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BENJAMIN ET AL
Chemotherapy for Bone Sarcomas in Adults: The MD
Anderson Experience
Robert S. Benjamin, MD, Michael J. Wagner, MD, J. Andrew Livingston, MD, Vinod Ravi, MD,
and Shreyaskumar R. Patel, MD
OVERVIEW
Increasing age is an adverse prognostic factor in the treatment of primary bone tumors. There are few published data on treatment
of primary bone tumors in adults. This paper presents data from the Department of Sarcoma Medical Oncology at The University
of Texas MD Anderson Cancer Center, summarizing our treatment results. To treat primary osteosarcoma, we used 90 mg/m 2
of doxorubicin as a continuous intravenous infusion over 48 to 96 hours and 120 to 160 mg/m 2 of cisplatin intravenously or
intra-arterially. Initially, we found a marked difference in postoperative continuous disease-free survival (CDFS) between those
with 90% or greater (i.e., good response) tumor necrosis and those with less than 90% (i.e., poor response) tumor necrosis.
The sequential addition of high-dose methotrexate and ifosfamide to patients with poorly responding disease improved their CDFS
to that of patients with good response. Older patients and those who have tumors with variant histology have inferior outcomes.
Evaluation of subsequent patients revealed similar outcomes for those with good or poor response to induction therapy, supporting our
practice of adaptation of postoperative chemotherapy to the results of preoperative chemotherapy. PET-CT is the best imaging
modality to screen for a response with tumors inside bone. To treat Ewing sarcoma, we have employed 2 mg of vincristine, 75
to 90 mg/m 2 of doxorubicin as a 72-hour infusion, and 2.5 g/m 2 of ifosfamide over 3 hours daily for 4 doses (i.e., vincristine,
doxorubicin, and ifosfamide [VAI]). Preliminary analysis indicates a higher CDFS when adjusted for patient age than seen with
the standard alternating regimen used in pediatrics. A screening MRI of the pelvis and spine can detect subtle metastatic disease
in bone or bone marrow that is missed by other imaging modalities or blind biopsy. Chondrosarcoma is treated surgically or on
investigational protocols. Giant cell tumor of bone is usually managed surgically, but multiple options exist for medical treatment,
and therapy is individualized with embolization, denosumab, and interferon.
Increasing age is an adverse prognostic factor in the treatment
of primary bone tumors. 1-3 There are few, if any,
randomized studies that address the treatment of primary
bone tumors in adults, and no data support the common
practice of extrapolating from the results of pediatric trials
to the adult population. We know from pediatric studies
that conclusions based on data derived from patients
younger than 18 do not always apply to those age 18 or
older. We know, for example, from the data presented at
American Society of Clinical Oncology, that compressed
VDC-IE (vincristine, doxorubicin, and cyclophosphamide
alternating with ifosfamide and etoposide) was not
more effective against Ewing sarcoma in patients older
than age 17 than standard dosing, but, because those patients
were included in the study, the overall results are
extrapolated to apply to them. 3 The therapies that we will
describe are derived from the experience of our group in
the Department of Sarcoma Medical Oncology at The
University of Texas MD Anderson Cancer Center and are
based on a sound rationale for individual regimens rather
than on randomized trial data showing the superiority of
any one regimen over another. Traditionally at our institution,
adult patients were at least age 16. In recent years,
the age of the pediatric service has expanded, and the majority
of patients in the age range of 16 to 21 years are seen
in pediatrics.
The two most common pediatric bone sarcomas, osteosarcoma
and Ewing sarcoma, are seen in adults as well. In addition,
chondrosarcoma, unclassifıed pleomorphic sarcoma
(UPS, previously called MFH) of bone, and giant cell tumor
of bone are seen mostly in adults.
CHONDROSARCOMA
Fortunately, because no systemic therapy has proven effective,
most patients with conventional chondrosarcoma have
From the Department of Sarcoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
Disclosures of potential conflicts of interest are found at the end of this article.
Corresponding author: Robert S. Benjamin, MD, Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 450, Houston, TX 77030;
email: rbenjami@mdanderson.org.
© 2015 by American Society of Clinical Oncology.
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