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Radiation-induced chondrosarcoma of the scapula after radiotherapy for lung cancer: a case report and review of the literature
© The Author(s). 2018
- Received: 20 September 2017
- Accepted: 6 February 2018
- Published: 5 March 2018
Radiotherapy associated with chemotherapy is a well-established treatment modality for locally advanced non-small cell lung cancers. Radiation-induced second malignancies, particularly radiation-induced sarcomas, are rare. Some authors reported a recent increase in the incidence of this rare complication, especially because of the improved prognosis and survival of patients after radiotherapy. Pathogenic mechanisms of radiation-induced sarcomas are poorly understood. However, diagnosis criteria are well established. Treatment options must be discussed and adapted to the patient’s profile. Surgery in irradiated tissue is challenging, with limited treatment options with chemotherapy and radiotherapy.
We report the case of a 62-year-old Moroccan man diagnosed as having chondrosarcoma of his right scapula, who was irradiated 10 years ago for stage IIIB non-small cell lung cancer. This case was managed by a complete resection of the tumor with good functional and oncological outcomes. To the best of our knowledge, the scapular location of radiation-induced sarcoma after irradiation for lung cancer has never been described in the literature.
Radiation-induced sarcoma of the scapula represents a rare situation that must be actively researched to have access to an optimal therapeutic approach.
Radiation therapy (RT) plays a significant role in the management of thoracic tumors . Most of these tumors require RT as a local measure for definitive treatment of medically inoperable or surgically unresectable disease, or as part of a multimodality regimen for locally advanced disease [1, 2]. The standard care for stage III unresectable disease is combined chemoradiotherapy [1, 2].
The occurrence of radiation-induced sarcoma (RIS) in the scapula after RT for lung cancer is a very rare complication . With improved oncologic outcomes, post-irradiation sarcomas are increasingly seen in long-term survivors with an estimated risk of up to 0.3% . The spectrum of radiation-induced tumors includes soft tissue sarcoma, osteosarcoma, squamous cell carcinoma (SCC), leukemia, and neuroendocrine carcinomas, which may develop in the head and neck, esophagus, lung, or stomach . We report here a case of chondrosarcoma of the right scapula occurring 10 years after completion of chemoradiotherapy for stage IIIB SCC developed in the upper lobe of the right lung.
This is a rare case of radiation-induced chondrosarcoma, occurring 10 years after chemoradiation for non-small cell lung cancer (NSCLC). RIS after chemoradiation for lung cancer is a very rare complication. The rarity of this situation is due to the poor prognosis of advanced stage of NSCLC with limited survival, which exceptionally exceeds 3 years .
The carcinogenic effects of ionizing radiation have been described in several publications . The real mechanisms in radiation-induced tumor genesis remain poorly known . In a published series, their frequency varies between 0.15 and 0.75% [5, 6]. Phillips and Sheline estimated the frequency of sarcomas after irradiation for breast cancer to be 0.23% . Mark et al. estimated the absolute risk of developing RIS to be from 0.03 to 0.8% after RT for gynecologic malignancies . Amendola et al. noted an estimated incidence of sarcomas of 0.09 to 0.11% after radiotherapy for any purpose . Furthermore, Huvos et al. and Souba et al. estimated that 5% of sarcomas developed after therapeutic or accidental irradiation . All tissue types can be processed by irradiation, although the radio sensitivity varies with the type of irradiated organ . There is no histological evidence to confirm the origin of radiation-induced tumors . Ionizing radiation causes damage to healthy tissue included in the radiation field. Some authors identified the specific mesenchymal stem cells that can regenerate on injury [7, 9]. On irradiation-induced injury, the stem cells rapidly start proliferating and can regenerate injured tumoral tissue .
Several risk factors are probably implicated in influencing the occurrence of these secondary tumors. The radiation dose which is a variable parameter depending on the irradiated organs, the type of chemotherapy that can potentiate the effect of RT, young age (children are especially sensitive to radiation oncogenesis), and a genetic predisposition to multiple tumors [9, 10]. Young age exposure seems to be an important risk factor, especially in tumors with a good prognosis such as hematologic malignancies . Relative risk (RR) of second solid cancer at high-dose sites for radiotherapy in lung cancer is different depending on the period of latency. For latency between 5 and 9 years the RR is estimated to be 1.12 (0.98–1.27), between 10 and 14 years it is estimated to be 1.37 (1.12–1.65), and after 15 years of latency the RR is estimated to be 1.62 (1.23–2.09) with p-trend at 0.0079 . There are no clear data reporting eventual implication of concurrent chemotherapy in the carcinogenesis of RIS.
The diagnosis is established by criteria established by Cahan et al. in 1948  and revised by Murray et al. in 1999 . A history of radiotherapy for cancer, an asymptomatic latency period of several years, the occurrence of tumor in the irradiation field, and histological evidence of the secondary tumor . Complete remission of the primary tumor is also necessary to establish this diagnosis . Our case meets the criteria of Murray et al. for RIS . They specify that radiotherapy must have been administered previously and that the sarcoma must have developed from an area within the 5% isodose line . To the best of our knowledge, radiation-induced scapular chondrosarcoma has not been described previously. The rarity of radiation-induced chondrosarcoma is reflected by the very few case series that have included such cases. In fact, in a multi-institutional series of 80 histologically confirmed cases that were diagnosed as RIS between 1975 and 1995, only one patient had chondrosarcoma . Some reviews reported a large predominance of osteosarcomas and fibrosarcomas in RIS of the chest wall .
Therapeutic approaches are often limited. Surgery is the only curative method, when it is possible. The difficulty of surgery in irradiated areas is known, but must be seriously considered if the tumor is diagnosed at an early stage and if the surgeon is experienced. In advanced stages, chemotherapy may have a place, despite poor tumor response in irradiated areas . In these cases the prognosis is also poor, and median survival does not exceed a few months. The use of new irradiation procedures reducing the field of exposure should allow a clear decrease in the incidence of RIS .
This case is about a very rare situation, radiation-induced chondrosarcoma of the right scapula. This event is very uncommon making it almost impossible to perform prospective clinical trials specifically designed to compare different treatment approaches. Surgery is the principal method of treatment. A close follow-up of irradiated patients is the only way for an early diagnosis of this serious complication.
We sincerely thank Mrs Souad TADLAOUI for her assistance.
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