Extraskeletal myxoid chondrosarcoma with massive pulmonary metastases

Extraskeletal myxoid chondrosarcoma (EMC) is a rare malignant mesenchymal neoplasm of uncertain differentiation characterized by rearrangements of the NR4A3 gene. EMC often affects adults around the age of 50 and arise in the deep tissues of the proximal extremities and limb girdles. EMC is characterized by indolent growth rate but strong tendency to local recurrence and metastatic spread. No systemic treatment is specifically approved by the FDA for this disease and surgery has been traditionally the only potentially curative strategy.

A 41-year-old Caucasian woman originally presented with a 14.8 cm left thigh mass. She was managed with wide local resection but after 2 years she developed recurrent disease in the pelvis and in the lungs; the lung involvement was characterized by innumerable nodules without any significant respiratory symptoms. After failing three clinical trials, she experienced prolonged disease control while on treatment with the tyrosine kinase inhibitor (TKI) pazopanib and radiation therapy delivered to the pelvic lesion. Dose reduction of pazopanib due to severe diarrhea was followed by rapid disease progression in the pelvis requiring vascular stenting; increase in tumor growth after discontinuation of a TKI has been described in other malignancies and is a possibility in this specific patient.

While surgical management of EMC with or without radiation therapy is still the preferable approach when feasible, small series support the use of tyrosine kinase inhibitors and possible new immunotherapies in selected patients. Basket trials focusing on diseases with unique genomic features such as EMC will hopefully provide a better understanding of new options for care.