title: Ewing sarcoma of the rib: results of an intergroup study with analysis of outcome by timing of resection.
abstract: OBJECTIVE
  We sought to establish the outcome and optimal therapeutic sequence for patients with nonmetastatic Ewing sarcoma/primitive neuroectodermal tumor of the chest wall.
  
  
  METHODS
  Patients 30 years of age or younger with nonmetastatic Ewing sarcoma/primitive neuroectodermal tumor of the bone were randomly assigned to receive vincristine, doxorubicin, cyclophosphamide, and dactinomycin or those drugs alternating with ifosfamide and etoposide. Local control was obtained with an operation, radiotherapy, or both.
  
  
  RESULTS
  Fifty-three (13.4%) of 393 patients had primary tumors of the chest wall (all rib). Event-free survival at 5 years was 57% for the chest wall compared with 61% for other sites (P >.2). Ifosfamide and etoposide improved outcome in the overall group (5-year event-free survival, 68% vs 54%; P =.002), and a similar trend occurred in chest wall lesions (5-year event-free survival, 64% vs 51%). Patients with chest wall lesions had more attempts at initial surgical resection (30%) than those with other primary tumor sites (8%, P <.01). The attempt at initial resection for chest wall lesions did not correlate with size. Initial resections at other sites were restricted to smaller tumors. Initial resection resulted in negative pathologic margins in 6 of 16 patients, whereas the delayed resection resulted in negative margins in 17 of 24 patients (P =.05). Although there was no difference in survival by timing of the operation in rib lesions, a higher percentage of patients with initial surgical resection received radiation than those with resection after initial chemotherapy (P =. 13).
  
  
  CONCLUSIONS
  Although rib primary tumors are significantly larger than tumors found in other sites, their outcome is similar. We favor delayed resection whenever possible to minimize the number of patients requiring radiation therapy.
authors.affiliation: Department of Surgery, Division of Pediatric Hematology/Oncology, at Children's Hospital, Boston, MA, USA. Shamberger@a1.tch.harvard.edu
authors.forename: R C
authors.initials: RC
authors.lastname: Shamberger
authors.forename: M P
authors.initials: MP
authors.lastname: Laquaglia
authors.forename: M D
authors.initials: MD
authors.lastname: Krailo
authors.forename: J S
authors.initials: JS
authors.lastname: Miser
authors.forename: D J
authors.initials: DJ
authors.lastname: Pritchard
authors.forename: M C
authors.initials: MC
authors.lastname: Gebhardt
authors.forename: J H
authors.initials: JH
authors.lastname: Healey
authors.forename: N J
authors.initials: NJ
authors.lastname: Tarbell
authors.forename: C J
authors.initials: CJ
authors.lastname: Fryer
authors.forename: P A
authors.initials: PA
authors.lastname: Meyers
authors.forename: H E
authors.initials: HE
authors.lastname: Grier
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001859:Bone Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D002648:Child; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D006801:Humans; D012272:Ribs; D012512:Sarcoma, Ewing / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D016896:Treatment Outcome