Chest Wall Ewing Sarcoma Family of Tumors: Long-Term Outcomes

Comprehensive Analysis of Treatment Approaches in Chest Wall Ewing Sarcoma: The Impact of Tumor Volume on Oncologic Outcomes

Purpose

Local treatment with surgery (S) and radiation therapy (RT) for chest wall Ewing sarcoma (cwES) is often challenging given the extent of the tumor and the aggressiveness of local treatments needed for cure. We report tumor and treatment characteristics, oncologic outcomes, and toxicities of patients with cwES at 2 centers of a single institution.

Methods and Materials

Consecutive patients with cwES treated from 1997 to 2022 were retrospectively reviewed. All patients were treated with standard 5-drug chemotherapy (vincristine, doxorubicin, cyclophosphamide, alternating with ifosfamide and etoposide) before initiation of local therapy. Local treatment was S, RT, or both. The decision on modality and timing was determined by a multidisciplinary sarcoma group or by consensus between sarcoma experts regarding patient preferences.

Results

The cohort consisted of 39 patients. The median age at diagnosis was 19.2 years (range, 3.5-53.6 years). Median tumor volume (TV) was 235.5 mL (range, 5.3-6761.9 mL). The local control (LC) modality was S in 18 patients (46%), RT in 4 (10%), and S + RT in 17 (44%). Four (10%) patients treated with S + RT had R1 margins. The median follow-up was 3.2 years (range, 0.1-21.6 years). Grade 3 radiation-associated toxicity relative to the RT modality was 16.7% and 7.1% for photons (n = 6) and protons (n = 14), respectively. The 2-year LC by modality was 100% for RT (95% CI, 100%-100%), 88.2% (95% CI, 74.2%-100%) for S, and 73.3% (95% CI, 54.0%-99.5%) for S + RT. The 5-year LC, failure-free survival, and overall survival for all patients were 79.7% (95% CI, 67.3%-94.4%), 52.3% (95% CI, 38.1%-71.9%), and 64.2% (95% CI, 49.6%-83.1%), respectively. In univariate and multivariate analysis, TV ≥ 130 mL was associated with a significantly worse 5-year failure-free survival (31.8% TV ≥ 130 mL vs 80.8% TV < 130 mL; hazard ratio, 4.94, p = .013 and adjusted hazard ratio, 5.43; 95% CI, 1.28-22.98; p = .022). The multivariate model was adjusted for age, metastatic disease at diagnosis, and S.

Conclusions

Outcomes for cwES tumors are highly dependent on tumor size, even with the use of combined modality local therapy. With early follow-up, smaller tumors may be well controlled with either S or RT.

Evaluating the Role of Surgical Resection and Reconstruction in the Management of Ewing sarcoma of the Chest Wall in the Paediatric Population: A Systematic Review

BACKGROUND AND OBJECTIVES

Ewing sarcoma is the most common malignant chest wall tumour in the paediatric population. Following neoadjuvant chemotherapy regimens, the role and extent of surgical resection and reconstruction of the chest wall remain unclear.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines across four major literature databases. Data regarding overall survival, rate of recurrence, role of surgery and adjuvant therapy role was extracted.

RESULTS

Three thousand ninety-one studies were initially identified via the search, with 25 single-centre observational studies (458 patients) and 10 retrospective reviews of multicentre trials (961 patients) included in the final analysis. Five-year overall survival ranged from 35% to 90%.

DISCUSSION

Along with chemotherapy, local control with surgical resection provides the cornerstone of the management of Ewing sarcoma of the chest wall in children. The literature favours delaying surgery until after neoadjuvant chemotherapy, and there appear to be limited benefits to extensive resection according to pre-chemotherapy margins, advocated for in current guidelines. Radiotherapy is no longer advocated for all patients, but rather should be guided by surgical margins and the histological response to chemotherapy in the resected specimens. Surgical reconstructive techniques need to be tailored for the growth potential of these paediatric patients to avoid long-term sequalae, including scoliosis and pulmonary restrictive disease.

Primary Chest Wall Ewing Sarcoma: Treatment and Long-Term Results

OBJECTIVE

The aim of the study is to evaluate early and long-term results of chest wall primary Ewing's sarcoma patients treated in the time period February 2000-February 2023 by a multidisciplinary approach.

METHODS

We retrospectively reviewed the medical records of patients who underwent chest wall resection for a primary tumor. Treatment approach, extent of resection, 30-day mortality, overall survival (OS), local recurrence-free survival (LRFS), and metastasis-free survival (MFS) were analyzed.

RESULTS

Overall, n = 15 consecutive patients were treated for chest wall primary Ewing's sarcoma. A median of n = 3 ribs was resected with a median of n = 2 ribs adjacent to the lesion. Resections were extended to the adjacent structures in n = 5 patients (33.3%). In all cases, we performed a prosthetic reconstruction, associated with muscle flap (n = 10, 66.6%) or with rigid titanium bars and muscle flap (n = 6, 40%). A radical resection was accomplished in n = 13 patients (84.6%). The median surgical time was 310 ± 120 min; median hospitalization was 7.8 ± 1.9 days. Post-operative mortality was zero. We recorded n = 4 (30.7%) post-operative complication. The median follow-up (FU) was 26 months. Moreover, 5-year overall and event-free survival were 52% and 48%, respectively.

CONCLUSIONS

This case series confirms the benefit of the multidisciplinary approach for Ewing sarcomas in early and long-term results.

Askin's Tumor in the Chest Wall-a Rare Clinical Entity and Review of Literature

Askin tumors are the rare malignancy of neuroectodermal origin of the thoracic wall. Its prevalence is more in younger age group who present with vague symptoms leading to delayed diagnosis. We hereby present a case report of complex management of large chest wall tumor in a young boy and review the literature of this entity.

A Single-center Experience of Radiotherapy in Pediatric Ewing Sarcoma/Primitive Neuroectodermal Tumor of the Chest Wall

AIM

To evaluate the treatment results, prognostic parameters, and treatment-related toxicity in patients with Ewing sarcoma (ES)/primitive neuroectodermal tumor (PNET) of the chest wall who underwent surgery, chemotherapy, and radiotherapy (RT) in a tertiary referral center.

METHODS

The data of 24 patients under 18 years of age with a histologic diagnosis of ES/PNET in the chest wall that received RT in our department between February 2003 and July 2020 were retrospectively evaluated. RT was applied to the primary site±whole involved chest wall and to the whole lung in patients with lung metastasis.

RESULTS

The median age was 8.5 years (range: 1.5 to 17 y), 15 (63%) patients were female and 9 were male (37%). The tumor localization was extrathoracic in 18 (75%) and intrathoracic in 6 (25%) patients. Mediastinal lymph node and distant metastasis (DM) was present in 5 (21%) and 4 (16%) cases at diagnosis, respectively. The median follow-up after RT was 47 months (range: 11 to 162 mo). The 2-year and 5-year overall survival, event-free survival, local recurrence-free survival, and pleural recurrence-free survival were 83% and 48%, 48% and 42%, 74% and 48%, and 61% and 52%, respectively. The overall local control rate was 83% and the pleural control rate was 67%. RT was well tolerated, with 1 case of grade 3 acute dermatitis and 1 case of grade 3 subacute radiation pneumonitis. Late toxicity was observed in 3 (13%) cases.

CONCLUSION

Long-term survival can be achieved with extended-field RT even in patients with ES/PNET of the chest wall with DM. The low toxicity rates allow us to draw the conclusion that RT with modern techniques is an effective and safe treatment modality for these patients.

Outcome Analysis of Treatment Modalities for Thoracic Sarcomas

BACKGROUND

Primary chest wall sarcomas are a rare and heterogeneous group of chest wall tumors that require multimodal oncologic and surgical therapy. The aim of this study was to review our experience regarding the surgical treatment of chest wall sarcomas, evaluating the short- and long-term results.

METHODS

In this retrospective single-center study, patients who underwent surgery for soft tissue and bone sarcoma of the chest wall between 1999 and 2018 were included. We analyzed the oncologic and surgical outcomes of chest wall resections and reconstructions, assessing overall and recurrence-free survival and the associated clinical factors.

RESULTS

In total, 44 patients underwent chest wall resection for primary chest wall sarcoma, of which 18 (41%) received surgery only, 10 (23%) received additional chemoradiotherapy, 7% (3) received surgery with chemotherapy, and 30% (13) received radiotherapy in addition to surgery. No perioperative mortality occurred. Five-year overall survival was 51.5% (CI 95%: 36.1-73.4%), and median overall survival was 1973 days (CI 95% 1461; -). As determined in the univariate analysis, the presence of metastasis upon admission and tumor grade were significantly associated with shorter survival (p = 0.037 and p < 0.01, respectively). Five-year recurrence-free survival was 71.5% (95% CI 57.6%; 88.7%). Tumor resection margins and metastatic disease upon diagnosis were significantly associated with recurrence-free survival (p < 0.01 and p < 0.01, respectively).

CONCLUSION

Surgical therapy is the cornerstone of the treatment of chest wall sarcomas and can be performed safely. Metastasis and high tumor grade have a negative influence on overall survival, while tumor margins and metastasis have a negative influence on local recurrence.

Pulmonary dose tolerance in hemithorax radiotherapy for Ewing sarcoma of the chest wall: Are we overestimating the risk of radiation pneumonitis?

BACKGROUND

Children with chest wall Ewing sarcoma with malignant pulmonary effusion or pleural stranding require hemithorax radiation, often with plans that exceed lung constraints. We investigated disease control and pneumonitis in children requiring hemithorax radiation.

PROCEDURE

Eleven children (median age 13 years) received hemithorax radiotherapy. Symptomatic radiation pneumonitis was considered National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grade 1+ with respiratory symptoms. Mean lung dose (MLD), volume of lung exposed to a dose ≥5 Gy (V5), ≥20 Gy (V20), and ≥35 Gy (V35) were recorded. Adult and pediatric lung constraints were obtained from Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines and Children's Oncology Group (COG) protocols, respectively.

RESULTS

Median hemithorax dose was 15 Gy (1.5 Gy/fraction). Median total dose was 51 Gy (1.8 Gy/fraction). Most plans delivered both protons and photons. The ipsilateral MLD, V5, and V20 were 27.2 Gy, 100%, and 48.3%; the bilateral MLD, V20, and V35 were 14.1 Gy, 22.8%, and 14.3%, respectively. One hundred percent, 36%, and 91% of treatments exceeded recommended adult ipsilateral lung constraints of V5 <65%, V20 <52%, and MLD of 22 Gy; 64%, 45%, and 82% exceeded COG bilateral lung constraints of V20 <20%, MLD <15 Gy, and MLD <12 Gy, respectively; 82% of treatments exceeded the COG ipsilateral lung constraint of V20 <30%. At a median 36 months (range 12-129), the symptomatic radiation pneumonitis incidence was 0%. Two patients progressed with nonpulmonary metastatic disease and died at a median 12 months following radiotherapy.

CONCLUSIONS

Existing guidelines may overestimate pneumonitis risk, even among young children receiving multiagent chemotherapy. For children with chest wall Ewing sarcoma and other thoracic malignancies, more data are needed to refine pediatric dose-effect models for pulmonary toxicity.

A rare case of chest wall reconstruction in a child

INTRODUCTION

Ewing sarcoma/primitive neuroectodermal tumour (ES/PNET) is the most common malignant tumour of the chest wall in children and young adults. Chest wall defect left after complete resection of the involved ribs and chest wall defect requiring reconstruction, is surgically challenging for cosmetic as well as for functional purposes especially in growing children.

IMPORTANCE

A rare but feasible and simple technique for a case of chest wall tumour reconstruction has been described here with its successful outcome with available composite muscular vascularised flap.

Primary chest wall sarcoma; a single institution experience of 3 years

INTRODUCTION

Primary chest wall sarcoma is a rare entity. It can be classified based on its origin, as bone sarcomas or soft tissue sarcomas. Various prognostic factors have been studied in different case series like age, sex, tumor histology, grade, resection margin status, adjuvant treatment, and others. The present study aimed to analyze common histological types, their management by resection and reconstruction and prognosis, in cases presenting at a regional cancer center in western India.

MATERIAL AND METHOD

This was an observational study from a prospectively maintained database. 57 patients with chest wall sarcoma treated with curative intent between January 2016 till January 2019 with a minimum follow-up of 3 months were included in the study. The goals of surgical treatment were to obtain a wide resection margin of 3-4 cm, preserve the function of the chest wall and provide stability and rigidity to protect intrathoracic organs.

RESULTS

The median follow-up of the present patient's cohort was for 20.2 months. Overall two-year survival was 74.7%. Two-year OS and DFS of bone sarcoma were 62.3% and 35% and soft tissue sarcomas were 91% and 71.3%. Ewing's sarcoma had the worst two-year overall survival of 50.6% and chondrosarcoma and fibromatosis had 100% two-year overall survival.

CONCLUSION

Chest wall sarcoma forms a heterogeneous group of tumors. In the present study, Ewing's sarcoma was the most common histology with the worst survival, since they presented in advanced stages. Management should be multidisciplinary and surgical resection should be aggressive to achieve an R0 resection. Reconstruction of chest wall should aim to provide structural and functional stability with minimal morbidity. Frozen section assessment should be utilized whenever in doubt.

Outcome of multidisciplinary treatment of peripheral primitive neuroectodermal tumor

Peripheral primitive neuroectodermal tumors (PNETs) constitute very rare and aggressive malignancies. To date, there are no standard guidelines for management of peripheral PNETs due to the paucity of cases arising in various body sites. Therapeutic approach is derived from Ewing sarcoma family, which currently remains multimodal. Our study retrospectively analyzed 86 PNET patients from February 1, 1998 to February 1, 2018 at Peking Union Medical College Hospital with an additional 75 patients from review of literature. The clinicopathologic and treatment plans associated with survival was investigated. Surgery, chemotherapy, female sex, small tumor size, no lymph node metastasis, R0 surgical resection, (vincristine + doxorubicin + cyclophosphamide)/(isophosphamide + etoposide) regimen, and more than 10 cycles of chemotherapy were associated with improved overall survival in univariate analysis. Surgery, more than 10 cycles of chemotherapy, and small tumor size were independent prognostic factors for higher overall survival. Our data indicates that multimodal therapy is the mainstay therapeutic approach for peripheral PNET.

Impact of different treatment techniques for pediatric Ewing sarcoma of the chest wall: IMRT, 3DCPT, and IMPT with/without beam aperture

Purpose

To evaluate the dosimetric differences between photon intensity‐modulated radiation therapy (IMRT) plans, 3D conformal proton therapy (3DCPT), and intensity‐modulated proton therapy (IMPT) plans and to investigate the dosimetric impact of different beam spot size and beam apertures in IMPT for pediatric Ewing sarcoma of the chest wall.

Methods and Materials

Six proton pediatric patients with Ewing sarcoma in the upper, middle, and lower thoracic spine regions as well as upper lumbar spine region were treated with 3DCPT and retrospectively planned with photon IMRT and IMPT nozzles of different beam spot sizes with/without beam apertures. The plan dose distributions were compared both on target conformity and homogeneity, and on organs‐at‐risk (OARs) sparing using QUANTEC metrics of the lung, heart, liver, and kidney. The total integral doses of healthy tissue of all plans were also evaluated.

Results

Target conformity and homogeneity indices are generally better for the IMPT plans with beam aperture. Doses to the lung, heart, and liver for all patients are substantially lower with the 3DPT and IMPT plans than those of IMRT plans. In the IMPT plans with large spot without beam aperture, some OAR doses are higher than those of 3DCPT plans. The integral dose of each photon IMRT plan ranged from 2 to 4.3 times of proton plans.

Conclusion

Compared to IMRT, proton therapy delivers significant lower dose to almost all OARs and much lower healthy tissue integral dose. Compared to 3DCPT, IMPT with small beam spot size or using beam aperture has better dose conformity to the target.

Risk stratification of pulmonary toxicities in the combination of whole lung irradiation and high-dose chemotherapy for Ewing sarcoma patients with lung metastases: a review

BACKGROUND

Whole lung irradiation (WLI) represents an important part of multimodal therapy in Ewing sarcoma (EwS) patients diagnosed with pulmonary metastases. This review discusses pulmonary toxicity in EwS patients with pulmonary metastases treated with WLI, who received different modes of high-dose chemotheray (HD-Cth).

METHODS

Literature was compiled using the Cochrane Library, PubMed database, and the National Institute of Health (NIH) clinical trials register. Relevant patient information, including nature of HD-Cth, acute and late lung toxicities, and pulmonary function disorders, was selected from the above databases.

RESULTS

Nine reports with a total of 227 patients, including 57 patients from a single randomized trial were included in this review. No acute or chronic symptomatic pulmonary toxicities were observed in patients that received WLI after HD busulfan-melphalan (HD-Bu/Mel), but 8% of these patients were diagnosed with asymptomatic restrictive lung disease. Grade 1 or 2 acute or chronic lung adverse effects were observed in up to 30% of patients that received WLI after HD treosulfan/Mel (HD-Treo/Mel) or HD etoposide (E)/Mel. Interstitial pneumonitis was present in 9% of patients treated concurrently with E/Mel and total body irradiation (TBI) with 8 Gy. Radiation doses as well as time between HD-Cth and WLI were both identified as significant risk factors for pulmonary function disorders.

CONCLUSION

The risk of adverse lung effects after WLI depends on several factors, including cumulative radiation dose and dose per fraction, HD-Cth regimen, and time interval between HD-Cth and WLI. A cumulative radiation dose of up to 15 Gy and a time interval of at least 60 days can potentially lead to a reduced risk of pulmonary toxicities. No evident adverse lung effects were registered in patients that received simultaneous therapy with HD-Cth and TBI. However, pulmonary function testing and lung toxicity reports were lacking for most of these patients.

Tumor de Askin. Caso radiológico

Nuevamente el estudio radiográfico demuestra ser de gran utilidad. En esta ocasión se muestra el diagnóstico de un interesante caso de una rara neoplasia confirmada por otro estudio de imagenología.

Chest wall Ewing sarcoma: a population-based analysis

BACKGROUND

The globally low incidence of pediatric chest wall Ewing sarcoma (CWES) has limited prior studies of this disease to mostly small, single-institution reviews. Our objective was to assess incidence, demographics, treatment patterns, and long-term survival of this disease through a population-based analysis.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results database was used to identify patients aged 0-21 y diagnosed with CWES from 1973 to 2011. Patients were grouped by decade to assess changes in treatment patterns and outcomes. The effects of clinical, demographic, and treatment variables on overall survival (OS) were assessed by the computation of Kaplan-Meier curves and the log-rank test, with Cox proportional hazard regression used for multivariable analysis.

RESULTS

A total of 193 pediatric patients with histologically confirmed CWES were identified. The disease was more common in men (61%), whites (92%), and 11- to 17-y olds (49%). It was metastatic at presentation in 37% of patients. When grouped approximately by decade, 10-y OS improved progressively from 38% in 1973-1979 to 65% in 2000-2011 (P = 0.033). The use of radiation decreased from 84% in the earliest period to 40% in the most recent, whereas the proportion of patients receiving surgery increased from 75% to 85%. When controlling for covariates in multivariable analysis, male patients were found to have a higher mortality than female patients (hazard ratio: 2.4; confidence interval: 1.4, 4.4; P = 0.0028).

CONCLUSIONS

This population-based analysis of CWES demonstrated an impressive trend of improving OS, with increasing use of surgery and decreasing use of radiation therapy. Our study demonstrated a gender difference in survival of CWES, with females having a better prognosis. The presence of metastatic disease is a very important prognostic factor for this illness.

Evaluation of outcome and prognostic factors in thoracic primitive neuroectodermal tumor: a study of 84 cases

BACKGROUND

Data on thoracic primitive neuroectodermal tumor (PNET) treated with a uniform chemotherapy protocol are minimal in the literature. We analyzed patients with thoracic PNET for outcome and prognostic factors.

METHODS

This is a single-institutional data review of patients treated between June 2003 and November 2011 with uniform neoadjuvant chemotherapy, surgical intervention, or radiotherapy (RT), or a combination of these treatments as local therapy followed by adjuvant chemotherapy.

RESULTS

Thoracic PNET was found in 84 of 374 (22%) patients with PNET with a median age of 15 years (range, 3-40 years); 27 (32%) of these patients had metastases. Thirty patients underwent surgical resection; 27 patients received radical RT after neoadjuvant chemotherapy. The radical RT group did not have adverse tumor characteristics or poor response to neoadjuvant chemotherapy. At median follow-up of 20.8 months (range, 2-104.6 months), 5-year event-free survival (EFS), overall survival (OS), and local control rate (LCR) were 24.4% ± 5.9%, 47.9% ± 8.4%, and 59.3% ± 9%, respectively, for the entire cohort, and 31% ± 7.7%, 59% ± 10.4%, and 67% ± 9.7%, respectively, for the group with localized tumors. In multivariate analysis, symptom duration longer than 4 months (p = 0.03), primary tumor of skeletal origin (p = 0.03), and radical RT (p = 0.006) predicted inferior EFS in the entire cohort and those with localized disease; metastatic disease (p = 0.002) predicted inferior OS. Radical RT predicted inferior LCR in the entire cohort and the group with localized tumor; tumor diameter larger than 8 cm (p = 0.02) and symptom duration longer than 4 months (p = 0.02) predicted inferior LCR in the group with localized tumor.

CONCLUSIONS

This is a single-institutional experience of 84 patients with thoracic PNETs who underwent a uniform chemotherapy protocol. Novel prognostic factors were identified for thoracic PNET. All efforts should be made to resect primary tumor after neoadjuvant chemotherapy because radical RT results in inferior EFS and LCR despite good response to neoadjuvant chemotherapy.

Prognostic factors in primary nonmetastatic Ewing sarcoma of the rib in children and young adults

BACKGROUND

The rarity of Ewing sarcoma of rib has resulted in paucity of data, particularly on the prognostic factors and pattern of relapses. We analyzed the recurrences in patients with primary nonmetastatic Ewing sarcoma of the rib and examined prognostic factors of poor outcome.

METHODS

From January 2004 to January 2011, 37 patients were treated. After induction chemotherapy, complete (from costal cartilage to vertebra) or partial excision of involved rib with or without adjacent ribs was performed. Postoperative radiotherapy was administered for positive margins, poor response to chemotherapy, and large primary tumors with significant soft tissue component at presentation.

RESULTS

Disease relapsed in 16 patients: at the local site (n = 5), both local and distant (n = 2), and distant site only (n = 9). The projected 5-year cause-specific, relapse-free survival and local control were 50%, 44%, and 72%. Poor response to chemotherapy (>5% residual tumor) and resection of adjacent lung parenchyma (a surrogate for tumor extension) were adverse prognostic factors for relapse-free survival in multivariate analysis.

CONCLUSION

Relapses occurred more often at distant sites and had a poor outcome. In this study, poor histologic response to chemotherapy (P = .04) and the infiltration of adjacent lung parenchyma (P = .01) are adverse prognostic factors.