Title
Extension of Pulmonary Embolus Despite Anticoagulation: A Case of Tumor Thrombi in Metastatic Chondrosarcoma
Introduction
Pulmonary tumor embolism refers to the spread of neoplastic cells throughout vasculature and the lymphatic system. It is most often associated with solid tumors such as primary lung, breast, or abdominal cancers. There are few case reports associating tumor emboli with chondrosarcoma, but it is exceedingly difficult to recognize leading to delayed diagnosis. We discuss how our multidisciplinary Pulmonary Embolism Response Team (PERT) was instrumental in recognizing tumor emboli, resulting in prompt diagnosis of metastatic chondrosarcoma and ability to expedite treatment.
Clinical Case
The patient is a 43 year-old male with history of childhood hemangiomas, low grade chondrosarcoma of right foot with recent diagnosis of bilateral pulmonary embolism (PE) treated with one month of enoxaparin who presented to an outside hospital with worsening dyspnea and fevers. Repeat computed tomography demonstrated extension of PE into the left main pulmonary artery with diffuse nodular opacities (Figure 1A, 1B). Transthoracic echocardiography revealed moderate dilation of the right ventricle with normal systolic function and moderate pulmonary hypertension with pulmonary artery systolic pressure estimated at 60 mmHg (Figure 2A-C). In comparison, the patient’s echocardiography completed at the time of his initial PE presentation one month prior was normal and without evidence of right ventricular dysfunction. Given the extension of thrombi despite compliance with anticoagulation, the patient was transferred to our institution for further care.
Discussion
Upon arrival, our PERT evaluated the case and determined that the patient’s worsening respiratory status was secondary to pulmonary tumor thrombi. Given patient's low grade chondrosarcoma of the right foot a positron emission tomography was ordered, which was highly suspicious for metastatic chondrosarcoma (Figure 3). Subsequent core biopsy of a right upper lobe pulmonary nodule was most consistent with metastatic chondrosarcoma (Figure 4). This case demonstrates the importance of a multidisciplinary PERT evaluation to integrate history, physical, imaging modalities, and clinical expertise in order to differentiate vascular thrombus from tumor thrombus, an uncommon complication of malignancy. Rapid recognition of tumor embolism is paramount in determining the most appropriate management of these complex patients.