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Systemic tumor embolism following thoracotomy partially masked by postoperative epidural analgesia
Systemic
Tumor Embolism Following Thoracotomy Partially Masked by Postoperative Epidural Analgesia
Jay B. Brodsky, MD, William G. Brose, MD, Walter B. Cannon, MD, and Robert E. McKlveen, MD
A
PATIENT experienced a numb, pulseless leg several hours following thoracotomy for adenocarcinoma of the lung. Embolectomy revealed the cause of the arterial occlusion to be fragmented lung tumor. Although uncommon, systemic embolization of malignant tumor should be considered in the differential diagnosis of arterial obstruction following thoracotomy. CASE REPORT During routine physical examination, a 59-year-old completely asymptomatic woman was noted on chest radiograph to have a nodule in the right midlung field. The lesion had not been present on a chest radiograph taken 2 years earlier. She denied any history of fever, night sweats, weight loss, productive cough, or hemoptysis. She did not smoke cigarettes and had no history of exposure to known pulmonary toxins. A fiberoptic bronchoscopy was performed at another hospital, and lung washings at that time revealed moderately differentiated adenocarcinoma. A computed tomography scan of the chest showed no pretracheal adenopathy, but posterior mediastinal involvement could not be ruled out. The patient was admitted to the Stanford University Medical Center on the morning of surgery. She underwent right thoracotomy with right upper and middle lobectomies. Microscopic examination of the lung specimen revealed poorly differentiated adenocarcinoma arising in the middle lobe bronchus with contiguous involvement of a large pulmonary vessel. Tumor was present in peribronchial lymph nodes at the margin of resection. During the 2-hour procedure, anesthesia consisted of isoflurane, 1% to 1.5%, and oxygen. She also received intravenous (IV) meperidine, 100 mg, intraoperatively. At the completion of surgery, the patient’s trachea was extubated in the operating room and she was transferred to the Intensive Care Unit (ICU). The patient was fully alert and complained of severe incisional pain. In the ICU, she received fentanyl, 50 rg, IV. The Acute Pain Service (APS) was consulted and advised epidural opioids for postthoracotomy analgesia; a lumbar epidural catheter was inserted. After a test dose of 3 mL of 1.5% lidocaine with epinephrine 1:200,000, an additional 12 mL of 0.125% bupivacaine was given through the epidural. Ten minutes later, 2 mg of hydromorphone in 10 mL of saline was also administered through the epidural catheter, and the patient was begun on a continuous infusion of epidural hydromorphone at 0.25 mg/ hr. The patient was quite comfortable and no longer complained of any incisional pain. The following morning (11.5 hours following surgery), the surgical intern was called to evaluate the patient because her temperature had risen to 39.4OC. The patient mentioned that her left foot felt numb. The APS resident was consulted to see if this problem was caused by the epidural.
Although she had no previous history of peripheral vascular disease, on physical examination her left foot was cold up to the knee. She was unable to move her left foot or toes, and she complained of severe pain when the leg was touched. There was no capillary refill in her pale foot nor palpable pulses; no Doppler sounds were obtainable over the left dorsalis pedis or posterior tibia1 arteries. She did have weak pulses over her left popliteal and femoral arteries. The right lower extremity was unremarkable. An arteriogram of the left leg was performed which confirmed arterial obstruction at the knee. The patient was taken immediately to the operating room where she underwent a transfemoral embolectomy of the left common femoral, profundis femoris, superficial femoral, popliteal, and tibioperoneal arteries. Following embolectomy, an intraoperative arteriogtam demonstrated recovery of perfusion to the left foot. Pathologic examination of the left femoral embolism specimen showed metastatic carcinoma in an organizing thrombus. Postoperatively, the patient was maintained for 4 days on a continuous epidural infusion of a combination of hydromorphone and bupivacaine for treatment of thoracotomy and lower extremity pain. The local anesthetics were also used to help improve circulation to the leg. In addition, she received antibiotics and an intravenous heparin infusion (500 U/hr). The patient had a complicated postoperative course, developing a compartment syndrome requiring fasciotomy and several skin grafting procedures. She also experienced a mild left peroneal palsy and weakness in the left toe extensor muscles. She made a complete neurologic recovery and was discharged home 4 weeks after the initial operation. DISCUSSION
Microscopic hematogenous spread of tumor is extremely common; however, such spread is usually via the portal circulation to the liver or through the systemic venous circulation to the lung.’ Systemic arterial embolization of malignant tumor to peripheral vessels is much less common. Tumor emboli to peripheral vessels usually arise from left atria1 myxomas. However, the second most common source of seeding is bronchogenic lung carcinoma, with primary lung neoplasms accounting for 11 of the 29 cases of
From the Departments of Anesthesia and Surgery, Stanford University School of Medicine, Stanford, CA. Address reprint requests to Jay B. Brodsky. MD, Department of Anesthesia, Stanford University Medical Center, Stanford, CA 94305. o 1990 by W. B. Saunders Company. 0888-6296/90/0401-0016503.00/O
Journalof Cardiothoracic Anesthesia, Vol4, No 1 (February), 1990: pp 95-96
95
BRODSKY ET AL
96
systemic tumor emboli reported in the largest series.* Tumor invasion of the pulmonary vein with subsequent dislodgement during surgical manipulation leading to systemic embolization accounts for the distribution of arterial emboli following thoracotomy. Although the site of origin of the tumor emboli is most often the lung, the site of lodgement of the emboli varies in a distribution similar to the more common types of emboli. The common femoral artery is most often the site of arterial tumor embolism, but unexpected occlusion of any artery following thoracotomy for tumor should raise suspicions of tumor emboli. A recent case report illustrates that acute arterial obstruction by tumor can be evident immediately.3 Intraoperative arterial embolization of a bronchogenic tumor led to occlusion of the axillary artery, causing damping of the radial artery trace during surgery. Embolization of tumor fragments producing clinically significant ischemia is usually a complication of advanced malignancy, from either primary or metastatic pulmonary disease. Although most patients are extremely ill, the patient presented was asymptomatic prior to surgery. Tumor emboli have actually been the presenting sign in rare cases of advanced disease.2 The observation by a nurse of a fever spike, which was probably secondary to atelectasis, led to physical examination of the patient by the surgical house officer. Otherwise, since the patient did not complain of leg pain, the ischemic leg might have gone unrecognized until morning.
The continuous infusion of epidural hydromorphone provided incisional and peripheral analgesia and probably masked pain from the ischemic leg. However, the feeling of numbness was present, was of concern to the patient, and led to the recognition of the problem. It is interesting that although the patient did not complain of pain in the leg at rest, she experienced severe pain when the leg was touched during examination. The experience of the APS with ischemic leg pain has been that epidural opioids are not usually adequate treatment, and that local anesthetics are also needed to relieve that type of pain. Because the patient had a lumbar epidural catheter placed immediately following surgery, was receiving a continuous infusion of epidural hydromorphone, and had received an epidural bolus of local anesthetics in the ICI-l, it was initially believed that the leg numbness was due to residual effect from the epidural medications or from an expanding epidural hematoma. It became obvious that with the absence of peripheral pulses, a mechanical obstruction was the true etiology. Embolectomy and subsequent pathologic examination confirmed the diagnosis, with fragmented tumor the cause of the arterial occlusion. Although much less common than other causes of systemic embolization, intraoperative dislodgement of tumor during manipulation of the pulmonary veins leading to systemic arterial embolization should be considered in arterial obstruction following thoracotomy for tumor.
REFERENCES 1. Bloch RS, Jacobs LA, Lewis LS, et al: Malignant tumor embolism: A rare presentation of malignant disease. J Cardiovasc Surg 27:630-631, 1986 2. Starr DS, Lawrie GM, Morris GC Jr: Unusual
presentation of bronchogenic carcinoma: Case report and review of the literature. Cancer 47:398-401,198l 3. Oxorn DC: Suspected tumor embolism as a cause of arterial line dysfunction. Can J Anaesth 35:440, 1988
Tumor Embolism Following Thoracotomy Partially Masked by Postoperative Epidural Analgesia
Jay B. Brodsky, MD, William G. Brose, MD, Walter B. Cannon, MD, and Robert E. McKlveen, MD
A
PATIENT experienced a numb, pulseless leg several hours following thoracotomy for adenocarcinoma of the lung. Embolectomy revealed the cause of the arterial occlusion to be fragmented lung tumor. Although uncommon, systemic embolization of malignant tumor should be considered in the differential diagnosis of arterial obstruction following thoracotomy. CASE REPORT During routine physical examination, a 59-year-old completely asymptomatic woman was noted on chest radiograph to have a nodule in the right midlung field. The lesion had not been present on a chest radiograph taken 2 years earlier. She denied any history of fever, night sweats, weight loss, productive cough, or hemoptysis. She did not smoke cigarettes and had no history of exposure to known pulmonary toxins. A fiberoptic bronchoscopy was performed at another hospital, and lung washings at that time revealed moderately differentiated adenocarcinoma. A computed tomography scan of the chest showed no pretracheal adenopathy, but posterior mediastinal involvement could not be ruled out. The patient was admitted to the Stanford University Medical Center on the morning of surgery. She underwent right thoracotomy with right upper and middle lobectomies. Microscopic examination of the lung specimen revealed poorly differentiated adenocarcinoma arising in the middle lobe bronchus with contiguous involvement of a large pulmonary vessel. Tumor was present in peribronchial lymph nodes at the margin of resection. During the 2-hour procedure, anesthesia consisted of isoflurane, 1% to 1.5%, and oxygen. She also received intravenous (IV) meperidine, 100 mg, intraoperatively. At the completion of surgery, the patient’s trachea was extubated in the operating room and she was transferred to the Intensive Care Unit (ICU). The patient was fully alert and complained of severe incisional pain. In the ICU, she received fentanyl, 50 rg, IV. The Acute Pain Service (APS) was consulted and advised epidural opioids for postthoracotomy analgesia; a lumbar epidural catheter was inserted. After a test dose of 3 mL of 1.5% lidocaine with epinephrine 1:200,000, an additional 12 mL of 0.125% bupivacaine was given through the epidural. Ten minutes later, 2 mg of hydromorphone in 10 mL of saline was also administered through the epidural catheter, and the patient was begun on a continuous infusion of epidural hydromorphone at 0.25 mg/ hr. The patient was quite comfortable and no longer complained of any incisional pain. The following morning (11.5 hours following surgery), the surgical intern was called to evaluate the patient because her temperature had risen to 39.4OC. The patient mentioned that her left foot felt numb. The APS resident was consulted to see if this problem was caused by the epidural.
Although she had no previous history of peripheral vascular disease, on physical examination her left foot was cold up to the knee. She was unable to move her left foot or toes, and she complained of severe pain when the leg was touched. There was no capillary refill in her pale foot nor palpable pulses; no Doppler sounds were obtainable over the left dorsalis pedis or posterior tibia1 arteries. She did have weak pulses over her left popliteal and femoral arteries. The right lower extremity was unremarkable. An arteriogram of the left leg was performed which confirmed arterial obstruction at the knee. The patient was taken immediately to the operating room where she underwent a transfemoral embolectomy of the left common femoral, profundis femoris, superficial femoral, popliteal, and tibioperoneal arteries. Following embolectomy, an intraoperative arteriogtam demonstrated recovery of perfusion to the left foot. Pathologic examination of the left femoral embolism specimen showed metastatic carcinoma in an organizing thrombus. Postoperatively, the patient was maintained for 4 days on a continuous epidural infusion of a combination of hydromorphone and bupivacaine for treatment of thoracotomy and lower extremity pain. The local anesthetics were also used to help improve circulation to the leg. In addition, she received antibiotics and an intravenous heparin infusion (500 U/hr). The patient had a complicated postoperative course, developing a compartment syndrome requiring fasciotomy and several skin grafting procedures. She also experienced a mild left peroneal palsy and weakness in the left toe extensor muscles. She made a complete neurologic recovery and was discharged home 4 weeks after the initial operation. DISCUSSION
Microscopic hematogenous spread of tumor is extremely common; however, such spread is usually via the portal circulation to the liver or through the systemic venous circulation to the lung.’ Systemic arterial embolization of malignant tumor to peripheral vessels is much less common. Tumor emboli to peripheral vessels usually arise from left atria1 myxomas. However, the second most common source of seeding is bronchogenic lung carcinoma, with primary lung neoplasms accounting for 11 of the 29 cases of
From the Departments of Anesthesia and Surgery, Stanford University School of Medicine, Stanford, CA. Address reprint requests to Jay B. Brodsky. MD, Department of Anesthesia, Stanford University Medical Center, Stanford, CA 94305. o 1990 by W. B. Saunders Company. 0888-6296/90/0401-0016503.00/O
Journalof Cardiothoracic Anesthesia, Vol4, No 1 (February), 1990: pp 95-96
95
BRODSKY ET AL
96
systemic tumor emboli reported in the largest series.* Tumor invasion of the pulmonary vein with subsequent dislodgement during surgical manipulation leading to systemic embolization accounts for the distribution of arterial emboli following thoracotomy. Although the site of origin of the tumor emboli is most often the lung, the site of lodgement of the emboli varies in a distribution similar to the more common types of emboli. The common femoral artery is most often the site of arterial tumor embolism, but unexpected occlusion of any artery following thoracotomy for tumor should raise suspicions of tumor emboli. A recent case report illustrates that acute arterial obstruction by tumor can be evident immediately.3 Intraoperative arterial embolization of a bronchogenic tumor led to occlusion of the axillary artery, causing damping of the radial artery trace during surgery. Embolization of tumor fragments producing clinically significant ischemia is usually a complication of advanced malignancy, from either primary or metastatic pulmonary disease. Although most patients are extremely ill, the patient presented was asymptomatic prior to surgery. Tumor emboli have actually been the presenting sign in rare cases of advanced disease.2 The observation by a nurse of a fever spike, which was probably secondary to atelectasis, led to physical examination of the patient by the surgical house officer. Otherwise, since the patient did not complain of leg pain, the ischemic leg might have gone unrecognized until morning.
The continuous infusion of epidural hydromorphone provided incisional and peripheral analgesia and probably masked pain from the ischemic leg. However, the feeling of numbness was present, was of concern to the patient, and led to the recognition of the problem. It is interesting that although the patient did not complain of pain in the leg at rest, she experienced severe pain when the leg was touched during examination. The experience of the APS with ischemic leg pain has been that epidural opioids are not usually adequate treatment, and that local anesthetics are also needed to relieve that type of pain. Because the patient had a lumbar epidural catheter placed immediately following surgery, was receiving a continuous infusion of epidural hydromorphone, and had received an epidural bolus of local anesthetics in the ICI-l, it was initially believed that the leg numbness was due to residual effect from the epidural medications or from an expanding epidural hematoma. It became obvious that with the absence of peripheral pulses, a mechanical obstruction was the true etiology. Embolectomy and subsequent pathologic examination confirmed the diagnosis, with fragmented tumor the cause of the arterial occlusion. Although much less common than other causes of systemic embolization, intraoperative dislodgement of tumor during manipulation of the pulmonary veins leading to systemic arterial embolization should be considered in arterial obstruction following thoracotomy for tumor.
REFERENCES 1. Bloch RS, Jacobs LA, Lewis LS, et al: Malignant tumor embolism: A rare presentation of malignant disease. J Cardiovasc Surg 27:630-631, 1986 2. Starr DS, Lawrie GM, Morris GC Jr: Unusual
presentation of bronchogenic carcinoma: Case report and review of the literature. Cancer 47:398-401,198l 3. Oxorn DC: Suspected tumor embolism as a cause of arterial line dysfunction. Can J Anaesth 35:440, 1988