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Teepen JC, Kremer LC, van der Heiden-van der Loo M, Tissing WJ, van der Pal HJ, van den Heuvel-Eibrink MM, Loonen JJ, Louwerens M, Versluys B, van Dulmen-den Broeder E, Visser O, Maduro JH, van Leeuwen FE, Ronckers CM. Clinical characteristics and survival patterns of subsequent sarcoma, breast cancer, and melanoma after childhood cancer in the DCOG-LATER cohort. Cancer Causes Control 2019; 30:909-922. [PMID: 31300947 DOI: 10.1007/s10552-019-01204-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/28/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Childhood cancer survivors are at increased risk of developing subsequent malignant neoplasms (SMNs). We compared survival and clinical characteristics of survivors with SMNs (sarcoma, breast cancer, or melanoma) and a population-based sample of similar first malignant neoplasm (FMN) patients. METHODS We assembled three case series of solid SMNs observed in a cohort of 5-year Dutch childhood cancer survivors diagnosed 1963-2001 and followed until 2014: sarcoma (n = 45), female breast cancer (n = 41), and melanoma (n = 17). Each SMN patient was sex-, age-, and calendar year-matched to 10 FMN patients in the population-based Netherlands Cancer Registry. We compared clinical and histopathological characteristics by Fisher's exact tests and survival by multivariable Cox regression and competing risk regression analyses. RESULTS Among sarcoma-SMN patients, overall survival [hazard ratio (HR) 1.88, 95% confidence interval (CI) 1.23-2.87] and sarcoma-specific mortality (HR 1.91, 95% CI 1.16-3.13) were significantly worse compared to sarcoma-FMN patients (foremost for soft-tissue sarcoma), with 15-year survival rates of 30.8% and 61.6%, respectively. Overall survival did not significantly differ for breast-SMN versus breast-FMN patients (HR 1.14, 95% CI 0.54-2.37), nor for melanoma-SMN versus melanoma-FMN patients (HR 0.71, 95% CI 0.10-5.00). No significant differences in tumor characteristics were observed between breast-SMN and breast-FMN patients. Breast-SMN patients were treated more often with mastectomy without radiotherapy/chemotherapy compared to breast-FMN patients (17.1% vs. 5.6%). CONCLUSIONS Survival of sarcoma-SMN patients is worse than sarcoma-FMN patients. Although survival and tumor characteristics appear similar for breast-SMN and breast-FMN patients, treatment differs; breast-SMN patients less often receive breast-conserving therapy. Larger studies are necessary to substantiate these exploratory findings.
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Affiliation(s)
- Jop C Teepen
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands. .,Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.
| | - Leontien C Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | | | - Wim J Tissing
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.,Department of Pediatric Oncology/Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Helena J van der Pal
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Marry M van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.,Department of Pediatric Oncology/Hematology, Sophia Children's Hospital/Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jacqueline J Loonen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marloes Louwerens
- Department of Internal Medicine/Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Birgitta Versluys
- Department of Pediatric Oncology and Hematology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Otto Visser
- Department of Registration, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - John H Maduro
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cecile M Ronckers
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
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Abdel Samie A, Sun R, Fayyazi A, Theilmann L. Leiomyosarcoma of the sigmoid colon: a rare cause of intestinal intussusception. J Gastrointest Cancer 2015; 45 Suppl 1:6-9. [PMID: 23812956 DOI: 10.1007/s12029-013-9520-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ahmed Abdel Samie
- Department of Gastroenterology, Pforzheim Hospital, Kanzlerstr. 2-6, 75175, Pforzheim, Germany,
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Olson MT, Wakely PE, Weber K, Siddiqui MT, Ali SZ. Postradiation sarcoma: morphological findings on fine-needle aspiration with clinical correlation. Cancer Cytopathol 2012; 120:351-7. [PMID: 22517661 DOI: 10.1002/cncy.21200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 03/02/2012] [Accepted: 03/09/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND The current study was conducted to describe the clinical features and presentation, cytomorphological characteristics with histological correlation, and prognosis of patients who undergo fine-needle aspiration (FNA) for postradiation sarcoma (PRS). METHODS A retrospective review was performed of 13 individual patients who were pooled from the FNA services of 3 academic institutions between 2001 and 2012. Cases were reviewed for the primary tumor, radiation history, latency period, and other distinguishing clinical features. The frequency of the various cytological preparations as well as the use of immunohistochemistry (IHC) on this material were reviewed. The cytopathology diagnosis was compared with the resection diagnosis, and the survival time was reviewed. RESULTS The median age of the patients was 61 years (range, 35 years-94 years) and no significant gender predilection was noted. The median latency period was 11 years (range, 5 years to > 50 years). Patients generally presented with large tumors (median, 8 cm [range, 3 cm-12 cm]), and the median survival was 14 months (range, 6 months-46 months). Nine of 13 patients died of their disease and 1 was lost to follow-up. The tumors were morphologically heterogeneous. IHC played an important role in excluding other diagnoses in those cases in which sufficient material was available. CONCLUSIONS PRS is a morphologically heterogeneous entity that can be diagnosed by FNA. It is a diagnosis of exclusion that requires a history of therapeutic radiation and often requires IHC to rule out locally recurrent malignancy.
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Affiliation(s)
- Matthew T Olson
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Vautravers C, Dewas S, Truc G, Penel N. Sarcomes en territoire irradié : actualités. Cancer Radiother 2010; 14:74-80. [DOI: 10.1016/j.canrad.2009.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 07/08/2009] [Accepted: 09/11/2009] [Indexed: 11/16/2022]
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Kuo JR, Chio CC, Wang CC, Chu YH, Lin KC, Chuang SS. Radiation-induced intra- and extra-cranial high-grade myxofibrosarcoma with tumor bleeding. J Clin Neurosci 2008; 15:1151-4. [DOI: 10.1016/j.jocn.2007.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Revised: 06/30/2007] [Accepted: 07/03/2007] [Indexed: 11/27/2022]
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Mavrodontidis A, Zalavras C, Skopelitou A, Karavasilis V, Briasoulis E. Leiomyosarcoma as a second metachronous malignant neoplasm following colon adenocarcinoma. A case report and review of the literature. Sarcoma 2008; 5:31-3. [PMID: 18521306 PMCID: PMC2395449 DOI: 10.1080/13577140120048926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Long-term cancer survivors are at increased risk for the development of second primary malignancies. This is usually associated with common genetic and etiologic factors and the treatment modality used for the primary cancer. In this paper we describe the case of a patient who developed a leiomyosarcoma in his left arm 5 years after he had a colon adenocarcinoma resected. Both primary tumours were treated successfully with surgical resection alone. The literature regarding second primary neoplasms, specifically focused on sarcomas, is briefly reviewed.
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Affiliation(s)
- A Mavrodontidis
- Department of Orthopaedic Surgery Ioannina University Hospital Ioannina Greece
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Affiliation(s)
- Andrew Horvai
- Division of Anatomic Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Kanamori M, Ohmori K, Nogami S, Maeda Y. Undifferentiated leiomyosarcoma showing various sarcomatous components with incidental B-cell lymphoma after tumor recurrence. J Orthop Sci 2003; 7:698-702. [PMID: 12486476 DOI: 10.1007/s007760200124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We report a rare case of undifferentiated leiomyosarcoma (LMS) with incidental B-cell lymphoma in a 70-year-old woman. T2-weighted magnetic resonance images revealed a high signal intensity mass measuring 9 x 8 cm in the gluteus muscle. The pathological diagnosis of repeated surgery was undifferentiated LMS that included various sarcomatous components, such as fibrosarcomatous, rhabdomyosarcomatous, and malignant fibrous histiocytoma-like elements. A specimen from a supraclavicular lymph node showed the characteristics of malignant B-cell lymphoma (follicle type). Adjuvant chemotherapy or radiation therapy was not performed because of the patient's advanced age. The patient died from liver metastasis and dysfunction 5 years 8 months after the initial therapy. This is a rare case of LMS with malignant lymphoma. Considerable debate remains whether the B-cell lymphoma developed incidentally.
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Affiliation(s)
- Masahiko Kanamori
- Department of Orthopaedic Surgery, Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama 930-0194, Japan
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9
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Cañizal-García JM, Bárcena-Orbe A, Mestre-Moreiro C, Rivero-Martín B, Rodriguez-Arias CA, Coca-Menchero S. [Radiation-induced intracerebral sarcoma]. Neurocirugia (Astur) 2001; 12:348-55. [PMID: 11706681 DOI: 10.1016/s1130-1473(01)70693-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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11
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Inoue YZ, Frassica FJ, Sim FH, Unni KK, Petersen IA, McLeod RA. Clinicopathologic features and treatment of postirradiation sarcoma of bone and soft tissue. J Surg Oncol 2000; 75:42-50. [PMID: 11025461 DOI: 10.1002/1096-9098(200009)75:1<42::aid-jso8>3.0.co;2-g] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES An analysis of the clinicopathologic features and treatment of patients with postirradiation sarcoma of bone and soft tissue was performed to guide modern evaluation and management. METHODS A retrospective analysis of 135 sarcomas in 130 patients was performed. RESULTS The mean age of the 130 patients was 48 years, and there was a female predominance because of irradiation for carcinomas of the breast and uterus. Indication for irradiation was a soft tissue lesion (such as lymphoma or breast cancer) in 58.5% of patients and a bone lesion (such as giant cell tumor or fibrous dysplasia) in 41.5%. The latent period (interval between irradiation and discovery of the sarcoma) ranged from 4-55 years (mean, 17 years). Of the lesions, 74% were stage IIB (high-grade extra-compartmental) and 24% were stage III (metastases). Ninety-four patients received their treatment at our institution. Of the 61 patients with resectable disease, 49 had amputations and 12 had limb salvage procedures. The 5-year cumulative survival rate was 68.2% for patients with peripheral (extremities, including proximal femur and hip) resectable lesions and 27.3% for patients with central (pelvis, head/neck, and ribs) resectable lesions. The local recurrence rate correlated with the surgical margin achieved: intralesional, 73%, marginal, 64%, and wide, 23%. CONCLUSIONS The prognosis for patients with peripheral resectable postirradiation sarcomas is good if a wide surgical margin can be achieved. This group of patients should be treated aggressively because they have a new cancer.
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Affiliation(s)
- Y Z Inoue
- Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Shoshan Y, Chernova O, Juen SS, Somerville RP, Israel Z, Barnett GH, Cowell JK. Radiation-induced meningioma: a distinct molecular genetic pattern? J Neuropathol Exp Neurol 2000; 59:614-20. [PMID: 10901233 DOI: 10.1093/jnen/59.7.614] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Radiation-induced meningiomas arise after low-dose irradiation treatment of certain medical conditions and are recognized as clinically separate from sporadic meningioma. These tumors are often aggressive or malignant, they are likely to be multiple, and they have a high recurrence rate following treatment compared with sporadic meningiomas. To understand the molecular mechanism by which radiation-induced meningioma (RIM) arise, we compared genetic changes in 7 RIM and 8 sporadic meningioma (SM) samples. The presence of mutations in the 17 exons of the neurofibromatosis type 2 (NF2) gene, which has been shown to be inactivated in sporadic meningiomas, was analyzed in RIM and SM using single-strand conformation polymorphism (SSCP) and DNA sequencing. In contrast to SM, which showed NF2 mutations in 50% of specimens, no mutations were found in RIM. In addition, Western blot analysis of schwannomin/merlin protein, the NF2 gene product, demonstrated protein levels comparable to normal brain in 4/4 RIM tumor samples analyzed. Loss of heterozygosity (LOH) of genomic regions, which were reported for SM, was also analyzed in all cases of RIM using 22 polymorphic DNA markers. Allele losses were found on chromosomes 1p (4/7), 9p (2/7), 19q (2/7), 22q (2/7), and 18q (1/7). From these observations we conclude that unlike sporadic meningiomas, NF2 gene inactivation and chromosome 22q deletions are far less frequent in RIM, and their role in meningioma development following low dose irradiation is less significant. Other chromosomal lesions, especially loss of 1p, possibly induced by irradiation, may be more important in the development of these tumors.
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Affiliation(s)
- Y Shoshan
- Center for Molecular Genetics, Department of Neurosurgery, The Cleveland Clinical Foundation, Ohio 44195, USA
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13
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Murray EM, Werner D, Greeff EA, Taylor DA. Postradiation sarcomas: 20 cases and a literature review. Int J Radiat Oncol Biol Phys 1999; 45:951-61. [PMID: 10571202 DOI: 10.1016/s0360-3016(99)00279-5] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- E M Murray
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, South Africa.
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Chauveinc L, Giraud P, Dahnier S, Mounier N, Cosset JM. [Radiotherapy-induced solid tumors: review of the literature and risk assessment]. Cancer Radiother 1998; 2:12-8. [PMID: 9749091 DOI: 10.1016/s1278-3218(98)89056-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although the first radiation-induced solid tumor was reported as early as 1902, the risk of second tumor has been underestimated by radiation oncologists who treated large numbers of patients with either benign or malignant diseases. Since then, numerous epidemiological studies yielded better knowledge of the risks of radiation-induced malignancies. For instance, radiation-induced tumors are the first cause of death 10 years after treatment for Hodgkin's disease. We present here a literature review of the risks of radiation-tumors in various organs, related to the irradiation dose, age, and associated diseases. The most sensitive organs are the thyroid, central nervous system, breast, bone, and lung, especially in smokers. Higher risks are observed with increasing doses, the shape of the dose-response curve depending on the tumor type, when the irradiation is performed in children or young adults and in patients with retinoblastomas. The risk of radiation-induced tumors should lead the radiation oncology committee to reconsider the dose and technique of irradiation and to reduce the use of ionizing radiation in benign diseases.
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Affiliation(s)
- L Chauveinc
- Département de radiothérapie, institut Curie, Paris, France
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Chauveinc L, Ricoul M, Sabatier L, Gaboriaud G, Srour A, Bertagna X, Dutrillaux B. Dosimetric and cytogenetic studies of multiple radiation-induced meningiomas for a single patient. Radiother Oncol 1997; 43:285-8. [PMID: 9215789 DOI: 10.1016/s0167-8140(97)01937-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
No criteria are currently available to determine the spontaneous or radiation-induced origin of a malignant tumor occurring in a previously irradiated area. This study presents the dosimetric and cytogenetic analysis of meningiomas diagnosed in irradiated brain areas from a single patient and a discussion of the karyotypes of spontaneous meningiomas and radiation-induced tumors published in the literature.
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Affiliation(s)
- L Chauveinc
- Radiotherapy A, Institut Curie, Paris, France
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Robinson E, Bar-Deroma R, Epelbaum R, Rennert G, Neugut AI. Clinical characteristics of non-Hodgkin's lymphoma as a second primary tumor: a population-based survey. Leuk Lymphoma 1996; 20:297-301. [PMID: 8624470 DOI: 10.3109/10428199609051621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Data from 29,845 patients with lymphomas, 981 of whom had lymphoma as a second primary tumor, registered in the Surveillance Epidemiology and End Results (SEER) program in the U.S.A. between 1973 and 1986 were analyzed. The characteristics of the 274 patients with lymphoma as a second tumor who had received chemotherapy and/or radiotherapy for their primary tumor (SEP PT) were compared with 675 patients with second primary lymphomas who had no prior treatment (SEP NT) and with patients with single lymphomas (SIP). Patients with SEP PT disease had a significantly higher percentage of intermediate and high-grade tumors (80%) compared to those with SEP NT or SIP tumors (73% and 72%, respectively). The survival of all patients with SIP tumors did not differ from those with SEP tumors, but the median survival of those with SEP PT disease was shorter than for SEP NT disease. This was most probably due to the high percentage of intermediate and high-grade lymphomas in the SEP PT group. This was statistically significant in the group treated by combined chemotherapy and radiotherapy but not in those treated by a single modality alone. These findings relating to a worse prognosis in patients with SEP PT lymphoma are in line with our previous observations of a poor survival in patients with other multiple primary tumors.
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Affiliation(s)
- E Robinson
- Northern Israel Oncology Center, Rambam Medical Center, Haifa, Israel
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Chang SM, Barker FG, Larson DA, Bollen AW, Prados MD. Sarcomas Subsequent to Cranial Irradiation. Neurosurgery 1995. [DOI: 10.1097/00006123-199504000-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
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.
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Affiliation(s)
- S M Chang
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, USA
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