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Radiation-induced malignant meningioma following proton beam therapy for a choroidal melanoma
Journal of Clinical Neuroscience 22 (2015) 1036–1037
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Radiation-induced malignant meningioma following proton beam therapy for a choroidal melanoma Claudia Scaringi a,⇑, Giuseppe Minniti a,b, Alessandro Bozzao c, Felice Giangaspero b, Teresa Falco a, Alessandro Greco a, Vitaliana De Sanctis a, Andrea Romano c, Riccardo Maurizi Enrici a a b c
Radiation Oncology Unit, Sant’ Andrea Hospital, University Sapienza, Via Grottarossa 1035, Rome 00189, Italy IRCCS Neuromed, Pozzilli, Italy Neuroradiology Unit, Sant’ Andrea Hospital, University Sapienza, Rome, Italy
a r t i c l e
i n f o
Article history: Received 8 September 2014 Accepted 20 December 2014
Keywords: Proton beam therapy Radiation-induced meningioma Secondary cancers
a b s t r a c t We report a woman with malignant meningioma diagnosed 9 years after the treatment of a choroidal melanoma with proton beam therapy. The risk of secondary cancers is a well-known adverse late effect of radiation therapy, especially with the use of advanced techniques such as intensity-modulated radiation therapy. However, this risk may be less with the use of proton beam therapy. A 79-year-old woman presented with symptoms of enophthalmos, ptosis and paralysis of the left medial rectus muscle. She had previously been successfully treated for a choroidal melanoma of the left eye with proton beam therapy (total dose: 60 cobalt gray equivalents) following local resection. MRI showed a lesion in the left cavernous sinus with extension into the orbit and a subsequent biopsy revealed a papillary meningioma. The cavernous tumor was treated with photon radiotherapy (total dose: 54 Gy) which achieved an initial partial response. However, 8 months later the tumor extensively metastasized to the skull and the spine and the patient died 1 year after the treatment. The incidence of secondary malignancies after proton beam therapy is low but not negligible, therefore, it must be taken into account when planning a treatment as secondary tumors may present with a highly aggressive behaviour. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction The risk of secondary cancers is a well-known adverse late effect of radiation therapy, especially with the use of advanced techniques such as intensity-modulated radiation therapy. However, this risk may be less, but not avoidable, with the use of proton beam therapy. We report a woman with malignant meningioma diagnosed 9 years after the treatment of a choroidal melanoma with proton beam therapy. The risk of secondary malignancies after proton beam therapy is low but not negligible, therefore, it should be carefully evaluated before any treatment decision as secondary tumors may present with a highly aggressive behaviour.
2. Case report A 79-year-old woman presented with symptoms of enophthalmos, ptosis and paralysis of the left medial rectus muscle over a duration of 3 months. She had been treated with adjuvant proton ⇑ Corresponding author. Tel.: +39 06 33776160; fax: +39 06 33776608. E-mail address: [email protected] (C. Scaringi).
beam therapy (total dose: 60 cobalt gray equivalents) for a choroidal melanoma of the left eye 9 years prior. MRI of the orbits and brain at presentation showed solid tissue in the left cavernous sinus with extension into the sellar region and Meckel’s cave. A subsequent MRI 3 months later found a marked increase in the size of the lesion, which was in contact with the lateral wall of the orbit. Moreover, it extended into the temporal fossa and reached the contralateral cavernous sinus. Following the progression of symptoms, a third MRI was performed after another 4 weeks and confirmed further pathologic tissue involving the left cavernous sinus and extending into the orbital cavity (Fig. 1). Biopsy of the lesion revealed a papillary meningioma (World Health Organization Grade III). The patient was referred to us for postoperative radiotherapy and a dose of 54 Gy in 30 fractions was administered. Follow-up MRI performed every 2 months showed an initial marked reduction in the size of the lesion. However, 8 months posttreatment, an MRI showed tumor dissemination to the skull and to the spine from C3 to C6, and the patient died a few months later.
Case Reports / Journal of Clinical Neuroscience 22 (2015) 1036–1037
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reduction in the incidence of secondary cancers with the use of proton machines that employ a pencil scanning beam technique [6]. However, whether there is a difference in potential risk of developing secondary tumors following photon and proton therapy compared to passive scattering and scanned beam techniques remains controversial and limited clinical data are available. Newhauser et al. [7] reported an estimated lifetime risk of developing a secondary tumor after craniospinal irradiation of 1.5% for passively scattered proton therapy and 0.8% for scanned beam treatment. More recently, Chung et al. [8] reported a 5.2% incidence of secondary malignancies among 558 patients treated with passively scattered protons compared to 7.5% in a control cohort of 558 patients treated with photons. Other studies have reported a lower risk with proton therapy compared to photon based radiotherapy and a small difference between passive modulation versus scanned proton therapy [9]. More data will probably be available in coming years as secondary malignancies have a significant lag time for development. 4. Conclusions
Fig. 1. Axial T1-weighted MRI with contrast showing the pathologic tissue involving the left cavernous sinus with invasion of the orbit.
3. Discussion Radiation-induced meningiomas are the most common brain tumors known to be induced by radiation and are considered to be a distinct clinical entity [1]. Radiation-induced meningiomas are more aggressive than sporadic tumors, with higher recurrence rates after treatment and more frequent findings of atypical or anaplastic histology [2,3], as in our patient. The risk of secondary malignancies after radiation therapy is well recognized and it is potentially increased with the use of advanced techniques such as intensity-modulated radiation therapy because of the larger volumes of normal tissues exposed to low dose radiation and the increased total body exposure due to radiation leakage [4]. Theoretically, a lower risk of secondary cancers may be achieved with the use of charged particles such as protons because of their ability to concentrate the dose in the tumor while simultaneously sparing surrounding healthy tissues. However, an unavoidable problem of most of the proton facilities currently in operation is that they employ passive modulation techniques, thus, generating secondary neutrons which deliver a total body dose to the patient that can be 10 times higher than that of intensity-modulated radiation therapy [5]. There is a potential http://dx.doi.org/10.1016/j.jocn.2014.12.021
The incidence of secondary cancers after proton therapy is low but not negligible, therefore, they must be taken into account when planning treatment as secondary malignancies may present with highly aggressive behaviour. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Umansky F, Shoshan Y, Rosenthal G, et al. Radiation-induced meningioma. Neurosurg Focus 2008;24:E7. [2] Rubinstein AB, Shalit MN, Cohen ML, et al. Radiation-induced cerebral meningioma: a recognizable entity. J Neurosurg 1984;61:966–71. [3] Godlewski B, Drummond KJ, Kaye AH. Radiation-induced meningiomas after high-dose cranial irradiation. J Clin Neurosci 2012;19:1627–35. [4] Hall EJ. Intensity-modulated radiation therapy, protons, and the risk of second cancers. Int J Radiat Oncol Biol Phys 2006;65:1–7. [5] Brenner DJ, Hall EJ. Secondary neutrons in clinical proton radiotherapy: a charged issue. Radiother Oncol 2008;86:165–70. [6] Schneider U, Agosteo S, Pedroni E, et al. Secondary neutron dose during proton therapy using spot scanning. Int J Radiat Oncol Biol Phys 2002;53:244–51. [7] Newhauser WD, Fontenot JD, Mahajan A, et al. The risk of developing a second cancer after receiving craniospinal proton irradiation. Phys Med Biol 2009;54:2277–91. [8] Chung CS, Yock TI, Nelson K, et al. Incidence of second malignancies among patients treated with proton versus photon radiation. Int J Radiat Oncol Biol Phys 2013;87:46–52. [9] Newhauser WD, Durante M. Assessing the risk of second malignancies after modern radiotherapy. Nat Rev Cancer 2011;11:438–48.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Radiation-induced malignant meningioma following proton beam therapy for a choroidal melanoma Claudia Scaringi a,⇑, Giuseppe Minniti a,b, Alessandro Bozzao c, Felice Giangaspero b, Teresa Falco a, Alessandro Greco a, Vitaliana De Sanctis a, Andrea Romano c, Riccardo Maurizi Enrici a a b c
Radiation Oncology Unit, Sant’ Andrea Hospital, University Sapienza, Via Grottarossa 1035, Rome 00189, Italy IRCCS Neuromed, Pozzilli, Italy Neuroradiology Unit, Sant’ Andrea Hospital, University Sapienza, Rome, Italy
a r t i c l e
i n f o
Article history: Received 8 September 2014 Accepted 20 December 2014
Keywords: Proton beam therapy Radiation-induced meningioma Secondary cancers
a b s t r a c t We report a woman with malignant meningioma diagnosed 9 years after the treatment of a choroidal melanoma with proton beam therapy. The risk of secondary cancers is a well-known adverse late effect of radiation therapy, especially with the use of advanced techniques such as intensity-modulated radiation therapy. However, this risk may be less with the use of proton beam therapy. A 79-year-old woman presented with symptoms of enophthalmos, ptosis and paralysis of the left medial rectus muscle. She had previously been successfully treated for a choroidal melanoma of the left eye with proton beam therapy (total dose: 60 cobalt gray equivalents) following local resection. MRI showed a lesion in the left cavernous sinus with extension into the orbit and a subsequent biopsy revealed a papillary meningioma. The cavernous tumor was treated with photon radiotherapy (total dose: 54 Gy) which achieved an initial partial response. However, 8 months later the tumor extensively metastasized to the skull and the spine and the patient died 1 year after the treatment. The incidence of secondary malignancies after proton beam therapy is low but not negligible, therefore, it must be taken into account when planning a treatment as secondary tumors may present with a highly aggressive behaviour. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction The risk of secondary cancers is a well-known adverse late effect of radiation therapy, especially with the use of advanced techniques such as intensity-modulated radiation therapy. However, this risk may be less, but not avoidable, with the use of proton beam therapy. We report a woman with malignant meningioma diagnosed 9 years after the treatment of a choroidal melanoma with proton beam therapy. The risk of secondary malignancies after proton beam therapy is low but not negligible, therefore, it should be carefully evaluated before any treatment decision as secondary tumors may present with a highly aggressive behaviour.
2. Case report A 79-year-old woman presented with symptoms of enophthalmos, ptosis and paralysis of the left medial rectus muscle over a duration of 3 months. She had been treated with adjuvant proton ⇑ Corresponding author. Tel.: +39 06 33776160; fax: +39 06 33776608. E-mail address: [email protected] (C. Scaringi).
beam therapy (total dose: 60 cobalt gray equivalents) for a choroidal melanoma of the left eye 9 years prior. MRI of the orbits and brain at presentation showed solid tissue in the left cavernous sinus with extension into the sellar region and Meckel’s cave. A subsequent MRI 3 months later found a marked increase in the size of the lesion, which was in contact with the lateral wall of the orbit. Moreover, it extended into the temporal fossa and reached the contralateral cavernous sinus. Following the progression of symptoms, a third MRI was performed after another 4 weeks and confirmed further pathologic tissue involving the left cavernous sinus and extending into the orbital cavity (Fig. 1). Biopsy of the lesion revealed a papillary meningioma (World Health Organization Grade III). The patient was referred to us for postoperative radiotherapy and a dose of 54 Gy in 30 fractions was administered. Follow-up MRI performed every 2 months showed an initial marked reduction in the size of the lesion. However, 8 months posttreatment, an MRI showed tumor dissemination to the skull and to the spine from C3 to C6, and the patient died a few months later.
Case Reports / Journal of Clinical Neuroscience 22 (2015) 1036–1037
1037
reduction in the incidence of secondary cancers with the use of proton machines that employ a pencil scanning beam technique [6]. However, whether there is a difference in potential risk of developing secondary tumors following photon and proton therapy compared to passive scattering and scanned beam techniques remains controversial and limited clinical data are available. Newhauser et al. [7] reported an estimated lifetime risk of developing a secondary tumor after craniospinal irradiation of 1.5% for passively scattered proton therapy and 0.8% for scanned beam treatment. More recently, Chung et al. [8] reported a 5.2% incidence of secondary malignancies among 558 patients treated with passively scattered protons compared to 7.5% in a control cohort of 558 patients treated with photons. Other studies have reported a lower risk with proton therapy compared to photon based radiotherapy and a small difference between passive modulation versus scanned proton therapy [9]. More data will probably be available in coming years as secondary malignancies have a significant lag time for development. 4. Conclusions
Fig. 1. Axial T1-weighted MRI with contrast showing the pathologic tissue involving the left cavernous sinus with invasion of the orbit.
3. Discussion Radiation-induced meningiomas are the most common brain tumors known to be induced by radiation and are considered to be a distinct clinical entity [1]. Radiation-induced meningiomas are more aggressive than sporadic tumors, with higher recurrence rates after treatment and more frequent findings of atypical or anaplastic histology [2,3], as in our patient. The risk of secondary malignancies after radiation therapy is well recognized and it is potentially increased with the use of advanced techniques such as intensity-modulated radiation therapy because of the larger volumes of normal tissues exposed to low dose radiation and the increased total body exposure due to radiation leakage [4]. Theoretically, a lower risk of secondary cancers may be achieved with the use of charged particles such as protons because of their ability to concentrate the dose in the tumor while simultaneously sparing surrounding healthy tissues. However, an unavoidable problem of most of the proton facilities currently in operation is that they employ passive modulation techniques, thus, generating secondary neutrons which deliver a total body dose to the patient that can be 10 times higher than that of intensity-modulated radiation therapy [5]. There is a potential http://dx.doi.org/10.1016/j.jocn.2014.12.021
The incidence of secondary cancers after proton therapy is low but not negligible, therefore, they must be taken into account when planning treatment as secondary malignancies may present with highly aggressive behaviour. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Umansky F, Shoshan Y, Rosenthal G, et al. Radiation-induced meningioma. Neurosurg Focus 2008;24:E7. [2] Rubinstein AB, Shalit MN, Cohen ML, et al. Radiation-induced cerebral meningioma: a recognizable entity. J Neurosurg 1984;61:966–71. [3] Godlewski B, Drummond KJ, Kaye AH. Radiation-induced meningiomas after high-dose cranial irradiation. J Clin Neurosci 2012;19:1627–35. [4] Hall EJ. Intensity-modulated radiation therapy, protons, and the risk of second cancers. Int J Radiat Oncol Biol Phys 2006;65:1–7. [5] Brenner DJ, Hall EJ. Secondary neutrons in clinical proton radiotherapy: a charged issue. Radiother Oncol 2008;86:165–70. [6] Schneider U, Agosteo S, Pedroni E, et al. Secondary neutron dose during proton therapy using spot scanning. Int J Radiat Oncol Biol Phys 2002;53:244–51. [7] Newhauser WD, Fontenot JD, Mahajan A, et al. The risk of developing a second cancer after receiving craniospinal proton irradiation. Phys Med Biol 2009;54:2277–91. [8] Chung CS, Yock TI, Nelson K, et al. Incidence of second malignancies among patients treated with proton versus photon radiation. Int J Radiat Oncol Biol Phys 2013;87:46–52. [9] Newhauser WD, Durante M. Assessing the risk of second malignancies after modern radiotherapy. Nat Rev Cancer 2011;11:438–48.