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Using Thalidomide in a Patient With Epithelioid Leiomyosarcoma and

Using Thalidomide in a Patient With Epithelioid Leiomyosarcoma and

Thalidomide (Thalomid) is recognized to have
antiangiogenic properties and has been shown to be effective in the treatment of
refractory myeloma.[1] As a result, thalidomide is now being investigated for
use in a number of malignancies, including breast, lung, and renal cell
carcinoma, as well as melanoma. The following is an account of a patient with
two unrelated disorders (one malignant, one benign), both of which have
responded to thalidomide.

Patient’s History

An active 77-year-old man in otherwise good health was referred to the
surgical department in July 1996 because of a large, protuberant abdominal mass.
The patient described a 1- to 2-year history of abdominal bloating and early
satiety, and reported that the mass became larger following meals. In addition,
he had lost 5 to 10 lb over the preceding 7 months. The patient also had a
history of Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia),
reporting nosebleeds every night as well as some rectal bleeding. His hematocrit
typically ranged from the high 20s to low 30s. A prior computed tomography (CT)
scan had shown cystic lesions in the liver. On physical examination, the patient
had lesions consistent with this disease on his lips and tongue.

An abdominal ultrasound taken in June 1996 showed a 16-cm mass in the right
upper quadrant, displacing the kidney and pancreas. The ultrasound was positive
for ascites. A cystic mass was also discovered in the dome of the right upper
lobe of the liver. A CT scan confirmed both masses (Figure
1
). Fine-needle
aspiration of the abdominal mass removed a large amount of bloody fluid, which,
at the time, was negative for malignant cells. Aspiration reduced the size of
the mass somewhat, but the mass did not resolve completely.

Series of Surgeries

In July 1996, the patient underwent surgery to remove the abdominal mass.
Macroscopically, the tumor appeared to be highly vascular. The mass was purplish
in color and was attached to one of the mesenteric arteries of the transverse
colon. There were numerous satellite cystic lesions throughout the abdomen.
Pathology revealed that the mass was a grade II epithelioid leiomyosarcoma, with
5 to 10 mitoses per high-powered field. All margins of all specimens, which
included a portion of the omentum, were positive for tumor cells. Adjuvant
chemotherapy was not recommended, based predominantly on concerns about
tolerability.

The patient later developed nodules in the area of the abdominal incision.
Following a CT scan, a second operation, performed in April 1998, removed the
gall bladder and a portion of the diaphragm due to tumor involvement. Two
additional operations were performed in September 1998 and June 1999 to remove
progressive tumor growth. On each occasion, numerous small lesions
(approximately 1 mm) were seen throughout the abdominal cavity. Following the
final operation, the patient developed a pulmonary embolus that was mild but
lengthened recovery time. This was treated by placement of a vena caval filter,
as anticoagulation therapy was contraindicated.

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