Successful resection of a huge metastatic liposarcoma in the pericardium resulting in improvement of diastolic heart failure: a case report
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Although liposarcoma often metastasizes to various organs, cardiac metastasis, including to the pericardium, is rare. We present a case of a third recurrence of pericardial metastasis from the thigh, which required surgical resection because of cardiac failure. Surgery was effective for improving cardiac function and reintroducing chemotherapy. This is the first reported case of metastatic pericardial liposarcoma, which was successfully resected three times. We believe that aggressive surgical treatment, when it can resolve cardiac impairment, potentially leads to a more favorable prognosis.
KeywordsLiposarcoma Pericardial metastasis Diastolic heart failure
Liposarcoma is one of the most common soft tissue sarcomas in adults and often develops in the retroperitoneum and lower limbs. This tumor usually metastasizes to different organs, but metastasis to the heart, including to the pericardium, is rare. We report a patient with repeated cardiac metastases that required surgical resection.
A 66-year-old woman was referred to our hospital because of recurrence of pericardial metastatic liposarcoma with progressive dyspnea. The patient had undergone surgical resection of a primary liposarcoma in the left thigh 19 years previously and resection of a locally recurrent tumor 13 years previously. She developed cardiac and pericardial metastasis 10 years later. Resection of a cardiac metastasis originating from the right ventricle was performed via median sternotomy 3 years previously, and a second resection followed by radiotherapy for recurrence of the pericardium metastasis adjacent to the diaphragm 2 years previously. Each of these metastatic tumors was large enough to result in cardiac failure. The pathological diagnosis of the resected primary and metastatic tumors was myxoid liposarcoma. The third recurrence of metastatic pericardial liposarcoma was detected 1 year previously and was followed by metastasis to the posterior mediastinum, liver, retroperitoneum, and peritoneum. Chemotherapy including gemcitabine, docetaxel, pazopanib, and epirubicin was administered for 1 year. Chemotherapy was effective for all of the metastases except those in the pericardium and posterior mediastinum. As the pericardial metastasis enlarged, the patient developed dyspnea over a period of several months. Her symptoms were speculated to be due to diastolic impairment by the large tumor. Reintroduction of chemotherapy was difficult because of cardiac failure. Therefore, she was referred to our hospital for surgical treatment of the pericardial metastasis.
Liposarcoma is the second most common malignancy of soft tissues. The most common primary sites of liposarcoma are the retroperitoneum and lower limbs. Although liposarcoma often metastasizes to different organs, cardiac metastasis, including to the pericardium, is rare. Thirty-five cases of metastatic cardiac liposarcoma have been reported in the literature [1, 2, 3, 4, 5, 6], with only nine cases of pericardial metastases [2, 3, 4]. According to the WHO classification, liposarcoma is divided into the following categories: well-differentiated, differentiated, myxoid, round-cell, pleomorphic, mixed-type liposarcoma, and liposarcoma, not otherwise specified. Myxoid and well-differentiated liposarcomas have more favorable 5-year survival rates than round-cell and pleomorphic types. The first choice of therapy for primary liposarcoma is surgical resection. However, local recurrence or distant metastasis often occurs even many years after surgery. Radiotherapy combined with surgery may be associated with less recurrence . Chemotherapy is an option in the case of metastatic or unresectable disease , but it is still an empirical decision owing to the lack of evidence. Pericardial metastasis of liposarcoma often manifests as diastolic cardiac impairment. Surgical resection of cardiac or pericardial metastasis is usually recommended as a potentially radical treatment for solitary lesions without any other metastasis and is occasionally adopted as a palliative procedure in patients with other metastases. In our case, the patient had symptoms of cardiac failure because of impaired diastolic filling caused by the pericardial metastasis. She could not undergo chemotherapy because of cardiac failure. Resection of the tumor was expected to relieve the diastolic impairment and provide a chance of reintroduction of chemotherapy, which could have potentially prolonged her prognosis. Therefore, we decided to perform a third intervention, and the strategy was effective. This is the first reported case of metastatic pericardial liposarcoma, which was successfully resected three times. The prognosis of patients with cardiac metastatic liposarcoma is usually poor. Aoyama et al.  reported 15 cases of metastatic cardiac liposarcoma; six patients died within 6 months, and the longest follow-up was 15 months. However, the follow-up period of our patient from the first resection of the pericardial metastasis was 51 months. To the best of our knowledge, this is the longest reported follow-up of pericardial metastasis of liposarcoma. Aggressive surgical treatment with the intention of resolving the cardiac impairment may provide a symptom-free interval, and even a prolonged prognosis.
We successfully resected a pericardial metastatic liposarcoma, resulting in symptom improvement and reintroduction of chemotherapy. Aggressive surgical therapy may provide a symptom-free interval and prolonged prognosis.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor in chief of this journal.
We thank Dr. Daisei Yasuda, a pathologist, for providing assistance with the pathological diagnosis.
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