Cerebral glioma after cranial prophylaxis for acute lymphoblastic leukaemia

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.

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.

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.

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).

Low incidence of second neoplasms among children diagnosed with acute lymphoblastic leukemia after 1983

Second malignant neoplasms are a serious complication after successful treatment of childhood acute lymphoblastic leukemia (ALL). With improvement in survival, it is important to assess the impact of contemporary risk-based therapies on second neoplasms in ALL survivors. A cohort of 8831 children diagnosed with ALL and enrolled on Children's Cancer Group therapeutic protocols between 1983 and 1995 were observed to determine the incidence of second neoplasms and associated risk factors. The median age at diagnosis of ALL was 4.7 years. The cohort had accrued 54 883 person-years of follow-up. Sixty-three patients developed second neoplasms, including solid, nonhematopoietic tumors (n = 39: brain tumors n = 19, other solid tumors n = 20), myeloid leukemia or myelodysplasia (n = 16), and lymphoma (n = 8). The cumulative incidence of any second neoplasm was 1.18% at 10 years (95% confidence interval, 0.8%-1.5%), representing a 7.2-fold increased risk compared with the general population. The risk was increased significantly for acute myeloid leukemia (standardized incidence ratio [SIR] 52.3), non-Hodgkin lymphoma (SIR 8.3), parotid gland tumors (SIR 33.4), thyroid cancer (SIR 13.3), brain tumors (SIR 10.1), and soft tissue sarcoma (SIR 9.1). Multivariate analysis revealed female sex (relative risk [RR] 1.8), radiation to the craniospinal axis (RR 1.6), and relapse of primary disease (RR 3.5) to be independently associated with increased risk of all second neoplasms. Risk of second neoplasms increased with radiation dose (1800 cGy RR 1.5; 2400 cGy RR 3.9). Actuarial survival at 10 years from diagnosis of second neoplasms was 39%. Follow-up of this large cohort that was treated with contemporary risk-based therapy showed that the incidence of second neoplasms remains low after diagnosis of childhood ALL.

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.

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.

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.

Cerebral radiation necrosis complicating stereotactic radiosurgery for arteriovenous malformation

A patient presented with symptoms and signs of raised intracranial pressure and increasing focal deficit 13 months after stereotactic radiosurgical treatment of an arteriovenous malformation (AVM). Computed Tomography (CT) showed a mass lesion at the site of the previous abnormality typical of radiation necrosis, but with features identical to those of a malignant neoplasm. Biopsy confirmed cerebral radiation necrosis. The radiation dose was 25 Gray to the periphery of two overlapping 14 mm collimator fields, delivered in a single dose. Treatment with steroids led to improvement in the symptoms and signs of raised intracranial pressure, but not the focal deficit. Radiation necrosis is a consequence of the large doses required to obliterate AVMs and is a limiting factor in their treatment. It is important for clinicians referring patients for stereotactic radiosurgery to be aware of this complication, and to be able to recognise and treat it.

Post-radiation glioma in a child. Case report and review of the literature

A case of primary brain neoplasm is reported that developed 11 years after prophylactic brain irradiation and intrathecal methotrexate (MTX) given for acute lymphocytic leukemia (ALL) at the age of 3 years. Cases of supposed postirradiation gliomas in children seem to have increased in recent years, particularly following apparently successful treatment for ALL or medulloblastoma. This increase might reflect the increased number of long-surviving cancer children and thus suggest that brain irradiation may be a potential risk factor in this population. After reviewing some general data on neurooncogenesis, two points are stressed: (1) the child's brain is particularly susceptible to the mutagenic effects of ionizing radiation owing to physiologically active postnatal glial cell proliferation, which takes place in the cerebral hemispheres, especially during myelinogenesis; (2) MTX could promote glial neoplasm by enhancing reparative glial cell proliferation. Prospective studies seem necessary to show whether or not prophylactic brain radiation in ALL plays an oncogenetic role. Nevertheless, besides recurrent leukemia, leukoencephalopathy, and radionecrosis, the remote possibility of radiation-induced glial neoplasms should always be considered in cases of children treated for leukemia who present with neurological complications.

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.

Improved survival for childhood acute lymphoblastic leukemia: possible effect of protocol compliance

Survival rates were analyzed for an effectively population-based series of 77 children with acute lymphoblastic leukemia treated at one hospital during 1970-1981. Treatment was according to Medical Research Council protocols UKALL I to UKALL VII but with a great emphasis on compliance. The relapse-free survival rate was 54.5% at 5 years. The overall 5-year survival rate of 64% was substantially higher than the 47% recorded during a similar period over the rest of Britain. The difference between survival rates in this series and nationally was especially marked for children aged 2-9 years (76% versus 50%) and with white blood count under 10 x 10(9)/L (87% versus 57%). For both of these groups, the survival rates achieved were similar to those now being recorded for the UKALL VIII trial in which treatment is more sustained than in its predecessors and there is greater emphasis on doctor compliance with protocol. These results suggest that although the advantage of UKALL VIII over previous trials for poor prognosis patients may be attributed to the more sustained treatment, the improvement for good prognosis patients may be due to more rigorous compliance with protocol.

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.

Patterns of multiple primary tumours in patients treated for cancer during childhood

One hundred and sixty one children who have developed more than one primary neoplasm have been identified. Children with tumours of the central nervous system, retinoblastoma and leukaemia were those most frequently observed to develop a second malignancy whilst osteosarcoma was the most common second tumour. The patterns of second neoplasms appear to be changing and a recent increase in the number of children with leukaemia and lymphoma who develop second primary tumours has been observed. In this series, the two most frequent associations of tumours were retinoblastoma followed by osteosarcoma and the combination of acute leukaemia with a tumour of the central nervous system. Genetic factors which may have contributed to the development of the second primary tumour were identified in 53 patients (33%), 33 of whom had the genetic form of retinoblastoma. In an analysis of the treatment of 151 patients, for whom the interval between the two neoplasms was greater than 12 months, the second malignancy was considered to be 'radiation associated' in 93 (61%). Fifty children (33%) had been treated with either single or multiple agent chemotherapy which included an alkylating agent in 38. Forty five children had received a combination of chemotherapy and radiotherapy and of these, 10 developed leukaemia as their second tumour. Of the 19 secondary leukaemias, 16 have occurred in patients treated since 1970.

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.

The correlation of neoplastic vulnerability with central neuroepithelial cytogeny and glioma differentiation

The vulnerability of neuroepithelial cells in the central nervous system (CNS) to neoplastic transformation results from the interaction of several factors: the existence of a reserve population of stem cells, the capability of differentiated cells to reenter the kinetic cycle, the number of replicating cells at risk at a particular time, the length of time during which a particular cell population remains in the cycle, the state of differentiation and the further differentiation potential of that population, and the steps of differentiation that are achieved in successive cell generations. This concept explains many aspects of CNS tumor incidence and the relationship of central neuroepithelial embryonal tumors to tumors of adult cell type. The incidence of different types of central neuroepithelial tumors can be correlated with the width of the window of neoplastic vulnerability. Examples illustrating the existence of only a narrow window include such rare tumors as medulloepitheliomas, cerebral neuroblastomas, gangliogliomas and ependymoblastomas. By contrast, cerebellar medulloblastomas, astrocytomas, mixed astrocytomas and oligodendrogliomas, and glioblastomas exemplify instances in which a relatively wider window of vulnerability exists in the light of cellular neuro-ontogeny and of the capacity of glial cells for postnatal replication. The relationship that may occasionally be established between the development of a glioma and the production of cellular gliosis such as may follow brain injury or accompany multiple sclerosis can also be viewed in the light of that concept. Increasing awareness is needed concerning the development of postradiation gliomas, in particular after the apparently successful treatment of acute lymphocytic leukemia.

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.