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Vennarini S, Colombo F, Mirandola A, Chiaravalli S, Orlandi E, Massimino M, Casanova M, Ferrari A. Clinical Insight on Proton Therapy for Paediatric Rhabdomyosarcoma. Cancer Manag Res 2023; 15:1125-1139. [PMID: 37842128 PMCID: PMC10576457 DOI: 10.2147/cmar.s362664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/05/2023] [Indexed: 10/17/2023] Open
Abstract
This paper offers an insight into the use of Proton Beam Therapy (PBT) in paediatric patients with rhabdomyosarcoma (RMS). This paper provides a comprehensive analysis of the literature, investigating comparative photon-proton dosimetry, outcome, and toxicity. In the complex and multimodal scenario of the treatment of RMS, clear evidence of the therapeutic superiority of PBT compared to other modern photon techniques has not yet been demonstrated; however, PBT can be considered an excellent treatment option, in particular for young children and patients with specific primary sites, such as the head and neck area (and especially the parameningeal regions), genito-urinary, pelvic, and paravertebral regions. The unique depth-dose characteristics of protons can be exploited to achieve significant reductions in normal tissue doses and may allow an escalation of tumour doses and greater sparing of normal tissues, thus potentially improving local control while at the same time reducing toxicity and improving quality of life. However, access of children with RMS (and more in general with solid tumors) to PBT remains a challenge, due to the limited number of available proton therapy installations.
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Affiliation(s)
- Sabina Vennarini
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Francesca Colombo
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
- Department of Oncology and Hemato-Oncology (DIPO), University of Milan, Milan, Italy
| | - Alfredo Mirandola
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Stefano Chiaravalli
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Michela Casanova
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
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Hol MLF, Indelicato DJ, Slater O, Kolb F, Hewitt RJ, Ong J, Becking AG, Gains J, Bradley J, Sandler E, Gaze MN, Pieters B, Mandeville H, Fajardo RD, Schoot R, Merks JHM, Hammond P, Smeele LE, Suttie M. Facial deformation following treatment for pediatric head and neck rhabdomyosarcoma; the difference between treatment modalities. Results of a trans-Atlantic, multicenter cross-sectional cohort study. Pediatr Blood Cancer 2023; 70:e30412. [PMID: 37249325 DOI: 10.1002/pbc.30412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/12/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND The four different local therapy strategies used for head and neck rhabdomyosarcoma (HNRMS) include proton therapy (PT), photon therapy (RT), surgery with radiotherapy (Paris-method), and surgery with brachytherapy (AMORE). Local control and survival is comparable; however, the impact of these different treatments on facial deformation is still poorly understood. This study aims to quantify facial deformation and investigates the differences in facial deformation between treatment modalities. METHODS Across four European and North American institutions, HNRMS survivors treated between 1990 and 2017, more than 2 years post treatment, had a 3D photograph taken. Using dense surface modeling, we computed facial signatures for each survivor to show facial deformation relative to 35 age-sex-ethnicity-matched controls. Additionally, we computed individual facial asymmetry. FINDINGS A total of 173 HNRMS survivors were included, survivors showed significantly reduced facial growth (p < .001) compared to healthy controls. Partitioned by tumor site, there was reduced facial growth in survivors with nonparameningeal primaries (p = .002), and parameningeal primaries (p ≤.001), but not for orbital primaries (p = .080) All patients were significantly more asymmetric than healthy controls, independent of treatment modality (p ≤ .001). There was significantly more facial deformation in orbital patients when comparing RT to AMORE (p = .046). In survivors with a parameningeal tumor, there was significantly less facial deformation in PT when compared to RT (p = .009) and Paris-method (p = .007). INTERPRETATION When selecting optimal treatment, musculoskeletal facial outcomes are an expected difference between treatment options. These anticipated differences are currently based on clinicians' bias, expertise, and experience. These data supplement clinician judgment with an objective analysis highlighting the impact of patient age and tumor site between existing treatment options.
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Affiliation(s)
- Marinka L F Hol
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Otorhinolaryngology, University of Utrecht, Utrecht, The Netherlands
- Department of Maxillofacial Surgery, Amsterdam UMC, Duivendrecht, The Netherlands
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | - Olga Slater
- Department of Pediatric Oncology, Great Ormond Street Hospital, NHS Foundation Trust, London, UK
| | - Frederic Kolb
- Department of Plastic Surgery, Institute Gustave Roussy, Paris, France
| | - Richard J Hewitt
- Department of Head & Neck and Tracheal Surgery Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Juling Ong
- Department of Craniofacial, Plastic and Reconstructive Surgery, Chelsea and Westminster NHS Hospital Foundation Trust, London, UK
| | - Alfred G Becking
- Department of Maxillofacial Surgery, Amsterdam UMC, Duivendrecht, The Netherlands
| | - Jenny Gains
- Department of Radiation Oncology, NHS Trust, London, UK
| | - Julie Bradley
- Department of Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | - Eric Sandler
- Division of Pediatric Oncology, Nemours Children's Specialty Clinic, Jacksonville, Florida, USA
| | - Mark N Gaze
- Department of Radiation Oncology, NHS Trust, London, UK
| | - Bradley Pieters
- Department or Radiation Oncology, Amsterdam UMC, Duivendrecht, The Netherlands
| | - Henry Mandeville
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, and Institute of Cancer Research, Sutton, UK
| | | | - Reineke Schoot
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | | | - Ludwig E Smeele
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Maxillofacial Surgery, Amsterdam UMC, Duivendrecht, The Netherlands
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Metts J, Xue W, Gao Z, Ermoian R, Bradley JA, Arnold MA, Dasgupta R, Venkatramani R, Walterhouse D. Survival of patients with orbital and eyelid rhabdomyosarcoma treated on Children's Oncology Group studies from 1997 to 2013: A report from the Children's Oncology Group. Cancer 2023; 129:1735-1743. [PMID: 36857314 PMCID: PMC10288338 DOI: 10.1002/cncr.34723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Orbital rhabdomyosarcoma (ORMS) commonly presents as low-risk disease (stage 1, group I-III, embryonal RMS) with excellent outcome. Long-term follow-up of patients with low-risk ORMS and outcomes of less common subgroups of ORMS treated on recent Children's Oncology Group (COG) trials have not been reported. METHODS Patients with ORMS enrolled on COG trials from 1997 to 2013 were identified. Demographic information and disease characteristics were collected. Outcomes were determined for the following subgroups: 1) low-risk ORMS, 2) resected (group I/II) low-risk ORMS, 3) non-low-risk ORMS, and 4) recurrent ORMS. Event-free survival (EFS) and overall survival (OS) were estimated using the Kaplan-Meier method. ResultsThe authors identified 218 patients with ORMS. Most tumors were embryonal/botryoid (n = 169; 77.5%), <5 cm (n = 213; 97.7%), group III (n = 170; 78.0%), and without lymph node involvement (N0; n = 215; 98.6%). For 192 patients with low-risk ORMS, the 10-year EFS and OS rates were 85.5% (95% confidence interval [CI], 77.0%-94.0%) and 95.6% (95% CI, 90.8%-100.0%), respectively. Those with group I/II low-risk ORMS (n = 5 in group I; n = 39 in group IIA) had 10-year EFS and OS rates of 88.0% (95% CI, 72.6%-100.0%) and 97.6% (95% CI, 90.0%-100.0%), respectively. Twenty-six patients with non-low-risk ORMS had 5-year EFS and OS rates of 88.5% (95% CI, 75.6%-100.0%) and 95.8% (95% CI, 87.7%-100.0%), respectively. For patients with recurrent ORMS, the 10-year OS rate from the time of recurrence was 69.4% (95% CI, 50.0%-88.8%). CONCLUSIONS Patients with ORMS had favorable long-term survival outcomes on COG studies from 1997 to 2013, including those who had both low-risk and non-low-risk disease. A significant proportion of patients with recurrent ORMS may achieve long-term survival.
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Affiliation(s)
- Jonathan Metts
- Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, St Petersburg, Florida, USA
| | - Wei Xue
- Department of Biostatistics, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Zhengya Gao
- Department of Biostatistics, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ralph Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Michael A. Arnold
- Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rajkumar Venkatramani
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - David Walterhouse
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Patterns of Hearing Loss in Irradiated Survivors of Head and Neck Rhabdomyosarcoma. Cancers (Basel) 2022; 14:cancers14235749. [PMID: 36497230 PMCID: PMC9736087 DOI: 10.3390/cancers14235749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The frequency and patterns of HL in a HNRMS survivor cohort were investigated. A dose-effect relationship between the dose to the cochlea and HL was explored. METHODS Dutch survivors treated for HNRMS between 1993 and 2017 with no relapse and at least two years after the end of treatment were eligible for inclusion. The survivors were evaluated for HL with pure-tone audiometry. HL was graded according to the Muenster, Common Terminology Criteria for Adverse Events (CTCAE) v4.03 and International Society for Paediatric Oncology (SIOP) classification. We defined deleterious HL as Muenster ≥ 2b, CTCAE ≥ 2, and SIOP ≥ 2. Mixed-effects logistic regression was used to search for the dose-effect relationship between the irradiation dose to the cochlea and the occurrence of HL. RESULTS Forty-two HNRMS survivors underwent pure-tone audiometry. The Muenster, CTCAE and SIOP classification showed that 19.0% (n = 8), 14.2% (n = 6) and 11.9% (n = 5) of survivors suffered from HL, respectively. A low-frequency HL pattern with normal hearing or milder hearing loss in the higher frequencies was seen in four survivors. The maximum cochlear irradiation dose was significantly associated with HL (≥Muenster 2b) (p = 0.047). In our series, HL (≥Muenster 2b) was especially observed when the maximum dose to the cochlea exceeded 19 Gy. CONCLUSION HL occurred in up to 19% of survivors of HNRMS. More research is needed on HL patterns in HNRMS survivors and on radiotherapy dose-effect relationships.
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Wyatt KD, Birz S, Hawkins DS, Minard-Colin V, Rodeberg DA, Sparber-Sauer M, Bisogno G, Koscielniak E, De Salvo GL, Ebinger M, Merks JHM, Wolden SL, Xue W, Volchenboum SL. Creating a data commons: The INternational Soft Tissue SaRcoma ConsorTium (INSTRuCT). Pediatr Blood Cancer 2022; 69:e29924. [PMID: 35969120 PMCID: PMC9560864 DOI: 10.1002/pbc.29924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 11/07/2022]
Abstract
In this article, we will discuss the genesis, evolution, and progress of the INternational Soft Tissue SaRcoma ConsorTium (INSTRuCT), which aims to foster international research and collaboration focused on pediatric soft tissue sarcoma. We will begin by highlighting the current state of clinical research for pediatric soft tissue sarcomas, including rhabdomyosarcoma and non-rhabdomyosarcoma soft tissue sarcoma. We will then explore challenges and research priorities, describe the development of INSTRuCT, and discuss how the consortium aims to address key research priorities.
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Affiliation(s)
- Kirk D. Wyatt
- Division of Pediatric Hematology/Oncology, Roger Maris Cancer Center, Sanford Health, Fargo, North Dakota, United States
| | - Suzi Birz
- Department of Pediatrics, University of Chicago, Chicago, Illinois, United States
| | - Douglas S. Hawkins
- Division of Hematology/Oncology, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
| | | | - David A. Rodeberg
- Division of Pediatric Surgery, University of Kentucky, Lexington, Kentucky, United States
| | - Monika Sparber-Sauer
- Klinikum der Landeshauptstadt Stuttgart, Olgahospital, Zentrum für Kinder-, Jugend - und Frauenmedizin, Pediatrie 5 (Pädiatrische Onkologie, Hämatologie, Immunologie), Stuttgart Cancer Center, Stuttgart, Germany; University of Tübingen, Medical Faculty, Tübingen, Germany
| | - Gianni Bisogno
- Hematology Oncology Division, Department of Women’s and Children’s Health, University Hospital of Padova, Padova Italy
| | - Ewa Koscielniak
- Klinikum der Landeshauptstadt Stuttgart, Olgahospital, Zentrum für Kinder-, Jugend - und Frauenmedizin, Pediatrie 5 (Pädiatrische Onkologie, Hämatologie, Immunologie), Stuttgart Cancer Center, Stuttgart, Germany; University of Tübingen, Medical Faculty, Tübingen, Germany
| | - Gian Luca De Salvo
- Clinical Research Unit, Istituto Oncologico Veneto IOV IRCCS, Padova, Italy
| | - Martin Ebinger
- Department Pediatric Hematology/Oncology, Children’s University Hospital, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | | | - Suzanne L. Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Wei Xue
- Department of Biostatistics, Children’s Oncology Group Statistics and Data Center, University of Florida, Gainesville, FL
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Sobel RK, Ford JR, Dong W, Shriver E, Griepentrog GJ, Debnam JM, Esmaeli B. Frequency and Clinical Course of Residual Orbital Masses After Treatment of Orbital Rhabdomyosarcoma. Am J Ophthalmol 2022; 234:28-36. [PMID: 34280364 DOI: 10.1016/j.ajo.2021.06.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE To evaluate the frequency and clinical course of residual orbital masses on imaging studies after multimodality treatment for orbital rhabdomyosarcoma. DESIGN Retrospective case series. METHODS We reviewed records of patients with primary orbital rhabdomyosarcoma who underwent chemotherapy and radiotherapy after surgical biopsy or debulking at 4 US centers during 1998-2019. Demographics, histologic subtype, tumor response 12 weeks after chemotherapy initiation and after completion of all treatment, and imaging findings were analyzed. RESULTS Thirty-two patients met inclusion criteria. Twenty-two were male, and 30 were younger than 18 years. Histologic subtype was embryonal in 22 patients, alveolar in 8, and mixed embryonal/alveolar in 2. Median follow-up time was 46 months (range, 4.9-199 months). Two patients died. Twenty-seven patients had reliable end-of-treatment imaging findings, of whom 9 had a residual mass. Three residual masses disappeared spontaneously (by 4, 32, and 53 months), 2 remained at last contact, at 2 and 7 years of follow-up, and 3 were excised; 1 progressed and underwent an exenteration. Complete response at 12 weeks was associated with complete response at the end of treatment (P < .001). Patients with T1 or T2 tumor at presentation were more likely to have complete response at last contact than were those with T3 or T4 tumor (P < .05). Biopsy type (incisional or excisional) was not associated with response to treatment at any time point. CONCLUSION A residual orbital mass on imaging may be present after multimodality treatment in approximately one-third of patients. Resolution without biopsy or excision varied from months to years.
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Affiliation(s)
- Rachel K Sobel
- From the Department of Ophthalmology, Vanderbilt University Medical Center (R.K.S.), Nashville, Tennessee, USA
| | - Joshua R Ford
- Orbital Oncology & Ophthalmic Plastic Surgery, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center (J.R.F., B.E.), Houston, Texas, USA
| | - Wenli Dong
- Department of Biostatistics, University of Texas MD Anderson Cancer Center (W.D.), Houston, Texas, USA; Department of Ophthalmology, University of Iowa (W.D.), Iowa City, Iowa, USA
| | - Erin Shriver
- Department of Ophthalmology, University of Iowa (W.D.), Iowa City, Iowa, USA
| | - Gregory J Griepentrog
- Department of Ophthalmology & Visual Sciences, Medical College of Wisconsin (G.J.G.), Milwaukee, Wisconsin, USA
| | - J Matthew Debnam
- Department of Neuroradiology, University of Texas MD Anderson Cancer Center (J.M.D.), Houston, Texas, USA
| | - Bita Esmaeli
- Orbital Oncology & Ophthalmic Plastic Surgery, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center (J.R.F., B.E.), Houston, Texas, USA.
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Dávila-Camargo A, Samaniego-Novelo FF, Vidal-Muñoz M, Jiménez-López JM, López-Facio E. Multidisciplinary approach to orbital embryonic rhabdomyosarcoma: About a case. ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA 2021; 96:552-555. [PMID: 34620486 DOI: 10.1016/j.oftale.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/02/2020] [Indexed: 10/22/2022]
Abstract
Of the head and neck tumoral lesions in children and adolescents, 5%-10% are primary malignant tumors. Among these tumors, orbital rhabdomyosarcoma stands out, which is the most common primary soft tissue sarcoma in children. Its diagnosis requires a high degree of clinical suspicion, and it can be corroborated with a series of examinations, in order to stage it and carry out the appropriate treatment. Currently, surgery and chemotherapy are the primary treatments, and the use of conventional radiotherapy is limited to cases where previous treatments fail or there is a risk of recurrence. The following case report aims to expose the clinical picture, diagnosis, staging and integral treatment of orbital rhabdomyosarcoma, as well as the interdisciplinary management that was performed to improve the patient's prognosis.
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Affiliation(s)
- A Dávila-Camargo
- Departamento de Oftalmología, Hospital Ángeles, Torreón (Coahuila), Mexico.
| | | | - M Vidal-Muñoz
- Departamento de Radiooncología, Unidad Médica de Alta Especialidad N.° 71 IMSS, Torreón (Coahuila), Mexico
| | - J M Jiménez-López
- Departamento de Radiooncología, Unidad Médica de Alta Especialidad N.° 71 IMSS, Torreón (Coahuila), Mexico
| | - E López-Facio
- Departamento de Oncología Pediátrica, Unidad Médica de Alta Especialidad N.° 71 IMSS, Torreón (Coahuila), Mexico
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Zloto O, Minard‐Colin V, Boutroux H, Brisse HJ, Levy C, Kolb F, Bolle S, Carton M, Helfre S, Orbach D. Second-line therapy in young patients with relapsed or refractory orbital rhabdomyosarcoma. Acta Ophthalmol 2021; 99:334-341. [PMID: 32833335 DOI: 10.1111/aos.14596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/23/2020] [Accepted: 07/09/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Localized orbital rhabdomyosarcoma (oRMS) has an overall favourable prognosis with more than 90% of survival. Little is known about the best strategy in recurrent/refractory (R/R) cases. The purpose is to examine the characteristics of patients with R/R-oRMS, focusing on local therapy. METHODS This is bicentric retrospective study. Analysis is of young patients (<30 years) with R/R-oRMS who were treated from 1989 to 2018 at the Institut Curie and Gustave Roussy Cancer Campus, France. RESULTS Twenty-seven out of 162 patients (17%) with oRMS presented with R/R disease. 6 of these patients had alveolar RMS (22%), 3 of whom had initial parameningeal extension (11%). During first-line treatment, 18 patients (67%) had orbital radiotherapy. Median age at R/R was 10 years (ranges: 4-28) after a delay of 19 months from diagnosis (ranges: 3-40). Tumoral events were local relapses (22 cases), local progression (3 cases) or regional relapses (2 cases). Second-line treatments included chemotherapy (27 cases), radiotherapy (16 cases), surgery (exenteration; 8 cases) and metastasis/ nodal removal (3 cases). After a median follow-up of 99 months (range: 10-306), 4 patients died and 23 are in complete remission (CR) without treatment. One patient had subsequent relapse treated with exenteration and brachytherapy until a new tumour remission. Five-year event-free and overall survivals after first tumour event are, respectively, 84.4% (95% confidence interval: 71.5%-98.8%) and 85.8% (95% confidence interval: 72.1%-100.0%) CONCLUSION: R/R-oRMS is a rare situation. Second-line therapy is efficient in this location, sometime at the cost of lifesaving mutilating surgery. Second-line local therapy needs therefore to consider local radiotherapy if possible or complete wide surgery.
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Affiliation(s)
- Ofira Zloto
- Goldschleger Eye Institute Sheba Medical Center Affiliated with The Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- SIREDO Oncology Center (Care, Innovation and Research for Children, Adolescents and Young Adults with Cancer) Institut Curie PSL University Paris France
| | - Veronique Minard‐Colin
- Pediatric Adolescent Young Adult Department Institut de Cancérologie Gustave Roussy Cancer Campus (GRCC) Villejuif France
| | - Helene Boutroux
- Department of Pediatric Hematology and Oncology Trousseau Hospital (AP‐HP) Paris France
| | | | | | - Frederic Kolb
- Plastic Surgery Department Institut de Cancérologie Gustave Roussy Cancer Campus (GRCC) Villejuif France
| | - Stephanie Bolle
- Radiation Oncology Department Institut de Cancérologie Gustave Roussy Cancer Campus (GRCC) Villejuif France
| | - Matthieu Carton
- Department of Biostatistics Institut Curie PSL University Paris France
| | | | - Daniel Orbach
- SIREDO Oncology Center (Care, Innovation and Research for Children, Adolescents and Young Adults with Cancer) Institut Curie PSL University Paris France
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9
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Palmer JD, Tsang DS, Tinkle CL, Olch AJ, Kremer LCM, Ronckers CM, Gibbs IC, Constine LS. Late effects of radiation therapy in pediatric patients and survivorship. Pediatr Blood Cancer 2021; 68 Suppl 2:e28349. [PMID: 33818893 DOI: 10.1002/pbc.28349] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/08/2022]
Abstract
Advances in multimodality therapy have led to childhood cancer cure rates over 80%. However, surgery, chemotherapy, and radiotherapy may lead to debilitating or even fatal long-term effects among childhood survivors beyond those inflicted by the primary disease process. It is critical to understand, mitigate, and prevent these late effects of cancer therapy to improve the quality of life of childhood cancer survivors. This review summarizes the various late effects of radiotherapy and acknowledges the Pediatric Normal Tissue Effects in the Clinic (PENTEC), an international collaboration that is systematically analyzing the association between radiation treatment dose/volume and consequential organ toxicities, in developing children as a basis to formulate recommendations for clinical practice of pediatric radiation oncology. We also summarize initiatives for survivorship and surveillance of late normal tissue effects related to radiation therapy among long-term survivors of childhood cancer treated in the past.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Ohio, Columbus
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Division of Haematology/Oncology, Hospital for Sick Children, University Health Network, Toronto, Canada
| | - Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of USC and Children's' Hospital Los Angeles, Los Angeles, California
| | - Leontien C M Kremer
- Department of Pediatrics, Amsterdam UMC, Emma Children's Hospital, Amsterdam, the Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Cecile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Brandenburg Medical School, Institute for Biostatistics and Registry Research, Neuruppin, Germany
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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Dávila-Camargo A, Samaniego-Novelo FF, Vidal-Muñoz M, Jiménez-López JM, López-Facio E. Multidisciplinary approach to orbital embryonic rhabdomyosarcoma: about a case. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2020; 96:S0365-6691(20)30360-9. [PMID: 33153818 DOI: 10.1016/j.oftal.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/23/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
Of the head and neck tumoral lesions in children and adolescents, 5 to 10% are primary malignant tumors. Among these tumors, orbital rhabdomyosarcoma stands out, which is the most common primary soft tissue sarcoma in children. Its diagnosis requires a high degree of clinical suspicion, and it can be corroborated with a series of examinations, in order to stage it and carry out the appropriate treatment. Currently, surgery and chemotherapy are the primary treatments, and the use of conventional radiotherapy is limited to cases where previous treatments fail or there is a risk of recurrence. The following case report aims to expose the clinical picture, diagnosis, staging and integral treatment of orbital rhabdomyosarcoma, as well as the interdisciplinary management that was performed to improve the patient's prognosis.
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Affiliation(s)
- A Dávila-Camargo
- Departamento de Oftalmología, Hospital Ángeles, Torreón (Coahuila), México.
| | | | - M Vidal-Muñoz
- Departamento de Radiooncología, Unidad Médica de Alta Especialidad N.° 71 IMSS, Torreón (Coahuila), México
| | - J M Jiménez-López
- Departamento de Radiooncología, Unidad Médica de Alta Especialidad N.° 71 IMSS, Torreón (Coahuila), México
| | - E López-Facio
- Departamento de Oncología Pediátrica, Unidad Medica de Alta Especialidad N.° 71 IMSS, Torreón (Coahuila), México
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11
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Ioakeim-Ioannidou M, MacDonald SM. Evolution of Care of Orbital Tumors with Radiation Therapy. J Neurol Surg B Skull Base 2020; 81:480-496. [PMID: 33072488 DOI: 10.1055/s-0040-1713894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Orbital tumors are rare lesions comprising 0.1% of all tumors and less than 20% of all ocular diseases. These lesions in children and adults differ significantly in their incidence, tumor type, and treatment management. Although surgery and systemic therapies are commonly used in the management of these diseases, radiation therapy has become a widely used treatment for both benign and malignant tumors of the orbit. Radiotherapy is used as a definitive treatment to provide local control while avoiding morbidity associated with surgery for some tumors while it is used as an adjuvant treatment following surgical resection for others. For many tumors, radiation provides excellent tumor control with preservation of visual function. This article is dedicated for presenting the most common applications of orbital radiotherapy. A brief overview of the commonly available radiation therapy modalities is given. Dose constraint goals are reviewed and acute and long-term side effects are discussed. Orbital tumors covered in this article include optic glioma, ocular melanoma, retinoblastoma, orbital rhabdomyosarcoma, orbital lymphoma, and lacrimal gland tumors. Background information, indications for radiotherapy, and goals of treatment for each case example are described.
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Affiliation(s)
- Myrsini Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
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12
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Zhang Y, He C, Lian Y, Xiao H. Score for the Survival Probability of Patients With Orbital Rhabdomyosarcoma After Surgery: A Long-Term and Large Cohort Study. Front Oncol 2020; 10:1590. [PMID: 32974196 PMCID: PMC7482652 DOI: 10.3389/fonc.2020.01590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/23/2020] [Indexed: 12/05/2022] Open
Abstract
Orbital rhabdomyosarcoma (RMS) is a relatively rare primary malignancy occurring in children. The objective of this study was to evaluate the cumulative incidence of cancer-specific death and competing risk of death among RMS patients after surgery and to build nomograms to predict overall survival (OS) and cancer-specific survival (CSS) based on a large population-based cohort. The records of 217 patients who were pathologically diagnosed with an orbital RMS between 1973 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. The 10-, 20-, and 40-years OS rates and cancer-specific mortality were 82.5, 72.2, and 48.9%, respectively, and 14.8, 21.7, and 21.7%, respectively. The established nomograms were well-calibrated and validated, with a concordance index (C-index) of 0.901 and 0.944 for OS prediction, 0.923 and 0.904, for CSS prediction in the training and validation cohorts, respectively. The values of area under the receiver operating characteristic curve (AUC) for 10-, 20-, and 40-years OS and CSS prediction were 0.908, 0.826, and 0.847, and 0.924, 0.863, and 0.863, respectively. The established nomogram showed relatively good performances and could be convenient individualized predictive tools for prognostic prediction in RMS patients.
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Affiliation(s)
- Yu Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Chaobin He
- State Key Laboratory of Oncology in South China, Department of Pancreaobiliary Surgery, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu Lian
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Huiming Xiao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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13
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Dose-Effect Analysis of Early Changes in Orbital Bone Morphology After Radiation Therapy for Rhabdomyosarcoma. Pract Radiat Oncol 2019; 10:53-58. [PMID: 31629089 DOI: 10.1016/j.prro.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE In survivors of orbital embryonal rhabdomyosarcoma (ERMS), late effects include facial deformation and asymmetry. We sought to quantify orbital asymmetry in ERMS survivors and characterize the dose effect of radiation to the orbital bones. METHODS AND MATERIALS We evaluated the most recent follow-up magnetic resonance imaging (MRI) in 17 children (≤21 years old) with stage 1 group III orbital ERMS treated with proton therapy between 2007 and 2018. For all patients, the orbital socket volumes were calculated and compared with the contralateral, unirradiated orbital socket. Patient age, orbital tumor quadrant, and the radiation dose delivered to the major orbital bones (maxillary, frontal, and zygomatic bones) were recorded and correlated with the orbital socket volume difference. RESULTS The mean age at diagnosis was 5.4 years old (range, 1.1-9.7 years). All patients received a prescription dose of 45 GyRBE. The mean time interval between radiation and MRI was 2.9 years (range, 0.8-3.2 years). The mean age at most recent MRI was 8.4 years (range, 2.3-12.9 years). In 16 of 17 patients, the volume of the ipsilateral orbit was significantly smaller than the contralateral orbit on follow-up MRI (P ≤ .0001). In one patient with nonviable tumor in situ, the irradiated orbit was larger. The volume difference increased with follow-up time and did not correlate with age at treatment or age at MRI. A dose >40 GyRBE to all bones of the orbital rim was associated with a significant decrease in orbital volume (P < .05), but an isolated dose of >40 GyRBE to either the frontal, maxillary, or zygomatic bone was not. CONCLUSIONS Despite the dosimetric precision of proton therapy, orbital asymmetry will develop after >40 GyRBE to multiple bones of the orbital rim. These data may be used to guide treatment planning and counsel patients on expected cosmesis.
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Indelicato DJ, Rotondo RL, Mailhot Vega RB, Uezono H, Bradfield S, Agarwal V, Hol ML, Bradley JA. 45 GyRBE for group III orbital embryonal rhabdomyosarcoma. Acta Oncol 2019; 58:1404-1409. [PMID: 31530120 DOI: 10.1080/0284186x.2019.1627412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Purpose: Despite widespread concerns of radiotherapy toxicity in children with head and neck tumors, recent Children's Oncology Group (COG) findings suggest that the use of 45 Gy results in an unacceptably high rate of local recurrences in patients with low-risk orbital rhabdomyosarcoma. We therefore evaluated outcomes in our pediatric patients who received 45 GyRBE using proton therapy. Material and methods: To assess disease control and toxicity, we reviewed the medical records of 30 children (≤21 years old) with COG stage 1, group III embryonal orbital rhabdomyosarcoma enrolled on a prospective outcome study and treated with proton therapy between 2007 and 2018. Results: Median age at the time of radiation was 4.8 years old. Twenty-one and nine patients received ifosfamide- and cyclophosphamide-based chemotherapy according to their respective cooperative group regimens. Median duration between the start of induction chemotherapy and radiation was 12 weeks. Two patients had a complete response to induction chemotherapy and two had stable disease. Twenty-six patients had a partial response to induction chemotherapy, with a median volume reduction of 66%. With a median follow-up of 4.0 years (range, 0.5-9.5 years), we observed 1 local failure 6 months following treatment in a patient who had a partial response to cyclosphophomide-based induction chemotherapy. The 5-year local control, progression-free survival, and overall survival rates were 97%, 97%, and 100%, respectively. Serious late toxicities included 18 patients with cataracts, 4 with exposure keratoconjunctivitis resulting in permanently reduced visual acuity, and 1 with chronic sinusitis. Conclusion: 45 GyRBE offers effective local control for most patients with group III orbital rhabdomyosarcoma. The delivery of proton therapy to the postinduction tumor volume plus a small margin can mitigate early- and intermediate-term toxicity, but side effects still occur and long-term data are needed to demonstrate the dosimetric advantage of proton therapy.
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Affiliation(s)
- Daniel J. Indelicato
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Ronny L. Rotondo
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Haruka Uezono
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Scott Bradfield
- Department of Pediatric Oncology, Nemours Children’s Health System, Jacksonville, FL, USA
| | - Vibhuti Agarwal
- Department of Pediatric Oncology, Nemours Children’s Health System, Jacksonville, FL, USA
| | - Marinka L. Hol
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Julie A. Bradley
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
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Abstract
Primary pediatric orbital tumors requiring surgery are uncommon and often require multidisciplinary management. Commonly used surgical approaches to the orbit include transconjunctival, transcutaneous (eyelid), transcranial, or extracranial osteotomies. This paper reviews a 10-year experience of cases that required a transcranial or extracranial surgical approach at the Birmingham Children's Hospital. A total of 9 patients were identified between the years 2008 to 2017. Pathologies included rhabdomyosarcoma, juvenile ossifying fibroma, optic nerve glioma, and retinoblastoma. Surgical approaches to the orbit included supraorbital bar osteotomy (transcranial) or lateral orbitotomy (extracranial). Surgical team members included neurosurgery, craniofacial surgery, and ophthalmology. This study aims to review the role of surgery in management as well as the specific indications for performing transcranial or extracranial osteotomies. It also highlights the excellent access achieved with the use of these osteotomies in certain cases, especially when compared with transconjunctival or transcutaneous approaches.
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16
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Mattos VDD, Ferman S, Magalhães DMA, Antunes HS, Lourenço SQC. Dental and craniofacial alterations in long-term survivors of childhood head and neck rhabdomyosarcoma. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 127:272-281. [PMID: 30685390 DOI: 10.1016/j.oooo.2018.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/26/2018] [Accepted: 12/13/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Rhabdomyosarcoma (RMS) represents the most common soft tissue sarcoma that affects children. Treatment involves chemoradiotherapy. This study aimed at evaluating the long-term alterations to teeth and cranial bones in children, teenagers, and young adults after oncologic treatment. STUDY DESIGN We conducted a cross-sectional study of patients undergoing treatment for head and neck RMS between 1988 and 2011. We evaluated demographic, clinical, and treatment data and performed panoramic radiography, cephalometry, and photography. RESULTS We evaluated 27 long-term survivors, most of whom had been treated between ages 0 to 5 years (51.9%). The total radiation dose applied was 50.4 Gy, and the chemotherapy combination included vincristine, actinomycin D, and cyclophosphamide in 51.9% of the cases. We observed 603 dental alterations, among which 377 (62.7%) occurred in patients ages 0 to 5 years, and root shortening was the most frequent alteration observed (24.2%). With regard to facial bones, 74% of the patients had some level of facial asymmetry, 70.4% had reduced facial depth, 48.4% had mandibles of short size, and 77.8% had reduced facial height. CONCLUSIONS Children submitted to RMS treatment involving chemotherapy and radiotherapy displayed significant dental and craniofacial alterations, especially when treatment occurred between ages 0 and 5 years.
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Affiliation(s)
| | - Sima Ferman
- Pediatric Oncology Division, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
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17
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Minard-Colin V, Walterhouse D, Bisogno G, Martelli H, Anderson J, Rodeberg DA, Ferrari A, Jenney M, Wolden S, De Salvo G, Arndt C, Merks JHM, Gallego S, Schwob D, Haie-Meder C, Bergeron C, Stevens MCG, Oberlin O, Hawkins D. Localized vaginal/uterine rhabdomyosarcoma-results of a pooled analysis from four international cooperative groups. Pediatr Blood Cancer 2018; 65:e27096. [PMID: 29781567 PMCID: PMC8117251 DOI: 10.1002/pbc.27096] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vaginal/uterine rhabdomyosarcoma (VU RMS) is one of the most favorable RMS sites. To determine the optimal therapy, the experience of four cooperative groups (Children's Oncology Group [COG], International Society of Pediatric Oncology (SIOP) Malignant Mesenchymal Tumor Group [MMT], Italian Cooperative Soft Tissue Sarcoma Group [ICG], and European pediatric Soft tissue sarcoma Study Group [EpSSG]) was analyzed. PROCEDURE From 1981 to 2009, 237 patients were identified. Median age (years) at diagnosis differed by tumor location; it was 1.9 for vagina (n = 160), 2.7 for uterus corpus (n = 26), and 13.5 for uterus cervix (n = 51). Twenty-eight percent of patients received radiation therapy (RT) as part of primary therapy (23% COG, 27% MMT, 46% ICG, and 42% EpSSG), with significant differences in the use of brachytherapy between the cooperative groups (23% COG, 76% MMT, 64% ICG, and 88% EpSSG). RESULTS Ten-year event-free (EFS) and overall survival (OS) were 74% (95% CI, 67-79%) and 92% (95% CI, 88-96%), respectively. In univariate analysis, OS was inferior for patients with uterine RMS and for those with regional lymph node involvement. Although EFS was slightly lower in patients without initial RT (71% without RT vs. 81% with RT; P = 0.08), there was no difference in OS (94% without RT vs. 89% with RT; P = 0.18). Local control using brachytherapy was excellent (93%). Fifty-one (51.5%) of the 99 survivors with known primary therapy and treatment for relapse were cured with chemotherapy with or without conservative surgery. CONCLUSIONS About half of all patients with VU RMS can be cured without systematic RT or radical surgery. When RT is indicated, modalities that limit sequelae should be considered, such as brachytherapy.
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Affiliation(s)
| | - David Walterhouse
- Division of Hematology, Oncology, and Stem Cell
Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago,
Illinois
| | - Gianni Bisogno
- Pediatric Hematology and Oncology Division, Padova
University, Padova, Italy
| | - Helene Martelli
- Department of Pediatric Surgery, CHU Bicetre, Le
Kremlin-Bicêtre, France
| | - James Anderson
- Department of Oncology Clinical Research, Merck Research
Laboratories, North Wales, Pennsylvania
| | - David A. Rodeberg
- Department of Surgery, East Carolina University,
Greenville, North Carolina
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto
Nazionale Tumori, Milano, Italy
| | - Meriel Jenney
- Department of Pediatric Oncology, University of Wales,
Cardiff, United Kingdom
| | - Suzanne Wolden
- Department of Radiotherapy, Memorial Sloan Kettering Cancer
Center, New York City, New York
| | - Gianluca De Salvo
- Clinical Trials and Biostatistics Unit, IRCCS Istituto
Oncologico Veneto, Padova, Italy
| | - Carola Arndt
- Department of Pediatric and Adolescent Medicine, Mayo
Clinic and Foundation, Rochester, Minnesota
| | - Johannes H. M. Merks
- Department of Pediatric Oncology, Emma Children's
Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - Soledad Gallego
- Department of Pediatric Oncology, Hospital Universitari
Vall d'Hebron, Barcelona, Spain
| | | | | | - Christophe Bergeron
- Department of Pediatric and Adolescent Oncology, Centre
Leon Berard, Lyon, France
| | - Michael C. G. Stevens
- Department of Paediatric Oncology, Bristol Royal Hospital
for Children, University of Bristol, Bristol, United Kingdom
| | - Odile Oberlin
- Department of Pediatric and Adolescent Oncology, Gustave
Roussy, Villejuif, France
| | - Douglas Hawkins
- Division of Hematology/Oncology, Seattle Children's
Hospital, University of Washington, Seattle, Washington,Fred Hutchinson Cancer Research Center, University of
Washington, Seattle, Washington
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18
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Tang LY, Zhang MX, Lu DH, Chen YX, Liu ZG, Wu SG. The prognosis and effects of local treatment strategies for orbital embryonal rhabdomyosarcoma: a population-based study. Cancer Manag Res 2018; 10:1727-1734. [PMID: 29983592 PMCID: PMC6025768 DOI: 10.2147/cmar.s163932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Orbital embryonal rhabdomyosarcoma is a rare childhood malignancy with a good prognosis, but the optimal treatment remains unclear. Using a population-based cancer registry, we assessed the prognoses and survival outcomes of patients with orbital embryonal rhabdomyosarcoma according to the local treatment strategy. Patients and methods Patients diagnosed with orbital embryonal rhabdomyosarcoma between 1988 and 2012 as part of the Surveillance Epidemiology and End Results program were included. Univariate and multivariate Cox regression analyses were performed to determine the prognostic factors associated with cause-specific survival (CSS) and overall survival (OS). Results In total, 102 patients were included; their median age was 6 years, 78.4% were white, and 56.9% were male. The median tumor size was 30 mm. Of 20 patients with an available histologic grade, the tumors of 90% were poorly differentiated/undifferentiated. Of 92 patients with available surgical and radiotherapy (RT) statuses, 50 (54.3%), 36 (39.1%), and 6 (6.5%) received surgery and RT, primary RT, and primary surgery, respectively. Ninety-five patients (93.1%) received chemotherapy. The 5- and 10-year CSSs of the entire cohort were 94.3% and 92.2%, respectively. The 5- and 10-year OSs were 93.3% and 91.3%, respectively. In 95 patients who were followed up for at least 12 months, there were no significant prognostic factors related to CSS and OS. Furthermore, the local treatment strategy did not significantly affect CSS (P=0.29) or OS (P=0.468). Conclusion There is no local treatment of choice for orbital embryonal rhabdomyosarcoma in terms of survival. However, RT is a reasonable alternative treatment to surgery.
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Affiliation(s)
- Li-Ying Tang
- Eye Institute of Xiamen University, Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Medical College, Xiamen University, Xiamen 361005, People's Republic of China,
| | - Mou-Xin Zhang
- Xiamen University Affiliated Xiamen Eye Center, Xiamen 361001, People's Republic of China,
| | - Di-Han Lu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, People's Republic of China
| | - Yong-Xiong Chen
- Eye Institute of Xiamen University, Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Medical College, Xiamen University, Xiamen 361005, People's Republic of China,
| | - Zu-Guo Liu
- Eye Institute of Xiamen University, Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Medical College, Xiamen University, Xiamen 361005, People's Republic of China, .,Xiamen University Affiliated Xiamen Eye Center, Xiamen 361001, People's Republic of China,
| | - San-Gang Wu
- Department of Radiation Oncology, Xiamen Cancer Hospital, the First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China,
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Fifty years of rhabdomyosarcoma studies on both sides of the pond and lessons learned. Cancer Treat Rev 2018; 68:94-101. [PMID: 29940525 DOI: 10.1016/j.ctrv.2018.06.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 06/17/2018] [Accepted: 06/18/2018] [Indexed: 11/21/2022]
Abstract
We review and summarize the highlights of almost five decades of cooperative group trials in rhabdomyosarcoma on both sides of the Atlantic, concentrating on chemotherapy regimens, what has been learned, and where remaining challenges are. The most important achievements have been to decrease or omit the dose of alkylator therapy for many patients, to clarify after much controversy that doxorubicin does not improve the outcome of patients even in the highest risk groups, and to show that high dose chemotherapy and stem cell rescue do not improve the outcome of the highest risk patients. In North America, vincristine/actinomycin/cyclophosphamide (VAC) remains an important part of therapy, whereas in Europe the alkylating agent of choice is ifosfamide. The highest risk patients, namely those with the poorest prognostic score, have had no improvement in outcome since the first cooperative group trial in 1972 and remain the greatest challenge. Philosophical differences between European and North American strategies still revolve somewhat around the total burden of therapy received, that is should certain groups of patients be spared aggressive local control in order to reduce late effects, recognizing that it is not possible to identify priori the children that can be cured with this approach exposing the whole population to a higher risk of relapse. Collaboration and joining resources may help answer some difficult questions.
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20
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van Koevering K, Prevedello DM, Carrau RL. Endoscopic endonasal approaches for the management of cranial base malignancies: histologically guided treatment and clinical outcomes. J Neurosurg Sci 2018; 62:667-681. [PMID: 29808637 DOI: 10.23736/s0390-5616.18.04507-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Malignancies of the skull base represent a highly diverse and challenging set of pathologies which exhibit a wide array of oncologic behavior. In recent decades, a number of important advances in treatment technique have evolved to improve oncologic outcomes and reduce morbidity in the treatment of these aggressive cancers. Intensity modulated radiation therapy has become the gold standard in radiotherapy owing to its precision planning and reduced morbidity. However heavy ion particle radiation (proton therapy, carbon ion, etc.) are recently emerging with promising results at the skull base related to the reduced exit dose to adjacent structures. Novel systemic therapeutics such as targeted and immunotherapies may dramatically alter the treatment paradigm for many of these pathologies. Nevertheless, most skull base malignancies remain surgical diseases. The evolution of the expanded endonasal approach for a minimally invasive surgical resection has proven validity in treating many of these pathologies when properly selected, and have largely supplanted open approaches owing to the reduced morbidity profile. In spite of these important advances, the most critical aspect in comprehensive treatment is a detailed understanding of the oncologic behavior and outcomes data for each of the specific histopathologies encountered at the skull base. The nuances in management strategy, histologic profile, and surveillance planning can be stratified through the development of a comprehensive, multidisciplinary skull base team to maximize therapeutic effect and minimize morbidity for each patient. This review aims to summarize the key body of data and approaches for each of the histologies frequently encountered in the skull base, while highlighting the value and technique of endonasal approaches.
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Affiliation(s)
- Kyle van Koevering
- Department of Otolaryngology, Head and Neck Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA -
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21
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Eghtedari M, Farsiani AR, Bordbar MR. Congenital Orbital Rhabdomyosarcoma. Ocul Oncol Pathol 2018; 4:165-169. [PMID: 29765948 DOI: 10.1159/000481533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 09/13/2017] [Indexed: 12/31/2022] Open
Abstract
Rhabdomyosarcoma (RMS) is the most common malignant tumor of the orbit in children, but it is rarely present at birth. We report a large congenital orbital RMS with intracranial extension in a newborn baby. A newborn baby girl was referred to our hospital due to severe right-eye exophthalmia. Imaging studies showed an orbital mass with intracranial extension. Treatment was started with a course of neoadjuvant chemotherapy followed by right orbital exenteration and intracranial resection of the tumor. Histologic examination of the mass showed undifferentiated malignant small-cell tumor. Immunohistochemical study proved it to be RMS. The patient was categorized as intermediate-risk RMS and chemotherapy was continued accordingly with VAC regimen. In spite of treatment, the infant developed intracranial recurrence at the age of 6 months and died 1 month later. Congenital orbital RMS has a poor prognosis. Reconstruction surgery should be deferred due to high rate of recurrence and low chance of survival. A multidisciplinary approach might increase the survival of these patients.
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Affiliation(s)
- Masoomeh Eghtedari
- Poostchi Ophthalmology Research Center, Department of Ophthalmology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Reza Farsiani
- Poostchi Ophthalmology Research Center, Department of Ophthalmology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Reza Bordbar
- Hematology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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22
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23
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Vaarwerk B, van der Lee JH, Breunis WB, Orbach D, Chisholm JC, Cozic N, Jenney M, van Rijn RR, McHugh K, Gallego S, Glosli H, Devalck C, Gaze MN, Kelsey A, Bergeron C, Stevens MCG, Oberlin O, Minard-Colin V, Merks JHM. Prognostic relevance of early radiologic response to induction chemotherapy in pediatric rhabdomyosarcoma: A report from the International Society of Pediatric Oncology Malignant Mesenchymal Tumor 95 study. Cancer 2017; 124:1016-1024. [DOI: 10.1002/cncr.31157] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/18/2017] [Accepted: 10/24/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Bas Vaarwerk
- Department of Pediatric Oncology; Emma Children's Hospital/Academic Medical Center; Amsterdam the Netherlands
| | - Johanna H. van der Lee
- Pediatric Clinical Research Office; Emma Children's Hospital/Academic Medical Center; Amsterdam the Netherlands
| | - Willemijn B. Breunis
- Department of Pediatric Oncology; Emma Children's Hospital/Academic Medical Center; Amsterdam the Netherlands
| | - Daniel Orbach
- Department of Pediatric, Adolescent, and Young Adult Oncology; Curie Institute; Paris France
| | - Julia C. Chisholm
- Children and Young People's Department; Royal Marsden Hospital; Sutton United Kingdom
| | - Nathalie Cozic
- Department of Biostatistics and Epidemiology; Gustave-Roussy; Villejuif France
| | - Meriel Jenney
- Department of Pediatric Oncology; Children's Hospital for Wales; Cardiff United Kingdom
| | - Rick R. van Rijn
- Pediatric Radiology; Emma Children's Hospital/Academic Medical Center; Amsterdam the Netherlands
| | - Kieran McHugh
- Department of Radiology; Great Ormond Street Hospital for Children; London United Kingdom
| | - Soledad Gallego
- Pediatric Oncology; Vall d'Hebron University Hospital; Barcelona Spain
| | - Heidi Glosli
- Department of Pediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Christine Devalck
- Pediatric Hematology Oncology Department; Children's University Hospital; Brussels Belgium
| | - Mark N. Gaze
- Department of Oncology; University College London Hospitals NHS Foundation Trust; London United Kingdom
| | - Anna Kelsey
- Pathology Department; Royal Manchester Children's Hospital; Manchester United Kingdom
| | | | - Michael C. G. Stevens
- Department of Pediatric Oncology; Bristol Royal Hospital for Children; Bristol United Kingdom
| | - Odile Oberlin
- Department of Pediatric and Adolescent Oncology; Gustave-Roussy; Villejuif France
| | | | - Johannes H. M. Merks
- Department of Pediatric Oncology; Emma Children's Hospital/Academic Medical Center; Amsterdam the Netherlands
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Ermoian RP, Breneman J, Walterhouse DO, Chi YY, Meza J, Anderson J, Hawkins DS, Hayes-Jordan AA, Parham DM, Yock TI, Donaldson SS, Wolden SL. 45 Gy is not sufficient radiotherapy dose for Group III orbital embryonal rhabdomyosarcoma after less than complete response to 12 weeks of ARST0331 chemotherapy: A report from the Soft Tissue Sarcoma Committee of the Children's Oncology Group. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26540. [PMID: 28548706 PMCID: PMC5568701 DOI: 10.1002/pbc.26540] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Recent Children's Oncology Group (COG) trials tested the efficacy of reduced therapy in an effort to lessen late effects compared to the Intergroup Rhabdomyosarcoma Study (IRS) IV regimen with associated hematologic and hepatic toxicity, and infertility. Here, we analyze the efficacy of 45 Gray (Gy) local radiotherapy (RT) in patients with Group III orbital embryonal rhabdomyosarcoma (ERMS) enrolled on the COG low-risk study ARST0331. PROCEDURE Sixty-two patients with Group III orbital ERMS were treated on ARST0331 with four cycles of vincristine (VCR), dactinomycin (DACT), and cyclophosphamide (CPM; VAC, total cumulative CPM dose 4.8 g/m2 ) followed by four cycles of VCR and DACT over 22 weeks. Forty-five Gray of radiation was administered in 25 fractions beginning at week 13 of therapy. RESULTS Fifty-three patients were evaluable for this response analysis; seven had missing week 12 response evaluation data and two had progressive disease prior to starting RT. Median follow-up was 7.8 years. None of the 15 patients with radiographic complete response (CR) compared to 6 of the 38 patients with <CR after 12 weeks of VAC chemotherapy had local recurrences (P = 0.11). There was no difference in overall survival by response at week 12 (P = 0.52). CONCLUSIONS For patients with Group III orbital ERMS achieving a CR following VAC chemotherapy that includes modest dose CPM, 45 Gy may be sufficient for durable failure-free survival. However, for those with <CR treated with the ARST0331 systemic therapy, a different local therapy approach may be needed to achieve the control rate of IRS-IV without its toxicity.
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Affiliation(s)
- Ralph P. Ermoian
- Department of Radiation Oncology, University of Washington, Washington
| | - John Breneman
- Department of Radiation Oncology, University of Cincinnati, Ohio
| | - David O. Walterhouse
- Department of Pediatrics-Hematology, Oncology and Stem Cell Transplantation, Northwestern University, Illinois
| | - Yueh-Yun Chi
- Department of Biostatistics, University of Florida, Florida
| | - Jane Meza
- Department of Biostatistics, University of Nebraska, Nebraska
| | - James Anderson
- Department of Biostatistics, University of Nebraska, Nebraska
| | | | - Andrea A. Hayes-Jordan
- Department of Pediatric Surgery, The University of Texas Health Science Center at Houston, Texas
| | - David M. Parham
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, California
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Massachusetts
| | - Sarah S. Donaldson
- Department of Radiation Oncology, Stanford University School of Medicine, California
| | - Suzanne L. Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York
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Mallebranche C, Carton M, Minard-Colin V, Desfachelle AS, Rome A, Brisse HJ, Mosseri V, Thébaud E, Pellier I, Boutroux H, Gandemer V, Corradini N, Orbach D. [Relapse after rhabdomyosarcoma in childhood and adolescence: Impact of an early detection on survival]. Bull Cancer 2017; 104:625-635. [PMID: 28687117 DOI: 10.1016/j.bulcan.2017.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/11/2017] [Accepted: 05/16/2017] [Indexed: 12/21/2022]
Abstract
SUBJECT Prognostic values of an early detection of a relapse after treatment of a localized rhabdomyosarcoma and the interest of performing systematic radiologic assessment after treatment have not yet been evaluated in Europe. MATERIAL AND METHODS Modalities of relapse of 99 patients under 20 years of age, after an initially localized rhabdomyosarcoma, treated in 9 French centers ("Société française des cancers de l'enfant" consortium) have been analyzed. Prognostic value of the protocol compliance during the observation period after therapy has been evaluated. RESULTS Relapses have been diagnosed in 59 cases by a "symptom" the child was complaining of, in 12 cases because of "physical signs" detected during the clinical examination of a systematic consultation and in 27 cases thanks to "systematic follow-up imaging" (missing data: 1 case). Survival after relapse at 3 years was 47.5 % (IC95 %: 37.1 %-57.1 %). Diagnosis of the relapse is established earlier in the group "systematic imaging" rather than with other methods of detection ("symptom", "physical signs"), (P= 0.025), with detection of smaller tumors (≤ 5 cm ; 100.0 % vs. 60.9 % vs. 77.8 %, P= 0.007) but without possibility of reaching a second remission (70.4 % vs. 50.8 % vs. 50.0 % P= 0.37), nor significant impact on 5-year overall survival (47.1 % vs. 47.1 % vs. 48.6 % P= 0.94). CONCLUSION Current methods of systematic surveillance after a first-line treatment of an initially localized rhabdomyosarcoma seem to improve the earliness of the diagnosis, but not the prognosis of the relapse.
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Affiliation(s)
- Coralie Mallebranche
- Centre oncologie SIREDO (soins, innovation, recherche autour des tumeurs de l'enfant, l'adolescent et le jeune adulte), institut Curie, 26, rue d'Ulm, 75005 Paris, France; CHU d'Angers, service d'immuno-hémato-oncologie pédiatrique, 4, rue Larrey, 49100 Angers, France.
| | - Matthieu Carton
- DCRI-ensemble hospitalier, institut Curie, unité de biométrie, 26, rue d'Ulm, 75005 Paris, France
| | - Véronique Minard-Colin
- Gustave-Roussy, département de cancérologie de l'enfant et l'adolescent, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
| | - Anne-Sophie Desfachelle
- Centre Oscar-Lambret, unité d'oncologie pédiatrique, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - Angélique Rome
- CHU de Marseille, hôpital de la Timone, service d'oncologie pédiatrique, 264, rue Saint-Pierre, 13385 Marseille, France
| | - Hervé J Brisse
- Institut Curie, département de radiologie, 26, rue d'Ulm, 75005 Paris, France
| | - Véronique Mosseri
- DCRI-ensemble hospitalier, institut Curie, unité de biométrie, 26, rue d'Ulm, 75005 Paris, France
| | - Estelle Thébaud
- CHU de Nantes, service d'hématologie et d'oncologie pédiatrique, 8, quai Moncousu, 44000 Nantes, France
| | - Isabelle Pellier
- CHU d'Angers, service d'immuno-hémato-oncologie pédiatrique, 4, rue Larrey, 49100 Angers, France
| | - Hélène Boutroux
- APHP, hôpital Armand-Trousseau, service d'hémato-oncologie pédiatrique, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - Virginie Gandemer
- CHU de Rennes, hôpital Sud, service d'hématologie et oncologie pédiatrique, 16, boulevard de Bulgarie, 35200 Rennes, France
| | - Nadège Corradini
- Institut d'hématologie et oncologie pédiatrique, 1, place Professeur-Joseph-Renaut, 69008 Lyon, France
| | - Daniel Orbach
- Centre oncologie SIREDO (soins, innovation, recherche autour des tumeurs de l'enfant, l'adolescent et le jeune adulte), institut Curie, 26, rue d'Ulm, 75005 Paris, France
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Haas-Kogan DA, Devine CA, Liu KX, Terezakis SA. A Cautionary Tale: Risks of Radiation Therapy De-Escalation in Pediatric Malignancies. J Clin Oncol 2017; 35:2471-2472. [PMID: 28594597 DOI: 10.1200/jco.2017.73.3485] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Daphne A Haas-Kogan
- Daphne A. Haas-Kogan, Brigham and Women's Hospital, Dana-Farber Cancer Institute; Boston Children's Hospital; and Harvard Medical School, Boston, MA; Christopher A. Devine and Kevin X. Liu, Harvard Medical School, Boston, MA; and Stephanie A. Terezakis, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher A Devine
- Daphne A. Haas-Kogan, Brigham and Women's Hospital, Dana-Farber Cancer Institute; Boston Children's Hospital; and Harvard Medical School, Boston, MA; Christopher A. Devine and Kevin X. Liu, Harvard Medical School, Boston, MA; and Stephanie A. Terezakis, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin X Liu
- Daphne A. Haas-Kogan, Brigham and Women's Hospital, Dana-Farber Cancer Institute; Boston Children's Hospital; and Harvard Medical School, Boston, MA; Christopher A. Devine and Kevin X. Liu, Harvard Medical School, Boston, MA; and Stephanie A. Terezakis, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephanie A Terezakis
- Daphne A. Haas-Kogan, Brigham and Women's Hospital, Dana-Farber Cancer Institute; Boston Children's Hospital; and Harvard Medical School, Boston, MA; Christopher A. Devine and Kevin X. Liu, Harvard Medical School, Boston, MA; and Stephanie A. Terezakis, Johns Hopkins University School of Medicine, Baltimore, MD
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Schoot RA, Saeed P, Freling NJ, Blank LECM, Pieters BR, van der Grient JNB, Strackee SD, Bras J, Caron HN, Merks JHM. Local Resection and Brachytherapy for Primary Orbital Rhabdomyosarcoma: Outcome and Failure Pattern Analysis. Ophthalmic Plast Reconstr Surg 2017; 32:354-60. [PMID: 26398242 DOI: 10.1097/iop.0000000000000562] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Survival in patients with orbital rhabdomyosarcoma (RMS) is excellent. Therefore, new local treatment modalities, such as brachytherapy, have been developed to minimize adverse events. Since 1990, patients with orbital RMS and a residual tumor after induction chemotherapy were eligible for resection and brachytherapy. Otherwise patients received external beam radiotherapy. In this study, the authors describe the outcome for 20 patients with primary orbital RMS. The aim was to assess risk factors for treatment failure in this single center cohort. METHODS In this retrospective cohort study, the authors reviewed imaging studies, surgery reports, histology reports, and radiotherapy plans in a multidisciplinary setting. The authors included 20 consecutive patients with orbital RMS, treated between 1990 and 2007, (median age: 7.4 years, range: 0.7-16.1; median follow up: 11.5 years). RESULTS After induction chemotherapy, 12 patients were treated with surgery and brachytherapy, 2 with external beam radiotherapy, and in 5 patients who achieved complete remission, local treatment was withheld. In 1 patient, brachytherapy was incorrectly withheld after delayed surgery. Seven patients relapsed (no local treatment, N = 2; surgery and brachytherapy, N = 2; external beam radiotherapy, N = 2; surgery only, N = 1). The authors found no patient, tumor, or treatment characteristics that predisposed for treatment failure. Ten-year-overall survival and event-free survival were 89% and 65%, respectively. CONCLUSIONS Overall survival in this cohort of orbital RMS patients was good, including surgery and brachytherapy as treatment modality for orbital RMS resulted in an effective local treatment approach with fewer adverse events than external beam radiotherapy. The authors could not identify factors predisposing for treatment failure.
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Affiliation(s)
- Reineke A Schoot
- *Department of Pediatric oncology, Emma Children's Hospital-Academic Medical Center (EKZ-AMC), Amsterdam; †Department of Ophthalmology, Orbital Center, ‡Department of Radiology, §Department of Radiation Oncology, ‖Department of Plastic, Reconstructive and Hand Surgery, and ¶Department of Pathology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
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Walterhouse DO, Pappo AS, Meza JL, Breneman JC, Hayes-Jordan A, Parham DM, Cripe TP, Anderson JR, Meyer WH, Hawkins DS. Reduction of cyclophosphamide dose for patients with subset 2 low-risk rhabdomyosarcoma is associated with an increased risk of recurrence: A report from the Soft Tissue Sarcoma Committee of the Children's Oncology Group. Cancer 2017; 123:2368-2375. [PMID: 28211936 DOI: 10.1002/cncr.30613] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/02/2016] [Accepted: 12/12/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Failure-free survival (FFS) and overall survival (OS) rates were found to improve on Intergroup Rhabdomyosarcoma Study (IRS) IV (IRS-IV) compared with IRS-III for patients with subset 2 (IRS stage 1, group III nonorbit or stage 3, group I/II) low-risk embryonal rhabdomyosarcoma with the addition of cyclophosphamide (total cumulative cyclophosphamide dose of 26.4 g/m2 ) to the combination of vincristine and dactinomycin (VAC). The goal of Children's Oncology Group ARST0331 for subset 2 low-risk patients was to reduce the total cumulative cyclophosphamide dose without compromising FFS. METHODS Therapy included 4 cycles of VAC (total cumulative cyclophosphamide dose of 4.8 g/m2 ) followed by 12 cycles of vincristine and dactinomycin over 46 weeks. Patients with group II or III tumors received radiotherapy, except for girls with group III vaginal tumors who enrolled before September 2009 and achieved a complete response with chemotherapy with or without delayed surgical resection. RESULTS Among 66 eligible patients who were followed for a median of 3.5 years, there were 20 failures versus 10.53 expected failures. The estimated 3-year FFS and OS rates were 70% (95% confidence interval [95% CI], 57%-80%) and 92% (95% CI, 83%-97%), respectively. The estimated 3-year FFS rate was 57% (95% CI, 33%-75%) for girls with subset 2 genital tract embryonal rhabdomyosarcoma (21 patients) and 77% (95% CI, 61%-87%) for all other subset 2 patients (45 patients) (P = .02). CONCLUSIONS The authors observed suboptimal FFS among patients with subset 2 low-risk rhabdomyosarcoma using reduced total cyclophosphamide. Eliminating radiotherapy for girls with group III vaginal tumors in combination with reduced total cyclophosphamide appeared to contribute to the suboptimal outcome. Cancer 2017;123:2368-2375. © 2017 American Cancer Society.
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Affiliation(s)
- David O Walterhouse
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alberto S Pappo
- Division of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jane L Meza
- Department of Biostatistics, University of Nebraska Medical Center College of Public Health, Omaha, Nebraska
| | - John C Breneman
- Division of Radiation Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrea Hayes-Jordan
- Division of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David M Parham
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Timothy P Cripe
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio
| | - James R Anderson
- Oncology Clinical Research, Merck Research Laboratories, North Wales, Pennsylvania
| | - William H Meyer
- Jimmy Everest Section of Pediatric Hematology and Oncology, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma
| | - Douglas S Hawkins
- Division of Hematology/Oncology, Seattle Children's Hospital, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
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Eade E, Tumuluri K, Do H, Rowe N, Smith J. Visual outcomes and late complications in paediatric orbital rhabdomyosarcoma. Clin Exp Ophthalmol 2016; 45:168-173. [DOI: 10.1111/ceo.12809] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/20/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Edwina Eade
- Department of Ophthalmology; Children's Hospital Westmead; Sydney New South Wales Australia
| | - Krishna Tumuluri
- Department of Ophthalmology; Children's Hospital Westmead; Sydney New South Wales Australia
| | - Helen Do
- Department of Ophthalmology; Children's Hospital Westmead; Sydney New South Wales Australia
| | - Neil Rowe
- Department of Ophthalmology; Children's Hospital Westmead; Sydney New South Wales Australia
| | - James Smith
- Department of Ophthalmology; Children's Hospital Westmead; Sydney New South Wales Australia
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Orbach D, Mosseri V, Gallego S, Kelsey A, Devalck C, Brenann B, van Noesel MM, Bergeron C, Merks JHM, Rechnitzer C, Jenney M, Minard-Colin V, Stevens M. Nonparameningeal head and neck rhabdomyosarcoma in children and adolescents: Lessons from the consecutive International Society of Pediatric Oncology Malignant Mesenchymal Tumor studies. Head Neck 2016; 39:24-31. [PMID: 27459057 DOI: 10.1002/hed.24547] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This article reports risk factors and long-term outcome in localized nonparameningeal head and neck rhabdomyosarcomas in children and adolescents from a combined dataset from 3 consecutive international trials. METHODS Data from 140 children (9.3% of total) prospectively enrolled in the International Society of Pediatric Oncology Malignant Mesenchymal Tumor (SIOP-MMT)-84/89/95 studies were analyzed. RESULTS Primary site was: superficial face in 46%; oral cavity (21%); neck (19%); and salivary glands (14%). Local control was achieved in 96%, but 49% relapsed (locoregionally 91%). At median follow-up of 10 years, 5-year overall survival (OS) was 74.7% (67.4% to 81.9%) and event-free survival 48.9% (40.6% to 57.2%), although this improved with successive studies. Radiotherapy (RT) as first-line treatment was independently prognostic for event-free survival (relative risk [RR] = 0.4 [range, 0.2-0.7]; p < .01) even if it did not impact OS (RR = 1 [range, 0.5-2]). CONCLUSION High rates of locoregional relapse were seen in head and neck rhabdomyosarcoma that should be prevented by more frequent use of RT in this primary. © 2016 Wiley Periodicals, Inc. Head Neck 39: 24-31, 2017.
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Affiliation(s)
- Daniel Orbach
- Adolescent and Pediatric Oncology Department, Institut Curie, Paris, France
| | | | - Soledad Gallego
- Paediatric Oncology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Anna Kelsey
- Pathology Department, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Christine Devalck
- Pediatric Haematology Oncology Department, Hopital Universitaire des enfants, Brussels, Belgium
| | - Bernadette Brenann
- Department of Paediatric Oncology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Max M van Noesel
- Center of Pediatric Oncology, Princess Máxima, Utrecht, The Netherlands
| | - Christophe Bergeron
- Department of Pediatric Oncology, Institut d'Hematologie et d'Oncologie Pédiatrique, Lyon, France
| | - Johannes H M Merks
- Department of Pediatric Oncology, Emma Children's Hospital - Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Meriel Jenney
- Department of Pediatric Oncology, Children's Hospital for Wales, Heath Park, Cardiff, United Kingdom
| | | | - Michael Stevens
- School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
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Bravo-Ljubetic L, Peralta-Calvo J, Larrañaga-Fragoso P, Pascual NO, Pastora-Salvador N, Gomez JA. Clinical Management of Orbital Rhabdomyosarcoma in a Referral Center in Spain. J Pediatr Ophthalmol Strabismus 2016; 53:119-26. [PMID: 27018885 DOI: 10.3928/01913913-20160122-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 12/07/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To review the systemic and ocular outcomes and long-term status of ocular rhabdomyosarcoma in pediatric patients in a tertiary center in Spain. METHODS All patients younger than 18 years who were diagnosed as having ocular rhabdomyosarcoma and treated between 1982 and 2011 at La Paz University Hospital, Madrid, Spain, were included. Clinical presentation, management, complications, and ocular and systemic outcomes were reviewed. RESULTS The mean age at presentation was 8 years (range: 3 months to 12.5 years). In all cases, the rhabdomyosarcoma was located primarily in the orbit. Treatment included surgical debulking and various regimens of chemotherapy and radiotherapy. All of the patients underwent surgical biopsy for diagnosis confirmation. Orbital exenteration was performed in 4 cases (28%). Twelve patients received radiotherapy. The long-term visual outcomes of the 10 patients who maintained their globe was as follows: best corrected visual acuity 20/20 to 20/40 in 6 patients (60%), 20/50 to 20/100 in 2 patients (20%), and 20/200 to no light perception in 2 patients (20%). Intraocular complications (primarily cataracts: 50%) were present in 7 patients (70%), ocular surface lesions occurred in 6 patients (60%), and orbital sequelae were found in 8 patients (80%). Local tumor recurrence was detected in 5 patients (35%) and distant metastasis occurred in 2 patients (14%). Tumor-related death occurred in 1 patient (7%). CONCLUSIONS Orbital rhabdomyosarcoma has an excellent prognosis; nevertheless, local complications are common, including surgery-related complications. To minimize them, initial surgical planning based on individual patient characteristics and an accurate diagnosis of relapses is mandatory. The clinical presentation, management, and long-term ocular and systemic outcomes are comparable with other series published to date.
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Hosoi H. Current status of treatment for pediatric rhabdomyosarcoma in the USA and Japan. Pediatr Int 2016; 58:81-7. [PMID: 26646016 DOI: 10.1111/ped.12867] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023]
Abstract
This article reviews the current status of treatment for children with rhabdomyosarcoma, according to the four risk groups. Low-risk subgroup A: the Children's Oncology Group in the USA recently performed a clinical trial consisting of a chemotherapy regimen with a shortened treatment period and a reduced drug dosage. Patients in this group received only four cycles of vincristine and actinomycin D (VA) after four cycles of vincristine, actinomycin D, and cyclophosphamide (VAC) with cyclophosphamide (CPM) 1.2 g/m(2) and their outcome was no worse than that obtained with previous regimens. Low-risk subgroup B: although marked improvement in survival was seen with an intensive VAC regimen with CPM 2.2 g/m(2) /cycle (Intergroup Rhabdomyosarcoma Study [IRS]-V, 1997-2004), the total dose of CPM in this regimen caused serious and fatal hepatic veno-occlusive disease during treatment and probably cannot avoid infertility or possible secondary cancer as a late effect. Thereafter, a reduced-dose regimen consisting of four cycles of VAC with CPM 1.2 g/m(2) followed by 12 cycles of VA was investigated in the next study, but the outcome appeared to be worse than in IRS-V. Intermediate-risk group: no significant difference was found between VAC/vincristine, topotecan and cyclophispahamide (VTC) and intensive VAC in IRS-V. The results of a subsequent regimen of VAC with CPM 1.2 g/m(2) alternating with vincristine and irinotecan are awaited. High-risk group: overall survival is approximately 30% and has not improved over the last 25 years. Although 18 month failure-free survival (FFS) was improved with an intensive combination therapy regimen, 36 month FFS dropped to 32% and thus better novel approaches or additive treatments are needed.
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Affiliation(s)
- Hajime Hosoi
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Radiation Therapy for Orbitopathy of Thyroid Eye Disease. Clin Ophthalmol 2016; 56:81-93. [DOI: 10.1097/iio.0000000000000098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Oberlin O, Rey A, Brown KL, Bisogno G, Koscielniak E, Stevens MC, Hawkins DS, Meyer WH, La TH, Carli M, Anderson JR. Prognostic Factors for Outcome in Localized Extremity Rhabdomyosarcoma. Pooled Analysis from Four International Cooperative Groups. Pediatr Blood Cancer 2015; 62:2125-31. [PMID: 26257045 PMCID: PMC5002346 DOI: 10.1002/pbc.25684] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/02/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Extremity rhabdomyosarcomas do not always show satisfactory outcomes. We analyzed data from 643 patients treated in 14 studies conducted by European and North American groups between 1983 and 2004 to identify factors predictive of outcome. PROCEDURE Clinical factors, including age; histology; site of primary (hand and foot vs. other); size; invasiveness (T stage); nodal involvement (N stage); and treatment factors, including post-surgical group; chemotherapy type and duration; radiotherapy; and treatment (before or after 1995); were evaluated for impact on overall survival (OS). RESULTS 5-year OS were 67% (se 1.8). Multivariate analysis showed that lower OS correlated with age >3 years, T2 and N1 stage, incomplete initial surgery, treatment before 1995, and European cooperative group treatment. Patients with gross residual disease after initial incomplete resection/biopsy had similar outcomes in both continental groups. The better global survival of patients treated in American studies was accounted for by differences in outcome in the subset of those with grossly resected tumors (OS 86% [se 3] for COG patients vs. 68% [se 4] for European patients (P = 0.004)). When excluding chemotherapy duration from the model, analysis in this subset of patients showed that cooperative group (P = 0.001), site (P = 0.001), and T stage (P = 0.05) were all significant. However, after adding duration of chemotherapy (≥27 weeks) to the model, only primary site remained significant (P = 0.006). CONCLUSION This meta-analysis confirms the role of many established prognostic factors but identifies for the first time that chemotherapy duration may have an impact on outcome in patients with grossly resected tumors.
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Affiliation(s)
- Odile Oberlin
- Departments of Pediatrics and Biostatistics, Institut Gustave Roussy, Villejuif, France,Correspondence to: Odile Oberlin, Department of Pediatrics, Institut Gustave Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif Cedex, France,
| | - Annie Rey
- Departments of Pediatrics and Biostatistics, Institut Gustave Roussy, Villejuif, France
| | - Kenneth L.B. Brown
- Departments of Pediatric Orthopedic Surgery, British Columbia Children's Hospital, Vancouver, British Columbia
| | - Gianni Bisogno
- Department of Pediatrics, Division of Hematology/Oncology, University Hospital of Padova, Padova, Italy
| | - Ewa Koscielniak
- Pediatric 5 (Oncology, Hematology, Immunolgy), Olga Hospital, Klinikum Stuttgart, Germany
| | - Michael C.G. Stevens
- Department of Paediatric Oncology, Bristol Royal Hospital for Children, Bristol, UK
| | - Douglas S. Hawkins
- Division of Hematology/Oncology, Seattle Children's Hospital, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
| | - William H. Meyer
- Department of Pediatric Hematology/Oncology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Trang H. La
- Radiation Oncology, Kaiser Permanente-Oakland, Oakland, California
| | - Modesto Carli
- Department of Pediatrics, Division of Hematology/Oncology, University Hospital of Padova, Padova, Italy
| | - James R. Anderson
- Department of Preventive and Societal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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Adverse events of local treatment in long-term head and neck rhabdomyosarcoma survivors after external beam radiotherapy or AMORE treatment. Eur J Cancer 2015; 51:1424-34. [DOI: 10.1016/j.ejca.2015.02.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 02/10/2015] [Accepted: 02/21/2015] [Indexed: 11/22/2022]
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Farnia B, Majumder MA, Paulino AC. Ethical analysis as a tool for addressing treatment controversies: radiotherapy timing in children with orbital rhabdomyosarcoma as a case example. J Am Coll Radiol 2014; 12:484-90. [PMID: 25544244 DOI: 10.1016/j.jacr.2014.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/16/2014] [Accepted: 10/20/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The treatment of orbital rhabdomyosarcoma is a topic of debate between North American and European clinicians, with the utility of radiation therapy as part of initial management in question. Despite differences in philosophy, the dominant North American approach of upfront radiation and the dominant European approach of radiation only in the event of recurrence yield a similar rate of overall survival. We sought to identify the ethical arguments for each approach. METHODS Established moral principles and appeals in contemporary medical ethics were utilized to identify the ethical arguments supporting each treatment approach. The potential for technologic advances to alter the analysis was considered. RESULTS Emphasizing the principle of beneficence, the North American approach seeks to reduce recurrence rates. In contrast, the European approach seeks to avoid radiation-induced sequelae, emphasizing the principle of nonmaleficence. Both approaches are based on well-established ethical principles, evidence, and clinical experience. Thus, both approaches currently appear to have legitimacy and should be included in the informed consent process. However, if treatment-related toxicity is reduced through improvements in radiation delivery, the North American approach could emerge as ethically superior. CONCLUSIONS Ethical analysis can aid in addressing challenges that arise when professional practices and perspectives differ in the management of cancer patients.
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Affiliation(s)
- Benjamin Farnia
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary A Majumder
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
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Orbital rhabdomyosarcoma in children: a favorable primary suitable for a less-invasive treatment strategy. J Pediatr Hematol Oncol 2014; 36:605-12. [PMID: 25171453 DOI: 10.1097/mph.0000000000000245] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Orbital rhabdomyosarcoma (ORMS) treatment is based on combination chemotherapy associated with best local therapy, sometimes surgery but more often radiation therapy. A retrospective single-center analysis was conducted to more clearly define the long-term outcome of patients with ORMS, to identify patients in whom aggressive first-line local therapy can be avoided. POPULATION A total of 95 patients with localized parameningeal (PM) or nonparameningeal (NPM) ORMS, treated at the Institut Curie between 1975 and 2010, were analyzed. RESULTS Median age at diagnosis was 6 years (range, 8 mo to 19.5 y), and median follow-up was 8.5 years (range, 7 mo to 24 y). A total of 25 patients presented PM extension. Radiation therapy was part of primary therapy for 78 patients. Five-year event-free survival and overall survival rates were 65.4%±5.2% and 85.6%±3.9%, respectively. On multivariate analysis, initial tumor size was identified as a significant prognostic factor. Event-free survival was similar for PM and NPM tumors (60.3%±10.4% vs. 62.7%±5.9%, P=0.57), whereas there was a trend for overall survival to be better for NPM tumors (90%±3.9% vs. 72.7%±9.6%, P=0.07). CONCLUSIONS Localized ORMS has a favorable outcome despite the current trend toward less aggressive and more limited indications of local therapy. Patients with a favorable pattern of strictly ORMS can be treated without first-line radiation therapy.
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Boutroux H, Levy C, Mosseri V, Desjardins L, Plancher C, Helfre S, Freneaux P, Cellier C, Orbach D. Long-term evaluation of orbital rhabdomyosarcoma in children. Clin Exp Ophthalmol 2014; 43:12-9. [PMID: 24923774 DOI: 10.1111/ceo.12370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 05/31/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Orbital rhabdomyosarcoma (ORMS) is associated with an excellent survival rate greater than 85%, and is considered to be a favourable site for this tumour. Treatment is based on combination chemotherapy together with best local therapy, sometimes surgery but more often radiation therapy. Local therapy is associated with frequent and potentially severe late sequelae. DESIGN Retrospective hospital single-centre analysis. PARTICIPANTS Eighty-two patients treated in Institut Curie, Paris. METHODS To define long-term status of survivors after localized ORMS, patients treated between 1975 and 2010 were analysed. MAIN OUTCOME MEASURES Clinical structural and functional orbital, and general sequelae. RESULTS Median age at diagnosis was 6 years (range: 8 months-19 years), and median follow up was 8.5 years (range: 7 months-24 years). The 5-year globe conservation rate was 90.4%. Ophthalmic dysfunction was present in 79% of patients. Impaired visual acuity (VA), was present in 62% of patients; 38% of them had severe visual disability with VA < 6/60. Late effects on orbitofacial structure were present in 39.8% of patients. Ocular or palpebral sequelae were present in 79% of survivors, mainly cataract (42%), ocular surface lesions such as keratoconjunctivitis (40%) and eyelid abnormalities (29%). General late effects were rare. CONCLUSIONS These data suggest that ocular and orbital late effects are frequent after treatment of ORMS, indicating the need for systematic long-term ophthalmologic follow up of these patients. Radiation therapy is an important part of the total burden of therapy.
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Affiliation(s)
- Helene Boutroux
- Department of Pediatric, Adolescent and Young Adult Oncology, Institut Curie, Paris, France
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Merks JHM, De Salvo GL, Bergeron C, Bisogno G, De Paoli A, Ferrari A, Rey A, Oberlin O, Stevens MCG, Kelsey A, Michalski J, Hawkins DS, Anderson JR. Parameningeal rhabdomyosarcoma in pediatric age: results of a pooled analysis from North American and European cooperative groups. Ann Oncol 2014; 25:231-6. [PMID: 24356633 DOI: 10.1093/annonc/mdt426] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Parameningeal (PM) site is a well-known adverse prognostic factor in children with localized rhabdomyosarcoma (RMS). To identify risk factors associated with outcome at this site, we pooled data from 1105 patients treated in 10 studies conducted by European and North American cooperative groups between 1984 and 2004. PATIENTS AND METHODS Clinical factors including age, histology, size, invasiveness, nodal involvement, Intergroup Rhabdomyosarcoma Study (IRS) clinical group, site, risk factors for meningeal involvement (MI), study group, and application of radiotherapy (RT) were studied for their impact on event-free and overall survival (EFS and OS). RESULTS Ten-year EFS and OS were 62.6 and 66.1% for the whole group. Patients without initial RT showed worse survival (10-year OS 40.8% versus 68.5% for RT treated patients). Multivariate analysis focusing on 862 patients who received RT as part of their initial treatment revealed four unfavorable prognostic factors: age <3 or >10 years, signs of MI, unfavorable site, and tumor size. Utilizing these prognostic factors, patients could be classified into different risk groups with 10-year OS ranging between 51.1 and 80.9%. CONCLUSIONS While, in general, PM localization is regarded as an adverse prognostic factor, the current analysis differentiates those with good prognosis (36% patients with 0-1 risk factor: 10-year OS 80.9%) from high-risk PM patients (28% with 3-4 factors: 10-year OS 51.1%). Furthermore, this analysis reinforces the necessity for RT in PM RMS.
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Affiliation(s)
- J H M Merks
- Department of Pediatric Oncology, Emma Children's Hospital-Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Soole F, Maupain C, Defachelles AS, Taque S, Minard-Colin V, Bergeron C, De Rycke Y, Orbach D. Synovial sarcoma relapses in children and adolescents: prognostic factors, treatment, and outcome. Pediatr Blood Cancer 2014; 61:1387-93. [PMID: 24664883 DOI: 10.1002/pbc.25001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/31/2014] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Twenty-five to 32% of patients with synovial sarcoma (SS) relapse after appropriate treatment, and experience a poor outcome. Patients who can be salvaged by second-line therapy need to be more clearly identified. PATIENTS AND METHODS Data of patients treated in SFCE (Société Française des Cancers de l'Enfant) centers with an initial diagnosis of localized SS before the age of 18 years and treated from 1/1988 to 12/2008, and who experienced at least one relapse, were retrieved. After descriptive analysis, statistical analysis was performed to determine prognostic factors. RESULTS Thirty-seven patients were identified. First relapse occurred after a median interval of 24 months and was localized in 73.0% of cases and metastatic in 24.3% of cases. Treatment of relapse consisted of new surgery in 75.7% of cases, second-line chemotherapy in 73.0% of cases and radiotherapy in 48.6% of cases. Response rate to ifosfamide-based regimens was 36.4%. Overall, 70.3% patients achieved a second complete remission. Median 5-year-event-free survival was 32.8% and 5-year overall survival was 42.1%. Factors significantly correlated with better survival were primary tumor involving the limbs, age less than 12 years at diagnosis, absence of chemotherapy or radiotherapy as initial treatment and local relapse. CONCLUSION Despite its poor overall outcome, relapse of synovial sarcoma sometimes remains curable. Aggressive surgery, when possible, in combination with chemotherapy and radiotherapy is the recommended treatment. Ifosfamide-based regimens may remain effective in patients with relapsed SS. However, alternative therapies should be proposed in patients with poor prognostic factors.
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Affiliation(s)
- Frederick Soole
- Pediatric Adolescent and Young Adult Department, Institut Curie, Paris, France
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Dantonello TM, Lochbühler H, Schuck A, Kube S, Godzinski J, Sköldenberg E, Ljungman G, Kosztyla D, Veit-Friedrich I, Hallmen E, Feuchtgruber S, Wessalowski R, Franke M, Bielack SS, Klingebiel T, Koscielniak E. Challenges in the local treatment of large abdominal embryonal rhabdomyosarcoma. Ann Surg Oncol 2014; 21:3579-86. [PMID: 25047462 DOI: 10.1245/s10434-014-3551-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Embryonal rhabdomyosarcoma is the most common pediatric soft tissue sarcoma. The best local treatment in large, nonmetastatic primary unresected nongenitourinary embryonal rhabdomyosarcoma of the abdomen (LARME) is however unclear. METHODS We analyzed patients with LARME treated in four consecutive CWS trials. All diagnoses were confirmed by reference reviews. Treatment included multiagent chemotherapy and local treatment of the primary tumor with surgery and/or radiotherapy. The impact of primary debulking surgery (PDS) also was studied. RESULTS One hundred patients <21 years with a median age of 4 years had LARME. Sixty-one of them had a tumor >10 cm in diameter at diagnosis. PDS was performed in 19 of 100 children. The outcomes of patients with PDS were similar to those of the other patients. In 36 children, the tumor was resected after induction chemotherapy; 60 RME were irradiated. The toxic effects of radiochemotherapy were not significantly increased compared with the nonirradiated patients. With a median follow-up of 10 years, the 5-year EFS and OS were 52 ± 10 and 65 ± 9 %, respectively. Significant risk factors in multivariate analysis were age >10 years; no achievement of complete remission; and inadequate secondary local treatment, defined as incomplete secondary resection or no radiation. CONCLUSIONS Children with LARME have a fair prognosis, despite an often huge tumor size and unfavorable primary site, if the tumors can either be resected or irradiated following induction chemotherapy. PDS was only performed in a small subgroup. Radiation performed concomitantly with chemotherapy did not increase the acute toxicity significantly.
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Affiliation(s)
- Tobias M Dantonello
- Pediatrics 5 (Oncology, Hematology, Immunology, Rheumatology, Gastroenterology and General Pedatrics), Olgahospital, Klinikum Stuttgart, Stuttgart, Germany,
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Hassan WM, Alfaar AS, Bakry MS, Ezzat S. Orbital tumors in USA: difference in survival patterns. Cancer Epidemiol 2014; 38:515-22. [PMID: 25052531 DOI: 10.1016/j.canep.2014.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 06/28/2014] [Accepted: 07/01/2014] [Indexed: 01/14/2023]
Abstract
INTRODUCTION There is a wide range of tumors affecting the orbital adnexa. Key such tumors include lymphomas, carcinomas, melanomas and rhabdomyosarcomas. Several studies have proposed that these histological subtypes differ in their survival outcomes. In this study we aim to describe the difference in survival outcomes between such subtypes. METHODS The SEER database was used to gather patient information. All 18 SEER registries were used. Patients diagnosed from 1996 to 2005 were included in the analysis. Observed five-year survival rate was calculated using the SEER*Stat software version 8.1.2. Data were extracted into IBM SPSS version 20 to generate Kaplan Meier curve for each group. RESULTS There were 2180 patients in the SEER databases who met the selection criteria. Lymphomas were the most common histology in adults. The overall five-year observed survival for all lymphoma patients was 75.9% (95% CI: 73.7-78.1). There was statistically significant difference between observed survival rates of lymphoma subtypes. Carcinomas were the second most common tumors. Their five-year observed survival rate in our study was 60.4%. There was no statistically significant difference between carcinoma subtypes' observed survival rates in the 20-49 age group, while, in the older age group, the difference was found to be statistically significant. Rhabdomyosarcomas were the most common tumors in children. The overall five-year observed survival rate for rhabdomyosarcomas patients was 89.8%. There was no statistically significant difference between observed survival rates of rhabdomyosarcomas subtypes. There was no statistically significant difference between relative survival rates according to gender and treatment received except within melanomas. CONCLUSION In adults, lymphomas have better survival rates than carcinomas. Whereas the lymphoma subtype can be used as a determinant prognostic factor in any age, the carcinoma subtype can be used as such a determinant in older age groups only. In children, rhabdomyosarcomas are the predominant tumors affecting the orbital adnexa. Further studies are needed to determine if the difference between embryonal rhabdomyosarcoma and alveolar rhabdomyosarcoma observed survival rates are statistically significant.
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Affiliation(s)
- Waleed M Hassan
- Department of Research, Children's Cancer Hospital Egypt 57357, Cairo, Egypt.
| | - Ahmad S Alfaar
- Department of Research, Children's Cancer Hospital Egypt 57357, Cairo, Egypt; Cairo University School of Medicine, Cairo, Egypt; Ulm University, 89069 Ulm, Baden-Württemberg, Germany.
| | - Mohamed S Bakry
- Department of Research, Children's Cancer Hospital Egypt 57357, Cairo, Egypt.
| | - Sameera Ezzat
- Department of Research, Children's Cancer Hospital Egypt 57357, Cairo, Egypt; National Liver Institute, Menoufiya University, Shebin Elkom, Egypt.
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Ferrari A, Casanova M. New concepts for the treatment of pediatric nonrhabdomyosarcoma soft tissue sarcomas. Expert Rev Anticancer Ther 2014; 5:307-18. [PMID: 15877527 DOI: 10.1586/14737140.5.2.307] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nonrhabdomyosarcoma soft tissue sarcomas form a group of rare tumors with a different biology and clinical behavior. The recently established European Pediatric Soft Tissue Sarcoma Study Group is organizing a new study devoted specifically to these tumors that were formerly treated according to the principles derived from experience with rhabdomyosarcoma, which is a clearly distinct entity. The new study includes two prospective trials, one for synovial sarcoma and the other for adult-type nonrhabdomyosarcoma soft tissue sarcomas. While surgery remains the mainstay of treatment, the role of adjuvant therapy is not yet clear and our understanding of the biology and natural history of nonrhabdomyosarcoma soft tissue sarcomas is still incomplete. This review presents the latest data on nonrhabdomyosarcoma soft tissue sarcoma treatment and outcome, and the rationale behind a risk-adapted treatment program that investigates the role of full-dose ifosfamide-doxorubicin chemotherapy in improving the response rate of patients with unresectable disease, the chances of avoiding adjuvant chemotherapy in low-risk synovial sarcomas, and the possible role of chemotherapy in high-risk adult-type soft tissue sarcomas.
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Affiliation(s)
- Andrea Ferrari
- Istituto Nazionale Tumori, Via G.Venezian, 1-20133 Milan, Italy.
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44
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Jurdy L, Merks JHM, Pieters BR, Mourits MP, Kloos RJHM, Strackee SD, Saeed P. Orbital rhabdomyosarcomas: A review. Saudi J Ophthalmol 2013; 27:167-75. [PMID: 24227982 DOI: 10.1016/j.sjopt.2013.06.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rhabdomyosarcoma (RMS) is a highly malignant tumor and is one of the few life-threatening diseases that present first to the ophthalmologist. It is the most common soft-tissue sarcoma of the head and neck in childhood with 10% of all cases occurring in the orbit. RMS has been reported from birth to the seventh decade, with the majority of cases presenting in early childhood. Survival has changed drastically over the years, from 30% in the 1960's to 90% presently, with the advent of new diagnostic and therapeutic modalities. The purpose of this review is to provide a general overview of primary orbital RMS derived from a literature search of material published over the last 10 years, as well as to present two representative cases of patients that have been managed at our institute.
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Affiliation(s)
- Lama Jurdy
- Orbital Centre, Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Zhang WL, Zhang Y, Huang DS, Guo F, Han T, Hong L, Hu HM, Zhi T. Clinical character of pediatric head and neck rhabdomysarcomas: a 7-year retrospective study. Asian Pac J Cancer Prev 2013; 14:4089-93. [PMID: 23991958 DOI: 10.7314/apjcp.2013.14.7.4089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The rhabdomysarcoma (RMS) is most common soft tissue carcinoma in children, mostly found in the head and neck with high degree of malignancy. The current study aimed to summarize clinical data and evaluate treatment outcome of cases in a single hospital. METHODS Forty-one (24 male, 17 female) children with newly diagnosed RMS in Beijing Tong Ren Hospital were enrolled between November, 2004 and May, 2011. The. Students' t and Chi tests were then performed on retrospectively reviewed clinical data, followed by survival analysis based on the Kaplan Meier method using SPSS 17.0 software. RESULTS Of all cases, 32 were treated by common chemotherapy, and 3 cases with stage III RMS received high-dose chemotherapy and auto-peripheral blood stem cell transplantation (APBSCT). Side-effects in the former were: I grade for 62.5% (20/32), II grade for 28.1% (9/32), III grade account for 9.275% (3/32). Side-effects of 3 cases with APBSCT: 2 were I grade, 1 was III grade. The median follow-up time of 41 RMS cases was 41 months. Four cases were lost to follow-up, 7 cases recurred, and 5 cases died of cerebral metastasis, witha total survival rate was 86.5% (32/37). CR rate was 67.6% (25/37), PR was 18.9% (7/37). CONCLUSION Multidiscipline treatment including chemotherapy, radiotherapy, surgery and auto-PBSCT is highly recommended for pediatric patients with head and neck RMS.
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Affiliation(s)
- Wei-Ling Zhang
- Department of Pediatrics, Tong Ren Hospital, Capital Medical University, Beijing, China.
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46
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Ge X, Huang DS, Shi JT, Ma JM. Multidisciplinary Collaborative Therapy for 30 Children with Orbital Rhabdomyosarcoma. Asian Pac J Cancer Prev 2013; 14:4641-6. [DOI: 10.7314/apjcp.2013.14.8.4641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Bagdonaite L, Jeeva I, Chang BYP, Kalantzis G, El-Hindy N. Multidisciplinary management of adult orbital rhabdomyosarcoma*. Orbit 2013; 32:208-210. [PMID: 23617582 DOI: 10.3109/01676830.2013.764442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
We report the case of a 52-year-old man who presented with a 10-day history of right eye and eyelid inflammation and intermittent diplopia following blunt trauma to the right eyebrow. The CT and MRI scans revealed an extraconal soft tissue mass on the orbital floor with maxillary and ethmoid sinus wall destruction, which on orbital biopsy was proven to be an Alveolar Rhabdomyosarcoma. The patient had a central retinal vein occlusion due to mass effect that resulted in total visual loss at 2 months. He was referred to oncologists who treated him according to the paediatric RMS protocol and is still in remission at 2-year follow-up. Rhabdomyosarcoma is a rare tumour in adults which requires multi-disciplinary management. This highlights the necessity of considering rhabdomyosarcoma in the differential diagnosis of orbital tumours in any age group.
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Affiliation(s)
- Laura Bagdonaite
- Department of Ophthalmology, St James' University Hospital, Leeds, United Kingdom
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48
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Minard-Colin V, Kolb F, Saint-Rose C, Fayard F, Janot F, Rey A, Canale S, Julieron M, Corradini N, Raquin MA, Habrand JL, Grill J, George B, Ba Huy PT, Couloignier V, Terrier-Lacombe MJ, Luboinski B, Valteau-Couanet D, Oberlin O. Impact of extensive surgery in multidisciplinary approach of pterygopalatine/infratemporal fossa soft tissue sarcoma. Pediatr Blood Cancer 2013; 60:928-34. [PMID: 23303699 DOI: 10.1002/pbc.24374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 09/27/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND To evaluate a strategy whereby extensive surgery ± external radiotherapy (RT) could improve local control in pterygopalatine/infratemporal fossa (PIF) sarcoma. PROCEDURE Forty-one patients with a diagnosis of sarcoma involving the PIF and referred to our Institute from 1984 to 2009 were included in the analysis. Patients received multidrug chemotherapy and radiotherapy ± surgery, depending on the period of treatment. RESULTS The median age at diagnosis was 7.6 years (range: 0.1-22 years). There were 36 RMS, 3 undifferentiated sarcoma and 2 other soft-tissue sarcomas. Sixty-eight percent of patients had meningeal risk factors at diagnosis. Local treatment consisted of RT alone in 19 patients, surgery in combination to RT in 19 patients and surgery alone in 3 patients. The local progression rate (LPR) at 5 years was 45% for the entire population, 59% for the 19 patients treated with RT alone and 34% for the 22 patients who had surgery as part of their treatment. All locoregional failures after extensive surgery occurred at the skull base and/or in leptomeningeal spaces. CONCLUSIONS Multidisciplinary approach including extensive surgery for PIF sarcoma is feasible and yields good local control with 15/22 patients in local complete remission. Future studies are warranted to confirm these promising results, to evaluate the possibility of avoiding RT or limiting the RT field, and to extend the indication for extensive surgery to other "worse" sites of PM sarcoma such as the paranasal sinuses.
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A clinical update and radiologic review of pediatric orbital and ocular tumors. JOURNAL OF ONCOLOGY 2013; 2013:975908. [PMID: 23577029 PMCID: PMC3610355 DOI: 10.1155/2013/975908] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 01/14/2013] [Accepted: 01/20/2013] [Indexed: 12/15/2022]
Abstract
While pediatric orbital tumors are most often managed in tertiary care centers, clinicians should be aware of the signs of intraocular and orbital neoplasms. In the pediatric population, a delay in diagnosis of orbital and intraocular lesions, even if benign, can lead to vision loss and deformity. Intraocular lesions reviewed are retinoblastoma, medulloepithelioma, and retinal astrocytic hamartoma. Orbital neoplasms reviewed are rhabdomyosarcoma, neuroblastoma metastases, optic pathway glioma, plexiform neurofibroma, leukemia, lymphoprolipherative disease, orbital inflammatory syndrome, dermoid and epidermoid inclusion cysts, and Langerhans' cell histiocytosis. Vascular lesions reviewed are infantile hemangioma and venous lymphatic malformation. In conjunction with clinical examination, high-resolution ophthalmic imaging and radiologic imaging play an important role in making a diagnosis and differentiating between benign and likely malignant processes. The radiologic imaging characteristics of these lesions will be discussed to facilitate prompt diagnosis and treatment. The current treatment modalities and management of tumors will also be reviewed.
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50
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Raney B, Huh W, Hawkins D, Hayes-Jordan A, Million L, Rodeberg D, Teot L, Anderson J. Outcome of patients with localized orbital sarcoma who relapsed following treatment on Intergroup Rhabdomyosarcoma Study Group (IRSG) Protocols-III and -IV, 1984-1997: a report from the Children's Oncology Group. Pediatr Blood Cancer 2013; 60:371-6. [PMID: 22961750 PMCID: PMC5140272 DOI: 10.1002/pbc.24289] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/22/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND We wanted to ascertain patterns of recurrence, re-treatment, and outcome among 188 eligible patients treated for localized orbital sarcoma on IRSG Protocols III/IV, 1984-1997. PROCEDURE Retrospective chart review. RESULTS Twenty-four of 188 patients (12.8%) developed local (n = 22) or distant relapse (n = 2) at 0.057-7.05 years (median, 1.58) after enrollment. Ages at study entry were 0.14-17 years (median, 5 years). Initial tumor operations included biopsy (n = 20) or gross resection with microscopic residual (n = 4). Initial tumor diameters were 0.5-7 cm (median, 3). Pathologic subtypes were embryonal rhabdomyosarcoma (ERMS, n = 19), sarcoma not otherwise specified (n = 2), and alveolar RMS, botryoid ERMS, or undifferentiated sarcoma (n = 1 each). Initial treatment included vincristine/dactinomycin (n = 24) including an alkylator (n = 4) and radiotherapy (RT, n = 21). Twenty patients responded, 14 completely, 6 partially. After recurrence, patients underwent orbital exenteration (n = 10), enucleation (2), tumor excision (3), or biopsy (1); 7 had no operation, and 1 had no data. Post-relapse chemotherapy included combinations of etoposide (n = 14 patients), doxorubicin (14), ifosfamide (12), cyclophosphamide (7), and dacarbazine (n = 1). Six patients received RT, including four previously treated and two not irradiated initially. Two patients died; one at 1.79 years after contralateral brain metastasis followed by local recurrence, and another at 2.49 years after multiple local recurrences. Twenty-two patients (91.7%) survived sarcoma-free for 0.04-17 years (median, 6.9) after relapse, and 18 of 22 (82%) were alive ≥5 years after relapse. CONCLUSION Survival following recurrent localized orbital sarcoma appears likely after vigorous re-treatment given with curative intent.
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Affiliation(s)
- Beverly Raney
- Division of Pediatrics and Children's Cancer Hospital, U.T. M.D. Anderson Cancer Center, Houston, Texas, USA.
| | - Winston Huh
- Division of Pediatrics and Children's Cancer Hospital, U.T. M.D. Anderson Cancer Center, Houston, TX
| | - Douglas Hawkins
- Seattle Children's Hospital, University of Washington School of Medicine, and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Andrea Hayes-Jordan
- Division of Pediatrics and Children's Cancer Hospital, U.T. M.D. Anderson Cancer Center, Houston, TX
| | - Lynn Million
- Radiation Oncology, Stanford University Medical Center, Stanford, CA
| | | | - Lisa Teot
- Dana Farber Cancer Institute, Boston, MA
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