Inferior vena cava--right atrial tumor thrombus in malignant pelvic bone tumors in children

Radiological characteristics and predisposing factors of venous tumor thrombus in pelvic osteosarcoma: A mono-institutional retrospective study of 115 cases

BACKGROUND

Venous tumor thrombus (VTT) in pelvic osteosarcoma has been regarded as a rare oncological condition and few literatures investigated this issue.

METHODS

We retrospectively reviewed 115 cases of pelvic osteosarcoma treated in our center from 2006 to 2016. Diagnosis of VTTs was made based on histo-pathological findings. We summarized the radiological manifestations of VTTs on CT, MRI, and PET/CT. We also compared the demographical, oncological, and radiological data between cases with or without VTTs to identify its predisposing factors.

RESULTS

Seventeen cases (14.8%) were diagnosed with VTT. Manifestations of VTTs on CT included increased caliber (64.7%), calcification (47.1%), low density on plain scan (100%), filling defect (100%), and streak-like enhancement (35.7%) on contrast enhancement. On MRI, the VTTs could be hypo- or iso-intense on T1WI (100%), hyperintense on T2WI (100%), and filling defect on contrast enhancement (100%). PET/CT showed high metabolic activity of the VTTs. The ranges of the VTTs included unilateral external iliac vein (EIV) (two cases), unilateral internal iliac vein (IIV) (one case), unilateral common iliac vein (CIV) and IIV (five cases), unilateral CIV + EIV (two cases), inferior vena cava (IVC) and unilateral CIV + EIV (one case), IVC and unilateral CIV + IIV (four cases), IVC and bilateral CIVs + IIVs (two cases). Multivariate analysis indicated that chondroblastic subtype and involvement of L5/S1 intervertebral foramen might predispose to VTTs.

CONCLUSION

The incidence of VTTs in pelvic osteosarcoma was 14.8%. Comprehensive radiological studies help preoperative diagnosis of VTTs. Predisposing factors included chondroblasic subtype and involvement of L5/S1 intervertebral foramen.

Right atrial tumor embolism from thoracic chondrosarcoma: A case report

Chondrosarcoma accounts for ~15% of all primary malignant bone tumors. Chondrosarcoma of the spine is rare, while intra-atrial tumor embolisms as a result of chondrosarcoma are extremely rare. In the present study, the case of a 70-year-old male with thoracic chondrosarcoma, who presented with a fever and exertional dyspnea, is reported. Following anti-infection treatment with cefoperazone sodium and sulbactam sodium, the patient developed shock and a mass was identified in the right atrium by echocardiogram. The patient subsequently developed acute circular breathing failure and succumbed to the disease. To the best of our knowledge, this is the first case of thoracic chondrosarcoma with a tumor embolism in the right atrium to be reported in the literature.

Osteosarcoma of the lumbosacral spine invading the central venous pathways, right-sided cardiac chambers, and pulmonary artery

We report an unusual case of lumbosacral osteogenic sarcoma with cauda equina syndrome and invasion into the central venous and cardiac system. A 41-year-old Hispanic man presented to the emergency department complaining of severe low back pain, cauda equina syndrome, bilateral lower extremity edema, and an extra heart sound on physical examination. CT of the lumbosacral spine done in the emergency department demonstrated a sclerotic lesion in the sacrum with cortical destruction, extension into the spinal canal and a bulky soft tissue mass containing calcifications. Supplemental MRI demonstrated marrow replacement of L4, L5, and the sacrum, soft tissue extension of the tumor, and invasion iliac veins extending into the IVC; however, the full extent of the intravascular tumor was not seen on this examination. Surgical laminectomy and biopsy of the spinal tumor provided the diagnosis of osteogenic sarcoma. A transthoracic echocardiogram was performed while the patient was recovering due to nonsustained ventricular tachycardia, which showed an echogenic mass within the right atrium and ventricle. CT pulmonary angiogram confirmed the echocardiogram showing a tumor extending through the pulmonary valve into the main pulmonary artery. The patient underwent en bloc resection of the tumor from the venous and cardiac systems. Histologic examination of the tumor confirmed osteogenic sarcoma. While vertebral osteogenic sarcoma is uncommon, invasion of the spinal canal is common in these tumors. However, tumor extending into the central venous and cardiac system is rare. The previously reported cases of central venous and cardiac involvement have been related to distant metastases or primary cardiac osteosarcomas. There is only one other reported case of direct extension into the venous system by an iliac bone osteosarcoma in an adolescent; however, the tumor did not extend into the pulmonary circulation.

Surgical management of pelvic sarcoma in children

Survival rates of children with pelvic sarcoma have demonstrated unprecedented improvement during the past few decades, with a corresponding increase in the number of limb-sparing surgical procedures being performed. This increase may be attributed to earlier detection with advanced imaging techniques, the availability of a wider armamentarium of surgical techniques of reconstruction and limb salvage, and advances achieved in neoadjuvant chemotherapy and radiation therapy. Undertaking reconstruction after resection of pelvic sarcoma while preserving function of the hip and limb can be extremely challenging; this is especially true in children, who invite concern regarding growth potential and limb-length discrepancy. Decisions for surgery and reconstruction are individualized based on tumor type, size, and location as well as the probability of achieving a wide resection with negative margins and acceptable morbidity.

High-Grade Pelvic Osteosarcoma With Intravascular Extension to the Right Side of the Heart: A Case Report and Review of the Literature

We describe a rare case of high-grade osteosarcoma with intravascular extension to the right atrium and right ventricle in a 23-year-old woman. Osteosarcomas rarely metastasize to the heart, and only a few cases have been reported in the literature thus far. Diagnoses in some of these cases were made during investigation for severe cardiac failure and in most of these cases at autopsy. We describe a unique case of intravascular extension of the tumor embolus in a cordlike fashion from the left femoral vein to the right side of the heart that morphologically resembled a chondrosarcoma.

Metastases detected at the time of diagnosis of primary pediatric extremity osteosarcoma at diagnosis: imaging features

BACKGROUND

The authors performed a retrospective study to estimate the incidence rate of metastatic disease at the time of diagnosis of extremity osteosarcoma (OS), to characterize its pattern of presentation, and to identify factors predictive of survival within a cohort of patients with pulmonary metastatic disease at diagnosis.

METHODS

From the institutional solid tumor database, the authors identified all patients diagnosed with extremity OS since CT became available at the study institution (1977). The authors recorded patient demographics, the site of primary disease, the histologic subtype of OS, and the presence of metastases at diagnosis. In those patients with pulmonary metastases at diagnosis, the presence of calcifications, the primary tumor volume, the number of pulmonary lobes with disease, and the number of pulmonary nodules were recorded.

RESULTS

Of an evaluable population of 215 patients, 32 (15%) had bone or pulmonary metastases at diagnosis, of whom original imaging from 28 patients was available for review. Osteoblastic histology correlated with lung metastases at diagnosis (P = 0.049). One of the 32 patients had a solitary bone metastasis without lung metastases. Four of 28 patients (14%) with original imaging available had calcifications within the pulmonary nodules. Both the number of nodules and the number of lobes involved were found to be significant predictors of survival (P = 0.0009 and P = 0. 04, respectively); multiple nodules were bilateral in 61% of patients.

CONCLUSIONS

The rate of incidence of computed tomography detected pulmonary metastases was found to be 14% (31 of 215 patients) at diagnosis and 0.5% (1 of 215 patients) for bone metastases in patients with primary extremity OS. Pulmonary metastases usually are multiple and bilateral and infrequently calcify. The number of nodules and lobes involved are predictors of patient survival.

Surgical treatment for transvenous tumor extension into the heart: four cases

From 1984 to 1996, four patients with transvenous intracardiac tumor extension underwent operations in the Kobe University Hospital. The primary tumors of two were intravenous leiomyomatoses originating from the uterus; a third patient had invasive thymoma, and the fourth patient had clear cell sarcoma of the kidney. In 1985, one patient had a curative, staged resection. One-stage operations were carried out in three patients, and all intracardiac tumors were successfully resected en bloc with the primary tumors under conditions of electrical ventricular fibrillation and mild hypothermia. Combined venous reconstructions were necessary for en bloc resection in three cases. Two patients with malignancy received postoperative chemoradiotherapy, and all four patients were discharged uneventfully from our hospital. We consider radical resection with curative intent only for patients with tumors extending into the heart. In these cases, a one-stage operation is preferable, and electrical ventricular fibrillation with mild hypothermia is a recommended method of circulatory assist because of its simplicity.

Pelvic girdle chondrosarcoma and inferior vena cava thrombosis

Pelvic girdle chondrosarcomas in children and adolescents are extremely rare. These high grade malignant chondrosarcomas with a locally aggressive growth pattern have a high tendency for thrombus formations in the afferent tumour vessels, associated with an increased risk of inferior vena cava thrombosis, pulmonary embolism and metastatic spread to the lungs. This tumour location is generally non-resectable for cure and, since adjuvant chemotherapy is ineffective, patients die from the tumour thrombus formation causing tumour emboli and metastatic disease to the lungs. Effective local tumour control can be achieved with high-dose hyperfractionated radiation therapy.