Management of malignant bone tumors in children and adolescents

Ten Years Experience with Ewing's Sarcoma

The series comprises 57 consecutive patients with Ewing's sarcoma admitted to the National Cancer Institute of Milan from 1965 to 1976. In 75 % the disease was confined to one bone, while in 25 % multiple bone and/or visceral lesions were present. Patients with clinically localized tumor treated before 1971 with local therapy, showed a median disease-free survival of 5 months. After 1971, radiotherapy and/or surgery to local tumor was combined with multiple drug chemotherapy (ADM, VCR, CTX) and the projected median disease-free survival increased to 24+ months. In previously untreated patients with advanced tumor adriamycin, used as single drug, achieved an overall response rate of 73 %. This is comparable to that achieved by a new combination including ADM, VCR, CTX, CCNU (75%). This multiple drug regimen is, however, expected to prolong the duration of response.

Primary Ewing sarcoma of the orbit

PURPOSE

To report the clinicopathologic features of a 17-year-old patient with primary Ewing sarcoma of the orbit.

METHODS

The patient was evaluated clinically before surgery with computed tomography scans of the orbit. After surgery, the patient was staged with computed tomography scans and bone scan and was treated with systemic chemotherapy and radiation therapy to the orbit. The orbital biopsy was evaluated with conventional light microscopy and immunohistochemistry.

RESULTS

Clinical evaluation revealed proptosis and limited upgaze. Computed tomography scans disclosed a mass involving the superior orbit, anterior cranial fossa, and temporal fossa. Microscopic examination revealed small, poorly differentiated cells with medium-sized nuclei containing finely granular chromatin and small nucleoli. The cytoplasmic borders of the cells were indistinct. A PAS stain revealed modest glycogen in many of the tumor cells. The tumor stained positive for O-13 and vimentin and was negative for neural, skeletal, and lymphoid cell markers. Computed tomography scan, bone scan, and blood chemistries revealed no other site of involvement. After treatment, the clinical symptoms and signs resolved, and there has been no evidence of residual orbital tumor or metastasis.

CONCLUSIONS

Primary Ewing sarcoma of the orbit should be considered in the differential diagnosis of children or young adults with proptosis, diplopia, or periorbital swelling. Immunohistochemistry is essential to distinguish Ewing sarcoma from other small round cell tumors.

The role of nuclear medicine in primary bone and soft tissue tumors

Although there is a limited role initially for staging the disease of primary bone and soft tissue tumors and for differentiation of benign from malignant lesions, nuclear medicine studies are recommended before starting treatment. A total body bone scan that includes a three phase study for the involved region helps to outline the vascularity of the lesion and both soft tissue and bony involvement, as well as involvement of other bones. A thallium 201 chloride or technitium 99m methoxy isobutyl isonitrile (SestaMIBI) tumor imaging study is recommended for baseline study and for future reference to evaluate the response to preoperative chemotherapy. This is of special importance to determine whether the patient needs an amputation or a limb-salvaging procedure. A follow-up thallium or 99mTc sesta MIBI study is not recommended early after surgery. A waiting period of at least 2 months is essential to avoid false-positive uptake caused by postoperative changes although this could be differentiated by comparing the ratios of lesion uptake in both early and delayed thallium imaging and with the ratios from the blood pool phase of the bone scan. Persistent thallium uptake in delayed images accompanied by ratios that are higher than the blood pool ratios is highly indicative of early recurrence. In the future, F-18 FDG tumor imaging acquired either on dedicated positron-emission tomography (PET) systems or by using a dual head gamma camera for coincidence detection will replace thallium and 99mTc sesta MIBI in those centers that have access to this technology. This is especially important at sites where thallium and MIBI have limitations because of normal uptake in adjacent organs.

Osteosarcoma

Osteosarcoma is the most common bone tumor of children and adolescents. The peak incidence of the disease is in the 15 to 19 year age group. The disease is more commonly seen in males than females. While several factors, including exposure to radiation, genetic disorders such as retinoblastoma, and high rate of bone growth, have been associated with osteosarcoma, in most cases no definite etiology can be established. Osteosarcoma usually originates in the metaphyseal region of long bones and extends through the cortex, causing varying degrees of bone destruction and expansion of periosteum. The radiographic appearance caused by this process is often referred to as "sun burst" sign. Positive diagnosis of osteosarcoma is made by histopathology. The histopathological classification of osteosarcoma can also predict the degree of aggressive behavior of this tumor and thus has prognostic significance. Surgery, including amputation or limb-salvage procedure, is the mainstay of treatment of osteosarcoma. It is now unequivocally established that adjuvant chemotherapy will prolong the survival of patients with this disease. Chemotherapy agents often used include platinum derivates, methotrexate, vincristine, cyclophosphamide, adriamycin, actinomycin D, bleomycin and DTIC. Depending on surgical decision, these agents can be used prior to or after the operation. Immediate fitting with prosthesis and provision of appropriate medical and psychological support in the care of these patients is essential.

Prognostic factors in the treatment of Ewing's sarcoma. The Ewing's Sarcoma Study Group of the German Society of Paediatric Oncology CESS 81

From 1981 up to February 1985, a total of 93 protocol patients entered the study CESS 81. The protocol recommended an initial 18-week period of polychemotherapy (VACA) followed by local therapy and two additional cycles of chemotherapy. Local therapy consisted either of radical surgery or of incomplete resection plus postoperative irradiation with 36 Gy or of radiotherapy alone (46 and 60 Gy). Centrally located lesions were always irradiated with 60 Gy. This article summarizes the data after 5 years. Data of 93 patients were analysed in October 1986 after a median follow-up of 37 months. The projected 5-year survival is 50%. The relapse rate was 42%, distant relapses occurred in 19%, local (plus distant) relapses in 23%. Most of the relapses occurred during the first 3 years of observation. Failure rate was high in patients undergoing irradiation alone (44%). Initial tumour mass (greater than 100 ml) and histopathologic response to initial chemotherapy were identified as major prognostic factors. Tumour site and type of local therapy were not significant if patients were categorised by tumour volume. In small lesions, surgery and radiotherapy were equally effective. In large lesions greater than 100 ml volume, a trend towards a better prognosis in surgically treated patients was observed. The results of CESS 81 emphasize the importance of permanent local control in Ewing's sarcoma even in the presence of systemic control by an effective multi-drug chemotherapy.

Primary Ewing's sarcoma of the ethmoid bone

Primary Ewing's sarcoma of the ethmoid bone has not been previously described. This case presented as a mass at the nasal bridge and posed diagnostic and therapeutic difficulties. The clinical, radiological, macroscopic and microscopic features are described. The treatment by the combined therapies of cranio-facial resection, radiotherapy and chemotherapy are discussed.

Influenza immunization of children with neoplastic diseases

During the National Influenza Immunization Program in 1976, 147 children with neoplastic diseases received Wyeth split-product bivalent influenza vaccine: A/New Jersey/8/76 (HSW1N1), A/Victoria/3/75 (H3N2). Thirteen normal siblings served as controls. Seventy-one patients received two doses of the vaccine four weeks apart. After the second injection of A/NJ/8/76, there was a difference between the response of the patients on chemotherapy and those off therapy greater than or equal to 30 days--38% vs. 76%, P less than 0.01 for four-fold rise and 26% vs. 57%, P less than 0.05 for the attainment of protective (greater than or equal to 32) hemagglutination inhibition (HI) titers. These differences were observed in both leukemia-lymphoma and solid tumor patients. There was a difference in HI titers to A/Vic/75 between patients on and off chemotherapy after a single injection, 34% vs. 71%, P less than 0.001 for a four-fold rise. After the second immunization, only 52% on, and 86% off therapy (P less than 0.05) had a four-fold rise in titers. Thirty-two percent of the patients on treatment who achieved "protective" titers did so only after the second immunization. Immunoglobulin levels and neutropenia did not correlate with the inability to obtain a four-fold rise in titers. Our findings suggest that patients on chemotherapy cannot be effectively vaccinated by a new antigen, and that single yearly boosters may be insufficient for recall of old antigens. Patients off chemotherapy greater than or equal to 30 days respond as normal controls.

Endodermal germ cell carcinoma (endodermal sinus tumor) of the vagina in infant girls

An endodermal sinus tumor (endodermal germ cell carcinoma) was diagnosed in a 1-year-old girl in the vagina after hemorrhage; the tumor was completely removed by radical abdominal surgery. Postoperative polychemotherapy was performed for two years with Actinomycin D, Adriamycin, Vincristin, and Cyclophosphamide. The infant is now tumor-free for 26 months, showing almost normal somatic and psychic development. The characteristic histological patterns and clinical course of this strongly malignant tumor are demonstrated, based on 25 published case reports of endodermal sinus tumors in the vagina of little girls (aged 5-26 months). This neoplasm in early infancy has to be separated from the clear-cell adenocarcinoma of the vagina which occurs after puberty in adolescent girls and young women, and is induced by stilbestrol therapy to the mother during early pregnancy.

Ewing's Sarcoma: An Approach to Radiological Diagnosis

All the pertinent radiographs of 83 patients with histologically proven Ewing's sarcoma were reviewed. Forty-nine patients were in the pediatric age group, and 34 were adults. The mean age, the symptoms and time from symptoms to diagnosis were evaluated in the 2 groups. The site of primary involvement was in 54 % the long bones, 35 % the flat bones, 8 % the small bones and 3 % extraosseous. For the primary site we considered the diagnostic results of the standard radiographic investigations and in some cases the usefulness of angiography, xeroradiography and telethermography. At presentation we also evaluated the possible diffusion of the disease with standard radiographic surveys (chest and skeletal, including limbs) and with foot lymphography in selected cases. In this way, 57 patients (69 %) were considered to have localized disease. In this group, we also considered the value of the periodic radiographic follow-up, which enabled us to disclose the appearance of metastases (chest 64 %, bone 54 %, lymph nodes 11 %) in 28 cases (49 %). Finally, we made a comparison of the different radiologic and epidemiologic findings between children and adults.

Ewing'S sarcoma: a clinical analysis of forty-six cases treated at Henry ford hospital

Our paper describes the clinical features, roentgenographic manifestations, pathology and the results of various modalities of treatments of 46 cases of Ewing's sarcoma seen and treated at Henry Ford Hospital during the past 36 years. Surgery alone (4 cases) produced a 25% five-year survival rate, whereas radiotherapy alone (33 cases) yielded only a 3% five-year survival rate. Radiotherapy plus chemotherapy (9 cases) have proven to be far superior than radiotherapy alone. The overall five-year survival rate of our series is only 7%.

Ewing's sarcoma of the mandible

Ewing's sarcoma of the mandible occurs rarely; there have been less than 50 reported cases in the past 30 years and none of these have been in the otolaryngologic literature. They usually present in the second decade of life with pain and swelling of the soft tissue overlying the mandible. The diagnosis can only be made by an adequate mandibular biopsy, although x-rays and clinical presentation are helpful. Current treatment consists of radiation therapy and sequential adjuvant chemotherapy.

Osteogenic sarcoma complicating osteogenesis imperfecta tarda

We describe the case history of a 13 years old boy who developed osteogenic sarcoma of the left thigh, six years after diagnosis of osteogenesis imperfecta tarda with a positive family history. Only four other patients with this disease combination are reported in the literature. Preoperative treatment with high-dose Methotrexate caused marked tumor regression, as shown at examination of amputation material. The inter-relationships between the two disorders are discussed and the literature is briefly reviewed.

Thoracotomy as adjuvant to chemotherapy in metastatic osteogenic sarcoma

This is a review of the experience at Memorial Hospital using chemotherapy combined with surgical excision for control of pulmonary metastases in osteogenic sarcoma. Effective multiple drug chemotherapy was able to control small deposits of osteogenic sarcoma in the lung, making surgical resection of residual visible nodules worthwhile. Surgical resection was most successful for solitary nodules or where multiple nodules were shrunk or at least prevented from growing by chemotherapy. Eight percent of these patients with pulmonary metastases initially or subsequently showed bilateral lung disease. When two or more nodules were found at th oracotomy, they were never confined to one lobe. For these reasons, wedge resections or segmental resections were the most commonly indicated procedures. Results justify an aggressive surgical approach to these lesions including multiple wedge resections of all lesions found at thoracotomy, chest wall resection and multiple bilateral thoracotomies. Chemotherapy alone cannot be expected to cure metastatic osteogenic sarcoma of the lung, but combined with surgical resection of residual disease the results are encouraging.

Combination chemotherapy with bleomycin, cyclophosphamide and dactinomycin for the treatment of osteogenic sarcoma

Thirteen patients with osteogenic sarcoma were treated with multiple drug chemotherapy consisting of bleomycin, cyclophosphamide and dactinomycin. The dosage schedule used was: bleomycin 12 mg/m2/day, cyclophosphamide 600 mg/m2/day, and dactinomycin 450 microgram/m2/day. All drugs were given intravenously for two consecutive days. Treatment was repeated every 2 weeks. Toxicity included severe nausea and vomiting (managed with antiemetics and intravenous hydration) and manifestations of bone marrow depression. Of 13 patients, eight were previously treated with high dose methotrexate with citrovorum factor rescue, cyclophosphamide and Adriamycin. Of these eight, three patients had objective evidence of tumor regression (37.5%). Five of five previously untreated patients had objective evidence of tumor regression. The overall response rate in osteogenic sarcoma patients to BCD was 61.5%. The combination of BCD appears to be more active against osteogenic sarcoma than cyclophosphamide alone or Adriamycin alone. The relative safety with which BCD can be administered makes this combination a valuable adjunct to high dose methotrexate with citrovorum factor rescue and Adriamycin in the treatment of osteogenic sarcoma.