|Ahead of print publication
Four case reports on pelvic tumors with deep venous thromboses as main symptoms and literature review
Cheng Liu1, Dingfeng Li1, Jun Guo1, Qiu Cui1, Linlin Zhang2, Yanjun Zeng3
1 Department of Orthopedics, The Affiliated Hospital of Academy of Military Medical Sciences, PLA 307th Hospital, 100071, China
2 Department of Engineering Mechanics, Beijing University of Technology, Beijing, 100124, China
3 Department of Biomechanics and Medical Information, Beijing University of Technology, Beijing, 100124, China
Beijing University of Technology, 100 Pingleyuan, Chaoyang District, Beijing 100022
Source of Support: None, Conflict of Interest: None
To probe into the reasons for misdiagnoses of pelvic tumor as deep venous thromboses as well as the diagnostic methods and effective treatments on pelvic tumor. Four case reports on misdiagnosing pelvic tumor as deep venous thromboses and further analysis on the causes of misdiagnosis, diagnosis, and treatment with the literature study. The four cases were misdiagnosed as pelvic tumor, which actually were fibroneuroma, myxo-fluidity liposarcoma, moderately differentiated squamous cell carcinoma, and synovial sarcoma, respectively. The tumor in first case was completely removed, and the tumor in other three cases, which were malignant tumors, were resected when the tumors shrank with clear boundary and less blood supply after applied with 3 cycles of intra-arterial chemotherapy via an implanted pumpies. Pelvic tumor usually show up or is misdiagnosed as deep venous thromboses for its untypical clinical manifestation, so it should be on the alert for pelvic tumor when deep venous thromboses occurs. Tumor resection is preferred for benign tumor, and intra-arterial intervention chemotherapy should be applied first for malignant tumor followed by surgery.
Keywords: Deep venous thromboses, DVTs, intra-arterial intervention chemotherapy, misdiagnosis, pelvic tumor
|How to cite this URL:|
Liu C, Li D, Guo J, Cui Q, Zhang L, Zeng Y. Four case reports on pelvic tumors with deep venous thromboses as main symptoms and literature review. J Can Res Ther [Epub ahead of print] [cited 2017 Jul 24]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=139521
| > Introduction|| |
Pelvic tumors complicated with deep vein thrombosis are rare in clinics, sometimes the clinicians pay attention only on the diagnosis and treatment of deep vein thrombosis and thereby delay the diagnosis and treatment of pelvic tumors because of its untypical clinical manifestations. Four cases of pelvic tumors misdiagnosed as deep venous thrombosis were hospitalized in our department from March 2006 to December 2011. The details of the cases are reported and discussed below.
| > Case report|| |
The four patients were hospitalized during 2006 to 2011 in our department. They all complained of repeated progressive swelling of the lower extremity combined with pain and limping without any incentives. Deep vein thrombosis in affected lower extremity was indicated by ultrasonography, and anticoagulation, thrombolysis and expansion treatment were applied but with unsatisfactory relief or only transient relief. After admitting to our hospital, all the four patients were found pelvic occupying lesions closely related to iliac blood vessels through reviewing disease history, physical examination, and image examination.
The later three cases were considered to have high probability of malignant lesions, and the pathological results were all malignant tumor as indicated in [Table 1]. Chemotherapy pump was implanted in common iliac artery through femoral artery for the above three cases to administrate cisplatin and doxorubicin as arterial interventional chemotherapy.  All the three patients felt relieved pain after three cycles of interventional chemotherapy, and the tumor shrank to display clear boundaries with the surrounding tissues. The comparison of the images before and after chemotherapy is shown in [Figure 1] and [Figure 2]. The local vascular compression alleviates due to the shrinking tumors, and the extremity swellings caused by the thrombus were relieved after chemotherapy. Radical resections of the tumors under naked eyes were performed after chemotherapy, and then subsequent chemotherapy was administrated to prevent the recurrence. The interval between chemotherapies was gradually prolonged till two years after surgery. Up to now, no patients were found any local recurrence and distant metastasis according to the follow-up.
|Figure 1: (a) Moderately differentiated squamous cell carcinoma (b) The tumor shrank apparently after three times of chemotherapy|
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|Figure 2: (a) Imaging changes: Huge myxo-fluidity liposarcoma in pelvic (b) Shrunk tumor after chemotherapy with clear boundary (c) Pathological changes: Large quantity of atypical cells before chemotherapy (d) Obvious necrosis after chemotherapy|
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| > Discussion|| |
The pelvic neoplastic diseases, especially malignant tumors, are prone to deep vein thrombosis (DVT) as they are usually and anatomically close to iliac blood vessels, , and in many cases are misdiagnosed, as their primary symptoms are thrombosis. It was reported that the maximum incidences of concomitant deep vein thrombosis in patients with malignant tumors could be more than 10%.  DVT is a major complication and the cause of death of malignant tumors, which not only complicates the therapy on malignant tumors and worsens the patient's quality of life, but also indicates a poor prognosis. 
Besides iliac vein compression, pelvic malignancy itself has influences on the DVT to make patients prone to DVT mainly: (1) Hemorrheologic changes: The vast majority of patients with malignant tumor are found with significantly high level of whole blood viscosity, plasma viscosity, fibrinogen, hematocrit and erythrocyte sedimentation rate (ESR);  (2) Hypercoagulable state: The venous flow stagnated, vein wall damage and hypercoagulable state are three major factors causing deep vein thrombosis. Hypercoagulable state occurs as a result of changes including blood cellular factor, the mechanism of coagulation and anticoagulation, and fibrinolysis. Once the body is in a hypercoagulable state, it may cause thrombotic diseases. However, the incidence of venous thrombosis is much higher than arterial thrombosis, and the ratio can reach 4:1. Hypercoagulable state is an important cause of the formation process of deep vein thrombosis, and also an important aspect of the treatment and prevention of deep vein thrombosis. Tumor can activate the body's blood clotting process through secreting clotting factors and activating prothrombin to initiate the blood clotting process on the one hand, and producing abundant fibrinolytic system regulating proteins and thrombin to form thrombus on the other hand.  Three patients in this article are associated with these changes on the formation of thrombosis, who came to the hospital for the swelling of the lower extremity, and were diagnosed as deep venous thromboses and subsequently identified as pelvic tumors on further examinations.
The main reasons causing misdiagnosis of pelvic tumor with DVT include: (1) Lack of knowledge on pelvic tumor. Clinical history was not inquired in detail as its low morbidity, which leads to the insufficient diagnosis and differential diagnosis on the disease. (2) The pelvic cavity, especially the iliac fossa susceptible to soft tissue malignant tumor, has a relatively large space. The patient with tumor has no obvious symptoms in the early stage. The enlarged tumor compresses the surrounding tissues and results in corresponding clinical manifestations, such as gastrointestinal symptoms, or genitourinary symptoms, the first manifestation of lower extremity thrombosis that is rare; diagnosis was based on history, symptoms and signs; laboratory tests including ultrasound, CT, MR or tumor markers.
Pelvic iliac fossa tumor was found by abdominal and pelvic ultrasound and CT examination in all the four patients misdiagnosed as DVT in this paper. Thus, we believe that imaging examination is necessary for identifying occult tumors from patients with spontaneous DVT, especially, for those aged patients without obvious factors leading to the formation of DVT.
Radical resection of malignant pelvic tumor is difficult as the anatomical structure of pelvic cavity is complex, therefore, the local recurrence rate of malignant tumors is relatively high after resection. Intra-arterial chemotherapy with subcutaneously implanted pump was applied in three patients with malignant tumor; 50 mg/m 2 epirubicin (EADM) and 120 mg/m 2 cisplatin were administered via intra-arterial chemotherapy for three days. The next cycle of chemotherapy was repeated 2-3 weeks later. Chemotherapeutic effect was evaluated by clinical symptoms, imaging diagnosis and intra-operative pathology.  The tumor shrank, the boundary became clear, and the blood supply was reduced after the chemotherapy to lay the foundation for radical resection of the tumors. The chemotherapy was continued after surgery to prevent the recurrence. If chemotherapeutic effect was pathologically proven to be good (necrosis rate >90%), then the original therapy strategy would be kept, otherwise, chemotherapeutics such as ifosfamide and dacarbazine were intravenously administered. The interval between chemotherapies was gradually prolonged to two years after surgery, usually 8-12 times of the post-operation chemotherapy would be performed.
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[Figure 1], [Figure 2]