Post radiation sarcoma (malignant fibrous histiocytoma) of the cervical spine following ependymoma (a case report)

Radiotherapy-induced tumors of the spine, peripheral nerve, and spinal cord: Case report and literature review

BACKGROUND

The development of a secondary malignancy in the field of radiation is a rare but well-recognized hazard of cancer treatment. The radiotherapy-induced (RT-I) tumors are even more aggressive and potentially lethal than the primary tumor. To goal of this article is to report a case of RT-I neural tumor located in the peripheral nerve and spinal cord and to perform a literature review of the subject.

CASE REPORTS

Thirty-year male with symptoms of hypoesthesia and dysesthesia of the L5 nerve root distribution and previous treatment of a testicular seminoma 20 years previously. The lumbar magnetic resonance imaging showed the growth of a nerve root tumor. Surgery was performed, and a fusiform tumor was resected with clear margins. The anatomopathological and immunohistochemical studies were compatible with a malignant peripheral nerve sheath tumor. A total of 30 cases were included in the review. The mean age of the patients at diagnosis of the induced tumor was 39.36 (±16.74) years. Most were male (63.3%). The main type of primary disease was neural tumors (30%). The most common type of histology was fibrosarcoma (20.0%). No difference was found in age, gender, and time of diagnosis between neural and nonneural tumors. The mean survival after the diagnosis of the secondary tumor was 10.7 months (±13.27), and neural tumors had a longer survival period (P = 0.031).

CONCLUSION

The current gold standard therapy is complete resection with clear margins, since most tumors do not respond to chemotherapy and RT. The neural type of RT-I tumor presented a longer survival period.

Prognosis by tumor location in adults with spinal ependymomas

OBJECT

Ependymomas are primary central nervous system tumors that occur more frequently in the spines of adults than they do there in children. Previous studies consist mainly of retrospective single-institutional experiences or case studies. In this study, a comprehensive literature review was performed on reported cases of spinal ependymoma treated with resection to determine whether tumor location along the spinal axis conveys important prognostic information.

METHODS

A PubMed search was performed to identify all papers that included data on patients with spinal ependymoma. Only cases involving adult patients who underwent ependymoma resection with a clearly reported tumor location were included for analysis. Tumor locations were separated into 6 groups: cervicomedullary, cervical, cervicothoracic, thoracic, thoracolumbar, and conus + cauda equina. Kaplan-Meier survival and Cox regression analyses were performed to determine the effect of tumor location on progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 447 patients who underwent resection of spinal ependymomas with clearly indicated location of tumor were identified. The most common locations of spinal ependymomas were the cervical (32.0%) and conus + cauda equina (26.8%) regions. The thoracolumbar and cervicomedullary regions had the fewest tumors (accounting for, respectively, 5.1% and 3.4% of the total number of cases). The conus + cauda equina and thoracolumbar regions had the highest percentage of WHO Grade I tumors, while tumors located above these regions consisted of mostly WHO Grade II tumors. Despite the tendency for benign grades in the lower spinal regions, PFS for patients with spinal ependymomas in the lower 3 regions (thoracic, thoracolumbar, conus + cauda equina) was significantly shorter (p < 0.001) than for those with tumors in the upper regions (cervicomedullary, cervical, cervicothoracic), but the difference in OS did not achieve statistical significance (p = 0.131).

CONCLUSIONS

Spinal ependymomas along different regions of spinal axis have different characteristics and clinical behaviors. Tumor grade, extent of resection, and PFS varied by tumor location (upper vs lower spinal regions), while OS did not. Recurrence rates were higher for the lower spinal cord tumors, despite a greater prevalence of lower WHO grade lesions, compared with upper spinal cord tumors, suggesting that tumor location along the spinal axis is an important prognostic factor.

Adjuvant radiotherapy delays recurrence following subtotal resection of spinal cord ependymomas

BACKGROUND

Ependymoma is the most common glial tumor of the adult spinal cord. Current consensus recommends surgical resection with gross total resection (GTR) whenever possible. We performed a comprehensive review of the literature to evaluate whether adjuvant radiotherapy after subtotal resection (STR) has any benefit.

METHODS

A PubMed search was performed to identify adult patients with spinal cord ependymoma who underwent surgical resection. Only patients who had clearly defined extent of resection with or without adjuvant radiotherapy were included for analysis. Kaplan-Meier and multivariate Cox regression survival analyses were performed to determine the effects of adjuvant radiotherapy on progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 348 patients underwent surgical resection of spinal cord ependymomas, where GTR was obtained in 77.0% (268/348) of patients. Among those who received STR, 58.8% (47/80) received adjuvant radiotherapy. PFS was significantly prolonged among those who received adjuvant radiotherapy after STR (log rank; P < .001). This prolonged PFS with adjuvant radiotherapy remained significant in multivariate Cox regression analysis (STR versus STR + RT group; hazard ratio (HR) = 2.26, P = .047). By contrast, improved OS was only associated with GTR (GTR versus STR + RT group; HR = 0.07, P = .001) and benign ependymomas (HR = 0.16, P = .001).

CONCLUSIONS

Surgery remains the mainstay treatment for spinal cord ependymomas, where GTR provides optimal outcomes with longest PFS and OS. Adjuvant radiotherapy prolongs PFS after STR significantly, and OS is improved by GTR and benign tumor grade only.

Sarcoma of the cervical spine after radiation treatment for thyroid cancer

STUDY DESIGN

Case report.

OBJECTIVE

We report a rare case of postradiation sarcoma of the cervical spine 30 years after treatment for thyroid cancer.

SUMMARY OF BACKGROUND DATA

The reported case is a 66-year-old man with a history of thyroid cancer treated with surgery and radiotherapy at the age of 36 years. He was disease-free for 30 years, but then developed left upper limb weakness and numbness. Magnetic resonance imaging showed a homogeneously enhanced mass lesion with cystic parts involving the C4 vertebral body and occupying the left side of the spinal canal with extension to the paraspinal space through the neural foramen.

METHODS

Using staged posterior and anterior approaches, gross total tumor excision, C4 corpectomy, and spinal fusion were achieved.

RESULTS

The histologic diagnosis revealed sarcoma that was immunoreactive to vimentin and focally to S100 and O13 antibodies. Radiation-induced sarcoma should be suspected in patients who have received radiation treatment previously and present with new neurologic symptoms and signs in the irradiated area. The patient's muscle power returned to 5/5, except for the left upper extremity, which reached 2/5; he was free from recurring symptoms during the follow-up period.

CONCLUSION

Because of advancements in diagnostic techniques and therapeutic methods, more patients survive primary cancer, and therefore an increase in the number of cases of postradiation sarcoma is expected. Postradiation sarcomas have extremely long latent periods, and one should therefore always keep in mind such a complication of previous radiation treatment.