Clinical aspects of tumour involvement of the pulmonary vessels

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.

Timely diagnosis of pulmonary artery tumor embolism by ultrasound-guided transbronchial needle aspiration

Pulmonary artery tumor embolism (PATE) is a rare disease without an established diagnostic method. In an autopsy series, however, the incidence of PATE was relatively high, between 3% and 26% in patients with a solid tumor. Here we report a case of a patient with a massive PATE from hepatocellular carcinoma diagnosed safely and promptly by endobronchial ultrasound-guided transbronchial needle aspiration.

Subacute cor pulmonale due to tumor embolism

We describe a patient wih subacute cor pulmonale caused by tumor emboli in the lungs. A 64-year-old female suffering from a subacute progressive cough and shortness of breathing died of severe pulmonary hypertension seven days after admission. Neither chest CT scans nor lung perfusion scintigraphy showed any abnormal findings. Microscopic examination after an autopsy revealed diffuse intravascular tumor emboli occluding not only the small pulmonary arteries and arterioles, but also the lymphatic vessels, which were suggested to be metastases of a breast carcinoma resected five years previously. Thus, pulmonary tumor embolism should be considered in the differential diagnosis of primary pulmonary hypertension, particularly in patients with a past history of cancers.

Massive pulmonary tumor emboli in a sarcoma. An unusual cause of sudden death

Although metastatic spread of tumor to the lungs is common, massive pulmonary tumor emboli are very unusual. Most tumor emboli originate from epithelial-derived tumors. Only a few cases of pulmonary embolism from sarcomata have been reported. We herein describe the case of a 36-year-old woman who died suddenly due to massive pulmonary tumor emboli from a retroperitoneal malignant mesenchymoma. We believe this is the first case report of a mesenchymoma causing sudden death due to massive tumor embolism.