Treatment of femoral Ewing's sarcoma

Local Control Modality and Outcome for Ewing Sarcoma of the Femur: A Report From the Children's Oncology Group

BACKGROUND

The choice of a local control (LC) modality for Ewing sarcoma (EWS) of the femur is controversial. This study aimed to determine the effect of LC modality on tumor LC and patient outcomes.

METHODS

The study reviewed the treatment and outcomes for 115 patients who had EWS of the femur treated with similar chemotherapy in three cooperative group trials. Patient outcomes were analyzed according to the LC modality using the log-rank test and the cumulative incidence of local or distant failure using competing risks regression.

RESULTS

The median age of the patients was 13 years. The most common tumor location was the proximal femur followed by the mid femur. For 55 patients with available data, the tumor was larger than 8 cm in 29 patients and 8 cm or smaller in 26 patients. For 84 patients (73 %), surgery only was performed, whereas 17 patients (15 %) had surgery plus radiation, and 14 patients (12 %) had radiation only. The 5-year event-free survival (EFS) rate was 65 % (95 % confidence interval [CI], 55-73 %), and the 5-year overall survival (OS) rate was 70 % (95 % CI, 61-78 %). Patient outcomes did not differ significantly according to tumor location within the femur (proximal, mid or distal) or tumor size (<8 vs ≥8 cm). The findings showed no statistically significant differences in EFS, OS, cumulative incidence of local failure, or cumulative incidence of distant failure according to LC modality (surgery, surgery plus radiation, or radiation).

CONCLUSIONS

The LC modality did not significantly affect disease outcome for EWS of the femur. Further study of treatment complications and functional outcome may help to define the optimal LC modality.

Pathological femoral fracture caused by primary bone tumour: a population-based study

This population-based study aimed to analyse the demographic, clinical and histological features of patients with a malignant primary bone tumour of the femur presenting with a pathological fracture. Eighty-four patients were identified from a prospectively gathered national tumour database between 1960 and 2004. Demographic data, presenting features, tumour location, histological diagnosis, treatment, local recurrence, metastasis and survival data were gathered. An estimate of the annual incidence was obtained using population data from the General Register Office and was 0.4 per million population per annum. The mean age was 56 years (range 4-87 years) with a bimodal distribution and 46% were men or boys. Forty-one percent of patients presented with a history of trauma. The average duration of symptoms before presentation was 1-3 months. The most common histological diagnoses were osteosarcoma (14 patients) and Paget's sarcoma (12 patients). The local recurrence rate was 38% and the overall five-year survival was 22%. The prognosis was made worse by local tumour recurrence, the development of metastasis and age at diagnosis greater than 21 years. Limb salvage surgery did not alter the prognosis. Patients who present with pathological fracture of a primary malignant bone tumour, carry a poor prognosis in all tumour types and no improvement in survival was identified over the period of the study.

Bone marrow cells participate in tumor vessel formation that supports the growth of Ewing's sarcoma in the lung

An MHC-mismatch bone marrow (BM) transplant Ewing's sarcoma mouse model was used to investigate whether BM cells participate in the vessel formation that support Ewing's sarcoma lung metastasis. BM cells from H-2K(b/d) donor mice were transplanted into sublethally irradiated H-2K(d) recipient mice. Donor BM cells were identified using the H-2K(b) marker. Engraftment was confirmed by identifying the H-2K(b) IL-1β-type specific polymorphism. After engraftment highly lung metastatic TC71-PM4 cells were injected intravenously. Mice were sacrificed 10 weeks after tumor cell injection. Hematoxylin-and-eosin staining was performed to identify lung metastatic foci. These tumors were then evaluated using immunohistochemical analysis. H-2K(b)-positive cells were found in lung metastases but not in normal lung, liver or spleen tissues. Injection of CM-Dil-labeled BM cells into tumor bearing and control mice showed that nonspecific organ migration occurred at 24 h, but that these cells were absent 1 week later in control mice. These data suggest that the migration of the H-2K(b) BM cells to lung nodules was specific because these cells were observed 14 weeks after transplantation. Co-localization of H-2K(b) and CD31 or VE-Cadherin demonstrated that some endothelial cells were BM-derived. Co-localization of H-2K(b) and Desmin, smooth muscle actin (α-SMA) or PDGFR-β indicated that a fraction of pericytes was also BM-derived. These results suggest that BM cells participate in the vascular formation that supports the growth of Ewing's sarcoma lung metastases. BM cells migrated to the metastatic tumor and differentiated into endothelial cells and pericytes. These data indicated that targeting this process may have therapeutic potential.

Ewing's sarcoma family tumors of the humerus: outcome of patients treated with radiotherapy, surgery or surgery and adjuvant radiotherapy

BACKGROUND AND PURPOSE

Local treatment for non-metastatic Ewing's sarcoma family tumors (ESFTs) is controversial. Results achieved in a single institution in patients with ESFT of the humerus are presented.

MATERIALS AND METHODS

Patients treated between 1983 and 2000 for ESFT of the humerus were included. The impact of local treatment (surgery, radiotherapy or both) on outcome was assessed.

RESULTS

55 patients: 34 males (62%); 21 females (38%); mean age: 17.9 (range: 3-40). Local treatment: surgery in 27 patients (49%), radiotherapy in 17 (31%) and surgery followed by radiotherapy in 11 (20%). After a mean follow-up of 15 years (range: 7-25 years), 27 patients (49%) remained continuously disease free, 27 (49%) relapsed and one died of chemotherapy toxicity. The local recurrence rate was 13% overall: 18% (3/17) after radiotherapy, 7% (2/27) after surgery and 19% (2/11) after surgery followed by adjuvant radiotherapy (p=ns). On the contrary, the 10-year EFS resulted significantly higher after surgery (64%) than radiotherapy (18%, p<0.01). The 10-year EFS after surgery followed by radiotherapy was 45%, non-significantly different from EFS of surgery or radiotherapy alone. The 3 treatment groups had a similar distribution of the most important prognostic variables for ESFT, except for the tumor-bone ratio, which was higher for patients who underwent radiotherapy, and surgical margins, more frequently inadequate in patients treated with a combination of radiotherapy and surgery compared to those managed by surgery alone.

CONCLUSIONS

In conclusion this study shows that in EFST of the humerus surgery is the best treatment for small tumors. Large tumors are probably best treated with surgery too, as long as good functional results and quality of life can be expected, and adequate surgical margins are achievable. Postoperative radiotherapy is mandatory when margins are inadequate. A high local control rate, of more than 80%, can be obtained also by means of radiotherapy alone.

Long-Term Clinical and Functional Outcomes After Treatment for Localized Ewing's Tumor of the Lower Extremity

PURPOSE

Retrospective review describing the 35-year University of Florida experience with Ewing's tumors of the lower extremity.

PATIENTS AND METHODS

Fifty-three patients were treated between 1971 and 2006. Thirty patients were treated with radiotherapy (RT) alone and 23 patients were treated with surgery +/- RT. Larger tumors and tumors of the femur were treated more often with definitive RT. Median potential follow-up was 19.2 years. Functional outcome was assessed using the Toronto Extremity Salvage Score (TESS).

RESULTS

Before 1985, 24% of patients were treated with surgery; since then, the rate has increased to 61%. The 15-year actuarial overall survival (OS), cause-specific survival (CSS), freedom from relapse, and limb preservation rates were 68% vs. 47% (p = 0.21), 73% vs. 47% (p = 0.13), 73% vs. 40% (p = 0.03), and 43% vs. 40% (p = 0.52), respectively, for patients treated with surgery +/- RT vs. RT alone. Excluding 8 patients who underwent amputation or rotationplasty, the 15-year actuarial local control rate was 100% for the surgery +/- RT group and 68% for the definitive RT group (p = 0.03). The ranges of the TESS for surgery +/- RT vs. RT alone were 70-100 (mean, 94) and 97-100 (mean, 99), respectively. Twenty-six percent (6/23) of patients had complications related to surgery requiring amputation or reoperation.

CONCLUSIONS

Overall survival and CSS were not statistically compromised, but we observed an increased risk of relapse and local failure in patients treated with RT alone, thereby justifying a transition toward primary surgical management in suitable patients. However, despite an adverse risk profile, patients treated with RT alone had similar long-term amputation-free survival and demonstrated comparable functional outcomes. Poor results observed in Ewing's of the femur mandate innovative surgical and RT strategies.

Expression of granulocyte-colony-stimulating factor and its receptor in human Ewing sarcoma cells and patient tumor specimens: potential consequences of granulocyte-colony-stimulating factor administration

BACKGROUND

Ewing sarcoma (ES) is a highly vascular malignancy. It has been demonstrated that both angiogenesis and vasculogenesis contribute to the growth of ES tumors. Granulocyte-colony-stimulating factor (G-CSF), a cytokine known to stimulate bone marrow (BM) stem cell production and angiogenesis, is routinely administered to ES patients after chemotherapy. Whether ES cells and patient tumor samples express G-CSF and its receptor (G-CSFR) and whether treatment with this factor enhances tumor growth was examined.

METHODS

Human ES cell lines were analyzed for expression of G-CSF and G-CSFR in vitro and in vivo. Sixty-eight paraffin-embedded and 15 frozen tumor specimens from patients with ES were also evaluated for the presence of G-CSF and G-CSFR. The in vivo effect of G-CSF on angiogenesis and BM cell migration was determined. Using a TC/7-1 human ES mouse model, the effect of G-CSF administration on ES tumors was investigated.

RESULTS

G-CSF and G-CSFR protein and RNA expression was identified in all ES cell lines and patient samples analyzed. In addition, G-CSF was found to stimulate angiogenesis and BM cell migration in vivo. Tumor growth was found to be significantly increased in mice treated with G-CSF. The average tumor volume for the group treated with G-CSF was 1218 mm(3) compared with 577 mm(3) for the control group (P = .006).

CONCLUSIONS

The findings that ES cells and patient tumors expressed both G-CSF and its receptor in vitro and in vivo and that the administration of G-CSF promoted tumor growth in vivo suggest that the potential consequences of G-CSF administration should be investigated further.

Ewing's sarcoma and primitive neuroectodermal family of tumors

Ewing's sarcoma (ES) initially was believed to be of perivascular endothelial origin. The Ewing's sarcoma family of tumors (EFT) includes ES of bone (ESB), extraosseous ES (EES), peripheral primitive neuroectodermal tumor of bone (pPNET), and malignant small-cell tumor of the thoracopulmonary region, or Askin's tumor, all of which are now known to be neoplasms of neuroectodermal origin. The degree of neuronal differentiation has been used for histopathologic subclassification of the EFT as classical ES (ESB or EES), which is characterized by minimal evidence of neural differentiation, and pPNET, which displays evidence of neural differentiation by standard microscopy, electron microscopy, or immunohistochemistry. Because the behavior, prognosis, and treatment appear to be similar for all subsets of EFT, this histopathologic subclassification may not be clinically significant, though some debate remains whether neural differentiation predicts for inferior outcome.

Neoadjuvant chemotherapy for Ewing's tumour of bone: recent experience at the Rizzoli Orthopaedic Institute

The results achieved in 157 patients with non-metastatic Ewing's sarcoma of the bone treated at a single institution between 1991 and 1997 according to a new protocol (REN-3) are reported. Induction chemotherapy consisted of two cycles of 'VAC': vincristine (V), doxorubicin (A), cyclophosphamide (C) alternated with one cycle of 'VIAc': V, ifosfamide (I), actinomycin (Ac). After local treatment, patients received three more cycles of VAC, two of VIAc, three cycles of I plus etoposide (E) and two cycles with V, C and Ac. Local treatment was surgery in 53% of patients, surgery+radiotherapy in 25% and radiotherapy only in 22%. With a follow-up ranging between 4 and 10 years (mean: 7 years), 110 patients (70%) remained continuously event-free, 2 patients died of toxicity and 45 patients relapsed: 33 due to metastases and 12 due to local recurrence always associated with metastases. The 5-year event-free survival (EFS) and overall survival (OS) were 71.0 and 76.5% respectively. These results are significantly better that the ones achieved in our previous three studies in which a three-drug VAC regimen (REA-1), and 4-drug VACAc regimen (REA-2 and REN-1) was used, and in our most recent study (REN-2) which was based on a six-drug regimen as in the present study, but where I and Ac were used only after the local treatment. However, since REN-3 surgery was used in a significantly larger number of patients, we cannot say whether the better outcome of this study was due to the use of a six-drug regimen with an early delivery of ifosfamide and actinomycin, or to the wider use of surgery as local treatment or both.

Regional drug delivery with radiation for the treatment of Ewing's sarcoma. In vitro development of a taxol release system

Recently, several studies have suggested the radiosensitizing effect of taxol, a microtubular inhibitor. Our overall hypothesis is that a combination of radiation and taxol may demonstrate therapeutic efficacy over doses of either individually. Studies examining taxol use have mostly focused on systemic administration, which can lead to undesired effects. To circumvent these side effects, we propose a locally administered polymeric microsphere delivery system combined with radiation therapy for the treatment of Ewing's sarcoma. The present study focuses on the in vitro ability of taxol when present as a microencapsulated drug delivery system, and delivered locally at the site of the sarcoma/tumor, to block cells in the G2/M phase of the cell cycle and potentially enhance the radiation sensitivity of cells. Using the bioresorbable poly(anhydride-co-imide), poly[pyromellityl-imidoalanine-1,6-bis(carboxy-phenoxy)hexane] (PMA-CPH), and the radiosensitizing agent taxol, a microsphere based delivery system was fabricated. A solvent evaporation technique was used to encapsulate taxol at doses of 1%, 5%, and 10% in PMA-CPH microspheres. Release kinetics studies demonstrated that the total amount of taxol released and the release rate were directly dependent on loading percentage. Taxol's bioactivity and radiosensitizing ability were measured using flow cytometry. Co-culture of Ewing's sarcoma cells with and without taxol-loaded microspheres demonstrated that released taxol retained its bioactivity and effectively blocked cells in the radiosensitive G2/M phase of mitosis. The taxol-radiation delivery system studied achieved an 83% decrease in tumor cell count compared to control. Taxol effectively sensitized Ewing's sarcoma cells to radiation with radiosensitivity shown to be independent of radiation dose at levels of dosages studied. This work has demonstrated that taxol can be effectively released from a biodegradable PMA-CPH microsphere delivery system while maintaining potent combined cytotoxic and radiosensitizing abilities.

Local therapy and other factors influencing site of relapse in patients with localised Ewing's sarcoma. United Kingdom Children's Cancer Study Group (UKCCSG)

Relapse patterns have been documented in 191 children with localised Ewing's sarcoma treated with the United Kingdom Children's Cancer Group (UKCCSG) Ewing's Tumour regimen ET2. All received chemotherapy comprising ifosfamide, vincristine, doxorubicin and actinomycin D. Local treatment modality was excision and or radiotherapy depending on tumour site and response to primary chemotherapy. Although not strictly comparable, due to the clinical indications used for each modality, local relapse rates were very low and were similar, irrespective of the type of local treatment modality: radiotherapy (3/56), surgery (7/114) or a combination (0/20). Combined relapse (local + distant) rates were similarly low irrespective of the type of local therapy: radiotherapy (4/56), surgery (4/114) or a combination (0/20). Overall survival was lower in females (P = < 0.04), older children (P = < 0.002) and those with primaries at sites other than long bones (P = < 0.02). It is concluded that with effective intensive chemotherapy combined with either radiotherapy or surgery, local control in this study was excellent at sites other than the pelvis. Preventing distant relapse, predominantly to lung and bone, remains the major challenge.

Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors

BACKGROUND AND OBJECTIVES

Limb-sparing surgery has become the preferred surgical treatment of malignant bone tumors. The objective of this study was to evaluate factors that influence the morbidity and outcome of prosthetic knee replacement after resection of malignant tumors of the distal femur.

METHODS

Eighty-two patients who had a resection of malignant tumor of the distal femur and implantation of a segmental knee prosthesis (minimum follow-up, 2 years) were retrospectively reviewed.

RESULTS

Twenty-nine patients (35%) underwent 32 prosthetic revisions, 6 from perioperative wound complications, 13 from aseptic loosening, and 13 from other complications. The 3-, 5-, and 10-year Kaplan-Meier prosthetic survival rates were 82%, 71%, and 50%, respectively. On univariate analysis, patients who had more than 40% resection of the distal femur (P = 0.010) and those who had all their vasti muscles resected (P = 0.011) had significantly worse prosthetic survivals than the others. On multivariate analysis, resection of more than 40% of the distal femur was a significant negative prognostic factor for prosthetic survival (P = 0.017). Aseptic loosening was the primary cause of late prosthetic failure. Differences in the magnitude of resection influenced prosthetic survivorship more than prosthetic design.

CONCLUSIONS

In the distal femoral endoprosthetic replacement, higher short- and long-term complications were found after extensive resections. Aseptic loosening was the primary cause of prosthetic failure.