Radiation induced neoplasia following external beam therapy for children with retinoblastoma

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.

Risk factors for metastases in patients with retinoblastoma

The study is based upon a review of data from 583 consecutive patients with retinoblastoma over the years 1956 to 1986. Mean follow-up was 8 years, and median was 5.5 years. In 41 patients, metastases developed within 5 years. The influence of clinical and histopathologic risk factors on the occurrence of metastases was first analyzed by univariate tests. Significant variables were then reevaluated using the Cox proportional hazards method. Four factors were found to be independently associated with the development of metastases: optic nerve invasion with and without involvement of the resection line, choroidal invasion and enucleation of an affected eye more than 120 days after initial diagnosis. The 5-year metastatic risks associated with these factors were 67%, 13%, 8%, and 4%, respectively. The relative risk estimate, calculated from the Cox model, was used for a score classification with groups of low, medium, and high metastatic risk. The 5-year incidence of metastases was 4%, 43%, and 68%, respectively.

Skeletal scintigraphy in patients with bilateral retinoblastoma

One hundred-seventeen radionuclide bone scans were performed on 46 patients with bilateral retinoblastoma between diagnosis and 19 years from diagnosis for the purpose of detecting skeletal metastases or other malignant neoplasms of bone that might develop in this group of patients at high risk for a second malignancy. Only one child, who had been symptomatic for 1.5 years, had a scan positive for metastasis at diagnosis. Scans in three additional children became positive (in one after the development of metastatic disease involving bone and soft tissue but not bone marrow 2 years after the diagnosis of retinoblastoma, and in two others after the development of osteosarcoma at 10.5 and 16 years from the diagnosis of retinoblastoma). Our data indicate that bone scans should not remain as part of the initial staging of patients with bilateral retinoblastoma unless there is clinical or pathologic evidence of extraocular disease at diagnosis. The performance of skeletal scintigraphy also is not warranted, with the expectation of diagnosing a second malignant neoplasm (namely osteosarcoma).

Tumors after radiotherapy for skin hemangioma in childhood. A case-control study

A case-control study was conducted to investigate the possible association between absorbed dose and cancer risk in a cohort of 14,647 individuals (33% males and 67% females) less than 18 months old and irradiated for skin hemangioma between 1920 and 1959. The cases consisted of 56 breast cancers (in 55 patients), 14 thyroid cancers, 16 brain tumors and 8 tumors of bone and soft tissues. Four controls were matched to each case. They were matched for sex, age at treatment, treatment modality and treatment year. Absorbed doses were categorized in three exposure groups, less than 0.1 Gy, 0.1-0.4 Gy, and greater than or equal to 0.5 Gy, and odds ratios (OR) were estimated with the lowest exposure group as reference. A statistically significant positive dose-response relationship was found for thyroid cancer (OR: 1.0; 4.8; 4.3) and for tumors of bone and soft tissues (OR: 1.0; 1.6; 19.5). For breast cancer and brain tumors no significant dose-response relationship could be found. The median absorbed dose in the tumor sites among the cases of thyroid cancer, tumors of bone and soft tissues, breast cancer and brain tumors was 0.2 Gy, 0.3 Gy, 0.03 Gy and 0.04 Gy respectively. The dose was probably too low to detect any dose-response relationship for breast cancer and brain tumors.

Aggressive management of second primary tumors in survivors of hereditary retinoblastoma

Survivors of hereditary retinoblastoma are at increased risk for the development of second primary tumors, most commonly osteosarcoma. Recent molecular genetic data demonstrate that a pleiotrophic effect of the retinoblastoma gene may be responsible for the development of these sarcomas. This report describes the incidence of second nonocular malignancies among 53 infants seen at Stanford University Medical Center who have been followed a median of 11.7 years. Of these, 42 initially had bilateral disease and eleven had unilateral disease. Of 53 infants, 50 received irradiation either as part of the initial therapy or as treatment for recurrent disease. The actuarial survival for the entire group is 67% at 30 year follow-up with a median survival of 79% at 11.7 years. Eight patients developed eleven second primary tumors. All occurred in the group having hereditary retinoblastoma. Eight were within the previously irradiated field and three were at distant sites. The second tumors included seven osteosarcomas, one angiosarcoma, one rhabdomyosarcoma, one malignant fibrous histiocytoma, and one unclassifiable round blue cell tumor. The actuarial incidence of the development of a second primary malignancy was 6% at 10 years, 19% at 20 years, and 38% at 30 years. The latent period from treatment of retinoblastoma to the diagnosis of malignancy ranged from 5.2 years to 36.2 years (median 16 years). An aggressive approach with combined modality therapy including radical resection, re-irradiation and/or chemotherapy was used to treat these second primary tumors in five of eight patients. In four of the five, there was no evidence of disease at 22-72 months following treatment. In the three patients who did not receive aggressive combined treatment, there were no survivors. These data confirm the previously reported risk of developing a second primary tumor among survivors with hereditary retinoblastoma. Careful long-term follow-up for this genetically susceptible group is essential for early detection and implementation of curative therapy.

Episcleral plaque radiotherapy for retinoblastoma

The authors report their preliminary results of episcleral plaque radiotherapy (cobalt 60, iridium 192, ruthenium 106, and iodine 125 plaques) in 50 selected patients with retinoblastoma. There were 97 plaque applications to 51 affected eyes in these 50 patients. The plaque was used as primary treatment in 15 eyes and as secondary treatment after failure of external beam radiotherapy, photocoagulation, and/or cryotherapy in 36 eyes. Vitreous seeding of tumor cells was evident ophthalmoscopically in 49 of the 51 eyes, negating the possibility of ultimate success by further photocoagulation or cryotherapy. In 18 patients, the contralateral eye had been enucleated and the remaining eye was being considered for enucleation because all other treatment modalities had failed. In 2 of these 18 patients (11%), the remaining eye was salvaged with plaque radiotherapy and some vision was preserved. In 33 eyes with less advanced tumors, 31 had some degree of vitreous seeding by tumor cells. The eye has been retained in all 33 of these patients and useful vision preserved in most. On the basis of these preliminary observations, the authors conclude that plaque radiotherapy can be used successfully as a primary treatment for selected cases of unilateral or bilateral retinoblastoma or as a supplemental treatment after other treatment methods have failed. The current indications for plaque radiotherapy and its advantages over other therapeutic modalities are discussed.

External beam irradiation for retinoblastoma: patterns of failure and dose-response analysis

Eighteen children with retinoblastoma (25 eyes) were treated with external beam radiation at the Mayo Clinic between January 1977 and January 1987; 15 eyes were in groups I to III and 10 were in groups IV and V (Reese-Ellsworth classification). The median number of tumors per eye was 3. Radiation therapy consisted of 4- or 6-MV photons. Doses varied from 39 to 51 Gy in 1.8- to 3.0-Gy fractions. Fourteen eyes were treated through lateral fields by anterior segment-sparing techniques, and 11 eyes were treated by an anterior approach with no attempt at anterior segment sparing. All patients survived (median follow-up, 31.5 months). Cataracts developed in five eyes at a median of 23 months, four in eyes treated with anterior segment-sparing techniques. Of the 15 group I to III eyes, 6 required additional treatment; 4 were salvaged with cryotherapy or photocoagulation and 2 were enucleated. Of the 10 group IV and V eyes, 8 required additional treatment; 4 were salvaged with cryotherapy or photocoagulation, 1 with persistent disease is being followed closely, and 3 were enucleated. Ten (71%) of the 14 eyes treated with anterior segment-sparing techniques required additional treatment (9 of the 10 for tumors anterior to the equator). Four (36%) of the 11 eyes treated with an anterior approach required additional treatment (3 of the 4 for tumors in the posterior pole of group IV or V eyes). Ninety percent of the tumors 10 disc diameters or smaller (1 disc diameter = 1.6 mm) were controlled independently of dose and fractionation used when they were not in the low-dose area of the anterior retina of an eye treated with an anterior segment-sparing technique. We find that use of lateral, anterior segment-sparing techniques has a high risk of anterior retinal tumor development and cataract formation and should be abandoned in favor of techniques that treat the entire retina. A dose of 45 Gy in 1.8-Gy fractions appears to be adequate for local control of tumors smaller than 10 disc diameters. Larger tumors may require additional treatment.

Incidence of second neoplasms in patients with bilateral retinoblastoma

The cumulative incidence of second neoplasms in 215 patients with bilateral retinoblastoma was calculated using the life-table method. Second tumors developed in 4.4% of the patients during the first 10 years of follow-up, in 18.3% after 20 years, and in 26.1% after 30 years. The 30-year cumulative incidence was 35.1% for the 137 patients who received radiation therapy compared with an incidence rate of 5.8% for the 78 patients who did not receive radiation. In the 137 patients who received radiation, second tumors developed both inside and outside the field of therapy. There was a 30-year incidence rate of second tumors of 29.3% within the field of irradiation and 8.1% outside the field. The rate outside the field of irradiation (8.1%) was similar to that observed in nonirradiated patients (5.8%). Our findings indicate that carriers of the retinoblastoma gene have an increased incidence of second tumors, and that the incidence rate is further increased in patients who receive radiation therapy.

Second malignant neoplasms in retinoblastoma. Fact and fiction

Second malignant neoplasms (SMN) are distinct from primary neoplasms in site, time and histology. SMN may arise by chance or due to the influences of chemotherapeutic agents, therapeutic irradiation or genetic predisposition. Patients with the hereditary form of retinoblastoma (RB) appear genetically predisposed to the development of connective tissue tumours, particularly osteosarcoma. Therapeutic irradiation is an additional risk. Quantitation of the risk of SMN in RB patients may be influenced by selection biases and inappropriate analyses. Much of the biases in reported series arises from the limitations of single-centre studies. Loss of patients to follow-up, failure to adhere to properly defined criteria of SMN and to consider the risk of malignancy in the general population may have led to over-estimation of the risk of SMN in retinoblastoma patients.

Embryonal rhabdomyosarcoma arising in the masseter muscle as a second malignant neoplasm

A case is reported about a patient who was originally treated for bilateral retinoblastoma and subsequently developed an embryonal rhabdomyosarcoma in the masseter. Such patients have a genetic predisposition to a second malignancy that statistically far exceeds the rate for the general population. In addition, current treatment methods also increase the patient's susceptibility to another malignancy. This case emphasizes the necessity of maintaining a high degree of clinical suspicion in the evaluation of any lesion that may appear subsequent to the treatment of cancer in children, particularly bilateral retinoblastoma.

Non-ocular cancer in patients with hereditary retinoblastoma and their relatives

In The Netherlands, retinoblastoma patients have been registered in the Utrecht national retinoblastoma registry since 1862. This register is virtually complete from 1945 onwards. We describe a unique epidemiological survey of the occurrence of non-ocular cancer in all patients registered during the period 1945-1970. The occurrence of non-ocular cancer in relatives of patients with hereditary retinoblastoma is also reported. One hundred and forty-one patients with hereditary retinoblastoma were studied for non-ocular second primary cancer. Nineteen patients died of retinoblastoma. The median follow-up of the surviving 122 patients was 25 years. Seventeen of these patients developed a second primary cancer, most frequently soft-tissue sarcoma. The cumulative incidence of non-ocular cancer was 19% at the age of 35, i.e., a 14-fold increase as compared to the general population. Twelve patients with hereditary retinoblastoma died of non-ocular cancer whereas none of 252 patients with non-hereditary retinoblastoma died of non-ocular cancer. Furthermore, among the parents of our hereditary retinoblastoma patients, 24 (born before 1945) had also been affected by retinoblastoma or had affected sibs. In the parents, 4 tumors occurred, of which 2 were rhabdomyosarcomas and 2 were urinary bladder cancers. Both types of non-ocular cancer were also encountered among the 122 patients with hereditary retinoblastoma. In 103 fathers and 103 mothers of patients with hereditary retinoblastoma who did not have retinoblastoma themselves, there was no previous family history of retinoblastoma. The fathers had a relative risk of 8.3 for pancreatic cancer compared to the general population. There was no significant increase in the number of non-ocular tumors in 332 sibs of patients with hereditary retinoblastoma.

Bone sarcomas linked to radiotherapy and chemotherapy in children

We estimated the risk of subsequent bone cancer among 9170 patients who had survived two or more years after the diagnosis of a cancer in childhood. As compared with the general population, the patients had a relative risk of 133 (95 percent confidence interval, 98 to 176) and a mean (+/- SE) 20-year cumulative risk of 2.8 +/- 0.7 percent. Detailed data on treatment were obtained on 64 patients in whom bone cancer developed after childhood cancer. As compared with 209 matched controls who had survived cancer in childhood but who did not have bone cancer later, patients who had had radiation therapy had a 2.7-fold risk (95 percent confidence interval, 1.0 to 7.7) and a sharp dose-response gradient reaching a 40-fold risk after doses to the bone of more than 6000 rad. The relative dose-response effect among patients who had been treated for retinoblastoma resembled that among patients with all other types of initial tumors, although the cumulative risk of bone cancer in the retinoblastoma group was higher. Similar numbers of patients were treated with orthovoltage and megavoltage; the patterns of risk among categories of doses did not differ according to the type of voltage. After adjustment for radiation therapy, treatment with alkylating agents was also linked to bone cancer (relative risk, 4.7; 95 percent confidence interval, 1.0 to 22.3), with the risk increasing as cumulative drug exposure rose. We conclude that both radiotherapy and chemotherapy with alkylating agents for childhood cancer increase the subsequent risk of bone cancer.

Recurrent dedifferentiated liposarcoma of the spermatic cord simulating malignant fibrous histiocytoma: an immunohistochemical and ultrastructural study

A case of recurrent dedifferentiated liposarcoma simulating malignant fibrous histiocytoma, with complete absence of lipoblastic differentiation, is described. The tumour cells showed strongly positive immunostaining for alpha-1-antichymotrypsin. Electron microscopy revealed a mixture of fibroblasts and histiocytes. Our findings suggest that the dedifferentiated component reflects an altered differentiation pathway of the primitive mesenchymal cells in the original liposarcoma.

Osteosarcoma as a Primary Second Tumor in a Patient with Nonhereditary Retinoblastoma

A case of osteosarcoma of the distal femur 13 years after the occurrence of a unilateral nonhereditary retinoblastoma is reported. The karyotype of circulating lymphocytis was found to be normal. The existence of a linkage between the two neoplasms due to a subtle chromosomal abnormality is discussed.

Malignant glioma following radiotherapy for unrelated primary tumors

Four cases are documented where a glioma was histologically verified in the irradiation field of a previously treated malignancy of a different cell line. Radiation-induced neoplasia in the central nervous system now has been established in the induction of meningioma and sarcoma. The association between therapeutic irradiation and glioma in the reported cases lends to the evidence that a causal relation does exist. This incidence is small and does not detract from the overall benefit of irradiation as a therapeutic modality.

Fibroblast radiosensitivity and intraocular fibrovascular proliferation following radiotherapy for bilateral retinoblastoma

A 5-day-old female patient was found to have large hereditary retinoblastomas in the posterior pole of each eye. The patient received radiation treatment over a 39-day period, with each retina receiving 4600 rad. Two weeks after the complete treatment the tumours had regressed to approximately one-quarter of their original size. By 14 weeks following completion of radiotherapy the patient had developed in each eye extensive iris neovascularisation with progressive closure of the filtration angles, secondary glaucoma, and retinal detachments resulting from fibrovascular proliferation on the retinal surface. Radiosensitivity studies were from separate conjunctival biopsies obtained before and after radiation. These showed a D0 (calculated survival curve parameters, defined in the Methods section) in the exponential growth phase of 110 prior to radiation and a postirradiation exponential growth phase D0 of 70. Karotype studies showed several chromosomal abnormalities following radiotherapy. The clinical course and pathology findings are thought to represent an unusually severe orbital and ocular response to radiation therapy. These findings are consistent with our hypothesis that some patients with hereditary retinoblastoma may have a defect in the accumulation repair of x-irradiation induced DNA damage.

Second primary neoplasms in patients with retinoblastoma

In a series of 882 retinoblastoma patients, 384 known to have the genetic form of the disease and 498 others, 30 patients developed second primary neoplasms. The spectrum of these second neoplasms is discussed in relation to the forms of treatment used for the retinoblastoma. Cumulative incidence rates of second tumours in the whole series are 2.0% at 12 years after diagnosis and 4.2% after 18 years. For patients with the genetic form of retinoblastoma the cumulative incidence rate after 18 years is 8.4% for all second neoplasms and 6.0% for osteosarcomas alone. The inherent risk among survivors from genetic retinoblastoma of developing an osteosarcoma, excluding all possible effects of treatment, is estimated to be 2.2% after 18 years. Within the field of radiation treatment the cumulative incidence rate for all second neoplasms after 18 years is 6.6% and for osteosarcomas alone 3.7%. There is some evidence that patients with genetic retinoblastoma are particularly sensitive to the carcinogenic effects of radiation. The results also suggest that the use of cyclophosphamide may increase the risk of second primary neoplasms in patients with genetic retinoblastoma. The incidence rates of second primary neoplasms in retinoblastoma survivors reported here are lower than those quoted for previously published series. Evidence from this and other papers strongly suggests an association between retinoblastoma and malignant melanoma.

Pineal malignant neoplasm in association with hereditary retinoblastoma

A patient with unilateral hereditary retinoblastoma who was successfully treated at the age of 7 weeks developed a tumour in the pineal region two and a half years later. The initial response to radiation treatment of the latter lesion was not maintained. Subsequent necropsy findings are described. Clinically and pathologically this case represents an example of the recently described trilateral retinoblastoma. The response to treatment after early recognition was disappointing.

Malignant fibrous histiocytoma of maxilla following radiotherapy for bilateral retinoblastoma

A 20-year-old man developed a malignant fibrous histiocytoma in the right maxilla 19 years after irradiation for bilateral retinoblastoma. The incidence of second tumours in patients who survived bilateral retinoblastoma treated with radiation was 8.5 per cent. Malignant fibrous histiocytomas which arise in a site of prior radiation are fatal. The present case is presumed to have the autosomal dominant retinoblastoma gene, not associated with deletion of the q 14 band of chromosome 13. The patient succumbed to the second tumour.

Postradiation osteogenic sarcoma of bone and soft tissues. A clinicopathologic study of 66 patients

Sixty-six patients with well-documented osteogenic sarcomas arising in bones and soft tissues after exposure to x-rays, which represent approximately 5.5 percent of all osteogenic sarcomas registered since 1921 at this institution, were studied. These secondary sarcomas occurred in equal proportion in both sexes, with the sixth decade of life being the most common age. In 42 patients, the bone had been normal at the time of irradiation, whereas in 24, the radiation was directed against an osseous tumor or tumor-like lesion. The median latent period was 10.5 years in both groups, ranging from 3.5 to 33 years. The radiation varied from diagnostic quality to 1 MeV x-rays. The dose was variable, but none was less than 2000 rads. Postradiation osteogenic sarcomas most commonly arose in the bones of the pelvic and shoulder regions. Histologically, the sarcomas were mostly of the fibrous type (46%) and radiographically showed a destructive bone lesion with or without signs of radiation osteitis. The cumulative disease-free survival rate at 5 years was 17%, with a median survival estimate of 1 year.

Treatment of retinoblastoma and choroidal melanoma. A multidisciplinary approach

Retinoblastoma and choroidal melanoma are two malignant ocular tumours that still give rise to discussions about diagnosis, natural history with respect to metastasis an choice of treatment. The therapeutic problems are best solved within a multidisciplinary oncology team in which the ophthalmologist, ophthalmopathologist and the general pathologist play an important role. In most institutes for ophthalmology a patient with a tumour in or in the region of the eye, is first seen by a specialist for eye diseases, who is also a surgeon in this field. In general the ophthalmologist decides on the diagnosis, the treatment and the follow-up without consulting other specialists in oncology. This solely ophthalmological approach can harbour a potential danger for the patient. Decisions on treatment made in a multidisciplinary team of specialists trained in oncological principles are responsible for the best results. Surgery combined with radiotherapy and chemotherapy can be a better choice than surgery alone, but even when surgery alone seems the best treatment, the discussion with the members of an oncological team can be of importance for the surgeon. The natural history of the tumour which includes the growth patterns, the growth rate and the tendency to metastasize may influence the choice of the surgical procedure; surgical intervention might be more or less extensive than previously foreseen. Dr. W.A. Manschot, professor in ophthalmic pathology, rightly advocates the contribution of the ophthalmopathologist to such an oncological team, because such a person has acquired knowledge in histopathology of the ocular tumours and experience in evaluating international literature in this field, the results of the treatment of groups of patients with the same tumour and publishing the statistically verified conclusions.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of retinoblastoma by precision megavoltage radiation therapy

The principal treatment concept in the Utrecht Retinoblastoma Centre is megavoltage irradiation, followed by light coagulation and/or cryotherapy if there is any doubt as to whether the residual tumour is still active. Radiation therapy is administered by means of a simple but highly accurate temporal beam technique. A standardized dose of 45 Gy is given in 15 fractions of 3 Gy at 3 fractions per week. From 1971 to 1982, 39 children with retinoblastoma have been irradiated in at least one eye. Of the 73 affected eyes, 18 were primarily enucleated, one received light coagulation only, and 54 received radiation therapy. Of the 54 irradiated eyes, 32 were additionally treated by light coagulation and/or cryotherapy for suspicious residual tumour (in 29 eyes), recurrent tumour (in 1 eye), and/or new tumour (in 3 eyes) and 10 were ultimately enucleated. Two eyes also received hyperthermia. The percentages of cure of the irradiated eyes with a minimum follow-up of 2 years were 100% (14/14), 100% (9/9), 83% (10/12), 79% (11/14) and 0% (0/5) in the Reese-Ellsworth groups I to V-A, respectively. Of the saved eyes 95% achieved useful vision. Eighteen eyes developed a clinically detectable radiation cataract; in five of these the lens was aspirated. Cataracts developed exclusively in those lenses of which a posterior portion of more than 1 mm had to be included in the treatment field. The likelihood and the degree of cataract formation was found to be directly related to the dose of radiation to the germinative zone of the lens epithelium. The minimum cataractogenic dose found in this series was 8 Gy.

Second nonocular tumors in retinoblastoma survivors. Are they radiation-induced?

A review of 693 patients with bilateral retinoblastoma and 18 patients with unilateral/germinal retinoblastoma was carried out to find the incidence, time, course and pattern of second nonocular tumors in retinoblastoma survivors. Of 688 patients who survived therapeutic radiation for retinoblastoma, 89 developed second tumors: 62 in the field of radiation and 27 out of the field. Of 23 patients who received no radiation, five developed second tumors: one in the field and four out of the field. The most common tumor found was a sarcoma both in and out of the field of radiation. The incidence of second tumors increases with time, although the mean latent period is 10.4 years. At 10 years, the incidence of second tumors is 20%, at 20 years, it is 50% and at 30 years, 90%. The incidence of tumors in patients treated without radiation and where tumors developed outside the field was 10% at 10 years, 30% at 20 years and 68% at 32 years. There was no relationship between incidence of tumors and dose of therapeutic radiation when analyzed with life tables. A second course of radiation therapy did not increase the incidence of second nonocular tumors.

Radiation to the breast. Complications amenable to surgical treatment

Major complications of radiation directed to the breast, axilla, and mediastinum were treated in 54 patients from 1974 to 1983. A classification of these complications facilitates both an understanding of the pattern of injury and the development of a treatment plan.

CLASSIFICATION

I. Breast necrosis; II. Radionecrosis and Chest Wall Ulceration; III. Accelerated Coronary Atherosclerosis with Median Sternotomy Wound Failure After Coronary Revascularization; IV. Brachial Plexus Pain and Paresis; V. Lymphedema and Axillary Cicatrix; VI. Radiation-induced Neoplasia. The treatment has evolved during the 10-year study period to excision of the necrotic wound, including any tumor, and closure with a transposed muscle or musculocutaneous flap of latissimus dorsi (II, III, V) or rectus abdominis (I, II, VI). This strategy reflects a change from primary use of the omentum during the first years of the study. The vascularity, oxygen and antibiotic delivery of these muscle and musculocutaneous flaps promote wound healing, usually with one operation. The transfer of these muscles has not caused significant functional deficits.

Development of additional primary tumors after 62 years in the first patient with retinoblastoma cured by radiation therapy

In the first well-documented case of bilateral retinoblastoma to be cured by X-irradiation of the nonenucleated eye, a basal cell carcinoma and then a squamous cell carcinoma of the eyelids developed 60 years after the original treatment. The patient, a 66-year-old man, had been treated by Verhoeff between 1917 and 1919. These new tumors may have been examples of second primary tumors, found in about 0.5% to 2.5% of patients with bilateral retinoblastoma, or they may have been coincidental. Because of the 60-year period between the patient's original treatment and the development of these tumors, it seems unlikely that they were the result of the irradiation.

Malignant fibrous histiocytoma arising in previous surgical sites. Report of two cases

Two patients who developed malignant fibrous histiocytoma in previous surgical sites are reported. One patient developed malignant fibrous histiocytoma in an amputation site, and the other patient developed it in a previous hernioplasty scar. Both patients presented with a mass, clinically interpreted as a subcutaneous abscess. The light microscopic and fine structural features of these tumors are described. A possible causal relationship between previous surgery and malignant fibrous histiocytoma is discussed in view of other reported cases arising in various conditions following chronic reparative reactions.

Ewing's tumor following bilateral retinoblastoma. A case report

Retinoblastoma is found in a hereditary and nonhereditary form. Long survivors treated for the hereditary form seem to be predisposed for developing a second primary tumor later in life. The retinoblastoma genes are supposed to be responsible for this disposition. This report describes the development of a Ewing's tumor in a nine-year-old girl, who had both eyes removed in early life for retinoblastoma.

Adjuvant chemotherapy of malignant fibrous histiocytoma of bone

Malignant fibrous histiocytoma (MFH) is a pleomorphic sarcoma that is uncommon in children. It most frequently arises from the soft tissues; however, it has been recently established that primary bone MFH also exists. Surgical resection or amputation is the cornerstone of treatment for MFH of bone. But, with this modality of therapy alone the majority of patients develop either distant metastases or local recurrence. This study reports on three adolescent girls with MFH of bone who were successfully treated with radical resection and 18 months of adjuvant chemotherapy with vincristine, high dose methotrexate, Citrovorum Factor rescue, and Adriamycin. All three patients remain disease-free for a follow-up period of 42-48 months. The current regimen was well tolerated. Morbidity was minimal, with no patient developing any significant drug-related complications. The adjuvant chemotherapy regimen described appears to be effective in prolonging survival in patients with MFH of bone and appears to warrant further study in additional patients.

Sister chromatid exchanges in patients with retinoblastoma

Spontaneous and mitomycin C(MMC)-induced sister chromatid exchanges were studied in 11 patients with retinoblastoma and 7 normal controls. Spontaneous rates were similar in patients and in controls. The MMC-induced rate was found to be significantly higher in bilaterally affected patients than in controls. It is suggested that this increase may be due to a DNA repair deficiency. However, it is not possible to clarify whether this abnormality is associated with the retinoblastoma gene or with another factor acting on the degree of expressivity of the disease in gene carriers.

Report of two Cases of Leiomyosarcoma after Radiotherapy

Two cases of leiomyosarcomas occurred as a rare complication, after megavoltage treatment. The latent period was of 17 and 9 years, respectively. The two malignant neoplasms arised within the treatment fields and each of these neoplasms differed histologically from the original tumor.

Epithelial second malignant tumours in retinoblastoma survivors. A review and report of a case

The first case of epidermoid carcinoma of the tongue found in a retinoblastoma survivors is described. The patient, 10-year-old girl, had been treated successfully for bilateral retinoblastoma 9 years earlier. According to the literature, second malignant epithelial tumours are, in contrast to mesenchymal tumours such as osteosarcoma, very rare in retinoblastoma survivors. Initially one eye of the patient was treated with irradiation using Stallard's disk (radioactive cobalt), but we consider that Stallard's disk was unconnected with the genesis of the carcinoma of the tongue.

Postirradiation sarcoma (malignant fibrous histiocytoma) following cervix cancer

A case of postirradiation sarcoma is described. The tumor, a malignant fibrous histiocytoma, occurred in the radiation field 11 years following postoperative external beam radiation therapy (7000 rad) for carcinoma of the cervix. Reports of postirradiation malignant fibrous histiocytoma are rare, and the occurrence of this neoplasm following treatment of cervix cancer has not previously been described. The literature concerning postirradiation bone and soft tissue sarcomas is briefly reviewed, with special attention to malignant fibrous histiocytomas.

Radiation-induced bladder carcinoma

Two cases are presented of radiation-induced bladder carcinoma which followed prior irradiation for cervical carcinoma of the uterus. One was a sixty-eight-year-old woman with bladder carcinoma fourteen years after irradiation (total dose of 4,500 rad) for cervical carcinoma of the uterus. The other was a sixty-four-year-old woman with bladder carcinoma twenty-five years after irradiation with 150-K volt apparatus for cervical carcinoma of the uterus. From the late radiation change of the skin, it was estimated that the total dose of prior radiation might be 4,000 rad or more. Both had high-grade, high-stage transitional cell bladder carcinoma, and the former was with marked mucus-forming adenomatous metaplasia.

Current approaches to the diagnosis and management of retinoblastoma

Retinoblastoma is the most common primary intraocular malignancy of childhood, occurring in about one out of 15,000 live births. A century ago, the mortality rate with this malignancy was nearly 100%; today, it is less than 10%. Furthermore, with recent advances in both diagnostic and therapeutic techniques, vision can often be preserved in one or both eyes. The approach to differential diagnosis utilized in the Wills Eye Hospital Ocular Oncology Service is outlined, and various diagnostic tests are described and illustrated. Procedures for examination under anesthesia are also detailed; it is emphasized that the physician should be prepared to institute appropriate treatment at the time of examination under anesthesia. Depending on the extent and nature of tumor involvement, treatment might consist of enucleation, external radiation, episcleral plaque irradiation, photocoagulation, cryotherapy, chemotherapy or a combination of these modalities. Indications, techniques and complications of each modality are discussed.

Neoplasms induced by megavoltage radiation in the head and neck region

Radiation-induced cancer, although fortunately a rare complication of radiotherapy, is nonetheless observed occasionally even after megavoltage radiation has been used. Over a 22-year period at the Curie Institute, four patients were found to have malignant neoplasms within the fields of megavoltage treatment given for various cancers of the head and neck region. Three of the neoplasms were sarcomas, two osteogenic and one fibrosarcoma, and the other tumor was a sarcomatoid epithelioma. The latent period ranged from 3 1/2-15 years. Although the evidence is strong that the neoplasms were causally related to the precedent irradiation, it is acknowledged that rare examples of the "double primary" phenomenon exist, even separated by five or more years, and that only one such instance would induce a large error in the estimated frequency of postirradiation neoplasms. Because clinical estimates after megavoltage irradiation are usually compounded by an association with a relatively high total absorbed dose, the issue of the incidence of postirradiation neoplasms as a function of the type of external beam (orthovoltage vs. megavoltage) may require resolution by experimental means. Another rare sequela of radiotherapy is injury to a peripheral nerve. One of the four patients with a second neoplasm after radiation also developed left hypoglossal nerve palsy 2 1/2 years post-therapy, and left optic nerve atrophy seven years postradiation treatment of a squamous cell carcinoma of the ethmoid and maxillary sinuses. The 51-year-old patient had received a tumor dose of 6800 rads (2043 rets).

Cancer following medical irradiation

Several generalizations about radiation carcinogenesis can be made: 1) a single exposure is sufficient to elevate cancer incidence many years later: 2) radiation-induced cancer cannot be distinguished from naturally occurring cancer, i.e., there is not unique radiogenic cancer; 3) all cancers appear to be increased after irradiation with the exception of chronic lymphocytic leukemia, and possibly Hodgkin's disease, cervical cancer, and a few others; 4) the breast, thyroid, and bone marrow appear especially radiosensitive; 5) leukemia is the most prominent radiogenic tumor and shows a wave-like pattern of excess incidence over time, and the excess begins within two to four years, peaks about six to eight years, and decreases to normal levels about 25 years later; 6) solid tumors have a minimum latent period of about ten years, and for several cancers, the temporal pattern of incidence appears to follow the natural incidence, i.e., the cancers do not occur before the ages normally associated with increased incidence, implying that age-dependent factors influence the expression of disease; 7) age at exposure is perhaps the most important host factor influencing subsequent cancer risk; 8) the percentage increase in cancer incidence per rad is not the same for all cancers, i.e., some cancer of high natural incidence, e.g., colon, have low "relative risks" and some cancers of low natural incidence, e.g., thyroid, have high "relative risks;" 9) dose-effect curves are often linear, but curvilinearity is also observed and is possibly associated with the need for "two ionizing events" for transformation to occur at low doses, the influence of cell sterilization at moderate doses, the likelihood of "wasted" dose at high doses, and/or the influence of factors that effect the expression of disease.

An in vitro investigation of genetic susceptibility to cancer in diploid fibroblasts from retinoblastoma patients

Thirty-two diploid fibroblast strains from individuals with the three forms of retinoblastoma were examined with an in vitro clonogenic survival assay to determine their sensitivity to killing by X rays. Strains from sporadic unilateral retinoblastoma patients and normal controls were indistinguishable from one another (group D0's = 147 +/- 15 rads and 146 +/- 5 rads, respectively) while the strains from patients with the hereditary form of the disease were significantly more X-ray sensitive (D0 = 111 +/- 12). Strains derived from individuals with the D-deletion form of the disease resembled the hereditary strains with respect to sensitivity and heterogeneity, suggesting a possible, common etiology for these two forms of the disease. A DNA-repair defect is hypothesized as reflected by the observed hypersensitivity to X-irradiation in these cells. We suggest that this defect may be associated with the enhanced frequency of spontaneous and radiation-induced second tumors seen in some retinoblastoma patients.