PULMONARY EMBOLISM IN

MALIGNANCY

ESSENCE OF THE POSTER

Is to highlight on,
Malignancy being a prothrombotic state.
Malignancy is associated with both thrombotic
and tumoral pulmonary embolism.
Although not always possible, imaging needs
to differentiate between thrombotic and
tumoral embolism.
Treatment strategies and regimens as well as
prognosis differ for thrombotic and tumoral
embolism.

Prologue

Introduction
Incidence
Risk factors
Types of tumoral embolism
Management
Prognosis
Take home points

TROUSSEAUS SYNDROME
Cancer is a major risk factor for
thrombotic pulmonary embolism.
Cancer induces not only thrombotic
PE but also tumor PE and tumor
invasion into large veins.

INCIDENCE
Cancer and Thrombotic embolism
(2.32%)
Thrombotic PE is seen in 80 90 % of
all PE, including thrombotic
embolism, bacterial embolism,
mycotic embolism and other emboli
(eg, fat, amniotic fluid etc).
Incidence is high in hematogenous
tissue, lung, ovary, biliary system
and pancreas, and low in liver.

 Cancer and Tumor embolism

(0.30%)
Comprises of 2.426% of embolism in
solid malignant tumors.
Pathological subtype higher in large
cell carcinoma, hepatic cell
carcinoma and adenocarcinoma.
Tumor site higher in lung, ovary,
kidney and liver.

RISK FACTORS
Thrombophilia
Alteration in blood flow, damage of endothelial
cells, and elaboration of procoagulants.

Chemotherapy
Increases risk of thromboembolic disease. i.e
Tamoxifen and L Asparaginase.

Indwelling central lines

Increased risk for DVT of the ipsilateral upper
extremity

Tumor invasion into a large vein

Relatively high for tumor present in liver or kidney.

TYPES OF TUMOR EMBOLISM

Macroscopic tumor embolism
Tumor cell emboli can lodge in
various vessels, including the main,
lobar, and segmental pulmonary
arteries.
Specific signs of tumor embolism
include,
Dilated and beaded peripheral
arteries,
Enhancement of intraarterial filling

 Microscopic tumor embolism

Imaging findings are subtle,
Enlarged small arteries with
beaded appearance,
Smooth or nodular interstitial
septal thickening,
Wedge-shaped, peripheral
opacities,
Tree in bud opacities occasionally
are seen.

IMAGING PROTOCOL: PULMONARY

EMBOLISM

TIMING BOLUS
AP scout
Timing bolus below
carina ROI in PA
Helical acquisition at
timing bolus
Peak + 5 sec
Contrast - Omnipaque
350
Caudal-cranial scan
direction from diaphragm
to lung
apices
Timing
bolus: 15 cc contrast (5 cc/s) + 15 cc

saline (5cc/s)
Primary bolus: 85 cc contrast (5 cc/s) + 30

ALCOHOLIC
PRESENTED
WITH
H/O
ABDOMINAL
DISTENSION.
USG
ABDOMEN
FIG 1.1
FIG 1.2
REVEALED
HETEROECHO
IC MASS
LESION IN
RIGHT LOBE
OF LIVER
WITH
PORTAL VEIN
THROMBOSIS
FIG 1.3
FIG 1.4

FIG 1.1 ARTERIAL PHASE SHOWING ILL DEFINED ENHANCING MASS

HEPATOCELLU
IN RIGHT LOBE. ASCITES +
LAR
FIG 1.2 SHOWS WASH OUT IN VENOUS PHASE
CARCINOMA
FIG 1.3 VENOUS PHASE SHOWING BLAND PORTAL THROMBOSIS

FIG 1.4 MASS EXTENDING INTO MIDDLE HEPATIC VEIN

FIG 1.5

FIG 1.6

FIG 1.7

FIG 1.8

FIG 1.5 FURTHER EXTENSION INTO INFERIOR VENACAVA (IVC) IS SEEN

WITH EXPANSION OF IVC
FIG 1.6 THROMBOEMBOLISM INVOLVING RIGHT MIDDLE AND LOWER
LOBE PULMONARY ART
FIG 1.7 INVOLVEMENT OF RIGHT LOWER LOBE SEGMENTAL ARTERY

H/O
SWELLING
OF
LOWER
LIMBS,
BONE PAIN.
USG
ABDOMEN
FIG 2.1
FIG 2.2
REVEALED
HETEROECHO
IC
MASS IN
RIGHT
KIDNEY WITH
EXTENSION
FIG 2.3
FIG 2.4
INTO
FIG
2.1 ARTERIAL PHASE SHOWING HETEROGENOUSLY ENHANCING
INFERIOR
MASS IN RIGHT KIDNEY WITH IVC EXTENSION.
VENACAVA

FIG 2.2 SHOWS EXTENSION INTO IVC WITH EXPANSION

RENAL
CELL
FIG 2.3,
2.4 MULTIPLE HYPERDENSE LIVER METASTASIS WITH
CAENHANCEMENT IN ARTERIAL PHASE

FIG 2.5

FIG 2.6

FIG 2.7

FIG 2.8

FIG 2.5 RIGHT LOWER PARATRACHEAL, PARA AORTIC ADENOPATHY

FIG 2.6 BILATERAL LOWER LOBE PULMONARY ENHANCING THROMBUS
MALIGNANT THROMBUS
FIG 2.7 NODULES DIFFUSELY INVOLVING LUNG PARENCHYMA
HEMATOGENOUS METASTASIS

AN ELDERLY
WOMAN
PRESENTED
WITH
BREATHLESS
NESS,
ALTERED
CONSCIOUSN
ESS.
CA 125
600U/ml
OVARIAN
CARCINOMA

FIG 3.1

FIG 3.2

FIG 3.3

FIG 3.4

FIG 3.1 T1W IMAGE WITH THICKENING OF SIGMOID MESOCOLON

FIG 3.2 T2W IMAGE SHOWS ADNEXAL COMPLEX CYSTIC LESION WITH
FREE FLUID
FIG 3.3 T1W PC IMAGE SHOWING ENHANCEMENT OF MESENTERY
FIG 3.4 T2W CORONAL IMAGE WITH NODULAR DEPOSITS ALONG RIGHT

FIG 3.5

FIG 3.6

FIG 3.7

FIG 3.8

FIG 3.5 DWI SHOWS RESTRICTED DIFFUSION OF DEPOSITS ALONG

RIGHT HEMIDIAPHRAGM
FIG 3.6 LUNG WINDOW SHOWING INFARCTS IN RT BASAL SEGMENTS
FIG 3.7 BILATERAL LOWER LOBE PULMONARY EMBOLISM WITH LEFT
PLEURAL EFFUSION

MANAGEMENT
Idiopathic pulmonary embolism
Anticoagulation for 3 months.

Tumoral embolism
Limited disease anticoagulation for a minimum
of 3 to 6 months.
In case of active malignancy, extensive tumoral
embolism, lifelong anticoagulation is needed.

Relative or absolute contraindication

Hemorrhagic intracranial metastasis - Oncological
DVT in such patients needs IVC filter placement.

PROGNOSIS
Up to 21.5% of patients with VTE
have another event within 5 years,
but the risk is two to three times
higher if they also have cancer.
Major bleeding on anticoagulation is
noted in 12.4% of patients with
cancer vs 4.9% of patients without
cancer.

TAKE HOME MESSAGES

Investigation for thromboembolism in
malignancy is necessary when patient presents
with dyspnea or invasion into large vein.
Thrombotic and tumoral embolism are often
indistinguishable.
Distinction is necessary by imaging or
pathological means as it has both treatment
and prognostic implications.
Long term anticoagulation forms basis of
therapy.
In case of known contraindications, IVC filter
placement is indicated for DVT management.

REFERENCES
1. Non thrombotic pulmonary embolism Alla
Khashper, Federico Discepola, John Kosiuk AJR
2012; 198:W152W159
2. Cancer, Coagulation, and Anticoagulation
Anthony Letai, David J. kutera The Oncologist
1999;4:443-449
3. Cancer and clots: All cases of venous
thromboembolism are not treated the same
Benson Babu, Teresa L. Carman Clev clin journal
of med Vol 76 2009
4. Thrombotic And Nonthrombotic Pulmonary
Arterial Embolism: Spectrum Of Imaging
Findings Daehee Han, Kyung Soo Lee
Radiographics Nov 03,23,1521-1539