Multiple Primary Cancers in Patients With Osteosarcoma Influence of Anticancer Drugs and Genetic Factors
Tsukasa Yonemoto, MD,* Shin-ichiro Tatezaki, MD,* Takeshi Ishii, MD,* Yoko Hagiwara, MD,* and Masatoshi Inoue, MD}
Abstract: One hundred thirty-five patients younger than 30 years with osteosarcoma were treated at the Chiba Cancer Center between 1976 and 1999. They included six patients with second cancer after cure of osteosarcoma (group A) and three patients with osteosar- coma as second cancer after cure of childhood cancers (group B). Third cancer occurred in one patient of group A. The clinical features of these nine patients were studied. The diagnoses of second cancer in group A consisted of two acute myelogenous leukemias, two breast carcinomas, one malignant phyllodes tumor of breast, and one ovarian carcinoma. The third cancer was uterine leiomyosar- coma. Second cancer occurred an average of 7.2 years after occur- rence of osteosarcoma. The diagnoses of first cancer in group B consisted of one adrenocortical carcinoma, one malignant teratoma of sacrum, and one ovarian carcinoma (yolk sac tumor). Osteosar- coma occurred on average 12.7 years after occurrence of first cancer. Two patients had germ-line p53 gene mutation. Anticancer drugs and genetic factors are presumed to be concerned with occurrence of second cancer. The frequency of multiple primary cancers in pa- tients with osteosarcoma is by no means low. Strict follow-up is thus needed over a long period.
Key Words: osteosarcoma, multiple primary cancers, chemotherapy, germ-line p53 gene mutation (Am J Clin Oncol 2004;27: 220-224)
O ☐ steosarcoma is a malignant bone tumor that occurs in adolescents and young adults by preference. Clinical results for this tumor were fatal until 30 years ago. With the advance of multidisciplinary therapy centering around che- motherapy in recent years, however, clinical results have improved markedly, leading to many patients being cured.1 As the cured patients with osteosarcoma increase in number,
From the *Division of Orthopaedic Surgery, Chiba Cancer Center and the ¿Division of Orthopaedic Surgery, National Chiba Higashi Hospital, Chiba, Japan.
Reprints: Dr. Tsukasa Yonemoto, Division of Orthopaedic Surgery, Chiba Cancer Center, 666-2 Nitona-cho, Chuo-ku, Chiba, 260-8717, Japan.
Copyright @ 2004 by Lippincott Williams & Wilkins ISSN: 0277-3732/04/2703-0220
DOI: 10.1097/01.COC.0000054534.43117.76
second cancer occurring after the cure of osteosarcoma has come to be noted in some patients. Clinical results of child- hood cancers have also improved markedly as the result of multidisciplinary therapy in recent years, with many patients being cured. The increase in the patients cured of childhood cancers has given rise to some patients with osteosarcoma as a second cancer after the cure of childhood cancers. The frequency of multiple primary cancers in patients with osteo- sarcoma has increased recently as described above. Antican- cer drugs, radiation, and genetic factors are presumed to be related to this increase.2-5 The present study was undertaken to clarify the clinical features of multiple primary cancers in patients with osteosarcoma.
MATERIALS AND METHODS
Patients
Osteosarcoma occurring in adolescents and young adults was studied. Osteosarcoma occurring in old adults and postirradiation osteosarcoma were excluded from the present study because they differ from osteosarcoma occurring in adolescents and young adults in terms of biologic behavior. We investigated the presence or absence of multiple primary cancers in 135 patients younger than 30 years with osteosar- coma who were treated at the Chiba Cancer Center between 1976 and 1999. Histologically, 129 patients belonged to high grade malignancy and 6 patients to low grade. Of the 135 patients, 6 patients had second cancer after previously cured osteosarcoma (group A) and 3 patients had osteosarcoma as second cancer after the cure of childhood cancers (group B). Third cancer occurred in one patient of group A. The staging of osteosarcoma in these nine patients was classified accord- ing to the Surgical Staging System of Enneking.6 All of the six patients in group A belonged to stage IIB, whereas one patient belonged to stage IB and two patients to stage IIB in group B. Stage IB indicated a histologically low grade and extracompartmental tumor. Stage IIB indicated a high grade and extracompartmental tumor.
In 8 patients (all except case 7), a large quantity of anticancer drugs was used in the treatment of first cancer.
Eight patients (all except case 8) had undergone wide exci- sion for the primary tumor of first cancer. Six (cases 1, 2, 4, 5, 6, and 8) of nine patients developed lung metastases, and five (all except case 8) had undergone thoracotomy.
Study of Clinical Features
Age at the occurrence of first cancer, diagnosis of first cancer, interval from the occurrence of first cancer to second (third) cancer, age at the occurrence of second (third) cancer, diagnosis of second (third) cancer, age at the final follow-up, and outcome were studied in these nine patients. In the eight patients in whom anticancer drugs were used for the treat- ment of first cancer, the kinds and total dose of the anticancer drugs were investigated.
Examination of Germ-Line p53 Gene Mutation Combining 52 patients without multiple primary can- cers who have been disease free for more than 3 years after treatment of osteosarcoma in the same period and these 9 patients who developed multiple primary cancers, we con- ducted a questionnaire survey as to whether they wished to undergo an examination for germ-line p53 gene mutation. We
directly interviewed those who wished to take the examina-
tion and fully explained to them the significance of the examination. The examination for germ-line p53 gene muta- tion using peripheral blood was performed only in the pa- tients who gave informed consent. High-molecular-weight DNA was isolated from peripheral blood according to stan- dard methods. Each exon (exons 4-11) of the p53 gene was screened by the polymerase chain reaction/single strand con- formation polymorphism (PCR-SSCP) analysis. Each primer sequence was obtained from published data.7 When an aber- rant band was found by the PCR-SSCP analysis, the direct sequencing of double-stranded PCR fragments was done. PCR-SSCP analysis and direct sequencing of the p53 gene were performed according to standard methods.7-10
RESULTS
In group A, the diagnoses included two acute myelog- enous leukemias, two breast carcinomas, one malignant phyl- lodes tumor of breast, one ovarian carcinoma for second cancer, and one uterine leiomyosarcoma for third cancer. All except one of the patients with acute myelogenous leukemia were female. The age at occurrence of second cancer ranged from 14 to 32 years (mean 22.5 years); second cancer oc- curred within 3 to 16 years from the time osteosarcoma occurred (mean 7.2 years). The age at occurrence of third cancer was 35 years; third cancer occurred within 6 years from the time osteosarcoma occurred. As for the outcome, two patients were alive with no evidence of disease and four patients died of disease.
In group B, the diagnoses of first cancer included one adrenocortical carcinoma, one malignant teratoma of the
| TABLE 1. Clinical Data of the Patients | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Case | Sex | First Cancer | Interval From 1st Cancer to 2nd (3rd) Cancer (y) | Second (Third) Cancer | Age at Final Follow-up (y) | Outcome | Germ-Line p53 Gene Mutation | ||
| Age (y) | Diagnosis | Age (y) | Diagnosis | ||||||
| Group A | |||||||||
| 1 | F | 12 | Osteosarcoma of left femur | 3 | 15 | Acute myelogenous leukemia | 15 | DOD | (-) |
| 2 | M | 7 | Osteosarcoma of left tibia | 7 | 14 | Acute myelogenous leukemia | 14 | DOD | CHEZ NI |
| 3 | F | 12 | Osteosarcoma of left femur | 9 | 21 | Malignant phyllodes tumor | 22 | DOD | (+) |
| 4 | F | 29 | Osteosarcoma of left ulna | 3 | 32 | Breast carcinoma | 38 | NED | NI |
| (6) | (35) | (Uterine leiomyosarcoma) | |||||||
| 5 | F | 13 | Osteosarcoma of right femur | 16 | 29 | Breast carcinoma | 35 | NED | |
| 6 | F | 19 | Osteosarcoma of sacrum | 5 | 24 | Ovarian carcinoma | 24 | DOD | CO |
| Group B | |||||||||
| 7 | F | 10 mo | Adrenocortical carcinoma | 10 | 11 | Osteosarcoma of right femur | 15 | NED | (+) |
| 8 | F | 2 | Malignant teratoma of sacrum | 12 | 14 | Osteosarcoma of left femur | 18 | NED | ECO |
| 9 | F | 8 | Ovarian carcinoma (yolk sac tumor) | 16 | 24 | Osteosarcoma of right ilium | 28 | NED | (-) |
DOD, died of disease; F, female; M, male; NED, no evidence of disease; NI, not investigated.
sacrum, and one ovarian carcinoma (yolk sac tumor), all the patients being female. The ages at occurrence of first cancer were 10 months, 2 years, and 8 years (mean 3.6 years). Osteosarcoma occurred in 10 years, 12 years, and 16 years (mean 12.7 years) from the time first cancer occurred. As for the outcome, all of the three patients were alive with no evidence of disease. Clinical data of the patients are shown in Table 1.
Table 2 lists the kinds and total dose of the anticancer drugs used for treatment of first cancer.
The examination of germ-line p53 gene mutation could be conducted in 45 of 52 patients without multiple primary cancers and in 7 of 9 patients who developed multiple primary cancers. No germ-line p53 gene mutation was found in the 45 patients without multiple primary cancers. On the other hand, two (case 3 and 7) of the seven patients with multiple primary cancers had germ-line p53 gene mutation.
Report of a Representative Case Case 3
A 12-year-old girl was referred to our hospital because of bone tumor of the left femur (Fig. 1). Diagnosis of osteosarcoma was made by open biopsy. After systemic chemotherapy had been administered for about 4 months, wide excision of the tumor and reconstruction by artificial joint were performed. After postoperative chemotherapy given for about 1 year, she had been alive with no evidence of disease for 8 years. At age 21, she came to our hospital again because a tumor mass was felt in the right breast. Diagnosis of malignant phyllodes tumor was made by open biopsy. Wide excision of the tumor was performed, but metastases to the lung and bone occurred. The patient died 7 months after the occurrence of malignant phyllodes tumor. Investigation of the patient’s family history at that point in time revealed frequent occurrence of cancer (Fig. 2). This
patient was found to have an aberrant band at exon 5 on examination of p53 gene in peripheral blood by PCR-SSCP analysis. It was also confirmed by the direct sequence anal-
| TABLE 2. Kinds and Total Dose of Anticancer Drugs Used for the Treatment of First Cancer (mg) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Case | CPM | IFM | MTX | DXR | ACR | BLM | ACD | VCR | VDS | VLB | VP-16 | CDDP | CBDCA |
| Group A | |||||||||||||
| 1 | 20,500 | 76,600 | 87,960 | 605 | 80 | 40 | 1.6 | 2 | 6 | 6,800 | 930 | ||
| 2 | 11,360 | 42,600 | 95,200 | 345 | 920 | 90 | 3 | 6 | 10.2 | 1,620 | 780 | 150 | |
| 3 | 2,900 | 18,000 | 170 | 65 | 2.1 | 3 | 450 | ||||||
| 4 | 4,800 | 69,900 | 28,000 | 240 | 90 | 3 | 2 | 300 | 800 | ||||
| 5 | 10,750 | 40,000 | 127,050 | 770 | 300 | 2.6 | 24 | 11 | 200 | 450 | |||
| 6 | 5,600 | 28,000 | 30,000 | 250 | 80 | 3.2 | 3 | 13 | 720 | 570 | 1,200 | ||
| Group B | |||||||||||||
| 8 | 16,800 | 500 | 20.5 | 28 | 112 | ||||||||
| 9 | 113.7 | 16.8 | 51.7 | ||||||||||
ACR, aclarubicin; ACD, dactinomycin; BLM, bleomycin; CBDCA, carboplatin; CDDP, cisplatin; CPM, cyclophosphamide; DXR, doxorubicin; IFM, ifosfamide; MTX, methotrexate; VCR, vincristine; VDS, vindesine; VLB, vinblastine; VP-16, etoposide.
@ 2004 Lippincott Williams & Wilkins
Gastric cancer / 40yrs.
blt. Breast cancer 38yrs. / 41yrs.
Osteosarcoma / 12yrs.
Malignant phyllodes tumor / 21yrs.
ysis that arginine (CGC) of codon 175 had been substituted by histidine (CAC) (Fig. 3). These findings made it clear that this patient had germ-line p53 gene mutation. There have been several reported cases of mutation at this site.11
DISCUSSION
With an increase in the number of patients cured of osteosarcoma, patients experiencing second cancer several
years later have become a subject of attention. Patients with osteosarcoma as second cancer have also been noted recently as the number of patients cured of childhood cancers in- creases. Multiple primary cancers in adolescents and young adults with osteosarcoma are expected to increase more with the advance of therapy. Leukemia, malignant fibrous histio- cytoma, breast carcinoma, colon carcinoma, astrocytoma, and thyroid carcinoma have been reported as second cancers after cure of osteosarcoma in the literature.12-15 On the other hand, Ewing sarcoma, malignant fibrous histiocytoma, retinoblas- toma, Hodgkin’s disease, rhabdomyosarcoma, neurofibrosar- coma, Wilms tumor, and neuroblastoma have been reported as first cancers in the patients developing osteosarcoma as second cancer.16-22 It is also known that secondary osteosar- coma occurs as a late side effect due to radiotherapy for malignant tumors.3-5,23 The frequency of multiple primary cancers among patients with osteosarcoma is by no means low.
Anticancer drugs used for the treatment of first cancer as well as genetic factors are likely to be concerned with the occurrence of multiple primary cancers. In eight of the nine patients with osteosarcoma who experienced multiple pri- mary cancers, a large quantity of anticancer drugs were used in the treatment of first cancer, suggesting that anticancer drugs are related to the occurrence of second cancer. It is known that alkylating agents are associated with the devel- opment of second cancer,4,24 and that etoposide is associated with the development of secondary leukemia.25 Alkylating
exon 5
G
T
codon
175
C
Arg
G/A
His
C
G
Aberrant band
G
control
Case 3
G
A
T
C
PCR-SSCP
Direct Sequence
C) 2004 Lippincott Williams & Wilkins
agents such as cyclophosphamide and ifosfamide were used in large dose for the treatment of first cancer in seven of the eight patients studied here. Etoposide was used in the two patients who developed secondary leukemia. However, we were unable to definitely prove an association between the development of second cancer and anticancer drugs in the present study because the number of cases was too small.
No germ-line p53 gene mutation was found in the 45 patients without multiple primary cancers. On the other hand, two (cases 3 and 7) of the seven patients with multiple primary cancers had germ-line p53 gene mutation. In these two patients (cases 3 and 7), the involvement of genetic factors in the occurrence of second cancer was suspected. There is a possibility of another malignant tumor (third cancer) occurring in the future, so long-term strict follow-up is needed. We were unable to definitely prove an association between the development of second cancer and genetic fac- tors in the present study because the number of cases was too small. A multiinstitutional large-scale survey will be neces- sary to prove that anticancer drugs and genetic factors are associated with second cancer.
Li-Fraumeni syndrome is known as an indicator of the pedigree of cancer manifesting as osteosarcoma.2,11,26-29 Malkin et al.29 have reported that germ-line p53 gene muta- tion is accountable for it. Of the nine patients with osteosar- coma studied this time, two patients of group A (cases 3 and 5) came under the category of Li-Fraumeni syndrome. Of them, one patient (case 3) had germ-line p53 gene mutation, whereas the other patient (case 5) did not. This patient (case 5) may have had the germ-line hCHK2 gene mutation re- ported by Bell et al.3º One patient of group B (case 7) also had germ-line p53 gene mutation. Since her family history of cancer was negative, this may have been de novo mutation, or a cancer may occur in her relatives in the future. Examining the germ-line p53 gene mutation would be useful for early detection and early treatment of second and third cancers.
REFERENCES
1. Whelan JS. Osteosarcoma. Eur J Cancer 1997;33:1611-9.
2. McIntyre JF, Smith-Sorensen B, Friend SH, et al. Germline mutations of the p53 tumor suppressor gene in children with osteosarcoma. J Clin Oncol 1994;12:925-30.
3. Meadows AT, Strong LC, Li FP, et al. Bone sarcoma as a second malignant neoplasm in children. Influence of radiation and genetic predisposition. Cancer 1980;46:2603-6.
4. Tucker MA, D’Angio GJ, Boice JD Jr, et al. Bone sarcomas linked to radiotherapy and chemotherapy in children. N Engl J Med 1987;317:588-93.
5. Vu BL, deVathaire FR, Shamsaldin A, et al. Radiation dose, chemo- therapy and risk of osteosarcoma after solid tumours during childhood. Int J Cancer 1998;77:370-7.
6. Enneking WF, Spanier SS, Goodman MA. System for the surgical staging of musculoskeletal sarcoma. Clin Orthop 1980;153:106-20.
7. Toguchida J, Yamaguchi T, Ritchie B, et al. Mutation spectrum of the p53 gene in bone and soft tissue sarcomas. Cancer Res 1992;52:6194-9.
8. Orita M, Suzuki Y, Sekiya T, et al. Rapid and sensitive detection of point mutations and DNA polymorphisms using the polymerase chain reac- tion. Genomics 1989;5:874-9.
9. Radig K, Schneider-Stock R, Haeckel C, et al. p53 gene mutation in osteosarcomas of low-grade malignancy. Hum Pathol 1998;29:1310-6.
10. Yandell D, Dryja T. Detection of DNA sequence polymorphisms by enzymatic amplification and direct genomic sequencing. Am J Hum Genet 1989;45:547-55.
11. Varley JM, Evans DGR, Birch JM. Li-Fraumeni syndrome. A molecular and clinical review. Br J Cancer 1997;76:1-14.
12. Ferrari C, Bohling T, Benassi MS, et al. Secondary tumors in bone sarcomas after treatment with chemotherapy. Cancer Detect Prev 1999; 23:368-74.
13. Pratt CB, Meyer WH, Luo X, et al. Second malignant neoplasms occurring in survivors of osteosarcoma. Cancer 1997;80:960-5.
14. Longhi A, Gamberi G, Bacci G. Brain tumors as second malignant neoplasms in patients with osteosarcoma treated with adjuvant and neoadjuvant chemotherapy: report of 2 cases. J Chemother 2000;12: 261-2.
15. Verneris M, McDougall IR, Becton D, et al. Thyroid carcinoma after successful treatment of osteosarcoma: a report of three patients. J Pe- diatr Hematol Oncol 2001;23:312-5.
16. Bechler JR, Robertson WW, Meadows AT, et al. Osteosarcoma as a second malignant neoplasm in children. J Bone Joint Surg [Am] 1992; 74:1079-83.
17. Bielack SS, Kempf-Bielack B, Heise U, et al. Combined modality treatment for osteosarcoma occurring as a second malignant disease. J Clin Oncol 1999;17:1164-74.
18. Draper GJ, Sanders BM, Kingston JE. Second primary neoplasms in patients with retinoblastoma. Br J Cancer 1986;53:661-71.
19. Pratt CB, Meyer WH, Rao BN, et al. Comparison of primary osteosar- coma of flat bones with secondary osteosarcoma of any site. Cancer 1997;80:1171-7.
20. Yonemoto T, Tatezaki S, Ishii T, et al. Two cases of osteosarcoma occurring as second malignancy of childhood cancer. Anticancer Res 1999;19:5563-6.
21. Chauveinc L, Mosseri V, Quintana E, et al. Osteosarcoma following retinoblastoma: age at onset and latency period. Ophthalmic Genet 2001;22:77-88.
22. Iwata A, Hirota T, Konno K, et al. Osteosarcoma as a second malig- nancy after treatment for neuroblastoma. Pediatr Hematol Oncol 2001; 18:465-9.
23. Meadows AT, Baum E, Fossati-Bellani F, et al. Second malignant neoplasms in children. An update from the late effects study group. J Clin Oncol 1985;3:532-8.
24. Heyn R, Haeberlen V, Newton WA, et al. Second malignant neoplasms in children treated for rhabdomyosarcoma. Intergroup Rhabdomyosar- coma Study Committee. J Clin Oncol 1993;11:262-70.
25. Kagan VE, Yalowich JC, Borisenko GG, et al. Mechanism-based che- mopreventive strategies against etoposide-induced acute myeloid leuke- mia. Free radical/antioxidant approach. Mol Pharmacol 1999;56:494- 506.
26. Burke E, Li FP, Janov AJ, et al. Cancer in relatives of survivors of childhood sarcoma. Cancer 1991;67:1467-9.
27. Carnevale A, Lieberman E, Cardenas R. Li-Fraumeni syndrome in pediatric patients with soft tissue sarcoma or osteosarcoma. Arch Med Res 1997;28:383-6.
28. Li FP, Fraumeni JF Jr. Rhabdomyosarcoma in children. Epidemiologic study and identification of a familial cancer syndrome. J Natl Cancer Inst 1969;43:1365-73.
29. Malkin D, Li FP, Strong LC, et al. Germ line p53 mutations in a familial syndrome of breast cancer, sarcomas, and other neoplasms. Science 1990;250:1233-8.
30. Bell DW, Varley JM, Szydlo TE, et al. Heterozygous germ line hCHK2 mutations in Li-Fraumeni syndrome. Science 1999;286:2528-31.
@ 2004 Lippincott Williams & Wilkins