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| Year : 2014 | Volume
: 60
| Issue : 2 | Page : 218-219 |
Radiation-induced intracranial osteosarcoma: A case report
RD Patel, NM Gadgil, M Khare, N Majethia
Department of Pathology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| Date of Web Publication | 13-May-2014 |
Correspondence Address:
Dr. R D Patel
Department of Pathology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0022-3859.132379
How to cite this article:
Patel R D, Gadgil N M, Khare M, Majethia N. Radiation-induced intracranial osteosarcoma: A case report. J Postgrad Med 2014;60:218-9 |
Sir,
Radiotherapy is the standard of care for many brain tumors. Unfortunately, it may induce undesirable late complications, such as radionecrosis and oncogenesis. Secondary tumors are most frequently meningiomas, sarcomas (especially fibrosarcoma), and gliomas. [1]
A 52-year-old man presented with sudden onset headache, with visual loss, aphasia, and left hemiparesis. He had a previous history of radiotherapy for an intracranial tumor diagnosed as craniopharyngioma 22 years prior [Figure 1]. External radiotherapy given to the pituitary area was 50 Gy, in 30 fractions, for 47 days. Magnetic resonance imaging (MRI) of the brain showed a well-defined mass in the sellar and suprasellar region, showing a mixed intensity on T2- as well as T1-weighted scans. A computed tomography (CT) scan showed a mass in the sellar and suprasellar region, arising from the clivus, showing a chunky calcification [Figure 2]. The impression on the radiological scans was residual / recurrent tumor. The histology of the tumor showed spindle-to-oval tumor cells with nuclear atypia, few giant cells, and osteoid formation [Figure 3]. A diagnosis of osteoblastic osteosarcoma was made. The patient was operated again for complete removal of the tumor, which improved the visual symptoms but the patient developed metabolic acidosis, likely due to destruction of the hypothalamic area. After initial remission following surgical intervention, the patient's condition deteriorated and he died a month after diagnosis. | Figure 1: MRI scan image of a primary tumor in the sagittal plane showing a midline sellar and suprasellar calcified space-occupying lesion (SOL)
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 | Figure 2: CT scan image of a secondary tumor in sagittal plane after radiotherapy showing a mass arising from the clivus, showing a chunky calcification
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 | Figure 3: Photomicrograph showing a tumor composed of malignant pleomorphic cells in the neoplastic osteoid (H and E stain; original magnification 400×)
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The estimated incidence of radiation-induced sarcoma is 0.03-0.22%. The second malignant neoplasm (SMN) in patients with a pituitary tumor treated with surgery and radiotherapy was 1.0% 10 years after treatment and 1.9% 20 years after treatment, with a relative risk, compared to the normal population of 10.5%. [2] As per our search of literature, only two cases of osteosarcoma have been described after radiotherapy for craniopharyngioma. [3]
Compared to primary craniofacial osteosarcoma, radiation-induced osteosarcoma tends to be of a higher grade, with a more aggressive course and a poor prognosis, with the median survival varying from 12 - 18 months, decreasing to less than one year in most patients with intracranial extension. [4]
As per Cathan et al., [5] the diagnosis of radiation-induced sarcoma must fulfill four prerequisites:
- There must have been roentgenographic evidence of the non-malignant nature of the initial bone condition;
- Sarcoma must develop on the previously irradiated field;
- A relatively long latent period must have elapsed between irradiation and the appearance of sarcoma; and
- The sarcoma must have been pathologically proven.
Radiosurgery or stereotactic radiotherapy aims for morlocalized high-dose irradiation, frequently irradiating larger volumes of the normal brain compared to the low doses, which may increase the risk of second tumors. Only six cases of second malignant neoplasms (SMNs) have been reported in the literature after radiosurgery, to date. [6] The reported radiation doses involved in customary radiotherapy vary from 50-60 Gy. Larger radiation dosages and higher degrees of malignancy may be associated with a shorter latency before the development of radiation-induced brain tumor.
Post-radiation intracranial osteosarcoma is very rare, but aggressive, with high recurrence and poor prognosis. Although patients will increasingly be reported with SMN after radiotherapy and radiosurgery in the future, the overall incidence seems quite low and should not alter the current practice, however, continual surveillance of the treated patients should be considered. The safe and routine use of both techniques depends on an accurate calculation of their risks.
| :: References | |  |
| 1. | Chabchoub I, Gharbi O, Remadi S, Limem S, Trabelsi A, Hochlef M, et al. Postirradiation osteosarcoma of the maxilla: A case report and current review of literature. J Oncol 2009;2009:876138. 
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| 2. | MinnitiG,TraishD, AshleyS,GonsalvesA,BradaM.Risk of second brain tumor after conservative surgery and radiotherapy for pituitary adenoma: Update after an additional 10 years. J Clin Endocrinol Metab 2005;90:800-4.
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| 3. | Patel AJ, Rao VY, Fox BD, Suki D, Wildrick DM, Sawaya R, et al. Radiation-induced osteosarcomas of the calvarium and skull base. Cancer 2011;117:2120-6.
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| 4. | Gonin-Laurent N, Hadj-Hamou NS, Vogt N, Houdayer C, Gauthiers-Villars M, Dehainault C, et al. RB1 and TP53 pathways in radiation-induced sarcomas. Oncogene 2007;26:6106-12.
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| 5. | Aanesen JP, Olofsson J. Irradiation-induced tumours of the head and neck. ActaOtolaryngolSuppl 1979;360:178-81.
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| 6. | Loeffler JS, Niemierko A,Chapman PH.Second tumors after radiosurgery:Tip of the iceberg or a bump in the road? Neurosurgery 2003;52:1436-42.
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[Figure 1], [Figure 2], [Figure 3]
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