Clinical Features and Outcomes of Pulmonary Artery Sarcoma

Pulmonary artery intimal sarcoma mimicking pulmonary thromboembolism: A case report and literature review

Pulmonary artery intimal sarcoma (PAIS) is a rare and highly aggressive form of hemangiosarcoma. The non-specific clinical manifestations, signs and routine imaging findings of this sarcoma often mimic those of pulmonary thromboembolism (PTE), resulting in frequent misdiagnosis as PTE prior to pathological confirmation in most patients. This delay in achieving an accurate diagnosis poses challenges for promptly initiating optimal treatment and further contributes to the unfavorable prognosis. The current study presents the case of a 68-year-old female who presented with acute chest tightness and dyspnea. Transthoracic echocardiography revealed the presence of atypical echogenic structures within the primary pulmonary artery, while computed tomography pulmonary angiography showed marked filling defects in the main trunk and branches of the pulmonary artery. The patient was initially misdiagnosed with PTE but did not respond well to anticoagulant therapy. Subsequent surgical resection confirmed the diagnosis of PAIS through pathological examination. Despite postoperative treatment with molecular-targeted antitumor drugs, the patient experienced tumor recurrence and intrapulmonary metastasis, ultimately succumbing to disease progression. This exceptional case is being presented to enhance the clinical understanding of PAIS, to encourage further extensive research for reliable diagnostic approaches and to provide further data that will help form efficacious therapeutic strategies to ameliorate the unfavorable prognosis of affected patients.

Clinical manifestations and misdiagnosis factors of pulmonary embolism patients seeking treatment in cardiology

To explore the clinical manifestations and factors leading to misdiagnosis in pulmonary embolism (PE) patients in a cardiology department. We retrospectively analyzed 74 patients diagnosed with PE at our hospital from March 2018 to March 2022, comparing them to 136 patients suspected of PE but excluded by computed tomography pulmonary angiography during the same period. Both groups received the same basic care, including disease counseling, nutritional planning, and monitoring. We compared general information, clinical manifestations, risk factors, and auxiliary examinations to identify correlations between specific manifestations and misdiagnosis factors. The male-to-female ratio in the PE group was approximately 3:4, which was statistically significant compared to the control group (P < .05), though its impact on PE incidence was low. Common symptoms in the PE group included chest tightness, shortness of breath, sweating, and chest pain, with no significant difference from the control group (P > .05). Notable risk factors included deep vein thrombosis (DVT) (43.24%), prolonged bed rest (32.43%), lower limb varicose veins (18.92%), trauma (21.62%), pulmonary infections (62.16%), coronary heart disease (37.84%), respiratory failure (32.43%), and chronic obstructive pulmonary disease (13.51%). DVT was significantly associated with PE (P < .05). Multivariate logistic regression identified DVT (OR = 118.528, 95% CI: 6.959-2018.906, P = .001) and lower limb varicose veins (OR = 212.766, 95% CI: 6.584-6875.950, P = .003) as independent predictive factors for suspected PE. Clinical manifestations strongly correlated with PE included pulmonary rales, cyanosis, tachycardia, hypotension, elevated D-dimer, positive N-terminal pro-brain natriuretic peptide, and sinus tachycardia on echocardiogram. PE in cardiology patients may present with pulmonary rales, hypotension, shortness of breath, and abdominal symptoms, warranting reexamination for PE. Misdiagnosis factors typically involve chest pain, tightness, and shortness of breath. Lower limb varicose veins and DVT are reliable predictors of suspected PE.

Emerging multimodality imaging techniques for the pulmonary circulation

Pulmonary hypertension (PH) remains a challenging condition to diagnose, classify and treat. Current approaches to the assessment of PH include echocardiography, ventilation/perfusion scintigraphy, cross-sectional imaging using computed tomography and magnetic resonance imaging, and right heart catheterisation. However, these approaches only provide an indirect readout of the primary pathology of the disease: abnormal vascular remodelling in the pulmonary circulation. With the advent of newer imaging techniques, there is a shift toward increased utilisation of noninvasive high-resolution modalities that offer a more comprehensive cardiopulmonary assessment and improved visualisation of the different components of the pulmonary circulation. In this review, we explore advances in imaging of the pulmonary vasculature and their potential clinical translation. These include advances in diagnosis and assessing treatment response, as well as strategies that allow reduced radiation exposure and implementation of artificial intelligence technology. These emerging modalities hold the promise of developing a deeper understanding of pulmonary vascular disease and the impact of comorbidities. They also have the potential to improve patient outcomes by reducing time to diagnosis, refining classification, monitoring treatment response and improving our understanding of disease mechanisms.

Pulmonary artery intimal sarcoma: Case report of a patient managed with multimodality treatment and a comprehensive literature review

Pulmonary artery intimal sarcoma (PAIS) is a rare and aggressive malignancy originating from the intimal layer of the pulmonary artery with poor prognosis due to its aggressive nature. The management of PAIS poses both diagnostic and therapeutic challenges. It presents with nonspecific symptoms and is often misdiagnosed as pulmonary embolism. While surgical resection is the primary treatment modality, the role of adjuvant chemotherapy and radiotherapy remains uncertain. However, given the high recurrence rate, adjuvant chemotherapy and/or radiotherapy have been utilized in a limited number of case reports. We present the case of a 46-year-old woman who was diagnosed with PAIS and underwent surgical resection followed by adjuvant chemotherapy (ChT) and radiotherapy (RT), demonstrating good tolerance to this multimodal treatment approach.

Outcomes of pulmonary endarterectomy for patients with pulmonary artery sarcoma

Objective

Pulmonary artery sarcoma (PAS) is an exceedingly rare and insufficiently investigated disease, leading to uncertain in its optimal management. This study aims to present our institutional experience and the outcomes of pulmonary endarterectomy for PAS.

Methods

We gathered clinical characteristics, intraoperative data, postoperative outcomes, and prognosis information from PAS patients who underwent surgical treatment at our institution between December 2016 and September 2023.

Results

A total of 20 patients with PAS underwent pulmonary endarterectomy. The median age of the patients was 52 (IQR 45, 57) years, with 12 patients (60%) being female. Intimal sarcoma was confirmed in 19 patients, while the remaining one was diagnosed with large cell neuroendocrine carcinoma. The perioperative mortality rate was three cases (15%). Follow-up was conducted for a median duration of 14 months (range: 1-61). During the follow-up period, 11 patients experienced recurrence or metastasis, and 5 patients succumbed to the disease. The estimated cumulative survival rates at 1 and 2 years for all 20 patients were 66.4% and 55.3%, respectively.

Conclusion

Pulmonary endarterectomy emerges as a palliative but effective approach for managing PAS, particularly when complemented with postoperative therapies such as chemotherapy and targeted therapy, which collectively contribute to achieving favorable long-term survival outcomes.

Massive primary pulmonary artery rhabomyosarcoma: A case report

BACKGROUND

Pulmonary artery sarcomas (PAS) are rare tumours causing an insidiously progressive obstruction of the pulmonary circulation. The clinical presentation is often indistinguishable from chronic thromboembolic pulmonary hypertension (CTEPH). However, the atypical appearance of a heterogeneous filling defect in CT pulmonary angiography (CTPA) should prompt further investigation.

CASE PRESENTATION

A previously healthy young man presented with massive haemoptysis, acute respiratory distress, and progressive exertional dyspnea since the year before. Echocardiography demonstrated severe right ventricular dysfunction and highly probable pulmonary hypertension. CTPA revealed an extensive filling defect with an appearance concerning PAS. Due to syncopal episodes at rest, the patient underwent urgent pulmonary artery endarterectomy (PEA). A massive tree-like tumour was excised as a result. Post-operatively, reperfusion injury and refractory pulmonary oedema mandated extracorporeal membrane oxygenation (ECMO). Unfortunately, ECMO was complicated with massive haemolysis and acute kidney injury. The patient succumbed to multi-organ failure. Through tissue analysis established a diagnosis of embryonal rhabdomyosarcoma.

DISCUSSION

Unfortunately, the patient had not reached out for his worsening dyspnea. PASs should not be mistaken for a thrombus and anticoagulation should be avoided. The urgent condition precluded biopsy and tissue diagnosis. Similarly, neoadjuvant chemotherapy was not feasible. Post-operatively, reperfusion injury and pulmonary oedema ensued, which mandated ECMO. This complication should be anticipated preoperatively. There is a need for more data on PASs to establish a consensus for management.

Clinical utility of 18F-FDG PET/CT imaging in patients with pulmonary artery sarcoma

Background

Pulmonary artery sarcoma (PAS) is a rare and fatal malignancy. Due to the lack of specific clinical and radiological features, PAS is always misdiagnosed as pulmonary thromboembolism (PTE). This study aimed to investigate ¹⁸F-FDG PET/CT in distinguishing PAS from PTE, and analyze its correlation with clinical and radiological findings and outcome of PAS.

Methods

Clinical, contrast-enhanced CT, and ¹⁸F-FDG PET/CT characteristics of 14 patients with PAS and 33 patients with PTE were retrospectively reviewed. The correlation between PET/CT metabolic parameters vs. clinical and CT findings was investigated in patients with PAS. The overall survival (OS) was analyzed in PAS patients.

Results

The SUVmax of PAS (median: 8.0, range 3.0–17.2) was significantly higher than PTE (1.8[0.8–3.7]) (P < 0.001), and at a cutoff value of 2.9, the sensitivity and specificity were 100.0% and 93.9%, respectively. Compared with PTE, PAS more frequently occurred in younger population (P = 0.011), involved pulmonary trunk (P < 0.001), and displayed higher enhanced CT (P < 0.001) and ΔCT (enhanced CT compared to non-enhanced CT) (P < 0.001) values. SUVmax of PAS was associated with tumor staging (P = 0.022) and enhanced CT (P = 0.013) and ΔCT (P = 0.005) values. The median OS of PAS patients was 10.5 months, and 12-month and 24-month OS rates were 58.0% and 12.0%, respectively. Only D-dimer level (P = 0.038) and tumor staging (P = 0.019) were associated with OS.

Conclusions

Most PAS displayed high glucometabolism, and SUVmax of ¹⁸F-FDG PET/CT was useful in distinguishing PAS from PTE.

Pulmonary artery sarcoma: An important mimic of pulmonary embolism-Case reports and literature review

Pulmonary artery intimal sarcoma (PAIS) is a rare malignancy which closely mimics acute or chronic pulmonary thromboembolism. There are clinical and radiological characteristics which may raise suspicion of this important differential diagnosis. These include disproportionately low d-dimer, troponin T or NT-proBNP, as well as characteristic findings on CT pulmonary angiography such as the 'wall eclipsing sign' and an non-dependent position of filling defects in the large arteries. Prompt diagnosis avoids inappropriate anticoagulation and facilitates early surgical management which may improve prognosis. There is emerging evidence of an effective treatment paradigm with surgical resection and adjuvant chemotherapy. We present two cases of PAIS diagnosed at a single centre within a 2-year period. We review the literature and demonstrate the features at presentation in our cases which were suggestive of the diagnosis.