Combined radical surgery, radiation therapy and chemotherapy in infants with vulvovaginal embryonal rhabdomyosarcoma

Uterine/female genital sarcomas

Choosing the best management of uterine and vulvo-vaginal sarcomas depends on careful histologic review of the pathologic specimen. Prognosis and treatment vary greatly depending on specific histology, grade, and tumor stage. The initial approach to sarcomas of the female genital tract, with the occasional exception of vulvo-vaginal rhabdomyosarcoma, is surgery. Adjuvant radiation decreases local recurrence rates for uterine sarcomas, but has not been clearly shown to improve overall survival. It is frequently used as adjuvant therapy for resected high-grade or margin-positive vulvo-vaginal sarcomas, and for endometrial stromal sarcomas. Adjuvant chemotherapy has not been demonstrated to improve survival in vulvo-vaginal sarcomas, with the exception of vulvo-vaginal rhabdomyosarcomas, nor has it been demonstrated to improve survival in uterine sarcomas. Chemotherapy may be used for recurrent or persistent disease. The choice of agent depends on the histologic type of sarcoma.

Nonsquamous cancer of the vagina

This report retrospectively analyzes 48 cases of primary vaginal cancer treated at Walter Reed Army Medical Center and the Naval Hospital, Bethesda, from 1962 through 1983. There was an unusually high number of uncommon histologic types. Nine patients had an adenocarcinoma, 5 had a sarcoma, 3 had a melanoma, 2 had an adenosquamous carcinoma, 1 had a lymphoma, and 1 had a carcinoid tumor. The remaining 27 patients had a squamous cell carcinoma. This represents a 43% prevalence of nonsquamous lesions. Nonsquamous cancer of the vagina occurred in patients at an earlier age than squamous cell carcinoma. Presenting symptoms, the location of the tumor within the vagina, and survival rates were similar for both groups. The clinical characteristics and treatment of the patients with nonsquamous tumors are discussed.

Embryonal rhabdomyosarcoma of the uterine corpus and cervix

Embryonal rhabdomyosarcomas of the uterus and cervix are rare tumors with a very poor prognosis historically. Adjuvant multidrug chemotherapy combined with local radiation therapy and/or surgery has resulted in markedly improved survival rates. Six patients with embryonal rhabdomyosarcoma of the uterus/cervix are reported, with a compilation of 28 additional patients from the literature. Nineteen of 24 patients (79%) treated with combination therapy were alive and well 4-147+ months (median 61 months) after diagnosis. The six cases from USC Medical Center and affiliated hospitals are all well 17-144 months (mean 95 months) after diagnosis. Analysis of the collected series indicates that extent of disease is an important prognostic factor. Adjuvant chemotherapy with vincristine, actinomycin D, and cyclophosphamide (VAC) improves survival. Initial therapy for embryonal rhabdomyosarcoma confined to the uterus/cervix should include radical hysterectomy, pelvic lymphadenectomy, and adjuvant chemotherapy with VAC. Pelvic radiotherapy should be employed for involved surgical margins or positive nodes. Advanced disease managed initially with chemotherapy and radiotherapy may allow subsequent curative extirpative surgery.

Alveolar rhabdomyosarcoma of the female genitalia

Eight cases of alveolar rhabdomyosarcoma of the female genitalia were diagnosed from 1963 to 1983 at The University of Texas M. D. Anderson Hospital. The primary sites were vulva in two, perineum in five, and broad ligament in one patient. When possible, therapy was initiated with local tumor excision (five patients). Surgery was followed by local or regional radiation (six patients) and chemotherapy (seven patients). Of the eight patients, five died within 9 months, one died 27 months after diagnosis, and only two are 5-year survivors. The aggressive behavior of this tumor is evidenced by autopsy findings of widespread metastases. Metastatic disease to the bone was present in four patients and to the breast in three patients. Local disease was controlled in two patients who died of distant metastases. Current therapy recommendations include excisional surgery, local radiation, and combination chemotherapy. A need for more effective chemotherapeutic programs is evident.

A therapeutic approach to childhood pelvic rhabdomyosarcoma without pelvic exenteration

A therapeutic approach using chemotherapy rather than radical surgery as the initial modality of treatment was employed in 13 children with pelvic rhabdomyosarcoma. One patient failed to respond to chemotherapy and required anterior pelvic exenteration. Eight patients are alive and free of disease 24 to 96 months after diagnosis. Limited surgery for minimal residual disease was used in two patients. Radiation therapy at lower than conventional doses was used in seven of eight patients. This experience supports a therapeutic approach to childhood pelvic rhabdomyosarcoma with an initial chemotherapy regimen, resulting in the use of surgical procedures less detrimental to pelvic organs without compromising survival.

Nonsurgical treatment of pelvic rhabdomyosarcoma: a case report

A 2 1/2-year-old male child with rhabdomyosarcoma of the prostate was treated with radiation of the pelvis, consisting of 5,600 rads in 7 1/2 weeks, and combination chemotherapy of Vincristine and Actinomycin D. Surgery had been refused. The child is alive and disease-free more than 5 years after diagnosis, and over 2 years following the cessation of all therapy. Recent advances in radiotherapy and adjuvant chemotherapy have significantly improved the outlook in this aggressive childhood neoplasm and have made a less aggressive and less mutilating surgical approach often desirable. This, in turn, holds out the prospect of improved quality of survival in children so afflicted.