Leiomyosarcoma of the pulmonary veins

Adjuvant chemoradiation for high-grade cardiac leiomyosarcoma in a child: Case report and review of literature

A 13-year-old healthy girl presented with dizziness and palpitations, found to have a left atrial mass. An 8-cm tumor was removed en bloc. Pathology confirmed grade 3 leiomyosarcoma with multifocal positive margins. She received adjuvant ifosfamide and doxorubicin, followed by concurrent proton radiotherapy and ifosfamide. Radiotherapy included 66 Gy (RBE) in 33 fractions to the operative bed. Prospectively graded toxicities included Grade 2 esophagitis and Grade 1 anorexia, dermatitis, and fatigue. She completed six cycles of ifosfamide. Two years post operation, she had no evidence of disease, intermittent palpitations with normal cardiac function, and no other cardiopulmonary or esophageal symptoms.

Primary Pulmonary Vein Leiomyosarcoma With Left Atrial Extension

Leiomyosarcoma (LMS) is a mesenchymal tumor originating from the smooth muscle cells. LMS of the great vessels accounts for 60% of cases, with inferior vena cava being the most common site. Pulmonary vein LMS is an extremely rare subset that was first reported in 1939. LMS is an aggressive tumor, making surgical resection the treatment of choice. Herein, we present a rare case of pulmonary vein LMS extending into the left atrium, which was resected.

Learning from the pulmonary veins

The purpose of this article is to review the basic embryology and anatomy of the pulmonary veins and the various imaging techniques used to evaluate the pulmonary veins, as well as the radiologic findings in diseases affecting these structures. Specific cases highlight the clinical importance of the imaging features, particularly the findings obtained with multidetector computed tomography (CT). Pulmonary vein disease can be broadly classified into congenital or acquired conditions. Congenital disease, which often goes unnoticed until patients are adults, mainly includes (a) anomalies in the number or diameter of the vessels and (b) abnormal drainage or connection with the pulmonary arterial tree. Acquired disease can be grouped into (a) stenosis and obstruction, (b) hypertension, (c) thrombosis, (d) calcifications, and (e) collateral circulation. Pulmonary vein stenosis or obstruction, which often has important clinical repercussions, is frequently a result of radiofrequency ablation complications, neoplastic infiltration, or fibrosing mediastinitis. The most common cause of pulmonary venous hypertension is chronic left ventricular failure. This condition is difficult to differentiate from veno-occlusive pulmonary disease, which requires a completely different treatment. Pulmonary vein thrombosis is a rare, potentially severe condition that can have a local or distant cause. Calcifications have been described in rheumatic mitral valve disease and chronic renal failure. Finally, the pulmonary veins can act as conduits for collateral circulation in cases of obstruction of the superior vena cava. Multidetector CT is an excellent modality for imaging evaluation of the pulmonary veins, even when the examination is not specifically tailored for their assessment.

An unusual case of peripartum pulmonary oedema

A previously healthy woman in her early 20s presented in week 38 of pregnancy with a 2-week history of haemoptysis, positional dyspnoea and an examination suggestive of pulmonary oedema. A chest CT showed a left lower lobe lung mass invading through the inferior pulmonary vein into the left atrium and abutting the posterior mitral leaflet. Pulmonary oedema consequent on left inferior pulmonary vein occlusion was initially restricted to the left lower lobe, but progressed to involve the contralateral lung following extension of the mass to the mitral orifice, resulting in functional mitral stenosis. A biopsy was positive for poorly differentiated spindle cell neoplasm. This is the first reported case of a pregnant patient with spindle cell neoplasm of lung and of a spindle neoplasm causing mitral stenosis, as well as the youngest known case of this disease.

Imaging features of primary sarcomas of the great vessels in CT, MRI and PET/CT: a single-center experience

Background

To investigate the imaging features of primary sarcomas of the great vessels in CT, MRI and ¹⁸ F-FDG PET/CT.

Methods

Thirteen patients with a primary sarcoma of the great vessels were retrospectively evaluated. All available images studies including F-18 FDG PET(/CT) (n = 4), MDCT (n = 12) and MRI (n = 6) were evaluated and indicative image features of this rare tumor entity were identified.

Results

The median interval between the first imaging study and the final diagnosis was 11 weeks (0–12 weeks). The most frequently observed imaging findings suggestive of malignant disease in patients with sarcomas of the pulmonary arteries were a large filling defect with vascular distension, unilaterality and a lack of improvement despite effective anticoagulation. In patients with aortic sarcomas we most frequently observed a pedunculated appearance and an atypical location of the filling defect. The F-18 FDG PET(/CT) examinations demonstrated an unequivocal hypermetabolism of the lesion in all cases (4/4). MRI proved lesion vascularization in 5/6 cases.

Conclusion

Intravascular unilateral or atypically located filling defects of the great vessels with vascular distension, a pedunculated shape and lack of improvement despite effective anticoagulation are suspicious for primary sarcoma on MDCT or MRI. MR perfusion techniques can add information on the nature of the lesion but the findings may be subtle and equivocal. F-18 FDG PET/CT may have a potential role in these patients and may be considered as part of the imaging workup.

Tumors of the pulmonary artery and veins

The pulmonary vasculature may be involved by different primary and secondary tumors. Poorly differentiated and undifferentiated sarcomas are the most common primary tumors of the pulmonary arteries. They tend to affect the large caliber pulmonary vessels and present with predominantly intraluminal growth. Pulmonary and mediastinal metastasis are common, and prognosis is poor. Clinical and imaging manifestations may mimic those of pulmonary embolism. Dyspnea, chest pain, cough, and hemoptysis are the most common presenting symptoms. Primary sarcomas arising from the central pulmonary veins are less common than their arterial counterpart. Secondary involvement of the pulmonary arteries and veins by primary and metastatic pulmonary malignancies is more common. Tumoral embolism may also affect the pulmonary arteries. They may develop from different intrathoracic and extrathoracic malignancies and may be indistinguishable from venous thromboembolism. It may manifest as cor pulmonale with right cardiac strain and dilated pulmonary arteries. Computed tomography, magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography may help in the differentiation between these 2 conditions.

Leiomyosarcoma of the right inferior pulmonary vein: 2 years survival with multimodality therapy

Primary leiomyosarcoma of the heart is an extremely rare and aggressive tumor. The authors report a case of a 29-year-old man with a leiomyosarcoma of the right inferior pulmonary vein who underwent surgery, chemotherapy, and radiotherapy. The patient experienced two local recurrences and he finally died 2 years after onset of symptoms because of multiple distal metastases.

Leiomyosarcoma of pulmonary vein presenting as left atrial mass: an outline of management principles

Leiomyosarcoma of the pulmonary vein is rare and has poor prognosis. Its clinical features are nonspecific and mimic benign conditions. Early diagnosis is challenging. Most cases have been diagnosed only at autopsy or on postoperative histology specimens. Treatment is essentially palliative complete surgical excision. We outline the principles of management with the case of a 39-year-old man with leiomyosarcoma of the left pulmonary veins extending into the left atrium. Extensive investigation to achieve early diagnosis and determine extent of disease is essential. Frozen section guided adequate excision of all cardiac tumours and resection of involved lung tissue achieve local disease control. Adjuvant chemoradiotherapy has been shown to enhance survival.

Non-vena cava venous leiomyosarcomas: a review of the literature

BACKGROUND

Leiomyosarcoma (LMS) is a rare malignant tumor of smooth muscle origin that generally stems from soft tissues and uterine tissue. However, a small percentage of this sarcoma subset may originate from the smooth muscle of vessel walls, most of which are of venous origin. Although the vena cava (VC) serves as the most likely source for these tumors and has been well described in the literature, there is limited information focused on non-VC LMS derived from large veins. The focus of this study was to consolidate the reports and previously published data of all non-VC LMS of venous origin to better characterize and describe this disease process.

METHODS

We reviewed information derived from 143 previously published cases.

RESULTS AND CONCLUSIONS

It was determined that women aged 60-69 years were most commonly diagnosed with this particular type of tumor, with the most common tumor site being the renal vein. Metastasis was present in 12% of this population at the time of diagnosis, and 32% of patients were alive 4 years later.

[Pulmonary vein leiomyosarcoma extending into the left atrium]

In this paper, the authors report the case of a 28-year-old man with pulmonary vein leiomyosarcoma presenting subacute respiratory distress. Thoracic computed tomography and transoesophagal ultrasonographic examination of the heart suggested the diagnosis of a heart tumour revealed by the obstruction of the mitral valve and pulmonary oedema. Emergency cardiac surgery revealed the mass to be a leiomyosarcoma, probably extending from the right inferior pulmonary vein and extending into the left atrium. The clinical evolution was complicated because of a sudden local relapse. The patient underwent a second cardiac intervention involving lower right lobectomy followed by adjuvant chemotherapy with an ifosfamide-adriamycin combination. This treatment failed to control the disease and a third cardiac intervention was necessary with second-line gemcitabine-paclitaxel adjuvant chemotherapy. Further recurrences were observed with metastases first in the scalp and then in the spine and adrenal glands leading to the death of the patient 2 years after the diagnosis.

Primary left atrial leiomyosarcoma: literature review and lessons of a case

Primary cardiac sarcoma is an uncommon disease. In particular, leiomyosarcoma of cardiovascular origin is extremely rare. Half of all cardiac leiomyosarcomas are located in the left atrium. Due to the extreme rarity of left atrial leiomyosarcoma, there is no great experience in its management. This review includes a report of a case of left atrial leiomyosarcoma followed up over 45 months. The literature review examines the distribution of left atrial leiomyosarcoma, the physiological reasons for the tendency of cardiac leiomyosarcoma to be localized to the left atrial cavity, the clinical and physical appearance of this disease, and the key differences between left atrial leiomyosarcoma and the most common left atrial tumor, myxoma. The morphological features, using light and electron microscopy and immunochemical staining, are discussed. Treatment modalities including adjuvant therapy and surgical resection are examined and their effectiveness compared. Opinions regarding the results and optimal treatment of leiomyosarcoma are not always in agreement. This highlights the need for inter-hospital comparison to determine the optimal treatment regimen.

Vascular smooth muscle tumors: Review of the literature

Vascular smooth muscle tumors are very rare. They can be benign or malign. Intravascular leiomyomatosis is a benign neoplasm that extends through the veins and caries significant morbidity. Angioleiomyoma is a benign neoplasm of the extremities that caries minimal morbidity. Vascular leiomyosarcomas are malign neoplasms derived from vascular smooth cells. They are usually localized to the inferior vena cava, but can also arise from the pulmonary arteries or veins or other peripheral vessels. This study reviews literature for epidemiology, clinical presentation, diagnosis and management of patients with vascular smooth muscle tumors.

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.

[Leiomyosarcoma of the inferior vena cava. Review of a rare disease]

Primary sarcomas of the great vessels are rare. Their most common site is the inferior vena cava. We report a primary leiomyosarcoma of a 41 year old female patient localised just below the right renal vein. The resected tumour showed the histological signs of a well differentiated, progesterone positive leiomyosarcoma. The case is discussed on the data of the reviewed literature.

Tumors of the pulmonary vasculature

Most primary tumors of the pulmonary vasculature are sarcomas arising in the main pulmonary arteries and veins with high mortality rates. Pulmonary artery sarcoma is far more prevalent than its venous counterpart, though both are rare. Pulmonary capillary hemangiomatosis is a rare low-grade tumor or tumor-like lesion of the pulmonary capillaries that causes severe pulmonary hypertension. Secondary involvement of pulmonary vasculature by malignant tumors may rarely mimic a primary vascular tumor or clinically present as unexplained pulmonary hypertension associated with thrombotic microangiopathy.

Leiomyosarcoma of the main bronchus in a girl: a long-time survivor with multiple lung metastases

Primary leiomyosarcoma of the respiratory tract is a very rare malignancy, especially in childhood, with only 15 cases in patients under 16 years old having been reported. In the present case, the survival period from the onset of symptoms has been over 7 years, despite incomplete resection. Based on the 15 published cases, the prognosis is poorer when the tumor is unresected or incompletely resected, but under favorable circumstances, prolonged survival is possible.

Fatal tumor thrombosis due to an inferior vena cava leiomyosarcoma in a patient with antiphospholipid antibody syndrome

We describe a patient with antiphospholipid antibody syndrome (APS) who died because of relentless inferior vena cava (IVC) tumor thrombosis due to an unsuspected leiomyosarcoma. Laboratory confirmation for APS was provided by functional identification of a lupus anticoagulant and anticardiolipin IgG and anti-beta2-glycoprotein I IgM antibodies. Although sensitive for detecting vascular obstruction, radiocontrast venography and magnetic resonance imaging and angiography detected the IVC thrombosis but failed to distinguish its malignant nature. Concomitant refractory thrombocytopenia prevented further invasive diagnostic and therapeutic maneuvers for progressive, severe IVC thrombosis unresponsive to aggressive treatment of APS. Deep venous thrombosis refractory to anticoagulant and immunomodulatory therapies in a patient with APS may be due to a concomitant underlying malignancy, such as a leiomyosarcoma, causing vascular obstruction.

Leiomiossarcoma pulmonar e renal em cão: relato de caso

Este relato descreve um caso de leiomiossarcoma pulmonar e renal em cão da raça Husky Siberiano, macho, de nove anos de idade e com histórico de emagrecimento progressivo há mais de três meses. Ao exame clínico, o animal apresentava palidez discreta das mucosas e dor intensa à palpação abdominal, além de aumento de volume acentuado dos rins. No hemograma, foi evidenciada anemia discreta e na urinálise foram observados isostenúria e grumos de células do epitélio renal. Os níveis plasmáticos de uréia e creatinina estavam dentro dos limites considerados normais. O animal foi sacrificado após a confirmação de neoplasia renal bilateral por laparotomia exploratória. À necropsia, os rins apresentavam vários nódulos de 0,5 a 4cm de diâmetro, esbranquiçados e firmes. Na região do hilo e no lobo apical esquerdo dos pulmões havia aumento de volume, com 11 × 7cm de extensão, de superfície irregular e bem vascularizada, esbranquiçada e com áreas de consistência ora firmes, ora friáveis. No lobo apical direito também havia um nódulo com 1cm de diâmetro, firme e esbranquiçado. Secções histológicas dos pulmões e dos rins foram coradas pela hematoxilina-eosina, Masson e Van Gieson. Foi detectada positividade, pela imuno-histoquímica, para a vimentina e actina alfa de músculo liso. Não houve imunomarcação para citoqueratinas 1, 5, 10, 14, 8 e 7, proteína S100 e para CD68. Com base nos achados anatomopatológicos e imuno-histoquímicos foi firmado o diagnóstico de leiomiossarcoma pulmonar e renal, sem, no entanto, definir o sítio primário da neoplasia.

Leiomyosarcoma of the pulmonary vein

A case of a 74-year-old man with leiomyosarcoma of the pulmonary vein is reported. The patient felt transient chest oppression while playing golf 1 week before he visited a clinic with a common cold. He underwent an ultrasonographic examination of the heart, which showed a mass lesion in the left atrium. The preoperative clinical diagnosis was myxoma of the left atrium. Cardiac surgery revealed the mass to be a leiomyosarcoma, probably extending from the left inferior pulmonary vein. The patient underwent a left lower lobectomy of the lung, and the tumor was confirmed to have originated from the wall of the left inferior pulmonary vein. Although the patient had a metastatic lesion in the right axillary lymph node 11 months later, which was excised, he remained free of disease 14 months after the initial operation. Histologically, the tumors were composed of pleomorphic cells with bizarre nuclei and spindle cells with blunt-ended nuclei with 1-4 mitotic figures in 10 high power fields. Immunohistologically, the tumor cells were positive for alpha-smooth muscle actin and desmin. We reviewed 17 cases of leiomyosarcoma of the pulmonary vein (six males and 11 females with a mean age of 50 years in each group). The present case was the oldest in age and to our knowledge was the first reported case with metastasis in a distant lymph node.