Late effects of therapy in 94 patients with localized rhabdomyosarcoma of the orbit: Report from the Intergroup Rhabdomyosarcoma Study (IRS)-III, 1984-1991

Ocular manifestations and long-term complications of rhabdomyosarcoma in children

BACKGROUND/OBJECTIVES

The purpose of the study was to describe the ocular manifestations of rhabdomyosarcoma in a large cohort of children.

SUBJECT/METHODS

This was a retrospective observational cohort study. The medical records of all pediatric patients with head and neck rhabdomyosarcoma diagnosed between 1997 and 2021 at a tertiary-care pediatric hospital were analyzed. The main outcome measures were the incidence and prognostic role of ocular findings at presentation and long-term ocular complications.

RESULTS

There were 77 children with head and neck rhabdomyosarcoma in the study cohort with 38 patients showing ocular manifestations at presentation. Median age at diagnosis was 6.0 years, the median follow-up was 5.7 years and 54.5% were male. At last follow-up, 70.1% had no evidence of progression, 26.0% were deceased, and 2.6% were on palliative treatment. Orbital signs were common (44.2%). The most common ocular findings were proptosis (18.2%), restriction of extraocular motility (28.6%), strabismus/diplopia (22.1%) and ptosis (16.9%). The most common long-term complications were bony hypoplasia/facial asymmetry (40.3%) and keratopathy/dry eye (31.2%). Poor visual acuity (≤20/200) was noted in 13 (16.9%) patients with 5 (6.5%) patients requiring an exenteration. Survival was 100% in primary orbital RMS (p = 0.02), whereas any or a combination of cranial nerve palsies carried a poor prognosis (42% survival, p = 0.008).

CONCLUSIONS

In our cohort, half of children with rhabdomyosarcoma had ocular manifestations at presentation with about one-third showing orbital tumor involvement. Cranial nerve involvement carried a significantly worse prognosis for survival.

Systemic sequelae and craniofacial development in survivors of pediatric rhabdomyosarcoma

INTRODUCTION

The aim of this study was to evaluate the systemic sequelae, as well as the dental and craniofacial development, of patients with rhabdomyosarcoma in relation to the treatment received and clinical-pathological variables.

MATERIALS AND METHODS

A retrospective cross-sectional study was performed. All individuals diagnosed with RMS between 1990 and 2022 were considered eligible. Cases who survived the primary tumor were included. Data were collected from medical records, and patients were called for clinical and radiographic examinations.

RESULTS

Thirty-eight patients were assessed, with a mean disease-free survival of 216.68 months (±84.99). The primary location of the tumor was mainly the head and neck region (57.9 %). All patients received chemotherapy, and 30 (78.9 %) also underwent radiotherapy. The most frequently observed sequela was sensory impairment, which was significantly associated with tumors in the head and neck (p < 0.05), as well as with the use of radiotherapy (p = 0.034). Root formation failure was observed in 60 % of cases, microdontia in 50 %, and delayed tooth eruption in 40 %. A convex profile was predominant (80 %), along with maxillary (50 %) and mandibular (80 %) retrusion and a skeletal class II diagnosis (60 %).

CONCLUSIONS

Late systemic, dental, and craniofacial developmental sequelae are observed in pediatric rhabdomyosarcoma survivors, especially in patients who underwent radiotherapy in the head and neck region. Younger individuals at the time of treatment are at greater risk of late sequelae.

Effect of Ionizing Radiation on the Mechanical Properties of Two Dental Materials Commonly Used in Primary Teeth

Aim

The purpose of this in vitro study was to evaluate the effect of radiotherapy on flexural strength, microhardness, and surface roughness of bulk fill composite (X-tra fil) and glass ionomer (EQUIA Forte HT).

Materials and methods

A total of 40 specimens were prepared for each test and were divided into two groups according to the material used (composite or glass ionomer cement), and each group was divided into two subgroups (n = 10) according to radiation condition, irradiated subgroup, subjected to 50 Gy by multienergy linear accelerator delivered in one shot and control subgroup.

Results

Control samples of flexural strength and microhardness had a significantly higher value than irradiated samples in both materials. Regarding the surface roughness, irradiated samples had a significantly higher value than the control samples in both materials.

Conclusion

Irradiation with a linear accelerator had a negative impact on the flexural strength and microhardness of both materials. Moreover, it increased the surface roughness for both materials. Bulk fill composite is the dental restorative material of choice in head and neck cancer patients undergoing radiotherapy due to its high mechanical properties before and after radiation.

How to cite this article

Nagi BM, El-Korashy DI, Amin A El-S, et al. Effect of Ionizing Radiation on the Mechanical Properties of Two Dental Materials Commonly Used in Primary Teeth. Int J Clin Pediatr Dent 2023;16(5):758-762.

A Long-Term Follow-Up of Dental and Craniofacial Disturbances after Cancer Therapy in a Pediatric Rhabdomyosarcoma Patient: Case Report

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents. A boy aged seven years and five months was diagnosed with stage three group III embryonal parameningeal RMS with intracranial extension. He received chemotherapy for 23 weeks in combination with localized radiotherapy during the inductive phase of nine weeks (a total tumor dose of 5040 cGy). Three months later, he was referred to the department of pediatric dentistry for radiation-induced caries, the treatment of which was later terminated because of severe trismus and radiation-induced oropharyngeal mucositis. Three years later, the patient returned for the fitting of a prosthesis because of mastication problems. The dental treatments performed included: extraction, banding, composite resin restorations, root canal fillings, and stainless steel crown fabrication. An interim denture was fitted due to the poor retention of the fixed prosthesis. As the patient grew older, they developed facial asymmetry as a result of the prominent atrophy of their right cheek. By the age of 32, they had lost multiple teeth and exhibited severe facial deformity. Therefore, it is essential not only to involve a multidisciplinary medical team before, during, and after cancer therapy, but also to initiate long-term follow-ups given the potential effects of late sequelae after chemoradiation in multiple developmental areas.

Radiation Therapy in the Treatment of Head and Neck Rhabdomyosarcoma

The use of radiation therapy is an important part of multimodality treatment for rhabdomyosarcoma. The specific doses, treatment volumes, and techniques used in radiation therapy can vary dramatically based upon a number of factors including location, tumor size, and molecular characteristics, resulting in complex decisions in treatment planning. This article reviews the principles of evaluation and management for head and neck rhabdomyosarcoma including a summary of the historical studies upon which current management is based.

Second-line therapy in young patients with relapsed or refractory orbital rhabdomyosarcoma

OBJECTIVE

Localized orbital rhabdomyosarcoma (oRMS) has an overall favourable prognosis with more than 90% of survival. Little is known about the best strategy in recurrent/refractory (R/R) cases. The purpose is to examine the characteristics of patients with R/R-oRMS, focusing on local therapy.

METHODS

This is bicentric retrospective study. Analysis is of young patients (<30 years) with R/R-oRMS who were treated from 1989 to 2018 at the Institut Curie and Gustave Roussy Cancer Campus, France.

RESULTS

Twenty-seven out of 162 patients (17%) with oRMS presented with R/R disease. 6 of these patients had alveolar RMS (22%), 3 of whom had initial parameningeal extension (11%). During first-line treatment, 18 patients (67%) had orbital radiotherapy. Median age at R/R was 10 years (ranges: 4-28) after a delay of 19 months from diagnosis (ranges: 3-40). Tumoral events were local relapses (22 cases), local progression (3 cases) or regional relapses (2 cases). Second-line treatments included chemotherapy (27 cases), radiotherapy (16 cases), surgery (exenteration; 8 cases) and metastasis/ nodal removal (3 cases). After a median follow-up of 99 months (range: 10-306), 4 patients died and 23 are in complete remission (CR) without treatment. One patient had subsequent relapse treated with exenteration and brachytherapy until a new tumour remission. Five-year event-free and overall survivals after first tumour event are, respectively, 84.4% (95% confidence interval: 71.5%-98.8%) and 85.8% (95% confidence interval: 72.1%-100.0%) CONCLUSION: R/R-oRMS is a rare situation. Second-line therapy is efficient in this location, sometime at the cost of lifesaving mutilating surgery. Second-line local therapy needs therefore to consider local radiotherapy if possible or complete wide surgery.

Late effects of radiation therapy in pediatric patients and survivorship

Advances in multimodality therapy have led to childhood cancer cure rates over 80%. However, surgery, chemotherapy, and radiotherapy may lead to debilitating or even fatal long-term effects among childhood survivors beyond those inflicted by the primary disease process. It is critical to understand, mitigate, and prevent these late effects of cancer therapy to improve the quality of life of childhood cancer survivors. This review summarizes the various late effects of radiotherapy and acknowledges the Pediatric Normal Tissue Effects in the Clinic (PENTEC), an international collaboration that is systematically analyzing the association between radiation treatment dose/volume and consequential organ toxicities, in developing children as a basis to formulate recommendations for clinical practice of pediatric radiation oncology. We also summarize initiatives for survivorship and surveillance of late normal tissue effects related to radiation therapy among long-term survivors of childhood cancer treated in the past.

ODONTOLOGICAL EFFECTS OF IONIZING RADIATION (review)

BACKGROUND

Odontological effects of ionizing radiation (IR) as a result of radiotherapy, the consequences of accidents at nuclear power plants and industry, individual occupational exposure, etc. deserve significant attention interns of radiation medicine and radiation safety.

OBJECTIVE

to analyze and summarize clinical and experimental data on the odontological radiation effects.

MATERIALS AND METHODS

OBJECT

the pathological changes in the hard tissues of teeth, pulp, periodontium, mucousmembranes of the mouth and jaws due to exposure to IR.

METHOD

search in the PubMed / MEDLINE, Google Scholarabstract medical and biological databases, scientific libraries of the relevant sources of scientific information.

RESULTS

Radiobiological effects of IR due to its direct and indirect action are manifested throughout the period ofodontogenesis and formation of the facial skeleton. Experimental and clinical data (in children and adults) indicatethe increased risk of dental caries, reduction of pain threshold and vascularization of tooth pulp along with its fibrosis and atrophy, periodontal dysfunction, which predispose to a high probability of tooth loss. Abnormalities in theactivity of osteoblasts and cementoblasts of dental periosteum and osteoblasts of alveolar process in combinationwith circulatory disorders due to endothelial cell death, hyalinization, thrombosis and vascular obliteration increasethe risk of jaw osteoradionecrosis. Children who have undergone a prenatal exposure to IR as a result of theChornobyl NPP accident have a premature change of teeth. Deterioration of periodontal tissues and early development of acute and complicated dental caries are typical for children and adults affected by the Chornobyl disaster.

CONCLUSIONS

Summarized data on the effects of radiation exposure under different conditions on teeth primordia(i.e. immature teeth), their formation and eruption in experimental and clinical settings, as well as on the odontological radiation effects in adults are summarized. Condition of the teeth in the Chornobyl NPP accident survivorsis described. Understanding and taking into account the radiobiological odontological effects is necessary in thelight of planning, preparing, and conducting local radiation therapy and developing the standards of radiation safety and measures to protect professionals and the public in the event of possible radiation accidents at the nuclearpower plants and industry facilities.

Interventional radiotherapy (brachytherapy) achieves very good long-term quality of life in children and adolescents with soft-tissue sarcoma

BACKGROUND

Effective local therapy (surgery, radiation) and systemic multidrug chemotherapy are mandatory for curing childhood sarcoma. The standard radiation therapy for pediatric patients with soft-tissue sarcoma (STS) is external beam radiotherapy (EBRT). Because EBRT may cause long-term side effects with adverse effects on the patients' health and quality of life (QoL), alternative strategies are required. Interventional radiotherapy (IRT; brachytherapy) is established as a standard treatment for several tumors in adulthood. Single-center series have reported low levels of late effects and improved QoL in survivors treated with IRT in childhood. However, IRT is still applied infrequently in pediatric patients.

METHODS

Thirty patients with STS were treated with IRT between 1992 and 2012 at the University Hospital Schleswig Holstein, Germany. Five patients were lost to follow-up, and 25 patients (mean age at time of data collection 24.8 years [range, 10.7-36.1]) could be analyzed focusing on overall survival and QoL (EORTC-C30 questionnaire). For more detailed information regarding general and health-specific questions, a separate questionnaire was developed.

RESULTS

Nineteen of 25 patients were alive 13.4 [1.6-25.2] years after first cancer disease, and the three-year overall survival was 76% (SE, 0.09). The score of QoL/global health status (76.2 [16.6-100]) in our patients outvalues the European (66.1) and equals the German (75.9) reference value.

CONCLUSION

IRT is an effective treatment option for pediatric patients with localized STS. Its role among other radiation dose-sparing techniques such as proton beam therapy has to be defined in prospective studies.

Efficacy and Safety of Limited-Margin Conformal Radiation Therapy for Pediatric Rhabdomyosarcoma: Long-Term Results of a Phase 2 Study

PURPOSE

Our purpose was to assess disease outcomes and late toxicities in pediatric patients with rhabdomyosarcoma treated with conformal photon radiation therapy (RT).

METHODS AND MATERIALS

Sixty-eight patients (median age, 6.9 years) were treated with conformal photon RT to the primary site on a prospective clinical trial. Target volumes included a 1-cm expansion encompassing microscopic disease. Prescribed doses were 36 Gy to this target volume and 50.4 Gy to gross residual disease. Chemotherapy consisted of vincristine/dactinomycin (n = 6), vincristine/dactinomycin/cyclophosphamide (n = 37), or vincristine/dactinomycin/cyclophosphamide-based combinations (n = 25). Patients were evaluated with primary-site magnetic resonance imaging, whole-body [¹⁸F]fluorodeoxyglucose positron emission tomography, and chest computed tomography for 5 years after treatment.

RESULTS

Five-year disease-free survival was 88% for low-risk (n = 8), 76% for intermediate-risk (n = 37), and 36% for high-risk (n = 23) patients (P ≤ .01 for low risk/intermediate risk vs high risk). The cumulative incidence of local failure (LF) at 5 years for the entire cohort was 10.4%. Tumor size at diagnosis was a significant predictor of LF (P < .01). Patients with head and neck primary tumors (n = 31) had a 35% cumulative incidence of cataracts; the risk correlated with lens dose (P = .0025). Jaw dysfunction was more severe when the pterygoid and masseter muscles received a mean dose of >20 Gy (P = .013). Orbital hypoplasia developed more frequently after a mean bony orbit dose of >30 Gy (P = .041). Late toxicity in patients with genitourinary tumors included microscopic hematuria (9 of 14), bladder-wall thickening (10 of 14), and vaginal stenosis (2 of 5).

CONCLUSIONS

Long-term LF rates were low, and higher rates correlated with larger tumors. Treatment-related toxicities resulting in measurable functional deficits were not infrequent, despite the conformal RT approach.

Dose-Effect Analysis of Early Changes in Orbital Bone Morphology After Radiation Therapy for Rhabdomyosarcoma

PURPOSE

In survivors of orbital embryonal rhabdomyosarcoma (ERMS), late effects include facial deformation and asymmetry. We sought to quantify orbital asymmetry in ERMS survivors and characterize the dose effect of radiation to the orbital bones.

METHODS AND MATERIALS

We evaluated the most recent follow-up magnetic resonance imaging (MRI) in 17 children (≤21 years old) with stage 1 group III orbital ERMS treated with proton therapy between 2007 and 2018. For all patients, the orbital socket volumes were calculated and compared with the contralateral, unirradiated orbital socket. Patient age, orbital tumor quadrant, and the radiation dose delivered to the major orbital bones (maxillary, frontal, and zygomatic bones) were recorded and correlated with the orbital socket volume difference.

RESULTS

The mean age at diagnosis was 5.4 years old (range, 1.1-9.7 years). All patients received a prescription dose of 45 GyRBE. The mean time interval between radiation and MRI was 2.9 years (range, 0.8-3.2 years). The mean age at most recent MRI was 8.4 years (range, 2.3-12.9 years). In 16 of 17 patients, the volume of the ipsilateral orbit was significantly smaller than the contralateral orbit on follow-up MRI (P ≤ .0001). In one patient with nonviable tumor in situ, the irradiated orbit was larger. The volume difference increased with follow-up time and did not correlate with age at treatment or age at MRI. A dose >40 GyRBE to all bones of the orbital rim was associated with a significant decrease in orbital volume (P < .05), but an isolated dose of >40 GyRBE to either the frontal, maxillary, or zygomatic bone was not.

CONCLUSIONS

Despite the dosimetric precision of proton therapy, orbital asymmetry will develop after >40 GyRBE to multiple bones of the orbital rim. These data may be used to guide treatment planning and counsel patients on expected cosmesis.

Physical activity and fitness among pediatric cancer survivors: a meta-analysis of observational studies

PURPOSE

The number of pediatric cancer survivors has increased dramatically over recent decades. Prior studies involving pediatric cancer survivors have reported reduced physical activity and fitness levels. Thus, the aim of this meta-analysis was to synthesize previous findings on physical activity and fitness levels of pediatric cancer survivors, who had completed cancer treatment and are in complete remission compared with age-matched, non-athletic healthy controls with no history of cancer diagnosis.

METHODS

Three electronic databases (PubMed, Web of Science, and EBSCO) were searched using a combination of 24 terms. Observational studies examining the post-treatment physical activity and/or fitness levels of pediatric cancer survivors compared with that of non-cancer controls and published in peer-reviewed, English-language journals before August 22, 2018 were eligible. Random-effect models were used in Comprehensive Meta-Analysis software for effect-size estimations of eight studies for physical activity and eight for fitness.

RESULTS

The studies included a total sample of 2628; 1413 pediatric cancer survivors and 1215 non-cancer controls. Both physical activity and fitness were significantly lower in childhood cancer survivors than in non-cancer controls (g = - 0.889; 95% confidence interval [CI] = - 1.648 - 0.130; p = 0.022) and (g = - 1.435; 95% CI = - 2.615 - 0.225; p = 0.017), respectively, with high heterogeneity.

CONCLUSIONS

Pediatric cancer sequelae and its treatment may limit participation in physical activity and fitness activities by survivors of pediatric cancer. Accentuating the need to incorporate physical activity and fitness into treatment protocols and post-treatment recommendations may improve pediatric cancer survivors' health and well-being.

The prognosis and effects of local treatment strategies for orbital embryonal rhabdomyosarcoma: a population-based study

Introduction

Orbital embryonal rhabdomyosarcoma is a rare childhood malignancy with a good prognosis, but the optimal treatment remains unclear. Using a population-based cancer registry, we assessed the prognoses and survival outcomes of patients with orbital embryonal rhabdomyosarcoma according to the local treatment strategy.

Patients and methods

Patients diagnosed with orbital embryonal rhabdomyosarcoma between 1988 and 2012 as part of the Surveillance Epidemiology and End Results program were included. Univariate and multivariate Cox regression analyses were performed to determine the prognostic factors associated with cause-specific survival (CSS) and overall survival (OS).

Results

In total, 102 patients were included; their median age was 6 years, 78.4% were white, and 56.9% were male. The median tumor size was 30 mm. Of 20 patients with an available histologic grade, the tumors of 90% were poorly differentiated/undifferentiated. Of 92 patients with available surgical and radiotherapy (RT) statuses, 50 (54.3%), 36 (39.1%), and 6 (6.5%) received surgery and RT, primary RT, and primary surgery, respectively. Ninety-five patients (93.1%) received chemotherapy. The 5- and 10-year CSSs of the entire cohort were 94.3% and 92.2%, respectively. The 5- and 10-year OSs were 93.3% and 91.3%, respectively. In 95 patients who were followed up for at least 12 months, there were no significant prognostic factors related to CSS and OS. Furthermore, the local treatment strategy did not significantly affect CSS (P=0.29) or OS (P=0.468).

Conclusion

There is no local treatment of choice for orbital embryonal rhabdomyosarcoma in terms of survival. However, RT is a reasonable alternative treatment to surgery.

45 Gy is not sufficient radiotherapy dose for Group III orbital embryonal rhabdomyosarcoma after less than complete response to 12 weeks of ARST0331 chemotherapy: A report from the Soft Tissue Sarcoma Committee of the Children's Oncology Group

BACKGROUND

Recent Children's Oncology Group (COG) trials tested the efficacy of reduced therapy in an effort to lessen late effects compared to the Intergroup Rhabdomyosarcoma Study (IRS) IV regimen with associated hematologic and hepatic toxicity, and infertility. Here, we analyze the efficacy of 45 Gray (Gy) local radiotherapy (RT) in patients with Group III orbital embryonal rhabdomyosarcoma (ERMS) enrolled on the COG low-risk study ARST0331.

PROCEDURE

Sixty-two patients with Group III orbital ERMS were treated on ARST0331 with four cycles of vincristine (VCR), dactinomycin (DACT), and cyclophosphamide (CPM; VAC, total cumulative CPM dose 4.8 g/m2 ) followed by four cycles of VCR and DACT over 22 weeks. Forty-five Gray of radiation was administered in 25 fractions beginning at week 13 of therapy.

RESULTS

Fifty-three patients were evaluable for this response analysis; seven had missing week 12 response evaluation data and two had progressive disease prior to starting RT. Median follow-up was 7.8 years. None of the 15 patients with radiographic complete response (CR) compared to 6 of the 38 patients with

CONCLUSIONS

For patients with Group III orbital ERMS achieving a CR following VAC chemotherapy that includes modest dose CPM, 45 Gy may be sufficient for durable failure-free survival. However, for those with Collapse

Key Words

• orbital rhabdomyosarcoma
• radiotherapy
• response based

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MESH Headings

• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Child
• Child, Preschool
• Combined Modality Therapy
• Female
• History, Ancient
• Humans
• Kaplan-Meier Estimate
• Male
• Orbital Neoplasms/drug therapy
• Orbital Neoplasms/mortality
• Orbital Neoplasms/radiotherapy
• Radiation Dosage
• Radiotherapy/methods
• Rhabdomyosarcoma, Embryonal/drug therapy
• Rhabdomyosarcoma, Embryonal/mortality
• Rhabdomyosarcoma, Embryonal/radiotherapy

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Grants

• U10 CA098413 NCI NIH HHS
• U10 CA098543 NCI NIH HHS
• U10 CA180899 NCI NIH HHS

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Affiliation(s)

Ralph P. Ermoian Department of Radiation Oncology, University of Washington, Washington
John Breneman Department of Radiation Oncology, University of Cincinnati, Ohio
David O. Walterhouse Department of Pediatrics-Hematology, Oncology and Stem Cell Transplantation, Northwestern University, Illinois
Yueh-Yun Chi Department of Biostatistics, University of Florida, Florida
Jane Meza Department of Biostatistics, University of Nebraska, Nebraska
James Anderson Department of Biostatistics, University of Nebraska, Nebraska
Douglas S. Hawkins Department of Pediatrics, University of Washington, Washington
Andrea A. Hayes-Jordan Department of Pediatric Surgery, The University of Texas Health Science Center at Houston, Texas
David M. Parham Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, California
Torunn I. Yock Department of Radiation Oncology, Massachusetts General Hospital, Massachusetts
Sarah S. Donaldson Department of Radiation Oncology, Stanford University School of Medicine, California
Suzanne L. Wolden Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York

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Local Resection and Brachytherapy for Primary Orbital Rhabdomyosarcoma: Outcome and Failure Pattern Analysis

PURPOSE

Survival in patients with orbital rhabdomyosarcoma (RMS) is excellent. Therefore, new local treatment modalities, such as brachytherapy, have been developed to minimize adverse events. Since 1990, patients with orbital RMS and a residual tumor after induction chemotherapy were eligible for resection and brachytherapy. Otherwise patients received external beam radiotherapy. In this study, the authors describe the outcome for 20 patients with primary orbital RMS. The aim was to assess risk factors for treatment failure in this single center cohort.

METHODS

In this retrospective cohort study, the authors reviewed imaging studies, surgery reports, histology reports, and radiotherapy plans in a multidisciplinary setting. The authors included 20 consecutive patients with orbital RMS, treated between 1990 and 2007, (median age: 7.4 years, range: 0.7-16.1; median follow up: 11.5 years).

RESULTS

After induction chemotherapy, 12 patients were treated with surgery and brachytherapy, 2 with external beam radiotherapy, and in 5 patients who achieved complete remission, local treatment was withheld. In 1 patient, brachytherapy was incorrectly withheld after delayed surgery. Seven patients relapsed (no local treatment, N = 2; surgery and brachytherapy, N = 2; external beam radiotherapy, N = 2; surgery only, N = 1). The authors found no patient, tumor, or treatment characteristics that predisposed for treatment failure. Ten-year-overall survival and event-free survival were 89% and 65%, respectively.

CONCLUSIONS

Overall survival in this cohort of orbital RMS patients was good, including surgery and brachytherapy as treatment modality for orbital RMS resulted in an effective local treatment approach with fewer adverse events than external beam radiotherapy. The authors could not identify factors predisposing for treatment failure.

Clinical Management of Orbital Rhabdomyosarcoma in a Referral Center in Spain

PURPOSE

To review the systemic and ocular outcomes and long-term status of ocular rhabdomyosarcoma in pediatric patients in a tertiary center in Spain.

METHODS

All patients younger than 18 years who were diagnosed as having ocular rhabdomyosarcoma and treated between 1982 and 2011 at La Paz University Hospital, Madrid, Spain, were included. Clinical presentation, management, complications, and ocular and systemic outcomes were reviewed.

RESULTS

The mean age at presentation was 8 years (range: 3 months to 12.5 years). In all cases, the rhabdomyosarcoma was located primarily in the orbit. Treatment included surgical debulking and various regimens of chemotherapy and radiotherapy. All of the patients underwent surgical biopsy for diagnosis confirmation. Orbital exenteration was performed in 4 cases (28%). Twelve patients received radiotherapy. The long-term visual outcomes of the 10 patients who maintained their globe was as follows: best corrected visual acuity 20/20 to 20/40 in 6 patients (60%), 20/50 to 20/100 in 2 patients (20%), and 20/200 to no light perception in 2 patients (20%). Intraocular complications (primarily cataracts: 50%) were present in 7 patients (70%), ocular surface lesions occurred in 6 patients (60%), and orbital sequelae were found in 8 patients (80%). Local tumor recurrence was detected in 5 patients (35%) and distant metastasis occurred in 2 patients (14%). Tumor-related death occurred in 1 patient (7%).

CONCLUSIONS

Orbital rhabdomyosarcoma has an excellent prognosis; nevertheless, local complications are common, including surgery-related complications. To minimize them, initial surgical planning based on individual patient characteristics and an accurate diagnosis of relapses is mandatory. The clinical presentation, management, and long-term ocular and systemic outcomes are comparable with other series published to date.

Hearing loss in survivors of childhood head and neck rhabdomyosarcoma: a long-term follow-up study

OBJECTIVES

To determine the hearing status of survivors treated for head and neck rhabdomyosarcoma (HNRMS) at long-term follow-up.

DESIGN

Cross-sectional long-term follow-up study.

SETTING

Tertiary comprehensive cancer centre.

PARTICIPANTS

Survivors treated for HNRMS during childhood in two concurrent cohorts; survivors in London had been treated with external beam radiotherapy (EBRT-based local therapy); survivors in Amsterdam were treated with AMORE (Ablative surgery, MOuld technique afterloading brachytherapy and surgical REconstruction) if feasible, otherwise EBRT (AMORE-based local therapy).

MAIN OUTCOME MEASURES

We assessed hearing status of HNRMS survivors at long-term follow-up. Hearing thresholds were obtained by pure-tone audiometry.

METHODS

We assessed the hearing thresholds, the number of patients with clinically relevant hearing loss and hearing impairment graded according to the Common Terminology Criteria for Adverse Events version 4.0 (CTCAEv4) and Boston criteria. Furthermore, we compared hearing loss between survivors treated with EBRT-based local therapy (London) and AMORE-based local therapy (Amsterdam).

RESULTS

Seventy-three survivors were included (median follow-up 11 years). We found clinically relevant hearing loss at speech frequencies in 19% of survivors. Multivariable analysis showed that survivors treated with EBRT-based treatment and those with parameningeal tumours had significantly more hearing impairment, compared to survivors treated with AMORE-based treatment and non-parameningeal tumours.

CONCLUSIONS

One in five survivors of HNRMS developed clinically relevant hearing loss. AMORE-based treatment resulted in less hearing loss compared to EBRT-based treatment. As hearing loss was highly prevalent and also occurred in survivors with orbital primaries, we recommend systematic audiological follow-up in all HNRMS survivors.

Current status of treatment for pediatric rhabdomyosarcoma in the USA and Japan

This article reviews the current status of treatment for children with rhabdomyosarcoma, according to the four risk groups. Low-risk subgroup A: the Children's Oncology Group in the USA recently performed a clinical trial consisting of a chemotherapy regimen with a shortened treatment period and a reduced drug dosage. Patients in this group received only four cycles of vincristine and actinomycin D (VA) after four cycles of vincristine, actinomycin D, and cyclophosphamide (VAC) with cyclophosphamide (CPM) 1.2 g/m(2) and their outcome was no worse than that obtained with previous regimens. Low-risk subgroup B: although marked improvement in survival was seen with an intensive VAC regimen with CPM 2.2 g/m(2) /cycle (Intergroup Rhabdomyosarcoma Study [IRS]-V, 1997-2004), the total dose of CPM in this regimen caused serious and fatal hepatic veno-occlusive disease during treatment and probably cannot avoid infertility or possible secondary cancer as a late effect. Thereafter, a reduced-dose regimen consisting of four cycles of VAC with CPM 1.2 g/m(2) followed by 12 cycles of VA was investigated in the next study, but the outcome appeared to be worse than in IRS-V. Intermediate-risk group: no significant difference was found between VAC/vincristine, topotecan and cyclophispahamide (VTC) and intensive VAC in IRS-V. The results of a subsequent regimen of VAC with CPM 1.2 g/m(2) alternating with vincristine and irinotecan are awaited. High-risk group: overall survival is approximately 30% and has not improved over the last 25 years. Although 18 month failure-free survival (FFS) was improved with an intensive combination therapy regimen, 36 month FFS dropped to 32% and thus better novel approaches or additive treatments are needed.

Impairments that influence physical function among survivors of childhood cancer

Children treated for cancer are at increased risk of developing chronic health conditions, some of which may manifest during or soon after treatment while others emerge many years after therapy. These health problems may limit physical performance and functional capacity, interfering with participation in work, social, and recreational activities. In this review, we discuss treatment-induced impairments in the endocrine, musculoskeletal, neurological, and cardiopulmonary systems and their influence on mobility and physical function. We found that cranial radiation at a young age was associated with broad range of chronic conditions including obesity, short stature, low bone mineral density and neuromotor impairments. Anthracyclines and chest radiation are associated with both short and long-term cardiotoxicity. Although numerous chronic conditions are documented among individuals treated for childhood cancer, the impact of these conditions on mobility and function are not well characterized, with most studies limited to survivors of acute lymphoblastic leukemia and brain tumors. Moving forward, further research assessing the impact of chronic conditions on participation in work and social activities is required. Moreover, interventions to prevent or ameliorate the loss of physical function among children treated for cancer are likely to become an important area of survivorship research.

Ethical analysis as a tool for addressing treatment controversies: radiotherapy timing in children with orbital rhabdomyosarcoma as a case example

PURPOSE

The treatment of orbital rhabdomyosarcoma is a topic of debate between North American and European clinicians, with the utility of radiation therapy as part of initial management in question. Despite differences in philosophy, the dominant North American approach of upfront radiation and the dominant European approach of radiation only in the event of recurrence yield a similar rate of overall survival. We sought to identify the ethical arguments for each approach.

METHODS

Established moral principles and appeals in contemporary medical ethics were utilized to identify the ethical arguments supporting each treatment approach. The potential for technologic advances to alter the analysis was considered.

RESULTS

Emphasizing the principle of beneficence, the North American approach seeks to reduce recurrence rates. In contrast, the European approach seeks to avoid radiation-induced sequelae, emphasizing the principle of nonmaleficence. Both approaches are based on well-established ethical principles, evidence, and clinical experience. Thus, both approaches currently appear to have legitimacy and should be included in the informed consent process. However, if treatment-related toxicity is reduced through improvements in radiation delivery, the North American approach could emerge as ethically superior.

CONCLUSIONS

Ethical analysis can aid in addressing challenges that arise when professional practices and perspectives differ in the management of cancer patients.

Delayed primary excision with subsequent modification of radiotherapy dose for intermediate-risk rhabdomyosarcoma: a report from the Children's Oncology Group Soft Tissue Sarcoma Committee

The majority of intermediate-risk rhabdomyosarcoma (RMS) patients have gross residual disease (Group III) after their first operative procedure. It is currently not known if local control rates can be maintained when, following induction chemotherapy, the radiation therapy (RT) dose is decreased after a delayed primary excision (DPE). To answer this question we evaluated patients enrolled on COG D9803 (1999-2005) who had Group III tumors of the bladder dome, extremity or trunk (thorax, abdomen and pelvis) were candidates for DPE at Week 12 if the primary tumor appeared resectable. RT dose was then adjusted by the completeness of DPE: no evidence of disease 36 Gy, microscopic residual 41.4 Gy and gross residual disease (GRD) 50.4 Gy. A total of 161 Group III patients were evaluated (24 bladder dome, 63 extremity and 74 trunk). Seventy-three patients (45%) underwent DPE which achieved removal of all gross disease in 61 (84%) who were then eligible for reduced RT dose (43/73 received 36 Gy, 19/73 received 41.4 Gy). The local 5-year failure rate (0% for bladder dome, 7% for extremity and 20% for trunk) was similar to IRS-IV, which did not encourage DPE and did not allow for DPE adapted RT dose reduction. In conclusion, DPE was performed in 45% of Group III RMS patients with tumors at select anatomic sites (bladder dome, extremity and trunk) and 84% of those who had DPE were eligible for RT dose reduction. Local control outcomes were similar to historic results with RT alone.

Orbital rhabdomyosarcoma in children: a favorable primary suitable for a less-invasive treatment strategy

BACKGROUND

Orbital rhabdomyosarcoma (ORMS) treatment is based on combination chemotherapy associated with best local therapy, sometimes surgery but more often radiation therapy. A retrospective single-center analysis was conducted to more clearly define the long-term outcome of patients with ORMS, to identify patients in whom aggressive first-line local therapy can be avoided.

POPULATION

A total of 95 patients with localized parameningeal (PM) or nonparameningeal (NPM) ORMS, treated at the Institut Curie between 1975 and 2010, were analyzed.

RESULTS

Median age at diagnosis was 6 years (range, 8 mo to 19.5 y), and median follow-up was 8.5 years (range, 7 mo to 24 y). A total of 25 patients presented PM extension. Radiation therapy was part of primary therapy for 78 patients. Five-year event-free survival and overall survival rates were 65.4%±5.2% and 85.6%±3.9%, respectively. On multivariate analysis, initial tumor size was identified as a significant prognostic factor. Event-free survival was similar for PM and NPM tumors (60.3%±10.4% vs. 62.7%±5.9%, P=0.57), whereas there was a trend for overall survival to be better for NPM tumors (90%±3.9% vs. 72.7%±9.6%, P=0.07).

CONCLUSIONS

Localized ORMS has a favorable outcome despite the current trend toward less aggressive and more limited indications of local therapy. Patients with a favorable pattern of strictly ORMS can be treated without first-line radiation therapy.

Preliminary results of a phase II trial of proton radiotherapy for pediatric rhabdomyosarcoma

PURPOSE

This prospective phase II study was designed to assess disease control and to describe acute and late adverse effects of treatment with proton radiotherapy in children with rhabdomyosarcoma (RMS).

PATIENTS AND METHODS

Fifty-seven patients with localized RMS (age 21 years or younger) or metastatic embryonal RMS (age 2 to 10 years) were enrolled between February 2005 and August 2012. All patients were treated with chemotherapy based on either vincristine, actinomycin, and cyclophosphamide or vincristine, actinomycin, and ifosfamide-based chemotherapy and proton radiation. Surgical resection was based on tumor site and accessibility. Common Terminology Criteria for Adverse Events, Version 3.0, was used to assess and grade adverse effects of treatment. Concurrent enrollment onto Children's Oncology Group or European Pediatric Sarcoma Study Group protocols was allowed. All pathology and imaging were reviewed at the treating institution.

RESULTS

Median follow-up was 47 months (range, 14 to 102 months) for survivors. Five-year event-free survival (EFS), overall survival (OS), and local control (LC) were 69%, 78%, and 81%, respectively, for the entire cohort. The 5-year LC by risk group was 93% for low-risk and 77% for intermediate-risk disease. There were 13 patients with grade 3 acute toxicity and three patients with grade 3 late toxicity. There were no acute or late toxicities higher than grade 3.

CONCLUSION

Five-year LC, EFS, and OS rates were similar to those observed in comparable trials that used photon radiation. Acute and late toxicity rates were favorable. Proton radiation appears to represent a safe and effective radiation modality for pediatric RMS.

Long-term evaluation of orbital rhabdomyosarcoma in children

BACKGROUND

Orbital rhabdomyosarcoma (ORMS) is associated with an excellent survival rate greater than 85%, and is considered to be a favourable site for this tumour. Treatment is based on combination chemotherapy together with best local therapy, sometimes surgery but more often radiation therapy. Local therapy is associated with frequent and potentially severe late sequelae.

DESIGN

Retrospective hospital single-centre analysis.

PARTICIPANTS

Eighty-two patients treated in Institut Curie, Paris.

METHODS

To define long-term status of survivors after localized ORMS, patients treated between 1975 and 2010 were analysed.

MAIN OUTCOME MEASURES

Clinical structural and functional orbital, and general sequelae.

RESULTS

Median age at diagnosis was 6 years (range: 8 months-19 years), and median follow up was 8.5 years (range: 7 months-24 years). The 5-year globe conservation rate was 90.4%. Ophthalmic dysfunction was present in 79% of patients. Impaired visual acuity (VA), was present in 62% of patients; 38% of them had severe visual disability with VA < 6/60. Late effects on orbitofacial structure were present in 39.8% of patients. Ocular or palpebral sequelae were present in 79% of survivors, mainly cataract (42%), ocular surface lesions such as keratoconjunctivitis (40%) and eyelid abnormalities (29%). General late effects were rare.

CONCLUSIONS

These data suggest that ocular and orbital late effects are frequent after treatment of ORMS, indicating the need for systematic long-term ophthalmologic follow up of these patients. Radiation therapy is an important part of the total burden of therapy.

Dental anomalies in children submitted to antineoplastic therapy

Cancer is the third most frequent cause of death in children in Brazil. Early diagnosis and medical advances have significantly improved treatment outcomes, which has resulted in higher survival rates and the management of late side effects has become increasingly important in caring for these patients. Dental abnormalities are commonly observed as late effects of antineoplastic therapy in the oral cavity. The incidence and severity of the dental abnormalities depend on the child's age at diagnosis and the type of chemotherapeutic agent used, as well as the irradiation dose and area. The treatment duration and aggressivity should also be considered. Disturbances in dental development are characterized by changes in shape, number and root development. Enamel anomalies, such as discoloration, opacities and hypoplasia are also observed in these patients. When severe, these abnormalities can cause functional and esthetic sequelae that have an impact on the children's and adolescents' quality of life. General dentists and pediatric dentists should understand these dental abnormalities and how to identify them aiming for early diagnosis and appropriate treatment.

Orbital rhabdomyosarcomas: A review

Rhabdomyosarcoma (RMS) is a highly malignant tumor and is one of the few life-threatening diseases that present first to the ophthalmologist. It is the most common soft-tissue sarcoma of the head and neck in childhood with 10% of all cases occurring in the orbit. RMS has been reported from birth to the seventh decade, with the majority of cases presenting in early childhood. Survival has changed drastically over the years, from 30% in the 1960's to 90% presently, with the advent of new diagnostic and therapeutic modalities. The purpose of this review is to provide a general overview of primary orbital RMS derived from a literature search of material published over the last 10 years, as well as to present two representative cases of patients that have been managed at our institute.

Outcome of patients with localized orbital sarcoma who relapsed following treatment on Intergroup Rhabdomyosarcoma Study Group (IRSG) Protocols-III and -IV, 1984-1997: a report from the Children's Oncology Group

BACKGROUND

We wanted to ascertain patterns of recurrence, re-treatment, and outcome among 188 eligible patients treated for localized orbital sarcoma on IRSG Protocols III/IV, 1984-1997.

PROCEDURE

Retrospective chart review.

RESULTS

Twenty-four of 188 patients (12.8%) developed local (n = 22) or distant relapse (n = 2) at 0.057-7.05 years (median, 1.58) after enrollment. Ages at study entry were 0.14-17 years (median, 5 years). Initial tumor operations included biopsy (n = 20) or gross resection with microscopic residual (n = 4). Initial tumor diameters were 0.5-7 cm (median, 3). Pathologic subtypes were embryonal rhabdomyosarcoma (ERMS, n = 19), sarcoma not otherwise specified (n = 2), and alveolar RMS, botryoid ERMS, or undifferentiated sarcoma (n = 1 each). Initial treatment included vincristine/dactinomycin (n = 24) including an alkylator (n = 4) and radiotherapy (RT, n = 21). Twenty patients responded, 14 completely, 6 partially. After recurrence, patients underwent orbital exenteration (n = 10), enucleation (2), tumor excision (3), or biopsy (1); 7 had no operation, and 1 had no data. Post-relapse chemotherapy included combinations of etoposide (n = 14 patients), doxorubicin (14), ifosfamide (12), cyclophosphamide (7), and dacarbazine (n = 1). Six patients received RT, including four previously treated and two not irradiated initially. Two patients died; one at 1.79 years after contralateral brain metastasis followed by local recurrence, and another at 2.49 years after multiple local recurrences. Twenty-two patients (91.7%) survived sarcoma-free for 0.04-17 years (median, 6.9) after relapse, and 18 of 22 (82%) were alive ≥5 years after relapse.

CONCLUSION

Survival following recurrent localized orbital sarcoma appears likely after vigorous re-treatment given with curative intent.

Changes in health status among aging survivors of pediatric upper and lower extremity sarcoma: a report from the childhood cancer survivor study

OBJECTIVE

To evaluate health status and participation restrictions in survivors of childhood extremity sarcomas.

DESIGN

Members of the Childhood Cancer Survivor Study cohort with extremity sarcomas who completed questionnaires in 1995, 2003, or 2007 were included.

SETTING

Cohort study of survivors of extremity sarcomas.

PARTICIPANTS

Childhood extremity sarcoma survivors (N=1094; median age at diagnosis, 13y (range, 0-20y); current age, 33y (range, 10-53y); 49% male; 87.5% white; 75% had lower extremity tumors) who received their diagnosis and treatment between 1970 and 1986.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence rates for poor health status in 6 domains and 5 suboptimal social participation categories were compared by tumor location and treatment exposure with generalized estimating equations adjusted for demographic/personal factors and time/age.

RESULTS

In adjusted models, when compared with upper extremity survivors, lower extremity survivors had an increased risk of activity limitations but a lower risk of not completing college. Compared with those who did not have surgery, those with limb-sparing (LS) and upper extremity amputations (UEAs) were 1.6 times more likely to report functional impairment, while those with an above-the-knee amputation (AKA) were 1.9 times more likely to report functional impairment. Survivors treated with LS were 1.5 times more likely to report activity limitations. Survivors undergoing LS were more likely to report inactivity, incomes <$20,000, unemployment, and no college degree. Those with UEAs more likely reported inactivity, unmarried status, and no college degree. Those with AKA more likely reported no college degree. Treatment with abdominal irradiation was associated with an increased risk of poor mental health, functional impairment, and activity limitation.

CONCLUSIONS

Treatment of lower extremity sarcomas is associated with a 50% increased risk for activity limitations; upper extremity survivors are at a 10% higher risk for not completing college. The type of local control influences health status and participation restrictions. Both of these outcomes decline with age.

Oral adverse effects of head and neck radiotherapy: literature review and suggestion of a clinical oral care guideline for irradiated patients

Radiotherapy, alone or associated with surgery or chemotherapy, produces a significant increase in cure rates for many malignancies of the head and neck region. However, high doses of radiation in large areas, including the oral mucosa, may result in several undesired reactions that manifest during or after the completion of therapy. The multidisciplinary management is the best alternative to minimize or even prevent such reactions, and the dentist has a fundamental role in this context. This paper reviews the literature related to the main oral sequelae from head and neck radiotherapy and establishes clinical oral management protocol for these irradiated patients.

Skull base reconstruction in the pediatric patient

Tumors of the skull base are rare in children and adolescents and present a complicated management problem for oncologists and surgeons alike. Surgical resection is an integral component of the management of many pediatric neoplasms, especially those that are benign or, though not frankly malignant, are locally invasive. The general principles of skull base reconstruction following tumor ablation are applicable to nearly all patients; the reconstructive algorithm, however, is particularly complex in the pediatric population and the potential benefits of therapy must be balanced against the cumulative impact on craniofacial growth and maturity and the donor site morbidity. A retrospective analysis of all patients less than 19 years of age who underwent resection of a skull base tumor was performed. Particular emphasis was placed on the 12 patients who required complex reconstruction by the plastic surgical service. This represents approximately a third of the operated patients. Data were recorded on patient age, tumor pathology and location, prior therapies, surgical approach, extent of resection, margin status, defect components, details of reconstructive methods employed, complications, additional procedures or interventions, and the use and timing of adjuvant therapies. Patient outcome at most recent follow-up was recorded. All patients were followed clinically and by MRI and/or CT scan of the skull base. The reconstructive details recorded included flap choice, recipient vessels, and any concomitant procedures performed. The indications for and details of any staged surgical revisions or prosthetics were also noted. Complications recorded included partial or total flap loss, cerebrospinal fluid leakage, meningitis, infection, abscess, hematoma or seroma formation, delayed healing, and donor site dysfunction. The vertical rectus abdominis myocutaneous free flap was the most common means of reconstruction utilized in this series. Three of 12 patients had reconstruction related complications. Delayed reconstructive procedures or prosthetic interventions have been performed in 6 of the 12 patients who underwent complex reconstructions. On the basis of our experience and previous reports in the literature, we offer the following guidelines for the successful multidisciplinary care of children and adolescents undergoing skull base reconstruction after tumor resection: (1) skull base reconstruction may be safely performed in children and adolescents using free tissue transfer or local flaps; (2) larger defects and those involving more than one anatomic region of the skull base should be repaired with soft-tissue free flaps; and (3) because of the versatility and reliability of free flaps, pedicled flaps should be reserved for limited defects. Because of the potentially synergistic effects of multimodality treatment for skull base malignancies on craniofacial growth and development, we advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity.

[Malignant extraconal tumors of the orbit in childhood]

Malignant extraconal orbital tumors are very rare during childhood and must be referred as soon as possible to a highly specialized center to be managed by a multidisciplinary team. They are often referred on an emergency basis. Both diagnosis and treatment must be undertaken as soon as possible. The course of these malignant tumors can be acute and can jeopardize the function of the eye or be life-threatening, especially in the event of metastatic locations. Extra-axial proptosis is by far the most frequent revealing symptom. Local and general examinations are of utmost importance. Sometimes diagnosis should be clear with the association of an orbital tumor and deterioration of the general health status favoring metastatic disease. Most metastatic neuroblastomas present such clinical symptoms in young children. Today both CT and MRI are highly valuable in assessing the diagnosis and starting the management of these tumors. Biopsy is mandatory to confirm the diagnosis. It can be reinforced by molecular biology. Among the primitive tumors, soft tissue sarcomas, especially rhabdomyosarcomas, are the most frequent. The diagnosis is suggested when the onset of the disease is acute and the course is rapid. Most respond to neoadjuvant chemotherapy. In the event of a residual tumor, local treatment is indicated so that surgery and/or radiotherapy are used as second-line treatment. Prognosis is closely related to histology. It can be satisfactory (Langerhans' cell histiocytosis, lymphoma, meningioma, infantile fibrosarcoma) or poor (metastatic tumor, rhabdoid tumor).

Imaging findings in craniofacial childhood rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the commonest paediatric soft-tissue sarcoma constituting 3-5% of all malignancies in childhood. RMS has a predilection for the head and neck area and tumours in this location account for 40% of all childhood RMS cases. In this review we address the clinical and imaging presentations of craniofacial RMS, discuss the most appropriate imaging techniques, present characteristic imaging features and offer an overview of differential diagnostic considerations. Post-treatment changes will be briefly addressed.

Ocular late effects in childhood and adolescent cancer survivors: a report from the childhood cancer survivor study

INTRODUCTION

Approximately 80% of children currently survive 5 years following diagnosis of their cancer. Studies based on limited data have implicated certain cancer therapies in the development of ocular sequelae in these survivors.

PROCEDURE

The Childhood Cancer Survivor Study (CCSS) is a retrospective cohort study investigating health outcomes of 5+ year survivors diagnosed and treated between 1970 and 1986 compared to a sibling cohort. The baseline questionnaire included questions about the first occurrence of six ocular conditions. Relative risks (RR) and 95% confidence intervals (CI) were calculated from responses of 14,362 survivors and 3,901 siblings.

RESULTS

Five or more years from the diagnosis, survivors were at increased risk of cataracts (RR: 10.8; 95% CI: 6.2-18.9), glaucoma (RR: 2.5; 95% CI: 1.1-5.7), legal blindness (RR: 2.6; 95% CI: 1.7-4.0), double vision (RR: 4.1; 95% CI: 2.7-6.1), and dry eyes (RR: 1.9; 95% CI: 1.6-2.4), when compared to siblings. Dose of radiation to the eye was significantly associated with risk of cataracts, legal blindness, double vision, and dry eyes, in a dose-dependent manner. Risk of cataracts were also associated with radiation 3,000+ cGy to the posterior fossa (RR: 8.4; 95% CI: 5.0-14.3), temporal lobe (RR: 9.4; 95% CI: 5.6-15.6), and exposure to prednisone (RR: 2.3; 95% CI: 1.6-3.4).

CONCLUSIONS

Childhood cancer survivors are at risk of developing late occurring ocular complications, with exposure to glucocorticoids and cranial radiation being important determinants of increased risk. Long-term follow-up is needed to evaluate potential progression of ocular deficits and impact on quality of life.

Brachytherapy as part of the multidisciplinary treatment of childhood rhabdomyosarcomas of the orbit

INTRODUCTION

Rhabdomyosarcomas in the orbit form a major challenge in terms of cure without severe side effects in childhood cancer. Our specifically developed approach consists of applying brachytherapy to the tumor area using a mold. Analysis of its results for 20 patients was performed.

METHODS AND MATERIALS

Thirteen patients were referred for brachytherapy if complete remission was not reached after chemotherapy (Group I) and 7 in case of relapse (Group II). In total, 20 patients were treated between 1991 and 2007. Four were female and 16 male; their ages varied from 1.1 to 16.5 years, with an average of 8.5 years. After macroscopically radical tumor resection, molds with holes drilled to hold flexible catheters were placed into the orbit. The dose to the clinical target volume was 40-50 Gy.

RESULTS

Three patients of Group I and 1 patient of Group II developed local recurrence and underwent exenteration. The progression-free survival in Group I is 71.9% (95% CI 0.44-1.0), in Group II 85.7% (95% CI 0.60-1.0), the overall 5-year survival rate of the entire group is 92% (95% CI 0.76-1.0). During treatment, no serious side effects were observed. The late complications encountered in this series were cataract in 2 patients, 1 of whom also developed mild retinopathy. Two patients with ptosis needed surgical correction. No facial asymmetries or bone growth anomalies were observed.

CONCLUSIONS

This entire procedure of brachytherapy with a mold offers a tailor-made treatment for orbital rhabdomyosarcomas with only few signs of late toxicity.

Non-traumatic enophthalmos: a review

Enophthalmos can be defined as a relative, posterior displacement of a normal-sized globe in relation to the bony orbital margin. Non-traumatic enophthalmos has a wide variety of clinical presentations and may be the first manifestation of a number of local or systemic conditions. It may present with cosmetic problems such as deep superior sulcus, pseudoptosis or eyelid retraction; or functional problems such as diplopia or exposure keratopathy. There are three main pathogenic mechanisms: structural alterations in the bony orbit; orbital fat atrophy; and retraction. Evaluation of enophthalmos patients includes orbital imaging and a thorough ophthalmic and systemic examination. In this review, we discuss the presenting features of non-traumatic enophthalmos and include a brief description of the more important causes. An approach to the clinical evaluation of these patients is also discussed together with a brief overview of the principles of management.

Diagnosis and management of enophthalmos

Enophthalmos is a relatively frequent and misdiagnosed clinical sign in orbital diseases. The knowledge of the different etiologies of enophthalmos and its adequate management are important, because in some cases, it could be the first sign revealing a life-threatening disease. This article provides a comprehensive review of the pathophysiology, evaluation, and management of enophthalmos. The main etiologies, such as trauma, chronic maxillary atelectasis (silent sinus syndrome), breast cancer metastasis, and orbital varix, will be discussed. Its objective is to enable the reader to recognize, assess, and treat the spectrum of disorders causing enophthalmos.