ONCOLOGY'PROBLEM'SOLVINGResident(s):'Cody'O’Dell,'MD,'MPH;'Bo'Liu,'MD;'Nathan'Kohler,'MD,'PhD'

Attending:''Alberto'Mansilla,'MD'

Program/Dept:'Florida'Hospital'Diagnostic'Radiology

CHIEF'COMPLAINT'&'HPI

▪Reason'for'consultation'▪Bleeding'right'thigh'mass'in'a'patient'being'anticoagulated'for'pulmonary'embolism

▪History'of'Present'Illness'▪86yo'hispanic'male'with'history'of'metastatic'pleomorphic'liposarcoma'of'the'right'thigh.''Staging'CT'chest'demonstrated'an'incidental'PE.''Anticoagulation'was'initiated'with'Lovenox'to'Coumadin'bridge.''The'patient'returned'with'several'days'of'persistent'bleeding'of'the'mass.''IR'was'consulted'to'assist'with'management.

RELEVANT'HISTORY

▪ Past'Medical'History'▪ Recent'PE,'metastatic'pleomorphic'liposarcoma'of'the'right'thigh,'DM,'HTN,'Dementia,'Anemia'

▪ Past'Surgical'History'▪ Prior'cholecystectomy,'prior'right'thigh'biopsy'

▪ Family'&'Social'History'▪ Not'obtainable'

▪ Review'of'Systems'▪ Not'obtainable'

▪Medications'▪ coumadin,'lovenox,'benazepril,'cyanocobalamin,'gabapentin,'insulin,'pantoprazole,'simvastatin'

▪ Allergies'▪ NKDA

DIAGNOSTIC'WORKUP

▪Physical'Exam'▪ 98.5,'80,'16,'142/99,'97%'RA'▪ 'NAD,'Lungs'clear'▪ Right'thigh'mass'covered'with'blood'saturated'dressing;'removal'of'dressing'shows'a'mass'with'open'wound,'exposed'muscle'and'oozing'blood.''The'right'thigh'is'erythematous'and'warm'with'1+'edema'of'the'lower'leg,'as'compared'to'the'normal'left'leg'

▪Laboratory'Data'▪ PT/INR'–'21.6/1.92'▪ LFTs'–'nml

8.6

8.6

306

35.4

21.6

1.92

1401.3

22106

294.4

141

PHYSICAL'EXAM

▪Figure'1.'Photograph'of'ulcerated'right'posterolateral'thigh'mass'demonstrating'underlying'muscle'tissue'and'briskly'oozing'blood.

DIAGNOSTIC'WORKUP

▪Figure'2.''Sonographic'image'of'the'right'thigh'mass'demonstrates'echogenic'fatty'components,'solid'components'with'increased'color'flow,'and'anechoic'cystic'components.'

DIAGNOSTIC'WORKUP

▪Figure'3.''CT'angiogram'of'the'right'thigh'demonstrates'a'large,'wellgcircumscribed,'heterogeneous,'highly'vascularized'mass'of'the'posterior'compartment'of'the'right'thigh'with'both'soft'tissue'and'fatty'components.''

DIAGNOSTIC'WORKUP

▪Figure'4.''Coronal'maximum'intensity'projection'PET'image'demonstrates'a'hypermetabolic'right'thigh'mass'with'numerous'hepatic,'pulmonary,'pelvic'lymph'node'and'osseous'metastatic'deposits.

DIAGNOSIS

▪Bleeding'Metastatic'Pleomorphic'Liposarcoma'in'a'Patient'Requiring'Anticoagulation'for'PE

INTERVENTION

• Objectives'

✓Primary:''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'femoral'artery.''Selectively'embolize'feeding'vessels'to'the'tumor.'

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

INTERVENTION

▪Figure'5.'Distal'abdominal'aortogram'was'performed'following'access'of'the'left'common'femoral'artery.''An'Omni'Flush'catheter'was'used'to'direct'guidewire'to'the'right'common'iliac'artery.

INTERVENTION

▪Figure'6.'Right'common'femoral'arteriogram'demonstrates'a'right'thigh'mass'with'multiple'feeding'collateral'vessels'arising'predominately'from'the'profunda'femoris'branches.

INTERVENTION

▪Figure'7.'Right'common'femoral'arteriogram'subtraction'image'demonstrates'profunda'femoris'branches'in'better'detail.''We'planned'to'selectively'embolize'the'first'and'second'perforator'branches'(yellow'arrows).

INTERVENTION

▪Figure'8.'Postembolization'right'common'femoral' artery' angiogram' demonstrates'decreased' vascularity' within' the' right'thigh' mass,' with' maintained' patency' of'the'superficial' femoral'artery.' 'Successful'embolization' of' 80%' of' the' vascular'supply' was' achieved' with' 500g700'micrometer'embospheres.

QUESTION'1

1) For'preoperative'embolization'of'a'soft'tissue'tumor'to'significantly'decrease'operative'bleeding,'by'what'percentage'does'tumor'enhancement'need'to'be'reduced?'

A:'5%'

B:'>20%'

C:'>70%'

D:'>95%

CORRECT!

1) For'preoperative'embolization'of'a'bone'or'soft'tissue'tumor'to'significantly'decrease'operative'bleeding,'by'what'percentage'does'tumor'enhancement'need'to'be'reduced?'

A:'5%'

B:'>20%'

C:'>70%.&&According&to&Sun&and&Lang,&preoperative&embolization&must&eliminate&>70%&of&the&arterial&supply&to&the&tumor&in&order&to&significantly&reduce&operative&bleeding.&&According&to&Barton&et&al.,&surgical&resection&should&occur&within&3&days&of&the&embolization&to&prevent&neovascularization.&

D:'>95%

Sun'S,'Lang'EV.'Bone'metastases'from'renal'cell'carcinoma:'preoperative'embolization.'J'Vasc'Interv'Radiol'1998;'9:263–269.'Barton'PP,'Waneck'RE,'Karnel'FJ,'et'al.'Embolization'of'bone'metastases.'J'Vasc'Interv'Radiol'1996;'7:81–88.'

RETURN'TO'CASE

SORRY,'THAT’S'INCORRECT.

1) For'preoperative'embolization'of'a'bone'or'soft'tissue'tumor'to'significantly'decrease'operative'bleeding,'by'what'percentage'does'tumor'enhancement'need'to'be'reduced?'

A:'5%'

B:'>20%'

C:'>70%.&&According&to&Sun&and&Lang,&preoperative&embolization&must&eliminate&>70%&of&the&arterial&supply&to&the&tumor&in&order&to&significantly&reduce&operative&bleeding.&&According&to&Barton&et&al.,&surgical&resection&should&occur&within&3&days&of&the&embolization&to&prevent&neovascularization.&

D:'>95%Sun'S,'Lang'EV.'Bone'metastases'from'renal'cell'carcinoma:'preoperative'embolization.'J'Vasc'Interv'Radiol'1998;'9:263–269.'Barton'PP,'Waneck'RE,'Karnel'FJ,'et'al.'Embolization'of'bone'metastases.'J'Vasc'Interv'Radiol'1996;'7:81–88.'

RETURN'TO'CASE

INTERVENTION

▪Figure' 9.' Right' common' femoral'vein' was' then' accessed' and' an'infrarenal'IVC'filter'was'placed.

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'anticoagulated.'

C:'To'maintain'patency'of'the'IVC'in'a'patient'with'intragabdominal'malignancy.'

D:'Prevention'of'pulmonary'embolism'in'a'patient'with'upper'extremity'DVT.

CORRECT!

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

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

B:&Prevention&of&pulmonary&embolism&in&a&patient&who&cannot&be&anticoagulated.&&IVC&filter&placement&is&indicated&in&patients&who&cannot&be&anticoagulated&due&to&recent&trauma&or&bleeding&risk,&and&in&patients&who&have&failed&anticoagulation&therapy.&

C:'To'maintain'patency'of'the'IVC'in'a'patient'with'intragabdominal'malignancy.''IVC&filters&are&not&used&to&stent&the&IVC,&but&to&prevent&clot&or&debris&from&migrating&to&the&pulmonary&arteries.&

D:'Prevention'of'pulmonary'embolism'in'a'patient'with'upper'extremity'DVT.''A&filter&in&the&INFERIOR&vena&cava,&would&not&prevent&an&upper&extremity&DVT&from&migrating&to&the&lungs.

RETURN'TO'CASE

SORRY,'THAT’S'INCORRECT.

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

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

B:&Prevention&of&pulmonary&embolism&in&a&patient&who&cannot&be&anticoagulated.&&IVC&filter&placement&is&indicated&in&patients&who&cannot&be&anticoagulated&due&to&recent&trauma&or&bleeding&risk,&and&in&patients&who&have&failed&anticoagulation&therapy.&

C:'To'maintain'patency'of'the'IVC'in'a'patient'with'intragabdominal'malignancy.''IVC'filters'are'not'used'to'stent'the'IVC,'but'to'prevent'clot'or'debris'from'migrating'to'the'pulmonary'arteries.'

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

RETURN'TO'CASE

CLINICAL'FOLLOW'UP

▪Bleeding'of'the'right'thigh'mass'stopped'on'POD#1.''Anticoagulants'were'resumed'at'that'time.'

▪Patient'was'discharged'home'on'POD#4'to'home'healthcare.'

▪Recommendations'were'to'have'outpatient'radiation'therapy'to'the'right'thigh'to'prevent'future'growth'and'revascularization'of'the'mass.

SUMMARY'&'TEACHING'POINTS

▪Embolization'of'bone'and'soft'tissue'tumors'is'well'described'in'the'literature'for'preoperative'conditioning'and'palliation.''Our'case'is'unique'in'that'it'represents'a'palliative'embolization'for'the'specific'purpose'of'decreasing'bleeding'in'an'anticoagulated'patient'with'an'unresectable'primary'tumor.'

▪Contraindications'to'bone'and'soft'tissue'embolization'include'coagulopathy,'thrombocytopenia'and'anemia.''For'this'reason,'we'corrected'the'coagulopathy'and'transfused'PRBCs'prior'to'the'procedure.'

▪ IVC'filter'placement'is'an'effective'way'to'prevent'PE'in'a'patient'with'contraindications'to'anticoagulation'(as'in'this'patient).

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.'Diagnostic'and'interventional'radiology'2007;'13:164g71.'

▪ [2]'Costea'R,'Vasiliu'E,'Zarnescu'NO,'Hasouna'M,'Neagu'S.'Large'thigh'liposarcomaggdiagnostic'and'therapeutic'features.'Journal'of'medicine'and'life'2011;'4:184g8.'

▪ [3]'Ibrahim'WH,'Safran'ZA,'Hasan'H,'Zeid'WA.'Preoperative'and'therapeutic'embolization'of'extremities'of'bone'and'soft'tissue'tumors.'Angiology'2013;'64:151g6.'

▪ [4]'Jagtap'SV,'Nikumbh'DB,'Jagtap'SS,'Kshirsagar'AY,'Badve'AS.'Huge'dedifferentiated'liposarcoma'of'the'left'thigh'with'a'high'grade'fibrosarcomatous'differentiation'and'a'local'recurrence.'Journal'of'clinical'and'diagnostic'research':'JCDR'2013;'7:553g6.'

▪ [5]'Mankin'HJ,'Hornicek'FJ.'Diagnosis,'classification,'and'management'of'soft'tissue'sarcomas.'Cancer'control':'journal'of'the'Moffitt'Cancer'Center'2005;'12:5g21.'

▪ [6]'Murphey'MD,'Kransdorf'MJ,'Smith'SE.'Imaging'of'Soft'Tissue'Neoplasms'in'the'Adult:'Malignant'Tumors.'Seminars'in'musculoskeletal'radiology'1999;'3:39g58.'

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

▪ [8]'Soulen'MC,'Weissmann'JR,'Sullivan'KL,'et'al.'Intraarterial'chemotherapy'with'limbgsparing'resection'of'large'softgtissue'sarcomas'of'the'extremities.'Journal'of'vascular'and'interventional'radiology':'JVIR'1992;'3:659g63.'

▪ [9]'Yoon'RS,'Benevenia'J,'Beebe'KS,'Hameed'M.'Dedifferentiated'liposarcoma'of'thigh'with'chondrosarcomatous'dedifferentiated'component.'American'journal'of'orthopedics'(Belle'Mead,'NJ)'2010;'39:E114g8.