The potential of combined modality approaches for the treatment of malignant bone tumors in children

Adriamycin plus Bleomycin versus Cyclophosphamide plus Vincristine in Advanced Carcinoma of the Uterine Cervix

The paper reports the results of a prospective controlled study with two drug combinations (adriamycin plus bleomycin versus cyclophosphamide plus vincristine) in 34 consecutive patients with advanced or recurrent carcinoma of uterine cervix. Despite adequate dosage, the incidence of complete and partial remission was low (10% vs 20%) and not superior to that usually obtained with single agent chemotherapy. By adding objective improvement, the over all response rate was 47% and 26%, respectively. The duration of complete plus partial remission was 7.5 and 7.2 months, the median survival for responders 19 and 8.3 months, respectively. After cross over, adriamycin plus bleomycin yielded response in 4/10 patients, cyclophosphamide plus vincristine objective improvement in 1/3 patients. Since the control of advanced cervical carcinoma remains difficult, a combined modality approach with radiotherapy plus adjuvant chemotherapy for stages IIB and III appears worth of trial.

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

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

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%.

[High-dose methotrexate/leucovorin adjuvant chemotherapy of osteogenic sarcoma: biochemical effects in DNA-synthesis of bone marrow cells (author's transl)]

DNA metabolism in bone marrow cells was measured under high-dose Methotrexate/Leucovorin adjuvant chemotherapy of a patient with primary amputation of his right leg because of osteogenic sarcoma. The biochemical data showed that there was no rescue effect of Leucovorin after 200 mg/kg Methotrexate. Corresponding to this "biochemical failure" of the rescue effect the patient died from the complications of a long and very severe bone marrow suppression. To improve the safety of this therapeutic regimen the intravenous injection and in some cases a higher dose of Leucovorin is recommended.

Actual volume doubling time values for pulmonary metastases from soft tissue sarcomas

Doubling time values of pulmonary metastases from soft tissue sarcomas were measured. Sixty metastases from 24 patients were measured 79 consecutive times, and, the values for 116 doubling times were calculated. Small volume metastases grew significantly faster (arithmetic mean 29.7 days) than large metastases (arithmetic mean 43.4 days). An assessment with comparative data obtained previously by measuring the doubling time values of pulmonary metastases from osteogenic sarcoma revealed similar growth characteristics. The possible involvment of identical control mechanisms operating in the growth process of pulmonary metastases in both soft tissues and osteogenic sarcomas are discussed.

Adjuvant multiple drug chemotherapy for osteosarcoma of the extremity

Results of treatment for osteosarcoma of the extremity have been poor with metastases usually causing death within 2 years following diagnosis. Because of the great risk of development of metastases, 20 patients have received adjuvant chemotherapy with Adriamycin, cyclophosphamide and high-dose methotrexate-leucovorin rescue for up to 12 months following amputation for osteosarcoma. Sixteen of these patients are surviving; 11 are free of evident tumor from 6 to 34 months following amputation. Five patients were found to have pulmonary metastases while receiving chemotherapy and three patients developed metastases following completion of chemotherapy. One patient died following her third treatment with high-dose methotrexate-leucorovin rescue. Other toxicity included nausea, vomiting, mucosal ulcerations, infections, hematologic abnormalities, changes in kidney and liver functions tests, and minor coagulation abnormalities. The natural history of osteosarcoma may have been modified by the use of these agents for periods exceeding the median time to predicted detection of pulmonary metastases. Microscopic metastases of some patients were eradicated by this adjuvant chemotherapy. For patients who developed metastases, these metastases were delayed in their time of detection and in their number at the time of detection.