A comprehensive review on the diagnosis and management of intimal sarcoma of the pulmonary artery

Imaging-Guided Percutaneous Endovascular Biopsy Applied in Patients with Pulmonary Artery Masses: A Review

INTRODUCTION

Pulmonary artery (PA) masses are rare. Distinguishing PA tumours from embolism is sometimes difficult, and surgical biopsy is expensive and risky. We aimed to evaluate the efficacy of imaging-guided percutaneous endovascular biopsy (PEB) for obtaining tissues for histological diagnosis.

METHODS

We searched Cochrane, Medline, Embase, and Web of Science for PEB trials involving patients with PA masses, published from the inception of the database until August 2023.

RESULTS

We retrospectively reviewed 33 studies including 87 patients (median age 55 ± 69.3 years, 44 men) with PA masses who underwent a total of 110 PEBs. Of these patients, 34.5% (n = 38) underwent PEB-catheter aspiration (PEB-CA), 50.9% (n = 56) underwent PEB-forceps biopsy (PEB-FB) and 2.7% (n = 3) underwent PEB-directional atherectomy (PEB-DA). The most common histological aetiology of PA masses was mesenchymal tumours (n = 67, 75.9%). Tumour embolism (n = 6, 6.9%) and pulmonary embolism (n = 3, 3.4%) were the second and third most common types of PA masses, respectively. The technical success rates of PEB-CA, PEB-FB and PEB-DA were 92.1%, 94.6% and 100% (p = 0.796), respectively. Histopathological analysis provided clinical diagnostic success rates of 44.7%, 85.7% and 100% for PEB-CA, PEB-FB and PEB-DA (p < 0.001), respectively. In pairwise comparison, PEB-FB had a higher success rate in pathological diagnosis than PEB-CA (p = 0.000). Apart from one patient suffering from haemorrhagic cardiac tamponade, no other complications occurred.

CONCLUSION

Imaging-guided PEB is a safe and effective technique for the early pathological diagnosis of PA masses.

Tislelizumab combined with GT chemotherapy for intimal sarcoma of inferior vena cava: A case report

RATIONALE

Intimal sarcoma of inferior vena cava (IVC) is a rare soft tissue sarcoma with no typical symptoms and specific imaging features in the early stage, and there is a lack of standardized treatment and methods.

PATIENT CONCERNS

A 54-year-old female patient presented to Fenghua District People's Hospital with a post-active cough and hemoptysis and was subsequently referred to our hospital.

DIAGNOSES

The patient was pathologically diagnosed as intimal sarcoma of IVC complicating multiple intrapulmonary metastases. Chest CT revealed left lung malignant tumor with multiple intrapulmonary metastases; while enhanced upper abdominal CT showed cancer embolus of IVC with extension to right atrium and bilateral renal veins. Besides, hematoxylin and eosin staining suggested intimal sarcoma of veins. Immunohistochemical staining showed positivity for PD-L1, Ki-67, CD31, Desmin and ERG.

INTERVENTIONS

The patient initially received GT chemotherapy (gemcitabine injection + docetaxel). Then, immunotherapy (tislelizumab) was added based on the results of genetic testing (TP53 gene mutation).

OUTCOMES

The disease was stabilized after receiving the treatment.

LESSONS

Given the lack of characteristic clinical manifestations in patients with intimal sarcoma of IVC, imaging examination combined with immunohistochemical index were helpful for diagnosis of intimal sarcoma of IVC. Furthermore, the combination of tislelizumab and GT chemotherapy was feasible in such patients with positive PD-L1 expression and TP53 mutation.

Case report: Pulmonary artery sarcoma diagnosed through rare brain metastases

We present the case of a 33-year-old male referred across several hospitals because of suspected chronic thromboembolic pulmonary hypertension (CTEPH). Initially admitted in October 2022 for a recurrent, severe cough and diagnosed with CTEPH, he received anticoagulant therapy. However, his symptoms worsened, necessitating a transfer to another facility for thrombolysis treatment. Following an episode of syncope, an MRI scan revealed a metastatic brain tumor. Subsequently, he experienced a third transfer to our hospital, emergency surgery was performed to alleviate cerebral edema and excise a lesion in the left frontal lobe. Postoperative pathology was inconclusive, but a multidisciplinary team meeting, aided by experienced radiologists, eventually confirmed a diagnosis of pulmonary artery sarcoma (PAS) with systemic metastases. This case underscores the necessity of promptly ruling out PAS in patients presenting with significant emboli in the central pulmonary arteries and suggests early referral to specialized centers for suspected cases.

Pulmonary arterial sarcoma: A case report

RATIONALE

Pulmonary artery sarcoma (PAS) is a rare malignant tumor primarily originating from the pulmonary artery's intima or subintima. Approximately one-third of cases are classified as undifferentiated type. Its clinical manifestations lack specificity, dyspnea is the main symptom but can also present with chest pain, cough, hemoptysis, and other discomforts, making it prone to misdiagnosis as pulmonary embolism (PE).

PATIENT CONCERNS

A 50-year-old woman was admitted to the hospital with "dyspnea for more than 3 months, aggravated for 2 days," and computed tomography pulmonary angiography suggesting "bilateral multiple pulmonary embolisms."

DIAGNOSES

The patient was initially misdiagnosed as PE, and was later definitively diagnosed as undifferentiated pleomorphic sarcoma of the pulmonary artery by pathologic biopsy.

INTERVENTIONS AND OUTCOMES

The patient was initially treated with anticoagulant therapy, but her dyspnea was not relieved. After that, she underwent positron emission computed tomography (PET-CT) and other investigations, which suggested the possibility of PAS, and then she underwent pulmonary endarterectomy to remove the lesion, which relieved her symptoms and was advised to seek further medical attention from the Department of Oncology and Department of Radiotherapy.

LESSONS

PAS can be easily misdiagnosed as PE. If a diagnosis of PE is made, but anticoagulation or even thrombolytic therapy proves ineffective, and there is no presence of PE causative factors such as deep vein thrombosis in the lower extremities, or D-dimer levels are not high, one should be cautious and consider the possibility of PAS.

[Pulmonary Artery Intimal Sarcoma Involving the Peripheral Pulmonary Artery, Initially Misdiagnosed as Pulmonary Artery Thromboembolism and Vasculitis: A Case Report]

Pulmonary artery sarcomas are rare, high-grade malignancies, primarily affecting the proximal elastic pulmonary artery and usually manifesting as tumoral impaction on imaging. Due to similar clinical and imaging findings, pulmonary artery sarcomas are frequently misdiagnosed as pulmonary thromboembolism or, occasionally, as vasculitis. Herein, we reported a case of pulmonary artery intimal sarcoma initially misdiagnosed as pulmonary thromboembolism and vasculitis due to its relatively atypical location and morphology, along with a literature review.

White Embolus-induced Basilar Artery Occlusion Due to Pulmonary Vein Invasion of a Metastasis of a Malignant Melanoma

An 80-year-old woman presented with impaired consciousness after malignant melanoma resection. Magnetic resonance angiography showed basilar artery occlusion, which was subjected to mechanical thrombectomy for recanalization. A pathological analysis of the retrieved embolus revealed that it was derived from a metastasis of malignant melanoma. Contrast-enhanced chest computed tomography showed multiple pulmonary metastases, one of which was in the right upper lobe and invaded the pulmonary vein. To our knowledge, this is the first case of white embolus-induced cerebral embolism due to pulmonary vein invasion of a metastasis of a pathologically diagnosed malignant melanoma.

Percutaneous endovascular biopsy for the diagnosis of pulmonary artery masses: A preliminary study of single-center

Percutaneous endovascular biopsy (PEB) including forceps biopsy and catheter aspiration has been used to make a pretreatment diagnosis for pulmonary artery (PA) masses. This retrospective study aims to describe the procedure of PEB and compare the diagnostic yield of forceps biopsy and catheter aspiration for a definite diagnosis in patients with PA masses. All consecutive 22 patients (53 ± 14 years), 11 males and 11 females, who underwent PEB for pathologic confirmation between November 2018 and November 2022 were enrolled. All 22 patients performed computed tomography pulmonary angiography or positron emission tomography-computed tomography to confirm the filling defects suspicious for PA malignancy before intervention. And then, all patients underwent PEB successfully without acute or fatal complications, including both forceps biopsy and catheter aspiration in 15 cases, only forceps biopsy in 5 cases, and only catheter aspiration in 2 cases. Histopathological analysis provided a definite diagnosis in all PEBs with a clinical success of 91.0% (20/22). Among them, in 15 patients who underwent both forceps biopsy and aspiration biopsy, the technical success using forceps biopsy was 93.3% (14/15), and aspiration biopsy was 6.7% (1/15), and there was a significant difference in diagnostic accuracy when comparing two techniques. Twenty-one out of 22 PA masses (95.5%) were malignant, of which, the most frequent malignant lesion observed was PA sarcoma (66.7%, 14/21). Benign lesion included one thrombus (4.5%, 1/22). In conclusion, PEB is an effective and safe diagnostic method for differentiating benign and malignant PA masses and could be peformed when PA masses appeared clinically malignant.

Case report: The diagnostic challenge of primary cardiac intimal sarcoma

Primary cardiac intimal sarcoma, an extremely rare cardiac tumor subtype, is often mis-diagnosed owing to its rarity and non-specific clinical and radiological features. We report a case of cardiac intimal sarcoma mimicking atrial myxoma in which the clinical presentation and multimodality imaging are described in detail, and diagnostic challenges are highlighted.

Pulmonary artery sarcoma masquerading as pulmonary embolism: an under-recognised entity

Pulmonary artery sarcoma is a rare disease with only a handful of cases reported. It is histologically classified as leiomyosarcoma, spindle cell sarcoma, fibrous histiocytoma or undifferentiated sarcoma. The disease is mostly misdiagnosed as pulmonary thromboembolism and carries a grim prognosis with an average survival of only a few months. Misdiagnosis often results in patients being treated inappropriately and diagnosed in later stages of the disease. This delay in diagnosis can be associated with significant mortality in the setting of an already poor prognosis. Early aggressive surgery targeting complete surgical resection is the standard treatment. Chemotherapy and radiation therapy have been tried with variable outcomes. Given the aggressive nature of pulmonary artery sarcoma, regular post-surgery follow-up is indicated.

Pulmonary artery intimal sarcoma: A rare cause of filling defects in pulmonary arteries

Pulmonary artery intimal sarcomas are very rare and arise from primitive pluripotent mesenchymal cells. They are often misdiagnosed as pulmonary thromboembolism, leading to futile anticoagulation treatment and delayed diagnosis. We present a case of a patient who showed nonspecific pulmonary symptoms and characteristic imaging manifestation. Progressive symptoms and additional imaging led to the suspicion of a pulmonary artery intimal sarcoma, which was finally confirmed by pathological biopsy. This case serves as a reminder to consider pulmonary artery intimal sarcomas in the differential diagnosis of patients with dyspnea and filling defects on computed tomography pulmonary angiography or contrast-enhanced computed tomography.

A 52-Year-Old Man With Chest Pain and Dyspnea

CASE PRESENTATION

A 52-year-old man came to the cardiac surgery clinic for pulmonary thromboendarterectomy (PTE) evaluation. He had initially appeared at an outside hospital 1 year earlier, with chest pain and shortness of breath. He had no known chronic conditions. A CT pulmonary angiogram (CTPA) at that time showed a filling defect at the bifurcation of the main pulmonary artery. A transthoracic echocardiogram revealed mild mitral valve regurgitation, but otherwise the results were normal. As he was hemodynamically stable and not hypoxemic, he was treated solely by anticoagulation. Despite adhering to prescribed apixaban, he developed progressive dyspnea and reduced exercise tolerance over the subsequent year. A repeat CTPA performed 12 months after the initial presentation showed a persistent filling defect at the level of the pulmonary artery bifurcation, with a new extension now completely occluding the right main pulmonary artery. A pulmonary angiogram confirmed this complete occlusion, and right heart catheterization revealed precapillary pulmonary hypertension, with a mean pulmonary artery pressure of 50 mm Hg. His anticoagulation was transitioned to enoxaparin for presumed apixaban treatment failure, and an investigation for hypercoagulable conditions was initiated. His lupus anticoagulant test result was positive, but he did not meet the criteria for antiphospholipid syndrome because he was negative for anticardiolipin and β2-glycoprotein antibodies. Assays for antithrombin III, protein C, prothrombin gene, and factor V Leiden mutations produced normal results.

Clinical Features and Outcomes of Pulmonary Artery Sarcoma

OBJECTIVES

A retrospective cohort study was designed to describe the clinical features and outcomes of pulmonary artery sarcoma (PAS).

METHODS

Twenty-two (22) consecutive patients diagnosed with PAS by pathological examination were enrolled and followed up until they died or until January 2020. The medical records were retrospectively reviewed to evaluate the clinical characteristics, image findings, and outcomes.

RESULTS

1) Twenty-one (21, 95.5%) patients were firstly misdiagnosed. Dyspnoea was the most common presenting symptom (19 of 22, 86.4%). 2) Filling defects in the right pulmonary artery were seen in 17 patients (77.3%) with computed tomography pulmonary angiography or magnetic resonance pulmonary angiography. Among those patients, 14 underwent positron emission tomography-computed tomography detection and 13 (92.9%) were found to have increased uptake value in the pulmonary artery. 3) The median survival (from diagnosis to death or January 2020) of the total series was 11.6 months (range, 0.7-68.5 months). The estimated cumulative survival rates at 1, 2, and 3 years were 52.6%, 32.8%, and 19.7%, respectively. Patients who received surgery and/or chemo-radiotherapy treatment had a better survival rate compared with patients without treatment (the estimated cumulative survival rates at 1, 2, and 3 years were 60.3%, 39.1%, and 29.3%, respectively, vs 33.3%, 16.6%, and 0, accordingly) and better survival time (median survival 17.02 vs 3.16 months, respectively) (p=0.025).

CONCLUSIONS

Pulmonary artery sarcoma is easily misdiagnosed, as the symptoms and routine image detection are nonspecific. Positron emission tomography-computed tomography may be helpful in diagnosis. Surgery and/or chemo-radiotherapy offer a chance for better outcomes.

Pulmonary angiosarcoma: A case report of surgical treatment

Pulmonary angiosarcoma (PAS) is a malignant tumor of the vascular wall of mesenchymal origin. PAS is rare and has unknown etiology and poor prognosis. Depending on the location, angiosarcoma can lead to serious obstructive and embolic complications, as well as severe pulmonary hypertension and right ventricular heart failure. Patients with PAS are often mistakenly diagnosed with pulmonary embolism, chronic thromboembolic pulmonary hypertension, or lung tumors. Here, we present a clinical case of combined treatment of PAS.

A 51-year-old man with chronic cough and left hilar prominence

A 51-year-old male in good overall health presented with a dry cough of 5 months' duration. He was working as a long-distance truck driver and was a life-long nonsmoker. He had no associated dyspnoea, wheezing, rhinosinusitis, haemoptysis or syncope, nor constitutional symptoms such as weight loss or fevers. Physical examination and vital signs were normal on presentation. Chest radiographs with posterior–anterior and lateral views are shown in figure 1.

What is the diagnosis of this man with a chronic dry cough and left hilar prominence on chest radiography?https://bit.ly/3fL7QMx

Radical surgery for recurrent pulmonary artery sarcoma with four-year survival

Primary pulmonary artery (PA) sarcoma (PAS) is a rare disease with poor prognosis. Radical resection provides the best curative chances. Our 60-year old male patient underwent PAS excision with pericardial patch repair of the main PA in 2017, but required reoperation in 2019 due to recurrence. Total PA bifurcation replacement was performed using a handmade two-limbed bovine pericardial tube graft, which has not previously been described in the literature. This technique is safe and reproducible, and may offer a valuable alternative surgical strategy for this patient cohort. Our patient is still alive four years after initial presentation.

Pulmonary artery intimal sarcoma - A primeval or rediscovered tumor? A report of 14 new cases with literature review

Pulmonary artery sarcomas (PAS) are rare with many being undifferentiated pleomorphic or spindle cell (UPSC) sarcomas with variable atypia. The term pulmonary artery intimal sarcoma (PAIS) was rarely coined in the early literature and sometimes used for luminal sarcomas. With the advent of immunohistochemistry and molecular genetics, many of these UPSC sarcomas were found to frequently overpress MDM2 and/or CDK4 and PDGFRA with genetic alterations in 12q12-15 and 4q12, where the MDM2, CDK4 and PDGFRA genes are located. These recent developments enabled refinement in diagnosis of PAIS. We diagnosed 14 cases of PAIS (6 males and 8 females, mean age 44 years) in 2015 - 2020 in our institution. Six were initially misdiagnosed as thromboembolism and the remaining pulmonary artery tumors. The tumors were pulmonary artery intraluminal polypoid masses with histology of spindle cell sarcomas exhibiting immunohistochemical positivity for MDM2 (100%) and CDK4 (79%) with MDM2 gene amplification (100%). Ten surgically treated patients fared better than four other biopsy only and not surgically treated patients, who died of disease within 5-11 months. PAIS needs to be differentiated from other spindle cell tumors and those exhibiting MDM2 gene amplification, especially dedifferentiated liposarcoma. The use of biopsy to provide diagnostic material poses a sampling error problem and correlation with clinical, radiologic, histologic, immunophenotypic and genotypic features are essential for accurate diagnosis and early surgical intervention of PAIS.

Pulmonary Artery Intimal Sarcoma Diagnosed Preoperatively by Endovascular Biopsy and Treated via Right Pneumonectomy and Pulmonary Arterioplasty

Introduction. Intimal sarcoma is a very rare tumor arising within the intima of the pulmonary artery. Preoperative diagnosis of pulmonary artery sarcoma is difficult, and the tumor is sometimes misdiagnosed as pulmonary thromboembolism. We report a case of pulmonary artery intimal sarcoma successfully diagnosed by preoperative endovascular biopsy and treated via right pneumonectomy and pulmonary arterioplasty. Presentation of a Case. A 72-year-old woman was referred to our hospital with a low-attenuation defect in the lumen of the right main pulmonary artery by computed tomography. Pulmonary artery thromboembolism was suspected, and anticoagulation therapy was administered. However, the defect in the pulmonary artery did not improve. Endovascular catheter aspiration biopsy was performed. Histological examination revealed pulmonary artery sarcoma. The patient was treated with right pneumonectomy and arterioplasty with the use of cardiopulmonary bypass. Discussion. Preoperative biopsy by endovascular catheter is worth considering for a patient with a tumor in the pulmonary artery and can help in planning treatment strategies.

Intimal Sarcoma of the Great Vessels

Intimal sarcomas of the pulmonary artery and aorta are rare entities with a poor prognosis. In many instances, pulmonary artery sarcomas are misinterpreted as acute or chronic pulmonary thromboembolism, whereas aortic intimal sarcomas are often misdiagnosed as protuberant atherosclerotic disease or intimal thrombus. Discernment of intimal sarcomas from these and other common benign entities is essential for the timely initiation of aggressive therapy. The most useful imaging modalities for assessment of a suspected intimal sarcoma include CT angiography, fluorine 18-fluorodeoxyglucose PET, and MRI. The authors discuss the clinical features, current treatment options, characteristic imaging findings, and underlying pathologic features of intimal sarcomas. The authors emphasize imaging discernment of intimal sarcomas and how their differential diagnosis is informed by knowledge of radiologic-pathologic correlation. The most reliable distinguishing imaging features are also emphasized to improve accurate and timely diagnosis. Online supplemental material is available for this article. ^©RSNA, 2021.