Long-term risk of sarcoma following radiation treatment for breast cancer

Radiation-induced sarcomas of the craniofacial region: A systematic review

BACKGROUND

Radiation-induced sarcomas (RIS) are rare entities that have been studied infrequently in large cohorts, with most data derived from case reports or small series. This study aims to systematically evaluate existing data to synthesize and consolidate current knowledge.

METHODS

An electronic literature search was conducted using PubMed and the Cochrane Library. The search included studies and case reports with clinico-histopathological and survival data on craniofacial RIS.

RESULTS

Among 1237 studies identified, 143 studies with 701 patients were included. The average patient age was 48 years, with men nearly twice as likely to develop RIS. RIS had an average latency period of 12 years, with an average radiation dose of 63 Gy. Radiation-induced osteosarcomas (42.1 %) were most common, followed by fibrosarcomas (21.1 %). Nasopharyngeal carcinoma (53.0 %) and retinoblastoma (10.3 %) were the most prevalent primary tumors. 5.4 % of patients received radiotherapy for benign disease. The average latency period in this group was approximately 1.5 times longer than that observed in the group with malignancies; however, the average radiation dose was also approximately 15 Gy lower. Local recurrences occurred after an average of 16 months. The 1-, 2-, and 5-year survival rates were 67.8 %, 47.1 %, and 25.0 %, respectively. Surgical therapy showed the best survival rates (33.3 % after 5 years) while isolated chemotherapy yielded the lowest (0.0 %).

CONCLUSION

The prognosis for craniofacial RIS remains poor despite aggressive treatment. Surgical intervention is the primary therapeutic approach, but optimal treatment regimens and the role of (neo-)adjuvant therapies require further investigation. This study underscores the complexity of managing RIS and highlights the need for ongoing research to improve outcomes.

Radiation-Associated Secondary Cancer in Patients With Breast Cancer Harboring TP53 Germline Variants

This cohort study examines the risk of radiation-associated sarcoma in patients with breast cancer harboring germline TP53 variants.

Treatment and Outcomes of Radiation-Induced Soft Tissue Sarcomas of the Extremities and Trunk-A Systematic Review of the Literature

INTRODUCTION

Radiation-induced soft tissue sarcomas (RISs) are rare secondary malignancies with a dire prognosis. The literature on the management of these tumors remains scarce due to their low incidence. Our systematic review sought to assess the treatment alternatives and outcomes of patients with RIS.

METHODS

A systematic review was conducted following the PRISMA guidelines. Our study was registered in PROSPERO (ID: CRD42023438415). Quality assessment was performed using the STROBE checklist. Weighted means for both continuous and categorical values were calculated.

RESULTS

Twenty-one studies comprising 1371 patients with RIS were included. The mean latency period from radiation to RIS diagnosis was 14 years, and the mean radiation dose delivered to the primary malignancy was 29.2 Gy. The most common histological type was undifferentiated pleomorphic sarcoma (42.2%), and 64% of all tumors were high-grade. The trunk was the most common location (59%), followed by extremities (21%) and pelvis (11%). Surgery was performed in 68% of patients and, among those with an appendicular tumor, the majority (74%) underwent limb-salvage surgery. Negative margins were attained in 58% of patients. Chemotherapy and radiotherapy were administered in 29% and 15% of patients, respectively. The mean 5-year overall survival was 45%, and the local recurrence and metastasis rates were 39% and 27%, respectively.

CONCLUSIONS

In our study, the most common treatment was surgical resection, with RT and chemotherapy being administered in less than one third of patients. Patients with RIS exhibited poor oncologic outcomes. Future studies should compare RIS with de novo STS while controlling for confounders.

Characteristics and therapeutic strategies of brain and cranial radiation-induced sarcoma: analysis of 165 cases from our case experience and comprehensive review

BACKGROUND

Radiation-induced sarcoma (RIS) is among the neoplasms potentially caused by radiation therapy (RT) for brain tumors. However, the clinical characteristics of and ideal treatment for RIS are unclear. We analysed our case experience and conducted a comprehensive literature review to reveal the characteristics of brain and cranial RIS.

METHODS

We analysed 165 cases of RIS from the literature together with the RIS case treated at our institution. In each case, the latency period from irradiation to the development of each RIS and the median overall survival (OS) of the patients was analysed by Kaplan-Meier analysis. Spearman's correlation test was used to determine the relationship between the latency period and radiation dose or age at irradiation.

RESULTS

The mean age at the development of RIS was 39.63 ± 17.84 years. The mean latency period was 11.79 ± 8.09 years. No factors associated with early development of RIS were detected. The median OS was 11 months, with fibrosarcoma showing significantly shorter OS compared with osteosarcoma and other sarcomas (p = 0.0021), and intracranial RIS showing a worse prognosis than extracranial RIS (p < 0.0001). Patients treated with surgery (p < 0.0001) and postoperative chemotherapy (p = 0.0157) for RIS presented significantly longer OS, whereas RT for RIS was not associated with a survival benefit.

CONCLUSIONS

Although prognosis for RIS is universally poor, pathological characteristics and locations are associated with worse prognosis. Surgery and chemotherapy may be the ideal treatment strategies for RIS.

Radiation-Induced Sarcomas of the Breast: A Review of a 20-Year Single-Center Experience

Background Radiation-induced sarcomas (RISs) are histologically proven sarcomas within or around a previously irradiated site, per Cahan's criteria. RIS incidence is higher in breast cancer compared to other solid cancers and the prognosis remains poor given limited treatment options. This study aimed to review 20-year experience with RISs at a large tertiary care center. Methodology Using our institutional cancer registry database, we included patients meeting Cahan's criteria diagnosed between 2000 and 2020. Patient demographics, oncologic treatment, and oncologic outcomes data were collected. Descriptive statistics were used to describe demographic data. Oncologic outcomes were assessed using the Kaplan-Meier method. Results A total of 19 patients were identified. The median age at RIS diagnosis was 72 years (range = 39-82 months), and the median latency period for the development of RIS was 112 months (range = 53-300 months). All patients underwent surgery, three patients received systemic therapy, and six patients received re-irradiation as salvage treatment. The median follow-up time was 31 months (range = 6-172 months) from the diagnosis of RIS. Overall, five patients had local recurrence, and one patient developed distant metastases. The median time to progression was seven months (range = 4-14 months). The progression-free survival (95% confidence interval (CI)) at two years was 56.1% (37.4-84.4%). At follow-up two years after the diagnosis of sarcoma, the overall survival (95% CI) was 88.9% (75.5-100%). Conclusions While breast RIS remains rare, when managed in a large tertiary care center, overall survival outcomes appear favorable. A significant proportion of patients recur locally after maximal treatment and require salvage therapy to improve outcomes. These patients should be managed in high-volume centers where multidisciplinary expertise is available.

Radiation-induced fibrosarcoma after breast-conserving therapy for breast cancer: a case report and literature review

BACKGROUND

Radiation-induced sarcoma (RIS) has a 10-year incidence of 0.2-0.27% and a poor prognosis, although the radiation should need for breast-conserving surgery. In particular, radiation-induced fibrosarcoma has been rarer, and its incidence is 2.6-3.7% of RIS.

CASE PRESENTATION

A 43-year-old woman with pT1N1M0 breast cancer underwent breast-conserving surgery, chemotherapy, radiation therapy 8 years ago, and continued hormonal therapy. She complained of a hard unprotruded mass palpated in her right upper outer quadrant of breast. Although we suspected local recurrence, core needle biopsy revealed atypical spindled tumor cells without mammary or epithelial markers. A diagnosis of fibrosarcoma was made via tumorectomy. She underwent additional enlarged surgery.

CONCLUSIONS

We report a rare case of fibrosarcoma in breast after breast-conserving surgery and radiation therapy. Fibrosarcoma after radiation therapy for breast cancer has been reported in 30 cases, including the present case. The dead and alive cases were not significantly different in terms of age, primary breast cancer, radiation dose, and following months. Patients with breast masses after radiation therapy should be suspected local recurrence and RIS.

Histology-Specific Prognostication for Radiation-Associated Soft Tissue Sarcoma

PURPOSE

Radiation-associated sarcomas (RAS) are rare but aggressive malignancies. We sought to characterize the histology-specific presentation and behavior of soft tissue RAS to improve individualized prognostication.

METHODS

A single-institutional prospectively maintained database was queried for all patients with primary, nonmetastatic RAS treated with surgical resection from 1982 to 2019. Patients presenting with the five most common RAS histologies were propensity-matched to those with sporadic tumors of the same histology. Incidence of disease-specific death (DSD) was modeled using cumulative incidence analyses.

RESULTS

Among 259 patients with RAS, the five most common histologies were malignant peripheral nerve sheath tumor (MPNST; n = 19), myxofibrosarcoma (n = 20), leiomyosarcoma (n = 24), undifferentiated pleomorphic sarcoma (UPS; n = 55), and angiosarcoma (AS; n = 62). DSD varied significantly by histology (P = .002), with RAS MPNST and UPS having the highest DSD. In unadjusted analysis, RAS MPNST was associated with increased DSD compared with sporadic MPNST (75% v 38% 5-year DSD, P = .002), as was RAS UPS compared with sporadic UPS (49% v 28% 5-year DSD, P = .004). Unadjusted DSD was similar among patients with RAS AS, leiomyosarcoma, or myxofibrosarcoma and sporadic sarcoma of the same histology. After matching RAS to sporadic patients within each histology, DSD only differed between RAS and sporadic MPNST (83% v 46% 5-year DSD, P = .013). Patients with RAS AS presented in such a distinct manner to those with sporadic AS that a successful match was not possible.

CONCLUSION

The aggressive presentation of RAS is histology-specific, and DSD is driven by RAS MPNST and UPS histologies. Despite the aggressive presentation, standard prognostic factors can be used to estimate risk of DSD among most RAS. In MPNST, radiation association should be considered to independently associate with markedly higher risk of DSD.

Radiation-induced sarcomas: A single referral cancer center experience and literature review

Background and objective

The oncogenic effect of ionizing radiation is widely known. Sarcomas developing after radiation therapy (RT), termed "iatrogenic disease of success", represent a growing problem, since the advancements in cancer management and screening programs have increased the number of long-term cancer survivors. Although many patients have been treated with radiation therapy, only few data are available on radiation-induced sarcomas (RIS).

Methods

We examined the medical and radiological records of 186 patients with histologically proven soft tissue and bone sarcomas, which referred to IRCCS CROB Centro di Riferimento Oncologico della Basilicata from January 2009 to May 2022. Among them, seven patients received a histological diagnosis of secondary RIS, according to Cahan's criteria. Clinicopathological features and treatment follow-up data of RIS patients were retrospectively analyzed.

Results

Among these secondary RIS, five arose in irradiated breast cancer (5/2,570, 0.19%) and two in irradiated head and neck cancer (2/1,986, 0.10%) patients, with a mean onset latency time of 7.3 years. The histology of RIS was one desmoid tumor, two angiosarcomas, one chondrosarcoma, two leiomyosarcomas, and one undifferentiated pleomorphic sarcoma. Out of the seven RIS, one received radiotherapy, one received electrochemotherapy (ECT), one received a second-line chemotherapy, three were subjected to three lines of chemotherapy, and one underwent radiofrequency ablation, chemotherapy, and ECT. Median survival time is 36 months. No significant survival differences were found stratifying patients for age at RT, latency time, and age at RIS diagnosis.

Conclusions

RIS represents a possible complication for long-survivor cancer patients. Therefore, adherence to a strict follow-up after the radiation treatment is recommended to allow early diagnosis and optimal management of RIS patients. After the planned follow-up period, considering the long-term risk to develop a RIS, a specific multispecialty survivorship care plan could be of benefit for patients.

Chemotherapy and targeted treatments of breast sarcoma by histologic subtype

Introduction: Breast sarcomas (BS) are uncommon and often present both diagnostic and therapeutic challenges. Historically, radical surgery has been the mainstay of treatment for localized breast sarcomas. On the other hand, in advanced disease, since they are a heterogeneous group of neoplasms consisting of several different subtypes including angiosarcoma, phyllodes tumor, and pleomorphic undifferentiated sarcoma, there is a lack of proven specific therapy. As a result, their treatment is based on the soft tissue sarcoma (STS) paradigm, whereas histotype-tailored approaches apply to specific subtypes like dermatofibrosarcoma protuberans. To date, advanced stages constitute an incurable form of disease and chemotherapy remains the cornerstone of treatment with the aim of palliation of symptoms and increase in survival.Areas covered: In this manuscript, we review the clinicopathologic characteristics of the most common subtypes of BS, as well as the current treatment landscape of BS, with a particular focus on opportunities and challenges provided by new targeted molecules and immunotherapy.Expert opinion: The treatment approach of advanced BS is based on the pathologic subtype. A true breakthrough has still to be obtained, as the development of new agents in BS suffers from the same weaknesses as in other STS.

Incidence of radiation induced sarcoma attributable to radiotherapy in adults: A retrospective cohort study in the SEER cancer registries across 17 primary tumor sites

BACKGROUND

Previous studies have noted the incidence of radiation-induced sarcomas (RIS) but have not investigated the relative risk (RR) of developing RIS based on primary tumor organ disease site. By examining data from the Surveillance, Epidemiology, and End Results (SEER) database, we hypothesized that breast cancer would have a higher incidence of RIS compared to seventeen other primary cancer sites.

METHODS

This was a retrospective cohort study that examined patients from SEER registries between 1973 and 2013. We included patients aged 18 years or older who were diagnosed with cancer and those diagnosed with a cancer who subsequently developed a sarcoma. We excluded patients with missing information on initial radiotherapy treatment or stage. RIS was defined as those who developed a secondary sarcoma near the site of their original malignancy and after a 24-month latency period.

RESULTS

Our patients had a mean age of 60 years and follow up time of 9.2 years. Breast cancer comprised the majority with 693,701(36.8%) patients of which 161 (0.02%) had a secondary sarcoma. Of the 359 patients with secondary sarcomas, 242 (67.4%) had RIS. Breast cancer had the highest number of RIS patients at 126 compared to all combined non-breast cancer sites at 116. The RR of RIS in breast cancer versus 19 other primary cancer sites was 1.21 (CI: 1.01-1.45, p < 0.03, adjusted for age at primary diagnosis, gender, and latency).

CONCLUSIONS

Our study demonstrated that breast cancer has a higher risk of developing RIS compared to other solid cancers.

Tumors associated with radiotherapy: a case series

BACKGROUND

Breast cancer is the cancer with the highest incidence and mortality worldwide. Its treatment is multidisciplinary with surgery, systemic therapy, and radiotherapy. In Colombia, according to Globocan 2018, there is an age-standardized incidence rate of 44 per 100,000 women. Radiotherapy improves local and regional control in patients with breast cancer, and it could even improve relapse-free survival and overall survival in patients with nodal disease. The toxicity of this treatment in most cases is mild and transient, but in a low percentage of patients, radiotherapy-induced tumors may develop.

CASE PRESENTATION

Seven Colombian patients treated for breast cancer at our institution developed radiotherapy-induced tumors between 2008 and 2018. The median age was 54.4 (range 35-72) years. Six patients had locally advanced tumors at the time breast cancer was diagnosed, and all of them received neoadjuvant or adjuvant chemotherapy and radiotherapy. The radiotherapy-induced tumors were five sarcomas, one of which was a well-differentiated angiosarcomatous vascular lesion with negative c-Myc (benign lesion), and the remaining patient had basal cell carcinoma associated with radiotherapy.

CONCLUSIONS

Sarcomas are the most common radiotherapy-induced tumors after breast cancer treatment. These are rare, aggressive tumors and represent between 0.5% and 5.5% of all sarcomas. Basal cell carcinoma has also been associated with breast cancer treatment. The management is individualized and multimodal, including surgical resection and chemotherapy. Different studies have shown that radiation therapy is a risk factor for the development of soft tissue tumors.

Postoperative radiotherapy-induced leiomyosarcoma in breast cancer: a case report and literature review

Radiation-induced sarcoma (RIS) is a late complication of breast cancer radiotherapy, with a very low incidence, long latent period and poor prognosis. Among them, leiomyosarcoma after radiation is an extremely rare radiation-associated sarcoma. In this study, we report a case of radiation-induced leiomyosarcoma 2 years after postoperative radiotherapy for breast cancer. After the diagnosis of leiomyosarcoma, the patient received radical resection of the left chest wall leiomyosarcoma. The patient showed no relapse or progression during the follow-up time of 1 year after operation. Rare occurrence of RIS induced by postoperative radiotherapy in breast cancer and limited experience concerning its diagnosis and treatment bring obstacle to both patients and doctors. Preoperative examinations must be carefully refined. With a perfect coordination between different disciplines, RIS induced by postoperative radiotherapy in breast cancer can be ideally treated with better prognosis.

Radiation-induced undifferentiated pleomorphic sarcoma of the breast

Breast sarcoma is a rare form of malignancy that arises from connective tissue within the breast, comprising less than 5% of all sarcomas. They develop as primary tumours or as secondary following radiation therapy. Diagnosis can be challenging as breast sarcomas are often asymptomatic and resemble benign breast tissue changes. Radiation-induced breast sarcomas present in various forms with an average latency period of 10-20 years following initial radiation therapy. Angiosarcomas are the most common form, while other types such as undifferentiated pleomorphic sarcomas remain rare. Here, we report a case of radiation-induced undifferentiated pleomorphic breast sarcoma in a 75-year-old woman that developed nearly 20 years following breast conserving surgery and radiation for invasive ductal carcinoma. The patient initially noticed a mass in 2017 on self-examination. The mammogram, ultrasound and biopsy at the time showed a benign 2.2 cm nodular fasciitis without malignancy. The mass grew rapidly in the next 6 months to 5.6 cm and repeat biopsy diagnosed undifferentiated pleomorphic sarcoma. The mass abutted the pectoralis muscle but staging workup ruled out distant metastasis and the patient underwent wide local resection of the mass with clear margins. The patient subsequently underwent further postoperative radiation due to insufficient posterior margin width on wide local excision, as chest wall resection would have been required for a wider posterior margin. Prognosis for postradiation sarcomas is generally poor with 27%-36% 5-year survival, with surgical resection as the main line of treatment. The patient currently remains disease-free after 15 months of surveillance.

Risk of Second Primary Bone and Soft-Tissue Sarcomas Among Young Adulthood Cancer Survivors

Excess sarcoma risks after childhood cancer are well established, but risks among young adulthood cancer survivors are poorly understood. Using US population-based cancer registry data, we compared bone and soft-tissue sarcoma risk vs the general population among 186 351 individuals who were diagnosed with nonsarcoma first primary malignancies at ages 20-39 years from 1975 to 2014 (follow-up through 2015) and survived at least 1 year. Bone sarcomas were rare (n = 50), but risk was statistically significantly elevated overall (2.9-fold) and greater than fivefold after Hodgkin lymphoma, non-Hodgkin lymphoma, and central nervous system tumors. Soft-tissue sarcomas were more common (n = 284) and risks were statistically significantly elevated approximately twofold overall and after melanoma and carcinomas of the breast, thyroid, and testis, and greater than fourfold after Hodgkin lymphoma and central nervous system tumors. Risks varied markedly by subtype, with the highest risks (greater than fourfold) for osteosarcoma and the soft-tissue subtypes of rhabdomyosarcoma and blood vessel and nerve sheath sarcomas. These data demonstrate elevated risk for sarcoma after a range of young adulthood cancers.

Predictive factors for persistent and late radiation complications in breast cancer survivors

PURPOSE

With improved diagnostic techniques and treatments of breast cancer, overall survival times are longer, giving more opportunity for normal tissue complications of treatment to manifest. Radiation late effects (RLEs) could have profound long-term impacts on the quality of life of the survivors. The aim of this study was to identify predictive factors influencing timing and types of complications in patients referred to the Adult Radiation Late Effects Clinic (ARLEC).

METHODS

In a period of 16 years, 296 breast cancer patients were referred to the ARLEC. The clinical records were retrospectively studied to collect epidemiologic, medical and treatment data. Associations were sought between candidate predictive factors and time to the first complication after radiation treatment (RT) completion (primary outcome), and pain or swelling (secondary outcomes) using univariable and multivariable linear and logistic regression analyses. All analyses were performed in SAS, version 9.4.

RESULTS

All patients were female with a mean age of 56.3 years. The first treatment-related complication occurred after a median of 3 months. Patients were followed at ARLEC for a median of 18 months. Older age and delay from surgery to RT (S-RT delay) were associated with earlier onset of complications (both p < 0.001). The most common complications were breast pain (62.1%) and swelling (45.9%). Histology and RT boost were associated with pain (p = 0.035 and 0.013). RT boost and S-RT delay on the other hand were associated with swelling (p = 0.013 and 0.005).

CONCLUSIONS

Clinical factors identified could help recognize the patients at high risk for developing RLEs and alert physicians to initiate earlier diagnostic and therapeutic measures.

RILA blood biomarker as a predictor of radiation-induced sarcoma in a matched cohort study

Purpose

Radiation-induced sarcoma (RIS) is a rare but serious event. Its occurrence has been discussed during the implementation of new radiation techniques and justified appropriate radioprotection requirements. New approaches targeting intrinsic radio-sensitivity have been described, such as radiation-induced CD8 T-lymphocyte apoptosis (RILA) able to predict late radio-induced toxicities. We studied the role of RILA as a predisposing factor for RIS as a late adverse event following radiation therapy (RT).

Patients and methods

In this prospective biological study, a total of 120 patients diagnosed with RIS were matched with 240 control patients with cancer other than sarcoma, for age, sex, primary tumor location and delay after radiation. RILA was prospectively assessed from blood samples using flow cytometry.

Results

Three hundred and forty-seven patients were analyzed (118 RIS patients and 229 matched control patients). A majority (74%) were initially treated by RT for breast cancer. The mean RT dose was comparable with a similar mean (± standard deviation) for RIS (53.7 ± 16.0 Gy) and control patients (57.1 ± 15.1 Gy) (p = .053). Median RILA values were significantly lower in RIS than in control patients with respectively 18.5% [5.5–55.7] and 22.3% [3.8–52.2] (p = .0008). Thus, patients with a RILA >21.3% are less likely to develop RIS (p < .0001, OR: 0.358, 95%CI [0.221–0.599].

Conclusion

RILA is a promising indicator to predict an individual risk of developing RIS. Our results should be followed up and compared with molecular and genomic testing in order to better identify patients at risk. A dedicated strategy could be developed to define and inform high-risk patients who require a specific approach for primary tumor treatment and long term follow-up.

Contemporary Guidelines in Whole-Breast Irradiation: An Alternative Perspective

The American Society for Radiation Oncology produced an evidence-based guideline on whole-breast radiation therapy for patients with early-stage invasive breast cancer and ductal carcinoma in situ. This commentary points out areas where we believe the data are too limited to make definitive recommendations and where alternative approaches are supported by evidence.

Post-radiation sarcoma: A study by the Eastern Asian Musculoskeletal Oncology Group

The oncologic risk of ionizing radiation is widely known. Sarcomas developing after radiotherapy have been reported, and they are a growing problem because rapid advancements in cancer management and screening have increased the number of long-term survivors. Although many patients have undergone radiation treatment in Asian countries, scarce reports on post-radiation sarcomas (PRSs) have been published. We investigated the feature and prognostic factors of PRSs in an Asian population. The Eastern Asian Musculoskeletal Oncology Group participated in this project. Cases obtained from 10 centers were retrospectively reviewed. Patients with genetic malignancy predisposition syndrome, or who had more than one type of malignancy before the development of secondary sarcoma were excluded. Forty-two high-grade sarcomas among a total of 43 PRSs were analyzed. There were 29 females and 13 males, with a median age of 58.5 years; 23 patients had bone tumors and 19 had soft tissue tumors. The most common primary lesion was breast cancer. The median latency period was 192 months. There were no differences in radiation dose, latency time, and survival rates between bone and soft tissue PRSs. The most common site and diagnosis were the pelvic area and osteosarcoma and malignant fibrous histiocytoma for bone and soft tissue PRSs. The median follow-up period was 25.5 months. Five-year metastasis-free and overall survival rates were 14.5% and 16.6%, and 39.1% and 49.6% for bone and soft tissue PRSs. Survival differences depending on initial metastasis and surgery were significant in soft tissue sarcomas. Although this study failed to find ethnic differences, it is the largest review on PRS in an Asian population. As early recognition through long-term surveillance is a key to optimal management, clinicians should take efforts to understand the real status of PRS.

Radiation-associated sarcoma after breast cancer in a nationwide population: Increasing risk of angiosarcoma

Radiation‐associated sarcoma (RAS) is a rare complication of radiation therapy (RT) to breast cancer (BC). This study explored RAS after RT to BC in a nationwide population‐based material. The Finnish Cancer Registry was queried for patients with BC treated during 1953‐2014 who were later diagnosed with a secondary sarcoma in 1953‐2014. Registry data, patient files, and sarcoma specimens were  analyzed to confirm diagnosis and location of RAS at or close to the RT target volume. A total of 132 512 patients were diagnosed with invasive BC during the study period. A subsequent sarcoma was diagnosed in 355 patients. After exclusion, 96 RAS were identified. Angiosarcoma (AS) was the most prevalent histology in 50 (52%) of 96 patients. However, the first radiation‐associated AS was diagnosed in a patient treated for BC with breast‐conserving surgery in 1984, and thereafter, the proportion of AS continuously increased. The 5‐year sarcoma‐specific survival was 75.1% for RAS treated with a curative intent. The distribution of histologic subtypes of RAS has changed during the 60 years of this registry study. The first radiation‐associated AS was diagnosed in 1989, and presently, AS is the most common histologic subtype of RAS. It is possible that changes in BC treatment strategies are influencing the characteristics of RAS.

Lymphangiosarcoma in a Chronic Lymphedematous Limb: A Case Report

A 69-year-old-woman developed a lymphangiosarcoma of the limb on chronic lymphedema after radical mastectomy and radiotherapy for primary breast cancer 12 years before. Since 1948, when Stewart and Treves described this entity, 200 cases have been described. We report this case because of its extremely rare frequency. Concepts of etiology, treatment and prognosis are reviewed.

MEASUREMENT OF THE CONTRALATERAL BREAST PHOTON AND THERMAL NEUTRON DOSES IN BREAST CANCER RADIOTHERAPY: A COMPARISON BETWEEN PHYSICAL AND DYNAMIC WEDGES

This research aimed to measure the received photon and thermal neutron doses to contralateral breast (CB) in breast cancer radiotherapy for various field sizes in presence of physical and dynamic wedges. The measurement of photon and thermal neutron doses was carried out on right breast region of RANDO phantom (as CB) for 18 MV photon beams. The dose measurements were performed by thermoluminescent dosimeter chips. These measurements obtained for various field sizes in presence of physical and dynamic wedges. The findings of this study showed that the received doses (both of the photon and thermal neutron) to CB in presence of physical wedge for 11 × 13, 11 × 17 and 11 × 21 cm2 field sizes were 5.92, 6.36 and 6.77% of the prescribed dose, respectively as well as for dynamic wedge were 2.92, 4.63 and 5.60% of the prescribed dose, respectively. The results showed that the received photon and thermal neutron doses to CB increase with increment of field sizes. The received photon and thermal neutron doses to CB in presence of physical wedge were more than dynamic wedge. According to obtained findings, it is suggested that using a dynamic wedge is preferable than physical wedge, especially for medial tangential field.

Stewart-Treves Syndrome Involving Chronic Lymphedema after Mastectomy of Breast Cancer

Steward-Treves syndrome is a cutaneous angiosarcoma that usually appears after long evolution of a lymphoedema after mastectomy for mammary neoplasia associated with an axillary dissection. This is a rare disease develop most of the time in upper arm and often confounded with cutaneous metastasis. Only the biopsy and immunohistochemical study confirm the diagnosis. The treatment is surgical and consists of large cutaneous excision, an amputation of the limb or even its disarticulation and will be followed by chemotherapy. Despite the treatment, the prognosis remains severe with poor survival. We report the case of a patient who had a Steward-Treves syndrome 20 years after lymphoedema following a left mastectomy with axillary dissection.

Radiation-induced osteosarcoma after Gamma Knife surgery for vestibular schwannoma: a case report and literature review

We present a rare case of radiation-induced osteosarcoma following Gamma Knife^® surgery (GKS) for a vestibular schwannoma (VS). A 49-year-old female with sporadic VS underwent GKS. Serial follow-up imaging showed that the tumor size decreased. Six years after GKS, magnetic resonance imaging demonstrated regrowth of the tumor. The tumor was removed via the retrosigmoid approach. Interestingly, the final pathology report confirmed osteosarcoma arising in schwannoma with direct transition (osteosarcoma component: 90 %, schwannoma component: 10 %). The osteosarcoma was considered to be a radiation-induced malignancy. The possibility of this rare complication should be explained to the patient before GKS, and the patient should be screened periodically after GKS.

Unusual Visceral Sarcomas: Report of 2 Cases with Review of Literature

Sarcomas account for only 1% of adult solid tumours. Visceral sarcomas except Gastrointestinal Stromal Tumours (GIST) are rare and therefore little is known about the natural history and prognosis of these tumours. They tend to occur in older adults with no sex predilection and are characterized by an aggressive behaviour. Proper evaluation of these tumours is necessary because these are uncommon tumours which often present with advanced disease in an anatomically complex location. Since there are very few published studies on visceral sarcomas, the data is insufficient to suggest prognosis and optimum treatment strategies. We present two cases of such unusual malignancies in spleen and urinary bladder.

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

Background

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

Methods

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

Results

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

Conclusions

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

Imaging Evaluation of Malignant Chest Wall Neoplasms

Neoplasms of the chest wall are uncommon lesions that represent approximately 5% of all thoracic malignancies. These tumors comprise a heterogeneous group of neoplasms that may arise from osseous structures or soft tissues, and they may be malignant or benign. More than 50% of chest wall neoplasms are malignancies and include tumors that may arise as primary malignancies or secondarily involve the chest wall by way of direct invasion or metastasis from intrathoracic or extrathoracic neoplasms. Although 20% of chest wall tumors may be detected at chest radiography, chest wall malignancies are best evaluated with cross-sectional imaging, principally multidetector computed tomography (CT) and magnetic resonance (MR) imaging, each of which has distinct strengths and limitations. Multidetector CT is optimal for depicting bone, muscle, and vascular structures, whereas MR imaging renders superior soft-tissue contrast and spatial resolution and is better for delineating the full extent of disease. Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is not routinely performed to evaluate chest wall malignancies. The primary functions of PET/CT in this setting include staging of disease, evaluation of treatment response, and detection of recurrent disease. Ultrasonography has a limited role in the evaluation and characterization of superficial chest wall lesions; however, it can be used to guide biopsy and has been shown to depict chest wall invasion by lung cancer more accurately than CT. It is important that radiologists be able to identify the key multidetector CT and MR imaging features that can be used to differentiate malignant from benign chest lesions, suggest specific histologic tumor types, and ultimately guide patient treatment. (©)RSNA, 2016.

A Case of Radiation-Induced Osteosarcoma after the Treatment of Pineoblastoma

Radiation therapy has an important role in postoperative treatment of neoplasms originated from central nervous system, but may induce secondary malignancies like as sarcomas, gliomas, and meningiomas. The prognosis of radiation-induced osteosarcomas is known as poor, because they has aggressive nature invasive locally and intractable to multiple treatment strategies like as surgical resection, chemotherapy, and so on. We report a case of radiation-induced osteosarcoma developed from skull after 7 years of craniospinal radiotherapy for pineoblastoma.

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

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

Growing Use of Mastectomy for Ductal Carcinoma-In Situ of the Breast Among Young Women in the United States

BACKGROUND

Ductal carcinoma-in situ (DCIS) is a preinvasive form of breast cancer associated with excellent outcomes after either mastectomy or breast conservation therapy. Previous studies have demonstrated declining rates of mastectomy. However, it is unclear how this pattern has changed in recent years.

METHODS

Women with DCIS were identified within the National Cancer Data Base. Patients treated with lumpectomy with or without radiotherapy were compared to women treated with mastectomy on the basis of demographic, clinicopathologic, and reporting facility details using χ (2) tests and multivariable logistic regression modeling to identify factors that may influence surgical choice. Changes in the proportion of women receiving contralateral prophylactic mastectomy (CPM) were assessed in a similar fashion.

RESULTS

We identified 212,936 women diagnosed with DCIS between 1998 and 2011. Lumpectomy was performed in 68 % (144,681) of patients. Mastectomy rates initially declined from 1998 (36 %) through 2004 (28 %), before increasing again through 2011 (33 %). Younger patient age, greater medical comorbidity, more extensive disease, higher tumor grade, treatment at an academic facility, and greater distance from the reporting facility were associated with heightened use of mastectomy (all p < 0.001). CPM also increased over time, particularly among younger patients, on multivariate analysis (p < 0.001).

CONCLUSIONS

Mastectomy utilization appears to be rising between 2004 and 2011, particularly among younger patients and those with higher-risk histopathologic features. CPM is increasing in a similar fashion. Further research is needed to understand the drivers of this change.

Partial–breast irradiation: towards a replacement for whole–breast irradiation?

Largely thanks to all of the investigators and patients who have participated in randomized breast-conservation trials, many women facing a diagnosis of breast cancer today can conserve their breast with the help of adjuvant radiation therapy. A standard course of radiation consists of 5-7 weeks of daily radiation treatments delivered to the whole breast. The success of this treatment has led investigators to attempt to determine whether the same control can be achieved while decreasing the volume of breast tissue irradiated, thus allowing treatment to be delivered in a shorter period of time. This approach could alleviate time and logistical problems faced by patients during their course of treatment as well as improving overall cost-effectiveness. It can also allow complete avoidance of the adjacent heart and lung tissue in the radiation treatment portal. Partial-breast irradiation (the delivery of radiation to the resection cavity, plus a safety margin) delivered in just hours or days, is currently under investigation. Although relatively new, its use is growing rapidly and many institutional and cooperative group trials are quickly enlisting patients, while physicians are gaining experience in a variety of partial-breast irradiation techniques.

[Stewart-Treves syndrome complicating chronic idiopathic lymphedema]

Le syndrome de Stewart-Treves (SST) est une entité rare, correspondant à un angiosarcome cutané compliquant un lymphoedème chronique. Il est de mauvais pronostic. Stewart et Treves ont rapportés en 1948, les premiers cas d'angiosarcome secondaire à un traitement du cancer du sein. Ce terme s'est généralisé pour regrouper l'ensemble des cas de lymphangiosarcome sur lymphoedème d'origine congénital héréditaire ou non héréditaire, post-traumatique ou post-infectieux. Le SST sur un lymphoedème idiopathique reste exceptionnel. Nous rapportons le cas rare d'une patiente présentant un lymphoedème chronique primitif idiopathique des quatre membres évoluant depuis l'adolescence et qui a développé un SST du membre supérieur droit. Elle a subi une amputation à mi- bras vu le caractère très évolué de la tumeur

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

Background

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

Methods

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

Results

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

Conclusions

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

Postmastectomy radiation therapy: an overview for the practicing surgeon

Locoregional control of breast cancer is the shared domain and responsibility of surgeons and radiation oncologists. Because surgeons are often the first providers to discuss locoregional control and recurrence risks with patients and because they serve in a key gatekeeping role as referring providers for radiation therapy, a sophisticated understanding of the evidence regarding radiotherapy in breast cancer management is essential for the practicing surgeon. This paper synthesizes the complex and evolving evidence regarding the role of radiation therapy after mastectomy. Although substantial evidence indicates that radiation therapy can reduce the risk of locoregional failure after mastectomy (with a relative reduction of risk of approximately two-thirds), debate persists regarding the specific subgroups who have sufficient risks of residual microscopic locoregional disease after mastectomy to warrant treatment with radiation. This paper reviews the evidence available to guide appropriate referral and patient decision making, with special attention to areas of controversy, including patients with limited nodal disease, those with large tumors but negative nodes, node-negative patients with high risk features, patients who have received systemic chemotherapy in the neoadjuvant setting, and patients who may wish to integrate radiation therapy with breast reconstruction surgery.

Sarcomas of the breast

Sarcomas of the breast are a rare group of heterogeneous mesenchymal tumors accounting for less than 1% of all breast malignancies. Owing to the rarity of the disease, current knowledge is mostly based on numerous case reports and relatively small retrospective series; unlike epithelial breast cancer, there is no high level evidence to support a standard of care for primary and/or adjuvant therapy. To overcome this relative shortage of data, most therapeutic strategies for breast sarcoma are extrapolated from current treatment for soft tissue sarcoma in other locations, mainly of the extremities and thoracic wall. In general, the therapeutic approach to sarcoma of the breast should be based on a multidisciplinary strategy including surgery, radiation to improve local control and systemic chemotherapy in selected patients. This review discusses the results of the key larger retrospective studies including data on incidence, etiology, presentation, diagnosis, management and prognosis of this challenging rare disease entity.

Diagnostic and therapeutic strategy and the most efficient prognostic factors of breast malignant fibrous histiocytoma

We analyzed the clinicopathological features of 9 breast malignant fibrous histiocytoma (MFH) patients. Immunohistochemistry was used to make both diagnosis and differential diagnosis, and to identify prognostic factors. All tumors lacked epithelial markers but expressed mesenchymal markers, suggesting a mesenchymal origin. Of the five cases expressing Ki-67, two of three patients with axillary lymph node involvement died between 6-8 months, and two died at 17 and 26 months after diagnosis. The two remaining cases, with low Ki-67 expression, had no recurrent or metastatic disease at 145 months after diagnosis. Previous studies have shown that surgery is the primary treatment of choice, but no clear benefit from adjuvant chemotherapy was observed. We demonstrate that axillary lymph node involvement and high expression of Ki-67 are associated with poorer prognosis. A literature review indicates surgery remains the first choice for MFH, but benefits from adjuvant chemotherapy remain unclear.

Other primary malignancies in breast cancer patients treated with breast conserving surgery and radiation therapy

BACKGROUND

Our purpose was to examine the incidence and impact on survival of other primary malignancies (OPM) outside of the breast in breast cancer patients and to identify risk factors associated with OPM.

METHODS

Patients with stage 0-III breast cancer treated with breast conserving therapy at our center from 1979 to 2007 were included. Risk factors were compared between patients with/without OPM. Logistic regression was used to identify factors that were associated with OPM. Standardized incidence ratios (SIRs) were calculated.

RESULTS

Among 4,198 patients in this study, 276 (6.6 %) developed an OPM after breast cancer treatment. Patients with OPM were older and had a higher proportion of stage 0/I disease and contralateral breast cancer compared with those without OPM. In a multivariate analysis, older patients, those with contralateral breast cancer, and those who did not receive chemotherapy or hormone therapy were more likely to develop OPM after breast cancer. Patients without OPM had better overall survival. The SIR for all OPM sites combined after a first primary breast cancer was 2.91 (95 % confidence interval: 2.57-3.24). Significantly elevated risks were seen for numerous cancer sites, with SIRs ranging from 1.84 for lung cancer to 5.69 for ovarian cancer.

CONCLUSIONS

Our study shows that breast cancer patients have an increased risk of developing OPM over the general population. The use of systemic therapy was not associated with increased risk of OPM. In addition to screening for a contralateral breast cancer and recurrences, breast cancer survivors should undergo screening for other malignancies.

Long-term outcomes in patients with radiation-associated angiosarcomas of the breast following surgery and radiotherapy for breast cancer

BACKGROUND

Radiation-associated angiosarcoma (RAAS) is a devastating disease occasionally observed in breast cancer patients treated with radiation. Due to its rarity, our knowledge-of disease risk factors, epidemiology, treatment, and outcome-is extremely limited. Therefore, we sought to identify clinicopathologic factors associated with local and distant recurrence and disease-specific survival (DSS).

METHODS

Radiation-associated angiosarcoma was defined as pathologically confirmed breast or chest wall angiosarcoma arising within a previously irradiated field. A comprehensive search of our institutional tumor registry (1/1/93 through 2/28/11) was used to identify patients (n = 95 females). Patient, original tumor, RAAS treatment, and outcome variables were retrospectively retrieved and assembled into a database.

RESULTS

The median follow-up for all RAAS patients was 10.3 (range, 2.4-31.8) years. The latency period following radiation exposure ranged from 1.4 to 26 (median, 7) years. One-year and 5-year DSS rates were 93.5 and 62.6 %, respectively. Reduced risk of local recurrence was observed in patients who received chemotherapy (P = 0.0003). In multivariable analysis, size was found to be an independent predictor of adverse outcome (P = 0.015).

CONCLUSIONS

Our study demonstrates that RAAS exhibits high recurrence rates. It also highlights the need for well-designed, multicenter, clinical trials to inform the true utility of chemotherapy in this disease.