Long-term adjuvant interferon treatment of human osteosarcoma. A pilot study.

During the period from 1971 to 1990 all osteosarcoma patients referred to the Karolinska Hospital without signs of metastases received human leukocyte interferon (IFN) as adjuvant treatment. Patients referred between 1985 and 1990 were given more intensive human leukocyte IFN treatment, i.e. a standard dose of 3 MU s.c. daily for 3-5 years. These 19 patients, all followed for 5 years, were included in a pilot study which entailed patients with central localization where radical surgery was not feasible. Metastases developed in 9 patients, of whom 3 had local recurrences. Sixty-three percent are free of disease at 5 years. Side-effects were negligible and long-term toxicity practically non-existent. It is suggested that a randomized multicenter IFN trial should be instituted on patients with poor prognosis receiving chemotherapy and/or that IFN treatment should be combined with other therapeutic modalities--irradiation, chemotherapy or anti-angiogenic substances--in osteosarcoma.

Local tumour resection in interferon treated osteosarcoma patients.

Fifteen patients with primary classical osteosarcoma tumours are presented, all of whom have been operated on with local en bloc resection of the tumour mass in combination with adjuvant treatment with human leucocyte interferon. All patients have at present been followed up for more than fifteen years and half of them have shown no tumour recurrence. One patient committed suicide and eight died of generalized tumour disease. Two patients developed lung metastases five and eight years after primary surgery. This form of treatment, allowing limb preservation, is presented as an alternative to conventional ablative surgery providing that it is reserved for centres with specialized surgical teams.

Adjuvant interferon treatment in human osteosarcoma.

An update of the adjuvant trial on osteosarcoma in Sweden comparing patients receiving natural interferon (IFN) alpha with a high-dose chemotherapy group and a nonadjuvant group is presented. The overall survival for the IFN group is 49%, for the chemotherapy group 54%, and for the nonadjuvant group 35%. Trial evaluation was complicated by group differences with respect to various clinicopathologic features of prognostic significance. The role of IFN in the treatment of osteosarcoma can still not be established.

Staging of soft-tissue sarcomas. Prognostic analysis of clinical and pathological features.

In a retrospective study of all 137 patients with soft-tissue sarcoma treated by surgery between 1972 and 1984, the clinical course was related to several host and tumour features, including the Surgical Staging System of Enneking, Spanier and Goodman (1980). Only patients free from metastasis with untreated primary lesions on admission were included. According to the Surgical Staging System, nine tumours were IA, 18 IB, 38 IIA and 72 IIB. Only 12 patients underwent amputation; 125 were treated by local surgery. The mean follow-up time was ten years (minimum five). For the whole series the probability of seven-year survival was 0.65; 42 patients (31%) died from tumour disease. All these had metastases and 24 also had local recurrence. The local recurrence rate was 36%. Multivariate analysis identified large tumour size and high histological grade as significant risk factors for metastatic disease and tumour-related death. Sex, age, tumour site, surgical margin and local recurrence showed no correlation with survival. The prognostic contribution of compartmentality was virtually nil. Histological grade combined with tumour size was found to give better prognostic information than that obtained by the Surgical Staging System.

Shoulder function after prosthetic replacement of proximal humerus.

Between 1973 and 1985 eighteen patients with bone tumours and two patients with comminuted fractures had their proximal humerus replaced with a custom made isoelastic hemiendoprosthesis. In 1987 a clinical and radiographical review was performed of eleven patients with a mean follow up time of seven years, range 3-10 years. Four patients had pain at rest and six patients experienced severe pain on exertion. Active range of motion was poor and constituted only half of the corresponding range of passive motion. Shoulder girdle muscles were generally weak, only one patient could keep the arm straight in a flexed or abducted position. All patients had returned to their previous occupations, but their ability to perform ADL functions was poor. Rotator cuff insufficiency was considered to be the major cause of poor shoulder function. In comparison to most other surgical alternatives in tumour cases endoprosthetic replacement of the proximal humerus appears to be a safe and reliable method. The endoprosthesis gives stability to the arm and normal elbow and hand function is preserved.

The age of osteosarcoma patients is increasing. An epidemiological study of osteosarcoma in Sweden 1971 to 1984.

We conducted an epidemiological study of osteosarcoma in Sweden from 1971 to 1984 to investigate whether the typical features of the disease had changed. Of 294 osteosarcoma patients reviewed, 249 had primary skeletal tumours, and for these the mean annual incidence was 2.1 per million, without any clear trend over time. The mean male/female ratio for the period was 1.6 again with no consistent pattern over time; nor was there any significant change in the distribution of tumours according to location. The only feature which showed a significant change over the 14-year period was the mean age of the patients, being at its lowest (19 years) in 1972 and at its highest (40 years) in 1981. Excluding the 22 patients with craniofacial tumours, the remaining 227 also showed a significant increase in mean age. Analysis of the annual age distribution disclosed an increasing fraction of patients older than those in the classical age peak between 10 and 29 years. A large number of trials have shown improved survival in osteosarcoma over the last 15 years, which has been attributed mainly to adjuvant chemotherapy. The change we have observed in age distribution should also be taken into account in the evaluation of the results of treatment; it may be that older patients have a better prognosis.

Lymphangiosarcoma in chronic hereditary oedema (Milroy's disease).

Lymphangiosarcoma arising in chronic lymphoedema is extremely rare. In a reference population of about four million people, during a thirty year period (1957-1987), only four patients were treated for such a tumour. The neoplasm is almost exclusively seen in elderly patients after mastectomy but in two of our patients, reported in this paper, it arose in chronic hereditary oedema (Milroy's disease). In both these patients there was a considerable treatment delay because of wrong diagnosis. The tumour extent was difficult to assess macroscopically and ablative surgery had to be a disarticulation of the involved extremity. Macular or papular purple lesions in a lymphoedematous extremity should be a manifestation of this aggressive neoplasm.

Survival of frozen bone allograft.

One case of transplantation of a large osteochondral allograft, with long (8 years) time follow up is reported. Following excision of a benign giant cell tumour the distal part of the left femur, including the joint surfaces, was replaced by a frozen osteochondral allograft. The patient regained function with pain-free weight bearing, and good walking ability. However, the development of a pseudarthrosis between the graft and the host bone necessitated internal fixation and bone grafting two years after the initial surgery. Due to a progressive instability of the knee joint, the graft was replaced by a prosthetic implant eight years after tumor resection. Preoperative scintigraphy showed a high uptake over the grafted area, which corroborated the finding of good vascularization of the graft at surgery. In contrast, histology and fluorochrome uptake of the allograft showed sparse areas of new bone formation. It is concluded that a frozen bone allograft may prove a useful alternative, with good long term results, in the replacement of bone after large resections, in spite of slow and incomplete incorporation.

Does successful interferon treatment of tumor patients require life-long treatment?

Case histories of 5 tumor patients treated with natural leukocyte interferon-alpha (IFN-alpha) are presented. One patient with juvenile laryngeal papillomatosis responded well to interferon treatment, but the disease recurred when therapy was withdrawn. Upon reinstitution of treatment, the patient once again responded well. Another patient with myelomatosis also responded well to interferon therapy and in this case, too, the tumor recurred when interferon treatment was withdrawn. Reinstitution of interferon therapy was, however, unsuccessful. One patient with generalized giant cell tumor of bone responded with regression after more than 5 years of interferon treatment. Another patient with pulmonary osteosarcoma metastases, having received irradiation and interferon combination therapy followed by sole interferon treatment, responded well with a lasting stationary radiogram after 6 years of interferon treatment. One patient with malignant glioma, showing signs of tumor growth during the first few months of interferon therapy, eventually responded, and became disease-free after 6 years. The latter 3 patients are continuously receiving interferon therapy although more than 5 years have elapsed since their interferon therapy was initiated. It is suggested that interferon therapy for malignant tumors be given for life (or to progression of disease) in responding patients. Such a concept entails biological implications for interferon therapy in general and for antitumor action of interferons in particular. Other possible clinical schedules should only be constructed within the framework of controlled clinical trials.

Lysis of autologous tumor cells by blood lymphocytes activated in autologous mixed lymphocyte tumor cell culture--no correlation with the postsurgical clinical course.

Mixed lymphocyte tumor cell cultures (MLTC) were initiated with cells collected at the time of surgery from 62 patients with the following diagnoses: 12 squamous cell carcinoma, 14 adenocarcinoma of the lung, 17 osteosarcomas, and 16 soft tissue sarcomas. The lytic effect generated against autologous tumor cells was tested on the 7th day. These patients had been part of previous evaluation, which revealed that the lysis of autologous tumor cells by freshly collected lymphocytes correlated with the postsurgical clinical course. Patients with long survival exhibited autotumor lysis without previous activation. Blood lymphocytes of about half of the primarily nonreactive patients were stimulated for lytic function in MLTC. However, this parameter showed no correlation with the clinical course.

Lysis of autologous tumor cells by blood lymphocytes tested at the time of surgery. Correlation with the postsurgical clinical course.

Lymphocyte-mediated lysis of autologous tumor cells (autologous lymphocyte cytotoxicity ALC) was tested at the time of surgery in 108 patients (46 squamous cell carcinomas of the lung, 25 adenocarcinomas of the lung, 19 soft tissue sarcomas and 18 osteosarcomas). The clinical course of these patients in relation to the test results has been published previously. The group was evaluated again after an extended observation time, now with a mean of 80.2 months (range 36-108). The test was rarely positive in patients with metastasis (2 out of 28 experiments). There was a correlation between the ALC results and the postsurgical clinical course for patients without detectable metastasis in that (1) a negative test was invariably a bad prognostic sign, i.e., all 32 patients with negative ALC died within 3 years (mean survival time 16.1 months). (2) The remission and survival times were longer for the ALC positive patients (p less than 0.001). (3) All 37 individuals who are alive at present without recurrence belong to the reactive group. The ALC results correlated with the clinical course in 88% of patients. The correlation was highest for the groups of soft tissue sarcoma and adenocarcinoma of the lung. There was no correlation between killing of K562 cells and ALC, or between lymphoproliferative response to PHA and ALC reactivity.

Influence of human alpha-interferon on four human osteosarcoma xenografts in nude mice.

Growth-inhibiting effects of human alpha-interferon (HuIFN-alpha) were investigated in four human osteosarcoma xenografts in nude mice. In addition to effects on growth, the HuIFN-alpha treatment was evaluated by histological examination and DNA flow cytometric analysis. Daily doses of 2 X 10(5) IU HuIFN-alpha completely arrested the growth of two osteosarcoma xenografts and partially inhibited one, whereas 1 X 10(6) IU/day were necessary to arrest the growth of the fourth. Growth inhibition was reversible and tumor size independent. The histological appearance, including mitotic indices, and S-phase proportions were unchanged in three xenografts. The mechanism of the HuIFN-alpha-induced growth inhibition of these three xenografts was therefore not considered to be a direct antiproliferative effect, but rather due to increased cell loss and/or increased cell cycle time. The modal DNA value of one xenograft was changed from aneuploid to diploid during HuIFN-alpha treatment. Histologically, these xenografts were partly replaced by normal appearing bone and bone marrow. The S-phase proportion was also reduced in these xenografts, implying that HuIFN-alpha can also have a direct antiproliferative effect.

Limb-preserving radical surgery for malignant bone tumors.

There is no proven evidence that ablative surgery is superior to radical local surgery of bone tumors in the process of survival. When locally radical bone tumor resection is anatomically possible, such a procedure is advantageous. Skip lesions are extremely rare and can be detected at present by refined methods of diagnosis; thus, they do not interfere with the principle of local bone tumor surgery. Replacement of the skeletal defect obtained can be managed by specialized surgical methods. Massive autologous and/or homologous bone grafting is often a useful technique. For replacement of large defects, custom-made endoprostheses serve a useful purpose regarding limb function. Resection of the total shoulder girdle can be performed without sacrificing normal hand function. A corresponding resection of the hip area, including the acetabular ring, can save a lower extremity having a good or acceptable function. Differentiated bone tumor surgery also calls for differentiated rehabilitative measures.

Effect of the antineoplastic agent methotrexate on experimental heterotopic new bone formation in rats.

Heterotopic new bone formation was induced by implanting pieces of demineralized bone matrix in the abdominal wall of 22 growing Sprague-Dawley rats. The animals were divided into three groups and were given, 24 hr after initiation of the bone induction process, a single i.v. injection of methotrexate, 100 or 250 mg/kg body weight, or placebo, followed after 2 hr by leucovorin rescue. A slight and transient arrest in weight gain was noted in the methotrexate-treated animals. New bone formation during 3 weeks after implantation was analyzed by the amount of ash in implants, and as a measure of bone formation at the end of the experiment, short-time incorporation of 45Ca and [3H]proline was used. The ash content of implants was reduced by 56 and 68% in the two methotrexate groups. Uptake of both nucleotides was also greatly reduced in heterotopic bone, whereas metaphysial and diaphysial tibia and teeth were not affected. The results indicate a pronounced inhibition of methotrexate on bone induction, persisting for at least 3 weeks. Methotrexate reduces the bone-forming potential, with possible consequences for the success of limb-saving surgery and fracture healing.

Effect of interferon on heterotopic new bone formation in mice.

To study the effect of interferon (IFN) on bone induction and new bone formation, heterotopic bone was induced by implanting pieces of demineralized bone matrix in soft tissue of mice. Mouse IFN was given as daily subcutaneous injections of 2 X 10(5) IU/mouse. Treatment was started one week before bone matrix implantation and continued until sacrifice. As a measure of chondrogenesis in the implants short-term incorporation of 35sulphur administered 11 days after implantation was measured. The amount of mineralized tissue formed in connection with the implant was estimated by 45calcium incorporation 20 days after implantation. There was no indication of a negative effect of IFN on bone induction, new bone formation, or metabolism of orthotopic bone. This is in agreement with our findings in the clinical use of IFN after reconstructive surgery in osteosarcoma.

Correlation between lymphocyte-mediated auto-tumor reactivities and clinical course. I. Evaluation of 46 patients with sarcoma.

T-cell-enriched blood lymphocyte populations from 24 osteosarcoma and 22 soft-tissue sarcoma patients were assayed at the time of surgery for proliferative response to, and/or cytotoxic potential against autologous tumor cells. Tumor-free period and survival of the patients were correlated with the results obtained in the in vitro tests. The observation time was between 18 and 118 months (mean 62) for the osteosarcoma patients and between 18 and 72 (mean 42) for the patients with soft-tissue sarcoma. In both groups tumor-free period and survival were longer for those individuals who had auto-tumor reactivity. In the non-reactive group, all patients died within 3 years. Almost all patients had cytotoxicity against K562.

Preoperative radiation therapy of high malignancy grade soft tissue sarcoma. A preliminary investigation.

Twenty-three patients with high malignancy grade soft tissue sarcoma received irradiation (about 40 Gy) followed by surgery. The follow-up time was 62 months or more in all patients. The local recurrence rate was 9 per cent (2/23). One of the patients was reoperated and is living free of disease, giving a local control rate of 95 per cent. Thirty per cent (7/23) of the cases developed distant metastases and died of the disease. Delayed wound healing was observed in 2 cases which was possibly due to the radiation therapy. Since surgery was regarded non-radical in 5 cases, the local control obtained by the combined radiation therapy and surgery is good and should be the subject for further investigations.