Evaluating the Soft Tissue Sarcoma Paradigm for the Local Management of Extraskeletal Ewing Sarcoma

David Boyce-Fappiano; B Ashleigh Guadagnolo; Ravin Ratan; Wei-Lien Wang; Michael J Wagner; Shreyaskumar Patel; John A Livingston; Patrick P Lin; Kevin Diao; Devarati Mitra; Ahsan Farooqi; Alexander J Lazar; Christina L Roland; Andrew J Bishop

doi:10.1002/onco.13616

Evaluating the Soft Tissue Sarcoma Paradigm for the Local Management of Extraskeletal Ewing Sarcoma

Oncologist. 2021 Mar;26(3):250-260. doi: 10.1002/onco.13616. Epub 2020 Dec 14.

Affiliations

¹ Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
² Departments of Sarcoma Medical Oncology, , The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
³ Departments of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
⁴ Division of Medical Oncology, University of Washington, Seattle, Washington, USA.
⁵ Departments of Orthopedic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
⁶ Departments of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Abstract

Objectives: We reviewed our experience treating patients with localized extraskeletal Ewing sarcoma (EES) to determine optimal local management strategies for this rare disease.

Methods: Sixty patients with localized EES treated at our institution between 1994 and 2018 were reviewed. The Kaplan-Meier method was used to estimates disease outcomes.

Results: The median follow-up time was 74 months (interquartile range [IQR], 17-121). Half the patients (n = 30) received combined-modality local therapy (CMT) with both surgery and radiation therapy (RT), whereas the other half received single-modality local therapy (SMT) with either surgery or RT. All patients received chemotherapy. The 5-year overall survival was 76%. Twenty-two patients (37%) developed recurrence at a median time of 15 months (IQR, 5-56 months) resulting in 3-year progression-free survival (PFS) of 65%. On univariate analysis, the use of both neoadjuvant and adjuvant chemotherapy was associated with improved 5-year PFS (71% vs. 50%, p = .04) compared with those who received one or the other. Furthermore, 11 patients (18%) developed local recurrences at a median time of 14 months (IQR, 2-19 months), resulting in a 5-year local control (LC) rate of 77%. Use of CMT was not associated with improved LC (83% vs. 72% SMT, p = .41). Also, use of CMT was the only factor associated with poorer disease-specific survival (vs. SMT; hazard ratio, 3.4; p = .047; 95% confidence interval, 1.01-11.4).

Conclusion: For patients with EES, CMT was not associated with a decreased rate of local relapse. These data suggest that SMT alone may be sufficient for LC in select patients. A multi-institutional collaborative effort should be considered to validate these findings.

Implications for practice: Extraskeletal Ewing sarcoma is a rare chemosensitive sarcoma whose clinical course more closely follows Ewing sarcoma of bone rather than that of other soft tissue sarcomas. Based on this study, combined-modality local therapy did not confer a local control advantage compared with single-modality local therapy. Therefore, single-modality local therapy is likely adequate in select patients with favorable disease features, which has the advantage of ensuring prompt administration of systemic therapy. A multi-institutional collaborative effort is warranted to determine which patients may benefit from de-escalated local therapy.

Keywords: Extraskeletal Ewing sarcoma; Local therapy; Radiation therapy; Sarcoma.

MeSH terms

Bone Neoplasms* / drug therapy
Combined Modality Therapy
Humans
Neoplasm Recurrence, Local
Retrospective Studies
Sarcoma*
Sarcoma, Ewing* / drug therapy
Soft Tissue Neoplasms*
Treatment Outcome