Arterial embolism of tumor causing fatal organ infarction

Neoplastic embolization to systemic and pulmonary arteries

OBJECTIVE

Arterial neoplastic emboli are uncommon, accounting for <1% of thromboemboli in the current literature. Nonetheless, this event may be associated with significant morbidity and mortality. Herein, we report a series of 11 cases of arterial neoplastic emboli from a single tertiary care center along with a comprehensive review of the literature to date. The aim of this study was to document the incidence, clinical presentations, and complications of arterial neoplastic emboli as well as to highlight the importance of routine histologic examination of thrombectomy specimens.

METHODS

Pathology archives from a single tertiary care institution were queried to identify cases of surgically resected arterial emboli containing neoplasm (1998-2014). Histopathology was reviewed for confirmation of diagnosis. Patient demographics and oncologic history were abstracted from the medical record. Comprehensive literature review documented 332 patients in 275 reports (1930-2016).

RESULTS

Eleven patients (six men) with a median age of 63 years (interquartile range, 42-71 years) were identified through institutional archives. Embolism was the primary form of diagnosis in seven (64%) cases. Cardiac involvement (primary or metastasis) was present in more than half of the cohort. Comprehensive literature review revealed that pulmonary primaries were the most common anatomic origin of arterial neoplastic emboli, followed by gastrointestinal neoplasia. Cardiac involvement was present in 18% of patients, and sentinel identification of neoplasia occurred in 30% of cases. Postmortem evaluation was the primary means of diagnosis in 27%.

CONCLUSIONS

This study highlights the importance of routine histopathologic evaluation of embolectomy specimens in patients with and without documented neoplasia.

Orbital Metastasis of Cervical Carcinoma - Case Report and Review of Literature

The orbit is a frequent site of metastasis, particularly from the breast, prostate gland and the lung. Carcinoma of the cervix metastasizing to the orbit is rare. We report a 27-year-old woman with Stage II B cervical cancer who presented with progressive painless protrusion of the left eye of one month duration associated with diplopia. Histology of the orbital mass was similar to that of the cervical cancer and reported as squamous cell carcinoma. She received palliative radiation to the left orbit 30 Gy in 10 fractions along with chemotherapy (Paclitaxel and Carboplatin). This resulted in regression of the proptosis. We review published literature of cases of carcinoma of the uterine cervix with metastasis to the orbit.

Coronary thrombus aspiration revealed tumorous embolism of myxofibrosarcoma from the left atrium

Thrombus aspiration is currently the standard strategy for primary PCI. Thrombus can be aspirated via aspiration catheters, restoring coronary blood flow. However, there are a limited number of reports regarding thrombus aspiration toward tumor embolized occlusion. We present a case of 90-year-old male with AMI caused by the metastatic tumor embolism. Emergent coronary angiography revealed total occlusion in three epicardial vessels. Histopathological examination of the aspirated specimen revealed the mixture of thrombus and metastatic tumor cells. Thrombus aspiration was partially effective for restoring coronary blood flow; however, it was very helpful for the final diagnosis of tumor embolism.

Esophageal squamous cell carcinoma presenting with systemic arterial embolism

Acute arterial occlusion as a result of embolization from a malignant tumor is rare and infrequently reported. Recently a 70-year-old man initially presented with acute arterial occlusion of the left lower limb. He underwent embolectomy, and embolus was diagnosed as a squamous cell carcinoma histologically. Subsequent upper gastrointestinal endoscopy showed superficial esophageal cancer in the thoracic esophagus. Although scheduled to undergo chemotherapy, he died of acute pneumonia on the 81st day from onset. Autopsy showed superficial esophageal cancer, measuring 1.5 cm in diameter, and widespread tumor extension into arterial vessels such as the left femoral artery, the superior mesenteric artery, bilateral intrapulmonary arteries and veins such as bilateral brachiocephalic vein to the supra vena cava, despite small tumor size and shallow tumor invasion depth of the submucosal layer. This case is particularly interesting because the cancer manifested as arterial cancer embolism.

Arterial thrombosis in a gynecologic oncology patient: evaluation and management

BACKGROUND

Arterial thrombosis is an extremely rare complication in gynecologic oncology with only two cases previously reported in the literature. Presentation, evaluation, and treatment varied considerably in all previous reports of arterial thrombosis associated with any malignancy.

CASE

We report a case of discontinuous arterial thrombosis in the upper extremity of a patient with fallopian tube cancer. Her initial evaluation, done in the acute setting of the thrombosis, revealed multiple thrombophilia abnormalities, including an elevated Factor VIII, and a borderline positive lupus anticoagulant. Follow-up studies over 2 years showed resolution of all coagulation abnormalities, thus indicating no genetic propensity for thrombosis.

CONCLUSION

This case highlights the need for appropriate timing of the initial laboratory studies and follow-up so that patients can be managed appropriately.

Massive tumour embolism from primary lung cancer

Massive systemic intra-arterial embolism of malignant lung cancer is a rare condition. When it occurs it usually follows pneumonectomy. Its occurrence is related to propagated tumour within a pulmonary vein and this may be suspected pre-operatively. Although the primary lung cancer may theoretically be curable, embolism is frequently widespread and is associated with a very poor prognosis. The importance of early intraoperative pulmonary vein interruption during lung cancer surgery is emphasized.

Acute limb ischemia due to arterial embolism of tumor

Arterial tumor embolism is a rare occurrence. We report such an embolus causing acute limb ischemia which was the first indication of malignancy in a patient who subsequently proved to have malignant melanoma.

Left atrial metastasis presenting as recurrent embolic strokes

Tumour emboli from an endocardial metastasis of an endometrial stromal sarcoma caused recurrent and ultimately fatal strokes in a woman of 40. Endocardial metastases are rare. They are known to embolise to the pulmonary and systemic arteries but not to cause recurrent cerebral emboli.

Subacute pulmonary hypertension and systemic tumour embolism from cervical cancer

Venous tumour embolization is not unusual in malignant disease (1-3) usually in the form of individual cells or small clumps. Malignant cells in the pulmonary vasculature are therefore not an uncommon finding, especially in patients with abdominal neoplasms (4-7). Arterial emboli from a malignant tumour are, however, rare (8, 9), particularly peripheral ones (9, 10) and those sufficiently large to cause organ infarction. An unusual case of pulmonary and widespread systemic tumour embolization from carcinoma of the cervix is described in which systemic dissemination of tumour emboli had apparently resulted from transpulmonary passage, without the development of pulmonary metastases.