Aust. N.Z.J .
Surg. 1992,62,317-319
317
MASSIVE TUMOUR EMBOLISM FROM PRIMARY LUNG CANCER B. G. FRENCH, S. E. PEEBLES,K. G. DAVIDSON AND J. G. POLLOCK Glasgow Royal Infirmary, Glasgow, Scotland, UK 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. Key words: embolism, lung neoplasms, neoplasm circulatingcells.
Introduction Massive systemic intra-arterial embolism by primary carcinoma of the lung is uncommon, with only 18 cases having previously been described, although tumour metastases commonly occur by this route. A case causing aortic bifurcation saddle embolus is reported and the literature regarding this condition is reviewed briefly. Case report
A 56 year old female who had presented with breathlessness and weight loss was referred with a large radiological mass in her right lung (Fig. 1). A bronchoscopy revealed a tumour occluding the apical segment of the right lower lobe, and a biopsy showed this to be adenocarcinoma. A mediastinoscopy was normal and the patient was scheduled for surgery. At thoracotomy there was an extensive hilar tumour mass and an intrapericardial pneumonectomy was performed. Tumour was noted in the inferior pulmonary vein. The patient was noted to have ischaemic lower limbs 4 h postoperatively, and clinically had an aortic bifurcation saddle embolus. Both femoral arteries were exposed under local anaesthesia and the embolus was removed using Fogarty embolectomy catheters. The patient made a satisfactory recovery and was discharged on the eighth postoperative day. At review 2 months later she was well, having no evidence of recurrent or metastatic disease. Histological examination of the embolectomy specimen demonstrated a blood clot containing small groups of adenocarcinoma cells (Fig. 2). The Correspondence: B. G. French, NHS Department of Surgery, Glasgow Royal Infumary, Glasgow, G4 OSF, Scotland, UK. Accepted for publication 20 February 1991
Fig. 1. Chest X-ray showing the large hilar tumour.
Fig. 2. Haematoxylin and eosin stained section of the embolus showing blood clot containing adenocarcinoma cells. Magnification X 316.
FRENCH ETAL.
318
primary tumour was a poorly differentiated adenocarcinoma involving one intrapulmonary lymph node.
Discussion
Primary lung tumours are capable of frank embolism in one of two settings. The first and most common is the pen-operative embolus. This occurs during or soon after pulmonary surgery and is presumed to be caused by the dislodgement, by hilar manipulation, of propagated tumour within a pulmonary vein. The second situation is tumour embolization in the absence of pulmonary surgery, which is presumed to be due to the spontaneous fragmentation of propagated tumour within a pulmonary vein. Table 1 summarizes the details of all reported cases of massive embolus secondary to primary lung cancer. Primary lung tumour embolism does not appear to have a predilection for any particular cell type. What is of more pathological importance is the presence of propagated tumour within a large pulmonary vein. This can be suspected pre-operatively if there is a large hilar mass on chest X-ray and may be visible on a contrast-enhanced computerized tomography (CT)scan. '9'
The condition carries a very poor prognosis with 50% of patients dying within the first week of the
embolus. This high initial mortality relates to the widespread distribution of emboli, with multiorgan ischaemia and the additional physiological insult this causes to a patient having undergone a major pulmonary resection, which is usually pneumonectomy. The average survival of patients who do survive the initial postoperative period is less than 4 months. Although one cannot be certain, this probably reflects metastatic Frequently the embolectomy specimen does not contain macroscopically recognizable tumour, but as in the case described, microscopic examination demonstrates both thrombus and tumour cells (Fig. 2).234Bearing in mind that occasionally systemic embolism can be a presenting feature of pulmonary tumours, this lends support to the view that embolectomy specimens should be examined microscopically. It is important to recognize that, as in this case, the primary lung tumours responsible for massive tumour embolism are occasionally localized and therefore theoretically c ~ r a b l e . ~In- ~this respect they differ from massive tumour embolism secondary to pulmonary metastases that are categorically disseminated and described elsewhere. 132*7
Table 1. Reported cases of massive embolism secondary to primary lung cancer Patient
Reference
1
9
2
10
Turnour embolus histology
Sex
Age (years)
M M M M
50 60 52
Oat cell Anaplastic Squamous cell Anaplastic
Artery of impaction
Postoperative
Survival time (postoperative)
Femoral Femoral Carotid Cerebral Axillary Aortic bif. Sup. mesenteric Hepatic Cerebral Iliac (both) Femoral Sup. mesenteric Aortic bif. Renal
No No Yes Yes
3 months 2 months 2 days 10h
Yes
15 h
No Yes
7 days Not stated
Yes
1 day
3
6
4
8
5
4
M
57
Adenocarcinoma
6 7
11
12
F M
52 57
Oat cell Not stated
8
13
M
69
Undifferentiated
43 64 64
Squamous cell
Aortic bif.
Yes
62
Undifferentiated Undifferentiated Adenocarcinoma Squamous cell Squamous cell Adenocarcinoma Squamous cell Small cell
Yes Yes Yes Yes No Yes No Yes
5 months 1 month 36 h 4 months 5 months 7 months 3 months Not stated 12 h
52
Undifferentiated
Femoral Aortic bif. Aortic bif. Subclavian Femoral (both) Aortic bif. Popliteal Aortic bif. Coronary Sup. mesenteric Cerebral
No
10 days
9
5
M
10
3
11 12
14
13 14
2
15 16
2
17
16
M M F M F M F M
18
17
15
2
7
M
61
56
53 67 69 64
M: Male; F: Female; Aortic bit aortic bifurcation; Sup. mesenteric: superior mesenteric.
TUMOUR EMBOLISM FROM PRIMARY LUNG CANCER
The prognostic importance of pulmonary venous interruption as the initial step in lung cancer surgery, f i s t suggested by Aylwin as a precaution to prevent both massive tumour embolism and microscopic metastases, is obvious.* In summary, massive systemic intra-arterial embolism of malignant primary 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 can be suspected pre-operatively . Although the associated primary lung cancer may theoretically be curable, tumour embolism is frequently widespread and carries a very poor prognosis. This emphasizes the importance of early intra-operative pulmonary venous interruption during lung cancer surgery.
References GENE W. H., BENJAMIN R. S., GLUSMAN S., WARD S. & WIERNIK P. H. (1974) Arterial embolism of tumour causing fatal organ infarction. Arch. Inr. Med. 134,545-8. PRIOLEAU P. G. & KATZENSTEIN A. A. (1978) Major peripheral arterial occlusion due to malignant tumour embolism. Histologic recognition and surgical management. Cancer 42,2009-14. H. W. (1969) MasDE BOERH.H. M. & PRILLEVITZ sive tumour embolism. Arch. Chir. Neerl. 21, 223-34. TABER R. E. (1961) Massive systemic tumour embolism during pneumonectomy: a case report with comments on routine primary pulmonary vein ligation. Ann. Surg. 154, 263-8. F. G. (1967) Massive systemic FIRORW. B., PEARSON tumour embolism during pneumonectomy: successful removal by means of balloon catheter. Can. J . Surg. 10, 200-2.
319 6. EASON E. H. (1950) A case of cerebral infarction due to neoplastic embolism. J . Path. Bact. 62, 454-7. 7. STARR D. S., LAWRIE G. M. & MORRIS G. C. (1981) Unusual presentation of bronchogenic carcinoma: case report and review of the literature. Cancer 47, 398-401. 8. Anwm J. A. (1951) Avoidable vascular spread in resection for bronchial carcinoma. Thorax 6, 250-67. 9. TILL A. S. & FAIRBURN E. A. (1947) Massive neoplastic embolism. Br. J. Surg. 35, 86-9. 10. BLUML. (1950) Successful removal of a tumour embolus from the femoral artery. JAMA 142, 986-7. 11. BUCKMASTER N. S. (1961) Simultaneous bilateral tumour embolism of the common iliac arteries: a case report. Med. J. Aust. 2, 516-18. 12. WEBBD. F., TOMATIS L., TABER R. E. & PONKA J. L. (1965) Successful management of superior mesenteric and femoral artery tumour emboli resulting from pneumonectomy. A case report. Henry Ford Hosp. Med. Bull. 13, 299-302. 13. CHRISTIANSEN T. W. & MORGAN S. (1965) Tumour embolism in a peripheral artery. Ann. Thorac. Surg. 1, 311-13. 14. BALASP., KATSARAS E. & ZOITOPOULOS M. (1971) Peripheral arterial embolism by malignant tumour. Vasc. Surg. 5 , 27-9. 15. MACMAHON H., FORRESTJ. V., WEISZD. & SAGEL S. S. (1974) Massive tumour embolism occurring during pneumonectomy . Ann. Thorac. Surg. 17, 395-7. R. A,, BAM~TON P. A. & BIGNOLD L. P. 16. CULVER (1987) Aortic and coronary embolism of anaplastic small-cell carcinoma of the lung. Med. J. Aust. 147, 455-6. 17. WARRENR. J., CUMMINGS M. C., MULLERWORTH M. H. W., BIERREA. R. & HUNTD. (1987) Lung carcinoma presenting with systemic embolism: an uncommon differential diagnosis for left atrial myxoma. Med. J . Aust. 147, 150-1.
Surg. 1992,62,317-319
317
MASSIVE TUMOUR EMBOLISM FROM PRIMARY LUNG CANCER B. G. FRENCH, S. E. PEEBLES,K. G. DAVIDSON AND J. G. POLLOCK Glasgow Royal Infirmary, Glasgow, Scotland, UK 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. Key words: embolism, lung neoplasms, neoplasm circulatingcells.
Introduction Massive systemic intra-arterial embolism by primary carcinoma of the lung is uncommon, with only 18 cases having previously been described, although tumour metastases commonly occur by this route. A case causing aortic bifurcation saddle embolus is reported and the literature regarding this condition is reviewed briefly. Case report
A 56 year old female who had presented with breathlessness and weight loss was referred with a large radiological mass in her right lung (Fig. 1). A bronchoscopy revealed a tumour occluding the apical segment of the right lower lobe, and a biopsy showed this to be adenocarcinoma. A mediastinoscopy was normal and the patient was scheduled for surgery. At thoracotomy there was an extensive hilar tumour mass and an intrapericardial pneumonectomy was performed. Tumour was noted in the inferior pulmonary vein. The patient was noted to have ischaemic lower limbs 4 h postoperatively, and clinically had an aortic bifurcation saddle embolus. Both femoral arteries were exposed under local anaesthesia and the embolus was removed using Fogarty embolectomy catheters. The patient made a satisfactory recovery and was discharged on the eighth postoperative day. At review 2 months later she was well, having no evidence of recurrent or metastatic disease. Histological examination of the embolectomy specimen demonstrated a blood clot containing small groups of adenocarcinoma cells (Fig. 2). The Correspondence: B. G. French, NHS Department of Surgery, Glasgow Royal Infumary, Glasgow, G4 OSF, Scotland, UK. Accepted for publication 20 February 1991
Fig. 1. Chest X-ray showing the large hilar tumour.
Fig. 2. Haematoxylin and eosin stained section of the embolus showing blood clot containing adenocarcinoma cells. Magnification X 316.
FRENCH ETAL.
318
primary tumour was a poorly differentiated adenocarcinoma involving one intrapulmonary lymph node.
Discussion
Primary lung tumours are capable of frank embolism in one of two settings. The first and most common is the pen-operative embolus. This occurs during or soon after pulmonary surgery and is presumed to be caused by the dislodgement, by hilar manipulation, of propagated tumour within a pulmonary vein. The second situation is tumour embolization in the absence of pulmonary surgery, which is presumed to be due to the spontaneous fragmentation of propagated tumour within a pulmonary vein. Table 1 summarizes the details of all reported cases of massive embolus secondary to primary lung cancer. Primary lung tumour embolism does not appear to have a predilection for any particular cell type. What is of more pathological importance is the presence of propagated tumour within a large pulmonary vein. This can be suspected pre-operatively if there is a large hilar mass on chest X-ray and may be visible on a contrast-enhanced computerized tomography (CT)scan. '9'
The condition carries a very poor prognosis with 50% of patients dying within the first week of the
embolus. This high initial mortality relates to the widespread distribution of emboli, with multiorgan ischaemia and the additional physiological insult this causes to a patient having undergone a major pulmonary resection, which is usually pneumonectomy. The average survival of patients who do survive the initial postoperative period is less than 4 months. Although one cannot be certain, this probably reflects metastatic Frequently the embolectomy specimen does not contain macroscopically recognizable tumour, but as in the case described, microscopic examination demonstrates both thrombus and tumour cells (Fig. 2).234Bearing in mind that occasionally systemic embolism can be a presenting feature of pulmonary tumours, this lends support to the view that embolectomy specimens should be examined microscopically. It is important to recognize that, as in this case, the primary lung tumours responsible for massive tumour embolism are occasionally localized and therefore theoretically c ~ r a b l e . ~In- ~this respect they differ from massive tumour embolism secondary to pulmonary metastases that are categorically disseminated and described elsewhere. 132*7
Table 1. Reported cases of massive embolism secondary to primary lung cancer Patient
Reference
1
9
2
10
Turnour embolus histology
Sex
Age (years)
M M M M
50 60 52
Oat cell Anaplastic Squamous cell Anaplastic
Artery of impaction
Postoperative
Survival time (postoperative)
Femoral Femoral Carotid Cerebral Axillary Aortic bif. Sup. mesenteric Hepatic Cerebral Iliac (both) Femoral Sup. mesenteric Aortic bif. Renal
No No Yes Yes
3 months 2 months 2 days 10h
Yes
15 h
No Yes
7 days Not stated
Yes
1 day
3
6
4
8
5
4
M
57
Adenocarcinoma
6 7
11
12
F M
52 57
Oat cell Not stated
8
13
M
69
Undifferentiated
43 64 64
Squamous cell
Aortic bif.
Yes
62
Undifferentiated Undifferentiated Adenocarcinoma Squamous cell Squamous cell Adenocarcinoma Squamous cell Small cell
Yes Yes Yes Yes No Yes No Yes
5 months 1 month 36 h 4 months 5 months 7 months 3 months Not stated 12 h
52
Undifferentiated
Femoral Aortic bif. Aortic bif. Subclavian Femoral (both) Aortic bif. Popliteal Aortic bif. Coronary Sup. mesenteric Cerebral
No
10 days
9
5
M
10
3
11 12
14
13 14
2
15 16
2
17
16
M M F M F M F M
18
17
15
2
7
M
61
56
53 67 69 64
M: Male; F: Female; Aortic bit aortic bifurcation; Sup. mesenteric: superior mesenteric.
TUMOUR EMBOLISM FROM PRIMARY LUNG CANCER
The prognostic importance of pulmonary venous interruption as the initial step in lung cancer surgery, f i s t suggested by Aylwin as a precaution to prevent both massive tumour embolism and microscopic metastases, is obvious.* In summary, massive systemic intra-arterial embolism of malignant primary 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 can be suspected pre-operatively . Although the associated primary lung cancer may theoretically be curable, tumour embolism is frequently widespread and carries a very poor prognosis. This emphasizes the importance of early intra-operative pulmonary venous interruption during lung cancer surgery.
References GENE W. H., BENJAMIN R. S., GLUSMAN S., WARD S. & WIERNIK P. H. (1974) Arterial embolism of tumour causing fatal organ infarction. Arch. Inr. Med. 134,545-8. PRIOLEAU P. G. & KATZENSTEIN A. A. (1978) Major peripheral arterial occlusion due to malignant tumour embolism. Histologic recognition and surgical management. Cancer 42,2009-14. H. W. (1969) MasDE BOERH.H. M. & PRILLEVITZ sive tumour embolism. Arch. Chir. Neerl. 21, 223-34. TABER R. E. (1961) Massive systemic tumour embolism during pneumonectomy: a case report with comments on routine primary pulmonary vein ligation. Ann. Surg. 154, 263-8. F. G. (1967) Massive systemic FIRORW. B., PEARSON tumour embolism during pneumonectomy: successful removal by means of balloon catheter. Can. J . Surg. 10, 200-2.
319 6. EASON E. H. (1950) A case of cerebral infarction due to neoplastic embolism. J . Path. Bact. 62, 454-7. 7. STARR D. S., LAWRIE G. M. & MORRIS G. C. (1981) Unusual presentation of bronchogenic carcinoma: case report and review of the literature. Cancer 47, 398-401. 8. Anwm J. A. (1951) Avoidable vascular spread in resection for bronchial carcinoma. Thorax 6, 250-67. 9. TILL A. S. & FAIRBURN E. A. (1947) Massive neoplastic embolism. Br. J. Surg. 35, 86-9. 10. BLUML. (1950) Successful removal of a tumour embolus from the femoral artery. JAMA 142, 986-7. 11. BUCKMASTER N. S. (1961) Simultaneous bilateral tumour embolism of the common iliac arteries: a case report. Med. J. Aust. 2, 516-18. 12. WEBBD. F., TOMATIS L., TABER R. E. & PONKA J. L. (1965) Successful management of superior mesenteric and femoral artery tumour emboli resulting from pneumonectomy. A case report. Henry Ford Hosp. Med. Bull. 13, 299-302. 13. CHRISTIANSEN T. W. & MORGAN S. (1965) Tumour embolism in a peripheral artery. Ann. Thorac. Surg. 1, 311-13. 14. BALASP., KATSARAS E. & ZOITOPOULOS M. (1971) Peripheral arterial embolism by malignant tumour. Vasc. Surg. 5 , 27-9. 15. MACMAHON H., FORRESTJ. V., WEISZD. & SAGEL S. S. (1974) Massive tumour embolism occurring during pneumonectomy . Ann. Thorac. Surg. 17, 395-7. R. A,, BAM~TON P. A. & BIGNOLD L. P. 16. CULVER (1987) Aortic and coronary embolism of anaplastic small-cell carcinoma of the lung. Med. J. Aust. 147, 455-6. 17. WARRENR. J., CUMMINGS M. C., MULLERWORTH M. H. W., BIERREA. R. & HUNTD. (1987) Lung carcinoma presenting with systemic embolism: an uncommon differential diagnosis for left atrial myxoma. Med. J . Aust. 147, 150-1.
