[Meningiomas of the wings of the basilar bone in patients undergone a course of radiation therapy for retinoblastoma in infancy (analysis of 3 cases)]

The paper presents 3 cases of radio-induced meningiomas in patients who underwent irradiation for retinoblastoma in infancy. Meningiomas of the middle cranial fossa were diagnosed in women aged 16, 34, and 47 years. Radiation therapy was in the complex treatment of retinoblastoma in all patients in infancy (4 months to 3 years). The latent period between the irradiation and diagnosis of meningioma was 15 to 44 years. The location of detected meningiomas (the wings of the basilar bone on the side of exenteration or enucleation) corresponded to the irradiation fields. Surgical treatment yielded good results. Histological study has indicated that meningiomas were fibroblastic in the former two cases and atypical meningioma was verified in the third case when the tumor infitratively spread. Our observations support the fact that there may be radio-induced meningiomas in the area exposed to irradiation.

Radiation-induced chondrosarcoma of the maxilla 7-year after combined chemoradiation for tonsillar lymphoma

Radiation-induced sarcoma is a rare complication of radiation therapy. We report a case of radiation-induced chondrosarcoma of the maxilla. An 80-year-old Persian woman developed radiation-induced chondrosarcoma of the left maxilla 7 years after combined chemotherapy and external beam radiation therapy for the Ann Arbor stage IE malignant lymphoma of the right tonsil. She underwent suboptimal tumour resection and died due to extensive locoregional disease 8 months later. An English language literature search of Medline using the terms chondrosarcoma, radiation-induced sarcoma and maxilla revealed only one earlier reported case. We describe the clinical and pathological features of this case and review the literature on radiation-induced sarcomas.

Long-term results with resection of radiation-induced soft tissue sarcomas

INTRODUCTION

Radiation therapy is increasingly used as adjuvant treatment of many childhood and adult malignancies. Radiation-induced sarcoma is a well recognized if uncommon event. The objective of this study is to determine the prevalence and long-term outcome for patients who develop radiation-induced sarcomas.

METHODS

From July 1982 to December 2001, 4884 adult patients with sarcoma were admitted and treated at our institution and recorded in a prospective database. There were 123 (2.5%) patients who had radiation-induced soft tissue sarcomas. Survival was determined by Kaplan-Meier analysis. Patient, tumor, and treatment characteristics were tested for their prognostic significance by log rank and the Cox proportional hazards model.

RESULTS

The median interval between radiation and development of sarcoma was 103 (6 to 534) months. In 114 patients with radiation-induced sarcoma who underwent curative resection, the 5-year actuarial survival was 41%, with a median survival of 48 months at a median follow-up of 36 months for survivors. The most common malignancy for which radiation was used was breast cancer (29%), followed by lymphoma (16%) and prostate cancer (15%). Malignant fibrous histiocytoma (23%) was the most common histologic diagnosis, followed by fibrosarcoma (15%) and angiosarcoma (15%). High-grade tumors (n = 85; 79%), age > 60 years (n = 61; 50%), and gross positive resection margin (n = 36; 32%) were predictive of poor sarcoma-specific survival on univariate and multivariate analysis.

CONCLUSIONS

The increasing utilization of adjuvant radiation therapy, especially for early-stage breast cancer mandates long-term follow-up to detect radiation-induced sarcoma. Surgical resection remains the primary therapy, but 5-year survival remains approximately 40%.

[Salvage of exposed alloplastic materials in irradiated wounds - a case report]

BACKGROUND

Modern multimodal concepts of complex reconstructions and advanced wound management enlarge strategies for surgical oncological therapies. One of the mainstays of classical surgical therapy in case of exposed alloplastic materials in irradiated wounds was to remove the foreign body due to the risk of infection. This loss of integrity and function of the contaminated host bed was to allow wound healing and closure.

METHOD

We report the management of a 56-year-old female patient who developed a lyomyosarcoma at her left shoulder girdle 8 years after radiation of the left thorax because of breast cancer. After radical tumor resection and exarticulation of her left arm in the shoulder joint a necrosis of the soft tissue envelope developed, leading to an exposed alloplastic mesh. Staged debridement and continuous application of negative pressure was performed three times. Ultimate plastic coverage was performed by means of a pectoralis myocutaneous island flap from the other breast.

RESULTS

After staged debridement and repeated vacuum application excellent wound cleaning, neovascularisation, wound contraction and formation of granulation tissue within the previously irradiated tissue zone was observed. Until fourteen months postoperative wound coverage remained stable and no signs of infection were observed.

DISCUSSION

By means of negative pressure therapy even in radiated wounds excellent wound cleaning and sufficient formation of granulation tissue can be achieved. In some cases negative pressure therapy together with staged debridement allows reintegration of exposed and therefore potentially contaminated alloplastic meshes into new formed granulation tissue in radiated wounds respectively radiation ulcers. Thus leading to the possibility of ultimate plastic coverage.

[Angiosarcoma following breast-conserving therapy]

Two women with breast cancer, 59 and 72 years of age, were treated by means of breast-conserving surgery and radiotherapy. At the age of 66 and 77, respectively, discolouration of the skin was seen in the treated breast. Punch biopsy did not show secondary malignancy. Diagnostic (deeper) excisional biopsy revealed angiosarcoma. Ablation of the breast was performed in both patients. The younger woman, however, had a recurrence four months later that was treated with wide local excision and omentum-plasty. The older woman died two years after the ablation as a result of haematogenous metastases. Knowledge of the symptoms and diagnostic pitfalls of radiotherapy-induced angiosarcoma after breast-conserving treatment is important in the follow-up of breast-cancer patients. Histological diagnosis of a biopsy taken at sufficient depth is indicated when a secondary angiosarcoma is suspected.

Keloidal basal cell carcinoma after radiation therapy

We report a case of keloidal basal cell carcinoma (BCC) that developed after radiation therapy. A 67-year-old Japanese man had received radiation therapy of an unknown amount for three years for the treatment of right cervical lymph node tuberculosis at the age of 7. Within the area of chronic radiation dermatitis, on the right preauricular region, he presented with a skin-colored to erythematous, firm nodule. Histopathologically, this nodule showed features of keloidal BCC. The stroma characteristically demonstrated the prominent, keloidal, thickened collagen bundles standing out against the surrounding actinic-damaged dermis, and well-circumscribed, keloidal collagen bundles that proliferated in a nodular form almost corresponding to a clinically firm, nodular lesion. There was no radiation fibrosis around the keloidal BCC. We discuss the differences between keloidal BCC and morpheiform BCC, and consider keloidal BCC to be a rare variant of BCC from a clinico- pathological basis.

Radiation-induced atypical meningioma with rapid growth in a 13-year-old girl

This case illustrates the potential growth rate of an atypical meningioma in a pediatric patient, emphasizes one of the potential risks after therapeutic radiation, and underscores the importance of clinical evaluation and follow up of the symptomatic patient after tumor resection and radiation therapy. The authors report a case of a radiation-induced atypical meningioma of the olfactory groove in a 13-year-old girl who received 36 Gy of radiation to the craniospinal axis and 72 Gy to the primary site of a primitive neuroectodermal epithelial tumor of the left parietooccipital lobe when she was 4 years of age. This tumor was not present on routine magnetic resonance imaging performed 13 months prior to the discovery of this lesion or on computerized tomography scanning obtained 6 months prior to the discovery of this tumor. At the time of its discovery, the tumor was 5 x 5 x 4 cm. This tumor was resected and the patient's symptoms improved. This case illustrates the importance of continued close follow up after cranial irradiation in the pediatric population.

Intracranial osteosarcoma after radiosurgery--case report

A 56-year-old woman presented with an intracranial osteosarcoma at the site of previous radiosurgery, manifesting as sudden onset of headache and left hemiparesis with aphasia. She had a previous history of stereotactic radiosurgery for an intracranial tumor under a diagnosis of falx meningioma. Computed tomography showed intratumoral and peritumoral hemorrhage at the right parietofrontal region. Gross total resection of the tumor with hematoma was performed. The histological diagnosis was osteosarcoma. Sarcomatous change is a rare complication of radiotherapy. This case illustrates that osteosarcoma may develop years after radiosurgery for benign brain neoplasm.

Radio-induced malignancies of the scalp about 98 patients with 150 lesions and literature review

INTRODUCTION

- The induction of malignant diseases is one of the most concerning late effects of ionizing radiation. The topic of this study deals with skin tumors developed in the irradiated areas in children given X-ray therapy for tinea capitis.

MATERIAL AND METHODS

- All patients with malignant tumors of the scalp referred to Salah Azaiz Institute between 1970 and 2001 have been questioned in order to determine if there had been a prior X-ray irradiation for tinea capitis, its modality, and its consequences. The first scalp irradiation goes back to 1922 and the last was performed in 1963.

RESULTS

- Ninety-eight patients with 150 radio-induced cancers of the scalp following irradiation for tinea capitis are reported (1.5 lesion per patient). The patients were irradiated in various hospitals and dispensaries throughout the country. Eighty-one patients (82%) had only one session of radiation. The average age at irradiation was 12 (+/-6) years, the latent period for radiation-induced skin cancers was 36 (+/-14) years. In 61 patients (62%), the scalp appeared normal and in 38% radiodermatitis was noted. Patient age at diagnosis of malignancy varied from 20 to 83 years with an average of 47 years. Basal cell carcinomas (125 cases) and spinocellular carcinomas (16 cases) were the most common, three other cases of annexial tumors, two malignant non-Hodgkin's lymphomas and four melanoma lesions are also present. Radiotherapy was used for the treatment of 74 patients (alone in 42 and associated with surgery in 32 patients); 14 patients had exclusive surgical excision.

CONCLUSIONS

- Basal cell carcinomas are the most frequent tumors arising on chronic radiodermatitis. In spite of the long latency period, patients' young age at irradiation explained the occurrence of these cancers at a relatively young age. Literature review is suggesting recessive mutation of tumor-suppressor genes as the characteristic abnormality in radio-induced cancer.

Radiation-induced malignant triton tumor associated with severe spinal cord compression. Case report and review of the literature

Malignant triton tumor (MTT) is a variant of malignant peripheral nerve sheath tumors. The authors report a case of radiation-induced MTT in a patient with severe cervicothoracic cord compression and review the related literature. This 36-year-old man presented with pain and weakness in his left arm. His medical history was significant for a biopsy procedure involving the sampling of an aneurysmal bone cyst located at T1-3 near the left lung apex; this was performed 6 years prior to presentation and was followed by radiotherapy. Neurological examination demonstrated radicular findings involving the left C-8 and T-1 nerve roots. Neuroimaging studies revealed a large mass lesion extending from C-6 to T-2 along the vertebral column, invading the upper thoracic cavity and the adjacent lung apex, and infiltrating the paravertebral muscles. A subtotal resection was performed, but the tumor regrew extensively within a short time. It invaded the spinal canal and caused significant cord compression. The patient underwent surgery two more times for tumor debulking and to relieve progressive airway and spinal canal compromise. He eventually became quadriplegic, however, and died 13 months after diagnosis of MTT. This is the seventh case of radiation-induced MTT and the fifth of MTT with spinal canal involvement to be reported in the literature.

Long-term expression of fibrogenic cytokines in radiation-induced damage to the internal anal sphincter

BACKGROUND

There is accumulating evidence, both quantitative and qualitative, that pelvic irradiation affects anorectal function. However, the molecular mechanisms responsible for radiation-induced damage to the anal sphincter remain unclear.

AIM

To determine the expression of transforming growth factor-beta 1 (TGF-beta 1) and its downstream effector connective tissue growth factor (CTGF) in the anal sphincter of a patient irradiated for prostate cancer.

PATIENT

A 82 year-old patient developed a rectal adenocarcinoma and underwent an abdomino-perineal resection (APR), four years after receiving pelvic irradiation for prostate carcinoma.

METHODS

Tissue sections of the anal sphincter were processed for histology. Immunostaining for TGF-beta 1 and CTGF were performed.

RESULTS

CTGF and TGF-beta 1 immunoreactivity was detected in the irradiated anal sphincter, and was absent in controls. Immunoreactivity for both cytokines predominated in the internal sphincter. CTGF and TGF-beta 1 were preferentially detected in endothelial cells, myofibroblasts and fibroblasts; in addition, there was strong immunoreactivity for TGF-beta 1, but not for CTGF in smooth muscle cells of the anal canal.

CONCLUSION

Four years after pelvic irradiation, radiation-induced damage appeared to affect predominantly the smooth muscle layer of the anal canal. The molecular mechanisms responsible for radiation-induced fibrosis to these tissues involve prolonged activation of TGF-beta 1 and its downstream effector CTGF.

[Surgical treatment of sporadic and radiation-induced thyroid cancer in young patients]

An analysis of results of treatment of sporadic thyroid cancer in 68 children and juveniles and in 119 adult patients with radio-induced carcinomas irradiated in childhood after the Chernobyl APS accident in 1986 has revealed that the sporadic thyroid cancer in children and adults with radio-induced carcinomas are highly aggressive. For all this, radio-induced carcinomas are known to have aggressive local growth that in most cases required extended operations. The surgical treatment of carcinomas allows to get survival of the absolute majority of the patients.

[Laryngeal radionecrosis]

Laryngeal radionecrosis is now an uncommon, late complication after radiotherapy. The authors presented the diagnostic difficulties with differeniation beetween radionecrosis and the recurrent cancer, as well as their own experience with the treatment. The material consisted of 6 cases with radionecrosis (Chandler grade IV) surgically treated during past 15 years. In 3 cases complications occurred in a year after radiotherapy, in 2--ten years and in one--45 years later. In all cases repeated biopses were negative. Laryngeal radionecrosis is life threatening complication, that is why it requires intensive pharmacological and surgical treatment. Despite repeated negative biopses, total laryngectomy is the operation of choice when the larynx is non-functioning. In chosen cases, due to often observed postoperative complications (necrosis of the skin, pharyngeal fistula), indication is the use of artery flaps with simultaneous total laryngectomy.

A late complication of pelvic radiotherapy: leiomyosarcoma of the rectum. Report of a case and review of the literature

Leiomyosarcoma of the rectum is an uncommon malignancy; it accounts for less than 0.1% of all malignancies of the colon and rectum and only one case has been reported long-term following pelvic radiotherapy. We report a second case of leiomyosarcoma of the rectum after radiotherapy in an elderly women who received external radiation therapy eighteen years before, for endometrial carcinoma. We confirm that leiomyosarcoma may be a late uncommon effect of pelvic irradiation and suggest that close and long-term surveillance of irradiated patients is highly recommended.

Salvage chemotherapy and surgery for radio recurrent carcinoma glottis

Chemoradiotherapy is increasingly used in advanced laryngeal cancers. Failures are generally managed by surgery. They include histologically confirmed recurrent or residual disease or a symptomatic life threatening treatment sequelae. Tumour recurrence or residivism can be managed by chemotherapy when radical surgery is either refused by the patient or if the general condition of the patient do not permit it. However surgery becomes inevitable when life threatening treatment sequelae like absolute pharyngo-oesophageal stricture and aspiration sets in.

Accuracy of fine-needle aspiration cytology in patients with radiation-induced thyroid neoplasms

BACKGROUND

Fine-needle aspiration cytology (FNAC) is useful for selecting patients with thyroid nodules for thyroidectomy. Its value in patients who have been exposed to low-dose therapeutic radiation is questionable because these patients have an increased risk of multifocal benign and malignant tumours, and thyroid cancer is common in such patients.

METHODS

Between 1960 and 1999, 171 patients with one or more thyroid nodules who had a history of exposure to radiation underwent operation; 49 of these patients had preoperative FNAC. The cytology results in these 49 patients were compared with those of an age- and sex-matched control group of patients with thyroid nodules who did not have a history of radiation exposure.

RESULTS

Of those who had been exposed to radiation, six of 20 patients with 'benign' cytology by FNAC and six of 16 patients with 'suspicious' cytology had thyroid cancer. All 13 specimens considered to be malignant on FNAC were indeed malignant. There was a higher rate of false-negative cytological examinations among patients with a history of irradiation that in those without.

CONCLUSION

FNAC of thyroid nodules in patients with a history of irradiation is not as accurate as that in non-irradiated patients, primarily because of coexisting occult thyroid cancers.

Radiation-induced schwannomas of the nervous system. Report of five cases and review of the literature

Radiation therapy has important delayed effects on the central nervous system. Prominent among these effects is radiation necrosis of nervous tissue, but an oncogenic effect is also recognized. Both benign and malignant intracranial tumors can develop in irradiated fields, particularly in children. Most of these tumors are sarcomas, meningiomas or gliomas and only occasionally schwannomas. We report 5 cases of postirradiation acoustic nerve schwannoma observed in our Department.

Sternal reconstruction with synthetic mesh and metallic plates for high grade tumours of the chest wall

OBJECTIVE

To present our experience of reconstruction of the chest wall after sternectomy for high grade tumours.

DESIGN

Retrospective study.

SETTING

University hospital, Italy.

SUBJECTS

18 patients who required sternectomy for high grade tumours.

INTERVENTIONS

After wide resection of the tumour the sternum and chest wall were reconstructed with polypropylene (Marlex) mesh and mouldable titanium plates. Pedicled muscle flaps were used to complete the reconstruction.

MAIN OUTCOME MEASURES

Morbidity, mortality, and outcome.

RESULTS

The 18 tumours were chondrosarcomas (n = 7); osteosarcomas, radiation-induced sarcomas, and local recurrences after breast cancer (n = 2 each); and angiosarcoma, Ewing sarcoma, liposarcoma, malignant fibrous histiocytoma, and metastatic renal carcinoma (n = 1 each). One patient died in hospital. Two patients developed wound infections, one required repeated aspirations of a pleural effusion, and one patient later developed loosening of the plate that had been sutured to the clavicular stump. At the time of follow-up (mean 32 months, range 12-74) 16 patients were alive, all of whom had returned to their normal life style.

CONCLUSIONS

The technique is easy to follow and has the advantages of a short hospital stay and good local control. It obviates the need for postoperative mechanical ventilation, and means that patients are not prevented from working because of incapacity.

[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".

Prognostic value of magnetic resonance imaging-guided stereotactic biopsy in the evaluation of recurrent malignant astrocytoma compared with a lesion due to radiation effect

OBJECT

The prognostic value of differentiating between recurrent malignant glioma and a lesion due to radiation effect by performing stereotactic biopsy has not been assessed. Thus, this study was undertaken to determine such value.

METHODS

Between 1995 and 2001, 114 patients underwent magnetic resonance (MR) imaging-guided stereotactic biopsy to differentiate lesions caused by a recurrence of malignant astrocytoma and by radiation effect. All patients had previously undergone tumor resection (World Health Organization Grade III or IV) followed by radiotherapy. Disease diagnosis based on biopsy and patient characteristics were assessed as predictors of survival according to results of a multivariate Cox regression analysis. The diagnosis determined with the aid of biopsy was compared with that established during a subsequent resection in 26 patients. Survival following stereotactic biopsy was markedly increased in patients suffering from radiation effect compared with those harboring recurrent malignant glioma (p < 0.0001). In patients with radiation effect on biopsy, an increasing patient age (p < 0.05), having had two compared with one prior resection (p < 0.05), and a decreasing time from radiotherapy to biopsy (p < 0.001) were factors associated with decreased survival. Nevertheless, in patients with biopsy-defined radiation effect at second progression or with an age younger than 50 years the survival rate remained higher than that in patients with recurrent tumor on biopsy (p < 0.01). A biopsy-based diagnosis of radiation effect obtained less than 5 months after radiotherapy was not associated with an increased rate of patient survival compared with a diagnosis of recurrent malignant glioma on biopsy (p = 0.286). Eighty-six percent of lesions initially determined to be due to radiation effect on biopsy fewer than 5 months after radiotherapy were characterized as recurrent glioma by a mean of 11 months later. In contrast, only 25% of lesions initially diagnosed as attributable to radiation effect on biopsy more than 5 months after radiotherapy were classified as recurrent glioma a mean of 12 months later (p < 0.05).

CONCLUSIONS

With the aid of stereotactic biopsy the authors demonstrated prognostic significance in differentiating recurrent malignant astrocytoma from a lesion due to radiation effect in patients presenting more than 5 months after having undergone radiotherapy. In patients who presented earlier than 5 months after radiotherapy, radiation effect on biopsy was not associated with an improved rate of survival compared with that in patients harboring recurrent malignant astrocytoma.