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CASE REPORT Table of Contents  
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Tumour embolism: Rare presentation as the first manifestation of cancer

1 Department of Laboratory and Blood Bank, King Fahad Hospital Hofuf, Kingdom of Saudi Arabia
2 Department of Vascular Surgery, King Fahad Hospital Hofuf, Kingdom of Saudi Arabia

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Tumour emboli are rare and usually end-stage manifestations of malignancy. They generally carry poor prognosis. Even rarer is the tumour emboli presenting as the first manifestation of an underlying malignancy. We take this opportunity to report a case of tumour emboli as the first presentation of a malignancy, occurring in a 58-year-old male, for its rare occurrence.

Keywords: Carcinoma, embolus, tumour

How to cite this URL:
Siddiqui FA, Al-Khalaf J, Al-Marzooq Y, Al-Momatten M. Tumour embolism: Rare presentation as the first manifestation of cancer. Hamdan Med J [Epub ahead of print] [cited 2020 Jan 27]. Available from: http://www.hamdanjournal.org/preprintarticle.asp?id=253927

  Introduction Top

Cancer is one of the leading causes of death worldwide. It can present in a variety of ways depending predominantly on the type and stage of the tumour. However, at times, it can present with very subtle non-specific features and can be missed easily, leading to late diagnosis and fatal outcome.[1] Consequently, the diagnosis might remain unsuspected and not made until autopsy. Tumour emboli are rare and even rarer is their first manifestation of an underlying malignancy.[2]

  Case Report Top

A 58-year-old male patient came to the Emergency Department of King Fahad Hospital Hofuf with the complaint of left lower limb pain for 15 days associated with left lower limb numbness for 2 h. The patient was a known case of diabetes mellitus, hypertension, ischaemic heart disease and bronchial asthma and was under proper medications with good compliance. He was a chronic smoker for 20 years. On examination, his general appearance was chronically ill-looking with moderate pallor and had cyanosed fingers with cold left lower limb. He had a blood pressure of 100/60 mmHg, a pulse rate of 76/min, a temperature of 36.3°C and a respiratory rate of 25/min. Computed tomography (CT) angiogram of the pelvic level was done which showed occlusion of the left superficial femoral artery and profunda femoris artery [Figure 1]. The patient was shifted for catheter-guided thrombolysis and improved with regaining of peripheral pulses. Electrocardiography showed features of right bundle branch block and sinus rhythm. Echocardiography showed no clear intra-cardiac thrombus or mass, intact inter-atrial and inter-ventricular septa with normal left ventricle function (55%).
Figure 1: Computed tomography angiogram – pelvic level showing occlusion of left superficial femoral artery and profunda femoris artery

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Five days later, the patient developed features of acute left upper limb ischaemia which were confirmed by CT angiography. Radial artery, brachial artery and ulnar artery could not be palpated directly and even on hand-held Doppler. Trans-left brachial artery thrombolectomy was done, and the patient improved with regaining of the pulses. Six hours later, the patient developed features of bilateral left lower limb acute ischaemia which was again confirmed by CT angiography. Bilateral transfemoral thromboembolectomy was done with good improvement and well-perfused limbs and palpable distal limb pulses.

The patient developed multiple thromboembolic episodes in spite of full anticoagulation therapy since then and underwent multiple successful revascularisation every time with reappearance of distal pulses and reperfusion of involved distal with retrieval of well-organised white emboli, which were confirmed to be old well-organised laminated emboli on histopathological examination. Immunological and haematological results for thrombophilia were negative. Trans-oesophageal echocardiography showed left atrial small thrombus, and CT thorax showed a soft tissue mass lesion in the left lower lobe of the lung [Figure 2]. A trucut biopsy under image guidance was performed on the left lower lobe suspicious area, and the histopathological examination revealed predominantly necrotic tissue.
Figure 2: Computed tomography thorax showing a soft tissue mass lesion in left lower lobe of lung

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However, the last embolus extracted from the right external iliac artery showed few clusters of malignant cells featuring hyper-chromatic nuclei, irregular nuclear contour with prominent eosinophilic nucleoli and moderate cytoplasm in a background of thrombi, featuring laminated layers of fibrin, with leukocytes (lines of Zahn), alternating with areas of red blood cells [Figure 3] and [Figure 4]. A tentative diagnosis of tumour emboli was rendered. Immunohistochemistry was performed, and tumour cells were positive for CK5/6 [Figure 5], CK7 and p63 (focally) and negative for CK20, TTF-1 and CDX-2. A final diagnosis of tumour emboli, consistent with squamous cell carcinoma was given.
Figure 3: Section shows clusters of malignant cells in a background of fibrin and leukocytes, with areas of red blood cells (H and E, ×40)

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Figure 4: Section showing clusters of malignant cells featuring hyper-chromatic nuclei, irregular nuclear contour with prominent eosinophilic nucleoli and moderate amount of cytoplasm (H and E, ×400)

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Figure 5: Section reveals malignant cells showing positivity to CK5/6 (×400)

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Later, the patient developed cerebral stroke and went into deep coma with jerky movement of right upper limb and Glasgow Coma Scale of about 4. He was intubated on the same day and transferred to intensive care unit. He unfortunately died after 1 day.

  Discussion Top

Globally, every sixth death is due to cancer. Cancer is the second leading cause of death worldwide, second only to cardiovascular diseases.[3] Depending on the type and stage of cancer, the clinical presentation varies. However, at times, the patient presents with non-specific and wide range features such as dyspnoea, chest pain and cough, making it difficult to diagnose on the daily routine clinical practice. Many times, the neoplastic nature of the disease remains unsuspected and the diagnosis is not made until autopsy. Cases of tumour embolism have been reported in 3%–26% of autopsies conducted on patients with solid tumours.[1]

Rarely, an embolus has a neoplastic nature except for systemic tumour emboli in cases of left atrial myxomas.[4] Embolisation of the peripheral artery is most commonly cardiogenic (80%–90%), while malignant tumour origin of emboli is rare.[5] Although tumour embolism can be seen with any malignancy including sarcomas and mesotheliomas, the risk appears to be more in patients with carcinomas of breast, lung, colon and stomach.[6] The first case was described by Schmidt in 1897 in a young man with primary gastric malignancy.[7]

Tumour emboli have found to be most frequently reported at the aortic bifurcation or femoral vessels and the cerebral circulation.[8],[9] Patient symptoms are related to the location of the tumour embolus and generally involve lower extremity, cerebral and myocardial ischaemic events.[10]

The possible hypothesis for tumour embolism includes infiltration of the veins by the tumour cells which then enter the circulation causing embolism of the pulmonary arteries. After gaining access to the pulmonary circulation, activation of coagulation cascade begins leading to an admixture of thrombus and tumour cells[11] as was seen in our case. Although rare, tumour embolism is more commonly seen in large cell carcinoma, hepatic cell carcinoma and adenocarcinoma as compared to other histological types.[12]

Non-specific subtle clinical presentation in previously unknown primary tumours can prevent both early diagnosis and effective treatment. Although rare, tumour embolism might be the first manifestation of such cancer cases, and therefore, it is very essential for all embolus to be examined properly for any tumour cells, even in the absence of any features of malignancy.

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There are no conflicts of interest.

  References Top

Heithaus RE Jr., Hitchcock MA, Guileyardo JM. Pulmonary tumor embolism syndrome from occult colonic adenocarcinoma. Proc (Bayl Univ Med Cent) 2013;26:290-2.  Back to cited text no. 1
Burchard KW, Carney WI Jr. Tumor embolism as the first manifestation of cancer. J Surg Oncol 1984;27:26-30.  Back to cited text no. 2
GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the global burden of disease study 2016. Lancet 2017;390:1151-210.  Back to cited text no. 3
Park JH, Seo HS, Park SK, Suh J, Kim DH, Cho YH, et al. Spontaneous systemic tumor embolism caused by tumor invasion of pulmonary vein in a patient with advanced lung cancer. J Cardiovasc Ultrasound 2010;18:148-50.  Back to cited text no. 4
Sadat U, Noor N, See TC, Varty K. Peripheral arterial ischemia by a primary lung tumour invading left atrium. Lung Cancer 2007;57:237-9.  Back to cited text no. 5
Abdulaziz S, Geddawy M, Al Efraij K, Jamil MG. Pleomorphic rhabdomyosarcoma with pulmonary tumour embolism. BMJ Case Rep 2012;2012. pii: bcr2012007163.  Back to cited text no. 6
Roberts KE, Hamele-Bena D, Saqi A, Stein CA, Cole RP. Pulmonary tumor embolism: A review of the literature. Am J Med 2003;115:228-32.  Back to cited text no. 7
Schreffler SM, Paolo WF, Kloss BT. Spontaneous showering of tumor emboli in a patient with advanced primary lung cancer: A case report. Int J Emerg Med 2012;5:27.  Back to cited text no. 8
Ohshima K, Tsujii Y, Sakai K, Oku H, Morii E. Massive tumor embolism in the abdominal aorta from pulmonary squamous cell carcinoma: Case report and review of the literature. Pathol Int 2017;67:467-71.  Back to cited text no. 9
Marinos T, Bitzikas G, Lymperiadis D, Galanos O. Peripheral tumor emboli to both lower extremity arteries after pneumonectomy for extensive pulmonary cancer. J Cardiovasc Surg (Torino) 2004;45:592-3.  Back to cited text no. 10
Laohachewin D, André F, Tschaharganeh D, Katus HA, Korosoglou G. Sudden unexpected death in a patient with tumour associated pulmonary embolism. Case Rep Med 2014;2014:396832.  Back to cited text no. 11
Okazaki S, Abe T, Takayanagi N, Yasuda M, Sakai F, Kobayashi K, et al. Pulmonary tumor embolism due to squamous cell carcinoma of the uterine cervix: A case report. In Vivo 2018;32:337-43.  Back to cited text no. 12

Correspondence Address:
Farhan Asif Siddiqui,
Department of Laboratory and Blood Bank, King Fahad Hospital Hofuf
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HMJ.HMJ_94_18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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