Analysis of local tumor control in Ewing's sarcoma: preliminary results of a cooperative intergroup study

Treatment of femoral Ewing's sarcoma

BACKGROUND

The treatment of Ewing's sarcoma consists of chemotherapy for systemic and local disease. However, the role of radiation therapy, and/or surgical resection for definitive local treatment has yet to be determined.

METHODS

A retrospective review of 32 patients (24 males and 8 females) treated for femoral Ewing's sarcoma between 1970 and 1985 was performed. Patients were divided into 3 treatment groups: chemotherapy and radiotherapy (CR) (10); chemotherapy and surgery (CS) (9); and chemotherapy, surgery, and radiotherapy (CSR) (13). Patients in the CR group received a mean of 5320 centigray (cGy) of radiation and patients in the CSR group received a mean of 3590 cGy. Multiagent cyclophosphamide/doxorubicin based chemotherapy was used in all cases. Surgery consisted of wide resection or amputation.

RESULTS

Patients in the CR group had a higher risk of local recurrence than patients in the CS and CSR groups (P=0.02, log rank). The combination of local recurrences and treatment complications necessitated surgery for 7 of 10 CR patients, whereas 1 of 9 and 4 of 13 in the CS and CSR groups required additional surgery. The median survival for the entire group was 39 months. Minimum follow-up for surviving patients was 45 months. Five-year survival consisted of 1 of 10 patients in the CR group, 2 of 9 in the CS group, and 7 of 13 in the CSR group. There were no statistically significant differences among the three survival curves. Tumor location within the femur was a significant prognostic variable. Distal femoral location had a survival advantage compared with proximal and mid-femur locations (P = 0.049, log rank).

CONCLUSIONS

Femoral Ewing's sarcoma remains a disease with a poor prognosis. Radiation alone for local treatment results in a high rate of local recurrence and complications. Our current local treatment strategy for femoral Ewing's sarcoma includes surgery in all and adjuvant radiotherapy in many of the patients.

Radiation therapy in Ewing's sarcoma: an update of the CESS 86 trial

PURPOSE

We present an update analysis of the multiinstitutional Ewing's sarcoma study CESS 86.

METHODS AND MATERIALS

From January 1986 through June 1991, 177 patients with localized Ewing's sarcoma of bone, aged 25 years or less, were recruited. Chemotherapy consisted of four 9-week courses of vincristine, actinomycin D, cyclophosphamide, and adriamycin (VACA) in low-risk (extremity tumors < 100 cm3), or vincristine, actinomycin D, ifosfamide, and adriamycin (VAIA) in high-risk tumors (central tumors and extremity tumors > or = 100 cm3). Local therapy was an individual decision in each patient and was either radical surgery (amputation, wide resection) or resection plus postoperative irradiation with 45 Gy or definitive radiotherapy with 60 Gy (45 Gy plus boost). Irradiated patients were randomized concerning the type of fractionation in either conventional fractionation (once daily 1.8-2.0 Gy, break of chemotherapy) or hyperfractionated split-course irradiation simultaneously with the VACA/VAIA chemotherapy (twice daily 1.6 Gy, break of 12 days after 22.4 Gy and 44.8 Gy, total dose and treatment time as for conventional fractionation). For quality assurance in radiotherapy, a central treatment planning program was part of the protocol.

RESULTS

Forty-four patients (25%) received definitive radiotherapy; 39 (22%) had surgery, and 93 (53%) had resection plus postoperative irradiation. The overall 5-year survival was 69%. Thirty-one percent of the patients relapsed, 30% after radiotherapy, 26% after radical surgery, and 34% after combined local treatment. The better local control after radical surgery (100%) and resection plus radiotherapy (95%) as compared to definitive radiotherapy (86%) was not associated with an improvement in relapse-free or overall survival because of a higher frequency of distant metastases after surgery (26% vs. 29% vs. 16%). In irradiated patients, hyperfractionated split-course irradiation and conventional fractionation yielded the same results (5-year overall survival of definitively irradiated patients 63% after conventional fractionation and 65% after hyperfractionation; relapse-free survival 53% vs. 58%; local control 76% vs. 86%, not significant). The six local failures after radiotherapy did not correlate with tumor size or response to chemotherapy. Radiation treatment quality (target volume, technique, dosage) was evaluated retrospectively and was scored as unacceptable in only 1 out of 44 patients (2%) with definitive radiotherapy. Grade 3-4 complications developed in 4 out of 44 (9%) patients after definitive radiotherapy.

CONCLUSIONS

Under the given selection criteria for local therapy, radiation therapy yielded relapse-free and overall survival figures comparable to radical surgery. Hyperfractionated split-course irradiation simultaneously with multidrug chemotherapy did not significantly improve local control or survival.

Primary Ewing's sarcoma of the skull: follow-up with bone scanning

The authors report and discuss an extremely rare case of primary Ewing's sarcoma originating in the flat bones of the skull. The case was followed up by serial bone scanning during the postoperative period. A subclinical recurrence was detected as a focus at the original site 2.5 years after the first operation. Following a second operation and adjuvant chemotherapy the patient is still asymptomatic.

Bulk disease as the major problem in the cure of paediatric sarcomas

Bulk disease is a problem in all the major paediatric sarcomas. It is the pre-eminent problem in parameningeal rhabdomyosarcoma but only a recently recognised problem in limb osteogenic sarcoma (only since the advent of limb-conserving surgery). In all cases where a large bulk of sarcoma threatens to relapse locally, multimodality therapy (surgery, radiotherapy, chemotherapy) stands a better chance of sterilisation than individual modalities of therapy, and such multimodality therapy stands its best chance when it is used early, that is, all three modalities are used at the beginning or shortly after commencement of the treatment course.

Multidisciplinary treatment of primary Ewing's sarcoma of bone. A 6-year experience of a European Cooperative Trial

The German Society of Pediatric Oncology in 1981 initiated the Cooperative Ewing's Sarcoma Study (CESS 81) using a four-drug combination of chemotherapy prior to definitive local control with surgery and/or radiation. From January 1, 1981 until February 28, 1985, 93 patients were registered at the trial office from 54 participating institutions in West Germany, Austria, Switzerland, and the Netherlands. On February 1, 1987, 54 of 93 patients were disease-free. Using the Kaplan-Meier life table analysis, the estimated disease-free survival (DFS) rate was 60% at 36 months and 55% at 69 months. The median period of observation was 29 months, ranging from 22 months to 69 months. Twenty-one of 93 patients (23%) had local failure, 18 of 93 patients (19%) developed systemic metastases. The local failure rate was particularly high in patients treated with radiation and was reduced when radiation planning was centralized within the study based upon the extent of disease at diagnosis. Cox regression analysis of prognostic factors showed that tumor volume was a significant factor influencing prognosis. The estimated 3-year DFS rate was 80% for patients with small tumors (volume less than 100 ml) compared to 31% for patients with large tumors (volume greater than or equal to 100 ml). In patients who had surgery for local control, the histologic response to chemotherapy was analyzed on the surgical specimen and had a strong influence on survival: 79% DFS at 3 years for patients with less than 10% viable tumor (good responders) compared to 31% DFS for patients with more than 10% viable tumor (poor responders). Tumor load and responsiveness to chemotherapy are the two major factors influencing prognosis in patients with primary Ewing's sarcoma of bone.

Ewing's sarcoma. A retrospective study of prognostic factors and treatment results

A material of 87 consecutive patients with Ewing's sarcoma referred for treatment in the period 1962-1983 was retrospectively analysed. Thirteen patients had metastases at the time of diagnosis. Of the remainder, 71 received radiation therapy and 32 adjuvant chemotherapy. Survival rate was not influenced by age, sex or treatment delay. Metastatic disease predictably shortened survival (median 6 months vs. 23 months for localized disease). Tumour site did not significantly influence survival rate, although pelvic localization was associated with a slightly shorter median survival. Both pain and objective impairment of movement at presentation correlated to a poorer prognosis, possibly because of larger tumours or soft tissue extension. Adjuvant chemotherapy prolonged recurrence-free survival from a median of 6 months to 16 months, but survival was not improved significantly. Local failure occurred in about 40 per cent, regardless of radiation dose and tumour site. At the time of evaluation, 13 patients (15%) were alive with no evidence of disease and a median follow-up time of 68 months (range 16-196). So far, 2 patients have developed secondary malignancies in irradiated areas (one malignant fibrous histiocytoma and one osteogenic sarcoma).

Therapy for primary non-Hodgkin's lymphoma of bone and a comparison of results with Ewing's sarcoma. Ten years' experience at the Istituto Ortopedico Rizzoli

The authors report on the results obtained in 30 consecutive cases of primary non-Hodgkin's lymphoma of bone (PNHLB) treated at the Istituto Ortopedico Rizzoli between 1972 and 1982. Four patients were treated with radiotherapy only and 26 were treated with radiotherapy plus adjuvant chemotherapy. At a median follow-up of 86 months (range, 30-160), among the 26 patients treated with chemotherapy also there were 3 relapses (2 had meningeal involvement and 1 had recurrence in another bone). Relapse (local recurrence plus multiple new localizations) was observed in one of the four patients treated with radiotherapy only. These results are compared with the results of 68 patients with Ewing's sarcoma who were treated during the same period with radiation therapy and adjuvant chemotherapy and reported in a previous study. In this group, the disease-free survival rate was only 32% (20/68) with a much higher incidence of local recurrence (31%). The necessity of making a clear distinction between PNHLB and Ewing's sarcoma is discussed.

Extraskeletal Ewing's sarcoma: a clinical, morphological and ultrastructural analysis of five cases with a review of the literature

In 1969 it was recognised that tumors with light microscopic appearances indistinguishable from Ewing's sarcoma of bone may arise in extraskeletal sites (extraskeletal Ewing's sarcoma). Here, we review the available literature and report five new cases. All five received combined modality therapy with combination chemotherapy and radiotherapy to the primary site followed by surgical excision in two. All attained complete remission; after a median follow-up of 26 months, three remain disease-free but two have relapsed and died. Our experience, in accord with previous series, suggests that extraskeletal Ewing's sarcoma compared with its bony counterpart tends to occur in older subjects, has a similar incidence in males and females, usually presents with a painless mass and readily responds to combined modality therapy. We detected no light or electron microscopic features to denote a histogenetic origin. However, we suspect extraskeletal Ewing's sarcoma may occur more frequently than previously supposed.

Histopathological predictive factors in Ewing's sarcoma of bone and clinicopathological correlations. A retrospective study of 261 cases

A retrospective multifactorial analysis on 261 previously untreated patients with Ewing's sarcoma (Es) of bone has been carried out in order to ascertain the prognostic value of several histological variables on survival. Among those cases accepted as Es, 208 (80% of the patients) were considered to be "typical Es", while 40 (15%) displayed a large cell predominance, being subclassified as "atypical large cell Es". Furthermore, 13 patients (5%) possessed tumours of endothelial-like appearance. Eleven cases which displayed a mixed histological configuration were finally included within one of the three previous groups according to their predominant histological pattern. After adjustment for therapeutic regimens and initial location of the tumour, only two histological characteristics remain significant; i.e. the presence of necrosis (p = 0.002) and, to a lesser degree, the presence of filagree "en damier" pattern (p = 0.08), both of which are of poor prognostic value. From this study, it can be assumed that the morphological (and possibly histogenetical) heterogeneity of Es of bone has no prognostic influence on survival.

Primary Ewing's sarcoma of the ethmoid bone

Primary Ewing's sarcoma of the ethmoid bone has not been previously described. This case presented as a mass at the nasal bridge and posed diagnostic and therapeutic difficulties. The clinical, radiological, macroscopic and microscopic features are described. The treatment by the combined therapies of cranio-facial resection, radiotherapy and chemotherapy are discussed.

The value of adjuvant chemotherapy in the management of sarcomas in children

Sarcomas of childhood rank fifth in incidence of malignant tumors in children younger than 15 years. Among the soft tissue sarcomas, approximately 50% are rhabdomyosarcomas. The remainder represent a heterogeneous group of diverse sarcomas which are not unique to children and include fibrosarcoma, synoviosarcoma, malignant fibrous histiocytoma, malignant schwannoma, angiosarcoma, leiomyosarcoma, and others. The most common bone cancers in childhood are osteosarcoma and Ewing's sarcoma. Although a multidisciplinary approach utilizing surgery, irradiation, and combination chemotherapy is routinely used in management of virtually all children with solid tumors, the value of adjuvant chemotherapy in select bone and rare soft tissue sarcomas is currently being tested. Multiagent chemotherapy including vincristine, dactinomycin, cyclophosphamide, and Adriamycin (doxorubicin) contribute to cure rates in 65% to 75% of children with localized rhabdomyosarcoma, Stages I to III, when combined with surgery and/or irradiation. Other drugs which hold promise include platinum, DTIC, methotrexate, and VP-16. The efficacy of similar drugs in the rarer pediatric soft tissue sarcomas other than rhabdomyosarcoma and its variants requires prospective randomized trials evaluating histologic grade, tumor size, and nodal status. It has been suggested that the high-grade sarcomas presenting with minimal tumor bulk are most sensitive to combined radiotherapy-chemotherapy, whereas the low-grade sarcomas are more resistant to such therapy. Tumor cell heterogeneity contributes to biologic diversity and response to treatment. Chemotherapy as adjuvant therapy to irradiation is currently recommended and utilized for Ewing's sarcoma with survival rates approaching 80%, and disease-free survival of approximately 75% for those with localized disease. Children with widespread and metastatic disease at presentation fare less well. Although multiple single agents exhibit response rates ranging from 40% to 60%, including cyclophosphamide, Adriamycin, dactinomycin, BCNU, mithramycin, and 5-fluorouracil, new and more effective agents are needed. Controversy regarding the value of multiagent chemotherapy in osteosarcoma has stimulated prospective randomized trials. Evaluation of local control rates as well as sites and occurrence of metastases are essential in assessing the contribution of aggressive combined modality therapy in the pediatric sarcomas. Emphasis on refinement of therapy in determining the risk/benefit ratio from adjuvant chemotherapy in pediatric sarcomas is mandatory. Enhancement of early local reactions is apparent when adjuvant chemotherapy is used with local radiotherapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Localized Ewing's sarcoma of bone: ten years' experience at the Istituto Ortopedico Rizzoli in 124 cases treated with multimodal therapy

The results obtained in the treatment by multimodal therapy (surgery, radiation therapy and chemotherapy) of 124 cases of Ewing's sarcoma are presented. At a medium follow-up of 65 months 48% of the patients are disease-free. One patient died of leukemia and two patients developed an irradiation-induced sarcoma. Analysing the data, three factors seem to be correlated to prognosis: location of the initial lesion outside the pelvis and sacrum, a four-drug chemotherapy protocol and the use of surgery in the treatment of the initial lesion seem to give better results.

Acute nonlymphocytic leukemia developing during the course of Ewing's sarcoma

Two children with Ewing's sarcoma developed acute nonlymphocytic leukemia (ANLL) during the course of their illness. One patient developed ANLL after apparently successful treatment of his primary malignancy with radiation therapy and multiagent chemotherapy. In the second patient, acute leukemia developed before the administration of radiotherapy or systemic chemotherapy. The development of secondary ANLL after Ewing's sarcoma has been reported only twice previously, most likely representing a therapy-induced complication. The occurrence of ANLL in Patient 2 prior to therapy suggests that these two disorders may have a more than treatment-related association. Close follow-up of long-term survivors of Ewing's sarcoma with surveillance for secondary acute leukemia is advised.

Intensive systemic chemotherapy in localized Ewing's sarcoma in childhood. A historical trial

To assess the value in Ewing's sarcoma of a new multiagent therapy (vincristine, cyclophosphamide, Adriamycin, (doxorubicin) procarbazine), 30 children with a localized tumor (eight distal, nine proximal, 13 central lesions) treated at the Institut Gustave-Roussy between 1973 and 1976 (E3), were pair-matched by site of primary with 30 control patients treated without intensive chemotherapy between 1967 and 1972 (E1) at the same institution, both groups having the same local radiotherapy. Actuarial survival and disease-free survival rates at six years were significantly higher in E3 at P less than 0.01, respectively, 58% and 49% versus 25% in E1. The prognostic value of the primary site was ascertained only in children under chemotherapy. In this group there were six early relapses with death within 14 months and nine late relapses at 21 to 38 months. Among these nine patients, six died, one is living with disease, and two are currently alive in second remission. Fifteen patients are continuously free of disease 50 to 90 months after first treatment (median, 69 months): functional sequelae are minimal in six, moderate in seven, and severe in two children with limb amputation. It is concluded that in future treatments chemotherapy must be intensified and begun prior to local treatment which has to be reevaluated for radiation modalities and for radical surgery indication.

The prognostic significance of soft tissue extension in Ewing's sarcoma

From January 1969 through December 1977, 28 patients were treated at the University of Florida with the diagnosis of Ewing's sarcoma. All patients received radiation therapy to the primary site and adjuvant chemotherapy according to several different regimens. A retrospective analysis was carried out to determine the prognostic significance of gross extraosseous extension by the primary lesion. Gross soft tissue extension at the primary site was found to be of prognostic importance. Patients with soft tissue extension more often presented with metastatic disease (39 versus 10%). The five-year survival rate for patients presenting without distant metastasis and whose primary lesions were grossly confined to bone was 87% compared to 20% for those with extraosseous extension. The decrease in survival with soft tissue extension resulted from an increase in distant metastasis as well as local failure, and was independent of primary site location. The proportion of patients with extraosseous extension should be reported in subsequent analyses of local control and survival.

The treatment of localized Ewing's sarcoma: the experience at the Istituto Ortopedico Rizzoli in 163 cases treated with and without adjuvant chemotherapy

Eighty consecutive patients with localized Ewing's tumor treated with adjuvant chemotherapy for two years plus local tumor control were retrospectively reviewed. Adjuvant chemotherapy protocol was constant for all patients, but local treatment consisted of amputation, resection (complete or incomplete) plus radiotherapy, or radiotherapy alone. The follow-up ranged from 21--101 months (mean = 50 months). The mortality rate and incidence of metastasis were significantly lower than in a comparable group of 83 patients previously treated by radiotherapy, or surgery plus radiotherapy but without chemotherapy. The percentage of local recurrence was not significantly different between the two groups. Of the patients treated with adjuvant chemotherapy, the percentage of local recurrence and metastases was much lower when the primary lesion was located in the extremities and when this lesion was treated by conservative surgery followed by irradiation. This was also true when the resection was not complete. Little discrepancy in functional results was observed using either resection plus radiotherapy or radiotherapy alone. The above data suggest that in treating Ewing's sarcoma, conservative surgery, even incomplete, can play an important role when associated with radiotherapy and adjuvant chemotherapy.

Ewing's sarcoma: 5-year survival under adjuvant chemotherapy

The results at 5 years of an adjuvant chemotherapy trial in primary Ewing's sarcoma, started in 1973, are presented. Twenty-three eligible patients were treated with radiotherapy (60 Gy) to the tumor site and given polychemotherapy either using the E3 protocol (12 patients) or the E76 protocol (11 patients). Overall survival at 5 years was 37%, with 34% disease-free survival. There was no significant difference between the two chemotherapy groups. Only three local relapses and one major orthopedic failure were reported. Among the distal relapses, no metastases to the brain have been observed. These results are encouraging and show a clear improvement over the classical survival rate. However, further improvement is necessary and may be obtained by using new active drugs, as well as earlier and probably more aggressive cyclic chemotherapy. But primary surgical amputation and prophylactic CNS irradiation are not indicated for treatment of primary Ewing's sarcoma.

Early results of combined modality therapy of patients with Ewing's sarcoma

Fourteen patients with localized Ewing's sarcoma were treated with radiation therapy to the involved bone and systemic chemotherapy. Nine patients remained free of disease for a median follow-up period of 3 years. The actuarial 5-year disease-free survival rate is 60%.

Ewing's sarcoma: treatment with high-dose radiation and adjuvant chemotherapy

Twenty-nine patients with pathologically proven Ewing's sarcoma without overt metastases at diagnosis were treated with a protocol designed by The Royal Marsden and St. Bartholomew's Hospital Children's Solid Tumour Group. They received megavoltage radiotherapy to the involved bone and adjuvant chemotherapy with a combination of four cytotoxic drugs. Comparison with a historical control group of 19 patients treated with local surgery or radiotherapy but no initial chemotherapy shows a significant improvement in survival for the study group (P = 0.022). Thirteen patients have failed on the protocol: eight at the original site, four in other bones and only one in the lungs. Sixteen patients remain alive and disease free, 11 of these for over 33 months. The treatment regimen was moderately toxic but there were no treatment-related deaths. These results confirm that an improved survival time and, hopefully, cure rate can be expected by treating Ewing's tumour with high-dose megavoltage radiation and combination chemotherapy. Future goals must be better control of primary lesions and eradication of micrometastases in other bones.

Ewing's sarcoma: ten-year experience with adjuvant chemotherapy

Since May 1970, 67 consecutive patients with primary (nonmetastatic) Ewing's sarcoma were treated with adjuvant chemotherapy (CT) in addition to radiation therapy (RT) or surgery for the primary tumor. The first 19 patients were treated with four-drug sequential CT (T-2). The second protocol was a seven-drug induction combination CT (T-6) followed by T-2 maintenance CT; in both protocols CT was continued for 18 months. The current protocol (T-9) consists of combination CT given continuously for a period of 9 months. Of the entire group of 67 patients, 47 (70%) had axial and proximal lesions (pelvis, spine, rib, humerus, and femur) and 20 (30%) had distal lesions (forearm, leg, and foot); 53/67 (79%) are surviving free of disease 12--118 months (median 41 months) from the start of treatment. Fifteen of 23 (65%) patients with axial lesions, 19/24 (79%) patients with proximal lesions, and 19/20 (95%) patients with distal lesions are free of disease. Disease-free survivors include 28/39 (72%) male patients and 25/28 (89%) female patients. Thirty-four patients had RT, and 33 had surgery or surgery and RT, in addition to chemotherapy, for local treatment. The disease-free survival rate was 76% in the RT group and 82% in the surgery group; failure in the RT group was attributable to local recurrence in 7/34 (21%) patients. Recent experience with T-9 CT has demonstrated that CT given prior to RT or surgery can cause a great reduction in the size of the primary tumor while allowing the pathologically-eroded bone to heal prior to the initiation of RT; this also allows the high-risk patient with an axial primary (pelvis or spine) to tolerate the aggressive CT needed to prevent distant metastases. In addition to dramatically increasing survival in patients with Ewing's sarcoma, combination CT has helped achieve permanent local control. The superior survival rates for all sites of primary tumor are attributable to the early use of aggressive combination CT.

Radiotherapy and combination chemotherapy in advanced Ewing's Sarcoma-Intergroup study

Forty-four patients with metastatic (36 patients) and advanced regional (eight patients) Ewing's sarcoma were treated on a protocol employing intensive combination chemotherapy and radiotherapy to all sites of overt disease (primary site and metastatic sites). Thirty-one patients achieved a complete remission, eight achieved a partial remission, and five patients did not respond to treatment. Of the 31 patients who achieved a complete remission (12 had metastases and six had regional spread), 18 remained disease-free with a median follow-up of 34 months, while recurrences occurred in nine patients. Four patients died of complications of treatment. Although late relapses can still be expected, it appears that intensive multimodal management in metastatic Ewing's sarcoma can produce prolonged disease-free survival and possibly cure in a significant percentage of patients.

Leg function after radiotherapy for Ewing's sarcoma

Twenty-nine patients with Ewing's sarcoma of the lower extremity who survived for two or more years following therapy (5000 rad locally and systemic chemotherapy) were studied to assess functional status of the affected leg. Twenty-two of twenty-nine were alive and were reexamined; the deceased patients were evaluated by record review. Twenty-two of the twenty-nine had serial radiographs, which were reviewed to assess growth change induced by radiation. The living patients were divided on the basis of clinical examination into four functional groups with Group I comprising patients with minor functional limitations and leg length discrepancy 1.5 cm or less. Group II patients had moderate functional limitations with 2.5-cm leg-length discrepancy or less. Group III patients had severe functional limitations with up to 4-cm leg length discrepancy. Group IV patients had severe complications, sufficient enough to warrant amputation. Thirteen of twenty-two patients were classified as functional Group I, five as Group II, three as Group III, and one as Group IV. Radiographic changes in growing bone did not correlate with functional results. Although a femoral fracture and an age less than 16 years at diagnosis were found to be less favorable prognostic factors for the functional treatment result, these results show that neither femoral location nor young age justify primary amputation for Ewing's sarcoma of the lower leg extremity.

Local control of Ewing's sarcoma of bone with radiotherapy and combination chemotherapy

Between 1964 and 1977, 94 patients with Ewing's sarcoma of bone were treated at the National Cancer Institute. They received 5000 rad to the whole bone and progressively more aggressive chemotherapy protocols. The patients were divided according to site of primary lesion into central, proximal and distal lesions, with 19%, 33% and 57%, respectively, alive and well. Of 28 patients autopsied, 11 (39%) had had a pathologic documentation of local recurrence. An additional three patients had a biopsy-proven local recurrence, for a total pathologically proven rate of 14/94 (15%). A total of 16/94 (17%) patients had clinical evidence of local recurrence. The overall local recurrence rate (clinical plus pathologic) was 22/94 (23%). This rate varied according to the site of the primary and was 14/42 (33%) for central, 6/24 (25%) for proximal, and 2/28 (7%) for distal lesions. The local recurrence rate did not change significantly either with the more aggressive chemotherapy regimens or with the presence of metastases at presentation. The local control rate is high (93%), with good functional results in the distal lesions, and no changes are needed in radiation therapy dose or volume. Control is not as satisfactory for central and proximal lesions and efforts need to be made to increase control at these sites. We are at present attempting to define more accurately the extent of soft tissue disease, increasing the dose to 6000 rad for central lesions, and using a more aggressive chemotherapy program, in the hope of increasing the local control in these more aggressive tumors.

Intergroup Ewing's Sarcoma Study: local control related to radiation dose, volume, and site of primary lesion in Ewing's sarcoma

One hundred ninety-three patients with localized Ewing's sarcoma treated at participating instutitions of the Intergroup Ewing's Sarcoma Study form the basis for this report. All patients received radiation therapy to the primary lesion and were randomized to receive vincristine, actinomycin-D, and cyclophosphamide (VAC) plus adriamycin (Regimen I); VAC alone (Regimen II); or VAC and bilateral pulmonary irradiation (Regimen III). Local control was achieved in 96% of the patients in Regimen I, and 86% of the patients in both Regimens II and III. The median duration of follow up was 83 weeks and median survival time was 172 weeks. Incremental doses of irradiation did not result in significant changes in the rate of local control of primary lesions. The local control rate was the same (92%) for tumors treated by means of whole-bone irradiation or with at least 5 cm of free margin around the lesion. The local control rate decreased to 79% for lesions treated with less than 5-cm margin. Excellent control was obtained for lesions involving the skull or spine (100%), and distal bones (fibula, 96% and tibia, 91%). Less favorable control rates were noted for pelvic and humeral lesions (84% and 79%, respectively). Bilateral pulmonary irradiation for subclinical disease played a role in lowering the incidence of lung metastases from 38% to 20% for patients treated with VAC. Lung metastases were similarly decreased (10%) when adriamycin was added to VAC chemotherapy.

Determination of prognostic factors and their influence on therapeutic results in patients with Ewing's sarcoma

We have analyzed the results of treatment of 117 patients with Ewing's sarcoma admitted to the National Cancer Institute since 1964. All patients received local irradiation to the primary site and a series of progressively more intensive systemic chemotherapy regimens using drugs known to be active as single agents in this disease. Four protocols were employed with varying numbers of patients in each treatment group. Initially, there appeared to be a difference among treatment groups with regard to disease-free survival (overall P = .06), with the later regimens having more favorable outcomes. We then undertook a statistical analysis of the influence of five pretreatment variables--age, sex, site of primary disease, serum lactic acid dehydrogenase (LDH), and metastatic status--on disease-free survival. Of these five factors, important indicators of favorable prognosis for the entire group (and for each of the treatment subgroups) were a distal site of primary disease, normal serum lactic acid dehydrogenase (LDH) level at presentation, and the absence of metastatic disease at the time of presentation. When we examined treatment results with respect to these prognostic factors, we found that the subgroups treated with the more agressive regimens contained higher proportions of patients with favorable prognostic factors. After adjustment for differences in composition of treatment groups with respect to prognostic factors, the apparent difference in disease-free survival vanished (P = .62). These results indicate that in the case of Ewing's sarcoma, prognostic factors must be carefully considered in the design of treatment protocols and the subsequent analysis of end results.

Ewing'S sarcoma: a clinical analysis of forty-six cases treated at Henry ford hospital

Our paper describes the clinical features, roentgenographic manifestations, pathology and the results of various modalities of treatments of 46 cases of Ewing's sarcoma seen and treated at Henry Ford Hospital during the past 36 years. Surgery alone (4 cases) produced a 25% five-year survival rate, whereas radiotherapy alone (33 cases) yielded only a 3% five-year survival rate. Radiotherapy plus chemotherapy (9 cases) have proven to be far superior than radiotherapy alone. The overall five-year survival rate of our series is only 7%.

Ewing sarcoma: treatment with high dose radiation and adjuvant chemotherapy

Twenty-one patients with pathologically proven Ewing sarcoma without overt metastases at diagnosis were treated with a protocol designed by the Royal Marsden/St. Bartholomew's Hospitals Children's Solid Tumour Group (CSTG). They received megavoltage radiotherapy to the involved bone and adjuvant chemotherapy with a combination of four cytotoxic drugs. Seven patients have so far relapsed, four at the original site and three in other bones. The other 14 are clinically free of disease a median of 36 months from diagnosis. Comparison with a historical control group of 19 patients treated with surgery or radiotherapy, but without initial chemotherapy, shows a significant improvement in survival for the study group (P = 0.03). Seventeen of the controls have died. The treatment regime was moderately toxic, but there were no treatment-related deaths. These results confirm that an improved survival time and hopefully cure rate can be expected from treating Ewing tumour with high doses of megavoltage radiation and combination chemotherapy. Future goals must be the better control of large primary lesions and the eradication of micrometastases in other bones. The place of surgery should be re-evaluated in the treatment of the primary tumour, and better adjuvant chemotherapy regimes are needed.

Primary Ewing's sarcoma of the sternum: a case report

A 12 1/2-year-old female presented with Ewing's sarcoma of the manubrium sterni which extended into the anterior mediastinum. At presentation there was no evidence of metastatic disease. Her initial treatment consisted of radiation therapy and chemotherapy. The residual tumor was subsequently resected and the sternal defect was repaired with Marlex mesh. Postoperatively, she was maintained on chemotherapy consisting of BCNU, cyclophosphamide, and adriamycin. The adriamycin was discontinued after she developed sterile fibrinous pericarditis. She remains free of her disease two years after diagnosis. Although extremely rare, Ewing's does occur in the sternum and this area is amenable to wide local resection without severe functional disability.