Radiation-induced

Osteosarcoma



Yasuo

SUGITA,

Case

Minoru

Souichi

LEE,

Report—

SHIGEMORI, Toshinori

and

of the Calvaria

Jun

MIYAGI,

WATANABE,

Minoru

Satoshi

Hitoshi

OCHIAI,

ABE*

MORIMATSU**

Departments of Neurosurgery, *Radiology, and **Pathology, Kurume University School of Medicine, Kurume, Fukuoka

Abstract The authors subtotal

report

a case of radiation-induced

removal

an osteoblastic

of the pituitary osteosarcoma

and chemotherapy. the margin lung

metastasis

Key words:

A chest

careful

acromegaly,

tomography x-ray

attention

computed

radiation-induced

calvarial

osteosarcoma.

and 5000 rads

region.

subsequently

film demonstrated

in radiation-induced tomography,

A 58-year-old

postoperative

in the frontotemporal

computed

flap.

require

osteosarcoma,

occurred

However,

of the bone

adenoma

magnetic

irradiation. She received revealed

lung

resonance

total

multiple

metastasis.

osteosarcoma

female Seven

Local

tumor small

received

years

later,

removal lesions

recurrence

at and

patients. imaging,

tumor

Introduction Radiation-induced osteosarcomas of the calvaria are rare, among the reported radiation-induced brain tumors. 15,10,19,21,27,29,30) Such complications of radia tion therapy") may occur when the therapy is used to treat secondary malignant neoplasms.1-3'5,6,10-12,14 16,21,25,27,29,30) Here, calvaria adenoma.

we report following

a case of osteosarcoma radiation therapy for

of the pituitary

Fig. 1

Case

Report

A 58-year-old female was first admitted in June, 1983, with a 6-month history of diabetes mellitus and hypertension, and symptoms of acromegaly. Com puted tomographic (CT) scanning indicated pituitary adenoma with extrasellar extension. Laboratory tests confirmed growth-hormone producing adenoma. The tumor was subtotally removed through a right craniotomy. Postoperative irradiation using a linear accelerator delivered 5000 rads to the square lateral opposing field over 5 cm distance. She was then discharged and followed as an out-patient. Received

February

22, 1991;

Accepted

June

7, 1991

Plain skull x-ray films on readmission. left: Lateral x-ray film showing marked sclerosis of the frontotemporal bone. right: Tangential x-ray film showing the typical "sun-ray ap pearance."

She complained of an enlarging mass in the right temporal region, and was readmitted on January 23, 1990. A lateral skull x-ray film indicated marked sclerosis of the frontotemporal bone (Fig. 1 left). A tangential skull x-ray film showed the typical "sun ray appearance" (Fig. 1 right). A bone window CT scan showed a mass originating in the fronto temporal bone (Fig. 2 left). Ti-weighted magnetic resonance (MR) imaging with gadolinium diethylene

Fig. 2

left: Bone window CT scan revealing a mass arising from the right frontotemporal bone. right: MR image with Gd-DTPA showing an irregularly enhanced tumor invading the brain parenchyma (arrowheads).

triamine-pentaacetic acid (Gd-DTPA) demonstrated an irregularly enhanced tumor in the right temporal region, invading the brain parenchyma (Fig. 2 right). Right craniectomy on March 9, 1990 demonstrated the tumor growing from the margin of the former free bone flap, and invading the temporal muscle, dura matter, and frontal lobe considerably. Gross total removal and cranioplasty were performed. Histological examination confirmed the diagnosis of osteoblastic osteosarcoma (Fig. 3). Postoperatively, she received methotrexate (500 mg/day) and vincristine (1.5 mg/day) intravenously at 3-week intervals for 2 months (total dose; metho trexate 1500 mg, vincristine 4.5 mg). However, sub sequent CT scans indicated multiple high-density small lesions at the site of the craniectomy. Cis platin (100 mg) through the external carotid artery was given on June 25, 1990. Partial tumor removal and dural plasty were again performed on September 7, 1990. Multiple tumor nodules were still present at the margin of the crani ectomy bone flap. The tumor had also invaded the superior margin of the zygomatic arch. Postopera tively, cisplatin (90 mg) and adriamycin (60 mg) were administered intravenously. On September 4, 1990, a chest x-ray film had indicated possible metastasis (Fig. 4). Chemotherapy is presently con tinuing.

Fig. 3

Photomicrograph ing

HE stain,

Fig. 4

Chest tatic

of the tumor

characteristic

x-ray tumor.

osteoblastic

specimen

show

osteosarcoma.

Discussion

x 200.

film demonstrating

possible

metas

In 1948, Cahan et al.') described the following criteria for postradiation sarcomas: 1) microscopic or roentogenographic evidence of a non-malignant initial bone condition; 2) sarcoma originating in an area within the previous radiotherapeutic beam; 3) a relatively long, asymptomatic latent period follow ing irradiation before the clinical appearance of a bone sarcoma; and 4) histological confirmation of sarcomas. Our patient satisfied all these criteria. Only eight cases, including ours, of calvarial osteosarcoma have been reported (Table 1).''13,18.22,23.26) Five patients were less than 40 years old. The latent period varied from 3.5 to 21 years (mean 9.1 years). The radiation dosage varied from 2052 to 11,000 rads (mean 6122 rads). The pathogenesis of radiation-induced cal varial osteosarcoma is unknown. Radiation dosages exceeding 3000 rads may induce sarcoma, although no significant relationship with orthovoltage, mega voltage equipment, age at irradiation, or fraction size has been established. 11.13,20) Goldberg et al." studied 104 acromegalic patients and found four cases of malignant intracranial

Table

1

Reported

cases

of radiation-induced

calvarial

osteosarcoma

neoplasms in the 75 irradiated patients. However, no non-irradiated patient demonstrated sarcoma. The importance of acromegaly in the carcinogenesis of calvarial sarcoma is unknown. A combination of surgical trauma and irradiation, however, may in duce sarcoma development.',"' Other related factors are genetic, such as a familial or previous history of malignant tumors and congenital anomalies.',"' Radiologically, osteosarcoma presents as three types: sclerosing, lytic, and mixed. 14,15,20,22) Bone destruction and periosteal reaction may also occur.'"' Our case showed sclerosing and typical periosteal reaction on the plain skull x-ray film. Lee et al. 15, found nine osteolytic (64%), three sclerosing (21 %), and two mixed (14%) among 14 cases of postradia tion craniofacial osteosarcoma. There were no cases with periosteal reaction. CT scanning is superior to conventional radiography for evaluation of intra medullary and soft-tissue extension of osteosar coma, as in the present case. MR imaging is even more effective in demonstrating intramedullary and extraosseous components, 14,15)T1-weighted MR im ages are best to demonstrate the anatomy involved, while T2-weighted MR images are best for peri tumoral edematous reactions. A MR image in our case clearly showed tumor invasion of the frontal lobe. The prognosis for radiation-induced calvarial osteosarcoma is poor. In our case, the tumor rapidly recurred in the margin of the craniectomy, in vading the muscle and skull base, and the frontal lobe. Skolnik et al.22) reported a similar course. Long bone osteosarcomas frequently cause lung metastasis.',") The present case demonstrated lung metastasis, an observation previously unreported. Therefore, local recurrence and lung metastasis re quire careful attention.

Recently, bromocriptine adenoma has been reported. preferable to radiation pituitary adenoma.

treatment for pituitary 17,24,21)This treatment is

for

postoperative

residual

Acknowledgment The authors preparing

wish to thank

for Ms.

Y. Masuda

for

this manuscript.

References 1)

Ahmand K, Fayos JV: Pituitary fibrosarcoma sec ondary to radiation therapy. Cancer 42: 107-110, 1978 2) Alpert L, Abaci IF, Werthamer S: Radiation-induced extraskeletal osteosarcoma. Cancer 31: 1359-1363, 1973 3) Arlen M, Higinbotham NL, Huvos AG, Marcove RC, Miller T, Shah IC: Radiation-induced sarcoma of bone. Cancer 28: 1087-1099, 1971 4) Asai A, Matsutani M, Kohno T, Nakamura O, Tanaka H, Fujimaki T, Funada N, Matsuda T, Nagata K, Takakura K: Subacute brain atrophy after radiation therapy for malignant brain tumor. Cancer 63: 1962-1974, 1989 5) Bernstein M, Perrin RG, Plastts ME, Simpson WJ: Radiation-induced cerebellar chondrosarcoma. J Neurosurg 61: 174-177, 1984 6) Cahan WG, Woodard HQ, Higinbotham NL, Stewart FW, Coley BL: Sarcoma arising in irradiated bone. Cancer 1: 3-29, 1948 7) Casentimi L, Visona A, Colombo F, Pensa VS, Pozza F, Benedetti A: Osteogenic osteosarcoma of the calvaria following radiotherapy for cerebellar astrocytoma. Tumori 71: 391-396, 1985 8) Dahlin DC, Coventry MB, Minnesota R: Osteogenic sarcoma. J Bone Joint Surg [Amer] 49: 102-110, 1967

DeAngelis LM, Delattre JY, Posner JB: Radiation-in duced dementia in patients cured of brain metastasis. Neurology 39: 789-796, 1989 10) Goldberg MB, Sheline GE, Malamurd N: Malignant intracranial neoplasms following radiation therapy for acromegaly. Radiology 80: 465-470, 1963 11) Jones A: Irradiation sarcoma. Brit J Radiol 26: 273 284, 1953 12) Kaae S, Glahn M: Case of sarcoma in irradiated mandible. Acta Radiol 31: 431-434, 1949 13) Kellie SJ, Hutchison RE, Robertson JT, Paratt CB: Successful treatment of a radiation-associated extra dural osteosarcoma with chemotherapy in an adoles cent girl. Med Pediatr Oncol 17: 514-519, 1989 14) Kim JH, Chu FC, Woodard HQ, Molamed MR, Huvous A, Cantin J: Radiation-induced soft tissue and bone sarcoma. Radiology 129: 501-508, 1978 15) Lee YY, Tassel PV, Nauert C, Raymond AK, Ediken J: Craniofacial osteosarcomas: Plain film, CT, and MR findings in 46 cases. AJR 150: 1397-1402, 1988 16) Lorigan JG, Libshitz HI, Peuchot M: Radiation induced sarcoma of bone: CT findings in 19 cases. AJR 153: 791-794, 1989 17) McGregor AM, Scanlon MF, Hall K, Cook DB, Hall R: Reduction in size of a pituitary tumor by bromo criptine therapy. N Engl J Med 300: 291-293, 1979 18) Meredith JM, Mandeville FB, Kay S: Osteogenic sar coma of the skull following roentgen-ray therapy for benign pituitary tumor. J Neurosurg 17: 792-799, 1960 19) Palma L, Vagnozzi R, Annino L, Ciapetta P, Maleci A, Cantore G: Post-radiation glioma in a child. Childs Nerv Syst 4: 296-301, 1988 20) Sabiston DC Jr: Davis-Christopher Textbook of Surgery. The Biological Basis of Modern Surgical Practice, ed 12. Philadelphia, WB Saunders, 1981, pp 1606-1607 21) Shapiro S, Mealey J, Sartorius C: Radiation-induced

intracranial

9)

82,

22)

23)

24)

25)

26)

27)

28)

29)

30)

malignant

gliomas.

J Neurosurg

71: 77-

1989

Skolnik EM, Fornatto EJ, Heydemann J: Osteogenic sarcoma of the skull following irradiation. Ann Otol Rhinol Laryngol 65: 915-936, 1956 Sparagana M, Eells RW, Stefami S, Jablkow V: Osteogenic sarcoma of the skull: A rare sequela of pituitary irradiation. Cancer 29: 1376-1379, 1972 Spark RF, Baker R, Biefang DC, Bergland R: Bromocriptine reduces pituitary tumor size and hypersecretion. JAMA 247: 247-312, 1982 Tabbet RD, Vickery RD: Osteogenic sarcoma follow ing irradiation for retinoblastoma. Amer J Ophthal 35: 811-818, 1952 Tanaka S, Nishio S, Morioka T, Fukui M, Kitamura K, Hikita T: Radiation-induced osteosarcoma of the sphenoid bone. Neurosurgery 25: 640-643, 1989 Terry RD, Hyams VJ, Davidoff LM: Combined nonmetastasizing fibrosarcoma and chromophobe tumor of the pituitary. Cancer 12: 791-798, 1959 Thorner MD, Martin WH, Rogol AD, Morris JL, Perryman RL, Conway BP, Howards SS, Walfman MG, Macleod RM: Bromocriptine treatment of acromegaly. Br Med J 1: 299-308, 1975 Triberin P, Coldstein J: Brain sarcoma of meningeal origin after cranial irradiation in childhood acute lymphocytic leukemia. J Neurosurg 61: 772-776, 1984 Waltz TA, Brownell B: Sarcoma: A possible late result of effective radiation therapy for pituitary adenoma. J Neurosurg 24: 901-907, 1966

Address of

reprint

requests

Neurosurgery,

Medicine, Japan.

to: Y. Sugita, Kurume

67 Asahi-machi,

M.D.,

University Kurume,

Department School Fukuoka

of 830,

Radiation-induced osteosarcoma of the calvaria--case report.

The authors report a case of radiation-induced calvarial osteosarcoma. A 58-year-old female received subtotal removal of the pituitary adenoma and 500...
339KB Sizes 0 Downloads 0 Views