Radiation-induced osteosarcoma of the chest wall

A case of radiation-induced sarcoma of the chest wall is reported. Twenty-seven years 11 months after orthovoltage radiotherapy of the right breast a 69-year-old woman developed a radiation-induced osteosarcoma of the right thoracic wall. Initial diagnosis has been T-cell lymphoma of the skin. The right breast was irradiated with tangential fields and a total dose of 40 Gy, 2 Gy/day, 5 days a week. Orthovoltage treatment was performed in two courses of 20 Gy, 3 months apart. The clinical appearance of the secondary sarcoma was a diffuse infiltrated area in the irradiated breast which seemed to be fixed to the chest wall. Magnetic resonance imaging (MRI) demonstrated a mass in the right anterior thoracic wall which destroyed the fourth to the sixth rib. The tumor infiltrated the thoracic wall, including subcutaneous tissue and pericardium, as well as extending into the subphrenic space. Biopsy of the lesion revealed a poorly differentiated osteosarcoma. The patient's general condition precluded surgical or chemotherapeutic intervention; she died due to a cerebral stroke 6 months later. This case fulfilled all criteria for radiation-induced sarcoma, as there was a prior history of radiotherapy, latency period of several years, development of sarcoma within the irradiated field, and histologic confirmation of sarcoma.     

Radiation therapy for angiosarcoma

BACKGROUND: Between 1964 and 1998, 19 patients with histologically proven angiosarcoma were treated with curative intent with radiation therapy. METHODS: Median follow-up was 37 months (range, 8-234 months). RESULTS: The actuarial 5-year absolute survival and local control rates were 51% and 50%, respectively. Of 12 patients who relapsed, 8 had isolated local recurrence as the first site of treatment failure, 2 had local (1 patient) or regional recurrence in conjunction with distant metastases, and 2 had distant metastases alone. Two of four patients who underwent further therapy for recurrent disease were successfully salvaged. CONCLUSIONS: Only the location of the primary tumor was a predictor of local control and absolute survival at 5 years. Angiosarcomas located on the scalp imply a dismal prognosis compared with those in other locations with the predominant pattern of failure being local recurrence. Patients should be treated aggressively with surgical resection and preoperative or postoperative radiation therapy.     

Partial Breast Irradiation or Whole Breast Radiotherapy for Early Breast Cancer: A Meta‐Analysis of Randomized Controlled Trials

Abstract: The purpose of the study was to compare treatment outcomes in patients with breast cancer treated with partial breast irradiation (PBI) and of those treated with whole breast‐radiation therapy (WBRT). We conducted a systematic review and meta‐analysis of published randomized clinical trials comparing PBI versus WBRT. Primary outcome was overall survival and secondary outcomes were locally, axillary, supraclavicular, and distant recurrences. A search of the literature identified three trials with pooled total of 1,140 patients. We found no statistically significant difference between partial and whole breast radiation arms associated with death (OR 0.912, 95% CI 0.674–1.234, p = 0.550), distant metastasis (OR 0.740, 95% CI, 0.506–1.082, p = 0.120), or supraclavicular recurrences (pooled OR 1.415, 95% CI 0.278–7.202, p = 0.560). However, PBI was statistically significantly associated with an increased risk of both local (pooled OR 2.150, 95% CI, 1.396–3.312; p = 0.001) and axillary recurrences (pooled OR 3.430, 95% CI, 2.058–5.715; p < 0.0001) compared with whole breast‐radiation. Partial breast irradiation does not seem to jeopardize survival and may be used as an alternative to whole breast‐radiation. Nevertheless the issue of loco‐regional recurrence needs to be further addressed.     

Radiation-induced occlusion of the artery in the distal lower extremity —A case report—

In a 54 year-old man, a symptomatic occlusion of the popliteal artery and its trifurcation occurred following radiotherapy. Three years following curative radiotherapy to the upper tibia for metastatic renal cell carcinoma, he began experiencing intermittent claudication of the calf, which suddenly progressed to severe rest pain and coldness of the foot, and eventually to ischemic ulcer. Angiogram revealed an atherosclerotic occlusion well localized within the field of the previous irradiation. The significance of this rare entity is discussed from various aspects.     

Carcinoma of the skin with perineural invasion

PURPOSE: To evaluate the outcome and patterns of relapse in patients treated for skin carcinoma of the head and neck with either microscopic or clinical perineural invasion. METHODS AND MATERIALS: Radiotherapy alone or combined with surgery was used to treat 135 patients with microscopic or clinical evidence of perineural invasion of skin carcinoma. All patients had at least 2 years of follow-up. RESULTS: The 5-year local control rates without salvage therapy were 87% with microscopic perineural invasion and 55% with clinical perineural invasion. Overall, 88% of the local failures occurred in patients with positive margins. Almost half of the recurrences in patients with microscopic perineural invasion were limited to the first-echelon regional nodes. However, only 1 of 11 patients with basal cell carcinoma with microscopic perineural invasion had a nodal failure. Ninety percent of recurrences in patients with clinical perineural invasion occurred at the primary site. Cranial nerve deficits rarely improved after successful treatment of the primary disease. Radiographic abnormalities remained stable 30% of the time when patients had clinical evidence of progressive disease. CONCLUSIONS: Radiotherapy in patients with skin cancer with clinical perineural invasion should include treatment of the first-echelon regional lymphatics. The risk of regional node involvement is also relatively high for patients with squamous cell carcinoma with microscopic perineural invasion. In patients with clinical perineural invasion, the poor local control rates with conventional radiotherapy suggest a need for dose escalation with or without concomitant chemotherapy.     

Myofibroblastoma in the Irradiated Breast

▪  Abstract: Myofibroblastoma after wide excision and radiation therapy for intraductal (duct carcinoma in situ) carcinoma is reported. Myofibroblastoma is a benign tumor, largely composed of myofibroblasts arranged in fascicular clusters with interspersed bands of hyalinized collagen, which is well circumscribed and occurs predominantly in men. This is the first documented instance of a postradiation myofibroblastoma of the breast.  ▪     

Quantitative Assessment of Radiation-Induced Fibrosis of the Breast with Tissue Compliance Meter, Palpation, and Radiological Imaging: Preliminary Results

Abstract:  Quantification of radiation (RT)-induced fibrosis (RIF) continues to present a challenge in breast cancer survivors. We compare assessment of RIF by palpation and tissue compliance meter (TCM) to the radiological findings in women treated with RT. Of 300 patients treated with adjuvant RT, 17 women had ≥2-year follow-up sufficient to document RIF. Palpation and TCM were employed by three radiation oncologists in a blinded fashion. Palpation grades 1, 2, and 3 denoted mild, moderate, and severe RIF. TCM measured degree of compliance (DC) of RIF in irradiated (RTB) and nonirradiated breasts (NRTB). Architectural distortions (AD) on mammograms, ultrasound (US), and MRI were assessed. Median time of follow up was 3.9 years (range 2.1–6.5 years). Palpation revealed RIF grades 1, 2, and 3 in four, 10, and three patients, respectively. Mean percent changes (PC) in DC between RTB and NRTB by TCM were 19.5%, 37.1%, and 57.5% for grades 1, 2, and 3 RIF, respectively (p < 0.0001). There was a strong linear correlation between palpation grade and PC of DC by TCM (spearman-rank correlation=0.88, p < 0.0001). Interobserver variability (reliability) was computed using intraclass correlation coefficient (ICC) for TCM and kappa statistic for clinical palpation (ICC=0.99 [p < 0.0001] and kappa=0.70 [p < 0.0001], respectively). There was no correlation between average size of the AD as measured by the imaging modalities and RIF as assessed by palpation or TCM. Our preliminary data suggest that quantification of RIF is best with TCM. TCM results correlate better with palpation than with radiological imaging. The study with larger number of patients required to confirm our findings is underway.     

The relationship of radiation pneumonitis to treated lung volume in breast conservation therapy

Breast conservation therapy has become a common modality for therapy of early stage breast cancer. Most studies of primary lung irradiation correlate the risk of pneumonitis with the volume of lung treated. It is proposed that the lung volume treated during tangential radiation of the intact breast may be calculated from a measurement of the central lung distance. Central lung distance is the distance from the chest wall to the edge of the field at the central axis. This study examines whether the incidence of radiation pneumonitis indeed correlates with the lung volume treated as calculated from a measurement of the central lung distance. From January 1, 1985, through December 31, 1998, 353 patients were treated with breast conservation therapy at the University of Louisville. The charts were reviewed for any evidence of clinically significant radiation pneumonitis. The treatment films were obtained and the central lung distance ascertained. Four cases of radiation pneumonitis were identified. Three of these occurred after tangential radiation and one occurred in a retreatment field after bone marrow transplant. The overall rate of radiation pneumonitis was 1.2%. A central lung distance of less than 3 cm was found in 78.3% of patients and 21.7% had a central lung distance of three or greater. There was no correlation between central lung distance and the risk of radiation pneumonitis. Breast conservation therapy is a well-tolerated modality for treatment of early stage breast cancer. The incidence of radiation pneumonitis is very low and is usually associated with other factors in addition to the tangential field lung volume.     

四联液雾化吸入治疗口鼻咽粘膜放射损伤疗效观察

目的：探讨对口,鼻咽癌放射治疗期间口鼻咽粘膜损伤的有效防治措施,减轻其粘膜反应。方法：采用随机分组,四联液组用庆大霉素,地塞米松,黄芪注射液,维生素Ｂ１２进行雾化吸入;对照组采用含漱,口服或静脉常规用药。结果：粘膜反应程度,出现时间,平均恢复时间两组比较,Ｐ〈０．０１,差异有显著性,四联液组治疗效果明显优于对照组。结论：放射治疗期间用四联液雾化吸入能明显减轻口鼻咽粘膜放射性损伤和口腔疼痛,增加进     

Prostate cancer radiotherapy dose response: an update of the fox chase experience

PURPOSE: The effectiveness of increasing radiotherapy dose for men with prostate cancer was evaluated with reference to prognostic groups as defined by pretreatment serum prostate specific antigen (PSA), Gleason score, T stage and perineural invasion. MATERIALS AND METHODS: There were 839 men treated between April 1989 and December 1997 with conformal radiotherapy alone. Cox multivariate analysis was used to establish important predictors of biochemical failure (BF) separately for patients with an initial pretreatment PSA (iPSA) of less than 10, 10 to 19.9, or 20 or greater ng/ml. Radiotherapy (RT) dose was evaluated as a continuous and categorical (dose groups of less than 72, 72 to 75.9 and 76 Gy or greater) variable. RESULTS: At a median 63-month followup multivariate analysis demonstrated that iPSA and radiotherapy (RP) dose were the most significant predictors of BF, followed by Gleason score and T stage. Perineural invasion was not an independent correlate of outcome. RT dose was significant in all iPSA groups (less than 10, 10 to 19.9 and 20 or greater ng/ml). Gleason score was significant when iPSA was less than 10 ng/ml. T stage was significant when iPSA was 20 ng/ml or greater and it was borderline when iPSA was 10 to 19.9 ng/ml (p = 0.08). Prognostic subgroups were derived from these results and tested for an effect of RT dose on univariate analysis. Radiation dose was not a correlate of BF in the most favorable (PSA less than 10 ng/ml and Gleason score 2 to 6) and the most unfavorable (PSA 20 ng/ml or greater and stage T3-T4) prognostic groups but it was otherwise an influential determinant of outcome. CONCLUSIONS: RT dose escalation to 76 Gy or greater improved patient outcome for all prognostic groups except those at the favorable and unfavorable extremes.