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Dirksen U, Brennan B, Le Deley MC, Cozic N, van den Berg H, Bhadri V, Brichard B, Claude L, Craft A, Amler S, Gaspar N, Gelderblom H, Goldsby R, Gorlick R, Grier HE, Guinbretiere JM, Hauser P, Hjorth L, Janeway K, Juergens H, Judson I, Krailo M, Kruseova J, Kuehne T, Ladenstein R, Lervat C, Lessnick SL, Lewis I, Linassier C, Marec-Berard P, Marina N, Morland B, Pacquement H, Paulussen M, Randall RL, Ranft A, Le Teuff G, Wheatley K, Whelan J, Womer R, Oberlin O, Hawkins DS. High-Dose Chemotherapy Compared With Standard Chemotherapy and Lung Radiation in Ewing Sarcoma With Pulmonary Metastases: Results of the European Ewing Tumour Working Initiative of National Groups, 99 Trial and EWING 2008. J Clin Oncol 2019; 37:3192-3202. [PMID: 31553693 PMCID: PMC6881099 DOI: 10.1200/jco.19.00915] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The R2Pulm trial was conducted to evaluate the effect of busulfan-melphalan high-dose chemotherapy with autologous stem-cell rescue (BuMel) without whole-lung irradiation (WLI) on event-free survival (main end point) and overall survival, compared with standard chemotherapy with WLI in Ewing sarcoma (ES) presenting with pulmonary and/or pleural metastases. METHODS From 2000 to 2015, we enrolled patients younger than 50 years of age with newly diagnosed ES and with only pulmonary or pleural metastases. Patients received chemotherapy with six courses of vincristine, ifosfamide, doxorubicin, and etoposide (VIDE) and one course of vincristine, dactinomycin, and ifosfamide (VAI) before either BuMel or seven courses of VAI and WLI (VAI plus WLI) by randomized assignment. The analysis was conducted as intention to treat. The estimates of the hazard ratio (HR), 95% CI, and P value were corrected for the three previous interim analyses by the inverse normal method. RESULTS Of 543 potentially eligible patients, 287 were randomly assigned to VAI plus WLI (n = 143) or BuMel (n = 144). Selected patients requiring radiotherapy to an axial primary site were excluded from randomization to avoid excess organ toxicity from interaction between radiotherapy and busulfan. Median follow-up was 8.1 years. We did not observe any significant difference in survival outcomes between treatment groups. Event-free survival was 50.6% versus 56.6% at 3 years and 43.1% versus 52.9% at 8 years, for VAI plus WLI and BuMel patients, respectively, resulting in an HR of 0.79 (95% CI, 0.56 to 1.10; P = .16). For overall survival, the HR was 1.00 (95% CI, 0.70 to 1.44; P = .99). Four patients died as a result of BuMel-related toxicity, and none died after VAI plus WLI. Significantly more patients in the BuMel arm experienced severe acute toxicities than in the VAI plus WLI arm. CONCLUSION In ES with pulmonary or pleural metastases, there is no clear benefit from BuMel compared with conventional VAI plus WLI.
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Affiliation(s)
| | | | | | | | - Henk van den Berg
- Emma Children Hospital – Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Vivek Bhadri
- Chris O’Brien Lifehouse, Camperdown, NSW, Australia
| | | | | | - Alan Craft
- Northern Institute for Cancer Research, Newcastle Upon Tyne, United Kingdom
| | - Susanne Amler
- Westfalian Wilhelms University Muenster, Muenster; and Friedrich- Loeffler Institute, Greifswald-Insel Riems, Germany
| | | | | | - Robert Goldsby
- University of California San Francisco Benioff Children’s Hospital, San Francisco, CA
| | | | - Holcombe E. Grier
- Dana-Farber/Boston Children’s Cancer and Blood Disorder Center, Boston, MA
| | | | | | | | - Katherine Janeway
- Dana-Farber/Boston Children’s Cancer and Blood Disorder Center, Boston, MA
| | | | - Ian Judson
- Royal Marsden Foundation NHS Trust, London, United Kingdom
| | - Mark Krailo
- University of Southern California, Los Angeles, CA
| | | | - Thomas Kuehne
- University Children’s Hospital Basel, Basel, Switzerland
| | | | | | - Stephen L. Lessnick
- Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - Ian Lewis
- University of Leeds, Liverpool, United Kingdom
| | | | | | | | - Bruce Morland
- Birmingham Women and Children's Hospital, Birmingham, United Kingdom
| | | | | | | | - Andreas Ranft
- Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | | | | | - Jeremy Whelan
- Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | | | | | | | - on behalf of the Euro-E.W.I.N.G. 99 and Ewing 2008 Investigators
- University Hospital Essen, Essen, Germany
- Royal Manchester Children's Hospital, Manchester, United Kingdom
- Centre Oscar Lambret, Lille; and Université Paris-Saclay, Villejuif, France
- Gustave Roussy, Villejuif, France
- Emma Children Hospital – Amsterdam University Medical Centres, Amsterdam, the Netherlands
- Chris O’Brien Lifehouse, Camperdown, NSW, Australia
- Cliniques Universitaires Saint Luc, Brussels, Belgium
- Centre Léon Bérard, Lyon; France
- Northern Institute for Cancer Research, Newcastle Upon Tyne, United Kingdom
- Westfalian Wilhelms University Muenster, Muenster; and Friedrich- Loeffler Institute, Greifswald-Insel Riems, Germany
- Leiden University Medical Center, Leiden, the Netherlands
- University of California San Francisco Benioff Children’s Hospital, San Francisco, CA
- MD Anderson Cancer Center, Houston, TX
- Dana-Farber/Boston Children’s Cancer and Blood Disorder Center, Boston, MA
- Hôpital René-Huguenin, Saint-Cloud, France
- Semmelweis University, Budapest, Hungary
- Lund University, Lund, Sweden
- Universitaetskinderklinik Muenster, Muenster, Germany
- Royal Marsden Foundation NHS Trust, London, United Kingdom
- University of Southern California, Los Angeles, CA
- Charles University Prague, Czech Republic
- University Children’s Hospital Basel, Basel, Switzerland
- Medical University of Vienna, Vienna, Austria
- Centre Oscar Lambret, Lille, France
- Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH
- University of Leeds, Liverpool, United Kingdom
- Centre Hospitalier Universitaire, Tours, France
- Institute of Pediatric Onco-Haematology, Lyon, France
- Five Time Therapeutics, South San Francisco, CA
- Birmingham Women and Children's Hospital, Birmingham, United Kingdom
- Institut Curie, Paris, France
- Witten/Herdecke University, Datteln, Germany
- University of California Davis, Sacramento, CA
- Gustave Roussy, Université Paris-Saclay, Villejuif, France
- University of Birmingham, Birmingham, United Kingdom
- University College Hospital, London, United Kingdom
- Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
- Seattle Children’s Hospital, Seattle, WA
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