Pulmonary tumor embolism occurs most commonly as a complication of breast, lung, and prostate carcinoma. An incidence rate of 0.9% to 8% has been reported; however, the true incidence and contribution to mortality of this entity is likely unknown. We report a case of myocardial infarction and cardiac arrest due to pulmonary and cardiac vessel tumor embolism from an adenoid cystic carcinoma.CASE PRESENTATIONS: A 50-year-old male with adenoid cystic carcinoma presented complaining of progressive dyspnea on exertion. His oxyhemoglobin saturation was 74% and his chest exam was normal. Sinus tachycardia with lateral ST depression was noted and cardiac enzymes were mildly elevated. The chest radiograph and heart catheterization were normal. CT-angiogram and pulmonary arteriogram were negative for pulmonary embolism, and the pulmonary artery pressure was 54/21. The patient became asystolic and expired 14 hours after intubation for refractory hypoxia. Microscopic examination of the lung and heart noted widespread occlusion of pulmonary arteries, arterioles, capillaries (Figure 1) and myocardial arterioles (Figure 2) with tumor emboli. Acute myocardial ischemic changes were seen in the left ventricle and left papillary muscle, with subacute changes noted in the interventricular septum. Special stains of the tumor emboli matched the staining pattern of the original tumor.
Pulmonary tumor embolism has been reported as a complication of multiple malignancies, but only once before when associated with adenoid cystic carcinoma. The presentation of this patient was typical for this entity, with subacute onset of dyspnea in the setting of a known malignancy. Radiographic studies are generally unrevealing, as was the case here.CONCLUSIONS: This case highlights that a high index of suspicion is required to make this diagnosis and possibly spare unnecessary anticoagulation. Chemotherapy, though not prospectively studied in this setting for any malignancy, may offer benefit in select patients.
J.A. Graham, None.