ODell Lipsarcoma 12102015

7/23/2019 ODell Lipsarcoma 12102015

1/24

Oncology Problem Solvin

Resident(s): Cody ODell, MD, MPH; Bo Liu, MD;

Attending: Alberto Mansilla, MD

Program/Dept: Florida Hospital Diagnostic Radio

Originally Posted: Mon


2/24

Chief Complaint & HPI

Chief Complaint

Bleeding right thigh mass in a patient being anticoagulated forpulmonary embolism

History of Present Illness

86yo Hispanic male with known history of metastatic pleomorpliposarcoma of the right thigh presents with a bleeding right thmass. On staging CT of the chest, there was an incidental PE

Anticoagulation was initiated with Lovenox to Coumadin bridgepatient returned with several days of persistent bleeding of theIR was consulted to assist with management.


3/24

Relevant History

Past Medical HistoryRecent PE, metastatic pleomorphic liposarcoma of the right thigh, DM, HTN, Dem

Past Surgical HistoryPrior cholecystectomy, prior right thigh biopsy

Family & Social HistoryNot obtainable

Review of SystemsNot obtainable

Medicationscoumadin, lovenox, benazepril, cyanocobalamin, gabapentin, insulin, pantoprazol

AllergiesNKDA


4/24

Diagnostic Workup

Physical Exam98.5, 80, 16, 142/99, 97% RA

NAD, Lungs clear

Right thigh mass dressed with blood saturated dressing; removal of dressing smass with open wound, exposed muscle and oozing blood. The right thigh iserythematous and warm with 1+ edema of the lower leg, as compared to the leg

Laboratory Data

PT/INR 21.6/1.92

LFTs nml

8.6

8.6

35.4

21.6

1.92

1401.3

22106

294.4

141


5/24

Physical exam

Figure 1. Photograph oposterolateral thigh maunderlying muscle tissuoozing blood.


6/24

Diagnostic workup

Figure 2. Sonographic imagethigh mass demonstrates echcomponents, solid componenincreased color flow, and anecomponents.


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Diagnostic workup

Figure 3. CT angiogram of the right thighdemonstrates a large, well-circumscribed, heterogeneous, highlyvascularized mass of the posteriorcompartment of the right thigh with bothsoft tissue and fatty components.


8/24

Diagnostic workup

Figure 4. Coronal maximum intensityprojection PET image demonstrates ahypermetabolic right thigh mass withnumerous hepatic, pulmonary, pelviclymph node and osseous metastaticdeposits.


9/24

Diagnosis

Bleeding Metastatic Pleomorphic Liposarcoma in a PatienRequiring Anticoagulation for PE


10/24

Intervention

ObjectivesPrimary: Stop the bleeding from the thigh mass

Secondary: Prevent new PE or worsening of current PE

Plan

1. RBC transfusion for anemia

2. Hold Lovenox and Coumadin to resolve coagulopathy

3. Arteriogram of right lower extremity following access of left common fartery. Selectively embolize feeding vessels to the tumor.

4. Place IVC filter via the opposite groin or transjugular approach


11/24

Intervention

Figure 5. Distal abdominal aortogram wasperformed following access of the leftcommon femoral artery. An Omni Flushcatheter was used to direct guidewire to theright common iliac artery.


12/24

Intervention

Figure 6. Right common femoral arteriogramdemonstrates a right thigh mass with multiplefeeding collateral vessels arisingpredominately from the profunda femorisbranches.


13/24

Intervention

Figure 7. Right common femoral arteriogramsubtraction image demonstrates profundafemoris branches in better detail. We plannedto selectively embolize the first and secondperforator branches (yellow arrows).


14/24

Intervention

Figure 8. Postembolization right commonfemoral artery angiogram demonstratesdecreased vascularity within the right thighmass, with maintained patency of thesuperficial femoral artery. Successfulembolization of 80% of the vascular supplywas achieved with 500-700 micrometer

embospheres.


15/24

Question 1

1) To significantly decrease operative bleeding of a soft tissue tumowhat percentage does tumor enhancement need to be reduced preoperative embolization?

A: 5%

B: >20%

C: >70%

D: >95%


16/24

Correct!

1) For preoperative embolization of a bone or soft tissue tumor to significdecrease operative bleeding, by what percentage does tumor enhanceneed to be reduced?

A: 5%

B: >20%

C: >70%. According to Sun and Lang, preoperative embolization must elim>70% of the arterial supply to the tumor in order to significantly reduce o

bleeding. According to Barton et al., surgical resection should occur withof the embolization to prevent neovascularization.

D: >95%

Return to Case

Sun S, Lang EV. Bone metastases from renal cell carcinoma: preoperative embolization. J Vasc Interv Radiol 1998; 9:263 26

Barton PP, Waneck RE, Karnel FJ, et al. Embolization of bone metastases. J Vasc Interv Radiol 1996; 7:8188.


17/24

Sorry, thats Incorrect.

1) For preoperative embolization of a bone or soft tissue tumor to significdecrease operative bleeding, by what percentage does tumor enhanceneed to be reduced?

A: 5%

B: >20%

C: >70%. According to Sun and Lang, preoperative embolization must elim>70% of the arterial supply to the tumor in order to significantly reduce o

bleeding. According to Barton et al., surgical resection should occur withof the embolization to prevent neovascularization.

D: >95%

Return to Case

Sun S, Lang EV. Bone metastases from renal cell carcinoma: preoperative embolization. J Vasc Interv Radiol 1998; 9:263 26

Barton PP, Waneck RE, Karnel FJ, et al. Embolization of bone metastases. J Vasc Interv Radiol 1996; 7:8188.


18/24

Intervention

Figure 9. Right common femoral vein wasthen accessed and an infrarenal IVC filter wasplaced.


19/24

Question 2

2) Which of the following is an indication for IVC filter placement?

A: Treatment of acute pulmonary embolism.

B: Prevention of pulmonary embolism in a patient who cannot be anticoag

C: To maintain patency of the IVC in a patient with intra-abdominal malign

D: Prevention of pulmonary embolism in a patient with upper extremity DV


20/24

Correct!


A: Treatment of acute pulmonary embolism. IVC filters are used to prevent PE in with lower extremity DVTs.

B: Prevention of pulmonary embolism in a patient who cannot be anticoagulatedfilter placement is indicated in patients who cannot be anticoagulated due to rectrauma or bleeding risk, and in patients who have failed anticoagulation therapy

C: To maintain patency of the IVC in a patient with intra-abdominal malignancy. IV

are not used to stent the IVC, but to prevent clot or debris from migrating to thepulmonary arteries.

D: Prevention of pulmonary embolism in a patient with upper extremity DVT. A fiINFERIOR vena cava, would not prevent an upper extremity DVT from migratinglungs.

Return to Case


21/24

Sorry, Thats Incorrect.


A: Treatment of acute pulmonary embolism. IVC filters are used to prevent PE in with lower extremity DVTs.

B: Prevention of pulmonary embolism in a patient who cannot be anticoagulatedfilter placement is indicated in patients who cannot be anticoagulated due to rectrauma or bleeding risk, and in patients who have failed anticoagulation therapy

C: To maintain patency of the IVC in a patient with intra-abdominal malignancy. IV

are not used to stent the IVC, but to prevent clot or debris from migrating to the parteries.

D: Prevention of pulmonary embolism in a patient with upper extremity DVT. A fiINFERIOR vena cava, would not prevent an upper extremity DVT from migrating to

Return to Case


22/24

Clinical Follow Up

Bleeding of the right thigh mass stopped POD#1 at whichanticoagulants were resumed.

Patient was discharged home on POD#4 to home healthc

Recommendations were to have outpatient radiation thethe right thigh to prevent future growth and revascularizathe mass.


23/24

Summary & Teaching Points

Embolization of bone and soft tissue tumors is well described in the literpreoperative conditioning and palliation. Our case is unique in that it reppalliative embolization for the specific purpose of decreasing bleeding in anticoagulated patient with an unresectable primary tumor.

Contraindications to bone and soft tissue embolization include coagulopthrombocytopenia and anemia. For this reason, we corrected the coaguand transfused PRBCs prior to the procedure.

IVC filter placement is an effective way to prevent PE in a patient withcontraindications to anticoagulation (as in this patient).


24/24

References & Further Reading

[1] Boruban S, Sancak T, Yildiz Y, Saglik Y. Embolization of benign and malignant bone and soft tissue tumors of the extremities. Diagninterventional radiology 2007; 13:164-71.

[2] Costea R, Vasiliu E, Zarnescu NO, Hasouna M, Neagu S. Large thigh liposarcoma--diagnostic and therapeutic features. Journal of m2011; 4:184-8.

[3] Ibrahim WH, Safran ZA, Hasan H, Zeid WA. Preoperative and therapeutic embolization of extremities of bone and soft tissue tumo2013; 64:151-6.

[4] Jagtap SV, Nikumbh DB, Jagtap SS, Kshirsagar AY, Badve AS. Huge dedifferentiated liposarcoma of the left thigh with a high grade fdifferentiation and a local recurrence. Journal of clinical and diagnostic research : JCDR 2013; 7:553-6.

[5] Mankin HJ, Hornicek FJ. Diagnosis, classification, and management of soft tissue sarcomas. Cancer control : journal of the Moffitt C2005; 12:5-21.

[6] Murphey MD, Kransdorf MJ, Smith SE. Imaging of Soft Tissue Neoplasms in the Adult: Malignant Tumors. Seminars in musculoskel1999; 3:39-58.

[7] Park JH, Kang CH, Kim CH, Chae IJ, Park JH. Highly malignant soft tissue sarcoma of the extremity with a delayed diagnosis. World joncology 2010; 8:84.

[8] Soulen MC, Weissmann JR, Sullivan KL, et al. Intraarterial chemotherapy with limb-sparing resection of large soft-tissue sarcomas Journal of vascular and interventional radiology : JVIR 1992; 3:659-63.

[9] Yoon RS, Benevenia J, Beebe KS, Hameed M. Dedifferentiated liposarcoma of thigh with chondrosarcomatousdedifferentiated coAmerican journal of orthopedics (Belle Mead, NJ) 2010; 39:E114-8.

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ODell Lipsarcoma 12102015