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Tumor Embolism After Pneumonectomy for Primary Pulmonary Neoplasia
Tumor Embolism After Pneumonectomy for Primary Pulmonary Neoplasia Juan-Ramdn Gdmez, MD, Juan Vah6, MD, Luis Luengo, MD, Jorge Escuder, MD, Manuel Castellote, MD, Susana Ros, MD, Jos~ Diaz, MD, and Vincente Martin-Paredero, MD, PhD, Tarragona, Spain
We report a case of tumor embolism of the lower right extremity after right pneumonectomy. This is an infrequent complication and in most cases occurs during the intraoperative or immediate postoperative period. Our patient underwent surgery for primary pulmonary neoplasia (squamous cell carcinoma) and 4 hours later showed clinical signs of acute arterial occlusion in the lower right extremity. An emergency embolectomy was performed and a thrombus with tumor characteristics was extracted from the right common femoral artery. The pathologic features of this thrombus were identical to those of the pulmonary tumor. (Ann Vasc Surg 1995;9:199-203.)
Peripheral arterial e m b o l i s m in association w i t h p r i m a r y p u l m o n a r y neoplasia is a n i n f r e q u e n t complication. ~ A review of the literature revealed only 31 cases. W i t h the publication of this report w e add a n e w case to the literature a n d d r a w a t t e n t i o n to a n intra- or postoperative complication w i t h serious clinical consequences.
CASE R E P O R T The patient, a 65-year-old man, was a smoker and had had an ischemic cerebral vascular accident 2 years previously, from which he completely recovered. He was admitted to our center to determine the cause of a 3-month period of occasional hemoptysis, weakness, slight dyspnea on exertion, and nonspecific thoracic pain and sensitivity. An x-ray examination of the thorax showed a mass in the middle lobe of the right lung (Fig. 1). Bronchoscopy demonstrated an endobronchial mass located in the middle lobe segmental bronchus. A biopsy and a cytologic examination (bronchial aspiration) were performed, and results were positive for squamous cell carcinoma. A nuclear bone scan showed no evidence of metastasis. ACT scan of
From the University of Rovira y VirgilL Department of Surgery, Joan XXIII Hospital, Tarragona, Spain. Reprint requests: Juan-Ram6n G6mez, MD, C. Pere Martell, No. 24 7-C, 43001 Tarragona, Spain.
the thoracoabdominal axis showed a pulmonary mass in the middle right lobe but no distant metastasis was observed (Fig. 2). Surgery consisted of a right pneumonectomy with initial ligation of the vascular pedicles with staples, beginning with the pulmonary veins and followed by the pulmonary artery. Four hours after surgery the patient developed clinical signs of acute arterial ischemia in the lower right extremity, necessitating a femoral embolectomy. A fleshy embolus involving the common femoral, superficial femoral, and deep femoral arteries was extracted. The patient showed signs of revascularization syndrome (edema, pain, and metabolic acidosis) that responded favorably to medical treatment (intravenous hydration, bicarbonate, and heparin) and distal pulses were recovered. Pathologic study following pneumonectomy showed squamous cell carcinoma that was nonkeratinizing and poorly differentiated, reaching the pleura, and with vascular invasion of both medium- and large-caliber veins and arteries at a distance from the tumor growth. There was no evidence of tumor infiltration of the lymph nodes examined (Figs. 3 and 4). Pathologic examination also revealed an embolus containing tumor tissue resembling squamous cell carcinoma (Fig. 5). Echocardiography was performed and no significant abnormalities were detected. The patient's recovery was uneventful and he was discharged. 199
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Fig. 1. Chest x-ray showing a mass in the middle right lobe.
Fig. 2. CT scan of the thoracoabdominal axis showing a puh~qonary mass in the middle right lobe.
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Fig. 3. Low-power photomicrograph showing pulmonary vein Containing neoplastic cells in the lumen.
Fig. 4. Higher power magnification showing poorly differentiated squamous cell carcinoma in the vein.
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Fig. 5. Photomicrograph of the tumor embolus showing squamous cell carcinoma.
DISCUSSION P r i m a r y n e o p l a s i a of the lung is a rare cause of arterial e m b o l i s m a n d c a n result in a c u t e peripheral ischemia. The first report in 1947 described p r i m a r y neoplasia of the l u n g w i t h p e r i p h e r a l arterial e m b o l i z a t i o n affecting the c o m m o n f e m o ral artery. 2 I n 1961 Taber 3 reported a case of e m b o l i s m occurring in the aortic b i f u r c a t i o n after a left p n e u m o n e c t o m y for a n a p l a s t i c c a r c i n o m a of the u p p e r left lobe. An e m b o l e c t o m y w a s perf o r m e d to r e m o v e the t u m o r material. Since 1947 t h i r t y - o n e cases of arterial e m bolization associated w i t h p r i m a r y n e o p l a s i a of the lung h a v e b e e n described. This e m b o l i z a t i o n m a y be the first m a n i f e s t a t i o n of the disease, or it m a y occur s p o n t a n e o u s l y in t h e n a t u r a l evolution of p u l m o n a r y n e o p l a s i a w i t h involvem e n t of the p u l m o n a r y veins or as a n intraoperative or i m m e d i a t e p o s t o p e r a t i v e complication. 4 Prioleau a n d K a t z e n s t e i n 5 reported a case occurring 5 days after excision of a p u l m o n a r y neoplasm. A review of the 31 cases reported in the literature revealed that 25 cases of einbolization (80.64%) occurred in the intra- or postoperative period a n d in six cases (19.36%) a f r a g m e n t of the t u m o r s p o n t a n e o u s l y dislodged into the circulation. E m b o l i z a t i o n m o s t f r e q u e n t l y occurred in the distal aortic a n d cerebral arteries, as w a s seen in 10 cases (26.31%), followed by the f e m o r a l sector in eight cases (21.05%), the m e s e n t e r i c superior
artery in three (7.89%), the carotid a n d axillary arteries in two 15.26%), a n d the c o m m o n iliac, hepatic, a n d c o r o n a r y arteries in one case (2.64%). I n 1951, to avoid this i n f r e q u e n t operative complication, Aylwin 6 p r o p o s e d c l a m p i n g the prim a r y p u l m o n a r y veins as a p r e v e n t i v e m e a s u r e before mobilization of the t u m o r . However, MacM a h o n et al. ~ in 1974 a n d M a n s o u r et aid in 1988 r e p o r t e d that this m e t h o d w a s n o t entirely effective in p r e v e n t i n g t u m o r e m b o l i s m . Intra- a n d p o s t o p e r a t i v e m o r b i d i t y a n d m o r t a l ity associated w i t h e m b o l e c t o m y are low, b u t l o n g - t e r m survival is closely related to the state of the p r i m a r y p u l m o n a r y t u m o r . These t u m o r e m b o l i s m s c a n n o t be considered d i s t a n t m e t a s t a s e s of the p r i m a r y tumor, since the v a s c u l a r e n d o t h e l i u m in the area w h e r e e m b o l i z a t i o n occurs is n o t affected, 9 REFERENCES 1 Senderoff E, Kirschner A. Massive tumor embolism during pulmonary surgery. J Thorac Cardiovasc Surg 1962:44:528535. 2 TillAS. Fairburn EA. Massive neoplastic embolism Br J Surg 1947:35:86-89. 3, Taber RE. Massive systemic tumor embolization during pneumonectomy, Ann Surg 1961:154:263-268,
4. Start DS, Lawrie GM, Morris GC. Unusual presentation of bronchogenic carcinoma. Cancer 1981;47:398-401. 5. Prioleau PG, Katzenstein ALA. Major peripheral arterial occlusion due to malignant tumor embolism. Cancer 1978;42: 2009-2014.
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Tumor embolism after pneumonectomy 203
6. Aylwin JA. Avoidable vascular spread in resection for bronchial carcinoma. Thorax 1951;6:250-267. 7. MacMalion H, Forrest JV, Weisz D, et al. Massive tumor embolism occurring during pneumonectomy. Ann Thorac Surg 1974; 17:395-397.
8. Mansour KA, Malone CE, Craver JM. Left atrial tumor embolization during pulmonary resection: Review of literature and report of two cases. Ann Thorac Surg 1988;46:455456. 9. Heitmiller RF. Prognostic significance of massive bronchogenic tumor embolus. Ann Thorac Surg 1992;53:153-155.
B O U N D V O L U M E S OF A N N A L S Bound volumes are available to subscribers only. The h a r d b o u n d volume of six issues of the 1995 Annals of Vascular Surgery m u s t be ordered by October 1, 1995, from Quality Medical Publishing, Inc., 11970 B o r m a n Dr., Ste. 222, St. Louis, MO 63146. P a y m e n t of $60 in U.S. f u n d s m u s t a c c o m p a n y all orders.
We report a case of tumor embolism of the lower right extremity after right pneumonectomy. This is an infrequent complication and in most cases occurs during the intraoperative or immediate postoperative period. Our patient underwent surgery for primary pulmonary neoplasia (squamous cell carcinoma) and 4 hours later showed clinical signs of acute arterial occlusion in the lower right extremity. An emergency embolectomy was performed and a thrombus with tumor characteristics was extracted from the right common femoral artery. The pathologic features of this thrombus were identical to those of the pulmonary tumor. (Ann Vasc Surg 1995;9:199-203.)
Peripheral arterial e m b o l i s m in association w i t h p r i m a r y p u l m o n a r y neoplasia is a n i n f r e q u e n t complication. ~ A review of the literature revealed only 31 cases. W i t h the publication of this report w e add a n e w case to the literature a n d d r a w a t t e n t i o n to a n intra- or postoperative complication w i t h serious clinical consequences.
CASE R E P O R T The patient, a 65-year-old man, was a smoker and had had an ischemic cerebral vascular accident 2 years previously, from which he completely recovered. He was admitted to our center to determine the cause of a 3-month period of occasional hemoptysis, weakness, slight dyspnea on exertion, and nonspecific thoracic pain and sensitivity. An x-ray examination of the thorax showed a mass in the middle lobe of the right lung (Fig. 1). Bronchoscopy demonstrated an endobronchial mass located in the middle lobe segmental bronchus. A biopsy and a cytologic examination (bronchial aspiration) were performed, and results were positive for squamous cell carcinoma. A nuclear bone scan showed no evidence of metastasis. ACT scan of
From the University of Rovira y VirgilL Department of Surgery, Joan XXIII Hospital, Tarragona, Spain. Reprint requests: Juan-Ram6n G6mez, MD, C. Pere Martell, No. 24 7-C, 43001 Tarragona, Spain.
the thoracoabdominal axis showed a pulmonary mass in the middle right lobe but no distant metastasis was observed (Fig. 2). Surgery consisted of a right pneumonectomy with initial ligation of the vascular pedicles with staples, beginning with the pulmonary veins and followed by the pulmonary artery. Four hours after surgery the patient developed clinical signs of acute arterial ischemia in the lower right extremity, necessitating a femoral embolectomy. A fleshy embolus involving the common femoral, superficial femoral, and deep femoral arteries was extracted. The patient showed signs of revascularization syndrome (edema, pain, and metabolic acidosis) that responded favorably to medical treatment (intravenous hydration, bicarbonate, and heparin) and distal pulses were recovered. Pathologic study following pneumonectomy showed squamous cell carcinoma that was nonkeratinizing and poorly differentiated, reaching the pleura, and with vascular invasion of both medium- and large-caliber veins and arteries at a distance from the tumor growth. There was no evidence of tumor infiltration of the lymph nodes examined (Figs. 3 and 4). Pathologic examination also revealed an embolus containing tumor tissue resembling squamous cell carcinoma (Fig. 5). Echocardiography was performed and no significant abnormalities were detected. The patient's recovery was uneventful and he was discharged. 199
200
Annals of Vascular Surgery
Gdmez et al.
Fig. 1. Chest x-ray showing a mass in the middle right lobe.
Fig. 2. CT scan of the thoracoabdominal axis showing a puh~qonary mass in the middle right lobe.
Vol. 9, No. 2 1995
Tumor embolism after pneumonectomy
Fig. 3. Low-power photomicrograph showing pulmonary vein Containing neoplastic cells in the lumen.
Fig. 4. Higher power magnification showing poorly differentiated squamous cell carcinoma in the vein.
201
202
Annals of Vascular Surgery
G&nez et al.
Fig. 5. Photomicrograph of the tumor embolus showing squamous cell carcinoma.
DISCUSSION P r i m a r y n e o p l a s i a of the lung is a rare cause of arterial e m b o l i s m a n d c a n result in a c u t e peripheral ischemia. The first report in 1947 described p r i m a r y neoplasia of the l u n g w i t h p e r i p h e r a l arterial e m b o l i z a t i o n affecting the c o m m o n f e m o ral artery. 2 I n 1961 Taber 3 reported a case of e m b o l i s m occurring in the aortic b i f u r c a t i o n after a left p n e u m o n e c t o m y for a n a p l a s t i c c a r c i n o m a of the u p p e r left lobe. An e m b o l e c t o m y w a s perf o r m e d to r e m o v e the t u m o r material. Since 1947 t h i r t y - o n e cases of arterial e m bolization associated w i t h p r i m a r y n e o p l a s i a of the lung h a v e b e e n described. This e m b o l i z a t i o n m a y be the first m a n i f e s t a t i o n of the disease, or it m a y occur s p o n t a n e o u s l y in t h e n a t u r a l evolution of p u l m o n a r y n e o p l a s i a w i t h involvem e n t of the p u l m o n a r y veins or as a n intraoperative or i m m e d i a t e p o s t o p e r a t i v e complication. 4 Prioleau a n d K a t z e n s t e i n 5 reported a case occurring 5 days after excision of a p u l m o n a r y neoplasm. A review of the 31 cases reported in the literature revealed that 25 cases of einbolization (80.64%) occurred in the intra- or postoperative period a n d in six cases (19.36%) a f r a g m e n t of the t u m o r s p o n t a n e o u s l y dislodged into the circulation. E m b o l i z a t i o n m o s t f r e q u e n t l y occurred in the distal aortic a n d cerebral arteries, as w a s seen in 10 cases (26.31%), followed by the f e m o r a l sector in eight cases (21.05%), the m e s e n t e r i c superior
artery in three (7.89%), the carotid a n d axillary arteries in two 15.26%), a n d the c o m m o n iliac, hepatic, a n d c o r o n a r y arteries in one case (2.64%). I n 1951, to avoid this i n f r e q u e n t operative complication, Aylwin 6 p r o p o s e d c l a m p i n g the prim a r y p u l m o n a r y veins as a p r e v e n t i v e m e a s u r e before mobilization of the t u m o r . However, MacM a h o n et al. ~ in 1974 a n d M a n s o u r et aid in 1988 r e p o r t e d that this m e t h o d w a s n o t entirely effective in p r e v e n t i n g t u m o r e m b o l i s m . Intra- a n d p o s t o p e r a t i v e m o r b i d i t y a n d m o r t a l ity associated w i t h e m b o l e c t o m y are low, b u t l o n g - t e r m survival is closely related to the state of the p r i m a r y p u l m o n a r y t u m o r . These t u m o r e m b o l i s m s c a n n o t be considered d i s t a n t m e t a s t a s e s of the p r i m a r y tumor, since the v a s c u l a r e n d o t h e l i u m in the area w h e r e e m b o l i z a t i o n occurs is n o t affected, 9 REFERENCES 1 Senderoff E, Kirschner A. Massive tumor embolism during pulmonary surgery. J Thorac Cardiovasc Surg 1962:44:528535. 2 TillAS. Fairburn EA. Massive neoplastic embolism Br J Surg 1947:35:86-89. 3, Taber RE. Massive systemic tumor embolization during pneumonectomy, Ann Surg 1961:154:263-268,
4. Start DS, Lawrie GM, Morris GC. Unusual presentation of bronchogenic carcinoma. Cancer 1981;47:398-401. 5. Prioleau PG, Katzenstein ALA. Major peripheral arterial occlusion due to malignant tumor embolism. Cancer 1978;42: 2009-2014.
Vol. 9, No. 2 1995
Tumor embolism after pneumonectomy 203
6. Aylwin JA. Avoidable vascular spread in resection for bronchial carcinoma. Thorax 1951;6:250-267. 7. MacMalion H, Forrest JV, Weisz D, et al. Massive tumor embolism occurring during pneumonectomy. Ann Thorac Surg 1974; 17:395-397.
8. Mansour KA, Malone CE, Craver JM. Left atrial tumor embolization during pulmonary resection: Review of literature and report of two cases. Ann Thorac Surg 1988;46:455456. 9. Heitmiller RF. Prognostic significance of massive bronchogenic tumor embolus. Ann Thorac Surg 1992;53:153-155.
B O U N D V O L U M E S OF A N N A L S Bound volumes are available to subscribers only. The h a r d b o u n d volume of six issues of the 1995 Annals of Vascular Surgery m u s t be ordered by October 1, 1995, from Quality Medical Publishing, Inc., 11970 B o r m a n Dr., Ste. 222, St. Louis, MO 63146. P a y m e n t of $60 in U.S. f u n d s m u s t a c c o m p a n y all orders.