A 71-year-old female patient presented with a four-month history of increasing difficulty with defecation and micturition and a swelling around her right elbow. On examination, it was found that the swelling was fixed to deep tissue.
A 71-year-old female patient presented with a four-month history of increasing difficulty with defecation and micturition and a swelling around her right elbow. On examination, it was found that the swelling was fixed to deep tissue. Her past medical history included the diagnosis of a sacral chordoma made eleven years earlier. This had been treated with subtotal excision and radiotherapy. Nine years later, she had represented with further bladder problems, and the imaging study performed at that time had revealed the chordoma to have locally recurred (Fig. 1). A further de-bulking operation had been performed. On this presentation, an MRI and a CT scan of her sacrum and arm were performed (Figs. 2–4) . The results of these findings showed that the sacral chordoma had once again increased in size, with an evidence of more bone destruction. The swelling in the arm was shown to be a large soft-tissue mass involving the triceps muscle with multiple fluid and solid compartments. Radiologically, it had similar features to the sacral chordoma. The differential diagnosis of this mass included a soft-tissue sarcoma or a metastasis from the chordoma. The subsequent histological study confirmed the latter.
Chordomas are rare, generally slow-growing malignant tumours, with 50% of them originating in the sacrum. Most sacral chordomas present with pain and at diagnosis are locally extensive which, given the proximity of vital structures, make the treatment options challenging and controversial. These include total excision, subtotal excision, radiotherapy and chemotherapy. Some studies advocate, where possible, radical surgery, which may increase the symptom-free interval before relapse. However, in many tumours this may not be surgically possible, and in addition it carries with it a high risk of morbidity. Therefore, a subtotal debulking procedure is often carried out. The adjuvant radiotherapy procedure remains controversial and can be used pre- or post-operatively, which may increase the remission period. The chordomas can commonly recur locally and more rarely with distant metastases. Local recurrence figures are quoted between 19% and 82% with most studies indicating figures towards the latter end of this spectrum. Distant metastases occur in 14%–30% of the cases, most commonly to the bones, the lung and the subcutaneous tissue. However, deposits in the brain, the pericardium, the ovary and the synovium have been described. Metastases to the skeletal muscle are rare and may be misdiagnosed as primary soft-tissue neoplasms. Their incidence is low in both patients with and without known malignancy, and the skeletal muscle itself is thought to be relevantly resistant to both primary and secondary cancer. In our case, the appearance of the metastatic deposit, despite being non-specific, was radiologically similar to the primary chordoma. This case highlights both that sacral chordomas can develop distant metastases, and that rare combinations of disease do exist. However, it is unlikely that the true incidence is known, as many such cases may well go unreported.
Recurrent sacral chordoma, metastatic to the skeletal muscle.
Based on the provided MRI and CT images, the local bone in the sacral region shows destructive changes, and the lesion exhibits mixed signals with indistinct boundaries, partially involving adjacent soft tissues, suggesting an invasive lesion. Considering the patient's complaints (difficulty with defecation and urination), the sacral lesion may be compressing and invading the surrounding tissues and nerves in the pelvis. In the MRI of the right elbow, a lesion is observed that is connected to deeper structures, with signal characteristics similar to the primary sacral lesion, raising the possibility of metastasis or multifocal disease.
Based on the typical location of the sacral lesion, its slow growth with invasion of surrounding tissues, and similar signal appearance of the right elbow lesion, chordoma metastasis aligns better with the clinical reality than other diagnoses.
Taking into account the patient’s age, chief complaints (dysfunction in defecation and urination), imaging findings of the sacrum and right elbow, as well as the biological behavior of chordoma, the most likely diagnosis is:
“Sacral chordoma with distant soft tissue (right elbow) metastasis.”
To confirm, a biopsy or surgical specimen may be considered for histopathological or immunohistochemical evidence.
After completing major treatments, an individualized and gradual exercise program should be designed under the assessment of physicians or rehabilitation specialists, focusing on:
If bone fragility or pain is present, extra caution is required. Early in recovery, gentle movements may be performed with support devices or medical personnel assistance, gradually transitioning to independent activity.
Disclaimer: This report is a preliminary analysis based on current information and should not replace in-person consultation or professional medical advice. For any concerns, please seek advice from specialists in orthopedics, oncology, and rehabilitation medicine.
Recurrent sacral chordoma, metastatic to the skeletal muscle.
