seminars in surgical oncology volume 6 issue 4

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Seminars in Surgical Oncology 6:231-233

1990)

Inc idence of Regional Lymph No de Metastasis in

Operab le Osteogenic Sarcoma

EDUARDO CACERES

MD

MAYER ZAHARIA MD FRCR

AND

RUTH CALDERON

MD

From the Instit uto Nacio nal de Enfermedades NeoplAsicas Lima Peru

Records of 182 consecutive patients with the diagnosis of operable osteo-

genic sarcoma, treated between 1954 through 1980 by the Breast, Bone

and Mixed Tumors Department of the Instituto Nacional de Enfermedades

Neoplasicas (Lima, Peru), were reviewed to study the incidence of re-

gional lymph node metastases in this disease.

All the patients included in this study had radical surg ery, which m eans

the complete resection of the bone where the tum or is located, including

the proximal joint, which permitted excision of th e regional lymph nodes.

Nineteen patients (10.4 ) had eviden ce of sarcom a metastatic to drain-

ing lymph nodes. A comprehensive analysis of the literature shows that

the incidence of metastasis to the lymph nodes in this stu dy, is higher than

those cited in a review of the liter ature, probably due to the policy in the

managem ent of osteogenic sarcom a in our institution , during the period of

study.

KEY

WORDS:

major amputations, eradication of lymph nodes, literature review

INTRODUCTION

At the Instituto Nacional de Enfermedades Neoplasi-

cas (INEN), since 1954, osteogenic sarcoma has been

treated by complete resection of the bone at the location

of the tumo r, including the proximal joint, w hich permits

excision of the regional lymph node.

Twenty years ago, a clinicopathologic analysis on the

incidence of lymph node m etastasis occurring in 35 con-

secutive cases of osteogenic sarcoma treated by radical

surgery, was made by Caceres et al. [l]. This is an

extension of that study and comprises 182 patients, in-

cluding the 35 previous reported cases are included.

Traditionally, it has been stressed that sarcomas

spread by the vascular system and seldom by the lym-

phatic system. However, with bone and soft tissue sar-

coma treated by radiation therapy and chemotherapy,

lymphatic metastasis occurs if the pa tient survives long

enough 121.

Tumor cells may penetrate the bloodstream either in

the primary tumor, by lymphatic or venous connections

in a lymph node, or by passage up to the lymphatic chain

to the thoracic duct. Whether lymph nodes can serve as

a temporary filter for metastatic tumor cells still is not

clear [3]. In most of the experimental animal systems

used t investigate this, normal nodes have been sub-

1990

Wiley-Liss,

Inc.

jected to an influx of a large number of tumor cells, a

situation that may not be an alogous at all to the regional

lymph nodes in the early stage of tumor spread in hu-

mans [4]. The development of metastasis is a highly

selective, complex process that is dependent on the in-

terplay of host and tumor cell properties.

MATERIAL AND METHODS

We reviewed the charts of 182 patients with osteo-

genic sarcoma of the extremities treated by radical sur-

gery by the Breast, Bone and Mixed Tumors Department

of

the Instituto Nacional de Enfermedades Neoplasicas

(INEN) (Lima, Peru) between January 1963 and Decem-

ber 1980. Patients considered operable at the time of

diagnosis and those who underwent major amputations

(modified hemipelvectomy interscapulothoracic ampu-

tation, forequarter-mid-thigh amputation) including re-

gional lymph node in the surgical specimen, form the

basis of this study . Patients with parosteal sarcoma were

excluded from the study.

Patients with local regional relapses or distant metasta-

sis were excluded. The lack of metastasis was routinely

Address reprint requests to Dr. Eduardo Caceres, Instituto Nacional

de

Enfermedades Neoplasicas, Lima

34,

Peru.



232

Caceres et al

assessed by complete physical exa mination, chest radi-

ography, lung linear tomography of the chest, bone scan,

and blood chemistries performed at the time of presen-

tation at

INEN.

There were 182 patients that conformed to the require-

ments of the study, consisting of

105

men and 77

wom en, ranging in age from

2

to 38 years. Th e primary

tumor location was femur 148 (81 .3 ), humerus 8

(4.4 ), tibia 23 (12.7 ), fibula 2 (l .l ), and scapula 1

(0.5 ).Most patients had large tumors, w ith the sma ll-

est 10.5 cm in diameter and the largest 1 6 cm .

Surgical treatment was as follows: 148 underwent

modified hemipelvectomy

9

interscapulothoracic ampu-

tation, and 25 mid-thigh amputation. From the operative

specimen, a11 the lymph nodes from the femoral iliac,

axillary and popliteal regions were individually dis-

sected and examined histologically for metastasis. In

each case, the microscopic picture was carefully com-

pared with the primary tum or; only those that were com-

patible were accepted as metastasis. The characteristics

of the 182 patients included in the study a re presented in

Table I.

INCIDENCE

OF

LYMPH

NODE

METASTASIS

Metastatic spread of osteogenic sarcoma of bone from

the original bone site to the regional lymph nod es is not

a frequent event in the na tural history of this disea se; it is

a subject that has received little attention in the literatu re.

It

is

difficult to estimate the true incidence of lymph

node metastasis in osteogenic sarcom a. Data are sca nt,

and most published series provide relatively brief com-

TABLE I. Clinical Cha racteristicsof

182

Patients Treated

for

Osteogenic Sarcoma by Radical Surgery, in Which Lymph Node

Metastasis Was Investigated

ments and im precise information regarding lymph node

metastasis.

In a review of the literature, five studies

1,5431 were devoted to lymph nodes spread from osteo-

genic sarcoma.

Detection of metastasis to regional lymph nodes at

diagnosis of the primary lesion is even less frequent.

Occasionally, however, it is possible to visualize in the

radiographic picture an ossifying metastasis in the re-

gional lymph node

[9],

since bone formation in the pri-

mary lesion and the m etastasis is a pec uliar characteristic

of these tumors (Fig. 1).

Regional lymph node involvem ent occurred in 10.4

of

the 182 patients treated by radical surgery at INEN

from 1963 through 1980. This observation

is

in disagree-

ment with those from other centers (Table

11),

which

report a lower incidence.

This

finding may have been influenced by the overall

design of

our

therapeutic procedure, which includes the

eradication of the reg ional lymph nodes; the probability of

metastasis depends on histologic grade of the tumor and

size of the primary sarcoma.

All

our tumors were larger

than the average reported in the literature (10.5-16 cm).

No. of patients

8

Sex

Female 77 42.3

Male

105 57.7

18 9.9

135 74.1

24 13.2

2.8

Site of primary tumor

Femur

148 81.3

Humerus

8 4.4

Tibia

23 12.7

Fibula

2 1.1

Scapula

1

0.5

Treatment of the primary tumor

Fig.

1.

Osteogenic sarcoma of the humerus, with

an

ossifying lymph

node metastasis. Patient alive 24

years

after interscapulothoracic am

putation. (Reproduced with the permission of J.B. Lippincott Co.,

Hemipelvectomy

148

Mid-thigh amputation

Interscapulothoracic amputation 9

25 13.8 from Cancer Vol. 30, pp. 63-38, 1972.)



Node Metastasis

and

Operable Osteogenic Sarcoma

233

TABLE 11. Incidence

of

Involvement

of

Lymph Nodes

n

Series

of

Patients Treated for Osteogenic Sarcoma

Cases with

involved nodes

No. of

Investigators cases N Comments

Jenkin et al. [5] 51 2 3.9

Caceres et al. [l ] 35 4 11.4

Rao and Nagaraj [6] 139 2 1.4

McKenna et al. [7] 276 18 6.5

Weingrad and

Rosenberg [8] 31 1 3.2

Jeffree et al. [ l l ] 24 4 3.2

Caceres et al. 182” 19 10.4

Phelan et al. [lo] 12 6 50.0 Autopsy

McKenna et al. [7] 48 15

31.3 Autopsy

Jeffree et al. [ l 11 29 3 10.0 Autopsy; regional

hmDh nodes

“This series included 35 cases previously reported.

There are few reports in the literature on the incidence

of

lymph node metastasis in autopsy material. Phelan

and Cabrera [lo] reported an incidence of 50 in 12

patients for whom a complete autopsy report was avail-

able and in the series of McKenna et al. [7],

15

of 48

patients (31.3 ) had involvement of nodes at the time of

autopsy, suggesting a progressive increase in metastasis

during the course of the disease.

Jeffree et al. 111 found 10 of regional lymph node

metastasis of the 29 autopsied cases of tumors of the long

bones and in only 3 of the 124 clinical records. How-

ever, none of these figures approaches the 50 fre-

quency of lymph node involvem ent reported by M akai et

a1 121 on lymphographic evidence.

DISCUSSION

There has been no internationally accepted method of

staging osteogenic sarcoma that could help us in deter-

mining the spread

of

disease. Traditionally, it has been

stated that lymph node metastases are seldom observed

or occur only occasionally in patients with osteogenic

sarcoma. This has been shown to be a misconception,

as

many of these tum ors metastasize directly to the regional

lymph node in the operable stage of the disease, and the

eradication of these lymph nodes represents an integral

part

of

the treatment policy.

The prognostic significance of the regional lymph

node in osteogenic sarcoma and their role in the immune

response against osteosarcoma has been suggested by

Shrikhande and R ao

[13],

who ha ve stressed its impor-

tance and suggest that preservation of regional nodes in

cases of osteogenic sarcoma is justified.

The involvement of regional lymph nodes has been

accepted as a powerful predictor

of

a poor outcome for

patients with osteogenic sarcoma. In our exp erience , the

results are more encouraging; 4 of 19 patients (21 )

remain free of disease for m ore than 5 years and 1 female

patient with osteogenic sarcoma of the humerus is alive

without evidence of disease for more than 24 years (see

Fig. 1). It is stressed that a significant number

of

osteo-

genic sarcomas metastasize to the lym ph nodes, and

the

eradication of these lymph nodes represents n integral

part of treatment policy.

REFERENCES

1. Caceres E, Zaharia M, Tantalean E: Lymph node metastasis in

osteogenic sarcoma. Surgery 65:421-422, 1969.

2. Lee YTNM: Lymph node involvement in soft tissue and bone

sarcomas. In Weiss L, Gilbert MA, Ballon SC (eds): “Lymphatic

System Metastasis.” Boston: GM Hall, 1980, 410433.

3. Sugarbaker EV: Cancer Metastasis: A Product of Tumour-Host

Interactions. Vol. 3. Chicago: Year Book Medical Publishers,

4. Cam I Lymphatic Metastasis. Cancer Metastasis Rev 2:307-319,

1983.

5. Jenkin RDT, Allt WEC, Fitzpatrick PJ: Osteosarcoma. An as-

sessment of management with particular reference to primary ir-

radiation and selective delayed amputation. Cancer 30:393-400,

1972.

6. Rao RS, Nagaraj D: Prognostic significance

of

the regional lymph

nodes in osteosarcoma.

J

Surg Oncol9:123-130, 1977.

7.

McKenna RJ Schwinn CP, Soong

KY,

Hinginbotham NL: Sar-

comata of the osteogenic series (osteosarcoma, fibrosarcoma,

chondrosarcoma, parosteal osteogenic sarcoma and sarcoma aris-

ing in abnormal bone). An analysis of 552 cases. J Bone Joint

Surg 48A:1-26, 1966.

8.

Weingrad DN, Rosenberg SA: Early lymphatic spread of osteo-

genic and soft tissue sarcomas. Surgery 84:231-240, 1978.

9. Case Records of the Massachusetts General Hospital: Osteogenic

sarcoma

of

humerus, with ossifying metastasis in the regional

nodes. N Engl J Med 225:953-956, 1941.

10. Phelan JT, Cabrera A: Osteosarcoma

of

bone. Surg Gynecol Ob-

stet 118:33 336, 1964.

11. Jeffree GM, Price HG, Sisson HA: The metastatic patterns of

osteosarcoma. Br Cancer 32537-107, 1975.

12. Makai

F,

Belan A, Malek P: Lymphatic metastasis of bone tu-

mours. Lymphology 3:109-113, 1971.

13. Shrikhande SS, Rao RS: Histopathological study of regional

lymph nodes in osteosarcoma. J Surg Oncol 9:371-377, 1977.

1979, 1-59.

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