Hemithorax irradiation for Ewing tumors of the chest wall

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.

Dilemma in diagnosis and management of rare primary pleural Ewing's sarcoma with synchronous limited metastatic disease

We present a case of a 34-year-old woman who presented with complaints of fever, cough and dyspnoea of 2 months' duration. On evaluation, she was diagnosed with a rare entity primary pleural Ewing's sarcoma with synchronous metastases to mediastinal, supraclavicular nodes and single vertebra. Due to the rarity of this entity and lack of treatment guidelines on extraosseous Ewing's sarcoma, the patient was managed with a combination of multiagent chemotherapy, surgery and radiotherapy as per standard guidelines for skeletal Ewing's sarcoma. We present this case to discuss differential diagnoses and management dilemmas encountered on the use of local modalities such as surgery and radiotherapy for control of primary and metastatic sites.

Ewing sarcoma

Ewing sarcoma is a rare tumor that requires complex multidisciplinary management. This report describes the general management and standard radiotherapy guidelines in both North America (Children's Oncology Group) and Europe (International Society of Pediatric Oncology). Standard treatment involves multiagent induction chemotherapy followed by local treatment with surgery, definitive radiation, or a combination of surgery and radiation followed by additional chemotherapy and consolidation local treatment to metastatic sites. The data supporting the role of chemotherapy, surgery, and radiation and specific radiation therapy guidelines are presented.

Evaluating the Soft Tissue Sarcoma Paradigm for the Local Management of Extraskeletal Ewing Sarcoma

OBJECTIVES

We reviewed our experience treating patients with localized extraskeletal Ewing sarcoma (EES) to determine optimal local management strategies for this rare disease.

METHODS

Sixty patients with localized EES treated at our institution between 1994 and 2018 were reviewed. The Kaplan-Meier method was used to estimates disease outcomes.

RESULTS

The median follow-up time was 74 months (interquartile range [IQR], 17-121). Half the patients (n = 30) received combined-modality local therapy (CMT) with both surgery and radiation therapy (RT), whereas the other half received single-modality local therapy (SMT) with either surgery or RT. All patients received chemotherapy. The 5-year overall survival was 76%. Twenty-two patients (37%) developed recurrence at a median time of 15 months (IQR, 5-56 months) resulting in 3-year progression-free survival (PFS) of 65%. On univariate analysis, the use of both neoadjuvant and adjuvant chemotherapy was associated with improved 5-year PFS (71% vs. 50%, p = .04) compared with those who received one or the other. Furthermore, 11 patients (18%) developed local recurrences at a median time of 14 months (IQR, 2-19 months), resulting in a 5-year local control (LC) rate of 77%. Use of CMT was not associated with improved LC (83% vs. 72% SMT, p = .41). Also, use of CMT was the only factor associated with poorer disease-specific survival (vs. SMT; hazard ratio, 3.4; p = .047; 95% confidence interval, 1.01-11.4).

CONCLUSION

For patients with EES, CMT was not associated with a decreased rate of local relapse. These data suggest that SMT alone may be sufficient for LC in select patients. A multi-institutional collaborative effort should be considered to validate these findings.

IMPLICATIONS FOR PRACTICE

Extraskeletal Ewing sarcoma is a rare chemosensitive sarcoma whose clinical course more closely follows Ewing sarcoma of bone rather than that of other soft tissue sarcomas. Based on this study, combined-modality local therapy did not confer a local control advantage compared with single-modality local therapy. Therefore, single-modality local therapy is likely adequate in select patients with favorable disease features, which has the advantage of ensuring prompt administration of systemic therapy. A multi-institutional collaborative effort is warranted to determine which patients may benefit from de-escalated local therapy.

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.

Impact of Whole Lung Irradiation on Survival Outcome in Patients With Lung Relapsed Ewing Sarcoma

PURPOSE

There is no standard treatment procedure for relapsed Ewing sarcoma (EwS). This retrospective analysis evaluates the survival outcome in patients with an isolated pulmonary relapse of EwS treated with whole lung irradiation (WLI) in addition to second line chemotherapy (Ctx).

METHODS AND MATERIALS

In our study, 136 patients with pulmonary relapsed EwS who were registered in the relapse register of the Cooperative Ewing Sarcoma Study group or the Sarcoma Relapse Registry for relapsed sarcoma of bone and soft tissues were analyzed. All patients received relapse Ctx or an additional total resection of lung metastasis. Of these patients, 88 (median age, 21 years; range, 7-52 years) achieved a second remission by the relapse treatment. Of these 88 patients, 48 patients received an additional WLI. The 3-year progression-free survival (PFS) and 3-year overall survival (OS) were analyzed (median follow-up, 3 years; range, 7 months to 11 years and 9 months). Additional prognostic factors for survival outcomes, including the response of lung metastases to Ctx, were also estimated.

RESULTS

The survival outcome was significantly improved after WLI when analyzing the entire group of pulmonary relapsed patients: 3-year PFS 36% (+WLI) versus 14% (-WLI) (P = .001); 3- year OS 47% (+WLI) versus 33% (-WLI) (P = .007). The 3-year PFS in patients with complete remission of lung relapse receiving WLI (n = 48) compared with those without WLI (n = 40), was 37% (+WLI) versus 21% (-WLI) (P = .18). The site of the primary tumor and the response of pulmonary lesions to Ctx were significant prognostic indicators for survival in patients treated with WLI. No severe pulmonary function disorders or lung toxicities were observed after WLI treatment in both pediatric and adult patients.

CONCLUSIONS

The WLI does not correlate with improved OS in patients with pulmonary relapsed EwS. However, a marginal trend toward superior PFS and improved local control of pulmonary disease suggests the application of WLI in patients with EwS with isolated lung relapse and second clinical remission.

Outcome of resectable pediatric Ewing sarcoma of the ribs

PURPOSE

Was to evaluate the outcome of multimodality treatment in resectable primary Ewing sarcoma/primitive neuroectodermal tumor ES/PNET of the ribs and role of thoracoscopy in facilitating resection of these tumors.

PATIENTS AND METHODS

This was a retrospective study including 22 patients with primary ES/PNET of the ribs surgically treated at Children's Cancer Hospital Egypt (CCHE) between January 2008 until the end of December 2014.

RESULTS

Median age was 8.5years (range 5months to 16years.). All patients received neoadjuvant chemotherapy. Thoracoscopic exploration was performed in 15 (68%) patients. Resection included 1,2,3 and 4 ribs in (7,4,8 and 3 patients) respectively, parts of the diaphragm (3 patients), wedge resection of the lung (10 patients) and pleural nodules (2 patients). Primary closure was feasible in 11 patients and rib transposition was done in one patient. Reconstruction by proline mesh covered by muscle flap was done in 10 patients. Margins were microscopically positive in 3 patients and close in 2 patients. Postoperative radiotherapy was given in 8 patients. With a median follow-up of 38.5months, the 3-year event -free survival (EFS) and overall survival(OS) rates were 31.6% and 55.6%, respectively.

CONCLUSION

Multimodality treatment is essential in the management of ES-PNET of the ribs. Neoadjuvant chemotherapy facilitates adequate resection. The role of thoracoscopy and the indications of postoperative radiotherapy need further evaluation.

Late toxicity and outcomes following radiation therapy for chest wall sarcomas in pediatric patients

PURPOSE

To investigate the contribution of radiation therapy to acute and late toxicity in pediatric chest wall sarcoma patients and evaluate dosimetric correlates of higher incidence toxicities such as scoliosis and pneumonitis.

METHODS AND MATERIALS

The data from 23 consecutively treated pediatric patients with chest wall sarcomas of various histologies (desmoid, Ewing, rhabdomyosarcoma, nonrhabdomyosarcoma-soft tissue sarcomas) were reviewed to evaluate the relationship between end-organ radiation dose, clinical factors, and the risk of subsequent late effects (scoliosis, pneumonitis). Cobb angles were used to quantify the extent of scoliosis. Doses to the spine and lung were calculated from the radiation treatment plan.

RESULTS

The range of scoliosis identified on follow-up imaging ranged from -47.6 to 64° (median, 2.95°). No relationship was identified between either radiation dose to the ipsilateral or contralateral vertebral body or tumor size and the degree or direction of scoliosis. The extent of surgical resection and number and location of resected ribs affected the extent of scoliosis. The dominant predictor of extent of scoliosis at long-term follow-up was the extent of scoliosis following surgical resection. Radiation pneumonitis was uncommon and was not correlated with mean dose or volume of lung receiving 24 Gy; however, 1 of 3 surviving patients who received whole pleural surface radiation therapy developed significant restrictive lung disease.

CONCLUSIONS

Acute and late radiation therapy-associated toxicities in pediatric chest wall sarcoma patients are modest. The degree of scoliosis following resection is a function of the extent of resection and of the number and location of ribs resected, and the degree of scoliosis at the last follow-up visit is a function of the extent of scoliosis following surgery. Differential radiation therapy dose across the vertebral body does not increase the degree of scoliosis. Severe restrictive pulmonary disease is a late complication of survivors after whole pleural surface radiation therapy.

Askin tumor: A rare neoplasm of thoracopulmonary region

Askin tumor is a rare neoplasm of thoracopulmonary region. But it mimics other common pediatric disorders, such as empyema, lymphoma, and tuberculosis, posing a great diagnostic and therapeutic challenge to the treating clinicians. So it is of utmost importance to make an early diagnosis and proper referral/treatment in such cases. We highlighted diagnostic challenge, treatment, and favorable outcome of a case that presented to us.

Protective, elective lung irradiation in non-metastatic Ewing's sarcoma

Ewing's sarcoma in childhood is a disease from family of the peripheral primitive neuroectodermal tumours. For a period of 16 y (1984-2000), 34 children with Ewing's sarcoma were treated and followed in our department. Twenty-seven of these patients were without distant metastases. Complex treatment was applied to all these patients-chemotherapy VACA (vincristine, actinomycin D, cyclophosphamide, adriamycin), local radiotherapy to a total dose of 50-56 Gy +/- surgery. After, a local tumour control was achieved in 11 children with non-metastatic Ewing's sarcoma, elective whole lung irradiation to a total dose of 12-15 Gy was applied. Our experience in these 11 patients with non-metastatic Ewing's sarcoma, in whom elective lung irradiation was applied, showed significant reduction in the lung metastases, improved free of disease survival and overall survival. The achieved good treatment results necessitate extending this treatment approach through defining the risk groups of patients, suitable for elective lung radiotherapy combined with chemotherapy in non-metastatic Ewing's sarcoma.

Treatment of an Askin tumor: A case report and review of the literature

Askin tumors are rare malignant neoplasms that are localized in the thoracopulmonary region and mainly occur in children and adolescents. Further investigation with regard to the effective treatment of this disease is required, since the disease has a low incidence and limited knowledge is available on the biological activity and prognostic factors of this type of tumor. The present study describes the case of a 30-year-old male patient with a histologically and morphologically proven Askin tumor who was treated in Shandong Cancer Hospital and Institute (Jinan, China). A chest computed tomography (CT) scan demonstrated a large mass filling the entire left lung, associated with mediastinum and right lung compression and accompanied by destruction of the 2nd rib. The patient accepted chemotherapy and radiotherapy instead of a radical mass resection since the mass was irresectable. A good clinical response was achieved to the chemotherapy and radiotherapy. The diagnosis and treatment of Askin tumors remains a challenge for clinicians and surgeons due to the absence of standard therapeutic guidelines for the treatment of this disease. According to the experience obtained from the cases encountered to date, treatment strategies should aim to reduce local recurrence and distant metastasis. Moreover, surgery, chemotherapy and radiotherapy or a combination of these methods appears to constitute an effective treatment strategy for Askin tumors.

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.

Timing of surgery and the role of adjuvant radiotherapy in ewing sarcoma of the chest wall: a single-institution experience

BACKGROUND

Ewing sarcoma (ES) is the most common chest wall malignancy in adolescents. Current therapy incorporates chemotherapy to treat systemic disease and radiotherapy to assist with local control. We sought to evaluate the timing of surgery and role of adjuvant radiotherapy.

METHODS

We reviewed the St. Jude Children's Research Hospital chest wall ES experience from 1979 to 2009. Patient demographics, tumor characteristics, treatment variables, and outcomes were analyzed with respect to timing of surgery and use of adjuvant radiotherapy.

RESULTS

Our cohort consisted of 36 patients with chest wall ES; median follow-up was 14.2 years, and 15-year estimate of overall survival was 66 %. In patients with localized disease, the timing of surgery (up-front vs. delayed) did not impact margin negativity or the use of adjuvant radiotherapy, but it did decrease the extent of chest wall resection. When considering radiotherapy in patients with localized disease, we found that patients who did not receive radiotherapy had smaller tumor size (median 6 vs. 10 cm) (p = 0.04) and were more likely to have had negative margins (p = 0.01) than patients who received adjuvant radiotherapy. One patient in each group developed a locoregional recurrence. The 15-year estimated of overall survival for patients who received adjuvant radiotherapy was 80 versus 100 % for those who did not.

CONCLUSIONS

Delayed surgery decreased the extent of chest wall resection and helped define a patient population with favorable tumor biology. Patients with complete pathologic responses to chemotherapy, and those with tumors <8 cm and negative surgical margins may be spared adjuvant radiotherapy without any decrement in overall survival.

Myeloablative therapy against high risk Ewing's sarcoma: A single institution experience and literature review

BACKGROUND

Attempts to improve survival outcomes of patients with high risk Ewing's sarcoma (ES) have focused on chemotherapy dose intensification strategies.

AIM

The objective of this study is to retrospectively evaluate clinical characteristics and outcome of pediatric patients with high risk ES treated at a single institution.

MATERIALS AND METHODS

From 1995 to 2008, seventeen patients (male:female, 14:3) were treated with dose-intensive therapy in our institution. Median age at diagnosis was 10 years (range: 2-15). Seven patients had metastases at diagnosis (lung in 6 cases and bone in one case). Eleven patients presented with unresectable disease. Fifteen (88.2%) received the Spanish Society of Pediatric Oncology protocol which includes six cycles of vincristine, doxorubicin, ifosfamide and etoposide. Two out of the six cases that were resectable received postoperative radiation. In addition, eleven patients received definitive radiation therapy. Finally, twelve (70.5%) out of 17 patients received myeloablative therapy with melphalan/etoposide. The rest of patients (N = 5) received busulfan/melphalan.

RESULTS

Median follow-up was 78 months (range: 15-155 months). Initial responses were complete in all patients, but 9 of them developed progression disease. Seven patients became long-term event-free survivors. No patient died of toxicity after transplantation. The 2- and 5-year overall survival rates for all patients were 93% and 73%, respectively. Event-free survival rates were 74% and 54% at 2 and 5 years, respectively.

CONCLUSION

This single-institution experience suggests that myeloablative therapy against high risk ES is effective and safe.

Prognostic factors and outcome in Askin-Rosai tumor: a review of 104 patients

PURPOSE

To evaluate the prognostic factors and treatment outcome of patients with Askin-Rosai tumor of the chest wall treated at a single institution.

METHODS AND MATERIALS

Treatment comprised multiagent chemotherapy and local therapy, which was either in the form of surgery alone, radical external-beam radiotherapy (EBRT) alone, or a combination of surgery and EBRT. Thirty-two patients (40%) were treated with all three modalities, 21 (27%) received chemotherapy and radical EBRT, and 19 (24%) underwent chemotherapy followed by surgery only.

RESULTS

One hundred four consecutive patients aged 3-60 years were treated at the Tata Memorial Hospital from January 1995 to October 2003. Most (70%) were male (male/female ratio, 2.3:1). Asymptomatic swelling (43%) was the most common presenting symptom, and 25% of patients presented with distant metastasis. After a median follow-up of 28 months, local control, disease-free survival, and overall survival rates were 67%, 36%, and 45%, respectively. Median time to relapse was 25 months, and the median survival was 76 months. Multivariate analysis revealed age ≥18 years, poor response to induction chemotherapy, and presence of pleural effusion as indicators of inferior survival. Fifty-six percent of patients with metastatic disease at presentation died within 1 month of diagnosis, with 6-month and 5-year actuarial survival of 14% and 4%, respectively.

CONCLUSION

Primary tumor size, pleural effusion, response to chemotherapy, and optimal radiotherapy were important prognostic factors influencing outcome. The combination of neoadjuvant chemotherapy, surgery, and radiotherapy resulted in optimal outcome.

Advanced-technology radiation therapy for bone sarcomas

BACKGROUND

Bone sarcomas are rare primary tumors. Radiation therapy (RT) can be useful in securing local control in cases where negative surgical margins cannot be obtained or where tumors are not resected. Recent technical advances in RT offer the opportunity to deliver radiation to these tumors with higher precision, thus allowing higher doses to the tumor target with lower doses to critical normal tissues, which can improve local tumor control and/or reduce treatment-related morbidity.

METHODS

The authors conducted a survey of recent technical developments that have been applied to the RT for bone sarcomas.

RESULTS

RT techniques that show promise include intensity-modulated photon radiation therapy, 3-D conformal proton RT, intensity-modulated proton RT, heavy charged-particle RT, intraoperative RT, and brachytherapy. All of these techniques permit the delivery of higher radiation doses to the target and less dose to normal tissue than had been possible with conventional 3-D conformal radiation techniques. Protons deliver substantially less dose to normal tissues than photons.

CONCLUSIONS

Data from clinical studies using these advanced radiation techniques suggest that they can improve the therapeutic ratio (the ratio of local control efficacy to the risk of complications). This is expected to improve the treatment outcome for these challenging tumors.

Management of tumors of the chest wall in childhood: a review

Chest wall tumors in childhood are major challenges with respect to diagnostic workup and treatment. Incidence rate is less than 1 per 1,000,000 and various benign and malignant diseases are noted. From the malignant diseases, Ewing tumors and rhabdomyosarcoma tumors are most often seen. Depending on diagnosis, staging, and age, therapy has to be tailored for each patient, which should be discussed in a multidisciplinary team setting. Radical resection is in most cases the major component of treatment. Use of chemotherapy depends on the diagnosis. In soft-tissue tumors, previously considered to be chemotherapy insensitive, favorable results are currently reported. The role of radiotherapy is debated owing to its pronounced late sequelae in children, but should be added when adequate margins cannot be achieved by surgery.

Treatment planning comparison of electron arc therapy and photon intensity modulated radiotherapy for Askin’s tumor of chest wall

BACKGROUND AND PURPOSE

A dosimetric study to quantitatively compare radiotherapy treatment plans for Askin's tumor using Electron Arc (EA) vs. photon Intensity Modulated Radiotherapy (IMRT).

MATERIALS AND METHODS

Five patients treated with EA were included in this study. Treatment plans were generated for each patient using EA and IMRT. Plans were compared using dose volume histograms (DVH) of the Planning Target Volume (PTV) and Organs at Risk (OAR).

RESULTS

IMRT resulted in superior PTV coverage, and homogeneous dose distribution compared to EA. For EA, 92% of the PTV was covered to 85% of the dose compared to IMRT in which 96% was covered to 95% of the dose. V(107) that represents the hot spot within the PTV was more in IMRT compared to EA: 7.4(+/-2)% vs. 3(+/-0.5)%, respectively. With PTVs located close to the spinal cord (SC), the dose to SC was more with EA, whereas for PTVs located away from the SC, the dose to SC was more with IMRT. The cardiac dose profile was similar to that of SC. Ipsilateral lung received lower doses with IMRT while contralateral lung received higher dose with IMRT compared to EA. For non-OAR normal tissues, IMRT resulted in large volumes of low dose regions.

CONCLUSIONS

IMRT resulted in superior PTV coverage and sparing of OAR compared to EA plans. Although IMRT seems to be superior to EA, one needs to keep in mind the volume of low dose regions associated with IMRT, especially while treating young children.

Chemotherapy response is an important predictor of local recurrence in Ewing sarcoma

BACKGROUND

Local recurrence in Ewing sarcoma is associated with a poor prognosis. The purpose of the study was to determine the factors that predict local recurrence after surgical treatment of the primary tumor.

METHODS

Between 1990 and 2001, 64 patients underwent surgical resection of Ewing sarcoma. Surgical margins were assessed histologically and radiologically. Response to preoperative chemotherapy was determined by detailed specimen mapping. Local recurrence-free survival (LRFS) was calculated by Kaplan-Meier analysis. Multivariate analysis was performed with the Cox proportional hazards model.

RESULTS

A number of factors were found to be associated with local recurrence on univariate analysis. Patients with a good response to chemotherapy (> or = 90% tumor necrosis), had superior LRFS at 5 years (86% vs 51%, P = .015). Central site of disease was associated with an increased rate of recurrence. The LRFS at 5 years was 50% for the chest wall, 74% for pelvic/scapular, and 86% for extremity tumors (P = .083). Positive surgical margin was not a strong predictor of recurrence (P = .72). A critical analysis of minimal surgical margin based on preoperative magnetic resonance imaging (MRI) and computed tomography (CT) scans also failed to reveal an association between margin and local recurrence. In multivariate analysis, the 2 independent predictors of local recurrence were histological response to chemotherapy and central site of disease.

CONCLUSION

Local recurrence after surgical resection is a complex phenomenon. An important predictive factor is the response to chemotherapy. In the current study, this seems to have the largest impact. Central site of disease may be a second independent predictive factor.

Definitive surgery and multiagent systemic therapy for patients with localized Ewing sarcoma family of tumors: local outcome and prognostic factors

BACKGROUND

The local management of Ewing sarcoma family of tumors (ESFT) often centers on the surgical resectability of the primary lesion and physician biases regarding differences in the morbidity between primary surgical and radiotherapeutic management.

METHODS

The authors retrospectively reviewed the records of 33 patients with localized ESFT who underwent surgery and received systemic chemotherapy at St. Jude Children's Research Hospital (Memphis, TN). Two multiagent systemic chemotherapy regimens were used: 14 patients received vincristine, doxorubicin, cyclophosphamide, and actinomycin D (VACA), and 19 received VACA in combination with ifosphamide and etoposide. The primary tumor was surgically resected via a wide, local excision (n = 32) or a marginal excision (n = 1)performed either at diagnosis or after 3-5 months of systemic chemotherapy. Clinical outcome and prognostic factors for disease control were reported in the current study.

RESULTS

The median follow-up for patients was 9.9 years. The 5-year and 10-year survival rates were 84.5% and 75.8%, respectively. At 5 years, the cumulative incidence of local disease recurrence was 12.5%, and the event-free survival (EFS) rate was 71.7%. The same values were found at 10 years. The site of tumor origin was a significant predictor of EFS. The survival rate of patients whose tumors arose in bone was 78.6%, and the survival rate of patients whose tumors originated in soft tissue was 25.0% (P = 0.028). No other factors investigated were predictive of outcome.

CONCLUSIONS

Local disease control and overall outcome for patients with ESFT managed by multiagent systemic therapy and surgery was excellent. Local disease control rates remained near 90% at 10-year follow-up. Patients with extraosseous primary sites of disease may fare less well with this approach to therapy.

Role of radiotherapy in Ewing tumors

BACKGROUND

The objective of this review article is to outline the role of radiotherapy in a curative multimodal treatment concept.

PROCEDURE

We have analyzed the data from major multi-institutional prospective trials in Ewing tumors for to evaluate the impact of radiotherapy on local control and survival.

RESULTS

Surgery yields in general better local control and survival figures as compared to radiotherapy. The efficacy of radiotherapy as compared to surgery varies among the studies and seems to be dependent on patient selection and sequencing with chemotherapy. Combined local therapy (surgery plus post- or pre-operative radiotherapy) has yielded excellent local control rates in patients with high-risk lesions (e.g., pelvic tumors); although not proven by randomized studies, an impact on survival is likely. Indications for post-operative radiotherapy are unradical or marginal resections and poor histological response. In patients with chest wall primaries, adjuvant hemithorax irradiation has reduced the relapse rate significantly. Pre-operative irradiation offers theoretical advantages. Bilateral lung irradiation (as consolidation after chemotherapy) seems to improve prognosis in patients with metastases at diagnosis.

CONCLUSIONS

Patients with high-risk lesions probably benefit from combined local treatment (surgery plus radiotherapy). Improving local control after radiotherapy is a major issue for future studies, and sequencing with chemotherapy seems to be critical factor. The possible curative potential of radiotherapy in metastatic disease requires further investigation.

Ewing's sarcoma and peripheral primitive neuroectodermal tumor cells produce large quantities of bioactive tumor necrosis factor-alpha (TNF-alpha) after radiation exposure

PURPOSE

In the present study, we examined human Ewing's sarcoma (ES) and peripheral primitive neuroectodermal tumor (pPNET) cell lines that are able to produce TNF-alpha as part of the response to irradiation. Radiation-induced tumor cell production of TNF-alpha may enhance irradiation efficacy and improve the effect of local tumor irradiation. On the other hand, radiation-induced tumor cell production of TNF-alpha may adversely affect the normal tissue.

METHODS AND MATERIALS

Twelve different ES/pPNET cell lines were investigated in vitro and (after establishment as tumor xenografts in athymic nude mice) in vivo for their TNF-alpha mRNA expression (real-time quantitative reverse transcriptase polymerase chain reaction) and TNF-alpha protein production (in vitro: enhanced amplified sensitivity immunoassay; in vivo: immunohistochemistry) after exposure to different irradiation doses (2, 5, 10, 20, 30, or 40 Gy) and after different time intervals (1, 3, 6, 12, 24, 48, or 72 h after irradiation). The bioactivity of the TNF-alpha protein was evaluated in chromogenic cytotoxicity and neutralization assays.

RESULTS

Nine out of 12 ES/pPNET cell lines express constitutively significant quantities of bioactive TNF-alpha in vitro. ES/pPNET cells originating from primary tumors secreted higher TNF-alpha levels than cells derived from metastatic lesions. In 5 of the 9 TNF-alpha-producing cell lines, TNF-alpha mRNA and protein levels were upregulated after irradiation exposure in a time- and dose-dependent manner. After establishment of the ES/pPNET cell lines in athymic nude mice, the radiation-induced TNF-alpha release could be demonstrated also in the xenograft tumors in vivo (analogous to the in vitro experiments). Using the same methods for quantitative analysis, it was determined that the TNF-alpha expression of the radiation-responsive tumor cells was up to 2000-fold higher compared to the maximal radiation-induced TNF-alpha release in normal lung tissue measured during the pneumonic phase.

CONCLUSION

Certain ES/pPNET cell lines produce extremely large quantities of bioactive TNF-alpha after radiation exposure in a time- and dose-dependent manner. Radiation-induced TNF-alpha production of tumor cells may be of paramount importance in respect to not only tumor behavior, but also to potential damage to normal tissue and the clinical status of the host.