Ann Thorac Surg 2004;77:1426-1428
© 2004 The Society of Thoracic Surgeons
Case report
Peripheral arterial embolism arising from pulmonary adenocarcinoma
Jesus Loscertales, MD, PhDa*,
Miguel Congregado, MD, PhDa,
Carlos Arenas, MD, PhDa,
Andres Arroyo, MDa,
Juan Carlos Giron, MDa,
Javier Ayarra, MD, PhDa,
Rafael Jimenez-Merchan, MD, PhDa
a Department of General and Thoracic Surgery, Virgen Macarena University Hospital, Seville, Spain
Accepted for publication April 11, 2003.
* Address reprint requests to Dr Loscertales, Hospital Universitario Virgen Macarena, Av Dr Fedriani No. 3, 41071 Seville, Spain
e-mail: jloscert{at}us.es
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Abstract
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Bronchogenic carcinoma is a rare source of peripheral arterial embolism. We present the case of a 28-year-old female nonsmoker with an adenocarcinoma of the left main bronchus involving the pulmonary veins. While the patient was hospitalized awaiting operation, she presented embolization in her legs; embolectomy and fasciotomy were necessary to treat compartment syndrome. Echocardiography disclosed floating tumoral masses in the left atrium. Seven days later, an operation was performed with cardiopulmonary bypass to remove the tumor masses from the atrial lumen; pulmonary veins were sutured from within the atrium, and pneumonectomy was performed. Fulminant infection of the lower limbs developed that led to gangrene and multiple organ failure, and the patient died 8 days after the operation.
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Introduction
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Coagulation disorders are a frequent complication of cancer. Hypercoagulation has been reported to cause thromboembolism in lung cancer patients. However, peripheral arterial embolism of tumoral origin is relatively uncommon [1]; in a 1996 review of the literature, Zurcher and colleagues [2] found 38 reported cases. Primary pulmonary tumor is thus a rare cause of arterial occlusion in the distal portion of the limbs.
In 1998, Fernandez and colleagues [3] reported a case of bronchogenic carcinoma that presented as an intracardiac mass with simultaneous popliteal artery embolization, for which the authors recommended echocardiography as the best means for achieving a precise diagnosis. Similarly, 1 year earlier, Jobic and colleagues [4] had reported on a 45-year-old female renal transplant patient in whom echocardiography disclosed the presence of bronchial carcinoma with intracardiac invasion; echocardiography was found to be the best diagnostic tool. Thus, although it is a rare occurrence, lung carcinoma should be considered as a possible source of peripheral arterial embolism if the atrium or pulmonary veins are invaded.
A 28-year-old female nonsmoker with no relevant history, presenting only nonspecific pain in the left hemithorax over the previous month, was referred to our department for surgical treatment. The referring hospital had diagnosed carcinoma of the left main bronchus, because radiography had disclosed complete atelectasis of the left lung and minimal ipsilateral hemoptysis. Fiberoptic bronchoscopy confirmed complete occlusion of the left main bronchus by a very poorly differentiated large-cell carcinoma, with a mass growing 3 cm from the carina. Computerized tomography scan (Fig 1)
findings were similar, showing a hilar mass apparently adhering to or invading the atrium, together with subcarinal and hilar adenopathies.
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Fig 1. Computerized tomography demonstrating lung tumor, minimal left atrial invasion, and intraatrial tumoral mass (arrow)
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The day after admission, while preoperative tests were being finalized, acute arterial ischemia developed in both legs that was caused by arterial embolism; coagulation tests yielded normal results, and electrocardiography showed no alterations. An emergency bilateral embolectomy was performed by using a Fogarty catheter with a perfect backflow; an epidural catheter was placed for postoperative analgesia. Subsequent echocardiography (Fig 2)
disclosed a hyperechoic tumoral mass within the left atrium; it did not adhere to the septum and infiltrated the pulmonary veins. Twenty-four hours later, fasciotomy was required on both legs because of postrevascularization compartment syndrome.
One week later, the patient underwent pneumonectomy by means of median sternotomy with cardiopulmonary bypass to avoid possible embolization due to the release of emboli during routine surgical handling at dissection of pulmonary veins. The left atrium was opened, and 2 tumoral masses growing from the pulmonary veins and floating in the atrial lumen, without atrial invasion, were removed; the mass in the upper pulmonary vein was the larger of the 2 (Fig 3).
This was followed, closing the atrium from inside and a pneumonectomy with partial resection of the left atrium from outside, in view of invasion of the veins just to the atrium. The intrabronchial tumor mass disclosed by fiberoptic bronchoscopy arose more than 3 cm from the carina; it was growing into the lumen but did not involve the bronchial wall. During the operation, the border of the bronchial section was confirmed by frozen section to be free of invasion.
The excised mass was identified histologically as a highly malignant adenocarcinoma with rhabdoid features and a maximum diameter of 7 cm. The same diagnosis was confirmed for the adenopathies and the intraatrial floating masses.
The postoperative course was unfavorable: compartmental ischemia of the lower limbs reappeared. This led to fulminant bilateral infection, gangrene, sepsis, kidney failure, and, eventually, heart failure. The patient died 8 days after the operation.
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Comment
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Arterial embolism of tumoral origin has been reported in atrial myxomas and, more rarely, in other primary intracardiac tumors, as well as in malignant primary lung tumors with which there is involvement of pulmonary vessels. This case fits into the last group, because embolism was produced by 2 masses floating in the left atrial lumen, from which emboli became detached [5, 6].
With regard to diagnosis, the best method of detecting these embolic masses seems to be conventional or transesophageal echocardiography, considered by many authors [7, 8] the best technique for studying this pathology. Singh and colleagues [9] confirmed this view with an embolism produced by atrial invasion from metastases from a pulmonary germ cell tumor. Another method that has proven valuable in diagnosing this condition is intravenous digital angiography, although it is more aggressive than echocardiography and does not yield better results [10]. In this case, echocardiography furnished a definitive diagnosis.
Regarding treatment, once the embolism has appeared, it should obviously be surgically removed, and anticoagulation and vasodilators should be started. This case also required fasciotomy to treat postbilateral revascularization compartment syndrome.
Once peripheral ischemia is under control, the best surgical approach to these tumors (T4 due to vascular or atrial invasion)—as long as they are resectable—is median sternotomy, with cardiopulmonary bypass to avoid the possible formation of new emboli at operation or during the postoperative period because of release of emboli caused by routine surgical dissection of veins, atrium, or both with conventional thoracotomy, as reported by Joshi and Pradhan [11]. Singh and colleagues [9], however, reported a case of embolism caused by atrial invasion, which was treated by thoracotomy with cardiopulmonary bypass, lower lobectomy, and partial resection of the atrium. There were no subsequent complications. Nevertheless, we believe that the safest approach is median sternotomy with cardiopulmonary bypass.
In conclusion, we think that if atrial invasion is suggested in a patient with lung cancer, special attention should be taken to avoid peripheral arterial embolism. Echocardiography should be performed before the intervention, and performing this operation by medial sternotomy with cardiopulmonary bypass.
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References
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- Xiromeritis N., Klonaris C., Papas S., Valsamis M., Bastounis E. Recurrent peripheral arterial embolism from pulmonary cancer. Case report and review of the literature. Int Angiol 2000;19:79-83.[Medline]
- Zurcher M., Gerber H., Gebbers J.O. Tumor embolism with fatal cerebral infarct in pneumonectomy. Case report and review of the literature 1996;67:959-962.
- Fernandez B.B., Grove M., Carman T.L. An unusual presentation of simultaneous bilateral popliteal artery embolism—a case report. Angiology 1998;49:573-576.
- Jobic Y., Moal M.C., Larlet J.M., et al. Systemic embolism in a renal transplant patient. Echocardiographic demonstration of bronchial carcinoma with intracardiac invasion. Arch Mal Coeur Vaiss 1997;90:1417-1421.[Medline]
- French B.G., Peebles S.E., Davidson K.G., Pollock J.G. Massive tumour embolism from primary lung cancer. Aust N Z J Surg 1992;62:317-319.[Medline]
- Jahns R., Kenn W., Stolte M., Inselmann G. A primary osteosarcoma of the heart as a cause of recurrent peripheral arterial emboli. Ann Oncol 1998;9:775-778.[Abstract/Free Full Text]
- Tassan S., Chabert J.P., Tassigny C., et al. Peripheral embolic arterial accident due to pulmonary vein thrombosis revealing bronchial carcinoma. Ann Cardiol Angeiol 1998;47:11-13.
- Dressler F.A., Labovitz A.J. Systemic arterial emboli and cardiac masses. Assessment with transesophageal echocardiography. Cardiol Clin 1993;11:447-460.[Medline]
- Singh A., Jenkins D.P., Dahdal M., Dhar S., Ratnatunga C.P. Recurrent arterial embolization from a metastatic germ cell tumor invading the left atrium. Ann Thorac Surg 2000;70:2155-2156.[Abstract/Free Full Text]
- Cornalba G.P., Rota L., De Flaviis L., Nessi R. Intravenous digital angiography in the control of the patency of extra-anatomical bypasses of the legs. Radiol Med 1985;71:555-559.
- Joshi P.S., Pradhan S.A. Acute neoplastic arterial embolism after pneumonectomy. Indian J Cancer 1998;35:112-114.[Medline]
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Abstract
Introduction
