Ewing sarcoma in an infant and review of the literature

Bedük Esen ÇS, Gültekin M, Aydın GB, Akyüz C, Karlı Oğuz K, Orhan D, Cengiz M, Gürkaynak M, Yıldız F. Ewing sarcoma in an infant and review of the literature. Turk J Pediatr 2019; 61: 760-764. Ewing sarcoma (ES) is a rare tumor in infants and prognosis is controversial. There are no standard recommendations for treatment in such very young patients. Generally, radiotherapy (RT) is not a part of treatment in infants due to the risk of severe late side effects. In this case report, we report a 7-month-old boy with diagnosis of left mastoid bone ES with lung metastases at diagnosis, showing a rapidly fatal outcome despite aggressive systemic chemotherapy and RT without surgery.

Comparison of Chest Wall and Lymphatic Radiotherapy Techniques in Patients with Left Breast Carcinoma

OBJECTIVE

The aim of this study was to find the most appropriate technique for postmastectomy chest wall (CW) and lymphatic irradiation.

MATERIALS AND METHODS

Partially wide tangent, 30/70 photon/electron mix, 20/80 photon/electron mix and CW and internal mammary en face electron field, were studied on computerized tomography (CT) scans of 10 left breast carcinoma patients and dosimetric calculations have been studied. Dose volume histograms (DVH) obtained from treatment planning system (TPS) were used for minimal, maximal and mean doses received by the clinical target volumes and critical structures.

RESULTS

Partially wide tangent field resulted in the most homogeneous dose distribution for the CW and a significantly lower lung and heart doses compared with all other techniques. However, right breast dose was significantly higher for partially wide tangent technique than that each of the other techniques. Approximately 0.6-7.9% differences were found between thermoluminescent dosimeter (TLD) and treatment planning system (TPS). The daily surface doses calculating using Gafchromic® external beam therapy (EBT) dosimetry films were 161.8±2.7 cGy for the naked, 241.0±1.5 cGy when 0.5 cm bolus was used and 255.3±2.7 cGy when 1 cm bolus was used.

CONCLUSION

As a result of this study, partially wide tangent field was found to be the most appropriate technique in terms of the dose distribution, treatment planning and set-up procedure. The main disadvantage of this technique was the higher dose to the contralateral breast comparing the other techniques.

Salvage reirradiaton with stereotactic body radiotherapy for locally recurrent head-and-neck tumors

PURPOSE

In this study, we present our results of reirradiation of locally recurrent head-and-neck cancer with image-guided, fractionated, frameless stereotactic body radiotherapy technique.

METHODS AND MATERIALS

From July 2007 to February 2009, 46 patients were treated using the CyberKnife (Accuray, Sunnyvale, CA) at the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey. All patients had recurrent, unresectable, and previously irradiated head-and-neck cancer. The most prominent site was the nasopharynx (32.6%), and the most common histopathology was epidermoid carcinoma. The planning target volume was defined as the gross tumor volume identified on magnetic resonance imaging and computed tomography. There were 22 female and 24 male patients. Median age was 53 years (range, 19-87 years). The median tumor dose with stereotactic body radiotherapy was 30 Gy (range, 18-35 Gy) in a median of five (range, one to five) fractions.

RESULTS

Of 37 patients whose response to therapy was evaluated, 10 patients (27%) had complete tumor regression, 11 (29.8%) had partial response, and 10 (27%) had stable disease. Ultimate local disease control was achieved in 31 patients (83.8%). The overall survival was 11.93 months in median (ranged, 11.4-17.4 months), and the median progression free survival was 10.5 months. One-year progression-free survival and overall survival were 41% and 46%, respectively. Grade II or greater long-term complications were observed in 6 (13.3%) patients. On follow-up, 8 (17.3%) patients had carotid blow-out syndrome, and 7 (15.2%) patients died of bleeding from carotid arteries. We discovered that this fatal syndrome occurred only in patients with tumor surrounding carotid arteries and carotid arteries receiving all prescribed dose.

CONCLUSIONS

Stereotactic body radiotherapy is an appealing treatment option for patients with recurrent head-and-neck cancer previously treated with radiation to high doses. Good local control with considerable 1-year survival is achieved with a relatively high rate of morbidity and related mortality.

Radiotherapy in the management of Klippel-Trénaunay-Weber syndrome: report of two cases

Klippel-Trénaunay-Weber syndrome (KTWS) is characterized by combined vascular malformations of capillary, venous, and lymphatic types usually observed during infancy or childhood. In this report, we describe two KTWS patients treated with radiotherapy after long-term conservative treatment or multiple surgical interventions. The first patient, a 15-year-old female, presented with vascular masses located on the right upper extremity. She was treated conservatively for 14 years, and amputation was offered at the age of 14 due to cardiac failure. A course of radiotherapy to a total dose of 40 Gy with conventional daily fractionation was administered as an alternative to the mutilating surgery, and prominent improvement both subjectively and objectively was detected 1 year after radiotherapy. The second patient, a 40-year-old male, suffered from huge vascular masses of both the trunk and lower extremities. Despite multiple surgical interventions and conservative treatment, disease progressed and neurological symptoms occurred due to compression of vertebral structures. He was administered a course of 30 Gy radiotherapy with 1.5 Gy daily fractions to the lower thoracic region and whole abdominal cavity. Six months after radiotherapy, subjective relief described by the patient but without any objective response was detected. Though considered as a benign disease, KTWS can cause life-threatening complications. The response of one of our patients is a hopeful finding for considering radiotherapy as an alternative treatment modality for these patients.

Prospective study of combined modality treatment or radiotherapy alone in the management of early-stage adult Hodgkin's disease

PURPOSE

To determine the efficacy and toxicity of combined modality treatment (CMT) or radiotherapy (RT) alone in the management of clinical Stage I-IIA adult Hodgkin's disease patients.

METHODS AND MATERIALS

Forty-seven patients with supradiaphragmatic clinical Stage I-IIA Hodgkin's disease without bulky mediastinal lymphadenopathy were enrolled into this prospective study between September 1997 and February 2002. Patients with very favorable criteria presenting with one or two nonbulky nodal areas involved, an erythrocyte sedimentation rate of <50 mm/h, age <40 years, and either lymphocyte predominant or nodular sclerosing histologic findings were treated by RT alone. Patients missing any of these favorable criteria were classified as the other favorable group and were treated with three courses of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy followed by involved-field RT. The median age was 36 years (range, 19-53 years). Of the 47 patients, 15 were women and 32 were men. Only 3 patients were classified as the most favorable group and treated with mantle RT alone; the remaining 44 were treated with CMT.

RESULTS

The median follow-up was 51 months (range, 20-74 months). Only 2 patients developed recurrence, both out of the irradiated field, one in the contralateral neck and the other in the abdomen. The 5-year relapse-free and overall survival rate was 95.4% and 97.8%, respectively. Although none of the prognostic factors were statistically significant for relapse-free survival, a trend was noted for the response to chemotherapy (p = 0.06). Only 2 patients developed treatment-related complications. One patient treated with mantle RT alone developed severe ischemic heart disease and one in the CMT arm developed subclinical hypothyroidism.

CONCLUSION

Despite the short follow-up, CMT or RT alone tailored according to the clinical prognostic factors were successful in terms of disease control in clinical Stage I-IIA Hodgkin's disease. Longer follow-up is required to make definitive conclusions.

Stage I Testicular Seminoma: Para-Aortic and Iliac Irradiation with Reduced Dose after Orchiectomy

BACKGROUND AND PURPOSE

Radiotherapy remains the treatment of choice for patients with stage I seminoma. The aim of this study is to report preliminary results of reduced dose radiotherapy to ipsilateral pelvic and para-aortic lymph nodes.

MATERIALS AND METHODS

Between February 1996 and December 2001, 53 patients with stage I testicular seminoma were treated with adjuvant radiotherapy after orchiectomy. The median age was 34 years (19-59 years). Four (7.5%) patients had a history of cryptorchidism. Eleven (20.8%) patients showed elevated beta-human chorionic gonadotropin. All patients had a radical inguinal orchiectomy and histopathological analysis yielded classic seminoma in 47 (88.7%), spermatocytic in 5 (9.4%) and anaplastic in 1 (1.9%) patients. A total of 19.6-20 Gy in 1.8- to 2-Gy daily fractions was administered to the para-aortic and ipsilateral iliac lymphatics.

RESULTS

Median follow-up time was 42 months (12-77 months). One patient developed para-aortic lymph node recurrence at month 28 of the follow-up. Five-year overall and disease-free survivals were 100 and 98%, respectively. Only grade I-II of the Radiation Therapy Oncology Group acute gastrointestinal complications without any severe late toxicity was detected.

CONCLUSION

Reduced dose radiotherapy seems to be as effective as higher doses in the management of stage I seminoma with an acceptable toxicity.

Radiotherapy in the management of Kasabach-Merritt syndrome: a case report

A 21-day-old infant with hemangioma was brought to the hospital with enlargement of the hemangioma of the left thigh and purple discoloration around umbilicus. This led to the diagnosis of Kasabach-Merrill syndrome. Initial treatment with corticosteroid failed. The patient underwent radiotherapy that led successfully to improvement of both hemangioma and thrombocytopenia. After 2 years of follow-up, the patient has experienced long-term complications, including atrophy and growth retardation of the irradiated leg.

Conventional external radiotherapy in the management of clivus chordomas with overt residual disease

Cranial chordomas are uncommon tumors accounting for less than 1% of all intracranial neoplasms. Although they are slowly growing, rarely metastasizing tumors, cranial chordomas are challenging to treat due to their critical location, invasive nature and aggressive recurrence. The aim of this retrospective study was to evaluate the role of conventional irradiation in the treatment of clival chordomas with overt residual disease after incomplete surgery. Between January 1979 and December 1997, 18 patients with histologically confirmed clival chordoma were treated with radiotherapy. Median age at the time of diagnosis was 32 years. The mean duration of the symptoms before diagnosis was 33.9 months. Median tumor diameter at initial presentation was 5 cm (range, 3-7 cm). The type of surgical procedure was subtotal excision in 11 patients and biopsy in 7. Radiation treatment was delivered with megavoltage units, and total doses between 50 Gy and 64 Gy (median, 60 Gy) were administered with conventional daily fractions. One patient received additional 12.50 Gy with linear accelerator-based stereotactic radiosurgery after subtotal excision and external irradiation. The mean follow-up time was 43.2 months. Overall survival at 5 years was 35%. Eleven patients showed progression after radiotherapy. The median time to progression after radiotherapy was 40.8 months (38.4-43.2) with a 5-year progression-free survival of 23%. Five patients (29.4%) showed symptomatic relief after radiotherapy while persistent symptoms were recorded for 6 patients. Incomplete surgery and conventional external radiotherapy with a dose of around 60 Gy seem to be inadequate in the treatment of clival chordomas.

The effect of verapamil in the prevention of radiation-induced cataract

PURPOSE

Cataract is an unavoidable complication when radiation therapy includes the lens, even in small doses. Alterations in the ion content of the lens were considered to play an essential role in cataract formation. In this experimental study, the effect of verapamil on ion concentrations within the irradiated lenses was investigated in rats.

METHODS AND MATERIALS

Forty female Wistar albino rats, each weighing 180-250 g, were divided into three groups: (a) radiation treated (n = 10); (b) no treatment (n = 10); (c) or a combination of radiation and verapamil (n = 20). Both the radiation group and verapamil-treated group received 5 Gy radiation to the cranium in a single fraction, including the eyes, within the irradiation volume. All animals were sacrificed by bleeding, 7.5 weeks posttreatment. Calcium, sodium, and potassium levels were measured in blood and in lens homogenates. However, for technical reasons, magnesium levels could only be studied in lens homogenates.

RESULTS

Potassium and sodium concentrations in lens homogenates did not differ in the control and radiation groups, but both were significantly lower in the verapamil-treated group (p = 0.001, p = 0.009, respectively). Calcium levels were higher in the radiation group and lower in the verapamil-treated group compared to the controls (p < 0.0001); magnesium levels did not differ (p = 0.37).

CONCLUSION

Verapamil effectively decreased the lens calcium concentration, which is accepted as the key element in radiation cataractogenesis. It is therefore concluded that verapamil may reduce the risk of radiation-induced cataract formation.

Intracranial ependymomas: treatment results and prognostic factors

Forty-nine intracranial ependymoma patients were postoperatively irradiated with craniospinal, cranial, or wide local fields. Thirty-two patients received an adjuvant chemotherapy regimen of vincristine and CCNU with or without procarbazine. The 10-year actuarial overall and progression-free survival rates were 57% and 57%, respectively. Age was the only significant prognostic factor in favor of adults (p = 0.01).

Cranial nerve involvement in nasopharyngeal carcinoma: its prognostic role and response to radiotherapy

Between 1975 and 1989, 23 nasopharyngeal carcinoma patients presenting with cranial nerve involvement (CNI) of one or more nerves at the time of diagnosis were treated and followed-up in our department. All patients were irradiated with curative intent, and total doses of 50 to 70 Gy (median 65 Gy) were delivered to the nasopharynx. Cranial nerves VI, III, V, IV, IX, and XII were the most commonly involved nerves. The total response rate of cranial nerves was 74% in a median follow-up time of 2 years, with the highest rate observed in the third and sixth cranial nerves. All complete responses except two were observed in the first month after radiotherapy.

Results of radiotherapy in craniopharyngiomas analysed by the linear quadratic model

In 23 craniopharyngioma patients treated by limited surgery and external radiotherapy, the results concerning local control were analysed by linear quadratic formula. A biologically effective dose (BED) of 55 Gy, calculated with time factor and an alpha/beta value of 10 Gy, seemed to be adequate for local control.

Results of post-operative or exclusive radiotherapy in grade I and grade II cerebellar astrocytoma patients

43 Patients with the diagnosis of cerebellar astrocytoma were post-operatively treated, between 1 January 1976 and 31 December 1985. Their age ranged between 2 and 51 years with a median of 13. There were 22 males and 21 females. The tumours were reported as grade I in 18, and grade II in 25 patients. The primary surgical intervention was in the form of biopsy in 3, subtotal excision in 24 and macroscopic total excision in 16. All patients were treated with cobalt-60 teletherapy unit, to a total tumour dose of 4500-5500 cGy in 6-7 weeks. The obtained 5 and 10 year actuarial survival rates are 78% and 78%. Our study gives the impression that, age, sex and tumour grade are not determining factors in survival and post-operative radiotherapy improves prognosis in cases treated by subtotal excision while it remains unnecessary in those who had undergone total surgical removal.

Post-irradiation osteosarcoma of the iliac bone: a case report

A case of osteosarcoma of the iliac bone developing 12 years after the successful management of childhood rhabdomyosarcoma is presented. The frequency of secondary tumors, mainly bone malignancies, following therapeutic irradiation in the pediatric age-group, and the criteria for the diagnosis of radiation-induced bone sarcoma are discussed.