ERG, or other ETS transcription factor family members. Thus far, no Ewing sarcoma has been identified with a fusion to transcription factors other than ETS. In this study, the investigators used molecular tools such as multicolor fluorescence in situ hybridization and array comparative genomic hybridization, and a ring chromosome containing chromosomes 20 and 22 was identified in four Ewing sarcoma cases. The breakpoint was mapped with (fiber-) fluorescence in situ hybridization and reverse transcription-PCR followed by sequencing of the fusion partners. Molecular karyotyping showed the translocation and amplification of regions of chromosomes 20q13 and 22q12. Cloning of the breakpoint showed an in-frame fusion between the EWSR1 and NFATc2 genes, resulting in loss of the NH2-terminal, calcineurin-dependent control region and an intact active domain of NFATc2 controlled by the transactivation domains of EWSR1. The investigators Conclude: A new translocation involving EWSRI and NFATc2 was cloned. NFATc2 is a transcription factor that is not a member of the ETS family and functions in T-cell differentiation and immune response. Direct involvement of NFATc2 has not yet been observed in oncogenesis. They show that due to the shared sequence recognition of NFATc2 and the ETS family, shared transcriptional control is possible using activating protein complex 1.

Expression of Cellular FLICE Inhibitory Protein, Caspase-8, and Protease Inhibitor-9 in Ewing Sarcoma and Implications for Susceptibility to Cytotoxic Pathways

Cellular immunotherapy may provide new treatment options for sarcoma and it depends on the cytolytic death receptor and perforin/granzyme pathways. Expression of death receptor pathway inhibitor cellular FLICE inhibitory protein (cFLIP), initiator caspase-8, and granzyme B inhibitor protease inhibitor-9 (PI-9) have been reported to determine susceptibility to cell- and chemotherapy-mediated killing in several tumor types. In this study, the investigators studied their in vitro and in vivo expression in Ewing’s sarcoma and the implications for susceptibility to cytotoxicity. Ewing’s sarcoma cell lines (n = 8) were tested for cFLIP, PI-9, and caspase-8 expression. Functional significance was tested by anti-Fas antibody (death receptor pathway) or natural killer cell (perforin/granzyme pathway) treatment. Immunohistochemistry was done on 28 sections from 18 patients. In half of the cases, sequential material, including metastases, was available. The Results were as follows: Although all tested Ewing’s sarcoma cell lines expressed cFLIP, resistance to CD95/Fas–mediated apoptosis was only observed in two cell lines lacking caspase-8 expression. PI-9 was expressed at low levels in four of eight Ewing’s sarcoma cell lines, but positive cell lines remained susceptible to perforin/granzyme–mediated killing. In primary Ewing’s sarcoma, including metastases, cFLIP was abundantly expressed in 18 of 18 patients. Caspase-8 was expressed in all patients but showed more intertumoral and intratumoral variation in both intensity and heterogeneity of staining. PI-9, in contrast, was undetectable. The investigators Conclude: The expression patterns of cFLIP, caspase-8, and the absence of PI-9 provide a rationale to preferentially exploit the perforin/granzyme pathway in cytotoxic therapies against Ewing’s sarcoma.

NK cells recognize and lyse Ewing sarcoma cells through NKG2D and DNAM-1 receptor dependent pathways

Ewing sarcoma (EWS) is a malignant bone-associated sarcoma, with poor prognosis in case of metastasis or relapse. To explore the feasibility of natural killer (NK) cell mediated immunotherapy and to identify molecular mechanisms involved, the susceptibility of EWS to NK cells was investigated in this study. All EWS cell lines tested (n = 7) were lysed by purified allogeneic NK cells from healthy donors, and the efficacy of lysis was increased by activating NK cells with interleukin-15 (IL-15). FACS analysis and immunohistochemistry revealed that EWS cell lines as well as primary tumor cells expressed ligands for the activating NK cell receptors NKG2D and DNAM-1. NK cell cytotoxicity to EWS cells critically depended on the combination of NKG2D and DNAM-1 signaling, since blocking either of these receptors abrogated lysis by resting NK cells. Cytokine-activated NK cells more efficiently recognized EWS cells, since only combined, but not single blockade of NKG2D and DNAM-1 by antibodies inhibited lysis of EWS cells. Induction or blockade of HLA class I on EWS cells did not significantly influence lysis. This suggests that predominantly activating, rather than inhibitory signals on EWS cells determined susceptibility to NK cell cytotoxicity. NK cell cytotoxicity to EWS cells and K562 was reduced in EWS patients at diagnosis (n = 11) compared to age matched controls, despite normal NK cell numbers and increased expression of NKG2D. The impaired function of these NK cells was restored after activation with IL-15 in vitro. The investigators Conclude: These results demonstrate that EWS cells are potentially susceptible to NK cell cytotoxicity due to the expression of activating NK cell receptor ligands. The use of cytokine-activated NK cells rather than resting NK cells in immunotherapy may be instrumental to optimize NK cell reactivity to EWS.

GLI1 Is a Direct Transcriptional Target of EWS-FLI1 Oncoprotein

Ewing sarcoma family of tumors (ESFT) is an undifferentiated neoplasm of the bone and soft tissue. ESFT is characterized by a specific chromosomal translocation occurring between chromosome 22 and (in most cases) chromosome 11, which generates an aberrant transcription factor, EWS-FLI1. The function of EWS-FLI1 is essential for the maintenance of ESFT cell survival and tumorigenesis. The Hedgehog pathway is activated in several cancers. Oncogenic potential of the Hedgehog pathway is mediated by increasing the activity of the GLI family of transcription factors. Recent evidence suggests that EWS-FLI1 increases expression of GLI1 by an unknown mechanism. The investigator’s data in this study from chromatin immunoprecipitation and promoter reporter studies indicated GLI1 as a direct transcriptional target of EWS-FLI1. Expression of EWS-FLI1 in non-ESFT cells increased GLI1 expression and GLI-dependent transcription. They also detected high levels of GLI1 protein in ESFT cell lines. Pharmacological inhibition of GLI1 protein function decreased proliferation and soft agar colony formation of ESFT cells. Thus the investigators believe their results establish GLI1 as a direct transcriptional target of EWS-FLI1 and suggest a potential role for GLI1 in ESFT tumorigenesis.

Neo/adjuvant chemotherapy does not improve outcome in resected primary synovial sarcoma: a study of the French Sarcoma Group

There is little date about the benefit of adjunctive chemotherapy in patients with localized synovial sarcoma (SS). In this study, data from 237 SS patients recorded in the database of the French Sarcoma Group were retrospectively analyzed. The respective impact of radiotherapy, neo-adjuvant chemotherapy and adjuvant chemotherapy on overall survival (OS), local recurrence-free survival (LRFS) and distant recurrence-free survival (DRFS) were assessed after adjustment to prognostic factors. The Results were as follows: The median follow-up was 58 months (range 1–321). Adjuvant, neo-adjuvant chemotherapy and postoperative radiotherapy were administered in 112, 45 and 181 cases, respectively. In all, 59% of patients treated with chemotherapy received an ifosfamide-containing regimen. The 5-year OS, LRFS and DRFS rates were 64.0%, 70% and 57%, respectively. On multivariate analysis, age >35 years old, grade 3 and not-R0 margins were highly significant independent predictors of worse OS. After adjustment to prognostic factors, radiotherapy significantly improved LRFS but not DRFS or OS. Neither neo-adjuvant nor adjuvant chemotherapy had significant impact on OS, LRFS or DRFS. The investigators Conclude: As for other high-grade soft-tissue sarcomas, well-planned wide surgical excision with adjuvant radiotherapy remains the cornerstone of treatment for SS. Neo-adjuvant or adjuvant chemotherapy should not be delivered outside a clinical trial setting.

Overcoming Resistance to Conventional Drugs in Ewing Sarcoma and Identification of Molecular Predictors of Outcome

The improvement of Ewing sarcoma (EWS) therapy is currently linked to the discovery of strategies to select patients with poor and good prognosis and of modified treatment regimens. In this study, the investigators analyzed the molecular factors governing EWS response to chemotherapy to identify genetic signatures to be used for risk-adapted therapy. Microarray technology was used for profiling 30 primary tumors and seven metastases of patients who were classified according to event-free survival. For selected genes, real-time polymerase chain reaction was applied in 42 EWS primary tumors as validation assay. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide test was used to evaluate in vitro drug sensitivity. The Results were as follows: The investigators identified molecular signatures that reflect tumor resistance to chemotherapy. Annotation analysis was applied to reveal the biologic functions that critically influenced clinical outcome. The prognostic relevance of glutathione metabolism pathway was validated. The expression of MGST1, the microsomal glutathione S-transferase (GST), was found to clearly predict EWS prognosis. MGST1 expression was associated with doxorubicin chemosensitivity. This prompted them to assess the in vitro effectiveness of 6-(7-nitro-2,1,3-benzoxadiazol-4-ylthio)hexanol (NBDHEX), a new anticancer agent that efficiently inhibits GST enzymes. Six cell lines were found to be sensitive to this new drug. The investigators Conclude: Classification of EWS patients into high- and low-risk groups is feasible with restricted molecular signatures that may have practical value at diagnosis for selecting patients with EWS who are unresponsive to current treatments. Glutathione metabolism pathway emerged as one of the most significantly altered prognosis-associated pathway. NBDHEX is proposed as a new potential therapeutic possibility.

Telomere-Maintenance Mechanisms in Soft-Tissue Malignant Fibrous Histiocytomas

Sarcomas are distinct from carcinomas in that a substantial portion of them use the alternative lengthening of telomeres (ALT) mechanism to maintain their telomeres. This study clarifies the prevalence of the ALT mechanism and examines the prognostic importance of telomere factors in soft-tissue malignant fibrous histiocytomas. The authors investigated a series of forty-three soft-tissue malignant fibrous histiocytoma samples from forty-three patients with regard to telomere length, telomerase activity, and human telomerase reverse transcriptase (hTERT) mRNA expression. Tumor samples were obtained from surgical specimens and were stored at –80°C until use. Univariate analysis of the tumor samples from patients for whom data were available on age, sex, histological grade, tumor size, surgical margin, recurrence, and telomere factors was performed with use of the log-rank test. Multivariate analysis with only significant variables was then performed. The Results were as follows: Telomerase activity was detectable in 79.1% of the tumor samples, hTERT expression was demonstrated in 90.7% of the tumor samples, and evidence of engagement of the ALT mechanism of telomere length maintenance was observed in 32.6% of the tumor samples. Among the variables tested, ALT-positive status emerged as the only independent prognostic factor for death of the patient (hazard ratio, 0.275; 95% confidence interval, 0.104 to 0.724; p = 0.0089). There were no significant differences in survival rates between patients with ALT-positive, telomerase-positive tumors and those with ALT-positive, telomerase-negative tumors (p = 0.301) or between patients with ALT-positive tumors that showed above-average telomerase activity and those with ALT-positive tumors that showed below-average telomerase activity (p = 0.900). The authors Conclude: Therefore, telomerase activity does not affect the prognosis in patients with ALT-positive malignant fibrous histiocytoma. High telomerase expression is associated with a poor prognosis in patients with ALT-negative malignant fibrous histiocytoma (p = 0.0027). More detailed analysis will be needed to identify the most valuable prognostic factor in patients with malignant fibrous histiocytoma, and a more thorough understanding of telomere biology may give an indication of telomere-targeting therapy in the future.

Cooperative Trial CWS-91 for Localized Soft Tissue Sarcoma in Children, Adolescents, and Young Adults

The purpose of this trial was to improve risk-adapted therapy for localized childhood soft tissue sarcoma within an international multicenter setting. Four hundred forty-one patients younger than 21 years with localized rhabdomyosarcoma and rhabdomyosarcoma-like tumors (i.e., extraosseous tumors of the Ewing family, synovial sarcoma, and undifferentiated sarcoma) were eligible. Therapy was stratified according to postsurgical stage, histology, and tumor site. In unresectable tumors, treatment was further adapted depending on response to induction chemotherapy, TN classification, tumor size and second-look surgery. A novel five-drug combination of etoposide, vincristine, dactinomycin, ifosfamide, and doxorubicin (EVAIA) was evaluated for high-risk patients, but cumulative chemotherapy dosage and treatment duration were reduced for the remaining individuals as compared with that of the previous trial CWS-86. Hyperfractionated accelerated radiotherapy (HART) was recommended at doses of either 32 or 48 Gy. The Results were as follows: At a median follow-up of 8 years, 5-year event-free survival (EFS) and overall (OS) survival for the entire cohort was 63% ± 4% and 73% ± 4%, respectively (all survival rates in this abstract are calculated and displayed with ±95% CI). EFS/OS rates by histology were 60% ± 5%/72% ± 5% in rhabdomyosarcoma, 62% ± 10%/69% ± 10% for Ewing tumors of soft tissues, 84% ± 12%/90% ± 10% for synovial sarcoma, and 67% ± 38%/83% ± 30% for undifferentiated sarcoma, respectively. Response to one cycle of the five-drug combination EVAIA was similar to that of the four-drug combination VAIA used in CWS-86. Two hundred twelve patients with rhabdomyosarcoma underwent radiation (EFS, 66% ± 6%); 53 of those patients had a favorable risk profile and received 32 Gy of HART (EFS, 73% ± 12%). TN classification, tumor site, tumor size, histology, and age were prognostic in univariate analysis. The authors Conclude: Improved risk stratification enabled decreased therapy intensity for selected patients without compromising survival. Intensified chemotherapy with EVAIA did not improve outcome of localized high-risk rhabdomyosarcoma.

How epigenetics can explain human metastasis

The metastatic process is characterized by the dissemination of tumoral cells throughout the bloodstream to distal sites, where these transformed cells proliferate and give rise to secondary tumors, which are the principal cause of mortality in cancer patients. In recent years, a significant number of metastasis-related genes have been described, such as cadherins, laminins, heparin sulfates and protease and angiogenesis inhibitors, among others. However, the mechanisms by which these genes are altered in metastasis remain unclear, since genetic alterations occur rarely, despite their widespread downregulation. Epigenetic alterations, and specifically CpG island hypermethylation-associated silencing, can potentially explain the aberrant expression of many of these genes. The disruption of histone modifiers and chromatinremodeling factors also contributes to the alteration of metastasis genes. Members of a new class of regulatory RNAs, microRNAs (miRNAs), have an important role in cancer and metastasis and are also regulated by epigenetic mechanisms in both malignancies. As we gain insight into the epigenetic mechanisms orchestrating all the metastatic steps, we broaden the therapeutic possibilities of epigenetic drugs, such as DNA demethylating drugs and histone deacetylase inhibitors, which can act upon metastasis-related genes and miRNAs, restoring their expression. In this review article, the latest studies relating cancer epigenetics and metastasis are analyzed, and the authors emphasize the importance of miRNAs and their epigenetic regulation in tumoral progression.

February 2009

Vascular Endothelial Growth Factor Overexpression by Soft Tissue Sarcoma Cells: Implications for Tumor Growth, Metastasis, and Chemoresistance

The investigators of this study wanted to better understand the role of vascular endothelial growth factor (VEGF)165 in soft tissue sarcoma (STS) growth, metastasis, and chemoresistance. They generated stably transfected human STS cell lines with VEGF165 to study the effect of VEGF165 on STS cells in vitro and the effect of culture medium from these cells on human umbilical vascular endothelial cells. Severe combined immunodeficient mice bearing xenografts of transfected cell lines were used to assess the effect of VEGF overexpression and the effect of VEGF receptor (VEGFR) 2 inhibition on STS growth, metastasis, and response to doxorubicin. They found as follows. VEGF165-transfected xenografts formed highly vascular tumors with shorter latency, accelerated growth, enhanced chemoresistance, and increased incidence of pulmonary metastases. Blockade of VEGFR2 signaling using DC101 anti-VEGFR2 monoclonal antibody enhanced doxorubicin chemoresponse; this combined biochemotherapy inhibited tumor growth and decreased pulmonary metastases without overt toxicity. Combined therapy reduced microvessel counts while increasing vessel maturation index. VEGF overexpression did not affect on the sarcoma cells per se; however, conditioned medium from VEGF transfectants caused increased endothelial cell proliferation, migration, and chemoresistance. Addition of DC101 induced endothelial cell sensitivity to doxorubicin and suppressed the activity of matrix metalloproteinases secreted by endothelial cells. They therefore Conclude: that VEGF is a critical determinant of STS growth and metastasis and that STS chemoresistance, in their model, is a process induced by the interplay between STS cells and tumor-associated endothelial cells. STS growth and metastasis can be interrupted by combined low-dose doxorubicin and anti-VEGFR2, a strategy that attacks STS-associated endothelial cells. In the future, such therapeutic approaches may be useful in treating STS before the development of clinically apparent metastases.

Related ESUN Article: What are Chemosensitivity and Chemoresistance Testing?

Glycosaminoglycans as Potential Regulators of Osteoprotegerin Therapeutic Activity in Osteosarcoma

Osteosarcoma is the most frequent primary bone malignant tumor. The survival rate is 50% after 5 years. Osteoprotegerin (OPG) is a potent inhibitor of osteoclast differentiation and activation, but its use as a therapeutic agent in cancer-associated osteolysis remains controversial due to its ability to bind and inhibit the apoptotic effect of tumor necrosis factor–related apoptosis-inducing ligand (TRAIL) on tumor cells. In this study, the therapeutic effects of full-length OPG (1-401) and OPG 1-194 lacking its heparin-binding domain delivered by nonviral gene therapy were compared in a murine model of osteolytic osteosarcoma. The study found that tumor incidence, progression, and associated bone lesions were significantly diminished in the OPG 1-194 group, but not in the OPG 1-401 group, compared with controls. As receptor activator of nuclear factor-B ligand (RANKL), TRAIL, and glycosaminoglycans (GAG) were shown to be overexpressed in osteosarcoma environment compared with control tissue, OPG 1-401 bioactivity may be modulated by one of these protagonists. Surface plasmon resonance analyses performed with OPG, TRAIL, and GAGs revealed that TRAIL binds both forms of OPG with the same affinity. In addition, as OPG 1-194 and OPG 1-401 similarly inhibit TRAIL-induced apoptosis, it suggests that TRAIL is not involved in the modulation of OPG bioactivity. However, as GAGs inhibit OPG 1-401 but not OPG 1-194 binding to TRAIL or to RANKL, they may represent potent regulators of OPG availability and antitumor activity in bone tumor microenvironment.

Inhibition of mTOR Radiosensitizes Soft Tissue Sarcoma and Tumor Vasculature

The PI3K/Akt/mTOR prosurvival pathway is frequently up-regulated in soft tissue sarcoma. Mammalian target of rapamycin (mTOR) inhibitors, such as rapamycin, have recently shown clinical benefit in soft tissue sarcoma, and mTOR inhibition has also been associated with radiosensitization of carcinoma and endothelial cells. This study tested the hypothesis that rapamycin radiosensitizes soft tissue sarcoma and endothelial cells in vitro and in vivo through the inhibition of mTOR. Experimental Design: Colony formation assays were done to determine the radiosensitizing properties of rapamycin on three human soft tissue sarcoma cell lines (SK-LMS-1, SW-872, and HT-1080) and human dermal microvascular endothelial cells (HDMEC). The functional effects of rapamycin and radiation on the endothelial compartment were evaluated with microvascular sprouting assays. The in vivo radiosensitizing activity of rapamycin was assessed with s.c. SK-LMS-1 nude mice xenografts treated with concurrent daily rapamycin, radiation, or both for three weeks. The Results were as follows: In vitro radiosensitization was shown in all three soft tissue sarcoma cell lines with minimally cytotoxic doses of rapamycin. SK-LMS-1 xenografts displayed significant tumor growth delay with rapamycin and radiation compared with either treatment alone. Radiation resulted in transient increased mTOR function, whereas rapamycin abolished this signaling in irradiated and unirradiated samples. In HDMEC, rapamycin and radiation reduced microvessel sprouting, but did not alter colony formation. The investigators Conclude: Minimally cytotoxic concentrations of rapamycin inhibited the mTOR cascade in culture and in vivo while radiosensitizing soft tissue sarcoma, and produced synergistic effects with radiation on HDMEC microvessel formation. By targeting both tumor and endothelial compartments, rapamycin produced potent radiosensitization of soft tissue sarcoma xenografts. Clinical trials combining rapamycin and radiotherapy in soft tissue sarcoma are warranted.

Gene expression profiling of alveolar soft-part sarcoma (ASPS)

Alveolar soft-part sarcoma (ASPS) is an extremely rare, highly vascular soft tissue sarcoma affecting predominantly adolescents and young adults. The investigators of this study performed the first genome-wide gene expression profiling study of ASPS in an attempt to gain insight into the pathobiology of this tumor. For seven patients with confirmed primary or metastatic ASPS, RNA samples were isolated immediately following surgery, reverse transcribed to cDNA and each sample hybridized to duplicate high-density human U133 plus 2.0 microarrays. Array data was then analyzed relative to arrays hybridized to universal RNA to generate an unbiased transcriptome. Subsequent gene ontology analysis was used to identify transcripts with therapeutic or diagnostic potential. A subset of the most interesting genes was then validated using quantitative RT-PCR and immunohistochemistry. The Results revealed the following: Analysis of patient array data versus universal RNA identified elevated expression of transcripts related to angiogenesis (ANGPTL2, HIF-1 alpha, MDK, c-MET, VEGF, TIMP-2), cell proliferation (PRL, IGFBP1, NTSR2, PCSK1), metastasis (ADAM9, ECM1, POSTN) and steroid biosynthesis (CYP17A1 and STS). A number of muscle-restricted transcripts (ITGB1BP3/MIBP, MYF5, MYF6 and TRIM63) were also identified, strengthening the case for a muscle cell progenitor as the origin of disease. Transcript differentials were validated using real-time PCR and subsequent immunohistochemical analysis confirmed protein expression for several of the most interesting changes (MDK, c-MET, VEGF, POSTN, CYP17A1, ITGB1BP3/MIBP and TRIM63). Thus, this first comprehensive study of ASPS gene expression identifies several targets involved in angiogenesis, metastasis and myogenic differentiation.

Molecular Classification of Rhabdomyosarcoma—Genotypic and Phenotypic Determinants of Diagnosis

Rhabdomyosarcoma (RMS) in children occurs as two major histological subtypes, embryonal (ERMS) and alveolar (ARMS). ERMS is associated with an 11p15.5 loss of heterozygosity (LOH) and may be confused with nonmyogenic, non-RMS soft tissue sarcomas. ARMS expresses the product of a genomic translocation that fuses FOXO1 (FKHR) with either PAX3 or PAX7 (P-F); however, at least 25% of cases lack these translocations. In this paper, the authors describe a genomic-based classification scheme that is derived from the combined gene expression profiling and LOH analysis of 160 cases of RMS and non-RMS soft tissue sarcomas that is at variance with conventional histopathological schemes. They found that gene expression profiles and patterns of LOH of ARMS cases lacking P-F translocations are indistinguishable from conventional ERMS cases. A subset of tumors that has been histologically classified as RMS lack myogenic gene expression. However, classification based on gene expression is possible using as few as five genes with an estimated error rate of less than 5%. Using immunohistochemistry, they characterized two markers, HMGA2 and TFAP2ß, which facilitate the differential diagnoses of ERMS and P-F RMS, respectively, using clinical material. These objectively derived molecular classes are based solely on genomic analysis at the time of diagnosis and are highly reproducible. The authors believe adoption of these molecular criteria may offer a more clinically relevant diagnostic scheme, thus potentially improving patient management and therapeutic RMS outcomes.

IFN Regulatory Factor 8 Sensitizes Soft Tissue Sarcoma Cells to Death Receptor–Initiated Apoptosis via Repression of FLICE-like Protein Expression

IFN regulatory factor 8 (IRF8) has been shown to suppress tumor development at least partly through regulating apoptosis of tumor cells. However, the molecular mechanisms underlying IRF8 regulation of apoptosis are still not fully understood. In this study the investigators showed that disrupting IRF8 function resulted in inhibition of cytochrome c release, caspase-9 and caspase-3 activation, and poly(ADP-ribose) polymerase cleavage in soft tissue sarcoma (STS) cells. Inhibition of the mitochondrion-dependent apoptosis signaling cascade is apparently due to blockage of caspase-8 and Bid activation. Analysis of signaling events upstream of caspase-8 revealed that disrupting IRF8 function dramatically increases FLIP mRNA stability, resulting in increased IRF8 protein level. Furthermore, primary myeloid cells isolated from IRF8-null mice also exhibited increased FLIP protein level, suggesting that IRF8 might be a general repressor of FLIP. Nuclear IRF8 protein was absent in 92% (55 of 60) of human STS specimens, and 99% (59 of 60) of human STS specimens exhibited FLIP expression, suggesting that the nuclear IRF8 protein level is inversely correlated with FLIP level in vivo. Silencing FLIP expression significantly increased human sarcoma cells to both FasL-induced and tumor necrosis factor–related apoptosis-inducing ligand (TRAIL)–induced apoptosis, and ectopic expression of IRF8 also significantly increased the sensitivity of these human sarcoma cells to FasL- and TRAIL-induced apoptosis. The investigators believe their data suggest that IRF8 mediates FLIP expression level to regulate apoptosis and targeting IRF8 expression is a potentially effective therapeutic strategy to sensitize apoptosis-resistant human STS to apoptosis, thereby possibly overcoming chemoresistance of STS, currently a major obstacle in human STS therapy.

Phase I Trial and Pharmacokinetic Study of Ixabepilone Administered Daily for 5 Days in Children and Adolescents With Refractory Solid Tumors

The objectives of this phase I trial were to determine the maximum-tolerated dose (MTD), toxicity profile, dose-limiting toxicities (DLTs), pharmacokinetics, and preliminary response rate for ixabepilone, a microtubule-stabilizing agent, administered intravenously daily for 5 days in children and adolescents. Patients 2 and 18 years with relapsed or refractory solid tumors were enrolled onto sequential cohorts to the following five dose levels: 3.0 (n = 3), 4.5 (n = 4), 6.0 (n = 3), 8.0 (n = 6), and 10 (n = 3) mg/m2/d. Eligibility criteria, dose levels, definitions of DLT and MTD, and pharmacokinetic sampling times were designed to be as similar as possible to the adult phase I trial of ixabepilone on the same schedule. The Results were as follows: Nineteen children (median age, 10 years; range, 2 to 18 years) were enrolled, and 18 (12 with sarcomas) were assessable for toxicity. DLTs (grade 4 neutropenia for > 5 days and grade 3 fatigue) were observed in two of three patients receiving 10 mg/m2/d. The MTD of ixabepilone administered daily for 5 days every 21 days was 8 mg/m2/d. Myelosuppression, GI, and hepatic toxicities were common non-DLTs. Peripheral neuropathy was uncommon. Ixabepilone clearance was 475 ± 247 mL/min/m2, volume of distribution at steady-state was 12.2 ± 5.4 L/kg, and half-life was 14 hours. The investigators Conclude: The recommended dose of ixabepilone for phase II trials in solid tumors is 8 mg/m2/d daily for 5 days every 21 days. This dose is 33% higher than the MTD in adults receiving the same dosing schedule. Pharmacokinetic parameters in children and adolescents were highly variable but similar to adults.

The Mechanisms of Differential Sensitivity to an Insulin-like Growth Factor-1 Receptor Inhibitor (BMS-536924) and Rationale for Combining with EGFR/HER2 Inhibitors

Overexpression and enhanced activity of insulin-like growth factor-I receptor (IGF-IR) in diverse tumor types make it an attractive target for cancer therapy. BMS-536924 is a potent small molecule inhibitor of IGF-IR, which shows antitumor activity in multiple tumor models, including sarcoma. To facilitate the development of IGF-IR inhibitors as cancer therapy, identification of biomarkers for selecting patients most likely to derive clinical benefit is needed. In this study, 28 sarcoma and neuroblastoma cell lines were screened for in vitro response to BMS-536924 to identify sensitive and resistant cell lines. Notably, Ewing's sarcoma, rhabdomyosarcoma, and neuroblastoma are more responsive to BMS-536924, suggesting these specific subtypes may represent potential targeted patient subpopulations for the IGF-IR inhibitor. Gene expression and protein profiling were performed on these cell lines, and candidate biomarkers correlating with intrinsic and/or acquired resistance to BMS-536924 were identified. IGF-I, IGF-II, and IGF-IR were highly expressed in sensitive cell lines, whereas IGFBP-3 and IGFBP-6 were highly expressed in resistant lines. Overexpression of epidermal growth factor receptor (EGFR) and its ligands in resistant cell lines may represent one possible resistance mechanism by the adaptation of IGF-IR–independent growth using alternative signaling pathways. Based on cross-talk between IGF-IR and EGFR pathways, combination studies to target both pathways were performed, and enhanced inhibitory activities were observed. Thus, the investigators believe these results provide a strategy for testing combinations of IGF-IR inhibitors with other targeted therapies in clinical studies to achieve improved patient outcomes. Further exploration of mechanisms for intrinsic and acquired drug resistance by these preclinical studies may lead to more rationally designed drugs that target multiple pathways for enhanced antitumor efficacy.

O-GlcNAcylation is involved in the transcriptional activity of EWS-FLI1 in Ewing's sarcoma

The oncogene EWS-FLI1 encodes a chimeric transcription factor expressed in Ewing's sarcoma family tumors (ESFTs). EWS-FLI1 target gene expression is thought to drive ESFT pathogenesis and, therefore, inhibition of EWS-FLI1 activity holds high therapeutic promise. As the activity of many transcription factors is regulated by post-translational modifications, the authors of this paper studied the presence of modifications on EWS-FLI1. The immuno-purified fusion-protein was recognized by an antibody specific for O-linked -N-acetylglucosaminylation, and bound readily to a phosphoprotein-specific dye. Inhibition of Ser/Thr-specific phophatases increased EWS-FLI1 molecular weight and reduced its O-GlcNAc content, suggesting that phosphorylation and O-GlcNAcylation of EWS-FLI1 interact dynamically. By mutation analysis, O-GlcNAcylation was delineated to Ser/Thr residues of the amino-terminal EWS transcriptional-activation domain. Metabolic inhibition of the hexosamine biosynthetic pathway abrogated O-GlcNAcylation of EWS-FLI1 and interfered specifically with transcriptional activation of the EWS-FLI1 target Id2. The authors thus believe these results suggest that drugs modulating glycosylation of EWS-FLI1 interfere functionally with its activity and might, therefore, constitute promising additions to the current ESFT chemotherapy.

Response to Sunitinib Malate in Advanced Alveolar Soft Part Sarcoma

Alveolar soft part sarcoma (ASPS) is a rare, chemoresistant soft tissue sarcoma. ASPS harbors the t(17-X) (p11.2;q25) translocation, resulting in the ASPACR1-TFE3 fusion protein, causing MET autophosphorylation and activation of downstream signaling. The tumor vascular pattern prompted the investigators of this study to use sunitinib malate (SM), a tyrosine kinase inhibitor with antiangiogenic properties. Since July 2007, five patients with progressive metastatic ASPS have been treated with continuous SM 37.5 mg/d on a named basis. Four patients were evaluable for response. In four cases, cryopreserved material was available. Upstream and downstream targets of receptor tyrosine kinase (RTK) pathways, as well as mechanisms of activation, were investigated by biochemical profiles, including human phospho-receptor RTK antibody arrays and immunoprecipitation/Western blotting, molecular analyses, immunohistochemistry, and fluorescence in situ hybridization analyses. The Results were as follows: After 3 months, two patients had RECIST (response evaluation criteria in solid tumor) partial response, as well as positron emission tomography response and subjective improvement. One had a RECIST stable disease. One progressed and stopped treatment. One patient is still responding after 12 months. The upstream analysis showed activation of all the platelet-derived growth factor receptor (PDGFR) family members, as well as epidermal growth factor receptor, MET families, and RET. Vascular endothelial growth factor receptors (VEGFR1 and VEGFR2) were activated only in one case. The downstream target analysis showed strong activation of phosphatidylinositol 3-kinase/AKT, extracellular signal-regulated kinase 1/2, and mTOR and its targets (S6K and S6). The absence of any upstream mTOR effector deregulation and the presence of RTK cognate ligands support an autocrine-paracrine activation loop mechanism. The investigators Conclude: SM may have antitumor activity in ASPS, possibly through a mechanism involving PDGFR and RET. The role of MET, epidermal growth factor receptor, and mTOR, as well as PDGFR inhibition, needs to be further explored.

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