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Pulmonary Embolism as Initial Presentation of Bronchogenic Carcinoma With Unexpected Response to Gefitinib Therapy FREE TO VIEW

Dr.Rajiv Garg, MD; Ankit Bhatia, MBBS; Ashwini Mishra, MD; Dr.Shailesh Singh, MD
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King George's Medical University, Lucknow, India

Chest. 2014;146(4_MeetingAbstracts):665A. doi:10.1378/chest.1993288
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SESSION TITLE: Cancer Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

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

INTRODUCTION: Pulmonary embolism and venous thrombosis is a common complication in lung cancer patients with a high misdiagnosis rate and high mortality. However when an undiagnosed lung cancer patient presents as pulmonary embolism, cancer as a cause may not always be explored.

CASE PRESENTATION: A 34-year-old smoker male with no significant medical history presented with insidious onset breathlessness associated with a sharp, retrosternal left-sided chest pain. The patient was noted to be in respiratory distress with markedly decreased breath sounds on the left. Chest X-ray revealed massive left sided pleural effusion, which on pleurocentesis revealed haemorrhagic exudative effusion. On routine clinical examination, patient was found to have dilated thrombosed veins over both lower limbs. D-dimer (82 mg/dl) was found to be elevated. Radiologic studies confirmed the presence of a pulmonary embolus in the left main pulmonary artery. The patient was treated with therapeutic anticoagulation. Venous Doppler of the lower limbs confirmed the presence of a complete thrombus of bilateral posterior tibial vein and popliteal vein. Pleural Biopsy confirmed the diagnosis of adenocarcinoma of lung origin. The EGFR mutation investigation of the histopathological specimen revealed an EGFR point mutation at exon 21. Gefitinib treatment was started and his levels of plasma D-dimer immediately decreased. Follow-up Chest X-ray showed nearly complete resolution of pleural effusion.

DISCUSSION: Venous thromboembolism and lung cancer are associated by a two way clinical association: venous thromboembolism may be the presenting feature of an occult cancer and patients with clinically visible cancer may develop a venous thromboembolic complication at any stage of their disease. Idiopathic pulmonary embolism may be a presenting complication of underlying undiagnosed lung cancer1. Underlying cancer biological features such as tumour mutations may contribute to VTE risk and cancer prognosis. EGFR activating mutations are more frequently found in this histological subtype than in other lung cancers.Gefitinib is observed to be a very effective treatment in pulmonary embolism due to lung cancer with reports of complete tumor regression and no recurrence after treatment2.

CONCLUSIONS: Investigating for underlying malignant disease in patients with idiopathic venous thrombosis presenting with pulmonary embolism is of benefit. The potential use of tyrosine kinase inhibitors in adenocarcinoma with pulmonary embolism needs to be studied further.

Reference #1: Patel V, Vakil A, Rooparelia M, Cervellione K, Sarkar S. Pulmonary embolism as initial presentation in patient with primary lung cancer with metastasis: a case report.Chest. 2014 Mar 1;145(3 Suppl):507A

Reference #2: Yanagitani N1, Horiike A, Kudo K, Ohyanagi F, Nishio M, Horai T. A case of adenocarcinoma of the lung with a pulmonary thromboembolism which improved with gefitinib. Nihon Kokyuki Gakkai Zasshi. 2011 Apr;49(4):282-6.

DISCLOSURE: The following authors have nothing to disclose: Dr.Rajiv Garg, Ankit Bhatia, Ashwini Mishra, Dr.Shailesh Singh

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