Clinician-to-Clinician Update Clinician-to-Clinician Update

Multidisciplinary Approach and Innovative Therapy Aid Sarcoma Patient

October 2016

Contributed by Emily Greengard, MD, and Brenda Weigel, MD

Under standard care with chemotherapy and surgical measures, the overall cure rate for people with metastatic Ewing sarcoma is 20%.1 In this case study, specialized, multidisciplinary care and treatment that included high-dose chemotherapy and a stem-cell rescue procedure provide a successful outcome for a young patient with Ewing sarcoma.

Patient

An 11-year-old patient presented with a diagnosis of Ewing sarcoma. Less than a month prior, the boy and his mother had visited his primary care physician to report a “lump” on his left forearm. The lump was not painful, discolored, or warm. There was no known injury. His mother was instructed to give him ibuprofen and to have the patient return to the clinic in 10 days if the lump persisted. At a return visit, the patient was referred to an orthopaedic surgeon who ordered an MRI, which showed a mass in the left radius. The orthopedic surgeon referred the patient to an orthopaedic oncologist at University of Minnesota Masonic Children’s Hospital who scheduled an incisional biopsy. The pathology report was consistent with Ewing sarcoma.

Peds-Cancer-Care-Consult-Oct-2016-Spec-Updates-UMMCH-Lobby
— Lobby of University of Minnesota Masonic Children’s Hospital. The hospital is a designated NIH-Children's Oncology Group facility that can deliver and evaluate phase I and pilot studies on new cancer therapies and approaches to treatment.

Management

The patient underwent a PET/CT scan, bilateral bone marrow aspirates and bone marrow biopsies to determine whether the tumor was localized or had metastasized. The bone marrow biopsies and aspirates showed no evidence of metastatic disease. The PET/CT showed enlarged axillary lymph nodes, potential signs of metastatic disease. The patient’s lymph nodes were biopsied, and the results were consistent with metastatic Ewing sarcoma.

The patient initiated treatment for metastatic Ewing sarcoma. This patient received 6 cycles of chemotherapy over 12 weeks. The PET/CT conducted post-chemotherapy showed no tumor at the primary tumor site or in the axillary lymph nodes. To remove any residual sarcoma, the patient underwent surgical resection of his primary tumor site. The orthopaedic oncologist removed part of his radius and performed an allograft reconstruction.

Because of the risk of disease recurrence, the patient was offered the opportunity to participate in a clinical trial for patients with metastatic solid tumors being conducted at University of Minnesota Masonic Children’s Hospital. The patient and family agreed to his enrollment in the clinical trial and to his receiving a treatment plan involving high-dose chemotherapy followed by “stem-cell rescue.” Stem cells were collected from the patient’s bone marrow and frozen for later use. The patient then began a chemotherapy regimen that resulted in bone marrow ablation, after which the patient’s stem cells were reinfused. He also received radiation therapy to his axilla due to the metastatic disease in his axillary lymph nodes.

The patient’s end-of-therapy scans showed no evidence of disease. He is now 3 years from the completion of his therapy with no evidence of recurrent disease.

Discussion

Multidisciplinary, collaborative care and the application of new therapies can provide the best outcomes for these young patients. Throughout their lifetimes, Ewing sarcoma survivors remain at increased risk of either disease recurrence or developing a secondary malignancy, which usually occurs in the field of previous radiation.1

This patient will require long-term monitoring and care for recurrence of a tumor and late effects of therapy.

References

  1. National Cancer Institute. Ewing Sarcoma Treatment—Health Professional. http://www.cancer.gov/types/bone/hp/ewing-treatment-pdq#. Accessed September 21, 2016.
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