Postradiation sarcoma involving the spine.

Postradiation sarcomas arising many years after treatment of cancer are long term sequelae of therapy. We describe the clinical features, radiographic findings, and results of treatment in 13 patients with such sarcomas encountered over a 6-year period. Of these patients, 9 had bone sarcomas and the remaining 4 had paraspinal tumors arising from adjacent soft tissue and nerve. The primary cancer for which radiation was given included Hodgkin's disease (4 patients), breast cancer (2 patients), cervix cancer (2 patients), and a variety of others (5 patients). The latent interval to the occurrence of the second neoplasm varied from 6 to 30 years (median, 10 years) after treatment of the original tumor. Despite aggressive treatment, the overall prognosis was poor. The median survival was 8 months, with only 3 surviving more than 2 years. Although rare, postradiation sarcoma should be considered in the differential diagnosis of patients presenting with late onset of spinal pain or neurological symptoms after clinical remission of an original cancer.

Postradiation osteogenic sarcoma of bone and soft tissues. A clinicopathologic study of 66 patients.

Sixty-six patients with well-documented osteogenic sarcomas arising in bones and soft tissues after exposure to x-rays, which represent approximately 5.5 percent of all osteogenic sarcomas registered since 1921 at this institution, were studied. These secondary sarcomas occurred in equal proportion in both sexes, with the sixth decade of life being the most common age. In 42 patients, the bone had been normal at the time of irradiation, whereas in 24, the radiation was directed against an osseous tumor or tumor-like lesion. The median latent period was 10.5 years in both groups, ranging from 3.5 to 33 years. The radiation varied from diagnostic quality to 1 MeV x-rays. The dose was variable, but none was less than 2000 rads. Postradiation osteogenic sarcomas most commonly arose in the bones of the pelvic and shoulder regions. Histologically, the sarcomas were mostly of the fibrous type (46%) and radiographically showed a destructive bone lesion with or without signs of radiation osteitis. The cumulative disease-free survival rate at 5 years was 17%, with a median survival estimate of 1 year.

Benign solitary lung lesions in patients with cancer.

The appearance of a lung opacity on a chest film of a patient with known cancer may present a diagnostic dilemma. From 1940 through 1975, over 800 patients with this problem underwent thoracotomy for confirmation of diagnosis. In some 500 of these patients, the lesion proved to be primary cancer of the lung; in 196 they were solitary metastases and in 11 patients the lesions were benign. There were six additional patients in whom multiple opacities were found which proved to be benign conditions. An approach to the investigation, diagnosis, and surgical management of such solitary pulmonary lesions is presented. It is emphasized that the appearance of a solitary pulmonary shadow in a patient with a history of cancer should not be assumed to be a metastasis. Appropriate investigations should be performed without delay in an effort to define the nature of the lesion by microscopic analysis permitting definitive therapy to be administered and a more accurate prognosis provided.

Separate primary carcinomas of the esophagus and head and neck region in the same patient.

From 1949 to 1972 at Memorial Sloan-Kettering Cancer Center, 60 patients with primary cancers of both the oral cavity, pharynx, larynx (OPL) and esophagus were studied. In 15, the cancers occurred synchronously, and in 68% they occurred within 2 years of each other, the longest interval being 27 years. The tongue and extrinsic larynx were the most common sites of origin together with the middle third of the esophagus. During the same period, over 7000 patients with OPL and over 1000 patients with esophageal cancers were seen at this institution. The majority of patients had a history of excessive smoking and alcohol intake. Four out of nine who had previous radiation therapy for their OPL cancer developed esophageal cancer within the therapeutic field (three after 16, 25, and 27 years). Thirty percent (18/60) had three primary cancers; one had four, of which two were in the head and neck region. Two patients survived more than 5 years; both also had a third primary cancer of the lung. There are broader implications in this study: multiple primary cancers in general, and this group in particular, give us especially valuable clues as to the oncogenic influence of environmental factors as well as cellular, organ, and also systemic susceptibility. With one cancer, one can anticipate formation in other related organs. This provides an opportunity for early diagnosis, more effective management, and improved survival. The cause and effect relationship of tobacco and alcohol must be emphasized at every opportunity and most particularly to those who have developed one cancer in the oropharyngeal-laryngeal region.

Significance of a solitary lung shadow in patients with breast cancer.

From 1949 through 1972 at Memorial Sloan-Kettering Cancer Institute, 72 breast cancer patients developed a synchronous or metachronous solitary lung shadow. Forty-three had separate primary lung cancers; 23 had breast carcinoma metastases and six had benign lung lesions. Of these, 47% were asymptomatic and the lesions were discovered by routine chest roentgenograms. Among 49 patients who underwent pulmonary procedures, secondary involvement of regional lymphatics was noted in 22, nine of which were daughter metastases secondary to the breast deposit. In such a setting, a radical lobectomy (or pneumonectomy) would seem the operation of choice. Four patients who had primary lung cancer and five patients with pulmonary breast metastases survived five years after the thoracic procedure. Prolonged survival in these patients bore no relationship to age, sex, state of axillary lymph nodes or length of interlude between the breast and the lung cancer. Early diagnosis, the extent of the cancer and adequate excision seem to influence end results. When other primary cancers were present, in addition to those of breast and lung, these did not seem to diminish the chance for survival provided they were treated as if they existed alone. The need for strict periodic and continual followup examinations, not only in breast, but also for all cancer patients is essential for early detection of metastases or new primaries. Chest roentgenograms are an integral part of such a plan. The ambiguity of a solitary lung shadow (or at the most two or three opacities) with a known primary breast cancer requires clarification without delay as to its histologic nature so that proper treatment can be instituted and an accurate prognosis given.