Ewing's sarcoma and primitive neuroectodermal tumour in adults: single-centre experience in The Netherlands

BACKGROUND

Ewing's sarcoma and peripheral primitive neuroectodermal tumours (PNET) are rare tumours and closely related. They occur most often in children and adolescents. Few studies have been published on treatment outcome in adult patients.

METHODS

We performed a retrospective analysis of patients aged >16 years who were primarily treated at our university hospital for Ewing's sarcoma or PNET. In general, treatment consisted of long-term multiagent chemotherapy, interrupted by individualised local treatment consisting of surgery and/or radiotherapy. We reviewed clinical features and outcomes to present our experience with Ewing's sarcoma and PNET in adults.

RESULTS

From 1979 to 2002, 27 patients with Ewing's sarcoma (20) or PNET (7) were treated. There were 22 men and 5 women, with a median age of 25 years (range 17-49). Ten patients presented with metastases predominantly in lungs (4) or bones (6). Combination therapy consisted of chemotherapy (27), surgery (16) and radiotherapy (16). After a median follow-up of ten years, 14 patients have died (toxicity = 2, progressive disease = 12) and 13 patients are alive and free of disease. Five-year overall survival was 58%. All four patients with bone metastases died, while all five patients presenting with lung metastases are disease-free.

CONCLUSION

The five-year overall survival of 58% in this small series on adult patients is in line with paediatric study outcomes. Patients with lung metastases may even be cured by multimodality therapy. We therefore strongly advocate referral of patients with this rare disease to a specialised oncology centre.

Peripheral primitive neuroectodermal tumor with postchemotherapy neuroblastoma-like differentiation

We report the case of an 11-year-old girl with a retroperitoneal tumor in the left upper quadrant. The girl was admitted to hospital with weight loss and a painless abdominal mass that on biopsy was diagnosed as a peripheral primitive neuroectodermal tumor/Ewing sarcoma (pPNET/EWS) of the soft tissue. The patient underwent chemotherapy followed by surgical resection of the tumor 5 months after diagnosis. The posttreatment residual viable tumor showed a morphologic appearance resembling a neuroblastoma. Interphase and metaphase fluorescent in situ hybridization (FISH) studies performed on the pretreatment and posttreatment samples showed the presence of a t(11;22) rearrangement resulting in EWSR1/FLI1 gene fusion consistent with pPNET/EWS in both specimens. This case is unusual in the sense of showing the typical gene fusion for pPNET/EWS both in the pretherapy sample with the typical morphological appearance of this tumor and in the posttherapy specimen showing neural differentiation suggestive of a neuroblastoma.

Multiagent chemotherapy and deferred radiotherapy in infants with malignant brain tumors: a report from the Children's Cancer Group

PURPOSE

To evaluate response rate, event-free survival (EFS), and toxicity of two chemotherapeutic regimens for treatment of children younger than 36 months with malignant brain tumors and to estimate control intervals without irradiation in children with no residual tumor after initial surgery and induction chemotherapy and with delayed irradiation in patients with residual tumor or metastatic disease at diagnosis.

PATIENTS AND METHODS

Patients were randomly assigned to one of two regimens of induction chemotherapy (vincristine, cisplatin, cyclophosphamide, and etoposide v vincristine, carboplatin, ifosfamide, and etoposide). Maintenance chemotherapy began after induction in children without progressive disease. Children with no residual tumors after induction therapy and no metastatic disease at diagnosis were not to receive radiation therapy unless their tumors progressed.

RESULTS

Two hundred ninety-nine infants were enrolled. Forty-two percent of patients responded to induction chemotherapy. At 5 years from study entry, the EFS rate was 27% +/- 3%, and the survival rate was 43% +/- 3%. There was no significant difference between the two arms in terms of response rate or EFS. For medulloblastoma, supratentorial primitive neuroectodermal tumor, ependymoma, and rhabdoid tumors, 5-year EFS rates were 32% +/- 5%, 17% +/- 6%, and 32% +/- 6%, and 14% +/- 7%, respectively. Fifty-eight percent of patients who were alive 5 years after study entry had not received radiation therapy.

CONCLUSION

Intensified induction chemotherapy resulted in a high response rate of malignant brain tumors in infants. Survival was comparable to that of previous studies, and most patients who survived did not receive radiation therapy.

Definitive irradiation in multidisciplinary management of localized Ewing sarcoma family of tumors in pediatric patients: outcome and prognostic factors

PURPOSE

To assess the effect of radiation dose on local tumor control of the Ewing sarcoma family of tumors in 79 patients with localized disease treated at a single institution.

METHODS AND MATERIALS

Thirty-seven patients received vincristine, actinomycin D, cyclophosphamide, and doxorubicin, and 42 received vincristine, actinomycin D, and cyclophosphamide, with alternating cycles of ifosfamide and etoposide; all underwent definitive radiotherapy (median dose, 37.5 Gy) with either low-dose (<40 Gy) or standard dose (> or =40 Gy) radiation delivered according to the protocol. We calculated the cumulative incidence of local treatment failure, disease recurrence, and overall survival and analyzed the effect of known prognostic factors and radiation dose.

RESULTS

The cumulative incidence of local treatment failure at 10 years was 30.4% and that of disease recurrence was 40%. The overall survival rate was 64.5%. Patient age > or =14 years and tumor size > or =8 cm were adverse prognostic factors for local treatment failure; patient age > or =14 years was also associated with worse survival. Although the radiation dose alone did not predict for local treatment failure, the cumulative incidence of local failure at 10 years was 19% when tumors <8 cm were treated with <40 Gy, and no patient treated with standard doses (> or =40 Gy) developed local recurrence (p = 0.084).

CONCLUSION

Tumor size and patient age predict for local tumor control in patients with Ewing sarcoma family of tumors treated with systemic therapy and definitive radiotherapy. Patients treated with reduced-dose radiotherapy experienced unacceptably high rates of local recurrence.

Ewing sarcoma: favourable results with combined modality therapy and conservative use of radiotherapy

BACKGROUND

At the Hospital for Sick Children (HSC), we have treated Ewing sarcoma (ES) with multi-agent chemotherapy, surgery and conservative use of radiotherapy for local control. Our objective was to describe the outcome and prognostic factors associated with this strategy.

PROCEDURE

We performed a retrospective chart review of children diagnosed with ES at HSC from Feb 1984 to June 1999.

RESULTS

Seventy-two evaluable children were identified. All received chemotherapy. Local control administered was surgery (n = 37), radiation (n = 23), both (n = 10) or neither (n = 2). The 7-year EFS was 66.4%. Recurrence occurred in 23 patients, 7 locally and 16 distantly. Better EFS was associated with male gender (78.5% vs. 52.1%; P = 0.007), localised disease (77.0% vs. 39.4%; P = 0.0004), extremity primary (88.2% vs. 52.8%; P = 0.005) and non-pelvic primary (75.7% vs. 18.2%; P < 0.0001).

CONCLUSIONS

Favourable outcomes were seen for patients treated with multi-agent chemotherapy, surgery and conservative use of radiotherapy. Metastatic disease rather than local control was the major cause of failure.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

Primitive neuroectodermal tumor of the uterus. A case report

BACKGROUND

Primitive neuroectodermal tumors (PNETs) of the uterus are very rare. Even preoperative curettage specimen morphology does not permit establishing a proper histogenetic diagnosis.

CASE

A 16-year-old woman was admitted to the hospital because of metrorrhagia of three months' duration. The curettage specimen was interpreted as poorly differentiated sarcoma. The patient was operated on, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy with omentectomy was performed. Histologically the tumor was composed of uniform, rounded, oval and sometimes spindle shaped cells with a narrow rim of eosinophilic cytoplasm. The cells were positive for neurogenic marker protein gene product, neuron-specific enolase and Ewing's sarcoma-related HBA-71. All cells were uniformly negative for Ber EP4 monoclonal antibody recognizing an epithelium-specific surface antigen. A diagnosis of PNET was rendered. The patient received combined therapy, external radiation to the pelvis and chemotherapy. Four years later she was alive, without signs of recurrent tumor.

CONCLUSION

In spite of the generally recognized aggressive behavior of PNET, it can have a long disease-free survival rate when appropriately treated.

Neoadjuvant chemotherapy for peripheral malignant neuroectodermal tumor of bone: recent experience at the istituto rizzoli

PURPOSE

The results achieved in 44 patients with nonmetastatic peripheral neuroectodermal tumor (PNET) of bone treated with neoadjuvant chemotherapy are reported.

PATIENTS AND METHODS

A six-drug regimen of chemotherapy (vincristine, doxorubicin, dactinomycin, cyclophosphamide, ifosfamide, and etoposide) was administered to all patients. Local treatment consisted of surgery in 20 patients, surgery followed by radiotherapy in 13, and radiotherapy only in 11.

RESULTS

At a mean follow-up of 4.5 years (range, 2 to 7 years), 23 patients (52%) remain event-free, 20 have relapsed (45%), and one has died of chemotherapy-related toxicity. The 5-year event-free survival and overall survival were 54.2% and 62.7%, respectively. To assess the prognostic significance of neural differentiation in the family of Ewing's sarcoma, these results have been compared with the outcomes of 138 concomitant patients with typical Ewing's sarcoma (TES) who were treated according to the same protocol. Of these, 103 (75%) remained continuously event-free, 34 (24%) relapsed, and one died of chemotherapy-related toxicity. It follows that PNET patients treated with this chemotherapy regimen have a significantly worse prognosis than typical ES patients (5-year event-free survival, 54.2% v 70.6%, P <.012; 5-year overall survival, 62.7% v 78.3%, P <.002).

CONCLUSION

The authors conclude that studies into new adjuvant therapy for Ewing's sarcoma modulated according to risk of relapse should also consider neural differentiation as a risk factor.

Intraspinal primitive neuroectodermal tumour: report of two cases and review of the literature

Two patients with primary intraspinal primitive neuroectodermal tumour are presented. In a 32-year-old man, the tumour evolved intradurally from a sacral nerve root. Despite repeated surgery and radiochemotherapy, the patient suffered multiple intraspinal tumour relapses and intracranial seedings, and died 29 months after the first diagnosis. In a 17-year-old male adolescent, the tumour was located in the lumbar epidural space, extending into the paraspinal muscles. Following resection and radiochemotherapy, the patient is free from disease 23 months after the initial presentation. The clinical, radiological, histopathological and cytogenetic findings of both patients are presented and the relevant literature is reviewed. Particular attention is given to the histogenetic relationship between peripheral primitive neuroectodermal tumour and Ewing's sarcoma.

Radiotherapy in Ewing's sarcoma and PNET of the chest wall: results of the trials CESS 81, CESS 86 and EICESS 92

PURPOSE

Treatment results and the pattern of relapse were evaluated in the multimodal treatment of Ewing's sarcomas of the chest wall.

METHODS AND MATERIALS

In a retrospective analysis, 114 patients with non-metastatic Ewing's sarcoma of the chest wall were evaluated. They were treated in the CESS 81, CESS 86, or EICESS 92 studies between January 1981 and December 1993. The treatment consisted of polychemotherapy (VACA, VAIA, or EVAIA) and local therapy, either surgery alone (14 patients), radiotherapy alone (28 patients) or a combination of both (71 patients). The median follow-up was 46.6 months (range 5-170). A relapse analysis for all patients with local or combined relapses was performed.

RESULTS

Overall survival was 60% after 5 years, event-free survival was 50%. Thirty-seven patients had a systemic relapse (32.4%), 11 patients had a local relapse alone (9.6%), and 3 patients had a combined local and systemic relapse (2.6%). The risk to relapse locally after 5 years was 0% after surgery alone, 19% after radiation alone, and 19% after postoperative irradiation. None of the 8 patients with preoperative irradiation have failed locally so far. With the introduction of central radiotherapy planning in CESS 86, local control of irradiated patients improved. Ten of 14 patients with local failure could be evaluated in the relapse analysis: 3 patients had an in-field relapse, 4 patients had a marginal relapse, 2 patients had a relapse outside the radiation fields, and 1 patient failed with pleural dissemination. Six treatment deviations were observed.

CONCLUSION

Local control was best after surgery alone in a positively selected group of patients. Local control after radiation or combined radiation and surgery was good. With diligent performance of radiotherapy, it will be possible to further improve the results in the radiotherapy group.

Is the ancillary chemotherapy approach of any value in the treatment of infratentorial primitive neuroectodermal tumors with surgery and radiotherapy?

A retrospective historical analysis of patients under 18 years of age with the histopathological diagnosis of infratentorial primitive neuroectodermal tumor (PNET) is presented. The survey embraced two different groups of children. Group 1 was defined as those patients treated from 1972 to 1984 with surgical resection plus neuraxis radiotherapy alone. Group 2 was made up of children treated from 1990 to 1996 with the same approach but with the addition of adjuvant chemotherapy: cisplatin (day 1) and etoposide (days 1-3) every 3 weeks for 6 months. Group 1 embraced 42 children with an age range of 1-16 years (mean 6 years, SD 4.4 years). In group 2 there were 34 children, their ages ranging from 1 to 18 years (mean 7.2, SD 4.6 years). The prevalence of stages T2M0 and T3M0 was similar in both groups, but in group 1 there were 4 patients (9.5%) whose spinal fluid was positive for tumor cells (M1), while in group 2 there were 7 children (20.5%) with positive spinal fluid. There was an unequivocal initial response to treatment in 86% of these children in group 1 and in 79% in group 2. The event-free survival (EFS) was 30% at 252 months in group 1, while for group 2 the EFS was 67.6% at 63 months (P 0.002). Mortality from tumor activity was noted in 26 patients (70%) in group 1, while in group 2 mortality attributable to tumor progression was documented in 11 children (32%). We conclude that the use of adjuvant chemotherapy in these patients improves survival without any significant morbidity.

[Peripheral neuroectodermal tumor of the thoracic wall. Experiences with surgical treatment]

The peripheral neuroectodermal tumor (PNET) is seen nowadays as a more specified form of Ewing's Sarcoma with a worse prognosis. We report our experiences of three children (10-14 years old) with PNET of the right thoracic wall, all treated surgically within 1 year. Complete local resection-the main aspect of PNET therapie-of the initially voluminous tumors was not difficult due to chemotherapy and radiotherapy for 5 months prior to surgery.

Low CD4 lymphocyte count in a patient with P. carinii pneumonia after autologous bone marrow transplantation

Authors report a case of P. carinii pneumonia in a child with 5% CD4 lymphocytes (absolute number 5/microliters) after autologous bone marrow transplantation followed by pulmonary irradiation. Serial evaluation of CD4 lymphocyte count or percentage or, at least, detection of significant and persistent lymphopenia could be useful for detecting a high risk of developing P. carinii pneumonia.

Sarcomas of the hand and foot: analysis of local control and functional result with combined modality therapy in extremity preservation

PURPOSE

The records of 28 patients with sarcomas of the hand and foot treated at the National Cancer Institute (NCI) between 1977 and 1992 were reviewed to assess local control and functional results.

METHODS AND MATERIALS

Histologic types included 15 cases of the Ewing's sarcoma family of tumors, 7 cases of alveolar rhabdomyosarcoma, and 6 cases of nonrhabdomyosarcoma soft tissue sarcomas. Median age of all patients was 18 years (range 4-61), with a median potential follow-up of 114 months following diagnosis. Surgery varied from incisional biopsies for Ewing's Sarcoma and rhabdomyosarcoma lesions to complete excision when possible for nonrhabdomyosarcoma soft tissue sarcoma lesions. Amputation was not primarily performed, except in two patients who underwent ray resections of hand lesions (patients 13 and 24). Radiotherapy generally consisted of 50 Gy/25 fractions (fx)/5 weeks for Ewing's Sarcoma, 54 Gy/30 fx/6 weeks for rhabdomyosarcoma, and 63 Gy/35 fx/7 weeks for nonrhabdomyosarcoma soft tissue sarcomas. Chemotherapy was administered on various NCI protocols.

RESULTS

Actuarial local control for Ewing's Sarcoma was 84% at 5 and 10 years. All but one survivor are capable of hand/foot function for routine activities without orthotic requirements. Five of six patients (83%) who died of metastatic disease had functional distal extremities. Actuarial local control for rhabdomyosarcomas was 100%, with equivalent function. No patient developed a second malignancy in the treatment field.

CONCLUSIONS

Although equivalent local control may be achieved in these lesions with either amputation or radiotherapy, a prudent management course would be to defer amputation for management of local recurrences. Many patients with these lesions fail in distant sites only and die without local failure. For these patients and for those who remain long-term survivors, we believe a functional hand and foot provides a better quality of life than a prosthesis.

Esthesioneuroblastoma: prognosis and management

Forty-nine patients with esthesioneuroblastoma were treated at the Mayo Clinic between 1951 and 1990. Their clinical manifestations and treatment results were reviewed to identify possible prognostic factors. The 5-year survival rate for all patients was 69%. Tumor progression occurred in 25 patients (51%; no local control in 6 and local recurrence in 19). Metastasis was found in 15 patients (31%; regional in 10 and distant in 9). Nineteen patients died directly from metastatic or intracranial tumor extension. The pathological grade of the tumor was the most significant prognostic factor identified. The 5-year survival rate was 80% for the low-grade tumors and 40% for the high-grade tumors (P = 0.0001). Surgical treatment alone is effective for low-grade tumors if tumor-free margins can be obtained. Radiation is used for low-grade tumors when margins are close, for residual or recurrent disease, and for all high-grade cancers. The poor prognosis associated with high-grade tumors may also mandate the addition of chemotherapy. Recurrent tumor and regional metastasis should be treated aggressively because this approach has been shown to be worthwhile. A craniofacial resection is now the surgical procedure performed in all cases. Because recurrence can occur after 5 or even 10 years, long-term follow-up is mandatory.

Esthesioneuroblastoma. A report of seven cases

The biologic behavior of esthesioneuroblastoma in seven patients, treated from 1978 to 1989, is reviewed. The patients were initially treated with surgical resection (2 cases), radiation alone (1 case) or a combination of radiation and surgery (4 cases). The radiation dose ranged from 30 to 62 Gy. Operations were performed via a transmaxillary approach (2 cases), lateral rhinotomy approach (3 cases) and craniofacial approach (1 case). Four of the seven patients experienced local recurrence, occurring after disease-free intervals as long as 6 years. The other three patients died of distant metastasis within one year after initial treatment. The effectiveness of radiation therapy varied, and in some patients a dose of 60 Gy was not enough to control microscopic disease. One patient developed bone marrow metastases which was fatal due to the ensuing pancytopenia. One patient developed a brain metastasis. Hyams' histopathologic staging of the tumor appeared to be related to prognosis.

Atypical aesthesioneuroblastoma: CT and MRI findings

Aesthesioneuroblastoma is an uncommon tumour of the superior nasal cavity, originating from the olfactory mucosa. Usually no specific radiological features indicate the diagnosis; normally these tumours are seen on CT as homogeneous, enhancing, soft tissue masses causing bone remodelling. Typical but quite nonspecific MRI findings include high signal on T2-weighted images and strong enhancement after gadolinium. The extent of tumour in the paranasal sinuses and anterior cranial fossa is best assessed with MRI after intravenous gadolinium, and this is considered as the most accurate method for assessing preoperative resectability. We report an aesthesioneuroblastoma in an atypical location, with extensive calcification.

Esthesioneuroblastoma: the UCLA experience 1970-1990

A retrospective review was conducted of all esthesioneuroblastoma cases treated at UCLA Medical Center from 1970 through 1990. Patients were staged according to the staging systems of Kadish, et al., Biller, et al., and a new staging system proposed by the authors. Of 26 patients treated, 74% were alive at 5 years and 60% were alive at 10 years. Combined treatment with surgery and radiation is advocated since a recurrence-free status was achieved in 92% of the patients, compared with 14% for surgery alone and 40% for radiation alone. A craniofacial resection was performed in 7 patients, all of whom have remained disease free. Negative prognostic factors included: age over 50 years at presentation, female sex, tumor recurrence, and metastasis. The proposed new staging system predicted disease-free status better than the other staging systems.

Radiation-induced bilateral cystic frontal lobe necroses demonstrating a fluid-blood level--case report

A 41-year-old male developed radiation-induced bilateral cystic frontal lobe necroses after irradiation for an olfactory neuroblastoma. Computed tomography (CT) and magnetic resonance (MR) imaging revealed the lesions, one containing a fluid-blood level on CT scans and niveau formation on MR images. It was proved to be a coagulated hematoma within the cyst at surgery. Such a fluid-blood level in a radiation-induced cyst has never been reported, although hemorrhage frequently accompanies delayed radiation necrosis. Positron emission tomography with multiple tracers may be useful in differentiating cerebral radiation necrosis from tumor recurrence, because of absence of abnormal tracer accumulation.

Retreatment of advanced esthesioneuroblastoma with high-activity I-125 endocurietherapy: a case report

A 67-year-old woman presented with an advanced esthesioneuroblastoma that recurred 2 years following external irradiation. She was successfully retreated with continuous low-dose rate interstitial irradiation from high-activity I-125 seeds implanted permanently into the tumor.

Prognostic significance of nuclear DNA content in human neuroepithelial tumors

The relationship between survival and flow cytometric DNA-ploidy and other prognostic factors such as histological subtype, anatomical tumor site, patient sex and age was investigated in 153 patients with intracranial neuroepithelial tumors who underwent surgical treatment. We found a trend toward poorer survival from anaplastic astrocytomas and glioblastomas with respect to low-grade (I and II) astrocytomas (which did not differ significantly); accordingly, patients were grouped into these 3 histologic subgroups. Thirty-seven of the 153 tumors (24.2%) were aneuploid with a median DNA-index (DI) of 1.3 (range: 1.2-2.0). DNA-ploidy correlated with histology, since anaplastic astrocytomas and glioblastomas were significantly (p = 0.041) more frequently aneuploid (around 30%) than low-grade astrocytomas (around 10%). Patients with DNA-aneuploid tumors (i.e., with DI not equal to 1.00) survived for a shorter time (31.4 weeks) than patients with DNA diploid tumors (75.1 weeks) (p less than 0.001). This difference was confirmed by Cox's multivariate analysis. Aneuploid tumors were associated with a poorer survival (p = .0002) when compared with diploid tumors, resulting in a relative risk point estimate (RR) of 2.41, 95% confidence interval (Cl) = 1.55-3.74. Histological subtype was also significantly associated with survival (p less than 0.0001), with RRs of 2.09, 95% Cl = 1.13-3.86 and 3.59, 95% Cl = 1.96-6.59 for anaplastic astrocytomas and glioblastomas, respectively, compared to low-grade astrocytomas. We therefore suggest that the flow cytometric measurement of DNA-ploidy has relevant significance in predicting survival in patients treated for intracranial neuroepithelial tumors.

[Olfactory neuroblastoma--a report of 4 cases and review of literature]

This paper reports 4 patients with pathologically proven olfactory neuroblastoma. This tumor most commonly occurs along the medial line of the nasal cavity, base of the anterior cranial fossa, or the ethmoid sinuses. Special stain or electron-microscopy should be done routinely to ensure diagnostic accuracy if a mass at the above sites was suspected to be an olfactory neuroblastoma. Ample excision and preoperative and/or postoperative radiotherapy was recommended. The irradiation field should be large enough and the dose more than 60 Gy. The prognosis of patients in Group C of Kadish classification and children was poor. Recurrence and metastasis might still occur many years after the initial treatment, necessitating close follow-up.

Esthesioneuroblastoma with intracranial extension

The authors present five cases of olfactory neuroblastoma with intracranial extension operated on in the Department of Neurosurgery in collaboration with otorhinolaryngologists. This tumor is most frequently reported as growing inside the nasal cavities, and it can extend to the paranasal sinuses. Cases presenting initially as intracranial tumors have been infrequently reported. At present, histological diagnosis of this tumor is aided by the use of electron microscopy and immunocytochemistry. Total resection combined with radiation therapy remains the most satisfactory treatment.

Esthesioneuroblastoma: surgical treatment without radiation

This study compares the treatment of two groups of patients diagnosed with esthesioneuroblastoma limited to the nasal cavity without evidence of cribriform plate erosion. Five patients were treated with radiation and extracranial excision, and eight patients were treated by craniofacial resection only. The incidences of local recurrence were 60% and 12%, respectively. The paper also presents a new staging classification for these tumors.

[Surgery and radiotherapy in esthesioneuroblastoma of the nose, apropos of 2 cases]

The esthesioneuroblastoma is a rare tumor localized in nose and sinus with difficult diagnosis (aspect like undifferentiated carcinoma and lymphosarcoma) local malignant. We have 2 cases in our hospital whose treatment and evolution is good. We have revised the diagnosis and treatment in these diseases.

[Esthesioneuroblastoma--treatment of recurrences using the remote-control afterloading technic. A case report]

At the Radiological Hospital of the Heidelberg University, one patient with a local recurrence of an esthesioneuroblastoma situated on the left-hand side of the skull base was treated between February 11 and March 18, 1986, by an afterloading contact therapy with curative intent. After preceding surgery and percutaneous radiotherapy, repeated local recurrences and locoregional lymph node metastases had occurred. The contact therapy was performed after adjusting an individual face mask in which the afterloading probe was placed and brought into its position in the tumor region. The irradiation scheme was based on the transformation of the source coordinates form the stereoscopic X-ray localization system into the coordinate system of the computed tomogram by means of X-ray tight reference points. The irradiation planning by computed tomography allows to optimize the arrangement of sources within the tumor region. The principles of the method as well as the treatment result are presented.

[Olfactory neuroblastoma complicated by postirradiation pneumocephalus. Case report]

A 56-year-old male was admitted with the complaints of nasal bleeding, gait disturbance, and disturbance of consciousness. Neurological examination revealed drowsiness, right hemiparesis, and choked discs. Computed tomography scan showed an enhanced mass at the frontal base, which extended to the left nasal and paranasal cavities. Angiography showed a tumor stain with a mass sign. The intracranial part of the tumor was removed completely and he was discharged ambulatorily. Two months after surgery, however, he was admitted again for the regrowth of the tumor. Ventriculoperitoneal shunting was placed and radiation therapy was given to the brain and nasal cavity. After 3000 rad irradiation the clinical condition suddenly became worse because of pneumocephalus. The cranial tumor disappeared after irradiation but he died of metastases and general prostration. Clinically this case was diagnosed as an olfactory groove meningioma at first, but immunohistochemical diagnosis was olfactory neuroblastoma.

[The value of radiotherapy in the treatment of esthesioneuroblastoma]

Three cases of aesthesioneuroblastoma highlight the problems of treatment of these extremely rare tumours. These tumours of the olfactory epithelium arise in the nasal cavity and invade the paranasal sinuses, the orbit and the skull base. As symptoms occur late in the disease, most cases are advanced when diagnosed. Early cases can be treated by surgery, by irradiation or by a combination of, but the local control rate is about 60% regardless of the treatment. Chemotherapy should be used in addition to operation and irradiation, especially in advanced cases with nodal and distant metastases. An irradiation dose of 40-60 Gy is recommended. CT-aided treatment planning, sophisticated irradiation techniques, the use of high-energy photons and reliable immobilization measures are indispensable. A 5-year survival rate for all stages of 50% is reported. The recurrence rate in advanced stages is high, so that the benefits and risks of the different, combined treatment modalities must be evaluated carefully.

Beam's-eye-view aided treatment planning for a nasopharyngeal lesion: a case report

We report on the application of CT-based multilevel treatment planning to achieve complete and uniform dose distribution over the entire target while sparing critical structures. Treatment strategy and parameters are chosen on the slice containing the isocenter. Target coverage and organ sparing is achieved on all other slices by independently adjusting the asymmetric field width at each level, stimulating the effects of custom blocks. The optimized field borders are back projected using beam's eye views (BEV) from each treatment angle. The BEV printouts are used to assist the physician in the delineation of field blocking on the simulation films.

[Radiation and combined treatment of anaplastic neuroepithelial neoplasms]

The data on 645 patients with anaplastic neuroepithelial tumors subjected to radiotherapy, irradiation with radiosensitizers (metronidazole) and chemoradiotherapy are presented. Total-differential brain irradiation was applied: 10-40 Gy on the whole brain and 10-20 Gy on the tumor bed. Fractionation depended on tumor radiosensitivity. The median survival time for anaplastic astrocytoma was 50 +/- 5.6 mos., oligodendroglioblastoma - 42 +/- 7.4 mos., ependymoblastoma - 61 +/- 8.2 mos. and glioblastoma - 22 +/- 1.5 mos. High-dose dynamic fractionation proved to be most effective in cases of glioblastoma. The outcome of glioblastoma was modified neither by radiosensitizers nor by cytotoxic agents.

Neuro-rhinosurgical treatment of aesthesioneuroblastoma

The results of a combined neuro-rhinosurgical procedure in eight cases of aesthesioneuroblastoma are presented. All patients were suffering from tumours in the advanced stage (stage C according to Kadish). Diagnosis was established by the clinical history, neuro-radiological imaging and by endoscopic endonasal biopsy. Contrary to most reports in the literature the authors performed a one step operative removal of the whole tumour mass by a combined transcranial-transbasal approach alone. A second transfacial operation was unnecessary in all our cases. To the best of our knowledge only Loew (see Jakumeit 1971) already in the 1960ties used a comparable one step transcranial approach for tumour removal. The long-term survival rate in our patients is 50%, a result comparable to reported series in the literature. Mortality is due to early recurrences and metastases within a few months after the initial treatment including post-operative irradiation. Four patients are living without evidence of tumour recurrence 1.5 to 5 years after treatment. The authors surgical technique is presented in detail and compared with the results of other treatment modalities.

Treatment of sarcomas of the chest wall using intensive combined modality therapy

As part of two sequential protocols using intensive combined modality treatment in pediatric and adolescent sarcomas, 31 consecutive patients with primary chest wall tumors were treated between November 1977 and March 1986. This group included 13 patients with peripheral neuroepithelioma (Askin's tumor), 11 patients with Ewing's sarcoma, 3 patients with rhabdomyosarcoma, and 4 patients with undifferentiated sarcomas. Following complete work-up, 17 patients presented with localized disease and 14 patients presented with metastases. Patients received intensive combined modality treatment with combination chemotherapy (vincristine, cyclophosphamide, Adriamycin, +/- actinomycin-D and DTIC) and high-dose conventionally fractionated radiation therapy to the primary (55-60 Gy) and non-pulmonary metastases (45-50 Gy). Radiation techniques used for the primary chest wall tumor varied with the clinical presentation. Patients achieving a complete response received either low-dose fractionated TBI (1.5 Gy/0.15 Gy fx/5 weeks) or high-dose TBI (8 Gy/4 Gy fx/2 days) and an intensive cycle of chemotherapy followed by autologous bone marrow transplantation. Twenty-five of 31 patients were judged to have a complete response (including 1 patient with complete resection). With minimum follow-up of 6 months and median follow-up of 36 months from completion of treatment, 14 patients remain disease-free with 2 additional patients alive in second remission after relapse. Patients with localized disease at presentation have improved disease-free survival and overall survival compared to patients with metastases at presentation. All 17 localized patients achieved a CR and 11 are NED compared to 8 of 14 metastatic patients achieving a CR and only 3 are NED. There have been 5 loco-regional recurrences with 3 "in-field" failures and 2 failures in the regional pleura. There were no treatment-related deaths and no clinically significant cases of pneumonitis. To date, 2 patients have significant treatment related morbidity, including 1 patient with scoliosis requiring surgery and 1 patient with acute leukemia developing 42 months after the start of therapy (presently in remission). We conclude that this intensive combined modality therapy results in a high CR rate and good local control with acceptable morbidity. Patients with metastatic disease at presentation remain a therapeutic challenge.

[Neuroblastoma of the olfactory nerve. Radiotherapy experiences in 6 patients]

Six patients with neuroblastomas of the olfactory nerve (esthesioneuroblastoma) are presented who were irradiated between 1983 and 1986 at the Medical Radiologic Institute of Tübingen. Clinical manifestations, diagnostics, histology, therapy, and courses are compared and discussed with regard to a survey of literature. An attempt is made to find out the value of radiotherapy in the treatment of this rare disease. In stage A (tumor restricted to the nasal cavity, 1 patient), a local tumor control of up to now 28 months could be achieved by a treatment combination of surgery and radiotherapy. A treatment consisting of surgery or radiotherapy alone should even in this stage only be performed in connection with a close follow-up because of the increased local recurrence risk. Tumors of stage B (manifestation in the nasal cavity and the paranasal sinuses) did not occur in this group of patients. Five patients suffered from tumors of stage C (tumor extent beyond the paranasal sinuses). A good palliative effect was obtained temporarily by radiotherapy alone in three out of these patients showing large inoperable tumors and rapidly progressing clinical symptoms. A complete remission now lasting 16 months was achieved only in one patient by radical surgery with unilateral evisceration of orbit and homogeneous postirradiation. In case of stage C tumors it is recommended to perform, if possible, a radical tumor excision with evisceration of orbit in case of unilateral manifestation in the orbit and a postirradiation applying a radical, large volume technique. In order to reduce the risk of radiogenic cerebral necroses, it should be attempted to avoid dose maxima as they can occur when applying a combined ventro-dorsal and lateral irradiation technique.

Preservation of the eye in paranasal sinus cancer surgery

Forty-one patients undergoing surgery between 1977 and 1985 for malignant tumors of the paranasal sinuses abutting or eroding the orbital walls were studied for the need to remove the orbital contents. All patients had preliminary computed tomographic scans to delineate the extent of orbital invasion. All were treated with preoperative radiotherapy. If the tumor mass could be peeled from the periorbita, the eye was saved. Preservation of eyes in the patients without periosteal invasion did not alter survival. Frozen-section control may be used to determine periorbital involvement. If the periorbita was minimally involved, it was locally resected. If invasion of the periorbita was extensive, an orbital exenteration was done. Only five of 41 patients required exenteration. Local recurrence of disease in the orbit has not occurred in these patients.

Treatment of peripheral neuroepithelioma in children and young adults

Seventeen patients with peripheral neuroepithelioma were treated with an intensive chemotherapy regimen of vincristine, Adriamycin (Adria Laboratories, Columbus, OH), and cyclophosphamide (VADRIAC) in combination with radiation therapy. Fifteen patients with stage III (seven) or stage IV (eight) at presentation were treated on a more intensive regimen including total body irradiation (TBI) (8 Gy). Two patients with stage I (one) or II (one) disease received a less intensive chemotherapy regimen of VADRIAC. Therapy was completed within 6 to 7 months in all patients. The disease arose in the chest wall in 12 patients, pelvis in three patients, and extremity in two patients. Sixteen of the 17 (94%) patients achieved a complete remission. With a median follow-up of 18 months, ten patients remain in complete remission with an actuarial survival of 68% and an actuarial relapse-free survival of 56% at 12 months. On the basis of our initial experience with this tumor, we believe that peripheral neuroepithelioma is a chemoresponsive and radioresponsive tumor.

Esthesioneuroblastoma: the University of Virginia experience 1960-1985

Twenty-six cases of esthesioneuroblastoma were treated by the Department of Otolaryngology-Head and Neck Surgery from 1960 to 1985. This period was divided into the precraniofacial period (1960 to 1975) and the craniofacial period (1976 to 1985) to denote the transition to a more aggressive combined therapeutic approach. Of the eight patients in the precraniofacial group (group I), only 37.5% are alive without disease. In group II (the craniofacial group), 82% of the patients are alive without disease with an average follow-up of 4 years. This latter survival rate compares favorably with the survival rate of group I and the cure rate of 10% to 67% as stated in other studies.

[Radiotherapy of olfactory neuroblastoma--report of 5 patients]

Olfactory neuroblastoma is a rare tumor arising from the olfactory mucosal epithelium. 5 patients with this tumor were treated in our hospital from 1978 to 1982. The youngest patient was 3 years old and the eldest was 66. The clinical symptoms were nasal stuffiness, rhinorrhea, epistaxis and vascular polypoid mass in the nasal cavity. According to the staging system proposed by Kadish et al, the five patients in this series were 3 stage A and 2 stage C patients. Treatment consisted of radiotherapy, surgery or combination of radiotherapy and surgery. Our data indicate that the olfactory neuroblastoma is a radiosensitive tumor with the prognosis favorable in the stages A and B patients as treated by these three modalities. Two stage A patients are alive for more than 5 years. One of them was treated by radiotherapy alone, the other by combination of surgery and radiation. The third stage A patient as treated by radiotherapy alone has survived more than 3 years. One stage C patient, treated by combination of radiation and surgery, is still alive for more than 3 years. The other stage C patient, treated by radiotherapy alone, had survived for only 7 months after the treatment. The radiation dose varies with the extent of invasion. In stages A and B lesions, a dose of 4,500-5,500 rad in 5 weeks may be reasonable but in stage C, a dose of 6,000-6,500 rad in 7 weeks should be given. The authors agree to the prognostic equation proposed by Homzie et al. It may be possible to predict the tumor control or recurrence after a period of 3 years which gives an accuracy rate of 87%.

MR imaging of esthesioneuroblastoma

The CT, magnetic resonance (MR), and histological features of a case of esthesioneuroblastoma, an uncommon tumor arising from the olfactory epithelium of the nasal vault are reported. The response to radiotherapy was followed up by MR imaging.

Olfactory neuroblastoma (esthesioneuroblastoma) in a 2-year-old boy

A 2-year-old boy presented with sudden blindness and epistaxis resulting from olfactory neuroblastoma with intracranial extension. This disease is uncommon in children, with only 27 cases reported in patients less than 17 years of age. This article reviews the clinical and histological features of this tumor and discusses treatment. Therapy has generally consisted of surgery and radiation. Our child and 2 others treated with radiation and combination chemotherapy (including cyclophosphamide and anthracyclines) have done well with follow-ups of up to 9 1/2 years. Chemotherapy is an important form of adjuvant therapy in this disease.

Esthesioneuroblastoma: diagnosis and management

Esthesioneuroblastoma is an uncommon nasal tumor originating from cells of neural crest origin. An increased awareness of this neoplasm by clinicians and pathologists has led to an increase in its diagnosis. In the Department of Otolaryngology--Head and Neck Surgery at the University of Virginia Medical Center, 22 cases have been treated. A review of the biologic course of these cases has allowed us to make certain recommendations for therapy. Patients with stage A and B disease are best treated with preoperative radiation therapy followed by craniofacial resection. Patients with stage C disease are treated with cyclophosphamide and vincristine before irradiation and craniofacial resection. If a significant response occurs these patients receive postoperative chemotherapy. We believe this treatment should result in five-year survivals in excess of 50%.

Olfactory Neuroblastoma: Chemotherapy and Radiotherapy for Extensive Disease

A patient with olfactory neuroblastoma had extensive involvement of the nasopharynx, sinuses and orbit, and cervical metastasis. After surgical biopsy and excision of metastatic disease, she was treated with chemotherapy: three cycles of high-dose cisplatin (100 mg/sq m) and infusion of fluorouracil (1 g/sq m/day for five days). Subsequent treatment included definitive radiation therapy followed by three additional cycles of chemotherapy. The patient is free of disease three years after initiating therapy. This case report demonstrates the potential efficacy of planned combined modality therapy, including early chemotherapy in the control of locally advanced, unresectable olfactory neuroblastoma.

Esthesioneuroblastoma

A retrospective review of the clinical records of 31 patients with esthesioneuroblastoma is presented. A bimodal age distribution was noted. The tumor is extremely rare among blacks. Most patients presented with locally advanced disease. However, regional and distant metastases at the time of initial diagnosis are uncommon. Local recurrence at the primary site was very common, and this reflects either the conservative initial surgical treatment employed or the multicentric nature of the tumor. Cervical lymph node metastasis is present in less than 10 percent of patients at the time of diagnosis. Survival rates were better in patients with early stages of disease. From this study we conclude that the current management of these tumors should consist of a combination of radiation and surgery. Radical resection followed by postoperative radiotherapy appears to be the treatment combination of choice. The 5 year survival rate in our series was 52 percent.