SESSION TITLE: Cancer Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Malignancy is one of the well-known risk factors for the development of pulmonary embolism (PE). However, it is rare for tumor tissue to be the direct cause of emboli in the main pulmonary arteries. We report a very rare case of a massive pulmonary chondrosarcoma embolus.
CASE PRESENTATION: An 18-year old African American male presented with sudden onset shortness of breath and hemoptysis. Past medical history was significant for asthma, hypertension, and morbid obesity (negative social/family history). The patient also had a recent history of an extended car ride with complaints of right leg pain for approximately two weeks prior to hospitalization. Upon presentation, the patient was worked-up for PE and deep vein thrombosis (DVT). CT scan was positive for a large saddle PE while work-up for DVT was negative. Patient was also found to have a new right iliac lytic lesion on CT. Initially, the patient was hemodynamically stable and admitted to the intensive care unit (ICU) for heparin infusion and respiratory monitoring. Over 24 hours, the patient’s condition rapidly declined. A 2D-echocardiogram demonstrated PE penetration into the right ventricle (RV) and atrium resulting in severe RV failure and pulmonary hypertension. The patient also demonstrated worsening hypoxia. He was emergently taken to the operating room for pulmonary embolectomy and right heart clot removal via cardio-pulmonary bypass. Post-operatively, the patient required aggressive inotropic and vasopressor support as well as nitric oxide. During the post-operative period, the patient was tested for a hypercoagulable disease process, which was negative. The patient was never stable enough for bone biopsy, however, tissue biopsy of his PE was positive for chondrosarcoma. Unfortunately, the patient expired on post-operative day nine.
DISCUSSION: Tumor embolism is a rare and clinically challenging disease process. Autopsy series have estimated an incidence of 3-26% among patients with solid tumors. Chondrosarcomas are also rare, being the third most common primary malignancy of the bone. To date, only two previous studies have described chondrosarcoma pulmonary emboli. Pulmonary embolectomy remains the therapy of choice for massive PE resulting in hemodynamic instability. Although mortality rates post embolectomy still remain high, advances in surgical technique has reduced the mortality rate from approximately 52.4% to 20% over the past two decades.
CONCLUSIONS: Although extremely rare, acute PE caused by chondrosarcoma (or other solid tumors) should be part of the differential diagnosis for patients lacking typical PE causes. Surgical intervention remains the therapeutic gold standard for massive PE with other treatment options utilized on a case appropriate basis.
Reference #1: Chandrasekharan, R, Bhagavaldas, MC, Mathew, AJ. Chondrosarcoma presenting as dyspnea in a 19-year-old man: a case report. Journal of Medical Case Reports. 2011; 5, 150-154.
DISCLOSURE: The following authors have nothing to disclose: Zachary Bauman, Mathilda Horst, Dionne Blyden, Jeffrey Morgan
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