Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Radiation-associated sarcomas

Robert Maki, MD, PhD
Section Editors
Thomas F DeLaney, MD
Alberto S Pappo, MD
Deputy Editor
Diane MF Savarese, MD


Improvements in therapy for a variety of malignancies have led to increasing numbers of people who are long-term cancer survivors. Survivors of both adult and childhood cancers are at risk for developing therapy-related complications, including second cancers, now aptly termed an "iatrogenic disease of success" [1]. (See "Overview of cancer survivorship care for primary care and oncology providers", section on 'Epidemiology of cancer survivors'.)

Therapeutic radiation has long been recognized as an inducing agent in the development of malignant neoplasms [2-5]. The first case reports of bone sarcomas in patients who had received radiation therapy (RT) for benign bone conditions were published in 1922, and a report of bone sarcomas in the jaws of radium-dial painters followed in 1929 [6,7].

Sarcomas are rare malignant tumors that arise from mesenchymal tissues at any location. The histopathologic spectrum of sarcomas is broad, reflecting the fact that the embryonic mesenchymal cells from which they arise have the capacity to mature into striated skeletal and smooth muscle, adipose and fibrous tissue, bone, and cartilage. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma", section on 'Histopathology'.)

Besides exposure to RT, pathogenetic factors include genetic predisposition, exposure to chemotherapy, and for certain types of soft tissue sarcoma, chronic edema, and viral infection. (See "Pathogenetic factors in soft tissue and bone sarcomas".)

This topic review will cover secondary soft tissue and bone sarcomas that arise after therapeutic irradiation in adults and children. Other radiation-associated malignancies (eg, thyroid cancer, acute and chronic myelogenous leukemia, breast and lung cancer, and secondary malignancies following hematopoietic cell transplantation) as well as an overview of the consequences of unintended radiation exposure, and the risk of malignancy due to diagnostic imaging are covered elsewhere.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 9, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Huvos AG, Woodard HQ, Cahan WG, et al. Postradiation osteogenic sarcoma of bone and soft tissues. A clinicopathologic study of 66 patients. Cancer 1985; 55:1244.
  2. Freiben H. Demonstration eines Cancroid des rechten Handrueckens, das sich nach Langdaurner Einwirkung von Roentgenstrahlen entwickelt hatte. Fortschr Geb Rontgenstr 1902; 6:106.
  3. Perthes G. Zur Frage Roentgentherapie des Carcinoms. Arch fur Klinische Chirurgie (Berlin) 1904; 74:400.
  4. Coenen H. Das Roentgenkarzinom. Berliner Klinische Wochenschrift 1909; 46:292.
  5. Marie P, Clunet J, Raviot-LaPointe G. Contribution a L'etude du development des tumeurs malignes sur le ulcers de Roentgen. Bull Assoc Franc l'etude de Cancer 1910; 3:404.
  6. Beck A. Zur Frage des Roritgensarkoms, zuglieich ein Beitrag zur Pathogenese des Sarkoms. Munch Med Wochenschr 1922; 69:623.
  7. Martland MS, Humphries RE. Osteogenic sarcoma in dial painters using luminous paint. Arch Pathol Lab Med 1929; 7:406.
  8. Mark RJ, Bailet JW, Poen J, et al. Postirradiation sarcoma of the head and neck. Cancer 1993; 72:887.
  9. Brady MS, Gaynor JJ, Brennan MF. Radiation-associated sarcoma of bone and soft tissue. Arch Surg 1992; 127:1379.
  10. Bjerkehagen B, Smeland S, Walberg L, et al. Radiation-induced sarcoma: 25-year experience from the Norwegian Radium Hospital. Acta Oncol 2008; 47:1475.
  11. Penel N, Grosjean J, Robin YM, et al. Frequency of certain established risk factors in soft tissue sarcomas in adults: a prospective descriptive study of 658 cases. Sarcoma 2008; 2008:459386.
  12. 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.
  13. Hawkins MM, Wilson LM, Burton HS, et al. Radiotherapy, alkylating agents, and risk of bone cancer after childhood cancer. J Natl Cancer Inst 1996; 88:270.
  14. Newton WA Jr, Meadows AT, Shimada H, et al. Bone sarcomas as second malignant neoplasms following childhood cancer. Cancer 1991; 67:193.
  15. Wong FL, Boice JD Jr, Abramson DH, et al. Cancer incidence after retinoblastoma. Radiation dose and sarcoma risk. JAMA 1997; 278:1262.
  16. Dineen SP, Roland CL, Feig R, et al. Radiation-Associated Undifferentiated Pleomorphic Sarcoma is Associated with Worse Clinical Outcomes than Sporadic Lesions. Ann Surg Oncol 2015; 22:3913.
  17. Amendola BE, Amendola MA, McClatchey KD, Miller CH Jr. Radiation-associated sarcoma: a review of 23 patients with postradiation sarcoma over a 50-year period. Am J Clin Oncol 1989; 12:411.
  18. Mark RJ, Poen J, Tran LM, et al. Postirradiation sarcoma of the gynecologic tract. A report of 13 cases and a discussion of the risk of radiation-induced gynecologic malignancies. Am J Clin Oncol 1996; 19:59.
  19. Xi M, Liu MZ, Wang HX, et al. Radiation-induced sarcoma in patients with nasopharyngeal carcinoma: a single-institution study. Cancer 2010; 116:5479.
  20. Nguyen F, Rubino C, Guerin S, et al. Risk of a second malignant neoplasm after cancer in childhood treated with radiotherapy: correlation with the integral dose restricted to the irradiated fields. Int J Radiat Oncol Biol Phys 2008; 70:908.
  21. Guérin S, Hawkins M, Shamsaldin A, et al. Treatment-adjusted predisposition to second malignant neoplasms after a solid cancer in childhood: a case-control study. J Clin Oncol 2007; 25:2833.
  22. Le Vu B, de Vathaire F, Shamsaldin A, et al. Radiation dose, chemotherapy and risk of osteosarcoma after solid tumours during childhood. Int J Cancer 1998; 77:370.
  23. Cohen RJ, Curtis RE, Inskip PD, Fraumeni JF Jr. The risk of developing second cancers among survivors of childhood soft tissue sarcoma. Cancer 2005; 103:2391.
  24. Eng C, Li FP, Abramson DH, et al. Mortality from second tumors among long-term survivors of retinoblastoma. J Natl Cancer Inst 1993; 85:1121.
  25. Henderson TO, Rajaraman P, Stovall M, et al. Risk factors associated with secondary sarcomas in childhood cancer survivors: a report from the childhood cancer survivor study. Int J Radiat Oncol Biol Phys 2012; 84:224.
  26. Wiklund TA, Blomqvist CP, Räty J, et al. Postirradiation sarcoma. Analysis of a nationwide cancer registry material. Cancer 1991; 68:524.
  27. Berrington de Gonzalez A, Kutsenko A, Rajaraman P. Sarcoma risk after radiation exposure. Clin Sarcoma Res 2012; 2:18.
  28. Riad S, Biau D, Holt GE, et al. The clinical and functional outcome for patients with radiation-induced soft tissue sarcoma. Cancer 2012; 118:2682.
  29. Woo KI, Harbour JW. Review of 676 second primary tumors in patients with retinoblastoma: association between age at onset and tumor type. Arch Ophthalmol 2010; 128:865.
  30. Cha C, Antonescu CR, Quan ML, et al. Long-term results with resection of radiation-induced soft tissue sarcomas. Ann Surg 2004; 239:903.
  31. Katz SC, Baldwin K, Karakousis G, et al. Soft tissue sarcoma diagnosed subsequent to lymphoma is associated with prior radiotherapy and decreased survival. Cancer 2011; 117:4756.
  32. Meadows AT, Friedman DL, Neglia JP, et al. Second neoplasms in survivors of childhood cancer: findings from the Childhood Cancer Survivor Study cohort. J Clin Oncol 2009; 27:2356.
  33. Laskin WB, Silverman TA, Enzinger FM. Postradiation soft tissue sarcomas. An analysis of 53 cases. Cancer 1988; 62:2330.
  34. Sheppard DG, Libshitz HI. Post-radiation sarcomas: a review of the clinical and imaging features in 63 cases. Clin Radiol 2001; 56:22.
  35. Koshy M, Paulino AC, Mai WY, Teh BS. Radiation-induced osteosarcomas in the pediatric population. Int J Radiat Oncol Biol Phys 2005; 63:1169.
  36. Paulino AC, Fowler BZ. Secondary neoplasms after radiotherapy for a childhood solid tumor. Pediatr Hematol Oncol 2005; 22:89.
  37. O'Brien MM, Donaldson SS, Balise RR, et al. Second malignant neoplasms in survivors of pediatric Hodgkin's lymphoma treated with low-dose radiation and chemotherapy. J Clin Oncol 2010; 28:1232.
  38. Bacci G, Longhi A, Barbieri E, et al. Second malignancy in 597 patients with ewing sarcoma of bone treated at a single institution with adjuvant and neoadjuvant chemotherapy between 1972 and 1999. J Pediatr Hematol Oncol 2005; 27:517.
  39. Rodjan F, Graaf Pd, Brisse HJ, et al. Second cranio-facial malignancies in hereditary retinoblastoma survivors previously treated with radiation therapy: clinic and radiologic characteristics and survival outcomes. Eur J Cancer 2013; 49:1939.
  40. Lagrange JL, Ramaioli A, Chateau MC, et al. Sarcoma after radiation therapy: retrospective multiinstitutional study of 80 histologically confirmed cases. Radiation Therapist and Pathologist Groups of the Fédération Nationale des Centres de Lutte Contre le Cancer. Radiology 2000; 216:197.
  41. Chan JY, Wong ST, Lau GI, Wei WI. Postradiation sarcoma after radiotherapy for nasopharyngeal carcinoma. Laryngoscope 2012; 122:2695.
  42. Fletcher CDM, Chibon F, Mertens F. Undifferentiated/unclassified sarcomas. In: WHO classifiction of tumours of soft tissue and bone, 4th, Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F. (Eds), IARC, Lyon 2013. p.236.
  43. Gladdy RA, Qin LX, Moraco N, et al. Do radiation-associated soft tissue sarcomas have the same prognosis as sporadic soft tissue sarcomas? J Clin Oncol 2010; 28:2064.
  44. Taghian A, de Vathaire F, Terrier P, et al. Long-term risk of sarcoma following radiation treatment for breast cancer. Int J Radiat Oncol Biol Phys 1991; 21:361.
  45. Davidson T, Westbury G, Harmer CL. Radiation-induced soft-tissue sarcoma. Br J Surg 1986; 73:308.
  46. Kleinerman RA, Schonfeld SJ, Tucker MA. Sarcomas in hereditary retinoblastoma. Clin Sarcoma Res 2012; 2:15.
  47. Gupta G, Hafiz A, Gandhi JS. Radiation-induced chondrosarcomas: a case report with review of literature. J Cancer Res Ther 2010; 6:394.
  48. Kalra S, Grimer RJ, Spooner D, et al. Radiation-induced sarcomas of bone: factors that affect outcome. J Bone Joint Surg Br 2007; 89:808.
  49. De Smet S, Vandermeeren L, Christiaens MR, et al. Radiation-induced sarcoma: analysis of 46 cases. Acta Chir Belg 2008; 108:574.
  50. Arlen M, Higinbotham NL, Huvos AG, et al. Radiation-induced sarcoma of bone. Cancer 1971; 28:1087.
  51. Inoue YZ, Frassica FJ, Sim FH, et al. Clinicopathologic features and treatment of postirradiation sarcoma of bone and soft tissue. J Surg Oncol 2000; 75:42.
  52. Li FP, Fraumeni JF Jr. Soft-tissue sarcomas, breast cancer, and other neoplasms. A familial syndrome? Ann Intern Med 1969; 71:747.
  53. Franco Gutiérrez V, Llorente Pendás JL, Coca Pelaz A, et al. Radiation-induced sarcomas of the head and neck. J Craniofac Surg 2008; 19:1287.
  54. Patel AJ, Rao VY, Fox BD, et al. Radiation-induced osteosarcomas of the calvarium and skull base. Cancer 2011; 117:2120.
  55. Seinen JM, Styring E, Verstappen V, et al. Radiation-associated angiosarcoma after breast cancer: high recurrence rate and poor survival despite surgical treatment with R0 resection. Ann Surg Oncol 2012; 19:2700.
  56. Wei Z, Xie Y, Xu J, et al. Radiation-induced sarcoma of head and neck: 50 years of experience at a single institution in an endemic area of nasopharyngeal carcinoma in China. Med Oncol 2012; 29:670.
  57. Torres KE, Ravi V, Kin K, et al. Long-term outcomes in patients with radiation-associated angiosarcomas of the breast following surgery and radiotherapy for breast cancer. Ann Surg Oncol 2013; 20:1267.
  58. Mavrogenis AF, Pala E, Guerra G, Ruggieri P. Post-radiation sarcomas. Clinical outcome of 52 Patients. J Surg Oncol 2012; 105:570.
  59. Neuhaus SJ, Pinnock N, Giblin V, et al. Treatment and outcome of radiation-induced soft-tissue sarcomas at a specialist institution. Eur J Surg Oncol 2009; 35:654.
  60. Deutsch M, Safyan E. Angiosarcoma of the breast occurring soon after lumpectomy and breast irradiation for infiltrating ductal carcinoma: a case report. Am J Clin Oncol 2003; 26:471.
  61. Longhi A, Ferrari S, Tamburini A, et al. Late effects of chemotherapy and radiotherapy in osteosarcoma and Ewing sarcoma patients: the Italian Sarcoma Group Experience (1983-2006). Cancer 2012; 118:5050.
  62. Dang ND, Teh BS, Paulino AC. Rhabdomyosarcoma arising in a previously irradiated field: an analysis of 43 patients. Int J Radiat Oncol Biol Phys 2013; 85:598.
  63. Goldsby R, Burke C, Nagarajan R, et al. Second solid malignancies among children, adolescents, and young adults diagnosed with malignant bone tumors after 1976: follow-up of a Children's Oncology Group cohort. Cancer 2008; 113:2597.
  64. Kim JH, Chu FC, Woodard HQ, et al. Radiation-induced soft-tissue and bone sarcoma. Radiology 1978; 129:501.
  65. Robinson E, Neugut AI, Wylie P. Clinical aspects of postirradiation sarcomas. J Natl Cancer Inst 1988; 80:233.
  66. Berrington de Gonzalez A, Gilbert E, Curtis R, et al. Second solid cancers after radiation therapy: a systematic review of the epidemiologic studies of the radiation dose-response relationship. Int J Radiat Oncol Biol Phys 2013; 86:224.
  67. Krueger EA, Fraass BA, McShan DL, et al. Potential gains for irradiation of chest wall and regional nodes with intensity modulated radiotherapy. Int J Radiat Oncol Biol Phys 2003; 56:1023.
  68. Hall EJ, Wuu CS. Radiation-induced second cancers: the impact of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys 2003; 56:83.
  69. Tukenova M, Guibout C, Hawkins M, et al. Radiation therapy and late mortality from second sarcoma, carcinoma, and hematological malignancies after a solid cancer in childhood. Int J Radiat Oncol Biol Phys 2011; 80:339.
  70. Menu-Branthomme A, Rubino C, Shamsaldin A, et al. Radiation dose, chemotherapy and risk of soft tissue sarcoma after solid tumours during childhood. Int J Cancer 2004; 110:87.
  71. Jenkinson HC, Winter DL, Marsden HB, et al. A study of soft tissue sarcomas after childhood cancer in Britain. Br J Cancer 2007; 97:695.
  72. Henderson TO, Whitton J, Stovall M, et al. Secondary sarcomas in childhood cancer survivors: a report from the Childhood Cancer Survivor Study. J Natl Cancer Inst 2007; 99:300.
  73. Rubino C, Shamsaldin A, Lê MG, et al. Radiation dose and risk of soft tissue and bone sarcoma after breast cancer treatment. Breast Cancer Res Treat 2005; 89:277.
  74. Rizzo JD, Curtis RE, Socié G, et al. Solid cancers after allogeneic hematopoietic cell transplantation. Blood 2009; 113:1175.
  75. Virtanen A, Pukkala E, Auvinen A. Incidence of bone and soft tissue sarcoma after radiotherapy: a cohort study of 295,712 Finnish cancer patients. Int J Cancer 2006; 118:1017.
  76. Berrington de Gonzalez A, Curtis RE, Gilbert E, et al. Second solid cancers after radiotherapy for breast cancer in SEER cancer registries. Br J Cancer 2010; 102:220.
  77. Inskip PD, Monson RR, Wagoner JK, et al. Cancer mortality following radium treatment for uterine bleeding. Radiat Res 1990; 123:331.
  78. Darby SC, Reeves G, Key T, et al. Mortality in a cohort of women given X-ray therapy for metropathia haemorrhagica. Int J Cancer 1994; 56:793.
  79. Lindberg S, Karlsson P, Arvidsson B, et al. Cancer incidence after radiotherapy for skin haemangioma during infancy. Acta Oncol 1995; 34:735.
  80. Haselow RE, Nesbit M, Dehner LP, et al. Second neoplasms following megavoltage radiation in a pediatric population. Cancer 1978; 42:1185.
  81. Samartzis D, Nishi N, Cologne J, et al. Ionizing radiation exposure and the development of soft-tissue sarcomas in atomic-bomb survivors. J Bone Joint Surg Am 2013; 95:222.
  82. Samartzis D, Nishi N, Hayashi M, et al. Exposure to ionizing radiation and development of bone sarcoma: new insights based on atomic-bomb survivors of Hiroshima and Nagasaki. J Bone Joint Surg Am 2011; 93:1008.
  83. Pollard JM, Gatti RA. Clinical radiation sensitivity with DNA repair disorders: an overview. Int J Radiat Oncol Biol Phys 2009; 74:1323.
  84. Yu CL, Tucker MA, Abramson DH, et al. Cause-specific mortality in long-term survivors of retinoblastoma. J Natl Cancer Inst 2009; 101:581.
  85. Hisada M, Garber JE, Fung CY, et al. Multiple primary cancers in families with Li-Fraumeni syndrome. J Natl Cancer Inst 1998; 90:606.
  86. Sheth GR, Cranmer LD, Smith BD, et al. Radiation-induced sarcoma of the breast: a systematic review. Oncologist 2012; 17:405.
  87. Bernier J. Potential risks and benefits of radiation therapy as adjuvant treatment in patients with low-risk carcinoma of the mammary gland: taking cutaneous postradiation angiosarcoma as an opportunity for a critical appraisal of postoperative radiotherapy. Ann Oncol 2007; 18:619.
  88. Fodor J, Orosz Z, Szabó E, et al. Angiosarcoma after conservation treatment for breast carcinoma: our experience and a review of the literature. J Am Acad Dermatol 2006; 54:499.
  89. Ahmad A, Jamieson T, Balsitis M, Diament R. Radiation-induced angiosarcoma of the rectum: a case report and review of literature. Colorectal Dis 2008; 10:847.
  90. Tardío JC, Nájera L, Alemany I, et al. Rectal angiosarcoma after adjuvant chemoradiotherapy for adenocarcinoma of the rectum. J Clin Oncol 2009; 27:e116.
  91. Pendlebury SC, Bilous M, Langlands AO. Sarcomas following radiation therapy for breast cancer: a report of three cases and a review of the literature. Int J Radiat Oncol Biol Phys 1995; 31:405.
  92. Brenin CM, Small W Jr, Talamonti MS, Gradisher WJ. Radiation-Induced Sarcoma Following Treatment of Breast Cancer. Cancer Control 1998; 5:425.
  93. Zelek L, Llombart-Cussac A, Terrier P, et al. Prognostic factors in primary breast sarcomas: a series of patients with long-term follow-up. J Clin Oncol 2003; 21:2583.
  94. Lorigan JG, Libshitz HI, Peuchot M. Radiation-induced sarcoma of bone: CT findings in 19 cases. AJR Am J Roentgenol 1989; 153:791.
  95. Makimoto Y, Yamamoto S, Takano H, et al. Imaging findings of radiation-induced sarcoma of the head and neck. Br J Radiol 2007; 80:790.
  96. Debnam JM, Guha-Thakurta N, Mahfouz YM, et al. Radiation-associated head and neck sarcomas: spectrum of imaging findings. Oral Oncol 2012; 48:155.
  97. Abrigo JM, King AD, Leung SF, et al. MRI of radiation-induced tumors of the head and neck in post-radiation nasopharyngeal carcinoma. Eur Radiol 2009; 19:1197.
  98. Yankelevitz DF, Henschke CI, Knapp PH, et al. Effect of radiation therapy on thoracic and lumbar bone marrow: evaluation with MR imaging. AJR Am J Roentgenol 1991; 157:87.
  99. Ramsey RG, Zacharias CE. MR imaging of the spine after radiation therapy: easily recognizable effects. AJR Am J Roentgenol 1985; 144:1131.
  100. Edeiken B, deSantos LA. Percutaneous needle biopsy of the irradiated skeleton. Radiology 1983; 146:653.
  101. Thariat J, Italiano A, Collin F, et al. Not all sarcomas developed in irradiated tissue are necessarily radiation-induced--spectrum of disease and treatment characteristics. Crit Rev Oncol Hematol 2012; 83:393.
  102. STEWART FW, TREVES N. Lymphangiosarcoma in postmastectomy lymphedema; a report of six cases in elephantiasis chirurgica. Cancer 1948; 1:64.
  103. CAHAN WG, WOODARD HQ. Sarcoma arising in irradiated bone; report of 11 cases. Cancer 1948; 1:3.
  104. Murray EM, Werner D, Greeff EA, Taylor DA. Postradiation sarcomas: 20 cases and a literature review. Int J Radiat Oncol Biol Phys 1999; 45:951.
  105. Strobbe LJ, Peterse HL, van Tinteren H, et al. Angiosarcoma of the breast after conservation therapy for invasive cancer, the incidence and outcome. An unforseen sequela. Breast Cancer Res Treat 1998; 47:101.
  106. Cowan JM, Beckett MA, Tarbell N, Weichselbaum RR. Symmetrical chromosome rearrangements in cell lines established from human radiation-induced sarcomas. Cancer Genet Cytogenet 1990; 50:125.
  107. Mertens F, Larramendy M, Gustavsson A, et al. Radiation-associated sarcomas are characterized by complex karyotypes with frequent rearrangements of chromosome arm 3p. Cancer Genet Cytogenet 2000; 116:89.
  108. Nakanishi H, Tomita Y, Myoui A, et al. Mutation of the p53 gene in postradiation sarcoma. Lab Invest 1998; 78:727.
  109. Gonin-Laurent N, Gibaud A, Huygue M, et al. Specific TP53 mutation pattern in radiation-induced sarcomas. Carcinogenesis 2006; 27:1266.
  110. Gonin-Laurent N, Hadj-Hamou NS, Vogt N, et al. RB1 and TP53 pathways in radiation-induced sarcomas. Oncogene 2007; 26:6106.
  111. Mentzel T, Schildhaus HU, Palmedo G, et al. Postradiation cutaneous angiosarcoma after treatment of breast carcinoma is characterized by MYC amplification in contrast to atypical vascular lesions after radiotherapy and control cases: clinicopathological, immunohistochemical and molecular analysis of 66 cases. Mod Pathol 2012; 25:75.
  112. Manner J, Radlwimmer B, Hohenberger P, et al. MYC high level gene amplification is a distinctive feature of angiosarcomas after irradiation or chronic lymphedema. Am J Pathol 2010; 176:34.
  113. Guo T, Zhang L, Chang NE, et al. Consistent MYC and FLT4 gene amplification in radiation-induced angiosarcoma but not in other radiation-associated atypical vascular lesions. Genes Chromosomes Cancer 2011; 50:25.
  114. Hadj-Hamou NS, Ugolin N, Ory C, et al. A transcriptome signature distinguished sporadic from postradiotherapy radiation-induced sarcomas. Carcinogenesis 2011; 32:929.
  115. Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res 1986; :9.
  116. Wolf RE, Enneking WF. The staging and surgery of musculoskeletal neoplasms. Orthop Clin North Am 1996; 27:473.
  117. Franzius C, Sciuk J, Daldrup-Link HE, et al. FDG-PET for detection of osseous metastases from malignant primary bone tumours: comparison with bone scintigraphy. Eur J Nucl Med 2000; 27:1305.
  118. Franzius C, Daldrup-Link HE, Sciuk J, et al. FDG-PET for detection of pulmonary metastases from malignant primary bone tumors: comparison with spiral CT. Ann Oncol 2001; 12:479.
  119. Bjerkehagen B, Småstuen MC, Hall KS, et al. Why do patients with radiation-induced sarcomas have a poor sarcoma-related survival? Br J Cancer 2012; 106:297.
  120. Chapelier AR, Bacha EA, de Montpreville VT, et al. Radical resection of radiation-induced sarcoma of the chest wall: report of 15 cases. Ann Thorac Surg 1997; 63:214.
  121. Bacci G, Longhi A, Forni C, et al. Neoadjuvant chemotherapy for radioinduced osteosarcoma of the extremity: The Rizzoli experience in 20 cases. Int J Radiat Oncol Biol Phys 2007; 67:505.
  122. Weatherby RP, Dahlin DC, Ivins JC. Postradiation sarcoma of bone: review of 78 Mayo Clinic cases. Mayo Clin Proc 1981; 56:294.
  123. Bielack SS, Kempf-Bielack B, Heise U, et al. Combined modality treatment for osteosarcoma occurring as a second malignant disease. Cooperative German-Austrian-Swiss Osteosarcoma Study Group. J Clin Oncol 1999; 17:1164.
  124. Marchal C, Weber B, de Lafontan B, et al. Nine breast angiosarcomas after conservative treatment for breast carcinoma: a survey from French comprehensive Cancer Centers. Int J Radiat Oncol Biol Phys 1999; 44:113.
  125. Feigenberg SJ, Mendenhall NP, Reith JD, et al. Angiosarcoma after breast-conserving therapy: experience with hyperfractionated radiotherapy. Int J Radiat Oncol Biol Phys 2002; 52:620.
  126. Palta M, Morris CG, Grobmyer SR, et al. Angiosarcoma after breast-conserving therapy: long-term outcomes with hyperfractionated radiotherapy. Cancer 2010; 116:1872.
  127. Sener SF, Milos S, Feldman JL, et al. The spectrum of vascular lesions in the mammary skin, including angiosarcoma, after breast conservation treatment for breast cancer. J Am Coll Surg 2001; 193:22.
  128. Kirova YM, Vilcoq JR, Asselain B, et al. Radiation-induced sarcomas after radiotherapy for breast carcinoma: a large-scale single-institution review. Cancer 2005; 104:856.
  129. Cafiero F, Gipponi M, Peressini A, et al. Radiation-associated angiosarcoma: diagnostic and therapeutic implications--two case reports and a review of the literature. Cancer 1996; 77:2496.
  130. Buatti JM, Harari PM, Leigh BR, Cassady JR. Radiation-induced angiosarcoma of the breast. Case report and review of the literature. Am J Clin Oncol 1994; 17:444.
  131. Wijnmaalen A, van Ooijen B, van Geel BN, et al. Angiosarcoma of the breast following lumpectomy, axillary lymph node dissection, and radiotherapy for primary breast cancer: three case reports and a review of the literature. Int J Radiat Oncol Biol Phys 1993; 26:135.
  132. Tan A, Ngan SY, Choong PF. Post-radiation sarcoma of the neck treated with re-irradiation followed by wide excision. World J Surg Oncol 2006; 4:69.
  133. de Jong MA, Oldenborg S, Bing Oei S, et al. Reirradiation and hyperthermia for radiation-associated sarcoma. Cancer 2012; 118:180.
  134. Stuschke M, Kaiser A, Abu-Jawad J, et al. Re-irradiation of recurrent head and neck carcinomas: comparison of robust intensity modulated proton therapy treatment plans with helical tomotherapy. Radiat Oncol 2013; 8:93.
  135. Björk-Eriksson T, Ask A, Glimelius B. The potential of proton beam radiation for palliation and reirradiation. Acta Oncol 2005; 44:918.
  136. Pearlstone DB, Janjan NA, Feig BW, et al. Re-resection with brachytherapy for locally recurrent soft tissue sarcoma arising in a previously radiated field. Cancer J Sci Am 1999; 5:26.
  137. Langer CJ, Harris J, Horwitz EM, et al. Phase II study of low-dose paclitaxel and cisplatin in combination with split-course concomitant twice-daily reirradiation in recurrent squamous cell carcinoma of the head and neck: results of Radiation Therapy Oncology Group Protocol 9911. J Clin Oncol 2007; 25:4800.
  138. Tabone MD, Terrier P, Pacquement H, et al. Outcome of radiation-related osteosarcoma after treatment of childhood and adolescent cancer: a study of 23 cases. J Clin Oncol 1999; 17:2789.
  139. Pervaiz N, Colterjohn N, Farrokhyar F, et al. A systematic meta-analysis of randomized controlled trials of adjuvant chemotherapy for localized resectable soft-tissue sarcoma. Cancer 2008; 113:573.