Edatrexate in patients with soft tissue sarcoma. Activity in malignant fibrous histiocytoma

Laparoscopic liver resection for liver metastasis of leiomyosarcoma of the thigh: a case report

Background

Although there is no established treatment strategy for liver metastasis of leiomyosarcoma, liver resection has been reported to be effective in some cases. However, almost all liver resections performed for liver metastasis of primary leiomyosarcoma are reported to be open resections, and there are few reports of liver resection performed by laparoscopy. Here, we report a case of laparoscopic liver resection for liver metastasis of a leiomyosarcoma in the right thigh.

Case presentation

An 80-year-old man was diagnosed with leiomyosarcoma of the right thigh with liver metastasis. The primary tumor was first resected, and he was discharged on the 25th postoperative day. Four months after primary tumor resection, a laparoscopic right posterior sectionectomy was performed. There were no postoperative complications, and the patient was discharged on the 11th postoperative day with a histopathological diagnosis of liver metastasis of leiomyosarcoma and negative resection margins. Currently, 9 months have passed since the resection of the primary tumor, and 5 months have passed since the laparoscopic liver resection; there is no recurrence.

Conclusions

The liver metastasis of leiomyosarcoma was successfully removed, with good short-term outcomes after the laparoscopic liver resection. Laparoscopic liver resection seems to be effective for liver metastasis of leiomyosarcoma, which is characterized by a high recurrence rate after surgery. However, more case studies may be necessary to examine the effectiveness and long-term results of laparoscopic liver resection for the treatment of liver metastasis of leiomyosarcoma.

Progress in the Systemic Treatment of Advanced Soft-Tissue Sarcomas

Background:

Despite the plethora of chemotherapeutic remedies for advanced soft-tissue sarcomas, little evidence has developed to indicate that these efforts have been curative. No controlled comparison has yet proven that patients receiving multidrug regimens survive longer than those receiving doxorubicin alone.

Methods:

The authors review current systemic treatments and then discuss some investigational efforts now in progress. Also, they seek to demonstrate how the therapies currently available can be integrated with surgery and radiation therapy to accomplish more than might be anticipated from chemotherapy alone.

Results:

While working to develop better systemic therapies for advanced soft-tissue sarcomas, the integrated use of our best chemotherapy regimens in combination with selected surgical and radiotherapy efforts may provide patients with the best available therapy. Some recent observations involving the use of molgramostim plus chemotherapy have been intriguing.

Conclusions:

Progress in the systemic treatment of advanced soft-tissue sarcomas may be gradual, but it is real. Our daily challenge is to be certain that we offer each patient the best available multimodality treatment applicable to his or her clinical situation. Molgramostim should be made available for further study with chemotherapy in controlled clinical trials.

Phase II Trial of Dolastatin-10, a Novel Anti-Tubulin Agent, in Metastatic Soft Tissue Sarcomas

PATIENTS

Soft tissue sarcomas are uncommon malignancies with few therapeutic options for recurrent or metastatic disease. Dolastatin-10 (Dol-10) is a pentapeptide anti-microtubule agent that binds to tubulin sites distinct from vinca alkaloids. Based on the novel mechanism of action, limited activity of other anti-microtubular agents, and anti-neoplastic activity in pre-clinical screening of Dol-10, this multi-institutional phase II study was conducted to determine the objective response rate of Dol-10 in recurrent or metastatic soft tissue sarcomas that had not been treated with chemotherapy outside of the adjuvant setting.

METHODS

Dol-10 was given intravenously at a dose of 400 mug/m(2) and repeated every 21 days. Toxicities were assessed using the Common Toxicity Criteria (version 2.0). Radiographic studies and tumor measurements were repeated every two cycles to assess response [Miller AB, et al. Cancer 1981; 47(1): 207].

RESULTS

Dol-10 was associated with hematological toxicity and with some vascular toxicities. There was no significant gastrointestinal, hepatic or renal toxicity. There was one death on study due to respiratory failure. There were no objective responses in 12 patients treated with Dol-10.

DISCUSSION

Based on this phase II trial, further study of Dol-10 on this schedule is not recommended in advanced or metastatic soft tissue sarcomas.

Phase II Trial of Dolastatin-10, a Novel Anti-Tubulin Agent, in Metastatic Soft Tissue Sarcomas

Patients: Soft tissue sarcomas are uncommon malignancies with few therapeutic options for recurrent or metastatic disease. Dolastatin-10 (Dol-10) is a pentapeptide anti-microtubule agent that binds to tubulin sites distinct from vinca alkaloids. Based on the novel mechanism of action, limited activity of other anti-microtubular agents, and anti-neoplastic activity in pre-clinical screening of Dol-10, this multi-institutional phase II study was conducted to determine the objective response rate of Dol-10 in recurrent or metastatic soft tissue sarcomas that had not been treated with chemotherapy outside of the adjuvant setting.

Methods: Dol-10 was given intravenously at a dose of 400 μg/m2 and repeated every 21 days. Toxicities were assessed using the Common Toxicity Criteria (version 2.0). Radiographic studies and tumor measurements were repeated every two cycles to assess response [Miller AB, et al. Cancer 1981; 47(1): 207].

Results: Dol-10 was associated with hematological toxicity and with some vascular toxicities. There was no significant gastrointestinal, hepatic or renal toxicity. There was one death on study due to respiratory failure. There were no objective responses in 12 patients treated with Dol-10.

Discussion: Based on this phase II trial, further study of Dol-10 on this schedule is not recommended in advanced or metastatic soft tissue sarcomas.

Evaluation of dose-intense Ifosfamide, with and without edatrexate, in adults with sarcoma

Purpose. To define the maximally tolerated dose (MTD) of ifosfamide when given with G-CSF on an every other week schedule, and to define the MTD of edatrexate that can be given every two weeks with an intense schedule of ifosfamide.

Patients and Methods. Forty-one patients with metastatic or unresectable, locally advanced sarcoma participated in this 2-step phase I trial.The starting dose of ifosfamide was 10 gm/m² given by continuous intravenous infusion over 4 days every 2 weeks.When the MTD was defined, edatrexate, beginning at a dose of 40 mg/m² intravenously every 2 weeks was added in subsequent cohorts of patients.

Results. Myelosuppression was the most prominent toxicity. Fatigue, nausea, and vomiting were observed in the majority of patients. Ifosfamide 12 gm/m² given every 2 weeks approached or exceeded the MTD. Edatrexate 100 mg/m² could be given safety as an intravenous bolus with ifosfamide 10 gm/m² every 2 weeks. Therapeutic responses were observed in patients with measurable disease.

Conclusions. This study demonstrates the feasibility of administering a dose-intense schedule of ifosfamide alone or ifosfamide with edatrexate that might be applied in the adjuvant or neo-adjuvant setting.

Primary intra-abdominal malignant fibrous histiocytoma presenting as pyrexia of unknown origin--report of a case with review of literature

Primary intra-abdominal malignant mesenchymal tumours are very rare and there are not many cases of visceral malignant fibrous histiocytoma in the English literature. We report a new case of abdominal malignant fibrous histiocytoma presenting as abdominal pain and pyrexia of unknown origin in a 54 year old female followed by a brief review of literature. Presentation with pyrexia of unknown origin is extremely rare in this condition.

Surgery including liver resection for metastatic gastrointestinal stromal tumors or gastrointestinal leiomyosarcomas

BACKGROUND

In recent years, imatinib mesylate (STI 571), a tyrosine kinase inhibitor, has shown short-term clinical usefulness for gastrointestinal stromal tumor or gastrointestinal leiomyosarcoma (GIST). The value of surgical resection, including hepatectomy, for metastatic GIST remains unknown. Our aim was to evaluate the outcome of surgical resection, including hepatectomy, for metastatic GIST at a single institute.

METHODS

Eighteen patients who underwent hepatectomy for metastatic GIST were identified and the clinicopathological data of these patients were analyzed retrospectively.

RESULTS

The primary site of GIST included stomach in 10, duodenum in five, ileum in two and esophagus in one patient. A hemihepatectomy or greater resection was undertaken in eight patients. Six patients underwent simultaneous resection for primary and hepatic disease. There was no in-hospital mortality in this series. The post-hepatectomy 3- and 5-year survival rates were 63.7 and 34.0% respectively, with a median of 36 (17-227) months. Recurrence after the initial hepatectomy was documented in 17 patients (94%), and metastatic mass of the remnant liver developed in 15 of these 17 patients (88%). Three patients survived >5 years after the initial hepatectomy who underwent multiple surgical resections during this period. No clinicopathological characteristic was a significant predictive factor for survival.

CONCLUSIONS

Multiple surgical resections, including hepatectomy, may contribute to important palliation in selected patients with metastatic GIST. Surgical cure seems to be difficult due to the high frequency of repeat metastasis to various sites. Therefore, adjuvant therapy must be required in the treatment of metastatic GIST.

Liver resection for metastatic non-colorectal non-neuroendocrine hepatic neoplasms

AIMS

Major liver surgery can be performed safely and hepatic resection for metastatic disease is increasingly carried out. However, the role of liver resection for hepatic metastases from non-colorectal, non-neuroendocrine (NCNN) cancers is unknown. Our aim was to evaluate our experience from hepatectomies for NCNN metastases. A retrospective study of 170 patients with liver resection performed the last 8 years was performed in two liver units in affiliated university hospitals.

METHODS

Eighteen patients underwent liver resection for NCNN tumours. Origins included kidney (n=6), breast (n=4), gastric tumours (n=4), intestinal leiomyosarcoma (n=2) and malignant melanoma and in one patient a metastatic papillary of unknown origin was found. Eleven patients underwent a hepatic lobectomy and seven had local resections. Ten hepatectomies were performed at the same time with the primary tumour resection (synchronous resections) with five of those in an en bloc fashion with the primary tumour.

RESULTS

There were no post-operative deaths and the peri-operative morbidity was minimal. During a median follow-up time of 3.2 years, 14 patients are alive with one of them having developed pulmonary metastases.

CONCLUSION

In carefully selected patients with NCNN liver metastasis, liver resection can prolong survival as well and improve quality of life.

Discriminant analysis of prognostic factors for malignant fibrous histiocytoma in soft tissue

We prospectively followed 32 patients with soft-tissue malignant fibrous histiocytoma (MFH). Parameters were age; sex; tumor size, location, and depth; operative method; chemotherapy; radiotherapy; and histology. Patients with recurrence or metastases due to MFH within 6 months after the initial operation were separated from those without these characteristics by discriminant analysis with statistically significant difference. The order of influential functions was histology, depth of tumor, operative method, and sex. Male patients with deep-seated storiform-pleomorphic type MFH, receiving less comprehensive surgery, had the greatest risk of local recurrence or early metastases. We have to pay particular attention to patients with these factors and perform adequate surgery, because local recurrence and metastases were found to be closely related, and to have a great influence on the prognosis of this disease. Discriminant analysis to separate patients with MFH recurrence or metastases within 6 months after the initial operation from those without these characteristics is worthwhile for prognostic assessment.

Additive effect of adenovirus-mediated E2F-1 gene transfer and topoisomerase II inhibitors on apoptosis in human osteosarcoma cells

Recently, it has been demonstrated that Etoposide, a topoisomerase II inhibitor, can induce apoptosis in MDM2-overexpressing tumor cells by inhibition of MDM2 synthesis. We have previously shown that E2F-1 overexpression induces apoptosis of MDM2-overexpressing sarcoma cells, which is related to the inhibition of MDM2 expression. Therefore, the present study was designed to investigate the in vitro and in vivo effect of combined treatment of adenovirus-mediated E2F-1 and topoisomerase II inhibitors on the growth inhibition and apoptosis in human sarcoma cells. Two human sarcoma cell lines, OsACL and U2OS, were treated with topoisomerase II inhibitors (Etoposide and Adriamycin), alone or in combination with adenoviral vectors expressing beta-galactosidase (Ad-LacZ) or E2F-1 (Ad-E2F-1). E2F-1 expression was confirmed by Western blot analysis. Ad-E2F-1 gene transfer at a low dose (multiplicity of infection, 2) markedly increased the sensitivity of human sarcoma cells to topoisomerase II inhibitor treatment. This cooperative effect of E2F-1 and topoisomerase II inhibitors was less marked in SAOS-2 cells (p53 and pRb null). Topoisomerase II inhibitors also cooperated with E2F-1 overexpression to enhance tumor cell killing in an in vivo model using xenografts in nude mice. When combined with Adriamycin or Etoposide, E2F-1 adenovirus therapy resulted in approximately 95% and 85% decrease in tumor size, respectively, compared to controls (P<.05). These results suggest a new chemosensitization strategy that is effective in MDM2-overexpressing tumors and may have clinical utility.

Sarcomas metastatic to the liver: response and survival after cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol chemoembolization

PURPOSE

To evaluate the response to and survival after chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol for patients with sarcomas metastatic to the liver that are surgically unresectable.

MATERIALS AND METHODS

Sixteen patients were treated. Primary tumors included 11 gastrointestinal leiomyosarcomas, two splenic angiosarcomas, one leiomyosarcoma of the broad ligament, one leiomyosarcoma of the inferior vena cava, and one malignant fibrous histiocytoma of the colon. Chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol particles was performed 1-5 times at approximately monthly intervals (mean, 2.8). Pre- and posttreatment cross-sectional imaging was performed 1 month after completion of treatment and then every 3 months. Thirty-day response was graded according to World Health Organization/Eastern Cooperative Oncology Group criteria. Survival was calculated with use of Kaplan-Meier analysis.

RESULTS

Two patients (13%) exhibited partial morphologic response, 11 patients (69%) were morphologically stable, and three (19%) demonstrated progression of disease 30 days after completion of treatment. Among the 13 responders, two underwent partial hepatectomy after initial treatment. Seven developed intrahepatic progression at a mean of 10 months and a median time of 8 months. The remaining four patients had no documented intrahepatic progression at the time of last imaging follow-up. Nine patients developed extrahepatic progression at a mean time of 6.3 months and a median time of 6 months, of whom four underwent additional surgical resection. Response to therapy was based on time of first intervention. Cumulative survival from time of diagnosis with use of Kaplan-Meier analysis was 81% at 1 year, 54% at 2 years, and 40% at 3 years. Median survival time was 20 months. Cumulative survival from initial chemoembolization was 67% at 1 year, 50% at 2 years, and 40% at 3 years, with a median survival time of 13 months. The thirty-day mortality rate was zero.

CONCLUSION

Durable tumor response with chemoembolization is possible in this form of metastatic disease, which is highly resistant to systemic chemotherapy.

Hepatic metastases from leiomyosarcoma: A single-center experience with 34 liver resections during a 15-year period

OBJECTIVE

To describe a large single-center experience with hepatic resection for metastatic leiomyosarcoma.

SUMMARY BACKGROUND DATA

Liver resection is the treatment of choice for hepatic metastases from colorectal carcinoma. In contrast, the role of liver resection for hepatic metastases from leiomyosarcoma has not been defined.

METHODS

The records of 26 patients who between 1982 and 1996 underwent a total of 34 liver resections for hepatic metastases from leiomyosarcoma were reviewed. There were 23 first, 9 second, and 2 third liver resections. The records were analyzed with regard to survival and predictive factors.

RESULTS

In the 23 first liver resections, there were 15 R0, 3 R1, and 5 R2 resections. Median survival was 32 months after R0 resection and 20.5 months after R1/2 resection. The 5-year survival rate was 13% for all patients and 20% after R0 resection. In 10 patients with extrahepatic tumor at the time of the first liver resection, 6 R0 and 4 R2 resections were achieved. After R0 resection, the median survival was 40 months (range 5-84 months), with a 5-year survival rate of 33%. After repeat liver resection, the median survival was 31 months (range 5-51 months); after R0 resection, median survival was 31 months and after R1/2 resection it was 28 months. There was no 5-year survivor in the overall group after repeat liver resection.

CONCLUSIONS

Despite frequent tumor recurrence, the long-term outcome after liver resection for hepatic metastases from leiomyosarcoma is superior to that after chemotherapy and chemoembolization. Although survival after tumor debulking also seems to be more favorable than after nonoperative therapy, these data indicate that only an R0 resection offers the chance of long-term survival. The presence of extrahepatic tumor should not be considered a contraindication to liver resection if complete removal of all tumorous masses appears possible. In selected cases of intrahepatic tumor recurrence, even repeated liver resection might be worthwhile. In view of the poor results of chemoembolization and chemotherapy in hepatic metastases from leiomyosarcoma, liver resection should be attempted whenever possible.

New chemotherapeutic strategies for soft tissue sarcomas

Advanced soft-tissue sarcomas are still incurable in the vast majority of patients. The currently available standard methods of treatment such as surgery, radiation therapy, and chemotherapy have a very modest impact on the natural history of advanced soft tissue sarcomas. Nevertheless, until new strategies become widely available and applicable to this disease, we are obligated to optimize the current resources and make the best use of these modalities. We discuss the approaches of standard chemotherapy used in a dose-intensive fashion (especially in high-risk patients at an earlier stage), attempts to find new drugs with activity in this disease, and tests of the concepts of anti-angiogenic and differentiation therapy. To improve cure rates, patients and physicians must be encouraged to participate in multidisciplinary clinical trials.

Gastrointestinal leiomyosarcoma metastatic to the liver. Durable tumor regression by hepatic chemoembolization infusion with cisplatin and vinblastine

BACKGROUND

Gastrointestinal leiomyosarcoma metastatic to the liver is considered most resistant to any combination of systemic chemotherapy containing doxorubicin and/or ifosphamide.

METHODS

Fourteen patients with gastrointestinal leiomyosarcoma metastatic to the liver were treated with hepatic chemoembolization infusion consisting of polyvinyl alcohol sponge particles mixed with cisplatin powder (150 mg) followed by an intrahepatic arterial infusion of vinblastine (10 mg/m2).

RESULTS

Ten major (> 50% regression) tumor responses were observed (70%) in patients lasting from 8 to 31+ months (median, 12 months) after an average of two hepatic chemoembolization procedures, usually 4 weeks apart. Transient side effects included right upper quadrant pain requiring narcotics, significant hepatic enzyme elevation, particularly of lactic dehydrogenase with a minimal increase in bilirubin, paralytic ileus requiring nasogastric suction up to 72 hours, urinary electrolyte losses (potassium+, magnesium++, sodium+) requiring supplements, and occasionally mild but transient leukopenia and thrombocytopenia.

CONCLUSIONS

Hepatic chemoembolization infusion appears to induce a high rate of durable tumor response in patients with notoriously chemoresistant gastrointestinal leiomyosarcoma metastatic to the liver.