Case Diagnosis: Post-irradiation Sarcoma Case Description: A 58-year-old woman with a history of stage IIIB squamous cell carcinoma of the cervix who was treated with chemoradiation, considered in remission 5 years prior on PET CT, and was under every 6-months surveillance for recurrence by gynecology. She presented to the Emergency Department for severe back pain, left sided sciatica, and paresthesias. In the absence of fracture or cord compression, she was discharged with recommendations for primary care follow-up. This took place over the telephone with referral to the spine center. One week later, her pain progressed to 10+/10 with dense left leg numbness, and multiple falls. Physiatry ordered a lumbar MRI for focal neurologic findings on exam, which revealed a large destructive lesion of the left ilium and left hemisacrum with soft tissue extension. This was later determined to be undifferentiated sarcoma, likely due to prior radiation. She is currently undergoing palliative chemotherapy. Discussions: Post-irradiation sarcomas (PIS) are a relatively rare event and exhibit dose dependency. Sarcomas can present with bone pain that can be worse at night and signs and symptoms of compression of surrounding structures. The pelvis is a common site for sarcoma development. Cases of PIS have presented in even just a few months post radiation therapy. The prognosis of patients with PIS is poorer than those with primary sarcomas. This patient would require hemipelvectomy to attempt curative treatment. Conclusions: PIS are typically aggressive, have poor prognosis, and can develop within months of high doses of radiation therapies; clinicians index of suspicion for sarcomas in patients with a history of radiation must be high. Evaluation for progressive pain, weakness, and numbness may not be amenable to telemedicine until technology improves. Patients that present with signs and symptoms of progressive nerve compression and bone pain should be re-examined early on.

A 79-year-old otherwise healthy Puerto Rican woman is seen for a 3-month history of a rapidly enlarging mass on her right foot. The involved areas are occasionally tender, affecting her ability to walk. Physical examination reveals many confluent, deep red to purple, eroded, grapelike nodules affecting all aspects of the foot and extending to the distal part of the leg. The largest confluent mass is on the heel extending to the posterior side of the ankle. She has no history of immunosuppression.

We present the first report of bilateral knee and left ankle osteonecrosis in a 58-year-old female patient on long-term intranasal corticosteroids. Initially, our patient presented with progressive disabling knee pain with normal radiographs. The patient was presumed to have mild degenerative joint disease; therefore, she was treated conservatively. Then, the patient developed severe left ankle pain, and she was thought to have L5/S1 radiculopathy; therefore, she underwent epidural steroid injection that did not provide any benefit. However, extensive bilateral osteonecrosis of the medial tibial plateau in addition to osteonecrosis of the talus bone of left ankle were later diagnosed by MRI. The patient underwent staged bilateral total knee arthroplasty. In conclusion, the diagnosis of osteonecrosis might be challenging because of overlapping clinical presentation with other disorders particularly in the early stage of the disease with normal radiographs. Therefore, a high index of suspicion and thorough history with supplemental MRI imaging are essential for the assessment of patients presented with atypical refractory joint pain particularly in the presence of risk factors.