Radiation induced neoplasia following external beam therapy for children with retinoblastoma

Retinoblastoma: the case for radiotherapy and for adjuvant chemotherapy

The results of treatment for 39 consecutive children with retinoblastoma that was diagnosed between 1951 and 1978 were analyzed. Failure to achieve local control within the eye and the development of metastatic disease occurred in seven patients. These patients are considered individually. Delay in diagnosis, older age at presentation, and extraocular extension of disease at diagnosis were associated with treatment failure and were closely interrelated. Modified radiotherapy techniques using wider fields may prevent failure even in those cases diagnosed late and in those with extraocular extension. Indications for intrathecal and systemic chemotherapy in this disease are discussed.

Osteogenic sarcoma of the humerus after cobalt plaque treatment for retinoblastoma

A 13-year-old boy developed an osteogenic sarcoma of the right humerus ten years after treatment for bilateral retinoblastoma. The bilateral retinoblastoma has been managed with enucleation of one eye and successful treatment of the solitary tumor in the other eye with a single application of a local 10-mm round cobalt plaque. Patients with bilateral retinoblastoma have a significant (15 to 20%) chance of developing a second, nonocular, neoplasm. These neoplasms have occurred from one to 42 years after the treatment for retinoblastoma. The most common of these tumors is an osteogenic sarcoma; it may occur after external beam irradiation, local cobalt plaque, or no irradiation. The tumors may be in the skull or at distant sites whether or not these patients receive radiation.

Osteosarcoma, fibrous dysplasia, and a chromosomal abnormality in a 3-year-old child

Osteosarcoma is a type of malignant bone tumor that is rare among children less than five years old. This report describes a 3-year-old boy with osteosarcoma of the right proximal femur and polyostotic fibrous dysplasia of the right femur and tibia. After hemipelvectomy, histologic examination of the amputated limb disclosed that the osteosarcoma had developed in a focus of fibrous dysplasia. Cytogenetic analysis of the patient's blood lymphocytes revealed a 4q-/7p + translocation in all cells. The patient's mother had an identical translocation but did not have a history of osteosarcoma or evidence of fibrous dysplasia. The chromosomal abnormality and the developmental osseous disorder may have predisposed this patient to developing osteosarcoma at an exceptionally young age.

Excess of cancer deaths in grandparents of patients with retinoblastoma

An excess of cancer deaths was found in grandparents of 308 children with retinoblastoma. This excess was found in all types of retinoblastoma, unilateral and bilateral, sporadic and familial. We postulated that the excess could be the result of a factor of susceptibility to cancer, different from the retinoblastoma gene, which would increase the mutation rate in retinal and germ cells as well as in other tissues.

The effect of radiotherapy in the treatment of retinoblastoma upon the developing dentition

Two patients who received supervoltage x-ray external beam irradiation for treatment of retinoblastoma by standard techniques showed interference with the root formation of the maxillary deciduous molars and abnormalities of crown and root formation of the permanent maxillary molars. Both patients showed a relative maxillary retrognathism thought to be related to radiation effects on maxillary bone growth. Simulation of lateral radiation portals with subsequent beam shaping using an appropriate block placed in the radiation beam is suggested as a means to eliminate the dental complications of radiation therapy for retinoblastoma.

Stage-related combined modality treatment of retinoblastoma. Results of a prospective study

Forty-two consecutive patients with retinoblastoma were evaluated by a new staging system and combined modality therapy instituted according to stage. Nineteen patients had bilateral tumors and 23 had unilateral tumors. The staging system was effective in identifying subpopulations of patients and successfully predicted those at greater risk of recurrence or death. Thirty-nine of 42 patients survive (Median survival time, 42 months). Two of 4 children with tumor extension beyond the eye died while 37 of 38 children with tumor presumed confined to the eye survive. Toxicity of the chemotherapy was mild. Radiation therapy of intraocular tumor was associated with cataract formation but most children had satisfactory vision after extraction and the use of corrective lenses. Ophthalmologic findings did not always correlate with histologic extent of tumor and both should be used in planning and evaluating treatment. Recommendations are made on the role of chemotherapy and the need to reduce the morbidity of treatment.

Osteogenic sarcoma following treatment with megavoltage radiation and chemotherapy for bone tumors in children

While osteogenic sarcoma has been well-recognized as a late complication of exposure to high doses of ionizing radiation in the orthovoltage energy range, it has been less frequently reported in patients treated with megavoltage radiation. This potential complication should, however, not be dismissed as an occurrence to be seen only after high-dose orthovoltage radiation. We have recently seen two children who developed osteogenic sarcoma following treatment with megavoltage radiation and combination chemotherapy for primary bone tumors. The implications in regard to aggressive multimodality treatment for pediatric malignancies are discussed.

Adenocarcinoma of the ethmoid following radiotherapy for bilateral retinoblastoma

Adenocarcinoma of the ethmoid sinus is rare, representing only 4-8% of malignancies of the paranasal sinuses. An extraordinary case of papillary adenocarcinoma of the ethmoid sinus arising 30 years following high-dose radiotherapy for bilateral retinoblastoma is presented. Retinoblastoma, though occurring only once in every 23,000 to 34,000 births, is the most common malignant intraocular tumor of childhood. Second fatal mesenchymal and epithelial primaries have been described in 8.5% of patients with bilateral retinoblastomas previously treated with radiotherapy; however, papillary adenocarcinoma arising within the paranasal sinuses has not been reported. Histologically, the findings of a papillary pattern of poorly differentiated, mucicarmine-staining cells enclosing gland-like spaces, and the absence of pseudorosettes, melanin, mesenchymal and peripheral neural elements supports an epithelial origin of this tumor. Agressive treatment including partial maxillectomy, radical pansinusectomy, radical neck dissection followed by regional radiotherapy and systemic chemotherapy failed to prevent the development of fatal hepatic metastases. The high incidence of second fatal primary neoplasms in patients with bilateral retinoblastomas receiving radiation suggests an innate susceptibility that may add to the risk of radiotherapy. Careful long-term head and neck surveillance is mandatory if early aggressive management of these extremely lethal tumors is to be successful.

Radiation-induced fibrosarcoma of the mandible following treatment for bilateral retinoblastoma

A case of fibrosarcoma of the mandible following radiotherapy for bilateral retinoblastoma and occurring in an 11-year-old female child is described. After a clinical description of the case, reported with histological documentation, problems connected with the pathogenesis of the malignancies are dealt with. Besides irradiation, genetic mutation as a carcinogenetic co-factor is taken into consideration.

Radiation-induced sarcomas of bone

Historically, the literature reveals that the incidence of radiation induced bone sarcomas is very low. Details related to epidemiology cannot be identified, however, because of the difficulty of identifying precisely the patient population at risk for development of the radiation induced sarcoma. The change in character of practice in cancer management with ever increasing numbers of patients receiving both radiation therapy and chemotherapy should alert physicians to the potential for increased incidence of this rare and unusual tumor.

New findings in the chromosome 13 long-arm deletion syndrome and retinoblastoma

New clinical and pathologic findings in patients with deletion of the long arm of chromosome 13 (13q-) include optic nerve hypoplasia and retinal dysplasia. Fibroblasts derived from patients with a 13q- syndrome with and without retinoblastoma, as well as from familial and sporadic retinoblastoma, are a useful model for the study of genetic susceptibility to the development of spontaneous and radiation-induced cancers. Fibroblasts from patients with hereditary retinoblastoma appear more radiosensitive than fibroblasts from patients with sporadic retinoblastoma or normal control patients.

Second tumors in nonirradiated bilateral retinoblastoma

We reviewed the records of 1,323 patients with retinoblastoma treated here between 1922 and 1978. Twenty-eight patients underwent bilateral enucleation alone and received no additional treatment for their advanced tumors. Of the 28 patients, 22 (92%) survived. Four patients were lost to follow-up, and two died of metastatic retinoblastoma. Of 22 survivors of bilateral retinoblastoma treated with enucleation alone, three developed second tumors at a mean of 15.3 years after bilateral enucleation. One patient developed a rhabdomyosarcoma in the left temple region, the second patient developed an osteogenic sarcoma of the right femur, and the third developed a malignant melanoma of the left thigh. All three patients died of their disease. The incidence of second tumors in patients who survived bilateral retinoblastoma treated without radiation was 14% (three patients), which is comparable to a series previously reported in which patients were treated with enucleation and irradiation.

Anaplastic cardcinoma of the thyroid in a population irradiated for Hodgkin Disease, 1910--1960

Post-irradiation carcinoma of the thyroid is usually histologically well-differentiated. In general, those subjects who developed carcinoma had been exposed to low-to-moderate doses of irradiation for benign conditions. We reviewed the charts of 520 patients with Hodgkin's disease seen at Roswell Park Memorial Institute, and found 2 cases of anaplastic carcinoma amongst other thyroidal abnormalities. The existing reports of post-irradiation carcinoma are reviewed and suggestions are made for the management of heavily irradiated, potentially cured patients with Hodgkin's disease.

Postirradiation sarcoma of bone: a perspective

Ten cases of irradiation induced sarcoma of bone which fulfilled Cahan's criteria were seen in a twenty year period at the Princess Margaret Hospital. The overall incidence of this complication is 0.035% of all irradiated five year survivors. Combining our data with three other large series presented in the literature, a dose complication curve could be deduced. On the basis of the human and animal data reviewed, it was concluded that the risk of radiation induced sarcoma is so low in the dose range of modern radiotherapeutic practise that it does not represent a contraindication to the use of radiation therapy.

Secondary malignant neoplasms following radiotherapy of a mouse mammary carcinoma

Long-term observations were made for the development of secondary neoplasms following radiotherapy of animal tumors. Experimental tumors were 3rd generation isotransplants of a mammary carcinoma which arose spontaneously in a C3Hf/He mouse. A single dose of TCD20-TCD98 was followed by weekly observations. Most recurrences were observed in the first 150 days, while only a few were seen in the subsequent 150 days. Secondary neoplasms developed frequently following this period, i.e., 41 out of 67 animals surviving more than 300 days developed secondary neoplasms. They were osteogenic and soft tissue sarcomas, and half the new tumors were found within 490 days after radiotherapy. The results obtained were compared with literature reports of secondary neoplasms following postoperative radiotherapy for carcinoma of the breast and treatment of retinoblastomas. Most of these secondary human neoplasms were nonepithelial sarcomas as in the present study. Secondary carcinomas have been reported following radiotherapy of carcinoma in other locations, i.e., the cervix or head and neck; however, only a limited number of studies have been reported.

Second neoplasms following megavoltage radiation in a pediatric population

Previous reports of radiation-related neoplasia have relied primarily upon patients treated by orthovoltage to low doses for benign disease. This survey is believed to be the first to assess the incidence of second neoplasms following megavoltage therapy. The source was the records of all long-term pediatric survivors (88 patients) who were treated with megavoltage radiation (cobalt 60) at the University of Minnesota. There was an average follow-up period of 14 years during which 7 second neoplasms were discovered (8%). Five were not associated with prior radiation. Both radiation-related neoplasms were associated with low doses and one was without significant morbidity. Two of the seven neoplasms were malignant; one was not associated with radiation while the other was associated with prolonged chemotherapy and low dose radiation (1%). The only fatal second neoplasm was not associated with radiation but developed 5 years after prolonged chlorambucil treatment. This review reveals the tendency of childhood cancer victims to develop other neoplasms regardless of radiation. The finding of neoplasia induction only at low radiation doses supports the Gray hypothesis of decreased tumor induction at high doses through increased cell killing.

Treatment results of retinoblastoma at Indiana University Hospitals

This paper summarizes a review of all cases (70) of retinoblastoma seen at Indiana University Hospitals over the past 25 years (from 1952 to 1977) to determine the results of treatment and causes of failure. All cases from July, 1967, to the present were managed by the same group of physicians, thus following a consistent philosophy of treatment for those patients. Thirty-two patients treated during this latter period have survived a minimun of two years and are alive. Visual acuity of 20/20 has been preserved in all 16 patients with unilateral disease and a range of 20/50 to 20/20 in 12 of the 16 patients with bilateral disease. Because of the highly specialized diagnostic and therapeutic techniques and equipment required for optimal treatment results, it is recommended that patients with retinoblastomas be referred to treatment centers specializing in the management of this disease.

Late effects of therapeutic irradiation on the skeleton and bone marrow

Sequelae in the skeleton and bone marrow can be important late consequences for survivors following radiation therapy of cancer. Skeletal sequelae of radiation therapy often are predictable, although they may not be avoidable. The growth suppressive effects of therapeutic irradiation may occur in any bone, but most often are noted in the spine after doses in excess of 2000 rads. Mature bone and cartilage may be devitalized by irradiation without clinical consequence until stressed. Although malignant tumors may arise in irradiated bone and cartilage, the risk is minimal and is readily accepted in modern-day radiation oncology. Radiation-induced suppression of bone marrow function usually is of immediate rather than late consequence; however, functional recovery after therapeutic irradiation, while prolonged, is more complete than formerly thought. Leukemia rarely develops secondary to therapeutic irradiation.

Fine structure of a radiation-induced osteogenic sarcoma

An osteogenic sarcoma arose in the right orbit of a 7-year-old boy some 5 years after the right orbit had been treated by four courses of radiotherapy (total dose approximately 13,000 rads) for a multicentric retinoblastoma. Death occurred 6 months after the orbital tumor was first detected. Study of the orbital tumor by electron microscopy revealed a cell population of varied morphology in which two main types were identified. In one group, the cells were large with radiolucent cytoplasm, which contained long branching segments of rough endoplasmic reticulum. In the second group, the cells were smaller with irregular nuclei and an electron-dense cytoplasm, which contained short segments of dilated rough endoplasmic reticulum and numerous mitochondria. The first group of cells closely resembled osteoblasts, while the second group had some features of osteoclasts or their percursors. The branching processes of the tumor cells were separated by an amorphous ground substance, which contained collagen-like fibrils and hydroxyapatite crystals. Crystal deposition was in some instances in close relation to extracellular membrane-bound vesicles.

Retinoblastoma: a study of natural history and prognosis of 268 cases

The natural history and prognosis of retinoblastoma were analysed using data relating to the 268 cases registered during 1962-8 in England, Scotland, and Wales. The children were followed up for a minimum of four years; the proportion surviving for four years was 86%. The most important factors affecting survival rate were the stage of the tumour at diagnosis and the hospital of treatment. Of children surviving for three years after treatment only three died during the subsequent period of follow-up, which varied from one to seven years. Among children with retinoblastoma treated between 1949 and 1968 nine died between seven and 13 years later of other cancers: seven from osteosarcomas, one from angiosarcoma, and one from fibrosarcoma.

The risk of tumor induction in man following medical irradiation for malignant neoplasm

A review of second malignant tumors (S.M.T.s.) following therapeutic irradiation formalignant neoplasm in man is presented. Twenty-one new cases are added to the literature, 3 of adenocarcinoma of the endometrium following treatment for squamous cell carcinoma of the cervix, 3 of adenocarcinoma of the large bowel following treatment for squamous cell carcinoma of the cervix, 9 S.M.T.s in irradiated oropharyngeal or oral mucosa, and 6 single cases of S.M.T.s following radiotherapy of cancers in other sites. It is suggested that there is relatively low incidence of S.M.T.s among patients formalignancy, but the risk remains to be established by an appropriate study of controland test populations.

Risk of second tumors in survivors of childhood cancer

A new malignancy was diagnosed in 19 of 414 long-term survivors of cancer in childhood. All but two lesions were attributable to prior radiotherapy; eight were successfully treated. Excluding 4 patients ascertained in connection with the second malignancy, there were 15 in the series who developed a new cancer, in contrast to 0.7 cases expected (p less than 0.001). The 20-year (5-24 years after initial diagnosis) cumulative probability of a second cancer was 12% (S.E. 4%), and the radiation-related cancer rate was 1.8 cases in exposed tissues per million person-years per rad. Host susceptibility may have had an etiologic role, but an oncogenic effect of chemotherapy was not demonstrable. Another 13 study patients developed benign tumors. These findings emphasize the importance of long-term surveillance of children with cancer.

The genetics of childhood cancer

Retinoblastoma should not be considered as the exceptional childhood cancer that shows dominant inheritance, but rather as the typical childhood cancer that embraces a prezygotic and postzygotic subgroup. Postzygotic cases are conceived as involving mutation as a first step too, but with the mutation in somatic rather than germinal cells. In both prezygotic and postzygotic cases a second event, possibly mutational, occurs before the cancer is initiated. The embryonal cancers are all visualized as genetic disease, and their frequencies limited by gene mutability. This mutability can be increased by environmental agents. Prezygotic cases may develop other primary tumors in other tissues. They may also have affected family members, the probability of affected offspring approaching 50%. A diagnostic test to identify prezygotic cases among those with a single primary tumor and a negative family history is sorely needed.

Retinoblastoma: an epidemiological study (survey and review)

An epidemiological study of retinoblastoma patients from Buffalo, New York, and Rio de Janeiro, Brazil, was conducted at Roswell Park Memorial Institute in 1974. Several important differences were uncovered as a result of this study. Patients in Buffalo with bilateral retinoblastoma were diagnosed most often within the first year of life and those with unilateral retinoblastoma after about 24 months of age. This difference in diagnostic age between the two forms of retinoblastoma is not demonstrated by the patients from Rio de Janeiro. Most of the Rio de Janeiro patients are 24 months or older before either type of retinoblastoma is diagnosed. By this time the disease has usually extended beyond the eyeball, and orbital exenteration is deemed necessary. Because the patients in Rio de Janeiro are diagnosed at an older age, these patients have a shorter length of survival and higher mortality as compared to the patients in Buffalo. Additional differences that were derived from this study will require further research for verification.

Pleiotropic effects of the gene for retinoblastoma

Vigorous treatment of retinoblastoma in the last 30 years has resulted in a large population of survivors with useful vision, in which the late effects of genetically associated tumours can be seen. An increase in second primary tumours, mainly osteogenic sarcoma, has been found in those children who carry the germinal mutations, and not in the majority of survivors of unilateral disease. The findings indicate a pleiotropic effect of the retinoblastoma gene which may act as an initiator in two forms of neoplasia.