Fertility-sparing strategy in a rare case of highly malignant Dicer-1-associated sarcoma of the cervix

Abstract

Introduction: We present the rare case of an 18-year-old patient with a Dicer-1 mutation-associated sarcoma of the cervix uteri.

Case: The patient presented with irregular vaginal bleeding in July 2022. The clinical examination showed an exophytic tumor of the cervix, uterus and ovaries were normal in sonogram. The tumor of the cervix was resected, followed by a diagnostic hysteroscopy and abrasion of the uterine cervix and cavity. Hysteroscopy showed normal findings of the cervix and uterus. After diagnosis of a highly malignant Dicer-1 mutation-associated sarcoma of the cervix, cryopreservation of oocytes was realized. Based on the principle of obtaining maximum oncological safety while preserving fertility in this 18-year-old patient, we recommended chemotherapy rather than radiation with its far severe implications on the patient´s reproductive organs. 4 cycles of chemotherapy consisting of doxorubicin and ifosfamide were applied until December 2022. After re-staging in December 2022 via CT scan and MRI, the abdomen and pelvis as well as control hysteroscopy and abrasion were unremarkable. Until now, the patient is tumor free.

Discussion: Primary sarcomas of the cervix are very rare. Recent literature hints towards a distinct DICER-1 sarcoma entity characterized by specific mutational clusters. Limited follow-up data suggested that DICER1-mutant tumors might exhibit a less aggressive clinical course than DICER1-wild-type tumors.

Conclusion: Decision-making in case of rare histological entities with sparse recommendations in the literature poses a challenge to the treating physician. Treatment strategies should consider oncological safety as well as options of preserving fertility. Gonadotoxic potential of different strategies should be taken into consideration and discussed in detail with the affected patient.

Keywords: Cervical sarcoma; Dicer-1 sarcoma; Fertility preservation; Fertility sparing.

Fig. 1

Transvaginal sonogram shows an exophytic tumor of the uterine cervix

Fig. 2

Transvaginal sonogram of the uterus and tumor of the cervix

Fig. 3

Transvaginal duplex sonography shows intensive vascularization of the tumor of the uterine cervix

Fig. 4

Unremarkable transvaginal sonogram of the uterus

Fig. 5

Unremarkable transvaginal sonogram of the right ovary

Fig. 6

Unremarkable transvaginal sonogram of the left ovary