Atypical fibroxanthoma developing on a pacemaker pocket mimicking a pyogenic granuloma

doi:10.1016/j.carpath.2012.03.006

Cardiovascular Pathology

Volume 22, Issue 1, January–February 2013, Pages 102-104

https://doi.org/10.1016/j.carpath.2012.03.006 Get rights and content

Abstract

Malignant tumors at the site of implantation of a pacemaker generator, although rare, have been reported in the literature. We present a case of an 89-year-old man with atypical fibroxanthoma in a pacemaker pocket. The device had been implanted for more than 4 years. An exophytic tumor had developed in this place and was clinically interpreted as a pyogenic granuloma. An excisional biopsy revealed the nature of the tumor. To our knowledge, the association of atypical fibroxanthoma arising from a pacemaker pocket has not been previously reported. A review of the literature has revealed four malignant soft tissue tumors previously reported at the pacemaker site. Routine examination in all patients with implanted pacemaker generators should be practiced at follow-up visits. This would allow an early diagnosis of a malignant associated neoplasm. Pathologists should become familiar with this type of devices and their potential neoplastic complications.

Introduction

Malignant neoplasms at the site of implantation of a pacemaker generator, although rare, have been reported in the literature. Breast carcinoma is the most frequently reported neoplasm related to this device [1]. Other tumors arising at the site of the generator pocket include plasmacytoma, multiple myeloma, non-Hodgkin's lymphoma, malignant melanoma, cutaneous leiomyosarcoma [2], metastasis of malignant fibrous histiocytoma [3], rhabdomyosarcoma [4], clear cell hidradenocarcinoma [5], malignant inflammatory myofibroblastic tumor (inflammatory fibrosarcoma) [6], and basal cell carcinoma [7]. However, the number of malignant cases reported is minuscule when compared with the number of pacemakers implanted every year in the world.

To the best of our knowledge, we report the first case of atypical fibroxanthoma (AFX) developing on a pacemaker pocket. This case raises concern whether this association is merely coincidental or whether the pacemaker generator is responsible for the occurrence in some inexplicable manner.

Section snippets

Case report

An 89-year-old man presented in April 2011 with a cutaneous ulcerated nodule on the subpectoral pacemaker pocket. A titanium-covered pulse generator (Medtronic KVDD901 Kappa 900 VDD, Fridley, MN, USA) had been implanted in July 2007 for complete (third-degree) atrioventricular block.

Physical examination revealed an exophytic, yellowish ulcerated nodule that had a tendency to bleed. The clinical diagnosis was pyogenic granuloma, and complete excision was performed.

Gross examination of the

Discussion

The results of a study on cancer risk among pacemaker recipients in Denmark showed that these patients had rates for most types of cancer that were not significantly different from those of the general population. However, for sarcoma, there was a suggestion of increased risk over time that warranted continued vigilance of the patients [8]. On the other hand, 9 of the 10 sarcomas observed in the study period (1982–1996) did not occur in proximity to the site of the pacemaker.

In our review of

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Citation Excerpt :
An in vivo study of titanium dioxide particles in rats has demonstrated effects that may contribute to the susceptibility of tumor growth, namely reduced activity of macrophages and natural killer cells and altered proliferation of B and T-lymphocytes [8]. Electromagnetic fields have also been proposed as potential causes for cancer induction, but animal experiments have not supported this idea [9]. Consequently, despite the theoretical rationale that metallic implants could predispose to the proliferation of malignant cells, this requires further investigation and validation.
The development of malignant neoplasms over the site of pacemaker implantation is a rare event, with a limited number of published case reports. We report the case of a 78-year-old male who presented with discomfort and pocket mass expansion, reportedly following trauma. Due to initial presumption of a simple hematoma, dissection and drainage were performed without tissue collection for histology. Later presentation with an exophytic ulcerated mass led to biopsy and identification of a lymphoplasmacytic lymphoma. To the best of our knowledge this is the first reported case of a cutaneous lymphoplasmacytic lymphoma presenting as a pacemaker pocket mass, and underlines the importance of systematic pacemaker inspection, of adequate histological characterization and of a high degree of clinical suspicion for the identification malignancy in this context.
<Learning objective: We report the first case of a lymphoplasmacytic lymphoma presenting primarily as a pacemaker pocket mass. Lymphoplasmacytic lymphoma is a rare and indolent subtype of Non-Hodgkin lymphoma that may present with cutaneous manifestations. Due to the extreme rarity of malignant neoplasms presenting as pacemaker pocket masses, a high degree is clinical suspicion is required, and tissue histology plays a key role in the diagnosis.>
An enlarging pacemaker pocket: A case report of a plasmablastic lymphoma arising as a primary tumor around a cardiac pacemaker and systematic literature review of various malignancies arising at the pacemaker pocket
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To date, there have been limited reports of oncogenesis occurring within pacemaker pockets. We report the case of a 100-year-old male who presented to the emergency department complaining of expansion of his pacemaker pocket over the period of 8 days. Dissection of the pacemaker pocket and pathological analysis of tissue samples revealed plasmablastic lymphoma, a subset of diffuse large B-cell lymphoma, commonly seen in immunocompromised elderly patients. This is the first known reported case of plasmablastic lymphoma occurring within a pacemaker pocket.
<Learning objective: We describe the first case of a plasmablastic lymphoma arising as a primary tumor around a pacemaker site. A thorough literature review of primary tumors arising around pacemakers is provided. As the life expectancy of our population increases, the amount of time that pacemakers are in place increases as well. Therefore, we discuss several mechanisms that may have led to the oncogenicty of pacemakers, as well as the role of titanium in carcinogenesis.>
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Furthermore, sarcomas are not the only type of neoplasms reported in association with Dacron grafts, as a case of primary cardiac lymphoma (giant cell centroblastic type) has also been reported [15]. Sarcoma development in relationship to chronically implanted devices also has been documented [16,17]. Salm offered a classification of vascular neoplasm into three categories consisting of polypoidal intraluminal tumors, intimal-type tumors which enlarge by surface extension, and an adventitial type [1].
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: Conflicts of interest: The authors declare that they have no conflicts of interest.

: There are no sources of external funding.

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Case ReportAtypical fibroxanthoma developing on a pacemaker pocket mimicking a pyogenic granuloma

Abstract

Introduction

Section snippets

Case report

Discussion

Br J Oral Maxillofac Surg

Mod Pathol

J Am Acad Dermatol

Ann Thorac Surg

Carcinoma of the breast at the site of migrated pacemaker generators

Postgrad Med J

Cutaneous leiomyosarcoma developing on a pacemaker pocket

Dermatol Surg

Sarcoma of the lung in a pacemaker pocket—simple coincidence or oncotaxis?

Thorac Cardiovasc Surg

Rhabdomyosarcoma at site of pacemaker implantation

Ann Dermatol Venereol

Clear cell hidradenocarcinoma developing in a pacemaker pocket

Pacing Clin Electrophysiol

Inflammatory myofibroblastic tumor at the pacemaker site

Interact Cardiovasc Thorac Surg

Case Report
Atypical fibroxanthoma developing on a pacemaker pocket mimicking a pyogenic granuloma