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Dantonello TM, Stark M, Timmermann B, Fuchs J, Selle B, Linderkamp C, Handgretinger R, Hagen R, Feuchtgruber S, Kube S, Kosztyla D, Kazanowska B, Ladenstein R, Niggli F, Ljungman G, Bielack SS, Klingebiel T, Koscielniak E. Tumour volume reduction after neoadjuvant chemotherapy impacts outcome in localised embryonal rhabdomyosarcoma. Pediatr Blood Cancer 2015; 62:16-23. [PMID: 25263634 DOI: 10.1002/pbc.25207] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/07/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Response (tumour volume reduction) to induction chemotherapy has been used to stratify secondary local and systemic treatment of Intergroup Rhabdomyosarcoma Study Group III (IRSG-III) embryonal rhabdomyosarcoma (RME) in consecutive CWS-trials. To evaluate its actual impact we studied response-related treatment and outcomes. PROCEDURE Patients with IRSG-III RME <21 years and non-response (NR, <33% volume reduction) in five consecutive CWS-trials were analysed and compared with partial responders (PAR, ≥ 33% reduction). The NR was reviewed and sub-classified as Objective Response (OR, <0%-33% reduction) or Stable/Progressive Disease (SPD). RESULTS Fifty-nine of 529 patients had NR (n = 34 OR, n = 25 SPD). Primary risk-factors including age, tumour size, and TN-classification did not differ between NR and PAR groups but NR had more patients with unfavourable sites comparatively (P = 0.04). There were no differences in primary risk-factors between OR and SPD. Significant factors associated with poor outcome in multivariate analysis were NR, TN-classification, age >10 years, tumour size >5 cm and therapy in older trials. After response assessment n = 24 NR continued to receive induction chemotherapy, n = 32 received other combinations and n = 3 no further chemotherapy. Forty-two non-responders were irradiated, and the tumours were completely resected in n = 20. After a median follow-up of 8 years, 34 NR are alive. Seventeen of 21 failures leading to disease-related deaths were locoregional. The five-year overall survival rate (OS) was 76 ± 4% for PAR, 79 ± 14% for OR, but only 40 ± 19% for SPD (P < 0.001). CONCLUSION Response to induction chemotherapy appears to be an important surrogate marker of poor outcome in patients with SPD largely due to ineffective local control.
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Affiliation(s)
- Tobias M Dantonello
- Paediatrics 5 (oncology, hematology, immunology), Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
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202
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Rodeberg DA, Wharam MD, Lyden ER, Stoner JA, Brown K, Wolden SL, Paidas CN, Donaldson SS, Hawkins DS, Spunt SL, Arndt CA. Delayed primary excision with subsequent modification of radiotherapy dose for intermediate-risk rhabdomyosarcoma: a report from the Children's Oncology Group Soft Tissue Sarcoma Committee. Int J Cancer 2014; 137:204-11. [PMID: 25418440 DOI: 10.1002/ijc.29351] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 10/09/2014] [Indexed: 12/19/2022]
Abstract
The majority of intermediate-risk rhabdomyosarcoma (RMS) patients have gross residual disease (Group III) after their first operative procedure. It is currently not known if local control rates can be maintained when, following induction chemotherapy, the radiation therapy (RT) dose is decreased after a delayed primary excision (DPE). To answer this question we evaluated patients enrolled on COG D9803 (1999-2005) who had Group III tumors of the bladder dome, extremity or trunk (thorax, abdomen and pelvis) were candidates for DPE at Week 12 if the primary tumor appeared resectable. RT dose was then adjusted by the completeness of DPE: no evidence of disease 36 Gy, microscopic residual 41.4 Gy and gross residual disease (GRD) 50.4 Gy. A total of 161 Group III patients were evaluated (24 bladder dome, 63 extremity and 74 trunk). Seventy-three patients (45%) underwent DPE which achieved removal of all gross disease in 61 (84%) who were then eligible for reduced RT dose (43/73 received 36 Gy, 19/73 received 41.4 Gy). The local 5-year failure rate (0% for bladder dome, 7% for extremity and 20% for trunk) was similar to IRS-IV, which did not encourage DPE and did not allow for DPE adapted RT dose reduction. In conclusion, DPE was performed in 45% of Group III RMS patients with tumors at select anatomic sites (bladder dome, extremity and trunk) and 84% of those who had DPE were eligible for RT dose reduction. Local control outcomes were similar to historic results with RT alone.
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203
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Altaf S, Enders F, Lyden E, Donaldson SS, Rodeberg D, Arndt C. Age-related toxicity in patients with rhabdomyosarcoma: a report from the children's oncology group. J Pediatr Hematol Oncol 2014; 36:599-604. [PMID: 24936741 PMCID: PMC4205169 DOI: 10.1097/mph.0000000000000192] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
On the Fourth Intergroup Rhabdomyosarcoma study, older children experienced excessive neurotoxicity, whereas younger children had increased myelosuppression. The purpose of this study was to determine whether the same pattern of toxicity was seen on the successor study when use of growth factor was required and dosing of chemotherapy was different by performing a retrospective cohort analysis on patients treated on Children's Oncology Group protocol D9803. Toxicity data were analyzed by stratifying children into 4 age groups. The frequency of grade 3/4 neurotoxicity, myelosuppression, infection, and mucositis was predicted for each age group. The cumulative doses of vincristine and cyclophosphamide administered were measured as percent of protocol-prescribed dose. Adolescents (aged 15+) were more likely to experience neurotoxicity compared with younger patients (odds ratio, 3.6; P<0.0001). There was no difference in myelosuppression, infection, or mucositis. The mean percent protocol-prescribed doses administered for vincristine and cyclophosphamide did not differ much by age group. Adolescents experienced more neurotoxicity with vincristine compared with younger patients. No differences in other toxicities were observed between age groups. As adolescents received at least 85% of protocol-prescribed doses of vincristine, it is difficult to attribute the poorer survival in this age group to inadequate protocol-delivered therapy.
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Affiliation(s)
- Sadaf Altaf
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Rochester MN
| | | | - Elizabeth Lyden
- University of Nebraska Medical Center, Preventive and Societal Medicine, Omaha, NE
| | | | - David Rodeberg
- East Carolina University, Division of Pediatric Surgery, Greenville NC
| | - Carola Arndt
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Rochester MN
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Ladra MM, Szymonifka JD, Mahajan A, Friedmann AM, Yong Yeap B, Goebel CP, MacDonald SM, Grosshans DR, Rodriguez-Galindo C, Marcus KJ, Tarbell NJ, Yock TI. Preliminary results of a phase II trial of proton radiotherapy for pediatric rhabdomyosarcoma. J Clin Oncol 2014; 32:3762-70. [PMID: 25332253 DOI: 10.1200/jco.2014.56.1548] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This prospective phase II study was designed to assess disease control and to describe acute and late adverse effects of treatment with proton radiotherapy in children with rhabdomyosarcoma (RMS). PATIENTS AND METHODS Fifty-seven patients with localized RMS (age 21 years or younger) or metastatic embryonal RMS (age 2 to 10 years) were enrolled between February 2005 and August 2012. All patients were treated with chemotherapy based on either vincristine, actinomycin, and cyclophosphamide or vincristine, actinomycin, and ifosfamide-based chemotherapy and proton radiation. Surgical resection was based on tumor site and accessibility. Common Terminology Criteria for Adverse Events, Version 3.0, was used to assess and grade adverse effects of treatment. Concurrent enrollment onto Children's Oncology Group or European Pediatric Sarcoma Study Group protocols was allowed. All pathology and imaging were reviewed at the treating institution. RESULTS Median follow-up was 47 months (range, 14 to 102 months) for survivors. Five-year event-free survival (EFS), overall survival (OS), and local control (LC) were 69%, 78%, and 81%, respectively, for the entire cohort. The 5-year LC by risk group was 93% for low-risk and 77% for intermediate-risk disease. There were 13 patients with grade 3 acute toxicity and three patients with grade 3 late toxicity. There were no acute or late toxicities higher than grade 3. CONCLUSION Five-year LC, EFS, and OS rates were similar to those observed in comparable trials that used photon radiation. Acute and late toxicity rates were favorable. Proton radiation appears to represent a safe and effective radiation modality for pediatric RMS.
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Affiliation(s)
- Matthew M Ladra
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jackie D Szymonifka
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anita Mahajan
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alison M Friedmann
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Beow Yong Yeap
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claire P Goebel
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shannon M MacDonald
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David R Grosshans
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos Rodriguez-Galindo
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen J Marcus
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy J Tarbell
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Torunn I Yock
- Matthew M. Ladra, Jackie Szymonifka, Alison M. Friedmann, Beow Yong Yeap, Claire Goebel, Shannon M. MacDonald, Nancy J. Tarbell, Torunn I. Yock Massachusetts General Hospital, Harvard Medical School;, Carlos Rodriguez-Galindo, Karen J. Marcus, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Anita Mahajan and David Grosshans, The University of Texas MD Anderson Cancer Center, Houston, TX.
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205
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Ladra MM, Edgington SK, Mahajan A, Grosshans D, Szymonifka J, Khan F, Moteabbed M, Friedmann AM, MacDonald SM, Tarbell NJ, Yock TI. A dosimetric comparison of proton and intensity modulated radiation therapy in pediatric rhabdomyosarcoma patients enrolled on a prospective phase II proton study. Radiother Oncol 2014; 113:77-83. [PMID: 25443861 DOI: 10.1016/j.radonc.2014.08.033] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 08/10/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pediatric rhabdomyosarcoma (RMS) is highly curable, however, cure may come with significant radiation related toxicity in developing tissues. Proton therapy (PT) can spare excess dose to normal structures, potentially reducing the incidence of adverse effects. METHODS Between 2005 and 2012, 54 patients were enrolled on a prospective multi-institutional phase II trial using PT in pediatric RMS. As part of the protocol, intensity modulated radiation therapy (IMRT) plans were generated for comparison with clinical PT plans. RESULTS Target coverage was comparable between PT and IMRT plans with a mean CTV V95 of 100% for both modalities (p=0.82). However, mean integral dose was 1.8 times higher for IMRT (range 1.0-4.9). By site, mean integral dose for IMRT was 1.8 times higher for H&N (p<0.01) and GU (p=0.02), 2.0 times higher for trunk/extremity (p<0.01), and 3.5 times higher for orbit (p<0.01) compared to PT. Significant sparing was seen with PT in 26 of 30 critical structures assessed for orbital, head and neck, pelvic, and trunk/extremity patients. CONCLUSIONS Proton radiation lowers integral dose and improves normal tissue sparing when compared to IMRT for pediatric RMS. Correlation with clinical outcomes is necessary once mature long-term toxicity data are available.
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Affiliation(s)
- Matthew M Ladra
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Anita Mahajan
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Fazal Khan
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Maryam Moteabbed
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | | | - Nancy J Tarbell
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Torunn I Yock
- Massachusetts General Hospital, Harvard Medical School, Boston, USA.
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206
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Merks JHM, De Salvo GL, Bergeron C, Bisogno G, De Paoli A, Ferrari A, Rey A, Oberlin O, Stevens MCG, Kelsey A, Michalski J, Hawkins DS, Anderson JR. Parameningeal rhabdomyosarcoma in pediatric age: results of a pooled analysis from North American and European cooperative groups. Ann Oncol 2014; 25:231-6. [PMID: 24356633 DOI: 10.1093/annonc/mdt426] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Parameningeal (PM) site is a well-known adverse prognostic factor in children with localized rhabdomyosarcoma (RMS). To identify risk factors associated with outcome at this site, we pooled data from 1105 patients treated in 10 studies conducted by European and North American cooperative groups between 1984 and 2004. PATIENTS AND METHODS Clinical factors including age, histology, size, invasiveness, nodal involvement, Intergroup Rhabdomyosarcoma Study (IRS) clinical group, site, risk factors for meningeal involvement (MI), study group, and application of radiotherapy (RT) were studied for their impact on event-free and overall survival (EFS and OS). RESULTS Ten-year EFS and OS were 62.6 and 66.1% for the whole group. Patients without initial RT showed worse survival (10-year OS 40.8% versus 68.5% for RT treated patients). Multivariate analysis focusing on 862 patients who received RT as part of their initial treatment revealed four unfavorable prognostic factors: age <3 or >10 years, signs of MI, unfavorable site, and tumor size. Utilizing these prognostic factors, patients could be classified into different risk groups with 10-year OS ranging between 51.1 and 80.9%. CONCLUSIONS While, in general, PM localization is regarded as an adverse prognostic factor, the current analysis differentiates those with good prognosis (36% patients with 0-1 risk factor: 10-year OS 80.9%) from high-risk PM patients (28% with 3-4 factors: 10-year OS 51.1%). Furthermore, this analysis reinforces the necessity for RT in PM RMS.
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Affiliation(s)
- J H M Merks
- Department of Pediatric Oncology, Emma Children's Hospital-Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Egas-Bejar D, Huh WW. Rhabdomyosarcoma in adolescent and young adult patients: current perspectives. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2014; 5:115-25. [PMID: 24966711 PMCID: PMC4069040 DOI: 10.2147/ahmt.s44582] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Rhabdomyosarcoma (RMS), a malignant tumor of mesenchymal origin, is the third most common extracranial malignant solid tumor in children and adolescents. However, in adults, RMS represents <1% of all solid tumor malignancies. The embryonal and alveolar histologic variants are more commonly seen in pediatric patients, while the pleomorphic variant is rare in children and seen more often in adults. Advances in the research of the embryonal and alveolar variants have improved our understanding of certain genes and biologic pathways that are involved in RMS, but much less is known for the other variants. Multimodality therapy that includes surgery and chemotherapy with or without radiation therapy is the mainstay of treatment for RMS. Improvements in the risk stratification of the pediatric patients based on presurgical (primary tumor site, tumor size, regional lymph node involvement, presence of metastasis) and postsurgical parameters (completeness of resection or presence of residual disease or metastasis) has allowed for the treatment assignment of patients in different studies and therapeutic trials, leading to increases in 5-year survival from 25%–70% over the past 40 years. However, for adult patients, in great part due to rarity of the disease and the lack of consensus on optimal treatment, clinical outcome is still poor. Many factors have been implicated for the differing outcomes between pediatric RMS versus adult RMS, such as the lack of standardized treatment protocols for adult RMS patients and the increased prevalence of advanced presentations. Now that there are increased numbers of survivors, we can appreciate the sequelae from therapy in these patients, such as bone growth abnormalities, endocrinopathies, and infertility. Improvements in risk stratification have led to clinical trials using lower doses of chemotherapy or radiation therapy with the intention of decreasing the incidence of side effects without compromising survival outcome.
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Affiliation(s)
- Daniela Egas-Bejar
- Division of Pediatrics, The Children's Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Winston W Huh
- Division of Pediatrics, The Children's Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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208
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Pappo AS, Vassal G, Crowley JJ, Bolejack V, Hogendoorn PCW, Chugh R, Ladanyi M, Grippo JF, Dall G, Staddon AP, Chawla SP, Maki RG, Araujo DM, Geoerger B, Ganjoo K, Marina N, Blay JY, Schuetze SM, Chow WA, Helman LJ. A phase 2 trial of R1507, a monoclonal antibody to the insulin-like growth factor-1 receptor (IGF-1R), in patients with recurrent or refractory rhabdomyosarcoma, osteosarcoma, synovial sarcoma, and other soft tissue sarcomas: results of a Sarcoma Alliance for Research Through Collaboration study. Cancer 2014; 120:2448-56. [PMID: 24797726 DOI: 10.1002/cncr.28728] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 12/23/2013] [Accepted: 12/24/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Insulin-like growth factor-1 receptor (IGF-1R) is implicated in the pathogenesis of rhabdomyosarcoma (RMS), osteosarcoma (OS), and synovial sarcoma (SS). The authors conducted a multi-institutional phase 2 trial of the monoclonal antibody R1507 in patients with various subtypes of recurrent or refractory sarcomas. METHODS Eligibility criteria included age ≥ 2 years and a diagnosis of recurrent or refractory RMS, OS, SS, and other soft tissue sarcomas. Patients received a weekly dose of 9 mg/kg R1507 intravenously. The primary endpoint was the best objective response rate using World Health Organization criteria. Tumor imaging was performed every 6 weeks × 4 and every 12 weeks thereafter. RESULTS From December 2007 through August 2009, 163 eligible patients from 33 institutions were enrolled. The median patient age was 31 years (range, 7-85 years). Histologic diagnoses included OS (n = 38), RMS (n = 36), SS (n = 23), and other sarcomas (n = 66). The overall objective response rate was 2.5% (95% confidence interval, 0.7%-6.2%). Partial responses were observed in 4 patients, including 2 patients with OS, 1 patient with RMS, and 1 patient with alveolar soft part sarcoma. Four additional patients (3 with RMS and 1 with myxoid liposarcoma) had a ≥ 50% decrease in tumor size that lasted for <4 weeks. The median progression-free survival was 5.7 weeks, and the median overall survival was 11 months. The most common grade 3/4 toxicities were metabolic (12%), hematologic (6%), gastrointestinal (4%), and general constitutional symptoms (8%). CONCLUSIONS R1507 is safe and well tolerated but has limited activity in patients with recurrent or refractory bone and soft tissue sarcomas. Additional studies to help identify the predictive factors associated with clinical benefit in selected histologies such as RMS appear to be warranted.
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Affiliation(s)
- Alberto S Pappo
- Solid Tumor Division, St. Jude Children's Research Hospital, Memphis, Tennessee
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight some of the advances in the way we think about rhabdomyosarcoma (RMS). Recent outcome and biological analyses have shifted the risk stratification and treatment paradigms for pediatric RMS. RECENT FINDINGS The presence or absence of the FOXO1 translocation is one of the most important prognostic factors in RMS. Future clinical studies will incorporate FOXO1 translocation status within risk stratification criteria. Molecular analyses have identified RAS/NF1, hedgehog, IL-4R, and ALK pathway abnormalities as potential therapeutic targets in RMS. Reductions in systemic therapy are possible, although radiation therapy remains essential to prevent local failures in most patients. SUMMARY Although survival for RMS has not improved in recent years, refinement in risk stratification, further understanding of the biological drivers of the disease, and modifications in treatment intensity have set the stage for the next generation of studies in RMS.
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Proton radiotherapy for pediatric sarcoma. Cancers (Basel) 2014; 6:112-27. [PMID: 24424260 PMCID: PMC3980591 DOI: 10.3390/cancers6010112] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 11/16/2022] Open
Abstract
Pediatric sarcomas represent a distinct group of pathologies, with approximately 900 new cases per year in the United States alone. Radiotherapy plays an integral role in the local control of these tumors, which often arise adjacent to critical structures and growing organs. The physical properties of proton beam radiotherapy provide a distinct advantage over standard photon radiation by eliminating excess dose deposited beyond the target volume, thereby reducing both the dose of radiation delivered to non-target structures as well as the total radiation dose delivered to a patient. Dosimetric studies comparing proton plans to IMRT and 3D conformal radiation have demonstrated the superiority of protons in numerous pediatric malignancies and data on long-term clinical outcomes and toxicity is emerging. In this article, we review the existing clinical and dosimetric data regarding the use of proton beam radiation in malignant bone and soft tissue sarcomas.
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211
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Early response as assessed by anatomic imaging does not predict failure-free survival among patients with Group III rhabdomyosarcoma: a report from the Children's Oncology Group. Eur J Cancer 2013; 50:816-23. [PMID: 24361229 DOI: 10.1016/j.ejca.2013.11.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/24/2013] [Accepted: 11/26/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prognostic significance of response to induction therapy for rhabdomyosarcoma (RMS) by anatomic imaging [computerised tomographic (CT) or magnetic resonance imaging (MRI) scan] is controversial. We previously reported no relationship between early response and failure-free survival (FFS) on Intergroup Rhabdomyosarcoma Study (IRS)-IV. We repeated the same analysis using a more recent clinical trial as an independent cohort of patients with non-metastatic, initially unresected RMS. METHODS A total of 338 patients enrolled in Children's Oncology Group (COG) study D9803 met the inclusion criteria for this analysis: (1) non-metastatic, initially unresected (Group III); (2) embryonal (ERMS) or alveolar (ARMS) histology; (3) documented protocol week 12 response to induction chemotherapy (excluding progressive disease) based on anatomic imaging (CT/MRI) and (4) documented protocol therapy beyond week 12. Response at week 12 was determined by the treating institution as complete response (CR), partial response (PR) or no response (NR). FFS was estimated using the Kaplan-Meier method and comparisons between patient subsets were made using the log-rank test. RESULTS Overall objective response rate (CR+PR) at week 12 of therapy was 85% and was similar between ERMS and ARMS. FFS was similar among all patients with CR, PR or NR (p=0.49). Restricting the analysis to either ERMS or ARMS, there was no difference in FFS by response within either histology subset (p=0.89 and p=0.08, respectively). CONCLUSIONS These findings provide additional evidence that anatomic imaging to assess early response to therapy among patients with RMS does not predict outcome and has questionable use in tailoring subsequent therapy.
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Spalding AC, Hawkins DS, Donaldson SS, Anderson JR, Lyden E, Laurie F, Wolden SL, Arndt CAS, Michalski JM. The effect of radiation timing on patients with high-risk features of parameningeal rhabdomyosarcoma: an analysis of IRS-IV and D9803. Int J Radiat Oncol Biol Phys 2013; 87:512-6. [PMID: 24074925 DOI: 10.1016/j.ijrobp.2013.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 06/27/2013] [Accepted: 07/02/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Radiation therapy remains an essential treatment for patients with parameningeal rhabdomyosarcoma (PMRMS), and early radiation therapy may improve local control for patients with intracranial extension (ICE). METHODS AND MATERIALS To address the role of radiation therapy timing in PMRMS in the current era, we reviewed the outcome from 2 recent clinical trials for intermediate-risk RMS: Intergroup Rhabdomyosarcoma Study (IRS)-IV and Children's Oncology Group (COG) D9803. The PMRMS patients on IRS-IV with any high-risk features (cranial nerve palsy [CNP], cranial base bony erosion [CBBE], or ICE) were treated immediately at day 0, and PMRMS patients without any of these 3 features received week 6-9 radiation therapy. The D9803 PMRMS patients with ICE received day 0 X-Ray Therapy (XRT) as well; however, those with either CNP or CBBE had XRT at week 12. RESULTS Compared with the 198 PMRMS patients from IRS-IV, the 192 PMRMS patients from D9803 had no difference (P<.05) in 5-year local failure (19% vs 19%), failure-free-survival (70% vs 67%), or overall survival (75% vs 73%) in aggregate. The 5-year local failure rates by subset did not differ when patients were classified as having no risk features (None, 15% vs 19%, P=.25), cranial nerve palsy/cranial base of skull erosion (CNP/CBBE, 15% vs 28%, P=.22), or intracranial extension (ICE, 21% vs 15%, P=.27). The D9083 patients were more likely to have received initial staging by magnetic resonance imaging (71% vs 53%). CONCLUSIONS These data support that a delay in radiation therapy for high-risk PMRMS features of CNP/CBBE does not compromise clinical outcomes.
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Affiliation(s)
- Aaron C Spalding
- Kosair Children's Hospital and Brain Tumor Center, Louisville, Kentucky.
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213
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Abstract
Rhabdomyosarcoma (RMS), the most common soft tissue sarcoma in children, has traditionally been classified into embryonal rhabdomyosarcoma (ERMS) and alveolar rhabdomyosarcoma (ARMS) for pediatric oncology practice. This review outlines the historical development of classification of childhood RMS and the challenges that have been associated with it, particularly problems with the diagnosis of "solid variant" ARMS and its distinction from ERMS. In addition to differences in clinical presentation and outcome, a number of genetic features underpin separation of ERMS from ARMS. Genetic differences associated with RMS subclassification include the presence of reciprocal translocations and their associated fusions in ARMS, amplification of genes in ARMS and its fusion subsets, chromosomal losses and gains that mostly occur in ERMS, and allelic losses and mutations usually associated with ERMS. Chimeric proteins encoded in most ARMS from the fusion of PAX3 or PAX7 with FOXO1 are expressed, result in a distinct pattern of downstream protein expression, and appear to be the proximate cause of the bad outcome associated with this subtype. A sizeable minority of ARMS lacks these fusions and shares the clinical and biological features of ERMS. A battery of immunohistochemical tests may prove useful in separating ERMS from ARMS and fusion-positive ARMS from fusion-negative ARMS. Because of limitation of predicting outcome solely based on histologic classification, treatment protocols will begin to utilize fusion testing for stratification of affected patients into low-risk, intermediate-risk, and high-risk groups.
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Skapek SX, Anderson J, Barr FG, Bridge JA, Gastier-Foster JM, Parham DM, Rudzinski ER, Triche T, Hawkins DS. PAX-FOXO1 fusion status drives unfavorable outcome for children with rhabdomyosarcoma: a children's oncology group report. Pediatr Blood Cancer 2013; 60:1411-7. [PMID: 23526739 PMCID: PMC4646073 DOI: 10.1002/pbc.24532] [Citation(s) in RCA: 174] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 02/19/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Rhabdomyosarcoma (RMS) is divided into two major histological subtypes: alveolar (ARMS) and embryonal (ERMS), with most ARMS expressing one of two oncogenic genes fusing PAX3 or PAX7 with FOXO1 (P3F and P7F, respectively). The Children's Oncology Group (COG) carried out a multi-institutional clinical trial to evaluate the prognostic value of PAX-FOXO1 fusion status. METHODS Study participants were treated on COG protocol D9803 for intermediate risk ARMS or ERMS using multi-agent chemotherapy, radiotherapy, and surgery. Central diagnostic pathology review and molecular testing for fusion genes were carried out on prospectively collected specimens. Event-free (EFS) and overall survival (OS) at 5 years were correlated with histological subtype and PAX-FOXO1 status. RESULTS Of 616 eligible D9803 enrollees, 434 cases had adequate clinical, molecular, and pathology data for definitive classification as ERMS, ARMS P3F+ or P7F+, or ARMSn (without detectable fusion). EFS was worse for those with ARMS P3F+ (54%) and P7F+ (65%) than those with ERMS (77%; P < 0.001). EFS for ARMSn and ERMS were not statistically different (90% vs. 77%, P = 0.15). ARMS P3F+ had poorer OS (64%) than ARMS P7F+ (87%), ARMSn (89%), and ERMS (82%; P = 0.006). CONCLUSIONS ARMSn has an outcome similar to ERMS and superior EFS compared to ARMS with either P3F or P7F, when given therapy designed for children with intermediate risk RMS. This prospective analysis supports incorporation of PAX-FOXO1 fusion status into risk stratification and treatment allocation.
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Affiliation(s)
- Stephen X. Skapek
- Children’s Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas,Correspondence to: Stephen X. Skapek, Center for Cancer and Blood Disorders, Children’s Medical Center; Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 9063, Dallas, TX 75390.
| | | | | | | | | | - David M. Parham
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Timothy Triche
- Children’s Hospital of Los Angeles, University of Southern California, Los Angeles, California
| | - Douglas S. Hawkins
- Seattle Children’s Hospital, Fred Hutchinson Cancer Research Center, and University of Washington, Seattle, Washington
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215
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Outcome of Rhabdomyosarcoma in First Year of Life: Children's Cancer Hospital 57357 Egypt. Sarcoma 2013; 2013:439213. [PMID: 23983569 PMCID: PMC3745951 DOI: 10.1155/2013/439213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 06/12/2013] [Accepted: 06/24/2013] [Indexed: 11/28/2022] Open
Abstract
Background. Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcoma in children. Fifty percent of RMS cases occur in the first 10 years of life and less commonly in infants younger than one-year old. These infants require adapted multimodality treatment approaches. Patients and Methods. We analyzed patients' characteristics, treatment modalities, and the outcome for RMS infants treated at Children's Cancer Hospital Egypt (CCHE) between July 2007 and December 2010 and compared them to patients above one year treated on the same protocol. Results. Out of the 126 RMS treated during this period, 18 were below the age of one year. The male: female ratio was 1.25 : 1. The median age at diagnosis was 0.7 ± 0.2 years. Most of the cases (27.8%) were presented in head and neck regions. The estimated 4-years failure-free survival and overall survival for infants were 49 ± 12% and 70 ± 12%, respectively. These failure-free survival rate and overall survival rate did not differ from those for older patients (P = 0.2). Conclusion. Infants with RMS are a unique group of RMS who needs special concerns in tailoring treatment in addition to concerns regarding toxicity and morbidity in infants.
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216
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Weiss AR, Lyden ER, Anderson JR, Hawkins DS, Spunt SL, Walterhouse DO, Wolden SL, Parham DM, Rodeberg DA, Kao SC, Womer RB. Histologic and clinical characteristics can guide staging evaluations for children and adolescents with rhabdomyosarcoma: a report from the Children's Oncology Group Soft Tissue Sarcoma Committee. J Clin Oncol 2013; 31:3226-32. [PMID: 23940218 DOI: 10.1200/jco.2012.44.6476] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To simplify the recommended staging evaluation by correlating tumor and clinical features with patterns of distant metastasis in newly diagnosed patients with embryonal rhabdomyosarcoma (ERMS) or alveolar rhabdomyosarcoma (ARMS). PATIENTS AND METHODS Patient data from the Intergroup Rhabdomyosarcoma Study Group and the Children's Oncology Group over two periods were analyzed: 1991 to 1997 and 1999 to 2004. We used recursive partitioning analyses to identify factors (including histology, age, regional nodal and distant metastatic status, tumor size, local invasiveness, and primary site) that divided patients into subsets with the most different rates of metastatic disease. RESULTS Of the 1,687 patients analyzed, 5.7% had lung metastases, 4.8% had bone involvement, and 6% had bone marrow (BM) involvement. Rhabdomyosarcoma (RMS) without local invasion (T1) had a low rate of metastasis for all distant sites, especially ERMS (0% bone, 0% BM). ARMS with local invasion (T2) had a higher rate of metastasis for all distant sites (13% lung, 18% bone, 23% BM). ERMS, T2 also had a higher rate of metastatic lung involvement (9%). The likelihood of bone or BM involvement increased in the presence of lung metastases (41% with, 6% without). Regional nodal metastases (N1) predicted a high rate of metastasis in all distant sites (14% lung, 14% bone, 18% BM). A staging algorithm was developed. CONCLUSION Staging studies in childhood RMS can be tailored to patients' presenting characteristics. Bone marrow aspirate and biopsy and bone scan are unnecessary in at least one third of patients with RMS.
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Affiliation(s)
- Aaron R Weiss
- The Soft Tissue Sarcoma Committee of the Children's Oncology Group, Monrovia, CA; Aaron R. Weiss, Maine Medical Center, Portland, ME; Elizabeth R. Lyden and James R. Anderson, University of Nebraska Medical Center, Omaha, NE; Douglas S. Hawkins, Seattle Children's Hospital, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sheri L. Spunt, St. Jude Children's Research Hospital and the University of Tennessee Health Science Center, Memphis, TN; David O. Walterhouse, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Suzanne L. Wolden, Memorial Sloan-Kettering Cancer Center, New York, NY; David M. Parham, University of Oklahoma Health Sciences Center, Oklahoma City, OK; David A. Rodeberg, Children's Hospital of Pittsburgh, Pittsburgh, PA; Simon C. Kao, University of Iowa Hospitals and Clinics, Iowa City, IA; and Richard B. Womer, The Children's Hospital of Philadelphia, Philadelphia, PA
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Fam HK, Walton C, Mitra SA, Chowdhury M, Osborne N, Choi K, Sun G, Wong PC, O'Sullivan MJ, Turashvili G, Aparicio S, Triche TJ, Bond M, Pallen CJ, Boerkoel CF. TDP1 and PARP1 Deficiency Are Cytotoxic to Rhabdomyosarcoma Cells. Mol Cancer Res 2013; 11:1179-92. [DOI: 10.1158/1541-7786.mcr-12-0575] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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218
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Rudzinski ER, Teot LA, Anderson JR, Moore J, Bridge JA, Barr FG, Gastier-Foster JM, Skapek SX, Hawkins DS, Parham DM. Dense pattern of embryonal rhabdomyosarcoma, a lesion easily confused with alveolar rhabdomyosarcoma: a report from the Soft Tissue Sarcoma Committee of the Children's Oncology Group. Am J Clin Pathol 2013; 140:82-90. [PMID: 23765537 DOI: 10.1309/ajcpa1wn7arpcmkq] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To examine whether the frequency of fusion-negative alveolar rhabdomyosarcoma (ARMSn) increased coincident with changes in the definition of alveolar histology. METHODS We re-reviewed alveolar rhabdomyosarcoma (ARMS) in the Children's Oncology Group study D9803, comparing histopathology with fusion status. RESULTS Our review of 255 original ARMS cases (compared with a control group of 38 embryonal rhabdomyosarcomas [ERMS] cases) revealed that many had an ARMS-like densely cellular pattern with cytologic features and myogenin expression more typical of ERMS. Following re-review, 84 (33%) cases of original ARMS were rediagnosed as ERMS. All reclassified ERMS, including dense ERMS, were fusion negative, whereas 82% of confirmed ARMS cases were fusion positive. Total ARMS diagnoses returned to historic rates of 25% to 30% of all rhabdomyosarcomas, and ARMSn decreased from 37% to 18% of ARMS cases. The outcome of reclassified ERMS was similar to confirmed ERMS. CONCLUSIONS To address the role of fusion status in risk stratification, pathologists should include both a histologic diagnosis and an evaluation of fusion status for all new ARMS diagnoses.
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Affiliation(s)
| | | | | | - Julie Moore
- Nationwide Children’s Hospital, Columbus, OH
| | | | | | | | | | - Douglas S. Hawkins
- Seattle Children’s Hospital, Seattle, WA
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
| | - David M. Parham
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Minard-Colin V, Kolb F, Saint-Rose C, Fayard F, Janot F, Rey A, Canale S, Julieron M, Corradini N, Raquin MA, Habrand JL, Grill J, George B, Ba Huy PT, Couloignier V, Terrier-Lacombe MJ, Luboinski B, Valteau-Couanet D, Oberlin O. Impact of extensive surgery in multidisciplinary approach of pterygopalatine/infratemporal fossa soft tissue sarcoma. Pediatr Blood Cancer 2013; 60:928-34. [PMID: 23303699 DOI: 10.1002/pbc.24374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 09/27/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND To evaluate a strategy whereby extensive surgery ± external radiotherapy (RT) could improve local control in pterygopalatine/infratemporal fossa (PIF) sarcoma. PROCEDURE Forty-one patients with a diagnosis of sarcoma involving the PIF and referred to our Institute from 1984 to 2009 were included in the analysis. Patients received multidrug chemotherapy and radiotherapy ± surgery, depending on the period of treatment. RESULTS The median age at diagnosis was 7.6 years (range: 0.1-22 years). There were 36 RMS, 3 undifferentiated sarcoma and 2 other soft-tissue sarcomas. Sixty-eight percent of patients had meningeal risk factors at diagnosis. Local treatment consisted of RT alone in 19 patients, surgery in combination to RT in 19 patients and surgery alone in 3 patients. The local progression rate (LPR) at 5 years was 45% for the entire population, 59% for the 19 patients treated with RT alone and 34% for the 22 patients who had surgery as part of their treatment. All locoregional failures after extensive surgery occurred at the skull base and/or in leptomeningeal spaces. CONCLUSIONS Multidisciplinary approach including extensive surgery for PIF sarcoma is feasible and yields good local control with 15/22 patients in local complete remission. Future studies are warranted to confirm these promising results, to evaluate the possibility of avoiding RT or limiting the RT field, and to extend the indication for extensive surgery to other "worse" sites of PM sarcoma such as the paranasal sinuses.
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220
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Hawkins DS, Spunt SL, Skapek SX. Children's Oncology Group's 2013 blueprint for research: Soft tissue sarcomas. Pediatr Blood Cancer 2013; 60:1001-8. [PMID: 23255356 PMCID: PMC3777409 DOI: 10.1002/pbc.24435] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/12/2012] [Indexed: 12/19/2022]
Abstract
In the US, approximately 850-900 children are diagnosed each year with soft tissue sarcomas (STS). Key findings from recent Children's Oncology Group (COG) clinical trials include safe reduction in therapy for low risk rhabdomyosarcoma (RMS), validation of FOXO1 fusion as a prognostic factor, a modest improvement in outcome for high-risk RMS, and a biologically designed non-cytotoxic therapy for pediatric desmoid tumor. Planned Phase 2 trials include targeted agents for VEGF/PDGF, mTOR, and IGF-1R for children with RMS and VEGF for children with non-RMS STS (NRSTS). For RMS, COG Phase 3 trials potentially will explore VEGF/mTOR inhibition or chemotherapy interval compression. For NRSTS, a COG Phase 3 trial will explore VEGF inhibition.
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Affiliation(s)
- Douglas S Hawkins
- Seattle Children's Hospital, University of Washington, and Fred Hutchinson Cancer Research Center, Seattle, WA 98015, USA.
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221
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Burke ME, Lyden ER, Meza JL, Ladas EJ, Dasgupta R, Wiegner EA, Arndt CA. Does body mass index at diagnosis or weight change during therapy predict toxicity or survival in intermediate risk rhabdomyosarcoma? A report from the Children's Oncology Group Soft Tissue Sarcoma Committee. Pediatr Blood Cancer 2013; 60:748-53. [PMID: 23335502 PMCID: PMC5152587 DOI: 10.1002/pbc.24322] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 08/20/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Weight loss prevalence and its impact on toxicities and survival in intermediate risk rhabdomyosarcoma (IRMS) patients are unknown. We evaluated the association between weight change during therapy and number of toxicities, hospital days, infections, and overall survival and between baseline body mass index (BMI) and survival in patients treated on Children's Oncology Group trial D9803. PROCEDURE Four hundred sixty-eight IRMS patients age ≥2 and <21 years treated on D9803 had required data. Regression models evaluated association between weight loss from baseline and toxicities, hospital days, infections, and survival. Kaplan-Meier curves and regression models evaluated baseline BMI percentile's association with survival. RESULTS Thirty-five percent and 37% of patients had >5% weight loss at 12 and 24 weeks, respectively, with 16% and 19% losing >10% weight respectively. Greater than 10% weight loss at 24 weeks was associated with more toxicities and hospital days during subsequent therapy but not infection rate or survival. Baseline underweight patients (<5th percentile BMI) had borderline inferior survival compared with baseline average weight patients while there was no difference in survival seen between average weight and overweight or obese patients. CONCLUSIONS Nearly one in five IRMS patients experienced >10% weight loss on therapy. This was associated with increased toxicity but not decreased survival compared with patients who had less weight loss. Baseline BMI percentile trended toward a significant association with survival. Future studies might investigate nutritional impact on quality of life and if weight loss is preventable by early nutritional intervention.
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Affiliation(s)
- Megan E. Burke
- Division of Hematology/Oncology, Children’s Hospital of The King’s Daughters, Norfolk, Virginia,Correspondence to: Megan E. Burke, MD, 601 Children’s Lane, Norfolk, VA 23507.
| | - Elizabeth R. Lyden
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jane L. Meza
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Elena J. Ladas
- Division of Pediatric Oncology, Columbia University, New York, New York
| | - Roshni Dasgupta
- Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Ellen A. Wiegner
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Carola A.S. Arndt
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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Marina N, Hudson MM, Jones KE, Mulrooney DA, Avedian R, Donaldson SS, Popat R, West DW, Fisher P, Leisenring W, Stovall M, Robison LL, Ness KK. Changes in health status among aging survivors of pediatric upper and lower extremity sarcoma: a report from the childhood cancer survivor study. Arch Phys Med Rehabil 2013; 94:1062-73. [PMID: 23380347 DOI: 10.1016/j.apmr.2013.01.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 12/18/2012] [Accepted: 01/02/2013] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate health status and participation restrictions in survivors of childhood extremity sarcomas. DESIGN Members of the Childhood Cancer Survivor Study cohort with extremity sarcomas who completed questionnaires in 1995, 2003, or 2007 were included. SETTING Cohort study of survivors of extremity sarcomas. PARTICIPANTS Childhood extremity sarcoma survivors (N=1094; median age at diagnosis, 13y (range, 0-20y); current age, 33y (range, 10-53y); 49% male; 87.5% white; 75% had lower extremity tumors) who received their diagnosis and treatment between 1970 and 1986. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Prevalence rates for poor health status in 6 domains and 5 suboptimal social participation categories were compared by tumor location and treatment exposure with generalized estimating equations adjusted for demographic/personal factors and time/age. RESULTS In adjusted models, when compared with upper extremity survivors, lower extremity survivors had an increased risk of activity limitations but a lower risk of not completing college. Compared with those who did not have surgery, those with limb-sparing (LS) and upper extremity amputations (UEAs) were 1.6 times more likely to report functional impairment, while those with an above-the-knee amputation (AKA) were 1.9 times more likely to report functional impairment. Survivors treated with LS were 1.5 times more likely to report activity limitations. Survivors undergoing LS were more likely to report inactivity, incomes <$20,000, unemployment, and no college degree. Those with UEAs more likely reported inactivity, unmarried status, and no college degree. Those with AKA more likely reported no college degree. Treatment with abdominal irradiation was associated with an increased risk of poor mental health, functional impairment, and activity limitation. CONCLUSIONS Treatment of lower extremity sarcomas is associated with a 50% increased risk for activity limitations; upper extremity survivors are at a 10% higher risk for not completing college. The type of local control influences health status and participation restrictions. Both of these outcomes decline with age.
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Affiliation(s)
- Neyssa Marina
- Department of Pediatrics, Stanford University & Lucile Packard Children's Hospital, Palo Alto, CA, USA.
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Hawkes CP, Betts DR, O'Brien J, O'Sullivan MJ, Capra M. Congenital sacrococcygeal PNET and chemotherapy. Indian J Med Paediatr Oncol 2012; 33:182-4. [PMID: 23248428 PMCID: PMC3523479 DOI: 10.4103/0971-5851.103151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We present the case of a congenital localised sacrococcygeal primitive neuroectodermal tumor treated aggressively with surgical resection and modified age-appropriate adjuvant chemotherapy. The conventional combination chemotherapy of vincristine, adriamycin, cyclophosphamide, ifosfamide and etoposide was modified to a regimen including vincristine, adriamicin, cyclophosphamide and actinomycin in order to minimise the predicted toxicity in this age group. Adjuvant “induction” chemotherapy commenced at 4 weeks of age and consisted of four cycles of vincristine, adriamycin and cyclophosphamide at 50%, 75%, 75% and 100% of recommended doses (vincristine 0.05 mg/kg, adriamycin 0.83 mg/kg daily × 2, cyclophosphamide 40 mg/kg) at 3-weekly intervals. This was followed by four cycles of “maintenance” chemotherapy with vincristine (0.025 mg/kg), actinomycin (0.025 mg/kg) and cyclophosphamide (36 mg/kg) at full recommended doses. Cardioxane at a dose of 16.6 mg/kg was infused immediately prior to the adriamycin. Our patient is thriving at 19 months out from end of treatment.
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Affiliation(s)
- Colin Patrick Hawkes
- Department of Haematology/ Oncology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
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224
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Abstract
Optimal management of rhabdomyosarcoma requires establishing the correct pathologic diagnosis, histologic sub-type, primary site, extent of disease (Stage), and extent of resection (Group). Based on these features, cooperative groups in North America and Europe have defined risk-adapted treatments that include surgery, chemotherapy, and usually radiotherapy. This article focuses on recent findings that can impact or have already impacted rhabdomyosarcoma treatment guidelines and highlights controversies that should be addressed in order to improve outcome for children with rhabdomyosarcoma. Rhabdomyosarcoma is currently sub-classified in children based on histology into the favorable embryonal/botryoid/spindle cell types and the unfavorable alveolar form. Risk group assignment depends in part on histologic sub-type. Alveolar rhabdomyosarcoma is sometimes associated with chromosomal translocations, which impact clinical behavior. An important ongoing debate is whether molecular diagnostic tools to identify chromosomal translocations and/or define gene expression profiles should be used to sub-classify rhabdomyosarcoma rather than histology. Clinical trials continue to evaluate retrospective as well as prospective cohorts in order to carefully determine the impact of histology versus biologic features on outcome in the context of specific therapeutic regimens. Most rhabdomyosarcoma recurrences involve the primary site or adjacent region. Cooperative groups continue to investigate new approaches to local control in order to reduce local recurrences and sequelae associated with local therapy. Delaying primary resection until after chemotherapy has started appears to increase the number of tumors that can be completely resected with acceptable morbidity in some primary sites. Radiation dose reductions following delayed primary resection have been investigated. Although outcomes appear similar to the conventional approach of full-dose radiotherapy without delayed primary resection, long-term effects of the two approaches have not been rigorously compared. Early evidence suggests that newer methods of delivering radiotherapy, including intensity-modulated radiotherapy (IMRT), proton beam radiotherapy, and brachytherapy maintain efficacy but may reduce long-term sequelae compared with 3-dimensional conformal radiotherapy. Chemotherapy regimens defined by the cooperative groups vary by risk group. The most commonly used regimens include vincristine and dactinomycin in combination with an alkylating agent, either cyclophosphamide or ifosfamide. In order to improve outcomes, recent clinical trials have introduced new chemotherapeutic agents (e.g. topotecan, carboplatin, or epirubicin) into the treatment regimens. However, outcomes have not been significantly impacted. Novel chemotherapy administration schedules have been tested in patients with metastatic rhabdomyosarcoma, including interval compressed dosing or maintenance therapy, and may be promising. Molecularly targeted agents are currently under investigation in combination with chemotherapy for patients with recurrent or metastatic rhabdomyosarcoma. It is hoped that these novel agents will benefit all patients with rhabdomyosarcoma in the future.
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Affiliation(s)
- Yasmin Gosiengfiao
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Division of Hematology/Oncology/Stem Cell Transplant, Chicago, IL, USA
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Ferrari A, Bisogno G, Meazza C, Vajna de Pava M, Sultan I, De Salvo GL, Clerici CA, Veneroni L, Casanova M. The challenge of access to care for soft tissue sarcomas bridging pediatric and adult age: the Italian pediatric oncology view. Expert Rev Anticancer Ther 2012; 12:243-54. [PMID: 22316372 DOI: 10.1586/era.11.209] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Synovial sarcoma and rhabdomyosarcoma are two high-grade soft tissue sarcoma subtypes that occur in adolescents and young adults. Managing these malignancies in patients in this age bracket poses various clinical problems, partly because different therapeutic approaches are sometimes adopted by pediatric and adult oncologists, even though they are dealing with the same condition. In this review, the doubts concerning how best to manage soft tissue sarcomas in patients between pediatric and adult ages lead up to a more general discussion of the issue of access to optimal cancer services for adolescents and young adults - a subset of patients acknowledged as being under-represented in clinical trials on therapies that may improve their outcome. The situation in Italy is described, along with action taken in an effort to bridge the gap and implement specific programs tailored to these patients.
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Affiliation(s)
- Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori Via G Venezian, Milan 1-20133, Italy.
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Terezakis SA, Wharam MD. Radiotherapy for rhabdomyosarcoma: indications and outcome. Clin Oncol (R Coll Radiol) 2012; 25:27-35. [PMID: 22990007 DOI: 10.1016/j.clon.2012.07.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 04/19/2012] [Accepted: 05/17/2012] [Indexed: 11/25/2022]
Abstract
Rhabdomyosarcoma is the most common soft tissue sarcoma of childhood. Improvements in the clinical outcomes of rhabdomyosarcoma have been secondary to the intensification and refinement of treatment investigated by the Intergroup Rhabdomyosarcoma Study Group. Advances in diagnostic imaging techniques have led to improvements in staging and contribute to precision in radiation field design. Radiation treatment has been integrated into the primary treatment of most patients with rhabdomyosarcoma. Each treatment site has special considerations with regards to prognosis, outcomes and potential morbidities that affect the choice of local therapy. Advanced radiotherapy techniques using conformal treatment with intensity-modulated radiotherapy and proton therapy are particularly advantageous for the treatment of sites close to critical structures, such as the head and neck and genitourinary system. Active investigation is underway to develop strategies to reduce the radiation dose and volume in an effort to minimise late toxicity and improve the therapeutic ratio.
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Affiliation(s)
- S A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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228
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Kojima Y, Hashimoto K, Ando M, Yonemori K, Yamamoto H, Kodaira M, Yunokawa M, Shimizu C, Tamura K, Hosono A, Makimoto A, Fujiwara Y. Comparison of dose intensity of vincristine, d-actinomycin, and cyclophosphamide chemotherapy for child and adult rhabdomyosarcoma: a retrospective analysis. Cancer Chemother Pharmacol 2012; 70:391-7. [PMID: 22806306 DOI: 10.1007/s00280-012-1920-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 06/25/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE The prognosis of adult rhabdomyosarcoma (RMS) has been considered dismal. The question is raised that vincristine, d-actinomycin, and cyclophosphamide (VAC) chemotherapy may not be administered as per schedule for adult RMS; consequently, low dose intensity (DI) leads to poor prognosis. Herein, we examined whether the administration of VAC chemotherapy for adults and children with RMS is feasible with regard to the DIs of VAC. METHODS Chart review was retrospectively performed for all identified patients. The percentage of relative DI (RDI) was calculated according to the Children's Oncology Group D9803 protocol. Further, we examined the RDI in the first 6 cycles of VAC (induction phase) and the DI after the first 6 cycles of VAC (maintenance phase). RESULTS We identified a total of 27 adults and 18 children with RMS, respectively. The mean RDIs of vincristine in total phase were significantly lower in adults than that in children (P = 0.04). In induction phase, the mean RDIs of vincristine and cyclophosphamide were similar for both groups; however, they were dropped significantly in adults during maintenance phase (P < 0.05). Mean RDIs of vincristine in elderly patients tended to become low. Low RDI was mainly attributable to hematologic toxicity, infection, and peripheral neuropathy. The prognosis of low versus high RDI was similar. CONCLUSIONS The RDIs of vincristine and cyclophosphamide in the maintenance phase were significantly lower than that in children. VAC chemotherapy for adults was not feasible; these patients require a different regimen.
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Affiliation(s)
- Yuki Kojima
- Department of Medical Oncology and Breast Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
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229
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Malempati S, Hawkins DS. Rhabdomyosarcoma: review of the Children's Oncology Group (COG) Soft-Tissue Sarcoma Committee experience and rationale for current COG studies. Pediatr Blood Cancer 2012; 59:5-10. [PMID: 22378628 PMCID: PMC4008325 DOI: 10.1002/pbc.24118] [Citation(s) in RCA: 273] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 02/03/2012] [Indexed: 11/07/2022]
Abstract
The prognosis for children and adolescents with rhabdomyosarcoma (RMS) has improved with refinements in multi-modal therapy. Since 1972, the Intergroup Rhabdomyosarcoma Study Group (now the Children's Oncology Group Soft-Tissue Sarcoma Committee) has conducted serial studies for RMS. This review describes the IRSG and COG experience with RMS, presents the current risk stratification definitions, and provides rationale for the current generation of COG RMS studies.
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Affiliation(s)
- Suman Malempati
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon 97239-3098, USA.
| | - Douglas S. Hawkins
- Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle, Washington
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230
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Oberlin O, Rey A, Sanchez de Toledo J, Martelli H, Jenney MEM, Scopinaro M, Bergeron C, Merks JHM, Bouvet N, Ellershaw C, Kelsey A, Spooner D, Stevens MCG. Randomized comparison of intensified six-drug versus standard three-drug chemotherapy for high-risk nonmetastatic rhabdomyosarcoma and other chemotherapy-sensitive childhood soft tissue sarcomas: long-term results from the International Society of Pediatric Oncology MMT95 study. J Clin Oncol 2012; 30:2457-65. [PMID: 22665534 DOI: 10.1200/jco.2011.40.3287] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE MMT95 was the fourth of a series of International Society of Pediatric Oncology (SIOP) collaborations for children with high-risk nonmetastatic soft tissue sarcoma (STS). The principal objective was to explore survival advantage for an intensified chemotherapy strategy in a randomized trial. PATIENTS AND METHODS From July 1995 to June 2003, 457 previously untreated patients with incompletely resected embryonal rhabdomyosarcoma (RMS), undifferentiated sarcoma, and soft tissue primitive neuroectodermal tumor at all sites except paratesticular, vagina, and uterus, or with alveolar RMS were randomly assigned to receive either ifosfamide, vincristine, and dactinomycin (IVA) or a six-drug combination (IVA plus carboplatin, epirubicin, and etoposide) both delivered over 27 weeks. Cumulative doses were as follows: ifosfamide 54 g/m(2) (both arms), epirubicin 450 mg/m(2), etoposide 1,350 mg/m(2) (six-drug regimen). Poor responders after three courses of IVA were to be switched to the other arm. Delivery of radiotherapy was determined according to site and/or response to chemotherapy with or without surgery. RESULTS Overall survival (OS) for all patients was 81% (95% CI, 77% to 84%) at 3 years. No significant difference in outcome in either OS or event-free survival was noted between the two arms (3-year OS: 82% [95% CI, 76% to 86%] for IVA and 80% [95% CI, 74% to 85%] for the six-drug arm). Toxicity was significantly greater (infection, myelosuppression, and mucositis) in the six-drug arm. Overall burden of local therapy was consistent with data from previous SIOP studies and showed no difference between the two chemotherapy regimens. CONCLUSION Intensification of chemotherapy for nonmetastatic RMS and other chemotherapy-sensitive STS provides no survival advantage or reduction in the intensity of local therapy and adds toxicity.
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231
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Meyer WH. Playing Bad Cards Properly: Challenges to Improving Cure Rates in Rhabdomyosarcoma. J Clin Oncol 2012; 30:2431-3. [DOI: 10.1200/jco.2012.42.4275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- William H. Meyer
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
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232
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Salman M, Tamim H, Medlej F, El-Ariss T, Saad F, Boulos F, Eid T, Muwakkit S, Khoury N, Abboud M, Saab R. Rhabdomyosarcoma treatment and outcome at a multidisciplinary pediatric cancer center in Lebanon. Pediatr Hematol Oncol 2012; 29:322-34. [PMID: 22568795 DOI: 10.3109/08880018.2012.676721] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. Outcome of patients treated on standard protocols, in a multidisciplinary cancer center setting outside of clinical trials, is not well reported. We reviewed characteristics and outcome of 23 pediatric patients treated at a single, multidisciplinary cancer center in Lebanon, between April 2002 and December 2010. Median follow-up was 41 months. The most commonly affected primary site was the head and neck (48%, n = 11). Nineteen tumors (82.6%) were of embryonal histology. Tumor size was ≥5 cm in eight (34.8%) patients. Sixteen patients (69.6%) had localized disease, and one (4.4%) had metastatic disease. Fifteen (65.2%) had Group III tumors. All patients received chemotherapy, for a duration ranging 21-51 weeks. Upfront surgical resection was performed in 10 patients (43.5%). Eighteen patients (78.3%) received radiation therapy. The 5-year overall and disease-free survival rates were 83% and 64%, respectively. Relapse correlated with absence of surgery. Treatment of childhood RMS in a multidisciplinary cancer center in Lebanon results in similar survival to that in developed countries when similar protocols are applied. There was a higher incidence of local relapse, but those were salvageable with further therapy and surgical local control.
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Affiliation(s)
- Maysaa Salman
- Department of Pediatrics, American University of Beirut, Beirut, Lebanon
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233
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Arndt CAS, Rose PS, Folpe AL, Laack NN. Common musculoskeletal tumors of childhood and adolescence. Mayo Clin Proc 2012; 87:475-87. [PMID: 22560526 PMCID: PMC3538469 DOI: 10.1016/j.mayocp.2012.01.015] [Citation(s) in RCA: 205] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 01/07/2012] [Accepted: 01/16/2012] [Indexed: 11/23/2022]
Abstract
Osteosarcoma, Ewing sarcoma, and rhabdomyosarcoma are the most common malignant musculoskeletal tumors in children and adolescents. Today, most patients can be cured. Numerous factors have contributed to improved outcome for these patients over the past several decades. These include multidisciplinary care involving oncologists, radiation oncologists, surgeons, pathologists, and radiologists and enrollment of patients in clinical trials. Better understanding of molecular mechanisms of disease have resulted in studies using molecular targets in addition to standard chemotherapeutic agents, which hopefully will lead to better outcomes in the future. Moreover, new orthopedic techniques and devices as well as new technologies in radiation oncology hold promise for better local control of primary tumors and the potential for fewer late adverse effects. Despite this progress, patients must undergo lifelong follow-up for possible late effects of intense chemotherapy and radiation therapy. We review the diagnosis, prognosis, staging, multidisciplinary therapy, new directions in therapy, and long-term complications of treatment for these tumors. For this review, we searched MEDLINE using the terms rhabdomyosarcoma, osteosarcoma, Ewing sarcoma, biology, and humans and limited the search to articles from 2000 to September 2011. Additional references found in these articles were utilized as appropriate, as well as references from the background information in current therapeutic studies of the Children's Oncology Group. The same database and time frame were searched for articles written by leading authorities in the field.
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Key Words
- arms, alveolar rhabdomyosarcoma
- cog, children's oncology group
- efs, event-free survival
- erms, embryonal rhabdomyosarcoma
- es, ewing sarcoma
- fdg-pet, fluorodeoxyglucose positron emission tomography
- ie, ifosfamide and etoposide
- map, methotrexate, doxorubicin (adriamycin), and cisplatin
- os, osteosarcoma
- pnet, primitive neuroectodermal tumor
- rms, rhabdomyosarcoma
- vdc, vincristine, doxorubicin, and cyclophosphamide
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Affiliation(s)
- Carola A S Arndt
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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234
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Belyea B, Kephart JG, Blum J, Kirsch DG, Linardic CM. Embryonic signaling pathways and rhabdomyosarcoma: contributions to cancer development and opportunities for therapeutic targeting. Sarcoma 2012; 2012:406239. [PMID: 22619564 PMCID: PMC3350847 DOI: 10.1155/2012/406239] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 01/17/2012] [Indexed: 11/18/2022] Open
Abstract
Rhabdomyosarcoma is the most common soft tissue sarcoma of childhood and adolescence, accounting for approximately 7% of childhood cancers. Current therapies include nonspecific cytotoxic chemotherapy regimens, radiation therapy, and surgery; however, these multimodality strategies are unsuccessful in the majority of patients with high-risk disease. It is generally believed that these tumors represent arrested or aberrant skeletal muscle development, and, accordingly, developmental signaling pathways critical to myogenesis such as Notch, WNT, and Hedgehog may represent new therapeutic targets. In this paper, we summarize the current preclinical studies linking these embryonic pathways to rhabdomyosarcoma tumorigenesis and provide support for the investigation of targeted therapies in this embryonic cancer.
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Affiliation(s)
- Brian Belyea
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
- Department of Pediatrics, University of Virginia, Charlottesville, VA 22908, USA
| | - Julie Grondin Kephart
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC 27710, USA
| | - Jordan Blum
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC 27710, USA
| | - David G. Kirsch
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - Corinne M. Linardic
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC 27710, USA
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235
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Ray A, Huh WW. Current State-of-the-Art Systemic Therapy for Pediatric Soft Tissue Sarcomas. Curr Oncol Rep 2012; 14:311-9. [DOI: 10.1007/s11912-012-0243-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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236
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Aragon-Ching JB, Maki RG. Treatment of Adult Soft Tissue Sarcoma: Old Concepts, New Insights, and Potential for Drug Discovery. Cancer Invest 2012; 30:300-8. [DOI: 10.3109/07357907.2012.658936] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Jeanny B. Aragon-Ching
- Division of Hematology and Oncology, Department of Medicine, George Washington University Medical Center,
Washington, District of Columbia, USA,1
| | - Robert G. Maki
- Departments of Medicine and Pediatrics, Tisch Cancer Institute, Mount Sinai School of Medicine,
New York, New York, USA2
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237
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Undifferentiated sarcoma of the liver: a single institution experience using a uniform treatment approach. J Pediatr Hematol Oncol 2012; 34:e114-6. [PMID: 22217489 PMCID: PMC4131680 DOI: 10.1097/mph.0b013e3182331fbe] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Undifferentiated (embryonal) sarcoma of the liver is a rare malignant tumor, most commonly seen in children aged 6 to 10 years. Previously believed to carry a poor prognosis, more recent reports indicate that treatment regimens combining surgical resection and adjuvant chemotherapy can yield long-term, disease-free survival. In this study, we review 5 pediatric patients with undifferentiated sarcoma of the liver treated with a uniform approach of resection followed by adjuvant chemotherapy and radiation when indicated. All 5 patients are disease free in their first remission at a median of 53 months.
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238
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Clinical outcomes of adult and childhood rhabdomyosarcoma treated with vincristine, d-actinomycin, and cyclophosphamide chemotherapy. J Cancer Res Clin Oncol 2012; 138:1249-57. [PMID: 22441933 DOI: 10.1007/s00432-012-1199-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Outcomes in adult patients with rhabdomyosarcoma are poor, with a 5-year survival rate of approximately 30 %. The current study aimed to compare the clinical outcomes of adult and childhood rhabdomyosarcoma patients with local and metastatic disease and to examine the impact and timing of local therapy on metastasis. METHODS Clinicopathological features and patient outcomes were reviewed retrospectively for rhabdomyosarcoma patients receiving chemotherapy between 1981 and 2010 at our institution. Adults were defined as those aged 21 years or older. RESULTS Of the 98 patients identified, 36 were adults (median age, 29; range, 21-72) and 62 were children (median age, 11; range, 0.6-20). Median progression-free survival of localized and metastatic disease for children and adults was as follows: localized disease, 166.9 versus 22.4 months (p = 0.005), and metastatic disease, 13.3 versus 13.3 months (p = 0.949), respectively. Multivariate regression analysis revealed that older age (≥ 21 vs. <21) was a significant poor prognostic factor in localized disease. Conversely, age was not related to survival in metastatic disease. Receiving radiotherapy to the primary site was an independent factor indicating a better prognosis. An analysis of the optimal timing of local therapy was performed for 53 patients; however, its significance on survival could not be determined. CONCLUSIONS Age was a negative prognostic factor in rhabdomyosarcoma patients with localized disease, but it did not affect the survival in metastatic disease. For metastatic disease, although local therapies may be effective for survival, the timing of such therapies should be determined individually.
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239
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Huh WW, Fitzgerald N, Mahajan A, Sturgis EM, Beverly Raney R, Anderson PM. Pediatric sarcomas and related tumors of the head and neck. Cancer Treat Rev 2011; 37:431-9. [DOI: 10.1016/j.ctrv.2011.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 04/12/2011] [Accepted: 04/18/2011] [Indexed: 01/07/2023]
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240
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Abstract
PURPOSE OF REVIEW To review the 2009/2010 literature on pediatric genitourinary tumors and highlight the most significant publications. RECENT FINDINGS New techniques such as gene expression profiling, PET, nephron-sparing surgery, and stem cell transplantation are being incorporated into contemporary treatments for pediatric patients with genitourinary tumors. Biologic markers are increasingly being used to help with risk stratification of patients. WT1 mutation and 11p15 loss of heterozygosity have been associated with relapse in very low-risk Wilms tumors treated with surgery alone and may help reduce the use of chemotherapy in some children. Discussion continues on the use of fusion gene status to risk stratify alveolar rhabdomyosarcoma. Meta-analysis of the use of high-dose chemotherapy with autologous hematopoetic stem cell rescue in patients with relapsed Wilms tumor and rhabdomyosarcoma suggests that some patients may benefit more from conventional salvage chemotherapy. New agents are needed for patients with high-risk and relapsed disease to improve outcomes. SUMMARY In general, the prognosis for patients with pediatric genitourinary tumors is favorable. The elucidation of the molecular abnormalities in these tumors is determining risk stratification, treatment strategies, and candidates for new drug development.
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241
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Ferrari A, Meazza C, Vajna de Pava M, Clerici CA, Casanova M. Two Cases of Adolescents with Paratesticular Rhabdomyosarcoma Inadequately Treated: The Problem of Referral. J Adolesc Young Adult Oncol 2011; 1:152-154. [PMID: 23610735 DOI: 10.1089/jayao.2011.0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
This paper reports on two cases of adolescents with paratesticular embryonal rhabdomyosarcoma completely resected at diagnosis (a pediatric disease potentially curable in more than 90% of cases) and treated at adult facilities with a strategy used for adult soft tissue sarcomas. The final outcome of the two patients was dismal after they received a treatment inconsistent with pediatric protocols. The cases reported here give us a chance to turn the spotlight on a crucial issue-the referral of adolescents with pediatric-type tumors and their access to experienced centers and clinical trials.
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Affiliation(s)
- Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori , Milan, Italy
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242
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Walterhouse DO, Meza JL, Breneman JC, Donaldson SS, Hayes-Jordan A, Pappo AS, Arndt C, Raney RB, Meyer WH, Hawkins DS. Local control and outcome in children with localized vaginal rhabdomyosarcoma: a report from the Soft Tissue Sarcoma committee of the Children's Oncology Group. Pediatr Blood Cancer 2011; 57:76-83. [PMID: 21298768 PMCID: PMC3459820 DOI: 10.1002/pbc.22928] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 10/29/2010] [Indexed: 11/06/2022]
Abstract
BACKGROUND The local control approach for girls with non-resected vaginal rhabdomyosarcoma (RMS) enrolled onto Intergroup RMS Study Group (IRSG)/Children's Oncology Group (COG) studies has differed from that used at other primary sites by delaying or eliminating radiotherapy (RT) based on response achieved with chemotherapy and delayed primary resection. PROCEDURES We reviewed locoregional treatment and outcome for patients with localized RMS of the vagina on the two most recent COG low-risk RMS studies. RESULTS Forty-one patients with localized vaginal RMS were enrolled: 25 onto D9602 and 16 onto Subset 2 of ARST0331. Only four of the 39 with non-resected tumors received RT. The 5-year cumulative incidence of local recurrence was 26% on D9602, and the 2-year cumulative incidence of local recurrence was 43% on ARST0331. Increased local failure rates appeared to correlate with chemotherapy regimens that incorporated lower cumulative doses of cyclophosphamide. Estimated 5-year and 2-year failure free survival rates were 70% (95% CI: 46%, 84%) on D9602 and 42% (95% CI: 11%, 70%) on ARST0331, respectively. CONCLUSIONS To prevent local recurrence, we recommend a local control approach for patients with non-resected RMS of the vagina that is similar to that used for other primary sites and includes RT. We recognize that potential long-term effects of RT are sometimes unacceptable, especially for children less than 24 months of age. However, when making the decision to eliminate RT, the risk of local recurrence must be considered especially when using a chemotherapy regimen with a total cumulative cyclophosphamide dose of ≤ 4.8 g/m².
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Affiliation(s)
| | | | | | | | | | | | | | - R. Beverly Raney
- The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - William H. Meyer
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
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243
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Gupta AA, Anderson JR, Pappo AS, Spunt SL, Dasgupta R, Indelicato DJ, Hawkins DS. Patterns of chemotherapy-induced toxicities in younger children and adolescents with rhabdomyosarcoma: a report from the Children's Oncology Group Soft Tissue Sarcoma Committee. Cancer 2011; 118:1130-7. [PMID: 21761400 DOI: 10.1002/cncr.26358] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 05/18/2011] [Accepted: 05/24/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients aged >10 years with rhabdomyosarcoma have an inferior outcome compared with patients ages 1 to 9 years, which may be explained by toxicities (adverse events [AEs]) that result in chemotherapy dose reductions. METHODS AEs observed during 1 of 3 randomized chemotherapy regimens (vincristine, dactinomycin, and cyclophosphamide [VAC]; vincristine, dactinomycin, and ifosfamide [VAI]; or vincristine, ifosfamide, and etoposide [VIE]) in the Fourth Intergroup Rhabdomyosarcoma Study were recorded. The incidence of toxicities by age and treatment regimen was determined. The odds of developing AEs in a particular age group (ages 5-9 years, 10-14 years, and 15-20 years) were compared with the odds in the control group of patients ages 1 to 4 years. RESULTS In total, 657 patients were eligible for analysis. The estimated 5-year event-free survival rates were 78%, 83%, 67%, and 58% for the groups ages 1 to 4 years, 5 to 9 years, 10 to 14 years, and 15 to 20 years, respectively. Patients ages 15 to 20 years experienced less neutropenia (odds ratio [OR], 0.43; P < .0001), thrombocytopenia (OR, 0.41; P < .0001), anemia (OR, 0.34; P < .0001), and infection (OR, 0.41; P < .0001) compared with younger patients, although they received similar amounts of chemotherapy. In contrast, peripheral nervous system toxicity was higher in adolescents aged >10 years (OR, 4.18; P < .0001). Females experienced more neutropenia (OR, 1.28; P = .05) and thrombocytopenia (OR, 1.26; P = .06) compared with males. CONCLUSIONS Adolescents who received treatment for rhabdomyosarcoma experienced significantly less hematologic toxicity and more peripheral nervous system toxicity compared with younger children despite receiving similar amounts of chemotherapy. Although outcomes were inferior in adolescents, it was unclear whether the differences in toxicity observed in the current study had an impact on outcome. The authors concluded that future studies examining the age-related and sex-related differences in pharmacokinetics of chemotherapy are necessary.
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Affiliation(s)
- Abha A Gupta
- Department of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.
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244
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Sultan I, Ferrari A. Selecting multimodal therapy for rhabdomyosarcoma. Expert Rev Anticancer Ther 2011; 10:1285-301. [PMID: 20735314 DOI: 10.1586/era.10.96] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Rhabdomyosarcoma is a typical tumor of childhood, characterized by a high grade of malignancy, local invasiveness and a marked propensity to metastasize, but also a generally good response to chemotherapy and radiotherapy. Multimodal therapy is essential to cure rhabdomyosarcoma patients, but different uses of surgery, radiotherapy and chemotherapy, and their intensity, need to be selected and modulated to different patient risk groups. This article attempts to give an account of the current treatment options, the open and debated issues and the potential novel strategies for the near future.
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Affiliation(s)
- Iyad Sultan
- Department of Pediatric Oncology, King Hussein Cancer Center, Irbid, Hashemite Kingdom of Jordan
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245
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Lin C, Donaldson SS, Meza JL, Anderson JR, Lyden ER, Brown CK, Morano K, Laurie F, Arndt CA, Enke CA, Breneman JC. Effect of radiotherapy techniques (IMRT vs. 3D-CRT) on outcome in patients with intermediate-risk rhabdomyosarcoma enrolled in COG D9803--a report from the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2011; 82:1764-70. [PMID: 21470795 DOI: 10.1016/j.ijrobp.2011.01.036] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 01/05/2011] [Accepted: 01/10/2011] [Indexed: 12/25/2022]
Abstract
PURPOSE To compare the dosimetric parameters of intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) in patients with intermediate-risk rhabdomyosarcoma and to analyze their effect on locoregional control and failure-free survival (FFS). METHODS AND MATERIALS The study population consisted of 375 patients enrolled in the Children's Oncology Group protocol D9803 study, receiving IMRT or 3D-CRT. Dosimetric data were collected from 179 patients with an available composite plan. The chi-square test or Fisher's exact test was used to compare the patient characteristics and radiotherapy parameters between the two groups. The interval-to-event outcomes were estimated using the Kaplan-Meier method and compared using log-rank tests. Cox proportional hazards regression analysis was used to examine the effect of the treatment technique on FFS after adjusting for primary site and risk group. RESULTS The median follow-up time was 5.7 and 4.2 years for patients receiving 3D-CRT and IMRT, respectively. No differences in the 5-year failure of locoregional control (18% vs. 15%) or FFS (72% vs. 76%) rates were noted between the two groups. Multivariate analysis revealed no association between the two techniques and FFS. Patients with primary tumors in parameningeal sites were more likely to receive IMRT than 3D-CRT. IMRT became more common during the later years of the study. Patients receiving IMRT were more likely to receive >50 Gy, photon energy of ≤6 MV, and >5 radiation fields than those who received 3D-CRT. The coverage of the IMRT planning target volume by the prescription dose was improved compared with the coverage using 3D-CRT with similar target dose heterogeneity. CONCLUSIONS IMRT improved the target dose coverage compared with 3D-CRT, although an improvement in locoregional control or FFS could not be demonstrated in this population. Future studies comparing the integral dose to nontarget tissue and late radiation toxicity between the two groups are warranted.
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Affiliation(s)
- Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA.
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Anderson JR, High R. Alternatives to the standard Fleming, Harrington, and O'Brien futility boundary. Clin Trials 2011; 8:270-6. [PMID: 21441286 DOI: 10.1177/1740774511401636] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Phase III clinical trials comparing a standard treatment to a new therapy are often monitored for futility, that is, convincing evidence that the outcome of the new treatment is not as good as that specified by the alternative hypothesis. Fleming, Harrington, and O'Brien (FHOB) proposed a popular futility monitoring method, based upon repeated testing of the alternative hypothesis at some fixed p-value (often set at p = 0.005). PURPOSE To demonstrate several interesting properties of the boundary, and to suggest alternative boundaries on the null hypothesis normalized test statistic, which cross zero at 50% of the expected total information. METHODS The FHOB boundary is redefined as a boundary on the null hypothesis normalized test statistic and re-parameterized. RESULTS FHOB-type boundaries are shown to be a function only of the significance level and power of the primary test of hypothesis, and the p-value used for repeated testing of the alternative hypothesis. The boundary can be 'centered' (in the sense of crossing zero) at some fixed percentage of the expected total information and the rate at which the boundary increases is related to the significance level and power of the primary test of hypothesis. LIMITATIONS Other futility monitoring boundaries exist and have differing operating characteristics. CONCLUSIONS The standard FHOB boundary, based upon repeated testing of the alternative hypothesis at p = 0.005 may be considered unnecessarily conservative in some settings and a monitoring boundary is proposed that is more likely to lead to a recommendation of futility when the null hypothesis is true.
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Affiliation(s)
- James R Anderson
- Department of Biostatistics, University of Nebraska College of Public Health, Omaha, USA.
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Proton radiotherapy for parameningeal rhabdomyosarcoma: clinical outcomes and late effects. Int J Radiat Oncol Biol Phys 2011; 82:635-42. [PMID: 21377294 DOI: 10.1016/j.ijrobp.2010.11.048] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 11/09/2010] [Accepted: 11/22/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE To report the clinical outcome and late side effect profile of proton radiotherapy in the treatment of children with parameningeal rhabdomyosarcoma (PM-RMS). METHODS AND MATERIALS Seventeen consecutive children with PM-RMS were treated with proton radiotherapy at Massachusetts General Hospital between 1996 and 2005. We reviewed the medical records of all patients and asked referring physicians to report specific side effects of interest. RESULTS Median patient age at diagnosis was 3.4 years (range, 0.4-17.6). Embryonal (n = 11), alveolar (n = 4), and undifferentiated (n = 2) histologies were represented. Ten patients (59%) had intracranial extension. Median prescribed dose was 50.4 cobalt gray equivalents (GyRBE) (range, 50.4-56.0 GyRBE) delivered in 1.8-2.0-GyRBE daily fractions. Median follow-up was 5.0 years for survivors. The 5-year failure-free survival estimate was 59% (95% confidence interval, 33-79%), and overall survival estimate was 64% (95% confidence interval, 37-82%). Among the 7 patients who failed, sites of first recurrence were local only (n = 2), regional only (n = 2), distant only (n = 2), and local and distant (n = 1). Late effects related to proton radiotherapy in the 10 recurrence-free patients (median follow-up, 5 years) include failure to maintain height velocity (n = 3), endocrinopathies (n = 2), mild facial hypoplasia (n = 7), failure of permanent tooth eruption (n = 3), dental caries (n = 5), and chronic nasal/sinus congestion (n = 2). CONCLUSIONS Proton radiotherapy for patients with PM-RMS yields tumor control and survival comparable to that in historical controls with similar poor prognostic factors. Furthermore, rates of late effects from proton radiotherapy compare favorably to published reports of photon-treated cohorts.
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Anderson JR, Krailo M. The Children's Oncology Group routinely applies "lack of efficacy" interim monitoring to its randomized clinical trials. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2011; 11:18-19. [PMID: 21400379 DOI: 10.1080/15265161.2011.552357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- James R Anderson
- College of Public Health, University of Nebraska Medical Center, 984395 Nebraska Medical Center, Omaha, NE 68198-4395, USA.
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Casanova M, Ferrari A. Pharmacotherapy for pediatric soft-tissue sarcomas. Expert Opin Pharmacother 2011; 12:517-31. [DOI: 10.1517/14656566.2011.524926] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Malempati S, Rodeberg DA, Donaldson SS, Lyden ER, Anderson JR, Hawkins DS, Arndt CAS. Rhabdomyosarcoma in infants younger than 1 year: a report from the Children's Oncology Group. Cancer 2011; 117:3493-501. [PMID: 21264837 DOI: 10.1002/cncr.25887] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 11/30/2010] [Accepted: 12/01/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND Rhabdomyosarcoma (RMS), the most common soft-tissue sarcoma in children, occurs less commonly in infants. Historically, poorer outcomes have been reported for infants diagnosed with RMS than for older children. METHODS The authors analyzed the characteristics, treatment administered, outcomes, and patterns of failure for infants aged < 1 year with nonmetastatic RMS who received multimodal therapy on Intergroup Rhabdomyosarcoma Study (IRS) protocols IRS-IV, D9602, and D9803. RESULTS Seventy-six infants with nonmetastatic RMS were treated on the 3 protocols from 1991 to 2005. Their median age was 7.4 months (range, 0.1-12 months). Tumor histology included embryonal (57%), alveolar (21%), and undifferentiated sarcoma/other (22%). A parameningeal primary tumor site was less common in this infant cohort (3%) than in all patients who were treated on IRS-IV (25%). The estimated 5-year failure-free survival and overall survival rates (95% confidence interval [CI]) were 57% (95% CI, 44%-67%) and 76% (95% CI, 65%-85%), respectively, for infants compared with 81% (95% CI, 79%-83%) and 87% (95% CI, 85%-89%), respectively, for children ages 1 to 9 years. Twenty-three of 32 infants with treatment failure had local recurrence/progression with distant failure (n = 3) or without distant failure (n = 20). The overall local failure rate was 30%. The median time to treatment failure was 13 months. The failure-free survival rate was worse for infants who had IRS Group III tumors and for those who received less than protocol-recommended radiation therapy. CONCLUSIONS Infants with RMS appeared to have worse outcomes than older patients, in part because of high rates of local failure. The authors concluded that concerns regarding morbidity in infants and reluctance to use aggressive local control measures may lead to higher rates of local failure.
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Affiliation(s)
- Suman Malempati
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239-3098, USA.
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