Massive pulmonary tumor microembolism from a hepatocellular carcinoma

doi:10.1016/j.prp.2006.01.005

Pathology - Research and Practice

Volume 202, Issue 5, 10 May 2006, Pages 395-399

https://doi.org/10.1016/j.prp.2006.01.005 Get rights and content

Abstract

A 48-year-old patient with known alcohol abuse and long-standing liver cirrhosis presented with spontaneous bacterial peritonitis and subsequent hepato-renal syndrome. Autopsy revealed a large hepatocellular carcinoma of the right liver lobe. Histologically, pulmonary arteries, arterioles, and capillaries were occluded by numerous tumor emboli. Small tumor emboli also covered the endocardium of the right ventricle. A review of the literature shows that macroscopic as well as microscopic pulmonary tumor embolism is often diagnosed in patients with a previously unknown malignancy. Moreover, pulmonary tumor embolism radiologically mimics pneumonia, tuberculosis, or interstitial lung disease. Therefore, an autopsy should be considered in cases of fulminant or massive pulmonary embolism to exclude tumor embolism even when the patients’ history is insignificant as to this point, and in cases with known malignant tumors and respiratory symptoms to exclude tumor microembolism.

Introduction

Pulmonary embolism and metastasis to the lung are frequent events, and it is likely that pulmonary microembolism of single tumor cells or small tumor cell clusters is a prerequisite of overt pulmonary metastasis detected clinically or at autopsy. There are, however, few reports as to pulmonary tumor microembolization [2], [4], [9], [10], [11], [12], [13], [14], [18], [19], [20], even in the context of larger microscopically and macroscopically detected metastases.

We herein report a case of a 48-year-old male, primarily presenting with the diagnosis of liver cirrhosis who at autopsy showed widespread hepatocellular carcinoma with pulmonary tumor microembolism.

Section snippets

Case report

The patient, a 48-year-old man with a history of long-lasting alcohol abuse and subsequent liver cirrhosis, presented with progressive ascites suspicious of spontaneous bacterial peritonitis. Paracentesis was repeatedly performed, and analysis of the ascitic fluid yielded 0.7 g/l leucocytes; cultures were negative. Cardiac ultrasound revealed normal right ventricular dimensions and function; chest radiographs were unremarkable. The patient's condition progressively worsened and took a rapid

Discussion

The lung is a frequent target of remote malignancy [16]. Pulmonary involvement in malignancy ranges from tumor-associated arterial thrombosis and ARDS to macroscopically obvious metastasis [6], [12]. Embolism to the pulmonary vasculature is a prerequisite for the development of metastasis, but has rarely been described. Macroscopic pulmonary tumor embolism has been reported in sarcomas [1], [8], [15], hepatocellular carcinomas [3], [5], breast carcinomas [7] and renal cell carcinomas [17],

References (20)

G.S. Chan et al.
Sudden death from massive pulmonary tumor embolism due to hepatocellular carcinoma
Forens. Sci. Int.
(2000)
K.E. Roberts et al.
Pulmonary tumor embolism: a review of the literature
Am. J. Med.
(2003)
K. Wilson et al.
Pulmonary tumor embolism as a presenting feature of cavoatrial hepatocellular carcinoma
Chest
(2001)
A.A. Ahmed et al.
Fatal pulmonary tumor embolism caused by chondroblastic osteosarcoma: report of a case and review of the literature
Arch. Pathol. Lab. Med.
(1999)
L. Chai et al.
A case of pulmonary tumour embolism mimicking miliary tuberculosis
Respirology
(2000)
K. Chinen et al.
Pulmonary tumor thrombotic microangiopathy caused by a gastric carcinoma expressing vascular endothelial growth factor and tissue factor
Pathol. Int.
(2005)
O. Diaz Castro et al.
Acute myocardial infarction caused by paradoxical tumorous embolism as a manifestation of hepatocarcinoma
Heart
(2004)
A.A. Frazier et al.
From the archives of the AFIP: pulmonary vasculature: hypertension and infarction
Radiographics
(2000)
J.F. Geschwind et al.
Metastatic breast carcinoma presenting as a large pulmonary embolus: case report and review of the literature
Am. J. Clin. Oncol.
(2003)
H. Grass et al.
Tumor embolism as a cause of an unexpected death: a case report
Pathol. Res. Pract.
(2003)

There are more references available in the full text version of this article.

Cited by (21)

Nonthrombotic Pulmonary Embolism Associated With Non-Hodgkin Lymphoma
2023, Current Problems in Cardiology
Nonthrombotic pulmonary embolism (NTPE) challenges the medical community with its diverse etiologies and potential life-threatening implications. The classification section delves into the multifaceted nature of NTPE, which includes various embolic agents that traverse the vascular system. From air and fat emboli to tumor and amniotic fluid emboli, this exploration of diverse etiologies sheds light on the complexity of NTPE. Diagnostic methods play a crucial role in the effective management of NTPE. This article describes a range of traditional and cutting-edge diagnostic techniques, from computed tomography angiography to novel biomarkers, enabling the accurate and timely identification of NTPE. NTPE treatment options are diverse and patient-specific, requiring customized approaches to address varying embolic sources. Anticoagulation, embolus removal, and emerging interventions under study are discussed, providing clinicians with a comprehensive understanding of management strategies. This article uncovers the rare but captivating association between NTPE and non-Hodgkin lymphoma. Although rare, documented cases have sparked curiosity among researchers and medical practitioners. We explore potential pathophysiological connections, discussing challenges and considerations when encountering this unique scenario. In conclusion, this captivating review encapsulates the multifaceted realm of NTPE, covering its classification, diagnostics, and treatment modalities. Moreover, it presents a fascinating connection with non-Hodgkin lymphoma. This article offers a comprehensive and concise review of NTPE, guiding readers through its intricate classification, diagnostic approaches, and therapeutic interventions.
Neoplastic embolization to systemic and pulmonary arteries
2018, Journal of Vascular Surgery
Arterial neoplastic emboli are uncommon, accounting for <1% of thromboemboli in the current literature. Nonetheless, this event may be associated with significant morbidity and mortality. Herein, we report a series of 11 cases of arterial neoplastic emboli from a single tertiary care center along with a comprehensive review of the literature to date. The aim of this study was to document the incidence, clinical presentations, and complications of arterial neoplastic emboli as well as to highlight the importance of routine histologic examination of thrombectomy specimens.
Pathology archives from a single tertiary care institution were queried to identify cases of surgically resected arterial emboli containing neoplasm (1998-2014). Histopathology was reviewed for confirmation of diagnosis. Patient demographics and oncologic history were abstracted from the medical record. Comprehensive literature review documented 332 patients in 275 reports (1930-2016).
Eleven patients (six men) with a median age of 63 years (interquartile range, 42-71 years) were identified through institutional archives. Embolism was the primary form of diagnosis in seven (64%) cases. Cardiac involvement (primary or metastasis) was present in more than half of the cohort. Comprehensive literature review revealed that pulmonary primaries were the most common anatomic origin of arterial neoplastic emboli, followed by gastrointestinal neoplasia. Cardiac involvement was present in 18% of patients, and sentinel identification of neoplasia occurred in 30% of cases. Postmortem evaluation was the primary means of diagnosis in 27%.
This study highlights the importance of routine histopathologic evaluation of embolectomy specimens in patients with and without documented neoplasia.
Pulmonary tumor thrombotic microangiopathy
2017, Revue des Maladies Respiratoires
Le syndrome de microangiopathie thrombotique tumorale pulmonaire est une entité clinicopathologique rare où des micro-emboles de cellules tumorales dans la microcirculation pulmonaire induisent une microangiopathie thrombotique, une insuffisance respiratoire et un tableau de cœur pulmonaire aigus ou subaigus. Ses caractéristiques histologiques comprennent des micro-emboles tumoraux dans les petites artères et artérioles du poumon, associés à une prolifération fibrocellulaire et fibromusculaire de l’intima et parfois à la formation de thrombus. Le diagnostic est extrêmement difficile avant le décès. Ainsi, un grand nombre des observations rapportées reposent sur des données autopsiques. De très rares observations de diagnostics réalisés avant le décès suggèrent l’éventuelle efficacité d’une chimiothérapie. De nombreux détails restent à élucider, la recherche interdisciplinaire étant une priorité avec une étroite collaboration entre pathologistes et cliniciens afin de mieux comprendre ce syndrome le plus souvent mortel. Grâce à cette collaboration, il est éventuellement possible que ce syndrome ne soit plus considéré comme toujours ultimement fatal, l’utilisation de thérapeutiques ciblées permettant des survies de plusieurs mois après le diagnostic.
Pulmonary tumor thrombotic microangiopathy syndrome is a rare clinicopathological entity in which tumor cell micro-emboli in the pulmonary microcirculation induced thrombotic microangiopathy. This can cause respiratory failure, and acute or sub-acute right heart failure. Histological features include micro tumor emboli in the small arteries and arterioles of the lung associated with thrombus formation and fibro-cellular and fibro-muscular intimal proliferation. The diagnosis is however extremely difficult to make before death. Thus, most of the observations reported are based on autopsy data. Very rare diagnostic observations made before death suggest the potential effectiveness of chemotherapy. Many details remain to be elucidated, interdisciplinary research is a priority with close collaboration between pathologists and clinicians to better understand this, often fatal, syndrome. It may be that the use of targeted therapies will improve the very poor prognosis allowing survival of several weeks or months after diagnosis.
Pulmonary artery sarcoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration
2013, Annals of Thoracic Surgery
Citation Excerpt :
Tumor emboli are usually microscopic, and patients typically present with dyspnea. In rare instances, the emboli can be macroscopic; in such cases, they are usually caused by tumors that have access to a venous plexus, such as hepatocellular, breast, and renal cell carcinomas [4]. In the present case, lung cancer was possible.
Pulmonary artery sarcoma (PAS) is a rare tumor that is often detected at an advanced stage, when disease is so widespread that a radical surgical procedure is no longer indicated. Therefore, less invasive biopsy techniques are required to establish a definitive preoperative diagnosis. Endobronchial ultrasound (EBUS) is useful for producing real-time images of both lymph nodes and the interior of pulmonary arteries adjacent to the bronchi. We report a case with masslike lesions in the pulmonary artery that were observed by EBUS and from which tissue was obtained by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to establish a diagnosis of PAS.
Imaging of nonthrombotic pulmonary embolism: Biological materials, nonbiological materials, and foreign bodies
2013, European Journal of Radiology
Citation Excerpt :
“True” tumor embolism has been described with almost any kind of tumor [42]; however, appear more often in tumors of the digestive system, the liver and in breast cancer [43,44]. The risk of tumor embolization is increased after procedures that can potentially promote the fragmentation and subsequent circulation of the tumor mass like chemotherapy, radiotherapy and surgical resection [7,8,40,41]. Tumor emboli often occur subclinically and are seen microscopically in up to 26% of autopsies of patients with a solid malignancy [2,8,39].
Nonthrombotic pulmonary embolism is defined as embolization to the pulmonary circulation caused by a wide range of substances of endogenous and exogenous biological and nonbiological origin and foreign bodies. It is an underestimated cause of acute and chronic embolism. Symptoms cover the entire spectrum from asymptomatic patients to sudden death.
In addition to obstruction of the pulmonary vasculature there may be an inflammatory cascade that deteriorates vascular, pulmonary and cardiac function. In most cases the patient history and radiological imaging reveals the true nature of the patient's condition.
The purpose of this article is to give the reader a survey on pathophysiology, typical clinical and radiological findings in different forms of nonthrombotic pulmonary embolism. The spectrum of forms presented here includes pulmonary embolism with biological materials (amniotic fluid, trophoblast material, endogenous tissue like bone and brain, fat, Echinococcus granulosus, septic emboli and tumor cells); nonbiological materials (cement, gas, iodinated oil, glue, metallic mercury, radiotracer, silicone, talc, cotton, and hyaluronic acid); and foreign bodies (lost intravascular objects, bullets, catheter fragments, intraoperative material, radioactive seeds, and ventriculoperitoneal shunts).
Atypical unilateral insterstitial disease
2011, Revue des Maladies Respiratoires

View all citing articles on Scopus

View full text

TEACHING CASEMassive pulmonary tumor microembolism from a hepatocellular carcinoma

Abstract

Introduction

Section snippets

Case report

Discussion

Forens. Sci. Int.

Am. J. Med.

Chest

Fatal pulmonary tumor embolism caused by chondroblastic osteosarcoma: report of a case and review of the literature

Arch. Pathol. Lab. Med.

A case of pulmonary tumour embolism mimicking miliary tuberculosis

Respirology

Pulmonary tumor thrombotic microangiopathy caused by a gastric carcinoma expressing vascular endothelial growth factor and tissue factor

Pathol. Int.

Acute myocardial infarction caused by paradoxical tumorous embolism as a manifestation of hepatocarcinoma

Heart

From the archives of the AFIP: pulmonary vasculature: hypertension and infarction

Radiographics

Metastatic breast carcinoma presenting as a large pulmonary embolus: case report and review of the literature

Am. J. Clin. Oncol.

Tumor embolism as a cause of an unexpected death: a case report

Pathol. Res. Pract.

TEACHING CASE
Massive pulmonary tumor microembolism from a hepatocellular carcinoma