INTRODUCTION: We report a case of malignant arterial tumor embolization immediately after resection of an adenocarcinoma of the lung.
CASE PRESENTATION: A 66 year-old female smoker presented with hemoptysis and dyspnea for 7 days. She has a history of colonic carcinoma resected in 2003 for which she also received chemotherapy. Chest radiograph (figure 1) and computed tomography of the chest revealed a 6 cm mass in the left upper lobe. Bronchoscopy showed a left upper lobe endobronchial lesion which was biopsied and revealed adenocarcinoma. The patient underwent a mediastinoscopy, which was negative and proceeded with thoracotomy and left upper lobectomy which was confirmed to be colonic metastases. Immediately after extubation she complained of pain, numbness in the right leg and was found to have signs of vascular occlusion with no femoral pulse. An immediate angiography confirmed total occlusion of the proximal right common iliac artery and an emergency embolectomy was done with complete return of circulation and pulse. A transthoracic echcardiography did not reveal any thrombus in the left atrium. Pathology confirmed malignant tumor emboli (figure 2). Upon discharge she was referred to oncologist for chemotherapy.
DISCUSSIONS: Macroscopic peripheral arterial tumor embolus is an uncommon event. Systemic arterial tumor embolization is a rare complication after pulmonary resection. It is seen more frequently after pneumonectomy rather than lobectomy. The event could also be the presenting manifestation of a bronchogenic carcinoma. Less than 70 cases of malignant tumor emboli due to primary or secondary bronchogenic carcinoma have been reported.  Other less common tumors are sarcomas. The source of tumor emboli could be the left atrium or pulmonary veins. During the surgical manipulation of the pulmonary veins at the time of resection, the tumor could dislodge and embolise to any major artery resulting in total occlusion with sudden onset of signs and symptoms of ischemia. Immediate recognition of these events is very critical and immediate intervention will restore circulation, relief of symptoms and full function to avoid compartment syndrome. Other common source for the arterial emboli is from a left atrial myxoma, which was excluded in our patient. Primary or secondary lung malignant tumor may involve the pulmonary vein, erode and partially occlude and gets dislodged during surgical manipulation. Depending on the size of the pulmonary lesion and its proximity to the major pulmonary vein, major tumor emboli may occur. Early intraoperative pulmonary vein ligation may prevent tumor emboli. Routine 2DEcho or transesophageal echocardiography may be useful in selected cases where the tumor is large and centrally located.  Overall prognosis is poor in this group despite aggressive intervention, as these patients tend to die from metastatic disease.
CONCLUSION: Malignant arterial tumor emboli are rare complications of pulmonary carcinoma. Immediate recognition and prompt intervention should result in good prognosis with no circulatory deficit. In patients with bulky central tumor careful isolation and ligation of the pulmonary vein may prevent arterial emboli. A pre-operative echocardiogram may be useful.
DISCLOSURE: Mustafa Salehmohamed, No Financial Disclosure Information; No Product/Research Disclosure Information