Thrombus or tumor? A case report of a rare sarcoma entity: intimal sarcoma of the pulmonary arteries

BACKGROUND

Tumor embolism is a very rare primary manifestation of cancers and the diagnosis is challenging, especially if located in the pulmonary arteries, where it can mimic nonmalignant pulmonary embolism. Intimal sarcoma is one of the least commonly reported primary tumors of vessels with only a few cases reported worldwide. A typical location of this malignancy is the pulmonary artery. Herein, we present a case report of an intimal sarcoma with primary manifestation in the pulmonary arteries. A 53-year-old male initially presented with dyspnea. On imaging, a pulmonary artery embolism was detected and was followed by thrombectomy of the right ventricular outflow tract, main pulmonary artery trunk, and right pulmonary artery after ineffective lysis therapy. Complementary imaging of the chest and abdomen including a PET-CT scan demonstrated no evidence of a primary tumor. Subsequent pathology assessment suggested an intimal sarcoma further confirmed by DNA methylation based molecular analysis. We initiated adjuvant chemotherapy with doxorubicin. Four months after the completion of adjuvant therapy a follow-up scan revealed a local recurrence without distant metastases.

DISCUSSION

Primary pulmonary artery intimal sarcoma (PAS) is an exceedingly rare entity and pathological diagnosis remains challenging. Therefore, the detection of entity-specific molecular alterations is a supporting argument in the diagnostic spectrum. Complete surgical resection is the prognostically most important treatment for intimal cardiac sarcomas. Despite adjuvant chemotherapy, the prognosis of cardiac sarcomas remains very poor. This case of a PAS highlights the difficulty in establishing a diagnosis and the aggressive natural course of the disease.

CONCLUSION

In case of atypical presentation of a pulmonary embolism, a tumor originating from the great vessels should be considered. Molecular pathology techniques support in establishing a reliable diagnosis.

Infantile Hemangiomas and Vascular Anomalies

Vascular anomalies represent a diverse group of disorders of abnormal vascular development or proliferation. Vascular anomalies are classified as vascular tumors and vascular malformations. Significant advances have been made in the understanding of the pathogenesis, natural history, and genetics of vascular anomalies, allowing for improvements in management including targeted molecular therapies. Infantile hemangiomas are the most common vascular tumor of childhood and follow a distinct natural history of proliferation and involution. Although benign, infantile hemangiomas can be associated with important complications. The use of beta-blockers has revolutionized the management of infantile hemangiomas. Other vascular tumors include pyogenic granulomas, congenital hemangiomas, and kaposiform hemangioendotheliomas, among others. Vascular malformations are categorized based on the type of involved vessel, including capillary malformations, venous malformations, lymphatic malformations, arteriovenous malformations, and mixed vascular malformations. Expert multidisciplinary management of vascular anomalies is critical to optimize outcomes in these patients. [Pediatr Ann. 2024;53(4):e129-e137.].

A Rare Case of Pulmonary Artery Sarcoma

Pulmonary artery sarcoma (PAS) is a rare and aggressive mesenchymal tumor with an overall poor prognosis1-5. Due to similar clinical and radiologic findings, PAS is often misdiagnosed as a pulmonary embolism (PE) frequently leading to prolonged anticoagulation therapy, which delays the correct diagnosis 1-3. By presenting this clinical case our objective is to emphasize characteristic CT findings that favour a neoplastic origin of a pulmonary intravascular filling defect. PET-CT and MRI have also an important potential role in its diagnosis and therapeutical management.

[Diagnosis and treatment of intravenous leiomyomatosis]

Intravenous leiomyomatosis is a rare type of tumor that is histologically benign but biologically invasive. It originates from the smooth muscle of the uterine or the uterine vein. It can grow through the uterus and extend into the pelvic cavity, or grow along the veins without invading the wall of the venous vessel itself. The tumors are estrogen-dependent and can metastasize through the bloodstream. Thus, in addition to continuous growth, some tumors exhibit isolated growths in the venous system and heart chambers or show disseminated growth in the lungs, although distant metastasis to other regions usually do not occur. Currently, there is limited research on this disease, the majority of which are case reports, surgical experience summaries, and differentiation from ordinary gynecological myomas in terms of pathogenesis and radiological diagnostic experience. There are two main theories on the origin of the disease: uterine smooth muscle and smooth muscle of the uterine veins. Some studies have verified the role of estrogen, progesterone receptor-related pathways, and angiogenesis in the development of the disease. The clinical symptoms of this disease are varied, depending on the affected area. In the early stages, when the tumor only affects the pelvic cavity, patients show mild symptoms resulting from pelvic organ compression. When it progresses to the inferior vena cava and heart, patients show more complex symptoms resulting from venous return obstruction, cardiac obstruction, and hemodynamics appearing. Different institutions have proposed different disease staging and classification strategies for different clinical purposes. Some are based on the affected area of the lesion; others are based on the size of the tumor. Although surgery remains the main treatment for this disease, the specific surgical approach, adjuvant drug therapy, and prognosis still need further exploration.

Epithelioid Vascular Lesions: The Differential Diagnosis and Approach in Cytology and Small Biopsies

Vascular neoplasms are rare tumors with a multitude of clinical presentations and behavior, which make accurate identification and subclassification challenging on limited small biopsies. Within the spectrum of these lesions, the ones with epithelioid morphology, such as epithelioid hemangioendothelioma and epithelioid angiosarcoma, are particularly challenging given the morphologic overlap with nonvascular lesions and the limited cells due to hemodilution on sampling. Herein, we review the differential diagnosis of epithelioid vascular neoplasms, with a focus on the cytomorphology, differential diagnoses, and ancillary studies that pathologists should be aware of when evaluating small biopsies and aspirates, including novel translocations, and associated monoclonal immunohistochemistry antibodies, that can help in the diagnosis of some of these tumors. Awareness of these morphologic and ancillary study findings in these rare tumors will hopefully allow pathologists to recognize and render-specific diagnoses on limited samples of these challenging lesions.

Presumptive metastatic leiomyosarcoma in a feedlot steer

A 14-month-old feedlot steer was depressed and died while being examined. The gross post-mortem examination of the steer conducted at the feedlot identified numerous masses within the abdomen and thorax, including a large mass in the liver that eroded into the vena cava. Many masses in the lungs appeared to be the result of hematogenous distribution. Histologic examination of the masses confirmed the presence of neoplasia. Although the histologic appearance of the neoplasms was not typical of well-differentiated leiomyosarcoma, immunohistochemical staining supported that diagnosis. Leiomyosarcomas are rare among North American cattle. In this case, the primary neoplasm appears to have originated in the wall of the vena cava within the liver. Key clinical message: This report adds to the limited information on leiomyosarcomas in cattle, while highlighting both the challenges faced by veterinarians conducting post-mortem examinations on large animals in below freezing temperatures, as well as the current methods available to arrive at a diagnosis of a rare disease.

Inferior vena cava leiomyosarcoma with liver metastasis at presentation in a young male: A challenging diagnostic quandary

Leiomyosarcomas of vascular origin are very rare tumors, predominantly affecting the inferior vena cava (IVC). Although vascular leiomyosarcomas are slow-growing, their non-specific and late presentation results in delayed diagnosis which portends a very poor prognosis. Here we report a case of a 24-year-old man who presented with abdominal pain since 15 days and was found to have unresectable metastatic leiomyosarcoma of the inferior vena cava at initial diagnosis.

Epithelioid hemangioendothelioma - an unexpected diagnosis of a mediastinal tumor with extensive local thrombosis

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor and the mediastinal localization is amongst the most infrequent. We present the case of a 37-year-old woman with a history of resected left thyroid tumor that presented to our department for evaluation of a left supraclavicular palpable mass in close contact with local vascular structures, and with heterogeneous contrast enhancement as described by computed tomography (CT) and magnetic resonance imaging (MRI). Considering the history of the patient, the presumptive diagnosis of thyroid tumor recurrence was established, and the patient was referred to surgical department. During procedure, we encountered important bleeding from a ruptured jugular vein branch, which we assumed to be a newly formed tumor blood vessel. After surgery (48 hours postoperatively), the patient developed important local thrombosis that encompassed the left internal jugular vein, left subclavian vein and the left brachiocephalic trunk that partially subsided after anticoagulant therapy. The histological examination revealed the presence of a vascular tumor proliferation of epithelioid endothelial cells that was characteristic of an EHE confirmed later on the immunohistochemical studies as Yes-associated protein 1-transcription factor E3 (YAP1-TFE3) subtype. In addition to the case report, some relevant information from the scarce literature data about mediastinal EHE were reviewed here.

[Intravascular large B-cell lymphoma diagnosed by total hysterectomy]

Intravascular large B-cell lymphoma (IVLBCL) is a rare form of non-Hodgkin B-cell lymphoma which occurs mainly in capillaries and small blood vessels. Successful diagnosis of IVLBCL is challenging since it lacks tumor formation and presents various clinical manifestations. An 82-year-old Asian female patient presented to our emergency department with a history of general fatigue, weight loss, and fever for two weeks. The patient's random skin biopsy was negative, and her bone marrow biopsy revealed hemophagocytic syndrome with no obvious involvement of lymphoma cells. Gallium scintigraphy showed mild uptake in the uterus, pelvis, and spine. The repetitive bone marrow biopsy result and the endometrial cytology/biopsy were negative; however, the pelvic MRI was compatible with lymphoma, revealing lesions in the corpus uteri, pelvis, and vertebral body. After laparoscopic-assisted vaginal total hysterectomy and bilateral salpingo-oophorectomy, the diagnosis of the Asian variant of IVLBCL was made. Although total hysterectomy remains controversial for elderly patients with declining performance status, we could successfully diagnose the condition and initiate the treatment. The patient's general condition improved soon after starting rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone regimen on day 26, and she was discharged on day 45.

Neonatal Vascular Tumors

Vascular tumors are a part of the vascular anomalies spectrum. Vascular malformations are congenital vascular lesions, originating from a mesenchymal stem cell defect and distinguished from vascular tumors by their low cell turnover and lack of invasiveness. They tend to grow in proportion to the child. Vascular tumors are proliferative and range from benign proliferation to malignant tumors. The appropriate differential diagnosis is imperative. Infantile hemangioma can be diagnosed clinically and rarely requires therapy; more rare tumors are difficult to diagnose and treat. This review provides an overview of vascular tumors seen in the neonatal period and summarizes treatment options.

Primary pulmonary arterial sarcoma treated with endostar injection and radiotherapy

We present a case of primary pulmonary arterial sarcoma (PPAS) treated with endostatin (endostar) injection and radiotherapy  discuss the diagnosis, clinical manifestations, and pathology of PPAS. The patient complained of cough with sputum, fever, and chest pain with hemoptysis. Numerous nodules were observed in the computed tomography (CT) scan. The patient was diagnosed with pulmonary embolism (PE) by computed tomography pulmonary angiography (CTPA). The pathology and immunohistochemistry results indicated soft tissue sarcomas, indicative of angiosarcoma. The nodules shrunk after 5 courses of endostatin and one course of radiotherapy, as determined in the CT scan. Primary pulmonary arterial sarcoma is clinically rare with nonspecific symptoms. Hence, it can be easily misdiagnosed as PE, and biopsy must be performed for confirmation. Current treatment methods, including surgery, are limited. Therefore, administration of endostatin injection combined with other therapies may be an alternative treatment methods.

Clinicopathologic features and clinical outcomes of intravenous leiomyomatosis of the uterus: A case series

RATIONALE

Intravenous leiomyomatosis (IVL) is a rare and special type of smooth muscle tumor originating in the uterus. It is classified as a benign disease according to its histological features but shows the behavioral characteristics of a malignant tumor. It is easily misdiagnosed and recurrent. The purpose of this study was to retrospectively analyze clinicopathological data of 25 cases of IVL in order to enhance clinicians' understanding of this rare disease.

PATIENT CONCERNS

We screened and identified 25 cases of IVL at our hospital from October 2013 to January 2020. Five patients had tumors.

DIAGNOSES

The diagnosis in each case was pathologically confirmed after surgical treatment.

INTERVENTIONS

All patients were managed surgically. Although the surgical procedures were different, the surgical approach was geared towards achieving complete excision. Three patients received hormonal therapy with gonadotropinreleasing hormone agonists after surgery.

OUTCOMES

We retrospectively reviewed all medical records and analyzed the clinicopathologic features and clinical outcomes of this disease as well as the correlations between the clinical features and risk of recurrence. Neither the symptoms nor the preoperative imaging results were suggestive of IVL in any of the cases. Except for two patients who were lost to follow-up, twenty-three patients who were followed up are still alive. Three patients experienced a recurrence.

LESSONS

The clinical manifestations and ultrasound images of IVL in the early stages are not typical; thus, IVL is easily misdiagnosed as uterine leiomyoma. Radiologists, pathologists, and surgeons should have a thorough understanding of IVL and a high index of vigilance for IVL in clinical practice. Surgery should always be aimed at achieving complete tumor excision. Patients with large lesions (≥7 cm) and lesions extending to the broad ligament may have an increased risk of recurrence. Early detection, diagnosis, and treatment are very important; once the diagnosis is confirmed, regular follow-ups are crucial.

Coagulation issues in vascular anomalies

Vascular anomalies, comprised of vascular tumors and malformations, are frequently associated with coagulopathy. Recognition of and familiarity with these vascular anomaly-associated hematologic abnormalities prior to surgery or interventional procedures is essential for pre-operative pre-operative planning. Complicated coagulopathies present within the framework of either Kasabach-Merritt phenomenon (KMP) or localized intravascular coagulopathy (LIC), and their management benefits from the expertise of a hematologist for optimal intra- and peri‑operative care. Furthermore, with the recent broadening of understanding of vascular anomalies and the addition of new classification sub-groups, distinctions of these two classic coagulopathy phenotypes have been recognized. This review summarizes the main features of these coagulopathies, described according to their vascular anomaly type, highlighting clinical aspects relevant to surgical management.

Real world clinical practice in treating advanced hepatocellular carcinoma: When East meets West

Background and aims

The Barcelona Clinic Liver Cancer (BCLC) stage C (BCLC C) of hepatocellular carcinoma (HCC) includes a heterogeneous population for which sorafeninb is one of the recommended therapies. We aim to evaluate the real world clinical treatment and survival of BCLC stage C patients in an Asian cohort.

Methods

This is a retrospective cohort study that enrolled 427 consecutive BCLC stage C patients diagnosed between 2011 and 2017 by using the HCC registry data for our hospital. All patients were managed via a multidisciplinary team (MDT) approach.

Results

Hepatitis B surface antigen positive was noted in 50.6% of the patients. The patients were classified as performance status (PS)1 alone (n = 83; 19.4%), PS2 alone (n = 23; 5.4%), or macrovascular invasion (MVI) or extrahepatic spread (EHS) (n = 321; 75.2%). The median overall survival (OS) was 11.0 months in the whole cohort. The most frequent treatments were transcatheter arterial embolization (TAE) in the PS1 (45.8%) and PS2 patients (52.2%) and sorafenib (32.4%) in the MVI or EHS patients. The independent prognostic factors were the PS, Child-Pugh class, MVI or EHS, alpha fetoprotein levels, and treatment type.

Conclusions

We reported the real world management in BCLC stage C patients in an Asian cohort through the use of personalized management via a MDT approach.

Pulmonary intimal sarcoma involving the pulmonary valve and right ventricular outflow tract: A case report and literature review

INTRODUCTION

Pulmonary artery intimal sarcoma (PAIS) is a rare and highly aggressive tumor, and approximately 80% of pulmonary cases occur in the pulmonary trunk. We report herein a case of retrograde extension of the sarcoma to the pulmonary valve and right ventricle, which is an uncommon manifestation of this lethal tumor.

PATIENT CONCERNS

A 41-year-old woman was initially diagnosed with pulmonary thromboembolism (PTE) and transferred to our hospital.

DIAGNOSIS

Computed tomographic pulmonary angiography (CTPA) showed that there are low-density filling defects in both pulmonary arteries, and the patient was diagnosed with PTE. However, the ultrasonographers considered that the lesion is a space-occupying type that involves the right ventricular outflow tract and pulmonary valve instead of PTE. Postoperative pathology confirmed the diagnosis of PAIS.

INTERVENTIONS

The patient underwent resection of pulmonary artery sarcoma and endarterectomy.

OUTCOMES

During the follow-up via telephone 1 month after discharge, the patient reported to have been feeling well.

CONCLUSION

Owing to the rarity of the disease and its non-specific clinical manifestations, approximately half of the PAIS cases are misdiagnosed or have a delayed diagnosis. Thus, improving our understanding of the disease and facilitating its early diagnosis are essential.

Oral and Topical Sirolimus for Vascular Anomalies: A Multicentre Study and Review

Vascular anomalies (VAs) may be associated with significant morbidity and mortality. The aim of this study was to evaluate the efficacy and safety of sirolimus (rapamycin) in the treatment of children and young adults with complicated VAs. A retrospective chart was created that included 19 patients treated with sirolimus for complicated VAs. Concurrently, a search of the PubMed database for VA cases treated with sirolimus was conducted. Descriptive analysis was performed and the efficiency rate of sirolimus was calculated. This retrospective study included 19 patients, 17 of whom were treated with oral sirolimus and 2 with topical sirolimus. Clinical improvement occurred in 15 patients (79%). One patient experienced near-complete resolution. Only 2 patients showed poor response and discontinued treatment. The literature review analysed 150 cases of VA treated with sirolimus. Sirolimus was efficient in 85% of cases, including 5 cases of complete resolution. Sirolimus appears to be an effective and safe treatment for children and young adults with complicated VAs.

[Diagnosis and management of vascular malformations : Interdisciplinary teamwork in demand]

Vascular anomalies are very rare, but can occur in children and adults in almost every region of the body. Due to the complexity of this disease, the path to a definitive diagnosis is often difficult. It requires interdisciplinary teamwork with close exchange of information between the individual treatment partners to reach the correct diagnosis and then to start the best therapy. This article provides an overview of the main types of vascular malformations from a clinical, imaging, and histological point of view, following the current classification of the International Society for the Study of Vascular Anomalies (ISSVA).

Primary pulmonary artery sarcoma with deep vein thrombosis: A case report

RATIONALE

Pulmonary artery sarcomas (PAS) are easily misdiagnosed as thromboembolic disease of pulmonary arteries, because of rarity and presenting with nonspecific signs, symptoms, or imaging findings.

PATIENT CONCERNS

A 26-year-old man was admitted to the department of invasive technology with fever and dyspnea. Blood tests showed inflammatory activity, a slight increase of D-dimer and Fibrin Degradation Product. A chest enhanced computed tomography (CT) scanning revealed multiple filling defects occurred in the main trunk of both pulmonary arteries and branches of the left pulmonary artery DIAGNOSES:: It was initially diagnosed with pulmonary embolism (PE) and deep vein thrombosis (DVT), but was eventually diagnosed with pulmonary artery sarcoma that was confirmed by biopsy.

INTERVENTIONS

The transcatheter thrombolysis therapy, inferior vena cava filter implantation, and operation were performed.

OUTCOMES

The Organized mass was removed by the operation and was pathologically diagnosed as pulmonary artery sarcoma, the patient received postoperative chemotherapy according to the recommendation of oncology department.

LESSONS

Coagulation markers have been reported to differentiate PAS from PE, but this case suggested that PAS can be associated with DVT and abnormal coagulation-fibrinolysis system.

Natural history of leiomyomas beyond the uterus

RATIONALE

Most leiomyomas are located in the uterus. Leiomyomas are rarely found outside the uterus and classified as leiomyoma beyond the uterus (LBU). This group consists of disseminated peritoneal leiomyomatosis, benign metastasizing leiomyoma, intravenous leiomyomatosis, parasite leiomyoma located in the broad ligament and retroperitoneal space. The descriptions of the patients who suffer from these types of leiomyomas are presented mainly in case reports.

PATIENT CONCERNS

A 34-year-old multiparous woman was operated on multiple recurrent uterine leiomyoma in parametrium. At one time, 32 leiomyomas were removed. Thirteen months following it, in next laparotomy, 132 leiomyomas were excised. Histologically, both were intravenous leiomyomas (IVLs).

DIAGNOSIS AND INTERVENTIONS

In follow-up, computed tomography (CT) and magnetic resonance imaging scans were performed to look for next recurrent leiomyoma. Accidentally, the mass was found in inferior vena cava which was diagnosed as intravenous vena cava leiomyoma. The mass was removed and the final diagnosis of intravenous myoma was confirmed in histopathology.

OUTCOMES

CT scan performed 3 months after the surgery for leiomyoma in vena cava revealed no pathology. Next 10 months' follow-up was uneventful.

LESSONS

The recurrent multiple uterine leiomyoma precede LBU. The uterine leiomyoma spreads intravenously route to parametria as parasite leiomyoma, then to vena cava. It has to be taken into account in follow-up.

Epithelioid Hemangioendothelioma Of The Internal Jugular Vein

Ephitelioid Hemangioendothelioma (EHE) is a rare type of tumor with vascular and sarcomatous components. There's only another case published of an internal jugular vein (IJV) EHE. A case of a 50 years-old woman with a palpable and pulsatile mass on the left cervical area is reported. Doppler ultrasound and magnetic resonance imaging showed an IVJ' 4 cm mass. Cytology was inconclusive. Surgical treatment was therefore decided and during surgery a mass inside the left IJV, with local nonsuspicious lymph nodes, was confirmed. The mass was resected including a segmental resection of the IJV and one affected tributary vessel. Lymphadenectomy of the adjacent cervical levels was performed. Histologic examination depicted an EHE without metastatic lymph nodes. Tumor was staged as pT1bN0M0 and a multidisciplinary sarcoma group proposed surveillance. Patient remained well, without evidence of disease and without complications in a twenty-four months follow-up period.

Intraventricular Meningioma Presenting as Lateral Posterior Choroidal Artery Stroke

BACKGROUND

Transient tumor attack is a rare but well-known phenomenon. Described by Ross in 1983, it demonstrated a transient ischemic attack-like picture in patients with intracranial mass lesions. Usually these attacks were recognized at sites anatomically away from the primary lesion that were not explained by primary mass effect of the lesion. The exact pathophysiology of such transient tumor attacks is postulated to be due to either a vascular steal phenomenon or compression of a vessel or localized prothrombotic state.

CASE DESCRIPTION

Here we describe a case who was being evaluated for a lacunar stroke involving the lateral geniculate body, and a surprising finding of left intraventricular meningioma was detected.

CONCLUSIONS

We try to shed some light on the pathophysiology of this unusual phenomenon.

The Molecular Diagnostics of Vascular Neoplasms

In this review, we provide an update of the recently discovered, diagnostically significant genetic aberrations harbored by a subset of vascular neoplasms. From benign (epithelioid hemangioma, spindle cell hemangioma), to intermediate (pseudomyogenic hemangioendothelioma), to malignant (epithelioid hemangioendothelioma, angiosarcoma), each neoplasm features a mutation or gene fusion that facilitates its diagnosis by immunohistochemistry and/or molecular ancillary testing. The identification of these genetic anomalies not only assists with the objective classification and diagnosis of these neoplasms, but also serves to help recognize potential therapeutic targets.

[Surgical treatment of pulmonary trunk malignancy]

Surgical treatment of a patient with primary sarcoma of pulmonary trunk is presented in the article. This rare disease is characterized by poor prognosis if early diagnosis and adequate surgical treatment are absent.

Intravascular large B-cell lymphoma presenting as multiple stroke: A case report

INTRODUCTION

Intravascular large B-cell lymphoma (IVLBCL) is an uncommon disease with a poor prognosis if not diagnosed early. It can present with central nervous system (CNS) manifestations. The diagnosis of IVCBCL is difficult to make given its varied clinical manifestations and the lack of a specific diagnostic modality.

CASE PRESENTATION

We report an interesting case of IVLBCL presenting as bilateral strokes. The diagnosis was made by a random skin biopsy, which confirmed IVLBCL. The patient was treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP).Neurological symptoms improved with R-CHOP. Repeat magnetic resonance imaging (MRI) of the brain showed improvement of the prior lesions.

CONCLUSION

IVLBCL is an aggressive disease with high mortality. Timely diagnosis and treatment can be lifesaving.

Treatment options and outcomes for caval thrombectomy and resection for renal cell carcinoma

OBJECTIVE

Advanced renal cell carcinoma (RCC) has a significant predisposition to vascular invasion. Tumor vascular invasion and thrombus are found in the renal vein and the inferior vena cava (IVC) in up to 10% to 25% of patients. This study reviewed the current status of radical nephrectomy with IVC thrombectomy for advanced RCC.

METHODS

A two-level search strategy of the literature (MEDLINE, PubMed, The Cochrane Library, and Google Scholar) for relevant articles listed between January 2000 and December 2015 was performed. The review was confined to patients with primary RCC associated with vascular invasion.

RESULTS

Untreated RCC with intravascular thrombus has a median survival of 5 months. Surgical exposure and intervention are tailored to the level of tumor thrombus. The 30-day mortality for radical nephrectomy with IVC thrombectomy is low (1.5%-10%), and the complication rates have been reported to be 18%, 20%, 26%, and 47% for IVC tumor thrombus level I, II, III, and IV disease, respectively. Disease-specific survival ranges from 40% to 60% at 5 years after nephrectomy and removal of the intravascular tumor.

CONCLUSIONS

Radical nephrectomy with IVC thrombectomy is an effective cancer control operation that can be safely performed with acceptable mortality and morbidity. Preoperative imaging coupled with perioperative surgical management of the IVC is critical to procedural success and patient outcomes.

Intravascular epithelioid hemangioendothelioma of the femoral vein diagnosed by contrast-enhanced ultrasonography: A care-compliant case report

RATIONALE

Intravascular epithelioid hemangioendothelioma (EHE) is a rare endothelial tumor with an intermediate grade of malignancy. We present a case of one woman affected by EHE of the femoral vein. Contrast-enhanced ultrasonography played a role in diagnosing EHE and helped differentiate it from thrombosis. To our knowledge, this is the first reported contrast-enhanced ultrasonography of intravascular EHE in the imaging literature.

PATIENT CONCERNS

A 46-year-old woman presented to our hospital due to pain and swelling in her right lower limb since 5 years prior to her presentation.

DIAGNOSES

The patient was misdiagnosed as having thrombosis by ultrasound. Contrast-enhanced ultrasonography showed solid lesions with visible blood supply, suggesting angiogenic tumors.

INTERVENTIONS

The patient was treated by complete surgical removal of the mass and postoperative radiotherapy. Pathological examination confirmed the diagnosis of EHE.

OUTCOMES

During follow-up, there were no signs of local or distant relapse.

LESSONS

Intravenous EHE may be misdiagnosed as thrombosis by ultrasound and contrast-enhanced ultrasonography can help make the differential diagnosis.

Vascular Lesions of the Head and Oral Cavity – Diagnosis and Management

Vascular anomalies constitute a diffuse group of conditions which can range in their significance from being completely harmless and of little clinical relevance to being potentially life threatening. It is important that dentists have a good understanding of these conditions so that the risk of potential complications of dental treatment in affected patients is reduced as much as possible. This article focuses on the pathogenesis, diagnosis and treatment of these conditions, with explanation on their relevance to the practising dentist. Clinical relevance: The paper describes several vascular anomalies that may be encountered in clinical practice with information that is relevant to their diagnosis and management.

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.

[Vascular anomalies in the neonatal period]

OBJECTIVE

Vascular anomalies in the neonatal period are a diagnostic challenge for the lack of evident signs, symptoms and follow-up, and the convenience of restricting aggressive diagnostic tests. The aim of this work is to review the characteristics of neonatal cases presented to our Vascular Anomalies Unit in the last 5 years.

MATERIALS AND METHODS

All cases of suspected vascular anomaly presented to our unit before 1 month of age between 2010 and 2015 were reviewed, diagnostic tests and treatments carried out with chronology were analyzed. Presumptive diagnosis and final diagnosis (when available) were compared.

RESULTS

Fifteen vascular tumors were found, 2 with visceral involvement: 6 infantile hemangiomas (IH), 3 NICH, 4 RICH, 1 tufted hemangioma, 1 unspecified liver vascular tumor, 3 venous malformations (2 equivocal MRI and a hyperkeratotic venous malformation), 4 lymphatic malformations, 3 of them macrocystic, and 2 vascular lesions that were diagnosed of fibrosarcoma and sclerema neonatorum and they were not vascular anomalies. Only 3 patients with macrocystic lymphatic malformations had prenatal diagnosis.

CONCLUSION

Accurate diagnosis of vascular anomalies during the first month of life is difficult, even with MRI. Only in a few cases early treatment is needed, so it is worth taking time to follow-up. Different types of treatment (observation, propranolol, biopsy, laser, embolization, and resection) will depend on the condition to be treated. A continuous observation can avoid unnecessary procedures and risks.

Limited Role of Random Skin Biopsy in the Diagnosis of Intravascular Lymphoma in Adult Patients with Hemophagocytic Lymphohistiocytosis

BACKGROUND/AIMS

This study examined the role of random normal skin biopsy in the diagnosis of intravascular lymphoma (IVL) in adult Western patients with clinically diagnosed hemophagocytic lymphohistiocytosis (HLH).

METHODS

In a retrospective chart review study, we analyzed a total of 59 skin biopsies that were performed to diagnose IVL in 21 adult patients with HLH seen at Stanford Hospital between 2004 and 2016.

RESULTS

Out of the 59 skin biopsies, 42 were taken from clinically normal-appearing skin and 17 from clinically abnormal-appearing skin. None of the 59 biopsies revealed a diagnosis of primary or metastatic malignancy, regardless of the malignancy history, clinical presentation, and biopsy and histopathologic characteristics. A review of 8 positive IVL cases at Stanford Hospital including 1 case associated with HLH showed 1 positive diagnosis by a targeted skin biopsy and other positive diagnoses by bone marrow (n = 4), lung (n = 2), brain (n = 2), muscle (n = 1), and nerve (n = 1).

CONCLUSION

Random skin biopsies have a limited role in diagnosing IVL in adult patients with HLH, in the setting of a single academic institution in the USA. A review of the literature emphasizes the role of a full body skin exam with a selective skin biopsy in these patients.

Intravascular large b-cell lymphoma diagnosed via transjugular liver biopsy in a patient with liver dysfunction and thrombocytopenia: A Case Report

RATIONALE

Intravascular large B-cell lymphoma (IVLBCL) is an extremely rare subtype of large B-cell lymphoma characterized by the presence of lymphoma cells within the lumen of small blood vessels. IVLBCL presents with nonspecific symptoms such as fever, weight loss, and bleeding. Because of its rarity and unremarkable clinical presentation, a timely diagnosis is very challenging.

PATIENT CONCERNS

A 71-year-old Korean man complained of fever, but apart from pretibial pitting edema and mild thrombocytopenia, the physical examination and laboratory test findings were unremarkable.

DIAGNOSES

A bone marrow biopsy was also nonspecific. The fever persisted and his thrombocytopenia became more pronounced, prompting further laboratory tests that indicated infiltrative liver disease.

INTERVENTIONS

Because of coagulopathy, a liver biopsy was performed using a transjugular instead of apercutaneous approach.

OUTCOMES

The procedure was performed without complications, and the pathologic examination findings were consistent with IVLBCL. Unfortunately, the patient died because of disease progression before treatment could be administered.

LESSONS

Given that an early diagnosis can affect the prognosis of IVLBCL, quickly and safely obtaining a biopsy specimen is very important. The case presented here shows that a liver biopsy obtained via a transjugular approach is safe and could be preferentially considered when there is a high risk for bleeding complications.

Intravascular Lymphoma: A Diagnostic Challenge

Intravascular large B-cell lymphoma (IVLBCL) is a rare type of extranodal large B-cell lymphoma that selectively affects small and medium-sized bloodvessels in the absence oflymph-adenopathy. The central nervous system (CNS) and skin are the organs most commonly affected. We describe the case of a 64-year-old male who presented to the emergency department (ED) complaining of asthenia and bilateral lower extremity edema that progressed rapidly to anasarca. On presentation, laboratory results were significant for elevated erythrocyte sedimentation rate (ESR) and lactate dehydrogenase (LDH) levels. A skin biopsywas performed, which revealed occlusion of blood vessels by atypical immunophenotype B lymphoid cells within the dermis and subcutaneous tissue. The immuno-histochemistry was consistent with IVLB CL. IVLBCL is an aggressive and rapidly fatal neoplasia with varied and nonspecific clinical manifestations, hence, a diagnostic challenge. This case shows an unusual presentation with asthenia and rapidly progressive edema.

An Autopsy Case of Intimal Sarcoma of the Abdominal Aorta with Bone Metastasis and Lymph Node Metastasis: A Case Report and Review of the Japanese Literature

A 73-year-old man complained of sternoclavicular joint pain; blood tests revealed elevated C-reactive protein. The patient developed delirium; magnetic resonance imaging showed metastatic bone tumors. He died two weeks after admission. Autopsy revealed abdominal aortic intimal sarcoma with metastasis to the peritracheal lymph nodes and sternum. Peripheral arterial embolism and bone metastasis are common symptoms of aortic intimal sarcoma, which implies a place for aortic intimal sarcoma in differential diagnoses of embolism or bone tumors of unknown origin.

Epithelioid hemangioendothelioma of right innominate vein mimics a teratoma: A case report

RATIONAL

Epithelioid hemangioendothelioma (EHE) is a rare neoplasm commonly known to arise from the soft tissue, lung, and liver. EHE arising from right innominate vein (RIV) has scarcely been reported in English literature.

PATIENT CONCERNS

Herein, we present a rare case of EHE of RIV in a 51-year-old woman with right-lower chest pain for 4 days. Computed tomography of the chest revealed a spherical mass with calcification and fatty foci located in the anterior mediastinum, thus a presumptive diagnosis of teratoma was made.

DIAGNOSES, INTERVENTIONS, AND OUTCOMES

Video-assisted thoracoscopic explorations and resection of mediastinal tumor were then performed. The pathological examination showed that the tumor was EHE. Postoperative radiotherapy was delivered to the patient. Pulmonary metastases were found by chest CT a year after surgery.

LESSONS

A diagnosis of EHE might be considered, when a mediastinal tumor closely related to veins showing intratumoral calcification and obvious enhancement, despite the presence of a clear boundary and visible fat content.

Pulmonary Artery Sarcoma Overexpressing Platelet-derived Growth Factor Receptor α

Pulmonary artery sarcoma is highly malignant and easily metastasizes to the systemic organs. Both the introduction of novel diagnostic procedures and the development of new treatment modalities are required to achieve long-term survival. Several studies have shown that platelet-derived growth factor receptor α (PDGFRα) gene amplification is frequently observed in pulmonary artery sarcoma. PDGFRα is known to be involved in cell proliferation in certain malignancies. PDGFRα may become a potential biological marker in pulmonary artery sarcoma. We report a case in which a diagnosis of pulmonary artery sarcoma overexpressing PDGFRα was made using endovascular catheter biopsy following positron emission tomography with integrated computed tomography (PET/CT) scans.

[Leiomyoma of external iliac vein]

Authors present a case report of a patient who was diagnosed with a tumour of external iliac vein. Excision of venous wall with tumour and reconstruction of external iliac vein with venous patch was performed. Postoperative course was without complication. The patient is without complications and also without signs of recurrence in one year follow up. Tumours of venous wall are rare. They originate from vena cava inferior, less often from extremity veins. The most frequent primary tumours of vein wall are leiomyosarcomas. Secondary tumours that involve venous wall are more common than primary tumours. Primary renal carcinoma or sarcomas of retroperitoneum represent a tumour that invades vena cava inferior. The diagnosis is based on CT and MRI. Surgical resection remains the mainstay of treatment. Chronic well collateralized obstruction is not necessary to reconstruct. Vena cava inferior and iliac veins are reconstructed with PTFE graft. Extremity veins are reconstructed using venous graft from great saphenous vein. Perioperative mortality after resection of vena cava inferior and pelvic veins is up to 6.9% major morbidity up to 33% and a fiveyear survival up to 52%. Patients with infrarenal involvement of vena cava have better outcomes than patients with involvement of retrohepatal vena cava inferior.Key words: venous tumour leiomyoma of venous wall.

Renal Intravascular Large B-cell Lymphoma: A Case Report and Review of the Literature

We herein report the case of a 52-year-old woman who consulted us because of a 2-month history of a fever, anorexia and weight loss. A physical examination was unremarkable. The blood count showed mild anemia and lymphopenia, and lactate dehydrogenase was elevated. Creatinine clearance was normal and proteinuria was undetectable. CT showed enlarged kidneys. A bone marrow biopsy was normal. PET-CT showed an intense uptake of ¹⁸fluorodeoxyglucose in both kidneys. A kidney biopsy provided the diagnosis of intravascular large B-cell lymphoma (IVLBCL). Kidney-limited IVLBCL without an impairment in the renal function or proteinuria has not been described. We analyzed the 38 published cases of IVLBCL involving the kidney to describe the main features of this entity.

Angiosarcoma of the pulmonary trunk mimicking pulmonary thromboembolic disease: A case report

We report on a 59-year-old male patient who suffered from dyspnea, cough and hemoptysis. Initial chest X-ray revealed a prominent right pulmonary artery (RPA) and MR imaging showed a “filling defect” within the main pulmonary trunk and RPA indicating pulmonary thromboembolic disease. Despite systemic anticoagulation, symptoms progressed. Follow-up CT showed an enlarging “filling defect” with additional extension into the left pulmonary artery as well as multiple intrapulmonary nodules. Lesion biopsy revealed a pulmonary artery angiosarcoma. Imaging findings are presented. Our case illustrates that pulmonary artery angiosarcoma should be included in the differential diagnosis of pulmonary thromboembolic disease in cases where a) symptoms do not respond to anticoagulation, b) no source of thrombi/emboli can be detected and c) pulmonary nodules/metastases develop on follow-up.

Intravascular lymphoma in a patient with systemic lupus erythematosus: a case report

Intravascular lymphoma IVL is a rare and aggressive disorder characterized by proliferation of large lymphoid cells (most commonly B-cells) within the lumen of small vessels of nearly every organ. Obliteration of vessels leads to the different clinical signs, being cutaneous lesions and neurological signs the most frequent presentations, whereas lymph node and reticuloendothelial system involvement is typically absent.1—4 No association with SLE has been described up to the present. We report a case of IVL in a patient with systemic lupus erythematosus (SLE) involving skin, central nervous system (CNS) and bone marrow. Lupus (2007) 16, 525—528.

An Autopsy Case of Aortic Intimal Sarcoma Initially Diagnosed as Polyarteritis Nodosa

A 61-year-old man had hypertension with stenosis in the left renal artery. When his fever, abdominal pain, and renal dysfunction progressed, he was admitted to our hospital. He was diagnosed with polyarthritis nodosa. His renal function rapidly deteriorated despite immunosuppressive therapy. His digestive tract perforated twice, and he subsequently died. An autopsy revealed that aortic intimal sarcoma caused stenosis in multiple arteries. Both polyarteritis nodosa and aortic intimal sarcoma are very rare diseases and the diagnoses are very difficult. It is very important to consider these entities when making a differential diagnosis of vasculitis.

Cardiovascular involvement by osteosarcoma: an analysis of 20 patients

BACKGROUND

Although hematogenous spread of osteosarcoma is well known, the imaging findings of cardiovascular involvement by osteosarcoma are seldom reported and can be difficult to recognize. The enhanced resolution of modern CT and MRI scanners may lead to better detection of cardiovascular involvement.

OBJECTIVE

To describe the key imaging findings and clinical behavior of cardiovascular involvement by osteosarcoma.

MATERIALS AND METHODS

We retrospectively reviewed the imaging findings and clinical characteristics of 20 patients with cardiovascular involvement by osteosarcoma identified by two pediatric radiologists from a review of imaging studies at our institution from 2007 to 2013.

RESULTS

At initial diagnosis, the median age of the patients was 15.1 years (range 4.8-24.6 years), and 7 (35%) patients had detectable metastases. Median time to detection of cardiovascular metastases was 1.8 years (range 0-7.3 years). Sixteen patients died of disease; 4 have survived a median of 7.4 years since initial diagnosis. The sites of cardiovascular involvement were the systemic veins draining the primary and metastatic osteosarcoma, pulmonary arteries, pulmonary veins draining the pulmonary metastases, and heart. A dilated and mineralized terminal pulmonary arteriole is an early sign of metastatic osteosarcoma in the lung. Unfamiliarity with the imaging features resulted in under-recognition and misinterpretation of intravascular tumor thrombus as bland thrombus.

CONCLUSION

Knowledge of imaging findings in the era of modern imaging modalities has enhanced our ability to detect cardiovascular involvement and lung metastases early and avoid misinterpreting tumor thrombus in draining systemic veins or pulmonary arteries as bland thrombus.

[A Case of Intravascular Lymphoma Mimicking Acute Sinusitis in Which the Outcome was Unfortunate]

Intravascular large B-cell lymphomas (IVLBCL) are a rare and aggressive non-Hodgkin Lymphoma characterized by proliferation of malignant lymphoid cells into the small blood vessels of the whole body. Making a diagnosis is very difficult due to the lack of mass formation and lymph node enlargement, resulting in a poor prognosis. We report herein on a case of IVLBCL which was proved by a biopsy of the nasal mucosa during endoscopic sinus surgery. A 77-year-old woman was admitted with complaints of headache, rhinorrhea, and fever. Computed tomography showed a shadow in the ethmoid sinus on both sides but without polyps. We suspected acute sinusitis and started therapy, however, high fever persisted with worsening of the patient's general condition. Pathological analysis of biopsy specimens from the nasal cavity and sinuses revealed proliferation of malignant lymphoid cells into the small blood vessels and the final diagnosis was IVLBCL. Chemotherapy was initially effective for her general condition but she died 13 months after the first visit. It is important to suspect IVLBCL, if there is any deterioration of the patient's general condition and persistence of the disease against treatment. The nasal cavity is recommended as a site of random biopsy because of its rich population of small blood vessels.

Diagnostically Challenging Epithelioid Vascular Tumors

The diagnosis of vascular tumors is a challenging area in soft tissue pathology. Epithelioid vascular tumors pose a particular challenge. Due to the epithelioid morphology of the tumor cells, they can be misdiagnosed as a variety of other entities, including metastatic carcinoma or epithelioid sarcoma. Furthermore, it can be difficult to distinguish between different epithelioid vascular tumors. This review focuses on vascular tumors characterized by epithelioid endothelial cells, including epithelioid hemangioma, cutaneous epithelioid angiomatous nodule, epithelioid hemangioendothelioma, epithelioid sarcomalike hemangioendothelioma/pseudomyogenic hemangioendothelioma, and epithelioid angiosarcoma.

[Retrospective analysis of management for primary leiomyosarcoma of inferior vena cava]

OBJECTIVE

To study the treatment strategy and survival of patients with primary leiomyosarcoma of inferior vena cava (PIVCLMS).

METHODS

Clinical data of 12 cases with PIVCLMS admitted in Peking University People's Hospital from January 2006 to September 2014 were reviewed retrospectively. All cases were confirmed by pathology examination. Among them, there were 4 male and 8 female patients with a mean age of (54 ± 9) years old. Tumors arose from the inferior vena cava (IVC) upper segment in 5 patients, from the middle in other 7 patients. Cardiac extension was observed in 4 cases. Tumor resection was undertaken in 8 patients, the other 4 patients were inoperable. The series was analyzed to identify clinical outcome of surgical strategy and protective factors for patient survival.

RESULTS

In tumor resection group, 6 patients had radical resection and 2 underwent palliative resection. As for IVC reconstruction, caval wall resection with a direct suture was carried out in 6 patients or with prosthetic patch in 1 patient. The other 1 patient underwent a segment caval resection and prosthetic graft replacement in situ. In 4 cases of suprahepatic PIVCLMS cardiopulmonary bypass or perfusion by right atrial intubation was performed to assist bleeding control and maintain circulation stabilization, among them 1 patient survived for more than 101 months with no tumor recurrence or metastasis. Among the patients submitted to tumor resection 2 early postoperative deaths occurred, and another 2 patients had complications. All 4 patients submitted to non-resective operation (only neoplasm biopsy) died of PIVCLMS within 8 months. Except for 2 cases of early death, mean survival after tumor resection was (54 ± 40) months. Two patients presented local recurrence and hepatic metastasis at follow-up of 16 months and 68 months.

CONCLUSIONS

Tumor resection is the only therapy for PIVCLMS with an expectation for long-term survival. The applicant of cardiopulmonary bypass makes some inoperable indicated to tumor resection.