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Baker R, Bakali Z, Crocker JS, Mowla A, Smith M, Grossman A, Hagen MC, Prestigiacomo CJ, Shirani P. Tumor Embolic Stroke: The Importance of Pathological Assessment of Clots after Thrombectomy. J Clin Med 2024; 13:1834. [PMID: 38610599 PMCID: PMC11012646 DOI: 10.3390/jcm13071834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
While tumor emboli are a rare cause of stroke in cancer patients, they highlight the importance of gross observations and pathological assessments in the evaluation of clots. In this case report, a 70-year-old male with type 2 diabetes mellitus and coronary artery disease presented with acute left-sided weakness. He was clinically diagnosed with stroke and given alteplase at 1.5 h from last known normal. He then underwent CT angiography that showed right internal carotid artery occlusion and immediate thrombectomy. The recovered clot was white and lipid-like; due to its atypical appearance, it was sent for pathological assessment, where it was shown to bear features of malignancy. Subsequent imaging identified masses indicating malignancy in the left gluteus, right pleural hilum, and spine. Tumor embolic stroke is a rare pathology. Embolic diseases such as strokes and pulmonary embolisms are common in patients with cancer. Embolic stroke of undetermined source (ESUS) represents a significant portion of cancer strokes. Tumor emboli, though rare, may be an underappreciated source of ESUS in cancer patients. We intend for this case to demonstrate the value of pathological assessment for atypical thrombi as well as highlight the etiology of tumor embolic strokes.
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Affiliation(s)
- Richard Baker
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
| | - Zohabe Bakali
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
| | - Jeffrey S. Crocker
- Department of Pharmacology & Systems Physiology, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Ashkan Mowla
- Department of Neurosurgery, University of Southern California, Los Angeles, CA 90033, USA;
| | - Matthew Smith
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Aaron Grossman
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Matthew C. Hagen
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Pathology & Laboratory Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Charles J. Prestigiacomo
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Peyman Shirani
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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Harnarayan P, Islam S, Naraynsingh V. Arterial Embolism in Malignancy: The Role of Surgery. Ther Clin Risk Manag 2021; 17:635-640. [PMID: 34177265 PMCID: PMC8219304 DOI: 10.2147/tcrm.s308026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background Peripheral arterial embolism from malignant disease is uncommon and a rare cause of limb ischemia. In the acute setting, patients can present with severe ischemia of either the upper or lower limb, and urgent surgical intervention is often required to avoid severe debilitation and limb loss. Patients Our case series comprised three patients who presented with upper and lower limb ischemia and were found to have concomitant malignancy. All three patients were female, with a median age of 54.3 years, and none of the patients was on active chemotherapy. One presented with stage IIb uterine carcinoma, one with stage IIIb ovarian carcinoma, and the other with stage IIIb cervical carcinoma. These patients were referred for vascular management, with two being acute and the other acute on chronic. Results Of the three patients, two presented with acute limb ischemia and underwent arterial thrombectomy, one of the upper and the other the lower limb. The third patient, with acute-on-chronic upper limb ischemia, was treated conservatively with intravenous heparin followed by oral anticoagulation. All three had limb salvage and survival outcome at 1 year post-treatment. Conclusion In this small series, surgical intervention in two patients and conservative management in the other patient led to limb salvage with a reasonably good quality of life. Even though the long-term survival for patients with malignant disease is generally poor, surgical intervention can achieve limb salvage with a reasonably good quality of life.
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Affiliation(s)
- Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Shariful Islam
- Department of Surgery, San Fernando General & Teaching Hospitals, San Fernando, Trinidad and Tobago
| | - Vijay Naraynsingh
- Department of Surgery, Medical Associates Hospital, St. Joseph, Trinidad and Tobago
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Bois MC, Eckhardt MD, Cracolici VM, Loe MJ, Ocel JJ, Edwards WD, McBane RD, Bower TC, Maleszewski JJ. Neoplastic embolization to systemic and pulmonary arteries. J Vasc Surg 2018; 68:204-212.e7. [PMID: 29502997 DOI: 10.1016/j.jvs.2017.09.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/23/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE 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. METHODS 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). RESULTS 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%. CONCLUSIONS This study highlights the importance of routine histopathologic evaluation of embolectomy specimens in patients with and without documented neoplasia.
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Affiliation(s)
- Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Michael D Eckhardt
- Department of Pathology and Laboratory Medicine, University of Chicago, NorthShore University HealthSystem, Evanston, Ill
| | | | - Matthew J Loe
- Interventional Radiology, St. Paul Radiology, St. Paul, Minn
| | - Joseph J Ocel
- Diagnostic Radiology, Mercy Health Services-Iowa Corporation, Mason City, Iowa
| | - William D Edwards
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Robert D McBane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph J Maleszewski
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.
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Bottoni DA, Franklin JH, Forbes TL. Acute Lower Extremity Ischemia Secondary to Salivary Gland Tumor Embolus. Vasc Endovascular Surg 2008; 42:85-7. [DOI: 10.1177/1538574407308943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Malignant arterial tumor emboli of sufficient size that is capable of causing organ infarction or ischemia are exceedingly rare. The majority of these emboli are associated with either primary or secondary pulmonary malignancies and commonly occur perioperatively or immediately postoperatively. This study describes an unusual case of acute lower extremity ischemia secondary to a malignant parotid tumor embolus with evidence of left ventricular involvement.
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Affiliation(s)
| | - Jason H. Franklin
- Department of Otolaryngology London Health Sciences Centre & The University of Western Ontario, London, Ontario, Canada
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Saint-Cyr I, Boisseau-Garsaud AM, Pont F, Cales-Quist D, Helenon R, Chinyavong T. Intravascular metastatic melanoma of the vena saphena magna. Int J Dermatol 2004; 43:590-2. [PMID: 15304184 DOI: 10.1111/j.1365-4632.2004.02142.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Melanoma blood vessel metastases are very uncommon. We report the first recorded case of intravascular metastatic melanoma of the vena saphena magna. CASE REPORT A 74-year-old woman presented with a swelling of the upper third of her left thigh and was suspected of superficial thrombophlebitis. Two intravascular black masses were excised in the vena saphena magna. Histopathologic examination showed an endovascular metastatic melanoma positively staining for HMB45 and S-100 proteins. Acral-lentiginous melanoma of her big toe was then found. Subcutaneous lymph node and chest metastases were discovered and treatment with dacarbazine was initiated, followed by treatment with fotemustine. The patient died 21 months after the diagnosis was made. CONCLUSIONS Only a few cases of blood vessel metastatic melanoma have been reported. We here report the first recorded case, to our knowledge, of intravascular metastatic melanoma of the vena saphena magna. Surgical exploration allowed rapid diagnosis, and histological examination confirmed the intravascular nature of a hematogenous melanoma metastasis. This case clearly illustrates the need for histologic examination of any thrombotic material.
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Affiliation(s)
- Isabelle Saint-Cyr
- Department of Dermatology, Centre Hospitalier Universitaire de Fort de France, Martinique, French West Indies.
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Abstract
Malignant arterial tumor emboli large enough to cause ischemia or organ infarction are a rare, but often fatal, complication of neoplastic disease. The majority of arterial emboli are associated with primary or secondary pulmonary malignancies. The sites where they impact are similar in distribution to arteriosclerotic emboli, and the treatment follows well-established principles developed for the treatment of arteriosclerotic emboli. The results of embolectomy in accessible sites are very good, thus treatment should always be attempted. A case of a superior mesenteric tumor embolus occurring after pneumonectomy is reported, together with a review of all published cases of arterial tumor emboli of sufficient size to cause organ infarction or ischemia.
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Affiliation(s)
- C Chandler
- Department of Thoracic Surgery, St. George's Hospital, London, England
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