Pulmonary artery sarcoma mimicking pulmonary embolism

Primary pulmonary artery sarcoma in the pediatric patient: Review of literature and a case report

Primary pulmonary artery sarcoma (PAS) is extremely rare in children. Nevertheless, distinguishing primary PAS from pulmonary embolism is critical to a child's survival. Primary PAS is commonly misdiagnosed as a pulmonary embolism due to similar presenting symptoms and radiographic findings. However, compared to adults, pulmonary embolism is rare in children, especially in patients who do not have predisposing factors or hypercoagulable state. We present a child with primary PAS which mimicked pulmonary embolism on presentation but eventually was resected and is doing well 5 years after resection. In the absence of predisposing factors or hypercoagulable state, solid tumors such as primary PAS should be considered when assessing a pediatric patient with presumed pulmonary embolism.

A comprehensive review on the diagnosis and management of intimal sarcoma of the pulmonary artery

Only a few hundred cases of intimal sarcomas of pulmonary artery (ISPA) were reported on the literature. Diagnosis of this rare entity is a challenging dilemma with the need for a high expertise in the radiological and pathological identification of ISPA. Treatment strategies rely initially on an early aggressive surgery aiming for complete surgical resection with clear margins while no clear recommendations guiding the choice for additional drug therapy or radiotherapy exist. In this article, we perform an extensive review of the literature on ISPA with details on the clinical presentation, diagnosis and management strategies. An additional goal of this paper is to make practicing oncologists aware of this rare entity with clear idea on the initial management.

Intraluminal Arterial Filling Defects Misdiagnosed as Pulmonary Emboli: What Else Could They Be?

Pulmonary artery filling defects can be observed in various pathologic processes other than pulmonary embolism, for example, nonthrombotic pulmonary embolism with biological and nonbiological materials and intrinsic pulmonary artery lesions. They have also been described in rare conditions, such as fibrosing mediastinitis and congenital absence or stenosis of pulmonary artery, and some pulmonary parenchymal and airway malignancies. Misdiagnosis is common owing to the relative rarity of these conditions. Correct diagnosis is based on the appropriate clinical suspicion considering the unique clinical features, laboratory findings, and additional radiologic clues inferring a pathology other than pulmonary embolism.

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.

Pseudo pulmonary embolism in cancer patients: a new clinical syndrome

To characterize the clinical features of oncology patients presenting with shortness of breath mistakenly diagnosed at first with pulmonary emboli, but later found instead to have extrinsic compression of the pulmonary artery or its tributaries by tumor. Medical charts and computed tomography (CT) angiographies of these patients were reviewed retrospectively. In a 7-year period, 11 patients from a single institute were identified. Five patients were excluded as they had a pleural and pericardial effusion that by itself could result in dyspnea. All had varied solid tumors and none had lymphoma. In three of six patients, an increased ratio between right and left ventricle was detected by CT angiography; however, in contradistinction to patients with pulmonary emboli, this was not found to be associated with short survival. The term 'pseudo pulmonary emboli' is suggested to describe this phenomenon. Anticoagulant treatment to avoid in-situ pulmonary artery thrombosis may be considered; however, misdiagnosis of pulmonary embolism may delay the appropriate treatment with chemotherapy, biological therapy, and radiotherapy.

A case of pulmonary artery sarcoma presented as cavitary pulmonary lesions

Pulmonary artery sarcoma (PAS) is a rare, poorly differentiated malignancy arising from the intimal layer of the pulmonary artery. Contrast-enhanced chest computed tomography (CT) is a good diagnostic modality that shows a low-attenuation filling defect of the pulmonary artery in PAS patients. An 18-year-old man was referred to our hospital for the evaluation and management of cavitary pulmonary lesions that did not respond to treatment. A contrast-enhanced CT of the chest was performed, which showed a filling defect within the right interlobar pulmonary artery. The patient underwent a curative right pneumonectomy after confirmation of PAS. Although lung parenchymal lesions of PAS are generally nonspecific, it can be presented as cavities indicate pulmonary infarcts. Clinicians must consider the possibility of PAS as well as pulmonary thromboembolism in patients with pulmonary infarcts. So, we report the case with PAS that was diagnosed during the evaluation of cavitary pulmonary lesions and reviewed the literatures.

Transthoracic echocardiographic assessment of spindle cell sarcoma of the pulmonary artery in a child

In this report, we present a case of spindle cell sarcoma of the pulmonary artery diagnosed by transthoracic echocardiography. To the best of our knowledge, this case is the youngest reported case of pulmonary artery sarcoma (PAS) to date. PAS is frequently confused for pulmonary embolism; in this case, echocardiographic findings allowed for differentiation between pulmonary embolism and solid tumor.

Pulmonary Hypertension due to a Pulmonary Artery Leiomyosarcoma: A Case Report

Background. Primary pulmonary artery sarcomas are very rare and their histologic type, called leiomyosarcoma, is even rarer. Case Report. A 64-year-old woman presented with progressive weakness, fatigue, malaise, and dyspnea, and a marked elevation of pulmonary artery pressure was admitted. She was initially diagnosed with chronic pulmonary thromboembolism and chest computed tomography (CT) scan revealed that lobulated heterogeneous left hilar mass extended to precarinal and subcarinal space. MRI demonstrated a polypoid lesion at trunk with extension to left main pulmonary artery and its first branch. She was operated, a yellowish-shiny solid mass in pulmonary trunk was seen intraoperatively, and pulmonary endarterectomy was performed. Her tumor was pathologically diagnosed as pulmonary artery leiomyosarcoma. She died 3 months later after one chemotherapy course. Conclusion. Initially, the patient underwent surgery due to pulmonary embolism but, during the operation, the observed mass increased the probability of pulmonary artery neoplasm. Clinicians must consider pulmonary artery sarcoma when making the differential diagnosis for patients with pulmonary arteries masses. In addition to clinical prediction scores and CT and MRI findings to identify the patients with pulmonary artery sarcoma, PET scanning is the diagnosis of choice in differentiating embolism and neoplasm and is strongly recommended in these patients.

Intima sarcoma of the pulmonary artery mimicking takayasu disease

Pulmonary artery intima sarcoma is an uncommon but fatal tumor, which often masquerades chronic thromboembolic pulmonary hypertension (CTEPH) and in the present case Takayasu arteritis. Pulmonary arterial pressure is mildly elevated in the presence of extensive proximal lesions. A parenchyma thin-walled cavitary lesion may be a sign of pulmonary extravasation of the tumor.

A rare reason for pulmonary hypertension: primary sarcoma of the pulmonary artery

Primary sarcoma of the pulmonary artery (PSPA) is an extremely rare tumor of the cardiovascular system. The prognosis is very poor. The clinical symptoms and imaging findings imitate those of pulmonary emboli, causing delays in diagnosis. In this case report, we describe a 73-year-old man with PSPA who initially was admitted with exertional shortness of breath. Transthoracic echocardiographic evaluation revealed 2 masses in the pulmonary artery causing pulmonary hypertension. The patient underwent operation, but he could not be weaned off cardiopulmonary bypass at the end of the operation and died. Pathologic examination of the masses revealed pulmonary sarcoma. Although this patient was admitted to our clinic only 2 weeks after the initial symptoms, he already had distal metastases.

Primary pulmonary artery sarcoma: surgical management and differential diagnosis with pulmonary embolism and pulmonary valve stenosis

BACKGROUND AND AIM OF THE STUDY

Primary pulmonary artery sarcomas are rare and lethal tumors that are usually diagnosed during surgery or autopsy. We present six cases of primary pulmonary artery sarcomas and discuss clinical features, differential diagnosis, surgical treatment, and outcome of the tumors.

METHODS

Between January 1994 and July 2008, six patients were identified with the disease during operation. Three patients were initially diagnosed with pulmonary valve stenosis, and two patients had a presumptive diagnosis of chronic pulmonary embolism. Two patients had simple or partial tumor resection. Four patients had radical tumor resection and homograft reconstruction of the pulmonary arteries.

RESULTS

Histological examinations showed five malignant mesenchymomas and one fibrosarcoma. One patient died of refractory pulmonary hypertension during operation. Two patients died 4 months postoperatively because of brain metastases. Two patients were alive for 3 and 9 months, respectively after the operation with recurrent tumor. One patient is alive even 2 years after resection with no signs of recurrence or metastasis.

CONCLUSIONS

Because of similar clinical features, pulmonary artery sarcomas are often confused with other pulmonary vascular obstructive diseases. Computed tomography scanning and gadolinium-enhanced magnetic resonance imaging could be useful methods for differential diagnosis. The prognosis is very poor. The survival time after resection varies from several months to several years depending on the presence of recurrence or metastasis. Early diagnosis and radical surgical resection presents the only opportunity for a potential cure.

Pulmonary artery sarcoma: a histologic and follow-up study with emphasis on a subset of low-grade myofibroblastic sarcomas with a good long-term follow-up

Primary sarcomas of the pulmonary artery are rare, with few series correlating histologic features with follow-up data. We present a series of 43 pulmonary artery sarcomas with primary intraluminal growth, 32 with follow-up information. Symptoms were generally related to shortness of breath and often attributed to recurrent pulmonary embolism. There was no sex predilection. There were 28 pleomorphic-fascicular sarcomas, ranging from relatively differentiated spindle cell myxofibrosarcoma to undifferentiated round-cell sarcoma, often with histologic heterogeneity and overlap. The remaining tumors were 7 osteosarcomas, 4 leiomyosarcomas, 1 rhabdomyosarcoma, and 3 intravascular low-grade myofibroblastic sarcomas. Of the pleomorphic-fascicular sarcomas, 2 demonstrated extensive fibrosis with hyalinization and pleomorphic tumor cells were confined to a luminal rim of neoplastic cells. Histologically, mitotic rate was significantly lower in low-grade myofibroblastic sarcoma than in the other histologic subtypes. Follow-up revealed that 2 of 3 intra-arterial low-grade myofibroblastic sarcomas were cured with no evidence of disease at long-term follow-up. The other tumor subtypes, which represented intermediate and high-grade sarcomas, demonstrated 5 survivors of greater than 3 years, none surviving without disease. The only parameters associated with prolonged survival, other than low-grade myofibroblastic phenotype, was age less than 40 years at onset of symptoms. We conclude that survival beyond 3 years is possible for primary pulmonary artery sarcoma, but cure without evidence of disease is currently possible only for the select subtype of intravascular low-grade myofibroblastic sarcoma.

Pulmonary artery sarcoma mimicking a pulmonary artery aneurysm

Pulmonary artery sarcoma is an uncommon neoplasm, and its clinical and radiological presentation usually simulates chronic thromboembolic disease. We present the case of a 77-year-old woman admitted with dyspnea, chest pain, and hemoptysis. A chest computed tomographic scan showed moderate right-sided pleural effusion and a saccular dilatation of the interlobar portion of the right pulmonary artery, which was filled with contrast and surrounded by an irregular soft-tissue attenuation mass, suggesting a ruptured pulmonary artery aneurysm. The patient was operated on. Intraoperatively, a pseudoaneurysm and a solid mass were identified within the oblique fissure around the interlobar artery. Therefore, a right pneumonectomy was performed. Definitive pathologic examination was consistent with pulmonary artery sarcoma. The patient had a good outcome and is free of disease 2 years after surgery.

Successful diagnosis of pulmonary artery sarcoma by contrast-enhanced computed tomography

Pulmonary artery sarcoma is a rare tumor of the cardiovascular system. We reported a case of primary pulmonary artery sarcoma. In this case, the patient was misdiagnosed with tuberculosis for nearly 1 year and diagnosed by contrast-enhanced computed tomography and histopathologic examination at last.

Management of primary pulmonary artery sarcoma: experience of a single center

Primary sarcoma of the pulmonary artery (PSPA) is extremely rare. Many cases are misdiagnosed as pulmonary arterial hypertension (PAH) because of chronic thromboembolic disease (CTD). Four cases of PSPA with the initial misdiagnosis are reported. The presence of a unique mass in the main pulmonary artery or proximal branches, rapidly progressive dyspnea, and constitutional symptoms should raise the suspicion of PSPA. The pathological diagnosis is usually confirmed during surgery, which is done along with adjuvant chemotherapy, the treatment of choice.

Pulmonary artery sarcoma masquerading as saddle pulmonary embolism

Pulmonary artery sarcoma is a highly malignant tumour. Therefore, making the diagnosis is very important. We describe a case which presented with dyspnea on exertion and was initially diagnosed as saddle pulmonary embolism per CT thorax with contrast. Despite adequate anticoagulation, symptoms still progressed. Follow-up CT thorax showed an extension of the presumed filling defect or clots into the left main pulmonary artery with new lung nodules. This prompted suspicion that this may not be a pulmonary embolism. Biopsy of the lung nodule revealed high grade soft tissue sarcoma with primary source from the pulmonary artery. Our case highlights that pulmonary artery sarcoma should always be included in the differential diagnosis of pulmonary embolism especially, if symptoms still progress while on adequate anticoagulation, or any pulmonary nodules develop on follow-up exam.

Successful treatment of pulmonary artery sarcoma by a two-drug combination chemotherapy consisting of ifosfamide and epirubicin

We describe a case of 63-year-old woman with pulmonary artery sarcoma successfully treated with chemotherapy. She developed acute shortness of breath, and left chest and shoulder pain. Although a diagnosis of acute pulmonary embolism was made at a local hospital and she received anticoagulation and thrombolysis therapy, no improvement was achieved. Thereafter, she underwent a pulmonary thromboectomy in our hospital, and the histological diagnosis was intimal sarcoma of the pulmonary artery. Since post-operative computed tomography (CT) scans of the chest showed obvious persistence of an intraluminal hypoattenuated area in the left main pulmonary artery, the patient was treated with four cycles of a doublet chemotherapy consisting of ifosfamide (2.5 g/m(2)/day) on days 1-5 and epirubicin (45 mg/m(2)/day) on days 2 and 3. CT scans of the chest after four cycles showed marked regression of the intraluminal hypoattenuated area in the left main pulmonary artery. This is the first case of pulmonary artery sarcoma responding to chemotherapy. Surgical resection is currently the most hopeful treatment for pulmonary artery sarcoma. However, intensive chemotherapy is worth trying in unresectable patients.

The importance of clinical suspicion in diagnosing pulmonary embolism: a case of false-positive high probability radionuclide perfusion lung scan

The accuracy of scintigraphic evidence of perfusion defects, even when classified as 'high probability' by matching with ventilation techniques or thoracic roentenograms is unsatisfactory when used without a pre-test clinical evaluation of probability. Although unusual, a complete or near-complete unilateral absence of perfusion in a lung with normal perfusion controlaterally must alert clinicians to the possibility of a false-positive result. In such instances, the administration of therapeutic dosages of fibrinolitic and antithrombotic agents (or even surgery) may lead to deleterious consequences. We report a patient with malignancy causing extrinsic narrowing of the pulmonary artery leading to a drastic impairment in the perfusion of an entire lung, compatible with, but not diagnostic of massive pulmonary embolism.

Quand, comment et pourquoi réaliser une imagerie des artères pulmonaires ?

For several years, catheter angiography was the standard imaging technique used for evaluating the pulmonary arteries. Technical advances with computed tomography have had a significant impact on chest imaging, especially the increasing availability of multidetector row CT units. CT pulmonary angiography (CTPA) is now the first line imaging technique to evaluate pulmonary arterial diseases, including pulmonary embolus. Pulmonary angiography is now essentially limited to the endovascular management of pulmonary arteriovenous malformations, pulmonary arteriovenous fistulas or pulmonary arterial aneurysms. Gadolinium enhanced MR angiography of the pulmonary arteries may be helpful in patients with contraindications to the use of iodinated contrast material.

Primary leiomyosarcoma of the pulmonary artery: a diagnostic dilemma

Primary leiomyosarcoma of the pulmonary artery is a rare malignancy arising from the multipotential mesenchymal cell of the intima of the pulmonary artery. Due to its rarity and nonspecific clinical symptoms, the correct diagnosis and proper management are often delayed. Furthermore, it is frequently misdiagnosed as pulmonary embolism, mediastinal mass, pulmonary stenosis and lung cancer. Therefore, it is important to consider primary leiomyosarcoma of the pulmonary artery a possibility when a persistent filling defect is present in the pulmonary artery and there is no response to optimal anticoagulation treatment. Radiologic findings such as a unilateral mass continuously filling the pulmonary artery, inhomogenous enhancement, vascular distension, extravascular invasion into adjacent structure or uptake in the area of tumor on the FDG-PET can be helpful when differentiating pulmonary artery sarcoma (PAS) from chronic thromboembolism.

Pulmonary artery sarcoma: a case report of surgical cure and 5-year follow-up

Pulmonary artery sarcoma is a rare tumor that is frequently misdiagnosed as chronic pulmonary embolism. With heightened clinical awareness and advancement in technology, the diagnosis is now increasingly being made preoperatively. Previous literature has described the disease to be uniformly fatal, with surgical resection as the single most effective modality for short-term palliation. We present the case of a patient in whom pulmonary artery sarcoma was diagnosed preoperatively and who underwent surgical resection with no evidence of recurrence during long-term follow-up, suggesting that early identification and aggressive surgical intervention has the potential to be curative.

Right pulmonary artery sarcoma

A 57-year-old man presented with cough, chest pain and dyspnea. Peripheral lung opacities detected radiologically on admission were surgically resected and histologically confirmed as pulmonary infarcts. Subsequent radiological examinations revealed a stricture of the right pulmonary artery with evidence of pulmonary hypertension. The patient was commenced on anticoagulant therapy, which resulted in some clinical improvement. A hilar mass detected later was resected together with the right lung. Pathological examination of the hilar mass revealed a tumour within the lumen of the pulmonary artery causing almost total occlusion of the artery. Histology showed angiosarcomatous and osteosarcomatous areas. The patient is well and disease-free 9 months following resection.

[Pulmonary artery primary sarcoma: diagnosis with transthoracic and transesophageal echocardiogram]

Pulmonary artery sarcoma is a rare malignant disease and diagnosis before surgery or autopsy is difficult. We present a case of a pulmonary artery sarcoma diagnosed with transtoracic and transesophagic echocardiogram which was treated surgically.

Spiral CT angiography of the pulmonary circulation

Spiral computed tomographic (CT) angiography of the pulmonary circulation has emerged recently as a potential useful diagnostic method for the evaluation of the pulmonary circulation. As a minimally invasive examination, this technique is becoming widely available and has progressively replaced conventional and digital pulmonary angiography as the standard diagnostic imaging modality of the pulmonary circulation. The purpose of this review is to capture the current state of the art of the technical aspects of spiral CT angiography, with special emphasis on the post-processing techniques currently available. As CT is responsible for a considerable part of the medical radiation dose applied to the population, the current trends for dose saving will also be emphasized. With regard to the clinical applications of spiral CT angiography, its introduction into the diagnostic work-up of pulmonary embolism has considerably modified the diagnostic algorithms. Our 8-year review of the literature presented herein is expected to provide the readers with a basis for formulating an informed opinion on this topic. In addition, a large number of congenital and acquired disorders of the pulmonary circulation are also relevant to this technique, and these indications are discussed in the context of the corresponding therapeutic options. Owing to the multiple possibilities inherent to this technique, spiral CT has the potential for cost savings without reduction in image quality or diagnostic accuracy.

Leiomyosarcoma of the pulmonary artery

Primary leiomyosarcoma of the pulmonary artery is an extremely rare tumor that is frequently misdiagnosed as chronic pulmonary embolism. In the present case, early diagnosis and location in the left pulmonary artery permitted resection by pneumonectomy with total cardiopulmonary bypass.

Primary pulmonary artery sarcoma

A 66-year-old woman with a history of mitral valve replacement with a Starr-Edwards ball valve 25 years ago was treated for refractory heart failure but died of right heart failure. At autopsy, primary pulmonary artery sarcoma was found in the right ventricular outflow tract, main pulmonary trunk, and bilateral pulmonary artery, and had invaded the aortic arch. The pathohistologic diagnosis was osteosarcoma. Echocardiography, chest computed tomography and right ventriculography performed 1 year before death did not reveal the presence of a tumor in the pulmonary artery. The history of this patient shows that primary pulmonary artery sarcoma grows rapidly, with, in this case, the patient dying within 1 year of its appearance.

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.

Digital clubbing associated with pulmonary artery sarcoma

A case of digital clubbing in a patient with pulmonary artery sarcoma and severe pulmonary hypertension is presented. The differential diagnosis of clubbing and clinical features of pulmonary artery sarcoma are reviewed with emphasis on the possible association of clubbing with pulmonary artery sarcoma.

Primary pulmonary artery sarcoma: a report of six cases

Pulmonary artery tumors are rare and a frequently overlooked cause of pulmonary artery occlusion. The presentation is one of progressive pulmonary dysfunction and right ventricular failure. The diagnosis seldom is made preoperatively. We report 6 cases of primary sarcoma of the pulmonary artery identified at operation, which were treated surgically. Resection with or without adjuvant therapy currently offers the only chance for survival. Emphasis must be placed on earlier identification of these tumors.

Pulmonary artery sarcoma mimicking chronic thromboembolic disease: computed tomography and magnetic resonance imaging findings

PURPOSE

The diagnosis of the rare primary malignant tumors of the pulmonary arteries is often delayed as symptoms are nonspecific.

METHODS

Computed tomography (CT) and magnetic resonance imaging (MRI) of three patients with occlusion of the right pulmonary artery, two with sarcoma and one with chronic thromboembolic disease were analyzed for discriminating diagnostic criteria.

RESULTS

Criteria suggesting pulmonary artery sarcoma are inhomogeneous high or low attenuation (hemorrhage, necrosis), soft-tissue density in pulmonary arteries, vascular distension, enhancement after administration of gadopentetate dimeglumine. Criteria for chronic thromboembolic disease are homogeneous soft-tissue lesions, abrupt vascular narrowings and cut-offs, as well as regional parenchymal hyperdensities.

CONCLUSION

CT and MRI provide complementary findings suggesting advanced pulmonary artery sarcoma instead of chronic thromboembolism.