Glioblastoma multiforme following prophylactic cranial irradiation and intrathecal methotrexate in a child with acute lymphocytic leukemia

Extraneural Metastasis of Primary Glioma Occurring in a Setting of Occupational Ionizing Radiation Exposure

Malignant gliomas account for 60% of all primary brain tumors in adults. Glioblastoma Multiforme (GBM) is the most common primary glial tumor with a dismal prognosis and a median survival of approximately 14 months. Extra-neural metastases from primary brain tumors are unusual with an incidence rate of less than 2%. This has been attributed to factors such as short survival, lack of true lymphatics in the CNS, and physical barriers provided by the dura, extracellular matrix, and basement membrane. Although most GBMs occur sporadically, there is a known association with therapeutic radiation exposure and with work in nuclear disaster cleanup. To our knowledge, no case of GBM with metastasis occurring in a patient with occupational radiation exposure currently exists in the literature. In this article, we present a case of GBM with lung metastasis occurring in a 51-year-old Caucasian male, whose history is significant for occupational exposure to ionizing radiation, and review the literature on GBM risk factors and potential mechanisms of metastasis.

Post-Radiation Gliomas

Aims and background

Radiotherapy is important in the treatment of neoplasm of the central nervous system, but various side effects, particularly neoplastic, have been described. Recently, post-radiation gliomas have been reported.

Methods

The authors review 88 cases of cerebral glioma following radiotherapy in patients operated for neoplasms of the nervous system, including 6 personal cases of post-radiation gliomas treated in the Neurosurgical Division of the Department of Neurological Sciences, “La Sapienza” University, Rome. The criteria used to define this unusual pathologic association are discussed.

Results

There was a male predominance. Post-radiation gliomas were particularly malignant, the average dose was 33 Gy, and average free latency was 9.6 years. The first disease was most frequently acute lymphatic leukemia.

Conclusions

Post-radiation gliomas have particular features but do not present a histologic or clinical behavior different from analogous spontaneous gliomas. The fact that 88 cases have been reported in recent years suggests that a thorough biological, clinical studies be carried out on this association.

Three case reports of radiation-induced glioblastoma after complete remission of acute lymphoblastic leukemia

Radiation therapy is sometimes performed to control intracranial acute lymphoblastic leukemia (ALL), but may lead to radiation-induced malignant glioma. The clinical, radiological, histological, and molecular findings are described of three cases of radiation-induced glioblastoma after the treatment for ALL. They received radiation therapy at age 6-8 years. The latency from radiation therapy to the onset of radiation-induced glioblastoma was 5-10 years. Magnetic resonance imaging demonstrated diffuse lesions with multiple small enhanced lesions in all cases. Histological examination showed that the tumors consisted of mainly small round astrocytic atypical cells in one case, and astrocytic atypical cells with elongated cytoplasm and nuclear pleomorphism with small cell component in two cases. Microvascular proliferation was present in all cases. Immunohistochemical analysis for B-Raf V600E, and mutational analysis for the isocitrate dehydrogenase (IDH) 1, IDH2, and H3F3A gene revealed the wild-type alleles in all three cases. The integrated diagnoses were IDH wild-type glioblastoma, and local irradiation and concomitant temozolomide were performed. After the initial treatment, significant shrinkage of the diffuse lesion and enhanced lesion was found in all cases. Radiation-induced glioblastoma occurring after the treatment for ALL had unique clinical, radiological, histological, and molecular characteristics in our three cases.

Seizures caused by brain tumors in children

PURPOSE

To review the epidemiology, clinical features, and treatment of seizures secondary to pediatric brain tumors.

METHOD

Literature review.

RESULTS

Pediatric brain tumors are the most common solid pediatric tumor and the most common cause of death in pediatric cancer. Seizures are one of the most common symptoms of pediatric brain tumors. Factors associated with increased risk of seizures include supratentorial location, gray matter involvement, low-grade, and certain histological features-especially dysembryoplastic neuroepithelial tumor, ganglioglioma, and oligodendroglioma. Leukemic infiltration of the brain, brain metastases of solid tumors, and brain injury secondary to chemotherapy or radiotherapy can also cause seizures. Mechanisms by which brain tumors cause seizures include metabolic, and neurotransmitter changes in peritumoral brain, morphologic changes - including malformation of cortical development - in peritumoral brain, and presence of peritumoral blood products, gliosis, and necrosis. As there is a high degree of uncertainty on how effective different antiepileptic drugs are for seizures caused by brain tumors, choices are often driven by the interaction and side effect profile. Classic antiepileptic drugs - phenobarbital, phenytoin, or carbamazepine - should be avoided as they may alter the metabolism of chemotherapeutic agents. Newer drugs - valproate, lamotrigine, topiramate, zonisamide, and levetiracetam - may be the preferred option in patients with tumors because of their very limited interaction with chemotherapy.

CONCLUSION

Seizures are a common presentation of pediatric brain tumors, especially in supratentorial tumors with gray matter involvement. Antiepileptic drug therapy is usually driven by the interaction and side effect profile and newer drugs with few interactions are generally preferred.

Radiation associated tumors following therapeutic cranial radiation

BACKGROUND

A serious, albeit rare, sequel of therapeutic ionizing radiotherapy is delayed development of a new, histologically distinct neoplasm within the radiation field.

METHODS

We identified 27 cases, from a 10-year period, of intracranial tumors arising after cranial irradiation. The original lesions for which cranial radiation was used for treatment included: tinea capitis (1), acute lymphoblastic leukemia (ALL; 5), sarcoma (1), scalp hemangioma (1), cranial nerve schwannoma (1) and primary (13) and metastatic (1) brain tumors, pituitary tumor (1), germinoma (1), pinealoma (1), and unknown histology (1). Dose of cranial irradiation ranged from 1800 to 6500 cGy, with a mean of 4596 cGy. Age at cranial irradiation ranged from 1 month to 43 years, with a mean of 13.4 years.

RESULTS

Latency between radiotherapy and diagnosis of a radiation-induced neoplasm ranged from 4 to 47 years (mean 18.8 years). Radiation-induced tumors included: meningiomas (14), sarcomas (7), malignant astrocytomas (4), and medulloblastomas (2). Data were analyzed to evaluate possible correlations between gender, age at irradiation, dose of irradiation, latency, use of chemotherapy, and radiation-induced neoplasm histology. Significant correlations existed between age at cranial irradiation and development of either a benign neoplasm (mean age 8.5 years) versus a malignant neoplasm (mean age 20.3; P = 0.012), and development of either a meningioma (mean age 7.0 years) or a sarcoma (mean age 27.4 years; P = 0.0001). There was also a significant positive correlation between latency and development of either a meningioma (mean latency 21.8 years) or a sarcoma (mean latency 7.7 years; P = 0.001). The correlation between dose of cranial irradiation and development of either a meningioma (mean dose 4128 cGy) or a sarcoma (mean dose 5631 cGy) approached significance (P = 0.059).

CONCLUSIONS

Our study is the first to show that younger patients had a longer latency period and were more likely to have lower-grade lesions (e.g. meningiomas) as a secondary neoplasm, while older patients had a shorter latency period and were more likely to have higher-grade lesions (e.g. sarcomas).

Atypical teratoid rhabdoid tumor located in the pineal region following prophylactic irradiation for acute lymphoblastic leukemia

Atypical teratoid rhabdoid tumor (AT/RT) is a rare entity. In the central nervous system, AT/RT generally arises from the posterior fossa of infants and behaves aggressively. AT/RT is reported to arise from the infratentorial region (63%) and other sites, such as the suprasellar region, cerebellopontine angle, and spinal cord. The pineal region is rare (6%) as a site of origin. Radiation-induced brain tumors are well known. In this report, we present a case of a pineal region tumor causing acute hydrocephalus that could be pathologically diagnosed as AT/RT following prophylactic cranial irradiation for acute lymphoblastic leukemia.

Radiation-induced glioblastoma multiforme in a remitted acute lymphocytic leukemia patient

Radiation therapy has been widely applied for cancer treatment. Childhood acute lymphocytic leukemia (ALL), characterized by frequent central nervous system involvement, is a well documented disease for the effect of prophylactic cranio-spinal irradiation. Irradiation, however, acts as an oncogenic factor as a delayed effect and it is rare that glioblastoma multiforme develops during the remission period of ALL. We experienced a pediatric radiation-induced GBM patient which developed during the remission period of ALL, who were primarily treated with chemotherapeutic agents and brain radiation therapy for the prevention of central nervous system (CNS) relapse. Additionally, we reviewed the related literature regarding on the effects of brain irradiation in childhood and on the prognosis of radiation induced GBM.

Radiation-induced brain tumours after central nervous system irradiation in childhood: a review

OBJECTS

Radiation-induced cerebral tumours constitute a significant risk for subjects undergoing radiotherapy for the management of cerebral neoplasms. Age-related cerebral vulnerability could be a specific factor in the genesis of these complications.

METHODS

The pertinent literature of both paediatric and adult series has been reviewed. Three personal cases were added.

RESULTS

One hundred forty-two paediatric second brain tumours were evaluated. Out of them, 69 were malignant gliomas, 33 meningiomas, 8 sarcomatous lesions and 13 low-grade astrocytomas. The average latency period for the appearance of the second tumour was 8 years. Among the second tumours occurring in adults, meningioma is the most common. In this subgroup, the latency period ranged between 16 and 30 years.

CONCLUSION

Paediatric radiation-induced brain tumours differ from the adult counterpart for both the histological subtypes. These figures indicate a specific vulnerability of the infantile brain demonstrated by the most frequent occurrence of highly malignant lesions.

Radiation-induced malignant gliomas: is there a role for reirradiation?

PURPOSE

To review the literature regarding the role of radiotherapy (RT) in the treatment of patients with radiation-induced malignant gliomas (RIMGs).

METHODS AND MATERIALS

A PubMed search of English-language articles dealing with RIMG was performed, yielding 52 articles with 92 patients available for review.

RESULTS

Initial tumor types treated with RT included brain tumor in 37 patients (40%), acute lymphoblastic leukemia in 33 (36%), benign disease in 11 (12%), and other in 11 (12%). Median time from RT to development of an RIMG was 8.75 years (range, 2.5-61 years). The RIMG occurred within 10 years after RT in 81% of patients with acute lymphoblastic leukemia/lymphoma, 59% of patients with brain/other, and 18% of patients with benign conditions (p = 0.002). Type of RIMG was glioblastoma in 69 (75%) and anaplastic astrocytoma in 23 (25%). One-, 2-, and 5-year overall survival rates were 29.3%, 7.3%, and 0% for patients with glioblastoma and 59.7%, 30.3%, and 20.2% for patients with anaplastic astrocytoma. For the 85 patients with data regarding treatment for RIMG, 35 underwent reirradiation to a median dose of 50 Gy (range, 30-76 Gy). For patients undergoing reirradiation, 1-, 2- and 5-year overall survival rates were 58.9%, 20.5%, and 6.8%. For those not undergoing reirradiation, they were 15.1%, 3%, and 0% (p = 0.0009).

CONCLUSIONS

The RIMG appeared earlier in patients treated for leukemia and lymphoma and latest for those treated for a benign condition. Patients who underwent reirradiation for RIMG have longer survival times compared with those not receiving RT.

Bilateral ptosis and supranuclear downgaze paralysis

The purpose of this article is to highlight an uncommon combination of supranuclear downward gaze paralysis with bilateral eyelid ptosis in a 53-years-old man with a radiation induced midbrain tumor and to discuss the aspects regarding the centers and pathways that mediate supranuclear vertical gaze movements.

Anaplastic oligoastrocytoma: previous treatment as a possible cause in a child with acute lymphoblastic leukemia

INTRODUCTION

The authors present a 14-year-old patient who developed an anaplastic oligoastrocytoma of the left parietal lobe 9 years after a successful treatment of acute lymphoblastic leukemia (ALL). He had a history of induction chemotherapy, intrathecal methotrexate and prophylactic whole brain irradiation (1,800 cGy in 10 fractions over 2 weeks).

DISCUSSION

Radiation-induced neoplasia is suggested to be the late complication of ALL treatment, and evaluation of large clinical series revealed a relationship between young age at ALL diagnosis (<6 years) and increased high-grade glioma occurrence risk.

CONCLUSION

The authors have reviewed previously reported cases of secondary central nervous system malignancies focusing on age at ALL diagnosis, and they think that synergistic action of therapeutic modalities could have played a role in the oncogenetic process. Detailed systematic radiological follow-up should be done in these patients especially if a personal history of cranial irradiation is present.

Glioblastoma multiforme following cranial irradiation and chemotherapy for acute lymphocytic leukaemia. Report of 3 cases

The most common secondary neoplasms which occur following cranial radiation therapy are sarcoma and meningioma. The occurrence of glioblastoma multiforme following radiation and chemotherapy in acute lymphocytic leukaemia (ALL) is rare. We report 3 cases of glioblastoma multiforme in children developing 11-72 months following completion of chemotherapy/radiotherapy for ALL. The exact cause for the development of glioblastoma multiforme following therapy for ALL is not clear. A genetic predisposition may be essential for the occurrence of such a highly malignant primary brain tumour in leukaemia patients, irrespective of radiation and/or chemotherapy. The pathogenesis and surgical management are discussed, and the literature on the subject is reviewed.

Ganglioglioma with anaplastic recurrence of the neuronal element following radiotherapy

Gangliogliomas are rare tumours in adults representing between 0.5% and 1% of all neuroepithelial tumours. They are of mixed cellularity comprised both of a neuronal and a glial population. Although malignant transformation is rare, and this mostly occurs in the glial element, we present a case of malignant neuroblastomatous transformation of a ganglioglioma. This is only the second ever case to our knowledge in the literature reporting the participation of the neuronal element in the malignant transformation of a ganglioglioma. In contrast with the previous published case, our patient has received post-operative therapeutic radiotherapy. The related literature is reviewed and the oncogenic role of therapeutic irradiation is discussed.

Radiation-induced gliomas: report of 10 cases and review of the literature

BACKGROUND

Radiotherapy and more recently radiosurgery represent important therapeutic methods for the treatment of tumors and arterovenous malformations affecting the central nervous system, even though several significant side-effects have been described (radionecrosis, tumors, etc.). Gliomas induced by radiation therapy are decidedly unusual, and the first descriptions of this association only appeared in the 1960s.

METHODS

The pertinent literature was reviewed to yield 116 cases in which a glioma developed after radiotherapy for cranial pathologies (included 10 personal cases treated in our Institution). One of our patients had undergone radiosurgery for a cavernous angioma.

RESULTS

Patients who developed a radiation-induced glioma were younger, as a group, than those affected with so-called "spontaneous" gliomas. The tumor originated in the previously irradiated area, after average doses of 32 Gy and an average latency period of 9.6 years in accordance with the findings reported by the authors and in our experience as well. Radiotherapy had most frequently been performed for acute lymphoblastic leukemia. Our Case 10 is the fourth case of intracranial tumor arising after radiosurgery to be described in the literature.

CONCLUSIONS

Though rare, gliomas may represent a late complication of radiation treatment. The behavior of the radiation-induced variety of glioma does not seem to differ significantly from that of its "spontaneous" counterpart. Late complications of the radiosurgery are probably underestimated because of the relatively recent introduction of this technique. On the contrary, these should be scrupulously evaluated when deciding whether to employ this method for therapeutic purposes for relatively benign or congenital lesions (which generally affect young patients with a long life expectancy).

Induction of glioblastoma multiforme in nonhuman primates after therapeutic doses of fractionated whole-brain radiation therapy

OBJECT

To determine the acute and long-term effects of a therapeutic dose of brain radiation in a primate model, the authors studied the clinical, laboratory, neuroimaging, molecular, and histological outcomes in rhesus monkeys that had received fractionated whole-brain radiation therapy (WBRT).

METHODS

Twelve 3-year-old male primates (Macaca mulatta) underwent fractionated WBRT (350 cGy for 5 days/week for 2 weeks, total dose 3500 cGy). Animals were followed clinically and with laboratory studies and serial magnetic resonance (MR) imaging. They were killed when they developed medical problems or neurological symptoms, lesions appeared on MR imaging, or at study completion. Gross, histological, and molecular analyses were then performed. Nine (82%) of 11 animals that underwent long-term follow up (> 2.5 years) developed neurological symptoms and/or enhancing lesions on MR imaging, which were defined as glioblastoma multiforme (GBM), 2.9 to 8.3 years after radiation therapy. The GBMs were categorized as either unifocal (three) or multifocal (six), and were located in the supratentorial (six), infratentorial (two), or both (one) cranial regions. Histological examination revealed distant, noncontiguous tumor invasion within the white matter of all nine animals harboring GBMs. Novel interspecies comparative genomic hybridization (three animals) uniformly showed deletions in the GBMs that corresponded to chromosome 9 in humans.

CONCLUSIONS

The high rate of GBM formation (82%) following a therapeutic dose of WBRT in nonhuman primates indicates that radioinduction of these neoplasms as a late complication of this therapy may occur more frequently than is currently recognized in human patients. The development of these tumors while monitoring the monkeys' conditions with clinical and serial MR imaging studies, and access to the tumor and the entire brain for histological and molecular analyses offers an opportunity to gather unique insights into the nature and development of GBMs.

Secondary tumours after prophylactic cranial irradiation

A 22 year old woman, who at the age of 6 years had prophylactic cranial irradiation for acute lymphoblastic leukaemia, presented with both astrocytoma of the brain and breast carcinoma. The link between the two solid tumours and previous cranial irradiation is discussed.

Radiation-induced gliosarcoma. Case report and review of the literature

A 13-year-old boy presented with a cerebral gliosarcoma 12 years after having acute lymphoblastic leukemia treated by chemotherapy and central nervous system prophylaxis treated by radiation therapy (24 Gy) and intrathecal methotrexate. A review of the literature disclosed 129 possible radiation-induced gliomatous and/or sarcomatous brain tumors: namely, 89 gliomas, 36 sarcomas, and four gliosarcomas, including the present case. An analysis of these cases revealed several characteristics that differentiate them from similar spontaneous brain tumors, thus providing arguments for the carcinogenic effect of radiation therapy on intracranial tumors.

Brain tumors following cure of acute lymphoblastic leukemia

The majority of children with acute lymphoblastic leukemia can be cured with effective modern day therapy. However, more and more long term sequelae including carcinogenic potential of the treatment are being recognised. We report two children who developed acute lymphoblastic leukemia at the age of 4 and 5 years respectively and were successfully treated. They developed meningioma and astrocytoma at 9 and 3 years respectively after completion of therapy. Both were treated surgically and the patient with astrocytoma also received radiotherapy. Both are now free of disease 19 months after diagnosis of second neoplasm.

Brainstem glioma after radiation therapy for acute myeloblastic leukemia in a child with Down syndrome. Possible pathogenetic mechanisms

A 13-year-old boy with Down syndrome (DS) had a brainstem glioma confirmed at autopsy, 10 years after receiving prophylactic cranial irradiation for acute myeloblastic leukemia. There is no clear association of brain tumors with DS; despite a reported link between leukemia and glioma, a causal association with radiation therapy is more likely.

Primitive neuroectodermal tumors after prophylactic central nervous system irradiation in children. Association with an activated K-ras gene

Three patients had supratentorial malignant brain tumors 7 to 9 years after prophylactic central nervous system (CNS) treatment for acute lymphocytic leukemia or malignant T-cell lymphoma. Therapy was administered at the age of 3 to 8 years and included cranial irradiation (total dose, 1800 to 2400 cGy) and intrathecal methotrexate. The brain tumors had histologic and immunohistochemical features of primitive neuroectodermal tumors (PNET), including neuroblastic rosettes, rhythmic arrangement of tumor cells, and immunohistochemical expression of glial, and in one patient neuronal, marker proteins. Using polymerase chain reaction-mediated DNA amplification from paraffin-embedded tissues and subsequent DNA sequence analysis, an activating point mutation was detected in the K-ras protooncogene in one tumor. This mutation was a G to A transition in position 2 of codon 12, substituting aspartate (GAT) for glycine (GGT). This type of mutation has not been observed before in human brain tumors, but it is frequent in radiation-induced murine lymphomas. These observations suggest that PNET can be induced after completion of the embryonal and fetal development of the human CNS. Oncogene-activating point mutations may represent a pathogenetic mechanism involved in the genesis of radiation-induced brain tumors.

Second malignant neoplasms in patients treated for childhood leukemia. A population-based cohort study from the Nordic countries. The Nordic Society of Pediatric Oncology and Hematology (NOPHO)

Among a cohort of 981 children who were followed up 4.3-26.5 years after cessation of antileukemic therapy, eight patients in remission of acute lymphoblastic leukemia (ALL) developed a distinctively new malignant disease. The second malignant neoplasms (SMN) included brain tumors, basal cell carcinomas, thyroid cancer, leiomyosarcoma and finally rhabdomyosarcoma in a patient who also had suffered from Hodgkin's disease while still on antileukemic treatment. Cranial radiation had been given to 58.4% of the patients in the study group, which consisted of 895 ALL patients who had completed various chemotherapy protocols. With one exception, the SMN appeared after 7.5-16.5 years at a location previously exposed to radiotherapy (RT). The estimated cumulative risk of SMN appearing within 20 years after diagnosis was 2.9%, and the corresponding risk for cases with RT was 8.1% compared to 0.3% for those without (p = 0.05). In a Cox regression analysis, the incidence rate ratio of SMN between patients with and without RT was 6.7 (95% CI = 0.8, 57.7). Based on age-, year- and sex-specific cancer incidence figures for Norway, the overall standardized incidence rate ratio (SIR) of SMN after treatment for ALL was 5.9 (95% CI = 2.2, 12.9). The number of brain tumors among patients who had received cranial radiation was nearly 27 times greater than expected, whereas no such tumors were seen after chemotherapy. Individuals treated for childhood ALL are at increased risk of a new malignancy, and this seems mainly to be associated with previous irradiation.

Long-term consequences of CNS treatment for childhood cancer, Part I: Pathologic consequences and potential for oncogenesis

The pathologic changes associated with the treatment of cancer of the nervous system are reviewed. Computed tomographic, magnetic resonance imaging, and positron emission tomographic findings of these abnormalities are described, followed by discussion of the known histopathologic features. For the most part, pathologic effects are primary vascular and/or demyelinating. We review each of these effects at all levels of the neural axis. This review concludes with a discussion of the risk of developing second malignancies. Although this complication is infrequent, the likelihood that survivors of childhood cancer will develop a second malignancy is 10 times that of age-matched controls. This phenomenon in part relates to genetic predisposition, environmental factors, and host susceptibility. These qualifications not withstanding, most studies implicate central nervous system radiation with and without chemotherapy as the primary etiology for second malignancies.

Second intracranial neoplasms following treatment of childhood acute lymphoblastic leukaemia

We report a boy with acute lymphoblastic leukaemia (ALL) treated with chemotherapy and prophylactic cranial irradiation to a dose of 24 Gy. Six years after diagnosis he developed a glioma and died. Prior to 1979, four cases of second malignant neoplasm (SMN) of the brain had been reported in children treated for ALL. These SMNs occurred within 2 years of the original diagnosis (median 1.3 years) and at least two of four patients had not received prior radiotherapy. Since 1979, 28 cases of SMN of the brain have been reported including nine of 468 (1.9%) long-term survivors in one study. All occurred more than 3.7 years from diagnosis (median 6.5 years; range 4-13 years) and all received cranial irradiation (median 24 Gy; range 20-48 Gy). These data indicate a change in the pattern of SMNs which is most likely due to the introduction of cranial irradiation. As well, the frequency of SMNs in children treated for ALL appears to have increased, although it is still no greater than the risk of SMNs developing following the treatment of any other primary childhood neoplasm.

A report on radiation-induced gliomas

Radiation-induced gliomas are uncommon, with only 73 cases on record to date. The disease that most frequently occasioned radiation therapy has been acute lymphoblastic leukemia (ALL). Three more cases are added here, two after irradiation for ALL and one after irradiation for tinea capitis. In a review of the relevant literature, the authors stress the possibility that the ALL-glioma and the retinoblastoma-glioma links point to syndromes in their own right that may occur without radiation therapy.

The long-term side effects of radiation therapy for benign brain tumors in adults

Radiation therapy plays an integral part in managing intracranial tumors. While the risk:benefit ratio is considered acceptable for treating malignant tumors, risks of long-term complications of radiotherapy need thorough assessment in adults treated for benign tumors. Many previously reported delayed complications of radiotherapy can be attributed to inappropriate treatment or to the sensitivity of a developing child's brain to radiation. Medical records, radiological studies, autopsy findings, and follow-up information were reviewed for 58 adult patients (31 men and 27 women) treated between 1958 and 1987 with radiotherapy for benign intracranial tumors. Patient ages at the time of irradiation ranged from 21 to 87 years (mean 47.7 years). The pathology included 46 pituitary adenomas, five meningiomas, four glomus jugulare tumors, two pineal area tumors, and one craniopharyngioma. Average radiation dosage was 4984 cGy (range 3100 to 7012 cGy), given in an average of 27.2 fractions (range 15 to 45 fractions), over a period averaging 46.6 days. The follow-up period ranged from 3 to 31 years (mean 8.1 years). Findings related to tumor recurrence or surgery were excluded. Twenty-two patients had complications considered to be delayed side effects of radiotherapy. Two patients had visual deterioration developing 3 and 6 years after treatment; six had pituitary dysfunction; and 17 had varying degrees of parenchymal changes of the brain, occurring mostly in the temporal lobes and relating to the frequent presentation of pituitary tumors (two of these also had pituitary dysfunction). One clival tumor with the radiographic appearance of a meningioma, developed 30 years post-irradiation for acromegaly. This study unveils considerable delayed sequelae of radiotherapy in a series of adult patients receiving what is considered "safe" treatment for benign brain tumors.

Monosomy 12p in a radiation-induced germ cell tumor

We report results of cytogenetic analysis of a cell line established from a radiation induced germ cell tumor. Tumors of this type are rare, and there is only one other report of chromosome analyses of solid tumors induced by radiotherapy (Cowan et al., 1990). The cells were grown for over a year, and harvested at passage 13. The karyotype was pseudodiploid, with several balanced translocations. Spontaneously occurring germ cell tumors are associated with i(12p). We did not observe an i(12p), but instead found monosomy of 12p and 7q22----q32.

CNS tumor induction by radiotherapy: a report of four new cases and estimate of dose required

We have analyzed 60 cases of intra-axial brain tumors associated with antecedent radiation therapy. These include four new cases. The patients had originally received radiation therapy for three reasons: (a) cranial irradiation for acute lymphoblastic leukemia (ALL), (b) definitive treatment of CNS neoplasia, and (c) treatment of benign disease (mostly cutaneous infections). The number of cases reported during the past decade has greatly increased as compared to previous years. Forty-six of the 60 intra-axial tumors have been reported since 1978. The relative risk of induction of an intra-axial brain tumor by radiation therapy is estimated to be more than 100, as compared to individuals who have not had head irradiation.

Central nervous system relapse prevention in 1165 standard-risk children with acute lymphoblastic leukemia in five BFM trials

In treatment of childhood ALL, prevention of CNS relapse by cranial irradiation is followed by considerable long-term sequelae. In the three ALL-BFM (Berlin-Frankfurt-Münster) trials 70, 76, and 79, employing radiotherapy (8.5 Gy craniospinal, 18 or 24 Gy cranial irradiation) in all arms, the incidence of CNS relapses (isolated and combined) in standard-risk patients (SR, 60% of all children) was consistently less than 6%. A risk factor (RF) calculated from absolute blast number, liver, and spleen size at diagnosis was used to stratify patients in the subsequent trials ALL-BFM 81 and 83. In ALL-BFM 81, SR patients (RF less than 1.2) were randomized to receive 18 Gy cranial irradiation or intermediate-dose i.v. methotrexate (ID-MTX) (4 x 0.5 g/m2). In ALL-BFM 83, the SR group was further subdivided into group SR low (SR-L, RF less than 0.8) and group SR high (SR-H, RF 0.8 - less than 1.2). SR-L patients received no irradiation, and were tested by randomization for the effectiveness of an intensive reinduction regimen (protocol III). SR-H patients were randomized for 12 or 18 Gy. The results were as follows: In patients of both trials with RF less than 0.8, radiotherapy could be replaced by ID-MTX plus protocol III. Without protocol III, relapses increased from 15.7% to 31.7%. Concomitantly, the fraction of relapses with CNS involvement increased from 26.7% to 36.4%. However, SR patients with RF between 0.8 and 1.2 could not be protected by reinduction alone (isolated/overall CNS relapse rate with irradiation, 4%/5%; without irradiation, 11%/22%). Dosages of 12 and 18 Gy were found to be equally protective.

Radiation-induced intracranial malignant gliomas

The authors present seven cases of malignant gliomas that occurred after radiation therapy administered for diseases different from the subsequent glial tumor. Included among these seven are three patients who were treated with interstitial brachytherapy. Previously reported cases of radiation-induced glioma are reviewed and analyzed for common characteristics. Children receiving central nervous system irradiation appear particularly susceptible to induction of malignant gliomas by radiation. Interstitial brachytherapy may be used successfully instead of external beam radiotherapy in previously irradiated, tumor-free brain, and thus may reduce the risk of radiation necrosis.

Postradiation astrocytoma. Report of two cases

The authors describe two cases of malignant astrocytomas associated with previous radiation therapy in childhood for intracranial germinoma and craniopharyngioma. In both patients, there was no recurrence at the primary tumor site. Because of a geometric coincidence between the tumor location and the radiation field, radiotherapy was strongly implicated as a cause of these two astrocytomas.

Late effects of antileukemic treatment

Increasing numbers of childhood ALL survivors have increased the need to assess the physical and psychosocial functioning of this group in a careful manner. This article reviews data on the frequency and types of second malignancies, structural and functional changes in the central nervous system, endocrine effects on growth and reproduction, and psychosocial aspects of development. Most long-term survivors of ALL do not have serious or life-threatening medical problems; however, medical and psychosocial problems may not be insignificant and may require coordinated management over prolonged periods.

Glioblastoma developing at the site of a cerebellar medulloblastoma treated 6 years earlier. Case report

The authors report the highly unusual development of a glioblastoma multiforme at the site of excision of a medulloblastoma 6 years earlier. The patient was operated on for a cerebellar medulloblastoma at the age of 13 years. Postoperative treatment included irradiation and chemotherapy. Six years later, a glioblastoma multiforme was found at the original site of the medulloblastoma. Intensive multimodality treatment is considered the likely cause for the later tumor development.

Oligodendroglioma occurring after radiation therapy for pituitary adenoma

A 38 year old male dentist developed an oligodendroglioma of the left medial temporal lobe and parasellar region 12 years after radiotherapy with 6600 rads of acromegaly. The 30 cases of radiation-induced gliomas reported in the English literature are reviewed and analysed. The criteria for defining radiation-induced tumours of the central nervous system are proposed as follows: the tumour has a long quiescent "latency period", a location in the previously irradiated field, a verified histological difference from a primary condition, and does not arise from a primary condition associated with a genetic syndrome such as neurofibromatosis or tuberous sclerosis. The reported case fulfilled these criteria but appears to be the only reported radiation-induced oligodendroglioma.

Late multifocal gliomas in adolescents previously treated for acute lymphoblastic leukemia

Three of 37 adolescents in long-term remission from childhood acute lymphoblastic leukemia (ALL) developed malignant multifocal gliomas several years after completing treatment that included central nervous system (CNS) prophylaxis with radiation (RT) and intrathecal methotrexate (IT-MTX). No recurrence of the leukemia was evident when the CNS tumors were discovered. Seventeen other similar cases have been recorded. The occurrence of second malignancies is reviewed in the context of this development and of the oncogenic effects of radiation. It is probable that prolonged exposure to IT-MTX may have had a synergistic effect with radiation in contributing to the unusual incidence of glial tumors in these patients.

Supratentorial malignant gliomas in childhood: a review of fifty cases

From 1977 to 1986, 50 children aged 15 months to 18 years were treated for supratentorial malignant gliomas at the Memorial Sloan-Kettering Cancer Center and the New York University Medical Center. Thirteen patients had glioblastoma multiforme, 29 had anaplastic astrocytomas, and 8 had malignant gliomas. In 10 patients the tumor evolved from a low-grade lesion. Seven patients, including 2 patients with neurofibromatosis, developed multiple primary malignant neoplasms. The median time to tumor progression after surgery was 31 weeks, with local recurrence representing the mode of treatment failure in nearly all patients. Notable clinical features included symptomatic leptomeningeal metastasis (13 patients) and intratumoral hemorrhage (9 patients). The estimated median survival time for all 50 patients was 98 weeks, with a 3-year survival rate of 32%. A trend toward longer survival was seen in patients 12 years of age or younger at diagnosis. There was no apparent correlation between survival and tumor histology or tumor location. Recommendations for management are presented.

Brain tumors after cranial irradiation for childhood acute lymphoblastic leukemia. A 13-year experience from the Dana-Farber Cancer Institute and the Children's Hospital

Brain tumors developed in two children after they had received cranial irradiation as central nervous system therapy for acute lymphoblastic leukemia. A review of the literature demonstrated an increased incidence of brain tumors in survivors of acute lymphoblastic leukemia who received central nervous system irradiation. Most of the brain tumors occurred within a decade after radiotherapy. Further data will be required to determine whether early post-radiation brain tumors in patients with acute lymphoblastic leukemia are due to the central nervous system irradiation or to a genetic predisposition.

Malignant glioma following radiotherapy for unrelated primary tumors

Four cases are documented where a glioma was histologically verified in the irradiation field of a previously treated malignancy of a different cell line. Radiation-induced neoplasia in the central nervous system now has been established in the induction of meningioma and sarcoma. The association between therapeutic irradiation and glioma in the reported cases lends to the evidence that a causal relation does exist. This incidence is small and does not detract from the overall benefit of irradiation as a therapeutic modality.

Cerebral astrocytoma as a complication of acute lymphoblastic leukaemia

A boy who developed acute lymphoblastic leukaemia at the age of two years and 10 months had several central nervous system relapses, and received two courses of cranial irradiation, each of 24 Gy, in addition to systemic and intrathecal chemotherapy. Nearly 10 years after the onset of his leukaemia he developed a brain stem astrocytoma from which he died. This appears to be a rare occurrence, and the role of the treatment in the induction of his second tumour is discussed. The need for the long-term follow-up of cancer patients after apparent cure is emphasized.

Astrocytoma as a second malignancy in patients with acute lymphoblastic leukemia

Three cases of astrocytoma, two cerebral (grades II and III) and one spinal (grade II) occurring as second malignancies in patients with previously diagnosed acute lymphoblastic leukemia are described. All had received prophylactic cranial irradiation and intrathecal methotrexate. All were in remission at the time of development of the second malignancy. The time interval between central nervous system (CNS) prophylaxis and symptoms of CNS tumor was between 3 and 5 years. The possible causes of the combination of astrocytoma with acute lymphoblastic leukemia are discussed.

The long-term effects of cranial irradiation on the central nervous system

Cranial irradiation and chemotherapy may have significant long-term deleterious effects on children with brain tumors. Intellectual deterioration, endocrinopathies, leukoencephalopathy, extraneural metastases, and oncogenesis may all complicate the treatment of central nervous system neoplasia. These long-term effects of therapy have important implications, as some are amenable to treatment and others may be prevented by the careful monitoring of drug and radiation administration. Until recently, the survivals of children with brain tumors were limited, so that concerns over long-term effects of therapy were unnecessary. As children with certain types of brain tumors now have a better prognosis, these long-term and possibly remediable effects have important implications. This article emphasizes radiation effects on intellect, endocrine function, and oncogenesis. Recommendations for baseline and longitudinal evaluations of children with brain tumors are suggested.

Occurrence of glioblastoma multiforme in three closely related patients

Three cases of glioblastoma multiforme are presented. These cases have in common the fact that all three patients were relatives but not blood relatives. There had been prolonged intimate contact between them before the development of the neoplastic lesion.

Astrocytoma following scalp radiotherapy in infancy

A 24 year old woman with a 15 year history of intractable seizures underwent resection of a small low grade astrocytoma of the right mesial frontal lobe. The tumor arose beneath a benign scalp nevus that had been treated in infancy with radium patches and focal x-irradiation. Neuropathological changes within the tumor were compatible with radiation injury. Meningiomas and sarcomas complicate cranial irradiation but the evidence that gliomas do so is less convincing. Our observations support an association between radiation exposure and the subsequent development of glial tumors.

Cerebral glioma after cranial prophylaxis for acute lymphoblastic leukaemia

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Second neoplasms in acute lymphoblastic leukemia

The authors reviewed 61 reported cases of second neoplasms in acute lymphoblastic leukemia (ALL), including 17 patients with ALL followed by another type of acute leukemia, 12 patients with ALL followed by chronic myelocytic leukemia, 19 patients with ALL followed by lymphoma, and 13 patients with ALL followed by other solid tumors. From a review of the literature, it is believed that there is no firm evidence yet that patients with ALL, intensively treated with chemotherapy and/or radiotherapy, are at increased risk of developing therapy-related second neoplasms. Because the number of cases reported is small, there is even insufficient data to firmly suggest that acute myeloblastic leukemia, following intensive therapy for ALL, occurs in a higher-than-expected frequency.