A systematic review of combined surgery and brachytherapy approaches for children and young people with relapsed and refractory rhabdomyosarcoma (Local-REFoRMS)

Approximately one third of children with rhabdomyosarcoma relapse or have refractory disease. Treatment approaches include a combination of systemic therapies and local therapies, directed at tumour site(s). This review was conducted to evaluate the effectiveness and safety of the combination of surgery and brachytherapy as local therapy for treating children and young people with relapsed/refractory rhabdomyosarcoma. This review identified studies based on a previous systematic review looking at the treatments for children and young people under 18 years old with relapsed/refractory rhabdomyosarcoma. Studies conducted after 2000 were included. Survival outcomes, relapse rates, adverse events and functional outcomes were extracted. From 16,965 records identified in the baseline systematic review, 205 included the words 'AMORE' or 'brachytherapy', and were screened for eligibility in this substudy. Thirteen studies met the inclusion criteria for Local-REFoRMS, including over 55 relapsed and refractory rhabdomyosarcoma patients. Most studies were retrospective cohort studies conducted within Europe. Most patients had embryonal disease within the head and neck or bladder/prostate regions, and received local therapy for first relapse. Approximately one quarter of patients relapsed following surgery and brachytherapy, with local relapses occurring more than metastatic relapse. Adverse events and functional outcomes were infrequently reported, but related to the site of surgery and brachytherapy. Study quality was limited by inconsistent reporting and potential selection bias. Outcomes following surgery and brachytherapy for a selected group of relapsed and refractory rhabdomyosarcoma show reasonable benefits, but reporting was often unclear and based on small sample sizes.

Adult head and neck rhabdomyosarcoma: radiotherapy- based treatment, outcomes, and predictors of survival

BACKGROUND

Adult head and neck rhabdomyosarcoma (HNRMS) is an exceptionally rare malignancy, and there is a paucity of data and research dedicated to understanding its characteristics and management in adult populations. This study aimed to assess the outcomes and identify survival predictors in adult HNRMS.

METHODS

We retrospectively evaluated 42 adult patients (> 16 years) with HNRMS who received radiotherapy (RT)-based treatment at our institute between 2008 and 2022. We analysed the clinical characteristics and prognosis of these patients, including the locoregional recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS), using the Kaplan-Meier method. The chi-square and Fisher's exact tests were used to analyse differences between groups for dichotomous and categorical variables, respectively. Survival rates were calculated using the Kaplan-Meier method. Prognostic variables were assessed through univariate Cox analyses.

RESULTS

The median patient age was 28 years (range, 16-82 years). Alveolar RMS was the most common histological type, observed in 21 patients (50.0%), followed by embryonal in 16 patients (38.1%). The anatomic sites of origin were orbital in one (2.4%), parameningeal in 26 (61.9%), and non-orbital/non-parameningeal in 15 (35.7%) patients. Nineteen patients (45.2%) had regional lymph node metastasis, and five patients (11.9%) presented with distant metastatic disease. Distant metastasis (n = 17) was the primary cause of treatment failure. At a median follow-up of 47.0 months, the 5-year LRFS, PFS, and OS rates were 69.0%, 39.7%, and 41.0%, respectively. Univariate analysis revealed that tumour size, lymph node involvement, and the local treatment pattern (surgery and RT vs. RT alone) were significant predictors of survival.

CONCLUSIONS

The main failure pattern in patients with HNRMS receiving RT-based treatment was distant metastasis. Tumour size > 5 cm and lymph node involvement were predictors of worse LRFS. Multimodality local treatment, combining surgery and RT, is effective and provides survival benefits.

Local Treatment of Children Suffering From Parameningeal Rhabdomyosarcoma: A Retrospective Single-Center Study From China

BACKGROUND

Treatment for parameningeal rhabdomyosarcoma (PM-RMS) has been a challenge since local control is difficult. The goal of this study was to analyse the impact of different local treatment approaches on childhood PM-RMS patients and help dispel the doubt that whether secondary radical surgery (SRS) should be encouraged in the management of PM-RMS.

METHODS

A total of 17 children with PM-RMS who received unified systemic chemotherapy and individualized local therapy such as radiotherapy (RT) and/or SRS were included in this retrospective study. The overall survival (OS) and event free survival (EFS) were compared between groups adopting different local strategies.

RESULTS

The 3-year OS and EFS of our PM-RMS patients was 75.5% and 56.5% respectively. The OS and EFS of patients who received SRS were both significantly lower than that of the non-SRS group (3-year OS: 50.0% vs 90.0%, P = .031; 3-year EFS: 33.3% vs 60.6%, P = .020). The OS and EFS of the patients who received RT was higher than that of the patients of the non-RT group (3-year OS: 85.6% vs 0%, P = .001; 3-year EFS: 64.0% vs 0%, P = .011).

CONCLUSION

This study illustrates that SRS was associated with poor prognosis of PM-RMS and should not be routinely performed. Optimized RT strategies along with more intensive chemotherapy may be alternative options to improve the survival of patients with PM-RMS. Multi-center, large sample and prospective studies are needed to further validate these findings.

Radiotherapy and long-term sequelae in pediatric patients with parameningeal rhabdomyosarcoma: Results of two Cooperative Weichteilsarkom Studiengruppe (CWS) trials and one registry

BACKGROUND

Parameningeal location of rhabdomyosarcoma (PM RMS) is known to be an unfavorable prognostic factor. Scarce data are available on radiotherapy (RT) concepts with regard to outcome.

METHODS

Treatment and outcome of 395 children with PM RMS registered within two Cooperative Weichteilsarkom Studiengruppe (CWS) trials and one registry (1995-2021) were evaluated.

RESULTS

Patients were IRS group II (n = 15) and III (n = 380) and received systemic treatment according to the enrolled protocols: I2VA (n = 172), VAIA/CEVAIE (n = 223). Delayed resection was performed in 88/395 (22%) patients, and RT was additionally given in 79/88 (90%) resected patients. RT was the predominant local treatment in 355/395 (90%) patients: hyperfractionated accelerated photon (HART; n = 77), conventionally fractionated photon (n = 91) or proton beam (n = 126), brachytherapy (n = 4), heavy ions (n = 1), not available (n = 56). In the subgroup of RT as only local treatment (n = 278), no intracranial tumor extension and complete remission at end of treatment were significant positive prognostic factors. No significant difference on tumor outcome was seen between different radiotherapy concepts. Long-term toxicity with mostly endocrinological and visual deficiencies was reported in 161/279 (58%) surviving patients with a lower trend after proton beam RT (48%) when compared to HART or conventionally fractionated photon RT (71% and 72%, respectively). Ten-year event-free and overall survival in the overall group were 62% (±5, 95% confidence interval [CI]) and 67% (±5, 95% CI); in the RT-only group 67% (±6, 95% CI) and 71% (±6, 95% CI), respectively.

CONCLUSION

CWS data confirm the recent RT concept in PM RMS. Long-term sequelae as endocrinological and visual deficiencies need to be addressed.

Treatment results of Para-Testicular Rhabdomyosarcoma (PT-RMS) using radiation as an alternative to retro-peritoneal nodal dissection: A single Institution experience

BACKGROUND

Para-testicular Rhabdomyosarcoma (PT-RMS) has a favorable treatment outcome adopting multidisciplinary management; resection, namely high inguinal orchiectomy ± retro-peritoneal lymph node dissection (RPLND) followed by standard or intensive chemotherapy ± adjuvant radiation therapy.

PATIENTS AND METHODS

This is a retrospective study including all patients with pathologically proven PT-RMS, presented to the National Cancer Institute, Cairo University, during the period from 2005 to 2020. Endpoints included overall survival, disease free survival and patterns of failure of different treatment modalities.

RESULTS

Forty one patients were identified. Median age in our cohort was 15 years (range: 2-54 years). After a median follow up of 26 months (range, 3-75 months) ,two and five years OS were 100% and 91.7% respectively and median survival was not reached. Patients who underwent retro-peritoneal nodal dissection had a 5-year DFS rate of 100% versus 73% for those who received radiation to para-aortic nodes (p = 0.185). Limitations include retrospective nature and deviation from COG protocol.

CONCLUSIONS

This study shows promising results suggesting that less aggressive local treatment modalities including radiation to para-aortic chain could be an option in PT-RMS, given the excellent results of this subtype. However further validation in a prospective study is warranted.

Use of Perirectal Hyaluronic Acid Spacer Prior to Radiotherapy in a Pediatric Patient With Bladder Rhabdomyosarcoma: A Case Report

Rhabdomyosarcoma (RMS) treatment involves surgery, chemotherapy, and radiotherapy. A radioprotective space between the bladder/prostate and rectum reduces postradiation complications, as reported in adult patients. Describe pediatric preradiotherapy perirectal hyaluronic acid (HA) spacer injection for bladder/prostate RMS. We present a case of a 17-month-old male with bladder/prostate RMS. Before radiotherapy, an HA spacer was injected peri-rectally. Under general anesthesia, a transrectal ultrasound was positioned and 1mL of HA spacer was injected into the perirectal space. No complications were reported at 6-month follow-up. This is the first report of pre-radiation therapy spacer injection for pediatric bladder/prostate RMS.

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

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.

Can 18 F-FDG-Positron Emission Tomography be a Prognostic Tool in Children With Rhabdomyosarcoma Treated With Definitive Radiotherapy?

BACKGROUND

Persisting residual masses at treatment completion are known in rhabdomyosarcoma (RMS) treated with definitive radiotherapy (RT) to the primary site, but their prognostic significance is uncertain. Tumor response as assessed by anatomic imaging is not prognostic and studies based on 18 F-FDG-PET response are limited. We report the prognostic significance of persistent FDG-avidity in residual masses, assessed 3-month postdefinitive RT, in pediatric RMS.

MATERIALS AND METHODS

Children 15 years old or below with Group III/IV RMS who received only definitive radiotherapy for local control from June 2013 to December 2018, and had 18 F-FDG-PET CT at 3 months post-RT were retrospectively analyzed for outcomes and other prognostic factors.

RESULTS

Sixty-three children were eligible (Group III-55, Group IV-8). 18 F-FDG-PET CT scan done 3 months postradiotherapy showed FDG-avid residual masses in 10 patients (15.9%), anatomic residual in 24 (38.1%), and no anatomic/FDG-avid residual in 29(46.0%). At a median follow-up of 38 months (interquartile range, 24 to 55 mo), 3-year EFS of patients with FDG-avid residual masses was 40.0% (95% CI: 18.7% to 85.5%) versus the rest of the cohort, which was 71.9% (95% CI: 59.8% to 86.5%) ( P =0.008). Three-year OS of patients with FDG-avid residual masses was 50.8% (95% CI: 25.7% to 100.0%) versus the rest of the cohort, which was 77.0% (95% CI: 65.1% to 91.0%) ( P =0.037). Presence of FDG-avid residual disease persisting post-RT affected both EFS [HR-3.34 (95% CI: 1.29 to 8.68) ( P =0.013)] and OS [HR-3.20 (95% CI: 1.01 to 10.12) ( P =0.048)] on univariate analysis and this significance was retained for EFS in multivariate analysis [HR-3.52 (95% CI: 1.33 to 9.30) ( P =0.011)].

CONCLUSIONS

Persistent metabolic activity in residual disease post-chemoradiotherapy in RMS may portend a poorer prognosis with an increased risk of relapse. This subset of high-risk patients needs to be identified, and further trials are warranted to develop strategies to improve their outcomes.

Adaptive Proton Therapy for Pediatric Parameningeal Rhabdomyosarcoma: On-Treatment Anatomic Changes and Timing to Replanning

PURPOSE

To characterize on-treatment changes in GTV morphology in children with parameningeal rhabdomyosarcoma receiving upfront proton therapy with concurrent chemotherapy and thereby provide guidance on the timing of on-treatment imaging and adaptive replanning.

METHODS AND MATERIALS

GTV was delineated on 86 simulation and weekly MR images of 15 prospectively enrolled patients (aged 1-21 years). Temporal changes from baseline in volume and surface (95% Hausdorff distance) were analyzed in relation to the need for plan verification and the resultant doses with hypothetical no treatment adaptation.

RESULTS

The median time was 6 days from the initiation of chemotherapy to CT+MR simulation and 15 days from the simulation to the start of radiotherapy. All but 1 patient showed a continuous decrease in GTV (0.16-1.52%/day) after simulation. At 3 weeks from simulation, 10 of 15 patients exhibited a significant reduction in volume (median, 20%; range, 6-29%). Without replanning, these changes could lead to a reduction in CTV V95 by 7-14% (n = 2) and/or an increase in D0.01 cc/Dmean of adjacent organs at risk by 6-21% of the prescribed target dose (n = 7). Significant dosimetric consequences occurred in cases with (1) a considerable weight gain, (2) shrinkage of the skin surface, or (3) tumor regression in the oral or nasal cavity and sinus that altered air-tissue components in the beam path. The subsequent GTV and dosimetry after 3 weeks from simulation (4 weeks from chemotherapy initiation) demonstrated a relatively stable trend.

CONCLUSIONS

On-treatment imaging at 3 weeks after simulation is recommended, if the simulation is performed at 1 week after the initiation of chemotherapy, to detect significant anatomic changes that could result in >5% deviation from planned target coverage and/or organ doses in pediatric patients with parameningeal rhabdomyosarcoma receiving early proton therapy.

Sensitization to Ionizing Radiation by MEK Inhibition Is Dependent on SNAI2 in Fusion-Negative Rhabdomyosarcoma

In fusion-negative rhabdomyosarcoma (FN-RMS), a pediatric malignancy with skeletal muscle characteristics, >90% of high-risk patients have mutations that activate the RAS/MEK signaling pathway. We recently discovered that SNAI2, in addition to blocking myogenic differentiation downstream of MEK signaling in FN-RMS, represses proapoptotic BIM expression to protect RMS tumors from ionizing radiation (IR). As clinically relevant concentrations of the MEK inhibitor trametinib elicit poor responses in preclinical xenograft models, we investigated the utility of low-dose trametinib in combination with IR for the treatment of RAS-mutant FN-RMS. We hypothesized that trametinib would sensitize FN-RMS to IR through its downregulation of SNAI2 expression. While we observed little to no difference in myogenic differentiation or cell survival with trametinib treatment alone, robust differentiation and reduced survival were observed after IR. In addition, IR-induced apoptosis was significantly increased in FN-RMS cells treated concurrently with trametinib, as was increased BIM expression. SNAI2's role in these processes was established using overexpression rescue experiments, where overexpression of SNAI2 prevented IR-induced myogenic differentiation and apoptosis. Moreover, combining MEK inhibitor with IR resulted in complete tumor regression and a 2- to 4-week delay in event-free survival (EFS) in preclinical xenograft and patient-derived xenograft models. Our findings demonstrate that the combination of MEK inhibition and IR results in robust differentiation and apoptosis, due to the reduction of SNAI2, which leads to extended EFS in FN-RMS. SNAI2 thus is a potential biomarker of IR insensitivity and target for future therapies to sensitize aggressive sarcomas to IR.

Bladder function after conservative surgery and high-dose rate brachytherapy for bladder-prostate rhabdomyosarcoma

BACKGROUND

Conservative surgery (CS) brachytherapy (BT) techniques for local therapy in bladder-prostate rhabdomyosarcoma (BP-RMS) seek to retain organ function. We report bladder function after high-dose rate (HDR) BT combined with targeted CS for any vesical component of BP-RMS.

PROCEDURE

Prospective cohort of all BP-RMS patients between 2014 and 2019 receiving HDR-BT (iridium-192, 27.5 Gy in five fractions) with/without percutaneous endoscopic polypectomy (PEP) or partial cystectomy (PC). Functional assessment included frequency-volume chart, voided volumes, post-void residual, flow studies, continence status and ultrasound scanning; abnormalities triggered video urodynamics.

RESULTS

Thirteen patients (10 male), aged 9 months to 4 years (median 23 months), presented with localised fusion-negative embryonal BP-RMS measuring 23-140 mm (median 43 mm) in cranio-caudal extent. After induction chemotherapy, local treatment consisted of PC+BT in three, PEP+BT in four and BT alone in six. At a median 3.5 years (range 21 months to 7 years) follow-up, all were alive without relapse. At a median age of 6 years (4-9 years), the median bladder capacity was 86% (47%-144%) of that expected for age, including 75% (74%-114%) after PC. Radiation dose to the bladder was associated with urinary urgency, but not bladder capacity or nocturnal enuresis. Complications occurred in two: one urethral stricture and one vesical decompensation in a patient with pre-existing high-grade vesico-ureteric reflux (VUR). The remaining patients were dry by day; five with anticholinergic medication for urinary urgency. Three patients are enuretic.

CONCLUSIONS

Day-time dryness at a median 3.5 years after CS-HDR-BT was achieved in 92%, with 85% voiding urethrally, and 62% attaining day-and-night continence aged 4-9 years. We report reduced open surgery with minimally invasive percutaneous surgery, with HDR-BT or BT alone being suitable for many.

Photodynamic therapy for radiation maculopathy: A case report

RATIONALE

The best treatment protocol for radiation maculopathy in children has not been determined. The purpose of this study was to determine the effect of photodynamic therapy (PDT) on radiation maculopathy.

PATIENT CONCERNS

An 11-year-old boy who was originally diagnosed with orbital rhabdomyosarcoma when he was 1 year old, in October 2008. The lesion improved after peripheral blood stem cell transplantation, chemotherapy and radiation therapy. A cataract was detected in his right eye in May 2011, and he underwent cataract surgery in July 2011. Continuous amblyopia training maintained his visual acuity in his right eye. In January 2017, his visual acuity was reduced and macular edema was detected with optical coherence tomography.

DIAGNOSES

We diagnosed radiation maculopathy, from the history of radiation therapy, macular edema by optical coherence tomography, and hyperfluorescent site by fluorescein angiography.

INTERVENTIONS

We performed PDT in June 2017.

OUTCOMES

Treatment with PDT improved macular edema and his visual acuity.

LESSONS

Radiation retinopathy is progressive disorder with poor prognosis. PDT could be considered to treat radiation maculopathy.

Rhabdomyosarcoma in adults: analysis of treatment modalities in a prospective single-center series

Rhabdomyosarcoma (RMS) is rare in adults and it is generally characterized by poor outcome. In a previous retrospective study, we demonstrated a better prognosis in adults treated with multimodality approach resembling pediatric protocols. Thereafter, we developed specific recommendations based on the principles adopted in pediatric oncology. The present analysis reports the results in a subsequent prospective series. The study included 95 consecutive patients (age 18-77 years) treated from 2002 to 2015 for embryonal and alveolar RMS. As in the previous series, patients were stratified by the appropriateness of their treatment according to therapeutic guidelines for childhood RMS. The 5-year event-free survival (EFS) and overall survival (OS) rates were 33.6% and 40.3%, respectively. The 5-year EFS was 40.8% for patients with the highest treatment score, and 15% for those with lower score, while OS was 44.4% and 24.5%, respectively. The developing of specific recommendations enabled an increase in the number of patients treated with intensive multimodal treatment resembling pediatric strategy (69.7% vs. 39.1% in the retrospective series). This study reinforced the idea that adherence to the principles of pediatric protocols, improves adult RMS outcomes. However, treating adults with pediatric-type strategy is not enough to achieve the results obtained in children. Issues in compliance and a more aggressive biology of adult RMS might have a role in the different outcome according to age. Improving the collaboration between pediatric and adult oncologists in promoting specific clinical and biological research is crucial to improve the outcome for this patient population.

Whole-body dose equivalent including neutrons is similar for 6 MV and 15 MV IMRT, VMAT, and 3D conformal radiotherapy

PURPOSE

This study investigates the difference in whole-body dose equivalent between 6 and 15 MV image-guided radiotherapy (IGRT) for the treatment of a rhabdomyosarcoma in the prostate.

METHODS

A previously developed model for stray radiation of the primary beam was improved and used to calculate the photon dose and photon energy in the out-of-field region for a radiotherapy patient. The dose calculated by the treatment planning system was fused with the model-calculated out-of-field dose, resulting in a whole-body photon dose distribution. The peripheral neutron dose equivalent was calculated using an analytical model from the literature. A daily cone beam CT dose was added to the neutron and photon dose equivalents. The calculated 3D dose distributions were compared to independent measurements conducted with thermoluminescence dosimeters and an anthropomorphic phantom. The dose contributions from the IGRT treatments of three different techniques applied with two nominal X-ray energies were compared using dose equivalent volume histograms (DEVHs).

RESULTS

The calculated and measured out-of-field whole-body dose equivalents for the IGRT treatments agreed within (9 ± 10) % (mean and type A SD). The neutron dose equivalent was a minor contribution to the total out-of-field dose up to 50 cm from the isocenter. Further from the isocenter, head leakage was dominating inside the patient body, whereas the neutron dose equivalent contribution was important close to the surface. There were small differences between the whole-body DEVHs of the 6 and 15 MV treatments applied with the same technique, although the single scatter contributions showed large differences. Independent of the beam energy, the out-of-field dose of the volumetric-modulated arc therapy (VMAT) treatment was significantly lower than the dynamic intensity-modulated radiation therapy (IMRT) treatment.

CONCLUSION

The calculated whole-body dose helped to understand the importance of the dose contributions in different areas of the patient. Regarding radiation protection of the patient for IGRT treatments, the choice of beam energy is not important, whereas the treatment technique has a large influence on the out-of-field dose. If the patient is treated with intensity-modulated beams, VMAT should be used instead of dynamic IMRT in terms of radiation protection of the patient. In general, the developed models for photon and neutron dose equivalent calculation can be used for any patient geometry, tumor location, and linear accelerator.

Complete resection of adult prostatic rhabdomyosarcoma with 3D video and printing model: A case report and literature review

Prostatic rhabdomyosarcoma (RMS) is a subtype of prostate sarcoma which is rarely reported in adults and usually huge in size. Although there is no consensus on the standard therapy to prostatic RMS, complete resection with negative margin is identified as the best way for maximum survival time. However, to remove a much enlarged prostate completely from a RMS patient is still a very difficult task for a skilled urologist so far. As three-dimension (3D) technology becomes more widely used in medicine, surgeons have the opportunity to challenge previously impossible surgery. In this paper, we reported a 36-year-old male patient with a 9.6*5.3*7.6 cm prostatic RMS. With the aid of 3D reconstructed video and printing model, the giant tumor was entirely removed without surgery complications and adjacent organs injury. The patient was alive and had no recurrence after 18 months from surgery. This case revealed that 3D reconstruction technology could help in the preoperative assessment and gave benefits to both patients and surgeons.

AMORE treatment as salvage treatment in children and young adults with relapsed head-neck rhabdomyosarcoma

BACKGROUND AND PURPOSE

Survival after relapse of head and neck rhabdomyosarcoma (HNRMS) after prior external beam radiotherapy (EBRT) is poor, since options for adequate local treatment are often lacking. In this study we describe our experience with salvage AMORE in patients with relapsed HNRMS after prior EBRT.

MATERIALS AND METHODS

Patients with relapsed HNRMS after prior EBRT in which salvage AMORE treatment was considered feasible were analysed; this includes patients with parameningeal, head and neck non-parameningeal and orbital localization. AMORE treatment consisted of Ablative surgery, MOuld technique brachytherapy and surgical REconstruction.

RESULTS

In total 18 patients received salvage AMORE treatment; nine patients had relapsed parameningeal (PM) RMS, two patients had relapsed head and neck non-parameningeal RMS (HN-nonPM) and seven patients had relapsed orbital RMS. Local control rate was 67% and 5-year overall survival was 54% (95% confidence interval: 31-78%); 3/9 patients with PM RMS, 0/2 patients with HN-nonPM RMS and 6/7 patients with orbital RMS were alive after a median follow-up of 8.6 years. One patient with PM RMS survived more than 5 years after which he died from a secondary cancer. Six patients developed a local relapse (of which one patient also developed a distant metastasis) and two patients developed distant metastases.

CONCLUSIONS

Salvage AMORE treatment is a feasible and effective local therapy approach even after prior EBRT. Since salvage AMORE treatment is sometimes the only curative option in patient with relapsed HNRMS, we encourage physicians to consider salvage AMORE treatment for patients with relapsed HNRMS after prior EBRT.

The Evolving Role of Radiation Therapy in the Optimal Multimodality Treatment of Childhood Cancer

Childhood cancer is rare, representing only 1% of the total cancer problem. Of children diagnosed with cancer today, more than 70% are predicted to be long-term survivors. Essentially all pediatric cancers are treated by interdigitating radiation with surgical resection and systemic chemotherapy. The use of irradiation, important to achieve high rates of disease local control, must be always balanced against late effects specifically related to this treatment modality, principally growth retardation and second tumors induction. Using neuroblastoma, Wilms’ tumor and rhabdomyosarcoma as examples, the advances in the optimal multimodality treatment of childhood cancer and the evolution of the role of radiation therapy are discussed.

Central nervous system relapse of rhabdomyosarcoma

PURPOSE

The optimal management of central nervous system (CNS) relapse of rhabdomyosarcoma (RMS) is unclear. We examined diagnosis, management, and outcomes of patients with RMS developing CNS relapse.

METHODS

Records of 23 patients diagnosed with CNS relapse between 1999 and 2016 were reviewed. Median age at presentation of CNS relapse was 15 years (range, 1-34 years). High-risk features at initial presentation were as follows: 16 alveolar patients, 13 Stage IV, and 13 with primary tumor in parameningeal locations.

RESULTS

CNS relapse occurred at a median 12 months (range, 1-23 months) from diagnosis and most common presenting symptoms were headache (n = 9), nausea/vomiting (n = 8), visual difficulty (n = 5), and none (n = 5). Leptomeningeal metastases were detected in 21 patients while only 2 developed parenchymal metastases without leptomeningeal involvement. Fifteen patients received CNS-directed radiation therapy (RT), including craniospinal irradiation to a median 36 Gy (range, 18-36 Gy) and/or whole brain radiotherapy to a median 30 Gy (range, 6-41.4 Gy). Three patients received concurrent chemotherapy. Follow-up magnetic resonance imaging was conducted in 13 patients after RT initiation with 8 demonstrating improvement, 2 with stable disease, and 3 with progression. Twelve patients were tested for reactivity to I-131-labeled monoclonal antibody 8H9, and three tested positive and received at least one intra-Ommaya dose; all three lived >12 months post-CNS relapse. Twenty‐two patients died of CNS disease and one of treatment complications, with metastatic disease at other sites. Median survival post-CNS relapse was 5 months (range, 0.1-49 months).

CONCLUSIONS

The prognosis for patients with RMS developing CNS relapse remains poor. Treatment including CNS-directed RT should be considered and investigation into preventative therapies is warranted.

Maxillary sinus mucoceles and other side effects of external-beam radiation in the pediatric patient: A cautionary tale

A sinonasal mucocele can develop after the obstruction of a sinus ostium, which can occur secondary to trauma, infection, a neoplasm, or an iatrogenic cause. These mucoceles typically arise in the frontal and ethmoid sinuses. Sinonasal mucoceles are epithelium-lined cysts that can gradually expand to fill a paranasal sinus. They can present with ophthalmologic, rhinologic, and neurologic symptoms. There are reports in the literature of sinonasal mucocele development after radiation for nasopharyngeal carcinoma. However, these cases are rare; when they do occur, they tend to arise in the sphenoid sinus. We describe the case of a 21-year-old man who had undergone external-beam radiotherapy for a right maxillary sinus rhabdomyosarcoma at the age of 4 years and who subsequently developed bilateral maxillary sinus mucoceles and multiple other known complications of radiation therapy. To the best of our knowledge, this is the first case of postirradiation bilateral maxillary sinus mucoceles to be reported in the literature.

Late Toxicities of Intensity-Modulated Radiation Therapy for Head and Neck Rhabdomyosarcoma

PURPOSE/OBJECTIVES

To examine the late effects of intensity-modulated radiation therapy (IMRT) in pediatric patients with rhabdomyosarcoma of the head and neck.

MATERIALS/METHODS

All 1-year survivors of pediatric head and neck rhabdomyosarcoma treated with IMRT at a single institution from 1999 to 2014 were assessed for long-term complications. Late toxicities were graded according to CTCAE version 4.03.

RESULTS

Among 30 patients, median age at IMRT was 7.4 (1.5-20.8) years, median follow-up was 7.7 (1.2-14.4) years, and median IMRT dose was 50.4 (36-50.4) Gy. Tumor subsites included parameningeal (80%), orbit (13%), and other (7%). Common late toxicities were facial disfigurement (n = 23, 77%), growth hormone deficiency (n = 11, 37%), cataract (n = 10, 34%), and dental problems (n = 10, 33%). Twenty-two patients (73%) had ≥2 late toxicities and 14 patients (47%) had ≥3 late toxicities. Seventeen patients (57%) experienced grade 2 toxicity and 10 patients (33%) had grade 3 toxicity. Grade 3 toxicities included visual disturbance, cataract, facial disfigurement, chronic sinusitis/otitis, and hearing loss. Severe facial deformity was noted in nine patients (30%), and three patients underwent cosmetic surgery. Patients with severe facial deformity were treated at younger ages (median 6.0 years vs. 8.1 years for patients with no/nonsevere facial deformity) and more likely to have infratemporal fossa tumors. There were no secondary solid malignancies.

CONCLUSIONS

Late radiation toxicities are common in survivors of pediatric head and neck rhabdomyosarcoma treated with IMRT. While the majority of late effects are mild-moderate, they can significantly impact quality of life, particularly facial disfigurement.

Tumour control and Quality of Life in children with rhabdomyosarcoma treated with pencil beam scanning proton therapy

PURPOSE

To assess clinical outcomes in children with rhabdomyosarcoma (RMS) treated with pencil beam scanning (PBS) proton therapy (PT).

METHODS AND MATERIALS

Eighty-three RMS (embryonal, n=74; 89%) patients treated between January 2000 and December 2014 were included. The median age was 4.5years (range, 0.8-15.5). All patients received systemic chemotherapy according to prospective protocols. Patients had low-, intermediate-, and high-risk disease in 24%, 63%, and 13% of cases, respectively. The median total dose delivered was 54Gy(RBE) (range, 41.4-64.8).

RESULTS

After a median follow-up time of 55.5 months (range, 0.9-126.3), local failure occurred in 16 patients. The 5-year local-control survival rate was 78.5% [95% confidence interval (CI), 69.5-88.5%]. Significant predictors for local failure were group/stage, tumour location, and size. Fourteen patients (16%) died, all from tumour progression. The 5-year overall survival was 80.6% (95%CI, 71.8-90.0%). The 5-year incidence of grade 3 non-ocular late toxicity was 3.6% (95%CI, 1-12%). No grade 4-5 late toxicities were observed. One radiation-induced malignancy was observed (1.2%). The Quality of Life (QoL) scores increased significantly after PT compared to baseline values.

CONCLUSIONS

PBS PT led to excellent outcome in children with RMS. Late non-ocular toxicity was minimal and QoL good.

Spindle cell rhabdomyosarcoma in the hypopharynx of an adult

We herein present the first-reported case in the English-language literature of a spindle cell rhabdomyosarcoma in the hypopharynx of an adult. A 58-year-old male presented with a progressive, 7-month history of discomfort during swallowing, accompanied by hoarseness for 1 month. Computed tomography and magnetic resonance imaging revealed a tumor in the left pyriform sinus; frozen section evaluation suggested that it was rhabdomyosarcoma. The tumor was removed completely via left lateral cervical incision. Section margins were negative, and laryngeal function was preserved. The postoperative pathological results indicated spindle cell rhabdomyosarcoma. The patient received postoperative radiotherapy (6,000 cGy in 200 cGy fractions, delivered over 30 days). However, he was also required to undergo urgent tracheostomy due to severe laryngeal obstruction, precipitated by laryngeal edema, 3 months subsequent to radiotherapy. The patient was free of disease 25 months postoperatively but is still unable to close his tracheostomy.

A new surgical approach of temporary ovarian transposition for children undergoing brachytherapy: technical assessment and dose evaluation

PURPOSE

We developed a new technique of temporary ovarian transposition (OT) for prepubertal girls undergoing brachytherapy. The aim of this study was to describe it, assess its feasibility and safety and calculate the dose delivered to the ovary in order to prove its efficacy.

METHODS

Sixteen prepubertal patients underwent temporary OT for brachytherapy at our center from March 2001 to December 2012. OT was done either by laparotomy or by laparoscopy. In all patients, the ovaries were grasped with an atraumatic forceps and mobilized above the iliac crest level as high as possible without any dissection or division of the ovarian ligaments or of the fallopian tube. They were sutured to the anterior abdominal wall by a transfixing stitch of non-dissolvable suture knotted on the outside of the patient on a pledget.

RESULTS

Median age at surgery was 3 years (range: 2-9 years). The integrity of the fallopian tube was respected and not a single ligament was dissected or divided. None of the patients had intraoperative or postoperative complications. The stitches were retrieved after completion of irradiation and the ovaries in all the patients fell back into the pelvis. The calculated median radiation dose to the ovary was 1.4 Gy (range: 0.4-2.4 Gy).

CONCLUSIONS

This surgical technique is simple and safe, either by laparotomy or by laparoscopy. It meets the radiation and physical constraints in prepubertal girls with vaginal or bladder RMS. However, longer follow-up is required to assess the ovarian function.

[Diagnosis and treatment of childhood soft tissue sarcomas]

Malignant tumors of mesenchymal origin are called sarcomas. Mesenchymal cells normally mature into skeletal muscle, smooth muscle, fat, fibrous tissue, bone and cartilage. Rhabdomyosarcoma (RMS) arises from immature mesenchymal cells that are committed to skeletal muscle lineage. However, it can also arise in tissues in which striated muscle is normally not found (such as the urinary tract). Undifferentiated sarcomas cannot be ascribed to any specific lineage. Treatment results improved significantly in the last decade by combined treatment (chemotherapy, surgery, irradiation, in some cases targeted therapy). Good treatment results can be achieved in pediatric oncology centers by early diagnosis and adequate treatment according to international treatment protocols.

Assessment of volume segmentation in radiotherapy of adolescents; a treatment planning study by the Swedish Workgroup for Paediatric Radiotherapy

BACKGROUND AND PURPOSE

The variability in target delineation for similar cases between centres treating paediatric and adolescent patients, and the apparent differences in interpretation of radiotherapy guidelines in the treatment protocols encouraged us to perform a dummy-run study as a part of our quality assurance work. The aim was to identify and quantify differences in the segmentation of target volumes and organs at risk (OARs) and to analyse the treatment plans and dose distributions.

MATERIALS AND METHODS

Four patient cases were selected: Wilm's tumour, Hodgkin's disease, rhabdomyosarcoma of the prostate and chordoma of the skull base. The five participating centres received the same patient-related material. They introduced the cases in their treatment planning system, delineated target volumes and OARs and created treatment plans. Dose-volume histograms were retrieved for relevant structures and volumes and dose metrics were derived and compared, e.g. target volumes and their concordance, dose homogeneity index (HI), treated and irradiated volumes, remaining volume at risk and relevant Vx and Dx values.

RESULTS

We found significant differences in target segmentation in the majority of the cases. The planning target volumes (PTVs) varied two- to four-fold and conformity indices were in the range of 0.3-0.6. This resulted in large variations in dose distributions to OARs as well as in treated and irradiated volumes even though the treatment plans showed good conformity to the PTVs. Potential reasons for the differences in target delineation were analysed.

CONCLUSION

Considerations of the growing child and difficulties in interpretation of the radiotherapy information in the treatment protocols were identified as reasons for the variation. As a result, clarified translated detailed radiotherapy guidelines for paediatric/adolescent patients have been recognised as a way to reduce this variation.

Management of dental complications in a child with rhabdomyosarcoma

Radiotherapy treatment options can cause adverse dental sequelae, including xerostomia, dental radiation caries, abnormal tooth development, and osteoradionecrosis (ORN). Hyperbaric oxygen (HBO) therapy can be used prophylactically or therapeutically to treat or reduce the risk of ORN. The purpose of this paper was to describe a case involving a 5-year-old male with rhabdomyosarcoma of the left temporal fossa and a history of radiation therapy who presented with gross radiation caries and xerostomia. Full-mouth extractions of all primary teeth were performed under general anesthesia, with the patient receiving HBO therapy before and after the surgery. The child was monitored postoperatively, and healing occurred with minimal post-operative complications. Based on his results, it can be concluded that hyperbaric oxygen therapy is an effective supplement to consider when treating children who have undergone radiation therapy and require dental care.

[Clinical application of 125I particle implantation in children with rhabdomysarcoma of the head and neck]

OBJECTIVE

To study the efficacy and safety of 125I particle implantation in the treatment of rhabdomysarcoma (RMS) of the head and neck in children.

METHODS

Eight children (four males and four females) with RMS of the head and neck received 125I particle implantation targeted to the primary lesion area. The primary lesions were noted in eyelids or eyes in two children, in the orbit in four children, and in the nasal cavity or nasal wing in two children. Treatment outcomes and side effects were observed.

RESULTS

The follow-up visits averaged 45±17 months (median 43 months) in the eight children receiving 125I particle implantation. Five children achieved a complete remission, 2 children achieved a complete remission and 1 child died. The total survival rate was 88% in the 8 children. Local pigmentation was observed in all eight children (100%). Nubecula (one case), eyeball pain (one case), serious blurred vision (one case), cornea ulcer and blindness (one case) and bleeding of the nasal cavity (one case) were also observed. Except for nubecula and blindness, these side effects were improved by symptomatic treatment.

CONCLUSIONS

125I particle implantation appears to be effective in the treatment of RMS of the head and neck in children. Most treatment-related side effects can be improved by symptomatic treatment.

Intensity modulated radiation therapy with dose painting to treat rhabdomyosarcoma

PURPOSE

To examine local control and patterns of failure in rhabdomyosarcoma patients treated with intensity modulated radiation therapy (RT) with dose painting (DP-IMRT).

PATIENTS AND METHODS

A total of 41 patients underwent DP-IMRT with chemotherapy for definitive treatment. Nineteen also underwent surgery with or without intraoperative RT. Fifty-six percent had alveolar histologic features. The median interval from beginning chemotherapy to RT was 17 weeks (range, 4-25). Very young children who underwent second-look procedures with or without intraoperative RT received reduced doses of 24-36 Gy in 1.4-1.8-Gy fractions. Young adults received 50.4 Gy to the primary tumor and lower doses of 36 Gy in 1.8-Gy fractions to at-risk lymph node chains.

RESULTS

With 22 months of median follow-up, the actuarial local control rate was 90%. Patients aged ≤7 years who received reduced overall and fractional doses had 100% local control, and young adults had 79% (P=.07) local control. Three local failures were identified in young adults whose primary target volumes had received 50.4 Gy in 1.8-Gy fractions.

CONCLUSIONS

DP-IMRT with lower fractional and cumulative doses is feasible for very young children after second-look procedures with or without intraoperative RT. DP-IMRT is also feasible in adolescents and young adults with aggressive disease who would benefit from prophylactic RT to high-risk lymph node chains, although dose escalation might be warranted for improved local control. With limited follow-up, it appears that DP-IMRT produces local control rates comparable to those of sequential IMRT in patients with rhabdomyosarcoma.

MEK/ERK inhibitor U0126 increases the radiosensitivity of rhabdomyosarcoma cells in vitro and in vivo by downregulating growth and DNA repair signals

Multimodal treatment has improved the outcome of many solid tumors, and in some cases the use of radiosensitizers has significantly contributed to this gain. Activation of the extracellular signaling kinase pathway (MEK/ERK) generally results in stimulation of cell growth and confers a survival advantage playing the major role in human cancer. The potential involvement of this pathway in cellular radiosensitivity remains unclear. We previously reported that the disruption of c-Myc through MEK/ERK inhibition blocks the expression of the transformed phenotype; affects in vitro and in vivo growth and angiogenic signaling; and induces myogenic differentiation in the embryonal rhabdomyosarcoma (ERMS) cell lines (RD). This study was designed to examine whether the ERK pathway affects intrinsic radiosensitivity of rhabdomyosarcoma cancer cells. Exponentially growing human ERMS, RD, xenograft-derived RD-M1, and TE671 cell lines were used. The specific MEK/ERK inhibitor, U0126, reduced the clonogenic potential of the three cell lines, and was affected by radiation. U0126 inhibited phospho-active ERK1/2 and reduced DNA protein kinase catalytic subunit (DNA-PKcs) suggesting that ERKs and DNA-PKcs cooperate in radioprotection of rhabdomyosarcoma cells. The TE671 cell line xenotransplanted in mice showed a reduction in tumor mass and increase in the time of tumor progression with U0126 treatment associated with reduced DNA-PKcs, an effect enhanced by radiotherapy. Thus, our results show that MEK/ERK inhibition enhances radiosensitivity of rhabdomyosarcoma cells suggesting a rational approach in combination with radiotherapy.

Kinetics of Depopulation, Repopulation and Host Cell Infiltration in the Rhabdomyosarcoma R1H After 14 MeV Neutron Irradiation

The kinetics of depopulation and repopulation of the solid transplantable rhabdomyosarcoma R1H in the rat was studied following irradiation with 5 Gy of 14 MeV neutrons. Several parameters were sequentially measured over a time period of 4 weeks after irradiation: the tumour volume was assessed by in situ caliper measurements; the numerical density of tumour cells was obtained by morphometry; the clonogenic fraction of tumour cells was derived from in vitro colony assay; and the numerical ratio of host to tumour cells was determined by flow cytometry. From these primary parameters the number of clonogenic tumour cells, non-clonogenic tumour cells, and nucleated host cells per tumour, as well as their variation with time, were derived. The results were compared with two sets of data obtained previously for the same tumour exposed to 15 Gy of 200 kVp X-rays. Survival of tumour cells was reduced to 5.5 +/- 0.5% by 5 Gy neutrons and to 4.5 +/- 0.5% by 15 Gy X-rays, i.e. an RBE of close to 3. There was a lag period before the onset of repopulation (4.9 +/- 0.4 days and 4.9 +/- 0.5 days, respectively), followed by a high initial rate of repopulation corresponding to a doubling time of 2.0 +/- 0.2 days for neutrons and 2.1 +/- 0.2 days for X-rays. The rate of depopulation was significantly different for the two treatment modalities; the halving time for the number of non-clonogenic tumour cells was 11 +/- 4 days for neutrons and 2.8 +/- 0.5 days for X-rays.(ABSTRACT TRUNCATED AT 250 WORDS)

Time benefit in the assessment of recurrences following fractionated radiotherapy in an experimental tumour system using positron‐emission tomography with18F‐fluorodeoxyglucose

PURPOSE

To determine the sensitivity and specificity of 18F-fluorodeoxyglucose-positron-emission tomography (FDG-PET) in the diagnosis of R1H tumours after fractionated radiotherapy, and the dependency of sensitivity and specificity on time after therapy. In addition, the time benefit of FDG-PET concerning early recognition of recurrences after fractionated radiotherapy was assessed.

MATERIAL AND METHODS

Subcutaneously growing rat rhabdomyosarcoma R1H tumours were irradiated by applying total doses of 80 or 85 Gy after reaching a start volume of 0.8 cm3. Twenty animals were treated. Tumour volume was determined twice a week. FDG-PET was performed weekly before, during and for 6 months after therapy using a conventional full-ring whole-body PET scanner. In total, 600 PET results were evaluated qualitatively using a six-scale score. PET results and actual tumour volumes were compared. The sensitivity and specificity of tumour detection by PET was calculated for different times after the onset of therapy. The optimal score for tumour detection and the influence of time after therapy on the quality of PET (time benefit) was evaluated using receiver-operating characteristics.

RESULTS

After irradiation, 8/20 tumours (40%) were locally controlled, while 12/20 recurred. In this tumour model, evidence of relapse is assured when a volume of 0.1 cm3 is reached. Sensitivity of tumour diagnosis by PET increases with time, i.e. with the volume of recurrent tumours after the onset of therapy, mounting to > 0.95 after 100 days. Specificities of 0.95-1.0 were determined after therapy, showing no increase with time. Tumour diagnosis by PET is highly accurate when performed 80 days after the start of treatment. On average, tumours were recognized by PET on 31, 62, 74 and 81 days (median) before approaching volumes of 0.2, 0.5, 0.8 or 1.0 cm3, respectively.

CONCLUSION

An experimental system was implemented that allows reproducible detection of recurrent R1H tumours after radiotherapy using FDG-PET. The usefulness of PET as a diagnostic test for R1H tumours is very good and a reliable resolution for PET is demonstrated for volumes < 1 cm3. The results indicate that FDG-PET enables early recognition of recurrences after fractionated radiotherapy.

The shrinking thyroid: how does thyroid size change following radiation therapy for laryngeal cancer?

BACKGROUND AND PURPOSE

External beam radiation therapy (XRT) for head and neck cancer is known to induce hypothyroidism and cause morphologic changes in the thyroid gland. This retrospective study investigates change in the size of the thyroid gland detectable by CT after XRT for laryngeal cancer.

MATERIALS AND METHODS

The measured width of the thyroid lobes in 61 patients treated nonsurgically with XRT for laryngeal cancer between 2000 and 2003 on posttherapy CT was compared with that on pretherapy CT. Absolute and percentage changes in measured thyroid width following XRT were analyzed according to chemotherapy administration and posttherapy thyroid function.

RESULTS

Eighty-five percent (52/61) of patients had a decrease in the width of the thyroid gland. The average change in width measuring -4.7 mm and -13.8% (SD, 5.7 mm and 19.9%) occurred at an average of 758 days following completion of XRT (mean, 402-1534 days) and was significant (P = .002). Average change in width between hypothyroid patients (n = 19, -6.1 mm and -20.0% change) and euthyroid patients (n = 42, -4.1 mm and -11.1% change) was not significant (P = .20 absolute change and P = .11 percentage change). The average change in width between patients receiving chemotherapy (n = 31, -5.5 mm and -16.1% change) and patients not receiving chemotherapy (n = 30, -3.9 mm and -11.5% change) was not significant (P = .26 absolute change and P = .37 for percentage change).

CONCLUSIONS

Most nonsurgical patients receiving XRT for laryngeal cancer have a significant decrease in the width of their thyroid glands detected on CT. The average change in the size of the thyroid gland does not differ when development of hypothyroidism or chemotherapy administration are considered.

Papules arising after radiotherapy for rhabdomyosarcoma

Radiation therapy, even at low doses, can induce a wide spectrum of vascular skin proliferations ranging from nonmalignant ones, such as benign lymphangiomatous papules (BLAP), to frankly malignant pathologies, such as angiosarcoma. We describe a 50-year-old Caucasian woman with a past history of uterine rhabdomyosarcoma, treated 22 years prior with surgical excision, chemotherapy, and radiotherapy. She presented with a few skin-colored papules and a clear discharge located in the previously irradiated area (right inguinal region). Histopathology showed a proliferation of irregular, interanastomosing vascular channels, thin walled and lined by prominent endothelial cells with focally hobnail features. Cytological atypia of endothelial cells, mitotic figures, hemorrhagic areas, and necrosis were not observed. The endothelial cells expressed D2-40 and CD31. A diagnosis of BLAP following radiotherapy for uterine rhabdomyosarcoma was made. The patient was treated with complete excision using electrodessication. At the 20-month follow-up visit the patient was still free of recurrence.

Anaplastic thyroid carcinoma with rhabdomyoblastic differentiation: a case report with a good clinical outcome

Anaplastic thyroid carcinoma is a rare and highly malignant disease. Usually, this type of tumor is irresectable, and almost all patients die within 1 year after diagnosis. We present a case of anaplastic thyroid carcinoma with rhabdomyoblastic differentiation and good therapeutic outcome. A 76-year-old female was referred to our hospital with a growing, painless neck mass which existed for 3 months. Biopsy of the mass showed microscopically and immunohistochemically a follicular (Hürthle cell) carcinoma of the thyroid, dedifferentiated to an anaplastic carcinoma with divergent differentiation along rhabdomyoblastic cell lines. The patient underwent a total thyroidectomy with additional lymph node dissection, followed by two episodes of 150 mC I(131) therapy and external radiotherapy. After a follow-up of 3 years, the patient still remains in a good condition without any signs of recurrent disease. Other cases of rhabdomyoblastic and rhabdoid anaplastic thyroid carcinomas have been described. Both types of carcinoma are associated with an aggressive clinical course. In our case, the patient is still alive without evidence of disease 3 years after primary therapy. The good clinical outcome of our patient suggests that surgical resection, radiotherapy, and I-131 ablation therapy with curative intent seems to be an adequate treatment option in patients with anaplastic thyroid carcinoma with rhabdoid and rhabdomyoblastic differentiation.

Brachytherapy for genital-tract rhabdomyosarcomas in girls: technical aspects, reports, and perspectives

Rhabdomyosarcoma is a mesenchymal disease that represents 15-20% of childhood cancers and is the most common soft-tissue tumour in children. Most reviews on paediatric brachytherapy have described the experience of expert institutions with different brachytherapy techniques in a heterogeneous set of childhood malignant diseases. Brachytherapy reports focusing on specific types or locations (or both) are scarce. Rhabdomyosarcoma of the genital tract is recognised as one of the most curable forms of rhabdomyosarcoma. A multidisciplinary approach with more efficacious multidrug chemotherapy, conservative surgery, and limited radiotherapy, such as brachytherapy, has been used to help improve success rates. This review aims to offer perspectives and analysis on the effectiveness and complications of brachytherapy in gynaecological rhabdomyosarcoma management.

Intensity Modulated Radiotherapy (IMRT) and Fractionated Stereotactic Radiotherapy (FSRT) for children with head-and-neck-rhabdomyosarcoma

Background

The present study evaluates the outcome of 19 children with rhabdomyosarcoma of the head-and-neck region treated with Intensity Modulated Radiotherapy (IMRT) or Fractionated Stereotactic Radiotherapy (FSRT) between August 1995 and November 2005.

Methods

We treated 19 children with head-and-neck rhabdomyosarcoma with FSRT (n = 14) or IMRT (n = 5) as a part of multimodal therapy. Median age at the time of radiation therapy was 5 years (range 2–15 years). All children received systemic chemotherapy according to the German Soft Tissue Sarcoma Study protocols.

Median size of treatment volume for RT was 93,4 ml. We applied a median total dose of 45 Gy (range 32 Gy – 54 Gy) using a median fractionation of 5 × 1,8 Gy/week (range 1,6 Gy – 1,8 Gy).

The median time interval between primary diagnosis and radiation therapy was 5 months (range 3–9 months).

Results

After RT, the 3- and 5-year survival rate was 94%. The 3- and 5-year actuarial local control rate after RT was 89%.

The actuarial freedom of distant metastases rate at 3- and 5-years was 89% for all patients.

Radiotherapy was well tolerated in all children and could be completed without interruptions > 4 days. No toxicities >CTC grade 2 were observed. The median follow-up time after RT was 17 months.

Conclusion

IMRT and FSRT lead to excellent outcome in children with head-and-neck RMS with a low incidence of treatment-related side effects.

Ovarian repositioning in pediatric cancer patients: Flexible techniques accommodate pelvic radiation fields

Treatments for childhood cancer and consequent long-term survival rates continue to improve. As the success of these therapies advances, premature ovarian failure and sterility have become an increasingly evident long-term morbidity. Abdominal and pelvic radiation have been specifically shown to induce early menopause and decreased fertility. In order to minimize radiation injury, we utilized novel techniques to reposition ovaries in two girls with pelvic tumors prior to initiation of pelvic radiation. One girl with a sacral Ewing sarcoma underwent laparoscopic anterior suspension of the ovaries, using a simple and easily reversible technique. The second patient, who underwent hysterectomy for a recurrent uterine rhabdomyosarcoma, underwent widely lateral and cephalad repositioning of the ovaries. Both procedures were well tolerated, with no significant morbidity. In both cases the ovaries were moved well beyond the planned radiation field. We propose that open or laparoscopic ovarian repositioning in children is a simple, flexible, and reversible option to reduce radiation injury to the ovaries in pediatric cancer patients.

Reconstruction of a Severe Maxillofacial Deformity After Tumorectomy and Irradiation Using Distraction Osteogenesis and LeFort I Osteotomy Before Vascularized Bone Graft

We present the successful reconstruction of a large mandibular defect with a severe maxillofacial deformity after malignant tumor resection and irradiation. The patient was a 16-year-old boy with a defect in the left mandible, which extended from the mandibular body to the condylar process and hypoplasia of the maxillozygomatic complex on the left side as a result of ablation and radiotherapy of a grown rhabdomyosarcoma in the left infratemporal fossa at the age of 10. We planned a two-stage reconstruction because of his wide mandibular defect and hypoplasia. LeFort I type osteotomy to correct the maxillary declination was combined with mandibular lengthening to decrease the width of the defect in the first stage. New bone formation was confirmed at the distraction site 4 months after surgery, and the second stage was performed. A free latissimus dorsi myocutaneous flap with a vascularized scapula and rib was transferred to reconstruct the ramus of the mandible, zygomatic arch, and soft tissues. This procedure resulted in satisfactory results. In conclusion, the combination of distraction osteogenesis and microsurgical bone transplantation facilitated the straightforward reconstruction of a three-dimensional deformity with huge bony defects. We think that this combined surgical procedure will become a favorable option in the treatment of severe maxillomandibular deformities with bone defects.

Radiofrequency ablation used for the treatment of frequently recurrent rhabdomyosarcoma in the masticator space in a 10-year-old girl

Radiofrequency (RF) ablation was performed for the treatment of recurrent rhabdomyosarcoma in a 10-year-old girl. The tumor measuring 2.4 cm in a maximum diameter was in the right masticator space and invaded the buccal mucosa at the time of third local relapse after surgical intervention, chemotherapy, radiotherapy, and photodynamic therapy. The RF electrode was placed into the center of the tumor with the computed tomography fluoroscopic guide under general anesthesia. Tumor enhancement disappeared on contrast-enhanced magnetic resonance images after RF ablation. The tumor deciduated into the oral cavity 34 days after RF ablation showing apoptosis throughout the tumor on histologic study. Buccal mucosal injury cured but she suffered from trismus. The tumor has completely disappeared for 18 months after RF ablation.

[Paratesticular pleomorphic rhabdomyosarcoma in an adult: diagnosis and management]

A paratesticular pleomorphic rhabdomyosarcoma occurring in a 63-year old man is reported. Clinical signs were like any intrascrotal tumor. CT-scan and histological examination with immunohistochemical study were necessary for the diagnosis and stadification of this cancer. The patient underwent a radical inguinal orchidectomy. The patient developed a local recurrence, which was treated by radiotherapy, and subsequently developed metastases two years later, which were treated by chemotherapy.

Surgical repositioning of the contralateral testicle before irradiation of a paratesticular rhabdomyosarcoma for preservation of hormone production

Little has been published so far about the possibility of preserving an uninvolved testicle by surgically transferring it out of the irradiation field. A then 16-year-old boy developed a right paratesticular embryonal rhabdomyosarcoma in 2003. Initial treatment consisted of orchiectomy and chemotherapy. Prior to local radiotherapy, the contralateral testicle was surgically transferred into the left groin region. Hyperfractionated, accelerated radiation therapy was administered to a total dose of 44.0 Gy. After radiotherapy, the testicle was returned. The patient's testosterone levels are still normal. No clinical abnormalities or signs of tumor had been observed as of June 2006.

Fatal pneumonitis in children with metastatic rhabdomyosarcoma following whole lung radiotherapy and sequential epirubicin

Interstitial pneumonitis is a recognized complication following whole lung radiotherapy. We report two cases in which fatal pneumonitis appeared to be precipitated by the administration of epirubicin-containing combination chemotherapy within 7 weeks of completion of whole lung radiotherapy. These cases highlight a potentially fatal interaction between radiotherapy and modern chemotherapy regimens.

Maxillofacial rhabdomyosarcoma in the canine maxillofacial area

Three dogs had a diagnosis of maxillofacial rhabdomyosarcoma. These dogs were treated with surgery and/or radiotherapy, and had poor clinical responses. The tumor tissues in all three cases were observed around the upper premolar teeth with ulcerative lesions and CT examinations in each case revealed extensive bony involvement into the maxilla. Two cases were subjected to surgical excision of the tissues, followed by an external radiation therapy. The other case was only treated with palliative radiation. Outcomes of the treatment of all the cases were quite poor because of the invasive and refractory nature of the tumor cells, leading to the local recurrence and lung metastasis early in the clinical course. All dogs died within two months of the first admission.

On the performances of different IMRT Treatment Planning Systems for selected paediatric cases

Background

To evaluate the performance of seven different TPS (Treatment Planning Systems: Corvus, Eclipse, Hyperion, KonRad, Oncentra Masterplan, Pinnacle and PrecisePLAN) when intensity modulated (IMRT) plans are designed for paediatric tumours.

Methods

Datasets (CT images and volumes of interest) of four patients were used to design IMRT plans. The tumour types were: one extraosseous, intrathoracic Ewing Sarcoma; one mediastinal Rhabdomyosarcoma; one metastatic Rhabdomyosarcoma of the anus; one Wilm's tumour of the left kidney with multiple liver metastases. Prescribed doses ranged from 18 to 54.4 Gy. To minimise variability, the same beam geometry and clinical goals were imposed on all systems for every patient. Results were analysed in terms of dose distributions and dose volume histograms.

Results

For all patients, IMRT plans lead to acceptable treatments in terms of conformal avoidance since most of the dose objectives for Organs At Risk (OARs) were met, and the Conformity Index (averaged over all TPS and patients) ranged from 1.14 to 1.58 on primary target volumes and from 1.07 to 1.37 on boost volumes. The healthy tissue involvement was measured in terms of several parameters, and the average mean dose ranged from 4.6 to 13.7 Gy. A global scoring method was developed to evaluate plans according to their degree of success in meeting dose objectives (lower scores are better than higher ones). For OARs the range of scores was between 0.75 ± 0.15 (Eclipse) to 0.92 ± 0.18 (Pinnacle³ with physical optimisation). For target volumes, the score ranged from 0.05 ± 0.05 (Pinnacle³ with physical optimisation) to 0.16 ± 0.07 (Corvus).

Conclusion

A set of complex paediatric cases presented a variety of individual treatment planning challenges. Despite the large spread of results, inverse planning systems offer promising results for IMRT delivery, hence widening the treatment strategies for this very sensitive class of patients.