Radiation-induced sarcomas

Secondary tumors developed in the zone of exposure fields in 6 patients treated with radiation for different malignancies. Tumors appeared, on the average, 12 years after radiotherapy.     

Treatment of sarcomas of the chest wall using intensive combined modality therapy

As part of two sequential protocols using intensive combined modality treatment in pediatric and adolescent sarcomas, 31 consecutive patients with primary chest wall tumors were treated between November 1977 and March 1986. This group included 13 patients with peripheral neuroepithelioma (Askin's tumor), 11 patients with Ewing's sarcoma, 3 patients with rhabdomyosarcoma, and 4 patients with undifferentiated sarcomas. Following complete work-up, 17 patients presented with localized disease and 14 patients presented with metastases. Patients received intensive combined modality treatment with combination chemotherapy (vincristine, cyclophosphamide, Adriamycin, +/- actinomycin-D and DTIC) and high-dose conventionally fractionated radiation therapy to the primary (55-60 Gy) and non-pulmonary metastases (45-50 Gy). Radiation techniques used for the primary chest wall tumor varied with the clinical presentation. Patients achieving a complete response received either low-dose fractionated TBI (1.5 Gy/0.15 Gy fx/5 weeks) or high-dose TBI (8 Gy/4 Gy fx/2 days) and an intensive cycle of chemotherapy followed by autologous bone marrow transplantation. Twenty-five of 31 patients were judged to have a complete response (including 1 patient with complete resection). With minimum follow-up of 6 months and median follow-up of 36 months from completion of treatment, 14 patients remain disease-free with 2 additional patients alive in second remission after relapse. Patients with localized disease at presentation have improved disease-free survival and overall survival compared to patients with metastases at presentation. All 17 localized patients achieved a CR and 11 are NED compared to 8 of 14 metastatic patients achieving a CR and only 3 are NED. There have been 5 loco-regional recurrences with 3 "in-field" failures and 2 failures in the regional pleura. There were no treatment-related deaths and no clinically significant cases of pneumonitis. To date, 2 patients have significant treatment related morbidity, including 1 patient with scoliosis requiring surgery and 1 patient with acute leukemia developing 42 months after the start of therapy (presently in remission). We conclude that this intensive combined modality therapy results in a high CR rate and good local control with acceptable morbidity. Patients with metastatic disease at presentation remain a therapeutic challenge.     

Radiation-induced sarcomas of the head and neck

With improved outcomes associated with radiotherapy, radiation-induced sarcomas (RIS) are increasingly seen in long-term survivors of head and neck cancers, with an estimated risk of up to 0.3%. They exhibit no subsite predilection within the head and neck and can arise in any irradiated tissue of mesenchymal origin. Common histologic subtypes of RIS parallel their de novo counterparts and include osteosarcoma, chondrosarcoma, malignant fibrous histiocytoma/sarcoma nitricoxide synthase, and fibrosarcoma. While imaging features of RIS are not pathognomonic, large size, extensive local invasion with bony destruction, marked enhancement within a prior radiotherapy field, and an appropriate latency period are suggestive of a diagnosis of RIS. RIS development may be influenced by factors such as radiation dose, age at initial exposure, exposure to chemotherapeutic agents and genetic tendency. Precise pathogenetic mechanisms of RIS are poorly understood and both directly mutagenizing effects of radiotherapy as well as changes in microenvironments are thought to play a role. Management of RIS is challenging, entailing surgery in irradiated tissue and a limited scope for further radiotherapy and chemotherapy. RIS is associated with significantly poorer outcomes than stage-matched sarcomas that arise independent of irradiation and surgical resection with clear margins seems to offer the best chance for cure.     

Soft tissue sarcomas of the adult thoracic wall

Forty-nine adult patients with soft tissue sarcomas of the thoracic wall have been treated by the Division of Surgical Oncology at the University of Illinois. Fibrosarcoma was the most common histologic type (20%). Patients with dermatofibrosarcoma protuberans had the longest mean overall survival time (150.8 months). The mean overall survival time for all patients was 98.2 months, and the disease-free 2-, 5-, and 10-year survival rates were 68%, 51%, and 34%, respectively. Wide excision was the treatment of choice; selected patients also received adjuvant radiotherapy, chemotherapy, or both. In all 10-year survivors, the sarcomas were low grade and well differentiated, or were less than or equal to 5.0 cm in diameter. Aggressive treatment afforded these patients good long-term results.     

Tikhoff-Linberg procedure and chest wall resection for recurrent sarcoma of the shoulder girdle involving the chest wall

Since the early 1980s, limb-sparing procedures have become the standard of care for the treatment of sarcoma involving the extremities. The Tikhoff-Linberg procedure has been described as a limb-sparing option for the treatment of neoplasms of the shoulder girdle. Historically, the involvement of the chest wall with tumor has been considered an absolute contraindication for this operation. We describe a case in which a recurrent sarcoma of the shoulder girdle with chest wall involvement was successfully treated with the Tikhoff-Linberg procedure modified to include chest wall resection, along with a simple reconstructive technique.     

Radiation-induced sarcomas of the clavicle following treatment of Hodgkin's disease. Report of two cases

Two patients who received combined chemo- and radiotherapy for Hodgkin's disease developed secondary tumors in irradiated fields by 15 and 24 years, respectively. All the necessary criteria for the diagnosis of radiation-induced sarcoma have been found.     

Radiation-induced sarcomas after radiotherapy for breast carcinoma: a large-scale single-institution review

BACKGROUND: Sarcomas are a rare complication of radiotherapy for breast carcinoma and patients have a poor prognosis. The incidence, histology, and management of patients with sarcomas were reviewed in the current study. METHODS: The authors reviewed the records of 16,705 patients with breast carcinoma. Of these, 13,472 (81%) were treated with megavoltage radiotherapy and 3233 were treated without at the Institute Curie (Paris, France) between 1981 and 1997. Median doses of 50-55 grays (Gy) in 25-27 fractions were delivered to the whole breast over a period of 5-5.5 weeks (2 Gy/day, 5 weekly fractions) followed, when indicated, by a 16-26-Gy boost to the tumor or tumor bed. Treatment of radiation-induced sarcomas (RIS) consisted mostly of radical surgery and chemotherapy. RESULTS: Overall, 35 patients developed sarcomas. Of these, 27 fulfilled the Cahan criteria. The median follow-up was 9.3 years (range, 1-22.4 years). The latency period ranged from 3 years to 20.3 years. Thirteen sarcomas were located in the breast, 5- in the chest wall, 3 in the sternum, 2 in the supraclavicle, 1 in the scapula, and 3 in the axilla. Histologic evaluation identified 13 angiosarcomas, 3 osteosarcomas, 5 undifferentiated sarcomas, 1 malignant fibrous histiocytoma, 2 leiomyosarcomas, 1 fibrosarcoma, 1 rhabdomyosarcoma, and 1 myosarcoma. The cumulative RIS incidence was 0.07% (+/- 0.02) at 5 years, 0.27% (+/- 0.05) at 10 years, and 0.48% (+/- 0.11) at 15 years. Standardized incidence ratios were 10.2 (95% confidence interval, 9.03-11.59) for irradiated patients and 1.3 (0.3-3.6) for nonirradiated patients. Of the 27 patients, 15 died of sarcoma within 1 month to 14.5 years (mean, 34.2 +/- 0.7 months). The 5-year actuarial survival rate after diagnosis of RIS was 36% (+/- 0.11). CONCLUSIONS: The current study confirmed the rarity of RIS. However, it showed that the risk increased with time. Therefore, careful, long-term follow-up of patients treated with radiotherapy is needed for early detection and efficacious treatment of these malignancies.     

胸壁肿瘤切除与胸壁重建

目的探讨胸壁肿瘤切除要点及缺损胸壁的重建方式。方法回顾分析1985年4月至2010年9月间手术治疗83例胸壁肿瘤患者的临床资料。其中胸骨肿瘤12例,肋骨肿瘤46例,软组织肿瘤25例。原发67例中良性40例,恶性27例;继发16例中转移10例,侵袭6例。手术行肿瘤切除48例,肿瘤切除加胸壁重建34例,探查1例。10例胸骨肿瘤和22例肋骨肿瘤切除后采用有机玻璃、同种异体胸骨、钢板、钢丝、缝线、涤纶布及胸大肌或膈肌重建;2例软组织肿瘤切除后采用转移肌瓣及转移皮瓣加植皮重建。结果 1例左全肺切除加胸壁重建患者突发心肌梗死死亡,1例全胸骨切除胸壁重建患者并发胸腔感染,其余81例术后恢复顺利,移植物未发生排斥反应。随访71例,其中恶性肿瘤总1,3,5年存活率分别为79.0%、48.0%和31.0%。良性肿瘤术后有2例复发,最长已观察12年。结论原发性胸壁肿瘤应首选手术,继发性胸壁肿瘤在原发灶可一并切除或控制前提下亦可手术。切线距肿瘤4 cm以上可降低复发。胸壁缺损较大者应行胸壁重建。骨性缺损宜选硬质材料如有机玻璃重建,软组织缺损可采用自体组织如肌瓣修复。     

Benign mesenchymoma of the chest wall in infancy

Chest wall mesenchymoma is a rare tumour in childhood and often presents in the neonatal period. In the past all patients have received surgical treatment with quite a high morbidity. We present here three further cases that presented in infancy, two of which received minimal therapy with good results in each case. We would propose from these cases that once the diagnosis has been established by biopsy that total surgical resection not be carried out unless cardiac or respiratory embarrassment is present.     

Radiation-induced skin changes after breast or chest wall irradiation in patients with breast cancer and skin of color: a systematic review

IntroductionThe purpose of this study is to systematically review data pertaining to breast cancer and radiation-induced skin reactions in patients with skin of color (SOC), as well as data pertaining to objective measurements of skin pigmentation in the assessment of radiation dermatitis (RD).Methods and materialsWe conducted a systematic review utilizing MEDLINE electronic databases to identify published studies until August 2022. Key inclusion criteria included studies that described RD in breast cancer with data pertaining to skin of color and/or characterization of pigmentation changes after radiation.ResultsWe identified 17 prospective cohort studies, 7 cross-sectional studies, 5 retrospective studies and 4 randomized controlled trials. Prospective cohort and retrospective series demonstrate worse RD in African American (AA) patients using subjective physician-graded scales. There is more limited data in patients representing other non-White racial subgroups with SOC. 2 studies utilize patient reported outcomes and 15 studies utilize objective methods to characterize pigmentation change after radiation. There are no prospective and randomized studies that objectively describe pigmentation changes with radiotherapy in SOC.ConclusionsAA patients appear to have worse RD outcomes, though this is not uniformly observed across all studies. There are no studies that describe objective measures of RD and include baseline skin pigmentation as a variable, limiting the ability to draw uniform conclusions on the rate and impact of RD in SOC. We highlight the importance of objectively characterizing SOC and pigmentation changes before, during and after radiotherapy to understand the incidence and severity of RD in SOC.     

Hodgkin's disease involving the breast and chest wall

Eighteen patients with Hodgkin's disease involving the breast or chest wall were identified from the M. D. Anderson Hospital and Tumor Institute pathology files from 1962 through 1984. All of these cases were nodular sclerosing Hodgkin's disease. Nine of the 18 patients had Hodgkin's disease involving the breast or chest wall at initial presentation. The remaining nine cases represented recurrences involving the breast or chest wall. Breast or chest wall involvement represented extranodal extension and/or involvement of another supradiaphragmatic lymph node group. No marked difference in survival was found between the initial and recurrent groups. Those patients with breast involvement had a better prognosis than those with chest wall involvement. Hodgkin's disease involving the breast or chest wall as an initial presentation or a recurrence does not necessarily indicate an accelerated phase of the disease. Breast or chest wall involvement is probably due to Hodgkin's disease involving the intramammary or internal mammary lymph nodes, or is due to direct mediastinal extension into the chest wall.     

Radionuclide lymphoscintigraphy performed on the mastectomized chest wall

Lymphatic flow in the anterior chest wall of 64 patients who underwent surgery for breast carcinoma was studies on images of lymphoscintigraphy using 99mTc-rhenium colloid. Scintigraphic images taken 4 hours after the intradermal injection of radionuclides along both sides of the surgical wound frequently made it possible to visualize the contralateral axillary lymph nodes. In particular, among 20 patients with local chest wall recurrence after the mastectomy, the contralateral axillary nodes were demonstrated in 13. Stimulated lymphatic flow seems to be manifested around the site of local recurrence over the chest wall. On the precise analysis of lymphographic images, faint lymphatic drainages were occasionally identified up to the contralateral axillary lymph nodes at various levels of the anterior chest wall. It is essential that the radiation field be made large towards the area including the downstream of the lymphatic flow. Additionally, accumulation of radionuclides in the lymph nodes appeared to be slowly impaired by the postoperative irradiation after the completion of radiotherapy.     

Tamoxifen for recurrent desmoid tumor of the chest wall

We report a case of a young woman with recurrent desmoid tumor. Computed tomography (CT) scans of the chest showed a large mass in the left chest wall. The tumor was unresectable because of the involvement of adjacent structures. Tamoxifen therapy led to marked tumor regression within 3 months. She had preserved her fertility, and thereafter she conceived a baby. In young women with recurrent desmoid tumor, tamoxifen should be considered as the first choice of treatment.     

Breast cancer: chest wall recurrences

Opinion statement Irradiation is indicated for patients undergoing mastectomy as surgical management for breast cancer treatment when clinical or pathologic tumor and nodal features predict risk of local/regional recurrence. Such features include: tumor size yy 5 cm, inadequate surgical margins; skin, facial, or skeletal muscle invasion; dermal lymphatic invasion; poorly differentiated tumor histology; four or more lymph nodes positive; gross extracapsular tumor nodal extension into soft tissues; and matted lymph nodes or enlarged lymph nodes > 2 cm. Patients who were treated with irradiation after mastectomy can develop local/regional recurrences despite such adjuvant therapy. General management for chest wall and nodal recurrences is structured on the extent and volume of local/ regional disease, the absence of distant metastases, the general health of the patient, and the extent of prior local/regional therapies, especially irradiation. Management of local/regional recurrence in the setting of no prior irradiation includes tumor debulking by systemic or surgical treatment followed by comprehensive chest wall and regional lymphatic irradiation. Doses are selected by tissue tolerances and volume of remaining disease. The management strategy for the patient with a history of irradiation parallels the nonirradiated patient with respect to systemic and surgical therapies to debulk the tumor to maximal response or no gross clinical disease. Radiation field design is determined by prior therapies. Doses to these fields are adjusted to normal tissue tolerance. Irradiation is given with a sensitizer such as hyperthermia or 5-fluorouracil chemotherapy. Use of radiation sensitizers can allow for a more meaningful biologic tumor effect when normal tissue tolerances prohibit delivery of standard tumor doses. Hyperthermia has been used effectively to promote complete tumor responses with use of irradiation in re-treatment cases.     

Peripheral neuroectodermal tumors of the chest wall in childhood

A retrospective review of primary chest wall malignant tumors of childhood collected at the Children's Memorial Hospital of Chicago was undertaken. Among twelve instances of poorly differentiated neoplasms whose uniform, monotonous structure made accurate classification difficult or impossible by conventional histologic study, there were three tumors with features suggestive of neuroectodermal differentiation. Electron microscopic and immunohistologic findings further strengthened this interpretation, despite the fact that none of the patients had evidence of a primary neuroblastoma outside the chest wall. These results and a review of the pertinent literature support the conclusion that neuroectodermal neoplasms in childhood may present in peripheral somatic tissues with greater frequency than is commonly assumed. The importance of this distinction is discussed, particularly the need to distinguish these neoplasms from Ewing's sarcoma.     

Hemithorax irradiation for Ewing tumors of the chest wall

PURPOSE: In the Cooperative Ewing's Sarcoma Study 86 and the European Intergroup Cooperative Ewing's Sarcoma Study 92, hemithorax irradiation (RT) was performed in patients with Ewing tumors of the chest wall involving the pleura or contaminating the pleural cavity. In a retrospective analysis, the outcomes of these patients were evaluated and compared with those of patients with chest wall tumors who did not receive hemithorax RT. METHODS AND MATERIALS: Between 1985 and 1996, 138 patients presented with nonmetastatic Ewing tumors of the chest wall. They were treated in a multimodal treatment regimen that included polychemotherapy and local therapy depending on the tumor characteristics. Hemithorax RT was performed at a dose of 15 Gy for patients <14 years old and 20 Gy for patients >or=14 years old. Forty-two patients received hemithorax RT (Group 1) and 86 patients did not (Group 2). The data were insufficient for the other 10 patients. RESULTS: Comparing both groups, the initial pleural effusion, pleural infiltration, and intraoperative contamination of the pleural space were significantly more frequent in Group 1. The event-free survival rate after 7 years was 63% for patients in Group 1 and 46% for patients in Group 2 (not statistically significant). The 7-year local relapse rate (including combined local-systemic relapses) was 12% in Group 1 and 10% in Group 2; the corresponding systemic relapse rates were 22% and 39%. CONCLUSION: Patients with chest wall tumors who received hemithorax RT were negatively selected; yet the rate of event-free survival was better for patients who received hemithorax RT than for those who did not (although the difference was not statistically significant). This result was due to a reduction of metastases, mainly lung metastases. Local control was equivalent between the two groups. These favorable results have caused us to continue using hemithorax RT to treat high-risk patients with Ewing tumors of the chest wall.     

Unusual postirradiation sarcoma of chest wall.

This paper reports a sarcoma of the chest wall following postoperative radiation therapy for breast carcinoma. A total of 9346 rads was delivered at a 2-cm tissue depth from two treatment courses separated by a five-year interval. The sarcoma appeared 16 years following the initial radiation course. The existence of two mesenchymal elements in the lesion led to the final diagnosis of malignant mesenchymoma. Criteria for evaluating a possible radiation-induced malignancy are discussed.     

Electrochemotherapy of chest wall breast cancer recurrence

Chest wall breast cancer recurrence after mastectomy is a disease difficult to treat. Its incidence varies between 5% and 30% in different subset of patients. When possible, radical surgical therapy represents the main treatment approach, however when the disease progresses and/or treatments are not successful, ulceration, bleeding, lymphedema and psychological distress of progressive disease significantly decrease the quality of the remaining life of a patient. When surgical excision of chest wall recurrence is not possible, other local treatments such as radiotherapy, radiotherapy with hyperthermia, topical chemotherapy and electrochemotherapy might be taken into account. Electrochemotherapy provides safe, efficient and non-invasive locoregional treatment approach for chest wall breast cancer recurrence. Several clinical studies have demonstrated high efficacy and a good safety profile of electrochemotherapy applied in single or multiple consecutive sessions, till clinical response was reached. Electrochemotherapy can be performed either with cisplatin injected intratumorally or with bleomycin given intratumorally or intravenously. Furthermore, it can be effectively used in heavily pre-treated areas, after surgery, radiotherapy or systemic chemotherapy. These are the advantages that might demand its use especially in patients with pre-treated extensive disease and in frail elderly patients. With development of the technology electrochemotherapy could even be suggested as a primary local therapy in patients not suitable for surgical removal of the primary tumor.