Is there a role for adjuvant therapy in radiation-induced angiosarcoma of the breast? A case report and review of the literature

BACKGROUND

Angiosarcoma (AS) of the breast is very rare, accounting for 1% of all soft tissue breast tumors. AS may present as primary tumors of the breast or as secondary lesions usually associated with previous radiotherapy. Commonly, secondary AS affects older women (median age 67-71 years) with a clinical history of breast cancer. The preferred site of onset of RIAS is the edge of radiation fields, where radiation doses and tumor necrosis may be heterogeneous, resulting in a DNA damage and instability. Radical surgery is the treatment of choice, but no clear consensus exists on surgical management of breast AS.

CASE REPORT

We describe an atypical case of relapsed RIAS after radical mastectomy, treated with new surgery and, considering the higher risk of recurrence, subsequent adjuvant chemotherapy with weekly paclitaxel.

CONCLUSIONS

The frequency of radiation-induced angiosarcomas (RIAS) after breast-conserving surgery and radiotherapy has been increased to 0.14-0.5% among long survivors. Nevertheless, even if RIAS continues to be prognostically an extremely unfavorable cancer due to a high rate of recurrence, distant spread, and median overall survival (OS) of about 60 months, the benefits of loco-regional breast radiotherapy are clearly higher than the risk in developing angiosarcoma.

Exercise Improves Cancer-free Survival and Health Span in a Model of Radiation-induced Cancer

INTRODUCTION

Radiation therapy increases the risk of secondary malignancy and morbidity in cancer survivors. The role of obesity and exercise training in modulating this risk is not well understood. As such, we used a preclinical model of radiation-induced malignancy to investigate whether diet-induced obesity and/or endurance exercise training altered lifelong survival, cancer incidence, and morbidity.

METHODS

Male CBA mice were randomly divided into control diet/sedentary group (CTRL/SED), high-fat diet (45% fat)/sedentary group (HFD/SED), control diet/exercise group (2-3 d·wk-1; CTRL/EX), or high-fat diet/exercise group (HFD/EX) groups then exposed to whole-body radiation (3 Gy). End point monitoring and pathology determined mortality and cancer incidence, respectively. Health span index, a measure of morbidity, was determined by a composite measure of 10 anthropometric, metabolic, performance, and behavioral measures.

RESULTS

Overall survival was higher in HFD/SED compared with CTRL/SED (P < 0.05). The risk of cancer-related mortality by 18 months postradiation was 1.99 and 1.63 in HFD/SED compared with CTRL/EX (RR = 1.99, 95% confidence interval = 1.20-3.31, P = 0.0081) and CTRL/SED (RR = 1.63, 95% confidence interval = 1.06-2.49, P = 0.0250), respectively. The number of mice at end point with cancer was higher in HFD/SED compared with CTRL/EX and CTRL/SED (P < 0.05). Health span index was highest in CTRL/EX (score = +2.5), followed by HFD/EX (score = +1), and HFD/SED (score = -1) relative to CTRL/SED.

CONCLUSION

This work provides the basis for future preclinical studies investigating the dose-response relationship between exercise training and late effects of radiation therapy as well as the mechanisms responsible for these effects.

Coexistence of Radiation-Induced Meningioma and Moyamoya Syndrome 10 Years after Irradiation against Medulloblastoma: a Case Report

Radiotherapy is one of the standard treatments for medulloblastoma. However, therapeutic central nervous system irradiation in children may carry delayed side effects, such as radiation-induced tumor and vasculopathy. Here, we report the first case of coexisting meningioma and moyamoya syndrome, presenting 10 years after radiotherapy for medulloblastoma. A 13-year-old boy presented with an enhancing mass at the cerebral falx on magnetic resonance imaging (MRI) after surgery, radiotherapy (30.6 Gy craniospinal axis, 19.8 Gy posterior fossa) and chemotherapy against medulloblastoma 10 years ago, previously. The second tumor was meningioma. On postoperative day 5, he complained of right-sided motor weakness, motor dysphasia, dysarthria, and dysphagia. MRI revealed acute cerebral infarction in the left frontal lobe and both basal ganglia. MR and cerebral angiography confirmed underlying moyamoya syndrome. Four months after the meningioma surgery, the patient presented with headaches, dysarthria, and dizziness. Indirect bypass surgery was performed. He has been free from headaches since one month after the surgery. For patients who received radiotherapy for medulloblastoma at a young age, clinicians should consider the possibility of the coexistence of several complications. Careful follow up for development of secondary tumor and delayed vasculopathy is required.

Ventricular tachycardia associated with radiation-induced cardiac sarcoma

Cardiac tumors can lead to distinct electrocardiographic changes and ventricular arrhythmias. Benign and malignant cardiac tumors have been associated with ventricular tachycardia. When possible, benign tumors should be resected when ventricular arrhythmias are intractable. Chemotherapy can shrink malignant tumors and eliminate arrhythmias. We report the case of a 52-year-old woman with breast sarcoma whom we diagnosed with myocardial metastasis after she presented with palpitations. The initial electrocardiogram revealed sinus rhythm with new right bundle branch block and ST-segment elevation in the anterior precordial leads. During telemetry, hemodynamically stable, sustained ventricular tachycardia with right ventricular localization was detected. Images showed a myocardial mass in the right ventricular free wall. Amiodarone suppressed the arrhythmia. To our knowledge, this is the first report of ventricular tachycardia associated with radiation-induced undifferentiated sarcoma. We discuss the distinct electrocardiographic changes and ventricular arrhythmias that can be associated with cardiac tumors, and we review the relevant medical literature.

Sunlight, vitamin D and malignant melanoma: an update

Solar radiation represents an essential requirement for life, not only by spending the thermal energy for photosynthesis in plants, which provides our atmosphere with oxygen, but also by facilitating the cutaneous synthesis of vitamin D in vertebrates and many other organisms. It is well known that humans and most vertebrates have to obtain an adequate source of vitamin D, in order to develop and maintain a healthy mineralized skeleton and in order to be protected against cancer and a broad variety of other diseases. On the other hand, solar UV radiation can be assumed to be the most relevant environmental carcinogen causing melanoma and nonmelanoma skin cancer with increasing incidences. During the last decades, epidemiological studies and experimental animal models, including genetically engineered mice, the Xiphophorus hybrid fish, the south american oppossum and human skin xenografts, have further elucidated the multi-step process of UV-induced melanomagenesis. It has to be emphasized that, in contrast to intermittent, short-term high-dose solar UV-exposure, more chronic less intense exposure (which is recommended by many experts in the field to obtain a sufficient vitamin D status) has not been found to be a risk factor for the development of melanoma and in fact has been found in several studies to be protective. Interestingly, several independent lines of investigation have demonstrated convincing evidence that vitamin D and/or analogs may be effective in the prevention and treatment of melanoma. This essay summarizes our present understanding about the pathogenic role of UV radiation and of vitamin D for malignant melanoma.

Radon and the risk of cancer mortality--internal Poisson models for the German uranium miners cohort

Uranium mining occurred between 1946 and 1990 at the former Wismut mining company in East Germany. 58,987 male former employees form the largest single uranium miners cohort, which has been followed up for causes of mortality occurring from the beginning of 1946 to the end of 2003. The purpose of this paper is to present the radon exposure related cancer mortality risk based on 20,920 deaths, 2 million person-years, and 6,373 cancers. The latter include 3,016 lung cancers and 3,053 extrapulmonary solid cancers. Internal Poisson regression was used to estimate the excess relative risk (ERR) per unit of cumulative radon exposure in Working Level Months (WLM) for all major sites and for the follow-up period from 1946 to 2003. The simple cohort ERR WLM for lung cancer is 0.20% [95% confidence interval (CI): 0.17%; 0.22%]. The ERR model for lung cancer is linear in radon exposure with exponential effect modifiers that depend on age at median exposure, time since median exposure, and radon exposure-rate. In this model the central estimate of ERR WLM is 1.06% (95% CI: 0.69%; 1.42%) for an age at median exposure of 33 y, a time since median exposure of 11 y, and an exposure-rate of 2.7 WL. This central ERR decreases by 5% for each unit exposure-rate increase. The ERR decreases by 32% with each decade increase in age at median exposure and also decreases by 54% with each decade increase in time since median exposure. The ERR WLM for all extrapulmonary solid cancers combined without effect modification is 0.014% (95% CI: 0.006%; 0.023%). The ERR model for extrapulmonary solid cancer is linear in radon exposure with an exponential effect modifier which depends on age-attained. In this model the central estimate of ERR WLM is 0.040% (95% CI: -0.001%; 0.082%) for an age-attained of 44. The ERR decreases by 37% with each decade increase in age-attained. The highest ERR WLM, after lung, is observed for cancers of the pharynx (0.16%), tongue/mouth (0.045%), and liver (0.04%).

Improving the interpretation of bone marrow imaging in cancer patients

Magnetic resonance imaging (MRI) is the best technique for bone marrow imaging. The MRI signal of bone marrow depends on the quantity of fat it contains and on its cellularity. Evaluation of marrow of patients treated for cancer is complicated by age and osseous site related changes in the distribution of normal haematopoietic (red) and fatty (yellow) marrow and by the changes induced by treatments: decrease in pathological cellularity, increase in fat proportion, conversion of red marrow to fatty marrow or, conversely, reconversion of fatty marrow in normal haematopoietic red marrow. The treatments used in oncology modify pathological marrow but also normal marrow and may sometimes lead to complications. These modifications may be focal or diffuse, homogeneous or patchy and symmetrical or asymmetric. The knowledge of bone marrow physiological status and post-therapeutic patterns is important for the interpretation of marrow disorders and effects of therapy and to avoid false-positive diagnosis of marrow metastases and tumour progression. The aim of this paper is to recall the MRI patterns of normal bone marrow and normal variations and to show the effects of treatments on bone tissue and normal bone marrow and treatment-related modifications on pathological marrow.

Central nervous system lymphoma in children

This paper describes the rare MR and CT features of central nervous system (CNS) lymphoma in immunocompetent children and in survivors of childhood acute lymphoblastic leukemia (ALL) and discusses the causative role of cranial irradiation and/or leukoencephalopathy preceding central nervous system (CNS) lymphoma in survivors of childhood leukemia. The authors reviewed MR and CT scans of 3 children with biopsy-proved CNS lymphoma. One child had tumor infiltration within the optic nerve sheaths and optic chiasm by previously known non-Hodgkin lymphoma. In 2 patients, CNS lymphoma developed 8 and 10 years after initial ALL treatment. In both cases CNS lymphoma was preceded by cranial irradiation and leukoencephalopathy. A single lesion was present in 3 out of 4 patients. All lesions were isointense or hypointense on the T1-weighted images relative to gray matter and showed homogeneous enhancement. One lesion was centered in the central gray matter, one lesion was centered within a cerebral hemisphere, one lesion was in optic nerve, and there were 2 parasellar lesions. CNS lymphoma has a variable appearance in children. Knowledge of risk factors in children may help in the early recognition of disease, allowing for timely intervention. This may prompt early biopsy or a conservative management in the appropriate clinical setting.

Radiation-induced malignant triton tumor associated with severe spinal cord compression. Case report and review of the literature

Malignant triton tumor (MTT) is a variant of malignant peripheral nerve sheath tumors. The authors report a case of radiation-induced MTT in a patient with severe cervicothoracic cord compression and review the related literature. This 36-year-old man presented with pain and weakness in his left arm. His medical history was significant for a biopsy procedure involving the sampling of an aneurysmal bone cyst located at T1-3 near the left lung apex; this was performed 6 years prior to presentation and was followed by radiotherapy. Neurological examination demonstrated radicular findings involving the left C-8 and T-1 nerve roots. Neuroimaging studies revealed a large mass lesion extending from C-6 to T-2 along the vertebral column, invading the upper thoracic cavity and the adjacent lung apex, and infiltrating the paravertebral muscles. A subtotal resection was performed, but the tumor regrew extensively within a short time. It invaded the spinal canal and caused significant cord compression. The patient underwent surgery two more times for tumor debulking and to relieve progressive airway and spinal canal compromise. He eventually became quadriplegic, however, and died 13 months after diagnosis of MTT. This is the seventh case of radiation-induced MTT and the fifth of MTT with spinal canal involvement to be reported in the literature.

[Thoracic spinal cord compression by radiation-induced exostosis: a case report and review of the literature]

A 38-year old man developed compressive myelopathy due to radiation-induced osteochondroma at T7. The patient had been given radiotherapy at the age of 7 years for a lymphosarcoma situated at the lower part of the neck. Radiation is an exceptional cause of spinal compression which can be avoided by regular surveillance of patients given radiotherapy in the spinal area as children.

Cancer-related thrombotic microangiopathy secondary to Von Willebrand factor-cleaving protease deficiency

Cancer-related thrombotic microangiopathy (TM) is a serious complication with a short-term life-threatening prognosis. This complication shares certain similarities with thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, both characterized by circulating platelet aggregates containing ultralarge multimers of Von Willebrand factor (VWF). We report a case of cancer-related thrombotic microangiopathy secondary to disseminated metastatic cancer with undetectable serum Von Willebrand factor-cleaving protease activity and no evidence of serum inhibitory antibody. A concomitant decrease of Ca 19-9 level and hemolysis was observed during chemotherapy, in parallel with normalization of Von Willebrand factor-cleaving protease activity. The role of ultralarge multimers of Von Willebrand factor in platelet aggregation in the context of metastatic disease is discussed with respect to our findings in this case of cancer-related thrombotic microangiopathy.

Radiation-induced osteochondroma of the T4 vertebra causing spinal cord compression

A case of a radiation-induced osteochondroma arising from the vertebral body of T4 in an 18-year-old man is reported. The patient presented with a history of progressive left lower extremity weakness. At 7 years of age, he had undergone resection of a cerebellar medulloblastoma and received adjunctive craniospinal irradiation and systemic chemotherapy. Both CT and MR imaging revealed an extradural mass contiguous with the posteroinferior endplate of the T4 vertebral body. This case indicates that radiation-induced osteochondroma should be considered in the differential diagnosis of patients with symptoms of myelopathy or nerve root compression and a history of radiation therapy involving the spine in childhood.

A newly recognized syndrome--radiation-related bronchiolitis obliterans and organizing pneumonia. A case report and literature review

Bronchiolitis obliterans and organizing pneumonia (BOOP) is a syndrome that has been associated with a variety of underlying disorders, including infection, collagen vascular diseases and toxic fume inhalation. Rarely, however, BOOP has been associated with radiation- or chemotherapy-induced pulmonary toxicity. Over the past 3 years, several case series have reported BOOP in the unique setting of radiation in breast cancer patients. This study describes our experience with this newly recognized syndrome and a review of the English-language literature on this syndrome.

Radiation induced vertebral osteosarcoma following treatment of an intradural extramedullary spinal cord tumor in a dog

A 2-year-old neutered female Rottweiler diagnosed with an intradural extramedullary spinal cord tumor at T12-T13 was successfully treated with cytoreductive surgery followed by Cobalt 60 teletherapy. The dog was euthanised 5-and-a-half years later following diagnosis of an osteosarcoma involving the L1 and L2 vertebrae. Evidence of the initial tumor was not present at necropsy. The vertebral neoplasm fulfilled all of the accepted criteria for a radiation induced tumor. It was concluded that adjunctive irradiation should be considered for treatment of intradural extramedullary tumors of young dogs when total surgical resection is not possible. Although tumor induction is a rare late effect of radiation therapy, the risk of this occurrence should be considered when irradiating young animals. Radiation induced tumors in dogs have been associated with coarse fractionation schemes, or when large intraoperative doses have been administered. A lower dose per fraction, e.g., 3 Gy/fraction or less, is advisable when irradiating young dogs or any dog in which the life expectancy is 3-5 or more years after irradiation.

UV-induced skin carcinogenesis in xeroderma pigmentosum group A (XPA) gene-knockout mice with nucleotide excision repair-deficiency

Nucleotide excision repair (NER) removes a wide variety of lesions from the genome and is deficient in the genetic disorder, xeroderma pigmentosum (XP). In this paper, an in vitro analysis of the XP group A gene product (XPA protein) is reported. Results of an analysis on the pathogenesis of ultraviolet (UV)-B-induced skin cancer in the XPA gene-knockout mouse are also described: (1) contrary to wild type mice, significant bias of p53 mutations to the transcribed strand and no evident p53 mutational hot spots were detected in the skin tumors of XPA-knockout mice. (2) Skin cancer cell lines from UVB-irradiated XPA-knockout mice had a decreased mismatch repair activity and an abnormal cell cycle checkpoint, suggesting that the downregulation of mismatch repair helps cells escape killing by UVB and that mismatch repair-deficient clones are selected for during the tumorigenic transformation of XPA (-/-) cells. (3) The XPA-knockout mice showed a higher frequency of UVB-induced mutation in the rpsL transgene at a low dose of UVB-irradiation than the wild type mice. CC-->TT tandem transition, a hallmark of UV-induced mutation, was detected at higher frequency in the rpsL transgene in the XPA-knockout mice than the wild type mice. This rpsL/XPA mouse system will be useful for further analysing the role of NER in the mutagenesis induced by various carcinogens. (4) The UVB-induced immunosuppression was greatly enhanced in the XPA-knockout mice. It is possible that an enhanced impairment of the immune system by UVB irradiation is involved in the high incidence of skin cancer in XP.

Long-term comparative cancer mortality after use of radio-iodine in the treatment of hyperthyroidism, a fully reported multicenter study

BACKGROUND

The Cooperative Thyrotoxicosis Therapy Follow-up Study reported cancer mortality after use of radio-iodine (131I), surgery, and other treatments in patients with hyperthyroidism, started during 1946-1964 and followed through 1968. In 1984, the National Cancer Institute initiated a continued follow-up (FU) of the same cohort through 1990, to assess potential carcinogenic effects of 131I through 1990, a potential FU ranging from 26 to 44 years.

RESULTS

With an initial cohort of 35,630 hyperthyroid patients, a mean entry age of 46 years and 738,831 patient-years of FU, the 2950 observed cancer deaths were only minimally over the 2858 expected cancer deaths from US population rates, after exclusion of first-year deaths. In the 64.7% of patients receiving 131I, the total cancer deaths were significantly above expected (258 versus 208), only at durations of 1-5 years, not thereafter. Thyroid cancer deaths were significantly elevated, but the number was very small, only 24 deaths in all exposures, as compared with 5.89 expected. The overall thyroid cancer mortality was higher in cases of toxic nodular goiter than in patients with Graves' disease.

CONCLUSIONS

Despite the small early increase in total cancer deaths and the relatively higher increase in thyroid cancer deaths (only 18 excess deaths), the authors conclude that therapy with the doses of 131I used is a safe procedure. The interpretation of cause-specific excess mortality is greatly influenced by the prevalence of the cause of death.

Spontaneous epidural haematoma associated with radiation-induced malignant fibrous histiocytoma

We report a case of spontaneous epidural haemorrhage associated with metastatic radiation-induced malignant fibrous histiocytoma of the dural meninges in a patient who had been previously treated for nasopharyngeal carcinoma with radiotherapy.

Can we predict solar ultraviolet radiation as the causal event in human tumours by analysing the mutation spectra of the p53 gene?

The tumour suppressor gene, p53, has proved to be one of the genes most often modified in human cancers. These alterations consist mainly of point mutations located in the evolutionarily conserved sequences which render the protein inactive for its normal biological functions. In fact the p53 gene presents nearly 300 potential mutation sites whose analysis should enable the correlation of specific mutation spectra with different causal agents in cancer development. In this study we have analysed the mutation spectrum of the p53 gene in skin tumours from normal individuals and repair-deficient xeroderma pigmentosum (XP) patients in comparison with mutations found in internal cancers. Point mutations are mainly GC-->AT transitions in skin tumours (74% in non-XP, 87% in XP), and also to a lesser extent in internal tumours (47%) where, however, they are mainly located at CpG (63%) sequences probably due to the deamination of the unstable 5-MeC. Moreover, mutations are targeted at py-py sequences in over 90% of skin tumours whereas the distribution of mutations in internal malignancies is proportional to the frequency of py-py sites (61%) and other sequences (39%) at mutable sites. Indeed, in XP skin tumours 100% of the mutations are targeted at py-py sequences and 55% of these are tandem CC-->TT transitions considered as a signature of UV-induced lesions. In skin tumours from normal individuals, 14% of the p53 mutations are double mutations and as in XP skin tumours all these are CC-->TT transitions. In contrast, internal tumours rarely contain tandem mutations (0.8%), and of these only 2/14 were CC-->TT transitions. Finally, nearly all (95%) of the mutations in XP are located on the non-transcribed strand while internal or non-XP skin tumours do not show this strand bias. Hence, the mutation spectrum analysed in XP skin tumours also demonstrates for the first time the existence of preferential repair in humans. In conclusion, the specificity of UV-induced p53 mutation spectra in skin tumours shows that this gene is a particularly appropriate candidate for the correlation of mutation spectra with specific damaging agents.

Malignancies in fibrous dysplasia

BACKGROUND

Malignancies in fibrous dysplasia are rare. Most cases have been published as single case reports. The role of radiation therapy in the occurrence of sarcoma in fibrous dysplasia is still controversial.

METHODS

The Mayo Clinic files were reviewed, including Mayo Clinic cases and consultation cases, to collect all cases of sarcomas arising in fibrous dysplasia.

RESULTS

Among 1122 cases with a histologic diagnosis of fibrous dysplasia, 28 cases of sarcoma were found. These 28 cases included 16 Mayo Clinic cases and 12 consultation cases. The sarcomas occurred in 19 cases of monostotic fibrous dysplasia and 9 cases of polyostotic disease (only 1 of Albright's syndrome). The most common histotype was osteosarcoma (19 cases), followed by fibrosarcoma (5 cases), chondrosarcoma (3 cases), and malignant fibrohistiocytoma (1 case). Of the 28 patients, 13 (46%) had received radiation therapy before the sarcoma developed. Most of these sarcomas occurred in the craniofacial bones (13 cases) or in the proximal femur (7 cases), followed by the humerus, pelvis, tibia, and scapula.

CONCLUSIONS

Prognosis was poor. Sarcomas may arise with or without radiation. Early diagnosis and adequate treatment may lead to improved prognosis.

[DNA repair and related diseases]

DNA-repair is a complex enzymatic process which enables all living cells to withstand the deleterious and mutagenic effects of most genotoxic agents. Defective DNA-repair is caused by mutations involving genes which encode the enzymes responsible for recognition and excision of DNA lesions. Some of these genes have been identified in humans. Several severe human diseases are caused by defective DNA repair affecting the entire genome (e.g. xeroderma pigmentosum and trichotiodystrophy) or only actively transcribed genes (Cockayne's syndrome). Some of these conditions are associated with extremely high rate of cancer.

Case report 691. Radiation-induced osteochondromas (RIO) arising from the neural arch and producing compression of the spinal cord

A case of a 16-year-old girl with a RIO of the T11 neural arch compressing the spinal cord is presented. The radiation therapy had been given after removal of a Wilms' tumor at 1 year of age. RIOs usually occur in the long bones and are diagnosed about 8 years following irradiation. Spinal cord or nerve root compression is usually associated with multiple cartilaginous exostoses.

Transtentorial herniation caused by an intracranial mass lesion following high-dose methotrexate

A patient with intracranial osteosarcoma that arose 16 years after radiation therapy for hereditary retinoblastoma developed fatal cerebral edema and brainstem herniation after she received a single dose of intravenous methotrexate. Autopsy demonstrated extensive necrosis of the tumor mass, as well as necrotizing vascular damage within the neoplasm. Although high-dose methotrexate has been shown to be useful in the treatment of primary osteogenic sarcoma, the tumoricidal effects of therapy appear to have caused a fatal rise in intracranial pressure.

Hemoptysis as the presenting manifestation of thyroid carcinoma. A case report

An unusual case of a 61-year-old man who had hemoptysis as the major presenting manifestation of radiation-induced thyroid carcinoma is reported. The diagnosis was made by bronchoscopic removal of a polypoid lesion that was a direct extension of tumor through the trachea. Bronchoscopy is an effective and reliable means of establishing the diagnosis in this unusual subset of patients with thyroid carcinoma invading the trachea, and should be considered as the first diagnostic procedure in a patient with a thyroid mass and hemoptysis.

Seizures and hemiparesis in a young woman 24 years after treatment of astrocytoma

An edited transcript of Neurology Grand Rounds held at the University of California, Los Angeles, Medical Center on January 27, 1988. John Mazziotta, MD, PhD, Professor of Neurology and Radiology, is the coordinator of these conferences. This conference was edited by Harry V. Vinters, MD.

Malignant glioma of the optic chiasm eight years after radiotherapy for prolactinoma

A 41-year-old man had rapidly progressive visual loss caused by a malignant glioma that developed in the optic chiasm eight years after radiation therapy for a recurrent prolactinoma. Radiation-induced glioma should be considered as a cause of progressive visual loss in patients who have received irradiation in the region of the sella turcica.

Hyperparathyroidism after neck irradiation

A retrospective review of 1550 cases of hyperparathyroidism (HPT) treated surgically over a 30-year period reveals a past history of exposure to neck irradiation in 10 cases (0.7 per cent). The indication for radiotherapy was benign disease in nine and papillary thyroid carcinoma in one case. The mean interval between radiation exposure and the detection of HPT was 32 years (range 3-63 years). Patients treated with radioactive iodine alone developed HPT after a mean of 5 years while the interval for those treated with external beam therapy alone was a mean of 44 years. The parathyroid histology was adenoma in six cases, carcinoma in three cases and nodular hyperplasia in one case. All patients had coincident benign thyroid disease apart from one that had previously had papillary carcinoma and another with follicular carcinoma. Neck irradiation has been shown to confer an increased risk of HPT due to parathyroid adenoma and carcinoma. Radiotherapy for benign disease has generally been abandoned and these cases demonstrate a further contra-indication for the use of neck irradiation.

Postirradiation malignant fibrous histiocytoma of the trachea

A 77-yr-old woman presented with a malignant fibrous histiocytoma (MFH) of the trachea 11 yr after right subtotal thyroidectomy and delivery of 5,400 rads to the neck for infiltrating papillary thyroid carcinoma. The tumor developed in the irradiated area. Postirradiation MFH tends to occur in subcutaneous tissues, and is rare in lung parenchyma or airways.

Cytobiologic and clinical aspects in a patient with chronic neutrophilic leukemia after thorotrast exposure

A patient with fairly typical chronic neutrophilic leukemia, as represented by some two dozen such reported cases, had been given Thorotrast more than 20 years before. Typical myeloblastic crisis developed with remarkable terminal leukocytosis. Mature blood neutrophils had normal function with respect to phagocytosis, bacterial killing, metabolic activation, and chemotactic response. The number of cells producing colonies of neutrophils and monocytes in in vitro semisolid cultures was normal in the blood and increased in marrow. Colony size was smaller than is usually observed in normal patients or in typical patients with chronic myeloid leukemia. Termination in blast crisis, also seen in a few other patients with chronic neutrophilic leukemia, indicates that this is indeed a form of leukemia and not a "leukemoid" reaction of obscure cause. The differential diagnosis of extreme neutrophilia is discussed.

Meningioma and occlusive vasculopathy: coexisting complications of past extracranial radiation

We present two cases in which a meningioma and occlusion of the internal carotid artery with development of transdural collateral circulation coexisted following extracranial radiation in childhood.

Hyperparathyroidism due to a cystic parathyroid adenoma after irradiation of the neck

A 48-year-old female with hypercalcaemia diagnosed 3 years prior to admission is described. The patient underwent x-ray therapy of the neck for keloid scars 35 years prior to the diagnosis of hypercalcaemia. The hypercalcaemia was found to be the result of primary hyperparathyroidism. A cystic parathyroid adenoma was identified during surgery and was, on microscopic examination, composed of oxyphil cells rich in mitochondria. The cystic fluid contained 360 times higher C-terminal PTH than peripheral serum and almost 4000 times higher PTH as intact 1-84 amino acid residue species. We concluded that previous X-ray irradiation was related to the pathogenesis of the patient's parathyroid adenoma. The mild nature of the patient's hyperparathyroidism was possibly related to the composition of the tumour of oxyphil cells, known to be a poorly functioning variant of the parathyroid cell. Since parathyroid 'cysts' are obviously necrotic parathyroid adenomas, aspiration of the cysts alone cannot be expected to be curative and, therefore, it is recommended to treat cystic parathyroid adenomas by surgical extirpation.

Microangiopathic hemolytic anemia associated with radiation-induced hemangiosarcomas

A retrospective study of red blood cell parameters in 53 dogs with experimental radiation-induced hemangiosarcoma showed 24 had anemia. Morphologic alterations in red blood cells in peripheral blood films from anemic dogs included signs of regeneration (anisocytosis and polychromasia), hypochromasia, red cell fragmentation and acanthocytosis. The degree and type of red cell changes varied from dog to dog and generally correlated with the principal site of tumor involvement. Blood from dogs with tumors principally involving liver had red cell regeneration, fragmentation and acanthocytosis. Blood from dogs with tumors primarily involving the heart had only red cell fragmentation. Blood films from dogs with skeletal and pulmonary hemangiosarcomas were similar to blood films from dogs with hepatic hemangiosarcoma except that red cell alterations generally were less severe. Scanning and transmission electron micrographic evaluation of neoplastic tissue showed large amounts of fibrin within neoplastic vascular sinuses and disruption and distortion of red blood cells traversing these abnormal vascular beds. The red blood cell fragmentation syndrome associated with radiation-induced hemangiosarcomas therefore was considered to be a microangiopathic hemolytic anemia of localized origin.

Hodgkin's disease complicated by radiation sarcoma in bone

Seven patients after treatment of Hodgkin's Disease who developed bone sarcomas in the radiation field were seen at this centre over the past eight years. Radiation-induced sarcoma in bone in patients with Hodgkin's Disease is poorly documented. The large number of cases appeared to be an important new development and led to our review of all the patients with radiation-induced sarcomas (RIS) seen at this centre over the past 40 years. Thirty-seven patients with RIS in previously normal bone were found, and of these, only one patient with underlying Hodgkin's Disease, who was seen here 27 years earlier. Hodgkin's Disease and breast cancer were the most common primary underlying conditions and, as a result, the bones of the shoulder girdle were the commonest site of radiation-induced sarcoma. The clinical histories and radiographic findings of the eight patients with underlying Hodgkin's Disease are discussed in detail.

Dumb-bell sarcoma of the foramen jugulare with syringomyelia. A radio-induced tumour?

The clinicopathological findings of a 50-year-old man, who developed cervicothoracic syringomyelia at the age of 25 are presented. He was given radiation therapy at the age of 33. At the age of 57 he developed a foramen jugulare syndrome on the left, caused by a low grade leiomyosarcoma. Etiologically, the most attractive hypothesis appears to be that the tumour was induced by radiation therapy administered 24 years previously.

Second malignancies in Hodgkin's disease: a complication of certain forms of treatment

A total of 764 patients with Hodgkin's disease treated with radiotherapy (RT) or chemotherapy or both were reviewed 3-186 months (median 43 months) after initial treatment to assess the incidence of second malignancies. Incidence of solid tumours and acute non-lymphoblastic leukaemia (ANLL) were calculated by a life-table method and percentages of patients affected derived from life-table plots. Within 10 years after initial treatment the overall incidence of second solid tumours was 7.3%, and over a comparable period 2.4% of patients developed ANLL. Solid tumours occurred only in patients given RT with or without adjuvant chemotherapy, and ANLL occurred only after treatment with MOPP (mustine, vincristine, procarbazine, and prednisolone) or modified MOPP regimens. Neither solid tumours nor ANLL occurred in patients given ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). The highest incidence of leukaemia (5.4%) occurred after treatment with extensive RT plus (5.4%) occurred after treatment with extensive RT plus MOPP; hence the benefits of this approach in Hodgkin's disease must be weighed against its carcinogenic potential.

Thyroid lesions in patients with hyperparathyroidism

Twenty of ninety patients with hyperparathyroidism had associated pathology of the thyroid gland. Three carcinomas of the thyroid were found incidentally at the time of surgery for hyperparathyroidism. The association of thyroid lesions and hyperparathyroidism was frequently reported and explained previously on the basis of hypercalcemia acting as a goitrogen. Current evidence, however, suggests radiation as a strong probable factor in the production of this association. Attention should be given to the thyroid gland and of dominant nodules inspected. Concomitant management of those nodules according to the degree of suspicion they arouse, should be undertaken at the time of neck exploration for hyperparathyroidism.

Responses of lymphocytic choriomeningitis carrier mice to X-ray-induced lymphoma

The data presented in this paper define the interrelationship between two endogenous diseases in the same host. The Haas strain of germfree mice with congenitally acquired persistent lymphocytic choriomeningitis (LCM) virus infection developed the X-ray-induced lymphatic leukemia independent of LCM viremia. The immunoproliferative LCM-related lesions appeared after age 7 months, and the radiogenic lymphatic leukemia appeared earlier or during the same age period. Both diseases evolved with distinctive lesions at the appropriate time, with no evidence of interference nor of synergism between the two syndromes. The Haas strain of mice showed an unusual sensitivity to X rays which was associated with depletion of blood components and coincident death. The sensitivity of the mice to X rays might be a characteristic of the Haas mouse or the result of an LCM virus-induced alteration in hematopoiesis.