Radiation carcinogenesis in man: new primary neoplasms in fields of prior therapeutic radiation

The risk of radiation-induced cancer in patients with squamous cell carcinoma of the head and neck and its results of treatment

The purpose of this study was to determine the incidence and the results of treatment of cancer induced by radiotherapy for early stage (stage I and II) squamous cell carcinoma of the head and neck (SCH). The clinical records of 355 patients with early stage malignant lymphoma of the head and neck region treated by radiotherapy were reviewed, and then the records of 1358 patients with early stage SCH (oral cavity, 956; larynx, 154; oropharynx, 110; maxillary sinus, 86; lip, 20; epipharynx, 17; hypopharynx, 15) who underwent radiotherapy were reviewed. The disease-specific 10-year survival rate of the patients with 355 malignant lymphoma was 61%, and 5 cases of radiation-induced cancer occurred more than 8 years after irradiation. The crude incidence of radiation-induced cancer in the malignant lymphoma patients was 1.4%, and the 10-year probability by the actuarial life table method was 0.8%. The 10-year survival rate of the early stage SCH patients was 71%. The crude incidence of a second cancer in a previously irradiated field after an 8-year latent period (SCI) in the SCH patients was 1.8% (25/1358), and the 10-year probability was 1.6%. 12 SCIs were treated by surgery and 8 of those 12 patients (67%) resulted in success, whereas treatment by radiation resulted in failure in every other case. The risk of SCIs in the SCH group was higher than in the early stage malignant lymphoma group, although the difference was not statistically significant. The possibility of radiation-induced cancer in SCH is small, and the advantage of radiation therapy compares favourably with the risks of other treatments.

[About an uncommon case of post-irradiation sarcoma of the chest wall]

A case of postirradiation leiyomyosarcoma of the chest wall is presented. The tumor occurred after 4 episodes of radiotherapy over a period of 12 years. Criterious to define the radiation-induced sarcoma are discussed. The location of the leiomyosarcoma in comparison with the different irradiated fields shows that the tumor occurred in the border line of the differents fields called "zone of penumbra".

[Radiation-induced intracerebral sarcoma]

We report a case of radiation-induced sarcoma in a 50 year-old male patient who was treated with total resection and radiation for right temporal lobe PNET. He received a dose of 60-Gy. A sequential magnetic resonance image 32 months after the completion of radiation therapy and 34 months after surgery showed a mass in the right temporal cerebral convexity. The postoperative diagnosis was sarcoma. Two years later the patient was operated because of a new lesion with similar characteristics. The follow up from the PNET diagnosis is 5 years and 10 months and the survival from sarcoma diagnosis is now 3 years and there is no evidence of recurrence. The development of sarcoma subsequent to cranial irradiation is an infrequent event but it should be considered in the differential diagnosis of a lesion that progresses several years after radiation therapy or when a new lesion appear.

Radiation-induced esophageal carcinoma 30 years after mediastinal irradiation: case report and review of the literature

A 54-year-old man who had been irradiated in 1964 for cervical involvement by Hodgkin's disease was admitted in December 1994 to our clinic with strong complaints of dysphagia. The reason was a moderately differentiated squamous cell carcinoma of the proximal esophagus in the previously irradiated region. The patient had no risk factors (abuse of nicotine or alcohol) for the developement of esophageal carcinoma. A reirradiation was performed, but the disease progressed locally and two weeks after the beginning of the therapy the patient developed two tracheoesophagocutaneous fistulae. The radiation therapy was discontinued and the tumor stenosis was bridged by a tube closing the fistulae. A retrospective dose analysis to evaluate the applied doses will be performed. Furthermore, an overview of 66 cases of the literature with radiation-induced esophageal carcinoma analysed concerning applied dose and latent interval will be given. In conclusion the reported case fits the criteria for radiation-induced malignancies (Chudecki Br J Radiol 1972;45:303-4) known from literature: (1) a history of previous irradiation, (2) a cancer occurring within the irradiated area, (3) gross tissue damage due to an excessive dose of radiation, and (4) a long latent interval between irradiation and development of cancer. Esophageal carcinomas belong to the rare secondary malignancies after the therapeutic use of ionizing radiation. Nevertheless in patients with dysphagia they should be suspected as a differential diagnosis even many years after mediastinal irradiation. The treatment of these tumors is very difficult and is associated with a poor prognosis.

[Bilateral breast cancer after Hodgkin disease. Clinical and pathological characteristics and therapeutic possibilities: an analysis of 13 cases]

PURPOSE

Though Hodgkin's disease (HD) is one of the malignancies in which considerable progress has been made, long-term side effects have been observed, second primary cancer being the most significant. Several recent reports have indicated an increased risk of breast cancer (BC) in girls and young women among HD patients.

MATERIALS AND METHODS

In a retrospective multicenter analysis, 63 women treated for HD subsequently developed BC. Results that were obtained in 13 women (21%) who developed either synchronous (five cases) or metachronous (eight cases) BC were analyzed. The median age at diagnosis of HD was 19 years. Seven patients underwent exclusive radiotherapy (RT) (including "mantle" supradiaphragmatic irradiation) and six received concomittant radiation therapy and chemotherapy.

RESULTS

The first breast tumor occurred after a median delay of 16 years. According to the TNM classification, we showed nine stage T0 (non palpable lesions), four stage T1, five stage T2, one stage T3, two stage T4 and five stage Tx BC. Seventeen infiltrating carcinomas, two fibrosarcomas and seven ductal carcinomas in situ were observed. Among 15 axillary dissections performed for invasive carcinomas, histological involvement was found in 10 cases. Seventeen tumors were treated by mastectomy and nine patients underwent conservative surgical treatment. With a 70-month median follow-up (range: 15-125), three patients developed locoregional recurrence and four other metastases. At present, eight are alive with no evidence of disease and one died of intercurrent disease.

CONCLUSION

According to previous works, BC represents 6.3 to 9% of all second cancers occurring after HD treatment. The risk is higher in young women treated before 20 years of age, especially before 15 years of age. Factors that favour the development of secondary BC are: supradiaphragmatic irradiation, very young age at treatment, chemotherapy with alkylating agents, and probably genetic factors. We conclude that young women and girls treated for HD should be carefully monitored at least 10 years after the end of the treatment for HD, using clinical examination, mammography and ultrasonography. The optimal rythm of this follow-up is not yet clearly defined. Moreover, after multidisciplinary concertation, we suggest that secondary BC be sometimes treated by conservative radiosurgical approach.

Glioma occurrence after sellar irradiation: case report and review

OBJECTIVE

Tumor neogenesis is an uncommon but known consequence after therapeutic irradiation of the central nervous system. Causative agents for glioma induction remain unknown, but laboratory and clinical data suggest a possible role for radiation as a promotor. In the treatment of both pituitary adenomas and craniopharyngiomas, adjunctive conventional radiation therapy has long played a role.

CLINICAL PRESENTATION

This report details two cases in which patients received standard sellar irradiation for growth hormone-secreting pituitary adenomas and later were diagnosed with gliomas, after a latency period of 11 and 18 years, respectively. Additionally, a comprehensive review of the literature with 30 reports of gliomas developing after conventional radiation for treatment of pituitary adenomas and craniopharyngiomas is presented. The mean dose for craniopharyngiomas (n = 8) was 5800 cGy, with a mean latency of 11.5 years from initial diagnosis to the eventual discovery of the gliomas. The mean dose for the treatment of pituitary adenomas (n = 24) was 5300 cGy, with a mean latency of 10.4 years.

CONCLUSION

Typical features of the resulting gliomas included presentation in young patients, histologically high grades, and occurrence within the temporal lobe. A large proportion of gliomas were associated with growth hormone-secreting adenomas. This review assesses the implication of doses of conventional radiotherapy that were previously thought to be benign and concludes that although radiation-associated gliomas are uncommon, they represent a potentially devastating long-term risk. Based on this analysis, treatment of sellar tumors with conventional fractionated radiotherapy should be carefully considered and perhaps used primarily in those cases for which radiosurgery is not appropriate.

Radiation-induced sarcoma of the skull: report of two cases

The authors describe two cases of sarcomas of the skull following cranial irradiation in patients treated for other neoplasms, acute lymphatic leukemia, and astrocytoma, respectively. The patients (one man and one woman: mean age 24.5 years) developed sarcomas within the irradiated field after a mean latency period of 11.5 years. Histologically, the tumor proved to be a fibrosarcoma. Despite aggressive surgery and other therapy, the survival of the patients was short (10 and 8 months, respectively). The pathological and clinical aspects of this unusual complication are analyzed with reference to 41 cases taken from the world literature.

Sarcomas subsequent to cranial irradiation

The development of sarcoma subsequent to cranial irradiation is a rare but serious and potentially fatal event. We describe seven patients who had undergone cranial irradiation (range, 1600-6000 cGy) to treat their primary disease and who developed sarcomas within the irradiated field. The median time from radiation therapy to the development of a sarcoma was 8 years (range, 4 to 15 yr). Fibrosarcomas developed in four patients, and malignant fibrous histiocytomas developed in three. Despite aggressive treatment, the prognosis was poor; the median survival from the diagnosis of sarcoma was 19 months. Sarcoma should be considered in the differential diagnosis of a new lesion or a lesion that progresses several years after radiation therapy.

Three cases of sarcoma occurring after radiation therapy of breast cancers

We report 3 cases of sarcomas following irradiation for breast carcinoma. Median latent period ranged from 7 to 17 years. Histologic types were 1 malignant fibrous histiocytoma, 1 osteochondrosarcoma, 1 chondrosarcoma. Diagnosis was often delayed because of non-specific clinical features. The prognosis of these postirradiation sarcomas was poor with the median survival ranging from 10 to 70 months. One patient had a complete resection and is alive at 70 months. In the other 2 non-resectable patients, chemotherapy and/or radiotherapy did not induce an objective response. The poor prognosis when these tumors are diagnosed late emphasizes the need for increased awareness, which should lead to earlier diagnosis and, it is hoped, permit radical surgical treatment.

Second primary bladder cancer following pelvic irradiation for other malignancies

Between 1985 and 1990, five cases of radiation-induced bladder cancer were treated at our center. The first primary neoplasm was uterine cervical cancer in three patients, uterine endometrial cancer in one patient, and Hodgkin's disease in one patient. Additional treatment for the primary neoplasm included panhysterectomy for the patient with endometrial cancer and cyclophosphamide-based combination chemotherapy for the patient with Hodgkin's disease. The mean age at development of bladder cancer was 60.4 years, and the average time interval between irradiation and development of bladder cancer was 14.6 years. All the bladder cancers were invasive. The treatment modalities included anterior pelvic exenteration in one patient, partial cystectomy in one patient, reirradiation in two patients, including the use of intraoperative electron therapy in one patient, and TUR plus endoscopic Nd:YAG laser treatment in one patient. Four patients are alive without disease at a mean follow-up period of 15 months from the diagnosis of bladder cancer.

Second cancer after radiation therapy for cancer of the uterine cervix

Radiation-induced cancers after radiation therapy for cancer of the uterine cervix were investigated on 11,855 patients including 5725 patients treated with radiation therapy alone, 1969 postoperative radiation therapy and 4161 surgery alone. The observed-to-expected ratios of the second primary cancer was 0.933 for the patients with radiation therapy alone and 1.074 for the patients with postoperative radiation therapy, respectively. No significant increase was observed in the risk of second primary cancers when all sites were combined. However, assessing on site by site basis, significant excess was noted for the rectum cancer, leukemia, and bladder cancer for the radiation therapy group but not for the surgery group. A significant excess of lung cancer was observed in both radiation therapy and surgery groups, which was attributed to some other causative factors. Radiation-induced cancers were suggested to develop apparently in organs involved in the irradiated field.

Management of the parotid pleomorphic adenoma, the problem of exposing tumour tissue at operation. The logical pursuit of treatment policies

The objective of treatment of a parotid pleomorphic adenoma is to remove all tumour cells with minimal short- and long-term morbidity and minimal recurrence rates. If an enucleation is carried out, the facial nerve may be put at risk and tumour fragments will inevitably be left in the wound. Most surgeons suggest that after enucleation, radiotherapy must be given to reduce the recurrence rate to an acceptable level. If during a formal superficial parotidectomy the tumour capsule is visualised, the objective of removing the tumour with an intact cuff of normal tissue has failed and the operation has in effect become an enucleation. This paper defines the problem and discusses its management.

Embryonal rhabdomyosarcoma arising in the masseter muscle as a second malignant neoplasm

A case is reported about a patient who was originally treated for bilateral retinoblastoma and subsequently developed an embryonal rhabdomyosarcoma in the masseter. Such patients have a genetic predisposition to a second malignancy that statistically far exceeds the rate for the general population. In addition, current treatment methods also increase the patient's susceptibility to another malignancy. This case emphasizes the necessity of maintaining a high degree of clinical suspicion in the evaluation of any lesion that may appear subsequent to the treatment of cancer in children, particularly bilateral retinoblastoma.

Mandibular sarcoma as a second neoplasm following radiotherapy for a nasopharyngeal carcinoma in childhood (case report)

We report an unusual case of mandibular sarcoma which developed in the field of irradiation of a patient treated successfully 10 years previously for nasopharyngeal carcinoma (NC). Although second malignant neoplasms are not rare among survivors of childhood cancer, this event is not included among the type of failures and complications of treatment of NC occurring either in children.

Radiation-induced sarcomas of the chest wall

Sixteen patients are presented who had sarcomas of the chest wall at a site where a prior malignancy had been irradiated. The first malignancies included breast cancer (ten cases), Hodgkin's disease (four cases), and others (two cases). Radiation doses varied from 4200 to 5500 R (mean, 4900 R). The latency period ranged from 5 to 28 years (mean, 13 years). The histologic types of the radiation-induced sarcomas were as follows: malignant fibrous histiocytoma, nine cases; osteosarcoma, six cases; and malignant mesenchymoma, one case. The only long-term survivor is alive and well 12 years after resection of a clavicular chondroblastic osteosarcoma. Three cases were recently diagnosed. Despite aggressive multimodality treatment, the remaining 13 patients have all died from their sarcomas (mean survival, 13.5 months). All patients have apparently been cured of their first malignancies. Chemotherapy was ineffective. No treatment, including forequarter amputation, appeared to palliate the patients with supraclavicular soft tissue sarcomas. Major chest wall resection offered good palliation for seven of eight patients with sarcomas arising in the sternum or lateral chest wall. Close follow-up is needed to detect signs of these sarcomas in the ever-increasing number of patients receiving therapeutic irradiation.

Recurrence rate of positive margin basal cell carcinoma: results of a five-year prospective study

The few previous studies on recurrence of incompletely excised basal cell carcinoma are retrospective, and the reported recurrence rate ranges from 19% to 67%. In a prospective study design, wer found a recurrence rate of 41% and 34 surgically excised positive-margin basal cell carcinomas. The mean time until tumor recurrence was 24.6 months. The mean follow-up time in those patients remaining free of tumor was 61.4 months.