Elsevier

European Journal of Cancer

Volume 37, Issue 13, September 2001, Pages 1599-1608
European Journal of Cancer

Neoadjuvant chemotherapy combined with regional hyperthermia (RHT) for locally advanced primary or recurrent high-risk adult soft-tissue sarcomas (STS) of adults: long-term results of a phase II study☆

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Abstract

In this phase II study, activity and safety of neoadjuvant regional hyperthermia (RHT) combined with chemotherapy was investigated in 59 patients with primary advanced or recurrent high-risk soft-tissue sarcoma (STS). Patients received four EIA cycles consisting of etoposide, ifosfamide and doxorubicin combined with RHT followed by surgical resection and adjuvant treatment. The overall objective response (OR) rate was 17%, with one complete (2%) and eight partial (15%) responses. In addition, 13 minor reponses (25%) were seen. At time of surgery, complete necrosis (pCR) occurred in 6 patients and >75% necrosis (favourable histological response (FHR)) in 12 patients. At the completion of protocol treatment, 36 patients were rendered disease-free which was significantly associated with the initial radiographic and/or pathological tumour response (P=0.004). Treatment-related toxicity was acceptable overall. At a medium follow-up of 82 months, local treatment failure occurred in 33 patients, median overall survival (OS) was 52 months, and the 5-year survival rate was 49% (95% confidence interval (CI): 36–61%). OS which did not differ for extremity versus non-extremity STS (P=0.21) was better for patients responding to EIA combined with RHT (P<0.01).

Introduction

Soft-tissue sarcomas (STS) represent a heterogeneous group of relatively rare malignancies with a wide spectrum in terms of histological type and prognosis [1]. In the last decade, the use of limb-sparing surgery and postoperative irradiation has become standard practice in the management of resectable extremity STS with 5-year rates of local control similar to those reported with radical resection or amputation 2, 3, 4. However, the anatomical location (e.g. retroperitoneal) and invasiveness of STS often prevents resection with adequate margins [5], and the toxicity of radiotherapy limits the use of potentially therapeutic doses with a negative impact on local control 6, 7.

In addition, patients with large (size >5 cm), high-grade and deep STS remain at increased risk for distant metastases and tumour-related mortality 8, 9, despite local control. There is also strong evidence that the occurrence of local relapse in high-risk patients has an unfavourable impact upon subsequent survival 10, 11. For high-risk patients with retroperitoneal STS, the overall 5-year survival rate is in the range of 15–35% 12, 13. A retrospective analysis showed that high-risk tumours were associated with only 20-month median survival compared with 80 months for low-risk tumours [14].

Neoadjuvant chemotherapy is intended to induce local tumour regression and eradicate systemic distant micrometastases before local treatment. Only a few phase-II studies of neoadjuvant chemotherapy have been carried out in patients with bulky STS according to risk factors 15, 16, 17. Within the last decade, hyperthermia in addition to radiation and/or chemotherapy has been tested in different tumour entities showing benefit in terms of tumour response, local control and survival 18, 19.

In 1986, at the Klinikum Grosshadern Medical Center (KGMC) we initiated a phase I/II study for patients with advanced chemoresistant sarcomas combining second-line chemotherapy (ifosfamide plus etoposide) with regional hyperthermia (RHT) [20]. Radiographic and/or pathological response rate of different types of sarcomas was within the range of 30–35% and associated with high temperatures as measured within the tumours 20, 21. In February 1991, a consecutive study designed for patients, that were not pretreated with chemotherapy, with local advanced high-risk STS of extremity and non-extremity tumours was initiated (RHT-91 protocol) combining RHT with neoadjuvant systemic chemotherapy (EIA) [22]. Here, we report on 59 patients treated within the RHT-91 protocol with respect to radiographic and/or pathological response rates, surgical results, control of disease and survival parameters.

Section snippets

Eligibility, patient characteristics and study design

Patients were required to have histologically-confirmed STS without evidence of distant disease. With regard to high-risk criteria, only progressively growing tumours of grade II or III, tumour size >8 cm and extracompartmental extension were eligible. Patients were required to have Karnofsky performance status of ⩾60%, normal haematological, renal and hepatic function. Patients with persistent or recurrent high-risk STS after previous attempts of resection with or without radiotherapy were

Patient characteristics

Between February 1991 and October 1994, 59 eligible patients were treated according to the RHT-91 study protocol, patient characteristics are listed in Table 1. The patients entered the trial either with primary tumours of size >8 cm and/or extracompartmental location (31 patients) or with local regional recurrence of tumours bearing these characteristics (28 patients). In 31 non-extremity STS, tumours were located in the trunk (8 patients) or within the abdomen and pelvis (23 patients). Of the

Discussion

This study is unique in that the application of RHT combined with systemic chemotherapy as part of a multimodality therapy has been prospectively performed for a defined cohort of high-risk STS patients. Most of these patients showed more than one of the independent high-risk criteria at the time of entering the protocol (e.g. tumour size >8 cm, extracompartimental extension, high-grade). In addition, approximately half of our patients (47%) already had local recurrences. This is known to be a

Acknowledgements

The following colleagues have contributed to this work and are gratefully acknowledged: Professor W. Wilmanns, Professor M. Reiser, Professor G. Baretton, Dr H.-G. Rau, Dr Heiss, Dr R. Wilkowski, Dr H.-R. Dürr, Dr C. Salat, M. Santl and M. Schmidt. We thank Martina Lahm for her assistance in the preparation of this manuscript.

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    ☆

    Presented in part at the ASCO Meeting, New Orleans, May 2000. Supported by the Deutsche Krebshilfe and the European Society of Hyperthermic Oncology (ESHO).

    1

    The KGMC is represented by R.D.I. within the Soft Tissue and Bone Sarcoma Group (STBSG) of the European Organization for Research and Treatment of Cancer (EORTC).

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