Case Report

Chondrosarcoma of the Pelvis after Radiotherapy for Cervical Cancer: A Case Report

by Alfonso Torres Lobatón1*, Rosalva Barra Martínez2, Myrna Doris Arrecillas Zamora3, Christian Molina Aguilar5, María Yicel Bautista Hernández4, Thania Castro Belio6, Carla América Suárez Juárez6, Reiko Margarita Rodríguez Nakamura7, Lizeth Carolina Cali Tobar8

1Surgeon Oncologist, Technical consultant, Oncology Gynecology Unit Surgical procedures, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

2Surgeon Oncologist, Master of science, Head of Skin and Soft tissue sarcomas, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

3Pathologist Oncologist and Cytopathologist, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

4Head of Radiotherapy Unit, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

5 Laboratorio Internacional de Investigación sobre el Genoma Humano, N ational Autonomous University of Mexico, Mexico Email: cmolina@liigh.unam.m

6Gynecologist and Oncologist, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

77th Year Oncologic Surgery Resident, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

87th Year Resident of Oncologic Gynecology, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

*Corresponding author: Alfonso Torres Lobatón, Surgeon Oncologist, Technical consultant, Oncology Gynecology Unit Surgical procedures, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico

Received Date: 07 June 2024

Accepted Date: 11 June 2024

Published Date: 13 June 2024

Citation: Torres LA, Martinez RB, Zamora MDA, Aguilar CM, Hernandez MYB, et al (2024) Chondrosarcoma of the Pelvis after Radiotherapy for Cervical Cancer: A Case Report. Ann Case Report. 9: 1846. https://doi.org/10.29011/2574-7754.101846

Abstract

The incidence of bone sarcomas in patients irradiated with cervical cancer who survive 5 years represents only 0.04% of radiationinduced sarcomas (RIS). This rate increases in the first 20 years and decreases thereafter. In this publication, we present the case of a patient who developed a sacroiliac chondrosarcoma 12 years after receiving chemo-irradiation for a cervical cancer.

Case Presentation

47-year-old patient first seen in 2011 for a stage III B adenocarcinoma of the cervix, receiving concomitant chemo-radiation that ended with tumor persistence. She underwent total pelvic exenteration and was kept under surveillance for 12 years. She consulted for lumbosacral pain and the computed axial tomography (CT) study showed a tumor lesion in the left sacroiliac joint with extension to the soft tissues. An incisional biopsy of the lesion was proposed, but the patient did not undergo the procedure. She returned 7 months later with severe sacroiliac pain and inability to ambulate, with increased volume in the region. A new CT scan showed in the left iliac bone a lesion of 13.8 x 13.4 x 9.4 cm compatible with chondrosarcoma and in the thorax, pulmonary metastasis. The biopsy reported chondrosarcoma grade 3 radium induced by radiation, so it was sent to medical oncology for palliative treatment without the patient attending her treatment.

Introduction

Reports on radiation-induced sarcomas were first documented in the early 20th century by Martland, who described the development of bone sarcomas in Swiss watchmakers exposed to radioactive phosphorus [1]. In 1929, Beck published the case of a patient who developed sarcoma sometime after receiving radiotherapy for a benign lesion [2,3] .Radiation-induced sarcoma (RIS) is a late and rare event, with an incidence ranging from 0.03-0.9% [1,4-8]. RIS accounts for 3-6% of all sarcomas, with the most frequent locations being the chest and pelvis [1,7-9]. 79% are soft tissue sarcomas, and 21% are bone sarcomas [2,7]. The latency period ranges from 7 to 40 years, with an average of 16.8 years [1,4-6,7,8], and its frequency has increased in recent years attributed to the longer lifespan of patients and the use of concomitant chemotherapy, which significantly shortens the time to presentation [1,4,6,7]. Chemotherapy has been reported to potentiate the effects of tissue damage produced by radiotherapy, interfering with DNA repair processes, reducing the time to development of RIS, and increasing its incidence [1]. Regarding cervical cancer (CC), RIS typically occurs late after receiving radiotherapy. It has been reported that 10-40% occur before the age of 50, and 22.8% occur after the age of 50 [3,10,11]. According to the Globocan 2022 platform, [12] cervical cancer presents the 4th position in the incidence of any type of cancer in woman (considering absolute numbers, incidence in females, and age 5-85+) with 14.1 cases for every 100,000 women and represents the 3rd position in mortality induced by any type of cancer with a rate of 7.1 per every 100,000 women.

In Mexico, cervix cancer is the 2nd cause of death for any type of cancer and also is in the 2nd position in incidence (15 cases per 100,000 women considering both, rates in women 5-85+ years). For the group from 50 to +85 years, the incidence is in the 3rd position but has increased to 36.3 cases per 100,000 and is the 2nd cause of death by cancer with 21.4 cases per 100,000 [12]. While isolated cases of RIS in CC, such as leiomyosarcomas [13], cutaneous angiosarcomas [14], and rhabdomyoblastic sarcomas [4], have been the most common sarcomas reported in some series are undifferentiated pleomorphic sarcoma, angiosarcoma, and leiomyosarcoma [2,4]. The incidence of bone sarcomas in patients irradiated for CC who survive 5 years represents only 0.04% [3], significantly increasing in the first 20 years and decreasing thereafter [11,15]. The most common are osteosarcoma, undifferentiated pleomorphic sarcoma, and chondrosarcoma [3].

This publication presents the case of a patient who developed a sacroiliac chondrosarcoma 12 years after receiving chemo radiation for stage IIIB cervical cancer. Her evolution is discussed, along with a review of the literature.

Case Presentation: The patient was first seen in June 2011 at the age of 47 with a history of sexual debut at 17 years old, one sexual partner, 2 births, one cesarean section, and menopause at 46 years old. Her condition started 6 months before admission with genital bleeding, leading to a positive biopsy for cervical adenocarcinoma. Gynecological examination revealed a cervix with infiltrating ulcerous lesions, bleeding, extending to two-thirds of the upper vagina and both parametria, with the right infiltrating to the pelvic wall and the left to its internal third. It was classified as Stage IIIB (FIGO-2009), and the slide review reported poorly differentiated cervical carcinoma (Figure 1). With negative staging for metastasis (computed tomography), she was administered concurrent chemoradiation (External Beam Radiotherapy 50 Gy plus 4 cycles of chemotherapy with cisplatin 50 mg per m2 of body surface area), plus 30 Gy of low-dose rate brachytherapy, which ended on 05-10-2011.One month after completing treatment, locoregional examination showed tumor activity in residual cervical tissue with positive biopsy for cancer, along with residual tumor in the upper half of the vagina and parametria with suspected tumor activity. On 30.01.2012, exploratory laparotomy revealed a uterus measuring 10x4x6 cm, left hydro ureter, and bilateral parametrial fibrosis. Total pelvic exenteration was performed with total colpectomy supported by a perineal procedure, along with partial resection of both levator ani muscles and pelvic floor reconstruction with a rectus muscle flap from the left side.

Intraoperative examination of the surgical specimen showed no residual tumor at surgical margins, and she had a satisfactory postoperative course, discharged 10 days after surgery. The pathology reports of the surgery indicated residual poorly differentiated endocervical adenocarcinoma (Figure 2) and in the lower uterine segment (1cm), plus high-grade cervical intraepithelial neoplasia with histological changes associated with HPV infection. The bladder, rectum, sigmoid colon, and anus were negative for neoplastic cells, and there was no tumor at surgical margins.

The patient remained under periodic follow-up without evidence of disease until 28-01-22 (12 years after completing treatment for cervical cancer), when she presented with severe lumbosacral pain requiring a CT scan, which reported a tumoral lesion in the left sacroiliac joint. Periosteal reaction towards soft tissues, incipient involvement of the left iliopsoas and gluteal muscles were noted (Figure 3). With a diagnosis of left sacroiliac bone neoplasia, it was decided to perform an incisional biopsy of the lesion under general anesthesia, which the patient did not undergo. She returned 7 months later with severe sacroiliac pain, inability to ambulate, and increased volume and consistency in the left iliac fossa, gluteal region, and inguinal region (Figure 4). A CT scan revealed a lesion in the left iliac crest with a blastic appearance, wide transition zone, brush-like bone destruction pattern, and popcorn-like cartilaginous matrix, with interrupted periosteal reaction extending into soft tissues and involvement of the ipsilateral iliopsoas, quadratus lumborum, and gluteus Maximus and medius muscles, measuring

13.8 x 13.4 x 9.4 cm with a volume of 909 cc and involvement of ipsilateral sacral neuroforamina (Figure 5). On the sagittal view, a blastic lesion with bone destruction and popcorn-like cartilaginous matrix was observed, along with periosteal reaction and extension into soft tissues, with greater prominence in the gluteal region (Figure 6). In the thorax, pleural thickening and multiple diffuse sub pleural nodules were observed, with the largest showing a cartilaginous matrix (Figure 7).

On October 7, 2022, under general anesthesia, an incisional biopsy of the lesion was performed, which reported conventional chondrosarcoma. Histological grade: 3, absent lymphovascular invasion, poorly differentiated. Tumor necrosis: <50% (2 points); histological grade 3 (high grade). Conclusion: Due to the history of radiotherapy, a radiation-induced chondrosarcoma is considered (Figures 8 and 9). With a diagnosis of grade 3 radiation-induced chondrosarcoma in the left iliac bone with pulmonary metastases, she was referred to Medical Oncology for palliative treatment, which the patient declined due to potential deterioration in quality of life. She was referred to palliative care and pain clinic, last seen on January 13, 2023.

 

Figure 1: Microphotography in H-E technique at 100x. Malignant epithelial neoplasia is observed, of an invasive type, with a solid growth pattern, with large, round cells, with abundant cytoplasm with some vacuoles, the nuclei present marked atypia, with hyperchromatic and/or vacuolated nuclei, with evident nucleoli.

 

Figure 2: Photomicrograph in H-E technique at 400x, where malignant epithelial neoplasia is observed, with a glandular, invasive growth pattern; The cells are large, with abundant cytoplasm with some vacuoles, eosinophilic, the nuclei present atypia and marked pleomorphism (anaplasia). This “monstrous” change.