Long-term results of combined modality therapy in primary bone lymphomas

PURPOSE

To report the Massachusetts General Hospital experience in the management of patients with primary bone lymphoma (PBL) treated with combined modality therapy (CMT).

METHODS AND MATERIALS

Records from 37 eligible patients were reviewed. Two patients were treated with complete resection of the tumor, while 35 patients underwent radiation therapy with a median total dose of 54 Gy (range 38.35-66.5). All patients received combination chemotherapy, which contained doxorubicin in 33 cases. We compared the current data with our previous experience in patients treated with local measures only.

RESULTS

Actuarial disease-free survival (DFS) at 5 and 10 years is 78% and 73%, respectively, while overall survival (OS) is 91% and 87%, respectively. No local failures were seen. Pathologic fracture at presentation influenced DFS (p = 0.005) and OS (p = 0.017) adversely. OS was compromised in patients older than 60 years (p = 0.059) and DFS in patients with pelvic primaries (p = 0.015). CMT was associated with improved DFS (p = 0.0008) and OS p = 0.0001) compared to our historical controls. Ten patients (27%) developed complications requiring orthopedic procedures following completion of therapy at a median of 25.5 months (range 4-228).

CONCLUSION

Patients with PBL have a favorable outcome with CMT, which appears superior to radiation therapy alone. Late complications can be seen, especially in weight-bearing bones.

Radiation treatment of benign mesenchymal disease

The benign mesenchymal diseases, for which radiation is often quite effective in halting progression or achieving complete and permanent resolution, include neoplastic and nonneoplastic processes (eg, giant cell tumor of bone to keloid). Radiation oncologists have been reluctant to employ radiation in the management of patients with benign disease for several reasons: (1) the small but nonzero risk of late appearance of radiation-induced malignant tumors; (2) were radiation subsequently required to be employed in the same region of the body for treatment of a separate and independent neoplasm, the radiation dose might have to be reduced to an ineffective level; and (3) nonmalignant tissue changes that might appear at quite remote times and complicate healing of surgical wounds. Currently a liberalization of the use of radiation is in progress because of the clinical seriousness of many benign processes for which radiation yields a major therapeutic benefit. This reassessment of radiation oncology in the United States has been stimulated by the much wider application of radiation for patients with a wide spectrum of benign diseases in several European countries. This article considers the major indications and the expected outcomes from radiation treatment of benign mesenchymal diseases. For benign neoplasms that are locally progressive, the radiation dose is usually in the range 50 to 60 Gy administered at 1.8 to 2.0 Gy/fraction, five fractions per week. The response is characteristically quite slow, and the long-term local control probability is high (80%). Further, the response probability is not sensitive to lesion size, in contrast to malignant tumors of the mesenchymal tissues. For the nonneoplastic processes managed in some instances by radiation, the doses recommended are usually in the range of 6 to 12 Gy as single-dose or 20 to 25 Gy as fractionated dose irradiation. The efficacy of such treatment tends to be equal to or less than that noted for the benign neoplastic diseases.

Radiation in management of patients with dermatofibrosarcoma protuberans

PURPOSE

The preferred treatment of dermatofibrosarcoma protuberans (DFSP) is wide resection, namely, margins > or = 3 cm beyond the evident disease and histologically negative margins. We assess the success achieved by radiation combined with surgery for positive/close margins or by radiation alone for those tumors that are not resectable for technical/medical reasons. The literature on this point is virtually nonexistent.

MATERIALS AND METHODS

The outcome of treatment of 18 patients with DFSP by radiation alone (n = 3) and radiation and surgery (n = 15) at the Massachusetts General Hospital was assessed. All of the lesions at the time of the treatment by radiation alone or combined with surgery were less than 10 cm. This was the maximum dimension. The actual tumor volume was much less than indicated by this maximum dimension, as the tumors were usually relatively flat.

RESULTS

The 10-year actuarial local control rate was determined to be 88%. Local control was realized in the three patients treated by radiation alone, with follow-up periods of > or = 9 years. Among 15 patients treated by radiation and surgery, there have been three local failures; the 10-year actuarial local control rate was 84%. The three local failures occurred in 12 patients whose surgical margins were positive. One of these three local failures developed in the group of two patients whose lesions were scored as grade II.

CONCLUSION

Radiation in well-tolerated dose schedules is an effective option in the management of patients with DFSP. This appears to be true for radiation alone or postoperatively for margin-positive disease (primary or recurrent).

Radiation as a therapeutic modality in sarcomas of the soft tissue

Management of the primary lesion in patients with soft tissue sarcomas is combined modality in the majority of instances. The modalities are surgery and irradiation. Radical surgery as currently practiced in major oncology centers does not achieve local control in an important proportion of patients.

Posttransplantation lymphoproliferative disorders in solid organ recipients are predominantly aggressive tumors of host origin

Patients immunosuppressed after organ transplantation have an increased frequency of lymphoproliferative disorders, known as posttransplantation lymphoproliferative disorders (PTLDs). In recipients of bone marrow allografts. PTLDs are often of donor origin. In only a few cases of lymphoma arising in solid-organ transplant recipients has the origin from host or donor lymphocytes been established. The authors have analyzed 11 cases of PTLD from Massachusetts General Hospital, arising in seven male and four female patients, aged 8 to 63, five with renal, four with cardiac, and two with hepatic allografts. Using the polymerase chain reaction (PCR) to investigate genetic polymorphism at the D4S174 locus on chromosome 4, the Rb1.20 locus on chromosome 13, and the D19S178 locus on chromosome 19, only one tumor (previously reported) was of donor origin, whereas 10 were of host origin. Follow-up revealed that six patients died of PTLD, one was alive with recurrent PTLD, and four were alive and well or had died of other causes, including the patient with donor-origin PTLD. Based on these cases and on a review of previously reported cases, the authors conclude that the majority of PTLDs in solid organ recipients are of host origin. There appears to be a trend toward a greater likelihood of persistent or recurrent PTLD among solid organ recipients with host-origin tumors than among those with donor-origin tumor.

Role of radiation in the management of adult patients with sarcoma of soft tissue

Radiation in moderate dose levels, viz. 60-65 Gy at 2 Gy/fraction, administered in combination with conservative surgery, yields local control frequencies at least comparable to those achieved by radical resectional surgery alone. The clinical interest in this management strategy is the reduction in the scope of the resection and a consequent gain in cosmetic and functional status. This combined approach is favored for sarcomas so situated that resection with wide margin, > or = 2 cm at the most narrow, cannot be realized unless there is a clinically important loss in function. Where radical surgery is planned, there must be great care in assessment of the probability of achieving good margins. The patient is ill served if there is radical surgery and then, because of close margins, postoperative radiation is required. There appears to be clinical gain for the patient with a large sarcoma by administering the radiation preoperatively. Advantages include smaller treatment volume and higher local control rates. The management of the surgical wound in the irradiated patient is discussed. Also, brief consideration is given to current use of brachytherapy, high linear energy transfer (LET) radiation, and combination of radiation and chemotherapy.

Malignant neoplasms of decidual origin (deciduosarcomas) induced by estrogen-progestin-releasing intravaginal devices in rabbits

A combination of estrogen and levonorgestrel was continuously delivered to 23 adult rabbits for up to 2 years via a Silastic ring device sutured into the vagina. Twenty-one control rabbits were given similar rings devoid of drugs. A marked decidual reaction of the endometrium occurred in 16 of 23 test rabbits. In 14 test rabbits (61%) malignant tumors developed of decidual type cells not heretofore described. The deciduosarcomas were composed of anaplastic cells that invaded the uterine walls, uterine lymphatics, and in 4 of 13 (31%) rabbits that survived 2 years of treatment, the tumors metastasized to the lungs. Several deciduosarcomas appeared to arise within the spleen or other abdominal organs. Other drug-related lesions included uterine or vaginal polyps, endometrial atrophy, and focal necrosis and mineralization of the uterine wall. Cells from several deciduosarcomas failed to produce tumors in nude mice or to colonize on soft agar. No decidualization or decidual neoplasms were seen in the controls.

Expression of H-ras correlates with metastatic potential: evidence for direct regulation of the metastatic phenotype in 10T1/2 and NIH 3T3 cells

Using three independent approaches, we studied the effects of H-ras on metastasis formation. Analysis of five in vitro-ras-transfected 10T1/2 clones with either flat or refractile morphologies revealed a relationship between metastatic potential, H-ras expression, and anchorage-independent growth. Four metastatic variants derived from a poorly metastatic, low-H-ras-expressing line all expressed high levels of H-ras RNA and grew efficiently in soft agar. Activation of H-ras expression in the metastatic tumors had occurred through amplification and rearrangement of H-ras sequences. In addition, preinduction of p21 synthesis in NIH 3T3 line 433, which contains v-H-ras under transcriptional control of the glucocorticoid-sensitive mouse mammary tumor virus long terminal repeat, significantly increased metastatic efficiency. Glucocorticoid treatment of normal or pEJ-transformed NIH 3T3 cells did not affect metastatic potential. These data reveal a direct relationship between ras expression and metastasis formation and suggest that metastatic and transformed phenotypes may be coregulated in ras-transformed 10T1/2 and NIH 3T3 cells.