Originally Posted: Month, 00, 20xx

Oncology Problem Solving

Resident(s): Cody ODell, MD, MPH; Bo Liu, MD; Nathan Kohler, MD, PhD
Attending: Alberto Mansilla, MD
Program/Dept: Florida Hospital Diagnostic Radiology

Chief Complaint & HPI

Chief Complaint
Bleeding right thigh mass in a patient being anticoagulated for
pulmonary embolism
History of Present Illness

86yo Hispanic male with known history of metastatic pleomorphic

liposarcoma of the right thigh presents with a bleeding right thigh
mass. On staging CT of the chest, there was 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 dressed 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
8.6
leg

Laboratory Data
PT/INR 21.6/1.92
LFTs nml

141
4.4

106
29

22

306

8.6

140
1.3

35.4

21.6
1.92

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, wellcircumscribed, 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 500-700 micrometer
embospheres.

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

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%
Return to Case
Sun S, Lang EV. Bone metastases from renal cell carcinoma: preoperative embolization. J Vasc Interv Radiol 1998; 9:263269.
Barton PP, Waneck RE, Karnel FJ, et al. Embolization of bone metastases. J Vasc Interv Radiol 1996; 7:8188.

Sorry, thats 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%
Return to Case
Sun S, Lang EV. Bone metastases from renal cell carcinoma: preoperative embolization. J Vasc Interv Radiol 1998; 9:263269.
Barton PP, Waneck RE, Karnel FJ, et al. Embolization of bone metastases. J Vasc Interv Radiol 1996; 7:8188.

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 intra-abdominal 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 intra-abdominal 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, Thats 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 intra-abdominal 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 POD#1 at which time
anticoagulants were resumed.
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; 13:164-71.
[2] Costea R, Vasiliu E, Zarnescu NO, Hasouna M, Neagu S. Large thigh liposarcoma--diagnostic and therapeutic features. Journal of medicine and life
2011; 4:184-8.
[3] Ibrahim WH, Safran ZA, Hasan H, Zeid WA. Preoperative and therapeutic embolization of extremities of bone and soft tissue tumors. Angiology
2013; 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 fibrosarcomatous
differentiation 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 Cancer Center
2005; 12:5-21.
[6] Murphey MD, Kransdorf MJ, Smith SE. Imaging of Soft Tissue Neoplasms in the Adult: Malignant Tumors. Seminars in musculoskeletal radiology
1999; 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 journal of surgical
oncology 2010; 8:84.
[8] Soulen MC, Weissmann JR, Sullivan KL, et al. Intraarterial chemotherapy with limb-sparing resection of large soft-tissue sarcomas of the extremities.
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 chondrosarcomatous dedifferentiated component.
American journal of orthopedics (Belle Mead, NJ) 2010; 39:E114-8.