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Bronk JK, McAleer MF, McGovern SL, Lassen-Ramshad Y, Safwat A, Daw NC, Rainusso N, Mahajan A, Grosshans DR, Paulino AC. Comprehensive radiotherapy for pediatric Ewing Sarcoma: Outcomes of a prospective proton study. Radiother Oncol 2024; 195:110270. [PMID: 38583721 DOI: 10.1016/j.radonc.2024.110270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/20/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND PURPOSE Patients with Ewing Sarcoma (EWS) are treated with multimodality therapy which includes radiation therapy (RT) as an option for local control. We report on the efficacy after proton radiation therapy (PRT) to the primary site for localized and metastatic EWS. MATERIALS AND METHODS Forty-two children with EWS (33 localized, 9 metastatic) treated between 2007 and 2020 were enrolled on 2 prospective registry protocols for pediatric patients undergoing PRT. PRT was delivered by passive scatter (74 %), pencil-beam scanning (12 %) or mixed technique (14 %). Treated sites included the spine (45 %), pelvis/sacrum (26 %), skull/cranium (14 %), extraosseous (10 %), and chest wall (5 %). Median radiation dose was 54 Gy-RBE (range 39.6-55.8 Gy-RBE). Patients with metastatic disease received consolidative RT to metastatic sites (4 at the time of PRT to the primary site, 5 after completion of chemotherapy). Median follow-up time was 47 months after PRT. RESULTS The 4-year local control (LC), progression-free survival (PFS), and overall survival (OS) rates were 83 %, 71 %, and 86 %, respectively. All local failures (n = 6) were in-field failures. Tumor size ≥ 8 cm predicted for inferior 4-year LC (69 % vs 95 %, p = 0.04). 4-year PFS and OS rates were not statistically different in patients with localized versus metastatic disease (72 % vs 67 %, p = 0.70; 89 % vs 78 %, p = 0.38, respectively). CONCLUSION In conclusion, LC for pediatric patients with EWS treated with PRT was comparable to that of historical patients who received photon-RT. Tumor size ≥ 8 cm predicted increased risk of local failure. Patients with metastatic disease, including non-pulmonary only metastases, received radiation therapy to all metastatic sites and had favorable survival outcomes.
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Affiliation(s)
- Julianna K Bronk
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Akmal Safwat
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Najat C Daw
- Department of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nino Rainusso
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine and Texas Children's Hospital Cancer and Hematology Centers, Houston, TX, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - David R Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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Kacar M, Nagel MB, Liang J, Li Y, Neel MD, Lucas JT, McCarville MB, Santiago T, Pappo AS, Krasin MJ. Radiation therapy dose escalation achieves high rates of local control with tolerable toxicity profile in pediatric and young adult patients with Ewing sarcoma. Cancer 2024; 130:1836-1843. [PMID: 38271232 PMCID: PMC11058012 DOI: 10.1002/cncr.35196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Local control for patients with Ewing sarcoma (EWS) who present with large tumors are suboptimal when treated with standard radiation therapy (RT) doses of 54-55.8 Gy. The purpose of this study is to determine local control and toxicity of dose-escalated RT for tumors ≥8 cm (greatest diameter at diagnosis) in pediatric and young adult patients with EWS. METHODS Eligible patients ≤30 years old with newly diagnosed EWS ≥8 cm treated with definitive conformal or intensity modulated photon, or proton radiation therapy techniques were included. All patients in the study received dose-escalated RT doses. Outcomes included overall survival (OS), event-free survival (EFS), local failure rates, and toxicity. RESULTS Thirty-two patients were included, 20 patients presented with metastatic disease and 12 patients with localized disease. The median RT dose was 64.8 Gy (range, 59.4-69.4 Gy) with variability of doses to protect normal surrounding tissues. All patients received systemic chemotherapy. The 5-year OS and EFS for the cohort was 64.2% and 42%, respectively. The 5-year cumulative incidence of local failure was 6.6%. There were two combined local and distant failures with no isolated local failures. Twenty-nine patients experienced short term toxicity, 90% of those being radiation dermatitis. Twenty-seven patients experienced long-term toxicity, with only one experiencing grade 4 toxicity, a secondary malignancy after therapy. CONCLUSION This study demonstrates that definitive RT for pediatric and young adult patients with EWS ≥8 cm provides high rates of local control, while maintaining a tolerable toxicity profile.
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Affiliation(s)
- Marija Kacar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Margaret B. Nagel
- Department of Pediatrics, UT Southwestern Medical Center Dallas, Dallas, Texas, USA
| | - Jia Liang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Yimei Li
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Michael D. Neel
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - John T. Lucas
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - M. Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Teresa Santiago
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Alberto S. Pappo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Matthew J. Krasin
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Kersting J, Ranft A, Bhadri V, Brichard B, Collaud S, Cyprová S, Eich H, Ek T, Gelderblom H, Hardes J, Haveman L, Hartmann W, Hauser P, Heesen P, Jürgens H, Kanerva J, Kühne T, Raciborska A, Rascon J, Rechl V, Streitbürger A, Timmermann B, Uhlenbruch Y, Dirksen U. Effect of Radiotherapy Dose on Outcome in Nonmetastatic Ewing Sarcoma. Adv Radiat Oncol 2023; 8:101269. [PMID: 37334316 PMCID: PMC10276219 DOI: 10.1016/j.adro.2023.101269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/12/2023] [Indexed: 06/20/2023] Open
Abstract
Purpose Radiation therapy (RT) is an integral part of Ewing sarcoma (EwS) therapy. The Ewing 2008 protocol recommended RT doses ranging from 45 to 54 Gy. However, some patients received other doses of RT. We analyzed the effect of different RT doses on event-free survival (EFS) and overall survival (OS) in patients with EwS. Methods and Materials The Ewing 2008 database included 528 RT-admitted patients with nonmetastatic EwS. Recommended multimodal therapy consisted of multiagent chemotherapy and local treatment consisting of surgery (S&RT group) and/or RT (RT group). EFS and OS were analyzed with uni- and multivariable Cox regression models including known prognostic factors such as age, sex, tumor volume, surgical margins, and histologic response. Results S&RT was performed in 332 patients (62.9%), and 145 patients (27.5%) received definitive RT. Standard dose ≤ 53 Gy (d1) was admitted in 57.8%, high dose of 54 to 58 Gy (d2) in 35.5%, and very high dose ≥ 59 Gy (d3) in 6.6% of patients. In the RT group, RT dose was d1 in 11.7%, d2 in 44.1%, and d3 in 44.1% of patients. Three-year EFS in the S&RT group was 76.6% for d1, 73.7% for d2, and 68.2% for d3 (P = .42) and in the RT group 52.9%, 62.5%, and 70.3% (P = .63), respectively. Multivariable Cox regression revealed age ≥ 15 years (hazard ratio [HR], 2.68; 95% confidence interval [CI], 1.63-4.38) and nonradical margins (HR, 1.76; 95% CI, 1.05-2.93) for the S&RT group (sex, P = .96; histologic response, P = .07; tumor volume, P = .50; dose, P = .10) and large tumor volume (HR, 2.20; 95% CI, 1.21-4.0) for the RT group as independent factors (dose, P = .15; age, P = .08; sex, P = .40). Conclusions In the combined local therapy modality group, treatment with higher RT dose had an effect on EFS, whereas higher dose of radiation when treated with definitive RT was associated with an increased OS. Indications for selection biases for dosage were found. Upcoming trials will assess the value of different RT doses in a randomized manner to control for potential selection bias.
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Affiliation(s)
- Josephine Kersting
- Pediatrics III, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partnersite Essen, Essen, Germany
| | - Andreas Ranft
- Pediatrics III, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partnersite Essen, Essen, Germany
| | - Vivek Bhadri
- Chris O´ Brien Lifehouse, Camperdown, Australia Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Bénédicte Brichard
- Cliniques Universitaires Saint Luc, Department of Pediatric Haematology and Oncology, Université Catholique de Louvain, Brussels, Belgium
| | - Stéphane Collaud
- Department of Thoracic Surgery, Lung Clinic, Cologne-Merheim City Hospital, University of Witten Herdecke, Cologne, Germany
| | - Sona Cyprová
- Charles University, Motol Children´s Hospital, Prague, Czech Republic
| | - Hans Eich
- Radiotherapy and Radiooncology, University Hospital Muenster, West German Cancer Center Network, Muenster, Germany
| | - Torben Ek
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jendrik Hardes
- German Cancer Consortium, Partnersite Essen, Essen, Germany
- Clinic of Orthopedics, University Hospital Essen, West German Cancer Centre, Essen, Germany
| | - Lianne Haveman
- Department of Solid Tumors, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Wolfgang Hartmann
- Gerhard Domagk Institute for Pathology, University Hospital Muenster, West German Cancer Center Network, Muenster, Germany
| | - Peter Hauser
- Second Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Philip Heesen
- Pediatrics III, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Heribert Jürgens
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, West German Cancer Center Network, Münster, Germany
| | - Jukka Kanerva
- HUS Helsinki University Hospital, New Children´s Hospital, Div. Hematology and Stem Cell Transplantation, Helsinki, Finland
| | - Thomas Kühne
- Department of Oncology/Haematology, University Children´s Hospital Basel, Basel, Switzerland
| | - Anna Raciborska
- Department of Oncology and Surgical Oncology for Children and Youth, Mother and Child Institute, Warsaw, Poland
| | - Jelena Rascon
- Center for Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Victor Rechl
- Pediatrics III, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Arne Streitbürger
- German Cancer Consortium, Partnersite Essen, Essen, Germany
- Clinic of Orthopedics, University Hospital Essen, West German Cancer Centre, Essen, Germany
| | - Beate Timmermann
- German Cancer Consortium, Partnersite Essen, Essen, Germany
- Clinic for Particle Therapy, West German Proton Beam Centre, University Hospital Essen, West German Cancer Centre, German Cancer Research Centre (DKTK), Essen, Germany
| | | | - Uta Dirksen
- Pediatrics III, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium, Partnersite Essen, Essen, Germany
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Ahmed SK, Witten BG, Harmsen WS, Rose PS, Krailo M, Marcus KJ, Randall RL, DuBois SG, Janeway KA, Womer RB, Grier HE, Gorlick RG, Laack NNI. Analysis of Local Control Outcomes and Clinical Prognostic Factors in Localized Pelvic Ewing Sarcoma Patients Treated With Radiation Therapy: A Report From the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2023; 115:337-346. [PMID: 36302496 PMCID: PMC9839580 DOI: 10.1016/j.ijrobp.2022.07.1840] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/13/2022] [Accepted: 07/24/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To identify potential clinical prognostic factors associated with a higher risk of local recurrence in patients with localized pelvic Ewing sarcoma treated with radiation therapy. METHODS AND MATERIALS Data for 101 patients treated with definitive radiation therapy (RT) or both surgery and radiation (S + RT) to primary pelvic tumors on INT-0091, INT-0154, and AEWS0031 were analyzed. Imaging data for patients who did not receive radiation were not available for central review; therefore, patients with surgery alone were not included. Cumulative incidence rates for local failure at 5 years from time of local control were calculated accounting for competing risks. RESULTS The most common pelvic subsite was sacrum (44.6%). RT was used in 68% of patients and S + RT in 32%. The local failure rate was 25.0% for RT and 6.3% for S + RT (P = .046). There was no statistically significant difference in local control modality by tumor characteristics. Tumors originating in the ischiopubic-acetabulum region were associated with the highest local failure incidence, 37.5% (P = .02, vs sacrum and iliac/buttock tumors), particularly those treated with RT (50.0%, P = .06). A higher incidence of local failure was seen with each additional 100 mL of tumor at diagnosis (P = .04). Multivariable analysis demonstrated RT alone (hazard ratio [HR], 5.1; P = .04), tumor subsite (particularly ischiopubic-acetabulum tumors; HR 4.6; P = .02), and increasing volume per 100 mL (HR, 1.2; P = .01) were associated with a higher incidence of local recurrence. CONCLUSIONS Combination surgery and RT is associated with improved local control in patients with pelvic Ewing sarcoma compared with definitive RT. Tumors involving the ischiopubic-acetabulum region and increasing tumor volume at diagnosis are associated with inferior local control. Tumor characteristics did not correlate with choice of local therapy modality suggesting an opportunity to develop best local therapy practices guidelines for future studies based on tumor features.
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Affiliation(s)
- Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Brent G Witten
- Orthopedic Surgery, Aurora Orthopedics, Milwaukee, Minnesota
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark Krailo
- Department of Preventative Medicine, University of Southern California, Los Angeles, California
| | - Karen J Marcus
- Department of Radiation Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - R Lor Randall
- Department of Orthopedic Surgery, UC Davis, Davis, California
| | - Steven G DuBois
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - Katherine A Janeway
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - Richard B Womer
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine & Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holcombe E Grier
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - Richard G Gorlick
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nadia N I Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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5
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Laskar S, Sinha S, Chatterjee A, Khanna N, Manjali JJ, Puri A, Gulia A, Nayak P, Vora T, Chinnaswamy G, Prasad M, Bajpai J, Juvekar S, Desai S, Janu A, Rangarajan V, Purandare N, Shah S, Rekhi B, Jambhekar N, Muckaden MA, Kurkure P. Radiation Therapy Dose Escalation in Unresectable Ewing Sarcoma: Final Results of a Phase 3 Randomized Controlled Trial. Int J Radiat Oncol Biol Phys 2022; 113:996-1002. [PMID: 35568246 DOI: 10.1016/j.ijrobp.2022.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Our aim was to assess the effect of radiation therapy (RT) dose escalation on outcomes in surgically unresectable Ewing sarcoma (ES)/primitive neuroectodermal tumor (PNET). METHODS AND MATERIALS Patients with nonmetastatic unresectable ES/PNET (excluding intracranial/chest wall) receiving vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide chemotherapy, planned for definitive RT, were accrued in this single-institution, open-label, phase 3 randomized controlled trial. Randomization was between standard dose RT (SDRT; 55.8 Gy/31 fractions/5 days a week) versus escalated dose RT (EDRT; 70.2 Gy/39 fractions/5 days a week) with a primary objective of improving local control (LC) by 17% (65%-82%). Secondary outcomes included disease-free survival (DFS), overall survival (OS), and functional outcomes by Musculoskeletal Tumor Society score. RESULTS Between April 2005 and December 2015, 95 patients (SDRT 47 and EDRT 48) with a median age of 17 years (interquartile range, 13-23 years) were accrued. The majority of patients were male (59%). Pelvis was the most common site of primary disease (n = 60; 63%). The median largest tumor dimension (9.7 cm) and the median maximum standardized uptake value (8.2) on pretreatment fluorodeoxyglucose positron emission tomography-computed tomography were similar. At a median follow-up of 67 months, the 5-year LC, DFS, and OS for the entire cohort was 62.4%, 41.3%, and 51.9%, respectively. The 5-year LC was significantly better in EDRT compared with SDRT (76.4% vs 49.4%; P = .02). The differences in DFS and OS at 5 years (for EDRT vs SDRT) did not achieve statistical significance (DFS 46.7% vs 31.8%; P = .22 and OS 58.8% vs 45.4%; P = .08). There was a higher incidence of Radiation Therapy Oncology Group grade >2 skin toxic effects (acute) in the EDRT arm (10.4% vs 2.1%; P = .08) with excellent functional outcomes (median Musculoskeletal Tumor Society score = 29) in both arms. CONCLUSIONS EDRT results in improved LC with good functional outcomes without a significant increase in toxic effects. Radiation dose escalation should be considered for surgically unresectable nonmetastatic ES/PNET.
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Affiliation(s)
- Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - Shwetabh Sinha
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Abhishek Chatterjee
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nehal Khanna
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Jifmi Jose Manjali
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ajay Puri
- Department of Orthopedic Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ashish Gulia
- Department of Orthopedic Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Prakash Nayak
- Department of Orthopedic Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Tushar Vora
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Girish Chinnaswamy
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Maya Prasad
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Shashikant Juvekar
- Department of Radiodiagnosis, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Subhash Desai
- Department of Radiodiagnosis, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Amit Janu
- Department of Radiodiagnosis, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine & Molecular Imaging, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nilendu Purandare
- Department of Nuclear Medicine & Molecular Imaging, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sneha Shah
- Department of Nuclear Medicine & Molecular Imaging, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Bharat Rekhi
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nirmala Jambhekar
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Mary Ann Muckaden
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Purna Kurkure
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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6
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Jawad MU, Pollock BH, Zeitlinger LN, O'Donnell EF, Traven SA, Carr-Ascher JR, Alvarez E, Malogolowkin MH, Thorpe SW, Randall RL. Impact of local treatment modality on overall- and disease-specific survival for nonmetastatic pelvic and sacral Ewing sarcoma. J Surg Oncol 2022; 126:577-587. [PMID: 35585834 DOI: 10.1002/jso.26922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/23/2022] [Accepted: 05/02/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The ideal local treatment modality for pelvic and sacral Ewing sarcoma (EWS) is controversial. METHODS We present the data from the American College of Surgeon's National Cancer Database (NCDB) and the National Cancer Institute's Surveillance, Epidemiology and End Result (SEER) database to investigate the impact of local treatment modalities on survival for nonmetastatic pelvic and sacral Ewing sarcoma. Local treatment includes "surgery," "radiation," and a combination of "surgery and radiation." RESULTS A total of 235 cases from SEER and 285 cases from NCDB were analyzed. Patients with "localized" stage (intraosseous) in the SEER database did not show any statistically significant difference in the disease-specific survival (DSS) for any of the local treatment modalities. Similar findings were observed for overall survival among patients with American Joint Committee on Cancer (AJCC) stage II and III in the NCDB database. However, patients with nonmetastatic disease, particularly regional disease (extraosseous), showed improved DSS with surgery only, in the SEER. CONCLUSION We found similar levels of efficacy for different treatment modalities for patients with intraosseous and AJCC II and III pelvic and sacral EWS. "Radiotherapy" is the most common local treatment modality employed in the United States. A prospective, randomized controlled trial with a direct head-to-head comparison is needed for a definitive conclusion.
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Affiliation(s)
- Muhammad Umar Jawad
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA
| | - Brad H Pollock
- Department of Public Health, University of California-Davis, Sacramento, California, USA
| | - Lauren N Zeitlinger
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA
| | - Edmond F O'Donnell
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA
| | - Sophia A Traven
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA
| | - Janai R Carr-Ascher
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA.,Department of Medicine, University of California-Davis, Sacramento, California, USA
| | - Elysia Alvarez
- Department of Pediatrics, University of California-Davis, Sacramento, California, USA
| | - Marcio H Malogolowkin
- Department of Pediatrics, University of California-Davis, Sacramento, California, USA
| | - Steven W Thorpe
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA
| | - R Lor Randall
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA
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7
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Piccolo O, Lincoln JD, Melong N, Orr BC, Fernandez NR, Borsavage J, Berman JN, Robar J, Ha MN. Radiation dose enhancement using gold nanoparticles with a diamond linear accelerator target: a multiple cell type analysis. Sci Rep 2022; 12:1559. [PMID: 35091583 PMCID: PMC8799734 DOI: 10.1038/s41598-022-05339-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/04/2022] [Indexed: 01/14/2023] Open
Abstract
Radiotherapy (RT) is an effective cancer treatment modality, but standard RT often causes collateral damage to nearby healthy tissues. To increase therapeutic ratio, radiosensitization via gold nanoparticles (GNPs) has been shown to be effective. One challenge is that megavoltage beams generated by clinical linear accelerators are poor initiators of the photoelectric effect. Previous computer models predicted that a diamond target beam (DTB) will yield 400% more low-energy photons, increasing the probability of interacting with GNPs to enhance the radiation dose by 7.7-fold in the GNP vicinity. After testing DTB radiation coupled with GNPs in multiple cell types, we demonstrate decreased head-and-neck cancer (HNC) cell viability in vitro and enhanced cell-killing in zebrafish xenografts compared to standard RT. HNC cell lines also displayed increased double-stranded DNA breaks with DTB irradiation in the presence of GNPs. This study presents preclinical responses to GNP-enhanced radiotherapy with the novel DTB, providing the first functional data to support the theoretical evidence for radiosensitization via GNPs in this context, and highlighting the potential of this approach to optimize the efficacy of RT in anatomically difficult-to-treat tumors.
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Affiliation(s)
- Olivia Piccolo
- Department of Biology, Dalhousie University, Halifax, NS, Canada
- Department of Pediatrics, IWK Health Centre/Dalhousie University, Halifax, NS, Canada
| | - John D Lincoln
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada
| | - Nicole Melong
- Children's Hospital of Eastern Ontario Research Institute/Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Benno C Orr
- Department of Pediatrics, IWK Health Centre/Dalhousie University, Halifax, NS, Canada
| | - Nicholas R Fernandez
- Department of Pediatrics, IWK Health Centre/Dalhousie University, Halifax, NS, Canada
| | - Jennifer Borsavage
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada
| | - Jason N Berman
- Department of Pediatrics, IWK Health Centre/Dalhousie University, Halifax, NS, Canada
- Children's Hospital of Eastern Ontario Research Institute/Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - James Robar
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - Michael N Ha
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada.
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8
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Abbas A, Alaa MN. Ewing Sarcoma Family Tumors: Past, Present and Future Prospects. CURRENT CANCER THERAPY REVIEWS 2021. [DOI: 10.2174/1573394716999201125204643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Ewing’s sarcoma (ES), also known as mesenchymal primitive neuroectodermal tumor
(PNET), is a malignant round blue cell tumor (MRBCT) with a varying degree of neuronal differentiation.
PNET arises from the primitive nerve cells of the central nervous system (CNS) but may
also occur in the bones of the extremities, pelvis, vertebral column, and chest wall. Extraskeletal
ES/PNET may affect the various soft tissues, including those of the pelvis, paraspinal region, and
thoracopulmonary region.
Histopathological differentiation between ES, PNET, and other related sarcomas is often difficult.
On light microscopy, the same histopathological appearance of ES has been termed PNET, Askin-
Rosay (A-R) tumor, and malignant neuroepithelioma by various other authors. The immunohistochemical
distinction is also difficult due to poor tissue differentiation and low intake of the various
specific immunohistochemical markers. The most frequent translocation is t (11; 22) (q24; q12), resulting
in the EWSR1-FLI1 fusion gene detected in nearly 90% of cases and is considered the hallmark
of the diagnosis of ES, PNET, atypical ES, and A-R tumor. Therefore, ES, atypical ES,
PNET, and A-R tumor are currently regarded as one entity grouped together under the Ewing Family
Tumor (EFT) and are treated in an identical way. EFT represents only about 3% of all pediatric
malignancies. The annual incidence is between 2 and 5 cases per million children per year. The
peak prevalence of the tumor is between the ages of 10 and 15 years. The incidence is higher in
males than in females, with a ratio of 1.3:1.
Newer groups of MRBCT that have great similarities to EFT are being recently described. These tumors,
atypical EFT and Ewing’s like Sarcomas (ELS), bear similarities to EFT but have basic morphological
and molecular differences. Optimal treatment requires the use of adjuvant and new-adjuvant
chemotherapy (CTR), radical surgical resection and/or involves field radiotherapy (RT). The
reported disease-free survival (DFS) and overall survival (OS) range between 45-80% and 36-71%,
respectively. The overall prognosis for the metastatic and recurrent disease remains poor. The use
of newer conventional and targeted medications, improved RT delivery, and surgical techniques
may further improve the outcomes. The past few years have seen advances in genomics-based sarcoma
diagnosis and targeted therapies. In this comprehensive review article, we provide a detailed
report of EFT and discuss the various clinical aspects and the recent advances used in the diagnosis
and treatment.
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Affiliation(s)
- Adil Abbas
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, The Pediatric Hematology/Oncology Setion, Princess Nourah Oncology Centre, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Mohammed N.S. Alaa
- Department of Laboratory Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Jeddah, Saudi Arabia
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9
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Eaton BR, Claude L, Indelicato DJ, Vatner R, Yeh B, Schwarz R, Laack N. Ewing sarcoma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28355. [PMID: 33818887 DOI: 10.1002/pbc.28355] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/27/2022]
Abstract
Ewing sarcoma is a rare tumor that requires complex multidisciplinary management. This report describes the general management and standard radiotherapy guidelines in both North America (Children's Oncology Group) and Europe (International Society of Pediatric Oncology). Standard treatment involves multiagent induction chemotherapy followed by local treatment with surgery, definitive radiation, or a combination of surgery and radiation followed by additional chemotherapy and consolidation local treatment to metastatic sites. The data supporting the role of chemotherapy, surgery, and radiation and specific radiation therapy guidelines are presented.
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Affiliation(s)
- Bree R Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Line Claude
- Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Daniel J Indelicato
- Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Ralph Vatner
- Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Brian Yeh
- Radiation Oncology, Mount Sinai Hospital, New York, New York
| | - Rudolf Schwarz
- Radiotherapy and Radiooncology, Outpatient Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nadia Laack
- Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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10
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Zöllner SK, Amatruda JF, Bauer S, Collaud S, de Álava E, DuBois SG, Hardes J, Hartmann W, Kovar H, Metzler M, Shulman DS, Streitbürger A, Timmermann B, Toretsky JA, Uhlenbruch Y, Vieth V, Grünewald TGP, Dirksen U. Ewing Sarcoma-Diagnosis, Treatment, Clinical Challenges and Future Perspectives. J Clin Med 2021; 10:1685. [PMID: 33919988 PMCID: PMC8071040 DOI: 10.3390/jcm10081685] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
Ewing sarcoma, a highly aggressive bone and soft-tissue cancer, is considered a prime example of the paradigms of a translocation-positive sarcoma: a genetically rather simple disease with a specific and neomorphic-potential therapeutic target, whose oncogenic role was irrefutably defined decades ago. This is a disease that by definition has micrometastatic disease at diagnosis and a dismal prognosis for patients with macrometastatic or recurrent disease. International collaborations have defined the current standard of care in prospective studies, delivering multiple cycles of systemic therapy combined with local treatment; both are associated with significant morbidity that may result in strong psychological and physical burden for survivors. Nevertheless, the combination of non-directed chemotherapeutics and ever-evolving local modalities nowadays achieve a realistic chance of cure for the majority of patients with Ewing sarcoma. In this review, we focus on the current standard of diagnosis and treatment while attempting to answer some of the most pressing questions in clinical practice. In addition, this review provides scientific answers to clinical phenomena and occasionally defines the resulting translational studies needed to overcome the hurdle of treatment-associated morbidities and, most importantly, non-survival.
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Affiliation(s)
- Stefan K. Zöllner
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
| | - James F. Amatruda
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
| | - Sebastian Bauer
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Medical Oncology, Sarcoma Center, University Hospital Essen, 45147 Essen, Germany
| | - Stéphane Collaud
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Thoracic Surgery, Ruhrlandklinik, University of Essen-Duisburg, 45239 Essen, Germany
| | - Enrique de Álava
- Institute of Biomedicine of Sevilla (IbiS), Virgen del Rocio University Hospital, CSIC, University of Sevilla, CIBERONC, 41013 Seville, Spain;
- Department of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, 41009 Seville, Spain
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Jendrik Hardes
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Wolfgang Hartmann
- Division of Translational Pathology, Gerhard-Domagk Institute of Pathology, University Hospital Münster, 48149 Münster, Germany;
- West German Cancer Center (WTZ), Network Partner Site, University Hospital Münster, 48149 Münster, Germany
| | - Heinrich Kovar
- St. Anna Children’s Cancer Research Institute and Medical University Vienna, 1090 Vienna, Austria;
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany;
| | - David S. Shulman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Arne Streitbürger
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Beate Timmermann
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre, 45147 Essen, Germany
| | - Jeffrey A. Toretsky
- Departments of Oncology and Pediatrics, Georgetown University, Washington, DC 20057, USA;
| | - Yasmin Uhlenbruch
- St. Josefs Hospital Bochum, University Hospital, 44791 Bochum, Germany;
| | - Volker Vieth
- Department of Radiology, Klinikum Ibbenbüren, 49477 Ibbenbühren, Germany;
| | - Thomas G. P. Grünewald
- Division of Translational Pediatric Sarcoma Research, Hopp-Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany;
- Division of Translational Pediatric Sarcoma Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Core Center, 69120 Heidelberg, Germany
| | - Uta Dirksen
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
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Al Dybiat I, Baitukha A, Pimpie C, Kaci R, Pocard M, Arefi Khonsari F, Mirshahi M. Multi-nanolayer drug delivery using radiofrequency plasma technology. BMC Cancer 2020; 20:565. [PMID: 32552705 PMCID: PMC7302375 DOI: 10.1186/s12885-020-06989-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It may be impossible to perform cancer surgery with free margins in the presence of an unresectable structure. Local drug treatment after surgery has been proposed to increase the rate of tumor control. METHODS Multi-nanolayers (10-330 nm) were generated by a low-pressure (375mTorr) inductively coupled plasma (13.56 MHz) reactor for anticancer drug delivery by the deposition of polycaprolactone-polyethylene glycol multistack barrier on the collagen membrane (100 μm thickness). Carboplatin (300 μg/cm2) was used for the in vitro and in vivo investigations. Energy-dispersive X-ray spectroscopy (15 keV), scanning electron microscopy and inductively coupled plasma mass spectrometry were used to detect the presence of carboplatin in the nanolayer, the tumor sample and the culture medium. Preclinical studies were performed on ovarian (OVCAR-3NIH) and colon (CT26) cancer cell lines as xenografts (45 days) and allografts (23 days) in Swiss-nude (n = 6) and immunocompetent BALB/cByJ mice (n = 24), respectively. RESULTS The loading of carboplatin or other drugs between the nanofilm on the collagen membrane did not modify the mesh complex architecture or the drug properties. Drugs were detectable on the membrane for more than 2 weeks in the in vitro analysis and more than 10 days in the in vivo analysis. Cytotoxic mesh decreased cell adherence (down 5.42-fold) and induced cancer cell destruction (up to 7.87-fold). Implantation of the mesh on the mouse tumor nodule modified the cell architecture and decreased the tumor size (50.26%) compared to the control by inducing cell apoptosis. CONCLUSION Plasma technology allows a mesh to be built with multi-nanolayer anticancer drug delivery on collagen membranes.
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Affiliation(s)
- Iman Al Dybiat
- CAP-Paris Tech, INSERM U1275, Department of Oncologic & Digestive Surgery, Université de Paris, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France
| | - Alibi Baitukha
- Laboratoire Interfaces et Systèmes Electrochimiques, Sorbonne Universités, University Paris 06, CNRS, 4 place Jussieu, 75005, Paris, France
| | - Cynthia Pimpie
- CAP-Paris Tech, INSERM U1275, Department of Oncologic & Digestive Surgery, Université de Paris, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France
| | - Rachid Kaci
- Central Department of Anatomy and Pathological Cytology, Hospital Lariboisière, 75010, Paris, France
| | - Marc Pocard
- CAP-Paris Tech, INSERM U1275, Department of Oncologic & Digestive Surgery, Université de Paris, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France
| | - Farzaneh Arefi Khonsari
- Laboratoire Interfaces et Systèmes Electrochimiques, Sorbonne Universités, University Paris 06, CNRS, 4 place Jussieu, 75005, Paris, France
| | - Massoud Mirshahi
- CAP-Paris Tech, INSERM U1275, Department of Oncologic & Digestive Surgery, Université de Paris, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France.
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12
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Uezono H, Indelicato DJ, Rotondo RL, Mailhot Vega RB, Bradfield SM, Morris CG, Bradley JA. Treatment Outcomes After Proton Therapy for Ewing Sarcoma of the Pelvis. Int J Radiat Oncol Biol Phys 2020; 107:974-981. [PMID: 32437922 DOI: 10.1016/j.ijrobp.2020.04.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/18/2020] [Accepted: 04/30/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Ewing sarcoma of the pelvis is associated with inferior local control compared with those arising from other primary sites. Despite its increased use, outcome data for treatment with proton therapy remain limited. We report 3-year disease control and toxicity in pediatric patients treated with proton therapy. METHODS AND MATERIALS Thirty-five patients aged ≤21 years (median, 14 years) with nonmetastatic pelvic Ewing sarcoma received proton therapy and chemotherapy between 2010 and 2018. Overall survival and tumor control rates were calculated using the Kaplan-Meier method. A log-rank test assessed significance between strata of prognostic factors. Significant toxicity was reported per the Common Terminology Criteria for Adverse Events, version 4.0. RESULTS Most patients received definitive radiation (n = 26; median dose 55.8 Gy relative biological effectiveness [RBE]; range, 54.0-64.8), 7 received preoperative radiation (50.4 Gy RBE), and 2 received postoperative radiation (45 Gy RBE and 54 Gy RBE). The median primary tumor size was 10.5 cm. With a median follow-up of 3 years (range, 0.3-9.0 years), the 3-year overall survival, progression-free survival, and local control rates were 83% (95% confidence interval [CI], 65%-93%), 64% (95% CI, 45%-79%), and 92% (95% CI, 74%-98%), respectively. There was no association between local control, progression-free survival, or overall survival and tumor size, patient age, radiation dose, or definitive versus pre-/postoperative radiation therapy. Median time to progression was 1 year (range, 0.1-1.9 years). All patients with large tumors (≥8 cm) who underwent definitive proton therapy with a higher dose (≥59.4 Gy RBE) remained free from tumor recurrence (n = 5). Five patients experienced grade ≥2 subacute/late toxicity, all of whom were treated with combined surgery and radiation. CONCLUSIONS Definitive proton therapy offers local control comparable to photon therapy in pediatric patients with pelvic Ewing sarcoma. These data lend preliminary support to radiation dose escalation without significant toxicity, which may contribute to the favorable outcomes. Combined surgery and radiation therapy, particularly preoperative radiation, is associated with postoperative complications, but not survival, compared with radiation alone.
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Affiliation(s)
- Haruka Uezono
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Scott M Bradfield
- Department of Pediatric Hematology/Oncology, Nemours Children's Specialty Care, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
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13
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Improved Outcome in Local Ewing Sarcoma With an Intensified Pilot Treatment Protocol SCMCIE 94. J Pediatr Hematol Oncol 2019; 41:105-111. [PMID: 30570510 DOI: 10.1097/mph.0000000000001384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study evaluated the effect of an intensified pilot protocol, SCMCIE 94, on the outcome of Ewing sarcoma (EWS). The cohort included 121 patients with local or metastatic EWS treated at a tertiary pediatric medical center with the SCMCIE 94 (protocol 3, 1994 to 2011) or an earlier protocol (protocol 2, 1988 to 1994; protocol 1, 1985 to 1988). All protocols included 4 to 6 courses of chemotherapy, radiation, and surgery. Clinical data were collected retrospectively by chart review. Survival rates for protocol 3 were as follows: all patients-5-year event-free survival (EFS): 52.5%±5.6%, 10-year EFS: 49.3%±5.8%, 5-year overall survival (OS): 68.8%±5.3%, and 10-year OS: 51.1%±6.3%; patients with localized disease (any site)-5-year EFS: 63.5%±6.0% and 5-year OS: 77.2%±5.3%; patients with localized extremity disease-5-year EFS: 78.95%±8.3%, 10-year EFS: 68.6%±10.0%, 5-year OS: 90.7%±6.2%, and 10-year OS: 71.1%±11.2%. Protocol 3 was associated with an increase in 10-year EFS of 16% overall and 33% in patients with localized extremity disease compared with protocols 1+2, and a significant improvement in 5-year EFS and OS in patients with any localized disease (P=0.001). No survival benefit was found for metastatic disease. On multivariate analysis, protocol and metastatic disease were significantly independent prognostic factors. The intensified SCMCIE 94 protocol seems to increase survival in patients with localized but not metastatic EWS.
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Mahjoub A, Morales-Restrepo A, Fourman MS, Mandell JB, Feiqi L, Hankins ML, Watters RJ, Weiss KR. Tumor Resection Guided by Intraoperative Indocyanine Green Dye Fluorescence Angiography Results in Negative Surgical Margins and Decreased Local Recurrence in an Orthotopic Mouse Model of Osteosarcoma. Ann Surg Oncol 2018; 26:894-898. [PMID: 30588559 PMCID: PMC6373227 DOI: 10.1245/s10434-018-07114-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Indexed: 12/19/2022]
Abstract
Background Surgical resection with negative margins is the foundation of extremity sarcoma management. Failure to achieve negative surgical margins can result in local recurrence (LR), a potentially devastating complication. Indocyanine green (ICG) is a US FDA-approved fluorophore previously used to guide carcinoma resections. We investigated the potential of ICG as an intraoperative guide during experimental sarcoma resection. Methods Fifty 6-week-old immunocompetent Balb/c female mice received left proximal tibia paraphyseal injections of 5 × 105 K7M2 murine osteosarcoma cells. Animals were separated into two groups (n = 25 each): (1) ICG-assisted surgical resection; and (2) no ICG-assisted resection. Resections were performed 4 weeks after primary tumor engraftment. All animals received 7.5 ug ICG via retro-orbital injection 12 h prior to surgery. ICG fluorescence measurements and clinical evaluations were performed 4 weeks after resection to detect LR. Results Eleven of 25 animals from each group developed gross tumors. Four weeks after resection, group 1 had 0/11 tumor recurrences, while group 2 had recurrences in 9/11 (81.8%) experimental mice (p < 0.0002) (Fig. 2). There was a 100% NPV in group 1, and no tumor recurrence with fluorescence-free margins after the primary surgery. Group 2 had a 100% positive predictive value for the development of an LR if any fluorescent signal was present at the surgical margin after resection. Conclusion Intraoperative ICG guidance led to reliably negative surgical margins and a diminished LR rate. Given the benign safety profile of ICG and its prior clinical success, these results could be immediately translatable to the clinical realm.
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Affiliation(s)
- Adel Mahjoub
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alejandro Morales-Restrepo
- Musculoskeletal Oncology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mitchell S Fourman
- Musculoskeletal Oncology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan B Mandell
- Musculoskeletal Oncology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lu Feiqi
- Musculoskeletal Oncology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,School of Medicine, Tsinghua University, Beijing, China
| | - Margaret L Hankins
- Musculoskeletal Oncology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rebecca J Watters
- Musculoskeletal Oncology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kurt R Weiss
- Musculoskeletal Oncology Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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15
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Extraskeletal versus Skeletal Ewing Sarcoma in the adult population: Controversies in care. Surg Oncol 2018; 27:373-379. [PMID: 30217290 DOI: 10.1016/j.suronc.2018.05.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/03/2018] [Accepted: 05/10/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES A lack of consensus exists on the prognosis of extraskeletal Ewing sarcoma (EES) relative to its skeletal (ES) counterpart in adults. This study sought to characterize outcome differences between the two diagnoses. METHODS From 2004 to 2014, the NCDB identified 2,660 Ewing Sarcoma patients. Cox proportional hazards regression analysis was used to identify risk factors for overall survival (OS). RESULTS EES patients were older, more likely to be female, and have smaller tumors. Among patients with ES, 4.0% received no treatment, 2.5% received local therapy only (surgery and/or radiation), 16.8% received chemotherapy only, while 52.2% received combination therapy (local and chemotherapy), and 17.0% recieived triple therapy (surgery, radiation and chemotherapy). Among patients with EES, 4.3% recived no treatment, 5.6% received local therapy only, 15.6% received chemotherapy only, while 47.0% received combination therapy, and 21.6% received triple therapy. No difference in OS was observed between the two groups (P = 0.816). Factors independently associated with OS for ES included age (HR = 1.26, P = 0.01), Charlson-Deyo Score (CDS) ≥2 (HR = 3.66, P < 0.001), combination therapy (HR = 0.39, P < 0.001) and triple therapy (HR = 0.34, P < 0.001). For EES, factors for OS were age (HR = 1.52, P < 0.001), CDS ≥2 (HR = 1.90, P = 0.02), combination therapy (HR = 0.44, P < 0.001), triple therapy (HR = 0.34, P < 0.001) and PNET histology (HR = 1.33, P = 0.02). CONCLUSIONS Demographic, histological, and treatment characteristics differ between adult patients diagnosed with ES and ESS. However, survival and independent predictors of survival are consistent between the two diagnoses.
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16
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Ahmed SK, Robinson SI, Arndt CAS, Petersen IA, Haddock MG, Rose PS, Issa Laack NN. Pelvis Ewing sarcoma: Local control and survival in the modern era. Pediatr Blood Cancer 2017; 64. [PMID: 28244685 DOI: 10.1002/pbc.26504] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/10/2017] [Accepted: 01/30/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE Local control for Ewing sarcoma (ES) has improved in modern studies. However, it is unclear if these gains have also been achieved for pelvis tumors. The purpose of this study is to evaluate local control and survival in pelvis ES patients treated in the modern era. METHODS All pelvis ES patients diagnosed from 1990 to 2012 and seen at Mayo Clinic were identified. Factors relevant to survival and local control were analyzed. RESULTS The cohort consisted of 48 patients. Fifty-two percent had metastatic disease at diagnosis. The 5-year overall survival and event-free survival was 73% and 65%, respectively, for localized disease. The 5-year cumulative incidence of local recurrence was 19%, with a 26% incidence for radiation, 13% for surgery, and 0% for surgery + radiation (P = 0.54). All local failures occurred in-field. Sacral involvement by tumor trended toward a higher incidence of local recurrence (hazard ratio 3.06, P = 0.09). Patients treated with definitive radiation doses ≥5,600 cGy had a lower incidence of local recurrence (17% vs. 28%, P = 0.61). CONCLUSIONS Our study demonstrates excellent survival for localized tumors in the modern era. Anatomical localization within the pelvis likely correlates with outcomes. Local control remains problematic, especially for patients treated with definitive radiation. Though statistically not significant, surgery + radiation and definitive radiation dose ≥5,600 cGy were associated with the lowest incidence of local failure, suggesting treatment intensification may improve local control for pelvis ES.
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Affiliation(s)
- Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Carola A S Arndt
- Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Peter S Rose
- Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota.,Division of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Ahmed SK, Randall RL, DuBois SG, Harmsen WS, Krailo M, Marcus KJ, Janeway KA, Geller DS, Sorger JI, Womer RB, Granowetter L, Grier HE, Gorlick RG, Laack NNI. Identification of Patients With Localized Ewing Sarcoma at Higher Risk for Local Failure: A Report From the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2017; 99:1286-1294. [PMID: 28964585 DOI: 10.1016/j.ijrobp.2017.08.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/01/2017] [Accepted: 08/16/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE To identify clinical and treatment variables associated with a higher risk of local failure in Ewing sarcoma patients treated on recent Children's Oncology Group protocols. METHODS AND MATERIALS Data for 956 patients treated with ifosfamide and etoposide-based chemotherapy on INT-0091, INT-0154, and AEWS0031 were analyzed. Local treatment modalities were defined as surgery, definitive radiation therapy (RT), or surgery plus radiation (S+RT). Five-year cumulative incidence of local failure was determined. RESULTS The local failure rate for the entire cohort was 7.3%, with a 3.9% rate for surgery, 15.3% for RT (P<.01), and 6.6% for S+RT (P=.12). The local failure incidence was 5.4% for extremity tumors, 13.2% for pelvis tumors (P<.01), 5.3% for axial non-spine tumors (P=.90), 9.1% for extraskeletal tumors (P=.08), and 3.6% for spine tumors (P=.49). The incidence of local failure was 14.8% for extremity tumors and 22.4% for pelvis tumors treated with RT, compared with 3.7% for extremity tumors and 3.9% for pelvis tumors treated with surgery (P≤.01). There was no difference in local failure incidence by local treatment modality for axial non-spine, spine, and extraskeletal tumors. The local failure incidence was 11.9% in patients aged ≥18 years versus 6.7% in patients aged <18 years (P=.02). Age ≥18 years (hazard ratio 1.9, P=.04) and treatment with RT (hazard ratio 2.40, P<.01) remained independent prognostic factors for higher local failure incidence on multivariate analysis. Tumor size (</≥ 8 cm) was available in 40% of patients and did not correlate with local failure incidence. CONCLUSIONS Local tumor control is excellent and similar between surgery and RT for axial non-spine, spine, and extraskeletal tumors. Age ≥18 years and use of RT, primarily for pelvis and extremity tumors, are associated with the highest risk of local failure. Further efforts should focus on improving outcomes for these patients.
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Affiliation(s)
- Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - R Lor Randall
- Department of Orthopedics, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah
| | - Steven G DuBois
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Mark Krailo
- Department of Preventative Medicine, University of Southern California, Los Angeles, California
| | - Karen J Marcus
- Department of Radiation Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - Katherine A Janeway
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - David S Geller
- Department of Pediatrics and Orthopedic Surgery, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York
| | - Joel I Sorger
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Richard B Womer
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine & Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Linda Granowetter
- Department of Pediatrics, New York University (NYU) Medical School and NYU Langone Medical Center, New York, New York
| | - Holcombe E Grier
- Department of Pediatrics, Dana-Farber/Boston Children's Cancer and Blood Disorders Center & Harvard Medical School, Boston, Massachusetts
| | - Richard G Gorlick
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nadia N I Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
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18
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Tinkle CL, Fernandez-Pineda I, Sykes A, Lu Z, Hua CH, Neel MD, Bahrami A, Shulkin BL, Kaste SC, Pappo A, Spunt SL, Krasin MJ. Nonrhabdomyosarcoma soft tissue sarcoma (NRSTS) in pediatric and young adult patients: Results from a prospective study using limited-margin radiotherapy. Cancer 2017; 123:4419-4429. [PMID: 28759114 DOI: 10.1002/cncr.30793] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/14/2017] [Accepted: 04/25/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Indications for and delivery of adjuvant therapies for pediatric nonrhabdomyosarcoma soft tissue sarcoma (NRSTS) have been derived largely from adult studies; therefore, significant concern remains regarding radiation exposure to normal tissue. The authors report long-term treatment outcomes and toxicities for pediatric and young adult patients with high-grade NRSTS who were treated on a prospective trial using limited-margin radiotherapy. METHODS Sixty-two patients (ages 3-22 years) with predominantly high-grade NRSTS requiring radiation were treated on a phase 2 institutional study of conformal external-beam radiotherapy and/or brachytherapy using a 1.5-cm to 2-cm anatomically constrained margin. The estimated cumulative incidence of local failure, Gray's method estimated cumulative incidence of local failure, Kaplan-Meier method estimated survival, competing-risk regression model determined predictors of disease outcome, and toxicity was reported according to CTCAE v2.0. RESULTS At a median follow-up of 5.1 years (range, 0.2-10.9 years), 9 patients had experienced local failure. The 5-year overall cumulative incidence of local failure was 14.8% (95% confidence interval [CI], 7.2%-25%), and all but 1 local failure occurred outside the highest-dose irradiation volume. The 5-year Kaplan-Meier estimates for event-free and overall survival were 49.3% (95% CI, 36.3%-61.1%) and 67.9% (95% CI, 54.2%-78.3%), respectively. Multivariable analysis indicated that younger age was the only independent predictor of local recurrence (P = .004). The 5-year cumulative incidence of grade 3 or 4 late toxicity was 15% (95% CI, 7.2%-25.3%). CONCLUSIONS The delivery of limited-margin radiotherapy using conformal external-beam radiotherapy or brachytherapy provides a high rate of local tumor control without an increase in marginal failures and with acceptable treatment-related morbidity. Cancer 2017;123:4419-29. © 2017 American Cancer Society.
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Affiliation(s)
- Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - April Sykes
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Zhaohua Lu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michael D Neel
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Armita Bahrami
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Barry L Shulkin
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sue C Kaste
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Alberto Pappo
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sheri L Spunt
- Department of Pediatrics, Stanford University, Stanford, California
| | - Matthew J Krasin
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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