Venous tumor thrombus decreased survival time in patients with pelvic osteosarcoma
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Venous tumor thrombus is a negative prognostic factor associated with several factors and most commonly occurs in patients with pelvic osteosarcoma, according to published results.
Researchers analyzed demographic data and the results of initial laboratory tests, imaging examinations and oncological evaluations for 451 patients with primary, bone-derived, treatment-naïve pelvic sarcomas. Researchers identified chondrosarcomas in 41.2% of patients, osteosarcomas in 30.4% of patients, Ewing sarcomas in 15.5% of patients, bone-derived undifferentiated pleomorphic sarcomas in 5.8% of patients and other bone sarcomas in 7.1% of patients.
Results showed 9.8% of patients had venous tumor thrombus, which was associated with a lactate dehydrogenase level of 230.5 U/L or greater and invasion of the L5-S1 intervertebral foramen. Researchers found a high prevalence of venous tumor thrombus among patients with pelvic osteosarcoma. Factors associated with venous tumor thrombus in patients with osteosarcoma included a chondroblastic subtype, a lactate dehydrogenase level of 187 U/L or greater and invasion of the obturator foramen and the L5-S1 intervertebral foramen, according to results. Researchers noted patients with venous tumor thrombus had a poor prognosis, with a median overall survival time of 14 months. The presence of venous tumor thrombus in patients with localized pelvic osteosarcoma decreased the median overall survival time, median recurrence-free survival time and median metastasis-free survival time, according to results of a subgroup analysis.
Researchers proposed an algorithm for the management of pelvis sarcomas with venous tumor thrombus stratified by the classification of the venous tumor thrombus, which included insertion of an inferior vena cava filter to prevent pulmonary embolism and recommended neoadjuvant chemotherapy for patients with Ewing sarcoma or osteosarcoma.
“Wide resection of the primary tumor and [venous tumor thrombus] VTT should be attempted for patients with type-1 or 2 VTT, as it may improve local control and overall survival,” the authors wrote. “As for type-3 VTT, surgery is recommended only for chemosensitive cases, as thrombectomy of the inferior vena cava is extremely challenging and type-3 VTT is prone to recurrence after such procedures.”
Perspective
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Despite advances in multimodality treatment, outcomes of pelvic sarcoma remain relatively poor and are worse than that of similar tumors in the extremities. This large retrospective study from Beijing adds to our understanding of these difficult tumors by focusing on an understudied and often underestimated event: extension of tumor into adjacent veins, causing venous tumor thrombus.
The main findings of the study are that osteosarcoma had a higher rate of venous tumor thrombus than other pelvic sarcomas (22.6% vs. 3.8%) and supported the previously suggested finding that the chondroblastic subtype of osteosarcoma had the highest rate within that diagnosis umbrella (20 out of 31 osteosarcoma venous tumor thrombus cases were chondroblastic). Elevated lactate dehydrogenase was associated with an increased rate of venous tumor thrombus, which may represent a marker for more metabolically active and more aggressive tumor biology, as was invasion of the L5-S1 intervertebral foramen, which may be due to increased anatomic access to the Batson’s venous plexus. As expected, patients with venous tumor thrombus had a poorer prognosis and increased risk of metastasis, but wide resection including resection of the involved vein did decrease local recurrence rates. This suggests that for otherwise resectable tumors, venous tumor thrombus is not necessarily a contraindication to surgical management.
The prognostic information presented will help surgeons better inform patients with venous tumor thrombus of the impact of their diagnosis. A classification system of venous tumor thrombus is proposed, which will need further study to validate. Overall, this is an important study that further refines our understanding of these difficult tumors.
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