Outcome of multimodality treatment of Ewing's sarcoma of the extremities

Characteristics and Outcome of Children and Adolescents Diagnosed With Ewing Sarcoma Treated at a Tertiary Cancer Center in India: A Single-Institution Experience

INTRODUCTION

Ewing sarcoma (ES) is a malignant, aggressive tumor most frequently diagnosed among pediatric and adolescent populations. Patients with ES in low-middle income countries (LMIC) have dismal outcomes. The aim of this study is to evaluate the outcomes in children and adolescents with ES treated using a multimodal uniform treatment protocol.

METHODS

A retrospective analysis was conducted on 54 children and adolescents <18 years of age diagnosed with ES who received treatment from January 2021 to December 2022 at a tertiary cancer center in Western India. Data were retrieved from the hospital database, including clinical and medical records.

RESULTS

The study included 32 males (59%) and 22 females (41%) with a male-to-female ratio of 1.45:1. The median age of presentation was 13 years (ranging from four to 17 years). Localized disease was observed in 36 patients (67%) and metastatic disease in 18 patients (33%). Extremities were the most common primary sites (35 patients, 65%). Among the patients, 15 (28%) achieved complete response (CR), seven (13%) had persistent disease, 25 (46%) had incomplete response, and seven (13%) experienced disease progression on chemotherapy. The median (IQR) OS was 36 months (30-42 months), with three-year overall survival (OS) and progression-free survival (PFS) rates of 55% and 40%, respectively.

CONCLUSION

In ES, complete resection of tumors with negative margins (i.e., R0 resection) significantly improves outcomes when combined with chemotherapy and radiotherapy. Survival is greatly increased upon achieving CR, highlighting the significance of successful early therapy. For this patient population to have better outcomes, further research and closing disparities in healthcare in LMICs are essential.

Clinicopathological and oncological outcomes in upper extremity Ewing's sarcoma: A single institutional experience

Background

Ewing's sarcoma is highly aggressive bone tumor having predilection for younger age groups with t (11,22) translocation, recombines the FLI-1 and EWS genes on chromosome 22. This disease requires multi-disciplinary treatment withneo-adjuvant chemotherapy followed by surgery or radiotherapy and adjuvant chemotherapy. This study was aimed to assess the demographic distribution, clinical behaviour and oncological outcome of Ewings Sarcoma involving upper extremity.

Methods

From 2015 to 2022, 45 patients of upper extremity Ewing's sarcoma underwent treatment at a territory cancer centre. A total of 26 patients treated with surgical management were included in the study comprising 15 males (57.7 %) and 11 females (42.3 %). Mean age of presentation was 26 years (3-43 years). The most common site for Ewings sarcoma of upper extremity was Humerus(42 %) followed by Scapula(27 %), Radius(15 %), Ulna(8 %), Metacarpals(4 %) and Clavicle(4 %). Out of 26 cases, 19 (73%) underwent limb salvage surgery and 7 (27%) underwent ampuation surgery.

Results

In limb salvage group reconstruction with Extra-corporeal radiotherapy (ECRT), Ulna centralization, Megaprosthesis and 3D printed scapula was performed following wide resection of tumor. In Amputation group ray resection in one case and forequarter amputation was performed in six cases. Mean serum LDH value was 335 IU/L (2.3X Normal value) and serum albumin was 4.04 gm/dl. Mean tumour necrosis after neo-adjuvant chemotherapy was 68 %. Out of 26 cases, 19(73 %) cases underwent limb salvage and 7 patients underwent amputation surgery. Out of 26, 13 (50 %) patients developed metastasis on follow up. The Event free survival (EFS) in current study was 70 % at 12 months and 40 % at 24 months. Mean Event free survival (EFS) in current study was 33.5 months (22.3-44.6) and Median Event free survival (EFS) in current study was 25 months (19.7-30.2).

Conclusion

This study characterises demographic and oncologic outcomes of upper extremity ewings sarcoma in Indian subpopulation. Pain and swelling were prominent clinical findings at presentation in patients with upper extremity Ewing's sarcoma. The survival rate following limb salvage surgery in Ewings sarcoma of upper extremity was comparable to that of patients with amputation surgery. Ewings sarcoma of upper extremity was associated with higher LDH level which was raised more than twice the normal range and can led to worse oncologic outcomes. A comparative study on upper extremity and lower extremity ewings sarcoma will be of help to improve literature on this rare disease.

Is High-dose Radiation Therapy Associated With Early Revision Due to Aseptic Loosening in Patients With a Sarcoma of the Lower Extremities Reconstructed With a Cemented Endoprosthesis?

BACKGROUND

The durability of endoprostheses after limb salvage surgery is influenced by surgical factors (resection length, implant location, and residual bone quality), implant design (modular versus custom design, rotating versus fixed hinge, coating, collars, and the use of cross pins), and host factors (patient's immune status, activity levels, and age). In general, radiation therapy increases the risk of fractures, infection, delayed wound healing, and impaired osseointegration. Several studies have shown exposure to radiation to be associated with higher endoprosthesis revision rates and higher periprosthetic infection rates, but results are inconsistent. Although radiation therapy is not routinely used in the treatment of many bone sarcomas in current practice, it is still used in high doses after resection and prosthetic reconstruction in patients who have Ewing sarcoma with close or positive margins and in patients with soft tissue sarcoma. It is also used in varying doses after prosthetic reconstruction in patients with myeloma or bone metastasis after resection of periarticular destructive tumors. These patients may be at an increased risk of complications due to their radiation exposure, but this is a difficult question to study given the rarity of these diagnoses and poor overall survival of these patients. We therefore leveraged a large, longitudinally collected, 40-year endoprosthesis database that included patients who received radiation to the extremity for many bone and soft tissue sarcomas to investigate the association between preoperative or postoperative radiation therapy and endoprosthesis survival.

QUESTIONS/PURPOSES

(1) Is receiving preoperative or postoperative radiation therapy in low or high doses for the treatment of bone or soft tissue malignancy of the lower extremities associated with decreased implant survivorship free from amputation or revision due to any cause? (2) Is receiving preoperative or postoperative radiation therapy in low or high doses for the treatment of bone or soft tissue malignancy of the lower extremities associated with decreased implant survivorship free from revision specifically due to aseptic loosening? (3) Is receiving preoperative or postoperative radiation therapy for the treatment of Ewing sarcoma of the femur specifically associated with decreased implant survivorship free from revision specifically due to aseptic loosening?

METHODS

This was a retrospective, comparative study using our institution's database of 822 endoprostheses. Between 1980 and 2019, we treated 541 patients with primary cemented endoprostheses of the extremities. Of those patients, 8% (45 of 541) were excluded due to unknown radiation status, 3% (17 of 541) because of prior failed allograft, 15% (83 of 541) due to metastatic disease from a carcinoma, 1% (6 of 541) due to a nononcologic diagnosis, 4% (20 of 541) due to benign tumor diagnosis, 16% (87 of 541) due to upper extremity tumor location, 9% (49 of 541) due to not receiving chemotherapy, and 3% (14 of 541) due to expandable prostheses. Of the remaining 220 patients, 6% (13) were considered missing because they did not have 2 years of follow-up and did not reach a study endpoint. No patients had surgery within the last 2 years of the study end date. In all, 207 patients met inclusion criteria and were eligible for analysis. Patients who had received radiation to the lower extremities at any point in their treatment course were included in the radiation group and were compared with patients who did not receive radiation. For patients where radiation dose was available, the radiation group was subdivided into a low-dose (≤ 3000 cGy) and high-dose (> 3000 cGy) group. Revision surgery was defined as any surgery necessitating removal or replacement of the tibial or femoral stem. The complications necessitating revision or amputation were poor wound healing, aseptic loosening, implant breakage, deep infection, and tumor progression. The primary outcome of interest was implant survival free from revision or amputation due to any cause. The secondary outcome of interest was implant survival free from revision or amputation specifically due to aseptic loosening. The Kaplan-Meier survivorship curves were generated with implant survival free from revision or amputation as the endpoint and patient death as a competing risk. A log-rank test was used to identify differences in survivorship between the patients who received radiation and those who did not. Multivariate regression was used to identify factors associated with decreased implant survival. An odds ratio was used to determine relative effect size among the factors associated with decreased implant survival.

RESULTS

The mean implant survival time for patients who did not receive radiation was 18.3 years (95% confidence interval [CI] 15.4 to 21.3) whereas the mean implant survival time for patients who received low- and high-dose radiation were 19.1 years (95% CI 14.5 to 23.7; p = 0.59) and 13.8 years (95% CI 8.2 to 19.5; p = 0.65), respectively. The mean implant survival free from revision for aseptic loosening for patients who did not receive radiation was 27.1 years (95% CI 24.1 to 30.1) whereas the mean implant survival for patients who received low- and high-dose radiation were 24.1 years (95% CI 19.1 to 29.1; p = 0.34) and 16.4 years (95% CI 10.6 to 22.2; p = 0.01), respectively. Patients who received high-dose radiation had decreased 5-year implant survivorship free from amputation or revision due to aseptic loosening (73% [95% CI 44% to 89%]) compared with patients who did not receive radiation (95% [95% CI 90% to 99%]; p = 0.01). For patients treated for Ewing sarcoma of the femur, the 5-year implant survival free from amputation or revision due to aseptic loosening for patients who did not receive radiation (100% [95% CI 100% to 100%]) was no different compared with patients who received radiation (71% [95% CI 35% to 90%]; p = 0.56).

CONCLUSION

The results of this study may apply to scenarios where radiation is used, such as Ewing sarcoma with positive margins or local recurrence and after prosthetic reconstruction in patients with myeloma or bone metastasis after resection of periarticular destructive tumors. Surgeons may consider closer monitoring for early clinical and radiographic signs of aseptic loosening in patients who received high-dose radiation. These patients may also benefit from constructs that have increased resistance to aseptic loosening such as cross-pin or side plate fixation. The association between radiation and aseptic loosening should be further studied with larger studies with homogeneity in tumor diagnosis and prosthesis. The dose-dependent relationship between radiation and bone-related complications may also benefit from controlled, laboratory-based biomechanical studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Outcomes with nondose-dense chemotherapy for Ewing sarcoma: A practical approach for the developing world

BACKGROUND

The current multidisciplinary approach in the treatment of Ewing sarcoma has improved cure rates, with contemporary dose-dense chemotherapy attaining 5-year event-free survival (EFS) of 73% in localized cases. Dose-intense and dose-dense chemotherapy is difficult in the majority of resource-limited settings with limited access to optimal supportive care. We report on patients with Ewing sarcoma treated on EFT-2001, a nondose-dense chemotherapy protocol.

PROCEDURE

A retrospective analysis was conducted of patients (<15 years) with Ewing sarcoma treated with curative intent during January 2013-June 2017 with an institutional ethics committee-approved nondose-dense protocol (EFT-2001). Local therapy was planned after 9-12 weeks of chemotherapy with metastatic sites addressed with radiotherapy. The study assessed outcomes and prognostic factors.

RESULTS

We analysed 200 patients with M:F ratio of 1.27:1 and metastases in 41 patients (20.5%). At a median follow up of 41.5 months (range 4.5-81.8 months), respective 3-year EFS and overall survival (OS) of the whole cohort is 65.3% (95% confidence interval [CI]: 58.1-71.7%) and 79.3% (95% CI: 72.8-84.5%); for localized and metastatic cohort, 70.9% (95% CI: 62.9-77.5%) and 82.8% (95% CI: 75.7-89.0%); and for metastatic cohort, 42.8% (95% CI: 28.0-58.6%) and 65.3% (95% CI: 47.7-78.3%). Presence of residual disease (morphologic/metabolic) on positron emission tomography-computed tomography scan done 3 months post definitive radiotherapy (hazard ratio [HR] 7.92 [95% CI: 3.46-18.14]) and delay in any form of local control >4 months (HR 3.42 [95% CI: 1.32-8.89]) affected outcomes. Nonrelapse mortality during treatment was 6.5%, mainly due to cardiomyopathy (3.0%) and bacterial sepsis (1.5%). Cardiotoxicity was seen in 11.5% of patients.

CONCLUSIONS

Nondose-dense chemotherapy provides good outcomes with manageable toxicities in a multidisciplinary treatment approach, while reducing cumulative drug exposures in the developing world where dose-intense or dose-dense chemotherapy could potentially increase toxicity, and hence seems a feasible approach in resource-limited settings. Presence of any residual disease post definitive radiotherapy or delay in local control portends poor outcome.

Ewing Sarcoma in Nepal Treated With Combined Chemotherapy and Definitive Radiotherapy

PURPOSE

To our knowledge, we conducted the first prospective oncologic clinical trial in Nepal aimed at providing state-of-the-art chemotherapy to patients with Ewing sarcoma. The efficacy of external-beam radiotherapy (RT) as the sole local treatment modality was explored and deemed justified as a result of the lack of available advanced tumor-orthopedic services in Nepal.

PATIENTS AND METHODS

Twenty patients, 11 female and 9 male patients between the ages of 6 and 37 years, with newly diagnosed Ewing sarcoma were enrolled. Neoadjuvant combination chemotherapy, comprising well-established drug combinations, was administered in five courses before external-beam RT, during which one course of etoposide and ifosfamide was given. After RT, six additional chemotherapy courses were scheduled.

RESULTS

RT was tolerated well, providing rapid symptom relief and local tumor control, with no pathologic fractures observed among the 15 patients who received such treatment. Eleven patients completed the entire treatment protocol; seven patients were under continued follow-up, with no evidence of disease in six patients at a median follow-up time of 2.3 years (range, 1.3 to 3.1 years) and one patient alive but with a regional recurrence. Four patients experienced metastatic relapse and died as a result of their disease. Three treatment-related deaths linked to toxicity from chemotherapy occurred. Four of the six patients who refused to complete the treatment protocol and were lost to follow-up experienced progressive disease and were assumed dead.

CONCLUSION

This study was feasible with RT as the sole local treatment modality in combination with chemotherapy. As a result of the high number of patients lost to follow-up, no firm conclusions can be drawn, but the majority of the patients who completed treatment obtained durable long-term remissions.

Trends in incidence of Ewing sarcoma of bone in India - Evidence from the National Cancer Registry Programme (1982-2011)

Background

Ewing sarcoma is a malignant tumour found mainly in childhood and adolescence. The present study aims at analyzing the data on Ewing sarcoma cases of bone from the National Cancer Registry Programme, India to provide incidence, patterns, and trends in the Indian population.

Materials and Methods

The data of five Population Based Cancer Registries (PBCR) of Bangalore, Mumbai, Chennai, Bhopal and Delhi over 30 years period (1982- 2011) were used to calculate the Age Specific and Age Standardized Incidence Rates (ASpR and ASIR), and trends in incidence was analyzed by linear and Joinpoint Regression.

Results

Ewing sarcoma comprised around 15 % of all bone malignancies. Sixty-eight percent were 0-19 years, with 1.6 times risk of tumour in bones of limbs as compared to other bones. The highest incidence rate (per million) was in the 10-14 years age group (male -4.4, female -2.9) with significantly increasing trend in ASpR observed in both sexes. Pooled ASIR per million for all ages was higher in male (1.6) than female (1.0) with an increasing rate ratio of ASIR with increase in age. Trend of pooled ASIR for all ages was significantly increased in both sexes. Twelve percent cases were reported in ≥30 years of age.

Conclusion

This paper has described population based measurements on burden and trends in incidence of skeletal Ewing in India. These may steer further research questions on the clinical and molecular epidemiology to explain factors associated with the increasing incidence of Ewing sarcoma bone observed in India.

Outcomes and prognostic factors for Ewing-family tumors of the extremities

BACKGROUND

There are few published studies describing the clinical results of patients uniformly treated for a Ewing-family tumor of an extremity.

METHODS

We performed a review of patients who had received uniform treatment consisting of neoadjuvant chemotherapy, surgery and/or radiation therapy as local treatment, and then adjuvant chemotherapy from June 2003 to November 2011 at a single institution.

RESULTS

There were 158 patients included in the study. The median age was fifteen years. Sixty-nine (44%) of the patients had metastatic disease at presentation. Fifty-seven patients underwent surgery, and forty-one received radical radiation therapy following neoadjuvant chemotherapy. After a median of 24.3 months (range, 1.6 to ninety-seven months) of follow-up, the five-year event-free survival, overall survival, and local control rates (and standard error) were 24.1% ± 4.3%, 43.5% ± 6%, and 55% ± 6.8%, respectively, for the entire cohort and 36.4% ± 6.2%, 57.6% ± 7.4%, and 58.2% ± 7.9%, respectively, for patients without metastases. In the multivariate analysis, metastases predicted inferior event-free survival (p = 0.02) and overall survival (p = 0.03) rates in the entire cohort, whereas radical radiation therapy predicted an inferior local control rate in the entire cohort (p = 0.001) and in patients without metastases (p = 0.04). In the group with localized disease, there was no difference between the patients who received radical radiation therapy and those who underwent surgery with regard to tumor diameter (p = 0.8) or post-neoadjuvant chemotherapy response (p = 0.1). A white blood cell count (WBC) of >11 × 109/L predicted inferior event-free survival (p = 0.005) and local control (p = 0.02) rates for patients without metastases.

CONCLUSIONS

To our knowledge, this is the largest study on extremity Ewing-family tumors treated with uniform chemotherapy and either surgical resection or radical radiation therapy in Asia. All possible efforts should be made to resect a primary tumor after neoadjuvant chemotherapy, as radical radiation therapy alone results in a poor local control rate despite a good post-neoadjuvant chemotherapy response. Patients without metastases but with a high WBC had inferior event-free survival and local control rates and may require more aggressive therapy.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High tumor volume and local recurrence following surgery in osteosarcoma: A retrospective study

BACKGROUND

Osteosarcoma is a high grade malignant, osteoid forming, primary bone tumor affecting the metaphysis of long bones. Local recurrence (LR) in osteosarcomas is a sinister. Theoretically, a high tumor volume at the time of presentation will limit surgical margins, involve vital neurovascular bundles and show poor response to chemotherapy thereby causing high rates of amputations (as against limb salvage surgery) and should be associated with poor survival rates. This study evaluated objectively if high tumor volume is a significant predictor of local recurrence (LR) in operated cases of osteosarcomas.

MATERIALS AND METHODS

Operated cases of osteosarcoma (presenting to the Orthopedic outpatient or the Medical Oncology outpatient between January 1, 2004 and January 1, 2011 were included in the study. Their preoperative clinical data and investigations along with the operative notes were traced from the medical/departmental records. Details of chemotherapy received in the neo-adjuvant and postoperative periods were noted. Besides, all demographic data were also noted. Tumor volume was calculated using the available magnetic resonance images using the formula: ([π/6] × length × width × depth). Post data extraction, patients were divided in two groups, Groups I (without LR) and Group II (with LR).

RESULTS

A total of 95 cases of biopsy proven osteosarcomas were identified. Of which 64 were male and 31 females. There were 15 (15.8%) local recurrences. 71% (57/80) patients without LR fell in the age group of 10-20 years, while 66% (10/15) patients with LR were in the age group of 10-20 years. Limb salvage surgery was done in 81.05% (77/95) patients while a total of 18 patients underwent amputation. Of the 80 cases in Group I (without LR), 40 (50%) patients had tumor volume >200 c.c., 30 patients (37.5%) had tumor volume between 50 and 200 c.c. while only 10 patients had tumor volumes <50 c.c. This was in contrast to the tumor volume noted in Group II (with LR) of 15 patients where 8 patients had a tumor volume between 50 and 200 c.c., five had bigger tumor volumes of >200 c.c. and only two patients were smaller in size, with a tumor volume <50 c.c. The mean tumor volume in the group without LR was 406.74 ± 771.67 c.c. as compared with 195.77 ± 226.8 c.c. in the group with local recurrence. Using Mann-Whitney test, the difference between the two groups was found to be statistically insignificant (P = 1.403).

CONCLUSIONS

We conclude that high tumor volume is not a significant predictor of LR in osteosarcomas thus patients with high tumor masses should not be denied limb salvage. However, we recommend that the decision on attempting limb salvage should not only be based on the tumor volume alone.