CTICasesEmbolizing Tumor Thrombus from Sacral Chordoma
Imaging findings
An older man with a remotely treated, presumed-cured sacral chordoma presented with multiple segmental and subsegmental pulmonary emboli that persisted and even extended more centrally despite appropriate anticoagulation. Imaging shows tumor or thrombus in the iliac veins, IVC, and a right atrial mass, with distended pulmonary vessels. Cardiac MRI was falsely read as clot because delayed-enhancement imaging was performed immediately after perfusion, off protocol, so the material appeared dark; correlation with the CT and the IVC findings established that the pulmonary and right atrial material was tumor.
Key takeaways
Pulmonary filling defects that persist or extend centrally despite adequate anticoagulation should raise suspicion for tumor embolus rather than bland thromboembolism, especially with a caval or right atrial mass from a source tumor such as chordoma. Cardiac MRI can falsely characterize tumor as clot if the delayed-enhancement protocol is not followed (proper myocardial nulling and full delay times), underscoring the value of reviewing each prior study and recognizing the vascular distribution.
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