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A case of primary peritoneal carcinoma with pulmonary embolism and severe left leg ischaemia.
Chacko C; Munyanyi N; Chidambaram V;Haqqee R
University Hospital of North Staffordshire, Stoke on Trent, United Kingdom
We present a case of a 60 year old patient with primary peritoneal adenocarcinoma who developed both massive pulmonary embolism and severe acute left leg ischaemia secondary to peripheral arterial occlusion. Because of haemodynamic instability she was given intravenous thrombolysis with alteplase for pulmonary embolism. This however resulted in good resolution of both the pulmonary embolism and the severe leg ischaemia. Subsequently the left leg recovered full motor function and the sensory symptoms disappeared. The patient has done well since diagnosis and has completely recovered from the pulmonary embolism and the left leg ischaemia. She is also responding well to the chemotherapy for the primary peritoneal adenocarcinoma.
Primary peritoneal carcinoma, Pulmonary embolism, Peripheral arterial occlusion, Severe leg ischaemia, Thrombolysis.
A 60 year old female was first admitted to our hospital in August 2006 with history of breathlessness for 4 weeks. She was previously well with no known chronic medical conditions and was not on any medications. She was a life long non-smoker. Prior to this admission she had seen her general practitioner who had diagnosed pneumonia and congestive cardiac failure. However treatments for these conditions did not result in any improvement.
On admission she was noted to have ascites and bilateral pleural effusions. CXR confirmed bilateral pleural effusions. Blood urea, creatnine, electrolytes, liver function tests and full blood count were all normal. CA125 was elevated at 125 998 units/ml. CA19.9 was also slightly elevated at 179u/ml. Other tumour markers which included Alpha-feto protein and CEA were normal. Diagnostic pleural aspiration was performed and the cytology from this confirmed a metastatic adenocarcinoma. CT scan of the chest, abdomen and pelvis showed a distinct peritoneal mass measuring 4.5cm in diameter consistent with a primary peritoneal tumour with extensive peritoneal metastases. The rest of the abdomen was unremarkable. There was no evidence of underlying bowel or gynaecological malignancy. There was a massive right sided pleural effusion with complete collapse of the right lung and a small left sided pleural effusion. Peritoneal biopsy confirmed a primary peritoneal adenocarcinoma. The diagnosis of primary peritoneal adenocarcinoma with peritoneal and pleural metastases was subsequently concluded.
The pleural effusion was drained by intercostal drain followed by medical pleurodesis with talc with good effect. The patient was then referred to oncology team as an outpatient for treatment with chemotherapy and radiotherapy.
Two weeks after discharge she was readmitted with severe breathlessness and sudden onset painful, cold and discoloured left leg with sudden loss of motor function. She was hypotensive with a blood pressure of 80/40. She also had severe type1 respiratory failure with paO2 of 6.83kPa on arterial blood gases. When she was initially assessed in A&E she was told that there was no specific treatment that could be given. The vascular surgeons also told her that there was no specific treatment they could offer for the left leg. After assessment by the medical team it was felt that the diagnosis was that of pulmonary embolism and severe left leg ischaemia from femoral artery thrombosis. An urgent CT Pulmonary angiogram (CTPA) confirmed a saddle pulmonary artery thrombus. She was immediately thrombolysed with alteplase 50mg intravenously followed by intravenous unfractionated heparin for five days. She was then switched to subcutaneous dalteparin. She had significant improvement of her symptoms. Interestingly there was rapid improvement of the left leg resolution of pain and return to normal colour within a few hours following thrombolysis. She was also able to use her left leg again a few hours after thrombolysis. She stayed in hospital for ten days whilst being established on anticoagulation with dalteparin. She was discharged home to complete six months of treatment with dalteparin and she continued with her follow up with the oncology team. She responded very well to chemotherapy and radiotherapy with evidence of tumour reduction on follow up CT scan.
The peritoneum and the ovaries have the same embryonic origin. As a result peritoneal and ovarian carcinomas behave in similar ways. This patient presented many typical features of primary peritoneal carcinoma. As is commonly found in patients with malignancy this patient also developed vascular thromboses. In our practice we had never come across a patient with both pulmonary and peripheral arterial thromboses affecting the legs. In our literature search we have not been able to find any reported similar cases.
The management and the outcome in this patient were also interesting. Firstly she had been told that there was nothing which could be done to save her leg as the vascular surgeons had concluded that she was not a candidate for surgery. However the presence of a massive pulmonary embolism helped to save her leg. The thrombolysis given was meant for the pulmonary embolus and by coincidence it gave the added benefit of reperfusing her left leg. If she did not have a pulmonary embolus she would not have been given thrombolysis and she may have lost her left leg and she may have died.
This case presents an important learning lesson about the management of similar patients with peripheral thrombi who may not have massive pulmonary emboli requiring thrombolysis. Thrombolysis for peripheral vascular occlusion remains controversial.2, 3, 4, 5 There is no consensus on the first line management of acute peripheral artery occlusions. Some favour thrombolysis especially catheter-directed thombolysis but some are against this and recommend open surgical interventions.2, 4 The treatment that is often considered the best by many for peripheral arterial thrombosis is surgical embolectomy1, 5. Unfortunately some patients may be considered not candidates for this for various reasons. Those against thrombolysis feel that the complications outweigh the benefits5. These conclusions are however based on small retrospective studies and may not be accurate. Thrombolysis may therefore have a place in the management of such cases and further randomised control studies are needed to resolve this confusion8.
1. Januzzi JL, Buros J, Cannon CP, Tactics TIMI 18 Investigators. Peripheral arterial disease, acute coronary syndromes, and early invasive management. Clin Cardiol. 2005 May; 28(5):238-42.
2. Drescher P etal. Catheter-directed thrombolytic therapy in peripheral artery occlusion: combining reteplase and abciximab. American journal of Roentgenology, 01 May 2003, 180/5(1385-1391). ISSN: 0361-803x.
3. Kessel DO, Patel JV. Current trends in thrombolysis: implications for diagnostic and interventional radiology. Clin Radiol, 2005 Apr; 60(4) Review.
4. Madhavan P etal. Low dose intra-arterial thrombolysis with tissue plasminogen activator: Does it deliver as promised? Vascular and endovascular surgery, 2002, 36/5 (351-356). ISSN: 1538-5744.
5. Stephan H etal. Peripheral artery occlusion: treatment with abciximab plus urokinase versus with urokinase alone. A randomised pilot trial. Radiology 2001, 221/3 (689-696).
6. Kroger K etal. Retrospective analysis of Rt-PA thrombolysis combined with PGE(1) in patients with peripheral artery occlusions.
7. Verstraete M. Thrombolytic therapy of non-cardiac disorders. Baillieres Clin Haematol, 1995 Jun; 8(2):413-24 Review.
8. Abel H. Thrombolysis: the logical approach for the treatment of vascular occlusions. Acta Cardiol, 1992;47(4):287-95
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First Published April 2008