Primary sarcoma of pulmonary artery and valve: multimodality treatment by chemotherapy and homograft replacement

Primary angiosarcoma of aorta: A systematic review

PURPOSE

To elucidate the epidemiology, anatomical, presentation, classification, pathology, investigative modalities, management and prognosis of primary angiosarcoma of the aorta.

MATERIAL AND METHODS

A systematic review of literature from the database inception to January 2021 in PubMed and Embase, CINAHL and Cochrane Library in accordance to PRISMA was conducted. Retrieval and extraction was performed by two independent reviewers. The hierarchy of the evidence was assessed through the National Institute for Health and Care Excellence Checklist. Data were subjected to pooled prevalence analysis, Kaplan-Meier survival and test of probability using log-rank analysis. This review is registered with International Prospective Register of Systematic Reviews: RD42021231314.

RESULTS

82 studies with n = 123 cases met the inclusion criterion. Abdominal (45%) aorta was the commonest anatomical site with female predominance in ascending aorta (4:1) and aortic arch (2:1). The longest survival was in the ascending aorta and the shortest in the abdominal aorta [540 (interquartile range [IQR], 7-1560 days vs. 180 (IQR, 1-5730 days)], respectively. The overall median survival was 210 days (IQR, 1-5730 days) or 7 months. Lack of metastasis (47%) was a marker of longer survival (p < 0.03) irrespective of other attributes.

CONCLUSION

The pathophysiology appears to be a trend of increasing fatigue, fever and weight loss associated with segmental dysfunction of the aorta projecting occlusive or destructive phenotypes. Computed tomography angiography features of volume-occupying, bulky, polypoid (intraluminal), protrusive vegetation, hyper vascular without atherosclerotic lesions are extremely suggestive of PA of the aorta at 5th and 6th decades of life.

Primary pulmonary angiosarcoma: case reports and review of the literature

Pulmonary artery angiosarcoma is a rare malignant vascular tumor with an aggressive clinical course and a poor prognosis. Hemoptysis and shortness of breath have been reported as common clinical presentations. The exact clinicopathology is unknown. A tissue specimen obtained by percutaneous fine-needle aspiration cytology or open/thoracoscopic biopsy can confirm the diagnosis based on histopathological and immunohistochemical features. The differential diagnosis includes pulmonary thromboembolism, vascular malformations, and lung carcinoma. There is a paucity of literature describing this tumor, with only a few case reports available. There is also a lack of standardized guidelines for management, which further worsens the survival outcome. We report 3 cases of pulmonary artery angiosarcoma and review the recent literature.

Pulmonary artery sarcoma mimicking pulmonary embolism: a case series

BACKGROUND

Pulmonary artery sarcoma (PAS) is a rare malignant neoplasm with an aggressive behavior and often difficult to distinguish from pulmonary thromboembolic disease.

AIM

To assess the demographic, clinical, and radiological characteristics of PAS and clinical course.

DESIGN AND METHODS

We retrospectively identified and analyzed all patients with PAS seen at Mayo Clinic in Rochester, Minnesota, between January 1, 1996 and July 31, 2015.

RESULTS

Of nine patients (5 women and 4 men; median age 55 years [range, 24-74 years]), eight were diagnosed while alive with surgical ( n  = 6) or catheter-based endovascular biopsy ( n  = 2); the remaining patient was diagnosed at postmortem examination. All tumors manifested on CT as filling defect in the main, right or left pulmonary artery and were not associated with peripheral filling defects in seven patients. Seven patients were initially treated with anticoagulant therapy for presumed PE; two patients were suspected to have tumor based on constrictive or expanding effect seen on CT. Five patients died after a mean duration of 2.1 years (10 months-4.25 years) after diagnosis. Two patients are alive with recurrence and metastases of the disease 23 and 27 months after diagnosis, respectively; one remaining patient is alive and disease-free 116 months after diagnosis.

CONCLUSIONS

Although PAS is associated with a poor prognosis, long-term survival is possible and can be improved by early diagnosis and prompt surgical resection. Atypical appearance on CT including central mass-like lesion without peripheral emboli and constrictive or expanding effect should raise suspicion of PAS.

Primary pulmonary artery sarcoma: a close associate of pulmonary embolism-20-year observational analysis

BACKGROUND

Primary pulmonary artery sarcoma (PPAS) is a rare tumor that mimics pulmonary thromboembolism (PE). Similarities to PE can delay the diagnosis and misguide the treatment of PPAS. This study aimed to evaluate tumor characteristics and outcome predictors among those diagnosed with PPAS and misdiagnosed as PE.

METHODS

From 1991-2010, 10 PPAS cases were available from the Cleveland Clinic (CC) institutional database and another 381 cases were reported in the literature. Patient characteristics, tumor subtypes, diagnostic testing & timing, interventions and clinical outcomes were analyzed. We also noted effects of misdiagnosis as PE and clinical outcome as a result of inappropriate intervention.

RESULTS

Among 391 confirmed cases of PPAS, the mean age at diagnosis was 52±14 years; 55% were male. The median duration of symptoms prior to diagnosis was 100 [interquartile range (IQR), 30-210] days. Nearly half (47%) of PPAS were originally misdiagnosed as PE including 39% that received thrombolytic and/or anticoagulation therapy. For every doubling of time from symptom onset to diagnosis, the odds of death increased by 46% (OR: 1.46, 95% CI: 1.21-1.82; P<0.001). The odds of death (OR: 2.66, 95% CI: 1.58-4.54; P=0.0003) and occurrence of distant metastasis (OR: 2.30, 95% CI: 1.30-4.15; P=0.049) were increased among those who did not receive chemotherapy but chemotherapy did not impact local recurrence. Those with complete resection had a better survival.

CONCLUSIONS

PPAS has a radiological appearance similar to PE, which makes accurate and timely diagnosis challenging. More rapid diagnosis may lead to earlier, appropriate surgical treatment and improved outcomes, when combined with adjuvant treatment.

A Case of Angiosarcoma Arising in Trunk of the Right Pulmonary Artery Clinically Simulating Pulmonary Thromboembolism

Angiosarcoma arising in the pulmonary artery is extremely rare. We herein report a case of angiosarcoma arising in the pulmonary artery trunk of 71 year-old woman. This case was clinically diagnosed as pulmonary thromboembolism but angiosarcoma of the pulmonary artery should be considered as the differential diagnosis of unusual clinical manifestations of pulmonary thromboembolism because of the extremely poor prognosis of the lesion.

Pulmonary artery leiomyosarcoma successfully treated by right pneumonectomy

A 79-year-old woman had a primary tumor of the pulmonary artery, which was initially diagnosed as chronic pulmonary thromboembolism. Multislice angio-computed tomography showed a solid mass in the right pulmonary artery. Radical resection of the tumor was achieved by right pneumonectomy via a transsternal transpericardial approach. The patient was alive and free of disease 36 months after surgery.

Management of primary pulmonary artery sarcomas

The objective of this review is to determine the outcome of patients with sarcomas involving the main pulmonary artery, pulmonic valve, or right ventricular outflow tract. Survival data were analyzed using an aggregate series derived from the published literature in conjunction with a current series. Median survival was 36.5 +/- 20.2 months for patients undergoing an attempt at curative resection compared with 11 +/- 3 months for those undergoing incomplete resection. Median survival was 24.7 +/- 8.5 months for patients undergoing multimodality treatment compared with 8.0 +/- 1.7 months for patients having single-modality therapy. A complete review of diagnosis, evaluation, treatment, and surveillance of primary pulmonary artery sarcomas follows.

Primary malignant sarcomas of the heart and great vessels in adult patients--a single-center experience

BACKGROUND

Sarcomas arising in the heart or the great vessels are rare entities. The prognosis of the patients is dismal.

METHODS

Between January 1993 and September 2006, of 1,429 patients registered to the Sarcoma Center, 14 had a primary sarcoma of the heart or large vessels.

RESULTS

Tumors were located in the left ventricle (n = 3), left/right atrium (n = 2/3), pulmonary artery (n = 2), and ventricular septum, aorta, pericardium, and inferior vena cava (n = 1 each). The most frequently encountered histologic subtypes were leiomyosarcoma and angiosarcoma. Six patients presented with distant metastases to the lungs (n = 5), lymph nodes (n = 2), and liver (n = 1). Eight patients had localized disease. Six of them underwent resection with curative intent. Of those, two developed local recurrence within 2 and 10 months from surgery. Eleven patients received palliative chemotherapy, seven of those as initial treatment. Eight patients attained a response to treatment, two had disease stabilization for 6 and 12 months. After a median follow-up of 14.5 months (range, 2-156), three patients were alive with no evidence of disease 11, 52, and 156 months after diagnosis. Two patients were alive with disease and nine patients had died.

CONCLUSIONS

Patients with primary sarcomas of the heart and the large vessels were of a young age, and more than half of them presented with advanced disease. Given the promising response to chemotherapy, an optimized treatment approach including neoadjuvant chemo-/radiotherapy in patients with locally advanced disease should be pursued.

Pulmonary artery angiosarcoma: a clinicopathologic and radiological correlation

A 69-year-old man presented with cough, shortness of breath, and fatigue. He was initially treated for allergies and then for pulmonary embolism. Radiologically, a tumor mass was found to occlude the right pulmonary artery and involve the pulmonary trunk. A right pneumonectomy was performed. Histologically, a cellular malignant spindle and epithelioid tumor with areas of necrosis and brisk mitotic activity was seen. In some areas, the tumor appeared to form vascular channels. Focal osteosarcomatous differentiation was present. Immunohistochemical studies were performed including vimentin, smooth muscle actin, desmin, CD31, CD34, S100, and pan-cytokeratin. The tumor cells were positive for CD31 and vimentin and negative for pan-cytokeratin, CD34, and S100. Two months after surgery, the patient was alive and well.

Intimal sarcoma of the pulmonary artery: Report of an autopsy case

Primary pulmonary artery sarcomas (PASs) are rare and lethal tumors. They are easily misdiagnosed as chronic pulmonary embolism, mediastinal mass or tumor emboli, which delay a proper treatment. Although the advanced technologies are now increasingly being used, their diagnosis is usually hard to establish preoperatively at the present time. We report here a case of a 68-year-old female with PAS with lung metastases, who firstly presented with symptoms of common cold and anemia. Although a PAS had been suspected, the final diagnosis of pulmonary intimal sarcoma was made only postoperatively by histological and immunohistochemical examination. The patient died 8 months after the operation because of tumor growth progression, despite adjuvant chemotherapy and radiation therapy. Although pulmonary intimal sarcomas are usually of poorly differentiated mesenchymal malignancy, most reported cases are immunohistochemically positive for vimentin, alpha-smooth muscle actin (SMA), and/or desmin, therefore resembling leiomyosarcomas. However, the diagnosis of leiomyosarcoma should not be made on the basis of immunostains in the absence of typical morphologic features, and PAS, like the present case, should be more appropriately classified as intimal sarcoma according to the new WHO Classification of Tumours of Soft Tissue and Bone published in 2002.

Surgical treatment for primary cardiac leiomyosarcoma causing right ventricular outflow obstruction

A 55-year-old man was admitted to another hospital because of dry cough and dyspnea that rapidly worsened before admission. Chest computed tomography revealed a low-density mass that nearly obstructed the main pulmonary arterial trunk. Pulmonary thromboembolism was suspected and treated with catheter-directed thrombolysis therapy. Despite optimal thrombolysis and anticoagulant therapy, his symptoms persisted. He was referred for further examination and possible surgery for presumed pulmonary thromboembolism. The mass appeared more likely to be a tumor than a thrombus on careful analysis of the magnetic resonance imaging. At surgery, the anterior wall of the main pulmonary arterial trunk, the pulmonary valve, annulus, and the right ventricular outflow tract were all invaded by what was found to be a tumor and were resected under conventional cardiopulmonary bypass. The resected area was reconstructed with a 25-mm-diameter bioprosthetic valve and Xenomedica patch. Final pathological diagnosis was primary cardiac leiomyosarcoma involving the pulmonary valve. Postoperative course was uneventful, and he was discharged 11 days after surgery without adjuvant therapy because he refused it. Ten months later, the patient was well, but a chest X-ray revealed some coin lesions in the bilateral lung fields that were thought to be metastatic tumor.

Cardiac Angiosarcoma Arising From Pulmonary Artery: Endovascular Treatment

We report a case of unusual origin of cardiac angiosarcoma rising from the pulmonary trunk. The tumor caused severe obstruction of the right ventricular outflow tract with serious symptoms of right ventricular failure and tricuspid insufficiency. The angiosarcoma was surgically unresectable because of infiltration of the pulmonary artery and cardiac structures. To relieve the patient's symptoms we chose an endovascular stent treatment to dilate the right ventricular outflow tract obstruction. Consequently this palliative treatment changed the short-term prognosis of the patient, improving his quality of life, and at 6 months follow-up he remains asymptomatic.

Right ventricular outflow tract reconstruction for primary pulmonary artery sarcoma

Primary pulmonary artery sarcoma is extremely rare and a lethal tumor. Complete resection of the tumor and following adequate reconstruction is the only hope for cure and prolonged survival. We report a case of successful surgical excision of primary pulmonary artery sarcoma involving pulmonary trunk, pulmonary valve and right ventricular outflow tract wall, which were replaced with prosthetic valved conduit. Postoperative histopathological diagnosis was leiomyosarcoma. The patient is well without any evidence of recurrence at 10 months after surgery.

Surgical treatment of primary pulmonary artery tumor

We report two cases of rare primary pulmonary artery (PA) tumor. Case 1 was a 65-year-old man with malignant fibrous histiocytoma which caused severe stenosis over the main PA and right PA. Case 2 was a 49-year-old woman with leiomyosarcoma which caused severe stenosis from the right ventricular outflow tract (RVOT) to the main PA. Both cases underwent endarterectomy, tumor resection, and PA reconstruction under cardiopulmonary bypass. The symptoms of right heart failure improved postoperatively. Tumor recurrences were however recognized in both cases in the early postoperative period, and both patients died of the disease 12 (case 1) and 21 (case 2) months after operation respectively. Tumor resection by endarterectomy techniques may be incomplete because of frequent local recurrence. Postoperative adjuvant therapy in addition to radical resection and reconstruction of the PA and tumor might increase the length of survival.

Heart Leiomyosarcoma Mimicking Pulmonary Thromboembolism

A 34-year-old man was admitted with a putative diagnosis of pulmonary artery trunk thromboembolism. Magnetic resonance imaging and angiography showed a solid mass extending from the pulmonary trunk to the right pulmonary artery. During surgery, a tumor was found arising from the pulmonary valve annulus. The tumor was completely removed and pulmonary valvuloplasty was performed. The result was satisfactory. Histopathology showed the tumor to be a leiomyosarcoma.

Surgical treatment of pulmonary artery sarcoma

OBJECTIVE

Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delayed in most cases. Newer imaging techniques could allow early diagnosis in patients with symptoms of pulmonary vascular obstruction. Surgical resection improves clinical symptoms and offers the only chance of cure. We report the case histories of 7 patients with primary pulmonary artery sarcomas treated by surgical resection with or without adjuvant therapy.

METHODS

Seven patients (3 women and 4 men; mean age, 52.3 years; preoperative New York Heart Association functional class III/IV, n = 5/2) underwent operations. Malignancy was preoperatively suspected in 5 patients, and 2 patients had a presumptive diagnosis of chronic pulmonary embolism. Tumor resection with partial or total prosthetic replacement (n = 2), reconstruction (n = 5), or both, of central parts of the pulmonary arteries was performed in 6 patients. Thromboendarterectomy was necessary in 4 patients, and pneumonectomy was necessary in 2 patients. Six patients received adjuvant therapy.

RESULTS

There was no perioperative mortality. All patients had a substantial improvement in exercise tolerance and hemodynamics 3 months after their operations. Four patients died 7, 9, 18, and 19 months after their operations because of recurrent tumor or pulmonary metastases. Two patients are alive 21 and 35 months after primary surgical repair, with pulmonary metastases detected by computed tomographic scans. One patient is alive 62 months after resection without clinical or radiologic signs of tumor recurrence or metastasis.

CONCLUSIONS

Early diagnosis of primary pulmonary artery sarcomas can be improved by computed tomography and magnetic resonance scanning. Radical surgical resection probably presents the only chance for cure. The role of neoadjuvant or adjuvant treatment modalities has to be defined. Pulmonary artery sarcoma need not necessarily be a fatal diagnosis.

Primary leiomyosarcoma of the pulmonary artery mimicking massive pulmonary thromboembolism

A 57-year-old man with dyspnea and dry cough exhibited pulmonary embolism. Pulmonary arteriography demonstrated absent perfusion of the left main and the right upper and middle lobe pulmonary arteries. A diagnosis of chronic pulmonary thromboembolism was assumed and surgical thromboendarterectomy was attempted under standard cardiopulmonary bypass. At operation, a tumor had invaded far into both the right and left pulmonary arteries and radical resection was impossible. The final pathological diagnosis was primary leiomyosarcoma of the pulmonary artery. The patient refused any adjuvant therapy and died 63 days after the surgery. The clinical presentation of this case was similar to that of pulmonary thromboembolism and its diagnosis and treatment were very difficult.

Complete resection of cardiac leiomyosarcoma extending into the pulmonary trunk and right pulmonary artery

A cardiac leimyosarcoma is an extremely rare tumor. We report a case of complete resection of a cardiac leiomyosarcoma extending into the pulmonary trunk and the right pulmonary artery using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, MN) and Xenomedica graft (Baxter Healthcare Corp, Horw, Switzerland). Extensive resection and reconstructive surgery with the addition of radiotherapy prolonged the patient's life.

Metastatic cardiac angiosarcoma of the cervical spine. Case report

STUDY DESIGN

A case report of metastatic cardiac angiosarcoma of the cervical spine.

OBJECTIVES

To show that this rare spine tumor behaves in the same manner as an arteriovenous malformation and embolization, which can allow for successful spine surgery, and to discuss the natural history and rarity of this tumor.

SUMMARY OF BACKGROUND DATA

Primary angiosarcoma of the heart is a very rare tumor, with fewer than 200 reports in the English literature and nothing reported in the spine literature.

RESULTS

The patient in this study initially sought treatment for neck pain, left arm pain, and weakness 17 months after cardiac surgery and subsequent chemotherapy. A cervical computed tomography scan demonstrated a C5 lytic vertebral body tumor with intracannilicular extension and cord compression. An anterior cervical approach was made, but the tumor was too vascular to resect, and surgery was aborted. The C5 vascular vertebral body metastasis subsequently was embolized successfully by an interventional neuroradiologist. Reoperation via an anterior approach with corpectomy, cadaveric fibula, and anterior locking plate internal fixation was successful, producing marked improvement in the patients' symptoms.

CONCLUSION

Spinal involvement by primary cardiac angiosarcoma is very rare, and this is only the second operative case ever reported. The vascular nature of this tumor makes it behave in a manner similar to that of a high-flow arteriovenous malformation. Surgery should not be undertaken before preoperative angiography and embolization. The dismal prognosis for this rare malignancy is discussed.

Primary leiomyosarcoma of the left atrium

A 69-year-old woman with symptoms of congestive heart failure had a left atrial leiomyosarcoma, an extremely rare cardiac tumor, which obstructed the mitral valve and pulmonary veins. Surgical resection was performed, but no other adjuvant therapy was administered because the patient refused it. Recurrence of the tumor occurred soon after surgery and the patient died 81 days postoperatively.

Primary pulmonary artery sarcoma

A 66-year-old woman with a history of mitral valve replacement with a Starr-Edwards ball valve 25 years ago was treated for refractory heart failure but died of right heart failure. At autopsy, primary pulmonary artery sarcoma was found in the right ventricular outflow tract, main pulmonary trunk, and bilateral pulmonary artery, and had invaded the aortic arch. The pathohistologic diagnosis was osteosarcoma. Echocardiography, chest computed tomography and right ventriculography performed 1 year before death did not reveal the presence of a tumor in the pulmonary artery. The history of this patient shows that primary pulmonary artery sarcoma grows rapidly, with, in this case, the patient dying within 1 year of its appearance.