Intensive induction chemotherapy and delayed irradiation in the management of parameningeal rhabdomyosarcoma

Local Treatment of Children Suffering From Parameningeal Rhabdomyosarcoma: A Retrospective Single-Center Study From China

BACKGROUND

Treatment for parameningeal rhabdomyosarcoma (PM-RMS) has been a challenge since local control is difficult. The goal of this study was to analyse the impact of different local treatment approaches on childhood PM-RMS patients and help dispel the doubt that whether secondary radical surgery (SRS) should be encouraged in the management of PM-RMS.

METHODS

A total of 17 children with PM-RMS who received unified systemic chemotherapy and individualized local therapy such as radiotherapy (RT) and/or SRS were included in this retrospective study. The overall survival (OS) and event free survival (EFS) were compared between groups adopting different local strategies.

RESULTS

The 3-year OS and EFS of our PM-RMS patients was 75.5% and 56.5% respectively. The OS and EFS of patients who received SRS were both significantly lower than that of the non-SRS group (3-year OS: 50.0% vs 90.0%, P = .031; 3-year EFS: 33.3% vs 60.6%, P = .020). The OS and EFS of the patients who received RT was higher than that of the patients of the non-RT group (3-year OS: 85.6% vs 0%, P = .001; 3-year EFS: 64.0% vs 0%, P = .011).

CONCLUSION

This study illustrates that SRS was associated with poor prognosis of PM-RMS and should not be routinely performed. Optimized RT strategies along with more intensive chemotherapy may be alternative options to improve the survival of patients with PM-RMS. Multi-center, large sample and prospective studies are needed to further validate these findings.

Treatment of Nonmetastatic Cranial Parameningeal Rhabdomyosarcoma in Children Younger Than 3 Years Old: Results From International Society of Pediatric Oncology Studies MMT 89 and 95

Purpose

To explore a strategy by which radiotherapy (RT) could be avoided in the treatment of young children with parameningeal rhabdomyosarcoma (PM RMS).

Patients and Methods

Fifty-nine children (median age, 2 years 3 months) with nonmetastatic cranial PM RMS were treated in the International Society of Pediatric Oncology MMT 89 and 95 trials between 1989 and 2003.

Results

Five-year EFS and OS rates were 46% and 54%, respectively, for the whole group. No standard clinical or pathologic variables had prognostic impact. Fifty (85%) of 59 patients achieved complete local control either with (n = 28) or without (n = 22) RT administered as part of their primary treatment. Nine patients (15%) did not achieve local control (four of whom had had RT), and all died. Patients who received RT had a significantly superior 5-year EFS rate compared with patients who did not receive RT (59% v 28%, respectively). Twenty-three patients (48%) experienced relapse at a median interval of 15 months. Ultimately, only seven patients (12%) were cured without RT, although this represented 32% of those who achieved local control with initial chemotherapy.

Conclusion

Despite concerns about the late effects of its use in young children, cure of PM RMS remains unlikely without systematic use of RT. The accurate prediction of the small subset of patients who achieve local control without RT and who do not experience relapse would provide an opportunity for a minority of patients to avoid RT.

Embryonal Rhabdomyosarcoma in a Young Maine Coon Cat

Embryonal rhabdomyosarcomas are uncommon tumors in all domestic species, especially cats. A 14-month-old Maine coon was diagnosed with an embryonal rhabdomyosarcoma in the rectus abdominus muscle, which was treated with complete surgical excision. Although no clinical progression was noted after surgery, the cat succumbed to pulmonary metastasis within 7 months. The histological diagnosis was embryonal rhabdomyosarcoma (myotubular subtype). This category of striated muscle tumors is thought to have a more aggressive clinical course. The rapid demise of this cat even with no clinical or histological evidence of metastasis at the time of resection may indicate that, as in human medicine, adjuvant chemotherapy should be considered in conjunction with early surgical excision in preventing disease progression.

Improved survival for children with parameningeal rhabdomyosarcoma: results from the AIEOP soft tissue sarcoma committee

BACKGROUND

Parameningeal rhabdomyosarcoma (PM-RMS) is a rare, highly malignant pediatric tumor arising from locations adjacent to the meninges, from where it can spread intracranially.

PROCEDURE

We reviewed 109 children with non-metastatic PM-RMS enrolled in the Italian RMS79, RMS88 and RMS96 protocols over a 24-year period. All patients received intensive chemotherapy and standard or hyperfractionated and accelerated radiotherapy. Some had delayed surgery.

RESULTS

Five-year overall survival rose from 40% in the RMS79 to 72% in the RMS88 and RMS96 protocols (P = 0.01), where more intensive chemotherapy and hyperfractionated accelerated radiotherapy (HART) was used. Delayed surgery after initial treatment was statistically associated with a better prognosis. Unfavorable tumor characteristics for RMS arising in other sites, for example, histology, invasiveness or node involvement, did not predict outcome for PM-RMS.

CONCLUSION

Outcome in PM-RMS patients enrolled in three consecutive Italian protocols has progressively improved, as a result of intensive chemotherapy, delayed surgery and, possibly, HART, though improved imaging and radiotherapeutic tools may have had a role as well.

Intensity Modulated Radiotherapy (IMRT) and Fractionated Stereotactic Radiotherapy (FSRT) for children with head-and-neck-rhabdomyosarcoma

Background

The present study evaluates the outcome of 19 children with rhabdomyosarcoma of the head-and-neck region treated with Intensity Modulated Radiotherapy (IMRT) or Fractionated Stereotactic Radiotherapy (FSRT) between August 1995 and November 2005.

Methods

We treated 19 children with head-and-neck rhabdomyosarcoma with FSRT (n = 14) or IMRT (n = 5) as a part of multimodal therapy. Median age at the time of radiation therapy was 5 years (range 2–15 years). All children received systemic chemotherapy according to the German Soft Tissue Sarcoma Study protocols.

Median size of treatment volume for RT was 93,4 ml. We applied a median total dose of 45 Gy (range 32 Gy – 54 Gy) using a median fractionation of 5 × 1,8 Gy/week (range 1,6 Gy – 1,8 Gy).

The median time interval between primary diagnosis and radiation therapy was 5 months (range 3–9 months).

Results

After RT, the 3- and 5-year survival rate was 94%. The 3- and 5-year actuarial local control rate after RT was 89%.

The actuarial freedom of distant metastases rate at 3- and 5-years was 89% for all patients.

Radiotherapy was well tolerated in all children and could be completed without interruptions > 4 days. No toxicities >CTC grade 2 were observed. The median follow-up time after RT was 17 months.

Conclusion

IMRT and FSRT lead to excellent outcome in children with head-and-neck RMS with a low incidence of treatment-related side effects.

Delayed radiotherapy following dose intensive chemotherapy for parameningeal rhabdomyosarcoma (PM-RMS) of childhood

PURPOSE

To evaluate the local control rates and survival rates of patients with Group III parameningeal rhabdomyosarcoma (PM-RMS) treated with a dose intensive chemotherapy regimen followed by irradiation.

MATERIALS AND METHODS

Twenty-six patients with group III, PM-RMS were enrolled in a prospective pilot trial at the Mayo Clinic, Rochester, MN and Children's Hospital and Regional Medical Center Seattle, WA. The median age at diagnosis was 8.5 years (range 1.5-19 years). The male to female patient ratio was 1.6:1. Twenty-three patients had embryonal histology with the remaining three alveolar. Risk factors indicating high risk disease included intracranial extension (10 patients), base of skull erosion (12 patients), and cranial nerve palsy (10 patients). The median follow-up period for all patients was 82 months (range 17-148 months). Patients were treated with an intensified chemotherapy regimen followed by definitive local irradiation at week 12 following further chemotherapy. The median time from initiation of chemotherapy to irradiation was 16 weeks (range 6-23). The median dose delivered was 50.4Gy (50.4-66.6Gy).

RESULTS

Response was assessed after the fourth course of chemotherapy. Three patients exhibited a complete response, 22 a partial response, and 1 patient had no response after two cycles of chemotherapy and proceeded to irradiation at week 6. The 5-year estimated event free survival was 81% (+/-15%, 95% CI). Two patients died from progressive metastatic disease; 1 patient died from secondary malignancy; and 2 patients died from locally progressive disease. The 5-year local control rate was 92% (+/-10.6%, 95% CI).

CONCLUSIONS

Treatment of group III PM-RMS patients with neo-adjuvant, intensive chemotherapy with a delay in irradiation resulted in excellent local-regional control rates and survival rates and may allow for a response-based radiotherapy approach.

Rhabdomyosarcoma: new windows of opportunity

Rhabdomyosarcoma is a highly malignant, small blue cell tumor characterized by muscle differentiation. With modern treatment, more than 70% of children and adolescents with this disease are cured. Adequate biopsy to obtain sufficient tissue for accurate diagnosis and molecular characterization is critical. Patients must be assessed for tumor extent; the Intergroup Rhabdomyosarcoma Study (IRS) clinical group and Staging system is universally applied in North America. Multidisciplinary therapy is necessary to maximize cure rates. Local control relies on complete surgical excision when possible; those whose tumors are not completely excised and those with alveolar histology tumors require local irradiation to maximize local control. In North America, vincristine (Oncovin); Eli Lilly and Company, Indianapolis, http://www.lilly.com), dactinomycin (Cosmegen); Merck & Co., Inc., Whitehouse Station, NJ, http://www.merck.com), and cyclophosphamide are the standard chemotherapy agents. The IRS has used therapeutic window studies to confirm the predictive nature of preclinical xenograft models and to identify several new single agents and combinations of agents with activity in high-risk patient groups. Despite these efforts, the outcome for these high-risk patients remains poor. The next generation of Children's Oncology Group studies will evaluate the efficacy of topoisomerase-I inhibitors and dose-compression therapy approaches. New advances in molecular characterization of tumors, including gene-expression analysis, may identify new therapeutic targets that can be exploited by expanded preclinical drug discovery efforts, and hold the promise of revolutionizing risk-based therapies.

Intensity-modulated radiotherapy for head-and-neck rhabdomyosarcoma

PURPOSE

To determine the preliminary results of intensity-modulated radiotherapy (IMRT) for head-and-neck rhabdomyosarcoma.

METHODS AND MATERIALS

Twenty-eight patients underwent IMRT as a part of multimodality therapy. Twenty-one tumors were parameningeal, three were orbital, and four were in other sites. The median age was 8 years (range, 1-29 years). Most (89%) had Group III disease. Intracranial extension was present in 71% of parameningeal tumors. A 1.5-cm margin was used, and the median dose was 50.4 Gy (range, 30-55.8 Gy).

RESULTS

The actuarial 3-year survival rate for patients with parameningeal tumors was 65%. The 3-year actuarial freedom from failure rate was 95% locally, 90% in regional nodes, 88% in the central nervous system, and 80% at distant sites. No failures occurred among patients with orbit tumors; a single central nervous system failure occurred in 1 patient with a lip/cheek tumor. Disease-free survival was significantly worse for patients with alveolar histologic features (p = 0.01). Acute radiation toxicity was similar to that reported by the Intergroup Rhabdomyosarcoma Study Group. Late radiation toxicity was recorded and was mild.

CONCLUSION

IMRT with image fusion results in outstanding local control despite the use of a reduced margin. However, survival among patients with alveolar histologic findings or intracranial extension remains unacceptably low.

Treatment for childhood rhabdomyosarcoma: the cost of cure

Survival of children and young people with rhabdomyosarcoma has improved substantially during the past 30 years. The improvement can be attributed to the introduction of coordinated multimodality therapy through the efforts of collaborative clinical-trial groups in the USA and Europe. As survival has improved, important late sequelae of treatment have been characterised, and many relate to the local therapy used. Efforts have since been made by some groups to explore ways in which local treatment, particularly radiotherapy, can be omitted for some patients in an attempt to reduce the risk of late sequelae without compromising prospects for cure. An important issue is the overall cost of cure in relation to the treatment received and the need for better selection of patients most likely to benefit from this approach to therapy.