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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 869-870

Radiation-induced osteosarcoma of the calvarium in a patient of left frontal oligodendroglioma following surgery and radiotherapy


1 Department of Radiology and Imaging, Fortis Memorial Research Institute, Gurgaon and SRL-FMRI Diagnostics, Gurgaon, Haryana, India
2 Department of Neurosurgery, Fortis Memorial Research Institute, Gurgaon and SRL-FMRI Diagnostics, Gurgaon, Haryana, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Rakesh K Gupta
Department of Radiology and Imaging, Fortis Memorial Research Institute, Gurgaon and SRL-FMRI Diagnostics, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263209

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How to cite this article:
Verma RK, Ahlawat S, Patir R, Gupta RK. Radiation-induced osteosarcoma of the calvarium in a patient of left frontal oligodendroglioma following surgery and radiotherapy. Neurol India 2019;67:869-70

How to cite this URL:
Verma RK, Ahlawat S, Patir R, Gupta RK. Radiation-induced osteosarcoma of the calvarium in a patient of left frontal oligodendroglioma following surgery and radiotherapy. Neurol India [serial online] 2019 [cited 2019 Dec 13];67:869-70. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/869/263209




Sir,

A 53-year old gentleman presented on 21/10/2012 with an episode of generalized tonic and clonic seizure. Magnetic resonance imaging (MRI) of the brain revealed a mass in the left frontal region showing mild patchy enhancement. Postoperative histopathology revealed WHO grade II oligodendroglioma. Postoperative MRI on 05/11/2012 revealed a small nonenhancing residual disease in the posterior and medial margins of the surgical cavity. The patient was started on intensity modulated radiotherapy (IMRT) on 27/11/2012 with 54 Gy/30 fractions over a period of 47 days. Post-radiation, he was on a regular follow-up with the yearly serial MRI showing no interval change in the primary disease. However, in October 2017, the follow-up perfusion MRI in an otherwise asymptomatic patient revealed development of an enhancing lesion in the left frontal bone with dural involvement. MR perfusion revealed a high-grade disease with markedly increased relative cerebral blood volume (rCBV) values. Wide excision of the lesion was performed, and the histology confirmed it to be an osteosarcoma [Figure 1].
Figure 1: Preoperative contrast-enhanced (CE) T1W and FLAIR axial images (a and b) show mildly enhancing lesion with surrounding edema. Postoperative CE T1W and FLAIR images (c and d) show the surgical cavity with surrounding FLAIR hyperintensity without any residual enhancing lesion. Follow-up study (e-g) after 5 years reveals nodular enhancing lesion anteromedial to the surgical cavity involving the dura mater with adjacent frontal bone. Color-coded perfusion image (h) reveals high rCBV values (arrow). Image of the resected specimen removed in toto (i). Hematoxylin and eosin stain (j and k) of the resected tumor shows telangiectatic dilated spaces (j) with osteoclastic giant cell (k) with tumor cells laying down osteoid (l) and showing brisk mitosis (m)

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Radiation therapy is widely used for patients with intracranial tumors. However, there are many complications, including the development of radiation-induced tumors. Radiation-induced central nervous system (CNS) neoplasms are rare, but the cumulative risk of brain tumor developing after therapeutic cranial irradiation is reported to be in the range of 0.5–2.7% at 15 years. Among the radiation-induced CNS neoplasms, meningiomas constitute about 70%, gliomas about 20%, and sarcomas less than 10%.[1]

Cahan et al.,[2] established the criteria to diagnose a radiotherapy-induced brain tumor as follows: (1) The tumor must appear within the irradiated field; (2) the tumor was not present prior to the radiotherapy; (3) a sufficient latency period must elapse between the irradiation and appearance of the tumor (usually >5 years); (4) the radiation-induced tumor must be histologically proven and should be a different histological type from the original neoplasm treated by the radiation therapy. All these conditions were fulfilled in the current case.

MR perfusion has been used to differentiate between radiation-induced necrosis and residual/recurrent tumors.[3] Applying the same parameters, high-grade tumors, including radiation-induced sarcomas, are likely to have high regional cerebral blood volume (rCBV) values, as observed in the present case.

Complete surgical excision is the treatment of choice for radiation-induced osteosarcomas. Patients with inoperable tumors may be treated with radiotherapy and/or chemotherapy.[4]

We conclude that a radiation-induced osteosarcoma of the calvarium is a rare complication of radiation therapy. A long-term follow-up is mandatory even in asymptomatic patients to look for interval changes in the irradiated field for establishing an early diagnosis of the lesion. Multiparametric imaging helps to differentiate a high-grade disease from radiation-induced changes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Yamanaka R, Hayano A. Radiation-Induced Glioma In: Lichtor T, editor. Molecular considerations and evolving surgical management issues in the treatment of patients with a brain tumor. InTech Open2015. p. 129-41. Available from: https://www.intechopen.com/books/molecular-considerations-and-evolving-surgical-managementissues-in-the-treatment-of-patients-with-a-brain-tumor/radiation-induced-glioma. [Last accessed on 2019 Jun 15].  Back to cited text no. 1
    
2.
Cahan WG, Woodard HQ, Higinbotham NL, Stewart FW, Coley EL. Sarcoma arising in irradiated bone; report of 11 cases. Cancer 1948;1:3-29.  Back to cited text no. 2
    
3.
Suh CH, Kim HS, Jung SC, Choi CG, Kim SJ. Perfusion MRI as a diagnostic biomarker for differentiating glioma from brain metastasis: A systematic review and meta-analysis. Eur Radiol 2018: 28-3819-31.  Back to cited text no. 3
    
4.
Echchikhi Y, Loughlimi H, Touil A, Kebdani T, Benjaafar N. Radiation-induced osteosarcoma of the skull base after radiation therapy in a patient with nasopharyngeal carcinoma: A case report and review of the literature. J Med Case Rep 2016;10:334.  Back to cited text no. 4
    


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