The Role of Radiation Therapy in Locally Advanced Breast Cancer in a Patient With Li-Fraumeni Syndrome

Li-Fraumeni syndrome (LFS) is associated with many different cancers, including early onset breast cancer. Due to an increased risk of radiation-induced malignancy, radiation therapy is often avoided in this patient population. This case study evaluates a 38-year-old female with a history of juvenile granulosa cell tumor of the ovary and malignant phyllodes tumor of right breast, who subsequently developed bilateral invasive ductal carcinoma and was treated with bilateral mastectomies. Studies show that in a high-risk patient, post-mastectomy radiation therapy (PMRT) should not be ruled out due to a history of LFS, as the benefit of PMRT may outweigh the risk of a radiation-induced malignancy.

Radiation-induced glioblastoma of the conus medullaris from radiation treatment of cervical cancer

Radiation-induced spinal glioblastoma is an extremely rare disease with only four previously published reports in the literature. We report the fifth case, a 69-year-old woman who previously underwent treatment with brachytherapy for cervical cancer, and thereafter presented with neurologic deficits from a conus medullaris tumour. Biopsy and histopathology confirm glioblastoma, not otherwise specified. Treatment of spinal glioblastoma consists of surgery, either biopsy or excision and chemoradiation. However, results are still unsatisfactory and prognosis remains poor.

Postoperative radiotherapy-induced leiomyosarcoma in breast cancer: a case report and literature review

Radiation-induced sarcoma (RIS) is a late complication of breast cancer radiotherapy, with a very low incidence, long latent period and poor prognosis. Among them, leiomyosarcoma after radiation is an extremely rare radiation-associated sarcoma. In this study, we report a case of radiation-induced leiomyosarcoma 2 years after postoperative radiotherapy for breast cancer. After the diagnosis of leiomyosarcoma, the patient received radical resection of the left chest wall leiomyosarcoma. The patient showed no relapse or progression during the follow-up time of 1 year after operation. Rare occurrence of RIS induced by postoperative radiotherapy in breast cancer and limited experience concerning its diagnosis and treatment bring obstacle to both patients and doctors. Preoperative examinations must be carefully refined. With a perfect coordination between different disciplines, RIS induced by postoperative radiotherapy in breast cancer can be ideally treated with better prognosis.

Non-Small-Cell Lung Cancer After Mantle Radiation: A Case Report and Brief Review

Survivors of childhood and young adult cancer are at risk for developing subsequent malignant neoplasms, including lung cancer. As survival rates in this group continue to improve and patients enter later decades in life, determining the optimal surveillance and counseling strategies with regards to subsequent cancers remains a challenge. In this case report, we present a non-Hodgkin lymphoma survivor who was incidentally found to have non-small-cell lung cancer 30 years after undergoing treatment that included mantle radiation. We discuss the treatment-related risk factors for lung cancer in this population and potential implications for long-term follow-up.

Radiation-Associated Sarcomas: An Update on Clinical, Histologic, and Molecular Features

Approximately half of all cancer patients receive radiation therapy as part of their oncologic treatment. Radiation-associated sarcomas occur in fewer than 1% of patients who receive radiation therapy but account for up to 5% of all sarcomas. As the use of radiation has increased in the past few decades and overall oncologic outcomes are improving, the incidence of radiation-associated sarcomas is also expected to increase. Historically, radiation-associated sarcomas have been associated with poor outcomes but recent data suggest the prognosis is improving. Distinguishing the sarcoma from the primary malignancy is a major diagnostic criterion.

Secondary basal cell carcinoma of scalp after radiotherapy: A case report

RATIONALE

Radiotherapy (RT) is widely used for both malignant and benign tumors in order to reduce the risk of recurrence, to promote tumor control, and to improve survival. However, there have been studies reported that RT is also a risk factor of secondary cancer. Very few cases of secondary malignancy after RT to high grade brain cancer have been reported due to short survival of this disease, and most RT-induced malignancies presented with sarcomatous histology. Here we present a patient with basal cell carcinoma (BCC) 14 years after RT to his brain.

PATIENT CONCERNS

A 28-year-old man without any underlying disease had suffered from left side weakness and clonic-tonic seizures for 12 days.

DIAGNOSES

His brain images showed a tumor in the right frontal lobe. The pathologic report confirmed anaplastic astrocytoma (WHO Grade III).

INTERVENTIONS

After craniotomy and tumor biopsy, RT was delivered. Fourteen years later, a gray-colored skin papule was noted in the previously irradiated area. The scalp biopsy revealed BCC. The scalp BCC was adequately resected. He then suffered from brain tumor recurrence and received further craniotomy for three times combined with chemotherapy with temozolomide.

OUTCOMES

After treatment, follow-up brain images showed that the disease was under control. There was no neurological sequela. For scalp BCC, no skin tumor recurrence has been noted to date after the resection 14 years after initial RT. He has survived for more than 26 years since his initial diagnosis of anaplastic astrocytoma, and more than 12 years from the diagnosis of scalp BCC.

LESSONS

Notwithstanding the risk of radiation-induced skin cancer, RT contributed to this patient's survival. The possible late adverse events should be informed to the patients.

Secondary mucinous carcinoma of the prostate after low dose rate brachytherapy

Radiation induced malignancy (RIM) after treatment for prostate cancer is well documented after external beam irradiation, but less so in the setting of brachytherapy. We report a case of mucinous adenocarcinoma of the prostate, consistent with a RIM, which developed 12 years after low dose rate brachytherapy for low risk prostate adenocarcinoma. Diagnostic and therapeutic considerations of RIM are discussed. As long term survivors are followed in the community by primary care physicians and urologists, awareness of RIM as a potential late effect of brachytherapy is important to ensure that cases are diagnosed and managed appropriately.

[A Case of Combined Treatment Approach of Endoscopic Submucosal Dissection and Transanal Minimally Invasive Surgery for Radiation Induced Rectal Cancer]

It is hard to determine treatment strategy for radiation induced carcinoma, because radiation cause fibrosis to adjacent organ.The patient was in the 70's, who underwent 70 Gy radiation therapy for prostate cancer 5 years ago.He visited hospital because of fecal occult blood.Endoscopic examination revealed laterally spreading tumor(LST)in rectal front wall, and he referred to our hospital in purpose of endoscopic submucosal dissection(ESD).We performed ESD for LST, following transanal minimally invasive surgery to suture mucosal defect.He discharged out hospital 9 days after operation without any adverse event except anal pain.Suturing of mucosal defect after ESD might be potent to prevent postoperative complications in radiation induced rectal cancer.

Cutaneous Radiation-associated Breast Angiosarcoma: Radicality of Surgery Impacts Survival

OBJECTIVE

Cutaneous radiation therapy (RT)-associated breast angiosarcoma (AS) is a rare consequence of breast RT associated with poor outcomes. Previous small case series have documented high recurrence rates and poor survival. We reviewed our experience and focused on the impact of conservative versus radical resections.

METHODS

Data for patients with RT-associated breast AS evaluated at our institution from 1993 to 2015 who underwent surgery were reviewed.

RESULTS

Seventy-six women were diagnosed with RT-associated breast AS at a median 85 months from surgery for invasive breast carcinoma or ductal carcinoma in situ. Thirty-eight underwent mastectomy/wide excision with partial skin resection ("conservative") and 38 underwent resection of all or nearly all previously irradiated skin plus mastectomy ("radical"). The radical group (vs the conservative group) more often had multifocal disease (80% vs 56%, P = 0.04), chemotherapy for AS (58% vs 22%, P < 0.01), margin-negative resection (100% vs 73%, P < 0.01), reconstructive surgery (100% vs 13%, P < 0.01), and re-operation (16% vs 3%, P = 0.04). Five-year crude cumulative incidences of local recurrence and distant metastasis for radical versus conservative groups were 23% versus 76% (P < 0.01) and 18% versus 47% (P = 0.02), respectively. Five-year disease-specific survival (DSS) for radical versus conservative groups was 86% versus 46% (P < 0.01), respectively. On multivariable analysis, age, radicality of surgery, and margin were predictive of DSS.

CONCLUSIONS

For patients with RT-associated breast AS, radical resection was associated with reduced recurrence rates and improved DSS. Although margin was predictive of DSS, multifocality calls into question the reliability of negative margin assessment.

[Breast angiosarcoma induced by radiotherapy - surgical treatment options and review of literature]

INTRODUCTION

Radiation-induced angiosarcoma is a rare but very aggressive tumour. The highest risk of sarcoma development is in patients after breast-conserving surgery.Case 1: The 66 years old patient underwent radical mastectomy with axillary dissection because of ductal carcinoma with consequent radiotherapy, chemotherapy and hormonal therapy. After 6 years, high-grade angiosarcoma was diagnosed and resected with negative resection margins. Within subsequent 24 months, additional three radical re-excisions were performed because of repeated sarcoma recurrence. 29 months from the diagnosis of the first sarcoma, another radical re-excision was performed, this time with positive resection margins and with consequent disease progression. The patient died three years after the first angiosarcoma diagnosis.Case 2: The 68 years old patient underwent breast-conserving surgery with axillary dissection because of ductal carcinoma and radiotherapy. Breast colour changes were observed 6 years later; radical mastectomy was performed after additional 16 months due to locally advanced angiosarcoma. Given positive resection margin, radical re-excision with musculocutaneous musculus latissimus dorsi flap was done. 24 months later, a small sarcoma recurrence was detected near the upper resection margin, which was managed by radical re-excision. 52 months after radical operation, a metastasis was diagnosed by means of PET/CT in the contralateral axilla. Radical axillary dissection was performed (two metastases were found in axillary lymph nodes). According to follow-up, the patient has been free of any recurrence for 66 months from the radical surgery.

CONCLUSION

Recommendations regarding the management of radiotherapy induced breast angiosarcoma are very vague due to limited evidence. Radical surgical excision with negative resection margins (potentially with complementary flap reconstruction) presents the fundamental approach to breast angiosarcoma.Key words: radiation-induced angiosarcoma - breast cancer - surgery.

Rare Dual Lesion: Extraskeletal Osteosarcoma Developing Within a Simple Lipoma

Extraosseous osteosarcoma is a rare malignancy, but simple lipomas are common. This article is the first report of a case of radiation-induced extraosseous osteosarcoma that developed within a simple lipoma in a 72-year-old woman. We correlate the magnetic resonance imaging, computed tomography, positron emission tomography, and plain radiographic findings. The patient, treated with systemic therapy and wide surgical resection of the neoplasm, remained clinically free of disease during the first 22 months of follow-up.

Angiosarcoma following radiation therapy for breast cancer Case report

More and better accessibility to screening and increasing women's knowledge about the main symptomatic breast cancer signs result in detection of this neoplasm at an early stage, allowing a conservative surgical treatment. Breast conserving therapy (BCT) due to breast carcinoma involves the use of adjuvant radiotherapy which carries a risk the secondary radiation-induced malignancy. Angiosarcoma of the breast is an extremely rare radiation-induced malignant tumor following breast conserving therapy (BCT), first described by Schmidt in 1887. In this article the authors presented the case of a 56-year-old woman who was admitted to the hospital because of diagnosed angiosarcoma of the right breast after breast conserving therapy (BCT) with the Sentinel Node Biopsy (SNB) and adjuvant radiotherapy of her breast carcinoma 5 years earlier. The patient had a simple mastectomy performed and on the second day after surgery was discharged home.

KEY WORDS

Angiosarcoma, Breast cancer, Radiation therapy, Surgery, Treatment.

[Not Available]

Summarizing paper contains short analysis of the publications resulting cell biological, molecular genetic and population genetic investigations devoted to studying of accute radiation exposure and chronic radiation contamination effects on biological systems after disaster on Chornobyl nuclear power station in 1986.

[Not Available]

In the last 60 years dramatically increased the content of nitrates in groundwater due to intensive use of nitrogen fertilizers in agriculture. Research in post-Chernobyl period has shown that a sharp increase in the incidence of thyroid cancer depends not only on the level of thyroid dose, but also on the level of nitrates in groundwater.

Radiation-Induced Differentiated Thyroid Cancer Is Associated with Improved Overall Survival but Not Thyroid Cancer-Specific Mortality or Disease-Free Survival

BACKGROUND

Radiation is a well-described risk factor for differentiated thyroid carcinoma (DTC). Although the natural history of DTC following nuclear disasters and in healthcare workers with chronic radiation exposure (RE) has been described, little is known about DTC following short-term exposure to therapeutic medical radiation for benign disease. This study compares DTC morphology and outcomes in patients with and without a prior history of therapeutic external RE.

METHODS

A retrospective review was performed of patients with DTC treated at The University of Chicago between 1951 and 1987, with a median follow-up of 27 years (range 0.3-60 years). Patients were classified as either having (RE+) or not having (RE-) a history of therapeutic RE. Variables examined included sex, age at RE, dose of RE, indication for RE, DTC histology, and outcome. Morphology was determined by blinded retrospective review of all available histologic slides. Outcomes were assessed using Cox proportional hazards model and Kaplan-Meier curves.

RESULTS

Of 257 DTC patients, 165 (64%) were RE- and 92 (36%) were RE+, with males comprising a greater proportion of the RE+ group (43.5% vs. 27.3%; p = 0.01). A total of 94.2% of DTC cases were classic papillary cancers; histology did not differ between RE+ and RE- cohorts (p = 0.73). RE was associated with an increased median overall survival (OS; 43 years vs. 38 years; hazard ratio [HR] = 0.55 [confidence interval (CI) 0.34-0.89]; p = 0.01). Survival for males in the RE- group was significantly worse than it was for RE- females (HR = 1.78 [CI 1.05-3.03]; p = 0.03) or RE+ males (HR = 2.98 [CI 1.39-6.38]; p = 0.01). Recurrence did not differ between the RE+ and RE- groups (HR = 0.85 [CI 0.52-1.41]; p = 0.54), nor did DTC-specific mortality (HR = 0.54 [CI 0.21-1.37]; p = 0.20).

CONCLUSIONS

While DTC following RE has historically been considered a more aggressive variant than DTC in the absence of RE, the present data indicate that RE+ DTC is associated with better OS than RE- DTC, especially for males. Additionally, recent reports are confirmed of equivalent rates of thyroid cancer recurrence. These results warrant further investigation into the factors underlying this unexpected finding.

Eyelid reconstruction in a child with xeroderma pigmentosum

CLINICAL CASE

Seven-year-old male patient, affected by xeroderma pigmentosum (XP) who was referred to ophthalmology due to the presence of numerous tumours in his left eye that affected the eyelids and conjunctiva. He had a tumour in his lower eyelid that affected the free edge, creating a secondary ectropion, and several lesions with a melanocytic appearance in conjunctiva. A resection of the eyelid tumour and the conjunctival lesions were performed by placing a skin graft and amniotic membrane, respectively, as covering.

DISCUSSION

XP patients have high probability of developing eye tumours. A thorough ophthalmic examination is necessary to establish an early diagnosis.

Bone mineral density in treated at a young age for differentiated thyroid cancer after Chernobyl female patients on TSH-suppressive therapy receiving or not Calcium-D3 supplementation

Long-term management of patients with differentiated thyroid cancer (DTC) commonly includes TSH-suppressive therapy with L-T4 and, in case of postsurgical hypoparathyroidism, Calcium-D3 supplementation, both of which may affect skeletal health. Experience with female patients treated for DTC at a young age and who were then receiving long-term therapy with L-T4 and Calcium-D3 medication is very limited to date. This cross-sectional study set out to investigate effects of Calcium-D3 supplementation and TSH-suppressive therapy on bone mineral density (BMD) in 124 young female patients treated for DTC at a mean age of 14 years and followed-up for an average of 10 years. BMD was found to be significantly higher in patients receiving Calcium-D3 medication than in patients not taking supplements. The level of ionized calcium was the strongest factor determining lumbar spine BMD in patients not receiving Calcium-D3 supplementation. Pregnancy ending in childbirth and HDL-cholesterol were associated with a weak adverse effect on spine and femoral BMD. No evidence of adverse effects of L-T4 and of radioiodine therapies on BMD was found. We conclude that Calcium-D3 medication has a beneficial effect on BMD, and that TSH-suppressive therapy does not affect BMD in women treated for DTC at young age, at least after 10 years of follow-up.

Postradiation dermatofibrosarcoma protuberans : case report and literature review

Radiotherapy has long been known to induce soft tissue sarcomas. However, there are only six cases of postradiation dermatofibrosarcoma protuberans (DFSP) reported in the literature, and no case in Asians has been reported so far. Herein, we report a case of DFSP, confirmed by immunohistochemistry, which developed on the old scar at the irradiated right chest wall of an Asian woman. We performed a radical surgical excision of the lesion and covered the defect with latissimus dorsi island myocutaneous flap followed the surgical treatment. 12 months postoperatively, the patient leads a good result without signs of recurrence.

[Occurrence of squamous cell lung carcinoma in the irradiated field after radiotherapy for breast cancer]

Radiotherapy for breast cancer reduces the incidence of disease recurrence and breast cancer mortality.However, it has also been associated with an increased risk of developing secondary cancers in exposed sites.Recently, we observed a 64-year-old woman who developed squamous cell lung carcinoma in the field irradiated with a total dose of 55 Gy after conservative breast surgery for left breast cancer 16 years previously.The patient underwent left upper lobectomy combined with chest wall resection.She had no recurrence of the breast cancer for 16 years.The secondary lung cancer tumor was of a different histological type than the primary breast cancer, and it appeared in the irradiated field.In conclusion, we regarded her lung cancer as a radiation-induced cancer, although it is difficult to clearly define radiation-induced cancer.In addition, the patient 's lung cancer may not only be a result of the late effect of irradiation, but might also be due to her smoking habit.

Radiation induced myxoma of superior vena cava origin presenting as a right atrial mass

Myxomas are the most common benign cardiac tumors. Myxomas are more common in the left heart chamber than the right side chamber. An extracardiac origin presenting as a right atrial mass is very rare. Right-sided tumors are considerably less common than left-sided tumors, and however myxoma of great vessels origin presenting as right atrial masses are rare but radiation induced villous myxoma in superior vena cava (SVC) is exceedingly rare tumor. A case of radiation induced myxoma originating in a previously undescribed location and presenting as a right atrial mass is reported.

Twenty-five years after Chernobyl: outcome of radioiodine treatment in children and adolescents with very high-risk radiation-induced differentiated thyroid carcinoma

CONTEXT

After severe reactor emergencies with release of radioactive iodine, elevated thyroid cancer risk in children and adolescents is considered the main health consequence for the population exposed.

DESIGN

We studied thyroid cancer outcome after 11.3 years' median follow-up in a selected, very high-risk cohort, 234 Chernobyl-exposed Belarusian children and adolescents undergoing postsurgical radioiodine therapy (RIT) in Germany.

INTERVENTIONS

Cumulatively 100 children with or (without; n = 134) distant metastasis received a median 4 (2) RITs and 16.9 (6.6) GBq, corresponding to 368 (141) MBq/kg iodine-131.

MAIN OUTCOME MEASURES

Outcomes were response to therapy and disease status, mortality, and treatment toxicity.

RESULTS

Of 229 patients evaluable for outcome, 147 (64.2%) attained complete remission [negative iodine-131 whole-body scan and TSH-stimulated serum thyroglobulin (Tg) < 1 μg /L], 69 (30.1%) showed nearly complete remission (complete response, except stimulated Tg 1-10 μg/L), and 11 (4.8%) had partial remission (Tg > 10 μg/L, decrease from baseline in radioiodine uptake intensity in ≥ 1 focus, in tumor volume or in Tg). Except for 2 recurrences (0.9%) after partial remission, no recurrences, progression, or disease-specific mortality were noted. One patient died of lung fibrosis 17.5 years after therapy, 2 of apparently thyroid cancer-unrelated causes. The only RIT side effect observed was pulmonary fibrosis in 5 of 69 patients (7.2%) with disseminated lung metastases undergoing intensive pulmonary surveillance.

CONCLUSIONS

Experience of a large, very high-risk pediatric cohort with radiation-induced differentiated thyroid carcinoma suggests that even when such disease is advanced and initially suboptimally treated, response to subsequent RIT and final outcomes are mostly favorable.

Uterine carcinosarcoma associated with pelvic radiotherapy for sacral chordoma: a case report

OBJECTIVE

Postirradiation sarcoma of the female genital tract is rare, but a recognized event. Most reported cases have been associated with history of radiotherapy for various gynecologic conditions, particularly cancer of the uterine cervix and abnormal uterine bleeding. The occurrence of uterine sarcoma secondary to radiotherapy for a non-gynecologic tumor and, furthermore, this condition being simultaneous with the recurrence of primary tumor is unique.

CASE REPORT

A 67-year-old woman presented with a uterine mass which was diagnosed as a sarcoma by endometrial curettage and history of pelvic radiotherapy 23 years previously for sacral chordoma. Surgical staging procedure for uterine malignancy was performed. The final pathologic diagnosis was carcinosarcoma of the uterus.

CONCLUSION

In uterine masses seen in patients with history of irradiation to the pelvic field, the probability of uterine sarcomas should always be kept in mind. These tumors may occur simultaneously with recurrence of primary tumor previously treated by adjuvant radiation therapy.

Fibroepithelioma of Pinkus induced by radiotherapy

Fibroepithelioma of Pinkus (FEP) is a rare cutaneous neoplasm. Evidence supports classification as a variant of either basal cell carcinoma (BCC) or trichoblastoma. Reports of FEP arising in sites of preceding radiation therapy have been documented in the literature, but the relationship between radiotherapy and the development of FEP has not yet been defined. We report a case of FEP following radiation therapy for testicular cancer.

Merkel cell carcinoma: case report and literature review

BACKGROUND

Merkel cell carcinoma is an aggressive neuroendocrine cell carcinoma arising in the epidermis of patients aged >60 years. This lesion is found in sun-exposed areas and presents as a small violet raised nodule. It is usually painless and rapidly growing. Although its clinical presentation and characteristic histology are usually sufficient, immunohistochemical features are helpful in making an accurate diagnosis.

CLINICAL CASE

We present the case of a 62-year-old male with epidermoid carcinoma of the lung who was treated with surgery and local radiation for 2 months. He presented a painless 8-cm subcutaneous mass of some weeks of evolution, without inflammatory signs. Computerized tomography demonstrated a mass of probable lymph node origin. Fine-needle aspiration biopsy (FNAB) reported malignant cells and excisional surgery of the mass was performed, revealing a subcutaneous Merkel cell carcinoma.

CONCLUSIONS

Merkel cell carcinoma is a rare entity that develops in mature patients, often in sun-exposed areas, and presents cutaneous injury in intact skin. Definitive diagnosis is done using immunohistochemistry.

I-131 dose response for incident thyroid cancers in Ukraine related to the Chornobyl accident

BACKGROUND

Current knowledge about Chornobyl-related thyroid cancer risks comes from ecological studies based on grouped doses, case-control studies, and studies of prevalent cancers.

OBJECTIVE

To address this limitation, we evaluated the dose-response relationship for incident thyroid cancers using measurement-based individual iodine-131 (I-131) thyroid dose estimates in a prospective analytic cohort study.

METHODS

The cohort consists of individuals < 18 years of age on 26 April 1986 who resided in three contaminated oblasts (states) of Ukraine and underwent up to four thyroid screening examinations between 1998 and 2007 (n = 12,514). Thyroid doses of I-131 were estimated based on individual radioactivity measurements taken within 2 months after the accident, environmental transport models, and interview data. Excess radiation risks were estimated using Poisson regression models.

RESULTS

Sixty-five incident thyroid cancers were diagnosed during the second through fourth screenings and 73,004 person-years (PY) of observation. The dose-response relationship was consistent with linearity on relative and absolute scales, although the excess relative risk (ERR) model described data better than did the excess absolute risk (EAR) model. The ERR per gray was 1.91 [95% confidence interval (CI), 0.43-6.34], and the EAR per 10⁴ PY/Gy was 2.21 (95% CI, 0.04-5.78). The ERR per gray varied significantly by oblast of residence but not by time since exposure, use of iodine prophylaxis, iodine status, sex, age, or tumor size.

CONCLUSIONS

I-131-related thyroid cancer risks persisted for two decades after exposure, with no evidence of decrease during the observation period. The radiation risks, although smaller, are compatible with those of retrospective and ecological post-Chornobyl studies.

Surgical management of vulvar lymphangioma circumscriptum: two case reports

OBJECTIVE

To evaluate the efficacy of major labiaectomy as a surgical management of vulvar lymphangioma circumscriptum, we report two cases of this rare clinical entity.

CASE REPORTS

Two female patients, aged 56 and 68 years, presented with persistent edema of the lower limbs, papule-like condyloma of the labia majora, and lymph oozing from these papules of the vulva, which had developed 24 and 10 years, respectively, after radical hysterectomy with adjuvant pelvic radiation therapy for cervical cancer. After major labiaectomy was performed, symptoms in the first case, of extensive resected skin margin, improved clearly, in the second case, vulvar lymphangioma circumscriptum was more severe than in the first case, and a small amount of lymph oozing occurred from residual papules of the labia majora. In both cases, histology revealed lymphangioma circumscriptum of the vulva.

CONCLUSION

Major labiaectomy is an effective therapy for vulvar lymphangioma circumscriptum. Particularly, in the case which was extensive and deep resected skin margin, symptoms such as papules of the labia majora and lymph oozing from these papules of the vulva associated with lymphangioma seemed to be clearly improved.

[Radiation-induced fibrosarcomas rapidly appeared more than 20 years after radiation therapy for germ cell tumors: report of two cases]

Radiation-induced brain tumor is a rare but serious and potentially fatal complication. We report two cases of radiation-induced fibrosarcomas which occurred more than 20 years after whole brain radiation therapy (60 Gy) for intracranial germinomas. Although both of them underwent imaging examination every year, the symptomatic sarcomas developed rapidly within a year. Eight months after total removal, the tumor recurred in the one case. Second surgery and gamma knife surgery could not prevent the tumor progression. In the other case, tumor regrowth was not observed during the five months follow-up after total removal surgery. It is important to keep in mind the possibility of a postradiation sarcoma that might have developed very aggressively after a long latent period.

A woman with reddish nodule on the skin of the breast

A 54-year-old woman presented a peri-areolar nodule located in the skin of the right breast. Clinical examination showed a 6 x 5 cm exophytic, lobed, ulcerated, and bleeding nodule. The patient reported that the tumor had grown gradually over a period of 3 months. The patient had been diagnosed 8 years prior to presentation with infiltrating ductal carcinoma of the right breast (pT2NO). This tumor was treated with partial mastectomy (conservative surgery) and lymph node dissection, then subsequently received 30 tangent field radiotherapy sessions to the breast for a total dose of 45 Gy. The rest of her cutaneous exam was normal. There was no family history of any similar tumor.

Therapeutic strategy of late cerebral radionecrosis. A retrospective study of 21 cases

AIM

Late cerebral radiation necrosis (LCR) is a serious complication of radiation treatment for brain tumors. This study investigates the diagnosis and management of patients with late clinical and neuroradiological cerebral radionecrosis after primary removal of brain neoplasm. The authors discuss the clinical features and long-term outcome of 21 patients with late cerebral radionecrosis and emphasize the importance of surgical and medical therapy.

METHODS

Twenty-one patients with brain tumor treated by surgical resection or brain biopsy alone after radiotherapy during follow-up developed radionecrosis. The magnetic resonance imaging (MRI), surgical and clinical findings of these patients with radionecrosis are reviewed.

RESULTS

MRI showed radionecrosis in 21 patients, 9 of which had undergone craniotomy for lesion removal.

CONCLUSION

Late radionecrosis is infrequent following radiation therapy and may simulate tumor recurrence on MRI scans. From the authors' experience it is evident that, once begun, radiation treatment of neoplastic lesions can lead to complications such as late cerebral radionecrosis which often require surgical treatment. As correct diagnosis is necessary for appropriate treatment, a fair balance needs to be struck when considering ionizing radiation, medical therapy, surgery and diagnostic imaging.

[Locally advanced soft-tissue sarcomas. An innovating triad to avoid amputation: isolated limb perfusion, TNFalpha, and free microsurgical flap]

We retrospectively studied the benefits of isolated limb perfusion combined with TNFalpha administration and free flap reconstruction in locally advanced soft-tissue sarcomas of the limbs. Between 2000 and 2008, we treated 37 patients (22 women and 15 men) with locally advanced soft tissue sarcomas. The sarcomas were located in the lower and upper limbs in respectively 26 and 11 cases, and had a mean diameter of 15 cm and 12 cm, respectively. They were multifocal in 8 cases and recurrent in 15 cases. Seventeen patients received neoadjuvant chemotherapy. Sarcoma excision was combined with a complementary procedure in 10 patients (vascular graft or nerve anastomosis). Reconstruction was performed with free flaps of the latissimus dorsi (n = 31), transverse rectus abdominis myocutaneous flaps (n = 4) or free forearm flaps (n = 2). Early postoperative radiotherapy was administered in 25 cases. Three major improvements were made in recent years, namely isolated limb perfusion, TNFalpha administration, and free flap reconstruction two months after resection of residual sarcoma. There were no early postoperative deaths. The procedure lasted a median of 7 hours. Two free flaps necrotized, and a new free flap was created with success. Tumor excision was stage R0 in 29 cases (clean margins), R1 in 7 cases (microscopic residue), and R2 in one case (macroscopic residue). With a median follow-up of 5 years, there were no local recurrences in R0 patients, and the overall survival rate was 65%. The limb was preserved in 78% of cases. Thirteen patients developed pulmonary metastases and seven of them died between the first and fifth years of follow-up. Isolated limb perfusion and free flap reconstruction permitted more extensive tumor excision. Amputation was avoided in 78% of our 37 patients, and early postoperative radiotherapy was possible in 25 cases.

Staged margin control techniques for surgical excision of lentigo maligna

For melanoma in situ (MIS) arising in chronically photodamaged skin (a.k.a. lentigo maligna, LM), the preferred treatment remains surgical excision. Yet, the standard 5-mm margins of excision recommended for other subtypes of MIS have proven insufficient for LM, due to the its indistinct borders. In this report, authors review specialized surgical techniques for the treatment of LM that focus on meticulous assessment of peripheral margins prior to closure (staged margin control) conducted with analysis of either frozen or permanent histologic sections. Techniques utilizing permanent sections include variations of the ''square'', ''perimeter'', and ''contoured'' excisions, and recurrence rates with these techniques are reportedly low based on short-term follow-up. Similarly, Mohs micrographic surgery (MMS) has been reported to be effective in LM, with recurrence rates generally less than 1% over three-five years of follow-up. In order to simplify margin assessment for MMS, many investigators have begun to rely on intraoperative immunohistochemistry (IHC) to identify melanocytes in frozen sections, and MART-1 is surrently the preferred immunostain for this purpose. Other methods of IHC are currently under investigation. Regardless, surgical methods that employ this degree of margin assessment offer superior cure rates compared to standard excision, and should be seriously considered when encountering patients with LM. Total peripheral margin assessment using staged excisions and analysis of permanent sections appears to be a simple and effective alternative to MMS, especially for institutions that prefer examination of permanent sections to frozen sections.

Encapsulated anaplastic thyroid carcinoma transformed from follicular carcinoma: a case report

BACKGROUND

Anaplastic thyroid carcinoma (ATC) is rare but is one of the most aggressive and lethal human malignancies. Cytologically, ATC has a variable morphologic appearance, including squamoid, giant, spindled and pleomorphic cells. The coexistence of ATC and differentiated or poorly differentiated thyroid carcinoma has been described and usually is diagnosed when the disease is locally advanced.

CASE

We describe a case of surgically resectable, encapsulated, well-circumscribed ATC occurring in association with a better differentiated follicular carcinoma diagnosed by fine needle aspiration in a patient exposed to external ionizing radiation.

CONCLUSION

Encapsulated variants of anaplastic carcinoma can be seen in association with lower grade thyroid carcinoma such as follicular carcinoma. Accurate diagnosis is dependent on adequate sampling.

Papules arising after radiotherapy for rhabdomyosarcoma

Radiation therapy, even at low doses, can induce a wide spectrum of vascular skin proliferations ranging from nonmalignant ones, such as benign lymphangiomatous papules (BLAP), to frankly malignant pathologies, such as angiosarcoma. We describe a 50-year-old Caucasian woman with a past history of uterine rhabdomyosarcoma, treated 22 years prior with surgical excision, chemotherapy, and radiotherapy. She presented with a few skin-colored papules and a clear discharge located in the previously irradiated area (right inguinal region). Histopathology showed a proliferation of irregular, interanastomosing vascular channels, thin walled and lined by prominent endothelial cells with focally hobnail features. Cytological atypia of endothelial cells, mitotic figures, hemorrhagic areas, and necrosis were not observed. The endothelial cells expressed D2-40 and CD31. A diagnosis of BLAP following radiotherapy for uterine rhabdomyosarcoma was made. The patient was treated with complete excision using electrodessication. At the 20-month follow-up visit the patient was still free of recurrence.

Resection of radiation-induced sarcoma of the clavicle

We report here the resection of a radiation-induced sarcoma (RIS) of the left clavicle developed in a 59-year-old woman 13 years after radiation for breast cancer. Surgery consisted of extirpation of the tumor with a combined resection of the total layer of the chest wall, the left brachiocephalic vein, and the left subclavian vein, reconstructed with a pediculated musculocutaneous graft using the right latissimus dorsi muscle. RIS of the clavicle is rare, and the prognosis might be poor. However, a complete removal of the tumor is feasible and can be performed safely.

Parotid acinar cell carcinoma in a long-term survivor of childhood acute lymphoblastic leukemia

Secondary malignancies are an important cause of morbidity and mortality in childhood cancer survivors. Salivary gland tumors account for about 6% of the second cancers. The majority of these are mucoepidermoid carcinomas (MEC) of the parotid gland. We report the clinical and pathological features of a rarer histological type, acinic cell carcinoma (ACC), in a childhood acute lymphoblastic leukemia (ALL) survivor. The behavior of secondary ACC appears similar to primary tumor and similar treatment may be adopted. Early recognition and complete resection is important for achieving a good outcome. Careful monitoring for recurrence or a third malignancy is needed.

Triology of neurosurgical complications after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

Radiotherapy is an effective treatment for NPC. With improved survival, radiation-induced neurological complications are being diagnosed more commonly. We presented a patient with a trilogy of radiation-induced pathologies after radiotherapy for NPC. The diagnostic and surgical implications are discussed.

CASE DESCRIPTION

A 57-year-old man, previously irradiated for NPC, presented with mental confusion and was found to have radiation-induced carotid stenosis and bitemporal lobe necrosis on MR imaging. His condition deteriorated suddenly a year later, and a gliosarcoma was found to have developed within the area of right temporal lobe necrosis. Tumor removal was complicated by injury to the MCA branches, causing basal ganglion infarction. This was likely because of a combination of technical error and arterial insufficiency secondary to radiation-induced arterial stenosis.

CONCLUSIONS

In patients with known temporal lobe radiation-induced necrosis, alternative diagnosis such as gliosarcoma should be considered when there is sudden clinical deterioration. Radiation-induced carotid stenosis may reduce the safety margin during surgery. Preoperative carotid screening may be indicated.