Thalidomide (Thalomid) is recognized to have antiangiogenic properties and has been shown to be effective in the treatment of refractory myeloma. As a result, thalidomide(Drug information on 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.
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.