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An Unusual Presentation of Metastatic Gastric Adenocarcinoma — Acute Onset of Right Neck Swelling
CASE REPORT
An Unusual Presentation of Metastatic Gastric Adenocarcinoma — Acute Onset of Right Neck Swelling Kuan-Ting Liu,1 Hon-Man Chan,1,2 Tzeng-Jih Lin1,3* Central venous thrombosis is an uncommon problem associated with malignancy. We present here a 53year-old male who visited the emergency room because of right neck swelling. Fluid accumulation over deep neck space led to the diagnosis of suspected hemorrhage, and central venous thrombosis was found by computed tomography. This patient had no other precipitating cause. Autoimmune disorders, hypercoagulation and malignancy surveys were performed during hospitalization. Elevated serum tissue polypeptide antigen and CA130 were noted, and multiple liver metastases were found by another computed tomography. Subsequently, gastric adenocarcinoma was confirmed after gastroendoscopy. Gastric adenocarcinoma with distal metastases was finally diagnosed. This case reminds us that central venous thrombosis is a sign of many diseases. Malignancy, including gastric adenocarcinoma, is one of the causes that should be considered. [J Formos Med Assoc 2007;106(7):589–591] Key Words: central vein, gastric cancer, malignancy, thrombosis
Venous thromboembolism is associated with coagulopathy, infection, malignancy or central venous devices. Sometimes, venous thromboembolism may be the first manifestation of cancer.1,2 We present a case who came to the emergency room due to right neck swelling. Neck computed tomography (CT) revealed fluid accumulation in the right posterior cervical space and supraclavicular area, and thrombosis in the left internal jugular vein and bilateral subclavian vein. The patient was diagnosed with gastric adenocarcinoma and distal metastasis later.
Case Report A previously healthy 53-year-old male presented to our emergency department in the evening with
swelling on the right side of the neck that he had noticed since that morning after waking up. As the swelling had progressed slightly during the day, he visited our hospital after work. He reported that he did not have any other symptom prior to the neck swelling. He was a building laborer and had smoked 1–2 packs of cigarettes a day for more than 30 years. The right neck swelling had been present for a period of less than 12 hours, and only mild pain was noted. Physical examination revealed normal vital signs. Examination of his neck showed swelling and slight tenderness along the anterior border of the right trapezius muscle and supraclavicular fossa. The color of the skin over the neck swelling had no obvious change. Laboratory evaluations in the emergency department included complete blood cell count,
©2007 Elsevier & Formosan Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Departments of 2Surgery and 3Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
Received: June 5, 2006 Revised: November 20, 2006 Accepted: January 2, 2007
*Correspondence to: Dr Tzeng-Jih Lin, Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. E-mail: [email protected]
J Formos Med Assoc | 2007 • Vol 106 • No 7
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K.T. Liu, et al
Figure. (A) Computed tomography (CT) reveals thrombosis in the left internal jugular vein and fluid accumulation in the right posterior cervical space (arrow). (B) Subclavian vein thromboses also noted on CT (arrow). (C) Another contrastenhanced CT including the chest region shows thrombosis in the right subclavian vein, right brachiocephalic vein and left subclavian vein and superior vena cava (arrow). (D) Multiple liver metastases as well as right pleural effusion were found.
A
B
C
D
blood sugar, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, creatinine, sodium, potassium, prothrombin time, partial thromboplastin time and C-reactive protein (CRP). The results were within normal limits except for mild anemia (hemoglobin, 11.2 g/dL; normal range, 13–17 g/dL) and elevated CRP (143.6 µg/ mL; normal range, < 5 µg/mL). Contrast-enhanced CT was performed, as a neck X-ray did not reveal any specific problem. CT revealed thrombosis in the left internal jugular vein and bilateral subclavian vein and fluid accumulation in the right posterior cervical space and supraclavicular area. There were multiple soft tissue nodules in the bilateral paratracheal space and bilateral jugular digastric chain and supraclavicular area (Figures A and B). He was referred to the hematology department for further evaluation of the central venous thrombosis, and received heparinization. Laboratory evaluations for autoimmune disorders and hypercoagulation included antiphospholipid antibody, VDRL test, anti-HCV, HBsAg, blood viscosity, antithrombin III, protein-C, protein-S, complement C3, complement C4, anticardiolipin, antinuclear antibody, fibrin split product, fibrinogen, and 590
D-dimer. The results were unremarkable except for elevated D-dimer (1102 µg/L; normal range, < 324 µg/L), decreased protein-C (73%; normal range, 80–132%), decreased viscosity (2.14; normal range, 3–5), positive antinuclear antibody (1:80) and positive antiphospholipid antibody. Serum tumor makers including CA19-9 and carcinoembryonic antigen were within normal limits, but elevated tissue polypeptide antigen (700.8 U/L; normal range, < 70 U/L) and CA130 (> 500 U/mL; normal range, < 35 U/L) were noted. Malignancy, especially adenocarcinoma, was suspected. Another contrast-enhanced CT that included the chest region was performed in the hematology ward and revealed thrombosis in the right subclavian vein, right brachiocephalic vein and left subclavian vein and superior vena cava (Figures C and D). Multiple liver metastases and metastatic lymphadenopathy in the subcarinal region and right hilum were found, as was right pleural effusion. As metastatic tumors were found in the liver, gastroendoscopy was performed and revealed a huge antral ulcer with oozing, surrounding nodular edge and uneven ulcer base. A biopsy was performed and histopathology revealed gastric adenocarcinoma. Chemotherapy was then planned. J Formos Med Assoc | 2007 • Vol 106 • No 7
Gastric cancer with central venous thrombosis
Discussion Our patient visited the hospital because of right neck swelling. Neck CT showed fluid accumulation in the right posterior cervical space and supraclavicular area. According to the disease course and physical examination, a hemorrhage was considered. The central venous thrombosis was found accidentally. It is hard to say whether the hemorrhage was due to the malignancy itself or to the central venous thrombosis. Malignancy may cause coagulopathy and spontaneous bleeding, but the basic profile of coagulopathy including prothrombin time, partial thromboplastin time and platelet counts were normal in our patient. We suspect that the central venous thrombosis resulted in venous pressure elevation and hemorrhage occurred in the small vessels of the neck in our patient. Central veins including superior vena cava, subclavian and internal jugular veins are uncommon sites of spontaneous venous thrombosis. Most central venous thromboses are related to central venous catheter, deep head and neck infection, trauma or hypercoagulability associated with malignancy.3 Most reports of spontaneous internal jugular vein thrombosis have been associated with malignant head and neck neoplasms. Reports of internal jugular venous thrombosis associated with distant malignancy are rare. Carrington and Adams reported two cases in whom ovarian tumor and mesothelioma were found.4 Unsal et al reported a case who presented with internal jugular vein thrombosis associated with coincidental prostate and lung malignancy.5 Leiomyosarcoma of the omentum associated with spontaneous internal jugular vein thrombosis was reported by Langlied et al.6 Liu et al reported a mucus-producing adenocarcinoma of unknown primary origin associated with bilateral internal and external jugular vein thrombosis.7 Contrast-enhanced CT is a diagnostic tool for central venous thrombosis.8 Magnetic resonance imaging (MRI), ultrasound and contrast venography can also establish the diagnosis of venous
J Formos Med Assoc | 2007 • Vol 106 • No 7
thrombosis. However, contrast venography is invasive and has many inherent risks such as dislodgement of the clot and dissemination of septic emboli. Ultrasound can diagnose internal jugular vein thrombosis but has limits in the subclavian vein and superior vena cava. Radiation exposure can be avoided with the use of MRI, and it is also very sensitive to blood flow rates.8 The therapy for venous thrombosis is anticoagulation. The most widely used form of therapy is heparinization, followed by anticoagulation with warfarin.9 Anticoagulation could prevent complications from thrombosis such as pulmonary embolism and septic embolism. In conclusion, central venous thrombosis is an uncommon problem. Patients presenting with spontaneous central venous thrombosis without any other precipitating cause may have distant malignant disease. Careful and early evaluation could reveal the underlying cause.
References 1. Piccioli A, Prandoni P. Venous thromboembolism as first manifestation of cancer. Acta Haematol 2001;106:13–7. 2. Sallah S, Wan JY, Nguyen NP. Venous thrombosis in patients with solid tumors: determination of frequency and characteristics. Thromb Haemost 2002;87:575–9. 3. Kennedy KS, Tami TA, Friedman JC, et al. Spontaneous thrombosis of the internal jugular vein. Ann Otol Rhinol Laryngol 1987;96:222–4. 4. Carrington BM, Adams JE. Jugular vein thrombosis associated with distant malignancy. Postgrad Med J 1988;64: 455–8. 5. Unsal EE, Karaca C, Ensari S. Spontaneous internal jugular vein thrombosis associated with distant malignancies. Eur Arch Otorhinolaryngol 2003;260:39–41. 6. Langlied AM, Dunton DJ, Carlson JA. Spontaneous internal jugular vein thrombosis associated with leiomyosarcoma of the omentum. Gynecol Oncol 1992;47:125–6. 7. Liu PG, Jacobs JB, Reede DL. Trousseau’s syndrome in the head and neck. Am J Otolaryngol 1985;6:405–8. 8. Albertyn LE, Alcock M. Diagnosis of internal jugular vein thrombosis. Radiology 1987;162:505–8. 9. Kale US, Wright RG. Primary presentation of spontaneous jugular vein thrombosis to the otolaryngologist in three different pathologies. J Laryngol Otol 1998;112:888–90.
591
An Unusual Presentation of Metastatic Gastric Adenocarcinoma — Acute Onset of Right Neck Swelling Kuan-Ting Liu,1 Hon-Man Chan,1,2 Tzeng-Jih Lin1,3* Central venous thrombosis is an uncommon problem associated with malignancy. We present here a 53year-old male who visited the emergency room because of right neck swelling. Fluid accumulation over deep neck space led to the diagnosis of suspected hemorrhage, and central venous thrombosis was found by computed tomography. This patient had no other precipitating cause. Autoimmune disorders, hypercoagulation and malignancy surveys were performed during hospitalization. Elevated serum tissue polypeptide antigen and CA130 were noted, and multiple liver metastases were found by another computed tomography. Subsequently, gastric adenocarcinoma was confirmed after gastroendoscopy. Gastric adenocarcinoma with distal metastases was finally diagnosed. This case reminds us that central venous thrombosis is a sign of many diseases. Malignancy, including gastric adenocarcinoma, is one of the causes that should be considered. [J Formos Med Assoc 2007;106(7):589–591] Key Words: central vein, gastric cancer, malignancy, thrombosis
Venous thromboembolism is associated with coagulopathy, infection, malignancy or central venous devices. Sometimes, venous thromboembolism may be the first manifestation of cancer.1,2 We present a case who came to the emergency room due to right neck swelling. Neck computed tomography (CT) revealed fluid accumulation in the right posterior cervical space and supraclavicular area, and thrombosis in the left internal jugular vein and bilateral subclavian vein. The patient was diagnosed with gastric adenocarcinoma and distal metastasis later.
Case Report A previously healthy 53-year-old male presented to our emergency department in the evening with
swelling on the right side of the neck that he had noticed since that morning after waking up. As the swelling had progressed slightly during the day, he visited our hospital after work. He reported that he did not have any other symptom prior to the neck swelling. He was a building laborer and had smoked 1–2 packs of cigarettes a day for more than 30 years. The right neck swelling had been present for a period of less than 12 hours, and only mild pain was noted. Physical examination revealed normal vital signs. Examination of his neck showed swelling and slight tenderness along the anterior border of the right trapezius muscle and supraclavicular fossa. The color of the skin over the neck swelling had no obvious change. Laboratory evaluations in the emergency department included complete blood cell count,
©2007 Elsevier & Formosan Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Departments of 2Surgery and 3Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
Received: June 5, 2006 Revised: November 20, 2006 Accepted: January 2, 2007
*Correspondence to: Dr Tzeng-Jih Lin, Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. E-mail: [email protected]
J Formos Med Assoc | 2007 • Vol 106 • No 7
589
K.T. Liu, et al
Figure. (A) Computed tomography (CT) reveals thrombosis in the left internal jugular vein and fluid accumulation in the right posterior cervical space (arrow). (B) Subclavian vein thromboses also noted on CT (arrow). (C) Another contrastenhanced CT including the chest region shows thrombosis in the right subclavian vein, right brachiocephalic vein and left subclavian vein and superior vena cava (arrow). (D) Multiple liver metastases as well as right pleural effusion were found.
A
B
C
D
blood sugar, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, creatinine, sodium, potassium, prothrombin time, partial thromboplastin time and C-reactive protein (CRP). The results were within normal limits except for mild anemia (hemoglobin, 11.2 g/dL; normal range, 13–17 g/dL) and elevated CRP (143.6 µg/ mL; normal range, < 5 µg/mL). Contrast-enhanced CT was performed, as a neck X-ray did not reveal any specific problem. CT revealed thrombosis in the left internal jugular vein and bilateral subclavian vein and fluid accumulation in the right posterior cervical space and supraclavicular area. There were multiple soft tissue nodules in the bilateral paratracheal space and bilateral jugular digastric chain and supraclavicular area (Figures A and B). He was referred to the hematology department for further evaluation of the central venous thrombosis, and received heparinization. Laboratory evaluations for autoimmune disorders and hypercoagulation included antiphospholipid antibody, VDRL test, anti-HCV, HBsAg, blood viscosity, antithrombin III, protein-C, protein-S, complement C3, complement C4, anticardiolipin, antinuclear antibody, fibrin split product, fibrinogen, and 590
D-dimer. The results were unremarkable except for elevated D-dimer (1102 µg/L; normal range, < 324 µg/L), decreased protein-C (73%; normal range, 80–132%), decreased viscosity (2.14; normal range, 3–5), positive antinuclear antibody (1:80) and positive antiphospholipid antibody. Serum tumor makers including CA19-9 and carcinoembryonic antigen were within normal limits, but elevated tissue polypeptide antigen (700.8 U/L; normal range, < 70 U/L) and CA130 (> 500 U/mL; normal range, < 35 U/L) were noted. Malignancy, especially adenocarcinoma, was suspected. Another contrast-enhanced CT that included the chest region was performed in the hematology ward and revealed thrombosis in the right subclavian vein, right brachiocephalic vein and left subclavian vein and superior vena cava (Figures C and D). Multiple liver metastases and metastatic lymphadenopathy in the subcarinal region and right hilum were found, as was right pleural effusion. As metastatic tumors were found in the liver, gastroendoscopy was performed and revealed a huge antral ulcer with oozing, surrounding nodular edge and uneven ulcer base. A biopsy was performed and histopathology revealed gastric adenocarcinoma. Chemotherapy was then planned. J Formos Med Assoc | 2007 • Vol 106 • No 7
Gastric cancer with central venous thrombosis
Discussion Our patient visited the hospital because of right neck swelling. Neck CT showed fluid accumulation in the right posterior cervical space and supraclavicular area. According to the disease course and physical examination, a hemorrhage was considered. The central venous thrombosis was found accidentally. It is hard to say whether the hemorrhage was due to the malignancy itself or to the central venous thrombosis. Malignancy may cause coagulopathy and spontaneous bleeding, but the basic profile of coagulopathy including prothrombin time, partial thromboplastin time and platelet counts were normal in our patient. We suspect that the central venous thrombosis resulted in venous pressure elevation and hemorrhage occurred in the small vessels of the neck in our patient. Central veins including superior vena cava, subclavian and internal jugular veins are uncommon sites of spontaneous venous thrombosis. Most central venous thromboses are related to central venous catheter, deep head and neck infection, trauma or hypercoagulability associated with malignancy.3 Most reports of spontaneous internal jugular vein thrombosis have been associated with malignant head and neck neoplasms. Reports of internal jugular venous thrombosis associated with distant malignancy are rare. Carrington and Adams reported two cases in whom ovarian tumor and mesothelioma were found.4 Unsal et al reported a case who presented with internal jugular vein thrombosis associated with coincidental prostate and lung malignancy.5 Leiomyosarcoma of the omentum associated with spontaneous internal jugular vein thrombosis was reported by Langlied et al.6 Liu et al reported a mucus-producing adenocarcinoma of unknown primary origin associated with bilateral internal and external jugular vein thrombosis.7 Contrast-enhanced CT is a diagnostic tool for central venous thrombosis.8 Magnetic resonance imaging (MRI), ultrasound and contrast venography can also establish the diagnosis of venous
J Formos Med Assoc | 2007 • Vol 106 • No 7
thrombosis. However, contrast venography is invasive and has many inherent risks such as dislodgement of the clot and dissemination of septic emboli. Ultrasound can diagnose internal jugular vein thrombosis but has limits in the subclavian vein and superior vena cava. Radiation exposure can be avoided with the use of MRI, and it is also very sensitive to blood flow rates.8 The therapy for venous thrombosis is anticoagulation. The most widely used form of therapy is heparinization, followed by anticoagulation with warfarin.9 Anticoagulation could prevent complications from thrombosis such as pulmonary embolism and septic embolism. In conclusion, central venous thrombosis is an uncommon problem. Patients presenting with spontaneous central venous thrombosis without any other precipitating cause may have distant malignant disease. Careful and early evaluation could reveal the underlying cause.
References 1. Piccioli A, Prandoni P. Venous thromboembolism as first manifestation of cancer. Acta Haematol 2001;106:13–7. 2. Sallah S, Wan JY, Nguyen NP. Venous thrombosis in patients with solid tumors: determination of frequency and characteristics. Thromb Haemost 2002;87:575–9. 3. Kennedy KS, Tami TA, Friedman JC, et al. Spontaneous thrombosis of the internal jugular vein. Ann Otol Rhinol Laryngol 1987;96:222–4. 4. Carrington BM, Adams JE. Jugular vein thrombosis associated with distant malignancy. Postgrad Med J 1988;64: 455–8. 5. Unsal EE, Karaca C, Ensari S. Spontaneous internal jugular vein thrombosis associated with distant malignancies. Eur Arch Otorhinolaryngol 2003;260:39–41. 6. Langlied AM, Dunton DJ, Carlson JA. Spontaneous internal jugular vein thrombosis associated with leiomyosarcoma of the omentum. Gynecol Oncol 1992;47:125–6. 7. Liu PG, Jacobs JB, Reede DL. Trousseau’s syndrome in the head and neck. Am J Otolaryngol 1985;6:405–8. 8. Albertyn LE, Alcock M. Diagnosis of internal jugular vein thrombosis. Radiology 1987;162:505–8. 9. Kale US, Wright RG. Primary presentation of spontaneous jugular vein thrombosis to the otolaryngologist in three different pathologies. J Laryngol Otol 1998;112:888–90.
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