Skip to main content

Advertisement

SpringerLink
Log in

Improved Survival in Osteosarcoma Patients with Atypical Low Vascularization

  • Bone and Soft Tissue Sarcomas
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Osteosarcoma is considered a highly vascularized bone tumor with early metastatic dissemination through intratumoral blood vessels mostly into the lung. Novel targets for therapy such as tumor vascularization are highly warranted since little progress has been achieved in the last 30 years. However, proof of relevance for vascularization as a major prognostic parameter has been hampered by tumor heterogeneity, difficulty in detecting microvessels by immunohistochemistry, and small study cohorts. Most recently, we demonstrated that highly standardized whole-slide imaging could overcome these limitations (Kunz et al., PloS One 9(3):e90727, 2014). In this study, we applied this method to a multicenter cohort of 131 osteosarcoma patients to test osteosarcoma vascularization as a prognostic determinant.

Methods

Computer-assisted whole-slide analysis, together with enzymatic epitope retrieval, was used for CD31-based microvessel quantification in 131 pretreatment formalin-fixed and paraffin-embedded biopsies from three bone tumor centers. Kaplan–Meier-estimated survival and chemoresponse were determined and multivariate analysis was performed. Conventional hot-spot-based microvessel density (MVD) determination was compared with whole-slide imaging.

Results

We detected high estimated overall (p ≤ 0.008) and relapse-free (p ≤ 0.004) survival in 25 % of osteosarcoma patients with low osteosarcoma vascularization in contrast to other patient groups. Furthermore, all patients with low osteosarcoma vascularization showed a good response to neoadjuvant chemotherapy. Comparison of conventional MVD determination with whole-slide imaging suggests false high quantification or even exclusion of samples with low osteosarcoma vascularization due to difficult CD31 detection in previous studies.

Conclusion

Low intratumoral vascularization at the time of diagnosis is a strong predictor for prolonged survival and good response to neoadjuvant chemotherapy in osteosarcoma.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Kunz P, Fellenberg J, Moskovszky L, et al. Osteosarcoma microenvironment: whole-slide imaging and optimized antigen detection overcome major limitations in immunohistochemical quantification. PloS One. 2014;9(3):e90727.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Dishop MK, Kuruvilla S. Primary and metastatic lung tumors in the pediatric population: a review and 25-year experience at a large children’s hospital. Arch Pathol Lab Med. 2008;132(7):1079–1103.

    PubMed  Google Scholar 

  3. Ek ET, Ojaimi J, Kitagawa Y, Choong PF. Does the degree of intratumoural microvessel density and VEGF expression have prognostic significance in osteosarcoma? Oncol Rep. 2006;16(1):17–23.

    CAS  PubMed  Google Scholar 

  4. Ek ET, Ojaimi J, Kitagawa Y, Choong PF. Outcome of patients with osteosarcoma over 40 years of age: is angiogenesis a marker of survival? Int Semin Surg Oncol. 2006;3:7.

    Article  PubMed Central  PubMed  Google Scholar 

  5. Kaya M, Wada T, Akatsuka T, et al. Vascular endothelial growth factor expression in untreated osteosarcoma is predictive of pulmonary metastasis and poor prognosis. Clin Cancer Res. 2000;6(2):572–577.

    CAS  PubMed  Google Scholar 

  6. Kreuter M, Bieker R, Bielack SS, et al. Prognostic relevance of increased angiogenesis in osteosarcoma. Clin Cancer Res. 2004;10(24):8531–8537.

    Article  PubMed  Google Scholar 

  7. Mantadakis E, Kim G, Reisch J, et al. Lack of prognostic significance of intratumoral angiogenesis in nonmetastatic osteosarcoma. J Pediatr Hematol Oncol. 2001;23(5):286–289.

    Article  CAS  PubMed  Google Scholar 

  8. Mikulic D, Ilic I, Cepulic M, et al. Tumor angiogenesis and outcome in osteosarcoma. Pediatr Hematol Oncol. 2004;21(7):611–619.

    Article  PubMed  Google Scholar 

  9. Oda Y, Yamamoto H, Tamiya S, et al. CXCR4 and VEGF expression in the primary site and the metastatic site of human osteosarcoma: analysis within a group of patients, all of whom developed lung metastasis. Mod Pathol. 2006;19(5):738–745.

    Article  CAS  PubMed  Google Scholar 

  10. Sorensen FB, Jensen K, Vaeth M, et al. Immunohistochemical estimates of angiogenesis, proliferative activity, p53 expression, and multiple drug resistance have no prognostic impact in osteosarcoma: a comparative clinicopathological investigation. Sarcoma. 2008;2008:874075.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Yang QC, Zeng BF, Dong Y, Shi ZM, Jiang ZM, Huang J. Overexpression of hypoxia-inducible factor-1alpha in human osteosarcoma: correlation with clinicopathological parameters and survival outcome. Jpn J Clin Oncol. 2007;37(2):127–134.

    Article  PubMed  Google Scholar 

  12. Clark JC, Dass CR, Choong PF. A review of clinical and molecular prognostic factors in osteosarcoma. J Cancer Res Clin Oncol. 2008;134(3):281–297.

    Article  CAS  PubMed  Google Scholar 

  13. Hogendoorn PC, Athanasou N, Bielack S, et al. Bone sarcomas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010;21 Suppl 5:v204–213.

    Article  PubMed  Google Scholar 

  14. Iwata S, Ishii T, Kawai A, et al. Prognostic factors in elderly osteosarcoma patients: a multi-institutional retrospective study of 86 cases. Ann Surg Oncol. 2014;21(1):263–268.

    Article  PubMed  Google Scholar 

  15. Okada K, Hasegawa T, Nishida J, et al. Osteosarcomas after the age of 50: a clinicopathologic study of 64 cases–an experience in northern Japan. Ann Surg Oncol. 2004;11(11):998–1004.

    Article  PubMed  Google Scholar 

  16. Xu M, Xu CX, Bi WZ, et al. Effects of endostar combined multidrug chemotherapy in osteosarcoma. Bone. Nov 2013;57(1):111–115.

    Article  CAS  PubMed  Google Scholar 

  17. Bielack SS, Kempf-Bielack B, Delling G, et al. Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols. J Clin Oncol. 2002;20(3):776–790.

    Article  PubMed  Google Scholar 

  18. Nathan SS, Healey JH. Demographic determinants of survival in osteosarcoma. Ann Acad Med Singapore. 2012;41(9):390–399.

    PubMed  Google Scholar 

  19. Salzer-Kuntschik M, Delling G, Beron G, Sigmund R. Morphological grades of regression in osteosarcoma after polychemotherapy – study COSS 80. J Cancer Res Clin Oncol. 1983;106 Suppl:21–24.

    Article  PubMed  Google Scholar 

  20. Salzer-Kuntschik M, Brand G, Delling G. Determination of the degree of morphological regression following chemotherapy in malignant bone tumors [in German]. Der Pathologe. 1983;4(3):135–141.

    CAS  PubMed  Google Scholar 

  21. Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res. 1980(153):106–120.

    PubMed  Google Scholar 

  22. Weidner N, Semple JP, Welch WR, Folkman J. Tumor angiogenesis and metastasis: correlation in invasive breast carcinoma. N Engl J Med. 1991;324(1):1–8.

    Article  CAS  PubMed  Google Scholar 

  23. Hara H, Akisue T, Fujimoto T, et al. Expression of VEGF and its receptors and angiogenesis in bone and soft tissue tumors. Anticancer Res. 2006;26(6B):4307–4311.

    CAS  PubMed  Google Scholar 

  24. Chen D, Zhang YJ, Zhu KW, Wang WC. A systematic review of vascular endothelial growth factor expression as a biomarker of prognosis in patients with osteosarcoma. Tumour Biol. 2013;34(3):1895–1899.

    Article  CAS  PubMed  Google Scholar 

  25. Qu JT, Wang M, He HL, Tang Y, Ye XJ. The prognostic value of elevated vascular endothelial growth factor in patients with osteosarcoma: a meta-analysis and systemic review. J Cancer Res Clin Oncol. 2012;138(5):819–825.

    Article  CAS  PubMed  Google Scholar 

  26. Chen P, Wang SJ, Wang HB, et al. The distribution of IGF2 and IMP3 in osteosarcoma and its relationship with angiogenesis. J Mol Histol. 2012;43(1):63–70.

    Article  CAS  PubMed  Google Scholar 

  27. Chen Z, Chen QX, Hou ZY, Hu J, Cao YG. Clinical predictive value of serum angiogenic factor in patients with osteosarcoma. Asian Pac J Cancer Prev. 2012;13(9):4823–4826.

    Article  PubMed  Google Scholar 

  28. Lammli J, Fan M, Rosenthal HG, et al. Expression of vascular endothelial growth factor correlates with the advance of clinical osteosarcoma. Int Orthop. 2012;36(11):2307–2313.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Rossi B, Schinzari G, Maccauro G, et al. Neoadjuvant multidrug chemotherapy including high-dose methotrexate modifies VEGF expression in osteosarcoma: an immunohistochemical analysis. BMC Musculoskelet Disord. 2010;11:34.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Fox SB, Leek RD, Smith K, Hollyer J, Greenall M, Harris AL. Tumor angiogenesis in node-negative breast carcinomas–relationship with epidermal growth factor receptor, estrogen receptor, and survival. Breast Cancer Res Treat. 1994;29(1):109–116.

    Article  CAS  PubMed  Google Scholar 

  31. Vermeulen PB, Gasparini G, Fox SB, et al. Second international consensus on the methodology and criteria of evaluation of angiogenesis quantification in solid human tumours. Eur J Cancer. 2002;38(12):1564–1579.

    Article  CAS  PubMed  Google Scholar 

  32. Gronchi A, Miceli R, Colombo C, et al. Primary extremity soft tissue sarcomas: outcome improvement over time at a single institution. Ann Oncol. 2011;22(7):1675–1681.

    Article  CAS  PubMed  Google Scholar 

  33. Hlatky L, Hahnfeldt P, Folkman J. Clinical application of antiangiogenic therapy: microvessel density, what it does and doesn’t tell us. J Natl Cancer Inst. 2002;94(12):883–893.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Heiner Sähr, Katrin Goetzke and Birgitta Maurer for their excellent technical assistance. This work was supported in part by a grant from the ‘Deutsche Kinderkrebsstiftung’ and the EuroBoNeT.

Disclosures

Pierre Kunz, Joerg Fellenberg, Linda Moskovszky, Zoltan Sápi, Tibor Krenacs, Isidro Machado, Johannes Poeschl, Burkhard Lehner, Miklos Szendrõi, Peter Ruef, Michael Bohlmann, Antonio Llombart Bosch, Volker Ewerbeck, Ralf Kinscherf, and Benedikt Fritzsching declare no conflicts of interest.

Author information

Authors and Affiliations

  1. Department of Orthopedics and Traumatology, University Hospital Heidelberg, Heidelberg, Germany

    Pierre Kunz, Joerg Fellenberg, Burkhard Lehner & Volker Ewerbeck

  2. 1st Department of Pathology and Experimental Cancer Research, Faculty of Medicine, Semmelweis University, Budapest, Hungary

    Linda Moskovszky, Zoltan Sápi & Tibor Krenacs

  3. Pathology Department, Instituto Valenciano de Oncologia, Valencia, Spain

    Isidro Machado

  4. Clinic of Neonatology, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany

    Johannes Poeschl

  5. Department of Orthopedics, Semmelweis University, Budapest, Hungary

    Miklos Szendrõi

  6. Clinic of Pediatrics, SLK-Clinics Heilbronn GmbH, Heilbronn, Germany

    Peter Ruef

  7. Department of Obstetrics and Gynecology, University Hospital of Schleswig–Holstein, Lübeck, Germany

    Michael Bohlmann

  8. Department of Pathology, Valencia University Medical School, Valencia, Spain

    Antonio Llombart Bosch

  9. Department of Medical Cell Biology, Institute of Anatomy and Cell Biology, University of Marburg, Marburg, Germany

    Ralf Kinscherf

  10. Department of Translational Pulmonology, Translational Lung Research Center (TLRC), Member of the German Center for Lung Research, University of Heidelberg, Heidelberg, Germany

    Benedikt Fritzsching

  11. Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, University of Heidelberg, Heidelberg, Germany

    Benedikt Fritzsching

Authors
  1. Pierre Kunz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joerg Fellenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Linda Moskovszky
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Zoltan Sápi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tibor Krenacs
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Isidro Machado
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Johannes Poeschl
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Burkhard Lehner
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Miklos Szendrõi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Peter Ruef
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Michael Bohlmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Antonio Llombart Bosch
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Volker Ewerbeck
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Ralf Kinscherf
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Benedikt Fritzsching
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Pierre Kunz.

Electronic supplementary material

Below is the link to the electronic supplementary material.

10434_2014_4001_MOESM1_ESM.tif

Effects of quantification methods on vessel quantification results in representative osteosarcoma samples with varying vascularization. Representative whole- slide scans of osteosarcoma samples with heterogeneous (a) and homogeneous (b) distribution of intra- tumor vessels after CD31-immunostaining. CD31-immunoreactive cells show red cell surface staining. Sections were counterstained by hematoxylin. Inserts show a 3.7-fold (a), respectivel 3.1-fold (b) magnification of a vascular hot spot (green circle). Vessel quantification result obtained by MVD within hot spots or CD31-immunoreactive area within the whole section are indicated. Note the varying micro vessel morphology and size, effecting MVD counts. Supplementary material 1 (TIFF 14,814 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kunz, P., Fellenberg, J., Moskovszky, L. et al. Improved Survival in Osteosarcoma Patients with Atypical Low Vascularization. Ann Surg Oncol 22, 489–496 (2015). https://doi.org/10.1245/s10434-014-4001-2

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-014-4001-2

Keywords

Search

Navigation