The role of Ifosfamide-doxorubicin chemotherapy in histology-specific, high grade, locally advanced soft tissue sarcoma, a 14-year experience

PURPOSE

To compare long-term outcomes of high-grade, primary soft-tissue-sarcoma (STS), using Ifosfamide-Doxorubicin vs local therapy alone, in histology-specific sarcomas.

METHODS

Retrospective analysis was performed on 127 patients from 2005 to 2018, with high-grade STS of extremity or trunk, >5 cm, that were either Synovial-Cell, Dedifferentiated-Liposarcoma (DDL), Myxofibrosarcoma, Round-Cell-Liposarcoma (RCLS), Undifferentiated-Pleomorphic-Sarcoma (UPS), or Undifferentiated-Sarcoma-not-otherwise-specified (US-NOS), with central pathology review. Ifosfamide-Doxorubicin was generally given neoadjuvant over 5 cycles, followed by radiation and wide excision, with chemotherapy given in 38 patients, while 89 received local therapy alone. Multi-variable-analysis (MVA) of prognostic factors was performed, and local-recurrence-free-survival (LRFS), distant-metastases-free-survival (DMFS), disease-specific-survival (DSS), and overall-survival (OS) were estimated using Kaplan-Meier, and adjusted using propensity-score matching.

RESULTS

Median follow-up was 4.5 years. Younger age (p < 0.0001) and Synovial histology (p = 0.0002) were more likely to undergo chemotherapy. Ifosfamide-Doxorubicin improved 5-year DMFS (p = 0.02), DSS (p = 0.01), and OS (p = 0.01), by univariate comparisons, as well as sub-analysis of non-synovial histology, but significance was lost after propensity-score matching for DMFS (p = 0.10), DSS (p = 0.09), and OS (p = 0.07). Size >10 cm, trunk location, and lack of chemotherapy significantly lowered DMFS, DSS, and OS on MVA, while DDL had more favorable survival; although size, trunk location, and DDL histology were not significantly different between treatment groups. Ifosfamide-Doxorubicin independently improved DMFS (p = 0.001), DSS (p = 0.01), and OS (p = 0.001) on MVA.

CONCLUSION

Ifosfamide-Doxorubicin may be more beneficial in younger patients with >5 cm, high-grade, STS of the trunk or extremity in Synovial-Cell, DDL, Myxofibrosarcoma, RCLS, UPS, and US-NOS.

Ten-year treatment complication outcomes of radical prostatectomy vs external beam radiation vs brachytherapy for 1503 patients with intermediate risk prostate cancer

PURPOSE

To compare 10-year late complications of radical prostatectomy (RP) versus external-beam-radiation-therapy (EBRT) versus brachytherapy (BT).

METHODS

Retrospective analysis was performed on 1503 intermediate-risk-prostate-cancer patients treated from 2004 to 2007, using univariate comparisons. Eight hundred and nineteen underwent RP, 574 EBRT, and 110 BT. RP urinary and rectal complications were graded severe if patients required ≥3 pads/diapers per day, chronic condom catheter or penile clamp, daily clean-intermittent-catheterization, sling, artificial-urinary-sphincter, or rectal fistula. Complications for EBRT/BT were severe if graded 3/4 on the Radiation-Therapy-Oncology-Group scale for late effects. The prevalence of erectile-dysfunction-devices (EDD) of injections, pumps and/or penile implants were compared.

RESULTS

Median follow-up for RP versus EBRT versus BT were 10.0, 9.6, and 9.8 years. Median age were 62.1, 70.8, 65.3, p < 0.0001. The 10-year prevalence of severe urinary complications for RP versus EBRT versus BT were 10.1%, 12.5%, 4.6%, p = 0.03, and were less for RP <64 years, p = 0.03, and lower Charlson score, p = 0.05. Pretreatment American-Urological-Association (AUA) score existed for 7.3%, 11.5%, 97.3% of RP versus EBRT versus BT, p < 0.0001, and the 10-year prevalence of EDD were 24.3%, 6.6%, 8.2%, respectively, p< 0.0001. Severe rectal complications were slightly higher for EBRT, p = 0.06.

CONCLUSIONS

BT had lower prevalence of severe urinary complications, possibly by using AUA score to avoid patients with obstructive uropathy. Urinary complications may be reduced by limiting RP to younger, healthier patients, and by avoiding EBRT/BT with obstructive symptoms. RP had higher prevalence of EDD, despite having younger, healthier patients.

The role of ifosfamide-doxorubicin chemotherapy in the treatment histology-specific, high grade, locally advanced soft tissue sarcoma: A 14-year experience

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Background: To compare long-term outcomes of high grade, locally advanced, primary soft tissue sarcoma (STS), using Ifosfamide-Doxorubicin vs local therapy alone, in histology-specific sarcomas. Methods: Retrospective analysis was performed on 127 patients from 2005 to 2018, who had STS of extremity or trunk, > 5cm, that were either Synovial Cell, Dedifferentiated Liposarcoma (DDL), Myxofibrosarcoma, Round Cell Liposarcoma (RCLS), Undifferentiated Pleomorphic Sarcoma (UPS), or Undifferentiated Sarcoma not otherwise specified (NOS), with central pathology review. Ifosfamide-doxorubicin was generally given neoadjuvant, followed by radiation and wide excision, with chemotherapy given in 38 patients, while 89 received local therapy alone. Multi-variable analysis of prognostic factors was performed, and local-recurrence-free-survival (LRFS), distant-metastases-free-survival (DMFS), disease-specific-survival (DSS), and overall-survival(OS) were estimated using Kaplan-Meier. Results: Median follow-up was 4.5 years. Younger age (p < 0.0001) and Synovial histology (p = 0.0002) had significantly higher rates of receiving chemotherapy. Size > 10cm and trunk location were poor prognostic features on multivariable analysis (MVA) affecting DMFS, DSS, and OS, while DDL histology had a more favorable effect; although size, trunk location, and DDL histology were not significantly different between treatment groups. Ifosfamide-Doxorubicin vs local therapy alone improved 5-year DMFS at 70.2% vs 49.5% ,p = 0.02, DSS 83.5% vs 57.9%, p = 0.009, and OS 80.6% vs 53.8%, p = 0.002. Sub-analysis of non-synovial histologies still showed a significant improvements in favor of chemotherapy in DMFS,(p = 0.04), DSS (p = 0.02), and OS (p = 0.003). Conclusions: Ifosfamide-Doxorubicin chemotherapy benefits younger patients with > 5cm, high grade, STS of the trunk or extremity, with histologies of Synovial Cell, DDL, Myxofibrosarcoma, RCLS, UPS, or Undifferentiated Sarcoma NOS.

Redefining the role of adjuvant versus salvage radiation therapy for prostate cancer after radical prostatectomy for T3 disease and/or positive margins

367

Background: SWOG 8794 recommends adjuvant radiation therapy (ART) after radical prostatectomy (RP) for T3 and/or positive margins. Our purpose was to assess 12-year outcomes on 862 RP patients who had either T3 and/or positive margins who underwent surveillance, salvage radiation therapy (SRT), or hormonal therapy (HT), while categorizing these patients into very low risk (VLR), low risk (LR), high risk (HR), and ultra high risk (UHR) groups. Methods: From 2004 - 2007, 862 RP patients had adverse factors of extracapsular penetration (T3a), seminal vesicle invasion (T3b), positive margins, and/or detectable post-operative PSA. Management included surveillance (54.8%), SRT (36.8%), and HT (8.5%) as first salvage therapy, and 21.5% eventually received hormonal therapy. Twenty patients underwent ART, and were excluded from this analysis. We assessed prognostic factors using multivariable analysis, and 12-year estimates of freedom from biochemical failure (FFBF), freedom from salvage therapy (FFST), distant metastases-free survival (DMFS), prostate cancer-specific survival (PCSS), and overall survival (OS). VLR were those with Gleason Score (GS) of 6. LR were GS 3+4 with only T3a or positive margins, but an undetectable postoperative PSA <0.1. HR were T3b with GS 7-10, any GS 7-10 with T3a/b and positive margins, but an undetectable PSA. UHR were those with a detectable PSA with a GS 7-10. Results: Median follow-up was 12.1 years. Median age was 61.6 years. Median time to first salvage treatment for VLR, LR, HR, and UHR were 10.8, 11.1, 5.3, and 0.6 years, p<0.001. 12-year estimates of FFBF for VLR, LR, HR, and UHR were 60.2%, 52.9%, 28.4%, and 0%, p<0.0001. For FFST, 70.9%, 68.6%, 40.5%, and 0%, p<0.0001. For DMFS, 99.1%, 97.8%, 88.6%, and 63.6%, p<0.0001. For PCSS, 99.4%, 99.5%, 93.5%, and 78.9%, p<0.0001. For OS, 91.8%, 91.8%, 81.0%, and 69.9%, p<0.0001. Conclusions: Outcomes of T3 and/or positive margins using surveillance or SRT as initial management yields excellent outcomes for VLR and LR groups, in which ART should be avoided. For HR, ART can be considered reasonable, since FFBF is only 28.4%. For VHR, these patients may benefit from combined hormonal therapy and ART.

Ten year treatment complication outcomes of radical prostatectomy versus external beam radiation therapy versus brachytherapy for 1,503 patients with intermediate risk prostate cancer

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Background: To compare 10 year treatment complication outcomes of radical prostatectomy(RP) vs external beam radiation therapy(EBRT) vs brachytherapy(BT) for patients with intermediate risk prostate cancer(IRPC). Methods: A retrospective analysis was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007, using univariate comparisons. 819 underwent RP, 574 underwent EBRT, and 110 underwent BT using iodine-125. Urinary and rectal complications for RP were graded as severe if patients required ≥ 3 pads/diapers per day, required chronic use of condom catheter or penile clamp, daily self-catheterization, placement of sling or artificial urinary sphincter, or developed rectal fistula/incontinence. Complications for EBRT and BT were graded as severe if they were classified as grade 3 or 4 on the Radiation Therapy Oncology Group grading system for late effects. For erectile dysfunction, the prevalence of patients requiring injections, pumps or penile implants were calculated after a minimum of 1 year of follow up. Results: Median follow up was 10.0 years for RP, 9.6 for EBRT, and 9.8 for BT. Neoadjuvant androgen deprivation therapy was given in 0.6% for RP patients vs 58.9% of EBRT vs 12.7% of BT, p < 0.0001. Median age for RP vs EBRT vs BT was 62.1, 70.8, 65.3, p < 0.0001. The 10-year prevalence of severe urinary complications for RP vs EBRT vs BT was 10.1%, 12.5%, 4.6%, p = 0.04. The percentage of patients having a pre-treatment American Urological Association(AUA) urinary score for RP vs EBRT vs BT was 7.3%, 11.5%, 97.3%, p < 0.0001. The 10-year prevalence of severe rectal complications for RP vs EBRT vs BT was 0.5%, 1.6%, 0.0%, p = 0.06. The 10-year prevalence of erectile dysfunction devices for RP vs EBRT vs BT was 24.3%, 6.6%, 8.2%, p < 0.0001. Conclusions: After 10 years of follow-up, BT had the lowest rate of severe urinary complications, which may due to using the AUA score to avoid implanting those who had significant baseline obstructive voiding symptoms. EBRT had a higher rate of severe rectal complications. RP had the highest probability of undergoing treatment using erectile dysfunction devices, despite having younger patients.

Ten year treatment complication outcomes of radical prostatectomy versus external beam radiation therapy versus brachytherapy for 1,503 patients with intermediate risk prostate cancer

67

Background: To compare 10 year treatment complication outcomes of radical prostatectomy(RP) vs external beam radiation therapy(EBRT) vs brachytherapy(BT) for patients with intermediate risk prostate cancer(IRPC). Methods: A retrospective analysis was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007, using univariate comparisons. 819 underwent RP, 574 underwent EBRT, and 110 underwent BT using iodine-125. Urinary and rectal complications for RP were graded as severe if patients required ≥ 3 pads/diapers per day, required chronic use of condom catheter or penile clamp, daily self-catheterization, placement of sling or artificial urinary sphincter, or developed rectal fistula/incontinence. Complications for EBRT and BT were graded as severe if they were classified as grade 3 or 4 on the Radiation Therapy Oncology Group grading system for late effects. For erectile dysfunction, the prevalence of patients requiring injections, pumps or penile implants were calculated after a minimum of 1 year of follow up. Results: Median follow up was 10.0 years for RP, 9.6 for EBRT, and 9.8 for BT. Neoadjuvant androgen deprivation therapy was given in 0.6% for RP patients vs 58.9% of EBRT vs 12.7% of BT, p < 0.0001. Median age for RP vs EBRT vs BT was 62.1, 70.8, 65.3, p < 0.0001. The 10-year prevalence of severe urinary complications for RP vs EBRT vs BT was 10.1%, 12.5%, 4.6%, p = 0.04. The percentage of patients having a pre-treatment American Urological Association(AUA) urinary score for RP vs EBRT vs BT was 7.3%, 11.5%, 97.3%, p < 0.0001. The 10-year prevalence of severe rectal complications for RP vs EBRT vs BT was 0.5%, 1.6%, 0.0%, p = 0.06. The 10-year prevalence of erectile dysfunction devices for RP vs EBRT vs BT was 24.3%, 6.6%, 8.2%, p < 0.0001. Conclusions: After 10 years of follow-up, BT had the lowest rate of severe urinary complications, which may due to using the AUA score to avoid implanting those who had significant baseline obstructive voiding symptoms. EBRT had a higher rate of severe rectal complications. RP had the highest probability of undergoing treatment using erectile dysfunction devices, despite having younger patients.

Ten year treatment outcomes of radical prostatectomy vs external beam radiation therapy vs. brachytherapy for 1,503 patients with intermediate risk prostate cancer

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Background: To compare 10-year treatment outcomes of RP (radical prostatectomy) vs EBRT (external beam radiation therapy) vs BT (brachytherapy) for patients with IRPC (intermediate risk prostate cancer). Methods: A retrospective analysis using propensity score matching was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007. 819 underwent RP, 574 underwent EBRT to a median dose of 75.3 Gray, and 110 underwent BT using iodine-125. Biochemical failure was defined by the AUA (American Urological Association) definition of PSA (prostate specific antigen) failure for RP patients, and the ASTRO-Phoenix definition (American Society of Therapeutic Radiology and Oncology) for the EBRT and BT patients. Results: Median follow up was 10 years for RP, 9.6 for EBRT, and 9.8 for BT (range 1-13.4 years). With RP 76.3% had Gleason score 7 vs 72.8% for EBRT vs 57.3% for BT, p = 0.0001. Median initial PSA was 7.4 for RP, 9.4 for EBRT, and 8.3 for BT, p < 0.0001. Neoadjuvant androgen deprivation therapy was given in 58.9% of EBRT patients vs 12.7% of BT vs 0.6% for RP, p < 0.0001. Only 14% of BT received supplemental external radiation. The 10-year FFBF (freedom from biochemical failure) was 82.0% for BT vs 58.0% for RP vs 58.8% for EBRT, p < 0.0001. Subset analysis of unfavorable IRPC patients showed a 10 year FFBF of 81.6% for BT vs 55.8% for RP vs 51.0% for EBRT, p < 0.0001. The 10-year freedom from salvage therapy was 89.5% for BT vs 64.0% for RP vs 73.4% for EBRT, p < 0.0001. There were no significant differences in distant metastases-free survival, prostate cancer-specific survival, or overall survival after adjusting for age. Multivariate analysis between pairwise groups with BT balanced by stabilized inverse probability of treatment weights showed that BT remained an independent predictor for improved FFBF, p = 0.049 for BT vs EBRT, and p < 0.0001 for BT vs RP. Conclusions: Brachytherapy using iodine-125 is a reasonable treatment option for IRPC patients. Although BT showed improved FFBF after propensity score matching, this did not impact overall survival.

Treatment results of brachytherapy vs. external beam radiation therapy for intermediate-risk prostate cancer with 10-year followup

PURPOSE

To compare 10-year treatment outcomes of brachytherapy vs. external beam radiation therapy for patients with intermediate-risk prostate cancer (IRPC).

METHODS AND MATERIALS

Between 2004 and 2007, 93 IRPC patients underwent brachytherapy using iodine-125 to a dose of 145 Gy without supplemental external radiation. A retrospective comparison was performed to a contemporary cohort of 597 patients treated with external beam radiation therapy to a median dose of 75.3 Gy using a propensity score-matched analysis.

RESULTS

Median followup was 7.8 years. With brachytherapy, 51.6% had Gleason score 7 vs. 72.0% for external radiation (p < 0.001). Median initial prostate-specific antigen was 8.3 for brachytherapy vs. 9.4 for external radiation (p = 0.01). Neoadjuvant androgen deprivation therapy was given in 59.5% of external radiation vs. 10.8% of brachytherapy patients (p < 0.001). The 10-year freedom from biochemical failure (FFBF) for brachytherapy was 81.7% vs. 54.5% for external radiation (p = 0.002). Unfavorable intermediate-risk patients experienced borderline significant improved FFBF with brachytherapy (p = 0.08). The 10-year freedom from salvage therapy for brachytherapy was 93.2% vs. 72.2% for external radiation (p = 0.006). There were no significant differences in distant metastases-free survival, prostate cancer-specific survival, or overall survival after adjusting for age. Multivariate analysis with propensity score matching showed that brachytherapy remained an independent predictor for improved FFBF (p = 0.007). Grade 1 and 2 late rectal complication rate was 6.5% for brachytherapy vs. 15.2% for external radiation (p = 0.02).

CONCLUSIONS

Brachytherapy using iodine-125 without supplemental external radiation is a reasonable treatment option for selected IRPC patients.

Treatment results of unresected or partially resected desmoid tumors

The authors compare the progression-free survival of patients with unresected or partially resected desmoid tumors treated with radiotherapy with those not given radiotherapy. A retrospective analysis and pathologic review was performed on 14 patients treated at the University of California Los Angeles School of Medicine from 1965 through 1992. Median follow-up was 6 years. The 6-year progression-free survival for irradiated patients was 100%, compared with 50% for those not irradiated (p = 0.04). Of the seven patients irradiated, only two had a complete response and one had a partial response. There was no difference in disease-specific survival between patients irradiated and those not irradiated, because only 1 of 14 patients died of desmoid tumor progression, which caused airway obstruction. This data suggest that radiotherapy may improve the progression-free survival of patients with unresected or partially resected desmoid tumor; however, the number of patients in this series is small. Most patients did not have a complete response to radiotherapy. For patients with tumor adjacent to the airway in the neck or upper thorax, the authors recommend radiotherapy because of the potential for mortality. Otherwise, because tumor progression rarely causes death, one must consider whether the morbidity of treatment would outweigh the morbidity of disease progression.

Gangliogliomas: experience with 34 patients and review of the literature

Ganglioglioma is an uncommon central nervous system tumor. The role of adjuvant postoperative radiation therapy is undefined. The authors retrospectively reviewed the clinicopathologic features and results of therapy for 34 patients with ganglioglioma treated at the University of California at Los Angeles. There were 18 women and 16 men. Median age was 18 years. Twenty-five tumors were low grade. Twenty-one patients underwent gross total resection. Three patients received adjuvant radiotherapy. The 4-year actuarial progression free and overall survival rates were 67% and 75%, respectively. The median time to progression was 14 months and all relapses were local. Factors significantly influencing progression-free or overall survival according to univariate analysis included degree of resection and tumor grade. Survival and relapse were not significantly influenced by any factor according to multivariate analysis. The progression-free survivals after gross total resection of low- and high-grade tumors were 78% and 75%, respectively. Respective rates after subtotal resection were 63% and 25%. Review of the literature demonstrates no role for radiotherapy after total resection of ganglioglioma or after partial removal of low-grade tumor. Radiation therapy appears to reduce the relapse rate after partial removal of high-grade lesions. A dose in excess of 5,000 cGy is necessary for ganglioglioma.

Cerebral gangliogliomas: preoperative grading using FDG-PET and 201Tl-SPECT

PURPOSE

To date there have been only scattered case reports comparing the nuclear medicine characteristics of gangliogliomas with their histologic grade. We sought to determine the relative usefulness of nuclear medicine scanning, CT, and MR imaging in predicting the histologic grade of these tumors.

METHODS

Eleven cases of pathologically proved ganglioglioma were analyzed retrospectively. Preoperative positron emission tomography with 18-fluorodeoxyglucose (FDG-PET), thallium chloride Tl 201 single-photon emission computed tomography (201Tl-SPECT), CT, and MR imaging studies were reviewed and compared with histologic tumor grade. FDG-PET scans were inspected visually for tumor metabolic activity relative to activity of normal gray and white matter. 201Tl-SPECT scans were analyzed for tumor activity using regions of interest and activity ratios. CT and MR studies were reviewed for the presence of conventional radiologic features of malignancy (ie, enhancement and edema).

RESULTS

Eleven patients had a total of 15 nuclear scans. Eight of nine gangliogliomas scanned with FDG-PET showed tumor hypometabolism, the ninth was normal. All nine were low-grade gangliogliomas. Increased 201Tl-SPECT activity was seen in two high-grade gangliogliomas. The third 201Tl-SPECT scan, of a low-grade ganglioglioma, was normal. CT and MR studies showed enhancement in four gangliogliomas, of which two were high grade and two low grade. Edema was seen only in conjunction with the two high-grade gangliogliomas.

CONCLUSION

FDG-PET and 201Tl-SPECT are 100% correlative in preoperative prediction of histologic grade of ganglioglioma. Tumors with decreased or normal PET or SPECT activity were low grade; tumors with increased SPECT activity were high grade. These results may be more reliable than CT and MR imaging findings in assessing tumor grade, and they may be of value for surgical planning and determining patient prognosis.

The role of adjuvant radiotherapy in the treatment of resectable desmoid tumors

PURPOSE

Desmoid tumors have a high propensity for local recurrence with surgical resection. There are many reports describing good responses of desmoid tumors to irradiation, but none have clearly established the indications for adjuvant radiotherapy in treating resectable desmoid tumors.

METHODS AND MATERIALS

A retrospective analysis was performed on 61 patients with resectable desmoid tumor(s) who were treated at our institution from 1965 to February of 1992. Five patients had multifocal disease and are analyzed separately. Fifty-six patients had unifocal disease, of which 34 had positive surgical margins. Forty-five of the 56 patients with unifocal disease were treated with surgery alone, while 11 were treated with surgery plus adjuvant radiotherapy. Median follow-up was 6 years. Local control was measured from the last day of treatment, and all cases were reviewed by our Department of Pathology.

RESULTS

Multivariate analysis of the 56 patients with unifocal disease revealed that positive margins independently predicted for local recurrence (p < or = 0.01). Only 3 of 22 patients with clear margins experienced a local recurrence, with a 6-year actuarial local control of 85%. Multivariate analysis of the 34 patients with positive margins revealed that adjuvant radiotherapy independently predicted for improved local control (p = 0.01), and patients with recurrent disease had a slightly higher risk of local recurrence (p = 0.08). The 6-year actuarial local control determined by Kaplan-Meier for patients with unifocal disease and positive margins was 32% (+/-12%) with surgery alone, and 78% (+/-14%) with surgery plus adjuvant radiotherapy (p = 0.02). Subgroup analysis of the patients with positive margins and recurrent disease revealed that those treated with surgery alone had a 6-year actuarial local control of 0% vs. 80% for those treated with surgery plus radiotherapy (p < or = 0.01). Patients with positive margins and primary disease had a trend towards improved local control with adjuvant radiotherapy, but this was not statistically significant. None of the patients treated with radiotherapy developed serious complications or a secondary malignancy.

CONCLUSIONS

Margin status is the most important predictor of local recurrence for patients with resectable, unifocal desmoid tumor. Adjuvant radiotherapy is indicated in the treatment of patients with positive margins following wide excision of recurrent disease. The role of adjuvant radiotherapy in patients with positive margins following resection of primary disease is controversial, and should be based on a balanced discussion of the potential morbidity from radiotherapy compared to the potential morbidity of another local recurrence. Adjuvant radiotherapy is less likely to benefit those with clear margins due to the excellent results for these patients treated with surgery alone. The local control of desmoid tumor in the adjuvant setting is excellent with total doses ranging from 50-60 Gy, with acceptable morbidity. Field sizes should be generous to prevent marginal recurrences, and large volume MRIs of patients with extremity lesions should be used to identify those patients with multifocal disease.