ctDNA quantification improves estimation of outcomes in patients with high-grade osteosarcoma: a translational study from the OS2006 trial

BACKGROUND

Osteosarcoma stratification relies on clinical parameters and histological response. We developed a new personalized stratification using less invasive circulating tumor DNA (ctDNA) quantification.

PATIENTS AND METHODS

Plasma from patients homogeneously treated in the prospective protocol OS2006, at diagnosis, before surgery and end of treatment, were sequenced using low-passage whole-genome sequencing (lpWGS) for copy number alteration detection. We developed a prediction tool including ctDNA quantification and known clinical parameters to estimate patients' individual risk of event.

RESULTS

ctDNA quantification at diagnosis (diagCPA) was evaluated for 183 patients of the protocol OS2006. diagCPA as a continuous variable was a major prognostic factor, independent of other clinical parameters, including metastatic status [diagCPA hazard ratio (HR) = 3.5, P = 0.002 and 3.51, P = 0.012, for progression-free survival (PFS) and overall survival (OS)]. At the time of surgery and until the end of treatment, diagCPA was also a major prognostic factor independent of histological response (diagCPA HR = 9.2, P < 0.001 and 11.6, P < 0.001, for PFS and OS). Therefore, the addition of diagCPA to metastatic status at diagnosis or poor histological response after surgery improved the prognostic stratification of patients with osteosarcoma. We developed the prediction tool PRONOS to generate individual risk estimations, showing great performance ctDNA quantification at the time of surgery and the end of treatment still required improvement to overcome the low sensitivity of lpWGS and to enable the follow-up of disease progression.

CONCLUSIONS

The addition of ctDNA quantification to known risk factors improves the estimation of prognosis calculated by our prediction tool PRONOS. To confirm its value, an external validation in the Sarcoma 13 trial is underway.

Use of totally implantable catheters for peripheral blood stem cell apheresis

Collection of PBSC by leukapheresis requires one venous access (VA) for inflow and one for outflow. The use of implantable venous access devices (IVAD) has never been reported in this setting. We retrospectively analyzed the use of IVAD for performing apheresis. The study was conducted between January 2000 and June 2005 on 64 patients (41 children) requiring intensification for treatment of a solid tumor. Mean body weight was 26 kg (range 8-91 kg) for a median age of 8.5 years (range 0.7-66 years). A total of 121 aphereses were performed (mean 1.89 apheresis/patient). The second VA was in a cubital vein in 84 procedures and was a temporary central VA in 31. Mean duration of apheresis was 3 h (range 30-274 min). Mean flow rate was 41.3 ml/min (range 12-85 ml/min). Mean collection rate was 59.2% for CD34+ cells and 70% for mononuclear cells. The total number of CD34+ cells collected was 2.5 x 10(6)/kg per apheresis, and 5.9 x 10(6)/kg per patient. Several complications occurred: one catheter-related sepsis (0.86%), four catheter occlusions (3.47%) and eight hemodynamic instabilities related to extracorporeal volume. Weight <10 kg is a risk factor for complication (P=0.0006). IVAD are effective and safe for PBSC collection. Placement of a second central VA (requiring general anesthesia for children) could be avoided.

Dénutrition en cancérologie pédiatrique : prévalence et dépistage

Algorithms for nutritional pediatric support have been proposed in a French national nutritional framework program. However, they are not specific for oncology. With the pediatric nutritional risk score (PNRS) all children with cancer have a high risk of malnutrition, but a systematic nutritional support is not possible for all of them.

AIM

Estimation of malnutrition prevalence and identification of predictive factors of major weight loss during treatment defined by a weight loss more than 5% within 1 month, 7.5% within 3 months, 10% within 6 months.

POPULATION AND METHODS

This historical study included children registered with a solid tumor in 2002 in an oncology pediatric unit. Data collected at diagnosis were weight, height, PNRS, the Lansky functional score, tumor type. Furthermore weight, height, and major weight loss were collected at each cure of chemotherapy and during evolution. Malnutrition at diagnosis was defined using the weight for height ratio. Relations between major weight loss and risks factors were estimated using logistic regression.

RESULTS

Seventy children were included, 16 (22.9%) were malnourished at admission. During chemotherapy, 29 (41.4%) children experienced a major weight loss. Odds ratio of those who were malnourished at diagnosis was not significantly higher in comparison to well-nourished children. Children with a high risk of malnutrition are those affected by Ewing tumor, B lymphom, head and neck localisations, osteosarcomas, metastatic cancers, or cancers treated by high dose chemotherapy with stem cell rescue. For these 29 (41.4%) children the major weight loss odds ratio was 5.9 [IC95% 2.0-16.7].

CONCLUSION

Taking into account others factors with items of PNRS allows to screen children with an higher risk of a major weight loss during treatment and to enhance nutritional care plan for them.

[Childhood cancer incidence and survival rates in the Rhône-Alpes regional paediatric registry 1987-1999]

Cancer is rare in children, and pediatric malignancies represent only 1% of all cancers.

OBJECTIVES

The cure rate is high and increasing, and ongoing data collection is therefore warranted.

MATERIALS AND METHODS

Here we report the incidence and survival rates of childhood cancers between 1987 and 1999 in the Rhône-Alpes region of France.

RESULTS

A total of 1945 cases were recorded during the study period, with an average of 149.6 new cases per year. The approximate incidence rate was 134.1/10(6) per year and the age-standardized incidence rate was 139.2/10(6) per year. The histological distribution and 5-year survival rates were respectively 30.2 and 73% for leukemia, 12.3 and 91.6% for lymphoma, 24.7 and 60.1% for CNS tumors, 9.1 and 71.1% for neuroblastoma, 2.5 and 94.1% for retinoblastoma, 5.8% and 89.9% for renal tumors, 1 and 75% for liver tumors, 6.1 and 60.9% for bone tumors, 4.1 and 58.6% for soft-tissue tumors, 1.1 and 71% for germ cell tumors, and 2.4 and 85.1% for carcinomas.

CONCLUSION

The overall survival rate was 75%. Long-term treatment complications warrant further studies of children who survive into adulthood.

[Cancer-related bone pain in children]

Pain often discloses the existence of bone tumors in children. The complex physiopathology of pain in malignant bone tumors remains largely unknown and is currently investigated. Cancer-related bone pain is independent from the type and the location of the tumor, and from the number and size of the malignant lesions. It does not necessarily increase with tumor growth. Pain, which is the most common early symptom of bone cancer, may also be present at every step of the disease. It may arise from postsurgery injury, side effects of chemo- or radiotherapy, tumor evolution, secondary sequels of treatments, phantom pain. Tumor eradication using cancer therapeutic strategies is the major etiological treatment option for bone cancer pain. Symptom control requires multidisciplinary medical management with drugs effective against bone lysis, analgesics, drugs with anti-neuropathic activity, as well as non-pharmacological techniques and psycho-social management. This psycho-social management must be tailored to the specific needs of teenagers who are particularly prone to this pathological manifestation. Measures to prevent the occurrence of residual chronic pain must be implemented, whereas children and their family should be clearly informed of the risks and of analgesic options available.

Recommandations pour la pratique clinique : Standards, Options et Recommandations pour la prise en charge par radiothérapie des patients atteints d'ostéosarcome

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French regional cancer centres, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVE

To update the SOR recommendations for the use of radiation therapy in the management of patients with osteosarcoma. This work was performed in collaboration with the French society against cancers in children and adolescent (SFCE).

METHODS

Data have been identified by literature search using Medline (from January 1992 to October 2003). In addition several Internet sites were searched in October 2003.

RESULTS

The 3 mains standards are: 1) local and exclusive curative irradiation is not indicated as primary treatment for osteosarcoma or for local and operable recurrence, except for lesion in inaccessible sites or if the patient refuses surgery; 2) local and prophylactic adjuvant irradiation is not indicated for the treatment of osteosarcoma after chemotherapy (neoadjuvant and/or adjuvant) and complete macro or microscopic surgery, except for non-operable R1 or R2 surgical resection; 3) whole-lung prophylactic irradiation is not indicated in non-metastatic osteosarcoma. Systemic metabolic radiotherapy for pain treatment, using samarium-153 ethylenediaminetetramethylene phosphonic acid (Sm-153-EDTMP) can be offered to patients with painful metastatic osteosarcoma or in case of recurrent bone sites inaccessible to local therapies (surgery, external irradiation).

Conformity to clinical practice guidelines, multidisciplinary management and outcome of treatment for soft tissue sarcomas

BACKGROUND

The primary management of adult soft tissue sarcomas (STS) is characterized by heterogeneity across centers. Several studies suggest that it is improved when coordinated by specialized sarcoma centers.

PATIENTS AND METHODS

This study, comparing STS patients of the Rhône-Alpes region treated within and outside the cancer network, retrospectively assesses the conformity of medical practice with 'evidence-based medicine' (EBM) reported under the clinical practice guidelines (CPGs) of the French Federation of Cancer Centers. Institutional records of 100 new STS patients seen between 1999 and 2001 in the regional comprehensive cancer center and Lyon University hospital were analyzed retrospectively (50/300 new files randomly selected in each institution). Medical decisions were checked for conformity with CPGs.

RESULTS

Median age was 58 years (range 18-88) and median tumor size was 9 cm (range 1-26). The most common primary sites were extremities, viscera or trunk. The most frequent histology was leiomyosarcoma (21%) or liposarcoma (12%). Only 7% of cases were reviewed by formal multidisciplinary committee before biopsy (with 42% pre-surgery biopsies only). The first surgical resection was R0, R1 and R2 in 26, 29 and 45% of cases, respectively. Conformity to CPGs was rated 52, 81, 94 and 95% for initial surgery, radiation therapy, chemotherapy and follow-up, respectively. At multivariate analysis, pre-surgery multidisciplinary discussion, management in reference center and management within cancer network independently predicted conformity to CPGs.

CONCLUSIONS

Conformity with EBM was similar to previous reports. Elaboration of treatment strategy within a formal multidisciplinary staff and treatment within a cancer network are both important prognostic factors for optimal clinical care.

[School reinsertion of children treated for tumors of the brain: experience of the Léon-Bérard center]

School integration of children with brain tumor is part of the quality of their life. It may also become a nightmare both for the child and for the teacher when no recommendation has been addressed to the latter. In France, official recommendations allow the meeting and information exchanges in the school between teachers and all the people who take care medically of the child. We report our experience in Centre Léon-Bérard of Lyon, concerning 38 children with brain tumors (102 meetings). Though difficult to assess scientifically, the benefit from these meetings is obvious. For the teachers: the knowledge and understanding of the physiopathology of brain tumors and secondary sequellae facilitates teaching. For the child: the disappearance of surrounding fears and fantasms make life easier. This experience is so rich that it should be extended to other pathologies.

[Immunization for children treated for solid tumors: what are the guidelines?]

There is no agreement on immunization of children treated with chemotherapy (CT) for solid tumors. Based on a review of the literature, we have attempted to establish guidelines on this subject. Except for hepatitis B vaccine, there is no argument to support the use of vaccine during CT. After a standard CT, a 3-month washout period appears to be necessary before starting an immunization program for a child not previously vaccinated, or to proceed with the recommended booster injections for diphteria anatoxin, tetanus vaccine, poliomyelitis inactivated vaccine, pertussis vaccine, and haemophilus influenza type b vaccine if the child is less than 5 years old. For mumps, measles, and rubella live vaccines, a longer post-CT washout of 6 months is suggested for the initial immunization, or for a revaccination of a child proved to be negative for all three serologies. Following high-dose CT a minimal 12-months term and a normalization of the blood lymphocytes count is necessary before planning booster injections once having checked for antidiphteria, tetanic, polio, measles, mumps, rubella and +/- haemophilus antibody titles. We don't find any reason to recommend a systematic varicella immunization in pediatric oncology. Pneumococcal vaccine is recommended in case of asplenia. Any other vaccination (BCG, influenza, yellow fever) must be evaluated individually.

[Prolonged remission in a child with late brain metastasis of retinoblastoma]

BACKGROUND

Outcome of patients with retinoblastoma is strongly related to the extent of the disease at diagnosis. Thus, prognosis of extra-ocular retinoblastoma is poor and metastases to central nervous system are usually fatal.

CASE REPORT

An 8-year-old child presented with a late recurrence of bilateral retinoblastoma. Initial treatment had associated enuclation of the left eye and radiation therapy on the right. At time of tumour recurrence, clinical examination showed cervical lymph nodes. There was a large frontal metastasis on the CT scan and bone marrow examination showed a minimal involvement by malignant cells. The patient achieved complete remission with high dose etoposide and carboplatin; he subsequently underwent massive chemotherapy followed by bone marrow rescue, and received additional radiation therapy on the frontal and cervical areas. He is well, five years after relapse.

CONCLUSIONS

This case highlights efficacy of chemotherapy in advanced retinoblastomas. Intensive chemotherapy is a promising and potentially curative approach in the management of advanced or metastatic retinoblastomas.