Synovial
Sarcoma of the Neck Associated With Previous Head and Neck Radiation Therapy Nicholas E. Mischler, MD; Thomas Chuprevich, DO; Guillermo Ramirez, MD; Eberhard A. Mack, MD
\s=b\ Synovial sarcoma is a rare neoplasm that uncommonly arises in the neck. Fourteen years after facial and neck radiation therapy for acne, synovial sarcoma of the neck developed in a young man. Possible radiation-induced benign and malignant neoplasms that arise in the head and neck region, either of thyroid or extrathyroid origin, remain a continuing medical problem.
(Arch Otolaryngol 104:482-483, 1978) exposure is
recognized Radicarcinogenic. ation Japanese
as
A-bomb survivors have an increased incidence of acute and chronic leukemia, as well
Douglass C. Tormey, MD, PhD;
sis.2 Inhabitants of the Marshall
Islands, who
were
accidentally
ex¬
posed to nuclear fallout in childhood, and Japanese atomic bomb survivors have an increased incidence of thyroid tumors.1 Likewise, radiation therapy
to the head and neck in childhood is associated with an increased incidence of benign and malignant thyroid neoplasms.3"7 We report a case of an unusual primary tumor that arose in the neck after head and neck radia¬ tion.
1
lymphomas, myelomas, aplastic anemia, and myelofibrosis.1 Radiation as
exposure has also been associated with skin cancer in dentists,1 with osteosarcomas, fibrosarcomas, and nasopharyngeal carcinomas in radium dial
and with breast cancer in women who received repeated fluoroscopic examination during lung col¬ lapse therapy in pulmonary tubérculo-
painters,1
Accepted for publication Feb 27, 1978. From the Departments of Human Oncology (Drs Mischler, Tormey, and Ramirez), Pathology (Dr Chuprevich), and Surgery (Dr Mack), University of Wisconsin, Madison. Dr Mischler is now with Quisling Clinic, Madison, Wis. Dr Chuprevich is now with St Vincent's Hospital, Green Bay, Wis. Reprint requests to Quisling Clinic, 2 W Gorham St, Madison, WI 53703 (Dr Mischler).
REPORT OF A CASE A 28-year-old man with a two-month history of a mass in the right side of the neck was hospitalized in January 1976 for evaluation. A thyroid scan showed a cold nodule on the right. A T4 was 7.2 µg/dl. Past medical history was significant only for four facial and neck irradiation treat¬ ments at the age of 14 years for acne. The total dose that was delivered is unknown. At surgery, a 3.5-cm tumor was found adherent to the right superior lobe of the thyroid. This mass invaded the cricothyroid muscle and infringed down on the thyrohyoid muscle. A thyroid nodule was pres¬ ent. Results of a pathologic examination of the thyroid nodule showed an encapsulated mass of eosinophilic cuboidal cells that formed acinar arrangements. No evidence of capsular invasion or vessel invasion was present. Sections of the suprathyroidal
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 06/19/2015
mass revealed a discrete neoplastic mass that was adjacent to thyroid tissue but not invading thyroid. Special stains and elec¬ tron microscopy disclosed a characteristic synovial sarcoma (Figure). The patient was referred to the University of Wisconsin Hospitals, Madison, for further surgery. On admission, the patient was a coopera¬ tive young man with a healed scar on the anterior side of the neck. No neck nodules nor masses were palpable, and the remain¬ der of the examination was unremarkable. Normal results were found for the hematocrit reading, WBC count, and levels of BUN, blood glucose, serum calcium, serum phosphorus, serum alkaline phosphatase, and serum lactic dehydrogenase. Results of urinalysis were normal, and a chest x-ray film was also normal. On Feb 18, 1976, the patient underwent a thyroid lobectomy on the left side and a modified neck dissection on the right. No malignant neoplasm was found. In December 1976, the patient noted a small nodule in the right side of the neck. Excisional biopsy of this nodule and a 1-cm nodule to the right of the thyroid cartilage revealed both to be encapsulated synovial sarcomas. After a normal evaluation, including whole lung tomography, radia¬ tion therapy to the neck (5,100 rads during five weeks) was delivered. The patient tolerated the radiation well, except for mild pharyngitis and laryngitis. One month after completion of radiation thera¬ py, the patient received 60 mg/M2 (110 mg) of intravenous doxorubicin (Adriamycin)
gland and brain tumors,5 fibrosarcomas, leukemias, lymphomas, and
tissue tumors.6 An excess of associated benign extrathyroid neo¬ plasms has also been reported in bone, breast, skin, nerve, salivary gland, and other tissues.6 Synovial sarcoma is an uncommon soft-tissue malignant neoplasm. It occurs primarily in the extremities and in the girdles, but may arise in the neck and trunk.910 A synovioblastic origin of the tumor is supported by the histologie appearance of the tumor and its staining characteristics. It most likely arises from undifferentiated mesenchyme that retains the potential for synovioblastic differen¬ tiation.910 This tumor has a high frequency of local recurrence.9 Al¬ though postoperative radiation de¬ creases the frequency of local recur¬ rence, it does not improve survival.9 In summary, we report the case of a young man with synovial sarcoma that arose in the neck 14 years after he received facial and neck radiation therapy. This report reemphasizes the continuing problem of possible radia¬ tion-induced benign and malignant neoplasms that arise in the head and neck region, either of thyroid or extranerve
thyroid origin.
References 1. Upton AC: Radiation, in Holland JF, Frei E (eds): Cancer Medicine. Philadelphia, Lea & Febiger, 1973, pp 99-101. 2. Boice JD, Monson RR: X-ray exposure and breast cancer. Am J Epidemiol 104:349-350,
sarcoma, biphasic pattern. Typical glandular and fibrosarcomatous elements present (hematoxylin-eosin, original magnification 25).
Synovial are
hydrochloride every three weeks. Pres¬ ently, he is disease free, working full time, and receives 0.2 mg of levothyroxine sodi¬ um daily. COMMENT The initial report of Duffy and Fitz¬ gerald,3 which linked thymic or tonsillar radiation with subsequent thyroid neoplasm, has been confirmed by others4-7 and is acknowledged to be a
continuing medical problem.8 Radia¬ tion treatment was commonly used in
the first half of this century to treat thymic enlargement, recurrent tonsil¬ litis, acne, impetigo, tinea capitis, and lymphadenitis.46 With a latent period of ten to 20 years,4 a variety of malig¬ nant neoplasms have been associated with head and neck irradiation. In addition to thyroid cancers, these malignant neoplasms include salivary
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 06/19/2015
1976. 3. Duffy BJ, Fitzgerald PJ: Cancer of the thyroid in children: A report of 28 cases. J Clin Endocrinol Metab 10:1296-1308, 1950. 4. DeGroot L, Paloyan E: Thyroid carcinoma and radiation: A Chicago endemic. JAMA 225:487-491, 1973. 5. Modan B, Baidatz D, Mart H, et al: Radiation-induced head and neck tumours. Lancet 1:277-279, 1974. 6. Hempelmann LH, Hall WU, Phillips M, et al: Neoplasms in persons treated with x-rays in infancy: Fourth survey in 20 years. J Natl Cancer Inst 55:519-530, 1975. 7. Favus MJ, Schneider AB, Stachura ME, et al: Thyroid cancer ocurring as a late consequence of head and neck irradiation. N Engl J Med 294:1019-1025, 1976. 8. Refetoff S, Harrison J, Karanfilski BT, et al: Continuing occurrence of thyroid carcinoma after irradiation to the neck in infancy and childhood. N Engl J Med 292:171-175, 1975. 9. Cadman ML, Soule EH, Kelly PJ: Synovial sarcoma. Cancer 18:613-627, 1965. 10. Roth JA, Enzinger FM, Tannenbaum M: Synovial sarcoma of the neck: A follow-up study of 24 cases. Cancer 35:1243-1253, 1975.
Sarcoma of the Neck Associated With Previous Head and Neck Radiation Therapy Nicholas E. Mischler, MD; Thomas Chuprevich, DO; Guillermo Ramirez, MD; Eberhard A. Mack, MD
\s=b\ Synovial sarcoma is a rare neoplasm that uncommonly arises in the neck. Fourteen years after facial and neck radiation therapy for acne, synovial sarcoma of the neck developed in a young man. Possible radiation-induced benign and malignant neoplasms that arise in the head and neck region, either of thyroid or extrathyroid origin, remain a continuing medical problem.
(Arch Otolaryngol 104:482-483, 1978) exposure is
recognized Radicarcinogenic. ation Japanese
as
A-bomb survivors have an increased incidence of acute and chronic leukemia, as well
Douglass C. Tormey, MD, PhD;
sis.2 Inhabitants of the Marshall
Islands, who
were
accidentally
ex¬
posed to nuclear fallout in childhood, and Japanese atomic bomb survivors have an increased incidence of thyroid tumors.1 Likewise, radiation therapy
to the head and neck in childhood is associated with an increased incidence of benign and malignant thyroid neoplasms.3"7 We report a case of an unusual primary tumor that arose in the neck after head and neck radia¬ tion.
1
lymphomas, myelomas, aplastic anemia, and myelofibrosis.1 Radiation as
exposure has also been associated with skin cancer in dentists,1 with osteosarcomas, fibrosarcomas, and nasopharyngeal carcinomas in radium dial
and with breast cancer in women who received repeated fluoroscopic examination during lung col¬ lapse therapy in pulmonary tubérculo-
painters,1
Accepted for publication Feb 27, 1978. From the Departments of Human Oncology (Drs Mischler, Tormey, and Ramirez), Pathology (Dr Chuprevich), and Surgery (Dr Mack), University of Wisconsin, Madison. Dr Mischler is now with Quisling Clinic, Madison, Wis. Dr Chuprevich is now with St Vincent's Hospital, Green Bay, Wis. Reprint requests to Quisling Clinic, 2 W Gorham St, Madison, WI 53703 (Dr Mischler).
REPORT OF A CASE A 28-year-old man with a two-month history of a mass in the right side of the neck was hospitalized in January 1976 for evaluation. A thyroid scan showed a cold nodule on the right. A T4 was 7.2 µg/dl. Past medical history was significant only for four facial and neck irradiation treat¬ ments at the age of 14 years for acne. The total dose that was delivered is unknown. At surgery, a 3.5-cm tumor was found adherent to the right superior lobe of the thyroid. This mass invaded the cricothyroid muscle and infringed down on the thyrohyoid muscle. A thyroid nodule was pres¬ ent. Results of a pathologic examination of the thyroid nodule showed an encapsulated mass of eosinophilic cuboidal cells that formed acinar arrangements. No evidence of capsular invasion or vessel invasion was present. Sections of the suprathyroidal
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 06/19/2015
mass revealed a discrete neoplastic mass that was adjacent to thyroid tissue but not invading thyroid. Special stains and elec¬ tron microscopy disclosed a characteristic synovial sarcoma (Figure). The patient was referred to the University of Wisconsin Hospitals, Madison, for further surgery. On admission, the patient was a coopera¬ tive young man with a healed scar on the anterior side of the neck. No neck nodules nor masses were palpable, and the remain¬ der of the examination was unremarkable. Normal results were found for the hematocrit reading, WBC count, and levels of BUN, blood glucose, serum calcium, serum phosphorus, serum alkaline phosphatase, and serum lactic dehydrogenase. Results of urinalysis were normal, and a chest x-ray film was also normal. On Feb 18, 1976, the patient underwent a thyroid lobectomy on the left side and a modified neck dissection on the right. No malignant neoplasm was found. In December 1976, the patient noted a small nodule in the right side of the neck. Excisional biopsy of this nodule and a 1-cm nodule to the right of the thyroid cartilage revealed both to be encapsulated synovial sarcomas. After a normal evaluation, including whole lung tomography, radia¬ tion therapy to the neck (5,100 rads during five weeks) was delivered. The patient tolerated the radiation well, except for mild pharyngitis and laryngitis. One month after completion of radiation thera¬ py, the patient received 60 mg/M2 (110 mg) of intravenous doxorubicin (Adriamycin)
gland and brain tumors,5 fibrosarcomas, leukemias, lymphomas, and
tissue tumors.6 An excess of associated benign extrathyroid neo¬ plasms has also been reported in bone, breast, skin, nerve, salivary gland, and other tissues.6 Synovial sarcoma is an uncommon soft-tissue malignant neoplasm. It occurs primarily in the extremities and in the girdles, but may arise in the neck and trunk.910 A synovioblastic origin of the tumor is supported by the histologie appearance of the tumor and its staining characteristics. It most likely arises from undifferentiated mesenchyme that retains the potential for synovioblastic differen¬ tiation.910 This tumor has a high frequency of local recurrence.9 Al¬ though postoperative radiation de¬ creases the frequency of local recur¬ rence, it does not improve survival.9 In summary, we report the case of a young man with synovial sarcoma that arose in the neck 14 years after he received facial and neck radiation therapy. This report reemphasizes the continuing problem of possible radia¬ tion-induced benign and malignant neoplasms that arise in the head and neck region, either of thyroid or extranerve
thyroid origin.
References 1. Upton AC: Radiation, in Holland JF, Frei E (eds): Cancer Medicine. Philadelphia, Lea & Febiger, 1973, pp 99-101. 2. Boice JD, Monson RR: X-ray exposure and breast cancer. Am J Epidemiol 104:349-350,
sarcoma, biphasic pattern. Typical glandular and fibrosarcomatous elements present (hematoxylin-eosin, original magnification 25).
Synovial are
hydrochloride every three weeks. Pres¬ ently, he is disease free, working full time, and receives 0.2 mg of levothyroxine sodi¬ um daily. COMMENT The initial report of Duffy and Fitz¬ gerald,3 which linked thymic or tonsillar radiation with subsequent thyroid neoplasm, has been confirmed by others4-7 and is acknowledged to be a
continuing medical problem.8 Radia¬ tion treatment was commonly used in
the first half of this century to treat thymic enlargement, recurrent tonsil¬ litis, acne, impetigo, tinea capitis, and lymphadenitis.46 With a latent period of ten to 20 years,4 a variety of malig¬ nant neoplasms have been associated with head and neck irradiation. In addition to thyroid cancers, these malignant neoplasms include salivary
Downloaded From: http://archotol.jamanetwork.com/ by a University of Iowa User on 06/19/2015
1976. 3. Duffy BJ, Fitzgerald PJ: Cancer of the thyroid in children: A report of 28 cases. J Clin Endocrinol Metab 10:1296-1308, 1950. 4. DeGroot L, Paloyan E: Thyroid carcinoma and radiation: A Chicago endemic. JAMA 225:487-491, 1973. 5. Modan B, Baidatz D, Mart H, et al: Radiation-induced head and neck tumours. Lancet 1:277-279, 1974. 6. Hempelmann LH, Hall WU, Phillips M, et al: Neoplasms in persons treated with x-rays in infancy: Fourth survey in 20 years. J Natl Cancer Inst 55:519-530, 1975. 7. Favus MJ, Schneider AB, Stachura ME, et al: Thyroid cancer ocurring as a late consequence of head and neck irradiation. N Engl J Med 294:1019-1025, 1976. 8. Refetoff S, Harrison J, Karanfilski BT, et al: Continuing occurrence of thyroid carcinoma after irradiation to the neck in infancy and childhood. N Engl J Med 292:171-175, 1975. 9. Cadman ML, Soule EH, Kelly PJ: Synovial sarcoma. Cancer 18:613-627, 1965. 10. Roth JA, Enzinger FM, Tannenbaum M: Synovial sarcoma of the neck: A follow-up study of 24 cases. Cancer 35:1243-1253, 1975.
