Bone sarcomas linked to radiotherapy and chemotherapy in children

Secondary solid malignant tumors occurring after bone marrow transplantation for severe aplastic anemia given thoraco-abdominal irradiation

PURPOSE

We have evaluated irradiation doses received at location of secondary solid tumors occurring after bone marrow transplantation (BMT) in five of 147 patients grafted for severe aplastic anaemia.

RESULTS

All 5 tumors occurred within the radiation field penumbra. The estimated received dose varied from 6 Gy for one inner field secondary tumor, to 2.5 Gy for the remaining secondary tumors.

CONCLUSION

Tumors may arise in the zone where the delivered radiation dose drops dramatically. Irradiation, with associated cofactors, may promote the development of epidermoid carcinoma in irradiated patients for BMT.

Second malignant tumors following treatment during childhood and adolescence for cancer

Many pediatric and adolescent cancer patients are treated with carcinogenic chemotherapeutic agents and radiation therapy to achieve permanent control of their malignancy. These modalities may induce a new cancer in the successfully treated patient. To identify disease and treatment factors which increased the risk of occurrence of a second malignant tumor following modern treatment for cancer during childhood or adolescence, we reviewed the courses of 1,406 previously untreated patients who were less than 20 years of age at diagnosis and were treated at Roswell Park Cancer Institute between January 1, 1960 and December 31, 1989. Eighteen patients developed a second malignant tumor, including two meningiomas, 2.65-25.65 years after diagnosis of the first cancer. The actuarial risk of a second malignant tumor was 5.6% at 25 years after diagnosis. Using Cox proportional hazards modelling, we identified prior therapy with BCNU (P = 0.0055) and doxorubicin (P = 0.0254) as the only factors that were significantly associated with the risk of a second malignant tumor. Three second malignant tumors of the central nervous system occurred following treatment with a nitrosourea. Successfully treated patients must be carefully followed to identify treatment related malignant tumors at an early stage.

The effect of age at diagnosis on outcome in rhabdomyosarcoma

BACKGROUND

Survival for rhabdomyosarcoma appears to be more favorable in children and adolescents compared with adults. To determine the significance of age at diagnosis as a prognostic indicator in rhabdomyosarcoma, we performed a retrospective analysis of a combined pediatric and adult rhabdomyosarcoma data base.

METHODS

Pertinent prognostic variables, including age, TNM stage, histopathologic subtype, anatomic site, resectability, radiation to the primary site, and dose intensity of chemotherapy, were compared in a Cox proportional hazards model with mortality as the outcome variable.

RESULTS

Age at diagnosis (P = 0.0001) and local tumor invasiveness (P < 0.0001), distant parenchymal metastases (P < 0.0001), regional lymph node involvement (P = 0.0027), and histopathologic subtype (P = 0.0446) contributed information to the proportional hazards model.

CONCLUSIONS

Age at diagnosis is an independent predictor of outcome in patients with rhabdomyosarcoma along with tumor invasiveness, metastases, regional lymph node involvement, and histopathologic subtype.

Cytogenetic findings in malignant triton tumor

Malignant triton tumor is a rare histologic variant of malignant schwannoma that shows both neural and skeletal muscle differentiation. In this study, cytogenetic analysis of a recurrent malignant triton tumor of the forearm from a 26-year-old female and a primary paraspinal malignant triton tumor from a 27-year-old female revealed complex karyotypes displaying multiple numerical and structural abnormalities. Abnormalities shared by both tumors included three copies of chromosome 22 and structural rearrangements of chromosomes 2, 7, and 21 at identical or closely located breakpoints.

Acute promyelocytic leukemia with t(15;17) abnormality after chemotherapy containing etoposide for Langerhans cell histiocytosis

BACKGROUND

Epipodophyllotoxins, etoposide and teniposide, have been shown to be implicated in the development, of acute myelogenous leukemia in patients treated for solid tumors or acute lymphoblastic leukemia. Etoposide has been shown to be an effective agent against Langerhans cell histiocytosis (LCH) and has gained wider use recently for first-line and salvage chemotherapy in cases of systemic LCH.

METHODS

The authors report two patients with secondary acute promyelocytic leukemia (APL) with a t(15;17) abnormality after chemotherapy that included etoposide for the treatment of LCH.

RESULTS

Patient 1, a 6-year-old girl, had APL develop 11 months after cessation of therapy that included vinblastine, prednisolone, and etoposide (9600 mg/m2 in total dose) for LCH. Patient 2, a 3-year-old girl, had APL develop 9 months after cessation of therapy that included vincristine, methotrexate, prednisolone, cyclophosphamide (10,800 mg/m2), and etoposide (4800 mg/m2) for LCH.

CONCLUSIONS

The authors have experience with four patients treated with etoposide for LCH and suggest that there is a predisposition to secondary APL with t(15;17) for patients with LCH treated with etoposide. The authors warn against the imprudent use of etoposide as a first-line therapy for LCH.

Second malignant neoplasms after cancer in childhood or adolescence. Nordic Society of Paediatric Haematology and Oncology Association of the Nordic Cancer Registries

OBJECTIVE

To assess the relative risk of developing a second malignant neoplasm in people with a diagnosis of cancer in childhood and adolescence.

DESIGN

Register based follow up study.

SETTING

Populations of Nordic countries.

SUBJECTS

30,880 people under the age of 20 with a first malignant neoplasm diagnosed during the period 1943-87.

MAIN OUTCOME MEASURES

Relative and attributable risks of second malignant neoplasms by type of first cancer, age at first diagnosis, calendar period, sex, and country. Expected figures were based on the appropriate national incidence rates for cancer.

RESULTS

247 cases of second malignant neoplasms were observed in 238 patients, yielding a relative risk for cancer of 3.6 (95% confidence interval 3.1 to 4.1). The risk changed significantly from 2.6 in people first diagnosed during the 1940s and 1950s to 6.9 among cohort members included in the late 1970s and 1980s. Increases were observed for most types of cancer. Highest levels of the relative risk were seen during the 10 years immediately after first malignant diagnosis. The incidence of second malignant neoplasms attributable to the first cancer and associated treatments, however, showed a consistent rise throughout the 45 years of follow up.

CONCLUSION

The estimated risks for a second malignant neoplasm were significantly lower than those found in most large hospital based studies but compatible with the results from a similar population based study in the United Kingdom. Extent of risk and cancer pattern were similar among the Nordic countries and are believed to be representative for a large part of the European population.

Forty-year experience with second malignancies after treatment of childhood cancer: analysis of outcome following the development of the second malignancy

As the cure rate for childhood malignancies increases, the number of patients at risk for development of second malignancies also increases. Due to the potentially long remaining life span, long-term follow-up is difficult and patients are often at risk after presumptive cures. Some authors believe that cure rates for second malignancies are similar to cure rates for primary malignancies. We reviewed the records of 162 patients seen at our institution who had developed a second malignancy after treatment for childhood cancer. Presentation, age at diagnosis, tumor histology, extent of tumor, treatment (including radiotherapy with dosage when available, and chemotherapy) plus outcome were recorded. Mean age at diagnosis of the primary malignancy was 10.3 years. The most common primary malignancy was Hodgkin's disease (33) followed by soft tissue sarcoma (28), retinoblastoma (20), bone tumor (17), central nervous system (CNS) tumor (13), leukemia (8), Wilms' tumor (7), non-Hodgkin's lymphoma (6), neuroblastoma (5), thyroid neoplasm (5), and others (20). The average interval between diagnosis of the first and second malignancy was 10.8 years. These second tumors carried a high mortality. Only 56 patients have no evidence of disease. Five patients are known to be alive with disease and 92 patients have expired due to their second malignancy. Disease status in 8 patients is unknown. The most common second malignancy was osteosarcoma (35) followed by soft tissue sarcoma (24), breast cancer (15), leukemia (14), thyroid carcinoma (14), CNS tumors (12), melanoma (8), nonmelanomatous skin cancer (8), lymphoma (5), and others (27).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of giant-cell tumor of the pelvis

Nineteen patients who had a giant-cell tumor of the pelvis were managed from 1944 through 1989. Thirteen of the patients were in the third or fourth decade of life. The ileum was involved in thirteen patients; the pubis, in two; the ischium, in three; and the pubis and ischium, in one. Five patients who had an initial Stage-II (active) lesion were managed with curettage; in one of the five, a local recurrence developed at twelve months, and the other four had no evidence of disease from nine to forty-six years after the curettage. Eight patients who had a Stage-III (aggressive) lesion were managed with resection of most of the lesion followed by curettage of any remaining positive margins; four of the eight also received adjuvant irradiation. None of the eight had a local recurrence; six had no evidence of disease from eight to twenty-seven years after the operation, one died because of a metastatic post-radiation sarcoma thirteen years after the operation, and one was asymptomatic but had pulmonary metastases three years after the operation. Four patients who had a Stage-III recurrent local tumor when they were first seen were managed with hemipelvectomy, wide resection, resection and curettage, and curettage and arthroplasty (one procedure each). Three had no evidence of disease seven to twenty years after the operation and one had died because of a post-radiation metastatic osteosarcoma eight years after the operation. Two patients who had Stage-III disease were managed with external beam radiation alone. One had no evidence of disease twenty-six years later. The other had a recurrence one year later, which was treated with additional irradiation; a second recurrence was treated with curettage and bone-grafting. Twenty-eight years after the initial radiation treatment, this patient had no evidence of disease. External beam irradiation was used for a total of eight patients; a post-radiation sarcoma developed in two.

Ewing sarcoma of the pelvis. Clinicopathological features and treatment

The results of treatment in twenty-seven patients who had a Ewing sarcoma of the pelvis were reviewed. Six patients had had metastatic disease at the time of the diagnosis. The three-year actuarial survival of these patients was 17 per cent (95 per cent confidence interval, 8 to 52 per cent). Of the twenty-one remaining patients, thirteen had received chemotherapy and radiation therapy to the primary lesion and eight had had chemotherapy and operative resection, with or without radiation therapy. The actuarial five-year over-all survival was 25 per cent (95 per cent confidence interval, 6 to 51 per cent) in the group that had had radiation without a resection and 75 per cent (95 per cent confidence interval, 31 to 93 per cent) in the group that had had a resection (p < 0.005, log-rank method). The actuarial over-all five-year survival was 45 per cent (23 to 65 per cent) for all patients who had had localized disease when first seen. Actuarial local failure analysis (the censoring of patients who died without evidence of local failure before the two-year follow-up examination) revealed a rate of local failure of 44 per cent (14 to 79 per cent) in the group that had been treated with chemotherapy and radiation alone compared with 13 per cent (0 to 53 per cent) in the patients who had had a resection, but this difference was not significant (p > 0.25, log-rank method).(ABSTRACT TRUNCATED AT 250 WORDS)

Deletion of chromosome 13 in osteosarcoma secondary to irradiation

The cytogenetic analysis of a radiation-induced osteosarcoma in a 31-year-old male is presented. Complex karyotypic changes with numerical and structural abnormalities, including a del(13)(q12.3q21.1), were observed. This deletion may indicate that loss of RB1 gene (locus in 13q14) may be involved in the development of radiation-induced osteosarcoma.

Postirradiation sarcoma of the head and neck

BACKGROUND

With improvement in survival after cancer treatment, it is becoming increasingly important to study treatment-related morbidity and mortality. Sarcoma can develop in the irradiated field after radiation therapy. The authors performed a study to estimate the risk, and compared the risk of sarcoma after radiation therapy with that of other treatment modalities used against cancer.

METHODS

Between 1955 and 1988, 229 patients with sarcoma of the head and neck were seen at the University of California, Los Angeles (UCLA), Medical Center. Of these, 13 (6%) had a previous history of radiation therapy to the head and neck.

RESULTS

Radiation doses were known in 10 of 13 patients and ranged from 30 to 124.4 Gy. The latency time from radiation therapy to the development of postirradiation sarcoma (PIS) ranged from 3 months to 50 years, with a median of 12 years. More than 2000 patients have received radiation therapy to the head and neck for various conditions at the UCLA Medical Center since 1955.

CONCLUSIONS

The authors conclude that most head and neck sarcomas are not radiation related and that the risk of PIS after head and neck irradiation for other diseases is low. From a review of the literature comparing mortality risks of chemotherapy, general surgery, and anesthesia, the risk of PIS appears no worse. Given the large number of patients who can be cured or receive palliation with radiation therapy, concern about PIS should not be a major factor influencing treatment decisions in patients with cancer.

Allogenic bone-marrow transfusion suppresses development of lung metastases in osteogenic sarcoma patients after radical surgery

On the basis of experimental data obtained in Syrian hamsters, demonstrating the highly efficient suppression of experimental and spontaneous metastases of highly-metastatic sarcoma cells by the use of allogeneic normal bone-marrow cells (BMC), a clinical protocol for the suppression of lung metastases of osteogenic sarcoma was started in 1984 in the Cancer Research Center, Moscow. From this time onwards, 24 osteogenic sarcoma patients, at stages 2A and 2B were treated with a combination of radical surgery and a single transfusion of normal (non-activated) allogeneic BMC (blood-group and Rhesus compatible). The first results of this ongoing study are now presented. Metastases appeared in 11 out of the 24 patients, generally very early during the first 3-9 months after treatment and in no case after 2 years. More than 50% of the BMC-treated patients were free of lung metastases after 2 or more years of observation; 8 out of 15 are still metastasis-free after 3-4 or more years of observation following treatment. The differences in the frequency of metastasis and duration of survival without metastasis of treated patients compared with a group of 41 osteogenic sarcoma patients at stages 2A and B, treated with radical surgery only (controls) reached significant levels 12 months after treatment and thereafter. Rapid recovery of NK cytotoxic activity has been observed in nearly all successfully BMC-treated patients.

Issues in the consideration of intervention strategies in long-term survivors of childhood cancer

With the improved survival of children with cancer, increased attention is being focused on the health status of survivors. The ultimate objective of this research is to use the results to design and test rational intervention strategies directed toward reduction of morbidity and mortality associated with the diagnosis and successful treatment of cancer. After treatment and patient characteristics that confer a high risk for adverse sequelae are identified, intervention programs targeting primary or secondary interventions must be actively pursued. Primary interventions would include modifications to cancer treatment protocols to maintain a high degree of effectiveness but reduce the occurrence of late effects. Opportunities exist for secondary intervention research in a number of areas, including second cancers (smoking cessation/prevention, early detection, chemoprevention), cardiopulmonary dysfunction (diagnosis and treatment of comorbid disease and promotion of healthy life style practices), and reproduction/genetic risks (management, counseling, networking). It is likely that testing of intervention strategies will require collaborative studies involving a multidisciplinary team of investigators and a multi-institutional structure for access to a suitable survivor population.

Bone tumors other than osteosarcoma after retinoblastoma

BACKGROUND

The most frequent second malignant neoplasm after retinoblastoma is osteosarcoma, which may be associated with radiation therapy or arise de novo in patients with bilateral retinoblastoma.

METHODS

Clinical, pathologic, and diagnostic imaging findings in two patients with Ewing sarcoma (ES) and one with peripheral neuroepithelioma (PN) are presented.

RESULTS

Second malignant neoplasms located in the extremities or pelvis were seen 12-18 years after initial diagnosis of unilateral (two patients) or bilateral (one patient) retinoblastoma. The patients with unilateral retinoblastoma were treated by enucleation only; the other received ocular radiation therapy and chemotherapy. To the knowledge of the authors, this is the first documentation of round blue cell tumor after unilateral retinoblastoma.

CONCLUSIONS

ES and PN should be included in the differential diagnosis of malignant neoplasms occurring after treatment of unilateral or bilateral retinoblastoma.

Ewing's sarcoma: long-term follow-up in 49 patients treated from 1967 to 1989

PURPOSE

Review of long-term results of therapy for Ewing's sarcoma in terms of survival, local tumor control, distant failure and complications rates.

METHODS AND MATERIALS

Retrospective review of the records of patients with Ewing's sarcoma of bone and soft tissues treated at The Prince of Wales Children's and Prince of Wales Hospitals, Sydney, between 1967 and 1989 and followed-up to July 1991.

RESULTS

There were 49 patients with median age 16 years (range 3-33 years) and average potential follow-up time 12.3 years (range 2-24 years). Forty patients presented with localized disease (three with regional lymph node involvement) and nine with distant metastases. Local therapy for the primary was by amputation in three patients, by resection and postoperative radiotherapy in five, and by definitive radiotherapy in 41 (median dose 50 Gy). Forty-four patients received adjuvant multi-agent chemotherapy. The overall actuarial survival rate was 33% (SE = 7%) at 5 years and 30% (SE = 7%) at 10, 15, and 20 years. The factors predictive of shorter survival were distant metastases at diagnosis (p = 0.036) and older age (p = 0.025). The actuarial local control rate for all 49 patients was 75% (SE = 8%) at 5, 10, 15, and 20 years. The only factor predictive of local failure was an inadequate target volume irradiated (p = 0.003). In 40 patients who presented with localized disease only, the actuarial rate of freedom from distant failure at 5 years was 44% (SE = 8%) and at 10, 15, and 20 years was 40% (SE = 8%). Seven patients experienced severe or fatal complications (defined as requiring investigation and treatment in hospital), namely stress fracture in two, fatal osteogenic sarcoma in one, fatal cardiotoxicity in one and severe hemorrhagic cystitis in three. The rate for severe or fatal complications at 5 years was 19% (SE = 8%), at 10 years was 29% (SE = 12%) and at 15 and 20 years was 53% (SE = 21%).

CONCLUSION

Survival to 5 years appears to confer probable cure and one third of our patients have achieved this. Long-term follow-up also reveals that an increasing number of patients experience treatment-related complications, the majority of which, however, can be corrected.

Association of malignancy and Langerhans' cell histiocytosis: report of three cases

Among 44 children with Langerhans' cell histiocytosis (LCH) seen at the Pediatric Department of the A.C. Camargo Hospital, São Paulo, Brazil, three developed malignancy, two before and one after the diagnosis of LCH. Malignancy could be attributed to treatment in one of the three children. Whether the cancer in the other two children represents a chance association of the two processes or is treatment-related, is unknown.

Primary osteogenic sarcoma of the posterior mediastinum. Case report

Extraosseous osteogenic sarcoma of the mediastinum is an extremely rare tumour, usually arising in the anterosuperior compartment. Clinical findings in the first reported case of high-grade osteogenic sarcoma arising in the posterior mediastinum are described.

Late effects of therapy in survivors of childhood and adolescent osteosarcoma

Adult survivors of childhood or adolescent osteosarcoma require ongoing medical follow-up in order to monitor for potentially life-threatening consequences of therapy, including second cancers and anthracycline cardiotoxicity. In the future, additional knowledge of tumor biology will likely change staging methods and allow intensive therapy to be given only to those most likely to benefit from it [25]; those with less risk of relapse may require less toxic therapy and still achieve acceptable levels of survival.

Report on the international workshop of the Kind Philipp Foundation on late effects after bone marrow transplantation in childhood malignancies

This report is a short summary of an international workshop on late effects after bone marrow transplantation in pediatric patients. Main topics of the report are chronic GVHD and immune reconstitution and the late effects of this kind of treatment on growth, respiratory function, the endocrinological system, teeth, and eyes. The development of secondary tumors is discussed as well as the influences on the central nervous system and behavior of children.

Chromosomal anomalies in radiation-induced fibrosis in the pig

R-banded karyotypes were established on fibroblasts from fibrotic tissues derived from experimental fibrosis induced in pigs, either surgically or by 64 Gy of gamma-rays from iridium-192. No chromosome aberrations were observed in the surgical fibrosis. In radiation-induced fibrosis, the high frequency of abnormal karyotypes and the frequent complexity of the chromosomal rearrangements suggest that the fibroblasts originated either from the 64-Gy area, or from the penumbra, but certainly not from non-irradiated areas. At early passages in vitro, almost all karyotypes were different, demonstrating a multiclonal origin of fibrotic tissue. At late passages (above 24), the situation was quite different, with the persistence of one or two clones only, demonstrating a strong selective pressure occurring in vitro.

Causes of death in children diagnosed with non-Hodgkin's lymphoma between 1974 and 1985

An investigation has been undertaken of 479 deaths occurring up to the end of 1990 among 883 patients diagnosed with non-Hodgkin's lymphoma from 1974 to 1985 who were included in the population based National Registry of Childhood Tumours. The objectives were to perform a descriptive analysis looking particularly at the deaths not directly due to non-Hodgkin's lymphoma, to determine the frequency of the different causes of death and to study the trends over time. Among the 476 patients with sufficient information for the cause of death to be established, these were: non-Hodgkin's lymphoma, 377 (79%); treatment related (other than second primary tumour), 86 (18%); second primary tumour, 10 (2%); and other, three (1%). The proportion of all deaths not directly due to non-Hodgkin's lymphoma increased from 15% for those diagnosed during 1974-6 to 32% for those diagnosed during 1983-5. Among the 86 treatment related deaths, the more precise causes were bacterial infections, 26 (30%); viral and other infection, 14 (16%); metabolic, 19 (22%); renal, eight (9%); anaesthetic related, seven (8%); respiratory, four (5%); cardiac, three (3%); graft versus host disease, three (3%); and other, two (2%). Treatment related deaths from infection accounted for 27 (6%) of all patients diagnosed in 1974-9, and 13 (3%) in 1980-5. Treatment related deaths not due to infection occurred in 23 (5%) of those diagnosed in 1974-9 and 23 (6%) in 1980-5. Five treatment related deaths, including four anaesthetic related deaths, were identified as avoidable. Some of the deaths from metabolic and renal disease may also have been avoidable. Only 11 deaths have been recorded more than five years after diagnosis, six being due to second primary tumours. As follow up is relatively short for patients diagnosed more recently, further deaths from second malignancies and treatment related cardiovascular problems may well occur. A substantial number of children with non-Hodgkin's lymphoma die to treatment related causes. Deaths from infection have decreased in line with the overall improvement in survival rates. Other treatment related mortality has remained constant. Further improvements in survival for childhood non-Hodgkin's lymphoma will depend on maintaining the fine balance between the therapeutic value of intensive treatment and its potential harmful effects.

Second malignancies in very-long-term survivors of childhood cancer

PURPOSE

Although most second malignancies are treatment related, their occurrence also may be due to an underlying systemic disease or chromosomal abnormalities shared by multiple organs in which they are tumorigenic. We attempted to identify unusual tumor pairs that might provide a clue to shared genetic etiologies.

PATIENTS AND METHODS

Medical records and tumor registry correspondence of 1,743 patients (0 to 18 years at diagnosis) were reviewed. For those said to have a second malignancy, biopsy and autopsy records and slides were reviewed to confirm initial and secondary diagnoses.

RESULTS

Two hundred fifty-eight patients had follow-up of at least 10 years and 157 of at least 20 years. Second malignancies were identified in 14 patients. The estimated cumulative incidence of a second cancer was approximately 1% within 10 years. At 20 years after diagnosis, the actuarial estimate was 3%. Although most second cancers were likely treatment related, several tumor pairs could not clearly be explained on that basis, including thyroid carcinoma followed by an ovarian sarcoma, and acute lymphoblastic leukemia associated with renal leiomyosarcoma. Based on one case in this series and a review of the literature, associations between Wilms' tumor, abdominal radiation, and adenocarcinoma of the colon and hepatocellular carcinoma are suggested.

CONCLUSIONS

We conclude that continued surveillance of very-long-term survivors of childhood cancer, which is usually accomplished by internists, family practitioners, and adult oncologists, may be one approach to defining the life-time incidence of second malignancies. In addition, although the yield is likely to be small, descriptions of unexpected tumor pairs may target families for studies of pleiotropic genetic abnormalities.

Cytogenetic abnormalities in an ossifying fibroma from a patient with bilateral retinoblastoma

Cytogenetic analysis of a cemento-ossifying fibroma from a patient with nonfamilial bilateral multicentric retinoblastoma revealed three reciprocal translocations with the karyotype 46,XY,t(1;18)(q21;q21.3),t(3;10)(p13;q22),t(6;11)(p22;p15). Routine and high-resolution cytogenetic analysis of peripheral blood leukocytes showed an apparently normal, 46,XY chromosome pattern with no deletion of chromosome 13. Molecular analysis demonstrated no gross differences in the retinoblastoma gene or the TP53 gene between constitutional and tumor DNA. This is the first cytogenetic analysis of a cemento-ossifying fibroma and the first report of this tumor in a retinoblastoma patient. The data may be added to the small, but growing literature on cytogenetic aberrations in benign tumors and may lend insight into genes involved in cell proliferation and neoplastic transformation.

Epidemiological evidence for a common mechanism for neuroblastoma and differentiated thyroid tumour

Because genetic predisposition probably plays an important role in the aetiology of most of childhood cancers, studies of second primaries occurring after these cancers may be particularly informative about possible common genetic mechanisms in both of these cancers. We have studied the incidence of thyroid tumours occurring after cancer in childhood in a cohort of 592 children treated before 1970. Among these children, six later developed a thyroid carcinoma, and 18 developed a thyroid adenoma. Radiation doses received to the thyroid by each of the irradiated children have been estimated using individual radiotherapeutic technical records. Thyroid carcinomas and thyroid adenomas were five times more frequent after irradiation for neuroblastoma than after irradiation for any other first cancer. This ratio did not depend on sex, nor on time elapsed since irradiation, nor on dose of radiation received for the thyroid gland. This result suggests that there is a common mechanism for the occurrence of neuroblastoma and of differentiated thyroid tumour.

Does malignant small round cell tumor of the thoracopulmonary region (Askin tumor) constitute a clinicopathologic entity? An analysis of 30 cases with immunohistochemical and electron-microscopic support treated at the Institute Gustave Roussy

The morphology and clinical outcome of 30 patients with malignant small round cell tumors located in the thoracopulmonary region (Askin tumor) are reported. Histologically, all tumors had similar patterns, with small round-to-oval cells and a lobulated stroma. Immunohistochemical analysis always resulted in positive staining for one or several neural markers. No significant differences were found compared with the immunomarkers in 26 typical Ewing's sarcomas located outside the thoracic wall. In three specimens, electron microscopy confirmed the presence of membrane-bound neurosecretory granules. It was confirmed that there is a remarkable similarity among all malignant small round cell tumors, including Askin tumor and Ewing's sarcoma. Overall survival was poor with a 2-year rate of 38% and a 6-year rate of 14%.

Late effects of therapy in adult survivors of osteosarcoma and Ewing's sarcoma

To study the late consequences of primary bone cancer, we interviewed 82 osteosarcoma and 29 Ewing's sarcoma survivors regarding their health, fertility and offspring, employment, annual income, and activities of daily living. All subjects had been diagnosed before age 20 (mean age, 14.6 years), had survived at least 5 years from diagnosis, and were at least 21 years of age. On average, they were 32.5 years of age at interview. As controls, 151 siblings were interviewed. During the follow-up period, eight survivors had died, and eight survivors had been diagnosed with a second malignancy (7.2%; P = .002). No other health condition distinguished survivors from controls. Although the survivors were more likely than controls to have some difficulty climbing stairs and to have had employment disability, employment status and annual income at follow-up were similar. Deficits in marriage and fertility were not significant. Adult survivors of primary bone tumors diagnosed during childhood or adolescence are at high risk for second malignancies and premature death, making continued medical follow-up of utmost importance. Despite the physical impairment following limb amputation for many, the majority of outcomes we measured did not differ from controls, suggesting few adverse psychosocial outcomes in this group of cancer survivors.

Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer

The frequency of brachial plexopathy, rib fracture, tissue necrosis, pericarditis, and second non-breast malignancies occurring in the treatment field among 1624 patients with early stage breast cancer treated with conservative surgery and radiation therapy at the Joint Center for Radiation Therapy between 1968 and 1985 is reported. The median follow-up time for survivors was 79 months (range 5-233 months). Brachial plexopathy was related to the use of a third field, the use of chemotherapy and the total dose to the axilla. Brachial plexopathy developed in 20 of 1117 women (1.8%) who received supraclavicular irradiation with or without axillary irradiation. The median time to its occurrence was 10.5 months (range 1.5-77 mo), and the majority (80%) of cases completely resolved. Among patients treated with a three-field technique, the incidence of brachial plexopathy was 1.3% (13/991) in patients treated with a dose to the axilla of less than or equal to 50 Gy, compared with 5.6% (7/126) in women treated with an axillary dose of greater than 50 Gy. The incidence of brachial plexopathy was 4.5% (15/330) among patients receiving chemotherapy, compared with 0.6% (5/787) when chemotherapy was not used (p less than 0.0001). Rib fracture was seen in 29 patients (1.8%), at a median time of 12 months following treatment (range 1-57). In all cases, the rib fracture healed without intervention. The incidence of rib fracture was 2.2% (28/1300) among patients treated on a 4 MV linear accelerator, compared with 0.4% (1/276) for patients treated on a 6 or 8 MV machine (p = 0.05). Of patients treated on a 4 MV machine, 0.4% (1/279) developed a rib fracture when a whole breast dose of 45 Gy or less was given, 1.4% (10/725) after receiving between 45 and 50 Gy, and 5.7% (17/296) following 50 Gy or higher. Tissue necrosis requiring surgical correction developed in three patients (0.18%) 22, 25, and 114 months after treatment. Presumed pericarditis (requiring hospitalization) was seen in 0.4% of women (3/831) who received radiation therapy to the left breast 2, 2, and 11 months after the start of treatment. Three women (0.18%) developed sarcomas in the treatments field at 72, 107, and 110 months, for a 10-year actuarial rate of 0.8%. Two of these sarcomas developed in areas of probable match-line overlap. One patient (0.06%) developed an in-field basal cell carcinoma at 42 months. In conclusion, the risk of significant complications following conservative surgery and radiation therapy for early stage breast cancer is low.(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term effects of adjuvant chemotherapy in breast cancer

Late effects of adjuvant chemotherapy (ACT) may include second malignant neoplasms (SMN), cardiotoxicity and ovarian suppression. Effects on the biology of residual tumour may be important in protocol design. Studies of SMN need large and reliable data sets. The leukaemia risk with current ACT is likely to be less than a five-fold increase. Leukaemia is predominantly a result of alkylating agents and peaks before 10 years. Solid SMN result also from radiotherapy and this risk continues after 10 years. Cardiotoxicity can be caused by anthracyclines but should not be a problem with current ACT regimens. It can be reduced by careful monitoring and by the cardioprotector ICRF-187. Amenorrhoea is a crude marker of ovarian suppression which may explain conflicting data on its relationship to outcome after ACT. Ovarian suppression following ACT is more likely and more permanent in older premenopausal women, but only explains a part of the ACT effects on outcome. Effects of early ACT on residual tumour are important for planning retreatments and combined modality protocols.

Second neoplasms after acute lymphoblastic leukemia in childhood

BACKGROUND

Effective forms of treatment for acute lymphoblastic leukemia (ALL) in childhood now result in survival rates above 70 percent at five years, but the treatments are potentially carcinogenic. To determine the magnitude of this risk and identify possible risk factors for the development of second neoplasms, we studied a large cohort of children treated for ALL. METHODS AND RESULTS. We undertook a retrospective cohort study of 9720 children who had been given a diagnosis of ALL between June 1972 and August 1988 and had been treated according to the therapeutic protocols of the Children's Cancer Study Group. The median follow-up was 4.7 years (range, 2 months to 16 years). We found that 43 second neoplasms occurred among the children in the cohort, including 24 neoplasms of the central nervous system, 10 new leukemias and lymphomas, and 9 other neoplasms. This represented a 7-fold excess of all cancers and a 22-fold excess of neoplasms of the central nervous system. The estimated cumulative proportion of children in whom a second neoplasm developed was 2.53 percent 15 years after diagnosis (95 percent confidence limits, 1.74 percent and 3.38 percent). An even higher risk, particularly of central nervous system tumors, was evident in children five years of age or less at the time of the diagnosis of ALL (P = 0.012). All central nervous system neoplasms developed in children who had previously undergone irradiation. There was no association with exposure to cyclophosphamide or anthracyclines.

CONCLUSIONS

There is a substantial excess of second neoplasms, especially of the central nervous system, among children treated for ALL. Children five years old or younger and those receiving radiation are at higher risk, especially for second tumors arising in the central nervous system.

Clinical oncology: case presentations from oncology centres. 1. Ewing's sarcoma. The London Bone Tumour Service

The management of a case of Ewing's sarcoma of the left proximal humerus in a 15-year-old girl is presented, and the radiological and pathological findings are described. The chemotherapeutic, radiotherapeutic and surgical management of Ewing's sarcoma are discussed with reference to the case.

Ewing's sarcoma. Radiographic pattern of healing and bony complications in patients with long-term survival

The radiographic appearance of Ewing's sarcoma was studied retrospectively in 22 patients who survived 5 years or longer after diagnosis and treatment. Expected changes from treatment, including regression of the extraosseous soft tissue mass, periostitis, and reconstitution of the cortex, occurred in all patients. Local recurrence occurred in one patient 10 years after complete remission whereas secondary osteosarcoma occurred more than 5 years after complete remission in two other cases. Both recurrent and secondary tumors presented as new lytic foci at the site of the original primary lesion. Lytic changes from radiation (radiation osteitis) may develop more than 2 years after treatment and in this sample; such findings were widely distributed in the radiation port. The authors conclude that bone remodeling and postradiation changes occur slowly over 2 years after treatment, and that any localized lysis at the primary site is suspicious for recurrence or secondary neoplasm. Knowledge of the expected changes and patterns of local recurrence and secondary neoplasms helps one to detect any significant change in its early phase.

Second non-ocular tumours in survivors of bilateral retinoblastoma. A 30-year follow-up

The authors have reviewed a series of 80 patients treated at the Curie Institute before 1965 for bilateral retinoblastoma. They present their cases of second non-ocular tumours in these patients and discuss their results and the possible factors influencing the percentage of second tumours in these patients.

Chemotherapy for retinoblastoma: where do we go from here? A review of published literature and meeting abstracts, including discussions during the Vth International Symposium on Retinoblastoma, October 1990

The history of the application of chemotherapy in the management of retinoblastoma (RB) may conveniently be divided into three eras: initial enthusiasm (from early 1950s to mid 1970s), realism (from late 1970s to mid 1980s) and possibility (from mid 1980s to the future). Available data from each of these eras are reviewed in the clinical categories of: intraocular RB, micrometastatic RB and overt dissemination. The latter is further sub-classified into: orbital invasion, central nervous system involvement and systemic metastases. Experimental models are described with particular emphasis on future directions. Early reports led to initial optimism subsequently dampened by a more critical approach. Recent results with increasingly effective chemotherapeutic regimens offer the possibility of a valid contribution in each of the above clinical settings. A multi-modality approach is recommended optimizing a combination of the most active drugs with continuing refinements of other techniques. In selected patients with intraocular, and particularly bilateral RB, visual outcome may be enhanced by the combined use of non-surgical modalities. Adjuvant treatment of presumed micrometastases needs to be studied within risk categories defined by prognostic factors. Invasion of the ocular coats and/or of the optic nerve are the most relevant factors but there are continued difficulties in defining the extent of involvement and eligibility criteria for such a strategy. Overt dissemination has recently been demonstrated to be curable in each of the three subgroups above. Intensive regimens incorporating cyclophosphamide, vincristine, cisplatinum, etoposide and possibly doxorubicin, plus intrathecal agents in combination with radiation therapy and, in some instances supplemented by bone marrow transplantation have produced promising results. Multi-institutional collaboration has been encouraged by the recently formed International Committee for the Staging and Management of Retinoblastoma, opening the way for prospective clinical trials. At the same time both laboratory and clinical experimental studies are being pursued and may produce further improvements in currently available strategies.

Sarcomas of soft tissue and bone

Sarcomas arise primarily from mesenchymal structures at any site in the body, even within visceral stroma and neurovascular bundles. Sarcomas have been associated with prior radiation therapy, toxic exposures, and genetic conditions and soft tissue sarcomas have been distinguished from bone sarcomas. For localized soft tissue sarcoma, tumor grade is the most important prognostic variable. Low-grade tumors are generally cured by wide surgical excision, but there is a significant rate of both local recurrence and development of distant metastasis in high-grade lesions. The treatment of soft tissue sarcoma histologic subtypes is generally similar grade-for-grade, with the exception of rhabomyosarcoma, Kaposi's sarcoma, and mesothelioma. Tumor location strongly influences resectability. Radiation therapy has been used successfully in conjunction with conservative surgery to improve local control rates for soft tissue sarcomas, particularly in extremity lesions. Currently, adjuvant chemotherapy remains unproven for most adult soft tissue sarcomas, but is established in the treatment of rhabdomyosarcomas, osteosarcomas, and Ewing's sarcomas.

Postirradiation sarcoma. Analysis of a nationwide cancer registry material

Thirty-three cases of postirradiation sarcoma (PIS) from the files of the Finnish Cancer Registry were analyzed. The most frequent first primary tumors were cancers of the breast (seven cases) and female reproductive organs (13 cases). Five patients had a childhood cancer. The median total radiation dose at the site of the PIS was 3600 cGy (1600 cGy to 11200 cGy). The median interval from start of radiation therapy to detection of PIS was 13.2 years (3.4 to 22.8 years). The PIS was of soft tissue origin in 25 of 33 cases. The most frequent histologic types were osteosarcoma (ten cases, including four extraskeletal tumors), malignant fibrous histiocytoma (ten cases), and fibrosarcoma (six cases). The overall crude 5-year survival rate was 29% (calculated from the start of treatment for PIS), and for patients initially treated with either radical surgery or combined marginal surgery and postoperative irradiation it was 67%. The authors conclude that there is a chance for cure for radically treated patients with postirradiation sarcoma that emphasizes the importance of regular long-term follow-up of cancer patients.

Long-term risk of sarcoma following radiation treatment for breast cancer

Between 1954 and 1983, 7620 patients were treated for breast carcinoma at Institut Gustave Roussy (France). Of these patients, 6919 were followed for at least 1 year. Out of these, 11 presented with sarcomas thought to be induced by irradiation, 2 of which were Steward-Treves Syndrome, and 9 of which were sarcomas within the irradiated fields. All histological slides were reviewed and a comparison with those of breast cancer was done. The sites of these sarcomas were: parietal wall, 1 case; second costal cartilage, 1 case; infraclavicular region, 1 case; supraclavicular region, 2 cases; internal third of the clavicle, 2 cases; axillary region 2 cases; and the internal side of the upper arm (Stewart-Treves syndrome), 2 cases. The median age of these 11 patients at the diagnosis of sarcomas was 65.8 (49-83). The mean latent period was 9.5 years (4-24). Three patients underwent radical mastectomy and nine modified radical mastectomy. Only one patient received chemotherapy. The radiation doses received at the site of the sarcoma were 45 Gy/18 fr. for 10 cases and 90-100 Gy for 1 case (due to overlapping between two fields). The histology was as follows: malignant fibrous histiocytoma, 5 cases; fibrosarcoma, 3 cases; lymphangiosarcoma, 2 cases; and osteochondrosarcoma, 1 case. The median survival following diagnosis of sarcoma was 2.4 years (4 months-9 years). Two patients are still alive: one with recurrence of her breast cancer, the other in complete remission, with 7 and 3 years follow-up, respectively. All other patients died from their sarcomas. The cumulative incidence of sarcoma following irradiation of breast cancer was 0.2% (0.09-0.47) at 10 years. The standardized incidence ratio (SIR) of sarcoma (observed n# of cases (Obs)/expected n# of cases (Exp) computed from the Danish Cancer Registry for the same period) was 1.81 (CI 0.91-3.23). This is significantly higher than one, with a p = 0.03 (One Tailed Exact Test). The mean annual excess (Obs-Exp)/100.000 person-years at risk during the same period/(100,000) was 9.92. This study suggests that patients treated by radiation for breast cancer have a risk of subsequent sarcomas that is higher than the general population. However, the benefit from adjuvant radiation therapy in the treatment of breast cancer exceeds the risk of second cancer; therefore, the potential of radiation-induced sarcomas should not be a factor in the selection of treatment for patients with breast cancer.