Fatal pulmonary tumor embolism caused by chondroblastic osteosarcoma

Chondroblastic osteosarcoma of the distal tibia: a rare case report

Chondroblastic osteosarcoma, representing about 25% of osteosarcoma, is a fatal primary malignancy of the skeleton if not diagnosed and treated appropriately. It most commonly occurs in the long bones of the extremities near the metaphyseal growth plates. In this report, we describe the occurrence of chondroblastic osteosarcoma involving the left distal tibia in a 14-year-old male. The diagnosis was confirmed by the histological examination of a surgical biopsy. The patient was treated by both surgery and neoadjuvant chemotherapy. No recurrence was noted at 3 years of follow-up. To our knowledge, only two cases describing chondroblastic osteosarcoma of the distal tibia had been reported through English medical literature. Therefore, the aim of our article is to make the clinician aware of this rare clinical presentation and also to provide a comprehensive review of the literature related to this uncommon malignant tumour.

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

BACKGROUND

Deep venous thrombosis (DVT) or pulmonary embolism (PE) is a rare, but not exceptional presentation of soft tissue sarcomas (STSs). Due to the remarkable difference in the incidence between DVT or PE and STSs, this type of STS presentation is usually associated with a considerable delay in tumor diagnosis and treatment.

CASE PRESENTATION

We describe two cases of STS who presented with DVT and PE. Physical and radiographic examination only showed the presence of DVT. Both patients were treated for DVT or PE for several months. Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, magnetic resonance imaging (MRI) was performed, which revealed the presence of a lower limb mass in both cases. The definite diagnosis was reached via excisional biopsy and histological examination.In one case, MRI showed a large tumor in the anterior muscle compartment of the right thigh, with thrombosis of the right common femoral vein and involvement of the ipsilateral common iliac vein and inferior vena cava until the confluence of the renal veins. In the other case, MRI showed a large tumor in the middle third of the right thigh. The lesion was in close proximity to the superficial femoral vein that appeared compressed and showed signs of thrombosis. In both cases, histological examination revealed a high-grade leiomyosarcoma.

CONCLUSION

STSs of the lower extremities can rarely present with DVT or PE. This possibility should be considered in the differential diagnosis of painful leg swelling, especially in patients with recurrent or refractory venous thrombosis. When a STS is suspected, MRI should be obtained followed by excisional biopsy of the eventual mass. A delay in diagnosis and treatment of STSs often results in very poor prognosis.Level of evidence. IV.

Chondroblastic osteosarcoma of the cuboid: a literature review and report of a rare case

Chondroblastic osteosarcoma accounts for about 25% of all cases of osteosarcoma, which is the most common primary malignancy of the skeleton. Currently, only a few cases of chondroblastic osteosarcoma have been reported to involve the bones of the foot. In this report, we describe the previously unreported occurrence of chondroblastic osteosarcoma involving the left tarsal cuboid in a 15-year-old male. Histologically, the tumor showed an unusually extensive osteoclastic giant cell reaction that initially led to an erroneous diagnosis of giant cell tumor of bone. Because treatment and prognosis are very different for chondroblastic osteosarcoma as compared to giant cell tumor of bone, it is important to make the distinction between these 2 different bone tumors. In this report, we wish to draw attention to occurrence of chondroblastic osteosarcoma in the small bones of the foot, and to the possibility of an extensive giant cell reaction making accurate diagnosis difficult. We also provide a comprehensive review of the literature related to chondroblastic osteosarcoma.

LEVEL OF CLINICAL EVIDENCE

4.

Fatal pulmonary tumor embolism in a child with chondroblastic osteosarcoma

Fatal embolic chondroblastic osteosarcoma to the lung is an extremely rare phenomenon. We report a case of a 15-year-old boy who developed bilateral pulmonary embolism shortly after resection of the right distal femur for chondroblastic osteosarcoma. The patient succumbed to right-sided heart failure 8 weeks later. An autopsy revealed extensive intravascular tumor emboli in the bilateral pulmonary arteries and their branches. No metastatic lesions were identified in the lungs. We review the clinical, radiologic, and pathologic findings of this patient and the literature.

Pulmonary thromboembolism in children

Pulmonary thromboembolism (PTE) is uncommonly diagnosed in the pediatric patient, and indeed often only discovered on autopsy. The incidence of pediatric PTE depends upon the associated underlying disease, diagnostic tests used, and index of suspicion. Multiple risk factors can be found including: peripartum asphyxia, dyspnea, haemoptysis, chest pain, dehydration, septicemia, central venous lines (CVLs), trauma, surgery, ongoing hemolysis, vascular lesions, malignancy, renal disease, foreign bodies or, uncommonly, intracranial venous sinus thrombosis, burns, or nonbacterial thrombotic endocarditis. Other types of embolism can occur uncommonly in childhood and need to be recognized, as the required treatment will vary. These include pulmonary cytolytic thrombi, foreign bodies, tumor and septic emboli, and post-traumatic fat emboli. No single noninvasive test for pulmonary embolism is both sensitive and specific. A combination of diagnostic procedures must be used to identify suspect or confirmed cases of PTE. This article reviews the risk factors, clinical presentation and treatment of pulmonary embolism in children. It also highlights the current diagnostic tools and protocols used to evaluate pulmonary embolism in pediatric patients.

Intraoperative TEE for the management of pulmonary tumour embolism during chondroblastic osteosarcoma resection

PURPOSE

Chondroblastic osteosarcoma requiring surgical intervention is associated with a high risk of pulmonary tumour embolism. Rapid intraoperative diagnosis with transesophageal echocardiography (TEE) allowed changing the management plan and treatment of a life-threatening pathology.

CLINICAL FEATURES

A 32-yr-old female with right pelvic chondrosarcoma presented for right hemipelvectomy. Two hours into the operation during ligation of the iliac blood vessels the patient's hemodynamic condition deteriorated and was followed by cardiac arrest. TEE was performed immediately and revealed massive tumour embolism in the right and left pulmonary arteries. Large tumour emboli were removed from the right and left pulmonary arteries after median sternotomy under cardiopulmonary bypass and moderate hypothermia. The hemipelvectomy was completed on the next day after fluid and inotropic agent resuscitation. An inferior vena cava filter was placed below the renal veins. The patient was discharged from hospital ten days after the surgery.

CONCLUSION

This case report illustrates the important role TEE can play in the early diagnosis and subsequent surgical treatment of noncardiac emergencies. Intraoperative TEE can have a significant impact on the decision making process in life threatening emergencies.