Chondrosarcoma

Acute arterial occlusive disease due to tumor thrombus from lung metastasis of breast cancer with cartilaginous and osseous metaplasia: a case report

BACKGROUND

Tumor embolization due to venous infiltration of breast cancer pulmonary metastases is very rare.

CASE PRESENTATION

A 72-year-old female was diagnosed with triple-negative breast cancer. Neoadjuvant chemotherapy was discontinued because of progressive disease, and a right mastectomy with sentinel lymph node biopsy was performed. The pathological analysis of surgical specimens revealed carcinoma with cartilaginous and/or osseous metaplasia. At 22 months after surgery, lung metastasis was observed, and 6 months after initiating treatment for lung metastases, she complained of sudden numbness in the left-lower limb with trouble walking. Ultrasonography showed an embolism in the left popliteal artery, and contrast computed tomography showed enlarged lung metastases and infiltration of the left-upper lobe disease into the left superior pulmonary vein and left atrium. Acute arterial occlusive disease in the left-lower limb caused by the tumor embolism was suspected, so an endovascular thrombectomy was performed. Tumor emboli were removed by embolectomy catheter.

CONCLUSION

This report of lung metastasis from breast cancer with cartilaginous and/or osseous metaplasia and acute lower-limb artery occlusion due to a tumor thrombus adds useful information to the literature on these extremely rare cases.

Metastasectomy of left atrial mesenchymal chondrosarcoma

Metastasis of chondrosarcoma of skeletal origin to the heart is uncommonly reported in the literature, with the majority of cases involving right atrial metastases. Surgical resection remains the mainstay of treatment, and the literature has shown improved median survival with this form of therapy, possibly by reducing thromboembolic risk in this patient population. We report the case of a patient with metastatic mesenchymal chondrosarcoma of the left atrium who underwent resection, following a lack of response to anticoagulation therapy. This is the first report of surgical resection of left atrial metastatic disease prior to the onset of thromboembolic sequelae.

Neoplastic embolization to systemic and pulmonary arteries

OBJECTIVE

Arterial neoplastic emboli are uncommon, accounting for <1% of thromboemboli in the current literature. Nonetheless, this event may be associated with significant morbidity and mortality. Herein, we report a series of 11 cases of arterial neoplastic emboli from a single tertiary care center along with a comprehensive review of the literature to date. The aim of this study was to document the incidence, clinical presentations, and complications of arterial neoplastic emboli as well as to highlight the importance of routine histologic examination of thrombectomy specimens.

METHODS

Pathology archives from a single tertiary care institution were queried to identify cases of surgically resected arterial emboli containing neoplasm (1998-2014). Histopathology was reviewed for confirmation of diagnosis. Patient demographics and oncologic history were abstracted from the medical record. Comprehensive literature review documented 332 patients in 275 reports (1930-2016).

RESULTS

Eleven patients (six men) with a median age of 63 years (interquartile range, 42-71 years) were identified through institutional archives. Embolism was the primary form of diagnosis in seven (64%) cases. Cardiac involvement (primary or metastasis) was present in more than half of the cohort. Comprehensive literature review revealed that pulmonary primaries were the most common anatomic origin of arterial neoplastic emboli, followed by gastrointestinal neoplasia. Cardiac involvement was present in 18% of patients, and sentinel identification of neoplasia occurred in 30% of cases. Postmortem evaluation was the primary means of diagnosis in 27%.

CONCLUSIONS

This study highlights the importance of routine histopathologic evaluation of embolectomy specimens in patients with and without documented neoplasia.

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.

Metastatic meningioma extending into the left atrium through the pulmonary vein

Left atrial extension of pulmonary tumors through the pulmonary vein is most often associated with primary malignancies and is rarely associated with metastatic disease. We present the first, to our knowledge, reported case of a patient with a history of intracranial meningioma resections presenting with metastatic meningioma to the right lower lobe with extension into the left atrium through the pulmonary vein.

Pulmonary metastatic chondrosarcoma with massive extension into left atrium and left ventricle: outcome of surgical management in emergency

We report a case of metastatic chondrosarcoma to the lung that invaded the right inferior pulmonary vein with massive cardiac extension and presented with an acute heart failure. CT scan showed a large mass of the right lower lobe which invaded and filled almost all the left atrium with an extension into left ventricle through the mitral valve. Surgical resection was performed in emergency. The patient is still alive 4 months after development of cardiac symptoms and surgery.

Left atrial extension of metastatic lung tumor via pulmonary vein: report on the first case of Ewing sarcoma

Extension of metastatic lung tumors into the left atrium via pulmonary veins is rare. Here, we report the first case of Ewing sarcoma exhibiting such extension. A 31-year-old man with pulmonary metastasis from Ewing sarcoma presented with a mass in the left lung, extending to the left atrium through the left inferior pulmonary vein. As the patient was considered to be at risk of tumor embolism, the mass was excised surgically.

Cardiac intracavitary metastasis of a malignant solitary fibrous tumor: case report and review of the literature on sarcomas with left intracavitary extension

BACKGROUND

Solitary fibrous tumor (SFT) of the pleura with malignant progression occurs uncommonly. Cardiac intracavitary extension of tumors is rarely seen, with left side location being exceptional.

METHODS AND RESULTS

The authors report the first case of a malignant SFT metastatic to the heart occurring in a 74-year-old woman. The tumor first presented as a slow-growing pleural SFT that in 6 years reached a size of 16 cm. Two months after a complete surgical resection, the tumor was found to spread to the left atrium by intracavitary extension from the left upper pulmonary vein, simulating a cardiac myxoma. The primary tumor showed established features of malignancy including size greater than 10 cm; gross findings of necrosis; high cellularity, cytological atypia, and eight mitoses per 10 high-power fields. Immunohistochemical study revealed positivity of the tumor cells for CD34, bcl-2, and CD99. Aside from the present report, 52 previous cases of sarcoma with intracavitary extension to the left side of the heart have been described. Bone sarcoma is the type most frequently found. Peripheral arterial embolism can be a complication of advanced mesenchymal malignancy in 21% (11/53) of reported cases.

CONCLUSION

Accurate histopathologic recognition of this rare type of metastatic disease is important because of the adverse prognosis as compared to cardiac myxoma.

Chondrosarcoma, lupus anticoagulant and cerebral ischaemia

Chondrosarcoma is a malignant disease of cartilage. Systemic embolisation usually arises from cancerous invasion of pulmonary vessels or the left atrium but cerebral embolisation or ischaemia is rarely recognised. We report a man with left leg amputation for tibial myxoid chondrosarcoma who suffered multiple cerebral embolisms one year later. Cerebral angiography and aortogram did not reveal luminal stenosis and a cardiac survey was normal. Lupus anticoagulant (LAC) and a prolonged activated partial thromboplastin time were detected. A molecular mimicry between prothrombin and paracrine hormones may have accounted for his LAC. A procoagulant autoantibody reacting against metastatic cancer cells may contribute to cancerous thrombosis, such as in chondrosarcoma.

Massive cardiac chondroma presenting with heart failure and superior vena cava obstruction in a teenage boy

Histologically benign soft-tissue chondromas have been reported at many anatomical sites but are an uncommon cause of soft tissue mass lesions in childhood, accounting for less than 1% of cases. The most frequent sites for extraosseous soft-tissue chondromas are the hands and feet. For the extremely rare visceral chondromas, the site can be lung, where they may represent a component of Carney's syndrome of extra-adrenal paraganglioma, pulmonary chondroma, and epithelioid leiomyosarcoma of the gastrointestinal tract. Primary cardiac chondromas are exceptionally rare in patients of any age although cardiac chondrosarcoma, both primary and metastatic, is well reported. We present a case of a teenage boy with a fatal cardiac chondroma

Tumor embolus: a case report and review of the literature

Peripheral embolization of macroscopic tumor fragments is an uncommon occurrence. A patient with a previously undiagnosed primary lung adenocarcinoma who presented with an acutely ischemic limb is described. Following review of the literature, the characteristics of tumor embolization are discussed.

Metastatic chondrosarcoma to the lung with extension into the left atrium via invasion of the pulmonary veins: presentation as embolic cerebral infarction

We present a case of metastatic chondrosarcoma to the lungs that invaded the left inferior pulmonary vein, extended into the left atrium and presented with an embolic cerebral infarct. CT findings included a large mass in the left lower lobe associated with enlargement of the left inferior pulmonary vein and a lobular filling defect in the left atrium. Systemic arterial embolization and obstruction of the mitral valve may be prominent features of pulmonary tumors that have invaded the pulmonary veins.

Cardiac myxoma with chondroid features

We report a case of a cardiac myxoma with cartilaginous differentiation. Cardiac myxomas are the most common primary neoplasms of the heart. The cell of origin is thought to be a pluripotential cell called the "myxoma cell," which is capable of differentiating towards various tissues, including endothelial, epithelial, and smooth muscle; however, cartilaginous differentiation is so uncommon that other entities such as metastatic chondrosarcomas must be considered in the differential diagnosis. These entities are discussed along with the radiologic-pathologic correlation.

Operative strategies for resection of pulmonary sarcomas extending into the left atrium

Pulmonary sarcomas may extend into the left atrium through the pulmonary veins, requiring the use of cardiopulmonary bypass for resection. The operative strategy for these complicated resections must account for the laterality of the tumor, the extent of atrial involvement, the severity of local invasion within the hemithorax, and intrinsic surgical heart disease, if present. We discuss these issues using an illustrative case of a patient with a right pulmonary sarcoma extending from the lateral chest wall into the left atrium.

Pulmonary vein thrombosis

Pulmonary vein thrombosis is difficult to diagnose clinically and requires a combination of conventional diagnostic modalities. Transesophageal echocardiography was used in the present case to readily diagnose this entity and follow thrombus regression on anticoagulant therapy. This limited experience suggests that transesophageal echocardiography may be the initial diagnostic study of choice for pulmonary vein thrombosis.

Malignant arterial tumor embolization

Malignant arterial tumor emboli large enough to cause ischemia or organ infarction are a rare, but often fatal, complication of neoplastic disease. The majority of arterial emboli are associated with primary or secondary pulmonary malignancies. The sites where they impact are similar in distribution to arteriosclerotic emboli, and the treatment follows well-established principles developed for the treatment of arteriosclerotic emboli. The results of embolectomy in accessible sites are very good, thus treatment should always be attempted. A case of a superior mesenteric tumor embolus occurring after pneumonectomy is reported, together with a review of all published cases of arterial tumor emboli of sufficient size to cause organ infarction or ischemia.

Chondrosarcoma metastatic to the heart

This review summarizes the clinical manifestations and results of treatment of chondrosarcoma metastatic to the heart. Including the patient in the present report, a total of 18 patients have been reported. The most common site of cardiac metastasis was the right atrium. Dyspnea and pleuritic chest pain were the most common symptoms associated with cardiac metastases. The median time from the initial diagnosis of primary chondrosarcoma to death was 36 months, and the median time from the initiation of cardiac symptoms to death was 2 months. Treatment of primary chondrosarcoma included local radical resection in 14 patients. Treatment of cardiac metastases consisted of palliative support in 13 patients and surgical resection in 5 patients. Median survival following the development of cardiac symptoms was 2 months for patients treated nonsurgically and 18 months for those who underwent resection of cardiac metastases. The longest survival (24 and 28 months) was obtained in 2 patients with metastases confined to the heart that were successfully resected soon after development of cardiac symptoms. These results suggest that surgical resection of cardiac metastases in patients without widespread other metastases can result in substantial prolongation of life.

Left atrial metastasis presenting as recurrent embolic strokes

Tumour emboli from an endocardial metastasis of an endometrial stromal sarcoma caused recurrent and ultimately fatal strokes in a woman of 40. Endocardial metastases are rare. They are known to embolise to the pulmonary and systemic arteries but not to cause recurrent cerebral emboli.

Pulmonary vein tumor thrombosis and left atrial extension in lung carcinoma

A case of lung carcinoma extending into left atrium through a pulmonary vein and mimicking left atrial myxoma is presented. The localized enlargement of a pulmonary vein is seen as a possible CT sign of pulmonary vein tumor thrombosis. Computed tomography (CT) and echocardiography are complementary in the correct diagnosis of this condition.

Surgical implications in malignant cardiac disease

Despite the rarity of primary malignant tumors of the heart (0.0017 to 0.03% of large postmortem series) and the infrequency of clinical signs and symptoms (0 to 50%) of the more common metastatic cardiac tumors, many cardiothoracic surgeons at some time will encounter a patient with one of these two conditions. A review of the medical literature yielded 28 cases of primary cardiac tumors, 10 of secondary tumors, and 12 of carcinoid heart disease treated surgically and followed sufficiently for retrospective evaluation. We summarized those cases and made the following conclusions. Primary malignant tumors of the heart are occasionally resectable, although cure is unlikely; survival may be enhanced by postoperative irradiation but probably not by postoperative chemotherapy. For patients with secondary malignant tumors of the heart, surgical intervention is rarely of benefit except for establishing a tissue diagnosis, effecting artificial cardiac pacing, decompressing symptomatic pericardial effusions, or reducing an obstructive tumor mass. Patients with carcinoid heart disease affecting the valves may derive benefit from valve replacement or repair. Thus, in selected patients with malignant cardiac disease, surgical intervention may be feasible and should always be among the therapeutic options considered.

Metastatic periosteal osteosarcoma causing cardiac and renal failure

The case of a 25-year-old man who had periosteal osteogenic sarcoma with intravascular metastases in unusual locations is reported. The patient presented with acute renal failure, unilateral pulmonary edema, functional mitral stenosis, and low cardiac output. After successful surgical removal of a left atrial metastasis with subsequent improvement in cardiac output, renal function improved only transiently and urinary output varied markedly. At autopsy, metastatic osteogenic sarcoma was discovered within the lumen of the abdominal aorta obstructing both renal arteries. The case is the first report of a neoplasm metastatic to the aorta causing intermittent bilateral renal arterial obstruction; it illustrates the diagnostic difficulties presented by intravascular metastatic disease.

Cardiac myxoma with chondroid features: a light and electron microscopic study

The first case of a cardiac myxoma exhibiting chondroid differentiation is described. The tumor showed lacunar spaces around clusters of typical myxoma cells on light microscopy. Ultrastructurally the tumor cells contained abundant glycogen, and the tumor stroma contained proteoglycan granules identical to those seen in the ground substance of cartilage. These findings lend further support to the belief that the primitive mesenchymal cell is the cell of origin in cardiac myxoma.

Latent pulmonary embolus from a retroperitoneal sarcoma

A 52-year-old female presented with an extensive retroperitoneal sarcoma and intraluminal inferior vena caval extension. Presumably during resection, embolization of a tumor fragment occurred to the right pulmonary hilum. The patient was asymptomatic for 16 months until a right hilar mass developed on a follow-up chest x-ray. Pathological examination of the gross and microscopic sections of the pneumonectomy specimen confirmed the intra-arterial location of the tumor mass. Widespread systemic metastasis became evident soon after pneumonectomy.

Pulmonary metastatic chondrosarcoma with intracardiac extension

An unusual case of pulmonary metastatic chondrosarcoma with intracardiac extension is presented. Echocardiography and right heart catheterization with pulmonary angiography demonstrated that resection using cardiopulmonary bypass was possible in a situation initially considered to be inoperable.