Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death

Pulmonary tumor embolism: A retrospective study over a 30-year period

Background

Pulmonary tumor embolism (PTE) is difficult to detect before death, and it is unclear whether the discrepancy between antemortem clinical and postmortem diagnosis improves with the advance of the diagnostic technologies. In this study we determined the incidence of PTE and analyzed the discrepancy between antemortem clinical and postmortem diagnosis.

Methods

We performed a retrospective autopsy study on patients with the history of malignant solid tumors from 1990 to 2020 and reviewed all the slides of the patients with PTE. We also analyzed the discrepancies between antemortem clinical and postmortem diagnosis in 1999, 2009 and 2019 by using the Goldman criteria. Goldman category major 1 refers to cases in which an autopsy diagnosis was the direct cause of death and was not recognized clinically, but if it had been recognized, it may have changed treatment or prolonged survival.

Results

We found 20 (3%) cases with PTE out of the 658 autopsy cases with solid malignancies. Out of these 20 cases, urothelial carcinoma (30%, 6/20) and invasive ductal carcinoma of the breast (4/20, 20%) were the most common primary malignancies. Seven patients with shortness of breath died within 3–17 days (average 8.4±2.2 days) after onset of the symptoms. Pulmonary embolism was clinically suspected in seven out of twenty (35%, 7/20) patients before death, but only two patients (10, 2/20) were diagnosed by imaging studies before death. The rate of Goldman category major 1 was 13.2% (10/76) in 1999, 7.3% (4/55) in 2009 and 6.9% (8/116) in 2019. Although the rate of Goldman category major 1 appeared decreasing, the difference was not statistically significant. The autopsy rate was significantly higher in 2019 (8.4%, 116/1386) than in 2009 (4.4%, 55/1240).

Conclusions

The incidence of PTE is uncommon. Despite the advances of the radiological techniques, radiological imaging studies did not detect the majority of PTEs. The discrepancy between the antemortem clinical and the postmortem diagnosis has not improved significantly over the past 30 years, emphasizing the value of autopsy.

Pulmonary thromboembolism secondary to pelvic thrombosis related to giant ovarian tumor

Pulmonary thromboembolism (PTE) is one of the major complications in oncologic patients. The incidence of PTE in these cases is 4 to 7 times higher than in non-oncologic patients. Ovarian tumors, specifically those of large sizes, may impair the blood flow through the pelvic veins as tumor pressure over the pelvic vessels increases the incidence of thrombosis. The authors report the case of the unexpected death of a 74-year-old female due to massive pulmonary thromboembolism, associated with an ovarian tumor almost of 15 kg of weight that filled the abdominal and pelvic cavities. The compressive effect on the walls of the pudendal and periuterine veins somehow facilitated the local thrombosis. According to the histological characterization on post-mortem samples, the mass was identified as an “atypical proliferative (borderline) mucinous tumor.” The case emphasizes the important association between pulmonary thromboembolism and ovarian tumors