Role of therapeutic radiology in cancer of bone

Staging, Therapy and Prognosis of Primary Non-Hodgkin's Lymphoma of Bone and a Comparison of Results with Localized Ewing's Sarcoma: Ten Years Experience at the Istituto Ortopedico Rizzoli

Thirty consecutive cases of localized primary non-Hodgkin's lymphoma of bone (PNHLB) were treated in a 10-year period at the Istituto Ortopedico Rizzoli with localized radiation (4 cases) and localized radiation and adjuvant chemotherapy (26 cases). The doses of radiation varied from 3000-4500 rad. A variety of staging procedures evolving with new diagnostic techniques over the 10 years were performed. Adjuvant chemotherapy comprised two different regimens of vincristine, adriamycin and cyclophosphamide. Twenty-four of the 26 patients (92 %) have been free of disease with a median follow-up of 75.5 months (18-144 months). Two patients developed meningeal involvement and one patient, treated with radiation therapy only, developed a local recurrence. The results are compared to the management of 68 Ewing's sarcoma patients treated during the same period. Here, higher doses of localized radiation therapy (approximately 5000 rad) and similar adjuvant chemotherapy were administered. The survival was 32 % (22/68) with a higher incidence of local recurrence (21 %). These data indicate that PNHLB should be considered a separate entity from Ewing's sarcoma and can be treated successfully with lower doses of radiation to the primary tumor and adjuvant chemotherapy. The observations are also compared to a variety of other biological characteristics of Ewing's sarcoma. Since only two patients developed meningeal relapse, our experience does not permit a firm recommendation for routine prophylactic treatment of the central nervous system in PNHLB.

Radiotherapy for lung metastases in a patient with ewing sarcoma

Purpose. To assess the benefit of therapy for multiple lung metastases in a young female patient previously treated with operation, local radiotherapy and chemotherapy.

Patient: Lung metastases occurred in a young female patient 13 months after finishing combined treatment of a Ewing sarcoma of the left eleventh rib. Primary treatment had included surgical removal, 51 Gy local radiotherapy and chemotherapy.

Method. 20 Gy total dose was applied to the lungs of both sides in two courses with an additional 15 Gy to the mediastinum.

Results and Discussion. Complete radiological regression was achieved at the end of therapy which was maintained during the follow-up period of 16 months.

Rhenium-186 HEDP as a boost to external beam irradiation in osteosarcoma

In this case report we demonstrate the usefulness of targeted radiotherapy in the form of rhenium-186 HEDP as a method for dose escalation in the treatment of osteosarcoma.

The Ewing family of tumors. Ewing's sarcoma and primitive neuroectodermal tumors

There has been an explosion of new knowledge regarding the Ewing family of tumors over the past 5 to 10 years. Classical Ewing's sarcoma and PNET are now known to be the same tumor with variable differentiation, defined by a translocation between the EWS gene on chromosome 22 with one of three ETS-like genes, especially the FLI-1 gene on chromosome 11. Molecular techniques used to identify this translocation along with the knowledge that the protein product of the MIC2 gene is highly expressed on the cell surface have greatly improved our diagnostic abilities in this family of tumors. Controversy still exists as to whether surgery improves event-free survival when compared with radiotherapy in Ewing's sarcoma. The high second tumor rate, if nothing else, has started moving many physicians to preferentially use surgery when the functional results are predicted to be reasonable. The addition of ifosfamide and etoposide to standard therapy in Ewing's sarcoma has improved survival for patients without metastases at presentation. However, outcome for patients with metastases or who develop metastases while on therapy or shortly thereafter remains poor. Preliminary reports of better outcome with megatherapy are interesting but not yet definitive. The decades ahead will probably see marked changes in therapy for Ewing's sarcoma. The unique translocation seen in virtually all of these tumors is a potential target for a "magic bullet" therapy, because the protein product of this translocation is present only in the malignant cells. Hopefully either immune modulation against this unique protein or further knowledge of how to use antisense genes will move us toward exquisitely targeted therapy in the Ewing family of tumors.

Osteosarcoma of the facial bones

Maxillo-facial osteosarcoma is a rare primary tumor in adults. Between 1980 and 1990, 11 patients were considered; 6 had primary tumors in mandible and 5 in the maxillo-paranasal region. All cases were treated with surgery as the primary modality. Resection was radical in 8 patients and palliative in the other 3. Adjuvant postoperative chemotherapy with adriamycin was administered for 6 months in the 8 patients treated with complete resection. After a median follow-up of 3 years, 7 patients are still alive and 4 died of progressive disease. In the group of patients treated with radical surgery and adjuvant chemotherapy only one died for distant metastases, and 7 are living free of disease. With complete surgical resection long term local tumor control was achieved in all patients. No patient treated with incomplete resection achieved local tumor control with subsequent radiotherapy. The possibility of performing a complete surgical resection of the primary appears to be an essential step to obtain long term local control and survival in maxillo-facial osteosarcoma. Our series is, however, too limited to evaluate the therapeutic benefit of adjuvant chemotherapy.

Primary lymphoma of bone: long term results in patients treated with vincristine--adriamycin--cyclophosphamide and local radiation

Primary lymphoma of bone (PLB) is an unusual but well-recognized extranodal presentation of non-Hodgkin's lymphoma. In most series treatment with radiotherapy alone results in a cure rate of approximately 40%. Between January 1972 and December 1982, 26 patients with biopsy proven PLB were treated at the Rizzoli Institute with radiotherapy (4000-5,500 rad) and chemotherapy (vincristine, cyclophosphamide and adriamycin). The minimal clinical staging included complete blood cell counts and serum chemistries, bone radiography, full lung tomography, isotope bone scan, bone marrow biopsy and bipedal lymphoangiograms. At a median follow-up of 13 years (8.5-18.5) there were only three relapses (2 cases of meningeal involvement and 1 recurrence in another bone). No local recurrences nor second tumor in the irradiated field were observed. We conclude that the addition of chemotherapy to radiotherapy results in an excellent cure rate for patients with PLB.

Bulk disease as the major problem in the cure of paediatric sarcomas

Bulk disease is a problem in all the major paediatric sarcomas. It is the pre-eminent problem in parameningeal rhabdomyosarcoma but only a recently recognised problem in limb osteogenic sarcoma (only since the advent of limb-conserving surgery). In all cases where a large bulk of sarcoma threatens to relapse locally, multimodality therapy (surgery, radiotherapy, chemotherapy) stands a better chance of sterilisation than individual modalities of therapy, and such multimodality therapy stands its best chance when it is used early, that is, all three modalities are used at the beginning or shortly after commencement of the treatment course.

Local control of Ewing's sarcoma: an analysis of 67 patients

Local control of Ewing's sarcoma was analysed in a series of 67 patients treated by surgery and/or radiotherapy as well as combination chemotherapy. Radiotherapy was employed with or without surgery in 60 patients and produced an overall local control rate of 55%; complete excision of the primary lesion seemed to be beneficial. There was a marked variation in control rates depending on the site of the primary lesion: limb 85%, rib 53%, pelvis 31% and other sites 33%. Primary tumours greater than 10 cm in diameter were significantly less likely to be controlled. Using daily fractions of approximately 180 cGy, total doses in excess of 6000 cGy seem more likely to produce serious late morbidity and may not increase the local control rate. No cases of second malignancy arising in irradiated tissue have been observed to date, but one patient developed acute lymphoblastic leukaemia.

Ewing's sarcoma. A retrospective study of prognostic factors and treatment results

A material of 87 consecutive patients with Ewing's sarcoma referred for treatment in the period 1962-1983 was retrospectively analysed. Thirteen patients had metastases at the time of diagnosis. Of the remainder, 71 received radiation therapy and 32 adjuvant chemotherapy. Survival rate was not influenced by age, sex or treatment delay. Metastatic disease predictably shortened survival (median 6 months vs. 23 months for localized disease). Tumour site did not significantly influence survival rate, although pelvic localization was associated with a slightly shorter median survival. Both pain and objective impairment of movement at presentation correlated to a poorer prognosis, possibly because of larger tumours or soft tissue extension. Adjuvant chemotherapy prolonged recurrence-free survival from a median of 6 months to 16 months, but survival was not improved significantly. Local failure occurred in about 40 per cent, regardless of radiation dose and tumour site. At the time of evaluation, 13 patients (15%) were alive with no evidence of disease and a median follow-up time of 68 months (range 16-196). So far, 2 patients have developed secondary malignancies in irradiated areas (one malignant fibrous histiocytoma and one osteogenic sarcoma).

Advances in pediatric radiotherapy in the last ten years and future proposals

Advances made can be divided into five main categories. Firstly, the problem of geographic miss which has been reduced by delivering effective radiation doses with greater precision. This has been accomplished with more sophisticated diagnostic and therapeutic equipment, immobilization techniques and computerized treatment planning. Second is the recognition of the interplay of radiation and chemotherapy on normal tissue tolerance and local tumor control. This interaction has necessitated reduction in both dose and volume of irradiation. Third is the use of wide field irradiation as a systemic treatment. Fourthly, the utilization of cooperative group trials to define the role of irradiation. Finally, with the improvement in survival has come the recognition of late effects of irradiation in the growing child and the means of reducing such effects. The current role of radiation therapy in childhood malignancies is summarized, controversies are identified, and future prospects explored.

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

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

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

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

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

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

Radiation therapy for primary lymphoma of bone

The records of 30 patients with primary lymphoma of bone (PLB) who were treated with radiation therapy were reviewed. The probability of NED-survival and overall survival at five-year follow-up was 53 and 63%, respectively. There were three local failures following treatment. The cumulative incidence of local recurrence was 14% at five years. No local failures were observed when tumors received doses higher than 50 Gy, or equivalent to a TDF of 70 or greater. The number of failures was too small to examine for a correlation between histologic subclassification and local control frequency if doses higher than 50 Gy were utilized. Complications of treatment occurred in four patients. Functional results were excellent in all except two patients. These data provide guidelines for determination of a clinically appropriate radiation dose level for PLB.

Intergroup Ewing's Sarcoma Study: local control related to radiation dose, volume, and site of primary lesion in Ewing's sarcoma

One hundred ninety-three patients with localized Ewing's sarcoma treated at participating instutitions of the Intergroup Ewing's Sarcoma Study form the basis for this report. All patients received radiation therapy to the primary lesion and were randomized to receive vincristine, actinomycin-D, and cyclophosphamide (VAC) plus adriamycin (Regimen I); VAC alone (Regimen II); or VAC and bilateral pulmonary irradiation (Regimen III). Local control was achieved in 96% of the patients in Regimen I, and 86% of the patients in both Regimens II and III. The median duration of follow up was 83 weeks and median survival time was 172 weeks. Incremental doses of irradiation did not result in significant changes in the rate of local control of primary lesions. The local control rate was the same (92%) for tumors treated by means of whole-bone irradiation or with at least 5 cm of free margin around the lesion. The local control rate decreased to 79% for lesions treated with less than 5-cm margin. Excellent control was obtained for lesions involving the skull or spine (100%), and distal bones (fibula, 96% and tibia, 91%). Less favorable control rates were noted for pelvic and humeral lesions (84% and 79%, respectively). Bilateral pulmonary irradiation for subclinical disease played a role in lowering the incidence of lung metastases from 38% to 20% for patients treated with VAC. Lung metastases were similarly decreased (10%) when adriamycin was added to VAC chemotherapy.

Acute and late effects on normal tissues following combined chemo- and radiotherapy for childhood rhabdomyosarcoma and Ewing's sarcoma

Twenty-three patients with rhabdomyosarcoma and 15 patients with Ewing's sarcoma, treated with radiation therapy to the local site and systemic multiagent chemotherapy are described. Acute reactions from combination chemotherapy and radiation therapy were noted in both groups of patients. These reactions often appeared after low doses of irradiation, required unplanned interruptions of treatments, and in some patients, led to discontinuation of radiation therapy. The chronic effects on normal tissues in both groups of patients have been severe in several cases.