Postradiation sarcomas: 20 cases and a literature review

A case of undifferentiated pleomorphic rectal sarcoma occurring after radiation exposure

A 72 year-old man was referred to our hospital for a detailed examination of a recurrent rectal polyp. He had past histories of surgery and radiation therapy for prostate cancer at the age of 66 and endoscopic excision of a rectal polyp at the age of 70. Colonoscopy revealed a semi-pedunculated lesion surrounded by friable mucosa, which was positive under positron-emission tomography-computed tomography. Histopathological examination of the endoscopically excised polyp revealed proliferation of atypical cells, characterized by strong pleomorphic or spindle morphology, which was immunohistochemically compatible with undifferentiated pleomorphic sarcoma. We diagnosed this case as sarcoma presumably associated with radiation proctitis.

Sinonasal Malignancy Following Cranial Irradiation: A Scoping Review and Case Report of Sinonasal Teratocarcinosarcoma

Background  Radiation therapy is a mainstay of treatment for brain tumors, but delayed complications include secondary malignancy which may occur months to years after treatment completion. Methods  We reviewed the medical records of a 41-year-old female treated with 60 Gy of radiation for a recurrent astrocytoma, who 6 years later developed a locally advanced sinonasal teratocarcinosarcoma. We searched MEDLINE, Embase, and Web of Science to conduct a scoping review of biopsy-proven sinonasal malignancy in patients who previously received cranial irradiation for a brain tumor. Results  To our knowledge, this is the first report of a patient to present with a sinonasal teratocarcinosarcoma after receiving irradiation for a brain tumor. Our scoping review of 1,907 studies produced 14 similar cases of secondary sinonasal malignancy. Median age of primary cancer diagnosis was 39.5 years old (standard deviation [SD]: 21.9), and median radiation dose was 54 Gy (SD: 20.3). Median latency time between the primary cancer and secondary sinonasal cancer was 9.5 years (SD: 5.8). Olfactory neuroblastoma was the most common sinonasal cancer ( n  = 4). Fifty percent of patients died from their sinonasal cancer within 1.5 years. Conclusion  Patients who receive radiation exposure to the sinonasal region for treatment of a primary brain tumor, including low doses or scatter radiation, may be at risk of a secondary sinonasal malignancy later in life. Physicians who monitor at-risk patients must be vigilant of symptoms which may suggest sinonasal malignancy, and surveillance should include radiographic review with careful monitoring for a secondary malignancy throughout the entire irradiated field.

Malignant transformation of vestibular schwannoma after radiation therapy

Stereotactic radiosurgery (SRS) is an effective treatment for vestibular schwannomas, offering high rates of tumor control and low neurological risks. Long-term complications of SRS are not fully understood, with several cases of malignant transformation reported in the literature. We report the case of a 50-year-old female with no prior history of neurofibromatosis who presented in 2013 with MRI evidence of a benign vestibular schwannoma. Despite treatment with CyberKnife SRS, she presented 6 years later with new onset neurologic symptoms. Further investigation showed stable lesion size with increasing vasogenic edema and a new area of enhancement in the brainstem, suspicious for malignant transformation. Subsequent treatment with partial craniectomy and histopathologic analysis was consistent with a malignant peripheral nerve sheath tumor diagnosis. Our case adds to a series of 24 similar cases in the literature, details of which have been summarized in our study. Overall, findings support the need for lifelong surveillance following SRS treatment of benign vestibular schwannomas. Patients should be educated on the potential risk of this complication, and clinicians must maintain a high level of suspicion for potential radiation-induced malignancy during the patient's clinical course.

[Does radiation therapy for prostate cancer increase the risk of second cancers?]

PURPOSE

The increased risk of second cancer after prostate radiotherapy is a debated clinical concern. The objective of the study was to assess the risk of occurrence of second cancers after prostate radiation therapy based on the analysis the literature, and to identify potential factors explaining the discrepancies in results between studies.

MATERIALS AND METHODS

A review of the literature was carried out, comparing the occurrence of second cancers in patients all presenting with prostate cancer, treated or not by radiation.

RESULTS

This review included 30 studies reporting the occurrence of second cancers in 2,112,000 patients treated or monitored for localized prostate cancer, including 1,111,000 by external radiation therapy and 103,000 by brachytherapy. Regarding external radiation therapy, the average follow-up was 7.3years. The majority of studies (80%) involving external radiation therapy, compared to no external radiation therapy, showed an increased risk of second cancers with a hazard ratio ranging from 1.13 to 4.9, depending on the duration of the follow-up. The median time to the occurrence of these second cancers after external radiotherapy ranged from 4 to 6years. An increased risk of second rectal and bladder cancer was observed in 52% and 85% of the studies, respectively. Considering a censoring period of more than 10 years after irradiation, 57% and 100% of the studies found an increased risk of rectal and bladder cancer, without any impact in overall survival. Studies of brachytherapy did not show an increased risk of second cancer. However, these comparative studies, most often old and retrospective, had many methodological biases.

CONCLUSION

Despite numerous methodological biases, prostate external radiation therapy appears associated with a moderate increase in the risk of second pelvic cancer, in particular bladder cancer, without impacting survival. Brachytherapy does not increase the risk of a second cancer.

Primary orbital sarcoma in adults: a case series with emphasis on post-irradiation sarcoma

PURPOSE

To describe a series of eight adult patients with primary orbital sarcoma and to review the existing literature on orbital sarcoma and post-irradiation sarcoma.

METHODS

Report of eight cases and literature review.

RESULTS

We report eight cases of primary orbital sarcoma, three of which were radiation-induced. Only one patient had a history of retinoblastoma. The most common presentations were painful proptosis and reduced vision. Most tumours arose in the extraconal compartment. The overall median age at diagnosis was 50 years. The pathology comprised a diverse group of tumours. Treatment and outcome varied between patients and their clinical circumstances.

CONCLUSIONS

Adult primary orbital sarcomas are rare. They can comprise a variety of tumour types and are difficult to treat. Irradiation is a significant risk factor, and the incidence of post-irradiation sarcoma of the orbit may be increasing due to the widespread use of radiotherapy and improved survival of patients with cancer. Post-irradiation sarcoma should be considered in the differential diagnosis of an orbital space-occupying lesion in a patient with a history of radiotherapy.

A rare case of thyroid carcinosarcoma arising from recurrent papillary thyroid cancer: Case report and review of the literature

BACKGROUND

Thyroid carcinosarcoma represents a rare subtype of thyroid cancer, distinguished by its unique histopathology-simultaneous malignant epithelial and mesenchymal cells. The occurrence of thyroid carcinosarcoma arising from recurrent papillary thyroid cancer is exceptionally infrequent.

METHODS

Study outlines a patient's thyroid carcinosarcoma journey, covering presentation, recurrence, diagnostics, surgeries, and follow-up. A PubMed search gathered data on pathological features and treatment approaches for thyroid carcinosarcoma.

RESULTS

The patient initially diagnosed with papillary thyroid cancer underwent thyroidectomy, neck dissection, and radioactive iodine therapy. Recurrence revealed thyroid carcinosarcoma, featuring papillary carcinoma, squamous cell carcinoma, and spindle cell components. Total laryngectomy followed by adjuvant radiotherapy and chemotherapy. The patient was followed for 17 months with no evidence of disease.

CONCLUSIONS

This extraordinary case exemplifies a rare instance of local relapse in form of thyroid carcinosarcoma following an initial diagnosis of papillary thyroid carcinoma. Surgical resection and chemoradiotherapy show promising outcomes in managing this challenging condition.

Malignant transformation of vestibular schwannoma following radiosurgery-a case report and review of the literature

Malignant transformation of vestibular schwannoma (VS) post-radiosurgery is an extremely rare but life-threatening complication. We present a patient who underwent two surgeries for a benign VS and received Gamma Knife radiosurgery for residual tumour. Five and a half years post-radiosurgery, the patient was reoperated for symptomatic recurrence of the tumour. Histopathology confirmed the diagnosis of a high-grade spindle cell sarcoma. Although near-total resection was uneventful, the patient deteriorated rapidly, and comfort care was chosen. This report is the 13th documented case of histopathologically confirmed malignant transformation of a benign VS that strictly meets the modified Cahan's criteria, suggesting the direct link to radiosurgery-induced malignancy.

Radiation-induced osteosarcoma of the chest wall after treatment for unresectable thymoma

Secondary osteosarcoma is a rare complication of radiation therapy for a primary tumor. Here we report a unique presentation of radiation-induced osteosarcoma of the chest wall after radiation treatment for thymoma. This patient underwent multiple imaging studies, including magnetic resonance imaging and computed tomography with cinematic rendering. Diagnosis of osteosarcoma was confirmed through imaging features and histology. Several surgical procedures were performed to evaluate and attempt resection of the tumor, but ultimately the tumor location and involvement prevented adequate resection and chemotherapy was initiated. This case highlights the importance of identifying clear cumulative dose thresholds for radiation therapy and rare complications of radiotherapy.

'Radiation-induced pleomorphic sarcoma with rhabdomyoblastic differentiation of the lower limb following treatment of vaginal squamous cell carcinoma - A case report and review of the literature'

We present the case of a 59-year-old woman who developed a right thigh pleomorphic sarcoma with rhabdomyoblastic differentiation 6 years following radiotherapy for a vaginal squamous cell carcinoma. The overall 5-year survival for a gynaecological malignancy is more than 80 % and as overall cancer survivorship and life expectancy improves, the incidence of radiation-induced malignancy is increasing (Bjerkehagen et al., 2013). As the prognosis of those malignancies is usually poor, clinicians must have a high index of suspicion to try to detect these cases early.

Radiation-Induced Oropharyngeal Squamous Cell Carcinoma: Case Report and Review of the Literature

BACKGROUND

Radiation therapy (RT) is a mainstay for the treatment of head and neck (HN) cancers, with 80% of patients receiving such treatment. Radiation-induced malignancies represent a life-threatening long-term effect of RT, with an incidence of 0.5% to 15%.

CASE DESCRIPTION

After 13 years, a 33-year-old woman treated with chemo-radiotherapy for nasopharyngeal carcinoma developed a locally advanced, radiation-induced, p16-negative oropharyngeal squamous cell carcinoma (SCC) at the base of the tongue. Chemo/immunotherapy was administered as a first-line treatment. Given the optimal response and the feasibility of surgery, after three cycles, the patient underwent a total glossectomy, bilateral neck dissection, and reconstruction with a thoraco-dorsal free flap. A histological examination found SCC with a residual cancer burden of 70% and free margins.

DISCUSSION

The mechanisms responsible for carcinogenesis after RT are still not completely clear. Diagnosis may be challenging due to the previous treatment; growth patterns are unusual, and lymphotropism is lower. Prognosis is usually poor since surgical resectability is often not achievable.

CONCLUSIONS

Radiation-induced malignancies are difficult to treat. Patient management should always be discussed at a multidisciplinary level. Future research is needed to assess whether the promising results of clinical studies with pre-operative immunotherapy in locally advanced HN SCC patients may be translated into radiation-induced cancers.

Radiation-induced sarcoma of head and neck: Clinical characteristics and molecular signatures

BACKGROUND

Radiation-induced sarcoma of the head and neck (RISHN) is a rare yet devastating potential complication of radiotherapy treatment. We aimed to evaluate the clinicopathological characteristics and molecular signatures of RISHN in patients who underwent radiotherapy for head and neck cancer (HNC) to identify high-risk patients and enable earlier cancer detection.

METHODS

This study retrospectively evaluated 24 sarcoma patients who received radiotherapy for HNC between 1994 and 2019. Patients were divided into two groups based on RISHN latency period. Patient demographics, initial tumor staging, risk factors, and survival between groups were analyzed, and whole-exome sequencing (WES) of selected samples was performed.

RESULTS

The median age at diagnosis of RISHN was 54 years, and the male-to-female ratio was 2:1. The latency period ranged from 0.8 to 64.4 years (median 6.5 years), with a median survival of 21.5 months. Primary cancer in the oral cavity, treatment with alkylating agents, alcohol consumption, betel nut chewing, and smoking were identified as risk factors for short (<5 years) latency periods. The majority of RISHN cases occurred in the oral cavity (58.3%). WES analysis showed that tumor necrosis factor and cell cycle checkpoint pathways were differentially involved in both patient groups.

CONCLUSIONS

Although case numbers were small, our cohort represents the largest case series of RISHN from a single institution to date. Clinicians must be aware of factors affecting RISHN development and latency, and risk factor identification may lead to earlier detection and prevention in the future.

Increased Burden of Second Bladder Cancer and Rectal Cancer in Prostate Cancer Treated With Radiotherapy: Results From Surveillance, Epidemiology, and End Results

BACKGROUND

Previous studies have confirmed the higher risk of bladder cancer (BC) and rectal cancer (RC) development among prostate cancer (PCa) patients receiving radiotherapy. In this study, we intend to explore the long-term trend in second BC and RC incidence among PCa patients undergoing radiotherapy.

METHOD

We identified first primary PCa patients diagnosed between 1975 and 2014 from the Surveillance, Epidemiology, and End Results (SEER)-9 cancer registries. Standardized incidence ratios (SIRs) were calculated by calendar year of diagnosis among PCa patients receiving radiotherapy and not. P trends were evaluated using Poisson regression. 10-year cumulative incidence of BC and RC was calculated utilizing competing risk regression model.

RESULT

Of PCa patients treated with radiotherapy, SIRs of BC increased from .82 (95% CI: .35- 1.61) in 1980-1984 to 1.58 (95% CI: 1.48-1.68) in 2010-2014 (Ptrend=.003). SIRs of RC increased from 1.01 (95% CI: .27-2.58) in 1980-1984 to 1.54 (95% CI: 1.31-1.81) in 2010-2014 (Ptrend=.025). No statistically significant change in both BC and RC incidence was observed. The 10-year cumulative incidence of BC increased from 1975-1984 (.04%) to 2005-2014 (.15%) among PCa treated with radiotherapy. Simultaneously, the 10-year cumulative incidence of RC was demonstrated to range from 1975-1984 (.02%) to 2005-2014 (.11%).

CONCLUSION

we have observed an increasing trend in second BC and RC incidence in PCa patients receiving radiotherapy. There was no significant change in the incidence of second BC and RC in PCa without radiotherapy. These results reflect the increasing clinical burden of second malignant tumors in PCa patients undergoing radiotherapy.

Radical abdomino-pelvic surgery in the management of uterine carcinosarcoma with concomitant para-aortic lymphadenopathy metastasising from anal carcinoma

Uterine carcinosarcomas are aggressive gynaecological cancers comprising less than 5% of uterine malignancies. We present the case of a woman in her 70s with a complicated history of advanced anal carcinoma treated with pelvic radiotherapy and multiple laparotomies, who was referred to gynae-oncology following MRI surveillance imaging showing evidence of endometrial carcinoma and para-aortic lymphadenopathy. Successful surgical excision required multidisciplinary teamwork between gynae-oncology, colorectal and urology surgeons. The patient underwent midline laparotomy, with adhesiolysis, ileum resection and side to side anastomosis, posterior exenteration, left kidney mobilisation and suspension, para-aortic lymph node debulking and left ureteric stent insertion. Significant challenge was posed by the extensive adhesions from previous laparotomies and the debulking of the para-aortic lymph nodes around the renal vessels. This case demonstrates the importance of a multidisciplinary approach in complex pelvic surgery and the vitality of good communication between colleagues in achieving effective patient care.

Nodular fasciitis arising from the buccal region after segmentectomy with rapid growth mimicking postirradiation myxofibrosarcoma: A case report

RATIONALE

Nodular fasciitis (NF) can be misdiagnosed as a sarcoma because of its rapid growth and pathological features, such as nuclear atypia and mitoses.

PATIENT CONCERNS

We present a rare case of a 72-year-old Japanese man who developed NF with suspected postirradiation myxofibrosarcoma (MFS) after segmentectomy for left-sided osteoradionecrosis (ORN) of the mandible.

DIAGNOSIS

A mass appeared in the intraoral postoperative wound 1 year after left-sided mandibular segmentectomy and showed rapid growth, reaching a size of 50 mm within 2 months. Incisional biopsy revealed strongly Ki-67-positive spindle-shaped cells with large irregular nuclei and a diagnosis of postirradiation MFS.

INTERVENTIONS

The patient was diagnosed with oropharyngeal cancer (T4aN2bM0) and underwent surgical resection of primary oropharyngeal squamous cell carcinoma with selective neck dissection and reconstruction with a rectus abdominis musculocutaneous flap at the age of 57 years, followed by postoperative 66 Gy of radiotherapy combined with cisplatin administration. No recurrent or metastatic lesions of oropharyngeal squamous cell carcinoma have been detected for > 10 years. However, the ORN of the jaw worsened, and the patient underwent sequestrectomy 3 times on the right side of the mandible, followed by a left-sided segmentectomy at the age of 72 years. One year after segmentectomy, a 10-mm mass with soft-to-firm consistency appeared in the buccal mucosa of the wound and grew rapidly. An incisional biopsy revealed MFS. Complete resection under general anesthesia was immediately performed.

OUTCOMES

The histopathological diagnosis of the excised specimen was NF without any malignant findings. Two years after surgery, there was no evidence of recurrence or metastasis.

LESSONS

NF grows rapidly and has pathological features similar to sarcoma, making differential diagnosis difficult at the time of incisional biopsy. Further studies should be conducted to determine the clinical and pathological features of this tumor.

Effects of Radiation Therapy and Chemotherapy on the Musculoskeletal System

The effects of radiation and chemotherapy on the musculoskeletal (MSK) system are diverse, and interpretation may be challenging. The different lines of treatment have effects on diseased and normal marrow, and they may lead to complications that must be differentiated from recurrence or progression. This review analyzes the changes induced by radiotherapy and chemotherapy in the MSK system in the adult and pediatric population, and the expected associated imaging findings. Treatments are often combined, so the effects may blend. Awareness of the spectrum of changes, complications, and their imaging appearances is paramount for the correct diagnosis. The assessment of body composition during and after treatment allows potential interventions to implement long-term outcomes and personalize treatments. Imaging techniques such as computed tomography or magnetic resonance imaging provide information on body composition that can be incorporated into clinical pathways. We also address future perspectives in posttreatment assessment.

Multimodal treatment of radiation-induced esophageal cancer: Results of a case-matched comparative study from a single center

PURPOSE

Radiation-induced esophageal cancer (RIEC) is a rare but severe late consequence of radiotherapy. The literature regarding this topic is predominately limited in describing the risk of this disease. Tumor behavior, treatment strategies, and prognosis of this cancer remain poorly defined.

PATIENTS AND METHODS

We collected data of patients who were referred to our unit between 2000 and 2020 for RIEC. After tumor board discussion, upfront surgery or neoadjuvant therapy and surgery were indicated as the main treatment. Preoperative characteristics, long-term and short-term postoperative outcomes of RIEC patients were compared with a 1:1 clustering-matched cohort of patients affected by primary esophageal cancer (PEC).

RESULTS

At pre-matching, 54 RIEC and 936 PEC patients were enrolled. The median time between primary irradiation and diagnosis of RIEC was 13.5 years, and the median primary radiation dose was 60 Gy. Compared to the unmatched cohort of PECs, RIEC patients were more frequently female (p = 0.0007), had earlier detection of disease (p = 0.03) and presented more frequently with upper esophageal cancers (p < 0.0001). Neoadjuvant treatment was used less frequently in RIEC patients (p < 0.0001). After matching, the 51 RIEC and 50 PEC patients showed comparable results in terms of exposure to neoadjuvant treatment, surgical radicality and survival outcomes. RIEC patients had more severe postoperative complications (p = 0.04) and a higher proportion of pulmonary complications (p = 0.04).

CONCLUSIONS

Curative treatments are feasible for RIEC. Neoadjuvant chemotherapy or chemoradiation can be used in this subgroup, treatment response and long-term outcomes are comparable to those of PEC. The risk of postoperative complications is probably related to the detrimental effect of primary irradiation on lung function.

Osteosarcoma of the sternum after radiotherapy for breast cancer in a patient with suspected hereditary cancer syndrome: a case report

Introduction:

Radiation-induced malignancies are a rare phenomenon. Post-radiation sarcoma accounts for 0·5–5·5% of all sarcomas. Adjuvant radiotherapy (RT) after surgery plays a significant role in the treatment of breast cancer. Sarcomas of the breast, chest wall, sternum, axilla or supraclavicular region have been reported as a rare complication of RT for breast cancer. Osteosarcoma (OS) of the sternal bone is a rarely reported entity. OS of the sternum secondary to therapeutic ionising radiation is an even rarer diagnosis, and no such cases have been reported in India as per our literature search. Here we report such a case of post-radiation sarcoma after breast cancer treatment—OS presenting in the sternum and both the second ribs in a young lady.

Findings:

Our patient developed a sarcoma within a previously irradiated field. The latent period was 7·5 years. She initially suffered from a breast carcinoma for which she underwent radical surgery in the form of modified radical mastectomy. She also received 50 Gy RT dose to the chest wall and axilla. She subsequently developed an OS of chest wall in the high-dose region of RT. Another key factor is the high possibility of familial/hereditary cancer inheritance syndrome like Li-Fraumeni in our patient. Though she was never tested for p53 mutations, her young age at first diagnosis (26 years), extremely strong positive family history and spectra of cancers affecting her first-degree blood relatives (brain tumours, leukaemia) strongly hint at the possibility of such a cancer syndrome. Retrospectively, the question certainly arises, given her young age and family history, whether this patient was a right candidate for RT even once as compared to the fact that she received radiation twice.

Management of late events after conventional radical prostate radiotherapy: against the odds of secondary tumours and recurrence of prostate cancer

We present two 85-year-old men, with a similar history of prostate cancer treated more than 10 years ago with radiotherapy, who were in remission, but sought medical care at a time, due to alarm sign and symptoms. Case 2 resulted in a locally advanced secondary radiation-induced sarcoma of the penile base. Case 1 suffered from a round, 2 cm soft-tissue lesion with spiculated borders at the ureterovesical junction responsible for ipsilateral iliac vein compression and urinary obstruction without proven biochemical prostate cancer relapse, raising concerns about recurrence or secondary tumour. Both patients followed an oncological geriatric assessment and were 'vulnerable' at their presentation. Hence, we describe the effort to perform medical care adequacy regarding patient's frailty and the anatomic locations within the prior radiation field. In case 2, we got a pathological diagnose and followed sequential multimodal treatments without success. But in case 1, minimal intervention resulted in improvement.

Clinical Outcome of Sacral Chordoma Patients Treated with Pencil Beam Scanning Proton Therapy

AIMS

Sacral chordomas are locally aggressive, radio-resistant tumours. Proton therapy has the potential to deliver high radiation doses, which may improve the therapeutic ratio when compared with conventional radiotherapy. We assessed tumour control and radiation-induced toxicity in a cohort of sacral chordoma patients treated with definitive or postoperative pencil beam scanning proton therapy.

METHODS AND MATERIALS

Sixty patients with histologically proven sacral chordoma treated between November 1997 and October 2018 at the Paul Scherrer Institute with postoperative (n = 50) or definitive proton therapy (n = 10) were retrospectively analysed. Only 10 (17%) patients received combined photon radiotherapy and proton therapy. Survival rates were calculated using the Kaplan-Meier actuarial method. The Log-rank test was used to compare different functions for local control, freedom from distant recurrence and overall survival. Acute and late toxicity were assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

RESULTS

The median follow-up was 48 months (range 4-186). Local recurrence occurred in 20 (33%) patients. The 4-year local control, freedom from distant recurrence and overall survival rates were 77%, 89% and 85%, respectively. On univariate analysis, subtotal resection/biopsy (P = 0.02), tumour extension restricted to bone (P = 0.01) and gross tumour volume >130 ml (P = 0.04) were significant predictors for local recurrence. On multivariate analysis, tumour extension restricted to bone (P = 0.004) and gross total resection (P = 0.02) remained independent favourable prognostic factors for local recurrence. Twenty-four (40%), 28 (47%) and eight (11%) patients experienced acute grade 1, 2 and 3 toxicities, respectively. The 4-year late toxicity-free survival was 91%. Two patients developed secondary malignancies to the bladder 3-7 years after proton therapy.

CONCLUSIONS

Our data indicate that pencil beam scanning proton therapy for sacral chordomas is both safe and effective. Gross total resection, tumour volume <130 ml and tumour restricted to the bone are favourable prognostic factors for local tumour control.

Primary and radiation induced skull base osteosarcoma: a systematic review of clinical features and treatment outcomes

PURPOSE

We aim to systematically review and summarize the demographics, clinical features, management strategies, and clinical outcomes of primary and radiation-induced skull-base osteosarcoma (SBO).

METHODS

PubMed, Scopus, and Cochrane databases were used to identify relevant articles. Papers including SBO cases and sufficient clinical outcome data were included. A comprehensive clinical characteristic review and survival analysis were also conducted.

RESULTS

Forty-one studies describing 67 patients were included. The median age was 31 years (male = 59.7%). The middle skull-base was most commonly involved (52.7%), followed by anterior (34.5%) and posterior (12.7%) skull-base. Headache (27%), exophthalmos (18%), and diplopia (10%) were common presenting symptoms. Sixty-eight percent of patients had primary SBO, while 25% had radiation-induced SBO. Surgery was the main treatment modality in 89% of cases. Chemotherapy was administered in 65.7% and radiotherapy in 50%. Median progression-free survival (PFS) was 12 months, and the overall 5-year survival was 22%. The five-year survival rates of radiation-induced SBO and primary SBO were 39% and 16%, respectively (P < 0.05).

CONCLUSION

SBO is a malignant disease with poor survival outcomes. Surgical resection is the primary management modality, in conjunction with chemotherapy and radiotherapy. Radiation-induced SBO has a superior survival outcome as compared to its primary counterpart. Complete surgical resection showed a statistically insignificant survival benefit as compared to partial resection.

Second Malignancies after Radiation Therapy: Update on Pathogenesis and Cross-sectional Imaging Findings

A wide spectrum of second cancers occur as late complications of radiation therapy (RT) used to treat various malignancies. In addition to the type and dose of radiation, lifestyle, environmental, and genetic factors are important to the development of second malignancies in cancer survivors. Typically, RT-induced malignancies (RTIMs) are biologically aggressive cancers with a variable period of 5-10 years for hematologic malignancies and 10-60 years for solid tumors between RT and the development of the second cancer. Although carcinomas and leukemias commonly develop after low-dose RT, sarcomas occur in tissues or organs that receive high-dose RT. Angiosarcomas and unclassified pleomorphic sarcomas are the two most common RT-associated sarcomas; other sarcomas include malignant peripheral nerve sheath tumors, leiomyosarcomas, osteosarcomas, chondrosarcomas, and dedifferentiated or pleomorphic liposarcomas. Select RTIMs show tumor genetic characteristics that allow accurate diagnosis. Nearly all cutaneous angiosarcomas after RT for breast cancer and 90% of RT-associated malignant peripheral nerve sheath tumors are characterized by MYC gene amplifications and loss of H3 K27me3 expression, respectively. Classic papillary thyroid carcinomas that develop after RT frequently harbor RET/PTC rearrangements and have a favorable prognosis, despite their advanced stage at patient presentation. Select RTIMs demonstrate characteristic imaging findings and typically develop in the prior radiation field. Imaging is essential to early diagnosis, characterization, localization, and staging of RTIMs. Familiarity of radiologists with the diverse spectrum of RTIMs is essential for early diagnosis and optimal management. An invited commentary by Shapiro is available online. ^©RSNA, 2021.

Radiation-Induced Hyalinizing Clear Cell Carcinoma of the Orbit

Radiation-induced malignancy is rare, occurring in approximately 0.4%-1.0% of patients receiving external beam radiation therapy. Sarcomas and squamous cell carcinomas are among the most common types of cancers to occur. A 74-year-old woman presented with redness and swelling in the right periorbital region. She had history of multiple recurrent ameloblastoma of the right maxilla, invading the right orbital floor status post 4 surgical resections and 66 Gray external beam radiotherapy 5 years prior. MRI showed a poorly circumscribed mass involving the inferior and lateral orbit. Orbital biopsy revealed clear cell carcinoma with hyalinizing sclerosis and Ewing sarcoma breakpoint region 1 gene arrangement. Due to the extent of orbital disease and presence of perineural invasion, she underwent orbital exenteration. Hyalinizing clear cell carcinoma, a rare cancer, has not been reported to occur in the orbit following radiation. This case highlights the importance of lifetime monitoring in patients who have undergone radiation therapy.

Radiation-Induced Sarcoma of the Head and Neck Following Radiotherapy for Nasopharyngeal Carcinoma: A Single Institutional Experience and Literature Review

Background and Objective

Radiotherapy (RT) is the primary treatment option for nasopharyngeal carcinoma (NPC), but it is associated with radiation-induced sarcomas (RISs). This study aims to investigate clinicopathological features and head and neck RIS prognosis after NPC RT.

Methods

The medical and radiological records of the NPC patients (n =14,074) referred to Zhejiang Cancer Hospital, Hang Zhou, China between January 1995 and December 2018 were retrospectively reviewed. Among them, 22 patients were determined to have RIS after RT for NPC. The clinicopathological data, diagnosis, treatment, and follow-up results of 22 patients with RIS were analyzed in this retrospective research. All 22 patients underwent surgery as the main treatment. The levels of Overall Survival (OS) were determined through the Log-rank test and Kaplan-Meier method.

Results

Among these patients, 13 were males and nine females with the male/female ratio of 1.44:1. The age during the primary RT of NPC ranged from 25 to 61 years old (median age: 37 years old). Patients' ages ranged from 33 to 73 years old (median age: 52.5 years old) when diagnosed with RIS. The latency period for development of the RIS was between 3 and 36 years (median: 8.5 years) after RT. In this cohort, R0 resection was achieved in 13 cases, R1 resection in five cases, and R2 resection in four cases. During the follow-up period ranged from 2 to 102 months (median 14 months), 15 patients had died of the disease. Kaplan-Meier method showed that the 2-year, 3-year, and the 5-year cumulative OS rate was 50.3, 43.2, and 14.4%, respectively. The median survival time was 34 months. Surgical resection with R0 resection achieves a significantly better prognosis (P = 0.012). Patients under the age of 37 years old at the time of initial RT had a relatively better prognosis (P = 0.035).

Conclusions

Although the incidence of RIS after RT of NPC is generally low, the treatment of RIS is very difficult. The RISs are associated with poor overall prognosis. R0 resection can improve the prognosis thus it should be considered as the primary and optimal choice for the treatment of RIS.

Radiation-Induced Sarcomas of the Head and Neck: A Systematic Review

Introduction

As a result of the increased use of radiotherapy (RT) and improved long-term overall survival of patients with cancers of the head and neck (HN), the frequency of radiation-induced sarcomas of the head and neck (RISHN) may be increasing. The main objective of this systematic review was to determine the existing evidence on the frequency, treatment, and outcome of RISHN.

Methods

Using PRISMA guidelines we conducted a systematic review of the literature published from 2000 to 2020.

Results

Our review includes data of 560 patients from 64 articles. The total frequency of RISHNs among the reviewed series was 0.15%. The most frequent location of the primary tumor treated by RT was the nasopharynx. The mean RT dose used was 62 Gy, mean latency interval between irradiation and occurrence of RISHN was 11.1 years, and the most common RISHN location was the sinonasal region. Osteosarcoma was the principal histology, followed by fibrosarcoma. Surgery was the most frequently applied treatment modality. Of all patients with RISHN, 40.7% died of this disease after a mean interval of 13.9 months.

Conclusions

Notwithstanding the increased use of RT, the number of reported RISHNs has not increased substantially during the past two decades. Surgery with wide margins forms the best therapeutic option for these cases, but the outcome remains poor.

Post-radiotherapy recurrence of conventional oral squamous cell carcinoma showing sarcomatoid components: an immunohistochemical study

Spindle cell squamous cell carcinoma (SpSCC) is a rare biphasic malignant neoplasm, uncommonly affecting the oral cavity. The SpSCC diagnosis is difficult, especially when it exhibits inconspicuous morphology, inadequate tissue sampling, or association with an exuberant inflammatory reaction. Post-radiotherapy recurrent SpSCC occurring at the same site of conventional SCC is a rare phenomenon. A 59-year-old man was complained of “painful injury on the tongue” with 20 days of duration. He reported smoking and alcohol consumption. Medical history revealed conventional SCC on the tongue treated with surgery and radiotherapy 10 years ago. Intraoral examination showed a polypoid lesion with ulcerated areas, measuring 3 cm in diameter, on the tongue and floor of the mouth, at the same site of previous conventional SCC. The microscopical analysis showed small foci of carcinomatous component admixed with an exuberant inflammatory reaction. Immunohistochemistry highlighted the sarcomatoid component. Both malignant components were positive for EMA, CD138, p40 (deltaNp63), p63, and p53. Moreover, CK AE1/AE3 evidenced the carcinomatous component, whereas vimentin stained the sarcomatoid component. The Ki-67 was >10%. The current case emphasizes the importance of immunohistochemistry in the differential diagnosis of SpSCC from mimics and documents a rare complication of Ionizing Radiation.

Laparoscopic-Assisted Hysteroscopic Surgery for Endometrial Tumors Arising after Pelvic Radiation Therapy

Uterine tumors detected after pelvic radiation therapy are rare. We report a case in which an endometrial tumor developed after pelvic radiation therapy for cervical cancer. The patient was a 70-year-old female with a history of pelvic radiotherapy for locally advanced cervical cancer. After 12 months of radiation therapy, magnetic resonance imaging showed tumors in the uterine cavity, and positron emission tomography-computed tomography showed no tumors, except uterine tumors. Since radiation therapy-induced cervical stenosis was conducted, endometrial examination could not be performed without anesthesia. As these tumors were detected after radiation therapy for uterine cancer, malignancy was considered. A laparoscopic-assisted transcervical hysteroscopic resection was performed for the diagnosis and treatment of uterine tumors after radiation therapy. This operative method was useful and enabled us to perform complete resection, observe the abdominal cavity, prepare for the possibility of secondary hysterectomy, and improve safety.

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.

Glioblastoma multiforme as a secondary malignancy following stereotactic radiosurgery of a meningioma: case report

The documentation and exact incidence of stereotactic radiosurgery (SRS)-induced neoplasia is not well understood, with most literature restricted to single case reports and single-center retrospective reviews. The authors present a rare case of radiosurgery-induced glioblastoma multiforme (GBM) following radiosurgical treatment of a meningioma. A 74-year-old patient with a sporadic meningioma underwent radiosurgery following surgical removal of a WHO grade II meningioma. Eighteen months later she presented with seizures, and MRI revealed an intraaxial tumor, which was resected and proven to be a glioblastoma. As far as the authors are aware, this case represents the third case of GBM following SRS for a meningioma. This report serves to increase the awareness of this possible complication following SRS. The possibility of this rare complication should be explained to patients when obtaining their consent for radiosurgery.

Association between Long-Term Second Malignancy Risk and Radiation: A Comprehensive Analysis of the Entire Surveillance, Epidemiology, and End Results Database (1973-2014)

Purpose

Second malignancies (SMs) after radiation therapy are rare but serious sequelae of treatment. This study investigates whether radiation therapy use is associated with changes in baseline SM risk.

Methods and Materials

We extracted all patients with cancer, with or without SM, in the Surveillance, Epidemiology, and End Results database from 1973 to 2014. Cumulative incidence of SM for patients stratified by radiation therapy status was calculated using a competing risk model, both for the entire cohort and for subgroups based on the primary tumor's anatomic location.

Results

We identified 2,872,063 patients with cancer, including 761,289 patients who received radiation therapy and 2,110,774 who did not. The SM rate at 20 years for patients receiving radiation therapy versus no radiation therapy was 21.4% versus 18.8%. The relative risk for SM associated with radiation therapy for the overall group was 1.138 at 20 years. The relative risks for SM associated with radiation therapy to malignancies arising from central nervous system and orbits, head and neck, thorax, abdomen, and pelvis at 20 years were 0.704, 1.011, 0.559, 0.646, and 1.106 for men and 0.792, 1.298, 1.265, 0.780, and 0.988 for women, respectively.

Conclusions

The association between SM and radiation therapy varies with both sex and disease anatomic location, with the largest increase in SM seen in females irradiated to the head and neck region. Overall, the absolute change in SM rates associated with radiation therapy remains small, with differences in various clinical contexts.

Myofibroblastic sarcoma of the breast. Report of a case induced by radiotherapys

Myofibroblastic sarcoma (MFS) is an uncommon tumor rarely located in the breast. Ionizing radiation is a carcinogen capable of inducing sarcomas through DNA damage. A 42-year-old woman was diagnosed with synchronous bilateral breast infiltrating ductal carcinoma with axillary lymph node metastases on the left side. After modified left radical mastectomy and simple right mastectomy, she underwent postoperative radiation with a total volume dose of 50 Gy that included the thoracic wall and the left axillary-supraclavicular region. After a latency period of 6 years and 4 months, the patient developed an MFS in the area of radiation (mammary upper outer quadrant). To our knowledge, only 11 cases of MFS have been previously published in the breast. The study of the 12 cases including the present one revealed that the ages of the patients ranged from 42 to 86 years (mean 60.3 years). There was a clear difference concerning sex (M:F, 1:5). The average duration of the lesion varied from 1 week to 8 months (mean 3.3 months). The size ranged from 2.2 to 22 cm (average 5.1 cm). The tumors showed frequent mitosis and areas of necrosis. The percentage of recurrences, metastasis, and death due to the tumor was 27.3%, 36.4%, and 27.3% respectively. MFS cases differ from those affecting extramammary regions. They are more common in females and show a greater degree of aggressiveness. Correct diagnosis of mammary MFS requires morphological and immunohistochemical study. We present for the first time a case of MFS of the breast induced by radiotherapy.

Management of localized extremity and retroperitoneal soft tissue sarcoma

The optimal management of localized soft tissue sarcomas of the extremities and retroperitoneum involves a high volume multidisciplinary team with expertise in sarcoma. In this review, we will highlight the importance of the sarcoma pathologist and imaging techniques prior to surgery and radiation. In addition, the data on neoadjuvant and adjuvant chemotherapy will be discussed. Finally, consideration is given to the importance of identifying genetic cancer predispositions, multidisciplinary management, long-term survivorship, and the current clinical trials for patients undergoing curative intent management.

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.

Proposal for Modification of Cahan's Criteria Utilizing Molecular Genetic Analyses for Cases without Baseline Histopathology: A Unique Method Applicable to Primary Radiosurgery

Background  Cahan's criteria have been utilized since 1948 to establish causality between prior radiation treatment and the development of secondary malignancy. One major criterion specifies that histological and radiographic evidence collected before and after radiation treatment must confirm separate tumor types; however, pretreatment biopsy is rarely obtained prior to radiosurgery for vestibular schwannoma and many other skull base and cranial lesions. Therefore, in these cases Cahan's criteria cannot be validly applied. Objective  This article proposes an update to Cahan's criteria using modern molecular genetic analysis for cases lacking baseline histopathology. Methods  Mate-pair sequencing and whole exome sequencing of a cerebellopontine angle undifferentiated high-grade pleomorphic sarcoma (UHGPS) that developed after stereotactic radiosurgery of a presumed benign vestibular schwannoma. Results  Mate-pair sequencing and whole exome sequencing of the sarcoma revealed complex chromosomal aberrations. Notably, the tumor contained a deletion in the NF2 gene at 22q12 and an in-frame deletion on exon 5 of the remaining copy of NF2 . Biallelic events impacting NF2 are atypical for UHGPS but are characteristic for vestibular schwannoma. These findings help support the conclusion that the UHGPS arose from a benign vestibular schwannoma all along. Conclusions  Next-generation sequencing can be successfully applied to a radiation-induced sarcoma when both the original and malignant tumors harbor separate signature genetic markers. As our understanding of the genetic profile of various tumors expand, we believe that next-generation sequencing and other genomic tools will play an increasingly important role in establishing causality between radiation and the development of secondary malignancy.

Risk of secondary rectal cancer and colon cancer after radiotherapy for prostate cancer: a meta-analysis

PURPOSE

To investigate whether radiotherapy for prostate cancer increases the risk of therapy-related rectal cancer and colon cancer.

METHODS

A systematic literature search was carried out using the Medline (PubMed), EMBASE, and the Cochrane Library to identify studies examining the association between radiotherapy for prostate cancer and secondary colorectal cancer (rectal cancer and colon cancer) published before March 19, 2018. The risk of second colorectal cancer after radiotherapy was summarized using unadjusted odds ratio (OR) and adjusted hazard ratio (HR) with their 95% confidence interval (CI). Subgroup and sensitivity analyses were conducted to detect potential bias and heterogeneity.

RESULTS

After study selection, 16 reports were retrieved for analysis. When patients received radiotherapy compared with those unexposed to radiation, there was an increased risk of the rectal cancer (OR 1.37, 95%CI 1.01 to 1.85), but not colon cancer. According to adjusted HR, there was an increased risk of the rectal cancer (HR 1.64, 95%CI 1.39 to 1.94), and colon cancer (HR 1.33, 95%CI 1.02 to 1.76). The OR for rectal cancer showed an increased risk with longer latent period (5 years lag time versus 10 years lag time, OR: 1.56 versus 2.22). Brachytherapy had no association with second cancer across all analyses.

CONCLUSIONS

Radiotherapy was associated with an increased risk of subsequent rectal cancer compared with patients unexposed to radiation. Colon may be free from the damage of radiation. Brachytherapy had no association with second rectal cancer or colon cancer.

Radiation-Induced Sarcoma Originating in Recurrent Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma is a benign disease affecting young males with a propensity to invade intracranially and into the orbit along preformed pathways. Complete surgical excision is the mainstay of management. Patients with multiple recurrences along with tumour extension into skull base and orbit can be considered for external beam radiation as either adjuvant or definitive treatment. Possibility of radiation-induced malignancy has been speculated by many authors, proof of which exists in only two studies so far. This report focuses on radiation-induced leiomyosarcoma in a patient with recurrent juvenile nasopharyngeal angiofibroma.

Radiation-induced chondrosarcoma of the scapula after radiotherapy for lung cancer: a case report and review of the literature

Background

Radiotherapy associated with chemotherapy is a well-established treatment modality for locally advanced non-small cell lung cancers. Radiation-induced second malignancies, particularly radiation-induced sarcomas, are rare. Some authors reported a recent increase in the incidence of this rare complication, especially because of the improved prognosis and survival of patients after radiotherapy. Pathogenic mechanisms of radiation-induced sarcomas are poorly understood. However, diagnosis criteria are well established. Treatment options must be discussed and adapted to the patient’s profile. Surgery in irradiated tissue is challenging, with limited treatment options with chemotherapy and radiotherapy.

Case presentation

We report the case of a 62-year-old Moroccan man diagnosed as having chondrosarcoma of his right scapula, who was irradiated 10 years ago for stage IIIB non-small cell lung cancer. This case was managed by a complete resection of the tumor with good functional and oncological outcomes. To the best of our knowledge, the scapular location of radiation-induced sarcoma after irradiation for lung cancer has never been described in the literature.

Conclusion

Radiation-induced sarcoma of the scapula represents a rare situation that must be actively researched to have access to an optimal therapeutic approach.

Primary Intracranial Extraskeletal Mesenchymal Chondrosarcoma: Clinical Mimicry as Glomus Jugulare

BACKGROUND

Extraskeletal mesenchymal chondrosarcoma (ESMCS) is an unusual pathologic variant of chondrosarcoma. There are no specific clinicoradiographic parameters to distinguish it from other intracranial pathologies. The diagnosis can be established only on the basis of histopathology, which may pose significant challenges in certain unusual locations.

PURPOSE

In this case, we discuss the pitfalls in diagnosis, management, and major characteristics of ESMCS with a review of current literature.

METHODS AND RESULTS

A 47-year-old female patient presented with a jugular foramen tumor which was misdiagnosed as glomus jugulare tumor for which she received primary gamma knife radiosurgery at 2 instances. But unfortunately, the patient died because of the increase in size of the lesion associated with necrosis. Autopsy analysis revealed a highly cellular tumor, rich in sarcomatous cells, and well-differentiated cartilages consistent with ESMCS.

CONCLUSION

A definite preoperative diagnosis of ESMCS is crucial though difficult especially when located at complex sites like jugular foramen and clinicoradiological mimicry. The most crucial step in the management of ESMCS is accurate diagnosis with critical evaluation of clinical, radiological, and histopathological parameters and realization of highly variable clinical course of the disease.

Secondary uterine carcinosarcoma after concurrent chemoradiotherapy for cervical cancer: Case reports

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Secondary uterine sarcomas occur in < 1% of patients treated with CCRT.

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Secondary uterine sarcomas can occur > 5 years from CCRT.

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The median survival period from the secondary tumor occurrence was only 4 months.

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All our patients had heterologous carcinosarcoma of the uterine corpus.

Survival and Margin Status in Head and Neck Radiation-Induced Sarcomas and De Novo Sarcomas

Objective To describe histologic subtypes and oncologic outcomes among patients with radiation-induced and de novo sarcomas of the head and neck. Study Design Retrospective case series with chart review. Setting Tertiary academic center. Subject and Methods In total, 166 adult patients with sarcoma of the head and neck treated from January 1, 1985, to January 1, 2010, were included. Tumors were characterized as radiation induced (15.1%) vs de novo sarcomas (84.9%). Clinical and tumor characteristics were compared. The primary outcomes were overall survival (OS) and disease-specific survival (DSS). Results Radiation-induced sarcomas were more likely to be high grade ( P = .006) and advanced stage ( P = .03). Chondrosarcoma was more common in de novo tumors ( P = .02) while leiomyosarcoma ( P = .01), sarcoma not otherwise specified ( P = .02), and undifferentiated pleomorphic sarcoma ( P < .001) were more common in radiation-induced sarcomas. Radiation-induced sarcomas were associated with statistically significantly worse DSS ( P = .019) and OS ( P = .005) compared with de novo sarcomas, but when only high-grade soft tissue sarcomas were analyzed, neither DSS ( P = .48) nor OS ( P = .29) differed. Margin status was a significant predictor of survival as both R0 and R1 resections correlated with statistically better DSS and OS compared with R2 ( P < .001) resections and patients treated with radiation therapy/chemoradiation therapy alone ( P = .005). Conclusion Radiation-induced sarcomas of the head and neck correlate with worse survival compared with de novo tumors; however, when controlling for tumor grade and resection status, there is no statistically significant difference in observed outcomes.

Surgical Management of the Radiated Chest Wall and Its Complications

Radiation to the chest wall is common before resection of tumors. Osteoradionecrosis can occur after radiation treatment. Radical resection and reconstruction can be lifesaving. Soft tissue coverage using myocutaneous or omental flaps is determined by the quality of soft tissue available and the status of the vascular pedicle supplying available myocutaneous flaps. Radiation-induced sarcomas of the chest wall occur most commonly after radiation therapy for breast cancer. Although angiosarcomas are the most common radiation-induced sarcomas, osteosarcoma, myosarcomas, rhabdomyosarcoma, and undifferentiated sarcomas also occur. The most effective treatment is surgical resection. Inoperable tumors are treated with chemotherapy, with low response rates.

Secondary Craniofacial Sarcomas Following Retinoblastoma: A Systematic Review

OBJECTIVE

We conducted the largest systematic review of individual patient data to characterize secondary craniofacial sarcomas following retinoblastoma.

METHODS

We conducted a systemic search of the PubMed databases and compiled a comprehensive literature review. Student t tests were used to evaluate differences between variables. Kaplan-Meier analysis was used to estimate survival. Statistical significance was assessed using a log-rank test.

RESULTS

We analyzed 220 cases of secondary craniofacial sarcomas, including 112 osteosarcomas. The average age (±SD) of onset for retinoblastoma was 1.20 ± 2.77 years. External-beam radiotherapy was delivered in 207 patients (94.0%) and chemotherapy was delivered in 53 patients (24.0%) patients. The latency period between retinoblastoma diagnosis and the onset of secondary sarcomas was 12 years. Cranial extension was found in 66 patients (30.0%). The median overall survival was worse with cranial extension (P = 0.0073). In cranial extended patients, the median survival in patients who received chemotherapy was 41 months, whereas patients who did not receive chemotherapy had a median survival of 12 months (P = 0.0020).

CONCLUSIONS

The risk of incidence of secondary sarcomas in retinoblastoma patients warrants longer follow-up periods. Moreover, chemotherapy should be considered as a potential treatment option for secondary cranial sarcomas following retinoblastoma.

Pattern of solid and hematopoietic second malignancy after local therapy for prostate cancer

BACKGROUND AND PURPOSE

Second malignancies (SM) after external beam radiotherapy (EBRT) or brachytherapy (BT) for prostate cancer (PCa) are rare but serious sequelae.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify men diagnosed with cT1-2N0M0 PCa between 1999 and 2005, who underwent EBRT, BT or radical prostatectomy (RP). Patients with time interval to second malignancy or follow-up shorter than five and two years were excluded for solid and hematopoietic SM analyses respectively. Risks for solid and hematopoietic SM were evaluated via the multivariate Fine and Gray proportional hazards model.

RESULTS

EBRT and BT resulted in similar increases in solid and hematopoietic SM compared to RP. In subgroup analysis stratified by treatment modality, only the EBRT cohort demonstrated significantly decreased solid and hematopoietic SM in years 2002-2005 compared to years 1999-2001, with adjusted-hazard ratios of 0.752 (p=0.001) and 0.815 (p=0.018) respectively.

CONCLUSIONS

EBRT and BT resulted in statistically equivalent increase in both solid and hematopoietic SM compared to RP. EBRT in more recent years resulted in significantly decreased solid and hematopoietic SM, coinciding with increased utilization of IMRT.

Radiation-induced osteosarcoma of the skull base after radiation therapy in a patient with nasopharyngeal carcinoma: a case report and review of the literature

Background

Radiation-induced osteosarcomas are a recognized complication of radiation therapy. Owing to the fact that it is rare, publications on radiation-induced osteosarcoma of the skull base are limited to a small series and some case reports.

Case presentation

We describe a rare case of a patient with a skull base radiation-induced osteosarcoma treated 11 years before with ionizing radiation for an undifferentiated carcinoma of the nasopharynx. The patient was treated with chemotherapy alone, but he died after the third cycle.

Conclusions

Radiation-induced osteosarcoma of the skull base after treatment of nasopharyngeal carcinoma is a very rare but very aggressive complication with a poor prognosis. Chemotherapy gives bad results, and regular follow-up of treated patients should be considered.

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.

Radiation-induced Leiomyosarcoma of the Oral Cavity: A Rare Occurrence Detected on 18F-FDG PET/CT

Radiation-induced sarcomas (RIS) or postirradiation sarcomas have been reported as a rare long-term complication of radiation therapy (RT). The survival benefit offered by radiotherapy has been masked by an increase in the incidence of these sarcomas, thus making radiotherapy a double-edged sword. RIS generally develop with a mean latency period of 10-15 years and encompass different histological types. We report a case of oral leiomyosarcoma with a rather short latency period of 4 years after the radiotherapy of the prior oral squamous cell carcinoma (OSCC) detected on fluorine-18 (18F)-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT). The rarity of occurrence of leiomyosarcoma in the oral cavity is also highlighted.