CASE 2007 Published on 18.02.2003
0

An usual cause of deep vein thrombosis

Section

Musculoskeletal system

Case Type

Clinical Cases

Authors

J. D. Birchall, S. Dawson, R. W. Kerslake, C. N. Ludman

Connected authors
James D. Birchall UNITED KINGDOM
Patient

29 years, female

Categories
No Area of Interest ; Imaging Technique Digital radiography, CT, MR, MR-Angiography, CT
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Clinical History
The patient presented with bilateral leg swellings with pain and paresthesia. Venogram demonstrated an occlusion of the right common iliac vein at the IVC. The paresthesia progressed and CT of the pelvis, MR of the lumbrosacral spine and MR angiography and venography were performed.
Imaging Findings
The patient, 2 days post lower segment caesarean section, presented with bilateral leg swellings, worse on the right, with pain and paresthesia affecting mainly the left leg. Venogram demonstrated an occlusion of the right common iliac vein at the IVC with extensive venous collaterals (Fig. 1). Coumarin therapy was commenced.

Three weeks later her paresthesia had progressed to the gluteal and genital regions with development of urinary and faecal incontinence. CT of the pelvis revealed an enhancing lobulated sacral tumour with fluid levels compressing the sacral spinal canal and extending into the right greater sciatic notch, with an enlarged IVC containing peripherally enhancing thrombus (Fig. 2). MRI confirmed the sacral mass containing fluid levels and loss of the sacral canal (Fig. 3). MR angiography and venography confirmed the slightly enhancing tumour thrombus within the IVC (Fig. 4).

Review of the original venogram showed right sacral bone destruction (Fig. 1). Subsequent CT of the thorax demonstrated multiple pulmonary metastases (Fig. 5).

Sacral surgical biopsy showed multinucleate giant cells with no aggressive features, confirming the diagnosis of giant cell tumour (osteoclastoma). In the presence of IVC "thrombus" with the "benign" metastases, a Gunter Tulip IVC filter was placed in the infra renal IVC with incidental demonstration of upper moiety hydronephrosis within the left duplex pelvicalyceal system (Fig. 6).

Subsequently, as the sacral giant cell tumour was deemed to be unresectable, the patient received external beam radiotherapy to the sacrum. Unfortunately her disease progressed quite rapidly despite radiotherapy with an increase in both the sacral and pulmonary disease, with her demise 8 months from presentation.

Discussion
Giant cell tumour of the sacrum is rare and can increase in size during pregnancy with pelvic pain and limb numbness. A subgroup of primary sacral giant cell tumours can behave very aggressively with pulmonary deposits at the time of presentation. In other cases pulmonary metastases develop at a much later time despite initially successful curettage, sacrectomy, or radiotherapy.

Occasionally sacral giant cell tumour undergoes spontaneous dedifferentiation into osteosarcoma without prior radiotherapy; this may be the course this case followed, notwithstanding the benign surgical biopsy. A recent paper suggests that the multinucleate giant cells are recruited and have their osteoclastic activity promoted by the associated transformed fibroblastic stromal cells.

Although a previous paper describes an incidental deep vein thrombosis with sacral giant cell tumour, we believe that this is the first described case of direct giant cell tumoral thrombus within the IVC, which succinctly explains the presence of pulmonary deposits. A similar picture is well known with renal cell carcinoma.

Differential Diagnosis List
Aggressive sacral giant cell tumour
Final Diagnosis
Aggressive sacral giant cell tumour
Case information
URL: https://www.eurorad.org/case/2007
DOI: 10.1594/EURORAD/CASE.2007
ISSN: 1563-4086
Figure 1

Right lower limb venogram

Right lower limb venogram
Occlusion of the right common iliac vein at the IVC with extensive venous collaterals.
Figure 2

CT of the abdomen post IV and PO contrast

CT of the abdomen post IV and PO contrast
Distended IVC containing peripherally enhancing thrombus.
CT of the abdomen post IV and PO contrast
Enhancing lobulated sacral tumour with fluid levels compressing the sacral spinal canal and extending into the right greater sciatic notch.
Figure 3

T1- and T2-weighted sagittal and STIR axial MR images

T1- and T2-weighted sagittal and STIR axial MR images
Fluid levels demonstrated in the large sacral mass with loss of the sacral canal.
T1- and T2-weighted sagittal and STIR axial MR images
Fluid levels demonstrated in the large sacral mass with loss of the sacral canal.
T1- and T2-weighted sagittal and STIR axial MR images
Fluid levels demonstrated in the large sacral mass with loss of the sacral canal.
Figure 4

MRA post Gd-DTPA administration (2mmols/kg))

MRA post Gd-DTPA administration (2mmols/kg))
Arterial phase: Enhancement of the right sided sacral mass and IVC thrombus.
MRA post Gd-DTPA administration (2mmols/kg))
Venous phase: IVC thrombus is demonstrated with extensive venous collaterals particularly on the right.
Figure 5

CT thorax

CT thorax
Multiple small pulmonary nodules.
CT thorax
Multiple small pulmonary nodules.
Figure 6

IVC flush prior to insertion of Gunter Tulip IVC filter

IVC flush prior to insertion of Gunter Tulip IVC filter
Infrarenal IVC thrombus occluding the right common iliac vein insertion. Extensive left iliolumbar and lumbar venous collaterals. Left duplex pelvicalyceal system.