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Pulmonary Vascular Disease |

Tumor Emboli as a Cause of Anticoagulation Resistant Pulmonary Embolism

Rami Jambeih, MD; Sarah Matousek, MD; Gary Kinasewitz, MD
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Oklahoma University, Oklahoma City, OK


Chest. 2014;146(4_MeetingAbstracts):870A. doi:10.1378/chest.1992365
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Abstract

SESSION TITLE: Pulmonary Vascular Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary arterial tumor embolization is a rare complication of neoplasms.

CASE PRESENTATION: A 35 year old female patient was complaining of dyspnea on exertion and was diagnosed with pulmonary embolism. Despite outpatient treatment with oral Rivaroxaban, she had worsening symptoms and hypoxic respiratory failure requiring ICU support and treatment with intravenous Heparin. CT angiogram revealed a large left pulmonary artery embolism with bilateral subsegmental emboli and a dilated main pulmonary artery. An IVC filter was placed. Patient continued to deteriorate requiring mechanical ventilation. She developed right ventricular failure and was started on thrombolytics without benefit. Finally, she developed arrhythmia, then cardiac arrest and died despite aggressive resuscitation. Her autopsy revealed metastatic ovarian adenocarcinoma and diffuse pulmonary tumor emboli associated with pulmonary infarctions.

DISCUSSION: The usual mechanisms of cancer induced VTE include hypercoagulable state by activation or overexpression of coagulation factors such as tissue factor and venous stasis by mechanical compression of venous circulation. On the other hand, tumor cells can invade the vascular system and get trapped in the pulmonary circulation or adhere to the pulmonary vessels via lung specific adhesion molecules causing pulmonary embolism with or without activation of the coagulation cascade and thrombus formation. This syndrome is rare and usually discovered on autopsies. It is important to differentiate between the above two mechanisms as the prognosis and treatment are different. In contrast to thromboembolism, pulmonary tumor embolism has a poor prognosis and its treatment is directed toward the primary tumor. Embolectomy and complete resection of the primary cancer has been shown to be helpful [1]. Most of the cases of pulmonary tumor emboli occur with breast, stomach and lung cancer and few cases are reported with ovarian cancer which rarely disseminates through the vasculature [2].

CONCLUSIONS: This case emphasizes the importance of considering malignancy as a differential diagnosis of pulmonary embolism, particularly when there’s recurrence despite adequate anticoagulation. Awareness of this syndrome will help focusing on different treatment options.

Reference #1: Daughtry JD et al. Pulmonary embolus presenting as the initial manifestation of renal cell carcinoma. Ann Thorac Surg. 1977;24(2):178.

Reference #2: Roberts KE et al. Pulmonary Tumor Embolism: A Review of the Literature. AmJ Med. 2003;115:228 -232.

DISCLOSURE: The following authors have nothing to disclose: Rami Jambeih, Sarah Matousek, Gary Kinasewitz

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