- Email: [email protected]
Outcome of Patients Treated with a Single-Fraction Dose of Radiation for Cutaneous T-cell Lymphoma and Mycosis Fungoides
Proceedings of the 53rd Annual ASTRO Meeting transfusional support for transient thrombocytopenia. Two patients (13%) treated following relapse and one (4%) for consolidation required transfusions. Conclusions: In a high-volume radioimmunotherapy center, both approved agents have been safe and effective, both in the relapsed setting as well as for consolidation. Rates of response and of relapse for both agents compare favorably to previously published studies. Zevalin was associated with higher median grades of hematologic toxicity but with fewer instances of transfusional support. Patients treated with consolidative intent were less like to require transfusions, likely due to fewer prior lines of therapy. Author Disclosure: M.B. Tomblyn: D. Speakers Bureau/Honoraria; Spectrum Pharmaceuticals.
2881
Local Radiotherapy for Early-stage Low Grade Follicular Lymphoma in the Post-PET Era
S. V. Bratman R. T. Hoppe Stanford Cancer Center, Stanford, CA Purpose/Objective(s): Involved field radiotherapy is curative for a subset of patients with Stage I and II low-grade follicular lymphoma. In prior studies of patients staged without the use of FDG-PET, most relapses have occurred at distant nodal sites within 5 years, with the most relapses detected within the first 1 - 2 years. The purpose of this study was to evaluate the efficacy of radiotherapy with curative intent and the patterns of relapse when PET scanning is incorporated into initial staging. Materials/Methods: We performed a retrospective analysis of patients treated at Stanford University Medical Center with radiotherapy as initial therapy for Stage I-II follicular B-cell lymphoma (WHO grades 1 - 2). Routine staging studies included computed tomography scanning and bone marrow biopsy. Only patients who had PET scans as part of the initial staging workup were included. FDG-avid disease sites were incorporated into the treatment design and allowed for tailoring of the involved fields. All patients were treated with involved field conventionally fractionated radiotherapy to a median dose of 36 Gy (range, 30 - 40 Gy). Results: We identified fifteen consecutive patients (ages 36 - 77) treated between 2003 and 2010, 9 with Stage I (60%) and 6 with Stage II (40%) low-grade follicular lymphoma. There were no recorded deaths. At a median follow-up duration of 45 months (range, 4 - 83 months), 10 of 15 patients remained relapse free. The 4-year Kaplan-Meier estimate of freedom from relapse rate was 65%. Early relapses, defined as occurring within two years of the completion of radiotherapy, were uncommon. The rate of relapse appeared to be constant over the duration of the study period, occurring at 5, 18, 37, 42, and 55 months. Of the 5 relapses, 1 was a local in-field recurrence, and the other 4 were at distant sites. Four were detected on surveillance imaging, and 1 was found on physical exam. Three of the 5 relapses have been biopsy-confirmed, and 2 of these patients have undergone additional treatment. All 4 distant relapses were on the opposite side of the diaphragm from the initial disease. Surprisingly, 2 of the initial relapses were in extranodal sites (submandibular gland and skin). Conclusions: Incorporating FDG-PET scanning into the initial staging of low-grade follicular lymphoma appears to reduce the likelihood of early relapse for early stage disease treated with radiotherapy alone. However, these patients are still at risk of late relapse. Author Disclosure: S.V. Bratman: None. R.T. Hoppe: None.
2882
Total Skin Electron Beam Therapy (TSEBT) As Palliative Treatment For Cutaneous Manifestations Of Advanced, Therapy-refractory T-cell Lymphoma (CTCL) And Leukemia
S. H. Hauswald, F. Zwicker, J. Debus, M. Bischof University of Heidelberg, Heidelberg 69120, Germany Purpose/Objective(s): The aim of this study was to access the outcome and toxicity of a total skin electron beam therapy (TSEBT) in patients with cutaneous manifestations of advanced non-Hodgkin’s lymphoma (CTCL) or leukemia. Materials/Methods: In a retrospective analysis the treatment results of 26 patients (median age 62 years; 5 female, 21 male) with cutaneous manifestations of advanced and therapy-refractory non-Hodgkin’s-lymphoma (n = 22, 82% T-cell lymphomas, 18% Bcell lymphomas) Stage IIB-IV or leukemia (n = 4, 50% AML, 25% CLL, 25% PDC) treated between 1993 and 2010 were reviewed. All patients were symptomatic. The median total dose was 29 Gy administered in daily fractions of median 1 Gy. Results: The median follow-up time was 10 months. Thirteen patients (50%) achieved a clinical complete response and eleven patients (42%) had a limited response. The median time to progression was 4 months (range, 1 - 18 months) and the actuarial oneyear progression-free survival 23%. The clinical symptoms were improved in 24 patients (92%). The median overall survival after the initiation of TSEBTwas 10 months and the actuarial one-year overall survival 38%. Treatment related acute side effects (grade 1 or 2) were observed in all patients during radiation therapy and acute grade 3 epitheliolyses developed in eight patients (31%). A hyperpigmentation of the skin (grade 1 or 2) was documented in 19 patients (73%), and a hypohidrosis in seven patients (27%). Conclusions: For palliation of symptomatic cutaneous manifestations of advanced, PUVA- and chemotherapy-refractory nonHodgkin’s lymphoma or leukemia, total skin electron beam therapy is an efficient and well tolerated treatment option. Author Disclosure: S.H. Hauswald: A. Employment; Is employed by the University Hospital of Heidelberg, Germany. F. Zwicker: A. Employment; Is employed by the University Hospital of Heidelberg, Germany. J. Debus: A. Employment; Is employed by the University Hospital of Heidelberg, Germany. M. Bischof: A. Employment; Is employed by the University Hospital of Heidelberg, Germany.
2883
Outcome of Patients Treated with a Single-Fraction Dose of Radiation for Cutaneous T-cell Lymphoma and Mycosis Fungoides
T. O. Thomas, P. Agrawal, J. Guitart, S. T. Rosen, T. M. Kuzel, J. P. Hayes, B. B. Mittal Northwestern University Feinberg School of Medicine, Chicago, IL Purpose/Objective(s): Mycosis Fungoides (MF), or cutaneous T-cell lymphoma (CTCL), is a radiosensitive tumor. Treatment with radiation is currently given in multiple fractions for patients presenting with unilesional or multilesional disease. However, a single fraction of radiation is more cost-effective and convenient to the patient. The current literature does not contain clinical
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data with a large number of sites treated with a single fraction. This retrospective review was undertaken to assess the clinical response in patients treated with a single fraction of radiation. Materials/Methods: The records of 58 (35 male, 23 female) patients with MF/CTCL, treated with a single fraction of palliative radiation therapy between 10/1991 and 5/2010, were reviewed. Minimum and median follow-up were 3 and 21 months (range, 3 170), respectively. Median age of the patients was 62 (range, 24 - 97). All patients had received multiple previous treatments such as chemotherapy, PUVA, topical nitrogen mustard, and UVB. A total of 265 sites with disease were given the following doses: 400 (n = 1), 500 (n = 2), 600 (n = 6), 700 (n = 40), 750 (n = 8), 800 (n = 207), or 900 cGy (n = 1). Radiation therapy was administered with electrons to 210 sites and with photons to 55. A bolus was used to increase the radiation dosage to the skin. Results: The morphology of the disease was identified for each patient: 25 patients had only patch/plaques, 4 patients were only tumor(T)-stage, 2 patients had only erythroderma (E), 25 patients had both patch/plaque and T disease, and 2 patients had patch/ plaque, T, and E. 14 patients (24.1%) had at least one site with a large cell transformation (LCT) irradiated. A complete response (CR) was seen in 247 of the 265 sites (93.2%), 12 sites (4.5%) achieved a partial response (PR), 4 sites (1.5%) achieved a PR which became a CR after a second single fraction radiation treatment, and 2 sites (0.8%) had no response (NR). Therefore, the overall response rate was 99.2%. Of the 9 sites treated between 400 - 600 cGy, 7 sites (77.8%) achieved a CR and 2 sites (22.2%) had a PR for a total response rate of 100%. Of the 256 sites given 700 cGy or higher, 240 (93.7%) achieved a CR, 10 (3.9%) had a PR, and 4 (1.6%) had a PR which became a CR after a second treatment, for a total response rate of 99.2%. Evaluation of patient characteristics and treatment did not reveal any differences between patients achieving a CR, PR, or NR. Currently, immunophenotypic data is being analyzed to determine if this was a factor in response. Conclusions: For previously treated, radiation-na€ıve MF/CTCL lesions, palliative radiation therapy with single fractions of 700 800 cGy is associated with an excellent CR. Patients with LCT responded equally well to radiation as other MF/CTCL patients. Author Disclosure: T.O. Thomas: None. P. Agrawal: None. J. Guitart: None. S.T. Rosen: None. T.M. Kuzel: None. J.P. Hayes: None. B.B. Mittal: None.
2884
Stage Presentation and Clinical Outcome by Race for Patients with Mycosis Fungoides: A National Population Based Registry Study
L. D. Wilson1, G. Hinds2, J. B. Yu1 1
Yale University School of Medicine, New Haven, CT, 2Johns Hopkins University School of Medicine, Baltimore, MD
Purpose/Objective(s): Mycosis fungoides (MF) is a T-cell lymphoma primarily involving the skin. Based on single institutional data, there is a suggestion that African Americans (AA) may present with more advanced disease compared with whites. A national population based registry was studied to determine if these preliminary findings were supported on a larger scale. Materials/Methods: The NCI Surveillance, Epidemiology, and End Results (SEER) public use dataset was analyzed for patients with a diagnosis of MF. The data were used to address the working hypothesis that AA may present with higher stages of disease than whites. The time period studied spanned from 2000 - 2007 for standard incidence data, and from 2004 - 2007 for data related to stage as stage was not reported until 2004. ICD-O-3 histology code 9700 was used to identify MF cases. Overall survival (OS) was calculated using the method of Kaplan Meier. Univariate and multivariate analysis for hazard of death was performed using Cox proportional hazards analysis. Odds ratios (OR) for presentation at a higher stage were calculated with logistic regression. Age adjusted incidence rates were calculated using the SEER*Stat program using the year 2000 standard population. Results: A total of 745 patients were AA and 4208 were white. Using data from 2000 - 2007, the incidence was 6.2 for AA, 4.1 for whites, 3.1 for Asian/Pacific Islanders, and 1.8 for American Indian/Alaska natives. These incidence rates are per 1,000,000 adjusted to the 2000 US standard population. Incidence by gender is 5.6 for males and 3.7 for females. Spanning age ranging from 20 - 85+, the highest incidence was in the 70 - 74 years of age cohort at 15.7. AA patients had a higher unadjusted frequency of presenting at higher stage (III/IV versus I/II) compared to whites (16.06% vs. 11.13%). However, after controlling for age, gender, and marital status, multivariate logistic regression revealed the increased OR for AA patients presenting with higher stage of disease than whites was not statistically significant, OR 1.48 [95% CI 0.84 - 2.60, P = 0.17]. Patients with Stage III/IV disease had worse OS (HR 5.56 [95% CI 3.59 - 8.62, p\.001) but race was not statistically significant. Unadjusted median survival was not different between races (14.0 years) [95% CI 13.1 - 14.7] for white, 12.2 years [95% CI 11.2 - 15.0] for AA. Conclusions: Based on this analysis, there is a trend for AA patients presenting with higher stages of MF compared to whites, but this difference was not statistically significant. It is important that additional work be done to more clearly elucidate whether a disparity exists and to immediately address this once identified. As SEER began recording the presenting stage of MF patients in 2004, additional study is needed for this rare disease. Author Disclosure: L.D. Wilson: B. Research Grant; Receives funding from MERCK. C. Other Research Support; Receives funding from the NCI. G. Hinds: None. J.B. Yu: B. Research Grant; Receives support from the NCI.
2885
Radiotherapy for Hemangioendothelioma: The University of Florida Experience
M. Scott, D. J. Indelicato, C. G. Morris, C. Gibbs, M. T. Scarborough, J. D. Reith, W. M. Mendenhall, R. B. Marcus, R. A. Zlotecki University of Florida, Gainesville, FL Purpose/Objective(s): Hemangioendotheliomas are malignant vascular tumors that frequently arise from osseous locations, such as the thoracic spine and long bones of the extremities. Nonmorbid wide local excision is the mainstay of treatment for operable sites. For patients with unresectable tumors or those who are at high risk of local recurrence, the therapeutic benefit of radiotherapy (RT) is unclear. This single-institution report describes the long-term effectiveness of RT in the treatment of this rare tumor. Materials/Methods: Between 1976 and 2009, 14 patients with nonmetastatic, histologically proven hemangioendothelioma were treated with RT at the University of Florida. The median age of the patients was 45 years (range, 20 - 71 years). Nine patients had a hemangioendothelioma of the upper (n = 4) or lower (n = 5) extremity, and 5 patients had tumors located to the spine (n = 4) and sacrum (n = 1). Most of the tumors (n = 12) were \ 5 cm in diameter. Four patients were treated with both surgery and
2881
Local Radiotherapy for Early-stage Low Grade Follicular Lymphoma in the Post-PET Era
S. V. Bratman R. T. Hoppe Stanford Cancer Center, Stanford, CA Purpose/Objective(s): Involved field radiotherapy is curative for a subset of patients with Stage I and II low-grade follicular lymphoma. In prior studies of patients staged without the use of FDG-PET, most relapses have occurred at distant nodal sites within 5 years, with the most relapses detected within the first 1 - 2 years. The purpose of this study was to evaluate the efficacy of radiotherapy with curative intent and the patterns of relapse when PET scanning is incorporated into initial staging. Materials/Methods: We performed a retrospective analysis of patients treated at Stanford University Medical Center with radiotherapy as initial therapy for Stage I-II follicular B-cell lymphoma (WHO grades 1 - 2). Routine staging studies included computed tomography scanning and bone marrow biopsy. Only patients who had PET scans as part of the initial staging workup were included. FDG-avid disease sites were incorporated into the treatment design and allowed for tailoring of the involved fields. All patients were treated with involved field conventionally fractionated radiotherapy to a median dose of 36 Gy (range, 30 - 40 Gy). Results: We identified fifteen consecutive patients (ages 36 - 77) treated between 2003 and 2010, 9 with Stage I (60%) and 6 with Stage II (40%) low-grade follicular lymphoma. There were no recorded deaths. At a median follow-up duration of 45 months (range, 4 - 83 months), 10 of 15 patients remained relapse free. The 4-year Kaplan-Meier estimate of freedom from relapse rate was 65%. Early relapses, defined as occurring within two years of the completion of radiotherapy, were uncommon. The rate of relapse appeared to be constant over the duration of the study period, occurring at 5, 18, 37, 42, and 55 months. Of the 5 relapses, 1 was a local in-field recurrence, and the other 4 were at distant sites. Four were detected on surveillance imaging, and 1 was found on physical exam. Three of the 5 relapses have been biopsy-confirmed, and 2 of these patients have undergone additional treatment. All 4 distant relapses were on the opposite side of the diaphragm from the initial disease. Surprisingly, 2 of the initial relapses were in extranodal sites (submandibular gland and skin). Conclusions: Incorporating FDG-PET scanning into the initial staging of low-grade follicular lymphoma appears to reduce the likelihood of early relapse for early stage disease treated with radiotherapy alone. However, these patients are still at risk of late relapse. Author Disclosure: S.V. Bratman: None. R.T. Hoppe: None.
2882
Total Skin Electron Beam Therapy (TSEBT) As Palliative Treatment For Cutaneous Manifestations Of Advanced, Therapy-refractory T-cell Lymphoma (CTCL) And Leukemia
S. H. Hauswald, F. Zwicker, J. Debus, M. Bischof University of Heidelberg, Heidelberg 69120, Germany Purpose/Objective(s): The aim of this study was to access the outcome and toxicity of a total skin electron beam therapy (TSEBT) in patients with cutaneous manifestations of advanced non-Hodgkin’s lymphoma (CTCL) or leukemia. Materials/Methods: In a retrospective analysis the treatment results of 26 patients (median age 62 years; 5 female, 21 male) with cutaneous manifestations of advanced and therapy-refractory non-Hodgkin’s-lymphoma (n = 22, 82% T-cell lymphomas, 18% Bcell lymphomas) Stage IIB-IV or leukemia (n = 4, 50% AML, 25% CLL, 25% PDC) treated between 1993 and 2010 were reviewed. All patients were symptomatic. The median total dose was 29 Gy administered in daily fractions of median 1 Gy. Results: The median follow-up time was 10 months. Thirteen patients (50%) achieved a clinical complete response and eleven patients (42%) had a limited response. The median time to progression was 4 months (range, 1 - 18 months) and the actuarial oneyear progression-free survival 23%. The clinical symptoms were improved in 24 patients (92%). The median overall survival after the initiation of TSEBTwas 10 months and the actuarial one-year overall survival 38%. Treatment related acute side effects (grade 1 or 2) were observed in all patients during radiation therapy and acute grade 3 epitheliolyses developed in eight patients (31%). A hyperpigmentation of the skin (grade 1 or 2) was documented in 19 patients (73%), and a hypohidrosis in seven patients (27%). Conclusions: For palliation of symptomatic cutaneous manifestations of advanced, PUVA- and chemotherapy-refractory nonHodgkin’s lymphoma or leukemia, total skin electron beam therapy is an efficient and well tolerated treatment option. Author Disclosure: S.H. Hauswald: A. Employment; Is employed by the University Hospital of Heidelberg, Germany. F. Zwicker: A. Employment; Is employed by the University Hospital of Heidelberg, Germany. J. Debus: A. Employment; Is employed by the University Hospital of Heidelberg, Germany. M. Bischof: A. Employment; Is employed by the University Hospital of Heidelberg, Germany.
2883
Outcome of Patients Treated with a Single-Fraction Dose of Radiation for Cutaneous T-cell Lymphoma and Mycosis Fungoides
T. O. Thomas, P. Agrawal, J. Guitart, S. T. Rosen, T. M. Kuzel, J. P. Hayes, B. B. Mittal Northwestern University Feinberg School of Medicine, Chicago, IL Purpose/Objective(s): Mycosis Fungoides (MF), or cutaneous T-cell lymphoma (CTCL), is a radiosensitive tumor. Treatment with radiation is currently given in multiple fractions for patients presenting with unilesional or multilesional disease. However, a single fraction of radiation is more cost-effective and convenient to the patient. The current literature does not contain clinical
S633
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Volume 81, Number 2, Supplement, 2011
data with a large number of sites treated with a single fraction. This retrospective review was undertaken to assess the clinical response in patients treated with a single fraction of radiation. Materials/Methods: The records of 58 (35 male, 23 female) patients with MF/CTCL, treated with a single fraction of palliative radiation therapy between 10/1991 and 5/2010, were reviewed. Minimum and median follow-up were 3 and 21 months (range, 3 170), respectively. Median age of the patients was 62 (range, 24 - 97). All patients had received multiple previous treatments such as chemotherapy, PUVA, topical nitrogen mustard, and UVB. A total of 265 sites with disease were given the following doses: 400 (n = 1), 500 (n = 2), 600 (n = 6), 700 (n = 40), 750 (n = 8), 800 (n = 207), or 900 cGy (n = 1). Radiation therapy was administered with electrons to 210 sites and with photons to 55. A bolus was used to increase the radiation dosage to the skin. Results: The morphology of the disease was identified for each patient: 25 patients had only patch/plaques, 4 patients were only tumor(T)-stage, 2 patients had only erythroderma (E), 25 patients had both patch/plaque and T disease, and 2 patients had patch/ plaque, T, and E. 14 patients (24.1%) had at least one site with a large cell transformation (LCT) irradiated. A complete response (CR) was seen in 247 of the 265 sites (93.2%), 12 sites (4.5%) achieved a partial response (PR), 4 sites (1.5%) achieved a PR which became a CR after a second single fraction radiation treatment, and 2 sites (0.8%) had no response (NR). Therefore, the overall response rate was 99.2%. Of the 9 sites treated between 400 - 600 cGy, 7 sites (77.8%) achieved a CR and 2 sites (22.2%) had a PR for a total response rate of 100%. Of the 256 sites given 700 cGy or higher, 240 (93.7%) achieved a CR, 10 (3.9%) had a PR, and 4 (1.6%) had a PR which became a CR after a second treatment, for a total response rate of 99.2%. Evaluation of patient characteristics and treatment did not reveal any differences between patients achieving a CR, PR, or NR. Currently, immunophenotypic data is being analyzed to determine if this was a factor in response. Conclusions: For previously treated, radiation-na€ıve MF/CTCL lesions, palliative radiation therapy with single fractions of 700 800 cGy is associated with an excellent CR. Patients with LCT responded equally well to radiation as other MF/CTCL patients. Author Disclosure: T.O. Thomas: None. P. Agrawal: None. J. Guitart: None. S.T. Rosen: None. T.M. Kuzel: None. J.P. Hayes: None. B.B. Mittal: None.
2884
Stage Presentation and Clinical Outcome by Race for Patients with Mycosis Fungoides: A National Population Based Registry Study
L. D. Wilson1, G. Hinds2, J. B. Yu1 1
Yale University School of Medicine, New Haven, CT, 2Johns Hopkins University School of Medicine, Baltimore, MD
Purpose/Objective(s): Mycosis fungoides (MF) is a T-cell lymphoma primarily involving the skin. Based on single institutional data, there is a suggestion that African Americans (AA) may present with more advanced disease compared with whites. A national population based registry was studied to determine if these preliminary findings were supported on a larger scale. Materials/Methods: The NCI Surveillance, Epidemiology, and End Results (SEER) public use dataset was analyzed for patients with a diagnosis of MF. The data were used to address the working hypothesis that AA may present with higher stages of disease than whites. The time period studied spanned from 2000 - 2007 for standard incidence data, and from 2004 - 2007 for data related to stage as stage was not reported until 2004. ICD-O-3 histology code 9700 was used to identify MF cases. Overall survival (OS) was calculated using the method of Kaplan Meier. Univariate and multivariate analysis for hazard of death was performed using Cox proportional hazards analysis. Odds ratios (OR) for presentation at a higher stage were calculated with logistic regression. Age adjusted incidence rates were calculated using the SEER*Stat program using the year 2000 standard population. Results: A total of 745 patients were AA and 4208 were white. Using data from 2000 - 2007, the incidence was 6.2 for AA, 4.1 for whites, 3.1 for Asian/Pacific Islanders, and 1.8 for American Indian/Alaska natives. These incidence rates are per 1,000,000 adjusted to the 2000 US standard population. Incidence by gender is 5.6 for males and 3.7 for females. Spanning age ranging from 20 - 85+, the highest incidence was in the 70 - 74 years of age cohort at 15.7. AA patients had a higher unadjusted frequency of presenting at higher stage (III/IV versus I/II) compared to whites (16.06% vs. 11.13%). However, after controlling for age, gender, and marital status, multivariate logistic regression revealed the increased OR for AA patients presenting with higher stage of disease than whites was not statistically significant, OR 1.48 [95% CI 0.84 - 2.60, P = 0.17]. Patients with Stage III/IV disease had worse OS (HR 5.56 [95% CI 3.59 - 8.62, p\.001) but race was not statistically significant. Unadjusted median survival was not different between races (14.0 years) [95% CI 13.1 - 14.7] for white, 12.2 years [95% CI 11.2 - 15.0] for AA. Conclusions: Based on this analysis, there is a trend for AA patients presenting with higher stages of MF compared to whites, but this difference was not statistically significant. It is important that additional work be done to more clearly elucidate whether a disparity exists and to immediately address this once identified. As SEER began recording the presenting stage of MF patients in 2004, additional study is needed for this rare disease. Author Disclosure: L.D. Wilson: B. Research Grant; Receives funding from MERCK. C. Other Research Support; Receives funding from the NCI. G. Hinds: None. J.B. Yu: B. Research Grant; Receives support from the NCI.
2885
Radiotherapy for Hemangioendothelioma: The University of Florida Experience
M. Scott, D. J. Indelicato, C. G. Morris, C. Gibbs, M. T. Scarborough, J. D. Reith, W. M. Mendenhall, R. B. Marcus, R. A. Zlotecki University of Florida, Gainesville, FL Purpose/Objective(s): Hemangioendotheliomas are malignant vascular tumors that frequently arise from osseous locations, such as the thoracic spine and long bones of the extremities. Nonmorbid wide local excision is the mainstay of treatment for operable sites. For patients with unresectable tumors or those who are at high risk of local recurrence, the therapeutic benefit of radiotherapy (RT) is unclear. This single-institution report describes the long-term effectiveness of RT in the treatment of this rare tumor. Materials/Methods: Between 1976 and 2009, 14 patients with nonmetastatic, histologically proven hemangioendothelioma were treated with RT at the University of Florida. The median age of the patients was 45 years (range, 20 - 71 years). Nine patients had a hemangioendothelioma of the upper (n = 4) or lower (n = 5) extremity, and 5 patients had tumors located to the spine (n = 4) and sacrum (n = 1). Most of the tumors (n = 12) were \ 5 cm in diameter. Four patients were treated with both surgery and