Cardiovascular involvement by osteosarcoma: an analysis of 20 patients

Epidemiology and nomogram of pediatric and young adulthood osteosarcoma patients with synchronous lung metastasis: A SEER analysis

BACKGROUND

Patients with osteosarcoma and synchronous lung metastasis (SLM) have poor survival. This study aimed to explore the epidemiology data and construct a predictive nomogram to identify cases at risk of SLM occurrence among pediatric and young adulthood osteosarcoma patients.

METHODS

All data were extracted from Surveillance, Epidemiology, and End Results 17 registries. The age-standardized incidence rate (ASIR) and annual percentage change was evaluated, and reported for the overall population and by age, gender, race, and primary site. Univariate and multivariate logistic regression analyses were used to identify risk factors associated with SLM occurrence, then significant factors were used to develop the nomogram. The area under the receiver operating characteristic curve (AUC) and calibration curve were used to evaluated the predictive power of the nomogram. Survival analysis was assessed by the Kaplan-Meier method and the log-rank test. Multivariate Cox analysis was used to determine the prognostic factors.

RESULTS

A total of 278 out of 1965 patients (14.1%) presented with SLM at diagnosis. The ASIR increased significant from 0.46 to 0.66 per 1,000,000 person-years from year 2010 to 2019, with an annual percentage change of 3.5, mainly in patients with age 10-19 years, male and appendicular location. All patients were randomly assigned into train cohort and validation cohort with a spilt of 7:3. In the train cohort, higher tumor grade, bigger tumor size, positive lymph nodes and other site-specific metastases (SSM) were identified as significant risk factors associated with SLM occurrence. Then a nomogram was developed based on the four factors. The AUC and calibration curve in both train and validation cohorts demonstrated that the nomogram had moderate predictive power. The median cancer-specific survival was 25 months. Patients with age 20-39 years, male, positive lymph nodes, other SSM were adverse prognostic factors, while surgery was protective factor.

CONCLUSIONS

This study performed a comprehensive analysis regarding pediatric and young adulthood osteosarcoma patients had SLM. A visual, clinically operable, and easy-to-interpret nomogram model was developed for predicting the risk of SLM, which could be used in clinic and help clinicians make better decisions.

PET/MR of pediatric bone tumors: what the radiologist needs to know

Integrated 2-deoxy-2-[fluorine-18]fluoro-D-glucose (18F-FDG) positron emission tomography (PET)/magnetic resonance (MR) imaging can provide "one stop" local tumor and whole-body staging in one session, thereby streamlining imaging evaluations and avoiding duplicate anesthesia in young children. 18F-FDG PET/MR scans have the benefit of lower radiation, superior soft tissue contrast, and increased patient convenience compared to 18F-FDG PET/computerized tomography scans. This article reviews the 18F-FDG PET/MR imaging technique, reporting requirements, and imaging characteristics of the most common pediatric bone tumors, including osteosarcoma, Ewing sarcoma, primary bone lymphoma, bone and bone marrow metastases, and Langerhans cell histiocytosis.

Right Ventricular Mass 12 Years after Osteosarcoma: Multimodality Imaging with Pathologic Correlation

The authors report a 27-year-old woman with a remote left femoral osteosarcoma and amputation above the left knee who presented with a large right ventricular mass. Initial evaluation with thoracic CT was inconclusive regarding thrombus versus tumor, but metastatic osteosarcoma was suggested by findings at transthoracic echocardiography, cardiac CT, and cardiac MRI. The patient underwent tumor debulking, and osteosarcoma was confirmed with pathologic examination. She responded to chemotherapy, which resulted in reduction in size of the residual right ventricular tumor and of a few pulmonary metastases. Following induction chemotherapy, patient remains well undergoing maintenance therapy with an oral tyrosine kinase inhibitor. Keywords: CT, Echocardiography, MR Imaging, Intraoperative, Cardiac, Heart, Right Ventricle, Imaging Sequences, Metastases, Oncology Supplemental material is available for this article. © RSNA, 2021.

Atypical pulmonary metastases in children: the spectrum of radiologic findings

Pulmonary nodules present a diagnostic challenge when they appear as atypical metastases in pediatric oncology patients. Chest computed tomography (CT) is the primary imaging modality for assessing lung nodules. In pediatric populations, Wilms tumor and osteosarcoma are the cancers most likely to produce pulmonary metastasis, both typical and atypical. This pictorial essay provides a thorough description of the specific radiologic features of atypical pediatric pulmonary metastases, and their pathogenesis and differential diagnosis. We also address diagnostic approaches to incidental lung nodules in healthy children found in the literature. Our aim is to help radiologists identify atypical lung metastases on CT, ensuring that children receive prompt, and potentially lifesaving, treatment.

Role of anticoagulation in the management of tumor thrombus: A 10-year single-center experience

BACKGROUND

Children with cancer diagnosis are overall at a higher risk of thrombosis. For a newly diagnosed blood clot, patients are commonly started on anticoagulants to prevent further extension and embolization of the clot. In the rare instance that a pediatric patient has a tumor thrombus, role of anticoagulation is less clear.

PROCEDURE/METHODS

Patients under 21 years of age with a finding of tumor thrombus on imaging from 2010 to 2020 at Texas Children's Hospital were identified and their medical records were reviewed.

RESULTS

A total of 50 patients were identified. Most thrombi were incidental findings at diagnosis; however, two patients presented with pulmonary embolism (PE). Inferior vena cava extension was noted in 36% of the patients, and 24% patients had an intracardiac tumor thrombus. Anticoagulation was initiated in 10 patients (20%). There was no difference in the rate of bland thrombus formation and/or embolization in patients who did or did not receive anticoagulation. However, three of the six patients with asymptomatic tumor thrombus who were started on anticoagulation had bleeding complications compared to only two patients in the no anticoagulation cohort (p < .05).

CONCLUSION

Children with intravascular extension of solid tumors were not commonly started on anticoagulation at the time of diagnosis, irrespective of the extent of tumor thrombus. Furthermore, we observed a significant trend toward higher incidence of bleeding complications after initiation of anticoagulation for asymptomatic tumor thrombus. There is inadequate evidence at this time to support routine initiation of anticoagulation in pediatric patients with intravascular extension of solid tumors.

Diagnostic transcatheter aspiration for pulmonary artery tumor embolism using an INARI Triever aspiration catheter

Pulmonary artery tumor embolism is a rare phenomenon and its diagnosis is important because of a poor prognosis. We report a 20-year-old male with history of metastatic osteosarcoma who presented with acute pulmonary embolism. He was urgently taken to the catheterization laboratory and underwent transcatheter aspiration of pulmonary artery mass using an INARI Triever aspiration catheter. Pathology of the aspirated specimen lead to the diagnosis of pulmonary artery tumor embolism, not thrombus. This case highlights the diagnostic utility of transcatheter aspiration for the pulmonary artery tumor embolism.

Temporal evolution of metastatic disease: part I-an in-depth review of the evolution of metastatic disease across diverse spectrum of non-neural solid tumors on serial oncologic imaging studies and relevant practical applications

With improved survival rates of patients with metastatic disease due to continuously evolving multimodality treatment options, radiologists are increasingly interpreting imaging studies from patients with protracted metastatic disease. It is thus crucial for radiologists to have an in-depth understanding of the temporal evolution of metastatic spread and the accompanying findings on imaging studies, to provide accurate interpretation that supports optimal management. A general overview of the evolution of cancer spread on serial imaging studies and common pathways of tumor spread across multiple tumor types and tumor locations is not readily available in radiology literature. The key common pathways of tumor spread across diverse spectrum of tumors relevant to radiologists are summarized in a logical schematic approach which focusses on aiding radiologists to understand the pathways of spread resulting in current sites of metastatic disease involvement and then to potentially predict future sites of metastatic involvement. This article also summarizes the practical applications of this knowledge to the routine oncologic imaging interpretation.

Primary Intimal Sarcoma of the Pulmonary Artery in a 25-Year-Old Woman with Dyspnea and Palpitation: A Case Report

Intimal sarcoma arising from the tunica intima of both systemic and pulmonary circulations is a rare disorder, whereas intimal sarcoma with chondroblastic osteosarcomatous differentiation (ISCOS) is even rarer. We present the case of a 25-year-old woman with ISCOS of the pulmonary artery (PA) where the patient went through surgical treatment after careful imaging assessment under a rather emergent situation. A 25-year-old Japanese female presented to our hospital with the chief complaints of dyspnea and palpitations on exertion. Upon arrival, she had systolic murmur, moderate tricuspid regurgitation, and possible pulmonary hypertension. A contrast-enhanced chest computed tomography (CT) showed dilatation of the main PA, filled with a hypodense area with calcification adjacent to the right and left PA. The calcified lesions within the tumor were the key findings suggesting osteoid-forming sarcoma, differentiating it from pulmonary embolism. Due to presence of critical symptomatic obliteration of the pulmonary circulation, an emergency surgery was performed. A whitish shiny mass filled the lumens from the main PA to the bilateral main PAs. The tumor was not attached to the surrounding intima, except for a slight attachment to the left interlobar PA, and could be completely removed from the vessel lumen. Based on the pathological findings, it was diagnosed as a primary ISCOS of the PA, which correlated with the findings of the CT, namely intratumoral calcification. Although the diagnosis-making is quite challenging, multidisciplinary collaboration between clinicians, radiologists, and pathologists is crucial for reaching the correct diagnosis.

Atypical pulmonary metastases in children: pictorial review of imaging patterns

Pulmonary metastases typically present as well-circumscribed solid nodules, often with a basilar and peripheral distribution due to hematogenous spread. When an atypical pattern of metastasis occurs, a lack of recognition may result in understaging or a delay in diagnosis. The purpose of this article is to review the imaging findings of atypical pulmonary metastatic disease in children. Atypical pulmonary metastatic patterns that can be seen in children include cavitary lesions, calcified pulmonary nodules, nodules with peritumoral halos, tree-in-bud or strial pattern secondary to tumor in peripheral pulmonary arterial branches, lymphangitic carcinomatosis, and miliary disease. An awareness of the spectrum of imaging findings of atypical pulmonary metastases along with an understanding of histopathological underpinnings will allow the radiologist to make an accurate diagnosis.

Small direct right ventricular cardiac metastasis of osteosarcoma in a 10-year-old boy affirmed by cardiac MRI

Background

Metastatic osteosarcoma with direct cardiac involvement is an exceptionally rare finding. Reliable detection of cardiac metastases is known to be crucial for patients therapy and prognosis.

Case Summary

In a 10-year-old boy affected by osteosarcoma of the left femur, a baseline Fluorine-18-fluorodeoxy-glucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) was performed to assess the full extent of disease. Whole-body scan detected numerous bone metastases together with a single pulmonary metastasis. Moreover, increased tracer uptake was observed in the intracavitary right cardiac ventricle in the position of a subtle spot of calcification. Because of nondetectability of a cavitary lesion on echocardiography, cardiac magnetic resonance imaging (CMRI) examination was performed to evaluate cardiac ¹⁸F-FDG PET/CT finding. CMRI revealed a small nodule in the right ventricle attached to the trabeculae, highly suspicious of a direct cardiac metastasis. After 4 cycles of chemotherapy, complete regression of tracer uptake of the lesion was observed on a follow-up ¹⁸F-FDG PET/CT scan.

Conclusion

CMRI is able to detect even small, clinically asymptomatic cardiac metastases in young patients affected by osteosarcoma.

Intraoperative considerations in a patient with chondroblastic osteosarcoma and saddle pulmonary embolism undergoing amputation

In patients presenting to the operating room with a saddle pulmonary embolism for noncardiac surgery, it is best to take a multidisciplinary approach and involve the cardiac and vascular surgeons.

Emergency Surgery in High Volume Osteosarcoma of Left Proximal Humerus Due to Vascular Compromise: A Case Report

BACKGROUND Osteosarcoma is the most common type of malignant bone tumor arising from mesenchymal stem cell. When occurring on the proximal humerus, it is associated with poor outcomes; there are numerous neurovascular structures around proximal humerus. Unfortunately, the degree of vascular involvement in osteosarcoma is rarely evaluated and reported. Thus, we would like to highlight our case. CASE REPORT We reported a case of left proximal humerus osteosarcoma causing dead limb in a 14-year-old boy. The dead limb progressed in the span of 3 weeks. An emergency forequarter amputation (FQA) was conducted to prevent further complications such as septicemia and mortality. Two months after the surgery, the patient had improved quality of life. One year after, the patient had no local recurrence. However, there was a lung metastasis detected 9 months after the surgery. The patient died 13 months after the surgery. CONCLUSIONS Osteosarcoma of the proximal humerus can potentially compromise vascular structures. Early diagnosis and treatment are mandatory to prevent such complications.

Rare haematogenous sarcoma metastasis to the heart in a child

Haematogenous non-contiguous metastatic spread of remote solid tumours to the heart is rare. We describe a previously healthy 5-year-old girl who presented with extensive intracardiac involvement by metastatic pelvic sarcoma.

Heart Osteosarcoma Presenting as Infective Endocarditis: A Case Report of a Patient With a Cardiac Pacemaker and Triple Malignancies

Primary and metastatic cardiac sarcomas represent rare neoplasms with a variable clinical course. We present a rare case of an 84-year-old man with a cardiac pacemaker and heart osteosarcoma, hepatocellular and prostatic carcinoma, who was admitted with suspected symptoms of infective endocarditis. Findings of cardiac osteosarcoma in a patient with a pacemaker and three malignancies have not been reported before in the literature.

Cardiovascular recurrence of high-grade osteosarcoma presenting as atrial thrombosis and pulmonary embolism: A case report and review of the pediatric literature

In the era of neoadjuvant and adjuvant chemotherapy, extrapulmonary involvement by high-grade osteosarcoma (HGOS) is rare. Importantly however, HGOS metastasis in the form of cardiovascular tumor thrombus portends a dismal prognosis. Thus, prompt and accurate identification of tumor thrombus is crucial. We report here two unique cases of recurrent HGOS, presenting as thrombotic events, in order to increase awareness and index of suspicion among practitioners regarding this presentation. Additionally, we review 14 previously reported pediatric cases of cardiovascular metastatic HGOS.

Tumor thrombus in the venous drainage pathways of primary, recurrent and metastatic disease on routine oncologic imaging studies: beyond hepatocellular and renal cell carcinomas

Radiologists routinely evaluate for tumor thrombus in the portal and hepatic veins in patients with hepatocellular carcinoma and in the renal vein and inferior vena cava in patients with renal cell carcinoma. However, tumor thrombus occurs in association with numerous other tumor types, e.g. colorectal carcinoma and pancreatic neuroendocrine tumor. Furthermore tumor thrombi are not limited to the primary tumor but also seen with local recurrence and metastatic disease. While less recognized, these thrombi nevertheless affect patterns of recurrence and prognosis. Their detection is critical for accurate local staging and early detection of local recurrence and metastatic disease. The purpose of this pictorial review is to draw the attention of radiologists to the less familiar manifestations of tumor thrombus, review the imaging findings and illustrate the clinical significance of these thrombi.

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.

Tumor thrombus in the large veins draining primary pelvic osteosarcoma on cross sectional imaging

PURPOSE

To evaluate the frequency of tumor thrombus in the large veins draining primary pelvic osteosarcoma on early cross-sectional imaging studies and its effect on patient survival.

MATERIALS AND METHODS

Our retrospective study included all patients with primary pelvic osteosarcoma treated at our facility between January 2000 and May 2014, who were ≤ 45 years of age, and had adequate imaging studies and clinical follow up. Four radiologists evaluated for tumor in the large draining veins on initial CT, MRI and PET/CTs. A consensus evaluation by the four radiologists together with findings on operative reports, pathology reports or follow-up imaging was used as the reference standard.

RESULTS

Thirty-nine patients with primary pelvic osteosarcoma met final inclusion criteria. Tumor thrombus was identified in the large draining veins in 10 of the 22 (45%) patients who underwent tumor resection and 10 of the 17 (59%) who did not. In the 22 patients who underwent tumor resection, tumor thrombus was significantly associated with worse overall survival (p = 0.03).

CONCLUSIONS

Tumor thrombus in the large draining veins is identified in a significant proportion of initial imaging studies in patients with pelvic osteosarcoma, and is associated with worse overall survival in patients who undergo tumor resection.

Osteosarcoma Metastases With Direct Cardiac Invasion: A Case Report and Review of the Pediatric Literature

Metastatic osteosarcoma with direct cardiac involvement is an exceptionally rare finding, with only 63 total reported cases in the English literature over the past 123 years. Although the precise incidence is unknown, we estimate that direct cardiac involvement currently occurs in <2% of metastatic osteosarcoma cases. We also find that before the adoption of adjuvant chemotherapy as a standard of care therapy for osteosarcoma, metastatic osteosarcoma to the heart was much more common than it is today, as cardiac involvement occurred in ∼20% of cases of metastatic osteosarcoma before the 1980s. This suggests that adjuvant chemotherapy has not only improved the overall prognosis of osteosarcoma, but also altered the metastatic pattern of disease. In this paper we present the case of an 11-year-old boy with metastatic osteosarcoma to the cardiac interventricular septum, as well as review 20 other previously reported pediatric cases of metastatic osteosarcoma to the heart. We also analyzed the cardiac surgical outcomes for 11 pediatric patients with metastatic osteosarcoma to the heart. The median disease-free survival time was 12 months, demonstrating that metastatic osteosarcoma to the heart is currently a rare occurrence with a poor prognosis.

Magnetic resonance imaging of osteosarcoma using a bis(alendronate)-based bone-targeted contrast agent

Magnetic resonance (MR) is currently used for diagnosis of osteosarcoma but not well even though contrast agents are administered. Here, we report a novel bone-targeted MR imaging contrast agent, Gd₂-diethylenetriaminepentaacetate-bis(alendronate) (Gd₂-DTPA-BA) for the diagnosis of osteosarcoma. It is the conjugate of a bone cell-seeking molecule (i.e., alendronate) and an MR imaging contrast agent (i.e., Gd-DTPA). Its physicochemical parameters were measured, including pK_a, complex constant, and T₁ relaxivity. Its bone cell-seeking ability was evaluated by measuring its adsorption on hydroxyapatite. Hemolysis was investigated. MR imaging and biodistribution of Gd₂-DTPA-BA and Gd-DTPA were studied on healthy and osteosarcoma-bearing nude mice. Gd₂-DTPA-BA showed high adsorption on hydroxyapatite, the high MR relaxivity (r₁) of 7.613mM^-1s^-1 (2.6 folds of Gd-DTPA), and no hemolysis. The MR contrast effect of Gd₂-DTPA-BA was much higher than that of Gd-DTPA after intravenous injection to the mice. More importantly, the MR imaging of osteosarcoma was significantly improved by Gd₂-DTPA-BA. The signal intensity of Gd₂-DTPA-BA reached 120.3% at 50min, equal to three folds of Gd-DTPA. The bone targeting index (bone/blood) of Gd₂-DTPA-BA in the osteosarcoma-bearing mice was very high to 130 at 180min. Furthermore, the contrast enhancement could also be found in the lung due to metastasis of osteosarcoma. Gd₂-DTPA-BA plays a promising role in the diagnoses of osteosacomas, including the primary bone tumors and metastases.

Pattern and Prognostic Implications of Cardiac Metastases Among Patients With Advanced Systemic Cancer Assessed With Cardiac Magnetic Resonance Imaging

BACKGROUND

Cardiac magnetic resonance (CMR) imaging is well validated for tissue characterization of cardiac masses but has not been applied to study pattern and prognostic implications of cardiac metastases (CMETs) among patients with systemic cancer.

METHODS AND RESULTS

The population consisted of 60 patients with stage IV cancer (32 patients with CMETs, 28 diagnosis-matched controls) undergoing CMR. CMET was defined as a discrete mass with vascular tissue properties on delayed enhancement CMR. CMET-positive patients and controls had similar clinical characteristics, cardiac geometry, and function (P=NS). Leading cancer types associated with CMET were sarcoma, melanoma, and gastrointestinal. Patients with CMETs had similar distribution of extracardiac metastatic disease compared with controls (organs involved: 3.4±2.0 versus 2.7±1.9, P=0.17). In 94% of patients with CMETs, there were metastases involving ≥1 extracardiac organ (66% lung involvement). CMET location varied (right ventricle 44%, right atrium 19%, left ventricle 28%, left atrium 9%, pericardial 25%); 22% of cases had multichamber involvement. Right-sided chamber involvement was common in hematologic/lymphatic spread (67%); pericardial involvement was common with direct spread (64%). Regarding tissue properties on delayed enhancement CMR, CMETs commonly (59%) demonstrated heterogeneous enhancement (41% diffuse enhancement). Heterogeneous lesions were larger and had increased border irregularity (P<0.05). Survival 6 months post-CMR was numerically lower among patients with CMETs (56% [95% CI 39-74%]) versus stage IV cancer-matched controls (68% [95% CI 50-86%]), although differences between groups were nonsignificant (P=0.42).

CONCLUSIONS

CMETs vary regarding etiology, location, and tissue properties on CMR, highlighting need for comprehensive surveillance of cardiac involvement regardless of cancer origin. Prognosis remains poor with for patients with CMETs, albeit similar to that for stage IV cancer controls matched for cancer etiology.