Primary pulmonary-artery sarcoma. Report of a case with complete resection and graft replacement, and review of 47 surgically treated cases reported in the literature

Leiomiossarcoma primário do pulmão - Relato de Caso

O leiomiossarcoma primário do pulmão é considerado uma entidade extremamente rara. Os achados radiológicos bem como a sua apresentação clínica não são patognomônicos. Ao contrário do carcinoma brônquico mantém-se confinado ao pulmão por muito mais tempo. A metastização ocorre tardiamente e em menos de 1/3 dos casos. O tratamento de eleição é a cirurgia. Os autores apresentam um caso de uma doente de 50 anos de idade com o diagnóstico de leiomiossarcoma do pulmão de alto grau de malignidade, seu prognóstico, tratamento e evolução.

Value of 18F-FDG PET/CT in differentiating malignancy of pulmonary artery from pulmonary thromboembolism: a cohort study and literature review

To determine the value of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in differentiating malignancy of pulmonary artery (PA) from pulmonary thromboembolism (PTE) based on a larger number of cases by pooling our cases and those from the literature. Consecutive patients with a PA lesion who had undergone ¹⁸F-FDG PET/CT in our hospital were retrospectively reviewed. Moreover, PubMed, Embase, and Medline were searched for literature reporting individual maximum standardised uptake value (SUV_max) of the malignant PA lesion and/or PTE. ¹⁸F-FDG activity was compared between PA malignancy and PTE by pooling the data from literature and our patients. Receiver operating characteristic curve analysis was performed to determine the ability of SUV_max to differentiate PA malignancy from PTE. From our database, we identified 11 patients with pulmonary artery sarcoma (PAS), and nine cases of PTE. Fifty patients with a malignant PA lesion (40 cases of PAS and 10 cases of tumor embolism) and 22 subjects with PTE were extracted from the literature. In our cases, the SUV_max of PAS (11.1 ± 4.9, range: 5.5-19.9) was significantly higher than that of PTE (1.9 ± 0.6, range: 1.1-3.2; P < 0.001). There was no significant difference in the SUV_max between the literature data and our cases in malignant lesions or in PTE. Based on the pooled analysis of the literature data and our cases (61 cases of malignant lesions and 31 cases of PTE), the area under the curve for SUV_max to differentiate PA malignancy from PTE was 0.996 (95% CI: 0.989-1.000). At a cutoff value of 3.3, the sensitivity, specificity, and accuracy were 98.4%, 96.8%, and 97.8%, respectively. The ¹⁸F-FDG uptake value is an accurate index for determining PA malignancy.

Primary pulmonary artery sarcoma: a close associate of pulmonary embolism-20-year observational analysis

BACKGROUND

Primary pulmonary artery sarcoma (PPAS) is a rare tumor that mimics pulmonary thromboembolism (PE). Similarities to PE can delay the diagnosis and misguide the treatment of PPAS. This study aimed to evaluate tumor characteristics and outcome predictors among those diagnosed with PPAS and misdiagnosed as PE.

METHODS

From 1991-2010, 10 PPAS cases were available from the Cleveland Clinic (CC) institutional database and another 381 cases were reported in the literature. Patient characteristics, tumor subtypes, diagnostic testing & timing, interventions and clinical outcomes were analyzed. We also noted effects of misdiagnosis as PE and clinical outcome as a result of inappropriate intervention.

RESULTS

Among 391 confirmed cases of PPAS, the mean age at diagnosis was 52±14 years; 55% were male. The median duration of symptoms prior to diagnosis was 100 [interquartile range (IQR), 30-210] days. Nearly half (47%) of PPAS were originally misdiagnosed as PE including 39% that received thrombolytic and/or anticoagulation therapy. For every doubling of time from symptom onset to diagnosis, the odds of death increased by 46% (OR: 1.46, 95% CI: 1.21-1.82; P<0.001). The odds of death (OR: 2.66, 95% CI: 1.58-4.54; P=0.0003) and occurrence of distant metastasis (OR: 2.30, 95% CI: 1.30-4.15; P=0.049) were increased among those who did not receive chemotherapy but chemotherapy did not impact local recurrence. Those with complete resection had a better survival.

CONCLUSIONS

PPAS has a radiological appearance similar to PE, which makes accurate and timely diagnosis challenging. More rapid diagnosis may lead to earlier, appropriate surgical treatment and improved outcomes, when combined with adjuvant treatment.

Treatment of a recurrent pulmonary artery leiomyosarcoma with a combination of surgery, chemotherapy, and radiotherapy: A case report and literature review

Pulmonary artery (PA) leiomyosarcoma (PAL) is a rare but extremely malignant tumor of the cardiovascular system, which is often misdiagnosed as pulmonary thromboembolism. Although the early detection and surgical resection improves patient survival, the benefits of adjuvant therapy are not well understood. The current study presents the case of a patient with primary PAL who underwent surgical resection along with three courses of chemotherapy. Despite these interventions, the patient experienced recurrence of the PAL within four months following treatment. The patient received localized radiotherapy and subsequently achieved a stable disease state. This case indicates that radiotherapy may offer a benefit to PAL patients, particularly those who do not respond to chemotherapy.

Management of primary pulmonary artery sarcomas

The objective of this review is to determine the outcome of patients with sarcomas involving the main pulmonary artery, pulmonic valve, or right ventricular outflow tract. Survival data were analyzed using an aggregate series derived from the published literature in conjunction with a current series. Median survival was 36.5 +/- 20.2 months for patients undergoing an attempt at curative resection compared with 11 +/- 3 months for those undergoing incomplete resection. Median survival was 24.7 +/- 8.5 months for patients undergoing multimodality treatment compared with 8.0 +/- 1.7 months for patients having single-modality therapy. A complete review of diagnosis, evaluation, treatment, and surveillance of primary pulmonary artery sarcomas follows.

Stenting for pulmonary artery stenosis due to a recurrent primary leiomyosarcoma

PURPOSE

To report stent implantation for a malignant obstruction within the pulmonary artery (PA) caused by a recurrent leiomyosarcoma in the pulmonary trunk.

CASE REPORT

A 62-year-old man with a non-metastatic primary leiomyosarcoma of the right PA underwent pneumectomy of the right lung and postoperative radiotherapy in 1994. Six years later, he presented with symptoms of progressive right ventricular dysfunction. Computed tomography (CT) identified a high-grade stenosis of the left PA due to recurrent tumor within the pulmonary trunk extending into the left PA. Transthoracic ultrasound documented severe pulmonary hypertension with a high pressure gradient across the stenosis. A stent was deployed percutaneously, successfully establishing PA patency. Pressure measurements showed a significantly reduced gradient across the stented area. In follow-up, the patient reported subjective improvement of symptoms; CT scans revealed a fully patent stent. His status remained stable 11 months after stent implantation.

CONCLUSIONS

PA leiomyosarcoma is a rare and highly malignant tumor. In most cases, surgery can only prolong survival for the short term. Palliative interventional PA stenting performed under local anesthesia can offer improvement in quality of life by reducing excessive pulmonary hypertension.

Surgical treatment of pulmonary artery sarcoma

OBJECTIVE

Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delayed in most cases. Newer imaging techniques could allow early diagnosis in patients with symptoms of pulmonary vascular obstruction. Surgical resection improves clinical symptoms and offers the only chance of cure. We report the case histories of 7 patients with primary pulmonary artery sarcomas treated by surgical resection with or without adjuvant therapy.

METHODS

Seven patients (3 women and 4 men; mean age, 52.3 years; preoperative New York Heart Association functional class III/IV, n = 5/2) underwent operations. Malignancy was preoperatively suspected in 5 patients, and 2 patients had a presumptive diagnosis of chronic pulmonary embolism. Tumor resection with partial or total prosthetic replacement (n = 2), reconstruction (n = 5), or both, of central parts of the pulmonary arteries was performed in 6 patients. Thromboendarterectomy was necessary in 4 patients, and pneumonectomy was necessary in 2 patients. Six patients received adjuvant therapy.

RESULTS

There was no perioperative mortality. All patients had a substantial improvement in exercise tolerance and hemodynamics 3 months after their operations. Four patients died 7, 9, 18, and 19 months after their operations because of recurrent tumor or pulmonary metastases. Two patients are alive 21 and 35 months after primary surgical repair, with pulmonary metastases detected by computed tomographic scans. One patient is alive 62 months after resection without clinical or radiologic signs of tumor recurrence or metastasis.

CONCLUSIONS

Early diagnosis of primary pulmonary artery sarcomas can be improved by computed tomography and magnetic resonance scanning. Radical surgical resection probably presents the only chance for cure. The role of neoadjuvant or adjuvant treatment modalities has to be defined. Pulmonary artery sarcoma need not necessarily be a fatal diagnosis.

Complete resection of cardiac leiomyosarcoma extending into the pulmonary trunk and right pulmonary artery

A cardiac leimyosarcoma is an extremely rare tumor. We report a case of complete resection of a cardiac leiomyosarcoma extending into the pulmonary trunk and the right pulmonary artery using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, MN) and Xenomedica graft (Baxter Healthcare Corp, Horw, Switzerland). Extensive resection and reconstructive surgery with the addition of radiotherapy prolonged the patient's life.

Death due to a leiomyosarcoma of the pulmonary artery

Leiomyosarcomas of the pulmonary arteries are rare neoplasms seldom diagnosed during the patient's lifetime. We report a case of unexpected death in a 44-year-old man due to a leiomyosarcoma originating from the main pulmonary trunk and involving the right and left arteries as far as the lobar ramifications. The patient died after a 2-year history of bronchiectasis and chronic bronchopneumonia with weight loss and occasional episodes of syncope during the last 4 months. Immunohistochemical demonstration for alpha-smooth muscle actin was necessary to make a histological diagnosis of leiomyosarcoma. A review of pulmonary artery leiomyosarcomas is also presented.