Adolescent and young adult patients with pelvic
sarcomas continue to have a poor prognosis with standard
combination chemotherapy and local irradiation. In addition to a significant risk of local failure, these patients are at high risk for systemic relapse. Twenty-three consecutive patients with
Ewing's sarcoma,
alveolar rhabdomyosarcoma, undifferentiated
sarcoma, or malignant
peripheral neuroepithelioma originating in the pelvis were treated with short, intensive
combined modality therapy. This approach integrates 5 cycles of VADRIAC
chemotherapy (
Vincristine,
Adriamycin,
Cyclophosphamide) with high dose irradiation to the primary lesion (55-60 Gy) and sites of gross metastatic disease (45-50 Gy). Following achievement of a complete response, intensification
therapy consisting of total body irradiation (TBI) (8.0 Gy), high dose VADRIAC
chemotherapy, and autologous bone marow
transplantation is given. All
therapy is completed within 6-7 months. No
maintenance chemotherapy is given; no surgery is intended. Of the twenty-three patients with pelvic
sarcomas treated on this combined modality protocol, 22 achieved a complete remission. Local control was achieved and maintained in all twenty-three patients. With a median follow-up of 21 months since initiation of treatment, there have been nine relapses (all systemic). Seven relapses occurred among the thirteen patients who presented with overt metastatic disease and the other two relapses were among the ten patients with localized disease at presentation. All seven metastatic patients who relapsed have died, whereas both of the relapsed localized patients remain alive. Acute and late toxicities have been acceptable using this aggressive combined modality approach.
Induction chemotherapy had a significant impact on reduction of the typically large (greater than 10 cm diameter) soft tissue mass associated with these pelvic
tumors, thus facilitating achievement of local control by high dose irradiation. Of 18 patients with measureable soft tissue
tumor, all experienced a partial response (greater than 50% reduction in size) following the initial two cycles of
chemotherapy given prior to local irradiation. In conclusion, this short, intensive chemoradiotherapeutic regimen is highly effective in controlling the primary lesion (100% local control) and inducing a complete response in a high proportion (96%) of these high risk pediatric and young adult patients with pelvic
sarcomas. The role of TBI as "systemic" adjuvant
therapy to control micrometastatic disease is discussed as still under investigation.