Radiation induced sarcoma of the head and neck

Management of head & neck sarcomas in adults: A retrospective study

The research purpose is to review the surgical approach and evaluate the results in adult patients with head and neck sarcomas. The histopathology varied, including two leiomyosarcomas, six malignant fibrous histiocytomas, two malignant peripheral nerve sheath tumors, four dermatofibrosarcomas protuberans, three osteosarcomas, two angiosarcomas, one liposarcoma, one Ewing sarcoma, one synovial sarcoma, two unclassified/non-differentiated sarcomas and one solitary fibrous tumor. Surgical resection included maxillectomy, mandibulectomy, craniectomy, parotidectomy, scalp resection, face skin resection and laminectomy. The reconstruction was performed with one rectus abdominis flap, four radial forearm flaps, two latissimus dorsi flaps, two vascularized fibula flaps, two pectoralis major myocutaneous flaps, two trapezius flaps, two temporalis flaps, seven scalp flaps and two nasolabial flaps. The total patient number was 24. The hospitalization was uncomplicated, followed by postoperative radiotherapy in the majority of cases. In a mean 15-year follow-up period, 11 patients are still alive and disease-free. There were four recurrences treated with palliative radiotherapy. The surgical approach for head and neck sarcomas, including the achievement of a functionally acceptable result by organ sparing techniques, remains challenging. Wide resection combined with the appropriate reconstruction, particularly with microsurgical techniques, and followed by adjuvant radiotherapy or chemotherapy offer improved prognosis and quality of life.

Radiation-induced soft tissue sarcoma of the neck after radiation therapy for Hodgkin's lymphoma: a clinical case

Background. Radiation-induced malignancies are one of the long-term complications of radiation therapy, which is widely used to treat some tumors. The latency period before a second tumor develops varies from 3 to 60 years. Epithelial tumors and hemoblastoses occur after low-dose radiation therapy and sarcomas after high-dose radiation therapy. Aim. To present a case of radiation-induced soft tissue angiosarcoma of the neck after the cure of Hodgkin's disease. Materials and methods. A 41-year-old patient with Hodgkin's nodular lymphoma with the lymphoid predominance of stage IIIA with involvement of the right cervical and clavicular lymph nodes, mediastinum, and abdominal lymph nodes was followed-up. In 2004 the patient underwent four cycles of polychemotherapy per ABVD regimen followed by radiotherapy of the right cervical and clavicular lymph nodes and mediastinum, with a total focal dose of 40 Gy. Results. Seventeen years after the treatment for Hodgkin's disease, including radiation therapy, the patient presented with painful swelling of the neck soft tissues in the radiation area with the transition to the anterior thoracic wall and an enlarged cervical lymph node. A lymph node dissection was performed. According to the combined positron emission tomography and X-ray computed tomography (PET/CT), histological and immunohistochemical studies, epithelioid angiosarcoma of soft tissues of the neck and thoracic wall stage IV cT2N1M1G3 with metastases to the skeleton bones, neck lymph nodes, left adrenal gland was established. Surgical treatment was not performed due to advanced disease. The patient received six cycles of polychemotherapy with doxorubicin + ifosfamide. PET/CT confirmed partial tumor regression. Conclusion. Radiation-induced soft tissue sarcoma is a late iatrogenic complication of radiation therapy for Hodgkin's lymphoma. The tumor occurred in the radiation area. PET/CT is the method of choice in diagnosing and evaluating the extent of cancer and response to treatment. Chemotherapy, as an option for complex treatment, can achieve adequate disease control when surgery is not feasible.

Nodular fasciitis arising from the buccal region after segmentectomy with rapid growth mimicking postirradiation myxofibrosarcoma: A case report

RATIONALE

Nodular fasciitis (NF) can be misdiagnosed as a sarcoma because of its rapid growth and pathological features, such as nuclear atypia and mitoses.

PATIENT CONCERNS

We present a rare case of a 72-year-old Japanese man who developed NF with suspected postirradiation myxofibrosarcoma (MFS) after segmentectomy for left-sided osteoradionecrosis (ORN) of the mandible.

DIAGNOSIS

A mass appeared in the intraoral postoperative wound 1 year after left-sided mandibular segmentectomy and showed rapid growth, reaching a size of 50 mm within 2 months. Incisional biopsy revealed strongly Ki-67-positive spindle-shaped cells with large irregular nuclei and a diagnosis of postirradiation MFS.

INTERVENTIONS

The patient was diagnosed with oropharyngeal cancer (T4aN2bM0) and underwent surgical resection of primary oropharyngeal squamous cell carcinoma with selective neck dissection and reconstruction with a rectus abdominis musculocutaneous flap at the age of 57 years, followed by postoperative 66 Gy of radiotherapy combined with cisplatin administration. No recurrent or metastatic lesions of oropharyngeal squamous cell carcinoma have been detected for > 10 years. However, the ORN of the jaw worsened, and the patient underwent sequestrectomy 3 times on the right side of the mandible, followed by a left-sided segmentectomy at the age of 72 years. One year after segmentectomy, a 10-mm mass with soft-to-firm consistency appeared in the buccal mucosa of the wound and grew rapidly. An incisional biopsy revealed MFS. Complete resection under general anesthesia was immediately performed.

OUTCOMES

The histopathological diagnosis of the excised specimen was NF without any malignant findings. Two years after surgery, there was no evidence of recurrence or metastasis.

LESSONS

NF grows rapidly and has pathological features similar to sarcoma, making differential diagnosis difficult at the time of incisional biopsy. Further studies should be conducted to determine the clinical and pathological features of this tumor.

Angiosarcomas of the head and neck: Impact of large data analysis on clinical management

Angiosarcoma is a rare but often fatal malignancy from blood and lymphatic vessels that can arise anywhere in the body and often affects the head and neck region. Although its dismal prognosis is predominantly explained by its aggressive biology, several secondary factors contribute to poor outcomes. These include a phenotypic resemblance to innocuous blood vessel lesions, which contributes to a significant degree of late diagnosis. Another important factor is the rarity of angiosarcoma, which has impaired scientific determination of its optimal treatment significantly. As a result, treatment of angiosarcomas has largely been guided by information derived from the study of sarcomas at large, themselves a highly heterogeneous group of mesenchymal cancers both from a diagnostic as well as therapeutical perspective. The Digital Revolution and resultant Information Age promise to focus the clinical management of rare cancers from a generic to a more customized approach. In this paper, we review the current understanding of head and neck angiosarcomas within the context of this process.

Radiation-Induced Olfactory Neuroblastoma Following Treatment for NK/T-cell Lymphoma, Nasal Type

Radiation-induced olfactory neuroblastoma (ONB) is an uncommon neoplasm that is generally associated with a poor prognosis. We experienced an unusual case of ONB in a patient who had received previous radiation therapy for extranodal NK/T-cell lymphoma 15 years previously. To our knowledge, this is the first report of a patient with radiation-induced ONB obtaining a complete response (CR) with radical re-irradiation alone. The purpose of this report is to discuss therapeutic strategies for radiation-induced ONB. We report an unusual case of ONB suspected to be a radiation-induced neoplasm in a 33-year-old female who had received 30 Gy of irradiation for extranodal NK/T-cell lymphoma, nasal type (NTCL) 15 years earlier. In this case, the patient presented with nasal obstruction and frequent epistaxis. The patient was diagnosed with ONB based on left nasal biopsy findings. The surrounding normal tissues tolerance of nasal ONB radiation had to be limited, because the previously radiated NTCL was located adjacent to critical organs. We performed intensity modulated radiation therapy (IMRT), which could offer precise irradiation (60 Gy in 2 Gy daily fractions) while sparing critical tissues. The present case was treated with radiation therapy alone, whereas previously reported cases were treated with a combination of chemotherapy and radiation therapy. We treated radiation-induced OBN successfully with radical re-irradiation using IMRT alone and the patient has had no recurrence for 3 years.

Update on MR Imaging of Soft Tissue Tumors of Head and Neck

This article reviews soft tissue tumors of the head and neck following the 2020 revision of WHO Classification of Soft Tissue and Bone Tumours. Common soft tissue tumors in the head and neck and tumors are discussed, along with newly added entities to the classification system. Salient clinical and imaging features that may allow for improved diagnostic accuracy or to narrow the imaging differential diagnosis are covered. Advanced imaging techniques are discussed, with a focus on diffusion-weighted and dynamic contrast imaging and their potential to help characterize soft tissue tumors and aid in distinguishing malignant from benign tumors.

Radiation-Associated Sarcoma of the Head and Neck: Incidence, Latency, and Survival

OBJECTIVES/HYPOTHESIS

Radiation-associated sarcomas of the head and neck (RASHN) are known but rare sequelae after radiation for squamous cell carcinoma. The purpose of this study was to characterize RASHN, estimate the risk of RASHN in head and neck squamous cell patients after therapeutic radiation, and compare their survival to that of patients with de novo sarcomas of the head and neck (dnSHN).

STUDY DESIGN

Retrospective database analysis.

METHODS

RASHN and dnSHN cases were collected from the Surveillance, Epidemiology, and End Results Database to identify risk factors and calculate incidence and latency. Survival was compared between RASHN and dnSHN.

RESULTS

The risk of RASHN was 20.0 per 100,000 person-years. The average latency period was 124.2 months (range 38-329). The cumulative incidence of RASHN at 20 years was 0.13%. Oral cavity and oropharynx primaries demonstrate increased risk. Five-year overall survival of RASHN was 22.4% compared to 64.5% for dnSHN.

CONCLUSIONS

RASHN are confirmed to be rare. RASHN have poor overall survival and worse survival compared to dnSHN. The impact of intensity-modulated radiation therapy protocols on this risk is unknown. Modifiable risk factors of smoking and alcohol consumption continue to dwarf radiation therapy as risk factors of second primary head and neck cancers.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Feline giant-cell pleomorphic sarcoma: cytologic, histologic and immunohistochemical characterization

OBJECTIVES

This study aimed to characterize the cytologic, pathologic and immunohistochemical (IHC) aspects of feline giant-cell sarcoma.

METHODS

Biopsy and necropsy reports from the Department of Veterinary Pathology were retrieved, and 13 cases of pleomorphic sarcoma (PS) were selected according to the established epidemiologic, pathologic and IHC criteria. All samples were fixed in 10% formalin, routinely processed for histology, and stained with hematoxylin and eosin. Samples also underwent IHC testing for vimentin, ionized calcium-binding adaptor molecule 1 (Iba-1), desmin, actin and S-100.

RESULTS

The mean age of the affected cats was 9.5 years, and females were over-represented. Most neoplasms were observed in the flank, lateral thorax, limbs and interscapular region, and were >2 cm in diameter. Cytology analysis revealed highly cellular preparations with three distinct populations (spindle cells, small round cells and multinucleated giant cells) in a dense eosinophilic stroma. Histologically, PS was composed of a combination of these three populations. IHC labeling for vimentin and Iba-1 was strongly positive for spindle cells and multinucleated giant cells, respectively. Desmin/actin showed variable labeling among the samples. S-100 was negative in all samples.

CONCLUSIONS AND RELEVANCE

PS is a neoplasm of mesenchymal origin, also known as malignant fibrous histiocytoma. The predominant subtype in this study that affected the cats was the giant-cell type, characterized by the presence of multinucleated giant cells among spindle-shaped cells. These findings are similar to those described in human patients; thus, a comparison between the neoplasms seen in these species might be useful, and the knowledge of biologic behavior and overall treatment approach for humans could be extrapolated to cats.

Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients

BACKGROUND

The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear.

METHODS

The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses.

RESULTS

The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59).

CONCLUSIONS

With careful selection, surgery alone for AJCC 7th pT0-T2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.

Second Malignancies after Radiation Therapy: Update on Pathogenesis and Cross-sectional Imaging Findings

A wide spectrum of second cancers occur as late complications of radiation therapy (RT) used to treat various malignancies. In addition to the type and dose of radiation, lifestyle, environmental, and genetic factors are important to the development of second malignancies in cancer survivors. Typically, RT-induced malignancies (RTIMs) are biologically aggressive cancers with a variable period of 5-10 years for hematologic malignancies and 10-60 years for solid tumors between RT and the development of the second cancer. Although carcinomas and leukemias commonly develop after low-dose RT, sarcomas occur in tissues or organs that receive high-dose RT. Angiosarcomas and unclassified pleomorphic sarcomas are the two most common RT-associated sarcomas; other sarcomas include malignant peripheral nerve sheath tumors, leiomyosarcomas, osteosarcomas, chondrosarcomas, and dedifferentiated or pleomorphic liposarcomas. Select RTIMs show tumor genetic characteristics that allow accurate diagnosis. Nearly all cutaneous angiosarcomas after RT for breast cancer and 90% of RT-associated malignant peripheral nerve sheath tumors are characterized by MYC gene amplifications and loss of H3 K27me3 expression, respectively. Classic papillary thyroid carcinomas that develop after RT frequently harbor RET/PTC rearrangements and have a favorable prognosis, despite their advanced stage at patient presentation. Select RTIMs demonstrate characteristic imaging findings and typically develop in the prior radiation field. Imaging is essential to early diagnosis, characterization, localization, and staging of RTIMs. Familiarity of radiologists with the diverse spectrum of RTIMs is essential for early diagnosis and optimal management. An invited commentary by Shapiro is available online. ^©RSNA, 2021.

A Case of Histiocytic Sarcoma Arising from Mycosis Fungoides

Histiocytic sarcoma (HS) is an uncommon malignant neoplasm arising from mature histiocytes and most commonly characterized by the immunophenotypic expression of CD68, CD163, or lysozyme. Although rare, HS arising as a second primary malignancy following hematolymphoid neoplasms has been reported. To our knowledge, this is the first reported case of HS occurring as a second primary malignancy in a patient with mycosis fungoides (MF), with the retained immunophenotype markers CD30 and CD4.

Conventional Western Treatment Associated With Chinese Herbal Medicine Ameliorates the Incidence of Head and Neck Cancer Among Patients With Esophageal Cancer

BACKGROUND

Because of advances in medical treatment, the survival of cancer patients is prolonged. In line with the prolonged survival time of cancer the incidence of second primary cancer has increased. There is currently no effective way to prevent the occurrence of secondary primary cancer (SPC).

OBJECTIVES

The aim of this study is to evaluate whether Chinese Herbal Medicine (CHM) is correlated with reduced occurrence of second primary cancer (SPC) of head and neck (H&N) in patients with esophageal cancer (EC).

METHOD

We identified 15,546 patients who were diagnosed with esophageal cancer between Jan 1, 2000, and Dec 31, 2010. The patients with H&N cancer before receiving CHM were excluded. After the selection and matching process, both CHM and non-CHM cohorts each contained 850 individuals. We compared the cumulative incidence of SPC of H&N with or without CHM treatment in patients with EC by the Kaplan-Meier method. NodeXL is used to run a network analysis of CHM to examine the association between herbs and formulas.

RESULTS

Compared with non-CHM users, CHM-users showed a reduced incidence rate of SPC of H&N among the patients with EC. Reduced cumulative incidence of SPC of H&N among patients with EC was noted in the CHM cohort compared to the non-CHM cohort. The most commonly used single herbs and formulas were associated with reducing SPC occurrence.

CONCLUSION

We propose that CHM as an adjuvant therapy may prevent the occurrence of SPC of H&N in patients with EC.

Radiation-Induced Sarcoma of the Head and Neck: A Review of the Literature

In the last decades, radiotherapy (RT) has become one of the cornerstones in the treatment of head and neck (HN) malignancies and has paralleled an increase in long-term patient survival. This lead to a concomitant increase in the incidence of radiation-induced sarcomas (RIS) of the irradiated field, with an annual rate up to 0.17%. The new techniques of irradiation do not seem to influence the risk of RIS of the HN (RISHN), which mainly develop within the middle-dose field. The median latency of RISHN after RT is 10–12 years and osteosarcoma is the most represented histotype, even though there is a high variability in time of occurrence and histological features observed. There is no clear evidence of predisposing factors for RISHN, and genetic findings so far have not revealed any common mutation. Early clinical diagnosis of RISHN is challenging, since it usually occurs within fibrotic and hardened tissues, while radiological findings are not pathognomonic and able to differentiate them from other neoplastic entities. Given the highly aggressive behavior of RISHN and its poor sensitivity to chemotherapy, radical surgery is the most important prognostic factor and the only curative option at present. Nevertheless, the anatomy of the HN district and the infiltrative nature of RIS do not always allow radical intervention. Therefore, a wise integration with systemic therapy and, when feasible, re-irradiation should be performed. Future findings in the genomic features of RISHN will be crucial to identify a possible sensitivity to specific drugs in order to optimize a multimodal treatment that will be ideally complementary to surgery and re-irradiation.

Salvage Carbon Ion Radiation Therapy for Locally Recurrent or Radiation-Induced Second Primary Sarcoma of the Head and Neck

Purpose: Salvage radiation therapy (RT) is a potentially curative treatment option for head and neck sarcomas (HNS) that did not respond to previous treatment(s). We report the first clinical experience of carbon ion radiotherapy (CIRT) for salvage treatment of locally recurrent (LR) or RT-induced secondary HNS after surgery and/or radiotherapy.

Methods and Materials: A retrospective analysis of the ongoing prospective data registries from the Shanghai Proton and Heavy Ion Center was conducted. Patients with LR-HNS who underwent surgery and/or RT and those with RT-induced second primary HNS were included. Acute and late toxicities were evaluated using the Common Terminology Criteria for Adverse Events version 4.0 and the Radiation Therapy Oncology Group late radiation toxicity scoring system, respectively. The actuarial 12-month local progression-free and overall survival rates (LPFS and OS) were calculated using the Kaplan-Meier method.

Results: Between 10/2015 and 7/2017, 19 consecutive and non-selected patients with LR-HNS or RT-induced secondary HNS received definitive doses of CIRT delivered with pencil beam scanning technology for salvage. Six patients had locally recurrent soft-tissue sarcoma, and another 6 had chondrosarcoma. Among these 12 patients, 4 had received one prior course of RT. Seven additional patients had an RT-induced second primary soft tissue sarcoma (STS)/osteosarcoma after RT. The median time between the completion of initial treatment (either surgery only or surgery followed by adjuvant RT) and salvage CIRT was 30.6 months.

The median follow-up time was 13.1 (range 1.6-41.1) months. All patients except one (for re-irradiation) completed the planned CIRT for salvage. The median dose of salvage CIRT was 60 GyE. Three patients developed local progression, and another 3 developed distant metastasis after salvage CIRT. Deaths occurred (3 patients) only in patients with radiation-induced second primary sarcoma at the time of analysis. The actuarial 12-month LPFS, DMFS and OS rates were 74.6%, 82.6% and 86.5%, respectively.

Two patients irradiated for a second primary sarcoma had Grade 4 bleeding during CIRT, including one who experienced the rupture of an optic artery aneurysm unrelated to his disease or the salvage treatment. No patient had Grade 5 toxicity during treatment. Except for one patient who died of hemorrhage 3.5 months after the completion of CIRT, no moderate or severe late toxicities were observed.

Conclusions: With few observed acute and late toxicities, salvage CIRT can provide effective short-term tumor control. Further research, preferably in a prospective fashion, will be required to confirm the efficacy and safety of salvage CIRT in this patient population.

Leiomyosarcoma: a rare sinonasal malignancy

Leiomyosarcomas (LMS) are rare sinonasal malignant tumours with 20 cases of nasal LMS previously reported in the literature. An 81-year-old man presented with an incidental left nasal lesion associated with left nasal obstruction and occasional left-sided blood-stained rhinorrhoea. Nasendoscopic examination showed green coloured polyps filling the left nasal cavity with biopsies showing LMS. CT imaging did not show any bony erosion. No metastases were found on positron emission tomography imaging. The patient underwent endoscopic resection and all surgical margins were clear of disease. The patient was declined postoperative radiotherapy, and serial follow-up has not shown any recurrence to date. Nasal LMS are rare sinonasal smooth muscle tumours and symptoms and radiological findings are often non-specific. Therefore, diagnosis is made on histopathological and immunohistochemical analysis. Due to their invasive nature, the treatment of choice is complete surgical resection, with adjuvant therapy reserved for patients with locally advanced or metastatic disease.

Primary Intracranial Extraskeletal Mesenchymal Chondrosarcoma: Clinical Mimicry as Glomus Jugulare

BACKGROUND

Extraskeletal mesenchymal chondrosarcoma (ESMCS) is an unusual pathologic variant of chondrosarcoma. There are no specific clinicoradiographic parameters to distinguish it from other intracranial pathologies. The diagnosis can be established only on the basis of histopathology, which may pose significant challenges in certain unusual locations.

PURPOSE

In this case, we discuss the pitfalls in diagnosis, management, and major characteristics of ESMCS with a review of current literature.

METHODS AND RESULTS

A 47-year-old female patient presented with a jugular foramen tumor which was misdiagnosed as glomus jugulare tumor for which she received primary gamma knife radiosurgery at 2 instances. But unfortunately, the patient died because of the increase in size of the lesion associated with necrosis. Autopsy analysis revealed a highly cellular tumor, rich in sarcomatous cells, and well-differentiated cartilages consistent with ESMCS.

CONCLUSION

A definite preoperative diagnosis of ESMCS is crucial though difficult especially when located at complex sites like jugular foramen and clinicoradiological mimicry. The most crucial step in the management of ESMCS is accurate diagnosis with critical evaluation of clinical, radiological, and histopathological parameters and realization of highly variable clinical course of the disease.

Survival and Margin Status in Head and Neck Radiation-Induced Sarcomas and De Novo Sarcomas

Objective To describe histologic subtypes and oncologic outcomes among patients with radiation-induced and de novo sarcomas of the head and neck. Study Design Retrospective case series with chart review. Setting Tertiary academic center. Subject and Methods In total, 166 adult patients with sarcoma of the head and neck treated from January 1, 1985, to January 1, 2010, were included. Tumors were characterized as radiation induced (15.1%) vs de novo sarcomas (84.9%). Clinical and tumor characteristics were compared. The primary outcomes were overall survival (OS) and disease-specific survival (DSS). Results Radiation-induced sarcomas were more likely to be high grade ( P = .006) and advanced stage ( P = .03). Chondrosarcoma was more common in de novo tumors ( P = .02) while leiomyosarcoma ( P = .01), sarcoma not otherwise specified ( P = .02), and undifferentiated pleomorphic sarcoma ( P < .001) were more common in radiation-induced sarcomas. Radiation-induced sarcomas were associated with statistically significantly worse DSS ( P = .019) and OS ( P = .005) compared with de novo sarcomas, but when only high-grade soft tissue sarcomas were analyzed, neither DSS ( P = .48) nor OS ( P = .29) differed. Margin status was a significant predictor of survival as both R0 and R1 resections correlated with statistically better DSS and OS compared with R2 ( P < .001) resections and patients treated with radiation therapy/chemoradiation therapy alone ( P = .005). Conclusion Radiation-induced sarcomas of the head and neck correlate with worse survival compared with de novo tumors; however, when controlling for tumor grade and resection status, there is no statistically significant difference in observed outcomes.

Case of glioblastoma patient treated with tumor treating fields therapy at recurrence degenerating to sarcoma

Optune^® treatment is a US FDA-approved treatment for glioblastoma (GBM) that employs alternating electric fields. Tumor treating field (TTF) therapy can exert its effects on GBM via cell cycle mitosis disruption and cytokinesis. We describe a patient with recurrent GBM who had disease progression following standard surgical treatment and concomitant chemoradiotherapy, and was found to have sarcomatous transformation after initiation of TTF therapy with bevacizumab. Upon tumor progression, repeat surgical resection revealed transformation into a GFAP-negative, reticulin-positive sarcoma with rhabdomyoid features. The possibility of a causal connection between TTF therapy and sarcomatous transformation needs to be further evaluated. No such case of apparent sarcoma formation in the CNS following chemoradiotherapy and/or TTF treatment for GBM has been reported.

Radiation-induced osteosarcoma of the skull base after radiation therapy in a patient with nasopharyngeal carcinoma: a case report and review of the literature

Background

Radiation-induced osteosarcomas are a recognized complication of radiation therapy. Owing to the fact that it is rare, publications on radiation-induced osteosarcoma of the skull base are limited to a small series and some case reports.

Case presentation

We describe a rare case of a patient with a skull base radiation-induced osteosarcoma treated 11 years before with ionizing radiation for an undifferentiated carcinoma of the nasopharynx. The patient was treated with chemotherapy alone, but he died after the third cycle.

Conclusions

Radiation-induced osteosarcoma of the skull base after treatment of nasopharyngeal carcinoma is a very rare but very aggressive complication with a poor prognosis. Chemotherapy gives bad results, and regular follow-up of treated patients should be considered.

Radiation-induced osteosarcoma of the maxilla and mandible after radiotherapy for nasopharyngeal carcinoma

Background

The increasing incidence of radiation-induced osteosarcoma of the maxilla and mandible (RIOSM) has become a significant problem that can limit long-term survival. The purpose of this study was to analyze the association of clinicopathologic characteristics with treatment outcomes and prognostic factors of patients who developed RIOSM after undergoing radiotherapy for nasopharyngeal carcinoma (NPC).

Methods

We reviewed the medical records of 53,760 NPC patients admitted to Sun Yat-sen University Cancer Center during the period August 1964 to August 2012. Of these patients, 47 who developed RISOM and met inclusion criteria were included in this study. Two of these 47 patients refused treatment and were then excluded.

Results

For all patients treated for NPC at Sun Yat-sen University Cancer Center during the study period, the total incidence of RIOSM after radiotherapy was 0.084% (47/53,760). Two patients (4.4%) had metastases at the diagnosis of RIOSM. Thirty-nine of the 45 (86.7%) patients underwent surgery for RIOSM; most patients (24/39; 61.5%) who underwent resection had gross clear margins, with 15 patients (38.5%) having either a gross or microscopic positive margin. All patients died. The 1-, 2-, and 3-year overall survival (OS) rates for the entire cohort of 45 patients were 53.3%, 35.6% and 13.5%, respectively. The independent prognostic factors associated with high OS rate were tumor size and treatment type.

Conclusions

RISOM after radiotherapy for NPC is aggressive and often eludes early detection and timely intervention. Surgery combined with postoperative chemotherapy might be an effective treatment to improve patient survival.

Effects of radiation on the temporal bone in patients with head and neck cancer

Radiotherapy is a key component in the treatment of many head and neck cancers, and its potential to cause long-term adverse effects has become increasingly recognized. In this review, we describe the short-term and long-term sequelae of radiation-associated changes in and injury to the temporal bone and its related structures. The pathophysiology of radiation-induced injury and its clinical entities, including sensorineural hearing loss, chronic otitis media, osteoradionecrosis, and radiation-associated malignancies, are described. We also discuss radiation dose to the head and neck as it relates to these conditions. An improved understanding of radiation's effects on the temporal bone will enable physicians and researchers to continue efforts to reduce radiotherapy-related sequelae and guide clinicians in diagnosing and treating the various otologic conditions that can arise in patients with head and neck cancer who have received radiotherapy. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1428-1435, 2016.

Sarcoma-like tumor originating from oligodendroglioma

We present a case of sarcoma occurring at a site of resected oligodendroglioma without preceding radiotherapy or chemotherapy. Oligosarcoma occurring at sites of resected oligodendroglioma or anaplastic oligodendroglioma with sarcomatous components are rare. Although meningioma or sarcoma-like lesions are sometimes reported after glioma-targeted radiotherapy, those without preceding radiotherapy are quite rare. Moreover, cases of sarcoma without oligodendroglial components occurring at a site of resected oligodendroglioma have never been reported. In this case, fluorescent in situ hybridization analysis revealed 1p/19q co-deletion in both the first tumor and second tumors. Additionally, immunohistochemistry revealed mutated isocitrate dehydrogenase 1 in both tumors. Taken together, these findings suggest a monoclonal tumor origin. Consequently, this case may indicate a new mechanism of development of sarcomatous lesions occurring at the site of a resected glioma.

Computed tomography and magnetic resonance imaging findings of malignant fibrous histiocytoma of the head and neck

The aim of this study was to analyze the imaging findings of 15 cases of malignant fibrous histiocytoma (MFH) of the head and neck, in order to better understand the tumor characteristics based on computed tomography (CT) and magnetic resonance imaging (MRI). CT (n=11) and MRI (n=4) images from 15 patients with histologically diagnosed MFH of the head and neck were retrospectively analyzed. The imaging characteristics were analyzed and compared among different histological subtypes. The lesions were primarily located in the maxillary sinus in 5 patients, the ethmoid sinus in 1 patient, the infratemporal fossa in 2 patients, the neck in 4 patients, the left mandible in 1 patient, the gingiva in 1 patient and the epiglottis in 1 patient. A total of 4 cases were associated with radiotherapy. All the lesions were ill-defined, ranging in size from 2.1 to 5.1 cm in the largest diameter. Bone fractures were evident in 9 cases. The attenuation, signal and enhancement patterns varied, although inflammatory MFH exhibited prolonged enhancement in dual-phase enhanced CT scans. MFH of the head and neck is rare but may be associated with radiotherapy. Although the imaging manifestations of MFH are various and non-specific, inflammatory MFH exhibits prolonged enhancement on dual-phase enhanced CT scans.

Cancers of the nose, sinus, and skull base

Malignancies of the nose, sinus, and skull base are rare. The most common histologies are squamous cell carcinoma and adenocarcinoma. The most common primary sites are the nasal cavity and maxillary sinus. Management of these tumors is technically challenging because they often present in advanced stages with extensive disease invading important structures such as the orbit and the skull base. In the last few decades advances in surgical resection techniques, as well as improved strategies to deliver adjuvant radiation, have substantially improved the outcomes in patients with malignancies of the sinonasal tract and skull base.

Clinical Characteristics of Radiation-Induced Sarcoma of the Head and Neck: Review of 15 Cases and 323 Cases in the Literature

PURPOSE

This retrospective study aimed to identify the clinical characteristics of radiation-induced sarcoma of the head and neck (RISHN) that could help in the early diagnosis of this rare disease.

MATERIALS AND METHODS

From August 1995 through October 2014, 15 cases of RISHN presenting at the authors' department and 323 cases in the literature were reviewed.

RESULTS

The incidence of RISHN was higher in men than in women (male-to-female ratio, 2.4:1). The mean latency was long (9.3 yr), and the tumor often occurred in middle age (50.0 yr old). Osteosarcoma was the predominant pathologic diagnosis (34.1%). The prognosis of RISHN was poor.

CONCLUSION

RISHN is a serious long-term complication of radiotherapy and its incidence has been increasing in recent years. Owing to the long latency period, its early diagnosis is difficult to make. RISHN should be considered when a patient who has undergone radiotherapy presents with a mass, pain, or trismus in the irradiated field.

CT and MRI findings of radiation-induced external auditory canal carcinoma in patients with nasopharyngeal carcinoma after radiotherapy

OBJECTIVE

To summarize the radiological and clinical features of radiation-induced external auditory canal carcinomas (RIEACCs) in patients with nasopharyngeal carcinomas (NPCs) after radiation therapy.

METHODS

CT, MRI and clinical features in 16 patients with histologically proven RIEACCs were retrospectively reviewed. There were 2 females and 14 males, with a median age of 52.5 years at the time of diagnosis of RIEACC. Imaging parameters including lesion extent, size, margin, shape, bone destruction, adjacent structure invasion, density/signal intensity, and pattern and degree of enhancement were assessed. Clinical features including clinical staging, histological type, treatment and radiation dose (RD) of primary NPC as well as the histological type, staging of radiation-induced tumour and the latent period between NPC and RIT were recorded.

RESULTS

All patients had a single RIEACC. The lesions had a size of 3.5 ± 1.4 cm and were localized (n = 7) or extensive (n = 9). Most of the lesions were partially or ill defined with an irregular shape and had an intermediate density/signal pattern and moderate homogeneous enhancement. The latent period of RIEACCs ranged from 10 to 20 years in nine patients with a RD of 68-70 Gy; from 2 to 10 years in five patients with a RD of 68-74 Gy; and more than 20 years in two patients with a RD of 70 or 72 Gy.

CONCLUSION

An external auditory canal (EAC) mass with homogeneous, intermediate CT density or signal intensity in patients with NPC after radiotherapy is highly suggestive of RIEACC, which should be included in the routine surveillance for patients with NPC after radiotherapy.

ADVANCES IN KNOWLEDGE

RIEACCs could occur as short as 2 years after radiotherapy in patients with NPC and have distinct features from otitis media and sarcomas. This EAC malignancy should be included in routine surveillance for patients with NPC after radiotherapy.

Hyperthermia in the treatment of post-actinic osteosarcomas: our anecdotal experience

Irradiation-induced sarcomas are a late sequelae of irradiation therapy. Most sarcomas have been reported to occur after exposure to a radiation dose of 55 Gys and above, with a dose ranging from 16 Gys to 112 Gys. These tumours are very aggressive and an early detection is needed for a timely intervention. Surgery is only effective treatment for local control instead chemotherapy is a valuable tool for systemic control of disease. Irradiation therapy use is controversial because of its side effects on a site previously irradiated. Irradiation therapy combined with hyperthermia is a new treatment that overcomes these problems without limiting the effect of radiation therapy. It may become a tool for local control of the unresectable tumours or an adjuvant treatment of the surgery. In this report we present a rare case of irradiation-induced recurrent osteosarcoma involving the chest wall that was treated with surgical resection followed by radiation therapy combined with hyperthermia as an adjuvant treatment of the surgery.

Analysis of Clinical Prognostic Factors for Adult Patients with Head and Neck Sarcomas

Objective

To evaluate the treatment, outcome, and prognostic factors in patients with head and neck sarcomas treated in an academic medical center.

Study Design

Case series.

Setting

Academic medical center.

Subjects and Methods

We performed a retrospective analysis of adult patients (n = 97) with primary head and neck sarcomas treated between 2000 and 2012. We analyzed the treatment, outcome, and potential factors predictive of disease-free survival and disease-specific survival. We also evaluated the outcome and prognostic factors in patients with bone and soft tissue sarcomas.

Results

The median overall survival was 6.8 years, with 2-year and 5-year overall survival rates of 78% (95% confidence interval [CI], 66%-86%) and 59% (95% CI, 44%-72%), respectively. Univariable analysis revealed that age at diagnosis (>60 years: hazard ratio [HR], 2.7; 95% CI, 1.2-6.2; P = .01), surgical intervention (HR, 8.3; 95% CI, 3.5-19.5; P < .001), and metastatic disease (HR, 4.3; 95% CI, 1.3-13.6; P = .01) were significantly associated with disease-specific survival.

Conclusion

In this study, patients over the age of 60 years at diagnosis and those with inoperable disease at initial presentation had significantly worse disease-specific survival. Surgical intervention remains the optimal treatment modality for those with resectable disease and was associated with significantly better survival in this heterogeneous series. Further multi-institutional studies are required to better define prognostic factors in individual histological subtypes.

Head and neck sarcomas: analysis of the SEER database

OBJECTIVE

To summarize the epidemiology of sarcomas occurring in the head and neck and identify prognostic factors for patient survival.

STUDY DESIGN AND SETTING

Cross-sectional analysis of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program.

METHODS

The SEER 18 registries, comprising sarcoma diagnoses made from 1973 to 2010, were queried for sarcomas arising in the head and neck. Pediatric and adult patients were analyzed separately, and multivariate and propensity-matched analyses were performed to identify predictors of disease-specific survival.

RESULTS

In all, 11,481 adult cases and 1244 pediatric cases were identified. In adults, the most common histologic subtypes were malignant fibrous histiocytoma (MFH), Kaposi sarcoma, and hemangiosarcoma, while in the pediatric cohort, the most common histologic subtypes were rhabdomyosarcoma, MFH, and osteosarcoma. Cause-specific 2-, 5-, and 10-year survival rates were 76%, 66%, and 61% for adults and 84%, 73%, and 71% for pediatric patients. Multivariate analysis performed for adults revealed that male gender, absence of radiation therapy, and stage I disease were associated with improved cause-specific survival reaching statistical significance. However, a propensity-matched model demonstrated no significant difference in cause-specific survival between patients who received radiation and those who did not.

CONCLUSION

Sarcomas, a heterogeneous group of malignant mesenchymal tumors, are uncommonly found in the head and neck. This study represents the largest analysis of patients with head and neck sarcomas in the literature and demonstrates the impact of age, gender, primary site, histology, and radiation status on overall prognosis.

Treatment outcomes of postradiation second head and neck malignancies managed by a multidisciplinary approach

BACKGROUND

The purpose of this study was to report on the treatment outcomes of patients with postradiation second head and neck malignancies.

METHODS

Fifty-seven consecutive patients with postradiation second malignancy were reviewed. Progression-free survival (PFS), overall survival (OS), and prognostic factors were analyzed.

RESULTS

Mean time interval between first course of radiation therapy to the development of postradiation second malignancy was 13.2 years. Median PFS and OS for the whole group were 12.0 and 67.0 months, respectively. Postradiation sarcoma conferred a worse PFS (p = .003) and OS (p = .001) as compared to postradiation carcinoma. Multivariate analysis revealed that Eastern Cooperative Oncology Group (ECOG) performance status ≥3 (p = .034), postradiation sarcoma (p = .007), and lack of radical surgery (p = .044) are prognostic of PFS, whereas postradiation sarcoma (p = .002), lack of postprogression surgery (p < .001), and lack of postprogression systemic therapy (p = .011) were prognostic factors of OS.

CONCLUSION

Treatment outcomes of postradiation second malignancy seemed promising under a multidisciplinary management.

Multifocal, recurrent sinonasal leiomyosarcoma: case report and review of literature

Leiomyosarcoma is a rare tumor encountered in the sinus and skull base, and can be difficult to control. We present a case of an 83 year old female with a recurrent sinonasal leiomyosarcoma. The tumor exhibited variable growth rates of recurrences in non-contiguous sites despite having obtained clear surgical margins and use of adjuvant therapy. This case illustrates unusual characteristics of this rare tumor that are important for clinicians to know. Patient demographics, presenting symptoms, risk factors, treatment options, and prognosis are also reviewed.

Neurosurgical interventions for patients with nasopharyngeal carcinoma: a single institution experience

Background

Nasopharyngeal carcinoma (NPC) is a frequent head and neck cancer in southern China and Southeast Asia. The majority of NPC patients are managed by radiation oncologists, medical oncologists and head and neck surgeons. Actually, neurosurgical interventions are warranted under specific circumstances. In this article, we described our experience as neurosurgeons in the management of NPC patients.

Methods

Medical records of NPC patients who received neurosurgical procedure at Sun Yat-sen University Cancer Center were reviewed.

Results

Twenty-seven patients were identified. Among 27 cases, neurosurgical procedures were performed in 18 (66.7%) with radiation-induced temporal necrosis, 2 (7.4%) with radiation-induced sarcoma, 4 (14.8%) with synchronous NPC with primary brain tumors, 2 (7.4%) with recurrent NPC involving skull base, and 1 (3.7%) with metachronous skull eosinophilic granuloma, respectively. The diagnosis is challenging in specific cases and initial misdiagnoses were found in 6 (22.2%) patients.

Conclusions

For NPC patients with intracranial or skull lesions, the initial diagnosis can be occasionally difficult because of the presence or a history of NPC and related treatment. Unawareness of these entities can result in misdiagnosis and subsequent improper treatment. Neurosurgical interventions are necessary for the diagnosis and treatment for these patients.

Head and neck sarcomas: epidemiology, pathology, and management

Sarcomas of the head, neck, and skull base represent a heterogeneous group of tumors with distinct prognostic features. There have been significant improvements in characterizing these sarcomas using traditional morphologic assessments and more recent immunohistochemical analysis. Surgery is the mainstay of treatment followed by radiation therapy. Treatment modalities have changed in select pediatric sarcomas, for which new chemotherapeutic combinations have improved survival statistics. The high rate of distant failure emphasizes the need for novel systemic and directed molecular therapies. Tumor grade, size, and margin status are key factors in survival.

Outcomes and prognostic factors of post-irradiation and de novo sarcomas of the head and neck: a histologically matched case-control study

BACKGROUND

This study was designed to compare post-irradiation sarcomas (PIS) and de novo sarcomas (DN) of the head and neck in terms of tumor characteristics, prognostic factors, and survival outcomes.

METHODS

All (N=83) head and neck sarcoma patients treated at National Cancer Centre, Singapore (Feb 2002-May 2011) were included: DN (N=60; 72%); PIS (N=23; 28%). Clinicopathologic features and outcomes of all patients and histologically matched pairs were compared. Prognostic factors were identified using univariate and multivariate analyses.

RESULTS

Median age, gender, smoking status, and tumor size were not significantly different. Significant differences were seen in histology (most prevalent: PIS-sarcoma-NOS; DN-angiosarcoma) and tumor subsite (most prevalent: PIS-nasal cavity and sinuses; DN-skin). Median latency of PIS development was 16.7 years. PIS patients had shorter overall survival (OS) and disease-specific survival (DSS) compared with DN patients, most clearly seen on histologically matched pair analysis: 2-year OS (PIS: 54%; DN: 83%; P=0.028). Multivariate analyses showed that age>50 years (hazard ratio (HR)=3.68; P=0.007), ever-smokers (HR=2.79; P=0.017), and larger tumor-size (cm) (HR=1.12; P=0.045) were associated with worse OS, and age at >50 years (HR=2.77; P=0.04) and ever-smokers (HR=2.94; P=0.021) were associated with worse DSS. When treated with curative intent, no significant survival difference was noted between DN and PIS patients.

CONCLUSIONS

In our cohort, PIS constituted 28% of head and neck sarcomas. Poorer prognosis traditionally associated with PIS compared with DN was not seen amongst patients treated with curative intent.

Radiation-induced leiomyosarcoma of the posterior neck region

INTRODUCTION

Leiomyosarcomas are mesenchymal malignant tumours that appear in smooth muscle cells. Their most frequent locations are the uterus and gastrointestinal tract. Their occurrence in head and neck is considered exceptional. We present a patient with a posterior neck region leiomyosarcoma who had received radiation for a nasopharyngeal carcinoma 20 years earlier. The incidence ratio of these tumours in radiated patients (therefore considered radiation-induced) ranges from 0,035 to 0,2%. Radiation-induced sarcomas are difficult to diagnose due to the induration and fibrosis in the radiated area and the non-specific symptoms that they present. Their prognosis is very poor.

Radiation-associated head and neck sarcomas: spectrum of imaging findings

Sarcomas developing after radiation treatment for primary malignancies of the head and neck are often detected clinically when they are very aggressive. We reviewed the patient demographics and imaging findings in 21 patients with radiation-associated sarcomas (RAS) of the head and neck treated at our institution. Twenty-one RAS of the head and neck were retrospectively reviewed. The lesions were assessed for presence of a soft tissue mass, enhancement pattern, bone destruction, characteristics of tumor matrix, and FDG avidity. The RAS developed 4.5-25 years (mean 12.7 years) after irradiation. On both CT and MRI, all 21 lesions presented with a soft tissue mass. A variable imaging appearance was noted on CT, MR, and PET/CT, most, but not all, demonstrated aggressive features. At a median follow-up time of 19.1 months, 11 of the 21 patients had died from the sarcoma. RAS have variable imaging appearances. While most demonstrate aggressive features, some appear benign, which can lead to misdiagnosis. Head and neck radiologists, surgeons and oncologists who manage patients after radiation treatment should be aware of the wide range of clinical presentations and imaging features of RAS, because failure to diagnose can delay appropriate treatment.

High-grade supraclavicular soft tissue sarcoma as secondary malignancy after successful treatment of acute myeloid leukemia: case report and literature review

It is well known that the treatment protocols for hematopoetic neoplasms carry a high risk of long-term oncogenicity. However, few reports have been published of sarcomas as secondary malignancies. An unusual case report of a soft tissue sarcoma appearing as a secondary cancer is presented, with a review of the published data. The present report involves a soft tissue sarcoma of the neck that occurred 18 years after curative treatment of acute myeloid leukemia by induction chemotherapy and bone marrow transplantation. Consecutive graft-versus-host disease affected the cervical skin. Soft tissue sarcomas appearing as secondary tumors are rare in oncology. The presented case describes the appearance of a sarcoma 18 years after curative treatment of acute myeloid leukemia. This is only the second case of this type reported in published studies.

[Radiation-induced sarcoma of the head and neck]

INTRODUCTION

Radiation-induced sarcoma (RIS) of the head and neck is a late and rare complication of cancer treatment by radiation therapy. It occurs mostly within the limits of the irradiated area. Its incidence is increasing and related to an improved survival rate of treated patients. But it does not rule out the use of radiotherapy in the treatment of this cancer.

OBSERVATION

We report two cases of sarcoma having appeared in the irradiated area, in patients treated by adjuvant radiotherapy for head and neck neoplasm.

DISCUSSION

The prognosis for this sarcoma depends mainly on how early the diagnosis is made and the quality of surgical resection. Adjuvant chemotherapy or radiotherapy can be considered. Ongoing research on the expression of RIS genes could soon lead to new treatments.