Recurrent arterial embolization from a metastatic germ cell tumor invading the left atrium

Tumor Embolic Stroke: The Importance of Pathological Assessment of Clots after Thrombectomy

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.

Arterial Embolism in Malignancy: The Role of Surgery

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.

Neoplastic embolization to systemic and pulmonary arteries

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.

Recurrent Peripheral Arterial Embolism from Metastatic Lung Choriocarcinoma

A patient with choriocarcinoma, most likely of ovarian origin, with lung metastasis is presented. The disease manifested itself by recurrent embolism into the peripheral arteries. Literature on this topic is reviewed.

Ischemic neuromyopathy due to peripheral arterial embolization of an adenocarcinoma in a cat

A case of peripheral arterial tumor embolization in a cat is described. The cat presented with signs of aortic thromboembolism, including decreased peripheral pulse quality, pallor, and coolness of the distal limbs, as well as proprioceptive deficits. Thoracic radiographs revealed a cavitary lung mass; echocardiography was unremarkable. Cytologic evaluation of aspirates of the mass suggested malignancy. The left hindlimb was amputated, and histopathology confirmed embolization of an adenocarcinoma. Although rare, peripheral arterial tumor embolization should be considered as a differential in cats presenting with signs of thromboembolic disease.

Cardiac metastasis from yolk sac tumor: case report and review

Cardiac metastasis of germ cell tumors is extremely rare, particularly in females. We report a case of a 26-year-old previously healthy woman who presented with a 5-month history of abdominal pain, weight loss, fever, generalized lymphadenopathy, and acanthosis nigricans. Biopsy of cervical lymph nodes revealed a poorly differentiated neoplasm. Immunohistochemical staining was positive for alpha-fetoprotein suggesting the diagnosis of a germ cell tumor. During the investigation, the patient developed heart failure and a mass attached to the right ventricle was detected by the echocardiogram. In a few days, she developed multiple organ failure and died. Post-mortem examination revealed a malignant mixed germ cell tumor of the right ovary with extensive hematogenic and lymphatic dissemination, a polypoid mass attached to the right ventricle, emboli in the endocardial and epicardial vessels, and infiltration surrounding the coronary arteries. To the best of our knowledge this is the third report of grossly visible heart metastases from a yolk sac tumor in a female patient. A summary of all published cases of germ cell tumors with cardiac metastasis over the last 20 years is also presented.

Oclusão arterial aguda de membros inferiores por êmbolo tumoral em paciente com neoplasia de pulmão

A embolia arterial periférica originada de tumores malignos é considerada uma manifestação rara da doença neoplásica, podendo se originar de vários sítios, incluindo coração, aorta e veias pulmonares, sendo estas últimas, fontes massivas de embolia por trombo ou tumores com erosão para seu lúmen. Apesar de infrequente, a neoplasia pulmonar deve ser considerada como uma fonte de êmbolos para as extremidades, principalmente quando há invasão neoplásica para as veias pulmonares. Apresentamos o caso de um paciente do sexo masculino submetido à pneumectomia por neoplasia pulmonar, que evoluiu com oclusão arterial aguda de membros inferiores por êmbolo tumoral " a cavaleiro".

Both-sided Intra-atrial Intracardiac Metastases as the Initial Presentation of Testicular Seminoma

We report a case of a 41-year-old man admitted with respiratory distress and found to have masses in both atria of the heart and in the testicle. The patient received palliative radiotherapy to relieving obstruction of blood flow tract caused by the intracardiac masses, followed by radical orchiectomy. After the diagnosis of testicular seminoma, he was treated successfully with 4 cycles of systemic chemotherapy. This is a rare case that presented with metastatic testicular seminoma involving both atria of heart and causing symptomatic obstruction of blood flow tract.

Intracardiac Extension of Lung Cancer Demonstrated on PET Scanning

Intracardiac tumors are unusual and can originate within the heart or spread from other sites. This is a report of a patient who presented with a TIA, and during the subsequent stroke workup, a right hilar nonsmall cell lung carcinoma was discovered. The tumor had extended into the left atrium through a pulmonary vein. The hilar tumor as well as intracardiac extension were demonstrated by PET scanning using FDG.

Left ventricular intracardiac metastatic germ cell tumor presenting with hemorrhagic cerebrovascular event

We describe an unusual case of a 26-year-old man admitted with respiratory distress and found to have testicular cancer metastatic to the lung and heart. Twelve days after admission, the patient experienced multiple hemorrhagic strokes. Echocardiography demonstrated testicular cancer metastatic to the septal surface of the left ventricle of the heart with presumed embolization to the cerebrovascular region. The patient received chemotherapy and radiation therapy to the areas of tumor mass with subsequent resolution of tumor burden. This is the first reported case of metastasis from embryonal carcinoma of the testis to the left ventricle of the heart.

Surgical management of thoracic malignancies invading the heart or great vessels

BACKGROUND

Surgical resection of thoracic malignancies involving either the heart or great vessels is uncommonly performed because of the potential morbidity and mortality for an unknown probability of significant palliation or cure. We reviewed our experience of 10 patients treated surgically, either primarily or as a component of multimodality therapy, to assess feasibility and results.

METHODS

A retrospective review of the results in 10 patients who underwent resection of thoracic malignancies that included either great vessel or the heart was conducted.

RESULTS

Histologic diagnoses included soft tissue sarcoma (n = 7), squamous cell carcinoma (n = 1), malignant thymoma (n = 1), and mediastinal teratoma (n = 1). Three patients underwent induction chemotherapy. Cardiopulmonary bypass was used in 7 patients. Structures resected included superior vena cava (n = 5), left atrium (n = 4), right atrium (n = 2), descending aorta (n = 1), and main pulmonary artery (n = 1). Concomitant anatomic pulmonary resections were performed in 3 patients. Seven patients had an R0 or R1 resection. There were no perioperative deaths. All symptomatic patients had immediate and sustained palliation of their presenting symptoms. The median length of stay was 6 days (range, 4 to 43 days). Six patients underwent postoperative systemic therapy. The overall median survival was 21.7 months (range, 3.2 to 69 months) and was 33.3 months (range, 3.7 to 69 months) for patients who had an R0 or R1 resection.

CONCLUSIONS

Resection of the heart and great vessels involved by thoracic malignancies can be performed with acceptable morbidity and mortality and results in significant palliation and, in some cases, prolonged survival.

Peripheral arterial embolism arising from pulmonary adenocarcinoma

Bronchogenic carcinoma is a rare source of peripheral arterial embolism. We present the case of a 28-year-old female nonsmoker with an adenocarcinoma of the left main bronchus involving the pulmonary veins. While the patient was hospitalized awaiting operation, she presented embolization in her legs; embolectomy and fasciotomy were necessary to treat compartment syndrome. Echocardiography disclosed floating tumoral masses in the left atrium. Seven days later, an operation was performed with cardiopulmonary bypass to remove the tumor masses from the atrial lumen; pulmonary veins were sutured from within the atrium, and pneumonectomy was performed. Fulminant infection of the lower limbs developed that led to gangrene and multiple organ failure, and the patient died 8 days after the operation.

Imaging of intrathoracic metastases of nonseminomatous germ cell tumors

Radiologic imaging is crucial in the evaluation of intrathoracic metastatic nonseminomatous germ cell tumors. Helical CT is the workhorse of radiologic staging and is sensitive in the detection of parenchymal nodules and mediastinal lymphadenopathy. CT may also demonstrate other less common sites of metastatic disease. Although, currently, no radiologic procedure is effective in distinguishing viable tumor or teratoma from residual fibrosis and necrosis, cross-sectional imaging remains essential in the presurgical evaluation of potential metastatic disease. FDG PET and CT-guided needle biopsy may be useful in select, high-risk patients.