Operative start time may impact the quality of mesorectal excision in minimally invasive rectal surgery: retrospective analysis of 137 patients

INTRODUCTION

Timing of major elective operations is a potentially important outcome variable. This study examined the impact of operative start time (OST) on pathologic and short-term outcomes of minimally invasive rectal surgery (MIRS).

METHODS

All rectal tumors patients who underwent MIRS from May 2012 to April 2016 were identified. Peroperative outcomes and the oncological quality of surgical excision were compared between patients with OST before 13.00h and after.

RESULTS

A total of 137 patients were included in the study (71 Romarobot-assisted and 66 conventional laparoscopic). Ninety-nine (72%) patients were operated before 13.00h and 38 after 13.00h. The majority of cases were low/middle rectal tumors (69%). Patient's baseline characteristics were quite similar in both groups. The rate of severe complication (p=0.460) or reoperation (p=0.614) was the same. Pathologic criteria (T or N stage, number of harvested lymph nodes, and presence of any positive margin) were the same between groups except for the quality of mesorectal excision (ME) that was significantly poorer for cases beginning after 13.00h (complete 91% vs 74%; p=0.016). The OST was found to be the only parameter associated with a poor quality of ME [OR 2.55 (1.08 - 6.36)].

CONCLUSION

Perioperative outcome after MIRS does not appear to be influenced by OST. Poorer quality of ME was observed and may thus raise important questions about the timing and sequence of case scheduling.

Combined therapy in children and adolescents with classical Hodgkin's lymphoma: A report from the SFCE on MDH-03 national guidelines

Hodgkin's lymphoma (HL) in children and adolescents is highly curable, but children are at risk of long-term toxicity. The MDH-03 guidelines were established in order to decrease the burden of treatment in good-responder patients, and this report should be considered a step toward further optimization of treatment within large collaborative trials. We report the therapy and long-term outcomes of 417 children and adolescents treated according to the national guidelines, which were applied between 2003 and 2007 in France. The patients were stratified into three groups according to disease extension. Chemotherapy consisted of four cycles of VBVP (vinblastine, bleomycin, VP16, prednisone) in localized stages (G1/95 pts/23%), four cycles of COPP/ABV (cyclophosphamide, vincristine, procarbazine, prednisone, adriamycin, bleomycin, vinblastine) cycles in intermediate stages (G2/184 pts/44%) and three cycles of OPPA (vincristine, procarbazine, prednisone, adriamycin) plus three cycles of COPP in advanced stages (G3/138 pts/33%). Radiation therapy of the involved field was given to 97% of the patients, with the dose limited to 20 Gy in good responders (88%). With a median follow-up of 6.6 years, the 5-year event-free survival (EFS) and overall survival (OS) were 86.7% (83.1-89.7%) and 97% (94.5-98.1%), respectively. EFS and OS for G1, G2, and G3 were 98% and 100%, 81% and 97%, and 87% and 95%, respectively. Low-risk patients treated without alkylating agents and anthracycline had excellent outcomes and a low expected incidence of late effects. Intensification with a third OPPA cycle in high-risk group patients, including stage IV patients, allowed for very good outcomes, without increased toxicity.

Development of curative therapies for Ewing sarcomas by interdisciplinary cooperative groups in Europe

Curative therapies for Ewing sarcoma have been developed within cooperative groups. Consecutive clinical trials have systematically assessed the impact and timing of local therapy and the activity of cytotoxic drugs and their combinations. They have led to an increase of long-term disease-free survival to around 70% in patients with localized disease. Translational research in ES remains an area in which interdisciplinary and international cooperation is essential for future progress. This article reviews current state-of-the art therapy, with a focus on trials performed in Europe, and summarizes novel strategies to further advance both the cure rates and quality of survival.

Educational trajectories after childhood cancer: When illness experience matters

With the increase in survival from childhood cancer, research has increasingly focused on the educational and professional achievements of childhood cancer survivors. Yet, if large-scale studies provide an acute description of the current situation of childhood cancer survivors, little is known about their trajectories and the social processes shaping these trajectories. Using a qualitative methodology, drawing from a life course perspective, this study sought to describe the role of childhood cancer and its side effects in educational trajectories, as perceived by the participants. We investigated related processes of social adjustment to cancer, that is to say, choices or decisions that survivors related to the illness in the making of their career plans. Eighty long-term French childhood cancer survivors participating in the Euro2K longitudinal study were interviewed through in-depth, face-to-face interviews undertaken in 2011-2012. There were various types of impact described by respondents of the diagnosis of cancer on their trajectories. These varied according to gender. In women, childhood cancer tended to result in poor educational achievement, or in steering the individual towards a health care or child care occupation. This was justified by a desire to return the support that had been offered to them as patients. In men, however, childhood cancer led to a shift in career plans, because of physical sequelae, or because of concerns about their future health. Paradoxically, this limitation had a positive impact in their occupational achievement, as most of these men disregarded blue-collar jobs and chose more qualified white-collar occupations. Overall, findings suggest that childhood cancer influenced educational trajectories and, thus, socioeconomic status in adulthood, through mechanisms embedded in gender norms. These mechanisms could explain gender inequalities in educational achievement after childhood cancer reported in large-scale cohort studies.

Synovial sarcoma in children and adolescents: the European Pediatric Soft Tissue Sarcoma Study Group prospective trial (EpSSG NRSTS 2005)

BACKGROUND

To report the results of the first European prospective nonrandomized trial dedicated to pediatric synovial sarcoma.

PATIENTS AND METHODS

From August 2005 to August 2012, 138 patients <21 years old with nonmetastatic synovial sarcoma were registered in 9 different countries (and 60 centers). Patients were treated with a multimodal therapy including ifosfamide-doxorubicin chemotherapy and radiotherapy, according to a risk stratification based on surgical stage, tumor size and site, and nodal involvement.

RESULTS

With a median follow-up of 52.1 months (range 13.8-104.4 months), event-free survival (EFS) was 81.9% and 80.7%, and overall survival (OS) was 97.2% and 90.7%, at 3 and 5 years, respectively. The only significant prognostic variable at univariate analysis was the risk group: 3-year EFS was 91.7% for low-risk, 91.2% for intermediate-risk, and 74.4% for high-risk cases. In 24 low-risk patients (completely resected tumor ≤5 cm in size) treated with surgery alone, there were two local relapses and no metastatic recurrences. Among 67 high-risk patients (unresected, or axial tumor or nodal involvement), 66 underwent surgery after neoadjuvant chemotherapy. Response to chemotherapy was 55.2%, including 22.4% cases with complete or major partial remissions, and 32.8% with minor partial remissions.

CONCLUSION

This study demonstrates that collaborative prospective studies on rare pediatric sarcomas are feasible even on a European scale, with excellent treatment compliance. The overall results of treatment were satisfactory, with higher survival rates than those previously published by pediatric groups. Nonetheless, larger, international projects are needed, based on a cooperative effort of pediatric and adult oncologists.

CLINICAL TRIALS NUMBER

European Union Drug Regulating Authorities Clinical Trials No. 2005-001139-31.

Parameningeal rhabdomyosarcoma in pediatric age: results of a pooled analysis from North American and European cooperative groups

BACKGROUND

Parameningeal (PM) site is a well-known adverse prognostic factor in children with localized rhabdomyosarcoma (RMS). To identify risk factors associated with outcome at this site, we pooled data from 1105 patients treated in 10 studies conducted by European and North American cooperative groups between 1984 and 2004.

PATIENTS AND METHODS

Clinical factors including age, histology, size, invasiveness, nodal involvement, Intergroup Rhabdomyosarcoma Study (IRS) clinical group, site, risk factors for meningeal involvement (MI), study group, and application of radiotherapy (RT) were studied for their impact on event-free and overall survival (EFS and OS).

RESULTS

Ten-year EFS and OS were 62.6 and 66.1% for the whole group. Patients without initial RT showed worse survival (10-year OS 40.8% versus 68.5% for RT treated patients). Multivariate analysis focusing on 862 patients who received RT as part of their initial treatment revealed four unfavorable prognostic factors: age <3 or >10 years, signs of MI, unfavorable site, and tumor size. Utilizing these prognostic factors, patients could be classified into different risk groups with 10-year OS ranging between 51.1 and 80.9%.

CONCLUSIONS

While, in general, PM localization is regarded as an adverse prognostic factor, the current analysis differentiates those with good prognosis (36% patients with 0-1 risk factor: 10-year OS 80.9%) from high-risk PM patients (28% with 3-4 factors: 10-year OS 51.1%). Furthermore, this analysis reinforces the necessity for RT in PM RMS.

Guidelines for time-to-event end point definitions in sarcomas and gastrointestinal stromal tumors (GIST) trials: results of the DATECAN initiative (Definition for the Assessment of Time-to-event Endpoints in CANcer trials)†

BACKGROUND

The use of potential surrogate end points for overall survival, such as disease-free survival (DFS) or time-to-treatment failure (TTF) is increasingly common in randomized controlled trials (RCTs) in cancer. However, the definition of time-to-event (TTE) end points is rarely precise and lacks uniformity across trials. End point definition can impact trial results by affecting estimation of treatment effect and statistical power. The DATECAN initiative (Definition for the Assessment of Time-to-event End points in CANcer trials) aims to provide recommendations for definitions of TTE end points. We report guidelines for RCT in sarcomas and gastrointestinal stromal tumors (GIST).

METHODS

We first carried out a literature review to identify TTE end points (primary or secondary) reported in publications of RCT. An international multidisciplinary panel of experts proposed recommendations for the definitions of these end points. Recommendations were developed through a validated consensus method formalizing the degree of agreement among experts.

RESULTS

Recommended guidelines for the definition of TTE end points commonly used in RCT for sarcomas and GIST are provided for adjuvant and metastatic settings, including DFS, TTF, time to progression and others.

CONCLUSION

Use of standardized definitions should facilitate comparison of trials' results, and improve the quality of trial design and reporting. These guidelines could be of particular interest to research scientists involved in the design, conduct, reporting or assessment of RCT such as investigators, statisticians, reviewers, editors or regulatory authorities.

MicroRNA-206 expression levels correlate with clinical behaviour of rhabdomyosarcomas

Background:

Rhabdomyosarcomas (RMSs) are primarily paediatric sarcomas that resemble developing skeletal muscle. Our aim was to determine the effects of microRNAs (miRNA) that have been implicated in muscle development on the clinical behaviour of RMSs.

Methods:

Expression levels of miR-1, miR-206, miR-133a and miR-133b were quantified by RT–PCR in 163 primary paediatric RMSs, plus control tissues, and correlated with clinico-pathological features. Correlations with parallel gene expression profiling data for 84 samples were used to identify pathways associated with miR-206. Synthetic miR-206 was transfected into RMS cell lines and phenotypic responses assessed.

Results:

Muscle-specific miRNAs levels were lower in RMSs compared with skeletal muscle but generally higher than in other normal tissues. Low miR-206 expression correlated with poor overall survival and was an independent predictor of shorter survival in metastatic embryonal and alveolar cases without PAX3/7-FOXO1 fusion genes. Low miR-206 expression also significantly correlated with high SIOP stage and the presence of metastases at diagnosis. High miR-206 expression strongly correlated with genes linked to muscle differentiation and low expression was associated with genes linked to MAPkinase and NFKappaB pathway activation. Increasing miR-206 expression in cell lines inhibited cell growth and migration and induced apoptosis that was associated with myogenic differentiation in some, but not all, cell lines.

Conclusion:

miR-206 contributes to the clinical behaviour of RMSs and the pleiotropic effects of miR-206 supports therapeutic potential.

[Malignant primary cardiac tumors in childhood and adolescence]

Primary heart tumors are uncommon in children. The majority of them are benign, with only 10% malignant. Among malignant cardiac tumors, sarcoma (rhabdomyosarcoma, angiosarcoma, synovial sarcoma) and lymphoma (Burkitt's lymphoma, large B-cell lymphoma, lymphoblastic lymphoma) predominate. There are few published pediatric series on malignant primary cardiac tumors. We report here 3 observations of primary malignant cardiac tumors, 2 cases of sarcoma (angiosarcoma and synovial sarcoma) and 1 case of Burkitt's lymphoma. A precise pathological diagnosis is necessary for the proper management of these patients. For sarcoma, treatment associates surgery and chemotherapy. Surgery should be as complete as possible because of the lack of chemotherapy sensitivity of some sarcomas, mainly angiosarcoma and synovial sarcoma. Therefore, the prognosis of cardiac sarcoma remains poor. For primary cardiac lymphoma, management should not be different from lymphoma in other locations. Chemotherapy is the main treatment, and surgery has to be used only when complications occur. Prognosis depends on histology and not lymphoma location, and so is better than the prognosis for sarcoma.

[Soft tissue tumors in neonates]

Soft tissue tumors account for approximately 25% of neonatal tumors and are most often benign (more than 2/3 of cases). Vascular tumors are the most frequent benign tumors and infantile hemangioma accounts for 32% of these tumors, affecting 1 out of 200 children at birth. Kaposiform hemangioendothelioma (KH) is a rare vascular tumor with locally aggressive behavior. More than 50% of KH are associated with the Kasabach-Merritt phenomenon, a condition characterized by thrombocytopenia and consumptive coagulopathy. Malignant soft tissue tumors are, after neuroblastoma, the second cause of cancer in neonates. Infantile fibrosarcoma (IF) is a rare tumor that most often affects the extremities of children aged 4 years or younger. A recurrent t(12;15) (p13;q25) rearrangement fusing the ETV6 gene with the NTRK3 neurotrophin-3 receptor gene has been identified in IF. Complete conservative surgical resection is usually curative. Chemotherapy is indicated when initial surgical removal cannot be accomplished without unacceptable morbidity. Prognosis of IF is excellent, with reported overall survival rates ranging from 80 to 100%. Neonatal rhabdomyosarcoma (RMS) is a rare tumor (0.5-1% of RMS). The primary tumor predominantly involves the limbs and the genitourinary tract. Treatment is based on age-adapted chemotherapy and surgery. Prognosis of RMS in children less than 1 year old appears to be comparable with that of older children.

Ovarian function after high-dose chemotherapy in childhood: Risk factors for developing partial ovarian failure and how to identify them early

e20665

Background: During the last 30 years, polychemotherapies, surgery and radiotherapy have been established as standard therapies for treating pediatric cancers thus leading to a significant improvement in terms of 5-year-overall-survival which is now around 70% among children and adolescents. On the other hand, these treatments cause severe sequelae such as ovarian failure (OF) in young girls leading to a premature menopause and infertility. Methods: 29 patients treated at the Institute Gustave Roussy (Villejuif, France) have been investigated in an attempt to find biological and/or clinical markers, and imaging predictive of a partial ovarian insufficiency leading to an early menopause. Eligibility criteria: age >12 years at time of analysis; peripheral stem cell graft between 2–20 years; high dose chemotherapy. Results: 23/29 were eligible for this analysis (6 withdrawn due to oral contraception). 13/23 patients (56.5%) show no clinical evidence of ovarian treatment-related toxicity with a 13 years median time to transplant. 10/23 (43.5%) have complete ovarian insufficiency, among whom the majority have already received substitution hormone therapy (SHT). Out of 75% of pre-pubescent patients at transplant, only 2 have OF. All patients grafted at puberty (15.3 years) have high-dose chemotherapy-related immediate or definitive OF. Thiotepa >900mg/mq is castrating (odds ratio-10.1; p-0.04). Dosages of anti-müllerian hormone (AMH) collapses in patients with IO (p=0.002). Mensed patients have lower AMH dosages compared to normal population (p=2.10-e9) as for antral follicule count (>2mm). Conclusions: 1) 13/23 patients show no evidence of OF. 2) Main risk factors of OF: age ≥ 12 years; post pubertal status; thiotepa >900 mg/m2 (OR=10.1 and p=0.04). 3) Despite normal menses, many women who underwent high dose chemotherapy exhibit low AMH and Inhibine B levels and low count of follicles at a young age. These are possible markers of ovarian depletion. Cryopreservation of the ovarian cortex should be proposed to patients grafted due to a cancer independently of the age at which they have undergone high-dose chemotherapy.

No significant financial relationships to disclose.

A prognostic score at diagnosis for Ewing tumor patients with metastatic disease at extrapulmonary sites

10544

Background: To assess prognostic factors at diagnosis in prospectively treated patients with primary extra-pulmonary metastatic Ewing tumors (EPM-ET) of the EURO-E.W.I.N.G. 99 Study. Methods: From 1999 to 2005, 281 patients were enrolled. Median age was 16.2 years (0.4–49). Primary site was extremity in 84 patients and axial in 197 (115 pelvic sites), with a tumor volume >200ml in 171 patients. Treatment consisted of 6 VIDE cycles, one VAI/VAC cycle, local treatment (surgery and/or radiotherapy), and high-dose busulfan-melphalan followed by peripheral stem cell transplantation (HDT/SCT). Results: After a median follow up of 3.8 years, event-free survival (EFS) and overall survival (OS) at 3 years for all 281 patients were 27%±3% and 34%±4%. Six VIDE cycles were completed by 250 patients (89%); 169 (60%) received HDT/SCT. Cox regression analyses demonstrated increased risk for patients with more than two bone metastatic sites (hazard ratio: HR 2.0), a primary tumor volume >200ml (HR 1.8), bone marrow metastases (HR 1.6), age >14 years (HR 1.6), and additional lung metastases (HR 1.5). A risk score based on these HR identified three risk groups with EFS rates of 50% for scores <_3 (82 patients), 25% for scores >3 to <5 (102 patients), and 10% for scores >_5 (70 patients), p< 0.0001. Conclusions: A proportion of EPM-ET patients may survive with intensive multimodal therapy. Age, tumor volume, and extent of metastatic spread are relevant risk factors. A score based on these factors identifies EPMD-ET patients with a more favorable outlook at diagnosis and may facilitate risk adapted treatment approaches.

No significant financial relationships to disclose.

Extra-abdominal primary fibromatosis: Aggressive management could be avoided in a subgroup of patients

OBJECTIVE

To evaluate the impact of surgery as first-line treatment on event-free survival (EFS) of primary aggressive fibromatosis.

PATIENTS AND METHODS

Treatments were categorized into: surgery with or without radiotherapy and nonsurgical strategies with systemic treatment alone or wait and see policy. Eighty-nine patients had initial resection of their primary tumour followed by postoperative radiotherapy in 13 cases. Twenty-three did not undergo surgery but received systemic treatment or watch and wait policy.

RESULTS

Median follow-up was 76 months. Overall 3 years EFS was 49%. In the univariate analysis, patients with microscopically complete surgery had a similar outcome to patients in the no-surgery group (3 years EFS of 65% and 68%, respectively). Gender, age, tumour size, treatment period and strategy (surgery versus no-surgery) were not statistically significant. Quality of resection according to margins and the tumour site were the only prognostic factors. There was a significant correlation between tumour site and quality of surgery (p=0.0002).

CONCLUSIONS

A subset of patients with extra-abdominal fibromatosis could be managed with a nonaggressive policy, as growth arrest concerned 2/3 of nonoperated patients. When surgery is finally necessary, it should be performed with the aim of achieving negative margins.

Multivariate analysis based risk grouping of ewing tumours (ET) with extra-pulmonary metastatic disease (EPMD): Final results from the Euro Ewing 99 study

9562

Background: To identify an effective treatment for patients with EPMD. Methods: 192 patients (pts) were registered. Median age is 15.8 years (yrs) (0.4–49.29). Primary site was extremity in 57 pts and axial/other in 135 pts (40.6% in the pelvis). Tumour volume was ≥ 200 ml in 114pts. Metastatic spread was bone marrow (BM) only in 19 pts, bone only in 93 pts and bone and BM in 79 pts. Six VIDE induction cycles were completed by 168 pts (85%). Local treatment included surgery when possible and/or radiotherapy (Rx) as indicated. Recommended HDT was busulphan (BU) 600 mg/m2 and melphalan (MEL) 140 mg/m2 with PSCR. Median follow up is 4.2 years (range: 1.9–6.6). Results: Partial remission or better was achieved after cycle 6 in 75/116 pts subjected to HDT/SCR (65%). The overall survival at 3 years for all 192 pts is 29% (95% CI=0.04). Significantly favourable univariate factors in the unselected cohort at diagnosis (Dx) were age < 14 yrs (event free survival at 3 yrs (EFS) 37%, p=0.006), BM involvement only (EFS 47%, p=0.024), single bone lesions only (EFS 35%, p=0.009), extremities (EFS 34%, p=0.007) and tumour volume of <200 ml (EFS 47%, p<0.001). For pts receiving BuMel it is noteworthy that 37 pts of <14a and EPMD achieved an EFS of 47% in comparison to older counterparts >14a (EFS 22% (p=0.026). Multivariate analysis identified two major risk factors at Dx: primary tumour volume >200 ml p<0.001 (RR 2.25) and > 5 bone metastases p=0.064 (RR 2.11). In these risk groups the 3 yr EFS was 56% for 35 pts with <200 ml and <5 bone lesions, for 17pts with <200 ml > 5 bone lesions 29%, for 67 pts >200 ml or < 5 bone lesions 19% and extremely dismal for 47 pts with >200 ml and > 5 bone lesions with 7% (p<0.001). Conclusions: Groups with differing prognoses from EPMD have been identified from this prospectively followed cohort. Aggressive treatment with HDT appears effective only for sub groups of patients with EPMD and ET.

No significant financial relationships to disclose.

Long-term evaluation of ifosfamide-related nephrotoxicity in children: The French experience

9551

Background: Ifosfamide-induced nephrotoxicity is a significant issue in patients treated for tumours during childhood. This study aimed at documenting incidence of late renal toxicity of ifosfamide and its risk factors. Methods: 183 patients have been investigated. 100 were male. Median age at treatment was 9.3 years (0.4–18 years). Median dose of ifosfamide was 54 g/m2 (18–77 g/m2). No patients received cisplatin and/or carboplatinum. Diagnoses included rhabdomyosarcoma (77), other soft tissue sarcoma (39), Ewing (39), and osteosarcoma (28). Investigations were performed at a median interval of 10.3 years (5–20.7) after the end of the treatment, at a median age of 21.6 years (7.1–44.2). No patient had electrolyte or vitamine supplementation. Glomerular and tubular functions were graded according to the Skinner's system. Results: After 5 year minimal follow-up 55% had normal tubular and 79% had normal glomerular functions. Natraemia, kalaemia, serum HCO3 and calcaemia were normal in all patients. Hypomagnesaemia was observed in 4, hypophosphaetemia in 8 %. The tubular threshold for phosphate was reduced in 44% of the patients (grade 2 or 3 in 15%, grade 3 in 1 pt). Significant glycosuria (> 0.5 g/24h) was detected in 5 % of the patients but it was clearly abnormal only in 5 patients. 34% of the patients had beta2 microglobulinuria, however, proteinuria was observed in only 12%. Cumulative dose of ifosfamide, older age at treatment and follow-up since treatment were predictor for tubulopathy in univariate and multivariate analyse. The glomerular filtration rate was normal in 79% of the patients. 21% had a grade 1 toxicity and 1 patient a grade 2. Univariate analysis did not find any prognostic factor for glomerular toxicity apart from the association with tubular toxicity. Conclusions: Since ifosfamide-induced renal toxicity can be severe, long term evaluation is important and this risk should be balanced carefully against efficacy.

No significant financial relationships to disclose.

Prognostic factors in metastatic rhabdomyosarcoma (RMS): The results of a pooled analyze from U.S. and European cooperative groups

9542

Background: Prognosis factors on outcome for metastatic RMS are still matter of discussion. The analysis of a large cohort of patients can give arguments for development of risk-based therapy. Methods: We studied data from SIOP 84, SIOP 98, European Intergroup MMT89–91, Italian RMS4.99, IRS-III, -IV Pilot, -IV, -V, -D9501 to look at the influence of age, histology, sites of primary and metastatic disease, and number of sites of metastatic disease at the 3 year event-free survival. Results: 788 patients were included in the analyze and 776 in the multivariate analyse. The 3 year overall survival and EFS were 34% (se 1.7) and 27 % (se 1.6) respectively. By univariate analysis, 3-year EFS was significantly influenced by age 10 years or more (15% vs 36%), alveolar histology (28% vs 40%), location of primary tumor in unfavorable site -parameningeal, extremity and “other” sites- (31% vs 48%) the presence of three or more metastatic (17% vs 38%), the presence of bone or bone marrow involvement (24% vs 45%). By multivariate analysis, histology had no more impact on EFS. The EFS was strongly correlated to the number of the 4 other unfavorable prognostic factors: age, site of the primary, number of metastis sites, bone/bone marrow involvement relative risks were 1.6 for age (p<0.0001), 1.4 for site of primary tumor (p=0.002), 1.3 for bone/bone marrow involvement (p=0.005), 1.4 for number of metastatic sites (p=0.002). EFS was 58% for the 46 patients without any factors and was respectively 40%, 22%, 14% and 4% in patients with 1 factor (250 patients), 2 factors (233 patients), 3 factors (177 patients) or 4 factors (70 patients) (p<0.01). Conclusions: This analysis identified subsets of patients with very different outcomes. Patients with EFS less than 50% might be appropriate candidates for experimental approaches.

No significant financial relationships to disclose.

Extra-abdominal fibromatosis: Can aggressive management be avoided in a subgroup of patients?

10077

Background: The objective was to evaluate the impact of surgery as first-line treatment on event -free survival (EFS) of primary aggressive fibromatosis. Methods: Treatments were categorized into: surgery with or without radiotherapy and non surgical strategies with systemic treatment alone or wait and see policy. Event-free survival curves were estimated using the Kaplan-Meier method. Results: The sex ratio was 39 males/73 females. The median age at the time of the first diagnosis was 30 years. The median size of the primary was 60 mm. Eighty-nine patients (79.5%) had initial resection of their primary tumor followed by postoperative radiotherapy in 13 cases. Twenty-three patients (20.5%) did not undergo surgery but received systemic treatment or watch and wait policy. Median follow-up was 76 months. Three years EFS was 49%. In the univariate analysis, patients with microscopically complete surgery had a similar outcome to that of patients in the non-surgery group (65% vs 68% for 3-yr EFS respectively). Gender, age, tumor size, treatment period and strategy (surgery versus no surgery) were not statistically significant. Quality of resection according to margins and the tumor site were the only prognostic factors. There was a significant correlation between the tumor site and the quality of surgery (p= 0.0002). Tumor site was the only prognostic factor that remained in the multivariate analysis. Conclusions: Surgical removal as initial treatment was not found to influence the outcome. A subset of patients could be managed with a non aggressive policy. When surgery is finally necessary, it should be performed with the aim of achieving negative margins. Predictive biological factors influencing tumor evolution have to be defined

No significant financial relationships to disclose.

Overall and cause specific long term mortality following childhood cancer: The role of cancer treatment

9520

Background: A multi-centre French cohort study was performed to evaluate the role of treatment in the long-term overall and cause-specific mortality among childhood cancer survivors. Methods: This study cohort included 3,057 patients treated for a solid tumours before the age of 17 between 1942–1986, in 5 French centres and who survived at least 5 years from diagnosis. Detailed clinical and therapeutic data were extracted for each patients from medical records. For 2,081of the 2,178 patients who received radiotherapy, radiation doses were estimated at 188 anatomical sites, including heart (7 sites) and lungs (10 sites). 98% of patients were identified in French National Registry of Physical Persons (RNIPP) and we obtained the death causes of 95% of dead patients. Overall and cause-specific mortality standardized ratios (SMR), absolute excess risk (AER) of death were studied using Poisson regression. Results: 50% of patients were treated by chemotherapy (CT) plus radiotherapy (RT), 22% by CT alone and 21% by RT alone. During an average follow-up of 25 years, 465 patients dead. The overall SMR was 7.3 (95% CI: 6.7–8.0) and AER was 6 deaths per 1,000 person-years. SMR for death due to cancer other than the 1st cancer (SC) was 16.1 (95%, CI 13.5–18.9). SMRs were significantly elevated for non-cancer overall mortality, infectious and parasitic diseases, diseases of the circulatory, nervous and respiratory system, congenital anomalies, symptoms, signs and ill- defined conditions’ (SMRs of 2.6, 15.7, 6.4, 8.5, 4.6, 3.2, respectively). RT was associated an increase in the risk for overall and SC related deaths (RR = 2.0; 95% CI: 1.5–2.7; RR = 1.8; 95% CI: 1.1–2.9; respectively). CT was associated with an increased risk for overall, SC and non- cancer related deaths (RR = 1.6; 95% CI: 1.3–2.0; RR = 1.9; 95% CI: 1.2–3.0; RR = 1.8; 95% CI: 1.1–2.9 respectively). We were not able to find any evidence for an interaction between CT and RT, whatever the end point considered. Among the 26 circulatory deaths, 24 received RT, the mean radiation dose of the heart (P=0.0006) and treatment with spindle inhibitors (P=0.009) were significantly associated to death by cardiac disease. Conclusions: In the future, death due to cardiac pathologies could be an important issue for long term survivors of childhood cancer.

No significant financial relationships to disclose.

Treatment-adjusted predisposition to second malignant neoplasms after a solid cancer in childhood: A case-control study

21031

Background: Previous therapy, genetic susceptibility and the type of the first cancer are known to be associated with the risk of a second malignant neoplasm (SMN) among patients treated for a childhood cancer. The aim of this study was to investigate the independent role of the type of first malignant neoplasm in the onset of any SMN taking into account treatment and family cancer syndromes. Methods: A case-control study nested in a European cohort of 4,581 patients, treated for a solid cancer during childhood was conducted. 146 cases with a SMN and 417 controls were matched according to sex, age at first cancer, chemotherapy, radiotherapy, the local radiation dose received at the site of the SMN for the case and at the same site for the matched controls and follow- up. Results: A significantly increased risk of developing any SMN was observed after Hodgkin's lymphoma, retinoblastoma, soft tissue sarcoma orand a malignant bone tumor as the first malignant neoplasm (FMN), independently of initial treatment and family cancer syndromes. A significantly increased risk of developing a sarcoma was observed among patients who had developed a retinoblastoma, OR=5.9 (95%CI : 1.0–34) a malignant bone tumor, OR=11.9 (95%CI : 1.5–95), or a soft tissue sarcoma, OR=5.1 (95%CI : 1.4–19) compared to patients with a Wilm's tumor as the FMN. Conclusions: Survivors of Hodgkin's lymphoma, retinoblastoma, soft tissue sarcoma or a malignant bone tumor are at increased risk of any SMN independently of initial treatment and genetic susceptibility.

No significant financial relationships to disclose.

Ifosfamide versus cyclophosphamide: Long term gonadal effects in 166 male survivors of childhood cancer

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Background: Alkylating agents are associated with a risk of male gonadal damage, even in patients treated during childhood. The purpose of this work was to compare this risk after treatment by ifosfamide vs cyclophosphamide during childhood. Methods: Evaluation was based on basal FSH measurement known for its correlation with spermatogenesis. LH and testosterone were also measured in most of the patients. 159 males were evaluated after treatment of a soft tissue sarcoma (79), osteoasarcoma (39), ewing (10), lymphoma (28), other (3). 100 patients received ifosfamide as unique alkylating agent and the other 59 received cyclophosphamide as the other unique alkylating agent between 1973 and 2000. Median age at treatment was 11.2 years (0–18 yrs). Median interval after the end of the treatment was 10.7 years (4.1–20.2 yrs), median age at evaluation was 21.4 years (17.5–36.1 yrs). Median dose of ifosfamide was 54 g/m2 (18- 114), median dose of cyclo was 8.3 g/m2 (4.6–22). Age at treatment and at evaluation were similar in both groups. Results: All males but two (17.5 and 26.5 yrs) had normal testosterone levels. LH was elevated in 14% of the patients. FSH was above laboratory upper limit in 28 of the 59 males (47.5%) treated with cyclophosphamide and was within the normal range in 94 of 100 patients (94%) treated with ifosfamide. Eight patients treated with cyclophosphamide fathered children. The median dose of cyclo was 5.6 g/m2 (4.8 - 10.8 g/m2). Six patients who received 51 to 54 g/m2 fathered children. The risk of abnormal FSH increased with the cumulative dose of cyclophosphamide: only 2/16 boys (12%) who received more than 12 g/m2 had a normal dosage of FSH, while 29/43 (67%) of the boys who received lower doses of cyclo did so. Conclusions: These results show a low risk of gonadal dysfunction in men exposed to ifosfamide (median dose 54 g/m2) compared to the results for males treated with cyclophosphamide. The risk of abnormal FSH increased with the cumulative dose of cyclophosphamide.

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