Intensive chemotherapy as primary treatment for rhabdomyosarcoma of the pelvis

Presence of well-differentiated rhabdomyoblasts at the end of therapy for pelvic rhabdomyosarcoma: implications for the outcome

The presence of well-differentiated rhabdomyoblasts at the end of therapy for rhabdomyosarcoma has been noted. This study was undertaken to investigate the therapeutic implications of the presence of well-differentiated rhabdomyoblasts at the end of therapy for pelvic rhabdomyosarcoma. Six patients with pelvic rhabdomyosarcoma (bladder-prostate, 4; vulvovaginal, 2) with disease diagnosed between the years 1974 and 1992 were sequentially investigated by cystoscopic or vaginoscopic examination and biopsy during and after completing therapy. All six patients received treatment according to prevailing therapeutic protocols. Biopsy material from all six patients at the end of therapy documented the presence of well-differentiated rhabdomyoblasts. Repeated biopsies demonstrated the presence of rhabdomyoblasts; however, they appeared to decrease in number with time. Mitotic activity was not observed in the biopsy materials obtained. All six patients are alive without evidence of disease from 37 to 233 months after therapy ended. The presence of well-differentiated rhabdomyoblasts at the end of therapy for pelvic rhabdomyosarcoma is a common finding. The biologic nature of these well-differentiated rhabdomyoblasts is not completely known, but they do not appear to connote the persistent presence of malignant disease and are not an indication for the continuation of therapy.

Primary chemotherapy for children with rhabdomyosarcoma of the 'special pelvic' sites: is preservation of the bladder possible?

Twenty-one children with rhabdomyosarcoma involving the "special pelvic" sites, defined as such occurring in the bladder, prostate, vagina and uterus, were treated with primary surgery between 1969 and 1977, and with primary chemotherapy beginning in 1978. Among 11 patients in the latter group who were placed in Clinical Group III (according to the classification of the US Intergroup Rhabdomyosarcoma Study (IRS), six showed partial response (PR) and underwent tumorectomy by radical surgery an average of 6 months after the start of treatment, and three showed complete response (CR) and were treated with further chemotherapy in the hope that cystectomy could be avoided. However, in the latter group, the tumor recurred (39 months, 35 months, and 27 months later), and all eventually underwent total cystectomy. Seven of the nine long-term survivors underwent total cystectomy and have premanent urinary-cutaneous stomas. Two had tumor-free bladders, but function was impaired in one because of the effect of irradiation. Normal function was preserved in only one patient in the series, whose tumor was located at the dome of the bladder. To preserve bladder function in children with rhabdomyosarcoma in these sites, more effective forms of chemotherapy will be required.

Bladder/prostate rhabdomyosarcoma: results of the multi-institutional trials of the Intergroup Rhabdomyosarcoma Study

Rhabdomyosarcomas (RMS) occurring in pelvic sites are almost entirely of the embryonal histologic subtype and are relatively responsive to chemotherapeutic agents. When treated by radical surgery, pelvic irradiation, and intensive chemotherapy for 2 years, survival rates of higher than 85% have been achieved. However, the effects of such therapeutic approaches have resulted in major changes in the quality of life of survivors, because of the loss of pelvic organs, primarily the bladder. Current efforts are directed towards achieving long range survival with procedures that are less extensive than pelvic exenteration or total cystectomy and by regimens that eliminate or reduce the intensity of radiotherapy. Until the past 5 years, these efforts have been relatively unsuccessful in both North America and Europe. However, the most recent studies of the IRS and European cooperative groups suggest that a majority of these patients can survive with intact pelvic organs when treated with currently available chemotherapeutic agents in conjunction with radiotherapy and limited surgery.

Conservative surgery of bladder-prostate rhabdomyosarcoma in children: results after long-term follow-up

Between 1968 and 1982, 10 children (7 boys and 3 girls) with a mean age of 3.2 years affected by bladder (8 cases) and prostate (2 cases) rhabdomyosarcoma (RMS)--all histologically embryonal--were seen. Three (1 with bone metastases at diagnosis and 2 with stage III tumor) underwent radical surgery; all died because of progression of the disease. Seven children were treated with conservative surgery: 3 solid type bladder tumors were removed together with a narrow strip of apparently healthy bladder wall, sparing 30% to 70% of the bladder; 3 botryoid type bladder tumors were removed bluntly and implantation sites fulgurated; in 1 prostate tumor osmotic cytolysis of the neoplastic mass was achieved with multiple injections of hypertonic saline solution (NaCl 30%). Surgery was followed by chemotherapy with a vincristine actinomycin D and cyclophosphamide protocol and radiotherapy (20 to 39.5 Gy). Six of the seven are alive and disease free with a normal functional bladder after 10 to 21 years. The validity of a primary conservative surgical approach with preservation of the bladder, followed by adjuvant therapy, is emphasized.

Local failure in childhood rhabdomyosarcoma and undifferentiated sarcoma: prognostic factors and implications for curative therapy

In this retrospective review, the risk factors for local failure in childhood rhabdomyosarcoma and undifferentiated sarcoma were assessed in 49 patients managed by a multi-disciplinary team at the Prince of Wales Children's Hospital, Sydney, between 1970 and 1988. Average follow-up time was 6.1 years. Sixteen of 49 patients experienced local failure defined as local recurrence after complete excision (5/20) or progressive local disease following incomplete resection (11/29). Fourteen of 16 patients who experienced local failure have died. Using logrank analysis of time to local failure, we found significantly increased risk with "non-embryonal" histology (P = 0.032), residual tumour (P = 0.052, higher IRS group (P = 0.088), "inadequate radiotherapy" for residual tumour (P = 0.001), delay in definitive local treatment (P = 0.038) and Adriamycin-containing chemotherapy (P = 0.017). When these factors were examined by multivariate analysis (Cox regression), only the presence of residual tumour after resection, "inadequate radiotherapy" for residual tumour (P < 0.001), and delay in definitive local therapy (P < 0.037) were shown to have independent significant association with local failure. We conclude that local failure may be avoided by prompt local treatment by either complete surgical resection or adequate radiotherapy.

The use of continent diversion in the management of rhabdomyosarcoma of the prostate in childhood

Three children with rhabdomyosarcoma of the prostate treated with combination chemotherapy and radiation therapy underwent radical extirpation with continent diversion to the urethra. This urological procedure is technically feasible even in the small child (2 years old) and offers chance for cure. Radical cystectomy with continent diversion need not be considered as mutilating surgery.

Rhabdomyosarcoma of the bladder and prostate in children

Fifteen children, 14 males and 1 female with a mean age of 4.9 years, were treated for rhabdomyosarcoma of the bladder and the prostate, between 1976 and 1985. In 14 patients, the disease was limited to the pelvis, while one had pulmonary metastases. The lesions were trigonal in 12 patients and involved the prostate in the other three. Eleven patients received vincristine-Adriamycin-cyclophosphamide (VAC) chemotherapy, followed by radiation therapy. Four of these 11 patients required cystoprostatectomy for residual or persistent disease. Of the remaining four patients, two underwent radical cystoprostatectomy, one partial cystectomy and the patient with pulmonary metastases received only chemotherapy. Six patients were alive at 5 years (40% 5-year survival). Six patients died of local relapse within 18 months, one patient died of an unknown cause, while two patients were lost to follow-up free of disease after 2 years.

Primary chemotherapy with or without radiation therapy and/or surgery for children with localized sarcoma of the bladder, prostate, vagina, uterus, and cervix. A comparison of the results in Intergroup Rhabdomyosarcoma Studies I and II

A major objective of the second Intergroup Rhabdomyosarcoma Study (IRS-II) (1978 to 1984) was to preserve the bladder without compromising the survival of children with localized genitourinary sarcomas arising in or near the bladder. After incisional biopsy, 109 patients with localized, gross residual sarcoma of the prostate (43 patients), bladder (43 patients), vagina (20 patients), or cervix/uterine corpus (3 patients) were treated with vincristine, dactinomycin, and cyclophosphamide (VAC). After two to four drug courses, radiation therapy and/or surgery were used to treat patients with residual or recurrent tumor. The 3-year survival rate of patients treated on this primary chemotherapy regimen (70%) was similar to that of the primary surgery regimens of IRS-I (78%; P = 0.46), but the 3-year disease-free survival rate was significantly inferior (52% versus 70%; P = 0.02). Since the IRS-II encouraged bladder preservation at the onset of therapy, the percentage of patients with bladder and prostate tumors who retained the bladder was initially substantially higher in IRS-II (97%) than in IRS-I (58%). However, the percentages of 95 patients with bladder-prostate (BP) tumors in IRS-II who retained the bladder and were alive at 2 and 3 years after starting treatment were only 33% and 22%, respectively, compared with 26% and 23%, respectively, in the 66 patients with BP tumors in IRS-I. Thus, sequential treatment with primary chemotherapy, followed by radiation therapy and/or surgery as given in IRS-II, failed to improve the eventual bladder salvage rate.

Sarcoma botryoides of the cervix: excision followed by adjuvant chemotherapy for preservation of reproductive function

Sarcoma botryoides is most often seen arising in the infantile vagina. Occasionally, disease will arise in the cervix in the adolescent. Most patients have been treated by radical surgery combined with multiagent chemotherapy. We recently treated a patient by local excision followed by multiagent chemotherapy in an attempt to preserve reproductive potential. The present case and a review of the literature suggest that excisional therapy with subsequent chemotherapy should be adequate for localized disease.

Rhabdomyosarcoma of the prostate in childhood: current challenges

Since 1978, six boys with prostatic rhabdomyosarcoma have been treated at our institution. Three had localized disease and were managed by initial biopsy, vincristine, actinomycin-D, and cyclophosphamide (VAC) chemotherapy, and bladder-sparing surgery with or without irradiation. Further combination chemotherapy ("pulse" VAC, Adriamycin, VP-16, cisplatin, and ifosfamide) was continued for 20 to 22 months following the induction course. Two boys had microscopic residual disease undetected by frozen section and unresponsive to radiotherapy. Subsequent total cystectomy 4 and 7 months later resulted in eradication of disease. In one patient, preservation of the bladder was achieved at the age of 3 months for 8 years. Artificial sphincter inserted to cure his urinary incontinence failed because of ischemia secondary to cuff compression and scar tissue. He is alive today with a modified Koch pouch urinary diversion. Of the 50% who had metastatic disease at presentation, two were dead within 12 months despite aggressive chemotherapy and irradiation. The third is currently on treatment. Although chemotherapy has markedly improved the prognosis, surgery is still necessary in most cases for cure. Bladder salvage is a desirable goal; however, residual microscopic disease, difficulty with frozen-section disease detection, and poor tissue vascularization for subsequent sphincter replacement remain significant obstacles.

Genitourinary rhabdomyosarcoma in children

Although rhabdomyosarcoma of the genitourinary tract occurs infrequently in children, it presents a challenging problem to the surgeon, radiotherapist, and oncologist. Thirty-six children with genitourinary rhabdomyosarcoma were treated at our institutions from 1957 to 1985. The primary site of tumor involved the bladder, prostate, or both in 15 patients, the paratesticular structures in 12, and female reproductive organs in nine. Although treatment modalities and philosophies of care varied over the past 27 years, the majority of patients were treated with a combination of surgery, chemotherapy, and radiation therapy. The event-free survival for all patients is 74%. Patients with paratesticular tumors had the best prognosis (88% event-free survival). Regional nodal radiation therapy is not necessary in this favorable group if the retroperitoneal lymph node dissection is negative. Of 15 children with bladder/prostate tumors nine had initial conservative surgery. Of these nine six are long-term survivors, but only three patients have intact bladders. The girls with tumors of the reproductive organs had an event-free survival of 63%; all patients in this group had hysterectomies. Chemotherapy and radiotherapy have not substituted for radical surgical procedures in most children with bladder or prostate rhabdomyosarcomas. Innovative therapeutic approaches are necessary for this group of patients.

Tracing expert thinking in clinical trial design

This paper describes a method for the analysis of the clinical trial design process used by experts. With this procedure, the scientific ideas and their sources can be identified and related to the clinical trial protocol actually prepared by the experts. An example is given using the work of the Intergroup Rhabdomyosarcoma Study Committee (IRS). That committee has been the primary contributor of information dealing with the treatment of rhabdomyosarcoma in children. The IRS-III protocol was used in this analysis of expert behavior because the protocol was adopted by the leading pediatric oncology clinical trial groups in North America and Europe. The analysis showed that the experts rely heavily, for much of the design, on ideas presented in numerical displays in published documents. Further, those aspects of the design which are innovative can be traced and better understood by applying the new procedure.

The predictive value of initial cytostatic response in primary unresectable rhabdomyosarcoma in children

The relation between the initial tumour regression produced by chemotherapy and the later event-free survival was studied in a prospective multicentre study on soft-tissue sarcomas in children. The event-free survival rate in patients with complete remission after seven weeks of chemotherapy was 95%; in patients with incomplete tumour reduction of greater than 2/3, 61%; and in patients with tumour reduction of less than 2/3 but greater than 1/3, 31%. Patients with partial remission at week 7, who achieved complete remission by week 16 after additional chemotherapy had an event-free survival rate of 64%. A multivariate analysis suggested that the response per unit of time was an important prognostic factor.

Pelvic rhabdomyosarcoma in children

Twenty children with pelvic rhabdomyosarcoma treated between 1976 and 1983 are reviewed. The survival rate was 55% (11/20), with a bladder salvage rate of 54.5% among survivors. Systemic chemotherapy combined with radiotherapy and/or surgery was most effective in producing cure.

Nonsquamous cancer of the vagina

This report retrospectively analyzes 48 cases of primary vaginal cancer treated at Walter Reed Army Medical Center and the Naval Hospital, Bethesda, from 1962 through 1983. There was an unusually high number of uncommon histologic types. Nine patients had an adenocarcinoma, 5 had a sarcoma, 3 had a melanoma, 2 had an adenosquamous carcinoma, 1 had a lymphoma, and 1 had a carcinoid tumor. The remaining 27 patients had a squamous cell carcinoma. This represents a 43% prevalence of nonsquamous lesions. Nonsquamous cancer of the vagina occurred in patients at an earlier age than squamous cell carcinoma. Presenting symptoms, the location of the tumor within the vagina, and survival rates were similar for both groups. The clinical characteristics and treatment of the patients with nonsquamous tumors are discussed.

Rhabdomyosarcoma of the uterine cervix. Sarcoma botryoides

Twenty-one cases of sarcoma botryoides of the uterine cervix, including four previously unreported cases, are reviewed. The age of the patients ranged from 5 months to 48 years, with a peak incidence in the group aged 14 to 18 years. Eighty percent of the patients are alive, with a mean follow-up period of 68 months. Seventy-five percent of the patients had Group I disease, of whom 88% are alive. Eleven of 14 patients (79%) receiving vincristine and dactinomycin based chemotherapy are alive. There were five patients with recurrent disease (24%) of whom two (40%) are alive. The prognosis for cervical sarcoma botryoides is similar to that of other female genital tract embryonal rhabdomyosarcomas. Primary therapy should consist of vincristine and dactinomycin based chemotherapy. Surgery should be guided by the response to initial chemotherapy and should attempt to conserve the function of the bladder, rectum, vagina, and ovaries.

The treatment of advanced or recurrent malignant genitourinary tumors in children

Wilms' tumor, embryonal rhabdomyosarcoma, and yolk sac tumor are the most frequently diagnosed malignant genitourinary tumors in children. The randomized therapeutic trials developed by the National Wilms' Tumor Study (NWTS) committee have produced significant improvements in the survival of Wilms' tumor patients. Those with Stage IV, favorable histology Wilms' tumor now have a 2-year survival rate of 87% to 93%. Patients with recurrent Wilms' tumor are being prospectively treated with new drugs and drug combinations with the goal of identifying active agents for inclusion in future therapeutic trials. Girls with localized embryonal rhabdomyosarcoma of the vagina have a 100% survival rate after treatment on the Intergroup Rhabdomyosarcoma Study (IRS) (IRS-1 or IRS-2). Primary treatment of patients with tumors of the prostate, bladder neck, or trigone with chemotherapy has demonstrated the need to establish local tumor control using surgery or radiation soon after diagnosis. The IRS-III currently is evaluating new drug combinations in this group of patients with locally advanced tumors. Patients with advanced yolk sac tumor have been treated using platinum-containing combination chemotherapy regimens with very encouraging results. Future research will evaluate the timing of second-look surgical procedures and the efficacy of etoposide-containing combination chemotherapy regimens.

Pelvic rhabdomyosarcoma: a review of the RPMI experience

Between 1959 and 1983, 16 patients with pelvic rhabdomyosarcoma were treated at Roswell Park Memorial Institute (RPMI). A multidisciplinary approach was utilized consisting of surgery, radiotherapy (XRT), and combined chemotherapy which resulted in prolonged survivals of thirteen to one hundred forty-four months in 10 patients. This improved survival was observed despite the fact that 63 per cent of the patients (10/16) presented with advanced stages of the disease. Herein we present a retrospective study of these 16 patients.

Embryonal rhabdomyosarcoma of the uterine corpus and cervix

Embryonal rhabdomyosarcomas of the uterus and cervix are rare tumors with a very poor prognosis historically. Adjuvant multidrug chemotherapy combined with local radiation therapy and/or surgery has resulted in markedly improved survival rates. Six patients with embryonal rhabdomyosarcoma of the uterus/cervix are reported, with a compilation of 28 additional patients from the literature. Nineteen of 24 patients (79%) treated with combination therapy were alive and well 4-147+ months (median 61 months) after diagnosis. The six cases from USC Medical Center and affiliated hospitals are all well 17-144 months (mean 95 months) after diagnosis. Analysis of the collected series indicates that extent of disease is an important prognostic factor. Adjuvant chemotherapy with vincristine, actinomycin D, and cyclophosphamide (VAC) improves survival. Initial therapy for embryonal rhabdomyosarcoma confined to the uterus/cervix should include radical hysterectomy, pelvic lymphadenectomy, and adjuvant chemotherapy with VAC. Pelvic radiotherapy should be employed for involved surgical margins or positive nodes. Advanced disease managed initially with chemotherapy and radiotherapy may allow subsequent curative extirpative surgery.

Advances in rational combination chemotherapy

Due to the high frequency of micro- or macrometastatic disease at the time of diagnosis of cancer, and to the increasing prevalence of cancer in this country, the use of chemotherapy to evoke cure or prolongation of survival has become critically important. In addition, the growth kinetics of large tumor burdens and the high probability of drug-resistant cells in a tumor mass at the time of diagnosis necessitate combinations of chemotherapeutic agents rather than single agents as the most effective mode of treatment. Since there are 40 to 50 active anticancer drugs now utilized, and since synergy between drug combinations is often dose and/or schedule dependent, the number of possible drug combinations and permutations is vast. Thus, screening for effective drug combinations requires a rational approach which will allow for accurate predictions of synergy. Most advances in this scientific approach have utilized biochemical modulation in conjunction with in vitro cytotoxicity assays, in particular, clonogenic assays. Such an approach has generated a number of drug combinations, such as sequential MTX-5FU, with widely applicable clinical efficacy. The continued use of biochemical modulation should rapidly generate new effective drug combinations which will, hopefully, allow us to cure even those cancers presently considered incurable.

Iridium afterloading curietherapy in the treatment of pediatric malignancies. The Institut Gustave Roussy experience

Between 1972 and 1980, 58 children with malignant tumors underwent iridium 192 (192Ir) curietherapy at the Institut Gustave Roussy. Data from only 45 of them were reviewed (bilateral retinoblastoma and salvage procedures were excluded). The pathologic diagnosis was rhabdomyosarcoma in 75% of cases, yolk sac tumor in 13% of cases, malignant mesenchymoma in two cases, clear cell carcinoma in two cases, and undifferentiated sarcoma in one case. The two major sites were pelvis-perineum (64.5%) and head and neck (31%). The treatment was essentially based on a combination of chemotherapy, which was adapted to the histologic type of the tumor, and curietherapy. Partial surgery was carried out in certain cases, either before chemotherapy for diagnostic purposes, or after chemotherapy to remove infiltrative residual tumor. External beam radiotherapy was used in a few cases in lymph node irradiation. The radioactive material was 192Ir, using afterloading techniques, either intracavitary or interstitially or both. The tumor dose, calculated by computerized dosimetry, was 60 to 65 Gy delivered over 5 to 7 days in the majority of cases. Two patients were lost to follow-up. Thirty-five patients (78%) are alive with no evidence of disease after a mean follow-up period of 5 years. Eight patients died, one of complications related to chemotherapy and seven of the evolution of their disease. The late-complication rate, studied in 33 patients with a minimum follow-up period of 3 years, is 18% (6/33). Curietherapy seems to be a preferable conservative treatment in children with localized and accessible malignant tumors.

Alveolar rhabdomyosarcoma of the female genitalia

Eight cases of alveolar rhabdomyosarcoma of the female genitalia were diagnosed from 1963 to 1983 at The University of Texas M. D. Anderson Hospital. The primary sites were vulva in two, perineum in five, and broad ligament in one patient. When possible, therapy was initiated with local tumor excision (five patients). Surgery was followed by local or regional radiation (six patients) and chemotherapy (seven patients). Of the eight patients, five died within 9 months, one died 27 months after diagnosis, and only two are 5-year survivors. The aggressive behavior of this tumor is evidenced by autopsy findings of widespread metastases. Metastatic disease to the bone was present in four patients and to the breast in three patients. Local disease was controlled in two patients who died of distant metastases. Current therapy recommendations include excisional surgery, local radiation, and combination chemotherapy. A need for more effective chemotherapeutic programs is evident.

Soft tissue sarcomas in childhood

The authors discuss the epidemiology, pathology, clinical presentation, and treatment of rhabdomyosarcoma as well as some of the less common sarcomas of childhood and adolescence. Special focus is placed on making careful histopathologic distinction between entities and on clearly recognizing distinct clinical syndromes.

Preoperative chemotherapy: advantages and clinical application in stage III breast cancer

Many lines of evidence support the view that BC is all too often a systemic disease and that micrometastases become enhanced after resection of the primary. Assuming that these two basic considerations do in fact apply, it can be argued that systemic treatment as the initial attack against operable BC has several advantages over the conventional postoperative adjuvant therapy: (a) Systemic treatment before operation may destroy clonogenic cells in the primary tumor which are responsible for the development of metastases; (b) primary tumor shrinkage following systemic therapy may serve as an early, simple, and inexpensive index of the overall chemosensitivity of the tumor; (c) systemic treatment as soon as the diagnosis is made may prevent the development of drug-resistant mutations, which are likely to form spontaneously early in the natural history of the disease; (d) preoperative chemotherapy may suppress the production of tumor-elaborated substances that protect the tumor from immune destruction by the host; (e) the average delay of about 1 month in the treatment of micrometastases in the postoperative adjuvant setting leads to at least a 30% increase of micrometastatic tumor burden, which can be prevented by preoperative treatment; (f) a number of other considerations suggest that the maximal chemosensitivity of each tumor exists at the earliest possible point in time, i.e., at the time of diagnosis; (g) after the initial postchemotherapy immunosuppression immunity recovers, in fact exceeding the pretreatment level, and if surgery is performed during this phase of heightened immunity chemotherapy is utilized as an immunostimulating agent; and finally (h) as more effective systemic agents are discovered, locoregional treatment with surgery and/or radiotherapy may become progressively more limited and it may ultimately be possible to dispense with these modalities. Experimental evidence scattered in the literature over the past three decades attests to the value of preoperative chemotherapy. Likewise, progressively greater numbers of uncontrolled studies have found preoperative chemotherapy most rewarding in miscellaneous sarcomas and in advanced tumors of the head and neck, kidney, and testes, as well as in a variety of other sites, including the breast.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of genitourinary rhabdomyosarcoma in children

We report on 27 children with rhabdomyosarcoma of the bladder, prostate, uterus, cervix and vagina treated with combined therapy of surgery, radiotherapy and multiple drug chemotherapy. Of the 27 patients 18 are alive for 13 to 147 months (median 86 months) and 9 have retained a functional bladder. Extirpative surgery followed by adjuvant chemotherapy and occasionally radiation therapy was most effective for local tumor control and 7 of 10 patients survived, including 5 with an intact functional bladder. Primary use of chemotherapy in 13 patients with extensive disease resulted in complete tumor control in only 3 but 7 survived, including 4 with an intact bladder. Radiation therapy used concomitantly with chemotherapy failed to control the local tumor but with subsequent extirpative surgery all 4 patients survived.

Diagnosis and behavior of juvenile rhabdomyosarcoma

The main problems in the diagnosis of rhabdomyosarcoma are 1) distinction of undifferentiated examples from other small cell malignancies, especially soft-tissue Ewing's tumor and lymphoma; 2) distinction of spindling examples from fibrosarcoma, leiomyosarcoma, malignant fibrous histiocytoma, polyhistioma, and other sarcomas; 3) recognition of minimal criteria on small samples such as needle biopsy specimens or frozen sections; and 4) recognition of rhabdomyosarcoma in uncommon sites such as bone (mandible), perineum, retroperitoneum, and chest. In 95 pediatric cases diagnosed and treated at Royal Alexandria Hospital for Children--45 after the introduction of combined therapy--minimal diagnostic criteria were assessed. Cross-striations were found in only one third of cases; longitudinal myofibrils were more common and more helpful. There was much overlap between histologic types, and the microscopic patterns had little bearing on prognoses in preadolescent children. Fourteen cases could not be further differentiated ("embryonal sarcoma, probably rhabdomyosarcoma")--nine small-cell tumors; four tumors from genitourinary tract or head for which very small biopsy specimens were available, and one spindling retroperitoneal neoplasm. In all, slight evidence suggested embryonal rhabdomyosarcoma; this evidence included oat-shaped nuclei and, in a few cells, deeply eosinophilic cytoplasm, small elongated processes, or myxoid or alveolar foci--features that exclude lymphoma and Ewing's tumor. In six cases that were originally classified as poorly differentiated or undifferentiated, later material confirmed the presence of rhabdomyosarcoma by showing a predominantly well-differentiated (pleomorphic) or alveolar pattern after therapy. In 14 remaining undifferentiated cases, immunoperoxidase staining with antihuman-myoglobin serum was positive in five. With combined therapy there was 100 per cent survival among patients with paratesticular, limb, and stage I and stage II tumors; considerably improved survival among patients with head and neck, pelvic, and stage III tumors; and 100 per cent mortality among patients with intra-abdominal and stage IV tumors.

Genitourinary rhabdomyosarcoma

Rhabdomyosarcoma is the most common soft tissue malignant neoplasm involving the pelvis of children. Debate still exists over whether the best treatment is pelvic exenteration, radiation and chemotherapy or chemotherapy as the cornerstone to treatment, with diminished needs for extensive surgery and prolonged radiotherapy. Contrariwise, there is little debate over the combined treatment modality for paratesticular rhabdomyosarcoma. We have evaluated and treated 19 children with rhabdomyosarcoma, including 17 with pelvic rhabdomyosarcoma and 2 with paratesticular rhabdomyosarcoma. This retrospective study was done to evaluate treatment regimens for patients with genitourinary rhabdomyosarcoma. For patients with pelvic rhabdomyosarcoma the study was divided into 2 series. In an early series 6 of 7 children had a pelvic exenteration with or without chemotherapy. Of these 7 children 3 are well 15 to 27 years following diagnosis. In a later series of 10 children, when chemotherapy was used more commonly, none underwent pelvic exenteration. Of these 10 patients 7 had chemotherapy or chemotherapy and biopsy only. Only 1 child, who presented with stage IV disease, died in this series. Another child with stage III disease had progressive disease despite chemotherapy and subsequent cystoprostatectomy. Thus, of 9 remaining patients 8 are well from 1 to 8 years. It appears that pelvic rhabdomyosarcoma can be treated effectively with chemotherapy, and limited surgery and radiation. Fortunately, pelvic exenteration can now be limited to a select few.

Bladder and prostatic tumors in the intergroup Rhabdomyosarcoma study (IRS-I): results of therapy

Sixty-four children with primary rhabdomyosarcoma of the bladder or prostate were enrolled in the IRS during the initial five years (October 1972-November 1977). Observation of these patients for from 2 1/2-8 years forms the basis of this report. The chemotherapy-radiotherapy regimens employed (IRS) for each Clinical Group were: (1) Group I (completely excised tumor), sequential actinomycin-D (ACD), vincristine (VCN), and cyclophosphamide (CYP), i.e., standard (VAC), with or without radiotherapy (RT); (2) Group II (resected local disease with node involvement, "microscopic" residual, or local extension), RT plus sequential ACD and VCN, or RT plus standard VAC; (3) Group III, (gross residual disease); and (4) Group IV (dissemination), RT and either pulse VAC or pulse VAC plus Adriamycin (ADR). Pulse VAC consisted of VCN (day 1), plus daily intravenous ACD and CYP (days 1-5). Relapse rates were: Group I, 0/8; Group II, 6/23; and the mortality in Group III, 6/23; and in Group IV, 7/10. Among patients with bladder tumors, the rate of relapse was 2/11 following pelvic exenteration (anterior, 10; total 1); 5/12 following partial cystectomy or gross tumor excision; and 3/5 following a primary chemotherapy-radiotherapy (PCR) regimen. In patients with prostatic tumors (Groups I-III), relapse occurred in 0/14 patients treated initially by pelvic exenteration (anterior, 12; total, 2); and in 2/11 patients treated by a PCR regimen.

Embryonal rhabdomyosarcoma of the genitourinary organs

We report on 14 patients with embryonal rhabdomyosarcoma of the genitourinary organs treated with combined modality therapy. Six patients with paratesticular lesions are free of tumor 7 to 72 months (mean 44) after diagnosis, while 6 of 8 with pelvic lesions are free of tumor 18 to 132 months (mean 61) following diagnosis. Two patients died of metastases. Over-all, 2-year survival free of relapse was obtained in 9 of 11 patients (81 per cent). Of 4 patients with pelvic lesions who were treated with primary radiation-chemotherapy without exenteration 3 were managed successfully but 1 required urinary diversion for vesical fibrosis. Current concepts in the management of embryonal rhabdomyosarcoma are discussed.

Combined modality therapy with conservation of organ function in childhood genitourinary rhabdomyosarcoma

Recent refinements in the multimodal therapy of childhood genitourinary rhabdomyosarcoma have produced striking improvements in long-term survival rates while still preserving pelvic organ function in the majority of cases. Three illustrative cases of childhood pelvic rhabdomyosarcoma are presented. Chemotherapy and surgical staging are employed in all 3 cases, with 2 of the cases requiring additional local tumor excision and intraurethral radiation for control of residual microscopic tumor. While long-term follow-up has not been achieved, all 3 patients have had their pelvic organs preserved and remain tumor-free in follow-up periods ranging from twelve to twenty-four months after the initial diagnosis.

Rhabdomyosarcoma

The care of patients with rhabdomyosarcoma has undergone significant change in the past decade. Careful staging and multidisciplinary treatment have improved the prognosis for patients with this neoplasm. A review of the medical literature of the past decade documents these changes in staging, therapy and prognosis.

Pararectal rhabdomyosarcoma: report of a case

Primary rhabdomyosarcoma of the alimentary tract is extremely rare, only 11 cases have been reported in the literature. Long-term survival in adults may be possible if the tumor is detected at an early stage even though it is asymptomatic. This highly malignant tumor can be treated by surgical excision, chemotherapy, and irradiation. A 12th case--of stage 1, pararectal, rhabdomyosarcoma--is reported.

Changing concepts in management of pelvic rhabdomyosarcoma in children

Survival with embryonal rhabdomyosarcoma of all sites has improved dramatically in recent years with the increased use of long-term, cyclic, multidrug chemotherapy. Protocols have been established and are currently being evaluated by the Intergroup Rhabdomyosarcoma Study. The management of embryonal rhabdomyosarcoma of the pelvic viscera, though, remains troublesome. Limited surgical excision is rarely possible and high-dose radiotherapy to the bony pelvis may cause severe and disabling growth disorders. Yet, survival with these lesions is increasing as with rhabdomyosarcoma from all sites and is directly related to a well-planned and aggressive multidisciplinary program. We have seen 12 cases of pelvic rhabdomyosarcoma within the last seventeen years at this institution. These cases will be reviewed in regard to varying modes of therapy and survival. Our current therapeutic approach, based on national and local experience, will be presented.

A therapeutic approach to childhood pelvic rhabdomyosarcoma without pelvic exenteration

A therapeutic approach using chemotherapy rather than radical surgery as the initial modality of treatment was employed in 13 children with pelvic rhabdomyosarcoma. One patient failed to respond to chemotherapy and required anterior pelvic exenteration. Eight patients are alive and free of disease 24 to 96 months after diagnosis. Limited surgery for minimal residual disease was used in two patients. Radiation therapy at lower than conventional doses was used in seven of eight patients. This experience supports a therapeutic approach to childhood pelvic rhabdomyosarcoma with an initial chemotherapy regimen, resulting in the use of surgical procedures less detrimental to pelvic organs without compromising survival.