Tumors after radiotherapy for skin hemangioma in childhood. A case-control study

Long-term outcomes of pediatric and young adult patients receiving radiotherapy for nonmalignant vascular anomalies

BACKGROUND

Nonmalignant vascular anomalies (VA) comprise a heterogeneous spectrum of conditions characterized by aberrant growth or development of blood and/or lymphatic vessels and can cause significant morbidity. Little is known about outcomes after radiotherapy in pediatric and young adult patients with nonmalignant VA.

METHODS

Thirty patients who were diagnosed with nonmalignant VA and treated with radiotherapy prior to 2017 and before the age of 30 were identified. Clinical and treatment characteristics and outcomes were recorded.

RESULTS

Median age at first radiotherapy was 15 years (range 0.02-27). Median follow-up from completion of first radiotherapy was 9.8 years (range 0.02-67.4). Lymphatic malformations (33%), kaposiform hemangioendothelioma (17%), and venous malformations (17%) were the most common diagnoses. The most common indication for first radiotherapy was progression despite standard therapy and/or urgent palliation for symptoms (57%). After first radiotherapy, 14 patients (47%) had a complete response or partial response, defined as decrease in size of treated lesion or symptomatic improvement. After first radiotherapy, 27 (90%) required additional treatment for progression or recurrence. Long-term complications included telangiectasias, fibrosis, xerophthalmia, radiation pneumonitis, ovarian failure, and central hypothyroidism. No patient developed secondary malignancies. At last follow-up, three patients (10%) were without evidence of disease, 26 (87%) with disease, and one died of complications (3.3%).

CONCLUSIONS

A small group of pediatric and young adult patients with nonmalignant, high-risk VA experienced clinical benefit from radiotherapy with expected toxicity; however, most experienced progression. Prospective studies are needed to characterize indications for radiotherapy in VA refractory to medical therapy, including targeted inhibitors.

Cancer mortality after radiotherapy for a skin hemangioma during childhood

BACKGROUND AND PURPOSE

A cohort study was performed as part of a European Radiation Protection Program to investigate the carcinogenic effect of treatment with ionizing radiation in early childhood. This paper presents mortality after radiotherapy in this cohort.

PATIENTS AND METHODS

The cohort comprised 7037 patients under 15 years of age treated for a skin hemangioma between 1940 and 1973 at the Institut Gustave-Roussy, among whom 4940 received radiotherapy. The vital status and causes of death were obtained as well as the mortality rates in the general French population. External and internal analyses were performed. Standardized mortality ratio (SMR) and relative risk (RR) variations according to exposure to radiotherapy or not and the type of treatment were studied.

RESULTS

During the 1969-1997 follow-up period, 16 cohort patients died of cancer, 14 after radiotherapy. A non-significant excess of cancer-related mortality was observed for irradiated patients as compared to the general population (SMR=1.53; 95% CI=0.86-2.48). Treatment with (226)Ra seemed to play a significant role (RR=2.53; 95% CI=0.84-7.07) compared to no radiotherapy.

CONCLUSION

This study suggests an excess risk of cancer-related mortality in patients treated during early childhood with radiotherapy for skin hemangioma, and especially with (226)Ra. These patients need to be followed up in the future.

Incidence of breast carcinoma in women with thyroid carcinoma

BACKGROUND

Breast carcinoma and differentiated thyroid carcinoma(the most common endocrine malignancy) occur predominantly in women. An association between the two tumors has been suggested by some investigators, but the potential impact of treatment of one of these diseases on the development of the other remains unclear. The authors examined the relation between the occurrence of these two tumors.

METHODS

There were 41,686 patients with breast carcinoma and 3662 with thyroid carcinoma who registered at The University of Texas M. D. Anderson Cancer Center between March 1944 and April 1997. Women who received both diagnoses since 1976 were identified and incidence rates and relative risks of secondary tumor development were calculated. Surveillance, Epidemiology and End Results (SEER) program data on the age-adjusted incidences of these diseases during the same time period were used for the expected incidences in the same population.

RESULTS

Among 18,931 women with a diagnosis of breast carcinoma since 1976, 11 developed differentiated thyroid carcinoma > or = 2 years after the diagnosis of breast carcinoma. These breast carcinoma patients contributed 129,336 person-years of follow-up; the observed incidence of thyroid carcinoma in this group was not different from that in a similar age group of women in the SEER database. Among 1013 women with a diagnosis of thyroid carcinoma since 1976, 24 developed breast carcinoma > or = 2 years after the diagnosis of thyroid carcinoma. These thyroid carcinoma patients contributed 8380 person-years of follow-up; the observed incidence of breast carcinoma in women ages 40-49 years was significantly higher than the expected incidence for women in the same age group in the SEER database.

CONCLUSIONS

Breast carcinoma developing after thyroid carcinoma was diagnosed more frequently than expected in young adult women seen at the study institution since 1976. This potential association and plausible mechanisms of breast carcinoma development after thyroid carcinoma should be evaluated in larger cohorts of patients.

Head and neck radiation carcinogenesis: epidemiologic evidence

This article provides an overview of the long-term carcinogenic effects of medical radiation exposure to the head and neck and focuses on studies that allow risk quantification. The thyroid gland in children is extremely sensitive to the tumorigenic effects of external radiation for many years after exposure. Risk of thyroid cancer decreases with increasing age at exposure, with little risk, if any, apparent among persons exposed as adults. Large risks of neural tumors have been reported after moderate- and high-dose radiotherapy in childhood; however, the magnitude of the risk at low doses and for adult exposures is unclear. Data on salivary gland tumors are limited but tend to support an association with radiation exposure. In contrast, the pituitary gland appears to be relatively resistant to the tumorigenic effects of radiation. Several cohort studies have reported an increased risk of hyperparathyroidism among irradiated populations. In summary, radiation exposure to the head and neck can result in tumors of the thyroid, salivary, and parathyroid glands, as well as the brain and central nervous system.

Radiation-induced thyroid neoplasia

Thyroid cancer is a well documented late effect of exposure to ionizing radiation. The excess risk begins 5-10 years after exposure and continues until at least 40 years after exposure. Females are roughly three times more susceptible to both radiogenic thyroid cancer and to thyroid cancer of other origins than are males. Therefore, relative risk estimates for radiogenic thyroid cancer do not necessarily differ by sex. The excess risk is higher among children exposed prior to five years of age than in those exposed later. The risk for radiogenic cancer following exposure to 131I appears to be lower than that following exposure to high dose-rate external irradiation, and in the Swedish diagnostic study 131I was nearly one fourth as efficient as external X-rays in inducing thyroid cancer. The Swedish data suggest that 131I is substantially less efficient in inducing thyroid cancer than high dose-rate exposures. In that study, however, 95% of the exposed individuals were 20 years or older (mean age 45 years).

Cancer occurring after radiotherapy and chemotherapy

Radiotherapy and chemotherapy can effectively control cancer but can also cause new cancers to develop as long-term complications. Almost all types of cancer have been associated with radiotherapy. The breast, thyroid, and bone marrow are the organs most susceptible to radiation carcinogenesis. The bone marrow is also most frequently involved by chemotherapy and the leukemia risk is much higher than after radiotherapy. The combination of intensive radiotherapy and chemotherapy is particularly leukemogenic. The latent period between radiotherapy/chemotherapy and the appearance of a second primary cancer ranges from a few years to several decades. The risk for a second primary cancer following radiotherapy or chemotherapy emphasizes the need for life long follow-up of patients receiving such treatments. This is particularly the case in individuals with long life expectancy, for example, patients treated for childhood neoplasms. The benefits of radiotherapy and chemotherapy in oncology exceed the risks for second primary cancers. Efforts should be directed towards identifying those patients who will benefit from the treatments so that only they are exposed to the risk.