Arterial Malignant Embolization in a Case of Metastatic Choriocarcinoma
Dhiren Patel, MD, Ranan Mendelsberg, MD, Kevin Taubman, MD.
University of Oklahoma at Tulsa., Tulsa, OK, USA.
INTRODUCTION: Arterial malignant embolization is rare but morbid condition, mostly associated with primary or secondary lung malignancies, originating from pulmonary vein metastasis or left sided heart mass. These tumors primarily disseminate to retroperitoneal nodes, lung, later to brain and liver. Involved arterial sites include aorta, ilio-femoral, intracerebral, and less frequently, visceral, coronary, and extremities. To our knowledge, germ cell tumor metastasis embolizing to the bilateral popliteal arterial system has not yet been reported. We report metastatic embolism in patient with disseminated choriocarcinoma causing bilateral acute limb ischemia, subsequently managed by surgical embolectomy. CASE REPORT: 28 year old Hispanic woman with history of miscarriages, dilation/curettage presented with bilateral lower extremity and abdominal pain developed discoloration and numbness of her toes. Exam demonstrated palpable femoral pulses but only monophasic signals in both posterior tibial arteries (ABI R-0.5/L-0.6). No ulcers or motor dysfunction was evident. β-HCG was 109,989. Pelvic ultrasound demonstrated normal ovaries without uterine mass or gestation. CT Chest revealed right middle lobe mass. Systemic anticoagulation started and she underwent successful bilateral femoral-popliteal-tibial Fogarty embolectomies. Next day, she developed acute dysarthria and left sided weakness. CT head confirmed acute hemorrhagic conversion around metastatic lesion. Anticoagulation then held and reversal agents administered. Neurosurgery consult and medical management followed. Systemic chemotherapy was initiated. Histologic results of embolic material showed metastatic choriocarcinoma. At discharge, patient had with residual left sided weakness and palpable distal pulses bilaterally. β-HCG levels dropped to 19,000.
DISCUSSION: Choriocarcinoma is rare trophoblastic germ cell tumor, often originating in the placenta and uterus. Rarely may be seen in association with a hydatidiform mole, spontaneous abortion or ectopic pregnancy. Approximately 30% of the patients have metastasis at diagnosis with lung (50%) and brain (10%) common, but arterial embolization is rare. Vaso-occlusive complications in malignancies arise from various mechanisms, including tumor embolization, hypercoagulable state, non-bacterial thrombotic endocarditis, or related to antineoplastic drugs. High risk patients include those with multiple pulmonary metastases, regardless of tumor origin. CONCLUSIONS: Despite its rarity, the development of limb ischemia in patients with germ cell tumors may reflect the possibility of tumor embolism, and should be considered in differential diagnosis. Arterial tumor embolization from germ cell tumor reflects systemic involvement with prognosis most closely related to tumor dissemination even when revascularization is successful.
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