to present a case of a patient with cervical carcinoma in stage iia who was diagnosed with pelvic bone sarcoma 28 years after radiotherapy . a 37-year - old woman with iia cervix cancer was treated with external beam irradiation and brachytherapy . the patient had undergone conventionally fractionated external beam irradiation using the  box  technique , with the total dose of 50 gy and brachytherapy with radium applicators ( intrauterine tube and fornix applicator ) with the dose of 60 gy calculated at point a. after treatment twenty - six years later , inoperable pelvic bone sarcoma was diagnosed within the irradiated field . for patients receiving radiotherapy , long - term careful follow - up is mandatory due to second cancer risk . in the case of any suspicious symptoms , an increasing number of women survive after cervical carcinoma treatment and live longer than 5 - 10 years without signs of recurrence . some of these survivors may develop a second cancer caused by primary anticancer treatment . both chemotherapy and radiotherapy increase the risk of second cancer . epidemiological data concerning irradiation - induced sarcoma risk showed an average relative risk of 1.42 at 1 sv ( unit of dose equivalent , for gamma irradiation 1 sv = 1 gy ) . we present a case of radiation - associated sarcoma of pelvic bone following radiotherapy for cervical carcinoma . the diagnostic and therapeutic dilemmas and mechanisms of development of irradiation - induced sarcoma are discussed . a 37-year - old polish woman was referred to the institute of oncology in krakow in july of 1980 with diagnosis of squamous cell cervical carcinoma in figo stage iia . between 31 july and 2 september 1980 , the patient underwent conventionally fractionated external beam irradiation with the total dose of 50 gy and brachytherapy with radium applicators ( intrauterine tube and fornix applicators ) with the dose of 60 gy calculated at point a. she was again referred to our hospital in may of 2008 , 28 years after radiotherapy . for five months , the patient had been suffering from pain spreading from the back to the right sacroiliac joint . x - ray of the pelvic bones showed an osteolytic focus of about 5 cm  8 cm , in the right iliac ala at the level of the right sacroiliac joint . a computed tomography ( ct ) scan confirmed the presence of inoperable osteolytic destruction in the right iliac ala along the sacroiliac joint , with penetration into the articular space and inflammatory reaction in surrounding soft tissues . the imaging results were returned to the patient , so the present paper does not contain any photographic documentation of the examinations performed . ultrasound controlled core - needle biopsy revealed malignant spindle cell neoplasm forming either long and storiform fascicles or haemangiopericytoma - like texture ( fig . the tumour cells were characterized by numerous pleomorphic cells and significant mitotic activity [ up to 2 - 3 mitotic figures in one high power field ( hpf ) ] ( fig . 2 ) . the tumour cells dyed positively with antibodies against vimentin ( strong diffuse cytoplasmic reaction ) , cd68 and desmin ( positive reaction in single cells ) ( fig . the immunohistochemical staining for broad spectrum of cytokeratins ( ae1/ae3 , ck7 , ck5/6 , cam5.2 ) gave negative results . malignant spindle cell neoplasm forming either long and storiform fascicles or haemangiopericytoma - like texture the tumour cells are characterized by numerous pleomorphic cells and significant mitotic activity ( up to 2 - 3 mitotic figures in one hpf ) ( fig . 2 ) . the tumour cells dyed positively with antibodies against vimentin ( strong diffuse cytoplasmic reaction ) , cd68 and desmin ( positive reaction in single cells ) ( fig . insert ) the histological and immunohistochemical picture of the tumour was consistent with high grade pleomorphic leiomyosarcoma . due to evidence of progression observed on x - ray and ct scan and rapid worsening of general status , chemotherapy was discontinued in october 2008 . the patient received symptomatic treatment prescribed by a general practitioner and later was lost from the follow - up . the criteria describing post - irradiation nature of second malignancy include second malignancy arising within the irradiation field , tumour histology other than primary , and a latent period of 5 years minimum . the present case fits the above criteria , so finally a diagnosis of irradiation - induced sarcoma was made . the risk of second malignancy within the irradiated area in patients with cervical carcinoma treated with irradiation has been assessed in large epidemiological studies presented by boice et al .   and kleinerman et al . . both authors noted increased incidence of rectal , bladder , vaginal and ovarian carcinoma , soft tissue sarcoma and leukaemia . consistently increasing risk particularly concerns organs receiving a dose higher than 1 gy , rising from 10% in the first decade after irradiation to about 50% after 30 or more years . the risk is highest when irradiation therapy was given at a young age [ 610 ] . a lot of authors have noted increased incidence of soft tissue and bone sarcoma [ 1116 ] . the overall incidence of post - irradiation sarcoma ranged from 0.03% after 10 years to 0.8% after 30 years [ 15 , 1719 ] . the most common types of radiation - induced sarcomas are osteosarcoma , fibrosarcoma , malignant fibrous histiocytoma , and angiosarcoma [ 9 , 2022 ] . lagrange et al .   in a retrospective analysis of 80 cases of post - irradiation sarcoma noted 3 cases with soft tissue leiomyosarcoma and one with bone leiomyosarcoma . kaczmarek - borowska et al .   noted one case with abdominal wall leiomyosarcoma that developed 11 years after cervical carcinoma irradiation . .   noted 3 cases of leiomyosarcoma occurring 9 - 27 years after radiation and chemotherapy . were able to find in the english language literature 33 cases ( mostly as single case reports ) of radiation - induced leiomyosarcoma , which developed 6 - 35 years after radiation therapy . radical resection remains the main method of treatment in radiation - induced sarcomas , but resectability depends on site ( bone or soft tissue ) and size of tumour . management of these tumours must take into consideration the possibility of complete resection and the impact of surgery on quality of life . in the present case , was one year , and the 5-year survival was 17% for patients with a tumour of more than 5 cm in diameter and not completely resected . inoue   noted 5-year overall survival for patients with resectable lesion of the extremities at the level of 68.2% compared with 27.3% for those with central type ( pelvis , head / neck , spine , scapula ) . the poor survival rate is the result of significant delay in diagnosis , large , unresectable and aggressive tumours , and lack of effective methods of treatment apart from radical surgery . chemotherapy and re - irradiation have very limited application , mainly as palliative treatment [ 26 , 29 ] . paclitaxel and anti - angiogenic drugs , such as sorafenib and sunitinib , have shown some efficiency in angiosarcomas . chemotherapy can be administered in the neoadjuvant pattern , before surgical resection , to improve local control and eradicate subclinical metastatic disease . noted clinical partial remission in 9 out of 19 patients ( 47% ) receiving neoadjuvant chemotherapy ( doxorubicin + ifosfamide + dacarbazine ) . re - irradiation can be relatively safe and effective in selected patients , but there are concerns about serious sequelae . furthermore , repeated high - dose radiotherapy is often impossible due to limited bone marrow function [ 32 , 33 ] . de jong   indicated re - irradiation plus hyperthermia as a feasible method in patients with post - irradiation sarcoma . suggested that critical cellular molecules are directly ionized , or irradiation indirectly acts through mediators such oxygen free radicals and finally dna injury results in induction of a somatic mutation and activation of proto - oncogene k - ras . experimental evidence showed p53 gene alterations or increased p53 messenger ribonucleic acid ( mrna ) levels in post - irradiation murine sarcomas . little   described evidence indicating that not only activation of oncogenes , tumour suppressor genes and the loss of cell - cycle checkpoints within irradiated cells are important . genetic consequences of irradiation may occur in the neighbouring cells by gap junction mediated cell - cell communication and activation of the p53 damage response pathway . in trott 's   opinion , second cancers in high dose volumes are caused by the promoting effects of chronic radiation damage : atrophy and persistent inflammation . holt   suggested a two - mutation model of carcinogenesis , which fitted the influence of low dose irradiation : a specific mutation in a stem cell increases its rate of proliferation and pre - malignant cells will develop . modern radiation techniques such as intensity - modulated radiotherapy ( imrt ) might increase the risk of radiation - induced sarcomas . the move from conventional to three - dimensional conformal radiotherapy was implicated in reduction of the normal tissue volume receiving a high dose and an increase in dose to the tumour and a limited part of normal tissue . however , the move to imrt involves more fields , and a larger volume of normal tissue receives lower doses while the total body exposure is increased . both factors may cause greater risk of radiation - induced tumours [ 19 , 38 , 40 , 41 ] . genetic predisposition and other risk factors such tobacco , alcohol , hormonal disturbance and diet also play an important role . the increased risk of second cancers is well documented in patients with hereditary form of retinoblastoma . in members of families with li - fraumeni syndrome , germline mutations in tumour suppressor genes may increase the risk of second cancer . the risk of radiation - induced sarcoma is relatively small compared with the benefits of radical or adjuvant radiotherapy . careful follow - up after effective radiotherapy should be continued for many years : early diagnosis of second cancer may help in more effective treatment of these tumours .
aim of the studyto present a case of a patient with cervical carcinoma in stage iia who was diagnosed with pelvic bone sarcoma 28 years after radiotherapy.case presentationa 37-year - old woman with iia cervix cancer was treated with external beam irradiation and brachytherapy . 
 the patient had undergone conventionally fractionated external beam irradiation using the  box  technique , with the total dose of 50 gy and brachytherapy with radium applicators ( intrauterine tube and fornix applicator ) with the dose of 60 gy calculated at point a. after treatment 
 she was followed up for 2 years . 
 twenty - six years later , inoperable pelvic bone sarcoma was diagnosed within the irradiated field . 
 the clinical course was aggressive and rapid progression during chemotherapy was observed.conclusionsfor patients receiving radiotherapy , long - term careful follow - up is mandatory due to second cancer risk . in the case of any suspicious symptoms , 
 such patients need proper diagnosis to detect any disease as early as possible .