Case Study: Acute Presentation of Pulmonary Vein Thrombosis in Lung Cancer Patient
A 66-year-old patient with squamous cell cancer experienced disease recurrence involving the right hilum and mediastinum post-lobectomy. After palliative radiotherapy, the patient presented with shortness of breath, cough with greenish sputum, and underwent further evaluations. Pulmonary vein thrombosis was identified as a postoperative complication, potentially linked to surgical factors and malignancy. Symptoms of pulmonary vein thrombosis can range from nonspecific to potentially lethal, necessitating swift evaluation and management to prevent adverse outcomes.
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Presentation Transcript
Clots somewhere Umair falak
Case 66 year old 2016 diagnosed with squamous cell cancer Underwent right middle and lower lobectomy Disease free till this year More breathless CT scan Extensive disease recurrence at the right hilum invading mediastinum. High right paratracheal adenopathy. Bronchoscopy and EBUS confirmed squamous cell cancer recurrence , PDL- 1 pending T3N1M0
Acute presentation Underwent palliative radiotherapy 2 weeks afterwards presented with : 1. Shortness of breath (ET reduced from 100 yards to few steps) 2. Cough with greenish sputum 3. No fever , haemoptysis , chest pain CTPA showed
Pulmonary Vein Thrombosis Postoperative 1. Lung transplant -15% , mechanical factors , weaks to 2 years 2. Lobectomy most commonly left upper lobectomy , incidence was 3.3% 3. RFA for A fibrillation Non-operative 1. Cancer Lung cancer most common , atrial myxoma 2. Atrial fibrillation - unclear 3. Trauma 4. Sickle cell crises 5. Left atrial thrombus 6. Mediastinitis Ohtaka K, Hida Y, Kaga K, et al. Left upper lobectomy can be a risk factor for thrombosis in the pulmonary vein stump. J Cardiothorac Surg. 2014;9:5. Published 2014 Jan 6. doi:10.1186/1749-8090-9-5
COVID-19 van Kruijsdijk RCM, de Jong PA, Abrahams AC. BMJ Case Rep 2020;13:e239986. doi:10.1136/bcr-2020- 239986
Pathogenesis Rich network of collaterals make it rare Mechanical due to direct injury during surgery , turbulent flow in the stump & stasis Malignancy hypercoagulable state as well as direct extension from tumor
Symptoms Can be potentially lethal Nonspecific , asymptomatic in Many Acute presentation with Cough, Dyspnea, Hemoptysis , pleuritic chest pain due to pulmonary infarction or pulmonary edema Chronic progressive symptoms with recurrent admissions for Pulmonary edema or fibrosis Cavaco RA, Kaul S, Chapman T, et al. Idiopathic pulmonary fibrosis associated with pulmonary vein thrombosis: a case report. Cases J. 2009;2:9156. Published 2009 Dec 7. doi:10.1186/1757-1626-2-9156
Complications Right ventricular failure Secondary infection especially postoperative pts Allograft Failure -Can mimic acute graft rejection in transplant pts Systemic embolization Strokes , Renal infarcts ,arterial embolization leading to limb ischemia
Diagnosis CTPA Echo differentiate between tumor and embolus , TTE or TOE , used in most case reports and ICU settings Associated left atrial thrombus MRI
Antibiotics for secondary infection especially post surgically Anticoagulation due to the systemic embolization risk of strokes/TIAs Thrombectomy for after transplant or lobectomy for larger obstructive thrombus Thrombolysis for large thrombus case reports Pulmonary resection has been tried Genta PR, Ho N, Beyruti R, Takagaki TY, Terra-Filho M: Pulmonary vein thrombosis after bilobectomy and development of collateral circulation. Thorax. 2003, 58:550-551.
Reference Chaaya G, Vishnubhotla P. Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus. 2017;9(1):e993. Published 2017 Jan 23. doi:10.7759/cureus.993
66 year old man admitted via ED with increasing SOB & general tiredness. Hx of - T3 N1 M0 squamous cell carcinoma of right lung (recurrent lung disease) with previous right middle & lower lobectomy in 2016. - Recent 12 localised radiotherapy sessions that finished around 2 weeks ago - Previous post-op bowel perforation in 2016 reated conservatively Normally lives in a ground floor flat, brother assists with shopping & ADL's, was independent and able to manage about 100 yards until 2 weeks ago Since then, increasing tiredness, increasing cough productive of green sputum Reduced appetite and progressive weight loss No abdominal pain No falls, but unsteady and lack of energy No recent courses of Abx Occasional dysphagia and coughing after liquids. Admitted on 12/8/21
Initial cancer and current ct Current ct -No PE. Minor reduction in the volume of mediastinal/hilar recurrence. Otherwise fairly similar appearances to before. T3 N1 M0 stage IIIA squamous cell carcinoma of right lung-recurrent disease following right middle and lower lobectomy in 2016. Malignant lesion in the middle lobe of the right lung centrally, with suspicion of a satellite nodule in the same lobe. No evidence of metastatic disease elsewhere. The metabolic stage is T3 N0 M0 The appearances are those of a non-small cell carcinoma with overall features most consistent with a squamous cell carcinoma on BAL and brushing
recurence Radiology review - CT 24.05.21 = Extensive disease recurrence at the right hilum invading mediastinum. High right paratracheal adenopathy. Histology review - EBUS 15.06.21 = Right station 4 lymph node EBUS cytology showing a basaloid non-small cell carcinoma with immunostaining supporting squamous differentiation - (LN5/C5 depending upon additional clinicoradiological correlation). MDT recommendation - PDL1 requested. Refer for consideration of high dose palliative radiotherapy. Defer appointment for systemic therapy pending PDL1 resul We had a discussion today regarding radiotherapy to your right lung. The purpose of this treatment would be to shrink down and control the cancer, rather than to cure the disease Finished radiotherapy on 5 /8/21
