What is the role of routine follow-up for localised limb soft tissue sarcomas? A retrospective analysis of 174 patients

Background:

There are neither prospective data nor agreement on the optimal routine follow-up procedures in patients treated for soft tissue sarcoma of the limb.

Methods:

Data on 174 consecutive patients with a soft tissue sarcoma of the limb undergoing follow-up by oncologists at a single centre from 2003 to 2009 were included in this analysis. The rate and site of recurrence and mode of detection were analysed. Outcome of the patients was assessed.

Results:

Eighty-two patients (47%) experienced relapse of any type. Isolated local recurrence occurred in 26 patients and local relapse with synchronous pulmonary metastases in five patients. Local recurrences were detected clinically in 30 of these 31 patients; magnetic resonance imaging identified only one local recurrence. Twenty-eight patients developed isolated lung metastases; in nine patients these were amenable to resections, seven of whom are currently free of disease after treatment. Lung metastases were detected by chest x-ray (CXR) in 19 patients, computed tomography scanning in 3 patients, and clinically in 11 patients. Twenty-three patients developed non-pulmonary metastases. More than 80% of relapses occurred in the first 2 years of follow-up; however, later recurrences were also observed.

Conclusions:

Routine follow-up CXR can detect lung metastases suitable for surgical resection, although the optimal interval of imaging has yet to be defined. Local relapse is almost always detected by patients or physicians, and routine scanning of the primary site is of doubtful benefit. Patient and physician education to detect local relapse may be helpful. Prospective evaluation of follow-up is recommended.

Phase II study of gemcitabine and docetaxel as first-line chemotherapy in locally advanced/metastatic leiomyosarcoma

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Background: Locally advanced/metastatic soft tissue sarcoma is invariably incurable with a poor prognosis. Recently gemcitabine and docetaxel have been shown to be active in pre-treated relapsed leiomyosarcoma. This study aims to investigate the combination as first line treatment in patients with unresectable incurable leiomyosarcoma. Methods: Patients received gemcitabine 900mg/m2 days 1 and 8, and docetaxel 100mg/m2 day 8, administered 3-weekly for up to 8 cycles, with GCSF support on days 9–15. Patients who had received previous radiotherapy were treated at 75% dose. Patients were evaluated for response by RECIST after cycles 2, 4, 6, and 8, and three-monthly after completing treatment. The study was conducted with a Simon 2-stage design, recruiting 19 patients in stage 1, and 25 patients in stage 2. The primary endpoint was response rate, and secondary endpoints progression free survival (PFS), overall survival (OS), and toxicity evaluation. Results: Forty-four patients were treated. Eligible patients had histologically proven leiomyosarcoma of the uterus (48.9%) or other sites (51.1%) unresectable for cure, with measurable disease, no previous chemotherapy, adequate organ function, and performance status 0–2. 84.4% had metastatic disease, and 15.6% had locally advanced disease. 11% of patients had grade 1 disease, and 89% had grade 2/3 disease. All patients had demonstrated disease progression prior to trial entry. Responses were as follows: partial response 12 (27%), stable disease (confirmed) 16 (36%), stable disease (unconfirmed) 5 (11%), progressive disease 11 (25%). Median OS and PFS were 578 (95% CI 131–322) and 216 (95% CI 24–169) days. Progression free rates at 3 and 6 months were 68.9% (95% CI 55.1–82.7%) and 57.8% (95% CI 43.1–72.5%). Conclusions: This study demonstrates gemcitabine and docetaxel to be active in leiomyosarcoma in the first line setting. Further investigation comparing the combination with current standard therapies for leiomyosarcoma is warranted.

No significant financial relationships to disclose.

Mechanisms and management of non-islet cell tumour hypoglycaemia in gastrointestinal stromal tumour: case report and a review of published studies

Tumour-related hypoglycaemia is a rare paraneoplastic phenomenon most frequently occurring with insulinomas, but also associated with non-islet cell tumours. It has been observed in a range of tumour types, but recently a small number of cases have been described in association with gastrointestinal stromal tumours. We describe a further case of a patient with gastrointestinal stromal tumour that was complicated by non-islet cell tumour hypoglycaemia, and discuss the mechanisms and management of non-islet cell tumour hypoglycaemia in the context of gastrointestinal stromal tumour.

Fatal radiation myelopathy after high-dose busulfan and melphalan chemotherapy and radiotherapy for Ewing's sarcoma: a review of the literature and implications for practice

Radiation myelopathy is a rare, devastating, late effect of radiotherapy to the spinal cord. Spinal cord tolerance is currently accepted as about 50 Gy in 1.8-2 Gy fractions. However, the effect of chemotherapy on cord tolerance is unclear. This issue is important, given the increasing use of chemotherapy in combination with radiotherapy. We describe the case of a 17-year-old boy with a right apical paraspinal Ewing's tumour in the neck treated with induction chemotherapy, high-dose chemotherapy (busulfan and melphalan) with peripheral stem-cell rescue and, 4 months later, radiotherapy to the primary tumour site (cervical cord received 50 Gy in 30 fractions). After a latent period of 4 months, he developed a progressive, severe and ultimately fatal radiation myelopathy, which we suggest was due to a synergistic interaction between the high-dose chemotherapy and the radiotherapy. The use of such chemotherapy regimens in Ewing's tumours should be carefully considered, particularly when radiotherapy encompassing the spinal cord is an essential component of management.

The role of functional and molecular imaging in cancer drug discovery and development

Studies of pharmacokinetics (which is what the body does to the drug) and pharmacodynamics (which is what the drug does to the body) are essential components of the modern process of cancer drug discovery and development. Defining the precise relationship between pharmacokinetics and pharmacodynamics is critical. It is especially important to establish a well understood pharmacological "audit trail" that links together all of the essential parameters of drug action, from the molecular target to the clinical effects. The pharmacological audit trail allows us to answer two absolutely crucial questions: (1) how much gets there; and (2) what does it do? During the pre-clinical drug discovery phase, it is essential that pharmacokinetic/pharmacodynamic (PK/PD) properties are optimized, so that the best candidate can be selected for clinical development. As part of contemporary mechanistic, hypothesis-testing clinical trials, construction of the pharmacological PK/PD audit trail facilitates rational decision-making. However, PK/PD endpoints frequently require invasive sampling of body fluids and tissues. Non-invasive molecular measurements, e.g. using MRI or spectroscopy, or positron emission tomography, are therefore very attractive. This review highlights the need for PK/PD endpoints in modern drug design and development, illustrates the value of PK/PD endpoints, and emphasises the importance of non-invasive molecular imaging in drug development. Examples cited include the use of PK/PD endpoints in the development of molecular therapeutic drugs such as the Hsp90 molecular chaperone inhibitor 17AAG, as well as the development of SR-4554 as a non-invasive probe for the detection of tumour hypoxia.

Measurement of tumor oxygenation: in vivo comparison of a luminescence fiber-optic sensor and a polarographic electrode in the p22 tumor

Hypoxia is important in tumor biology and therapy. This study compared the novel luminescence fiber-optic OxyLite sensor with the Eppendorf polarographic electrode in measuring tumor oxygenation. Using the relatively well-oxygenated P22 tumor, oxygen measurements were made with both instruments in the same individual tumors. In 24 air-breathing animals, pooled electrode pO(2) readings lay in a range over twice that of sensor pO(2(5min)) values (-3.2 to 80 mm Hg and -0.1 to 34.8 mm Hg, respectively). However, there was no significant difference between the means +/- 2 SE of the median pO(2) values recorded by each instrument (11.0 +/- 3.3 and 8.1 +/- 1.9 mm Hg, for the electrode and sensor respectively, P = 0.07). In a group of 12 animals treated with carbon monoxide inhalation to induce tumor hypoxia, there was a small but significant difference between the means +/- 2 SE of the median pO(2) values reported by the electrode and sensor (1.7 +/- 0.9 and 2.9 +/- 0.7 mm Hg, respectively, P = 0.009). A variable degree of disparity was seen on comparison of pairs of median pO(2) values from individual tumors in both air-breathing and carbon monoxide-breathing animals. Despite the differences between the sets of readings made with each instrument from individual tumors, we have shown that the two instruments provide comparable assessments of tumor oxygenation in groups of tumors, over the range of median pO(2) values of 0.6 to 28.1 mm Hg.