Curability of Ewing's sarcoma and considerations for future therapeutic trials

Multidisciplinary treatment of primary Ewing's sarcoma of bone. A 6-year experience of a European Cooperative Trial

The German Society of Pediatric Oncology in 1981 initiated the Cooperative Ewing's Sarcoma Study (CESS 81) using a four-drug combination of chemotherapy prior to definitive local control with surgery and/or radiation. From January 1, 1981 until February 28, 1985, 93 patients were registered at the trial office from 54 participating institutions in West Germany, Austria, Switzerland, and the Netherlands. On February 1, 1987, 54 of 93 patients were disease-free. Using the Kaplan-Meier life table analysis, the estimated disease-free survival (DFS) rate was 60% at 36 months and 55% at 69 months. The median period of observation was 29 months, ranging from 22 months to 69 months. Twenty-one of 93 patients (23%) had local failure, 18 of 93 patients (19%) developed systemic metastases. The local failure rate was particularly high in patients treated with radiation and was reduced when radiation planning was centralized within the study based upon the extent of disease at diagnosis. Cox regression analysis of prognostic factors showed that tumor volume was a significant factor influencing prognosis. The estimated 3-year DFS rate was 80% for patients with small tumors (volume less than 100 ml) compared to 31% for patients with large tumors (volume greater than or equal to 100 ml). In patients who had surgery for local control, the histologic response to chemotherapy was analyzed on the surgical specimen and had a strong influence on survival: 79% DFS at 3 years for patients with less than 10% viable tumor (good responders) compared to 31% DFS for patients with more than 10% viable tumor (poor responders). Tumor load and responsiveness to chemotherapy are the two major factors influencing prognosis in patients with primary Ewing's sarcoma of bone.

Primary Ewing's sarcoma involving the bones of the head and neck

Ewing's sarcoma is a rare tumor of the bone. In the Intergroup Ewing's Sarcoma Study (IESS) approximately 4% of the primary bone tumors arose in the bones of the head and neck. The mean age of patients was 10.9 years; boys slightly dominated the group. Signs and symptoms were local in distribution, with a mass or swelling most frequent. As in other sites, we categorized the dominant histologic pattern as diffuse or filigree, the latter carrying a more unfavorable prognosis. The radiographic appearance may be atypical as compared to Ewing's sarcoma at other sites. Prognosis of head and neck Ewing's is significantly better than Ewing's sarcoma overall. The gnathic bones were commonly affected, yet there was no associated mortality. No patient with primary disease in the bones of the head and neck who survived for 5 years on any of the IESS protocols has subsequently died.

Indications for and benefits of intensive therapies in treatment of childhood cancers

There has been a striking improvement in the overall numbers of children and adolescents who become disease-free and remain disease-free as a result of intensive therapy as defined today, for the following cancers: acute nonlymphocytic leukemia (ANLL), non-Hodgkin's lymphoma (NHL), poor risk acute lymphocytic leukemia (ALL), osteosarcoma, and Ewing's sarcoma. The therapy for each of these tumors, with the exception of osteosarcoma, consisted of combination chemotherapy with or without radiotherapy and was started as soon after diagnosis as possible. Aggressive therapy of osteosarcoma has consisted of surgical removal of lung metastases and chemotherapy. Intensive chemotherapy recently has included the use of high doses of certain drugs such as cytosine arabinoside (Ara-C), methotrexate, VP-16-213 and melphalan in the treatment of patients with tumors that are currently difficult to treat.

Therapy for primary non-Hodgkin's lymphoma of bone and a comparison of results with Ewing's sarcoma. Ten years' experience at the Istituto Ortopedico Rizzoli

The authors report on the results obtained in 30 consecutive cases of primary non-Hodgkin's lymphoma of bone (PNHLB) treated at the Istituto Ortopedico Rizzoli between 1972 and 1982. Four patients were treated with radiotherapy only and 26 were treated with radiotherapy plus adjuvant chemotherapy. At a median follow-up of 86 months (range, 30-160), among the 26 patients treated with chemotherapy also there were 3 relapses (2 had meningeal involvement and 1 had recurrence in another bone). Relapse (local recurrence plus multiple new localizations) was observed in one of the four patients treated with radiotherapy only. These results are compared with the results of 68 patients with Ewing's sarcoma who were treated during the same period with radiation therapy and adjuvant chemotherapy and reported in a previous study. In this group, the disease-free survival rate was only 32% (20/68) with a much higher incidence of local recurrence (31%). The necessity of making a clear distinction between PNHLB and Ewing's sarcoma is discussed.

Histopathological predictive factors in Ewing's sarcoma of bone and clinicopathological correlations. A retrospective study of 261 cases

A retrospective multifactorial analysis on 261 previously untreated patients with Ewing's sarcoma (Es) of bone has been carried out in order to ascertain the prognostic value of several histological variables on survival. Among those cases accepted as Es, 208 (80% of the patients) were considered to be "typical Es", while 40 (15%) displayed a large cell predominance, being subclassified as "atypical large cell Es". Furthermore, 13 patients (5%) possessed tumours of endothelial-like appearance. Eleven cases which displayed a mixed histological configuration were finally included within one of the three previous groups according to their predominant histological pattern. After adjustment for therapeutic regimens and initial location of the tumour, only two histological characteristics remain significant; i.e. the presence of necrosis (p = 0.002) and, to a lesser degree, the presence of filagree "en damier" pattern (p = 0.08), both of which are of poor prognostic value. From this study, it can be assumed that the morphological (and possibly histogenetical) heterogeneity of Es of bone has no prognostic influence on survival.

Advances in rational combination chemotherapy

Due to the high frequency of micro- or macrometastatic disease at the time of diagnosis of cancer, and to the increasing prevalence of cancer in this country, the use of chemotherapy to evoke cure or prolongation of survival has become critically important. In addition, the growth kinetics of large tumor burdens and the high probability of drug-resistant cells in a tumor mass at the time of diagnosis necessitate combinations of chemotherapeutic agents rather than single agents as the most effective mode of treatment. Since there are 40 to 50 active anticancer drugs now utilized, and since synergy between drug combinations is often dose and/or schedule dependent, the number of possible drug combinations and permutations is vast. Thus, screening for effective drug combinations requires a rational approach which will allow for accurate predictions of synergy. Most advances in this scientific approach have utilized biochemical modulation in conjunction with in vitro cytotoxicity assays, in particular, clonogenic assays. Such an approach has generated a number of drug combinations, such as sequential MTX-5FU, with widely applicable clinical efficacy. The continued use of biochemical modulation should rapidly generate new effective drug combinations which will, hopefully, allow us to cure even those cancers presently considered incurable.

Primary spinal epidural Ewing's sarcoma

A rare case of Ewing's sarcoma, originating primarily in the spinal epidural space is reported. Only five similar case reports are available in the English literature. Full recovery from a state of complete paraplegia, due to malignant compression, local recurrence without distant metastases and the longest survival of more than three years and six months, makes a unique combination. Pathology and therapy are briefly discussed and the pertinent literature reviewed.

Redefined role of radiation in combined treatment of Ewing's sarcoma

Eighty-six patients with Ewing's sarcoma were analyzed as to the role of radiation therapy. Fifty-eight patients (P group) had removal of the involved part of the bone after preoperative chemotherapy, and 28 (NP group) had local treatment either at the same time or before chemotherapy. Thirty-six of 58 P-group patients (61%) and 13 of the 28 NP-group patients (48%) are alive. Five of 48 patients in P-group, who had postoperative radiation, had local recurrence, as did 6 of 11 without postoperative radiation, a statistically significant difference (p = 0.001).

High dose melphalan in children with advanced malignant disease. A pharmacokinetic study

Nine children with poor-prognosis malignancies--seven with advanced neuroblastoma and two with metastatic Ewing's sarcoma--were given high doses of melphalan (HDM), 150 mg/m2 (3 patients) and 180 mg/m2 (6 patients), as a 'late intensification' agent combined with noncryopreserved autologous bone marrow transplants. Melphalan levels in the plasma decreased biphasically, with mean half-lives of 6.6 min and 3.0 h. At the time of marrow reinfusion (12-21 h after HDM) the melphalan plasma level was generally below 0.1 microgram/ml. The renal contribution to melphalan clearance was low, a mean of 5.8% of the injected dose being found in patients' urine over the 12 h following HDM administration. No significant difference was seen in pharmacokinetic parameters between patients undergoing and not undergoing forced diuresis.

Multiagent chemotherapy for sarcoma diagnosed during pregnancy

A 21-year-old, gravida 1, para O, woman presented at approximately 25 weeks gestation with a large Ewing's sarcoma involving her iliac wing. She was treated with multiagent chemotherapy before a successful Cesarean delivery of a normal infant at approximately 34 weeks gestation. Four years later both the mother and child are doing well. The literature regarding sarcoma occurring during pregnancy and that regarding multiagent chemotherapy in pregnant patients is reviewed. Chemotherapy should be instituted early in the course of many malignant sarcomas, despite pregnancy, to prevent the occurrence of metastases.

Local therapy of rhabdomyosarcoma, osteosarcoma and Ewing's sarcoma of children and adolescents

Local control of the primary tumour is a fundamental requirement for clinical cure. Towards this aim, the primary tumour must be diagnosed early and identified histologically. The size, extension, and spread within the patient must be defined precisely. In planning effective local therapy, additional questions must be answered including resectability, mutilation, sensitivity to radio- and chemotherapy, anticipated morbidity from therapeutic measures, etc. For osteosarcoma there is no reasonable alternative to radical surgery. Because of the 20% local recurrence rate of Ewing's sarcoma following radiotherapy, radical surgical removal of the primary tumour should be attempted whenever possible. For rhabdomyosarcoma, particularly for its embryonal histology, non-radical removal of the primary sarcoma is still compatible with a cure, provided adequate radio- and chemotherapy is also administered. Primary irradiation is indicated in radiosensitive unresectable primary tumours and may convert these into an operable state. Chemotherapy is the domain of prevention and treatment of metastatic disease. It has, however, also a proved effect on primary tumours and, in several recent protocols, precedes local therapy.

The value of adjuvant chemotherapy in the management of sarcomas in children

Sarcomas of childhood rank fifth in incidence of malignant tumors in children younger than 15 years. Among the soft tissue sarcomas, approximately 50% are rhabdomyosarcomas. The remainder represent a heterogeneous group of diverse sarcomas which are not unique to children and include fibrosarcoma, synoviosarcoma, malignant fibrous histiocytoma, malignant schwannoma, angiosarcoma, leiomyosarcoma, and others. The most common bone cancers in childhood are osteosarcoma and Ewing's sarcoma. Although a multidisciplinary approach utilizing surgery, irradiation, and combination chemotherapy is routinely used in management of virtually all children with solid tumors, the value of adjuvant chemotherapy in select bone and rare soft tissue sarcomas is currently being tested. Multiagent chemotherapy including vincristine, dactinomycin, cyclophosphamide, and Adriamycin (doxorubicin) contribute to cure rates in 65% to 75% of children with localized rhabdomyosarcoma, Stages I to III, when combined with surgery and/or irradiation. Other drugs which hold promise include platinum, DTIC, methotrexate, and VP-16. The efficacy of similar drugs in the rarer pediatric soft tissue sarcomas other than rhabdomyosarcoma and its variants requires prospective randomized trials evaluating histologic grade, tumor size, and nodal status. It has been suggested that the high-grade sarcomas presenting with minimal tumor bulk are most sensitive to combined radiotherapy-chemotherapy, whereas the low-grade sarcomas are more resistant to such therapy. Tumor cell heterogeneity contributes to biologic diversity and response to treatment. Chemotherapy as adjuvant therapy to irradiation is currently recommended and utilized for Ewing's sarcoma with survival rates approaching 80%, and disease-free survival of approximately 75% for those with localized disease. Children with widespread and metastatic disease at presentation fare less well. Although multiple single agents exhibit response rates ranging from 40% to 60%, including cyclophosphamide, Adriamycin, dactinomycin, BCNU, mithramycin, and 5-fluorouracil, new and more effective agents are needed. Controversy regarding the value of multiagent chemotherapy in osteosarcoma has stimulated prospective randomized trials. Evaluation of local control rates as well as sites and occurrence of metastases are essential in assessing the contribution of aggressive combined modality therapy in the pediatric sarcomas. Emphasis on refinement of therapy in determining the risk/benefit ratio from adjuvant chemotherapy in pediatric sarcomas is mandatory. Enhancement of early local reactions is apparent when adjuvant chemotherapy is used with local radiotherapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Actuarial risk of isolated CNS involvement in Ewing's sarcoma following prophylactic cranial irradiation and intrathecal methotrexate

Records of 154 patients with Ewing's sarcoma treated at the National Cancer Institute were reviewed to assess the incidence and risk of developing isolated central nervous system (CNS) Ewing's sarcoma. Sixty-two of the 154 patients had received CNS irradiation and intrathecal (i.t.) methotrexate as part of their initial therapy to prevent the occurrence of isolated CNS Ewing's sarcoma. The risk of developing isolated CNS Ewing's sarcoma was greatest within the first two years after diagnosis and was approximately 10%. The overall risk of CNS recurrence in the group of patients receiving CNS treatment was similar to the group receiving no therapy directed to the CNS. The occurrence of isolated CNS involvement was not prevented by the use of CNS irradiation and i.t. methotrexate. Because of a lack of efficacy to the CNS irradiation regimen, current treatment regimens do not include therapy directed to the CNS.

Localized Ewing's sarcoma of bone: ten years' experience at the Istituto Ortopedico Rizzoli in 124 cases treated with multimodal therapy

The results obtained in the treatment by multimodal therapy (surgery, radiation therapy and chemotherapy) of 124 cases of Ewing's sarcoma are presented. At a medium follow-up of 65 months 48% of the patients are disease-free. One patient died of leukemia and two patients developed an irradiation-induced sarcoma. Analysing the data, three factors seem to be correlated to prognosis: location of the initial lesion outside the pelvis and sacrum, a four-drug chemotherapy protocol and the use of surgery in the treatment of the initial lesion seem to give better results.

Tumours and pseudotumours of the chest wall

In 78 patients a total of 89 chest wall tumours were considered for surgery between 1960 and 1982. There were 63 neoplasms (12 benign, 51 malignant) and 26 pseudotumours (1 chest wall deformity, 6 inflammatory tumours and 19 hydatid cysts of the chest wall). Radical resection of some kind was possible for 67 tumours and 2 patients underwent palliative resection. Exploratory thoracotomy and biopsy were performed in 9 patients and thoracoscopy and biopsy in 10. One hydatid cyst was managed with mebendazole. There were 11 postoperative complications and three hospital deaths. Chest wall prostheses were used in 13 patients. There was no operative mortality. The mean survival time for the patients with malignant tumour was 12.3 months in pleural mesothelioma and in metastatic pleural tumours, 15.2 months in primary rib tumours and 6.4 months in metastatic rib tumours. There was one death in the benign tumour group and one in the pseudotumour group.

Sequential half-body irradiation (SHBI) and combination chemotherapy as salvage treatment for failed Ewing's sarcoma--a pilot study

This study was undertaken to evaluate the toxicity of sequential half-body irradiation (SHBI) and combination chemotherapy (5-FU, VM-26 and BCNU) in patients who had failed primary aggressive therapy for their Ewing's sarcoma. A secondary goal was to evaluate the response of these previously treated patients to the combination of systemic radiation and multi-agent chemotherapy. The first patient in the study was treated with SHBI only and died 139 days following retreatment. Four subsequent patients successfully received the first cycle of combination chemotherapy. However, only one completed both upper and lower half-body irradiation while the remaining three patients, because of rapid progression of their disease, completed either the upper or the lower portion of their half-body irradiation (HBI). The time from retreatment to disease progression in these four patients ranged from 45 to 97 days (mean 79 days) and the time from retreatment to death ranged from 72 to 193 days (mean 126 days). The combination chemotherapy was tolerated well by all the patients, and the SHBI was accompanied by mild nausea and some vomiting within the first few hours following treatment. Failure to give the second half of the half-body irradiation and to complete further chemotherapy in three of the patients was a result of the progressive nature of the patients' disease and not to any limitations imposed by poor blood counts. Half-body irradiation provided good pain relief within 24 hours for all of the patients. Systemic radiation contributes to the palliative treatment of patients with failed Ewing's sarcoma, but appears to be relatively ineffective when the tumor burden is high.

Intrapleural endodermal sinus tumor arising from the diaphragm

We report a primary endodermal sinus tumor (EST) of the right hemidiaphragm, presenting as a right-sided hemothorax in an 18-month-old female. Four operations were performed, the last three being indicated solely by an elevated level of serum alpha-fetoprotein (AFP). Cyclic chemotherapy with varying drug combinations together with irradiation therapy were not effective in controlling the disease. To our knowledge, this is the first instance of a primary EST arising from the diaphragm.

Use of absorbable mesh to displace bowel and avoid radiation enteropathy, during therapy of pelvic Ewing's sarcoma

The use of absorbable polyglactin 910 mesh (Vicryl) is described in a case of Ewing's sarcoma of the pelvis. An operation was performed to hold the small bowel and colon out of the pelvis for a temporary period during which radical radiotherapy was delivered. The mesh allowed the temporary displacement of bowel and obviated bowel radiation morbidity.

Resection followed by vascularized bone autograft in patients with possible recurrence of malignant bone tumors after conservative treatment

In conservative treatment of malignant bone tumors, assessment of the local condition is difficult. The radiological changes seen in the irradiated tumor and the frequent occurrence of pathological fractures at this site may give rise to the fear that the tumor has relapsed. Resection of the whole of the involved bone is the best way to assure adequate local control but the extent of the bone defect and the bad local conditions secondary to irradiation make reconstruction hazardous. In two patients (one with Ewing's sarcoma of the femur and one with osteogenic sarcoma of the humerus) the authors used a free, vascularized fibular graft for the reconstruction having obtained consolidation of the limb after resection of the irradiated tumor, with preservation of its function. The encouraging results obtained have suggested a conservative attitude as primary treatment of specific malignant bone tumors.

Acute nonlymphocytic leukemia developing during the course of Ewing's sarcoma

Two children with Ewing's sarcoma developed acute nonlymphocytic leukemia (ANLL) during the course of their illness. One patient developed ANLL after apparently successful treatment of his primary malignancy with radiation therapy and multiagent chemotherapy. In the second patient, acute leukemia developed before the administration of radiotherapy or systemic chemotherapy. The development of secondary ANLL after Ewing's sarcoma has been reported only twice previously, most likely representing a therapy-induced complication. The occurrence of ANLL in Patient 2 prior to therapy suggests that these two disorders may have a more than treatment-related association. Close follow-up of long-term survivors of Ewing's sarcoma with surveillance for secondary acute leukemia is advised.

Ewing sarcoma of the hand: literature review and a case report of nonsurgical management

A case of a 12-year-old girl with Ewing sarcoma of the third metacarpal bone is described. Following an incisional biopsy, radiation therapy and adjuvant chemotherapy were given. The girl is now 34 months postdiagnosis and 25 months off therapy in sustained complete remission and functionally normal right hand. Of the seven previously published cases only two are long-term survivors (one had disarticulation, and the other resection of the fourth and fifth rays).

Intensive systemic chemotherapy in localized Ewing's sarcoma in childhood. A historical trial

To assess the value in Ewing's sarcoma of a new multiagent therapy (vincristine, cyclophosphamide, Adriamycin, (doxorubicin) procarbazine), 30 children with a localized tumor (eight distal, nine proximal, 13 central lesions) treated at the Institut Gustave-Roussy between 1973 and 1976 (E3), were pair-matched by site of primary with 30 control patients treated without intensive chemotherapy between 1967 and 1972 (E1) at the same institution, both groups having the same local radiotherapy. Actuarial survival and disease-free survival rates at six years were significantly higher in E3 at P less than 0.01, respectively, 58% and 49% versus 25% in E1. The prognostic value of the primary site was ascertained only in children under chemotherapy. In this group there were six early relapses with death within 14 months and nine late relapses at 21 to 38 months. Among these nine patients, six died, one is living with disease, and two are currently alive in second remission. Fifteen patients are continuously free of disease 50 to 90 months after first treatment (median, 69 months): functional sequelae are minimal in six, moderate in seven, and severe in two children with limb amputation. It is concluded that in future treatments chemotherapy must be intensified and begun prior to local treatment which has to be reevaluated for radiation modalities and for radical surgery indication.

Ewing tumor of rib: radiologic findings and computed tomography contribution

The ribs are frequent sites of primary Ewing tumor accounting for about 10-12% of all cases. The lesions may be predominantly lytic or sclerotic or show a combination of bone destruction and secondary reactive changes. In some patients bony changes are subtle and are obscured initially by frequently associated large extrapleural masses or pleural fluid. These patients may present clinically with findings secondary to compression of mediastinal structures by the soft tissue masses. Computed tomography (CT) is of great value in the diagnosis of such difficult cases and better demonstrates the tumor extent and relationships than other available imaging modalities. CT is also of considerable help in determining the optimal time for en bloc tumor resection. Many tumors are initially considered non-resectable due to extensive involvement of the lung, the mediastinum, or the diaphragm. CT accurately documents tumor regression during preoperative courses of chemotherapy.

VM-26 and dimethyl triazeno imidazole carboxamide in Ewing's sarcoma

Twenty-seven patients with biopsy proven Ewing's sarcoma were randomised to receive one of two adjuvant chemotherapy regimens for two years. Group A were given monthly courses of vincristine, adriamycin and dimethyl triazeno imidazole carboxamide (DIC); Group B received monthly courses of VM-26, adriamycin and DIC. Chemotherapy was commenced after biopsy confirmation of disease. The primary tumour was treated with irradiation to 3,000-5,000 rad and by resection in three patients. With a median follow-up of 26 months, 52% of patients are disease free. Ten patients died, seven from recurrent disease and three from complications of treatment. There was a significant difference in disease free survival rate of patients with long bone lesions (11/12) compared with patients with flat bone lesions (6/15). The disease free survival rate of Groups A and B was similar. Our results suggest that in combination chemotherapy for Ewing's sarcoma, vincristine and VM-26 have similar anti-tumour activity.

Scanning and transmission electron microscopy of Ewing's sarcoma of bone (typical and atypical variants). An analysis of nine cases

Scanning electron microscopy (SEM) is of value for the differential diagnosis of Ewing's tumor of bone. Based upon 9 new cases which were observed with SEM and TEM (transmission electron microscopy), this paper puts into consideration, for the first time, the SEM ultrastructure of Ewing's sarcoma (both variants; typical Ewing's sarcoma and the large cell Ewing's sarcoma). Furthermore, a new case of vascular Ewing's sarcoma, studied with TEM, is discussed and included in the differential diagnosis with other round cell sarcomas of bone. Both Ewing's sarcoma types evidence common ultrastructural characteristics, but the atypical variant (large cell type) shows a greater variation in cell size and contour. The cell surfaces displayed smooth structures, interrupted only by clusters of short, stub-like microvilli. Isolated cilia were also observed. Variations in cell contour and size within the same tumour are also induced through intensive chemotherapy, as noted in one of our cases. SEM seems to be suitable for the differentiation of Ewing's tumours from other primary malignancies of the bone marrow, as is the case of the so-called "reticulum cell sarcoma of bone" or malignant non-Hodgkin lymphoma. SEM studies associated with TEM give further support to the mesenchymal origin of this neoplasm.

Initial and long-term results in the management of primary chest wall neoplasms

One hundred ten patients with primary chest wall neoplasms were analyzed for long-term results. The diagnosis of 59 malignant and 51 benign tumors was confirmed by the Armed Forces Institute of Pathology. No deaths were associated with primary definitive therapy. Among the five most frequently encountered malignant tumor types, five-year survivals were obtained in 9 of 17 (53%) patients with fibrosarcoma, 8 of 9 (89%) patients with chondrosarcoma, 2 of 8 (25%) patients with solitary chest wall plasmacytoma (multiple myeloma), 1 of 6 (17%) patients with Ewing's sarcoma, and 2 of 4 (50%) of patients with osteogenic sarcoma. Although the five-year survival appears to indicate therapeutic success in patients with Ewing's sarcoma and osteogenic sarcoma, patients with chondrosarcoma or fibrosarcoma may have a more protracted course, and those with solitary plasmacytoma usually develop multiple myeloma. The findings suggest that radical surgical excision is the treatment of choice for chondrosarcoma; radical surgical excision combined with chemotherapy, for fibrosarcoma and osteogenic sarcoma; surgical excision combined with radiation and chemotherapy, for Ewing's sarcoma; and systemic surveillance and therapy, for pathologically confirmed solitary plasmacytoma.

Sequential half-body irradiation as systemic treatment of progressive Ewing sarcoma

Sequential half-body irradiation (HBI) to be delivered in two sessions was used in 18 consecutive patients with metastatic Ewing sarcoma who relapsed after radiotherapy and multidrug chemotherapy. The HBI program to both upper and lower hemi body was completed in 11 patients (61%). The remaining 7 patients received only one single treatment of HBI because of relapse before the completion of the treatment program. In 20 of the 29 sessions HBI was employed to treat overt metastases. The overall objective response rate was 50%. Six of 18 patients (33%) are alive from 4 to 27 months, 3 of them without evidence of disease. No severe toxicity was observed. HBI as systemic treatment was more effective in patients who relapsed while off chemotherapy, with metastases confined to the lungs or to one single bone segment.

Impaired PWM-induced polyclonal B-cell activation in patients with malignancies treated with various intermittent combination chemotherapies including doxorubicin

The effect of various intermittent combination chemotherapies on the immune status of 30 patients with malignancies was examined 1-3 weeks after they received their last injection. PWM-induced polyclonal B-cell activation of lymphocytes from patients treated with combination chemotherapies that included doxorubicin was impaired despite a normal 3H-thymidine uptake by lymphocytes stimulated with PHA, PWM, and insoluble SPA. This suppressive effect was always found in patients with ALL. However, in patients with solid tumors, PWM-induced immunoglobulin production returned to normal 7-8 weeks after the last doxorubicin injection. Serum immunoglobulin levels in patients treated with doxorubicin were slightly lower than in those treated without doxorubicin. It is hypothesized that doxorubicin may change the lymphocyte surface membrane and interrupt the T- and B-cell interaction that is needed for immunoglobulin production.

The treatment of localized Ewing's sarcoma: the experience at the Istituto Ortopedico Rizzoli in 163 cases treated with and without adjuvant chemotherapy

Eighty consecutive patients with localized Ewing's tumor treated with adjuvant chemotherapy for two years plus local tumor control were retrospectively reviewed. Adjuvant chemotherapy protocol was constant for all patients, but local treatment consisted of amputation, resection (complete or incomplete) plus radiotherapy, or radiotherapy alone. The follow-up ranged from 21--101 months (mean = 50 months). The mortality rate and incidence of metastasis were significantly lower than in a comparable group of 83 patients previously treated by radiotherapy, or surgery plus radiotherapy but without chemotherapy. The percentage of local recurrence was not significantly different between the two groups. Of the patients treated with adjuvant chemotherapy, the percentage of local recurrence and metastases was much lower when the primary lesion was located in the extremities and when this lesion was treated by conservative surgery followed by irradiation. This was also true when the resection was not complete. Little discrepancy in functional results was observed using either resection plus radiotherapy or radiotherapy alone. The above data suggest that in treating Ewing's sarcoma, conservative surgery, even incomplete, can play an important role when associated with radiotherapy and adjuvant chemotherapy.

Ewing's sarcoma: 5-year survival under adjuvant chemotherapy

The results at 5 years of an adjuvant chemotherapy trial in primary Ewing's sarcoma, started in 1973, are presented. Twenty-three eligible patients were treated with radiotherapy (60 Gy) to the tumor site and given polychemotherapy either using the E3 protocol (12 patients) or the E76 protocol (11 patients). Overall survival at 5 years was 37%, with 34% disease-free survival. There was no significant difference between the two chemotherapy groups. Only three local relapses and one major orthopedic failure were reported. Among the distal relapses, no metastases to the brain have been observed. These results are encouraging and show a clear improvement over the classical survival rate. However, further improvement is necessary and may be obtained by using new active drugs, as well as earlier and probably more aggressive cyclic chemotherapy. But primary surgical amputation and prophylactic CNS irradiation are not indicated for treatment of primary Ewing's sarcoma.

Early results of combined modality therapy of patients with Ewing's sarcoma

Fourteen patients with localized Ewing's sarcoma were treated with radiation therapy to the involved bone and systemic chemotherapy. Nine patients remained free of disease for a median follow-up period of 3 years. The actuarial 5-year disease-free survival rate is 60%.

Ewing's sarcoma: treatment with high-dose radiation and adjuvant chemotherapy

Twenty-nine patients with pathologically proven Ewing's sarcoma without overt metastases at diagnosis were treated with a protocol designed by The Royal Marsden and St. Bartholomew's Hospital Children's Solid Tumour Group. They received megavoltage radiotherapy to the involved bone and adjuvant chemotherapy with a combination of four cytotoxic drugs. Comparison with a historical control group of 19 patients treated with local surgery or radiotherapy but no initial chemotherapy shows a significant improvement in survival for the study group (P = 0.022). Thirteen patients have failed on the protocol: eight at the original site, four in other bones and only one in the lungs. Sixteen patients remain alive and disease free, 11 of these for over 33 months. The treatment regimen was moderately toxic but there were no treatment-related deaths. These results confirm that an improved survival time and, hopefully, cure rate can be expected by treating Ewing's tumour with high-dose megavoltage radiation and combination chemotherapy. Future goals must be better control of primary lesions and eradication of micrometastases in other bones.

A prospective randomized clinical trial of total parenteral nutrition in children with cancer

A prospective randomized clinical trial was undertaken to test the efficacy of total parenteral nutrition (TPN) among previously untreated children receiving abdominal/pelvic irradiation with or without adjuvant chemotherapy who were at risk for weight loss, malnutrition, and complications from treatment. Children were evaluated by weight/height determinations, anthropomorphic measurements, and laboratory studies. TPN was associated with an improved nutritional status during therapy as compared with control patients on ad libitum intake. However, when TPN was discontinued, weight declined and there were no differences among treated and control patients detected at three-month follow-up. Likewise there was no obvious effect from TPN on tolerance to therapy in the adequately nourished child. TPN as initial supportive therapy should be reserved for those children who are malnourished or marginally malnourished at the time of presentation. Close nutritional assessment during treatment is essential since approximately 25% of children undergoing abdominal/pelvic radiotherapy with chemotherapy can be expected to become malnourished during an initial course of therapy.

Acute monocytic leukemia complicating combined-modality therapy for localized childhood Ewing's sarcoma

Rapidly fatal acute monocytic leukemia occurred in an 11-year-old by 33 months after the beginning of irradiation and chemotherapy for non-metastatic pelvic Ewing's sarcoma. At autopsy, no recurrent primary disease was seen. An analysis of this case together with a review of the literature suggests therapy-related leukemogenesis. Thus, the decline in mortality rate for childhood cancer may be accompanied by an increased incidence of second neoplasms in cured children having the potential of a normal life span.

Ewing's sarcoma: ten-year experience with adjuvant chemotherapy

Since May 1970, 67 consecutive patients with primary (nonmetastatic) Ewing's sarcoma were treated with adjuvant chemotherapy (CT) in addition to radiation therapy (RT) or surgery for the primary tumor. The first 19 patients were treated with four-drug sequential CT (T-2). The second protocol was a seven-drug induction combination CT (T-6) followed by T-2 maintenance CT; in both protocols CT was continued for 18 months. The current protocol (T-9) consists of combination CT given continuously for a period of 9 months. Of the entire group of 67 patients, 47 (70%) had axial and proximal lesions (pelvis, spine, rib, humerus, and femur) and 20 (30%) had distal lesions (forearm, leg, and foot); 53/67 (79%) are surviving free of disease 12--118 months (median 41 months) from the start of treatment. Fifteen of 23 (65%) patients with axial lesions, 19/24 (79%) patients with proximal lesions, and 19/20 (95%) patients with distal lesions are free of disease. Disease-free survivors include 28/39 (72%) male patients and 25/28 (89%) female patients. Thirty-four patients had RT, and 33 had surgery or surgery and RT, in addition to chemotherapy, for local treatment. The disease-free survival rate was 76% in the RT group and 82% in the surgery group; failure in the RT group was attributable to local recurrence in 7/34 (21%) patients. Recent experience with T-9 CT has demonstrated that CT given prior to RT or surgery can cause a great reduction in the size of the primary tumor while allowing the pathologically-eroded bone to heal prior to the initiation of RT; this also allows the high-risk patient with an axial primary (pelvis or spine) to tolerate the aggressive CT needed to prevent distant metastases. In addition to dramatically increasing survival in patients with Ewing's sarcoma, combination CT has helped achieve permanent local control. The superior survival rates for all sites of primary tumor are attributable to the early use of aggressive combination CT.

Radiotherapy and combination chemotherapy in advanced Ewing's Sarcoma-Intergroup study

Forty-four patients with metastatic (36 patients) and advanced regional (eight patients) Ewing's sarcoma were treated on a protocol employing intensive combination chemotherapy and radiotherapy to all sites of overt disease (primary site and metastatic sites). Thirty-one patients achieved a complete remission, eight achieved a partial remission, and five patients did not respond to treatment. Of the 31 patients who achieved a complete remission (12 had metastases and six had regional spread), 18 remained disease-free with a median follow-up of 34 months, while recurrences occurred in nine patients. Four patients died of complications of treatment. Although late relapses can still be expected, it appears that intensive multimodal management in metastatic Ewing's sarcoma can produce prolonged disease-free survival and possibly cure in a significant percentage of patients.

Leg function after radiotherapy for Ewing's sarcoma

Twenty-nine patients with Ewing's sarcoma of the lower extremity who survived for two or more years following therapy (5000 rad locally and systemic chemotherapy) were studied to assess functional status of the affected leg. Twenty-two of twenty-nine were alive and were reexamined; the deceased patients were evaluated by record review. Twenty-two of the twenty-nine had serial radiographs, which were reviewed to assess growth change induced by radiation. The living patients were divided on the basis of clinical examination into four functional groups with Group I comprising patients with minor functional limitations and leg length discrepancy 1.5 cm or less. Group II patients had moderate functional limitations with 2.5-cm leg-length discrepancy or less. Group III patients had severe functional limitations with up to 4-cm leg length discrepancy. Group IV patients had severe complications, sufficient enough to warrant amputation. Thirteen of twenty-two patients were classified as functional Group I, five as Group II, three as Group III, and one as Group IV. Radiographic changes in growing bone did not correlate with functional results. Although a femoral fracture and an age less than 16 years at diagnosis were found to be less favorable prognostic factors for the functional treatment result, these results show that neither femoral location nor young age justify primary amputation for Ewing's sarcoma of the lower leg extremity.