Phase 2 single arm study of nivolumab and ipilimumab (Nivo/Ipi) in previously treated classical Kaposi Sarcoma (cKS)

BACKGROUND

Classical Kaposi Sarcoma (cKS) is a rare HHV8-associated sarcoma with limited treatment options. We evaluated the efficacy and safety of nivolumab in combination with ipilimumab (Nivo/Ipi) in patients with previously treated progressive cKS.

PATIENTS AND METHODS

cKS pts with progressive disease after > 1 lines of systemic therapy and measurable disease by PET/CT and/or physical examination received nivolumab 240mg every two weeks and ipilimumab 1mg/kg every six weeks until progression or toxicity for a maximum of 24 months. The primary endpoint was overall response rate (ORR); secondary endpoints included 6-months progression free survival rate (PFS) and safety. Immune correlates were explored using IHC, DNAseq (596/648 genes) and RNAseq (exome capture transcriptome) of tumor specimens and matched blood.

RESULTS

Eighteen male patients (median age 76.5) were enrolled between April 2018 and Dec 2020. At a median follow up of 24.4 months, ORR by RECIST v1.1 was 87%. Metabolic complete response as assessed by PET CT was observed in 8 of 13 (62%) evaluable patients. 6/13 achieved pathological CR post treatment. In two patients, palliative limb amputation was prevented. Median PFS was not reached. The 6mo and 12m PFS rate was 76.5% and 58.8%, respectively. Only four patients (22%) experienced grade 3-4 adverse events. The most frequent genomic alteration was biallelic copy number loss of FOX1A gene. The majority of tumors carried a low TMB, were microsatellite stable (MSS), MMR proficient, did not express PD-L1 and displayed only low lymphocytic infiltrates, rendering them immunologically "cold".

CONCLUSIONS

This prospectively designed phase II study of nivolumab and ipilimumab demonstrates promising activity of this combination in progressive cKS representing a new treatment option in this population.

Epithelioid hemangioendothelioma, an ultra-rare cancer: a consensus paper from the community of experts

Epithelioid hemangioendothelioma (EHE) is an ultra-rare, translocated, vascular sarcoma. EHE clinical behavior is variable, ranging from that of a low-grade malignancy to that of a high-grade sarcoma and it is marked by a high propensity for systemic involvement. No active systemic agents are currently approved specifically for EHE, which is typically refractory to the antitumor drugs used in sarcomas. The degree of uncertainty in selecting the most appropriate therapy for EHE patients and the lack of guidelines on the clinical management of the disease make the adoption of new treatments inconsistent across the world, resulting in suboptimal outcomes for many EHE patients. To address the shortcoming, a global consensus meeting was organized in December 2020 under the umbrella of the European Society for Medical Oncology (ESMO) involving >80 experts from several disciplines from Europe, North America and Asia, together with a patient representative from the EHE Group, a global, disease-specific patient advocacy group, and Sarcoma Patient EuroNet (SPAEN). The meeting was aimed at defining, by consensus, evidence-based best practices for the optimal approach to primary and metastatic EHE. The consensus achieved during that meeting is the subject of the present publication.

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This consensus paper provides key recommendations on the management of epithelioid hemangioendothelioma (EHE).

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Recommendations followed a consensus meeting between experts and a representative of the EHE advocacy group and SPAEN.

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Authorship includes a multidisciplinary group of experts from different institutions from Europe, North America and Asia.

Interferon-Related Leukoencephalopathy in a Patient with Renal Cell Carcinoma

A 75-year-old patient with metastatic renal cell carcinoma was treated with recombinant interferon alpha-C and thereafter developed a neurologic syndrome of dementia, ataxia, confusional state, loss of concentration ability and cortical blindness. CT scan findings were compatible with leukoencephalopathy, which is reported as being a toxic effect of interferon.

Skin Metastasis of Ovarian Cancer: Report of Three Cases

Three cases of skin metastases in patients with ovarian cancer are reported. The late onset of skin metastases in the course of the disease represents an advanced stage accompanied by Intraperitoneal spread and has a poor prognosis. Diagnosis and differentiation from herpes zoster and other skin tumors were based on histologic examination. Palliation of symptoms and partial local response were achieved by electron beam irradiation.

Sphenoid and Cavernous Sinuses Involvement as First Site of Metastasis from a Fallopian Tube Carcinoma. Case Report

The occurrence of central nervous system metastases in ovarian cancer patients ranges from 0.88 to 4.5 %. Centra nervous system involvement in a fallopian tube carcinoma is extremely rare. A 77-year-old woman with an invasive tubal carcinoma was admitted because of ophthalmoplegia, sparing the lateral rectus muscle of the left eye, a decreased left corneal reflex and hypoesthesia along the distribution of the ophthalmic and maxillary branches of the left trigeminal nerve. CT scan showed a space occupying lesion in the left sphenoid sinus invading the left cavernous sinus and the submucosa of the left lateral wall of the nasopharynx, proven histologically to be a metastasis from her primary cancer. Attention should be paid to the possibility of distant and unusual metastases associated with tubal cancer in order to treat the patients promptly.

Kaposi's Sarcoma on a Lymphedematous Arm following Radical Mastectomy

Chronic lymphedema predisposes for local Immune incompetence, manifested by development of Stuart-Treves syndrome, Kaposi's sarcoma and fibroma-like lesions. A 91-year-old female with multiple cancers developed classic Kaposi's sarcoma on a chronically lymphedematous arm 26 years after radical mastectomy and irradiation of the involved axilla. The Kaposi lesion partially responded to electron beam irradiation.

Metastatic Disease of the Cavernous Sinus: Contribution of Computed Tomography and Magnetic Resonance Imaging to Diagnosis

The clinical presentation of metastatic disease to the cavernous sinus includes ophthalmoplegia, pain and sensory deficit along the optic or maxillary branches of the trigeminal nerve. The role of a CT scan and magnetic resonance imaging in the diagnosis is discussed. It was found that magnetic resonance imaging is superior to CT scan in demonstrating the cavernous sinus and pontine borders, especially in lymphomatous involvement of these structures.

Endobronchial Metastasis of Ovarian Cancer. A Case Report

An 83 years old woman with known ovarian carcinoma complained of dyspnea, dysphagia and hoarseness. Clinical and radiological investigations revealed a mediastinal metastasis involving and penetrating the right main bronchus. Palliation of dyspnea was achieved by laser therapy.

Pazolimus: pazopanib plus sirolimus following progression on pazopanib, a retrospective case series analysis

Background

To explore the activity of pazopanib (P) + sirolimus (S) in patients who progressed after previous clinical benefit on pazopanib.

Methods

Eight patients with progressing metastatic high grade soft tissue sarcoma (STS) whose disease advanced on P following a response duration of at least 4 months were offered re-challenge of P supplemented by off-label S and a single patient with progressing metastatic chondrosarcoma was offered the combination as compassionate treatment. Patients were treated in two centers: Hadassah Medical Center and Tel Aviv Medical Center. Patients received oral P 200–600 mg once a day supplemented by S 3–4 mg taken separately, 12 h after the P dose.

Results

Patients received treatment from December 2012 to February 2016. Four progressed on the combination and their treatment was terminated. Two patients were undergoing treatment when data was summarized. Best Response Evaluation Criteria in Solid Tumour (RECIST) responses were: one partial response (PR), four stable disease (SD), and four progressive disease (PD), corresponding to five PR and four PD on the Choi criteria. Median progression free survival was 5.5 months (range 4–17).

Conclusions

Our series showed that the combination of P + S has activity in STS patients selected by previous response to P and in a patient with chondrosarcoma, suggesting this can serve as a mechanism to reverse resistance to P and extend the chemotherapy-free window.

Hypofractionated adjuvant radiation therapy of soft-tissue sarcoma achieves excellent results in elderly patients

OBJECTIVE

Adjuvant radiation therapy (RT) is an essential part of combined limb-sparing treatment of soft-tissue sarcoma (STS). Elderly or medically unfit patients often have difficulty in completing 6-7 weeks of standard fractionated daily treatment. Our aim was to evaluate the efficacy of a hypofractionated adjuvant approach with RT for STS in elderly and debilitated patients.

METHODS

21 elderly patients were treated with a short course of adjuvant RT (39-48 Gy, 3 Gy per fraction) for STS. The medical records of the patients were retrospectively reviewed for local or distant recurrence and side effects of RT.

RESULTS

At a mean 26 months of follow-up, three local recurrences (14%) were detected. Eight patients (38%) had lung metastases during the observed period. Three of them died from metastatic disease. The hypofractionated radiation was well tolerated with minimum long-term side effects.

CONCLUSION

Hypofractionated adjuvant radiation appears to be an effective treatment in terms of local control in elderly and debilitated patients.

ADVANCES IN KNOWLEDGE

The results of this study might provide an alternative to commonly used standard fractionation of radiotherapy in sarcoma patients.

Tamoxifen for disease-negative but MCA-positive breast cancer patients

Increased levels of mucin-like carcinoma-associated antigen (MCA) in breast cancer patients with no evidence of disease following the treatment of the primary disease created a dilemma of 'to treat' or 'wait and see'. One might assume that early treatment of clinically undetectable disease on the basis of an elevated serum level of a sensitive and reliable tumor marker, may improve the treatment results, and even prolong the patient's survival. 'Wait and see' on acceptance of the notion that even early metastatic disease, still manifested only by uprising MCA levels, is incurable, and treatment should be kept in reserve for palliation of symptomatic disease. Sixty-one breast cancer patients with increasing MCA levels but without evidence of metastatic disease were randomized for tamoxifen 20 mg b.i.d. or to follow-up till relapse. The results for a median follow-up period of one year were encouraging. The non-treated patients experienced a significantly higher relapse rate (24.1%) than the tamoxifen-treated subjects (0%; p=0.012). The results for a median follow-up of 5 years were disappointing. The overall relapse rate was 22.2%. The relapse rate among the control patients was 25.8% while in the treatment arm it was 17.4% (p=0.46). The event-free survival and the pattern of relapse were similar in both arms. Tamoxifen may therefore be reserved for overt metastases, and not wasted on asymptomatic subclinical disease. It seems that there is no yield in terms of event-free survival for MCA measurements in breast cancer patients during the 5-year follow-up period.

Primary liposarcoma of the mediastinum

Patient. A 62-year-old man presented with effort dyspnea, non-productive cough and weakness of 4 month duration. He had no findings on physical examination.

Discussion. Chest X-ray revealed a large mass in the left anterior mediastinum. Computerized tomography of the chest showed a well-delineated homogeneous mediastinal mass with fat-equivalent density and a small pleural effusion. Fiberoptic bronchoscopy revealed narrowing of the left main bronchus, secondary to external compression. The bronchial mucosa was normal and brush cytology was negative. A CT-guided fine needle aspiration (FNA) of the mass yielded fragments of cells embedded in myxoid background material and closely packed atypical lipoblasts, compatible with liposarcoma. The patient underwent a left lateral thoracotomy and margibnal resection of the mass. The histopathological examination confirmed the diagnosis of mixed-type liposarcoma, consisted of myxoid and pleomorphic liposarcoma. Postoperative two-field radiation therapy was delivered to the mediastinum for a total midplane dose of 40 Gy. After a disease-free interval of 8 months the disease recurred in the mediastinum and pleura. Palliative chemotherapy achieved a short duration partial response but the patient succumbed to local recurrence 2 years after the diagnosis.

Periosteal Ewing's Sarcoma: Report of Two New Cases and Review of the Literature

Background. The origin of Ewing's sarcoma in a periosteal location is rare and not clearly documented. Other malignant bone tumors appear to have a somewhat better prognosis when confined between periosteum and bone. Is it the same for periosteal Ewing's sarcoma?Methods. We describe two new cases and comprehensively review the literature consisting of 18 documented cases since the condition was first described in 1986 (S.M. Bator.Cancer 58:1781- 4).Results. Periosteal Ewing's sarcoma differs from the other forms of Ewing's sarcoma in terms of sex predominance, location of tumor, surgical stage at presentation and typical imaging studies. Eighteen out of the 20 patients were reported to be alive with no evidence of disease.Conclusions. It seems that the prognosis of this rare variant of Ewing's sarcoma family of tumors might be better but the small number of cases precludes such a firm conclusion.

Do oncologists engage in bereavement practices? A survey of the Israeli Society of Clinical Oncology and Radiation Therapy (ISCORT)

e20588

Background: What happens to the patient-physician relationship after the patient succumbs to the illness? To begin answering this question, we determined the extent to which oncologists are involved in bereavement rituals for their patients. Methods: An e-mail survey was sent to ISCORT oncologists querying them as to their involvement in bereavement rituals including funerals, visitations (e.g., shiva), condolence phone calls, and condolence letters. Results were described using summary statistics, Wilcoxon, and Fisher's exact test. Results: The survey response rate was 69% (126/182). Median age of respondents was 49 y and the male:female ratio was 2:1. Generally, only 2% of oncologists attend funeral services and 1% visit the family. A higher number telephoned the surviving family members (27%) or sent written condolences (18%). When a ‘special bond‘ developed between doctor and patient, there was a significant increase in those who attended the funeral (8%), participated in a visitation (18%), or made phone calls (54%), p < .0001 for all three rituals. There was no higher likelihood to participate in bereavement practices as a function of subspecialty (Medical v. Radiation v. Surgical Oncologist), gender, religiosity, or personal death anxiety. The rank ordered reasons for not participating in bereavement activities are lack of time, fear of burnout, need to maintain boundaries, and death anxiety. Males, more often than females, indicated that time constraints were the most important factor in determining their participation (P = .025). There was a weakly significant association between the physician's spirituality and participation in specific bereavement rituals. Interestingly, 11% of oncologists indicated that they would participate in bereavement visits if compensated for their time. Conclusions: Most oncologists do not engage in bereavement rituals for their deceased patients. When they do, they are less likely to attend a funeral or visit the family, and more likely to send a condolence card or call.

No significant financial relationships to disclose.

Hypofractionated radiation therapy for palliation of sarcoma metastases

e21517

Background: RT is our preferred modality for local palliation of metastatic STS, regardless of systemic chemotherapy. While a protracted course of RT may be given as postoperative adjuvant treatment, a short and intense course of RT is usually needed for rapid palliation and local control of metastatic disease. Sarcomas are usually considered, at best, as moderately radio responsive tumors. RT doses within the range of 60 - 70 Gy are usually needed to be delivered in order to eradicate microscopic disease, while 50 Gy doses are needed for other malignancies such as breast or rectal cancer. Methods: Seventeen patients, 8 women and 9 men, at a median age of 61 years (range 53–95 years) had symptomatic metastatic sarcoma, and required rapid palliation. In total there were 20 sites of involvement by metastatic disease: trunk (chest wall, groin, axilla)- 13 cases, limb- 7 cases. The symptoms related to the metastases were either pain or discomfort in all the patients. In 15 cases the RT was the only modality for local palliation and in 5 cases RT was given following metastasectomy with close or involved margins. All the patients were treated by a short and intensive course of administration: 39 Gy were given in 13 fractions of 3 Gy/day, 5 times a week. Results: Median follow-up period was 25 weeks. The treatment was well tolerated. Acute side effects included first-degree burn (skin redness) and mild superficial pain in all the cases. No wound complications were noted among those undergoing surgery. Late side effects included skin pigmentation and induration of irradiated soft tissues. Durable pain control was achieved in 12 out 15 cases treated for gross metastases. Tumor progression was seen in the 3 other cases within a period of 2 to 9 months. Among 5 lesions which were irradiated as an adjunctive treatment following resection, no local recurrence was observed. Conclusions: The results of this series, although limited in size, point to the safety and feasibility of hypofractionated RT for palliation of musculoskeletal metastases from sarcoma.

No significant financial relationships to disclose.

Synovial sarcoma of the extremities and trunk: a long-lasting disease

Synovial sarcoma (SS) of an extremity or trunk is relatively rare and is approached by limb sparing surgery (LSS), radiation therapy (RT) and chemotherapy. We conducted a retrospective analysis of the clinical and histopathological data of 73 patients with proven SS. At a median follow-up time of 6 years, local recurrence was seen in 17.8 and systemic recurrence 35.6% of patients (local-only, 6.8; systemic-only, 24.6; combined, 11%). The 10-year local recurrence-free survival (LRFS), systemic recurrence-free survival (SRFS) and overall survival (OS) rates were 78, 68 and 61%, respectively. LRFS was significantly better in patients treated with isolated limb perfusion (ILP); SRFS was influenced by the delay until diagnosis. The practical aspects of our observations are the need for long-term follow-up in order to diagnose recurrences, the fact that not all local or distant recurrences are necessarily associated with a shortening of OS time and the important role of induction ILP with TNF in cases of extremity SS.

Female patients with soft tissue sarcoma are at a higher risk for developing breast cancer

10071

Background: An increased incidence of MPM has been reported in association with STS. In a series of 1350 adults with STS almost 10% were diagnosed with additional primaries. The incidence of breast cancer (BC) in the general population is 97/105,(Israel-Cancer-Registry) and the incidence of STS is 1.5/105 (Enzinger&Weiss). It is expected that approx. 1.5/105 × 97/105 of the general population will have both BC and STS. Methods: A retrospective search of the database of approx. 1,350 adult STS patients, who were referred, diagnosed, or treated at our center between 1995- 2005. Results: A group of 132 patients (F=62) with STS had at least one additional malignancy. Twenty-five (25/62=40%) had BC, before or after STS. A family history of malignancy was reported by 8/25 patients (32%), 3 with a specific breast cancer family history. STS types varied. Sixteen (16/25) patients had breast cancer as their first primary, 9 as their second or third. Of 17 patients with first primary BC, the sarcoma appeared in the RT field in 2, and in 1 it appeared in a lymphedematous ipsilateral arm. Of eight patients with first primary sarcoma, only one got chemotherapy prior to the diagnosis of BC. Median interval between 1st to 2nd malignancy was 6.9 years (0.7–31y) when the BC was diagnosed first, and 3.8y (0–47y) when the BC was the second. Exposure to carcinogens, or therapeutic radiation and cytotoxics, given for the 1st tumor prior to the 2nd tumor, was recorded in 58%. The incidence of BC among all patients (females + males) with STS-first (in our database) followed by a second malignancy is 8/58 (14%), or 7/23 (30%) female patients with STS-first, or 25/890 (3%) of all female patients with STS in the registry of STS. The incidence of STS among the BC patients is rather low, and most of the cases in this series are not therapy related (14/17). The median survival of patients with BC-first was 312 months, versus 383 months for STS-first (p=NS). Among patients with BC-first, the median survival of patients with RT related sarcoma was 265 months, versus 312 months for RT unrelated STS (p= 0.6). Conclusions: Second primary BC in patients with STS-first is higher than the expected incidence of BC for this population. Screening for BC should be incorporated into the regular follow-up of patients with STS.

No significant financial relationships to disclose.

Synovial sarcoma of the extremities and trunk: A long lasting disease

10073

Background: Synovial sarcoma (SS) of an extremity or trunk is a relatively rare type of soft tissue sarcoma. SS most commonly affects adolescents and young adults. SS usually originates at an extremity, carries a t(X;18)(p11;q11) translocation, and approached by limb sparing surgery, radiation therapy, and chemotherapy. Methods: A retrospective analysis of clinical and histopathological data of 73 patients with proven SS, treated at the National Unit of Orthopedic Oncology, from January 1991 through December 2004 was performed. Results: At a median follow-up time of 6 years, a local-recurrence was observed in 17.8% of the patients, while systemic recurrence in 35.6% (local-only in 6.8 %, systemic-only in 24.6 %, and combined in 11%). Accumulation of events of local and systemic recurrence following a limb sparing approach, did not reach a plateau even after 192 months from diagnosis. The 10-year local recurrence free survival (LRFS), the 10-year systemic recurrence-free survival (SRFS), and the 10-year overall survival (OS) were 78%, 68%, and 61%, respectively. The median SRFS time was 180 months, while the median LRFS and OS have not been reached yet. LRFS was significantly better for ILP treated patients; SRFS was influenced by a shorter delay in diagnosis. Conclusions: The practical aspects of our observations are the need for long-term follow-up for diagnosis of recurrence, the fact that not all local or distant recurrences are necessarily associated with shortening of overall survival, and the important role of induction ILP with TNF in cases of extremity SS.

No significant financial relationships to disclose.

Liposarcoma in adult limbs treated by limb-sparing surgery and adjuvant radiotherapy

Between December 1995 and March 2003, 38 adult patients with intermediate or high-grade liposarcoma in a limb were treated by limb-sparing surgery and post-operative radiotherapy. The ten-year local recurrence-free survival was 83%, the ten-year metastasis-free survival 61%, the ten-year disease-free survival 51% and the ten-year overall survival 67%. Analysis of failure and success showed no association with the age of the patients, gender, the location of the primary tumour, the type of liposarcoma and the quality of resection. Our results indicate that liposarcoma may recur even ten years after the end of definitive therapy and may spread to unexpected sites as for soft-tissue sarcoma.

Decreased prevalence of asymptomatic choroidal metastasis in disseminated breast and lung cancer: argument against screening

AIM

To determine the frequency of visually asymptomatic choroidal metastases in patients with disseminated breast and lung carcinomas in order to establish optimal patient management policies.

METHODS

All patients with confirmed metastatic disease treated in our institution between January 2002 and December 2003 were invited to undergo a funduscopic examination and a B-scan ultrasound evaluation.

RESULTS

Of the 169 study participants, 77 had breast cancer (64 with metastases in one organ and 13 with multiple-organ involvement) and 92 had lung cancer (85 with metastases in one organ and 7 with multiple-organ involvement). No patient with metastatic breast cancer and two patients with metastatic lung disease (each with multiple-organ involvement) were found to have choroidal metastases. The choroidal metastases were detected by both the funduscopic and ultrasound examinations.

CONCLUSIONS

The 2.17% incidence of choroidal metastasis in disseminated lung cancer and the 0% incidence in disseminated breast cancer speaks against the practicality of screening for early detection of choroidal metastasis among these patients, even though it would lead to early implementation of appropriate, often vision saving, therapeutic management. Its low incidence probably testifies to progress achieved by enhanced systemic oncological treatment policies that have been introduced into routine patient management over the past few years.

Multiple primary malignancies (MPM) in Israeli patients with soft tissue sarcomas (STS)

9571

Background: An increased incidence of MPM has been reported in association with STS. In a previous series we reported 28 patients out of 375 patients with STS as having second or third additional primary malignancies not all accountable by previous chemotherapy or radiotherapy. In the present series we re-examined the phenomenon in a large Israeli database of adult STS patients. Methods: A retrospective search of the database of approx.1350 adult STS patients who were referred, diagnosed or treated at our center between 1995–2005. Results: A group of 132 patients (F=66, M=66, age 1–87y, median 59y) with STS and at least one additional malignancy was retrieved. Overall, a family history of malignancy was reported by 26%, exposure to carcinogens prior to 1st tumor by 10%. Exposure to carcinogens/RT/Chemo given for the 1st tumor prior to the 2nd tumor was recorded in 61%. Taken together (n=132), STS were associated with a second malignancy arising mainly from the various sites of the urogenital system (18%), breast (17%), GIT (11%), lung (8%), and thyroid (7%). When non-STS was the first malignancy (n=73 at a median age 59y), the main malignancies included breast (23% ), colorectal (11%), melanoma (10%), prostate (8%), thyroid (7%), and bladder (5%). STS as a second primary (n=66) after a median time of 8y, included MFH (28%), LMS (16%), and liposarcoma (15%). The STS originated in a limb in 42%, trunk- 12%, retroperitoneum or viscera-34%, and unknown origin-1%. In the other 6 patients (median age 76.5), STS was the 3rd or more primary tumor. When STS was the first malignancy (n=59 at a median age of 59y), the second primary cancers were diagnosed after a median of 5 years, and included lung (15%), STS of different type (12%), kidney (10%), skin (10%), breast (10%), colorectal (8.5%), prostate (8.5%), and thyroid (7%). Updated survival data will be presented. Conclusions: The incidence of malignancies among patient population of primary STS is higher than the incidence of the same malignancies in the general population. This implies for the need to search for an occult second primary tumor in patients with STS as an integral part of their follow-up.

No significant financial relationships to disclose.

A single team experience of adjuvant radiation therapy in adults with intermediate or high-grade limb soft tissue sarcoma

19509

Background: Limb Soft tissue sarcomas (STS) are currently treated with limb sparing surgery (LSS) followed by radiation therapy (RT). This paper summarizes a one-team experience with homogenous population of adult patients, with intermediate or high grade STS confined to a limb, who were approached by LSS and postoperative RT. Methods: From October 1994 through October 2002, 133 adult patients (75 males, 58 females, age range 18–88 years, median 54) with biopsy-proven intermediate or high-grade limb STS were approached by LSS followed by RT. Their files were retrospectively reviewed for treatment outcome: local control, RT side effects, and time to progression. Tumor site was classified according to its proximal border. STS that involved the arm and the upper axilla was classified as axillary STS. Results: RT related toxicity was manageable, with a low rate of severe effects. At 4-year median follow up, there were 48 recurrences of any type, 23 of isolated local failure, and 35 of systemic spread w/o local failure. DFS and OS were influenced by disease stage II versus I, primary site in the upper limb versus lower limb, MPNST versus other types, induction therapy versus no induction, adequate resection Vs marginal resection or involved margins, and good response to induction therapy versus bad response. DFS and OS were Patient’s age and sex, tumor depth, acute or late toxicity of RT, or the interval of time between the date of definitive surgery and the start of RT did not affect DFS and or OS. Conclusions: The RT protocol is applicable in the era of complicated, expensive and time-consuming 3-D therapy. Our results of LSS + RT in adults with limb HG STS are satisfactory.

No significant financial relationships to disclose.

Induction of apoptosis in non-small lung carcinoma cell line (H1299) by combination of anti-asthma drugs with gemcitabine and cisplatin

Gemcitabine and cisplatin are commonly used in chemotherapy, however, these drugs may cause severe cytotoxic side effects. Theophylline and aminophylline are commonly used as anti-asthma drugs and can block anti-phosphodiesterase activity. We examined whether these methylxanthins could effect lung cancer cell survival and synergise with gemcitabine and cisplatin to induce apoptosis. We found that theophylline induced apoptosis in the cultured H1299 cell line already at concentrations of 30 microg/ml, reaching an ED50% at 100 microg/ml. In contrast, aminophylline induced apoptosis at concentrations of 300 microg/ml and 17% apoptosis was evident at concentrations as high as 900 microg/ml, which is a lethal dose for in vivo treatment. Cisplatin induced apoptosis with ED50% of 0.8 microg/ml, while gemcitabine induced apoptosis with ED50% of 20 ng/ml. Using a combination of 20 microg/ml of theophylline (calculated as an effective but not toxic anti-asthma drug) with 10 ng/ml gemcitabine or with 0.3 microg/ml cisplatin significantly elevated incidence of apoptosis compared to gemcitabine or cisplatin alone at similar concentrations. In contrast, an observed synergistic effect between aminophylline and gemcitabine was evident only at concentrations of 80 microg/ml and 10 ng/ml respectively. However, no effect was apparent in combination doses of aminophylline (80 microg/ml) with cisplatin (0.3 microg/ml). The combined treatments involved reduction in the intracellular level of the anti-apoptotic Bcl-2 gene product. This corresponded with the extent of apoptosis induced by the various drug combinations. Thus, theophylline is significantly more effective than aminophylline in increasing the sensitivity of the H1299 lung cancer cells to the induction of cell death by gemcitabine and cisplatin. Thus, combination of theophylline with these drugs may permit a reduction in the effective dose needed in chemotherapy treatment of lung cancer patients.

Closed argon-based cryoablation of bone tumours

We report our experience with a new technique for cryosurgical ablation of bone tumours which allows accurate determination of the temperature and freezing time within a cavity of any geometrical shape. Between 1997 and 2000, 58 patients diagnosed with 13 malignant and 45 aggressive benign bone tumours underwent argon-based cryoablation. This technique includes removal of the tumour by curettage and filling the cavity with a gel medium into which metal probes are inserted. Argon gas is delivered through the metal probes and both time and temperature are computer-controlled. After formal reconstruction, all patients were followed for more than two years. None had skin necrosis, infection, neurapraxia or thromboembolic complication. Fractures occurred in two patients (3.4%) and the tumour recurred in two patients (3.4%).

Targeting pulmonary metastases of renal cell carcinoma by inhalation of interleukin-2

INTRODUCTION

Pulmonary metastases of renal cell carcinoma (RCC) are associated with poor prognosis. Inhalation therapy with interleukin-2 (IL-2) is thus an appealing method for palliation. This multicenter study summarizes the national experience of IL-2 inhalation in patients with lung metastases of RCC.

PATIENTS AND METHODS

Forty patients (median, 66.5 years of age) with radiologically documented progressing pulmonary metastases were enrolled. All patients had to be able to comply with inhalation technique, and were not candidates for other treatment options. Twenty-eight patients were systemic treatment-naïve. The protocol included three daily inhalations of IL-2 to a total dose of 18 MU. Treatment had to be continued until one of the following occurred: progression; a complete response; a life threatening toxicity; or patient refusal. Response was assessed using the Response Evaluation Criteria in Solid Tumors (RECIST) system.

RESULTS

The disease-control rate reached 57.5%, with a partial response rate of 2.5% and a disease stabilization rate of 55%. Median time to progression was 8.7 months. The main side-effects were cough and weakness.

CONCLUSIONS

Inhalation of IL-2 for the treatment of pulmonary metastases in RCC is feasible, tolerable and beneficial in controlling progressive disease for considerable periods of time. The definition of response of biological therapy may need to be re-assessed and modified: stable disease should be regarded as a favorable response.

The use of surgery and yttrium 90 in the management of extensive and diffuse pigmented villonodular synovitis of large joints

OBJECTIVE

The surgical treatment of extensive diffuse pigmented villonodular synovitis (PVNS) of large joints alone is unsatisfactory, with high rates of local recurrence. Post-synovectomy adjuvant treatment with external beam radiation therapy or intra-articular injection of yttrium 90 (90Y) yielded better results. We report our experience with 10 cases treated with debulking surgery followed by intra-articular injection of 90Y.

PATIENTS AND METHODS

Between January 1989 and June 1998, 10 patients (eight males and two females aged 15-49 yr) with extensive diffuse PVNS were treated. In six patients the knee joint, in three patients the ankle joint, and in one patient the hip joint were involved. The 10 patients underwent 15 operations, one patient had three surgical procedures, and three patients underwent two surgeries (the intervals between re-operations for local recurrence were 2-4 yr). All patients had an intra-articular injection of 15-25 mCi (555-925 MBq) 90Y, 6-8 weeks after the last surgery.

RESULTS

Mean follow-up time was 6 yr (range 2.5-12 yr). All patients were followed using repeated computerized tomography (CT) scans, magnetic resonance imaging (MRI), plain X-ray films and bone scans semi-annually. In nine patients, neither evidence of disease nor progression of bone or articular destruction were noted. In one patient, stabilization of disease was achieved with no further evidence of bony or articular damage. No complications were noticed after surgery or after the intra-articular 90Y injection.

CONCLUSION

A combination of debulking surgery with intra-articular injection of 90Y for extensive diffuse PVNS of major joints is a reliable treatment method, with good results.