Multiple instances of peripheral artery emboli from occult primary small cell lung cancer

Abstract

Most peripheral artery emboli originate in the heart, and systemic neoplastic emboli are infrequently associated with bronchogenic carcinoma. To our knowledge, there have been no reports of pulmonary vein infiltration by small cell lung cancer.We describe a highly unusual case of multiple instances of peripheral embolism as the first overt sign of occult primary small cell lung cancer. Tumor emboli infiltrated the pulmonary veins of a 62-year-old man who presented first with a transient ischemic attack and then with other ischemic symptoms. The uncommonly wide distribution of tumor emboli over a short time resulted in death.Improvements in diagnostic imaging have led to the early identification of relatively isolated small cell lung cancers. This patient's case underscores the importance of transesophageal echocardiography in detecting cardiac emboli when the cause of cerebral ischemic attack is unknown or if there might be multiple instances of arterial embolism. Computed tomography also has a role in the investigation of possible sources of emboli and unrecognized, asymptomatic embolization.

Keywords: Carcinoma, bronchogenic/complications/pathology; carcinoma, small cell; embolism/complications/diagnosis/pathology; ischemic attack, transient/etiology; lung neoplasms/complications; neoplasm invasiveness; neoplastic cells, circulating; pulmonary veins/pathology/ultrasonography.

Fig. 1 Transesophageal echocardiograms (apical 4-chamber views) show A) the right lower pulmonary vein with patency evaluation by color-flow duplex scan, and B) the left pulmonary veins in B-mode scan. LA = left atrium; LAA = left atrial appendage; LUPV = left upper pulmonary vein; LV = left ventricle

Fig. 2 Computed tomographic angiography shows A) a lung mass (arrow) adhering to the right pulmonary artery and infiltrating the right lower pulmonary vein (arrowhead), and B) a 3 × 2-cm right-lower-lobe lung mass (arrow) (lung parenchymal window settings).

Fig. 3 Computed tomograms (axial views) show A) segmental obstruction of the superior mesenteric artery (arrow) and B) obstruction of the left renal artery (arrow).

Fig. 4 Computed tomograms with maximum intensity projection reconstruction show A) segmental obstruction of the superior mesenteric artery (arrow) in sagittal view, and B) obstruction of the left renal artery (arrow) in coronal view.