Pulmonary Vascular Disease |

Pulmonary Embolism as Initial Presentation in Patient With Primary Lung Cancer With Metastasis: A Case Report FREE TO VIEW

Viral Patel, MD; Abhay Vakil, MD; Mehul Rooparelia, MD; Kelly Cervellione, PhD; Samir Sarkar, MD
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Jamaica Hospital Medical Center, Jamaica, NY

Chest. 2014;145(3_MeetingAbstracts):507A. doi:10.1378/chest.1836716
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SESSION TITLE: Pulmonary Vascular Disease Cases

SESSION TYPE: Case Reports

PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM

INTRODUCTION: Thromboembolic events including pulmonary embolism (PE) are known to occur in association with advanced stages of lung cancer. Known cancer is a risk factor for development of venous thromboembolism, including PE. However, when a patient without known cancer presents with acute PE, cancer as a potential cause of PE may not always be explored. We present a case of acute PE, later found to have adenocarcinoma of lung with metastasis.

CASE PRESENTATION: A 54-year-old non-smoker male with no medical history presented with sudden onset shortness of breath associated with a sharp, retrosternal left-sided chest pain. He denied any cough, sputum production, hemoptysis, weight loss, night sweats and loss of appetite. He denied any changes in his functional status. He was tachycardic, afebrile and saturating 98 % on 3 liter oxygen with normal blood pressure. The patient was noted to be in mild respiratory distress with decreased breath sounds on the left. There was no organomegaly or palpable lymphadenopathy. Laboratory studies showed normal hemogram and chemistries. Troponin (0.048 ng/ml), pro-BNP (1460 pg/ml) and D-dimer (4841 ng/ml) were mildly elevated. Arterial blood gas revealed respiratory alkalosis with high A-a gradient hypoxia. EKG showed sinus tachycardia with non-specific ST-T changes. Radiologic studies confirmed the presence of a pulmonary embolus in the left main pulmonary artery (Fig 1b) with bilateral pleural effusion and multiple nodular densities (Fig 1a). The patient was treated with therapeutic anticoagulation. Venous Doppler of the extremities confirmed the presence of a venous clot in right lower leg. Thoracocentesis revealed exudative fluid with special stains (Fig 2 A, B, C) on cytology positive for Napsin A, EpCam, BerEP4, and TTF-1 which confirms diagnoses of adenocarcinoma of lung origin.

DISCUSSION: Venous thromboembolism and cancer are linked by a two way clinical association: venous thromboembolism may be a presenting feature of an occult cancer and patients with clinically overt cancer may develop a venous thromboembolic complication at any stage of their disease. The incidence of malignancy at the time of diagnosis of venous thromboembolism, in the absence of conventional risk factors, is between 1.9% and 7.5%. The value of investigating for underlying malignant disease in patients with idiopathic venous thrombosis, who are otherwise well is still undefined: intensive diagnostic screening versus routine management is under evaluation. Further Studies required determining the effectiveness and cost-effectiveness of testing for occult cancer in a patient with venous thromboembolism (VTE).

CONCLUSIONS: Apparently unprovoked, idiopathic pulmonary embolism may be a presenting complication of underlying undiagnosed cancer and should be explored.

Reference #1: Prins MH, Lensing AW, Hirsh J. Idiopathic deep venous thrombosis: is a search for malignant disease justified? Arch Intern Med 1994;154: 1310-1312.

DISCLOSURE: The following authors have nothing to disclose: Viral Patel, Abhay Vakil, Mehul Rooparelia, Kelly Cervellione, Samir Sarkar

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