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Localized Ewing Tumor of Bone: Final Results of the Cooperative Ewing’s Sarcoma Study CESS 86

From the Departments of Pediatric Hematology/Oncology and Orthopedic Surgery, and Gerhard Domagk Institute of Pathology, University of Münster, Münster; Department of Radiotherapy, University of Halle, Halle; Institute of Paidopathology, University of Kiel, Kiel; Department of Pediatric Hematology/Oncology, Schwabing Children’s Hospital, Munich Technical University, Munich; Departments of Pediatric Hematology/Oncology, University of Hannover, Hannover, University of Frankfurt, Frankfurt, University of Hamburg, Hamburg, and University of Düsseldorf, Düsseldorf; and Olga Children’s Hospital, Stuttgart, Germany; Department of Orthopedic Surgery, University of Zürich, Zurich, Switzerland; Departments of Orthopedic Surgery and Pathology, University of Vienna, and St Anna Children’s Hospital, Vienna, Austria; and Department of Pediatric Hematology/Oncology, Emma Children’s Hospital, University of Amsterdam, the Netherlands.

Address reprint requests to Michael Paulussen, MD, Department of Pediatric Hematology/Oncology, Albert-Schweitzer Str 33, D-48129, University of Münster, Germany; email; michael.paulussen{at}uni- muenster.de.

PURPOSE: Cooperative Ewing’s Sarcoma Study (CESS) 86 aimed at improving event-free survival (EFS) in patients with high-risk localized Ewing tumor of bone.

PATIENTS AND METHODS: We analyzed 301 patients recruited from January 1986 to July 1991 (60% male; median age 15 years). Tumors of volume >100 mL and/or at central-axis sites qualified patients for "high risk" (HR, n = 241), and small extremity lesions for "standard risk" (SR, n = 52). Standard-risk patients received 12 courses of vincristine, cyclophosphamide, and doxorubicin alternating with actinomycin D (VACA); HR patients received ifosfamide instead of cyclophosphamide (VAIA). Tumor sites were pelvis (27%), other central axis (28%), femur (19%), or other extremity (26%). The initial tumor volume was <100 mL in 33% of cases and 100 mL in 67%. Local therapy was surgery (23%), surgery plus radiotherapy (49%), or radiotherapy alone (28%). Event-free survival rates were estimated by Kaplan-Meier analyses, comparisons were done by log-rank test, and risk factors were analyzed by Cox models.

RESULTS: On May 1, 1999 (median time under study, 133 months), the 10-year EFS was 0.52. Event-free survival did not differ between SR-VACA (0.52) and HR-VAIA (0.51, P = .92). Tumor volume of >200 mL (EFS, 0.36 v 0.63 for smaller tumors; P = .0001) and poor histologic response (EFS, 0.38 v 0.64 for good responders; P = .0007) had negative impacts on EFS. In multivariate analyses, small tumor volumes of <200 mL, good histologic response, and VAIA chemotherapy augured for fair outcome. Six of 301 patients (2%) died under treatment, and four patients (1.3%) developed second malignancies.

CONCLUSION: Fifty-two percent of CESS 86 patients survived after risk-adapted therapy. High-risk patients seem to have benefited from intensified treatment that incorporated ifosfamide.

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