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Arya VK, Gourav KP, Gandhi KA, Singh H. Paraplegia after Pneumonectomy - A Rare Complication. Ann Card Anaesth 2024; 27:79-81. [PMID: 38722129 PMCID: PMC10876134 DOI: 10.4103/aca.aca_115_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 05/12/2024] Open
Abstract
ABSTRACT Cardiac metastases of lung cancers are common and are associated with serious complications. Locally aggressive lung tumors have the potential to extend into the left atrium via pulmonary veins, which can further complicate by embolizing into the systemic circulation. Pulmonary blastoma (PB) is one of the rare forms of primary lung malignancy and is locally aggressive. We report a rare case of 30 years old male patient who underwent left pneumonectomy for PB. During resection, the tumor was embolized into the descending thoracic aorta, leading to an acute circulatory compromise of both the lower limbs.
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Affiliation(s)
- Virendra K. Arya
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishna Prasad Gourav
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Komal Anil Gandhi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harkant Singh
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Tathireddy H, Rice D, Martens K, Shivakumar S, Shatzel J. Breaking down tumor thrombus: Current strategies for medical management. Thromb Res 2023; 230:144-151. [PMID: 37722206 PMCID: PMC11027429 DOI: 10.1016/j.thromres.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/13/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023]
Abstract
Tumor thrombus, the intravascular extension of tumor into adjacent blood vessels, is frequently encountered in patients with renal cell carcinoma and hepatocellular carcinoma, and often involves the abdominal vasculature including the renal vein, portal vein, and the inferior vena cava. While a bland thrombus is composed of platelets and fibrin, in contrast, a tumor thrombus refers to an organized collection of tumor cells. Though oftentimes detected incidentally on imaging, tumor thrombus may have significant clinical implications and can be challenging to differentiate from bland thrombus. Additionally, the optimal management of tumor thrombus, including the use of anticoagulation, remains poorly described. This review summarizes common causes of tumor thrombus, as well as its impact on staging, prognosis, and treatment.
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Affiliation(s)
- Harsha Tathireddy
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Douglas Rice
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Kylee Martens
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | | | - Joseph Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA; Department of Biomedical Engineering, Oregon Health & Science University, OR, USA
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3
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Bagai S, Malik V, Prasad P, Singh P, Sahu A, Khullar D. Poorly Differentiated Lung Cancer with Intracardiac Extension Causing Malignant Stroke in a Peritoneal Dialysis Patient: a Case Report. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 4:255. [PMCID: PMC9662106 DOI: 10.1007/s42399-022-01331-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Sahil Bagai
- Department of Nephrology and Renal Transplant Medicine, Max Super Speciality Hospital, Saket, Delhi India
| | - Vipra Malik
- Department of Pathology, Core Diagnostics Pvt Ltd, Gurugram, India
| | - Pallavi Prasad
- Department of Nephrology and Renal Transplant Medicine, Max Super Speciality Hospital, Saket, Delhi India
| | - Priyanka Singh
- Department of Radion Oncology, Max Super Speciality Hospital, Saket, Delhi India
| | - Amit Sahu
- Department of Radiology, Max Super Speciality Hospital, Saket, Delhi India
| | - Dinesh Khullar
- Department of Nephrology and Renal Transplant Medicine, Max Super Speciality Hospital, Saket, Delhi India
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Hussain SMA. Tumor embolism and acute arterial occlusion: A systematic review. Surg Open Sci 2022; 10:216-222. [PMID: 36389271 PMCID: PMC9664516 DOI: 10.1016/j.sopen.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/18/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Objective To determine common etiologies, presentations, management strategies and outcomes in patients with tumor embolism causing acute arterial occlusion. Study design This is a systematic review of published case reports on tumor embolism. Search strategy All published cases of tumor embolism in the MEDLINE and EMBASE databases were reviewed. The search terminologies were (Tumor Embolism), (Ischemia), (Occlusion) and (Infarction). Inclusion and exclusion criteria All published reports of tumor embolism were included. Studies regarding venous thromboembolism and cancer-associated thromboembolism without tumor embolization were excluded. The cases included numbered 42. Outcome measures These included the frequencies of different primary tumor types, clinical presentations, anatomical sites of embolization, types of intervention and outcomes including number of deaths and successful discharges. Results Lung cancer and Atrial Myxoma each accounted for 14 out of 42 cases (33%). There were 11 cases (26.9%) of stroke and 9 cases (21.4%) of myocardial infarction and limb ischemia. Femoral thrombo-embolectomy was performed in all 9 cases of limb ischemia and Primary coronary intervention was performed in 7 out of 9 (77.8%) cases of myocardial infarction. There were 14 inpatient deaths (33.3%) and 19 patients were successfully discharged (45.2%). Conclusion Lung cancer and atrial myxoma were the most common sources for tumor embolism. Acute stroke was the most common presentation. This is treated with antiplatelets or anticoagulation as well as chemotherapy and resection of primary tumor. Early revascularisation can prevent severe complications such as death, paralysis, heart failure and limb loss in selected cases of tumor embolism. Key message Histopathological examination of embolic tissue can demonstrate tumor tissue and alert the clinician to a cancer elsewhere. This is most likely to be lung cancer or atrial myxoma. Early revascularisation in selected cases of acute tumor embolism can prevent severe complications and these patients should not be automatically palliated due to their underlying neoplasm.
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Affiliation(s)
- Syed Mohammad Asim Hussain
- Department of Vascular Surgery, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley GU16 7UJ, United Kingdom
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5
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Asymptomatic Tumor Thrombus in the Left Atrium from Squamous Cell Carcinoma. Case Rep Med 2022; 2021:4256471. [PMID: 34970316 PMCID: PMC8714348 DOI: 10.1155/2021/4256471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/29/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022] Open
Abstract
A 67-year-old female patient presented asymptomatically for further evaluation of a chest mass. Other than significant smoking history, the patient had been healthy with a recently treated case of uncomplicated pneumonia. The mass originated in the aortopulmonary window of the left mediastinum and invaded proximally into the left superior pulmonary vein and subsequently into the left atrium. The mass protrusion into the mitral valve occupied 50% of the left atrium space but showed no clinical symptoms of a valvular blockade. Poorly differentiated squamous cell carcinoma was identified upon biopsy. These findings of a primary lung tumor with atrial extension in an asymptomatic patient point to the importance of age-appropriate screening and standardization treatment modalities.
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Harnarayan P, Islam S, Naraynsingh V. Arterial Embolism in Malignancy: The Role of Surgery. Ther Clin Risk Manag 2021; 17:635-640. [PMID: 34177265 PMCID: PMC8219304 DOI: 10.2147/tcrm.s308026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background Peripheral arterial embolism from malignant disease is uncommon and a rare cause of limb ischemia. In the acute setting, patients can present with severe ischemia of either the upper or lower limb, and urgent surgical intervention is often required to avoid severe debilitation and limb loss. Patients Our case series comprised three patients who presented with upper and lower limb ischemia and were found to have concomitant malignancy. All three patients were female, with a median age of 54.3 years, and none of the patients was on active chemotherapy. One presented with stage IIb uterine carcinoma, one with stage IIIb ovarian carcinoma, and the other with stage IIIb cervical carcinoma. These patients were referred for vascular management, with two being acute and the other acute on chronic. Results Of the three patients, two presented with acute limb ischemia and underwent arterial thrombectomy, one of the upper and the other the lower limb. The third patient, with acute-on-chronic upper limb ischemia, was treated conservatively with intravenous heparin followed by oral anticoagulation. All three had limb salvage and survival outcome at 1 year post-treatment. Conclusion In this small series, surgical intervention in two patients and conservative management in the other patient led to limb salvage with a reasonably good quality of life. Even though the long-term survival for patients with malignant disease is generally poor, surgical intervention can achieve limb salvage with a reasonably good quality of life.
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Affiliation(s)
- Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Shariful Islam
- Department of Surgery, San Fernando General & Teaching Hospitals, San Fernando, Trinidad and Tobago
| | - Vijay Naraynsingh
- Department of Surgery, Medical Associates Hospital, St. Joseph, Trinidad and Tobago
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Layfield LJ, Freeman D, Crim JR. Left atrial tumor thrombus with emboli to the brain and distal extremities: A case report. Pathol Res Pract 2020; 216:152911. [PMID: 32178936 DOI: 10.1016/j.prp.2020.152911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/17/2020] [Accepted: 02/28/2020] [Indexed: 11/27/2022]
Abstract
Cardiac metastases are an uncommon phenomenon associated with neoplasms from a variety of primary sites. Pulmonary involvement often accompanies metastases involving the left atrium or ventricle and clinical presentation may be associated with stroke or emboli involving distal sites. We report a patient who presented acutely to the Emergency Department with symptoms of a cerebrovascular accident and bilateral cold pulseless lower extremities. Computerized Tomographic (CT) angiogram of the chest, abdomen, pelvis and lower extremities disclosed pulmonary veins with large filling defects in the right superior and inferior vessels as well as the left atrium and atrial appendage. Mediastinal and hilar adenopathy was detected. The patient had a history of tonsillar squamous cell carcinoma eighteen months prior. The patient underwent operative intervention with removal of a large left intra-atrial mass, histologic evaluation of which demonstrated groups of malignant squamous cells meshed in fibrin clot. The patient died three days post operatively due to multiple brain infarctions.
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Affiliation(s)
- Lester J Layfield
- Department of Pathology and Anatomical Sciences, United States of America.
| | - Douglas Freeman
- Department of Pathology and Anatomical Sciences, United States of America
| | - Julia R Crim
- Department of Radiology University of Missouri, Columbia, MO, United States of America
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Pham N, Bonnen MD, Ghebre YT. Silent Neoplastic Cardiac Invasion in Small Cell Lung Cancer: A Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:619-622. [PMID: 29844305 PMCID: PMC6004049 DOI: 10.12659/ajcr.908374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Female, 66 Final Diagnosis: Small cell lung cancer Symptoms: Impaired memory Medication: — Clinical Procedure: Chest X-ray • computed tomography • magnetic resonance imaging • electrocardiogram Specialty: Oncology
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Affiliation(s)
- Ngoc Pham
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Mark D Bonnen
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Yohannes T Ghebre
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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Bois MC, Eckhardt MD, Cracolici VM, Loe MJ, Ocel JJ, Edwards WD, McBane RD, Bower TC, Maleszewski JJ. Neoplastic embolization to systemic and pulmonary arteries. J Vasc Surg 2018; 68:204-212.e7. [PMID: 29502997 DOI: 10.1016/j.jvs.2017.09.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/23/2017] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Michael D Eckhardt
- Department of Pathology and Laboratory Medicine, University of Chicago, NorthShore University HealthSystem, Evanston, Ill
| | | | - Matthew J Loe
- Interventional Radiology, St. Paul Radiology, St. Paul, Minn
| | - Joseph J Ocel
- Diagnostic Radiology, Mercy Health Services-Iowa Corporation, Mason City, Iowa
| | - William D Edwards
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Robert D McBane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph J Maleszewski
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.
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Quencer KB, Friedman T, Sheth R, Oklu R. Tumor thrombus: incidence, imaging, prognosis and treatment. Cardiovasc Diagn Ther 2017; 7:S165-S177. [PMID: 29399520 PMCID: PMC5778532 DOI: 10.21037/cdt.2017.09.16] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/12/2017] [Indexed: 12/11/2022]
Abstract
Intravascular tumor extension, also known as tumor thrombus, can occur in many different types of cancer. Those with the highest proclivity include Wilm's tumor, renal cell carcinoma (RCC), adrenal cortical carcinoma (ACC) and hepatocellular carcinoma (HCC). The presence of tumor thrombus markedly worsens prognosis and impacts treatment approach. Imaging plays a key role in its diagnosis. Endovascular methods also play a large role in treatment.
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Affiliation(s)
| | - Tamir Friedman
- Division of Interventional Radiology, Department of Radiology, Cornell University, New York, NY, USA
| | - Rahul Sheth
- Division of Interventional Radiology, Department of Radiology, MD Anderson Cancer, Houston, TX, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Department of Radiology, Mayo Clinic-Arizona, Phoenix, AZ, USA
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11
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Li Y, Lou J, Qiu S, Guo Y, Pan M. Stereotactic radiotherapy for the treatment of lung cancer with a giant left atrial tumor thrombus: A case report and literature review. Oncol Lett 2016; 11:2229-2232. [PMID: 26998153 DOI: 10.3892/ol.2016.4215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 12/16/2015] [Indexed: 11/06/2022] Open
Abstract
Lung cancer presenting with a giant atrial tumor thrombus is particularly rare. Surgical resection, aided by a cardiopulmonary bypass, is the standard treatment of choice if there is no distant metastasis. However, this form of surgery carries a high risk, with the subsequent patient prognosis being extremely poor. The current study describes the case of a 52-year-old man presenting with left lung squamous cell carcinoma that had extended into the left atrium. The patient was treated with stereotactic radiotherapy, and regarding the atrial disease, a complete response was achieved within 12 months. The present case demonstrates that stereotactic radiotherapy may be a beneficial palliative treatment for patients with stage IV lung cancer invading the left atrium.
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Affiliation(s)
- Yong Li
- Center of Radiation Oncology, Wujing Hospital, Shanghai 201103, P.R. China
| | - Jinrong Lou
- Department of Cardiology, Jiading Central Hospital, Shanghai 201800, P.R. China
| | - Shujun Qiu
- Center of Radiation Oncology, Wujing Hospital, Shanghai 201103, P.R. China
| | - Yutian Guo
- Center of Radiation Oncology, Wujing Hospital, Shanghai 201103, P.R. China
| | - Mianshun Pan
- Center of Radiation Oncology, Wujing Hospital, Shanghai 201103, P.R. China
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Segrelles Calvo G, García Pérez S, Cabrera I. Vascular manifestations of pulmonary adenocarcinoma: a case report. Arch Bronconeumol 2014; 51:201-2. [PMID: 24928304 DOI: 10.1016/j.arbres.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Affiliation(s)
| | - Silvia García Pérez
- Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Irene Cabrera
- Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, España
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Fatal paraneoplastic embolisms in both circulations in a patient with poorly differentiated neuroendocrine tumour. Case Rep Vasc Med 2014; 2013:739427. [PMID: 24490097 PMCID: PMC3893835 DOI: 10.1155/2013/739427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 10/19/2013] [Indexed: 11/17/2022] Open
Abstract
Arterial embolism with lower limb ischemia is a rare manifestation of paraneoplastic hypercoagulability in cancer patients. We report a unique case of fatal thromboembolism involving both circulations associated with a poorly differentiated neuroendocrine tumor of the lung with rapid progress despite high doses of unfractioned heparin and review the current literature on anticoagulative regimen in tumour patients.
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Schreffler SM, Paolo WF, Kloss BT. Spontaneous showering of tumor emboli in a patient with advanced primary lung cancer: a case report. Int J Emerg Med 2012; 5:27. [PMID: 22673136 PMCID: PMC3414810 DOI: 10.1186/1865-1380-5-27] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 06/06/2012] [Indexed: 11/10/2022] Open
Abstract
Extension of primary lung tumors into the left atrium via pulmonary veins is a well-documented phenomenon. Peripheral arterial embolism and cerebral embolism originating from a primary lung neoplasm are rare events. We report a case of simultaneous acute bilateral lower limb ischemia, bilateral renal infarction, splenic infarction and cerebral infarction as a result of multiple emboli originating from primary lung malignancy invasion of the left atrium. An emergent embolectomy revealed pathologic features of the extracted thrombus that were identical to the pulmonary neoplasm.
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Affiliation(s)
- Susan M Schreffler
- SUNY Upstate Medical University, Department of Emergency Medicine, 550 E, Genesee Street, Syracuse, NY, USA.
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Ucak A, Inan K, Onan B, Temizkan V, Alp I, Yilmaz AT. Free‐Floating Tumor Thrombus in the Left Atrium Associated with Non‐Small Cell Lung Cancer. J Card Surg 2009; 24:686-9. [DOI: 10.1111/j.1540-8191.2009.00927.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Alper Ucak
- Department of Cardiovascular Surgery, GATA Haydarpasa Education Hospital, Istanbul, Turkey
| | - Kaan Inan
- Department of Cardiovascular Surgery, GATA Haydarpasa Education Hospital, Istanbul, Turkey
| | - Burak Onan
- Department of Cardiovascular Surgery, GATA Haydarpasa Education Hospital, Istanbul, Turkey
| | - Veysel Temizkan
- Department of Cardiovascular Surgery, GATA Haydarpasa Education Hospital, Istanbul, Turkey
| | - Ibrahim Alp
- Department of Cardiovascular Surgery, GATA Haydarpasa Education Hospital, Istanbul, Turkey
| | - Ahmet Turan Yilmaz
- Department of Cardiovascular Surgery, GATA Haydarpasa Education Hospital, Istanbul, Turkey
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