Ewing's sarcoma of the axial system in patients older than 15 years: dismal prognosis despite intensive multiagent chemotherapy and aggressive local treatment

BACKGROUND: Older age and axial location of Ewing's sarcoma have been reported as unfavorable prognostic factors. METHODS: The records of patients older than 15 years with the Ewing's family of tumors were reviewed retrospectively. After the induction chemotherapy consisting of alternating vincristine, adriablastin, cyclophosphamide (VAC) and etoposide, ifosfamide with mesna protection (IE), a local treatment modality was chosen based on tumor and patient characteristics. RESULTS: Twenty-five patients with a median age of 19 years were evaluated. Median follow-up was 26 months (range 4-58). Seventeen patients (68%) had died. In univariate analysis, factors predictive of shorter survival were the patients presenting with metastatic disease, with the primary tumor located at the pelvis, those who never achieved complete response to chemotherapy and those who had chemotherapy for <12 months. Only a negative link with pelvic location was observed in multivariate analysis [risk ratio 7.5; 95% confidence interval (CI) 1.52-37.06; P = 0.0134]. Median progression-free survival (PFS) and overall survival (OS) were 10 months (95% CI 6.2-13.8) and 14 months (95% CI 9.3-18.7), respectively. Cumulative 2-year PFS and OS were 19.0% (95% CI, SD +/-8.4) and 32.7% (95% CI, SD +/-9.8), respectively. CONCLUSIONS: The prognosis of patients with axial Ewing's sarcoma is dismal despite an intensive, multimodality approach including multiagent, alternating chemotherapy, surgery and/or radiotherapy. A more aggressive approach should be considered for this group of Ewing's sarcoma patients.     

Curability of Ewing's sarcoma and considerations for future therapeutic trials

Twenty previously untreated children with primary Ewing's sarcoma and 8 children with primary tumor and metastatic disease were treated with surgery or radiation therapy (6,000-7,000 rads) for their primary tumor and T-2 chemotherapy. Of the 20 children with primary Ewing's sarcoma treated with T-2 "adjuvant" chemotherapy, 15 had no evidence of recurrent disease for from 31+-82+ months (median 46+ months) from the start of treatment. The actuarial 5-year disease-free survival rate for this group of patients was 75%. Eight patients presenting with metastatic disease had complete responses to T-2 chemotherapy, but 7/8 with metastatic disease eventually had tumor recurrence. Examination of the treatment failures, both those patients relapsing after adjuvant chemotherapy for primary Ewing's sarcoma (5), and those relapsing after having a complete response of metastatic disease (7) to T-2 chemotherapy, revealed that all relapses occurred at the end of the second year of T-2 chemotherapy or after chemotherapy was stopped. In addition, of 23 patients receiving "curative" radiation therapy to their primary tumor, 5 had local recurrence (22%) and 6 (26%) had severe functional debility secondary to combined radiation therapy and T-2 chemotherapy. The conclusions drawn from this experience have led us to consider a new approach to the treatment of Ewing's sarcoma, namely: 1) more aggressive initial or "induction" chemotherapy with subsequent T-2 "maintenance" chemotherapy to eradicate more completely all metastatic microfoci of disease presumed to be present in patients with primary tumor at the time of diagnosis, and ostensively present in patients with metastatic disease; 2) the use of surgery alone or in combination with moderate doses of radiation therapy in those patients in whom we can predict a high frequency of local recurrence (pelvic lesions) or a high percentage of "functional failures" (young children with lower extremity lesions). Preliminary results with this latter approach are encouraging with 11/13 patients with primary Ewing's sarcoma free of disease at 12+-26+ months. A longer follow-up of this more aggressive treatment is needed to determine the superiority of this approach for both increased survival and improved late physical rehabilitation.     

Quality of Life and Psychological Wellbeing of Breast Cancer Survivors in the Kingdom of Saudi Arabia

Introduction: Breast cancer is the most common cancer among Saudi population. Breast cancer patients suffer from several negative consequences after treatment and these include pain, fatigue, sexual problems, appearance and body image concerns, with psychological dysfunction. This could affect the patient quality of life and psychological well-being. Methods: a multicenter cross-sectional study to assess quality of life and psychological wellbeing and their predictors for female breast cancers survivors diagnosed between 1 January 2015 and May 2017 with the assessment conducted at 12 to 36 months after initial diagnosis. Assessment was performed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Breast Module (QLQ-BR23) and the Hospital Anxiety and Depression Scale (HADS). Results: 246 Breast cancer patients participated in the study with a mean age of 49.5±10.9. The mean global health status has a mean of 72.7±23.5. The worst domain of the functioning scales was physical functioning (mean score of 62.14±26.03, while the best scores were for social functioning of 80.06±29.18. For the symptom scales, the worst scores were reported for fatigue and pain. Results of HADS scale showed that 57% had moderate to severe depression, while 44% had moderate to severe anxiety. Only 6.8% of the participants reported receiving psychosocial support. Discussion: Breast cancer survivors in the KSA have overall good quality of life scores when compared with patients from Western countries. However, their psychological wellbeing is more impaired. There is an urgent need for psychosocial support programs and psychological screening and consultation for breast cancer patients at cancer care centers in the KSA.     

Adjuvant and neo-adjuvant chemotherapy for Ewing's sarcoma family tumors and osteosarcoma of the extremity: further outcome for patients event-free survivors 5 years from the beginning of treatment.

BACKGROUND: In 326 patients with Ewing's sarcoma family tumor (ESFT) and 628 extremity osteosarcoma (OS) treated with adjuvant and neo-adjuvant chemotherapy and event-free survivors 5 years from the beginning of treatment we evaluated outcome in the following years. Post 5-year follow-up for these patients was 9.7 years (5.5-29 years). PATIENTS AND METHODS: Adverse events observed after 5-year follow-up were 73 (7.6%): 38 late relapses, nine leukemia, 14 second solid tumor, seven radioinduced sarcoma, three severe adriamycin-related cardiomyopathy, one suicide and one death by car crash. RESULTS: Of the patients who developed late events, 16 (22.5%) are alive and event free after 8 years from the last treatment (2-22 years). CONCLUSION: We conclude that the high rate of late adverse events after 5 years in patients with OS and ESFT is noteworthy and indicates that these patients should be followed for >5 years.     

Chondrosarcoma of the pelvis: oncologic and functional outcome

Purpose. Chondrosarcoma (CS) most commonly involves the pelvis. The factors that influence local and systemic control of pelvic CS and the functional outcome should be evaluated.Patients. Fifty-one patients (37 males and 14 females; mean age, 39.4 years) with pelvic CS were included in this retrospective study.Methods. The tumor stage, surgical treatment, surgical margin achieved, complications, incidence of local recurrence (LR), incidence of distant metastases, and the oncologic and functional status were evaluated. Oncologic outcome was estimated by the method of Kaplan and Meier, and the functional status was scored according to Musculoskeleral Tumor Society (MSTS) criteria. Analysis of variance was used to determine the factors that influence the oncologic and functional outcome.Results. Surgical stages were IA in three cases, IB in 23, IIB in 23, and III in two. Hemipelvectomy (H) was performed in 13 cases, internal hemipelvectomy (IH) with endoprosthetic replacement in 17, and continuity resection (CR) in 23.Two patients received IH and CR, one due to LR, and one due to instability. Radical or wide margins were achieved in 27 cases, marginal margins in 16, and intralesional margins in eight. Local complication required additional surgery in 10 cases due to local infections and/or hematomas.Two patients died perioperatively. In 48 out of the 49 remaining patients, follow-up was available with a mean duration of 73.4 months (range, 4-229 months).Twenty patients died of the disease, two patients are alive with metastases, four patients are disease free after LR, and 22 patients show no evidence of the disease. LR occurred in 10 cases (20.4%), and 17 patients (34.6%) developed distant metastases. Functional evaluation of the 28 survivors revealed good and excellent results in 19 cases, fair in three and poor in six.The mean MSTS score of all survivors was 69.2%, after H it was 37.6%, after IH was 61.4%, and after CR was 79.5%.Conclusion. In pelvic chondrosarcoma, survival was determined by the tumor stage and the surgical margin achieved.The incidence of LR was influenced by the surgical margin achieved, whereas the incidence of distant metastases was influenced by the tumor stage. The best oncologic results in chondrosarcoma involving the innominate bone could be found in low-grade tumors, and the best functional results after continuity resection and restoration of the pelvic girdle.     

反向聚合酶链式反应测定Ewing肉瘤患者骨髓微小残留病变

目的　建立以EWS FLI 1融合基因为标志 ,用反向聚合酶链式反应 (PCR)测定骨髓Ewing肉瘤细胞的体系。方法　用RPMI 16 40培养液培养Ewing肉瘤T1细胞系 ,将其与正常人骨髓单个核细胞按比例混合 ,使T1细胞浓度依次为 10 0 % ,10 -3 ,10 -4 ,10 -5,10 -6,10 -7,0 ,提取总RNA ,合成cDNA ,PCR扩增EWS FLI 1;同时选择 5例骨髓转移的Ewing肉瘤患者 ,测定诊断时及缓解后骨髓EWS FLI 1融合基因。结果　T1细胞浓度为 10 0 % ,10 -3 ～ 10 -6时 ,EWS FLI 1均阳性 ;10 -7及 0时阴性。 5例患者诊断时骨髓EWS FLI 1均阳性 ,完全缓解后 2例转阴。结论　以EWS FLI 1融合基因为标志的反向PCR测定骨髓Ewing肉瘤细胞的灵敏度为 10 -6,它是测定骨髓Ewing肉瘤细胞高度敏感的方法 ;Ewing肉瘤患者完全缓解时 ,部分患者骨髓仍存在肿瘤细胞。     

Outcomes after limb sparing resection in primary malignant pelvic tumors

Aim

To evaluate morbidity, oncologic results and functional outcome in patients with malignant tumors of pelvis treated with limb sparing resection.

Methods

Between March 2002 and November 2010, 106 cases of non metastatic malignant pelvic tumors were treated with limb sparing resections of pelvis. Diagnosis included chondrosarcoma (65), Ewing's sarcoma (25), osteogenic sarcoma (10), synovial sarcoma (3) and malignant fibrous histiocytoma, high grade sarcoma, epitheloid hemangiothelioma (1 each). Three patients had intralesional surgery because of erroneous pre-operative diagnosis of benign tumor and were excluded from final analysis. Remaining 103 patients underwent limb sparing resections with intent to achieve tumor free margins. In 1 case, an intraoperative cardiac event lead to the surgery being abandoned. Reconstruction was done in 2 of 38 cases that did not include resection of acetabulum. For 64 resections involving acetabulum various reconstruction modalities were used.

Results

Surgical margins were involved in 20 patients. Forty five patients had complications. 91 patients were available for follow up. Follow up of survivors ranged from 24 to 122 months (mean 55 months).Twenty one patients (23%) had local recurrence. Sixty patients are currently alive, 46 being continuously disease free. Overall survival was 67% at 5 years. Patients in whom acetabulum was retained had better function (mean MSTS score 27) compared to patients in whom acetabulum was resected (mean MSTS score 22).

Conclusions

Though complex and challenging, limb sparing surgery in non metastatic malignant tumors is oncologically safe and has better functional outcomes than after an amputation surgery.     

Local and distant control in non-metastatic pelvic Ewing's sarcoma patients

BACKGROUND AND OBJECTIVES: Due to possible complication and loss of function, surgery is not often indicated in pelvic Ewing's sarcoma (ES). The purpose of this study was to review our experience and evaluate the role of different local treatment in non-metastatic pelvic ES patients. METHODS: One hundred twenty-nine patients with pelvic ES were treated at our institution between 1975 and 1999. We excluded patients presenting metastases, patients who had died of other causes, or those with incomplete clinical documentation. Among the 73 eligible patients, 17 (23%) with progression of tumor growth during induction chemotherapy eventually died. The analysis was focused on the remaining 56 patients with good or stable clinical response to the chemotherapy. RESULTS: Patients treated with surgery, with or without radiation therapy, had a better local control (82.6% vs. 66.7%) and a significantly higher rate of 5-year EFS (73.9% vs. 30.3%, P = 0.036) than those who were only treated with local radiation therapy. CONCLUSION: Chemotherapy is the key factor in the treatment of pelvic ES. In our series, surgical treatment was associated with good prognosis for pelvic ES. The use of radiotherapy alone was less effective and should be only used in non-operable patients. Radiotherapy after surgery as a rescue method might not act effectively, while preoperative radiotherapy was associated with good clinical response and should be recommended.     

Multimodal therapy for the management of localized Ewing's sarcoma of pelvic and sacral bones: a report from the second intergroup study

A total of 59 eligible patients with localized Ewing's sarcoma of the pelvic and sacral bones were entered into a multimodal Intergroup Ewing's Sarcoma Study (IESS-II) (1978 to 1982) and compared with a historical control series of 68 patients entered into an earlier multimodal Intergroup Ewing's Sarcoma Study (IESS-I) (1973 to 1978). High-dose intermittent multiagent chemotherapy (vincristine, cyclophosphamide, Adriamycin [doxorubicin; Adria Laboratories, Columbus, OH], and dactinomycin) was given to all patients for 6 weeks before and for 70 weeks following local therapy. All patients who had a tumor biopsy or incomplete resection performed received a dose of 55 Gy to the tumor bed. With a median follow-up time of 5.5 years, two of 59 patients (3%) had a local recurrence, five patients (8%) had a local recurrence and metastases, and 17 patients (29%) developed metastases only. There was significant statistical evidence of an advantage in relapse-free survival (RFS) and survival (S) for patients on IESS-II versus IESS-I, P = .006 and P = .002, respectively. At 5 years, the comparison between IESS-II versus IESS-I was 55% versus 23% for RFS and 63% versus 35% for S.     

Phase II Clinical Trial With Pegylated Liposomal Doxorubicin (CAELYX(R)/Doxil(R)) and Quality of Life Evaluation (EORTC QLQ-C30) in Adult Patients With Advanced Soft Tissue Sarcomas: A study of the Spanish Group for Research in Sarcomas (GEIS)

Background: Pegylated liposomal doxorubicin (PLD), a formulation with pharmacokinetic differences with respect to doxorubicin (DXR), might benefit patients with advanced soft tissue sarcoma (STS) pretreated with DXR.Patients and methods: Patients with measurable and progressive STS received PLD at 35 mg/(2) every 3 weeks. Quality of life before and during treatment was assessed with EORTC QLQ-C30.Results: Twenty-eight patients, 22 DXR-pretreated, were given 140 cycles (median 3, range 1-18). Activity in 27 patients (5 GIST): one complete and one partial remission (both non-GIST and without prior DXR), 12 stabilizations and 13 progressions (response rate 7.4%, 95% CI: 0-17%). Grade 3 toxicity: palmar-plantar erythrodysesthesia (19% of patients), stomatitis (4%) or cutaneous (4%). Neutropenia grade>/=3 was detected in 16% of patients. Median relative dose intensity was 95%. Progression-free rate at 3 and 6 months was, respectively, 48 and 22%, median progression-free survival 5.8 months and median overall survival 8.7 months. QLQ-C30 at baseline and at weeks 6-11 in 23 and 13 patients, respectively, showed good reliability and validity. Quality of life did not seem to worsen during therapy.Conclusions: PLD did not induce objective remissions in 22 STS patients pretreated with DXR, but progression-free rate figures support the use of this agent in patients who have not progressed under a DXR-containing regimen. The toxicity observed was comparable to that of other PLD schedules.     

Brain metastases in musculoskeletal sarcomas.

BACKGROUND: In musculoskeletal sarcomas, brain metastases are rare, but severely affect quality of life. METHODS: All patients with musculoskeletal sarcomas who were treated at our institutions from 1975 to 1997 were reviewed for examples of brain metastasis. RESULTS: Of 480 sarcoma patients, 179 had distant metastases, including 20 patients with brain metastases (4.2%). Alveolar soft part sarcoma (3/4), extraskeletal Ewing's sarcoma (2/8), rhabdomyosarcoma (2/13) and bone Ewing's sarcoma (2/18) tended to metastasize to the brain. All 20 patients had distant or local relapses and 16 of the 20 patients had pulmonary metastases. Three patients underwent surgical treatment and two of them survived over 1 year. Mean survival after diagnosis of brain metastasis was 5.1 months. CONCLUSIONS: Patients with alveolar soft part sarcoma, Ewing's sarcoma, rhabdomyosarcoma and pulmonary metastases have a high risk of brain metastasis.     

Malignant peripheral neuroectodermal tumor and its necessary distinction from Ewing's sarcoma. A report from the Kiel Pediatric Tumor Registry.

A new classification scheme is proposed for the differential diagnosis of Ewing's sarcoma and malignant peripheral neuroectodermal tumor (MPNT) based on conventional light microscopic and immunohistochemical findings. The presence of Homer-Wright rosettes and/or the expression of at least two neural markers is diagnostic of MPNT Ewing's sarcoma. Ewing's sarcoma was diagnosed in cases lacking Homer-Wright rosettes and expressing no neural marker or only one in immunohistochemistry. Using this "new" approach considerable differences were found between both tumor types. Although most MPNT were located in the thoracopulmonary region, Ewing's sarcoma was located predominantly in the pelvis and extremities. The mean age of MPNT patients was greater than that of Ewing's sarcoma patients. Most importantly, however, was a statistically significant difference in prognosis: disease-free survival in Ewing's sarcoma patients at 7.5 years follow-up was 60% compared with 45% MPNT patients (P = 0.026). The detection of HNK-1 in MPNT indicated a more aggressive biologic behavior, and the expression of protein S-100 appeared to be correlated with a more favorable clinical course.     

Potential use of imatinib in Ewing's Sarcoma: evidence for in vitro and in vivo activity

BACKGROUND: Ewing's sarcoma cells express c-kit, a receptor tyrosine kinase, and its ligand, stem cell factor (SCF), creating a potential autocrine loop that may promote tumor survival. We thus examined whether the specific tyrosine kinase inhibitor imatinib mesylate (hereafter imatinib; formerly STI571) could inhibit the proliferation of Ewing's sarcoma cells in vitro and in vivo. METHODS: The effect of imatinib on c-kit expression and phosphorylation in Ewing's sarcoma cells was examined by immunoblotting. The effect of imatinib on cell growth and apoptosis was examined with an MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide] assay and with a morphologic test and Annexin V staining, respectively. The effect of imatinib oral therapy (every 12 hours for 5-7 days) on primary tumor growth was assessed in Ewing's sarcoma xenografts in SCID/bg mice (5 or 10 mice per group). RESULTS: All Ewing's sarcoma cell lines tested were sensitive to imatinib-mediated apoptosis with a concentration inhibiting growth by 50% (IC50) of 10-12 micro M. Imatinib inhibited SCF-mediated c-kit phosphorylation (IC50 = 0.1-0.5 microM). In the xenograft model, imatinib treatment resulted in the regression or control of primary Ewing's sarcomas. After 6 days of treatment, the mean lower extremity volume including xenograft tumor was 3744 mm3 (95% confidence interval [CI] = 3050 to 4437 mm3), 1442 mm3 (95% CI = 931 to 1758 mm3), and 346 mm3 (95% CI = 131 to 622 mm3) in mice treated with carrier alone or with imatinib at 50 mg/kg or at 100 mg/kg, respectively. CONCLUSIONS: Imatinib interferes with growth of all Ewing's sarcoma cell lines tested in vitro and in vivo. Targeted inhibition of tyrosine kinase-dependent autocrine loops, therefore, may be a viable therapeutic strategy for Ewing's sarcoma.     

Extraosseous Ewing's sarcoma. A study of 42 cases

Fifty patients at the Mayo Clinic (Rochester, MN) from 1935 to 1985 met the histologic criteria for extraosseous Ewing's sarcoma. Forty-two had soft tissue primaries without bony involvement and formed the basis for this retrospective study of the clinical behavior and management of extraosseous Ewing's sarcoma. There were 19 male and 23 female patients (mean age, 22 years). Metastases were documented in 30 of the patients, six at the time of presentation and 24 occurring up to 11 years later, most commonly to lungs or bone. Three patients were lost to follow-up. Sixteen of 35 patients (46%) had local recurrence. Overall survival was 15 of 39 (38.5%) at 5 years. Decreased survival was noted with pelvic tumors, incomplete resections, and presence of metastatic disease, whereas increased survival was associated with wide surgical resection with negative microscopic margins, adjuvant local radiation therapy, and presentation since 1970 (48% 5-year survival compared with 28% before 1970).     

Current treatment for Ewing's sarcoma

Ewing's sarcoma is the second most common primary bone tumor seen in children and adolescents, and was described by James Ewing in 1921 as a diffuse endothelioma of bone. It is one of the differential diagnoses of pediatric small round blue cell tumors. This is not a single condition, but a group of morphologically and clinically closely related disorders with similar molecular biology -- expression of tumor-specific chimeric oncoproteins through balanced chromosomal translocations involving the EWS gene -- often referred to as the Ewing family of tumors. This includes Ewing's sarcoma of bone, extra-osseous Ewing's sarcoma, Askin tumor and peripheral neuroectodermal tumor. These are aggressive neoplasms with almost 25% of patients having clinically evident metastases at presentation. Ewing's sarcoma has therefore been considered as a systemic disease necessitating local as well as systemic treatment. An aggressive multidisciplinary approach has resulted in significant improvement in prognosis for patients with these tumors. Despite aggressive treatment, 20-40% of patients with localized disease and almost 80% of patients with metastatic disease at presentation succumb to the illness. Advances in understanding the molecular biology of these tumors will hopefully result in the development of novel treatment approaches. The aim of this article is to review the existing treatment methods and to highlight the more recent approaches to the treatment of this condition.     

Radiologic diagnosis of malignant tumors of the pelvic bones in children

An analysis of the data on radiodiagnosis of malignancies of pelvic bones in 50 patients, aged 10-15, is presented. Diagnosis was morphologically confirmed in all the cases: Ewing's sarcoma (41)--82%, primitive neuroectodermal tumor (6)--12% and chondrosarcoma (3)--6%. The leading clinical syndrome was pain in the loin. The significantly most frequent site was the iliac bone. X-ray imaging of tumor site and adjacent areas using standard direct, lateral and oblique projections, ultrasonography, X-ray contrast tomography, radioisotope examination, puncture and open biopsy (when indicated) proved useful.     

Continuously infused carboplatin used as radiosensitizer in locally unresectable non-small-cell lung cancer: a multicenter phase III study.

PURPOSE: To determine the radiosensitizing effect of prolonged exposure of carboplatin in patients with locally unresectable non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Patients with histologically proven NSCLC, performance score <2, weight loss <10%, and normal organ functions were randomized between carboplatin 840 mg/m2 administered continuously during 6 weeks of radiotherapy or thoracic radiotherapy alone (both 60 Gy). Toxicity was evaluated with National Cancer Institute Common Toxicity Criteria (NCI CTC) and the Radiation Therapy Oncology Group (RTOG) criteria. Quality of life was measured with European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30/LC13 questionnaires. RESULTS: One-hundred and sixty patients were included. Pathologically confirmed persistent tumor was present in 53% of patients in the combination arm versus 58% in the radiotherapy alone arm (P=0.5). Median survival in the combination arm was 11.8 [95% confidence interval (CI) 9.3-14.2] months and in the radiotherapy alone arm 11.7 (95% CI 8.1-15.5) months; progression-free survival was not different between arms [6.8 and 7.5 months, respectively (P=0.28)]. Acute toxicity was mild, late toxicity was radiation-induced cardiomyopathy (three patients) and pulmonary fibrosis (five patients). Quality of life was not different between arms, but in all measured patients cough and dyspnea improved, pain became less, and slight paresthesia developed 3 months after treatment. CONCLUSION: Addition of continuously administered carboplatin as radiosensitizer for locally unresectable NSCLC does not improve local tumor control or overall survival.     

Local recurrence, rate and sites of metastases, and time to relapse as a function of treatment regimen, size of primary and surgical history in 62 patients presenting with non-metastatic Ewing's sarcoma of the pelvic bones

This report reviews the experience of 62 patients who presented between 1972 and 1978 with non-metastatic Ewing's sarcoma of the pelvis and were entered on IESS I. Seventeen patients (27%) developed a local recurrence, 38 patients (61%) demonstrated metastases and 21 (34%) neither. In the dose range 4000 rad to 6000 rad no dose response could be detected for local control of tumor. Forty-six patients (74%) had a biopsy or exploratory surgery only, 5 patients (8%) had an incomplete resection and 11 patients (18%) had a complete resection of their tumor. In the 46 patients having a biopsy only, 13 developed a local recurrence (28%) as compared to 2 of 11 patients undergoing a complete resection (18%). The most common sites for metastases were lung in 19 patients (31%) and bone in 23 patients (37%). No significant difference was noted in the frequency of overall metastases or metastases to any site between those patients receiving one of the three treatment regimens used in IESS I: VAC and Adriamycin (regimen I), VAC alone (regimen II) and VAC plus bilateral pulmonary irradiation (regimen III). At a median follow-up of 135 weeks no significant difference in median survival could be detected in patients with pelvic primaries between regimens I, II and III. The mean diameter of the pelvic primaries was comparable to the nonpelvic, however, one half of the pelvic cases were in the range 10-15 cm. The median time to relapse of the 241 non-pelvic patients on IESS I was 222 weeks as contrasted with the median time to relapse of 92 weeks in the 62 pelvic patients on the same study (p = 0.002). The possible reasons for the poor prognosis of pelvic primary patients are discussed together with treatment policies that might improve the survival of this group of patients.     

Quality of Life and Psychological Wellbeing of Colorectal Cancer Survivors in the KSA

Introduction: Colorectal cancer (CRC) ranked first among cancers reported in males and ranked third amongst females in Saudi Arabia. CRC cancer symptoms or symptoms secondary to treatment, such as diarrhea, constipation, fatigue and loss of appetite are very common and has significant negative effects on the quality of life (QoL). Methods: This project was a cross-sectional study of colorectal cancer survivors diagnosed between 1 January 2015 and May 2017. Assessment was performed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the colorectal cancer specific module (EORTC QLQ-CR 29) and the Hospital Anxiety and Depression Scale (HADS). Data on potential predictors of scores were also collected. Results: 115 CRC patients from Middle, Eastern and Western regions of the KSA participated in the study. Participants have unexpectedly low global health score with a mean of 56.9±31.3. Physical functioning scale had the lowest score of 61.3±27.7. Regarding the generic symptoms of cancer, fatigue was the worst symptom, followed by appetite loss. Psychological wellbeing assessment utilizing HADS reveals alarming outcomes for survivors of CRC in the KSA with high proportion of participants with moderate to severe depression (55%) and a good proportion of participants with moderate to high anxiety (31%). Only 3.7% of participants reported receiving psychosocial support. Discussion: Results of this project reveal an overall trend of low scores of quality of life amongst colorectal cancer patients in the KSA when compared with regional or international figures. Consistent results for psychological wellbeing were reached. We recommend routine screening for quality of life and psychological wellbeing and including the outcomes per individual patient care. Psychological support is highly needed for cancer survivors.     

Quality of life among disease-free survivors of rectal cancer.

PURPOSE: To identify factors affecting the quality of life (QoL) of disease-free survivors of rectal cancer. PATIENTS AND METHODS: One hundred twenty-one patients in complete remission more than 2 years after diagnosis were asked to complete three QoL questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30; its colorectal module, QLQ-CR38; and the Duke generic instrument. RESULTS: Patients reported less pain (P =.002) than did controls drawn from the general population. EORTC QLQ-C30 physical scores were also higher among rectal cancer survivors than in the general Norwegian or German population (P =.0005 and P =.002, respectively). Unexpectedly, stoma patients reported better social functioning than did nonstoma patients (P =.005), with less anxiety (P =.008) and higher self-esteem (P =.0002). In the present authors' experience, the QLQ-CR38 does not discriminate between these groups. Residual abdominal or pelvic pain and constipation had the most negative influence on QoL. CONCLUSION: QoL is high among rectal cancer survivors, including stoma patients. Simultaneous use of several QoL questionnaires appears to have value in follow-up and in monitoring the effects of therapy. The impact of residual pain and constipation on long-term QoL should be considered when establishing a treatment regimen.