Misdiagnosis of primary intimal sarcoma of the pulmonary artery as chronic pulmonary embolism: A case report

CT of a pulmonary artery intimal sarcoma: A case report

Pulmonary artery intimal sarcomas are rare, malignant tumors often associated with poor prognoses. These highly lethal tumors are difficult to distinguish given their nonspecific symptoms and challenging imaging interpretations, often being misdiagnosed as acute or chronic pulmonary embolisms, tumor emboli, or mediastinal masses. Given the poor survival rate associated with this malignancy and surgical resection is the absolute choice of treatment, early and accurate diagnoses are essential. In this article, we report the case of a 78-year-old female who was diagnosed with a pulmonary artery intimal sarcoma. We focus on optimizing diagnosis and management through the application of radiological imaging modalities, specifically computed tomography angiography scans.

Pulmonary artery sarcoma: an unexpected settler in the right ventricular outflow tract

Pulmonary artery sarcoma (PAS) is a sporadic malignant tumor that mainly originates from the pulmonary arteries. However, PAS may also involve the right ventricular outflow tract (RVOT) and lead to obstruction, syncope, or sudden death. Early diagnosis and complete surgical resection are essential to prolong survival and improve the quality of life of patients with PAS. Herein, we report a case of a young female patient admitted for pulmonary malignancy and acute pulmonary embolism. The patient had a mass in the RVOT, which was detected by transthoracic echocardiography. Computed tomography and magnetic resonance imaging revealed the invasion depth and extent of the lesions. Surgical resection improved hemodynamics, while pathological and immunohistochemical tests confirmed the diagnosis of a pulmonary artery sarcoma. Local recurrence was detected in the adjacent tissues about two months after the surgery. Given the potential risk of reoperation, the patient was suggested to undergo conservative treatment.

A Journey From Cardiology to Oncology Reveals a Rare Case of Primary Intimal Sarcoma in a Patient With Dyspnea: A Case Report

Primary intimal sarcoma of the pulmonary artery is a rare and aggressive malignancy that arises from the intimal layer of the pulmonary artery. It typically presents with nonspecific symptoms such as dyspnea, chest pain, and hemoptysis, making early diagnosis challenging. Computed tomography (CT) and magnetic resonance imaging (MRI) are useful in identifying the tumor's location and extent. A definitive diagnosis is established by biopsy, either via surgical resection or percutaneous needle biopsy. However, diagnosis can be difficult due to the rarity of the disease and the need for specialized expertise in interpreting pathology specimens. Treatment of primary intimal sarcoma of the pulmonary artery involves surgical resection, followed by adjuvant chemotherapy and radiation therapy. Despite aggressive treatment, the prognosis remains poor, with a median survival of approximately two years. However, early detection and aggressive multimodal therapy can improve outcomes. We hereby report a rare case of primary intimal sarcoma of the pulmonary artery and discuss its pathophysiology, presentation, diagnostic approach, and treatment options.

Not always embolism: A case of pulmonary artery intimal sarcoma - The role of the radiologist in early diagnosis

Introduction

Pulmonary artery intimal sarcoma (PAIS) is a rare malignant neoplasm with imaging features that can mimic pulmonary embolism (PE). It must be recognized early because a radical resection may be useful to prolong survival.

Case description

A clinical case of a 57-year-old Caucasian male affected by PAIS is presented, which describes the computed tomography (CT) findings found in PAIS and the elements of overlap and differentiation with PE. The main common element is represented by the endoluminal filling defect of the pulmonary arterial vessels in contrast-enhanced CT examinations; a characteristic polypoid morphology or polylobulated contours are typical findings of PAIS. Other specific elements of the neoplasm such as wall eclipse sign, extension beyond the arterial wall, and metastasis are also explained.

Conclusions

The overlap of the clinical-radiological findings and the epidemiological difference between PAIS and PE cause a diagnostic delay. By knowing the differential elements, the radiologist can detect the neoplasm early to accelerate diagnosis and suggest optimal management.

Pulmonary thromboembolic disease or pulmonary artery intimal sarcoma: Case report and literature review

The present case study reported on a patient initially diagnosed with pulmonary embolism at the First Affiliated Hospital of Fujian Medical University (Fuzhou, China) in May 2021. Furthermore, a relevant literature review was performed. The patient was a 57-year-old Chinese male who presented with dyspnea and wheezing following exercise. Physical examination revealed pulmonary valve second heart sound > aortic valve second heart sound but lack of swelling on both lower limbs, while the imaging results suggested pulmonary artery filling defects. Initially, the patient was diagnosed with pulmonary embolism and was administered anticoagulation treatment, which lasted for 3 months but proved to be ineffective. Subsequent re-examination via chest computed tomography further indicated multiple nodules in the left hilum and lung. Therefore, the patient was hospitalized for lung aspiration biopsy, which led to the final diagnosis of pulmonary artery intimal sarcoma based on the pathological review.

Clinicopathological features of pulmonary artery and vein intimal sarcomas: case series of rare pulmonary vessel intimal sarcoma

Background

Pulmonary vessel intimal sarcoma (IS) is rare.

Methods

We studied gross pathology, microscopic images and immunohistochemistry of 2 pulmonary artery ISs (PAISs) and 2 pulmonary vein ISs (PVISs), followed up the prognosis. The clinical manifestations of IS, imaging examination, electrocardiographic examination and serological examination were also studied.

Results

Grossly, the tumors were grayish yellow or grayish-white accompanied by local bleeding, and were manifested as sticky and slippery nodules. PAISs were located in the lumen of the pulmonary trunk or right ventricular outflow tract, and 1 of them had pedicle. PVISs were mainly located in the left atrium. Microscopically, the heteromorphic spindle cells were arranged in lobules and bundles, partially epithelioid, with visible mitotic figures. There were interstitial mucoid degeneration and local hemorrhage and necrosis/infarction. Immunohistochemistry showed that vimentin, h-caldesmon and MDM2 were all positive, SATB2 (+, 3/4); Ki67 proliferation rate was 30–60%; smooth muscle actin, desmin and CD56 were partially positive; cytokeratin and CD34 were locally positive; CD31, FLI-1, and ERG vascular markers were negative; and S-100 was negative. Case 4 showed MDM2 (12q15) amplification. Tumor markers were negative in venous blood; and lactate dehydrogenase increased in 2 cases. 3 patients died after surgery, 1 still survives after 14 months with lung and chest metastases for immunotherapy and 9 courses of chemotherapy.

Conclusions

IS is rare. Microscopically, it is mainly composed of spindle cells (or local epithelioid), along with interstitial mucoid degeneration. IS can differentiate into tumor of fibroblasts, bone, cartilage and smooth muscle, etc. The prognosis is poor.

A case report of primary cardiac intimal sarcoma presenting with atrial fibrillation and a left atrial mass

BACKGROUND

Intimal sarcoma is an exceedingly rare type of primary cardiac tumour. It is characterized by poorly differentiated spindle-shaped cells that can mimic smooth muscle and is strongly associated with MDM2 genetic amplification. Owing to its rarity and non-distinctive histological features, diagnosis remains a significant challenge.

CASE SUMMARY

In this case report, we describe a case of primary cardiac intimal sarcoma in a 37-year-old woman who presented with atrial fibrillation (AF) and a left atrial mass. Despite having a histological sample from an excised left atrial mass, the diagnosis was not made until she presented with back pain secondary to metastatic disease to the spine.

DISCUSSION

Primary cardiac intimal sarcoma is an extremely rare diagnosis. The mainstay management of intimal cardiac sarcoma is aggressive surgical resection. Unfortunately, the prognosis of cardiac sarcomas remains very poor, with a mean survival between 3 months and 1 year. This case of cardiac intimal sarcoma highlights the difficulty in establishing a diagnosis, particularly given the unusual presentation of AF.

Transient Response of Olaparib on Pulmonary Artery Sarcoma Harboring Multiple Homologous Recombinant Repair Gene Alterations

Primary pulmonary artery sarcoma (PPAS) is a rare malignancy arising from mesenchymal pulmonary artery cells and mimics pulmonary embolism. Palliative chemotherapy such as anthracycline- or ifosfamide-based regimens and targeted therapy are the only options. However, the evidence of clinically beneficial systemic treatment is scarce. Here, we report a case of disseminated PPAS achieving clinical tumor response to olaparib based on comprehensive genetic profiling (CGP) showing genetic alterations involving DNA repair pathway. This provides supportive evidence that olaparib could be a promising therapeutic agent for patients with disseminated PPAS harboring actionable haploinsufficiency of DNA damage repair (DDR).

Radiological, histopathological findings, and clinical outcome of pulmonary artery sarcoma

Pulmonary artery sarcoma is a rare malignancy with poor prognosis. Lack of specific clinical manifestations, some patients are even confirmed postoperatively or at autopsy, that leads to the delay in treatment. Early diagnosis and radical surgical resection provide the possibility of prolonged survival. We retrospectively enrolled 13 patients diagnosed with pulmonary artery sarcoma at our hospital between 2015 and 2019. Their clinical, laboratory, radiological, and histopathological data were collected and analyzed. Published case series were also reviewed. Results show that, the median age of the patients was 53 years, with 6 (46.2%) males. The most common symptom is exertional dyspnea. Erythrocyte sedimentation rate and C-reactive protein were increased in 76.9% and 69.2% of these patients, while D-Dimer remained normal or elevated slightly. Metastasis was present at diagnosis in eight (61.5%) patients. Ten patients were diagnosed histologically: three were diagnosed after pulmonary endarterectomy, four by endobronchial ultrasound-guided transbronchial needle aspiration, two by percutaneous lung biopsy, and one by endovascular aspiration biopsy. Four patients underwent surgery and one is waiting for surgery. Nine patients received chemotherapy; and three of them received targeted therapy with anlotinib after chemotherapy. Two patients received anti-PD-1 monoclonal antibody. One patient died during endobronchial ultrasound-guided transbronchial needle aspiration. Two patients died 9 and 13 months after diagnosis, respectively; one refused invasive diagnostic procedures and died three months after clinical diagnosis. In conclusion, the most appropriate approach to get tissue specimen needs to be tailored to every pulmonary artery sarcoma patient. Pulmonary endarterectomy combined with chemotherapy and targeted therapy has prolonged their survival time.

Primary intimal sarcoma of the pulmonary artery misdiagnosed as pulmonary thromboembolism: A case confirmed at medicolegal autopsy

Misdiagnosed PAS confirmed at medicolegal autopsy Pulmonary artery sarcoma (PAS) is a rare disease and usually indistinguishable from acute or chronic thromboembolic disease of the pulmonary arteries. We present a case of pulmonary artery sarcoma in a 54-year-old male, who was clinically misdiagnosed as pulmonary thromboembolism. The patient died of disease; however, the actual diagnosis of PAS was made after a medicolegal autopsy. PAS can be a diagnostic challenge for both clinicians and pathologists. In an autopsy case with a clinical suspicion of pulmonary thromboembolism, if there is an abnormal gross appearance in the pulmonary artery, the forensic pathologist should have a high index of suspicion of PAS, which should be ruled out by a histopathologic examination.