Multiple primary cancers in patients treated for carcinoma of the cervix

Postirradiation sarcoma of the gynecologic tract. A report of 13 cases and a discussion of the risk of radiation-induced gynecologic malignancies

With improvement in survival after cancer treatment, it is becoming increasingly important to examine treatment-related morbidity and mortality. Sarcomas can develop within the irradiated field after radiation therapy (RT) for gynecologic malignancies. We undertook a study to assess the outcome after treatment of postirradiation sarcoma (PIS) of the gynecologic tract. In reviewing our data and the literature, we compare the absolute risk of PIS and other radiation-associated second malignant neoplasms (SMNs) with the mortality risk of surgery and general anesthesia. Between 1955 and 1987, 114 patients with uterine sarcomas were seen at the University of California, Los Angeles (UCLA), Medical Center. Thirteen had a prior history of RT. Conditions for which these patients received RT included choriocarcinoma (one), menorraghia (four), cervical cancer (six), and ovarian cancer (two). RT doses were known in six cases and ranged from 4,000 to 8,000 cGy. Latency time from RT to the development of PIS ranged from 3 to 30 years, with a median of 17 years. Twelve patients were treated with surgery or additional RT. Two patients remain alive 5 months and 57 months, respectively, following salvage therapy. Five-year disease-specific survival for all patients is 17%. From our data and a review of the literature, we estimate that the absolute risk of PIS with long-term follow-up ranges from 0.03 to 0.8%. Postirradiation sarcoma of the gynecologic tract is a relatively rate event associated with a poor prognosis. Mortality risks of radiation-associated SMN are similar to mortality risks of surgery and general anesthesia. Given the large number of patients with gynecologic malignancies who can be cured or palliated with RT, concern regarding radiation sarcomagenesis should not be a major factor influencing treatment decisions.

Uterine papillary serous carcinoma after radiation therapy for carcinoma of the cervix

This article describes the clinicopathologic features of six cases of uterine papillary serous carcinoma (UPSC), which developed several years after radiation therapy (RT) for cervical carcinoma. The possible etiologic role of radiation is discussed, and the literature on endometrial carcinomas developing after RT is reviewed.

Multiple primary gynecologic neoplasms

Some patients may be predisposed to the development of more than one gynecologic neoplasm. We evaluated 130 cases of synchronous or metachronous tumors among 5967 patients followed up by The Ohio State University Gynecologic Tumor Registry for the past 44 years from 1939 to 1983. Based on primary tumor site and invasive behavior, expected incidences for a specific second malignancy were calculated by the person-years method. A second malignancy of the lower genital tract occurred in patients with cervical, vulvar, and vaginal cancers, 1.6%, 4.3%, and 9.6%, respectively, which supports the theory of multicentric cancer of the lower genital tract. Prior radiation therapy was rarely associated with increased second gynecologic malignancies (two of 41 patients, 4.9%). Four patients had three gynecologic tumors.

Endometrial cancer following radiation therapy for cervical cancer

The clinical and histologic features of eight cases of carcinoma of the endometrium which developed following radiation therapy for squamous cell carcinoma of the cervix are described. No patient had a well-differentiated tumor and significant myometrial invasion was present in all cases. Three of the eight tumors were papillary serous adenocarcinoma. Five of the eight patients developed recurrent tumor and died of their disease. The risk of endometrial cancer in patients previously radiated for cervical cancer is evaluated.

Long-term observations of cervical cancer

A consecutive series of approximately 1100 patients, treated for cancer of the cervix over a span of 45 years, presents an increasingly favorable stage distribution. Emergence of exfoliative cytology as a diagnostic technique accelerates allocation of new patients to Stage I. Cumulative rates of dying from cervical cancer equate improved survival in terms of differences in prognosis and in effectiveness of treatment. Long-term observations bring into focus interval changes affecting the reservoir of individuals remaining at risk, which is maintained in accordance with rates of new patient inflow, as well as withdrawal for all categories of attrition. The several factors determining that balance, including age at diagnosis of cervical cancer, do not fall equally on all clinical stages. Age, a dominant factor determining incidence of second primary malignancies, may also have significance in unraveling the obscure etiology of corporeal malignancies evolving among patients irradiated in the treatment of cervical cancer.

An excess of uterine sarcomas after pelvic irradiation

The Ohio State University Registry recorded 1208 uterine corpus malignancies between 1940 and 1983. Thirty cases occurred in women with a history of pelvic irradiation. Eight patients had previously been irradiated for pelvic malignancy, four of whom presented with advanced stage sarcomas and died of their disease within 14 months. This represents an increase over the expected sarcoma prevalence which is less than 5%. In contrast, the majority of women (20 of 22) previously irradiated for benign conditions were diagnosed with endometrial adenocarcinoma. In 18, the adenocarcinoma was diagnosed as Stage I, and the prognosis was only slightly less favorable than for nonirradiated women. No significant effect of age at the time of irradiation was apparent. This study of women with a history of pelvic irradiation who later developed uterine cancer demonstrates a tendency for patients previously irradiated for pelvic malignancy to present with advanced stage, extremely aggressive uterine tumors compared to those previously irradiated for benign conditions.

Multiple primary cancers in Indian population: metachronous and synchronous lesions

A retrospective study of 177 patients attending Tata Memorial Hospital over a period of 40 years from 1942 through 1981 is presented. These patients who had "primary lesions" in the head and neck region, breast, esophagus, lung, and elsewhere as carcinoma or sarcoma developed "second primary" at different sites, after the treatment for the primary lesion after a variable period over years--as "metachronous lesions" (139 patients). Another group of patients presented with "double primary" at initial clinical examination and investigations, and these were "synchronous" lesions (38 patients). The analysis brings out the relationship of these lesions in both groups to each other with reference to habits in Indian population, viz, pan chewing, tobacco smoking, and alcohol consumption and time interval and histological variations among these lesions. An interesting relationship has been observed in certain aerodigestive tract primary lesions developing second cancer due to continued effect of "carcinogens," as habits are hard to die even after developing cancer. Analysis also brings out an interesting observation of involvement of "physiologically and anatomically" related organs developing second cancer at an interval or concurrently. A solitary pulmonary nodule or an opacity in a patient with extrathoracic cancer should not be considered as "metastatic" unless proved otherwise; metachronous lesions need to be treated energetically, adequately, efficiently, and aggressively in certain clinical situations for better results and salvage.

Multiple primary malignant tumors (MPMT): study of 68 autopsy cases (1963-1980)

Review of 8428 autopsies (1870 for known cancer) showed that 68 patients had had multiple primary malignant tumors (MPMT). Those 68 cases represented 0.8 per cent of all autopsies done, 3.6 per cent of all cancer autopsies. Diagnosis of MPMT was made only at autopsy in 24 cases (35.3 per cent). Thirty-six patients were male, 32 female. Their average age was 64 +/- 2.3 years. Cancers were "synchronous" (diagnosed within a six-month period) in 15 patients, "metachronous" (diagnosed at greater than six-month intervals) in 49, and "combined" in four. Metastatic foci were seen in 53 patients. Fifty-nine patients had two primary malignant tumors (PMTs); seven had three PMTs; one had four PMTs; and one had five PMTs, for a total of 148 tumors. Over half (53.1 per cent) of the second PMTs occurred within five years of the first PMTs. First PMTs were most common in the hematopoietic system and the cervix; second PMTs were most common in the lungs and the hematopoietic system. Second PMTs were less well differentiated than index PMTs. Forty-four deaths had not been directly tumor-related. Nineteen patients with metachronous MPMT lived more than ten years. Of 23 patients with one pulmonary PMT, 22 died within two years. Concomitant findings of pulmonary artery embolism, gallstone(s), thyroid or prostatic hyperplasia, and benign tumor were common in these patients. It is hoped that accumulation of data from this and other series of MPMT will provide insight into the clinicopathologic characteristics, the causes, and the interrelationships of these lesions that constitute primarily a disease of the elderly.

Early and late morphological changes (including carcinoma of the urothelium) induced by irradiation of the rat urinary bladder

Effects of X-irradiating the urinary bladder of female F344 rats with a single dose of 20 Gy were studied by light and electron microscopy. The animals were killed 1 week-20 months post-irradiation, and all tissues of the bladder wall were found to be affected by the irradiation. In the urothelium, damage was initially restricted to the basal cells but slowly extended to intermediate cells, and by 6 months post-irradiation the urothelium was focally hyperplastic. Twenty months post-irradiation, transitional-cell carcinomas were found in 10 of the surviving 17 animals (59%). The blood vessels in the bladder wall showed damage to both the endothelial cells and the smooth muscle. The fibroblasts in the connective tissue of the bladder wall appeared to show increased secretion after irradiation, and there was abundant collagen deposition, resulting in severe fibrosis of the bladder wall. After a latent period of a few months, focal degeneration and extensive necrosis of the smooth muscle cells were seen, leading to severe destruction and disorganization of the muscular coats of the bladder wall. Thus, a single dose of irradiation of 20 Gy was sufficient to produce severe fibrosis of the bladder wall with smooth muscle degeneration and to induce carcinoma of the urothelium in most of the treated animals within 20 months.

Subsequent malignancies associated with carcinoma of the uterine cervix: including an analysis of the effect of patient and treatment parameters on incidence and sites of metachronous malignancies

The incidence and sites of metachronous malignancies were retrospectively determined from the records of 763 patients seen at Yale University medical Center and affiliated hospitals with previously untreated, invasive carcinoma of the uterine cervix from 1953-1972. These patients were treated predominantly with radiation therapy; follow-up status was known for periods of 5-25 years or until time of death in over 96% of the patients. Forty-four patients had second malignancies noted at least 6 months after the initial cervical cancer was diagnosed. The expected incidence of second malignancies was determined from the Connecticut State Tumor Registry data controlling for year of diagnosis of the cervical cancer, patient age, sex, and time at risk (person-years exposure). To correct for any error in estimation of second malignancies introduced by the existence of a latency period for the development of a second cancer, the expected incidence of malignancies was also computed for 5-year time intervals following the cervical cancer. No significant increase in second malignancies was found (observed/expected-44/36) for the entire follow-up period nor for any individual 5-year interval. However, a statistically significant increase in lung cancer and vulva-vaginal cancer was noted and a significant decrease in breast cancer was observed. Cox regression analyses were performed to study the effect of total radium exposure and total external beam treatment, adjusting for other factors. No statistically significant increased risks were found.

The risk of second primaries subsequent to irradiation for cervix cancer

A review of 1048 patients with cancer of the cervix treated with radiation, either alone or combined with surgery, disclosed 32 cases of second primary malignancies occurring from 1 to 16 years subsequent to treatment. Using the person years approach, the incidence rate of second primaries was 5.49 per 1000 person years, which is not significantly different from population based rates. The anatomic locations of the new malignancies and the times from treatment of the cervix cancer to diagnosis of a new primary are presented; the possible carcinogenic effects of radiation are discussed. In this group of patients, it was concluded that under the period of observation irradiation administered at therapeutic doses did not increase the probability of second malignancy in the pelvis or at other sites.

The value of "routine tests" in the staging evaluation of gynecologic malignancies: a cost effectiveness analysis

The value of tests employed in the clinical staging of patients with carcinomas of the cervix and endometrium has been examined in a retrospective review of 739 consecutive patients seen at Tufts-New England Medical Center. The yield of positive results of the barium enema (0%) and proctosigmoidoscopy (0.8%) in carcinoma of the cervix suggests that some of these studies may be omitted in asymptomatic patients with early disease on pelvic examinations. Similarly, for carcinoma of the endometrium, the yields from barium enema (0.9%) cytoscopy (0.9%) and proctosigmoidoscopy (0.6) are low. It is concluded that optimal patient care (with respect to morbidity and costs) may be provided without routinely performing these studies in staging asymptomatic patients with cervical and endometrial carcinomas.

Exploratory thoracotomy on a patient with previous malignancy--"metastasis" or "new primary" or "unrelated lesion"

Surgical resection of a solitary pulmonary metastasis is an established procedure. A medical generation ago when such a shadow appeared on chest roentgenogram of a patient who had known cancer elsewhere in body, it was assumed to be "metastasis" from an extrathoracic site. With increasing advances in knowledge, the occurrence of second primary or new lesion is now no more curiosity in clinical practice. To one's surprise, the lesions that are assumed to be metastatic have often turned out to be "fresh" lesion or even unrelated benign, granulomatous, inflammatory, or parasitic lesion. This paper analyses 66 patients during a period of 20 years who underwent thoracotomy for such solitary pulmonary lesions, and emphasizes the role of diagnostic-cum-therapeutic-thoracotomy in such a clinical situation where in prethoracotomy tissue diagnosis is not forthcoming.

New primary malignant tumors in patients treated for carcinoma of the uterine cervix or corpus

Subsequent primary malignancy was revealed in 1.8 per cent of 2, 689 cases with cervical and in 1.7 per cent of 773 cases with corpus carcinoma. In the cervical carcinoma series the most frequent new primary sites were the skin, breast and recto-sigmoid. Of the cases with cervical and corpus carcinoma 18.8 and 30.7 per cent, respectively, had a family history of malignant disease.

Multiple primary cancers: review of clinical studies from two Missouri hospitals

A composite review of a series of hospital-based, clinical studies on the prevalence of simultaneous and nonsimultaneous multiple primary cancers, including those in which data were recorded by the life table method for six different series of cancer patients and one "control" series of patients who did not have cancer at first contact is provided. The studies came from Barnes Hospital and the Ellis Fischel State Cancer Hospital (EFSCH) and span the period from 1914 through 1964. The conclusions of the studies support the concept that the presence of one primary cancer neither increases nor decreases the chances for developing additional cancers with the possible exception of a few "target organ" areas. One study of this period showed a nonrandom distribution of patients with multiple primary cancers referred to EFSCH and this observation merits further epidemiologic research.

Radiation-induced bladder tumors

A recent 25-year experience with patients treated for carcinoma of the uterine cervix who subsequently had bladder tumors is presented. Of the 3,091 patients treated 2,674 had received radiotherapy and 8 suffered vesical malignancies of varied histopathological type 6 months to 20 years after irradiation. This incidence rate is 299.9 per 100,000, which is 57.6 times that of the general female population. Benign radiation reactions of the bladder and the possible etiology of radiation-induced bladder cancers are discussed.

Carcinoma of vagina 10 or more years following pelvic irradiation therapy

Gynecologic cancer records of 4,238 patients treated between 1956 and 1974 were reviewed. Sixteen patients developed noeplasia in the cervix or vagina 10 or more years following pelvic irradiation. Three patients had squamous carcinoma in situ; the other 13 patients had invasive squamous cancer involving the upper vagina. Only 1.26 per cent of invasive carcinoma of the cervix treated by radiation therapy from 1956 to 1966 presented with a late or recurrent or new primary tumor involving the vagina or cervix 10 or more years after primary treatment. The authors conclude that the risk of developing radiation-induced carcinoma in the upper vagina or cervix following pelvic irradiation is low. Follow-up Pap smears are indicated for all patients treated for cervical or vaginal malignancies by radiation therapy in order to detect vaginal neoplasia as well as recurrent carcinoma of the cervix.