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

Grifolic acid causes osteosarcoma cell death in vitro and in tumor-bearing mice

Grifolic acid is a natural compound isolated from the fungus Albatrellus confluens. In the present study, we assessed the effects of grifolic acid on human osteosarcoma cells. We found that grifolic acid dose- and time-dependently induced cell death in the U-2 OS, MG-63, Saos-2, and 143B human osteosarcoma cell lines. Grifolic acid decreased osteosarcoma cell mitochondrial membrane potential, ATP production, and cellular NADH levels, but did not impact mitochondrial membrane potential in isolated mitochondria from human osteosarcoma cells. Intratumoral injection of grifolic acid also promoted tumor cell death and prolonged survival in nude mice bearing human osteosarcoma xenografts. Grifolic acid had no obvious toxicity in mice, with no histological changes in liver, kidney, lung, or heart, and no changes in blood cell counts or levels of plasma total protein, alanine aminotransferase, or aspartate aminotransferase. These results show that grifolic acid induces osteosarcoma cell death by inhibiting NADH generation and ATP production without obvious toxicity. Intratumoral injection of grifolic acid may be a promising anti-osteosarcoma therapeutic option in patients.

Age-based disparities in treatment and outcomes of retroperitoneal rhabdomyosarcoma

BACKGROUND

Elderly patients (EPs) suffering from retroperitoneal rhabdomyosarcoma (RRMS) carry a considerably poorer prognosis compared to younger patients (YPs). We hypothesized that EPs received less aggressive and comprehensive treatment than YPs, resulting in poorer survival outcomes.

MATERIALS AND METHODS

All patients diagnosed with RRMS since 1998 in the National Cancer Data Base (NCDB) were reviewed for patient demographics, tumor characteristics, treatment modalities and survival outcomes.

RESULTS

Of the 100 patients identified, 35 % were ≥65 years of age. EPs (aged ≥65 years), when compared to YPs (aged <65), were less likely to receive systemic chemotherapy (20 % EPs vs 71 % YPs, p < 0.001) and treatment at an academic center (34 % EPs vs 60 % YPs, p = 0.05), although the frequency of radiation (23 % EPs vs 31 % YPs, p = 0.40) and radical surgery (26 % EPs vs 22 % YPs, p = 0.55) were similar. EPs received treatment more frequently at comprehensive community cancer programs (57 %) and had a shorter median distance of travel for care (6.4 vs 13 miles, p = 0.009). After adjusting for gender and tumor size, EPs had a hazard ratio of 3.6 (95 % CI 1.8-7.2, p < 0.001), with a median survival of 2 months (interquartile range [IQR] 1-8 months) versus 17 months for YPs (IQR 8-43 months).

CONCLUSION

Altered practice patterns exist for EPs and include reduced use of systemic chemotherapy which may contribute to poorer outcomes for RRMS patients. Although regionalization of care poses challenges, this may offer benefit to the EP group.

Clinicopathological characteristics and treatment outcomes of Chinese patients with genitourinary embryonal rhabdomyosarcoma

Background

Genitourinary embryonal rhabdomyosarcoma is rarely reported in China. This retrospective analysis aimed to characterize the clinicopathologic features and treatment outcomes of genitourinary embryonal rhabdomyosarcoma in a sample of Chinese patients.

Methods

Basic demographic and clinical data of 29 patients, who were diagnosed with genitourinary embryonal rhabdomyosarcoma between January 2000 and December 2011, were retrieved and analyzed.

Results

In these patients, 25 were males and 4 were females with a median age of 12 years. Paratesticule was the most common lesion site, followed by the prostate, bladder, and vagina. The median tumor size was 5.80 cm. Six patients had clinically positive regional nodes. At the initial diagnosis, patients had a metastatic disease. According to the TNM staging classification for the IRS-IV, phase I lesions were detected in ten cases, phase II lesions in six cases, phase III lesions in four cases, and phase IV lesions in nine cases. The median survival of all patients was 63 (range from 6 to 118) months. The 1-, 3-, and 5-year survival rates for these patients were 93%, 83%, and 52%, respectively. Multivariate analyses demonstrated that staging and anemia were significant predictors of prognosis.

Conclusions

Our findings suggest that metastasis predicts a poor prognosis. Chemotherapy played an important role in comprehensive treatment. Palliative and neo-adjuvant chemotherapy could increase median survival time.

Rhabdomyosarcoma of the trachea: first reported case treated with proton beam therapy

Objective:

We report a case of rhabdomyosarcoma of the trachea in a 14-month-old child, and we present the first reported use of proton beam therapy for this tumour.

Case report:

A 14-month-old girl presented acutely with a seven-day history of biphasic stridor. Emergency endoscopic debulking of a posterior tracheal mass was undertaken. Histological examination revealed an embryonal rhabdomyosarcoma with anaplasia. Multimodality therapy with surgery and chemotherapy was administered in the UK, and proton beam therapy in the USA.

Conclusion:

Only three cases of rhabdomyosarcoma of the trachea have previously been reported in the world literature. This is the first reported case of treatment of this tumour with proton beam therapy. Compared with conventional radiotherapy, proton beam therapy may confer improved long-term outcome in children, with benefits including reduced irradiation of the spinal cord.

Prognostic factors in sinonasal sarcomas: analysis of the surveillance, epidemiology and end result database

OBJECTIVES/HYPOTHESIS

Sinonasal sarcomas are rare and often aggressive malignant tumors. Although tumor histology and location are the only reported prognostic indicators for this disease, we sought to determine if additional clinical factors might influence patient survival.

STUDY DESIGN

Retrospective cohort study using a national cancer database.

METHODS

Cases of sinonasal sarcomas from 1973 to 2008 were extracted from the Surveillance, Epidemiology and End Result (SEER) database. The influence of patient age, gender, race, and prior irradiation, as well as tumor histology and subsite, was calculated using the Kaplan-Meier method.

RESULTS

A total of 352 patients with sinonasal sarcomas were identified. Histologic subtype, tumor location, gender, and patient age were found to influence patient survival. Specifically, increased age, male sex, frontal and maxillary sinus subsites, and rhabdomyosarcoma and Kaposi sarcoma histologies were associated with a significant increase in mortality rate (P < .05).

CONCLUSIONS

This study comprises the largest analysis of patients with sinonasal sarcoma in the literature and demonstrates the impact of patient age, tumor histology, and tumor location on the overall survival of individuals with these rare malignancies.

Doxorubicin for prevention of epineurial fibrosis in a rat sciatic nerve model: outcome based on gross postsurgical, histopathological, and ultrastructural findings

Object

Epineural fibrosis may complicate peripheral nerve surgeries and currently is considered as one of the main factors responsible for failed surgeries. The authors investigated the postoperative antiscarring effects of topically applied doxorubicin (DXR) on rat sciatic nerves.

Methods

The sciatic nerves were dissected from the surrounding tissue and exposed bilaterally in 20 Wistar albino adult male rats. Abrasion trauma was produced on the exposed surface of the biceps femoris muscle in the vicinity of the sciatic nerves and their main branches in all animals. In the DXR Group, cottonoid pads soaked with DXR (0.5 mg/ml) were placed around the nerves for 5 minutes, whereas cotton pads soaked with saline (0.9% NaCl) were applied to nerves of animals in the Control Group for the same duration. Twelve weeks after the procedure, all of the rats were killed and the sciatic nerves were examined. Epineural adhesions were evaluated histopathologically and ultrastructurally. Additionally, quantitative histological parameters, the scar tissue formation index and the scar density, were calculated in histological evaluation.

Results

Gross postsurgical evaluation as well as histopathological and electron microscopic examination of involved nerve segments showed significantly less epineurial adhesions in the DXR Group than in the Control Group. Quantitative analysis of the epineurium revealed a statistically significant reduction in the density and amount of epineural scarring in specimens from the DXR Group than in those from the Control Group.

Conlusions

The results of gross postsurgical anatomical evaluation and histopathological and ultrastructural studies suggested that topical application of DXR effectively reduced epineural scar formation on rat sciatic nerves. These promising findings merit further experimental and clinical studies to determine the efficacy and safe applicability of DXR in human subjects.

Rhabdomyosarcoma of the bladder, prostate or vagina: the role of surgery

OBJECTIVE

To retrospectively analyse the outcome of children with rhabdomyosarcoma (RMS) of the bladder, prostate or vagina who were treated with chemotherapy, with or without radical surgery or additional radiotherapy, at our institution since 1968.

PATIENTS AND METHODS

From a total of 107 children with RMS seen between 1968 and December 2001, 22 (mean age 5.9, range 0.5-18) had RMS of bladder/prostate or vagina. Twenty of the patients received primary polychemotherapy (vincristine, actinomycin D, cyclophosphamide, adriamycin, and more recently including etoposide and ifosfamide), two had primary surgery and seven had additional radiotherapy. Fourteen patients had radical cystoprostatectomy, with continent cutaneous urinary diversion with an ileocaecal pouch in seven, in one each a transverse colonic pouch, orthotopic ileocaecal bladder substitution, a rectal reservoir and rectosigmoid pouch and a colonic conduit diversion in two patients.

RESULTS

After a mean (range) follow-up of 8.6 (1.0-26) years, 17 patients had no evidence of disease. Five patients presenting initially with advanced tumour stages died from progressive RMS. Two patients with a continent urinary diversion required ureteric reimplantation for stenosis. In two patients severe bladder contraction after radiotherapy required bladder augmentation.

CONCLUSION

Primary chemotherapy followed by radical surgery of RMS of the prostate and/or bladder allows complete tumour resection in most cases, and yields excellent cure rates.

Treatment of non-metastatic rhabdomyosarcomas in childhood and adolescence. Results of the second study of the International Society of Paediatric Oncology: MMT84

The second International Society of Paediatric Oncology (SIOP) study for rhabdomyosarcoma (MMT84) had several goals. The two principal aims were: (1) to improve the survival of children with rhabdomyosarcoma; and (2) to reduce the late effects from therapy by restricting the indications for surgery and/or radiotherapy after good response to initial chemotherapy. A further aim was to investigate the role of high-dose chemotherapy in young patients with parameningeal primary tumours. 186 previously untreated eligible patients entered the study. Patients with completely resected primary tumour received three courses of IVA (ifosfamide, vincristine and actinomycin D). Patients with incompletely resected tumour received six to 10 courses of IVA according to stage. Patients achieving complete remission with chemotherapy alone did not usually receive radiotherapy or undergo extensive surgery, but patients remaining in partial remission received local therapy with surgery and/or radiotherapy. Only patients over 5 years of age with parameningeal disease and patients over 12 years with tumours at any site were given systematic irradiation. Complete remission was achieved in 91% (170/186) of all patients. With a median follow-up of 8 years, the 5-year overall survival was 68% (+/- 3% standard error of the mean (SEM) and the 5-year event-free survival 53% (+/- 4% SEM). These results show an improvement over previous SIOP study (RMS75) in which survival was 52% and event-free survival was 47%. Among the 54 patients who exhibited isolated local relapse, 35% (19/54) survived in further remission longer than 2 years after retreatment, including local therapy (surgery +/- radiotherapy). Analysis of the overall burden of therapy received by all surviving children (including primary treatment and treatment for relapse if required) showed that 24% (28/116) were treated by limited surgery followed by three courses of IVA, 29% (34/116) were treated by chemotherapy alone (after initial biopsy) and 13% (15/116) received chemotherapy plus conservative local treatment (limited surgery or radiotherapy for residual disease). Only 34% (39/116) received intensive local therapy defined as radical wide field radiotherapy or radical surgery or both. Compared with the results obtained in the previous SIOP study, treatment in MMT84 was based on response to initial chemotherapy and, despite an overall reduction of the use of local therapy, significantly improved survival for patients with non-metastatic disease. This trial, also for the first time, provides evidence that retreatment after local relapse can achieve long-term second remissions.

Rhabdomyosarcoma. Biology and treatment

Rhabdomyosarcoma is the most common soft-tissue sarcoma of childhood. Recognition of specific genetic changes in the two most common subtypes of rhabdomyosarcoma has allowed better understanding of the pathogenesis of this disease. In addition, identification of prognostic factors and the use of risk-directed multimodal therapy have improved the outcome for these patients significantly, with cure rates approaching 70%.

Outcome of treatment for pediatric sarcoma of the foot: a retrospective review over a 20-year period

Soft tissue sarcomas (STS) arising in the foot are rare in children. From 1975 to 1994, 18 children (median age, 13.5 years) were treated at St Jude Children's Research Hospital for STS of the foot. Five children had rhabdomyosarcoma (RMS), with alveolar histology in four cases. All of these patients presented with metastatic disease, which proved fatal within 9 to 24 months despite combined modality treatment with chemotherapy, radiation, and surgery. Thirteen patients had nonrhabdomyosarcoma soft tissue sarcoma (NRSTS). The most common histological variant was synovial sarcoma (7 patients). Of the 10 who presented with localized disease, seven survived 1 to 12 years (median, 7 years). Surgical treatment for these consisted of local excision (n = 2), wide local excision (n = 3), below knee amputation (n = 1 ), ray amputation (n = 1). Three received supplemental radiation, and one was also treated with chemotherapy. Local or distant recurrence proved fatal in the three other children who had localized disease. Three children who presented with metastatic NRSTS died 8 to 14 months after diagnosis. All surviving patients are without significant functional disability. In our experience, pediatric RMS of the foot has a poor outcome, attributable to both alveolar histology and presence of metastatic disease at diagnosis. In contrast, NRSTS of the foot is more often localized, and limited surgery with adjuvant radiation in the absence of clear margins should be the treatment of choice.

Fibrosarcoma in children--a rare tumour with long-term survival even with advanced disease--a report of 3 cases

Fibrosarcoma is a rare tumour in children. The potential of malignancy has been questioned. We present three cases of fibrosarcoma in children . The follow-up periods range from 10 to 37 years. The first patient had pulmonary metastases at the time of diagnosis in 1958. The primary tumour in fossa ischio-rectalis was resected in 1960. Lung metastases were resected in 1960 and 1989. Radiotherapy was given in 1992. He is still alive with metastases 37 years after the first manifestation of disease. The second patient had a primary tumour and several local recurrences in the mandible. He is alive without evidence of disease 4 years after resection of pulmonary metastases and 21 years after resection of the primary tumour. The third patient has no signs of recurrence or metastatic spread 10 years after a wide excision of subcutaneous tumours of the left upper arm. The cases demonstrate a special tumour-entity of low-grade malignancy, which show a good prognosis and a wide spectrum of biological behaviour.

High-dose VP16 cisplatinum in soft tissue sarcoma of children

Nine children with soft tissue sarcomas, five of them rhabdomyosarcomas with initial metastatic disease, (one patient, partial response, one patient), refractory primary, (two patients, relapse, five patients) were treated with a combination of high-dose VP16 (100 mg/m2 daily for 5 days) and cisplatin (40 mg/m2 daily for 5 days). The response rate was five out of nine or 55% (+/- 32%) (two complete and three partial, responses). Three of the five responders had rhabdomyosarcomas. The duration of response was 4-58 months (median 11 months). The toxicity was mainly hematological. Thus, the high-dose VP16-cisplatin association warrants further evaluation in soft tissue sarcoma in children.

Nonrhabdomyosarcoma in children: prognostic factors influencing survival

In approximately 90% of children with nonrhabdo soft tissue sarcoma (NRSTS) local control can be obtained by either surgery alone or with supplemental radiation. The disease-free survival is, however, only about 50%. To determine factors influencing overall survival, we undertook a retrospective review of the 154 children with NRSTS. We used the American Joint Committee on Cancer staging system (1988), using invasiveness, size, and a Pediatric Oncology Group grading system. Using this system we documented that 72 (46%) were noninvasive (T1) lesions. Of these 72 patients 50 (70%) were < or = 5 cm A, and only 9 (18%) had G3 lesions. Overall 7/72 (10%) have died. In contrast to the 82 patients with invasive (T2) lesions, 65 (79%) were > 5 cm (B), with approximately 80% G3. Of all T2 lesions, 56/82 were G3 (65%). Here, overall 58/82 (70%) have died, primarily because 49/58 had G3 lesions. Important prognostic factors include primarily G3 lesion 52/71 (73%) mortality, as compared to 13/83 (15%), G1-2 dying. Children with invasive lesions tended to have larger tumors, 50/65, most of which were higher grades. We feel that patients with histologic grade G3 and T2 lesions should be enrolled in effective chemotherapy protocols.

Pediatric soft tissue sarcomas of nonmyogenic origin

Nonrhabdomyosarcoma soft tissue sarcomas (NRSTS) are relatively rare tumors, which nonetheless constitute 50% of the soft tissue sarcomas seen in the pediatric population. The prognosis for these tumors is good, with 92% of patients in our series alive and 61% free of their disease at 5 years follow-up. The most important prognostic factor among our 35 patients was the grade of the tumor. More than 70% of our patients with grade I or II lesions are disease-free at 5 years, compared to only 39% of patients with grade III lesions. The patients with the best outlook are those who can be treated with surgery alone as the definitive care for this disease. Resection remains the primary treatment modality in NRSTS, whereas, unlike the treatment of rhabdomyosarcomas, the value of radiation therapy and chemotherapy in treating NRSTS remains undefined.

A phase II trial of ifosfamide in previously untreated children and adolescents with unresectable rhabdomyosarcoma

BACKGROUND

Children and adolescents with unresectable rhabdomyosarcoma fare poorly when treated with contemporary chemotherapeutic regimens. Evaluation of newly developed agents in these patients is important to improve their outcome. Based on a preclinical rhabdomyosarcoma xenograft model that accurately predicted the activity of new agents, the safety and efficacy of ifosfamide was evaluated as part of a Phase II clinical trial in previously untreated children with unresectable rhabdomyosarcoma.

METHODS

Twenty-two children and adolescents (median age, 9 years) with newly diagnosed unresectable rhabdomyosarcoma (Intergroup Rhabdomyosarcoma Study Group III [n = 15] or IV [n = 7]) received two courses of ifosfamide at a dose of 1.6 g/m2 intravenously for 5 days over a 6-week period. Then the patients were evaluated for response, and additional treatment with surgery, radiation therapy, and multiagent chemotherapy (vincristine, cyclophosphamide, dactinomycin, and doxorubicin) was administered.

RESULTS

Nineteen of 22 patients (86%) had a partial response to ifosfamide given as a single agent. No complete responses to this agent alone were observed. After administration of additional chemotherapy and local control measures (radiation therapy and surgery), the estimated proportion of patients surviving progression-free at 2 years was 63% (95% confidence interval, 37-80%). Ifosfamide was tolerated well; the most frequent toxicity was nondose-limiting myelosuppression. Transient mild renal toxicity infrequently was observed, and no central nervous system toxicity occurred in this group of patients.

CONCLUSIONS

Ifosfamide appears to have significant clinical activity in untreated patients with unresectable rhabdomyosarcomas. These findings provide an accurate estimate of the response rate to single-agent ifosfamide in this group of previously untreated patients and thus provide a foundation for its rational incorporation into multiagent clinical trials. In addition, the potential benefits of this type of new drug development were demonstrated.

Insulin-like growth factor-I-dependent growth and in vitro chemosensitivity of Ewing's sarcoma and peripheral primitive neuroectodermal tumour cell lines

Serum-free growth of Ewing's sarcoma (ES) and primitive peripheral neuroectodermal tumour (pPNET) cell lines was achieved by supplementing a basal medium with insulin-like growth factor-I (IGF-I). These cultures were used to investigate the sensitivity of 3 ES (EW-2, RD-ES, SK-ES-1) and 3 pPNET (SIM-1, KAL, SAL) cell lines to a panel of anti-tumour agents in short-term (48-h) proliferation assays. Of the four cytostatic drugs included in the currently used multi-drug regimens, cyclophosphamide, doxorubicin and actinomycin-D inhibit the proliferation of the cell lines with high efficacy, whereas the vinca alkaloids were less effective. Cisplatin, etoposide, mitomycin-C and mitoxanthrone were also found to have a high inhibitory activity in this in vitro ES/pPNET system. The most remarkable effect was observed for cytosine arabinoside (ARA-C), which gave a half-maximal inhibition at drug concentrations approximately 5000 times below the clinical peak plasma concentrations (250 micrograms/ml). The ARA-C sensitivity of ES and pPNET cell lines is comparable with the established ARA-C sensitivities of leukaemia-derived cells. The different ES and pPNET cell lines showed a rather uniform response to the different cytostatic drugs with decreased sensitivity of individual pPNET cell lines to vinblastin, ARA-C and mitoxanthrone. Modulation of the IGF-I/IGF-I receptor/IGF-I binding protein system, which seems to constitute an important stimulator of cell growth in neuroectoderm-derived or -related tumours, can be used to enhance the drug sensitivity of the tumour cells in vivo or in vitro therapeutic procedures. According to our results, serum-free conditions for autologous bone marrow purification are expected to result in significantly increased chemosensitivity of ES and pPNET cells in response to anthracyclines and cisplatin.

Head and neck sarcoma: report of the Head and Neck Sarcoma Registry. Society of Head and Neck Surgeons Committee on Research

A Head and Neck Sarcoma Registry was established by the Society of Head and Neck Surgeons to review treatment results of a rare tumor by surgeons with special interest in this anatomic site. Two hundred fourteen patients were analyzed. There were 194 adult tumors and 20 pediatric tumors. The major sites included parotid and neck, 20%; face and forehead, 18%; maxilla and palate, 13%; scalp, 12%; mandible, 11%; paranasal sinuses, 7%; larynx, 2%; and oral cavity, 5%. Eighty-four percent were resectable. The disease-free survival was 56%; overall survival was 70% at 5 years. Major determinants of survival were adequacy of resection (margins free of tumor) and tumor type. Survival differed according to tumor cell type (tumor grade was not available). Patients with chondrosarcoma and dermatofibrosarcoma had survival approaching 100%. Patients with malignant fibrous histiocytoma (MFH) and fibrosarcoma (FSA) had intermediate survival of 60% to 70%. The worst survival, less than 50% at 5 years, occurred in patients with osteosarcoma, angiosarcoma, and rhabdomyosarcoma in decreasing order. This suggests a rationale for identifying high-risk patients for prospective adjuvant protocols. This study emphasizes the value of recording uncommon tumors to provide relevant information for future study and possibly therapy.

Management and prognosis of head and neck sarcomas

Between 1962 and 1988, a total of 104 patients with head and neck rhabdomyosarcoma (RMS) and 17 patients with nonrhabdomyosarcoma (NRMS) were evaluated and treated at St. Jude Children's Research Hospital. All parameningeal sites (middle ear, orbit, or nasopharynx) were excluded from further analysis; thus, 50 patients represent the cohort of head and neck sarcomas for this review. Survival was good in this group of patients, 28 of 50 being alive and disease-free at last follow-up. Twenty of the 38 patients with RMS were alive and disease-free. Similarly, 8 of the 12 patients with NRMS were disease-free at a median follow-up of 5 years. However, the site and size of the primary tumor impacted on the extent of the initial resection and further treatment in addition to surgery. Although the treatment policy evolved over time to a stage-specific strategy for treatment modalities, the data suggest that surgery alone may be sufficient initial therapy for a subset of patients. For patients in whom complete resection is not achieved, the addition of radiotherapy and chemotherapy may result in improved survival.

Infantile fibrosarcoma in the mandible: case report

A case of an infantile fibrosarcoma in the mandible is described. The primary tumor was seen in a 2.5 yr-old boy. In spite of repeated surgical interventions the tumor recurred five times during a 15-yr period, but no metastases have been observed. The difficulty in arriving at a correct histopathologic diagnosis on an unusual tumor in the oral region is demonstrated by the fact that 16 consulted pathologists suggested a long list of different tumors. The treatment of choice seems to be radical surgery. The patient has remained well and without recurrence for the last 7 yr.

Present-day concepts in the management of sarcomas in children

1. NRSTS tumors represent 20-20% of all soft tissue sarcomas. In only the extremity primary are both RMS and NRSTS occurring with almost equal frequency. 2. Modern diagnostic imaging studies are invaluable to staging and preoperative planning. 3. The most important need is to standardize biopsy techniques, since an ill-conceived biopsy has an adverse effect on the definitive surgical procedure. 4. Standardization of surgical procedures is necessary to adequately define extent of local resection varying with site, type of tumor, and its biological behavior. Less radical procedures do not seem to have had an adverse effect in local control or survival as is evidenced in RMS of the orbit, vagina, and bladder. 5. Though complete surgical extirpation is the treatment of choice in RMS, incomplete surgical excision leaving microscopic disease can result in adequate local control following chemotherapy and radiation therapy. However, less than optimum responses to chemotherapy in the NRSTS makes it imperative that efforts be made to completely resect these lesions. 6. It is in the realm of initially unresectable primary lesion that the surgical oncologist's role be refined. Consideration here includes: (a) use of newer surgical techniques such as laser, or free microvascular grafts, (b) protocols to define the optimum timing of delayed surgery following preoperative chemotherapy with or without radiation therapy.

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.

New aspects in the treatment of childhood rhabdomyosarcoma: results of the German Cooperative Soft-Tissue Sarcoma Study (CWS-81)

The results of the German Co-operative Soft-Tissue Sarcoma Study (CWS-81) of the treatment of rhabdomyosarcoma are presented. Prior to the introduction of chemotherapy only 10%-20% of the children were successfully treated. Combined multi-agent cytostatic treatment improved the results dramatically. In patients with primary stage III rhabdomyosarcoma, local tumour control by surgery or radiotherapy should be undertaken earlier than week 16, if complete remission has not been achieved by 7-9 weeks. Patients with complete remission or partial tumour regression should be treated with the same combination of chemotherapy, while only partial responders need radiotherapy in addition. Patients with tumours which are primarily resectable without mutilation have a 90% chance of cure; this also applies to patients with primarily unresectable tumours who achieve complete remission after 7-9 weeks of chemotherapy. Total disease-free survival rate for stage III rhabdomyosarcoma patients was 53%. The role of surgery includes primary removal of the tumour or assessment of remission by means of histological spot checks.

Adjuvant chemotherapy of solid tumors

Adjuvant chemotherapy for microscopic disease following eradication of clinically detectable lesions by primary surgery and/or radiotherapy is of documented benefit for some oncology patients. However, for many primary cancers efficacy is limited to specific subgroups of patients or has demonstrated no advantage over primary therapy alone. The rationale for adjuvant chemotherapy and results of selected trials are reviewed. In patients for whom adjuvant therapy is of demonstrated benefit, further trials aimed at delineation of patient selection factors, optimal chemotherapy regimens and schedules, and duration of therapy are needed; progress in adjuvant treatment of other subgroups may require development of more effective antineoplastic drugs, in addition to exploration of these factors.

Congenital fibrosarcoma. Preoperative chemotherapy and conservative surgery

Three cases of congenital fibrosarcoma are reported. The use of preoperative chemotherapy, a VAC regimen, allowed conservative surgery in two of them. The three children are well, with no evidence of disease and without sequelae after completion of postoperative chemotherapy.

Experimental studies on interactions of radiation and cancer chemotherapeutic drugs in normal tissues and a solid tumour

The interactions of radiation and seven cancer chemotherapeutic drugs have been investigated in four normal tissues (intestinal crypts, skin, haemopoietic tissue and lung) and in a solid C3H mouse mammary carcinoma in vivo. All experiments were carried out with male C3D2F1 mice. The investigated drugs were adriamycin (ADM), bleomycin (BLM), cyclophosphamide (CTX), 5-fluorouracil (5-FU), methotrexate (MTX), mitomycin C (MM-C) and cis-diamminedichloroplatinum(II) (cis-DDP). Single drug doses were given at different intervals before, simultaneously with and after single doses of radiation. The normal tissue reactions following drug-radiation combinations were found to be highly complex. The interactions varied both quantitatively and qualitatively from drug to drug and from tissue to tissue. The drugs enhanced the radiation response in most cases. However, signs of radioprotection was observed for CTX in skin and for MTX in haemopoietic tissue. The interval and the sequence of the two treatment modalities were of utmost importance for the normal tissue reactions. In general, the most serious interactions occurred when drugs were administered simultaneously with or a few hours before radiation. The radiation-modifying effect of the drugs deviated from this pattern in the haemopoietic tissue as the radiation response was most enhanced on drug administration 1-3 days after radiation. Enhancement of the radiation response was generally less pronounced in the tumour model than in the normal tissues. The combined drug-radiation effect was apparently less time-dependent in the tumour than in the normal tissues.

Long-term results in childhood rhabdomyosarcoma: a retrospective study in Italy

This paper reviews a series of 70 consecutive children with rhabdomyosarcoma (RMS) diagnosed during 1971-1978 and treated in five Italian institutions. Thirteen were classified as group I, 12 as group II, 37 as group III, and 8 as group IV according to the Intergroup RMS Study staging system. Survival was influenced by tumor extension at diagnosis, primary site, and response to therapy. The 5-year-survival rate was 92% for group I patients, 67% for group II, 44% for group III, and 0% for group IV. Thirty-four children had all therapy stopped after 12-32 months of complete remission, 7 had late recurrences, and 3 died from disease. Musculoskeletal sequelae were diagnosed in 11 children, short stature in 3, corneal opacity in 2, and cardiac failure in 1.