Experimentally induced nasal hypersecretion does not reduce the efficacy of intranasal levocabastine

Pulmonary tumor embolism is an often missed antemortem diagnosis in patients with cancer and respiratory failure. Although rare, this complication is an important cause of additional morbidity. Referred for radionuclide pulmonary perfusion and ventilation scintigraphy, a typical pattern of multiple subsegmental peripheral defects on perfusion lung scanning without matching ventilation defects, suggesting a high probability of pulmonary thromboembolism, often leads to false conclusions. We present a case of bilateral multiple subsegmental mismatched defects in lung ventilation perfusion scintigraphy, where autopsy confirmed the diagnosis of pulmonary tumor embolism, secondary to an undifferentiated ductal type adenocarcinoma of the pancreas. Pulmonary tumor embolism is an entity to keep in mind in patients treated for carcinoma presenting with (sub) acute dyspnea.     

Quality of death certificates in cases of cancer death in France

The prognosis of pulmonary tumor embolism is said to be poor and only a limited number of patients with this disease have survived. The patient was a 64-year-old male suffering from left renal cell carcinoma complicated with tumor extending from the left renal vein to the inferior vena cava. The patient underwent an operation for left renal cell carcinoma during which he developed tumor embolus to the pulmonary artery. The occurrence of the acute embolism was promptly detected and the removal of tumor was performed under cardiopulmonary bypass. The patient made good postoperative progress.     

An autopsy case of urinary bladder carcinoma with pulmonary infarction and subacute cor pulmonale caused by tumor embolization

Pulmonary tumor embolism is a common finding at autopsy but is difficult to diagnose clinically antemortem. We report an autopsy case of urinary bladder carcinoma associated with tumor emboli of the pulmonary arteries and subsequent pulmonary infarctions. An eighty-six-year-old man with bloody sputum showed multiple infiltrates on chest X-ray and multiple pleural based parenchymal lesions with truncated apex on computed tomography. The patient had a history of radiation therapy against urinary bladder carcinoma two years earlier. Transitional type carcinoma cells were identified from a urine sample obtained on admission. Three weeks later, the patient developed subacute cor pulmonale and died in severe respiratory distress. Postmortem examination revealed primary carcinoma of the urinary bladder. Multiple tumor emboli of pulmonary arteries and subsequent pulmonary infarctions were visible microscopically. There was a large amount of effusion in both the pleural and the abdominal space. The heart contained focal scarring and mild right ventricular hypertrophy and there was congestion of the lungs, liver, kidneys and spleen. Pulmonary tumor embolization may present at any stage of the patient's illness but rarely causes subsequent pulmonary infarctions. Cytologic examination of blood samples obtained from Swan-Ganz catheters may be useful in the diagnosis of tumor embolization.     

Massive tumorous pulmonary embolism in hepatocarcinoma

Tumoral pulmonary embolism is among the causes of acute dyspnea in patients with neoplasia. This phenomenon, different to thrombotic embolism, occurs frequently in patients with lung, gastrointestinal, liver, breast and uterus neoplasia. It is usually asymptomatic and usually constitutes an autopsy finding in these patients. More rarely it manifests as a cor pulmonale which evolves subacutely. Exceptionally large tumoral emboli spread from a primary tumoral mass, and obstruct main pulmonary arterial vessels, causing a clinical picture indistinguishable from massive pulmonary thromboembolism. We present case of massive tumoral pulmonary embolism by an hepatocarcinoma. In spite of an early thrombolytic treatment the patient died from acute pulmonary hypertension.     

Diagnosis of superficial-type early carcinoma of the gallbladder by endoscopic ultrasonography--comparison with ultrasonography

The detectability of superficial-type carcinoma of the gallbladder by ultrasonography (US) and endoscopic ultrasonography (EUS) were investigated. Eight patients with such carcinoma of the gallbladder were reviewed. They had undergone both US and EUS previous to surgery. The tumor was detected in 3 patients by US, 2 patients with IIa + IIb-type carcinoma and 1 patient with IIa-type carcinoma. Those lesions were visualized as localized thickening of the gallbladder wall or as broad-based tumor. In 2 patients, lesions were not initially detected by US, but were shown by US after the examination by EUS. The tumor was detected by EUS also in 1 case of IIb + IIa-type carcinoma besides those 3 patients mentioned above. All four of these lesions were visualized as broad-based tumor by EUS. It was difficult to detect pure IIb-type or small IIa-type carcinoma even by EUS. In patients with concomitant acute cholecystitis or gallbladder stone, it was difficult to evaluate the abnormal findings of the gallbladder wall.     

Anesthetic management of a patient with renal cell carcinoma extending into the right atrium

A 60-year-old man with renal cell carcinoma extending through inferior vena cava into the right atrium was scheduled for the removal of the right kidney under general anesthesia and the cardiopulmonary bypass technique. In order to obtain a clear operative field and to minimize the risk for pulmonary embolism of necrotizing tumor, total circulatory arrest under profound hypothermia (20 degrees C) was performed. Anesthesia was maintained with high doses of fentanyl (62 micrograms.kg-1), midazolam and supplemented with enflurane. We attempted to prevent circulatory collapse due to acute pulmonary embolism by tumor fragments during operation. The body temperature of the patient was decreased down to 20 degrees C for protecting central nervous system with the minimal damage. No complications occurred during anesthesia and the post-operative period. For the safe anesthetic management of the patient such as our case, adequate monitoring of circulation and protection of central nervous system are essential.     

Detailed deletion mapping at chromosome 9p21 in non-small cell lung cancer by microsatellite analysis and fluorescence in situ hybridization

We describe a case of pulmonary embolism and ischemic stroke due to paradoxical embolism in a healthy young woman taking oral contraceptives to treat an ovarian cyst. It was not possible to identify the site of the thromboembolus. Ultrasound techniques played an important role in identifying the peripheral arterial obstructions and in diagnosing acute pulmonary hypertension. Transesophageal echocardiography provided detailed information on both the morphology and the evolution of the atrial thrombus straddling the foramen ovale within the aneurysmal interatrial septum. The patient was given anticoagulant treatment, initially with heparin and subsequently with warfarin over a period of six months. Repeated ultrasound controls showed no thrombus, regression of the signs of pulmonary hypertension and, lastly unchanged systemic arterial obstruction.     

Leiomyosarcoma of the pulmonary artery

Primary leiomyosarcoma of the pulmonary artery is an extremely rare tumor that is frequently misdiagnosed as chronic pulmonary embolism. In the present case, early diagnosis and location in the left pulmonary artery permitted resection by pneumonectomy with total cardiopulmonary bypass.     

Improved exposure of the pulmonary arteries for thromboendarterectomy

Pulmonary thromboendarterectomy is a surgical technique for treating pulmonary hypertension caused by unresolved pulmonary embolism. It has been recommended to perform this procedure under deep hypothermic circulatory arrest. Here we describe two technical modifications: (1) improved exposure to the right pulmonary artery by division of the superior caval vein and (2) thromboendarterectomy in normothermic cardiopulmonary bypass, with beating heart or electrically induced ventricular fibrillation. These modifications allow complete endarterectomy of both pulmonary arteries under normothermic conditions, thus avoiding hypothermic circulatory arrest, which results in short cardiopulmonary bypass times and reduces the morbidity and mortality of this procedure.     

Angiographic evaluation of chronic pulmonary embolism

In some patients acute pulmonary emboli may fail to resolve normally, resulting in chronic pulmonary embolism. This may lead to pulmonary hypertension, respiratory insufficiency, cor pulmonale, and death. The angiographic evaluation in nine patients with chronic pulmonary embolism who underwent embolectomy is presented. Particular emphasis on the predictive value of selective bronchial arteriography in four of these patients is considered. In chronic pulmonary embolism, pulmonary arteries distal to obstructed areas may remain patent and be supplied by hypertrophied bronchial arteries. Since back-bleeding of arterial blood from the bronchial circulation at surgery may predict the success of embolectomy, preoperative bronchial arteriography may be useful for predicting potential surgical success.     

Small cell carcinoma of gallbladder: report of two cases

Extrapulmonary small cell carcinoma has been reported from multiple sites, including the gallbladder. Small cell carcinoma of the gallbladder is a very rare tumor, found usually in elderly women and associated with cholelithiasis. It carries a grave prognosis, metastasizing early and causing death shortly after diagnosis. Treatment of metastatic disease with two different chemotherapeutic regimens has been shown to improve survival. To the best of our knowledge, this tumor has not been previously reported in a black individual, or in any subject less than 49 yr or more than 79 yr old. We report two cases: one is the first black and youngest reported case. The second is the oldest person reported with this rare malignancy. Radiological studies such as ultrasound and CT scan were useful in evaluating tumor spread and follow-up.     

Cardiac metastasis from squamous cell carcinoma of gallbladder

A 65-year-old woman was admitted to our hospital with the diagnosis of gallbladder tumor. Right extended hepatic lobectomy plus lymph node dissection of the hepatoduodenal ligament and left hepaticojejunostomy with Roux-en-Y reconstruction was performed in July, 1993. The gallbladder tumor was histologically proven to be squamous cell carcinoma. Seventeen months later, the patient experienced dyspnea and pitting edema of the lower legs and was admitted, in December 1994, with a diagnosis of heart failure. Despite intensive cardiac support, she died 12 days after the second admission. Autopsy revealed multiple cardiac tumors in the left and right ventricles, left atrium, left coronary artery, and left diaphragm. Histologically, these tumors were shown to be squamous cell carcinoma, considered to have metastasized from the primary gallbladder carcinoma. As neither local recurrence of the gallbladder carcinoma nor any lymph node metastasis was found, the cardiac metastasis of the gallbladder carcinoma may have occurred via the hematogenous route. Although rare, this route of cardiac metastasis of gallbladder carcinoma may be an important aspect of distant metastasis, which should be monitored for during follow-up after resection of the primary tumor.     

Pulmonary tumor emboli and cor pulmonale in primary carcinoma of the lung

Tumor embolization was found at autopsy in the pulmonary arteries of 33 of 331 patients dying with primary carcinoma of the lung (other than oat cell carcinoma). Venous or lymphatic vascular involvement, or both, was greater frequency of tumor embolization htan epidermoid carcinomas (16.5% vs. 5.8%). In 16 of the 33 cases, diffuse, obliterative intimal fibrosis was found in small arteries affected by the tumor embolization. Enlargement of the right cardiac ventricle was present in 26 of the 33 cases. Dyspnea as the initial symptom or as one of the major symptoms, occurred in 21 patients. The average interval between onset of dyspnea and death was 4 weeks. It is concluded that pulmonary arterial embolization is a relatively frequent complication of primary lung carcinoma, particularly adenocarcinoma, which may lead to the developemnt of pulmonary hypertension and cor pulmonale Dyspnea, occurring de novo in patients with primary lung carcinoma is an ominous sign and should alert the clinician to the possibility of arterial pulmonary tumor embolization.     

Inferior vena cava filter used for unresectable renal cell carcinoma with tumor thrombi

A titanium Greenfield inferior vena cava filter was used for the treatment of 2 patients with unresectable renal cell carcinomas with tumor thrombi to prevent a fatal pulmonary embolism induced by tumor clots released during systemic interferon therapy and embolization of the primary tumor. After treatment, the size of the renal cell carcinomas at the primary site and the tumor thrombi decreased by 50%. There were no fatal pulmonary embolisms or complications related to the filter during the observation period (24 and 25 months) after therapy. This method may be useful in the prevention of a fatal pulmonary embolism induced by embolization and systemic interferon therapy in these patients.     

Pulmonary embolus presenting as initial manifestation of renal cell carcinoma

Pulmonary emboli from renal cell carcinoma may be more common than previously suspected. A case is reported of renal cell carcinoma presenting with a massive pulmonary embolus. Pulmonary embolectomy followed by radical nephrectomy with venocavotomy and tumor thrombectomy was successfully performed.     

Ischaemic necrosis of the gallbladder following hepatic artery embolism

A case of ischaemic necrosis of the gallbladder due to hepatic artery embolism diagnosed at operation and treated successfully by cholecystectomy and embolectomy is presented. The clinical and biochemical features are described, together with a short review of the literature.     

Effect of pulmonary microembolism on arteriovenous shunt flow

The effects of acute pulmonary hypertension on the fraction of cardiac output shunted through pulmonary arteriovenous communications have been studied in dogs as a possible cause of hypoxia following pulmonary embolization. Pulmonary artery pressure was increased twofold and then fourfold above control values by embolization of the pulmonary vascular bed with polystyrene microspheres. Quantitative measurements of arteriovenous shunt were determined from the fraction of 50 mu radioactively labeled microspheres injected into the inferior vena cava which passed through the pulmonary circulation into systemic vascular beds. There was no increase in the fraction of pulmonary blood flow passing through pulmonary arteriovenous connections, 50 mu in diameter or greater, with pulmonary microembolism when FIo2 was 1. There was a small increase in arteriovenous shunt fraction when pulmonary artery pressure was increased with an FIo2 of 0.21. Physiological shunt measured by the oxygen technique did not increase with pulmonary embolism, but total venous admixture rose significantly. Postmortem gravimetric measurements of lung water indicated pulmonary edema. We conclude that anatomic arteriovenous shunt channels have little physiological significance after pulmonary microembolism in the dog lung. The major cause of hypoxia immediately after pulmonary microembolism is ventilation/perfusion imbalance, probably caused by pulmonary edema.     

A rare case of severe pulmonary artery hypertension. Thrombosing pulmonary microangiopathy due to tumor

We report a case of acute respiratory insufficiency with acute cor pulmonale and a fatal outcome. Right cardiac catheterisation enabled a diagnosis of precapillary pulmonary arterial hypertension to be made with a mean pulmonary arterial pressure of 61 mmHg and a pulmonary capillary pressure of 12 mHg. An autopsy was carried out and this revealed a microscopic pulmonary tumour emboli with lymphangitis carcinomatosis. In particular, it showed an association of fibrocellular proliferation at the level of the intima in the small calibre pulmonary arteries and arterioles permitting the unusual diagnosis of thrombosing pulmonary microangiomathy due to tumour. The physiopathological mechanism of this particular form of pulmonary tumour emboli is discussed; it would be secondary to an activation of the coagulation systems by the embolic tumour cells. Once activated, it is the lesions in the intima and not the carcinoma cells which generate the pulmonary arterial hypertension by vascular obstruction.     

Pulmonary embolism and impending paradoxical embolism: a role for transesophageal echocardiography?

Thrombolysis is advocated as the treatment of choice for hemodynamically important pulmonary embolism. This paper reports the case of a patient with subacute massive pulmonary embolism in which thrombolysis was not considered appropriate because transesophageal echocardiography demonstrated a patent foramen ovale and impending paradoxical embolism.