Trousseau syndrome in a patient with advanced oral squamous cell carcinoma: a case report

Clinical features of Trousseau's syndrome with multiple acute ischemic strokes

BACKGROUND

Trousseau's syndrome or migrating thrombophlebitis can cause venous or arterial thrombosis; however, multiple acute ischemic strokes (MAIS) caused by Trousseau's syndrome are rare. The aim of this study was to analyse the clinical features of Trousseau's syndrome with MAIS and to improve the awareness and the knowledge of this disease.

METHODS

Clinical data from fifteen patients who were diagnosed as Trousseau's syndrome with MAIS in Rizhao People's Hospital from January 2017 to April 2020 were collected and analysed. The clinical data included the following: patients' basic information (including gender, age, underlying diseases, and tumour stage), laboratory results, imaging features, treatment regimens, and short-term prognoses were collected.

RESULTS

The mean age was 65.5 years, with thirteen males and two females. Most patients (11/15) had a history of smoking and (or) drinking. The average score of NIHSS was 2.13. 6 of the 15 patients first presented with ischemic stroke and then found the primary tumour. Most common types of primary tumour was lung cancer (11/15), and other types of primary tumour were gastric adenocarcinoma, renal cell carcinoma, oesophageal adenosquamous carcinoma, and cholangiocarcinoma (one in each). All the 15 patients showed different levels of increase of D-dimer. The increase in CRP appears in 10 of the 15 patients. Various tumour markers were increased in the 15 patients, especially for CYFRA-211, all the patients of which were higher than normal. All of the 15 patients had multiple vascular territory lesions in DWI, and most lesions were near the cortex areas. Only 4 of the 15 patients (26.7%) occurred with peripheral venous thrombosis. Thirteen patients were given low molecular heparin for anticoagulant therapy, of which 9 patients were improved in short-term while 4 patients were not.

CONCLUSION

Trousseau's syndrome with MAIS was associated with old-age male, smoking and (or) drinking history, low NIHSS score, increased D-dimer, CRP and tumour markers, and lesions near the cortex areas with multiple vascular territories in DWI. Patients with these features should be alert of malignant tumour. Most common types of primary tumour were lung cancer. Treatment with low molecular heparin may be effective in short term.

Oral Squamous Cell Carcinoma Is Associated with a Low Thrombosis Risk Due to Storage Pool Deficiency in Platelets

Venous thrombo-embolism (VTE) disease is the second most common cause of mortality in cancer patients, and evaluation and prevention of thrombosis risk is essential. VTE-associated risk varies according to the type of tumor disease. Oral cancer is the most frequent type of head and neck cancer, and it represents approximately 2.1% of all cancers worldwide. Most tumors are squamous cell carcinomas and are mainly due to tobacco and alcohol abuse. VTE risk associated with oral squamous cell carcinoma (OSCC) is low. However, many studies have shown that OSCC has the following biological features of cancers associated with a high thrombosis risk: modified thrombosis and fibrinolysis mechanisms; strong expression of procoagulant proteins; secretion of procoagulant microparticles; and production of procoagulant cytokines. Using an original mouse model of tongue squamous cell carcinoma, our study aimed to clarify this paradoxical situation. First, we showed that OSCC tumors have a pro-aggregatory phenotype and a high local thrombosis risk. Second, we found that tongue tumor mice do not have an elevated systemic thrombosis risk (the risk of an "at distance" thrombosis event such as lower extremity deep venous thrombosis or pulmonary embolism) and even show a reduction in risk. Third, we demonstrated that tongue tumor mice show a reduction in platelet reactivity, which explains the low systemic thrombosis risk. Finally, we found that tongue tumor mice present granule pool deficiency, thereby explaining the reduction in platelet reactivity and systemic thrombosis risk.

An autopsy case of Trousseau's syndrome with tumor thrombosis in unknown primary squamous cell carcinoma of the head and neck

Trousseau's syndrome (TS) and tumor thrombosis (TT) are known as cancer-associated thrombosis with poor prognosis. TS is extremely rare in patients with squamous cell carcinoma. In this study, we report an unknown primary squamous cell carcinoma of the head and neck (SCCHN) patient with TS and TT in pulmonary artery definitely diagnosed by autopsy. A 73-year-old man had a past surgical history for unknown primary SCCHN and lung metastases. Three years after the initial surgery, the patient had multiple cerebral infarction, deep venous thrombosis in the legs and mediastinum metastases. Our diagnosis was TS and treatment with chemotherapy and unfractionated molecular heparin started. It could help control the hypercoagulative state and cancer progression, but finally, he died from progressive disease (mediastinum metastases and pulmonary embolism) five years after the initial surgery. An autopsy revealed multiple metastases and thrombosis in the pulmonary artery with squamous cell carcinoma microscopically. Although there is no established treatment for managing TS, intensive therapy such as a combination of chemotherapy and anticoagulant therapy can be effective in improving hypercoagulation therapy. In addition, an autopsy should be considered for patients with thrombosis to distinguish between TS and TT.