Colorectal adenocarcinoma as a second malignant neoplasm following Wilms' tumor and rhabdomyosarcoma

Late Health Outcomes Among Survivors of Wilms Tumor Diagnosed Over Three Decades: A Report From the Childhood Cancer Survivor Study

PURPOSE

To evaluate long-term morbidity and mortality among unilateral, nonsyndromic Wilms tumor (WT) survivors according to conventional treatment regimens.

METHODS

Cumulative incidence of late mortality (≥ 5 years from diagnosis) and chronic health conditions (CHCs) were evaluated in WT survivors from the Childhood Cancer Survivor Study. Outcomes were evaluated by treatment, including nephrectomy combined with vincristine and actinomycin D (VA), VA + doxorubicin + abdominal radiotherapy (VAD + ART), VAD + ART + whole lung radiotherapy, or receipt of ≥ 4 chemotherapy agents.

RESULTS

Among 2,008 unilateral WT survivors, 142 deaths occurred (standardized mortality ratio, 2.9, 95% CI, 2.5 to 3.5; 35-year cumulative incidence of death, 7.8%, 95% CI, 6.3 to 9.2). The 35-year cumulative incidence of any grade 3-5 CHC was 34.1% (95% CI, 30.7 to 37.5; rate ratio [RR] compared with siblings 3.0, 95% CI, 2.6 to 3.5). Survivors treated with VA alone had comparable risk for all-cause late mortality relative to the general population (standardized mortality ratio, 1.0; 95% CI, 0.5 to 1.7) and modestly increased risk for grade 3-5 CHCs compared with siblings (RR, 1.5; 95% CI, 1.1 to 2.0), but remained at increased risk for intestinal obstruction (RR, 9.4; 95% CI, 3.9 to 22.2) and kidney failure (RR, 11.9; 95% CI, 4.2 to 33.6). Magnitudes of risk for grade 3-5 CHCs, including intestinal obstruction, kidney failure, premature ovarian insufficiency, and heart failure, increased by treatment group intensity.

CONCLUSION

With approximately 40% of patients with newly diagnosed WT currently treated with VA alone, the burden of late mortality/morbidity in future decades is projected to be lower than that for survivors from earlier eras. Nevertheless, the risk of late effects such as intestinal obstruction and kidney failure was elevated across all treatment groups, and there was a dose-dependent increase in risk for all grade 3-5 CHCs by treatment group intensity.

Risk of subsequent colorectal cancers after a solid tumor in childhood: Effects of radiation therapy and chemotherapy

BACKGROUND

Very few previous studies have addressed the question of colorectal cancer (CRC) after childhood cancer treatment. We aimed to quantify the roles of radiation therapy and chemotherapy agents in the occurrence of subsequent CRC.

METHODS

A nested case-control study was conducted using 36 CRC cases and 140 controls selected from 7032 five-year survivors of the French Childhood Cancer Survivor Study (FCCSS) cohort, treated from 1945 to 2000 in France. The radiation dose-distribution metrics at the site of CRC and doses of individual chemotherapeutic agents were calculated. Conditional logistic regressions were performed to calculate odds ratios (ORs).

RESULTS

Overall, patients who received radiotherapy with estimated dose to colon had a 4.3-fold (95% CI, 1.3-17.6) increased risk for CRC compared with patients who did not receive radiotherapy, after adjustment for chemotherapy. This risk increased to 8.9-fold and 19.3-fold among patients who received radiation doses ranging from 20 to 29.99 Gy and ≥30 Gy, respectively. Our data reported a significantly elevated OR for anthracyclines, after controlling for radiotherapy and MOPP regimen. But, restricted analyses excluding patients who had received ≥30 Gy showed that only radiation doses ranging from 20 to 29.99 Gy produced a significant increase in subsequent CRC risk (OR = 7.8; 95% CI, 1.3-56.0), after controlling for anthracyclines and MOPP regimen.

CONCLUSIONS

The risk of subsequent CRC was significantly increased after radiation dose (even < 30 Gy). This novel finding supports the need to update monitoring guidelines for CRC to optimize the long-term follow-up for subsequent CRC in survivors of childhood cancer.

Colorectal carcinoma in the first decade of life: a systematic review

PURPOSE

The aim of this study is to better understand the main aspects related to colorectal carcinoma diagnosed in the first 10 years of life, through a systematic review.

METHODS

We carried out a bibliographic search in PubMed and LILACS, focusing on identifying publications or case reports about colorectal carcinoma in the first 10 years of life. The bibliographical analysis was made in two steps. During the first phase, we excluded those articles whose titles or abstracts did not correspond with the objective settled. Publications without abstract were also included in this phase. During the second phase, we look at the articles and evaluated their content, selecting the cases with colorectal cancer under 10 years old.

RESULTS

From 3880 publications, 132 were selected in the first phase and 84 were evaluated in the second phase. Based on these conditions, 33 articles have cases presented which 4 articles were case reviews and 29 were case reports. Duplicated cases were excluded from the analysis. Fifty-nine cases were described in English and Latin literature. There is an apparent similar proportion between the sexes, and the mean age was 8.6 years old. The main localization was the rectum and sigmoid (45.8 %). Pathologic findings showed that 86.4 % were adenocarcinoma. These tumors are frequently advanced at diagnosis. The Kaplan-Meier 60-month overall survival was 15.3 %. Dukes classification represents a factor related to survival (p = 0.03).

CONCLUSIONS

In children, colorectal carcinoma presents distinctive characteristics, which determines poor survival.

Colonic adenocarcinoma as a secondary malignancy after treatment of embryonal rhabdomyosarcoma

BACKGROUND

Survivors of childhood malignancies are known to be at an increased risk for developing a variety of secondary cancers. Primary adenocarcinoma of the colon is very rare in children and adenocarcinoma of the colon occurring as a secondary malignancy in children is much rarer.

METHODS

A boy with a history of successfully treated embryonal rhabdomyosarcoma developed adenocarcinoma of the colon as a secondary cancer.

RESULTS

The boy presented with a solid mass of the left cheek at 3 years of age. The mass was excised and histological examination showed embryonal rhabdomyosarcoma. He was treated with multi-agent chemotherapy and local radiotherapy, which resulted in complete remission. Four years later, he presented with recurrent colicky abdominal pain and bleeding per rectum and was found to have intussusceptions. Colonoscopy revealed a tumor in the transverse colon, which was biopsied and proved to be an adenocarcinoma. The boy underwent excision followed by chemotherapy using an adult colon cancer regimen. He is currently off chemotherapy for 2 years with no evidence of the disease.

CONCLUSIONS

We report a rare case of colon cancer after treatment of rhabdomyosarcoma. Colorectal adenocarcinoma must be kept in mind as a secondary neoplasm following treatment for early childhood malignancies although it is extremely rare.

Secondary Colorectal Carcinoma After Childhood Cancer

Purpose

Colorectal carcinoma (CRC) has been described as a subsequent malignant neoplasm (SMN), although little is known about associated risk factors. We aimed to quantify the long-term risk of secondary CRC and identify treatment-related risk factors.

Patients and Methods

In this nested case-control study, 19 cases of adenocarcinoma of the colon or rectum were identified from 13,048 oncology patients treated for childhood cancer at St Jude Children's Research Hospital. Group 1 controls (n = 148) were matched for age at primary malignancy and follow-up interval. Group 2 controls (n = 72) were matched on primary diagnosis in addition to group 1 criteria. Exact conditional logistic regression was performed to calculate odds ratios (ORs) for chemotherapy and radiation exposure.

Results

Forty-year cumulative incidence of secondary CRC was 1.4%. Standardized incidence ratio was 10.9 (95% CI, 6.6 to 17.0) compared with that in the general US population. Secondary CRC was more likely in an irradiated segment of the colon (group 1 OR, 7.7; P = .001; group 2 OR, 15.4; P = .002). Risk increased by 70% with each 10-Gy increase in radiation dose. Increasing radiation volume increased risk (group 1 OR, 1.5; P < .001; group 2 OR, 1.8; P < .001). Alkylating agent exposure was associated with an 8.8-fold increased risk of secondary CRC (P = .03).

Conclusion

In matched analyses, radiation and alkylator exposure are associated with secondary CRC. This risk is proportional to dose and volume of radiation. Surveillance should be initiated at a young age among survivors receiving high-risk exposures.

Health status of the oldest adult survivors of cancer during childhood

BACKGROUND

Young adult survivors of childhood cancer have an increased risk for treatment-related morbidity and mortality. In this study, the authors assessed how treatment for childhood cancer affects older-adult health and health practices.

METHODS

One hundred seven adults treated for childhood cancer between 1947 and 1968, known to have survived past age 50 years, were identified from a single-institution cohort established in 1975. Updated vital status on eligible cases was obtained from public records. Survivors and a control group of their age-matched siblings and cousins completed a mailed survey to assess physical and social function, healthcare practices, and the prevalence of common adult illnesses.

RESULTS

Of the 107 survivors known to be alive at age 50 years, 16 were deceased at follow-up; 7 deaths could be associated with prior treatment (second malignancy in radiation field [3], small bowel obstruction after abdominal radiation [2], and cardiac disease after chest irradiation [2]). The 55 survivors (median age, 56 years; range, 51-71 years), and 32 family controls (median age, 58 years; range, 48-70 years), reported similar health practices, health-related quality of life, and social function. However, survivors reported more frequent visits to healthcare providers (P < .05), more physical impairments (P < .05), fatigue (P = .02), hypertension (P = .001), and coronary artery disease (P = .01). An increased risk of hypertension was associated with nephrectomy during childhood (odds ratio, 18.9; 95% confidence interval, 3.0-118.8).

CONCLUSIONS

The oldest adult survivors of childhood cancer continue to be at risk for treatment-related complications that potentially decrease their life expectancy and compromise their quality of life.

Successful resection of a re-occurred pulmonary myosarcoma in a patient with turner syndrome mosaic

We describe a patient who underwent thoracic radiation therapy for biopsy-proven pulmonary spindle cell sarcoma in the left lower lobe, 15 months after birth. At the age of 37 she developed shoulder pain, fatigue, and progressive exertion dyspnoea. Chest X-ray revealed a pulmonary mass in the left lower lobe due to a cytology-proven malignant tumour.The patient underwent left pneumonectomy. Histology revealed a myosarcoma of the lung, similar to the previous sarcoma. Furthermore, the patient was diagnosed to have Turner syndrome mosaic and chromosomal analysis revealed a translocation t(1;13) in 3/50 metaphases. However a germline mutation of the p53 tumour suppressor gene was excluded. After 2 years of follow-up the patient is stable and there are no signs of recurrence of the tumour.We conclude a re-occurrence of this very rare malignant disorder of the lung after a 36-year interval in a patient with Turner syndrome mosaic. Following initial curative radiation therapy, with a remission over 36 years, lung resection was now successfully performed.

Rectal adenocarcinoma following cranio-spinal radiotherapy for cerebellar medulloblastoma

The authors present a case of a 16-year-old female diagnosed with rectal adenocarcinoma 10 years after receiving cranio-spinal radiotherapy for a cerebellar medulloblastoma. While the risk of a second malignancy is recognised to be increased in children previously treated with radiotherapy, rectal adenocarcinoma is a rare presentation. A child presenting with symptoms of weight loss and a change in bowel habit in a patient who has previously received radiotherapy should alert practitioners to the possibility of a colorectal malignancy.

Radiation therapy in childhood cancer

OBJECTIVES

To review treatment-related issues and acute and late side effects of radiation therapy for the treatment of childhood malignancies.

DATA SOURCES

Research and review articles, oncology textbooks, and clinical experience.

CONCLUSIONS

Radiation therapy is a key component in the treatment of childhood malignancies. Children receiving radiation have special nursing care needs that are dependent on growth and developmental issues.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in the education of families and children receiving radiation therapy. In addition, nurses are key in the management of acute and late toxicities from childhood radiation therapy.

Development of flat adenoma and superficial rectal cancer after pelvic radiation

Little is known about the early development of rectal cancer in patients with radiation-induced colitis. We describe two patients with a history of radiation colitis who developed rectal cancer. The macroscopic appearance of these lesions suggested that they arose de novo, but the histologic findings were more consistent with progression along the adenoma-to-carcinoma sequence, a hybrid of de novo lesion and adenoma. Early rectal cancer associated with chronic inflammation should be considered if a nonpolypoid adenomatous lesion is detected in a patient who has received pelvic radiation.