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Role of High-Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation for Children and Young Adults with Relapsed Ewing's Sarcoma: A Systematic Review. Sarcoma 2018; 2018:2640674. [PMID: 29973774 PMCID: PMC6008812 DOI: 10.1155/2018/2640674] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/24/2018] [Accepted: 05/13/2018] [Indexed: 12/27/2022] Open
Abstract
Background Relapsed Ewing's sarcoma (RES) is an aggressive malignancy with poor survival. Although high-dose chemotherapy (HDCT) with autologous stem cell transplantation (ASCT) given after conventional chemotherapy (CC) has shown survival benefits, it is not generally used in the United States for RES. We performed a systemic review to evaluate the benefits of HDCT for RES. Methods Literature search involved Medline, Embase, and Cochrane database. We included studies with RES patients treated with HDCT/ASCT. Results Twenty-four studies with total of 345 reported RES patients that got HDCT were included in final analysis. Seventeen studies had patients with multiple malignancies including RES, while seven had only RES patients. At 2 and 3–5 years, event-free survival (EFS) in studies with only RES patients ranged 42–47% and 20–61% and overall survival (OS) ranged 50–66% and 33–77%, respectively. In studies with combined patients that reported outcomes of RES separately, the EFS at 1–3 and 4 years was 36–66% and 17–50%, respectively. The OS at 1-2 and 3-4 years was 40–60% and 50–70%. Conclusions Most studies using HDCT/ASCT as consolidation regimen showed improved survival benefits compared to CC. Randomized controlled studies are needed to determine true clinical benefits of HDCT followed by ASCT in patients with RES.
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Kurucu N, Sari N, Ilhan IE. Irinotecan and temozolamide treatment for relapsed Ewing sarcoma: a single-center experience and review of the literature. Pediatr Hematol Oncol 2015; 32:50-9. [PMID: 25252096 DOI: 10.3109/08880018.2014.954070] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Long-term survival in relapsed Ewing sarcoma (ES) is less than 20%. Encouraging results have been reported with irinotecan and temozolomide combinations (IRN/TMZ). We aimed to share our experience and compare it with previously published studies using this combination to treat relapsed ES. We retrospectively evaluated 20 patients treated with a combination of IRN (20 mg/m(2)/d × 5 for 2 weeks) and temozolomide (100 mg/m(2)/d × 5). Patients received a total of 97 courses. An objective response was achieved in 11 patients (55%) and maintained for a median of 12 months. Five patients were alive for a median of 12 months. Median time to progression was 5.5 (2-57) months. After the IRN/TMZ treatment, 1-year overall and event-free survival rates were 54.2% and 44.4%, respectively. Grade 3-4 toxicities included diarrhea (9.2%), neutropenia (11.3%), and thrombocytopenia (6.2%). Three retrospective trials were found in our literature review, which used an IRN/TMZ combination to treat ES. There was one other study which retrospectively evaluated the efficacy of vincristine, IRN, and TMZ combination in relapsed ES. A total of 81 patients were treated with IRN/TMZ in four studies including ours. The objective response rate was 55.1%, and median time to progression ranged from 5.5 to 8.3 months. Twenty-six (7.5%) of a total of 346 courses were associated with grade 3-4 diarrhea. Grade 3-4 neutropenia and thrombocytopenia were reported in 9.2% and 7.2% of the courses, respectively. Results showed that an IRN/TMZ combination is effective and tolerable in patients with relapsed ES.
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Affiliation(s)
- Nilgun Kurucu
- Department of Pediatric Oncology, Institute of Cancer, Hacettepe University , Ankara , Turkey
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Kasper B, Dietrich S, Mechtersheimer G, Ho AD, Egerer G. Large institutional experience with dose-intensive chemotherapy and stem cell support in the management of sarcoma patients. Oncology 2008; 73:58-64. [PMID: 18334832 DOI: 10.1159/000120629] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 09/04/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND The prognosis of patients with advanced sarcoma remains poor. Whether high-dose chemotherapy with stem cell support improves the long-term outcome for these patients or not is controversial. METHODS We present a large institutional experience of sarcoma patients treated with this therapy option. Thirty-eight patients with bone (n = 17) and soft tissue sarcomas (n = 21) were included. Apart from haematological complications, no WHO grade III-IV complications were observed. One patient died due to cardiac arrest after transplantation. RESULTS Following chemotherapy and/or surgery, but prior to high-dose chemotherapy, diagnoses were made of: no evidence of disease (NED; n = 12), partial remission (n = 17), stable disease (n = 3) and progressive disease (PD; n = 6). Six patients died within 8 months due to PD, in 18 patients disease recurred and led to death and 13 patients are alive with/without disease. Median progression-free survival was 19.1 months (range: 0-121) for all patients, and 48.8 months (range: 3-121) for 12 patients with NED. CONCLUSION A subgroup of patients with NED before high-dose chemotherapy gained survival benefit. Therefore, we emphasize the value of high-dose chemotherapy as a treatment option for younger patients with a good performance status in partial or complete remission.
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Affiliation(s)
- Bernd Kasper
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.
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Burke MJ, Walterhouse DO, Jacobsohn DA, Duerst RE, Kletzel M. Tandem high-dose chemotherapy with autologous peripheral hematopoietic progenitor cell rescue as consolidation therapy for patients with high-risk Ewing family tumors. Pediatr Blood Cancer 2007; 49:196-8. [PMID: 17417796 DOI: 10.1002/pbc.21182] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The role of tandem high-dose chemotherapy (HDC) with autologous peripheral hematopoietic progenitor cell rescue (APHPCR) in patients with Ewing Family Tumors (EFT) is controversial. We initiated treatment for eight consecutive patients with high-risk EFT with HDC and APHPCR from 1992 to 2003. There were no treatment related deaths. Four patients remain in complete remission, including three who did not undergo local therapy to bone at either the primary or metastatic sites. Our experience has shown that treatment of EFT patients with tandem HDC with APHPCR may benefit a subgroup of high-risk patients in whom optimal local therapy is not possible.
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Affiliation(s)
- Michael J Burke
- Division of Hematology, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60614-3394, USA
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Al-Faris N, Al Harbi T, Goia C, Pappo A, Doyle J, Gassas A. Does consolidation with autologous stem cell transplantation improve the outcome of children with metastatic or relapsed Ewing sarcoma? Pediatr Blood Cancer 2007; 49:190-5. [PMID: 17262797 DOI: 10.1002/pbc.21140] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate the role of high-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT) as consolidation therapy for children with high-risk Ewing sarcoma (ES) treated at The Hospital for Sick Children (SickKids), Toronto. PATIENTS AND METHODS The charts of children treated for high-risk ES (defined as metastatic at diagnosis or relapsed) between 1990 and 2005 at SickKids were reviewed. Forty-five children were identified. Twenty patients received ASCT after induction with vincristine, doxorubicin, ifosfamide, cyclophosphamide, and etoposide. Patients with resectable tumor or lung metastases underwent surgery and those with non-resectable tumors were treated with irradiation. Twenty-five patients were treated with conventional chemotherapy (CC). Primary metastatic patients were treated with either a local protocol or as per POG 9354. At relapse, patients were treated with topotecan, cyclophosphamide, then ifosfamide, carboplatin, and etoposide (ICE). Local control was attained with surgery and/or irradiation. RESULTS Ten of the 20 patients treated with ASCT are alive (median follow-up 6 years), with 8/10 being in remission more than 5 years from diagnosis. The 3-year overall survival (OS) for ASCT was 59%, (95% CI: 36%, 81%) compared to 34% (14%, 53%) for patients treated with CC (P-value = 0.06). The 3-year event-free survival (EFS) for the ASCT was 39% (17%, 60%) compared to 32% (13%, 50%) in the CC group (P = 0.08). CONCLUSION ASCT appears to add some benefit to conventional multimodality therapy for children with high-risk ES. Randomized controlled trials are warranted.
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Affiliation(s)
- Nafisah Al-Faris
- Department of Pediatrics, Division of Hematology, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
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Fraser CJ, Weigel BJ, Perentesis JP, Dusenbery KE, DeFor TE, Baker KS, Verneris MR. Autologous stem cell transplantation for high-risk Ewing's sarcoma and other pediatric solid tumors. Bone Marrow Transplant 2006; 37:175-81. [PMID: 16273111 DOI: 10.1038/sj.bmt.1705224] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The prognosis for many pediatric and young adult patients with solid tumors that have metastasized at the time of diagnosis or have relapsed after therapy remains very poor. The steep dose-response curve of many of these tumors to alkylating agents makes myeloablative chemotherapy followed by autologous stem cell transplantation (ASCT) an attractive potential therapy. The role of ASCT for these high-risk patients is yet to be conclusively determined. We have transplanted 36 patients on two consecutive protocols with a variety of histological diagnoses. Overall survival (OS) was 63% (95% CI: 47-79%) at 1 year and 33% (95% CI: 16-50%) at 3 years. Patients with a diagnosis of Ewing's sarcoma (ES) or desmoplastic small round cell tumor (DSRCT) had significantly better survival than those with other diagnoses with estimated 3-year OS of 54% (95% CI: 29-79%) for this group of patients (P = 0.03). There were two transplant-related deaths both attributable to hepatic veno-occlusive disease. Median follow-up among survivors is 3.5 years (range: 0.6-7.9 years). These data justify continued investigation of ASCT as a consolidation therapy in patients with metastatic or relapsed ES and DSRCT.
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MESH Headings
- Adolescent
- Adult
- Bone Neoplasms/complications
- Bone Neoplasms/mortality
- Bone Neoplasms/pathology
- Bone Neoplasms/therapy
- Child
- Child, Preschool
- Disease-Free Survival
- Female
- Fibroma, Desmoplastic/complications
- Fibroma, Desmoplastic/mortality
- Fibroma, Desmoplastic/pathology
- Fibroma, Desmoplastic/therapy
- Follow-Up Studies
- Hepatic Veno-Occlusive Disease/etiology
- Hepatic Veno-Occlusive Disease/mortality
- Humans
- Male
- Neoplasm Recurrence, Local/complications
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/therapy
- Risk Factors
- Sarcoma, Ewing/complications
- Sarcoma, Ewing/mortality
- Sarcoma, Ewing/pathology
- Sarcoma, Ewing/therapy
- Stem Cell Transplantation/methods
- Stem Cell Transplantation/mortality
- Survival Rate
- Transplantation, Autologous
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Affiliation(s)
- C J Fraser
- Department of Pediatrics, Division of Hematology, Oncology and Bone Marrow Transplantation, University of Minnesota, Minneapolis, MN 55455, USA
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Gow KW, Wulkan ML, Heiss KF, Haight AE, Heard ML, Rycus P, Fortenberry JD. Extracorporeal membrane oxygenation for support of children after hematopoietic stem cell transplantation: the Extracorporeal Life Support Organization experience. J Pediatr Surg 2006; 41:662-7. [PMID: 16567173 DOI: 10.1016/j.jpedsurg.2005.12.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) is a means of respiratory and hemodynamic support for patients failing conventional therapies. Children requiring hematopoietic stem cell transplantation who develop complications during therapy may require ECMO. Such patients pose medical and ethical challenges for clinicians considering initiation of ECMO. The authors review the outcomes of these patients and propose recommendations. METHODS The Extracorporeal Life Support Organization Registry was queried for all patients younger than 18 years with an International Classification of Diseases, Ninth Revision, or Current Procedural Terminology code related to bone or stem cell transplant. RESULTS Nineteen children in the registry met inclusion criteria. The median age was 9.6 years (7 months to 17.5 years). Initiation of ECMO was for pulmonary support (n = 17), cardiac support (n = 1), or cardiopulmonary resuscitation (n = 1). The median duration of ECMO support was 5.1 days (range, 30 hours to 42 days). Pulmonary infections included 3 parainfluenza, 2 Pneumocystis carinii, 1 influenza A, and 1 respiratory syncytial virus. Overall, 15 (79%) died during their ECMO run, whereas only 4 (21%) survived to come off ECMO. Furthermore, of those who survived their ECMO run, only one patient survived to discharge from the hospital. Risk factors for death on ECMO include development of renal complications and development of multiorgan dysfunction. CONCLUSION Patients who require ECMO for cardiopulmonary support after hematopoietic stem cell transplantation have a poor prognosis. Clinicians must be cautious in presenting this option to parents and present them with appropriate expectations in this high-risk population.
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Affiliation(s)
- Kenneth W Gow
- Department of Surgery, Emory University, Atlanta, GA 30322, USA.
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Hendershot E. Treatment approaches for metastatic Ewing's sarcoma: a review of the literature. J Pediatr Oncol Nurs 2006; 22:339-52. [PMID: 16216896 DOI: 10.1177/1043454205279300] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The Ewing's sarcoma family of tumors (ESFT) is an aggressive group of neoplasms that represent approximately 3% of all pediatric malignancies. The overall survival rates in patients with localized disease are approaching 75%. The outcome for the 25% of patients who present with metastatic disease, however, remains poor, with long-term survival rates of less than 30%. This review will explore the natural history of ESFT including clinical presentation, molecular pathology, and high-risk features of the disease. Outcomes of metastatic treatment protocols to date will be examined as well as the rationale for current and future therapies. Nursing considerations in caring for patients with metastatic ESFT will be discussed. A case scenario will be reviewed to highlight treatment and supportive care issues in the management of the disease. Cancer therapy in general is becoming more complex; treatment approaches involve different ways of targeting tumor cells. It is crucial that nurses caring for these patients understand the rationale behind treatment strategies so that appropriate patient education and support may be given.
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Affiliation(s)
- Eleanor Hendershot
- Solid Tumor Program in the Division of Hematology/Oncology at Hospital for Sick Children, Toronto, Ontario, Canada.
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Abstract
Ewing's sarcoma is the second most common primary bone tumor seen in children and adolescents, and was described by James Ewing in 1921 as a diffuse endothelioma of bone. It is one of the differential diagnoses of pediatric small round blue cell tumors. This is not a single condition, but a group of morphologically and clinically closely related disorders with similar molecular biology -- expression of tumor-specific chimeric oncoproteins through balanced chromosomal translocations involving the EWS gene -- often referred to as the Ewing family of tumors. This includes Ewing's sarcoma of bone, extra-osseous Ewing's sarcoma, Askin tumor and peripheral neuroectodermal tumor. These are aggressive neoplasms with almost 25% of patients having clinically evident metastases at presentation. Ewing's sarcoma has therefore been considered as a systemic disease necessitating local as well as systemic treatment. An aggressive multidisciplinary approach has resulted in significant improvement in prognosis for patients with these tumors. Despite aggressive treatment, 20-40% of patients with localized disease and almost 80% of patients with metastatic disease at presentation succumb to the illness. Advances in understanding the molecular biology of these tumors will hopefully result in the development of novel treatment approaches. The aim of this article is to review the existing treatment methods and to highlight the more recent approaches to the treatment of this condition.
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Affiliation(s)
- Mihir M Thacker
- Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine (D-27), PO Box 016960, Miami, FL 33101, USA.
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Schultze-Mosgau S, Thorwarth M, Wehrhan F, Holter W, Stachel KD, Grabenbauer G, Amann K, Beck JD. Ewing Sarcoma of the Mandible in a Child: Interdisciplinary Treatment Concepts and Surgical Reconstruction. J Craniofac Surg 2005; 16:1140-6. [PMID: 16327573 DOI: 10.1097/01.scs.0000180005.52986.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Ewing's sarcoma is the second most common primary bone malignancy in childhood and adolescence. We present a standardized interdisciplinary treatment protocol according to the EURO-E.W.I.N.G. 99 study, applied in the treatment of a 7-year-old patient with localized Ewing's sarcoma of the left mandible. After six blocks of VIDE (vincristine/ifosfamide/doxorubicin/etoposide) chemotherapy and stem cells rescue, intensity modulated external radiation with 48.6 Gy and subsequent high dose therapy with busulphan-melphalan were administered. Tumor resection and immediate bony reconstruction was performed using a microvascular fibula graft 10 weeks after radiation. Because of the effective neoadjuvant treatment, no extensive soft tissue resection was necessary. Healing of the osteosynthesis was uneventful. No local or systemic recurrence and no signs of significant facial deformity were found after 12 month follow-up. The presented case underlines the requirement for multidisciplinary protocols involving radiologists, pathologists, oncologists, radiation oncologists, and surgeons for accurate diagnosis and appropriate therapy. To preserve cosmetics and function within the craniofacial area after tumor resection in children, microvascular reconstructive procedures can be successfully performed with a vascularized fibular graft.
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Affiliation(s)
- Stefan Schultze-Mosgau
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, University of Jena, Jena, Germany.
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Radeva JI, VanScoyoc E, Smith FO, Curtis LH, Breitfeld PP. National estimates of the use of hematopoietic stem-cell transplantation in children with cancer in the United States. Bone Marrow Transplant 2005; 36:397-404. [PMID: 15995713 DOI: 10.1038/sj.bmt.1705077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
National utilization data for hematopoietic stem-cell transplantation (HSCT) for childhood cancers in the United States have not been reported. We identified cancer encounters for children aged 18 years and younger from 1997 to 2001 in US nonfederal, acute care hospitals. We compared patient, hospital, and resource use characteristics and in-patient mortality associated with HSCT and non-HSCT encounters, estimated the number of HSCT encounters by stem-cell source and cancer type, and examined resource use and mortality in each category. We identified 461,175 cancer encounters, of which 6380 (1.4%) were HSCT encounters. There was wide variation in resource use and mortality by stem-cell source and cancer type. Of note, 17% of HSCT encounters were for patients with acute lymphoblastic leukemia without remission or sarcoma, conditions for which there is little evidence of benefit from HSCT in children. These encounters were associated with high in-patient mortality and long lengths of stay. Also, we observed an increasing use of cord blood over the study period. Future research should examine potentially important sociodemographic differences in patients undergoing HSCT compared to those who do not. Additional analyses incorporating disease stage and severity are needed.
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Affiliation(s)
- J I Radeva
- Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Durham, NC 27715, USA.
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Kasliwal MK, Agrawal D, Mahapatra AK. Magnetic resonance imaging of primary orbital Ewing's sarcoma. Pediatr Neurosurg 2005; 41:192-6. [PMID: 16088254 DOI: 10.1159/000086560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2004] [Accepted: 12/29/2004] [Indexed: 11/19/2022]
Abstract
The authors describe the MRI findings of a primary orbital Ewing's sarcoma in a 5-year-old boy, who underwent an extensive tumour surgery as these findings were mistaken for more chemoresistant sarcomas such as rhabdomyosarcoma. This case illustrates the fact that MR findings of primary orbital Ewing's sarcoma may be different from those of Ewing's sarcoma present elsewhere in the body. An accurate preoperative diagnosis may therefore result in a more conservative approach and prove extremely useful in such tumours.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India
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