Malignant glioma following radiotherapy for unrelated primary tumors

Remote Development of Symptomatic Intracranial Cavernous Malformation After Stereotactic Radiosurgery

Cavernous hemangiomas, or cavernomas, are vascular malformations that affect about 0.1-0.5% of the population and usually result from sporadic or familial mutations of genes involved with endothelial cell junctions. They are histologically described as dilated vascular clusters, and they may occur in various areas of the body. Cavernomas of the central nervous system can generate localizing symptoms, including focal neurological defects, headaches, seizures, and hemorrhage. Radiation-induced cavernomas (RICs) have been described in the literature since 1994 and have been more frequently described in children. Although there has been speculation about the pathophysiology of RICs, no consensus exists in the literature, and pathological evaluation of RICs remains sparsely reported. We present the case of a 63-year-old patient who underwent stereotactic radiosurgery for treatment of an intracranial arteriovenous malformation (AVM) and subsequently developed a symptomatic RIC seven years later that required microresection. Clinicians should exercise diligence when monitoring patients with a history of intracranial radiation because of growing evidence supporting cavernomas as potential late-stage sequelae.

Glioblastoma Occurring as Second Primary in a Treated Case of Diffuse Large B-Cell Lymphoma

Glioblastoma as second primary malignancy (SPM) has been reported after prostate cancer, meningiomas, Hodgkin's lymphoma. We report an extremely rare case of glioblastoma as SPM, occurring after remission of diffuse large B-cell lymphoma (DLBCL). Fifty-year-old male presented with loss of consciousness followed by right-sided weakness. He was treated with chemotherapy for DLBCL of the cervical lymph nodes, 5 years back. Present scans revealed well-defined intra-axial lesion in the left parietal lobe, suggestive of central nervous system (CNS) involvement by lymphoma. Left parieto-occipital craniotomy was performed and microscopic examination revealed the tumor to be Glioblastoma, WHO Grade IV. The tumor cells were positive for glial fibrillary acid protein and negative for leucocyte common antigen. He was treated by radiotherapy and temozolomide. Pathologic examination is a must for CNS lesions. Had it not been for the biopsy, the patient would have been treated as a recurrence of CNS lymphoma by chemotherapy and would have probably succumbed.

Radiation-induced glioblastoma of the conus medullaris from radiation treatment of cervical cancer

Radiation-induced spinal glioblastoma is an extremely rare disease with only four previously published reports in the literature. We report the fifth case, a 69-year-old woman who previously underwent treatment with brachytherapy for cervical cancer, and thereafter presented with neurologic deficits from a conus medullaris tumour. Biopsy and histopathology confirm glioblastoma, not otherwise specified. Treatment of spinal glioblastoma consists of surgery, either biopsy or excision and chemoradiation. However, results are still unsatisfactory and prognosis remains poor.

Hypothalamic Endocrine Tumors: An Update

The hypothalamus is the site of synthesis and secretion of a number of endocrine peptides that are involved in the regulation of hormonal activity of the pituitary and other endocrine targets. Tumors of the hypothalamus have been recognized to have both structural and functional effects including hormone hypersecretion. The classification of these tumors has advanced over the last few years, and biomarkers are now available to classify these tumors and provide accurate structure-function correlations. This review provides an overview of tumors in this region that is critical to metabolic homeostasis with a focus on advances in the diagnosis of gangliocytomas, neurocytomas, and pituicytomas that are unique to this region.

Extraneural Metastasis of Primary Glioma Occurring in a Setting of Occupational Ionizing Radiation Exposure

Malignant gliomas account for 60% of all primary brain tumors in adults. Glioblastoma Multiforme (GBM) is the most common primary glial tumor with a dismal prognosis and a median survival of approximately 14 months. Extra-neural metastases from primary brain tumors are unusual with an incidence rate of less than 2%. This has been attributed to factors such as short survival, lack of true lymphatics in the CNS, and physical barriers provided by the dura, extracellular matrix, and basement membrane. Although most GBMs occur sporadically, there is a known association with therapeutic radiation exposure and with work in nuclear disaster cleanup. To our knowledge, no case of GBM with metastasis occurring in a patient with occupational radiation exposure currently exists in the literature. In this article, we present a case of GBM with lung metastasis occurring in a 51-year-old Caucasian male, whose history is significant for occupational exposure to ionizing radiation, and review the literature on GBM risk factors and potential mechanisms of metastasis.

Post-Radiation Gliomas

Aims and background

Radiotherapy is important in the treatment of neoplasm of the central nervous system, but various side effects, particularly neoplastic, have been described. Recently, post-radiation gliomas have been reported.

Methods

The authors review 88 cases of cerebral glioma following radiotherapy in patients operated for neoplasms of the nervous system, including 6 personal cases of post-radiation gliomas treated in the Neurosurgical Division of the Department of Neurological Sciences, “La Sapienza” University, Rome. The criteria used to define this unusual pathologic association are discussed.

Results

There was a male predominance. Post-radiation gliomas were particularly malignant, the average dose was 33 Gy, and average free latency was 9.6 years. The first disease was most frequently acute lymphatic leukemia.

Conclusions

Post-radiation gliomas have particular features but do not present a histologic or clinical behavior different from analogous spontaneous gliomas. The fact that 88 cases have been reported in recent years suggests that a thorough biological, clinical studies be carried out on this association.

A 58-Year-Old Woman with Left-Sided Weakness and a History of a Pediatric Brain Tumor: A Case Report

Background

An uncommon but well-established complication of cranial irradiation is secondary neoplasm. This case presentation documents a radiation-induced malignant glioma 55 years after being diagnosed with “cerebral sarcoma,” now defined as atypical meningioma. This not only represents the longest reported latency period for a patient initially receiving over 30 Gy, but also provides a valuable historical perspective of neuro-oncology.

Clinical Presentation

A 58-year-old female presenting with progressive left-sided upper and lower extremity weakness with a past medical history significant for “cerebral sarcoma” was diagnosed with glioblastoma multiforme. This patient had previously been treated with resection and adjuvant radiation therapy via a 280-kVP orthovoltage machine and received 3,390 rad to the posterior three-quarters of the skull for “cerebral sarcoma.”

Conclusion

A comprehensive investigation of the past medical history helped uncover a mysterious pediatric diagnosis, helped drive the management 5 decades later, and serves as a reminder that seemingly safe interventions may still cause harm.

Secondary Intracranial Tumors Following Radiotherapy for Pituitary Adenomas: A Systematic Review

Pituitary adenomas are often treated with radiotherapy for the management of tumor progression or recurrence. Despite the improvement in cure rates, patients treated by radiotherapy are at risk of development of secondary malignancies. We conducted a comprehensive literature review of the secondary intracranial tumors that occurred following radiotherapy to pituitary adenomas to obtain clinicopathological characteristics. The analysis included 48 neuroepithelial tumors, 37 meningiomas, and 52 sarcomas which were published between 1959–2017, although data is missing regarding overall survival and type of irradiation in a significant proportion of the reports. The average onset age for the pituitary adenoma was 37.2 ± 14.4 years and the average latency period before the diagnosis of the secondary tumor was 15.2 ± 8.7 years. Radiotherapy was administered in pituitary adenomas at an average dose of 52.0 ± 19.5 Gy. The distribution of pituitary adenomas according to their function was prolactinoma in 10 (7.2%) cases, acromegaly in 37 (27.0%) cases, Cushing disease in 4 (2.9%) cases, PRL+GH in 1 (0.7%) case, non-functioning adenoma in 57 (41.6%) cases. Irradiation technique delivered was lateral opposing field in 23 (16.7%) cases, 3 or 4 field technique in 27 (19.6%) cases, rotation technique in 10 (7.2%) cases, radio surgery in 6 (4.3%) cases. Most of the glioma or sarcoma had been generated after lateral opposing field or 3/4 field technique. Fibrosarcomas were predominant before 1979 (p < 0.0001). The median overall survival time for all neuroepithelial tumors was 11 months (95% confidence intervals (CI), 3–14). Patients with gliomas treated with radiotherapy exhibited a non-significant positive trend with longer overall survival. The median overall survival time for sarcoma cases was 6 months (95% CI, 1.5–9). The median survival time in patients with radiation and/or chemotherapy for sarcomas exhibited a non-significant positive trend with longer overall survival. In patients treated with radiotherapy for pituitary adenomas, the risk of secondary tumor incidence warrants a longer follow up period. Moreover, radiation and/or chemotherapy should be considered in cases of secondary glioma or sarcoma following radiotherapy to the pituitary adenomas.

Malignant Astrocytoma of the Optic Nerve in a Child

Malignant gliomas of optic nerve and chiasm are rare, rapidly fatal neoplasms of adulthood. This report documents the occurrence of a malignant astrocytoma of the optic nerve in an 11-year-old boy who 9 years previously had a cerebellar medulloblastoma treated with surgery and irradiation. This malignant optic nerve glioma followed the same aggressive clinical course as that seen in adults, with death 9 months after diagnosis despite surgery and chemotherapy: Radiation may have been an important factor in the development of this malignant tumor which is almost never seen in the pediatric age group.

Short Interval Infield Sarcoma Development following Resection of Glioblastoma and Adjuvant Radiotherapy and Temozolomide

Background. The development of 2 unassociated brain cancers in the same patient is a rare occurrence. Secondary cancers are generally thought to develop as an oncogenic consequence of the radiation therapy delivered to treat the primary cancers, always requiring a significant time interval between radiation treatment and secondary cancer development. Case Description. We report the development of an undifferentiated myxoid sarcoma only 13 months following radiation therapy for a glioblastoma. Conclusion. This case represents the shortest time interval reported between radiation therapy and secondary brain cancer development.

Radiation-induced spinal cord glioblastoma with cerebrospinal fluid dissemination subsequent to treatment of lymphoblastic lymphoma

Background:

Radiation-induced glioma arising in the spinal cord is extremely rare. We report a case of radiation-induced spinal cord glioblastoma with cerebrospinal fluid (CSF) dissemination 10 years after radiotherapy for T-cell lymphoblastic lymphoma.

Case Description:

A 32-year-old male with a history of T-cell lymphoblastic lymphoma presented with progressive gait disturbance and sensory disturbance below the T4 dermatome 10 years after mediastinal irradiation. Gadolinium-enhanced magnetic resonance (MR) imaging revealed an intramedullary tumor extending from the C6 to the T6 level, corresponding to the previous radiation site, and periventricular enhanced lesions. In this case, the spinal lesion was not directly diagnosed because the patient refused any kind of spinal surgery to avoid worsening of neurological deficits. However, based on a biopsy of an intracranial disseminated lesion and repeated immmunocytochemical examination of CSF cytology, we diagnosed the spinal tumor as a radiation-induced glioblastoma. The patient was treated with radiotherapy plus concomitant and adjuvant temozolomide. Then, the spinal tumor was markedly reduced in size, and the dissemination disappeared.

Conclusion:

We describe our detailed diagnostic process and emphasize the diagnostic importance of immunocytochemical analysis of CSF cytology.

Intracranial malignancies occurring more than 20 years after radiation therapy for pituitary adenoma

A 37-year-old woman developed a left third cranial nerve palsy 28 years after radiation for a nonsecreting pituitary adenoma. Imaging disclosed a left parasellar mass and a midbrain/pontine signal abnormality. Biopsy of the parasellar mass revealed a malignant sarcoma. The brainstem abnormality was presumptively diagnosed as a malignant glioma. A 63-year-old man developed a malignant astrocytoma of the left optic nerve and chiasm 23 years after partial excision and radiation of a nonsecreting pituitary adenoma. Both patients died of their malignancies. Although secondary malignancies have been described in this setting, such long latencies have not been reported.

Malignant glioma arising at the site of an excised cerebellar hemangioblastoma after irradiation in a von Hippel-Lindau disease patient

We describe herein a malignant glioma arising at the site of the resected hemangioblastoma after irradiation in a patient with von Hippel-Lindau disease (VHL). The patient was a 25 year-old male with multiple hemangioblastomas at the cerebellum and spinal cord, multiple pancreatic cysts and a renal cell carcinoma; he was diagnosed as having VHL disease. The largest hemangioblastoma at the right cerebellar hemisphere was completely removed, and he received high-dose irradiation postoperatively. The tumor recurred at the same site 7 years later, which was a malignant glioma with no evidence of hemangioblastoma. The malignant glioma showed molecular genetic profiles of radiation-induced tumors because of its diffuse p53 immunostaining and the loss of p16 immunoreactivity. The genetic study to find the loss of heterozygosity (LOH) of VHL gene revealed that only the cerebellar hemangioblastoma showed allelic losses for the gene. To the best of our knowledge, this report is the first to show a malignant glioma that developed in a patient with VHL disease after radiation therapy at the site of an excised hemangioblastoma. This report also suggests that radiation therapy should be performed very carefully in VHL patients with hemangioblastomas.

Radiation-induced brain tumours after central nervous system irradiation in childhood: a review

OBJECTS

Radiation-induced cerebral tumours constitute a significant risk for subjects undergoing radiotherapy for the management of cerebral neoplasms. Age-related cerebral vulnerability could be a specific factor in the genesis of these complications.

METHODS

The pertinent literature of both paediatric and adult series has been reviewed. Three personal cases were added.

RESULTS

One hundred forty-two paediatric second brain tumours were evaluated. Out of them, 69 were malignant gliomas, 33 meningiomas, 8 sarcomatous lesions and 13 low-grade astrocytomas. The average latency period for the appearance of the second tumour was 8 years. Among the second tumours occurring in adults, meningioma is the most common. In this subgroup, the latency period ranged between 16 and 30 years.

CONCLUSION

Paediatric radiation-induced brain tumours differ from the adult counterpart for both the histological subtypes. These figures indicate a specific vulnerability of the infantile brain demonstrated by the most frequent occurrence of highly malignant lesions.

Radiation-induced malignant gliomas: is there a role for reirradiation?

PURPOSE

To review the literature regarding the role of radiotherapy (RT) in the treatment of patients with radiation-induced malignant gliomas (RIMGs).

METHODS AND MATERIALS

A PubMed search of English-language articles dealing with RIMG was performed, yielding 52 articles with 92 patients available for review.

RESULTS

Initial tumor types treated with RT included brain tumor in 37 patients (40%), acute lymphoblastic leukemia in 33 (36%), benign disease in 11 (12%), and other in 11 (12%). Median time from RT to development of an RIMG was 8.75 years (range, 2.5-61 years). The RIMG occurred within 10 years after RT in 81% of patients with acute lymphoblastic leukemia/lymphoma, 59% of patients with brain/other, and 18% of patients with benign conditions (p = 0.002). Type of RIMG was glioblastoma in 69 (75%) and anaplastic astrocytoma in 23 (25%). One-, 2-, and 5-year overall survival rates were 29.3%, 7.3%, and 0% for patients with glioblastoma and 59.7%, 30.3%, and 20.2% for patients with anaplastic astrocytoma. For the 85 patients with data regarding treatment for RIMG, 35 underwent reirradiation to a median dose of 50 Gy (range, 30-76 Gy). For patients undergoing reirradiation, 1-, 2- and 5-year overall survival rates were 58.9%, 20.5%, and 6.8%. For those not undergoing reirradiation, they were 15.1%, 3%, and 0% (p = 0.0009).

CONCLUSIONS

The RIMG appeared earlier in patients treated for leukemia and lymphoma and latest for those treated for a benign condition. Patients who underwent reirradiation for RIMG have longer survival times compared with those not receiving RT.

Spinal cord glioblastoma multiforme induced by radiation after treatment for Hodgkin disease

✓The authors report on a 26-year-old man with a very rare case of radiation-induced intramedullary spinal cord glioblastoma multiforme, which developed several years after radiotherapy for Hodgkin disease.

Preferential Recurrence of a Sarcomatous Component of a Gliosarcoma after Boron Neutron Capture Therapy: Case Report

Gliosarcoma, a rare pathological entity composed of 2-8% malignant gliomas, is characterized by a biphasic tissue pattern with alternating areas displaying glial and mesenchymal differentiation. Here we report the preferential recurrence of a sarcomatous component in gliosarcoma after boron neutron capture therapy (BNCT), while a gliomatous component disappeared as a result of the treatment. A 56-year-old woman with a left frontal tumor was introduced to our clinic. After stereotactic biopsy, craniotomy was applied and 90% of the mass was resected. The histological diagnosis was glioblastoma with small amounts of sarcomatous component, that is, gliosarcoma. BNCT was applied 30 days after craniotomy. Two weeks after BNCT, almost all of the contrast-enhanced mass had disappeared on magnetic resonance images; however, a half year later, the mass recurred just below the original site and extended posteriorly. Irrespective of repetitive salvage surgeries, the patient died of the recurrent tumor. At autopsy, tumor cells of the frontal lobe were absent. A well-circumscribed mass of the parietal and occipital lobes was composed of sarcomatous material, with very little glial fibrillary acid protein-positive glial material. We found in this patient the preferential recurrence of the sarcomatous component of a gliosarcoma after potent radiotherapeutics in the form of BNCT.

Radiation-induced Spinal Cord Glioma Subsequent to Treatment of Hodgkin’s Disease: Case Report and Review

Radiation-induced neoplasms of the central nervous system generally present as meningioma or sarcoma. Spinal cord glioma after radiation therapy is rare and half of the cases documented occurred after treatment of Hodgkin's disease.A 39-year-old male presented with a 1-month history of gradually worsening neck ache and paraparesis. The patient had been treated for stage IB Hodgkin's disease 9 years previously with combined therapy: MOPP-ABV and a 40-Gray mediastinal radiotherapy from T1 to T10. Magnetic resonance imaging disclosed an intramedullary lesion from C6 to T2 and histopathological examination from biopsy demonstrated a malignant glioma. Despite chemotherapy and additional radiotherapy, the patient's neurological status worsened and he died 11 months after initial presentation. We suggest a strategy aimed solely at obtaining a tissue diagnosis to differentiate myelitis from tumor, and, in the event of tumor, confirming the strong likelihood of a high histopathological grade. The very limited survival associated with these tumors regardless of therapy advocates palliative therapies without attempting complete resection.

Radiation-induced gliomas: report of 10 cases and review of the literature

BACKGROUND

Radiotherapy and more recently radiosurgery represent important therapeutic methods for the treatment of tumors and arterovenous malformations affecting the central nervous system, even though several significant side-effects have been described (radionecrosis, tumors, etc.). Gliomas induced by radiation therapy are decidedly unusual, and the first descriptions of this association only appeared in the 1960s.

METHODS

The pertinent literature was reviewed to yield 116 cases in which a glioma developed after radiotherapy for cranial pathologies (included 10 personal cases treated in our Institution). One of our patients had undergone radiosurgery for a cavernous angioma.

RESULTS

Patients who developed a radiation-induced glioma were younger, as a group, than those affected with so-called "spontaneous" gliomas. The tumor originated in the previously irradiated area, after average doses of 32 Gy and an average latency period of 9.6 years in accordance with the findings reported by the authors and in our experience as well. Radiotherapy had most frequently been performed for acute lymphoblastic leukemia. Our Case 10 is the fourth case of intracranial tumor arising after radiosurgery to be described in the literature.

CONCLUSIONS

Though rare, gliomas may represent a late complication of radiation treatment. The behavior of the radiation-induced variety of glioma does not seem to differ significantly from that of its "spontaneous" counterpart. Late complications of the radiosurgery are probably underestimated because of the relatively recent introduction of this technique. On the contrary, these should be scrupulously evaluated when deciding whether to employ this method for therapeutic purposes for relatively benign or congenital lesions (which generally affect young patients with a long life expectancy).

Brain neoplasms: epidemiology, diagnosis, and prospects for cost-effective imaging

Currently, the literature lacks a solid body of research on decision and cost-effectiveness analysis of imaging strategies for adults and children suspected of having a brain neoplasm. This article describes the epidemiology and clinical presentation of brain neoplasms, reviews current diagnostic strategies, highlights gaps in the literature on decision and cost-effectiveness analysis, and suggests directions for future research.

Gamma knife radiosurgery and its possible relationship to malignancy: a review

✓ The question has been raised recently whether gamma knife radiosurgery (GKS) can induce secondary neoplasia. Because there is little or no detailed knowledge about this potential complication, background information culled from the radiotherapy literature is reviewed as a guide to the clinical situations in which radiotherapy may induce secondary neoplastic change. Available case reports are then reviewed and discussed against the background of the current knowledge. On the basis of the review, the following suggestions are proposed on how to limiting the extent of this complication, document its frequency, and inform patients. It should be remembered that: the benefits of GKS are great; its alternatives also have risks; there often are no alternatives to GKS; follow-up documentation should be pursued more actively so that, if possible, no patient falls through the net; practitioners should be proactive in defining the problem, and genetic analysis of tumor biopsy specimens obtained in patients who will undergo or have undergone GKS should become routine; the extent of secondary neoplasia is not known; and patient information should be guided by what is known rather than by what is feared.

Radiosurgery-induced brain tumor. Case report

The authors describe a case of glioblastoma multiforme (GBM) associated with previous gamma knife radiosurgery for a cerebral arteriovenous malformation (AVM). A 14-year-old boy had undergone radiosurgery for an AVM, which was performed using a 201-source 60Co gamma knife system at another institution. The maximum and margin radiation doses used in the procedure were 40 and 20 Gy, respectively. One year after radiosurgery, the patient noticed onset of mild left hemiparesis due to radiation necrosis. Six and one-half years after radiosurgery, at the age of 20 years, the patient experienced an attack of generalized tonic-clonic seizure. Magnetic resonance (MR) imaging revealed the existence of a brain tumor in the right parietal lobe. The patient underwent an operation and the histological diagnosis of the lesion was GBM. Ten months following the operation, that is, 99 months postradiosurgery, this patient died. To the best of the authors' knowledge, this is the first reported case of a neoplasm induced by radiosurgery for an AVM and the second case in which it occurred following radiosurgery for intracranial disease.

[Radiation-induced intracerebral sarcoma]

We report a case of radiation-induced sarcoma in a 50 year-old male patient who was treated with total resection and radiation for right temporal lobe PNET. He received a dose of 60-Gy. A sequential magnetic resonance image 32 months after the completion of radiation therapy and 34 months after surgery showed a mass in the right temporal cerebral convexity. The postoperative diagnosis was sarcoma. Two years later the patient was operated because of a new lesion with similar characteristics. The follow up from the PNET diagnosis is 5 years and 10 months and the survival from sarcoma diagnosis is now 3 years and there is no evidence of recurrence. The development of sarcoma subsequent to cranial irradiation is an infrequent event but it should be considered in the differential diagnosis of a lesion that progresses several years after radiation therapy or when a new lesion appear.

Radical excision of intramedullary spinal cord tumors: surgical morbidity and long-term follow-up evaluation in 164 children and young adults

OBJECT

The majority of intramedullary spinal cord tumors (IMSCT) in children and young adults are low-grade gliomas. Radical resection of similar tumors in the cerebral hemisphere or cerebellum is usually curative; however, the conventional management for IMSCTs remains partial resection followed by radiotherapy because of the concern for surgical morbidity. Nevertheless, radical resection of IMSCTs without routine adjuvant treatment has been the rule at our institution since 1980. In an attempt to resolve this controversy, the long-term morbidity and survival in a large series of children have been retrospectively reviewed.

METHODS

The database records and current status of 164 patients 21 years of age and younger in whom an IMSCT was resected were reviewed. A gross-total resection (>95%) was achieved in 76.8% of the surgical procedures. Subtotal resections (80-95%) were performed in 20. 1%. The majority of patients (79.3%) had histologically low-grade lesions. There were no deaths due to surgery. When comparing the preoperative and 3-month postoperative functional grades, 60.4% stayed the same, 15.8% improved, and 23.8% deteriorated. Only 13 patients deteriorated by more than one functional grade. Patients with either no deficits or only mild deficits before surgery were rarely injured by the procedure, reinforcing the importance of early diagnosis and treatment. The major determinant of long-term patient survival was histological composition of the tumor. The 5-year progression-free survival rate was 78% for patients with low-grade gliomas and 30% for those with high-grade gliomas. Patients in whom an IMSCT was only partially resected (<80%) fared significantly worse.

CONCLUSIONS

The long-term survival and quality of life for patients with low-grade gliomas treated by radical resection alone is comparable or superior to minimal resection and radiotherapy. The optimum therapy for patients with high-grade gliomas is yet to be determined.

Primary brain tumor incidence in mice exposed to split-dose ionizing radiation and circularly polarized 60 Hz magnetic fields

Three sections of brain tissue from 2,657 female C57BL/6 mice were stained with hematoxylin and eosin and evaluated microscopically for proliferative lesions. Mice had been treated with either split-dose ionizing radiation (0, 3.0, 4.0 and 5.1 Gy), chronic lifetime 60 Hz circularly polarized magnetic field exposure (ambient or 14.2 G, 1.4 mT), or both, and were evaluated after natural death or euthanasia for humane reasons. Among 950 mice which were not treated with ionizing radiation, two benign spontaneous lipomatous hamartomas were observed. Seven primary brain tumors of various types not found in untreated animals were observed among the 1,707 irradiated mice. Possible promotional effects of magnetic field exposure on primary brain tumor development and incidence could not be assessed due to the low number of tumors observed.

Postradiation sarcomas: 20 cases and a literature review

PURPOSE

To analyze 20 cases of postradiation sarcoma (PRS) to determine dose levels at which this condition developed, the pathology of the initial and postradiation tumors, latency period, and outcome; and to review the literature and propose modified criteria for diagnosis.

METHODS AND MATERIALS

Patient records were reviewed. Previous radiation fields and isodose charts were reconstructed to determine the dose received in the tissue in which the PRS subsequently developed.

RESULTS

There were 16 female patients and 4 male patients. Mean age at the time of initial radiotherapy was 28 years. Mean latency was 14 years, with no difference in latency between the adult and pediatric group (t = 0.45, p = 0.37), but shorter latency in the retinoblastoma than in the nonretinoblastoma patients (t = 3.18, p = 0.003). The outcome was poor; 2 patients were alive and disease-free at 2 and 5 years. The 18 patients who died as a result of PRS had a median survival of 1 year.

CONCLUSION

PRSs are rare. Unnecessary radiation must be avoided. Cases should be reported with full details so that risk factors can be ascertained. PRSs usually arise in moderate to higher dose areas. Diagnostic criteria should allow soft tissue tumors and short latency.

Secondary supratentorial anaplastic astrocytoma following treatment of medulloblastoma

The development of secondary tumours is a rare but well known late effect of radiation therapy of lesions in the central nervous system. Most radiation-induced tumours are of mesenchymal origin, but on rare occasions gliomas can occur. We describe a patient in whom a supratentorial anaplastic astrocytoma developed 15 years after surgery and radiotherapy for a childhood posterior fossa medulloblastoma. A concise review of the pertinent literature is given.

Risk factors for glioma in adults: a case-control study in northeast China

A case-control study of risk factors for glioma in adults was carried out in Heilongjiang province in northeast China. Between September 1989 and May 1995, 218 histologically confirmed cases of glioma requiring surgery for tumor removal (139 astrocytoma glioma and 79 other glioma) and 436 controls with non-neoplastic and non-neurological disease were recruited and personally interviewed in the wards of six major hospitals. Controls were matched by sex, age, and area of residence. Occupational, lifestyle, and medical information was obtained through a standardized questionnaire. Use of liquor was associated with cancer risk. Compared with males who never drank liquor, males with total lifetime liquor consumption of less than 1000 liters had an adjusted odds ratio (OR) of 1.60 (95% CI: 0.89-2.88) and for more than 1000 liters, 2.73 (95% CI: 1.06-7.08). Statistically significant associations were also found for diseases related to the brain (OR: 5.75; 95% CI: 1.08-30.47) and trauma to the head requiring medical attention (OR: 4.09; 95% CI: 2.51-10.31). Increased consumption of vegetables and of fruit were each associated with decreased glioma risk. Compared with lowest quartile intake, adjusted risks associated with highest quartile intake were 0.51 (95% CI: 0.29-0.89) for total vegetables and 0.28 (95% CI: 0.16-0.51) for total fruit.

Glioma occurrence after sellar irradiation: case report and review

OBJECTIVE

Tumor neogenesis is an uncommon but known consequence after therapeutic irradiation of the central nervous system. Causative agents for glioma induction remain unknown, but laboratory and clinical data suggest a possible role for radiation as a promotor. In the treatment of both pituitary adenomas and craniopharyngiomas, adjunctive conventional radiation therapy has long played a role.

CLINICAL PRESENTATION

This report details two cases in which patients received standard sellar irradiation for growth hormone-secreting pituitary adenomas and later were diagnosed with gliomas, after a latency period of 11 and 18 years, respectively. Additionally, a comprehensive review of the literature with 30 reports of gliomas developing after conventional radiation for treatment of pituitary adenomas and craniopharyngiomas is presented. The mean dose for craniopharyngiomas (n = 8) was 5800 cGy, with a mean latency of 11.5 years from initial diagnosis to the eventual discovery of the gliomas. The mean dose for the treatment of pituitary adenomas (n = 24) was 5300 cGy, with a mean latency of 10.4 years.

CONCLUSION

Typical features of the resulting gliomas included presentation in young patients, histologically high grades, and occurrence within the temporal lobe. A large proportion of gliomas were associated with growth hormone-secreting adenomas. This review assesses the implication of doses of conventional radiotherapy that were previously thought to be benign and concludes that although radiation-associated gliomas are uncommon, they represent a potentially devastating long-term risk. Based on this analysis, treatment of sellar tumors with conventional fractionated radiotherapy should be carefully considered and perhaps used primarily in those cases for which radiosurgery is not appropriate.

Cerebral primitive neuro-ectodermal tumour following treatment of a unilateral retinoblastoma

Cerebral primitive neuro-ectodermal tumour (PNET) occurring as a second primary malignancy in childhood is exceedingly rare. We present a 7-year-old boy who developed a proven supratentorial PNET five years after enucleation and radio-/chemotherapy for a sporadic, unilateral retinoblastoma with optic nerve invasion. The association with this malignant eye disease as well as the effect of irradiation and multi-agent chemotherapy on second tumour induction are evaluated.

Classification and grading of low-grade astrocytic tumors in children

This article reviews current perspectives in the classification and grading of astrocytomas in children and calls attention to several histologically distinct groups of low-grade tumors that characteristically arise during childhood. Recognition of these tumors and the range of histological features that they may exhibit is essential for making rational assessments regarding their expected behavior and, more importantly, for guiding therapeutic intervention. For example, pleomorphic xanthoastrocytoma, which may exhibit "anaplastic" features, generally carries a relatively favorable prognosis and should not be classified with other high-grade gliomas, such as anaplastic astrocytoma and glioblastoma multiforme. Similarly, the finding of anaplastic features, such as vascular proliferation or necrosis, in pilocytic astrocytomas does not automatically portend the unfavorable prognosis that such features would imply for "diffuse" astrocytomas. Increased appreciation of the morphological diversity of astrocytomas in children should help to improve the management of children with low-grade astrocytic tumors by avoiding potentially dangerous overtreatment of otherwise indolent lesions.

Radiation-induced sarcoma of the skull: report of two cases

The authors describe two cases of sarcomas of the skull following cranial irradiation in patients treated for other neoplasms, acute lymphatic leukemia, and astrocytoma, respectively. The patients (one man and one woman: mean age 24.5 years) developed sarcomas within the irradiated field after a mean latency period of 11.5 years. Histologically, the tumor proved to be a fibrosarcoma. Despite aggressive surgery and other therapy, the survival of the patients was short (10 and 8 months, respectively). The pathological and clinical aspects of this unusual complication are analyzed with reference to 41 cases taken from the world literature.

Multiple neoplasms following craniospinal irradiation for medulloblastoma in a patient with nevoid basal cell carcinoma syndrome. Case report

A 28-year-old man presented to the authors' hospital with multiple intracranial tumors. At 2 years of age, he had undergone resection of a medulloblastoma and received adjunctive craniospinal irradiation. Subsequently, he was diagnosed with nevoid basal cell carcinoma syndrome, Gorlin's syndrome. Since his first presentation, he has required surgery for multiple basal cell carcinomas, an osteochondroma of the rib, two meningiomas, a trigeminal schwannoma, and a pleomorphic liposarcoma, all of which arose within the radiation field. Despite this impressive list of benign and malignant neoplasms, the patient is relatively well and leads a normal life. The authors examine the relationships between Gorlin's syndrome and radiation therapy and the subsequent development of tumors.

Glioblastoma multiforme arising in the irradiated spinal cord of a rhesus monkey (Macaca mulatta)

An adult female rhesus monkey that had received 44.0 Gy of cobalt 60 radiation to 8 cm of the cervical and upper thoracic spinal cord approximately 2.8 years postirradiation developed a sudden onset of self-mutilation and loss of function of the right arm followed progressively by loss of function of the left arm and terminally bilateral paresis of the legs. Histopathologic examination of the cervical spinal cord revealed a glioblastoma multiforme that extended from the cervical medullary junction to the sixth cervical vertebrae. Because of the infrequent occurrence of spontaneous neoplasia in rhesus monkeys and the location in the radiation field, the glioblastoma is believed to be radiation induced.

Magnetic resonance imaging and magnetic resonance angiography in long term survivors of acute lymphoblastic leukemia treated with cranial irradiation

BACKGROUND

Successful treatment of acute lymphoblastic leukemia (ALL) has resulted in an increasing number of patients whose disease is cured. This treatment includes cranial irradiation as prophylaxis against central nervous system relapse. The late effects of irradiation are well documented, but their incidence is unknown. The authors investigated the late effects of this treatment modality further by scanning 35 long term survivors of ALL who received cranial irradiation.

METHODS

Thirty-five survivors of ALL with no known complication of treatment were included in this study. They were examined with magnetic resonance imaging (MRI) of the brain and magnetic resonance angiography (MRA) of the circle of Willis. A control group of 24 patients who were cured of other childhood malignancies without exposure to cranial irradiation also were scanned.

RESULTS

Fifteen of 35 (43%) abnormalities were found in the study group versus 4/24 (17%) in the control group. Excluding minor atrophic changes that are known to be produced by irradiation and chemotherapy, there were 9/35 (26%) abnormalities in the study group and 1/24 (4%) in the control group (P < 0.05). These abnormalities included three tumors, a meningioma, a paranasal sinus rhabdomyosarcoma, and an anaplastic astrocytoma. In addition, there were two cases of large vessel vasculopathy, two small cystic infarcts, one diffuse white matter abnormality, and one cryptic vascular malformation. The abnormal control patient had a cerebellar infarct.

CONCLUSION

Complications of cranial irradiation in the treatment of ALL appear to be more frequent than currently are appreciated. That these complications include tumors that are potentially treatable suggests that screening may be valuable for these patients.

Radiation-induced gliosarcoma. Case report and review of the literature

A 13-year-old boy presented with a cerebral gliosarcoma 12 years after having acute lymphoblastic leukemia treated by chemotherapy and central nervous system prophylaxis treated by radiation therapy (24 Gy) and intrathecal methotrexate. A review of the literature disclosed 129 possible radiation-induced gliomatous and/or sarcomatous brain tumors: namely, 89 gliomas, 36 sarcomas, and four gliosarcomas, including the present case. An analysis of these cases revealed several characteristics that differentiate them from similar spontaneous brain tumors, thus providing arguments for the carcinogenic effect of radiation therapy on intracranial tumors.

Sarcomas subsequent to cranial irradiation

The development of sarcoma subsequent to cranial irradiation is a rare but serious and potentially fatal event. We describe seven patients who had undergone cranial irradiation (range, 1600-6000 cGy) to treat their primary disease and who developed sarcomas within the irradiated field. The median time from radiation therapy to the development of a sarcoma was 8 years (range, 4 to 15 yr). Fibrosarcomas developed in four patients, and malignant fibrous histiocytomas developed in three. Despite aggressive treatment, the prognosis was poor; the median survival from the diagnosis of sarcoma was 19 months. Sarcoma should be considered in the differential diagnosis of a new lesion or a lesion that progresses several years after radiation therapy.

Malignant transformation of benign gliomas during interstitial irradiation

Interstitial curietherapy with 125-Iodine is an effective therapeutic option in the treatment of low grade gliomas. Four cases with astrocytoma grade II are presented, where tumour growth characteristics have changed to anaplasia during interstitial irradiation after a primary period of tumour regression. Anaplastic transformation could be due to a radiation effect or an insufficient therapeutic influence of interstitial irradiation on natural tumour progression of glioma growth due to genetic events.

The significance of atypia and histologic malignancy in pilocytic astrocytoma of the cerebellum: a clinicopathologic and flow cytometric study

Biologically malignant pilocytic astrocytomas are rare. Precise morphologic criteria permitting their identification and clinically meaningful distinction from more ordinary pilocytic astrocytomas have not been developed. The histologic grading schemes applied to fibrillary astrocytomas--ones based on nuclear atypia, increased cellularity, mitotic activity, endothelial proliferation, and necrosis--are thought not to correlate with prognosis in pilocytic astrocytomas. Nonetheless, these features were systematically sought in 107 cerebellar pilocytic astrocytomas, four of which were histologically malignant. The clinical, morphologic, and flow cytometric features of these cases were studied. The incidence of histologic malignancy occurring spontaneously in otherwise typical pilocytic astrocytomas was 0.9%; that occurring after radiation was 1.8%. The four histologically malignant tumors occurred in two males and two females, ages 6 to 18 years. All showed increased mitotic activity (three to five mitoses per high-power microscopic field [250x]). Endothelial proliferation and necrosis were present in three and two cases each. DNA ploidy analysis showed the spontaneously occurring malignant-appearing tumors to be aneuploid, whereas both previously radiated tumors were tetraploid; 5% to 11% of cells were in S phase. The appearance of histologic malignancy in pilocytic astrocytoma is rare and less reliably correlated with prognosis than in patients with fibrillary astrocytomas. Essential features of such tumors include a high mitotic index and perhaps a high percentage of cells in S phase.

Glioma arising after radiation therapy for pituitary adenoma. A report of four patients and estimation of risk

BACKGROUND

Many case reports in the literature associate cranial radiation therapy with the development of brain tumors. Quantitation of the risk of second brain tumors after irradiation in childhood is available, but it is seldom reported for those treated by radiation therapy as adults.

METHODS

A retrospective review was made of 367 patient records registered at the Princess Margaret Hospital with a diagnosis of pituitary adenoma from 1972 to 1986. Three hundred five patients treated with megavoltage radiation therapy form the basis of this report. Second brain tumors were identified and the patient case histories described. The risk of second brain tumor after irradiation was estimated by calculating the observed/expected (O/E) ratio, age- and sex-adjusted to the Ontario population.

RESULTS

Of the 305 patients in this study, 4 had glioma of the brain. All gliomas arose within the previous radiation field(s), with a latency of 8-15 years after radiation therapy. Additional treatment was compromised by the location of the glioma and the moderately high doses of radiation received previously; all four patients died of their gliomas. Our cohort of patients had a relative risk of malignant brain tumor 16 times greater than that of the general population in Ontario (P < 0.001; 95% confidence interval, 4.4-41). The cumulative actuarial risk of secondary glioma after radiation therapy was 1.7% at 10 years and 2.7% at 15 years.

CONCLUSIONS

There was a clinically significant increased risk of malignant brain tumor developing after radiation therapy for pituitary adenoma. Because there is no reported association between pituitary adenomas and gliomas of brain, this excess risk is attributed to irradiation. Before advising radiation therapy for pituitary adenoma, the risk:benefit ratio, including the risk of secondary brain tumors, should be carefully considered.

Brainstem glioma after radiation therapy for acute myeloblastic leukemia in a child with Down syndrome. Possible pathogenetic mechanisms

A 13-year-old boy with Down syndrome (DS) had a brainstem glioma confirmed at autopsy, 10 years after receiving prophylactic cranial irradiation for acute myeloblastic leukemia. There is no clear association of brain tumors with DS; despite a reported link between leukemia and glioma, a causal association with radiation therapy is more likely.