Misdiagnosis of soft tissue sarcomas of the lower limb associated with deep venous thrombosis: report of two cases and review of the literature

Venous Thromboembolism in Metastatic Uterine Leiomyosarcoma: A Case Report and Review of the Literature

We report an unusual case of extensive deep vein thrombosis (DVT) and pulmonary embolism (PE) in the setting of metastatic uterine leiomyosarcoma. Recognition of the associated sequelae of this condition may improve short- and long-term outcomes. A 56-year-old black female with a history of uterine leiomyosarcoma diagnosed incidentally after total abdominal hysterectomy for fibroid uterus without initiation of chemoradiation treatment presented to the emergency department complaining of generalized weakness and progressively worsening stridor for 2 weeks. The patient was experiencing shortness of breath, dysphagia, and hoarseness. Physical exam was remarkable for rhonchi but was otherwise normal. Diagnostic imaging via CT of the abdomen, pelvis, and chest revealed DVTs of the left common and external iliac veins, the superior mesenteric artery, multiple pulmonary emboli of the right pulmonary artery, several nodular lesions within the lungs, and scattered peritoneal necrotic lesions, which were suspicious for metastatic disease. Additionally, CT of the neck showed an exophytic mass protruding into the airway from the subglottic region and thyromegaly with bilateral thyroid lobe nodules. The patient was subsequently started on Eliquis and chemotherapy. The rarity of this case is rooted in the extent of the patient's DVTs and PEs secondary to hypercoagulability in metastatic cancer. This presentation should be further evaluated to exclude thrombophilias or underlying malignancies. Drawing from the lessons of this case will help guide future clinical management regarding the care of metastatic uterine leiomyosarcoma.

Shortening the Time Interval for the Referral of Patients With Soft Tissue Sarcoma to Expert Centers Using Mobile Health: Retrospective Study

BACKGROUND

According to guidelines, all patients with sarcoma must be managed from initial diagnosis at expert sarcoma centers. However, in everyday practice, the time interval to an expert center visit can be long, which delays presentation to an expert multidisciplinary tumor board and increases the risk of inappropriate management, negatively affecting local tumor control and prognosis. The advent of mobile health offers an easy way to facilitate communication and cooperation between general health care providers (eg, general practitioners and radiologists) and sarcomas experts. We developed a mobile app (Sar'Connect) based on the algorithm designed by radiologists from the French Sarcoma Group. Through a small number of easy-to-answer questions, Sar'Connect provides personalized advice for the management of patients and contact information for the closest expert center.

OBJECTIVE

This retrospective study is the first to assess this mobile app's potential benefits in reducing the time interval for patient referral to an expert center according to the initial clinical characteristics of the soft tissue tumor.

METHODS

From May to December 2021, we extracted tumor mass data for 78 patients discussed by the multidisciplinary tumor boards at 3 centers of the French Sarcoma Group. We applied the Sar'Connect algorithm to these data and estimated the time interval between the first medical description of the soft tissue mass and the referral to expert center. We then compared this estimated time interval with the observed time interval.

RESULTS

We found that the use of Sar'Connect could potentially shorten the time interval to an expert center by approximately 7.5 months (P<.001). Moreover, for half (31/60, 52%) of the patients with a malignant soft tissue tumor, Sar'Connect could have avoided inappropriate management outside of the reference center. We did not identify a significant determinant for shortening the time interval for referral.

CONCLUSIONS

Overall, promoting the use of a simple mobile app is an innovative and straightforward means to potentially accelerate both the referral and management of patients with soft tissue sarcoma at expert centers.

Preoperative anemia and deep vein thrombosis in patients with perioperative bone trauma: a cohort study

Background

In current active prevention (including physical and drug prevention), the incidence of perioperative deep vein thrombosis (DVT) of the lower extremities remains high in patients with bone trauma. Risk factors need to be further optimized, and high-risk patients must be identified early. Preoperative comorbidities, especially preoperative anemia, and DVT in patients with perioperative bone trauma are not clear. The purpose of this study was to explore the causal relationship between preoperative anemia and DVT in patients with perioperative bone trauma, and further reduce the incidence of DVT in patients with bone trauma.

Objectives

To analyze the relationship between preoperative anemia and perioperative DVT in patients with femoral and pelvic fractures and provide a reference for the optimization of risk factors for DVT.

Methods

The clinical data of 1049 patients with femoral and pelvic fractures who received surgical treatment from May 2018 to June 2021 were retrospectively analyzed. Propensity score matching (PSM) was performed for the covariates of DVT. Modified Poisson regression was used to analyze the relationship between preoperative anemia and DVT.

Results

After matching 1:1 propensity scores in 1049 patients included in this study, there were 258 patients in the anemic and non-anemic groups. Preoperative anemia was statistically significant for the formation of DVT in patients with perioperative bone trauma (P = 0.000, RR = 1.567 [95% CI 1.217–2.017]). This conclusion remained true after PSM (P = 0.009, RR = 1.500 [95% CI 1.105–2.036]). Preoperative anemia has some predictive value for perioperative DVT, with DVT-associated preoperative anemia thresholds of 125 g/L and area under the receiver operating characteristic curve of 0.5877 (95% CI 0.5345 to 0.6408). On this basis, sensitivity and specificity were 89.2 and 30.3%, respectively, with a Youden index of 0.195. In addition, we conducted an E-value determination of the propensity score; the E-value analysis showed robustness to unmeasured confounding.

Conclusions

Preoperative anemia is highly correlated with perioperative DVT in patients with bone trauma, which is the cause of perioperative DVT in these patients.

Case 290: Intravascular Cystic Synovial Sarcoma

History A 26-year-old man presented with a 1-month history of chest pain, a palpable and painful right inguinal mass, and edema in the right lower extremity. One month earlier, he started to experience left chest pain with no cough. Pulmonary CT angiography (CTA) revealed a left lower lobe segmental pulmonary embolus. The local hospital made a diagnosis of pulmonary embolism. He received anticoagulants, and his chest pain was gradually relieved. At the time of current presentation, the patient was experiencing right lower extremity swelling and pain. Physical examination revealed a 4 × 3 cm palpable right inguinal mass with no redness. His medical history and family history were negative. The results of laboratory work-up were normal, with a d-dimer level of 0.16 mg/L fibrinogen equivalent units (reference range, <0.46 mg/L) and an international normalized ratio of 2.45 (therapeutic range, 2.0-3.0 for a patient taking warfarin), except the prothrombin time was 28.2 seconds (reference range, 9.6-12.8 seconds) and the activated partial thromboplastin time was 52.2 seconds (reference range, 24.8-33.8 seconds). Echocardiography, chest radiography, chest CT, and contrast-enhanced (CE) CT revealed no abnormalities. The patient underwent right lower extremity vascular conventional US (Philips IU22; Philips) with an L9-3 probe (3-9 MHz, venous condition) and contrast-enhanced US (1.5-2.0 mL, SonoVue; Bracco) with an intravenous bolus injection at the initial evaluation. Two days later, noncontrast and contrast-enhanced CT images of the lower abdomen (1.5 mL per kilogram of body weight, 300 mg/mL iomeprol, Iomeron; Bracco) were acquired for further evaluation.

Femoral Vein Leiomyosarcoma Mimicking Thrombosis

BACKGROUND

Leiomyosarcoma represents a diagnostic challenge since it is often misdiagnosed as deep venous thrombosis (DVT).

METHODS

A 49-year-old woman with history of DVT and diagnosed with recurrency of thrombosis came to our observation for right thigh pain persistency.

RESULTS

Duplex-Ultrasound (US) examination showed an oval mass inside the superficial femoral vein with color spots and blood flow signal in its context. Contrast enhanced computed tomography and magnetic resonance of the lower limbs showed the presence of vascularized lesion into the distal superficial femoral vein. Echo-guided biopsy revealed the presence of high grade leiomyosarcoma. A total body 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography demonstrated a rounded area of pathological increased FDG uptake, at the distal thigh level without metastatic localization.

CONCLUSIONS

Our experience demonstrated that a multimodality approach may help to distinguish leiomyosarcoma from a blood clot in doubtful cases.

Giant Lower Limb Myxoid Liposarcoma Causing Deep Vein Thrombosis, Complicated with Pulmonary Embolism Case Report

Liposarcoma (LPS) is one of the most common histologic subtypes of adult soft tissue sarcoma. Here, we report the case of a 52-year-old woman complaining of shortness of breath, chest pain, painful leg swelling 24 hour before presentation at our institution.

Despite a vascular, soft part ultrasound and CTA, which suspected a voluminous haematoma, a huge tumour was found and a myxoid liposarcoma was identified by surgical excision and a histological examination, respectively.

Recurrence of Primary Vascular Leiomyosarcoma Five Years after Initial Diagnosis in the Lower Extremity

Primary leiomyosarcomas of vascular origin are rare tumors. They frequently arise within the inferior vena cava; however, the peripheral vein was also affected. To date, only a few hundred cases have been reported in the world literature. Although it is an extremely aggressive tumor, the symptoms may be unspecific, especially in the lower extremities. In this report, we present a case of primary vascular leiomyosarcoma, arising from the short saphenous vein, with symptoms mimicking thrombus in the initial diagnosis. The diagnosis of leiomyosarcomas was confirmed by standard H&E staining and immunohistochemical staining. Recurrence of the tumor has been observed five years after surgical treatment. Due to its rarity, experience in the management of this type of tumor is limited. The mainstay of treatment for these tumors is complete surgical resection. The purpose of the presented case is to discuss the clinicopathological features and management options of this tumor, under the light of the most recent literatures.

Pulmonary Embolism Caused by Intravenous Leiomyosarcoma of the Lower Limb

Pulmonary embolism (PE) is usually caused by thrombosis or tumor. We report the long-term survival of a patient with PE due to a leiomyosarcoma in the deep vein. A 71-year-old woman complained of dyspnea and swelling of the left lower limb. Computed tomography revealed filling defects in the pulmonary arteries and deep vein. She was diagnosed with PE caused by venous thrombosis and treated with anticoagulant therapy. Her symptoms were prolonged, and D-dimer tests remained negative. Biopsy of the substance in the deep vein revealed leiomyosarcoma. The possibility of PE caused by extravascular or intravascular tumors should be considered when a patient is negative for D-dimer.

Multimodal ultrasonographic assessment of leiomyosarcoma of the femoral vein in a patient misdiagnosed as having deep vein thrombosis: A case report

RATIONALE

Primary leiomyosarcoma (LMS) of the vein is a rare tumor that arises from the smooth muscle cells of the vessel wall and has an extremely poor prognosis. This tumor can occur in vessels such as the inferior vena cava, great saphenous vein, femoral vein, iliac vein, popliteal vein, and renal vein; the inferior vena cava is the most common site. LMS of the femoral vein can result in edema and pain in the lower extremity; therefore, it is not easy to be differentiated from deep vein thrombosis (DVT). Moreover, virtually no studies have described the ultrasonographic features of LMS of the vein in detail.

PATIENT CONCERNS

We present a case of a 55-year-old woman with LMS of the left femoral vein that was misdiagnosed as having deep vein thrombosis (DVT) on initial ultrasonographic examination. The patient began to experience edema and pain in her left leg seven months previously. She was diagnosed as having DVT on initial ultrasonographic examination, but the DVT treatment that she had received for 7 months failed to improve the status of her left lower limb.

DIAGNOSES

She subsequently underwent re-examination by means of a multimodal ultrasonographic imaging approach (regular B-mode imaging, color Doppler imaging, pulsed-wave Doppler imaging, contrast-enhanced ultrasonography), which confirmed a diagnosis of LMS.

INTERVENTIONS

This patient was treated successfully with surgery.

OUTCOMES

This case demonstrates that use of multiple ultrasonographic imaging techniques can be helpful to diagnose LMS accurately. Detection of vasculature in a dilated vein filled with a heterogeneous hypoechoic substance on ultrasonography is a sign of a tumor.

LESSONS

The pitfall of misdiagnosing this tumor as DVT is a useful reminder.

Desmoid Fibromatosis Presenting as Deep Venous Thrombosis: A Case Report and Discussion

Patient: Male, 40

Final Diagnosis: Desmoid fibromatosis

Symptoms: Discomfort

Medication: —

Clinical Procedure: Surgery and radiotherapy

Specialty: Surgery

Sarcoma the great "masquerader" hematoma/deep vein thrombosis manifestation

INTRODUCTION

The clinical presentation of patients with soft-tissue sarcoma is highly variable. Most patients present with a painless mass, typically one that is increasing in size, and few have systemic symptoms such as fever, weight loss, or malaise. Soft tissue sarcomas can initially present as, or even be misdiagnosed as, deep venous thrombosis (DVT), leading to a late diagnosis.

CASE REPORT

A 51-year-old woman presented to the hospital with complaints of pain and swelling in her left thigh, interpreted as an infected hematoma with an associated deep vein thrombosis and treated accordingly. The patient presented to our emergency department two more times. In the last visit and due to an unresolving clinical scenario a MRI and surgical byopsies were made that confirmed a sarcoma diagnosis.

DISCUSSION

When a patient presents with an expanding, nontraumatic mass simulating a haematoma, several other differential diagnoses should be considered including aneurysm, bleeding tendency, chronic expanding haematoma and soft-tissue sarcoma. The growth of the tumor undetected while being treated for the DVT and then posteriorly for the hematoma, was without a doubt dismal to the patient, so earlier diagnosis would have been preferable.

CONCLUSION

When a patient presents with an unusual history of hematoma in the extremities, it is necessary to consider the possibility of a malignant soft tissue tumor.

Primary Leiomyosarcoma in the Inferior Vena Cava Extended to the Right Atrium: A Case Report and Review of the Literature

A 38-year-old woman had developed an abdominal distention, lower extremity edema, and dyspnea. Imaging examination revealed a large mass in the right atrium which was connected to lesions within the inferior vena cava. Although complete resection of the mass was not possible, partial surgical tumor resection was performed to avoid pulmonary embolization and circulatory collapse. Leiomyosarcoma was diagnosed histologically, and chemotherapy (doxorubicin) followed by radiotherapy was started. By reviewing papers published in the past 10 years that included 322 patients, we also discuss the clinical presentations and prognosis of leiomyosarcoma in the inferior vena cava.