Denosumab in patients with giant-cell tumor of bone in Norway: results from a nationwide cohort

BACKGROUND

Denosumab is a relatively new treatment option for patients with giant-cell tumor of bone (GCTB). The purpose of this study was to report the results for patients treated in Norway.

MATERIALS AND METHODS

Patients treated with denosumab for GCTB were identified from the clinical databases at the Norwegian sarcoma reference centers. Data were retrieved from the clinical databases and supplemented by retrospective review of patient records. Denosumab was given as a subcutaneous injection every 4 weeks with loading doses on day 8 and 15 in cycle 1.

RESULTS

Eighteen patients treated with denosumab for GCTB were identified. Denosumab was given for recurrent disease in seven cases and as first-line treatment in 11 patients, of which 6 received therapy as part of a neoadjuvant/adjuvant strategy and 5 for surgically unsalvageable primary tumor. Ten of 12 patients with unresectable disease are still on denosumab without progression with median treatment duration of 41 months (range 18-60). Two patients discontinued treatment due to osteonecrosis of the jaw and reduced compliance, respectively. In the adjuvant group, four patients experienced disease recurrence after stopping denosumab. In three of six patients, the extent of surgery was reduced due to neoadjuvant therapy. Seventeen of 18 patients underwent response evaluation with 18F-FDG PET/CT at median 4.7 weeks from starting denosumab. Median baseline SUV_max was 11.0 and median SUV_max at evaluation was 4.9 (p < 0.001).

CONCLUSIONS

In a nationwide GCTB patient cohort, denosumab was an effective agent and durable responses were observed. Our results do not support the use of adjuvant therapy in routine clinical practice. 18F-FDG PET/CT could be a valuable tool for early response evaluation.

A phase II study of clinical activity of SCH 717454 (robatumumab) in patients with relapsed osteosarcoma and Ewing sarcoma

BACKGROUND

Robatumumab (19D12; MK-7454 otherwise known as SCH717454) is a fully human antibody that binds to and inhibits insulin-like growth factor receptor-1 (IGF-1R). This multiinstitutional study (P04720) determined the safety and clinical efficacy of robatumumab in three separate patient groups with resectable osteosarcoma metastases (Group 1), unresectable osteosarcoma metastases (Group 2), and Ewing sarcoma metastases (Group 3).

PROCEDURE

Robatumumab infusions were administered every 2 weeks and were well tolerated with minimal toxicity. Centrally reviewed response data were available for 144 patients.

RESULTS

Low disease burden was important for osteosarcoma response: three of 31 patients had complete response or partial response (PR) by Response Evaluation Criteria in Solid Tumors (RECIST) in resectable patients (Group 1) versus zero of 29 in unresectable patients (Group 2); median overall survival was 20 months in Group 1 versus 8.2 months in Group 2. In centrally reviewed patients with Ewing sarcoma with PET-CT data (N = 84/115), there were six PR, 23 stable disease, and 55 progression of disease by RECIST at 2 months. Patients with Ewing sarcoma had a median overall survival of 6.9 months. However, responding patients with Ewing sarcoma were allowed to continue on treatment after study closure. A minority of patients with metastatic Ewing sarcoma showed clinical responses and have remained healthy after receiving 25-115 doses of robatumumab with remissions of >4 years duration (N = 6).

CONCLUSIONS

These findings show that although the IGF-1R remains an attractive treatment target, additional research is needed to identify responders and/or means to achieve durable remissions in order to successfully exploit IGF-1R signal blockade in Ewing sarcoma (clinicaltrials.gov: NCT00617890).

Adjuvant radiotherapy in retroperitoneal sarcomas. A Scandinavian Sarcoma Group study of 97 patients

BACKGROUND

Currently there is no consensus on the use of adjuvant radiotherapy (RT) in retroperitoneal sarcoma (RPS). We have analysed clinical outcomes in patients with localised RPS treated at two Scandinavian Sarcoma Group (SSG) centres: Haukeland University Hospital (HUH), Bergen, Norway and Skåne University Hospital (SUH), Lund, Sweden to clarify the effects of adjuvant RT on local control and overall survival (OS).

MATERIAL AND METHODS

Local databases and registers at HUH and SUH as well as the SSG central register were used to identify RPS patients. Patients with localised RPS who underwent surgery in Bergen between 1988 and 2009 and in Lund from 1998 to 2009 were included. Medical records were examined for clinical data, tumour characteristics, treatment factors and follow-up status. Archived tumour sections and tumour tissue were reviewed, and when necessary, restained and reclassified. Cox regression was used to analyse the association of potential prognostic factors with local recurrence-free survival (LRFS), metastasis-free survival (MFS) and OS.

RESULTS

The study included 97 patients: 52 from Norway and 45 from Sweden. The proportion of high-grade tumours was 73%. The five-year LRFS, MFS and OS were 55%, 59% and 60%, respectively. RT was significantly associated with improved local control resulting in a five-year LRFS of 77% compared with 39% without (p < 0.001). Furthermore, five-year OS was 71% in the RT group in contrast to 52% with surgery alone (p = 0.019). In the adjusted analysis RT proved to be a significant factor also for MFS (HR = 0.42, 95% CI 0.20-0.88, p = 0.021). In addition, high-grade malignancy, large tumour and positive surgical margin were risk factors for local recurrence. High malignancy grade was the only significant adverse prognostic factor for metastasis. High age and high-grade malignancy were negative prognostic factors for OS.

CONCLUSION

Adjuvant RT was significantly associated with an improved five-year LRFS and OS.

Patterns of local recurrence and dose fractionation of adjuvant radiation therapy in 462 patients with soft tissue sarcoma of extremity and trunk wall

PURPOSE

To study the impact of dose fractionation of adjuvant radiation therapy (RT) on local recurrence (LR) and the relation of LR to radiation fields.

METHODS AND MATERIALS

LR rates were analyzed in 462 adult patients with soft tissue sarcoma who underwent surgical excision and adjuvant RT at five Scandinavian sarcoma centers from 1998 to 2009. Medical records were reviewed for dose fractionation parameters and to determine the location of the LR relative to the radiation portals.

RESULTS

Fifty-five of 462 patients developed a LR (11.9%). Negative prognostic factors included intralesional surgical margin (hazard ratio [HR]: 7.83, 95% confidence interval [CI]: 3.08-20.0), high malignancy grade (HR: 5.82, 95% CI: 1.31-25.8), age at diagnosis (HR per 10 years: 1.27, 95% CI: 1.03-1.56), and malignant peripheral nerve sheath tumor histological subtype (HR: 6.66, 95% CI: 2.56-17.3). RT dose was tailored to margin status. No correlation between RT dose and LR rate was found in multiple Cox regression analysis. The majority (65%) of LRs occurred within the primary RT volume.

CONCLUSIONS

No significant dose-response effect of adjuvant RT was demonstrated. Interestingly, patients given 45-Gy accelerated RT (1.8 Gy twice daily/2.5 weeks) had the best local outcome. A total dose of 50 Gy in 25 fractions seemed adequate following wide margin surgery. The risk of LR was associated with histopathologic subtype, which should be included in the treatment algorithm of adjuvant RT in soft tissue sarcoma.

One vs three years of adjuvant imatinib for operable gastrointestinal stromal tumor: a randomized trial

CONTEXT

Adjuvant imatinib administered for 12 months after surgery has improved recurrence-free survival (RFS) of patients with operable gastrointestinal stromal tumor (GIST) compared with placebo.

OBJECTIVE

To investigate the role of imatinib administration duration as adjuvant treatment of patients who have a high estimated risk for GIST recurrence after surgery.

DESIGN, SETTING, AND PATIENTS

Patients with KIT-positive GIST removed at surgery were entered between February 2004 and September 2008 to this randomized, open-label phase 3 study conducted in 24 hospitals in Finland, Germany, Norway, and Sweden. The risk of GIST recurrence was estimated using the modified National Institutes of Health Consensus Criteria.

INTERVENTION

Imatinib, 400 mg per day, orally for either 12 months or 36 months, started within 12 weeks of surgery.

MAIN OUTCOME MEASURES

The primary end point was RFS; the secondary end points included overall survival and treatment safety.

RESULTS

Two hundred patients were allocated to each group. The median follow-up time after randomization was 54 months in December 2010. Diagnosis of GIST was confirmed in 382 of 397 patients (96%) in the intention-to-treat population at a central pathology review. KIT or PDGFRA mutation was detected in 333 of 366 tumors (91%) available for testing. Patients assigned for 36 months of imatinib had longer RFS compared with those assigned for 12 months (hazard ratio [HR], 0.46; 95% CI, 0.32-0.65; P < .001; 5-year RFS, 65.6% vs 47.9%, respectively) and longer overall survival (HR, 0.45; 95% CI, 0.22-0.89; P = .02; 5-year survival, 92.0% vs 81.7%). Imatinib was generally well tolerated, but 12.6% and 25.8% of patients assigned to the 12- and 36-month groups, respectively, discontinued imatinib for a reason other than GIST recurrence.

CONCLUSION

Compared with 12 months of adjuvant imatinib, 36 months of imatinib improved RFS and overall survival of GIST patients with a high risk of GIST recurrence.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00116935.

Results of the Scandinavian Sarcoma Group XIV protocol for classical osteosarcoma: 63 patients with a minimum follow-up of 4 years

BACKGROUND AND PURPOSE

The Scandinavian Sarcoma Group (SSG) XIV protocol is based on experience from previous SSG trials and other osteosarcoma intergroup trials, and has been considered the best standard of care for patients with extremity localized, non-metastatic osteosarcoma. We analyzed the outcome in 63 consecutive patients. Patients and methods From 2001 through 2005, 63 patients recruited from centers in Sweden, Norway, and Finland were included. They received preoperative chemotherapy consisting of 2 cycles of paired methotrexate (12 g/m²), cisplatin (90 mg/m²), and doxorubicin (75 mg/m²). 3 cycles were administered postoperatively, and poor histological responders were given 3 additional cycles of ifosfamide (10-12 g/m²) as a salvage strategy.

RESULTS

With a median follow-up of 77 months for survivors, the estimated metastasis-free and sarcoma-related survival at 5 years was 70% and 76%, respectively. 53 patients were treated with limb salvage surgery or rotationplasty and 2 patients experienced a local recurrence. 3 toxic deaths were recorded, all related to acute toxicity from chemotherapy. The 5-year metastasis-free survival of poor histological responders receiving add-on treatment with ifosfamide was 47%, as compared to 89% for good histological responders.

INTERPRETATION

Outcome from the SSG XIV protocol compares favorably with the results of previous SSG trials and other published osteosarcoma trials. However, salvage therapy given to poor responders did not improve outcome to a similar degree as for good responders. In a multi-institutional setting, more than four-fifths of the patients were operated with limb salvage surgery or rotationplasty, with few local recurrences.

Surgery and postoperative radiotherapy a valid treatment for advanced oropharyngeal carcinoma

Since 1992 we have prospectively included all head and neck cancer patients in our health region in a departmental based register. Our hospital takes care of all head and neck cancer patients in our health region consisting of approximately 1 million people. In 1997, we evaluated the results of the treatment of oropharyngeal cancer in the 1992–1997 period. On the basis of this evaluation, we changed our treatment policy for tonsillar and base of tongue carcinoma. We first changed the treatment for the lesions with worst prognosis, i.e., those with T3–T4 carcinomas, from radiotherapy only, to radical surgery and postoperative radiotherapy. We have since that time increasingly also operated the smaller oropharyngeal carcinomas. The 2 years’ overall survival and disease-specific survival for all patients diagnosed in the 1992–1997 period was 56 and 63%, respectively. The results from a similar group of patients in the 6 years’ period from 2000 to 2005, after the change in treatment, have increased to 83 and 88%. When we looked at the subgroup of patients in the 2000–2005 period treated with surgery and postoperative radiotherapy, 45 out of 69 patients (65%) presenting with an oropharyngeal cancer were fit for operation. With radical surgery and postoperative radiation therapy, the 2 years overall survival is now 91%. The 2-year disease-specific survival is 96% and the locoregional control is 98%. This is a marked improvement as compared to radiotherapy alone and definitely competitive with modern radiochemotherapy.

High-dose chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer: a retrospective cohort study

Background

We aimed to assess whether high-dose preoperative chemoradiotherapy (CRT) improves outcome in esophageal cancer patients compared to surgery alone and to define possible prognostic factors for overall survival.

Methods

Hundred-and-seven patients with disease stage IIA - III were treated with either surgery alone (n = 45) or high-dose preoperative CRT (n = 62). The data were collected retrospectively. Sixty-seven patients had adenocarcinomas, 39 squamous cell carcinomas and one undifferentiated carcinoma. CRT was given as three intensive chemotherapy courses by cisplatin 100 mg/m² on day 1 and 5-fluorouracil 1000 mg/m²/day, from day 1 through day 5 as continuous infusion. One course was given every 21 days. The last two courses were given concurrent with high-dose radiotherapy, 2 Gy/fraction and a median dose of 66 Gy. Kaplan-Meier survival analysis with log rank test was used to obtain survival data and Cox Regression multivariate analysis was used to define prognostic factors for overall survival.

Results

Toxicity grade 3 of CRT occurred in 30 (48.4%) patients and grade 4 in 24 (38.7%) patients of 62 patients. One patient died of neutropenic infection (grade 5). Fifty percent (31 patients) in the CRT group did undergo the planned surgery. Postoperative mortality rate was 9% and 10% in the surgery alone and CRT+ surgery groups, respectively (p = 1.0). Median overall survival was 11.1 and 31.4 months in the surgery alone and CRT+ surgery groups, respectively (log rank test, p = 0.042). In the surgery alone group one, 3 and 5 year survival rates were 44%, 24% and 16%, respectively and in the CRT+ surgery group they were 68%, 44% and 29%, respectively. By multivariate analysis we found that age of patient, performance status, alcoholism and > = 4 pathological positive lymph nodes in resected specimen were significantly associated with overall survival, whereas high-dose preoperative CRT was not.

Conclusion

We found no significant survival advantage in esophageal cancer stage IIA-III following preoperative high-dose CRT compared to surgery alone. Patient's age, performance status, alcohol abuse and number of positive lymph nodes were prognostic factors for overall survival.

High-dose definitive concomitant chemoradiotherapy in non-metastatic locally advanced esophageal cancer: toxicity and outcome

This study is a retrospective analysis of high-dose definitive concomitant chemoradiotherapy in locally advanced esophageal cancer in a single institution. The aim of the study was to identify and quantify the toxicity associated with the high-dose treatment and to analyze the outcome of this treatment. Forty-six patients (41 men and 5 women, median age of 67.5 years) with disease stage IIA-III esophageal cancer were treated with high-dose definitive chemoradiotherapy. Thirty patients had squamous cell carcinomas and 16 had adenocarcinomas. The patients were treated with three courses of chemotherapy. Each chemotherapy course consisted of cisplatin 100 mg/m(2), day 1 and 5-Fluorouracil 1000 mg/m(2)/day, day 1-5. One course was given every 3 weeks. Concurrent radiotherapy (66 Gy/33 fractions) was administered during the last two courses of chemotherapy. Toxicity grades three and four were seen in 47.5% and 40% of the patients, respectively. Treatment related mortality occurred in one patient (2.5%) due to neutropenic septicemia. Follow-up time for surviving patients (2/46) was 45 and 112 months. For the entire study population, the median time to local recurrence in the radiotherapy field was 33 months and the median time to distant metastasis was 8.7 months, whereas median overall survival was 10.8 months and median disease-specific survival 11 months. For responders to chemoradiotherapy, the median time to local recurrence was 76 months, the median time to distant metastasis 16.8 months, the median overall survival and the median disease-specific survival for the responders were both 17 months. The 2, 3 and 5-year survival rates were 22%, 15% and 11% for the entire study population, and 31%, 24% and 17% for the responders to chemoradiotherapy, respectively. By multivariate analysis response to chemoradiotherapy and lower disease stage were positive prognostic factors for survival. The results of our study have shown that concurrent high-dose chemoradiotherapy provides long-term local tumor control in locally advanced esophageal cancer. However, toxicities following this high-dose treatment, while manageable, were significant. Survival rates were not improved by high-dose chemoradiotherapy compared with what is reported in previous studies applying lower doses of definitive chemoradiotherapy.

Radiotherapy to improve local control regardless of surgical margin and malignancy grade in extremity and trunk wall soft tissue sarcoma: a Scandinavian sarcoma group study

PURPOSE

Adjuvant radiotherapy has during the past decades become increasingly used in the treatment of localized soft tissue sarcoma. We evaluated the effect of radiotherapy (RT) on local recurrence rates (LRRs) in Scandinavia between 1986 and 2005.

METHODS AND MATERIALS

A total of 1,093 adult patients with extremity or trunk wall soft tissue sarcoma treated at four Scandinavian sarcoma centers were stratified according to the treatment period (1986-1991, 1992-1997, and 1998-2005). The use of adjuvant RT, quality of the surgical margin, interval between surgery and RT, and LRR were analyzed. The median follow-up was 5 years.

RESULTS

The use of RT (77% treated postoperatively) increased from 28% to 53%, and the 5-year LRR decreased from 27% to 15%. The rate of wide surgical margins did not increase. The risk factors for local recurrence were histologic high-grade malignancy (hazard ratio [HR], 5), an intralesional (HR, 6) or marginal (HR, 3) surgical margin, and no RT (HR, 3). The effect of RT on the LRR was also significant after a wide margin resection and in low-grade malignant tumors. The LRR was the same after preoperative and postoperative RT. The median interval from surgery to the start of RT was 7 weeks, and 98% started RT within 4 months. The LRR was the same in patients who started treatment before and after 7 weeks.

CONCLUSION

The results of our study have shown that adjuvant RT effectively prevents local recurrence in soft tissue sarcoma, irrespective of the tumor depth, malignancy grade, and surgical margin status. The effect was most pronounced in deep-seated, high-grade tumors, even when removed with a wide surgical margin.

Posterior uveal melanoma treated with I-125 brachytherapy or primary enucleation

PURPOSE

To study the incidence, clinical findings, and tumour characteristics of posterior uveal melanoma in Western Norway, and to report the results of a consistent treatment strategy (I-125 brachytherapy or primary enucleation) over a 13-year period.

METHODS

The clinical records of all patients with posterior uveal melanoma referred between January 1993 and December 2005 were reviewed. Clinical data, radiation parameters, visual outcome, and mortality were analysed in a dedicated database.

RESULTS

The study included 111 consecutive patients. The annual age-adjusted incidence (per million population) of posterior uveal melanoma was 8.5 for women and 8.9 for men. Fifty-six patients underwent I-125 brachytherapy, 52 were enucleated, and three received no treatment. The median follow-up time was 36 months (mean, 52 months; range, 2 months to 13 years). In the brachytherapy group, two eyes were enucleated owing to tumour recurrence and two because of neovascular glaucoma. A visual acuity of 0.1 or better, present in 87% of the patients before brachytherapy, was retained in 40% after a median follow-up of 61 months. After brachytherapy, the 5- and 10-year melanoma-specific mortality rates were 13.4 and 23.8%, respectively. The corresponding mortality rates for patients treated with primary enucleation were 49.5 and 49.5%.

CONCLUSION

After brachytherapy, many patients lost useful vision due to radiation-induced complications. The probability of retaining the eye was high and only two patients experienced recurrent tumour growth. The mortality rates compare well with published series, and the differences in tumour size explain the difference in mortality between the two treatment groups.

[Conjunctival primary acquired melanosis]

BACKGROUND

Pigmented lesions of the conjunctiva may represent primary acquired melanosis. If histological examination reveals atypical melanocytes in the epithelial layer of the conjunctiva, there is a close to 50% risk of transformation to a conjunctival malignant melanoma. A combination of surgical excision and cryotherapy is the most widely recommended treatment for conjunctival primary acquired melanosis with atypia. Recently, topical chemotherapy with mitomycin-C eye drops has been established as a therapeutic option.

MATERIAL AND METHODS

Based on two case reports and a review of the literature, clinical aspects and the use of topical chemotherapy are presented.

RESULTS AND INTERPRETATION

Pigmented conjunctival lesions arising in adults may represent primary acquired melanosis with atypia. In patients with large or multiple pigmentations, extensive surgery with cryotherapy is necessary. In such circumstances, topical chemotherapy with mitomycin-C eye drops is a good alternative and may lead to complete regression, as in our two patients.

[Treatment of patients with gastrointestinal stromal tumour with imatinib mesylate]

BACKGROUND

Gastrointestinal stromal tumour (GIST) is the most frequent mesenchymal tumour type of the digestive tract. Between 30 and 40% of patients have high-risk, malignant GIST with poor prognosis after surgery. Imatinib mesylate is a recently introduced KIT tyrosine kinase inhibitor with effect on metastatic GIST. We report our experience with imatinib mesylate in the treatment of GIST.

MATERIAL AND METHODS

Nine patients diagnosed with GIST have received imatinib mesylate since August 2001. Eight patients had metastatic disease, one patient received adjuvant treatment. The patients were evaluated according to standard protocols for clinical performance, effect of treatment, and adverse effects. Tumour tissue was analysed for mutational status in KIT and PDGFRA.

RESULTS

All patients with metastatic disease had palliative benefit; three had partial response and the remaining stable disease. The single patient receiving adjuvant treatment had no sign of recurrence. Side effects were mainly mild diarrhoea, nausea and vomiting. Seven patients had mutations in KIT exon 11, one in KIT exon 9, and one in PDGFRA exon 12.

INTERPRETATION

The results demonstrate that imatinib mesylate is an effective drug that can stabilise and reduce disease in patients with advanced GIST.

Dosimetric verification of a dedicated 3D treatment planning system for episcleral plaque therapy

PURPOSE

Episcleral plaque therapy (EPT) is applied in the management of some malignant ocular tumors. A customized configuration of typically 4 to 20 radioactive seeds is fixed in a gold plaque, and the plaque is sutured to the scleral surface corresponding to the basis of the intraocular tumor, allowing for a localized radiation dose delivery to the tumor. Minimum target doses as high as 100 Gy are directed at malignant tumor sites close to critical normal tissues (e.g., optic disc and macula). Precise dosimetry is therefore fundamental for judging both the risk for normal tissue toxicity and tumor dose prescription. This paper describes the dosimetric verification of a commercially available dedicated treatment planning system (TPS) for EPT when realistic multiple-seed configurations are applied.

MATERIALS AND METHODS

The TPS Bebig Plaque Simulator is used to plan EPT at our institution. Relative dose distributions in a water phantom, including central axis depth dose and off-axis dose profiles for three different plaques, the University of Southern California (USC) #9 and the Collaborative Ocular Melanoma Study (COMS) 12-mm and 20-mm plaques, were measured with a diode detector. Each plaque was arranged with realistic multiple 125I seed configurations. The measured dose distributions were compared to the corresponding dose profiles calculated with the TPS. All measurements were corrected for the angular sensitivity variation of the diode.

RESULTS

Single-seed dose distributions measured with our dosimetry setup agreed with previously published data within 3%. For the three multiple-seed plaque configurations, the measured and calculated dose distributions were in good agreement. For the central axis depth doses, the agreement was within 4%, whereas deviations up to 11% were observed in single points far off-axis.

CONCLUSIONS

The Bebig Plaque Simulator is a reliable TPS for calculating relative dose distributions around realistic multiple 125I seed configurations in EPT.

Transillumination for accurate placement of radioactive plaques in brachytherapy of choroidal melanoma

PURPOSE

To present a technique for accurate plaque placement in episcleral brachytherapy of choroidal melanoma.

METHODS

The tumor margins are marked on the scleral surface, and a dummy plaque is temporarily sutured to the globe. A fiber optic light pipe is then wedged into the space between the sclera and the plaque. Because of the reflecting inner surface of the plaque, the perimeter of the plaque can easily be observed during indirect ophthalmoscopy as a circle of light surrounding the tumor. By this method, it is possible to determine the exact position of the entire plaque in relation to the tumor and make the necessary adjustments. When the correct position is found, the dummy plaque is replaced by a radioactive plaque.

RESULTS

Since 1993, we have routinely used this procedure in episcleral brachytherapy.

CONCLUSION

This modified transillumination technique facilitates a correct positioning of episcleral plaques.

Chemotherapy in Ewing's sarcoma. The Scandinavian Sarcoma Group experience

During the past 15 years the Scandinavian Sarcoma Group has treated 140 patients with Ewing's sarcoma. Two protocols have been used. SSG IV included 52 patients between 1984 and 1990 and SSG IX, 88 patients since 1990. After 5 years of treatment, local recurrences occurred in 19% of the patients (M0 + M1) in the SSG IV group and 10% in the SSG IX group. Distant metastases developed in 57% of the M0-patients in the SSG IV group and in 33% in the SSG IX group. Tumor-related survival (overall) of M0-patients was 49% in SSG IV and 70% in SSG IX, and the metastasis-free survival rate 45% and 58%, respectively. Patients having a localized extremity tumor had a survival rate of 90% (SSG IX). In both treatment groups, good responders to chemotherapy had a better survival rate than poor ones (SSG IV, p < 0.02, GI-II vs. G II-IV and SSG IX, p < 0.003, GI-III vs. G IV). In conclusions local control and survival rates were better with SSG IX than SSG IV.

Ewing's sarcoma treatment in Scandinavia 1984-1990--ten-year results of the Scandinavian Sarcoma Group Protocol SSGIV

A report on the long-term follow up of the first cooperative Scandinavian Sarcoma Group study in Ewing's sarcoma of bone is presented. Fifty-two previously untreated patients entered the study between 1984 and 1990. Half of the tumors were located in the extremities and one quarter in the pelvis. The combined modality treatment consisted of 5 cycles of chemotherapy--including vincristine, methotrexate, doxorubicin, cyclophosphamide, bleomycin and dactinomycin. The first two cycles were followed by local resection or amputation in 35 patients and by radiotherapy alone in 17 patients. When surgery was not performed, was incomplete or yielded poor margins radiotherapy was given at a dose of 40-60 Gy. Local tumor relapses developed in 10 patients and in all but one patient were accompanied by metastatic disease. Five patients had metastasis at diagnosis and distant metastases developed after primary treatment in 27 patients after a median of 14 months. The median follow-up time for the 20 surviving patients is 10 years. At 5 years the tumor-related survival was 46% and the metastasis-free survival 43%. Late tumor relapses occurred in 4 patients, which reduced the 10-year tumor related survival to 41% and the metastasis-free survival to 38%. Histopathological tumour response correlated with survival with 5-year metastasis-free survival rates of 73% for the good responders and 35% for the poor responders.

Ifosfamide and continuous infusion etoposide in advanced adult soft tissue sarcoma. A Scandinavian Sarcoma Group Phase II Study

The purpose of this study was to evaluate tumour response and toxicity to ifosfamide and continuous infusion etoposide in metastatic or locally advanced soft tissue sarcoma, with dose escalations under G-CSF (granulocyte colony-stimulating factor) support. Of 92 eligible patients (median age 51 years), 85% had tumours of high-grade malignancy and 82% had metastatic disease. Chemotherapy, the baseline dose, consisted of etoposide 600 mg/m2 as a 72 h infusion and ifosfamide 1500 mg/ m2/day for 3 days, followed by G-CSF support (VIG regimen). Stepwise 10% dose escalations were performed depending on haematological toxicity. For patients considered operable after induction chemotherapy, surgical resection of all identifiable residual tumour was attempted. Complete and partial response rates were 11% and 31%, for an overall response rate of 42% (95% CI 31-52%). Forty-eight per cent of courses were dose escalated by a median of 20%. Complete responders had significantly higher, and patients with progressive disease had significantly lower, dose levels than other patients. None of 20 patients with liver metastases responded despite high dose levels. Compared to a preceding pilot study, the addition of G-CSF led to significantly higher dose levels, improved schedule adherence and less haematological toxicity, but no apparent increase in response rate. In view of the modest dose of ifosfamide applied in this study, it is possible that the prolonged infusion of etoposide made a significant contribution to the regimen's antitumour activity, although this can only be determined definitively in a randomised study.

Fibrosarcoma in children--a rare tumour with long-term survival even with advanced disease--a report of 3 cases

Fibrosarcoma is a rare tumour in children. The potential of malignancy has been questioned. We present three cases of fibrosarcoma in children . The follow-up periods range from 10 to 37 years. The first patient had pulmonary metastases at the time of diagnosis in 1958. The primary tumour in fossa ischio-rectalis was resected in 1960. Lung metastases were resected in 1960 and 1989. Radiotherapy was given in 1992. He is still alive with metastases 37 years after the first manifestation of disease. The second patient had a primary tumour and several local recurrences in the mandible. He is alive without evidence of disease 4 years after resection of pulmonary metastases and 21 years after resection of the primary tumour. The third patient has no signs of recurrence or metastatic spread 10 years after a wide excision of subcutaneous tumours of the left upper arm. The cases demonstrate a special tumour-entity of low-grade malignancy, which show a good prognosis and a wide spectrum of biological behaviour.

Prediction of treatment temperatures in clinical hyperthermia of locally advanced breast carcinoma: the use of contrast enhanced computed tomography

PURPOSE

Nineteen patients with locally advanced breast carcinoma were subjected to computed tomography examinations prior to thermoradiotherapy. Pre- and postcontrast computed tomography images were obtained, and tumor contrast enhancement was studied in relation to tissue perfusion, PERF, and steady state temperature, TS, in an attempt to develop an assay for prediction of treatment temperatures in clinical hyperthermia of breast carcinoma.

METHODS AND MATERIALS

PERF and TS were calculated from temperature data achieved during the first fraction of the heat treatment regimen. The computed tomography images were subjected to image analysis, and two parameters representing tumor contrast enhancement were calculated from the computed tomography numbers; the absolute increase in mean attenuation, delta N, and the fraction of the postcontrast attenuation values that was higher than the mean precontrast attenuation value, F+C.

RESULTS

delta N and F+C were clearly correlated to each other. The two parameters differed considerably among the patients, showing that the accumulation of contrast medium was higher in some tumors than in others. Tumor contrast enhancement increased with increasing PERF, suggesting that the accumulation of contrast medium in the tumors was determined mainly by the effective tissue perfusion. There was also a clear correlation between tumor contrast enhancement and TS. The tumors showing a high accumulation of contrast medium were more difficult to heat than those showing a low accumulation.

CONCLUSION

The results indicate that contrast enhanced computed tomography images may give information about the treatment temperatures that can be achieved in clinical hyperthermia of breast carcinoma. The computed tomography images may possibly be used to predict those tumors that can be heated to therapeutic temperatures.

Changes in temperatures and thermal doses with fraction number during hyperthermic treatment of locally advanced breast carcinoma

Seventeen patients with locally advanced breast cancer were given hyperthermic treatment, and changes in temperatures and thermal doses with fraction number were studied. The changes were related to the vascular density of the treated volume before treatment. Multi-point thermistor probes were used for temperature measurements. Two parameters were determined for each probe location, a steady-state temperature, Ts, and a thermal dose, t43. To quantify changes in Ts and t43, linear curves were fitted to plots of these temperature parameters versus fraction number. The slopes of the curves, kTs and kt43, were used to represent the changes in Ts and t43, respectively. Vascular density was determined by histological analysis of biopsies taken from the temperature probe locations before the first heat treatment. Generally, Ts and t43 increased with increasing fraction number. kTs and kt43 were positively correlated to the vascular density of the normal tissue in the treatment volume, i.e. the increase in Ts and t43 was largest in the best-vascularized tissue. The cooling capacity of the normal tissue was probably reduced during the later heat fractions, either because of direct damage to the blood vessels or because of an impaired thermoregulative response. No relationship was found between the temperature parameters and the vascularization of the malignant tissue in the treatment volume. The present results show that the use of a fractionated schedule for heat treatment of locally advanced breast carcinoma may increase the temperatures and thermal doses achieved during treatment. A more uniform heating of the tumours can therefore be achieved by giving multiple heat fractions in the tumour areas that are difficult to heat adequately in one session.

The relevance of tumour and surrounding normal tissue vascular density in clinical hyperthermia of locally advanced breast carcinoma

It follows from the present work that the vascularization of the normal tissue present in the treatment volume limits the temperatures achieved during heat treatment of invasive ductal breast carcinoma. The temperatures can often be increased by giving fractionated heat treatment because heat treatment may reduce the cooling capacity of the normal tissue vasculature. Significant damage to supplying vessels occurs at the heat doses necessary to cause necrosis in the tumour and surrounding normal tissue, indicating that secondary cell death is an important mechanism for cell inactivation following hyperthermic treatment of breast carcinoma.

Fractionated thermochemotherapy in vivo of a C3H mouse mammary carcinoma

The interaction between fractionated heat treatment and fractionated drug treatment with cyclophosphamide (CTX) was investigated in a transplantable C3H mouse mammary carcinoma inoculated into the hind leg of C3D2F1/Bom mice. A tumour core temperature of 43.5 +/- 0.1 degrees C was achieved by immersing the tumour-bearing leg into a water bath thermostatically maintained at 43.7 +/- 0.1 degrees C. CTX was administered i.p. using the maximum tolerated dose (MTD) (LD 1%) for single fraction treatment (100 mg/kg) as the maximum fraction dose. For combined treatment CTX was given 15 min prior to heating. The endpoint was the time to reach a tumour volume of 5 times the volume at first treatment. Specific growth delay was used as effect parameter. In dose-effect experiments using total treatment time at 43.5 degrees C as dose parameter, drug enhancement ratio (DER) was determined as the ratio of the slope of the dose-effect curve for MTD of CTX plus heat to the slope of the curve for heat alone. In dose-effect experiments using total CTX dose as dose parameter, thermal enhancement ratio (TER) was determined as the ratio of the slope of the dose-effect curve for CTX plus 43.5 degrees C for 30 min to the slope of the curve for CTX alone. The regimens investigated were single fraction treatment and 3 and 5 fractions with time intervals of 3 and 5 days. For single fraction treatment DER was 1.4 +/- 0.1 and TER 2.3 +/- 0.2. The drug sensitization of the effect of heat treatment tended to increase with increasing number of fractions.(ABSTRACT TRUNCATED AT 250 WORDS)

Temperature distribution in locally advanced breast carcinoma during hyperthermic treatment: relationship to perfusion, vascular density, and histology

Temperature distributions achieved during hyperthermic treatment of 16 patients with locally advanced breast cancer were analyzed in relation to tissue perfusion, vascular density, and histology of treated volume. Temperatures were measured using multi-sensor thermistor probes inserted in the center and periphery of the treatment volume. A steady state temperature, Ts, and a perfusion related parameter, PERF, were determined for each probe location. Vascular density and tissue composition were determined by histologic analysis of biopsies taken from the temperature probe locations before treatment. Both malignant and normal tissue were found in the biopsies, reflecting a diffusive tumor growth pattern. The malignant and normal tissue compartments were analyzed separately using stereologic techniques. Ts, PERF, vascular density, and tissue composition differed significantly between patients. There was a clear relationship between Ts and PERF, showing that the local tissue perfusion was decisive for the temperatures achieved. Ts and PERF showed a clear correlation with the normal tissue vascular density, but not with the malignant tissue vascular density; that is, the treatment temperatures achieved were mainly determined by the vascularization of the normal tissue compartment. Fraction of necrosis was the only tissue compartment parameter that showed a clear relationship to Ts and PERF. Ts increased and PERF decreased with increasing necrotic fraction.

Relationships between thermal dose and heat-induced tissue and vascular damage after thermoradiotherapy of locally advanced breast carcinoma

Twenty-four patients with locally advanced breast carcinoma were given thermoradiotherapy, and heat-induced damage to tissue and vasculature was studied in relation to thermal dose. Thermometry was performed using six to eight multi-point thermistor probes. Heat-induced damage was quantified by histopathological analysis of biopsies taken from the temperature probe locations shortly after treatment. Both tumour and normal tissue were found in the biopsies. Fraction of tissue and fraction of vessels with heat-induced damage were determined for the malignant and the normal tissue compartment separately, using stereological techniques. Clear relationships were found between these parameters and the largest thermal dose achieved in one heat fraction. The data were subjected to logit analysis, and the thermal doses (eqv. min at 43 degrees C) that caused massive necrosis in 50% of the tissue were calculated to be 116 +/- 31 for the malignant tissue compartment and 205 +/- 49 for the normal tissue compartment. Similarly, the thermal doses that caused damage to 50% of the vessels were found to be 63 +/- 34 and 144 +/- 46 for the malignant and the normal tissue compartment, respectively. Thus, the tumour tissue was more sensitive to heat than was the surrounding normal tissue, irrespective of whether necrosis or vessel damage was considered. This was probably a consequence of physiological and vascular differences between the two tissue compartments. Evidence for primary and secondary cell death was found both in the malignant and the normal tissue, although primary cell death probably was of minor importance in the normal tissue. The data indicate that selective heat-inactivation of tumour tissue is possible by external microwave hyperthermia of locally advanced breast carcinoma.

Positioning of temperature measurement points using multiplanar computed tomography

A method is described for the use of computed tomography and multiplanar reconstruction to depict in single images the full course of obliquely running thermometry catheters. In 14 patients given thermoradiotherapy for locally advanced breast carcinoma, reformatted images of the full catheter course were obtained for all 98 catheters so far tested. The main clinical advantage of this time-consuming procedure was the ability to determine the localization within the catheters of individual temperature measurement points of multipoint thermistor probes. It was also possible to study the localization of the measurement points in relation to the tumour margins.

[Locally advanced breast cancer--primary treatment with tamoxifen]

Tamoxifen was given as primary systemic treatment to 28 patients with locally advanced breast cancer. In all tumours, receptors for estrogen (ER) and/or progesterone (PGR) were positive. All patients (15) with high levels of hormone receptors (ER greater than or equal to 100 mumols/g protein and/or PGR greater than or equal to 200 mumols/g protein) were alive after two years of observation as against 60% of the patients (13) with lower hormone receptor values.

Thermochemotherapy in vivo of a C3H mouse mammary carcinoma: thermotolerant tumours

The ability of cyclophosphamide (CTX) and mitomycin C (MMC) to modify the expression of thermotolerance in vivo at 43.5 degrees C was investigated in a transplantable C3H mouse mammary carcinoma grown s.c. in feet of C3D2F1/Bom mice. Dose-effect curves subjected to linear regression analysis were constructed for single-fraction treatment and for a second treatment 24 h after a priming heat treatment of 43.5 degrees C for 30 min. Tumour volume doubling time during regrowth showed no significant variation among treatment groups, justifying the use of tumour growth time as effect parameter. Thermotolerance ratio for heat alone was 11.6 +/- 2.3. Drug enhancement ratio in thermotolerant tumours was 6.2 +/- 1.4 for CTX (100 mg/kg) and 3.5 +/- 0.9 for MMC (3 mg/kg). These values are about 4 and 3 times larger than the corresponding enhancement ratios found for previously untreated tumours. Thermotolerance ratio for thermochemotherapy was 2.6 +/- 0.3 for CTX and 4.4 +/- 0.7 for MMC, i.e. the degree of thermotolerance was substantially reduced by both drugs, but not completely overcome. Thermal enhancement ratio for CTX and MMC was about equally large in thermotolerant and previously untreated tumours. Thermotolerant tumours showed a tendency for increased resistance to drug treatment alone. Both CTX and MMC may be used clinically to reduce the expression of thermotolerance, particularly in situations with inhomogeneous heating and short fractionation intervals.

Thermochemotherapy in vivo of a C3H mouse mammary carcinoma: single fraction heat and drug treatment

The interaction between water bath hyperthermia (43.5 degrees C) and six cancer chemotherapeutic agents in vivo was studied in a transplantable C3H mouse mammary carcinoma grown s.c. in the feet of C3D2F1/Bom mice. Due to differences in tumour regrowth rate between treatment groups, both tumour growth time (TGT) and specific growth delay (SGD) were used as effect parameters. The largest tumour response was observed when the drug was given 15 min prior to heat--this timing was used for dose-effect experiments. Enhancement ratios were the ratios of slopes of dose-effect curves subjected to linear regression analysis. The drug enhancement ratio (DER) was not significantly larger than 1.0 for LD 1% of adriamycin, 5-fluorouracil, methotrexate and vincristine. For cyclophosphamide (CTX) and mitomycin C (MMC) both DER and TER (thermal enhancement ratio) were significantly larger than 1.0. The TGT ratios (SGD ratios in parentheses) were: DER (LD 1%): CTX 1.4 +/- 0.1 (2.1 +/- 0.1), MMC 1.3 +/- 0.1 (1.4 +/- 0.1); TER (43.5 degrees C 30 min): CTX 1.6 +/- 0.1 (2.7 +/- 0.2), MMC 2.8 +/- 0.5 (3.3 +/- 0.7). The data support the choice of CTX and MMC in preference to the other drugs investigated for clinical thermochemotherapy studies.

Epithelial ovarian tumor in a phenotypic male

Laparotomy in a 41-year-old married man with non-treated left cryptorchidism revealed female internal genitals on the left side, and an epithelial ovarian tumor of intermediate malignancy. Germinal malignancies are frequent in intersexes, but non-germinal gonadal neoplasms are rare. This is the second reported case of epithelial ovarian tumor in intersexes, and the first case of epithelial ovarian tumor in an intersex registered as male.

Sightsaving therapy in retinoblastoma. Experience with external megavoltage radiotherapy

In Norway, sightsaving therapy in retinoblastoma has only been given to least affected eyes in bilaterally affected children. The results in 8 eyes given external high energy radiotherapy are reported. Additional focal therapy was given to 3 eyes for residual tumours and to one eye with new tumour at the ora serrata. Cataract was treated in 2 of the 3 eyes in which it developed. Vitrectomy was performed in 2 eyes with vitreous haemorrhage and persisting vitreous haze. Secondary enucleation has been avoided in all eyes 3-9 years after irradiation. One patient developed metastases in the temporal region at the enucleated side. Visual acuity is 6/12-6/6 if the macula has not been destroyed by tumour or focal therapy. Sightsaving therapy is presently also offered to unilateral cases and worst affected eyes in bilateral cases if the eyes belong to Reese-Ellsworth groups I-IV.

Survival curves after X-ray and heat treatments for melanoma cells derived directly from surgical specimens of tumours in man

X-ray and heat survival curves were established for melanoma cells derived directly from surgical specimens of tumours in man by using the Courtenay soft agar colony assay. The plating efficiency for 11 of the 14 melanomas studied was sufficiently high (PE = 0.3-58%) to measure cell survival over at least two decades. Experiments repeated with cells stored in liquid nitrogen showed that the survival assay gave highly reproducible results. The melanomas exhibited individual and characteristic survival curves whether exposed to radiation or heat (43.5 degrees C). The Do-values were in the ranges 0.63-1.66 Gy (X-rays) and 33-58 min (heat). The survival curves were similar to those reported previously for human melanoma xenografts. The radiation sensitivity of the cells was not correlated to the heat sensitivity. Since the melanomas appeared to be very heterogeneous in radiation response in vitro as melanomas are known to be clinically, it is suggested that melanomas may be suitable for prospective studies aimed at establishing whether clinical radioresponsiveness somehow is related to in vitro survival curve parameters.