The value of high-dose methotrexate-based neoadjuvant chemotherapy in malignant fibrous histiocytoma of bone

PURPOSE

The value of high-dose methotrexate (HD-MTX)-based neoadjuvant chemotherapy was evaluated in patients with malignant fibrous histiocytoma (MFH) of bone.

PATIENTS AND METHODS

Since 1977, MFH of bone was diagnosed in 17 patients (12 males and five females). Ten patients (59%), completed treatment with four courses of neoadjuvant chemotherapy as follows: HD-MTX, vincristine, doxorubicin, cyclophosphamide, bleomycin, and dactinomycin, or HD-MTX, 4(1)-epidoxorubicin, and carboplatin followed by local tumor resection (n = 3), curettage-cryosurgery (n = 2), amputation (n = 2), or tumor resection-endoprosthetic replacement or allograft (n = 3). After recovery from surgery, an additional six courses of polychemotherapy, including HD-MTX in nine patients, were administered. One patient changed to cisplatin- instead of HD-MTX-containing chemotherapy postoperatively. One additional patient received only adjuvant HD-MTX-containing polychemotherapy. Neoadjuvant MTX-containing chemotherapy was contraindicated in five patients (29%) due to age, cardiac insufficiency, or mental disorder. In one patient, neoadjuvant chemotherapy was cancelled after one course due to renal failure. Treatment consisted of amputation (n = 2), one course of chemotherapy and amputation (n = 1), hyperthermic isolated limb perfusion (HILP; n = 1), intraarterial chemotherapy, radiotherapy, and endoprosthetic replacement (n = 1), and a combination of chemotherapy and radiation treatment (n = 1).

RESULTS

Five of six patients who received no HD-MTX-based neoadjuvant chemotherapy developed metastatic disease (83%); the median time to metastatic disease was 17 months (range, 3 to 44). In contrast, in 10 patients who completed treatment with HD-MTX-based neoadjuvant chemotherapy, with a mean follow-up time of 9.8 years (range, 2.3 to 15.7) and a median follow-up time of 10.8 years (range, 2.3 to 15.7) after diagnosis, no local recurrence or distant metastases were diagnosed (P < .005).

CONCLUSION

Neoadjuvant HD-MTX-containing chemotherapy in addition to surgery has dramatically improved the prognosis of patients with MFH of bone.

Evaluation of P-glycoprotein expression in soft tissue sarcomas of the extremities

Soft tissue sarcomas comprise a heterogeneous group of mesenchymal tumors accounting for less than one-percent of adult neoplasms. In the last few years, the use of adjuvant chemotherapy has been proposed for the treatment of these lesions in order to obtain a better systemic control, but its usefulness is still controversial. In this study, we evaluated whether P-glycoprotein, a membrane protein strictly associated with multidrug resistance, is overexpressed in soft tissue sarcomas. By using human multidrug resistant sarcoma cell lines as controls, we analyzed P-glycoprotein expression in 34 primary and in 23 relapsed soft tissue sarcomas of the extremities. Overexpression of P-glycoprotein was found in 6 out of 34 primaries (18%) and in 8 out of 23 relapses (35%). In particular, in malignant fibrous histiocytoma, the most frequent soft tissue sarcoma of adults, P-glycoprotein overexpression was found in 23% of primary untreated cases, in agreement with the reported relapse rate of this tumor after surgery and chemotherapy. These data suggest that, in soft tissue sarcomas, overexpression of P-glycoprotein may be of prognostic value and that the assessment of P-glycoprotein expression may be useful for the design of chemotherapy protocols.

Myxoid malignant fibrous histiocytoma: experience with chemotherapy

Myxoid malignant fibrous histiocytoma (MFH) is an intermediate grade tumor with a definite metastatic potential but a relatively indolent natural history compared to the pleiomorphic variant of MFH. Little is known about its sensitivity to chemotherapy. We reviewed our experience with chemotherapy in myxoid MFH between 1986 and 1992. The patient population was identified through a search of the database maintained by the Departments of Melanoma-Sarcoma Medical Oncology and Pathology: 55 patients with histologically confirmed diagnosis of myxoid MFH were identified. Chemotherapy was administered to 18 of these patients (10 females, 8 males). The median age was 65 (range: 30-76). Ten patients had an extremity primary, seven had a trunk or retroperitoneal primary, and one patient had head and neck as the site of primary tumor. The median size of the primary tumor was 11 cm (range: 5-23 cm) in maximum dimension. Seven patients received chemotherapy in the neoadjuvant setting, eight received it for recurrent or metastatic disease, and three received it postoperatively after complete resection of the tumor. All patients received doxorubicin and dacarbazine with or without cyclophosphamide. Of the 15 patients evaluable for response, 4 achieved an objective response (one CR, 3 PRs, RR = 27%) to a median of 3 cycles (range: 1-7 cycles). At the time of last follow-up, eight patients are alive with no evidence of disease, two patients are alive with disease, and eight patients have expired. The median follow-up is 51 months (range: 26-216 months) from diagnosis. The relatively small sample precludes any definitive conclusions; however, it seems that doxorubicin- and dacarbazine-based chemotherapy has modest activity in myxoid MFH.

[Percutaneous drainage of refractory necrotizing tumors: experience in 9 patients]

PURPOSE

The ranking of percutaneous drainage treatment in necrolytic advanced tumours was assessed.

METHOD

9 patients with refractory symptomatic necrolytic tumours were treated for alleviation by percutaneous drainage. Additionally, an attempt to sclerose the necrotic cavity was performed in 6 patients (6 x mitoxantrone 30 mg/24 hrs, of which 1 x additionally 98% alcohol).

RESULTS

In 5 of the 9 patients symptomatic relief was obtained, but complete sclerosing of the necrotic cavity succeeded in only two patients. In two patients with necrotic tumours of the pelvis there was a bacterial superinfection of the tumour necrosis.

CONCLUSION

Percutaneous alleviation is only occasionally successful in patients with necrolytic tumours. Therapy becomes effective probably only in case of successful sclerosing of the tumorous cavity.

[Successful chemotherapy and concurrent radiotherapy for metastatic lung. mediastinal malignant fibrous histiocytoma]

We treated a patient for malignant fibrous histiocytoma (MFH) which metastasized to mediastine and lung from left femur. The patient was a sixty-three year old man. He had his left femur, the primary lesion, resected. After the first operation, we found metastasis to his lung and mediastine and we performed twice thoracotomy. Then he was found to have the third metastasis which we decided was inoperable, this time we tried chemotherapy and concurrent radiotherapy. CDDDP and ACR with radiotherapy showed significant effect. The patient died after eight months at last because of fistula between the descending aorta and the ileum, and as we performed an autopsy on him, his MFH proved pathological CR.

[Pulmonary malignant fibrous histiocytoma treated with cisplatin plus etoposide followed by surgery]

A 47-year-old woman was admitted to our hospital with a mass shadow in the upper lobe of the right lung. Undifferentiated carcinoma was diagnosed after transbronchial biopsy. Combination chemotherapy consisting of cisplatin and etoposide was given. After two cycles of chemotherapy, partial response was obtained, and surgery was done because there was no evidence of lymph node metastasis or distant metastasis. After successful surgery, malignant fibrous histiocytoma was diagnosed because histological examination revealed the typical storiform pattern and most tumor cells showed positive cytoplasmic staining for alpha 1-antitrypsin, alpha 1-antichymotrypsin, and CD68. No evidence of another primary lesion was found, so this tumor was thought to be a pulmonary malignant fibrous histiocytoma. Cisplatin and etoposide have synergistic effect in vivo, and this combination is widely used as a standard regimen for small cell lung cancer and other malignancies. It might also be effective against pulmonary malignant fibrous histiocytoma.

[A case of malignant fibrous histiocytoma treated with intraarterial chemotherapy under complete venous isolation and charcoal hemoperfusion]

Herein reported is a case with malignant fibrous histiocytoma (MFH) at the left elbow treated successfully with intraarterial chemotherapy under complete brachial venous isolation and charcoal hemoperfusion (BVI-CHP). A 56-year-old man was admitted to our institution because of local recurrence at the left elbow 6 months after extended local resection combined with systemic chemotherapy. We treated the patient with a 15-min intraarterial infusion of adriamycin (100 mg/body) and cisplatin (30 mg/body) under a concomitant 30-min BVI-CHP. Two weeks after the first treatment, he received a repeated intraarterial infusion of adriamycin (80 mg/body) and cisplatin (50 mg/body) under BVI-CHP. The tumor became necrotic one week after the first treatment, resulting in 60% reduction in tumor diameter. In addition, angiography demonstrated a remarkable shrinkage of the tumor stain. Despite repeated intraarterial high-dose infusions of chemotherapeutic agents, systemic toxicities, such as leukopenia, nausea/vomiting and alopecia, were not observed. These results indicate that this approach offers a novel therapeutic option for malignant tumors in the extremities.

Late development of a malignant fibrous histiocytoma at the site of a giant cell tumor

A case of late development of a high grade malignant fibrous histiocytoma at the site of a previously surgically treated giant cell tumor is reported. The patient initially was treated for a benign giant cell tumor of the lateral condyle of the distal femur by curettage, implant of auto and allograft bone, but no radiation. Eighteen years later, he noted progressively increasing pain and disability. Radiographs showed some change, but magnetic resonance imaging clearly disclosed a tumor arising at the site and extending outside the bone. After chemotherapy, the tumor was resected and histologically showed no evidence of a recurrent giant cell tumor, only a high grade malignant fibrous histiocytoma.

Correlation of in vitro and in vivo effects of interferon-gamma with the spontaneous regression of a rat histiocytoma

Cytokines trigger activation of different lymphocyte populations, resulting in augmentation of humoral and cell-mediated immunity. We have examined the role of IFN-gamma in mediating AK-5 tumor regression. High levels of circulating IFN-gamma and IL-2 marked the process of regression. Moreover, interaction of immune NK cells with antibody-tagged AK-5 resulted in IFN-gamma secretion, providing in vitro evidence for the involvement of this cytokine. IFN-gamma and IL-2 potentiated the cytolytic activity of naive NK cells, suggesting their role in antitumor activity. Furthermore, pretreatment of immune NK cells with protein tyrosine kinase inhibitor downregulated the IFN-gamma release, suggesting that the secretion of IFN-gamma is phosphorylation dependent. Nonimmune cells could be induced to secrete IFN-gamma when exposed to rIL-12, demonstrating IL-12 dependence in inducing IFN-gamma release. In vivo administration of anti-IFN-gamma inhibited the cytotoxic activity and the process of tumor regression, further substantiating the role of IFN-gamma in regulating the rejection of AK-5 tumor. These observations suggest a definitive role for IFN-gamma in AK-5 regression. This cytokine in concert with IL-2 and IL-12 might aid in designing effective anticancer therapy.

Antitumor effects of liposomes containing adriamycin on chemically-induced rat malignant fibrous histiocytoma

Malignant fibrous histiocytoma (MFH) is the most common soft tissue sarcoma. No effective chemotherapeutic agents, however, have been reported. Here we report our evaluation of the antitumor effects of liposomes containing adriamycin (LADM) against chemically-induced rat MFH. Either free adriamycin (ADM) or LADM was administered at dosages of 4.0, 8.0 or 12.0 mg/kg by intravenous injection. The tumor responded to LADM with prolonged growth delay, but equivalent doses of free ADM were less effective. Additionally, LADM prolonged the life span of rats longer than did free ADM. Also, the body weight loss was less with LADM than with equivalent doses of free ADM. In tissue distribution studies, we observed that the ADM level in the blood and in the tumor with LADM remained higher than with free ADM. These results indicate that liposomes alter in vivo ADM tissue distribution and increase antitumor activity against rat MFH with reduced toxic side effects.

Adjuvant chemotherapy for treatment of unresectable and metastatic angiomatoid malignant fibrous histiocytoma

Angiomatoid malignant fibrous histiocytoma (AMFH) is a low grade soft tissue sarcoma usually treated with surgery alone. Only one adult patient has been treated with systemic chemotherapy. The authors report a case of unresectable, metastatic AMFH treated initially with vincristine, doxorubicin, dactinomycin, and cyclophosphamide. A complete response at the metastatic site and a marked reduction in the size of the primary tumor allowed complete surgical excision 7 months after treatment was initiated. The patient remains disease free 19 months after being diagnosed. It was concluded that systemic chemotherapy may be effective in patients with AMFH.

[Successful preoperative intra-arterial chemotherapy and concurrent radiotherapy for recurrent chest wall malignant fibrous histiocytoma]

A case of malignant fibrous histiocytoma (MFH) of the chest wall is reported. A fifty-nine-year-old male admitted into our hospital suffering from a giant chest wall tumor that had recurred after three separate resections. Thrice preoperative intra-arterial infusions of ADR 50 mg/m2, CDDP 100 mg/m2 and ADR 50 mg/m2 were respectively administered along with 60 Gy of concurrent radiotherapy. After that, we widely resected the tumor, chest wall, clavicle, subclavian vein and part of the deltoid muscle. The defect of the chest wall was reconstructed with Marlex-Mesh and covered with a rectus abdominis muscle flap. No viable tumor cells were detected in the resected specimen. Aggressive preoperative chemoradiotherapy was very useful for the treatment of MFH in this case.

Analysis of prognostic factors and chemotherapy of malignant fibrous histiocytoma of soft tissue: a preliminary report

The inter-group study of malignant fibrous histiocytoma of soft tissue (MFH) was performed during the period January, 1988, to August, 1992 (4 yr 7 mo). There were 107 patients evaluated with an age range of 11 to 92 yr and an average age of 62.0 yr. There were 63 males and 44 females. The duration of follow-up was from 7 mo to 4 yr 5 mo with an average of 2 yr 6.2 mo. MFH occurred principally as a mass on an extremity (lower extremity 62%), upper extremity 18%, trunk 25%, head and neck 2%). It typically involved deep fascia or skeletal muscle (68%) or superficial subcutis (35%). There were 77 storiform-pleomorphic, 22 myxoid, three giant cell, two inflammatory and three angiomatoid variants. The absolute three-year survival rate for all 107 patients was 72%. Patients with tumors located on extremities had a better three-year survival rate than patients with tumors located on the trunk or head and neck (81 vs 54%). There was, however, no statistical difference between the two groups. The prognosis for patients with deep muscular lesions, > 10 cm in diameter, was poor. The depth of the tumor significantly affects survival. The group with superficial tumors had a significantly better three-year survival rate than the other group (86 vs 68%). Local recurrences were found in 8% of patients who had had "complete" excisions. Inadequate surgery greatly increases the incidence of local recurrence and compromises longterm survival. Evaluations of tumor responses to preoperative chemotherapy and radiotherapy by histological studies were made. In total, 38 patients were evaluated. Responses to single and combination chemotherapy occurred in 31% of patients, a rate similar to that seen for other sarcomas.

Soft-tissue sarcoma of the extremity. Experience with limb-sparing surgery

OBJECTIVES

To assess the degree to which limb-sparing surgery is implemented in patients with soft-tissue sarcoma, and its outcome.

DESIGN AND SETTING

A detailed review of 40 patients who were all tertiary referrals to one surgeon, and general review of all 215 patients with sarcoma treated in South Australia between 1986 and 1992.

INTERVENTIONS

Conservation of the limb by wide resection or marginal resection of soft tissue, combined when necessary with radiotherapy. Amputation was used when limb conservation failed or was not possible.

MAIN OUTCOME MEASURES

Median survival time after treatment.

RESULTS

Limb-sparing treatment was successful in 37 of the group of 40 patients. Thirty-two patients received adjuvant radiotherapy, and 19 received chemotherapy. Median survival time was 35 months. Review of all 215 patients with sarcoma revealed a higher initial amputation rate and a lower use of combined treatment methods than in our series. Twenty-six patients (65%) were initially incorrectly diagnosed before referral, resulting in a median delay in treatment of 16 weeks.

CONCLUSIONS

The concept of limb-sparing surgery is well established, but is not yet as widely practised for limb sarcomas as it could be. Delay in diagnosis is a significant problem.

Intraarterial cisplatinum and intravenous adriamycin for primary hypervascular bone tumor: experience of seven cases

Seven consecutive cases of primary hypervascular bone tumor, encountered between January 1991 and September 1992, were treated with intraarterial cisplatinum and intravenous adriamycin infusion. There were four osteosarcomas, one malignant fibrous histiocytoma, one chondrosarcoma and one case of primitive neuroectodermal tumor. Local symptoms were markedly relieved, or disappeared, in 71% (5/7) of cases after the first course of treatment. Sclerotic changes of bone tumor occurred in 100% (6/6) of cases after two courses of chemotherapy. Progressive decrease of tumor stains was noted in 100% (6/6) of patients during angiographic assessments. On exploration, no gross tumors were found in 80% (4/5) of the cases that received limb-sparing surgery. Although disappearance of symptoms and sclerotic changes of bone tumor predicted a good response to treatment, the degree of decrease of tumor stains corresponded best with the extent of tumor necrosis. Our study verified the effectiveness of intraarterial cisplatinum and intravenous adriamycin infusion in treating primary hypervascular bone sarcomas. Further studies with more cases are necessary to define the optimal duration of postoperative adjuvant chemotherapy.

Expression of MDR1/P glycoprotein in human sarcomas

Conflicting reports of MDR1 gene expression in human tumours are observed according to whether studies are performed at the mRNA or P-glycoprotein level. We have investigated this expression in 22 clinically drug-resistant sarcomas at the mRNA level by Northern blot (NB), Dot blot (DB), in situ hybridisation (ISH), and at the protein level by immunohistochemistry (IHC) using three monoclonal antibodies (MoAbs): C219, JSB1, MRK16. Increased MDR1 mRNA expression was detected by NB, DB, and ISH in 1/22 sarcoma (an Ewing's sarcoma). ISH was perfectly correlated with DB hybridisation and confirmed the expression of tumoral cells alone. Specific staining of 100% of tumoral cells was obtained with the three MoAbs in the same sarcoma. Expression in tumoral cells of 12 other sarcomas was detected with MRK16, and positive staining of stromal cells with both C219 (1/22) and MRK16 (8/22) was observed. This study confirms that MDR1 overexpression occurs in human sarcomas but is not the principal mechanism of drug-resistance. Furthermore, positivity with one antibody does not necessarily imply the presence of P glycoprotein (P-gp) and a disparity may exist between the levels of P-gp and its mRNA in the same sample. So care must be taken in interpreting results and more sensitive techniques such as the polymerase chain reaction (PCR) could prove useful.

[A case of malignant fibrous histiocytoma of jejunal origin with marked response to cisplatin, ifosfamide and adriamycin]

A case of malignant fibrous histiocytoma (MFH) of jejunal origin with brain and lung metastases was treated by jejunal resection. Four courses of sequential chemotherapy that combined cisplatin, ifosfamide and adriamycin were performed starting on day 20 following operation. Both brain and lung metastases showed marked reduction in size, and toxicity was minimal.

[Chemotherapy for Ewing's sarcoma, malignant fibrous histiocytoma and malignant lymphoma]

Recent advances in adjuvant chemotherapy for malignant bone tumor have been improving the survival rate and making limb-salvage surgery a reliable technique. Ewing's sarcoma is treated by multiple agent chemotherapy. We treat Ewing's sarcoma by Rosen's T-11 protocol (CYT.ADM.MTX.VCR.ACT-D.BLM). This protocol is very effective, but results are poorer than for osteosarcoma. Newly developed protocols such as EICESS (European Intergroup Cooperative Ewing's Sarcoma Study)-92, including new drugs, should be investigated. The results with malignant fibrous histiocytoma are comparable to those for osteosarcoma. We have performed an original chemotherapy protocol, called "K-1 protocol." Patients were treated with three courses of intraarterial infusion of cisplatin (120 mg/m2) and caffeine (1.0-1.5 mg/m2/day for three days continuously) at two-week intervals. If the effect was insufficient, ADM (30 mg/m2/day for two days continuously) is added to this protocol. We treat malignant lymphoma in collaboration with a hematologist and radiologist. The 5-year survival rate of non-Hodgkin's lymphoma in our series was 56% in clinical stage III and 34% in clinical stage IV. We are trying third-generation chemotherapy to improve the survival rate.

Serial thallium-201 scintigraphy in osteosarcoma. Correlation with tumor necrosis after preoperative chemotherapy

In 27 patients with extremity lesions (24 osteosarcoma, three malignant fibrous histiocytoma), a notable decrease in thallium-201 uptake was correlated with a good response to preoperative chemotherapy of the primary tumor. A good response is indicated by a greater than 95% tumor necrosis. Serial quantitative thallium-201 uptake of malignant bone tumors in patients receiving preoperative chemotherapy therefore can accurately predict a good histologic response and prognosis. Serial thallium scintigraphy can furthermore identify poor responses within two weeks after the initiation of treatment, or can prompt an early change in preoperative chemotherapy and facilitate limb salvage surgery.

Edatrexate in patients with soft tissue sarcoma. Activity in malignant fibrous histiocytoma

BACKGROUND

Chemotherapy has had little impact on the natural history of soft tissue sarcoma, and often is associated with serious toxicity. Edatrexate, an investigational antifolate, is active in patients with lung cancer, and has cytotoxic activity in human sarcoma cell lines.

METHODS

Edatrexate was administered to 36 patients with measurable, advanced soft tissue sarcoma who had not previously received chemotherapy. The drug was given weekly for 5 weeks, then every other week. The initial dose, 80 mg/m2, was escalated by 10 mg/m2 every 2 weeks in the absence of toxicity. Eleven patients had leiomyosarcoma, 7 had malignant fibrous histiocytoma (MFH), and 5 had liposarcoma; the remainder of cell types included hemangiopericytoma (4), angiosarcoma (3), synovial (2), spindle cell (2), extraosseous chondrosarcoma (1), and fibrosarcoma (1).

RESULTS

Thirty-five patients are evaluable. Partial response (PR) was seen in five of the seven patients with MFH; no other major responses occurred. Overall, the response frequency was 14% (two-sided 95% confidence interval, 3% to 26%). Median duration of PR was 6 months (range, 4-18 months). One patient had a minor tumor regression, and six had stable disease. Myelosuppression was generally mild; only three patients had grade 3 hematologic toxicity. Modification of dose or schedule was required in 50% of patients for mucositis. Fatigue was a common toxicity, seen in 66% of patients, but was tolerable in the majority. A rash was seen in 46% of patients; one patient had hepatic toxicity.

CONCLUSIONS

Overall, the activity of edatrexate in this study, dominated by patients with either visceral or vascular sarcoma, was poor. However, the responses observed in patients with metastatic MFH suggests that further evaluation of edatrexate in patients with soft tissue sarcoma is warranted.

[A combination chemotherapy of carboplatin and etoposide for malignant fibrous histiocytoma with marked effect on the metastatic lung region]

For metastatic lung region, a 82-year-old woman with malignant fibrous histiocytoma was successfully treated with combination chemotherapy of Carboplatin and Etoposide. First, the tumor appeared on her right thigh, and we operated on August 1991. However, at the same time, a metastatic lung region was also noticed. Over a year, it worsened. We gave her 350 mg Carboplatin once a week and 100 mg Etoposide 3 times a week. After 3 weeks' treatment, we stopped treatment because of sudden granulocytopenia and thrombocytopenia. But to our surprise, the metastatic lung region almost disappeared 2 months after therapy. Considering the difficulty of medical treatment for malignant fibrous histiocytoma, this case suggests that combination chemotherapy of Carboplatin and Etoposide is valuable. However, due care must be taken for side effects such as granulocytopenia and thrombocytopenia.

Malignant fibrous histiocytoma in childhood

BACKGROUND

Malignant fibrous histiocytoma (MFH) is a neoplasm of late adult life and often is reported in the pediatric population. It is thought to behave more benignly in children than in adults.

METHOD

Clinical and pathologic features, treatment, and outcome of nine pediatric patients seen at British Columbia's Children's Hospital between 1983 and 1990 were examined. The literature regarding pediatric malignant fibrous histiocytoma was reviewed.

RESULTS

The tumors included one primary renal tumor and two occurring in the orbit after radiation therapy for retinoblastoma during the neonatal period. Histologic examination showed that six tumors had a storiform-pleomorphic pattern, one was myxoid, and two were angiomatoid in type. Six children are alive with a disease-free survival of 20 months to 8 years after surgical resection. Two of these received adjuvant chemotherapy, none had radiation therapy. Three patients have died of disease, two with pulmonary metastases that developed despite multiagent chemotherapy and radiation therapy. Poor outcome was associated with large tumors, deep and proximal location, and the storiform-pleomorphic histologic type with atypical mitoses.

CONCLUSION

Malignant fibrous histiocytoma is similar in children and adults. Surgery is the mainstay of therapy, but the risk of local recurrence and pulmonary metastases indicates the need for adjuvant therapy in selected patients.

Malignant fibrous histiocytoma of the limbs

Between June 1985 and May 1990 we treated 12 patients with malignant fibrous histiocytoma (MFH) of the limbs by a combination of wide excision and adjuvant radiotherapy. The Enneking surgical staging was II in 11 cases and III in 1. There were 6 women and 6 men, with an average age of 54 years. The leg was involved in 8 patients and the arm in 4. Limb salvage was achieved in 10 patients and amputation was performed in 2. All received adjuvant radiotherapy, with an average of 51.5 Gy. In 6 patients adjuvant CYVADIC chemotherapy was administered for an average of 4 cycles. In the other patients this treatment was not tolerated. Local recurrence occurred in 2 patients and metastases to the lung were seen in a further 2. At an average follow-up of 41.3 months, the Kaplan-Meier estimation of 5 year survival was 87.5%, with a 5 year continuous disease-free survival rate of 66.7%.

Chemotherapy of malignant fibrous histiocytoma of bone

BACKGROUND

Malignant fibrous histiocytoma of bone (MFHB) is a rare tumour with a 3 year survival of 30%-40% when treated with surgery alone. A small number of patients have previously been treated with pre-operative chemotherapy and responses observed. The aim of the present study was to further determine the response of MFHB to pre-operative chemotherapy.

PATIENTS AND METHODS

A non-randomised study of 18 patients with MFHB. Twelve had localised disease and 6 had pulmonary metastases. In 14 patients pre-operative treatment consisted of methotrexate 8 g/m2 on day 1, ifosfamide 3 g/m2 and doxorubicin 60 mg/m2 on day 10. This regimen was given twice and twice post-operatively. A further 4 patients received cisplatin 100 mg/m2 on day 1 and doxorubicin 25 mg/m2 on days 1, 2, 3. Three cycles were given pre- and post-operatively.

RESULTS

15 patients had surgery after chemotherapy. Tumour necrosis was present in all resection specimens and ranged from 50%-100%. 7/15 had > 90% necrosis. Disease free survival is 82% for those patients with a greater than 2 year follow-up.

CONCLUSION

This study confirms previous reports that MFHB is a chemosensitive tumour. In view of its rarity collaborative trials are needed to establish the optimum drug treatment including drug selection dose and duration.

Thallium-201 scanning for the evaluation of osteosarcoma and soft-tissue sarcoma. A study of the evaluation and predictability of the histological response to chemotherapy

We evaluated sequential thallium scans, made before and after a period of preoperative chemotherapy, for sixteen patients who had a high-grade sarcoma of bone or soft tissue. The purpose was to determine whether this technique could be used to ascertain accurately the amount of viable tumor as well as to predict the response to chemotherapy. Nine of the ten patients who had a reduced thallium uptake after chemotherapy also had a marked histological response, with necrosis of the tumor of at least 95 per cent. Six patients were seen to have no improvement on the thallium scans, and this finding correlated with necrosis of the tumor of less than 95 per cent. Thallium chloride has been shown to have an affinity for a variety of osteosarcomas and soft-tissue sarcomas. The mechanism of intracellular uptake is one of active transport, which makes thallium chloride a more accurate barometer of the viability of the tumor cells and of metabolic activity than scanning agents that are flow-dependent. We believe that sequential thallium scintigraphy should be used in conjunction with other imaging modalities in the diagnosis, planning of treatment, and follow-up evaluation of patients who have a sarcoma of bone or soft tissue. This technique appears to be useful in the prediction of the histological response of high-grade osteosarcomas and soft-tissue sarcomas to preoperative chemotherapy.