Local Control in Ewing Sarcoma of the Chest Wall
Benedetta Bedetti
Andreas Ranft
Heribert Jürgens
Karsten Wiebe
Uta Dirksen
The story behind......
Is there a benefit from combined modality local treatment?Who needs additional radiotherapy?? Large Tumor ? Pre-Chemo Resection? Poor Response to Inductionchemotx? Shaved MarginWhat is an appropriate surgical procedure?
CESS EURO E.W.I.N.G.- 99 cohort
198 patients
July 1998- April 2009
119 male (60 %), 79 female (40 %)
Age at diagnosis: 13,9 (0,5-60)
Localized disease only
Primary:134 Rib28 Scapula 23 Soft Tissue12 Clavicula1 Sternum
Cohort
Local treatment modalities
Surgery in 191 patients:
Surgery only (OP): 85 pts, 43 %Radiotherapy only (RT): 7 pts, 3,5 %OP + RT: 106 pts, 53,3%
130 complete en bloc resections81 reconstructions of the thoraxic wall
Local treatment modalities
5y-EFS (OP) = 0,75 (SE = ,07)5Y-EFS (RT) = 0,63 (SE = ,05)5y-EFS (OP+RT) = 0,65 (SE = ,07)
Recurrence Group OP+RT Group OP- Local 26 % 29,5 %- Systemic 53 % 41 %- Combined relapse 21 % 29,5 %
Years
Surv
ival
p=.233
Is there a group of patients that benefit from combined modality local treatment?
Tumorvolume < 200 ml Tumorvolume > 200 ml
OP= 39OP + RT = 60ALL= 995y-EFS (OP) = 0,56 (SE = ,05)5y-EFS (OP+RT) = 0,55 (SE = ,07)
OP = 44OP+ RT = 51ALL= 955y-EFS (OP) = 0,86 (SE = ,05)5y-EFS (OP+RT) = 0,73 (SE = ,07)
Years
Surv
ival
Surgical margin: R1&R2Surgical margin: R0
OP = 77OP + RT = 58ALL= 995y-EFS (OP) = 0,74 (SE = ,05)5y-EFS (OP+RT) = 0,62 (SE = ,07)
OP = 8OP + RT = 48ALL = 565y-EFS (OP) = 0,57 (SE = ,19)5y-EFS (OP+RT) = 0,64 (SE = ,07)
Years
Surv
ival
Good histological response Poor histological response
OP = 59OP + RT = 81ALL= 1405y-EFS (OP) = 0,75 (SE = ,07)5y-EFS (OP+RT) = 0,65 (SE = ,07)
OP = 8OP + RT = 20ALL= 285y-EFS (OP) = 0,46 (SE = ,07)5y-EFS (OP+RT) = 0,41 (SE = ,07)
Surv
ival
Years
Risk Factor N 3y-EFS 5y-EFS P valueSurgical Margins (n=191) 0.142- R0 135 73 % 69 % - R1 48 70 % 65. 5% - R2 8 43 % 43 % Histological tumor response (n=145) <0.001- Good 104 76 % 70 % - Poor 41 45 % 45 % Tumor size (n=194) 0.007- < 200 ml 95 79 % 79 % - >= 200 ml 99 63 % 55 % Not malignant pleural effusion (n=198) 0.041No 132 76 % 72 % Yes 66 60 % 56 % Local treatment (n=198) 0.233Radiotherapy 8 63% 63%Surgery 85 76% 75%Surgery & Radiotherapy 106 66% 65%
Univariate analysis
Multivariate analysis
• Tumor size (</>=200ml), • Surgical margins (R0/R1 and R2) • Pleura effusion• Local therapy modality (OP/OP&RT)
Poor histological response (Hazard Ratio=2.74; 95 %CI 1.54-4.89)
Complete versus partialresection of the affected rib
Unknown5Y-EFS complete resection= 0,63 (SE= ,07)5y-EFS partial resection = 0,65 (SE = ,06)
P=0.685
Complications after surgery Prosthetic Material N Complication NNon rigid 46 Pneumothorax after chest drain
removal7
- Gore Tex 28 Paralysis after surgery involving vertebra
1
- Prolene 5 Bleeding 1
- Vicryl 12 Anemia 2
- Biopatch 1 Pneumonia 1
Spontaneous pneumothorax 1
Rigid 5 Phrenic nerve paralysis 1
- Stratos 1 Subcutanous emphysema 2
- Marlex 4 Tension pneumothorax 2
Pleural effusion 3
Combined with or without muscular flap
20 Wound dehiscence 3
No Seroma 1
Late effect N Radiotherapy No Radiotherapy
Secondary malignancies 7 7
Thyroid cancer 3 1 2
AML 2 2 1
Tongue cancer 1 1
Colorectal cancer 1 1
Thoracic bone hypoplasia 3 3 1
Myelopathy 1 1 1
Heart /valular disease 6 3 3
Lung function impairment 14
Restricitive 11 5 6
Obstructive 3 2 1
Late effects
95 patients INT-0091 & POG 9354“The 5-year event-free survival was 56% (SE 7%) for the chest wall lesions compared with 64% (SE 2.4%) for the entire cohort of patients.”
Conclusions
• In patients with close margins additional radiotherapy seems recommended (small number of pts w/o additional RT)
• No added value in patients with other risk factors such as large tumorvolume, poor histological response
• Surgery should be done by an experienced team in the technique that seems appropriate
36 patients , St. Judes“The 15-year estimates of EFS and survival were 56.3% ± 11.2% and 65.6% ± 10.7%, respectively.” Five year EFS app. 65%.