Peripheral arterial embolism due to a renal sarcoma

Eur J Vasc Endovasc Surg 10, 122-124 (1995)

CASE REPORT P e r i p h e r a l A r t e r i a l E m b o l i s m D u e to a Renal S a r c o m a Christos D, Liapis, Michael Sechas, Evangelos Misiakos, Dimitrios Iliopoulos, Phedon Kaklamanis and Gregory Skalkeas

2nd Department of Propedeutic Surgery, Athens University Medical School, Laiko General Hospital, Greece.

Introduction Peripheral arterial embolisation due to malignancy is rare. Most of the reported cases are due to atrial myxoma or intraoperative seeding of bronchogenic carcinoma. The first reported case was by Busse in 1903 who described embolism of the carotid artery by a chorioepithelioma with lung metastasis. This is a brief report of a case of embolisation to the popliteal artery due to a renal tumour infiltrating the abdominal aorta.

Case Report A 75-year-old man was admitted with a 7-month history of backache radiating towards the lateral abdominal and the gluteal regions. The patient was originally thought to suffer from degenerative arthropathy and was given non-steriod anti-inflammatory drugs. However, pain and anaemia accompanied by weakness and malaise became worse and he was admitted for diagnostic evaluation. On the first day of hospitalisation he developed acute pain in his left calf and the limb became cold, cyanotic and pulseless. On physical examination the femoral pulses were weak and no distal pulses were present on the left. Doppler examination showed an ankle/brachial index of 0.1 on the left leg and 0.6 on the right. Digital subtraction angiography demonstrated a filling defect in t h e l o w e r abdominal aorta (Fig. 1) and acute occlusion of the left tibio-peroneal Please address all correspondence to: Christos D. Liapis, MD, Associate Professor of Surgery, 131, Vas. Sofias Ave, 115 21 Athens, Greece.

trunk. Computerised tomography of the abdomen showed an extensive tumour originating from the right kidney involving the abdominal aorta (Fig. 2). An embolectomy via the left femoral artery was performed and large amounts of clots and solid emboli were extracted. Histological examination of the emboli revealed necrotic tissue with isolated, diffusely developed malignant cells, the exact origin of which it was not possible to define. A needle aspiration biopsy of the right renal mass under ultrasound guidance was performed. Cytology confirmed a tumour of the sarcomatous type. Due to its extent, the tumour was classified as inoperable and patient was treated with palliative radiation and adjuvant chemotherapy. He died three months postoperatively because of advanced malignancy. Necropsy was denied by his relatives.

Discussion Haematogenous spread of tumours is common and usually occurs via the portal circulation to the liver and via the systemic circulation to the lung. However, arterial tumour embolisation is a rare presentation of malignant disease. Most reported cases have been caused by atrial myxomas ~ or intraoperative seeding of bronchogenic lesions. A review of the literature revealed 47 cases of arterial tumour embolism, excluding cases of atrial myxoma. In most reported cases the tumour fragments came from an advanced primary lung turnout 2'3 or a metastatic lung tumour. 4 Table 1 summarises all reported cases since 1903 by type of malignancy and site of embolus.

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Malignant Embolus

This is the first reported case of peripheral arterial embolisation due to a p r i m a r y t u m o u r of the k i d n e y of s a r c o m a t o u s type. The t u m o u r i n v a d e d the wall of the a b d o m i n a l aorta a n d f r a g m e n t s dislodged into the circulation causing peripheral embolisation. H o w e v e r , infiltration of the aortic wall f r o m a non-aortic wall t u m o u r has v e r y rarely b e e n reported.

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Clinical manifestations of peripheral t u m o u r e m b o l i s m varN d e p e n d i n g on the site of e m b o l i s m but do not differ f r o m that of n o n - t u m o u r embolism. Cerebral or carotid embolisation presents with s y m p t o m s of acute cerebrovascular ischaemia w h i c h is usually fatal. 3 Some patients present with an acute h y p e r t e n s i v e crisis due to renal artery embolisation.

Fig. 1. DSA of the abdominal aorta with filling defects at the IMA level.

Fig. 2. CT scan of the abdomen showing a tumour originating from the right kidneN and involving the abdominal aorta. Eur J Vasc Endovasc Surg Vol 10, July 1995

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C.D. Liapis et aL

Table 1.

Cases of arterfial tumour e m b o l i s m since 1903

Type of tumour 1.

n

Lung tumour (I) Primary

19

(II) Secondary (metastatic)

20

Site of occlusion

n

Common femoral artery Distal aorta, aortic bifurcation Internal carotid artery Intracerebral arteries Visceral arteries Iliac arteries Popliteal artery Axillary-brachial arteries Common femoral artery Aorta, aortic bifurcation Intracerebral arteries Internal carotid artery Coronary arteries Visceral arteries Iliac arteries Popliteal artery Axillary artery Mitral valve annulus

5 7 2 2 3 1 1 2 6 7 4 1 2 2 2 1 1 1

2. Direct errosion by extrinsic tumour Osteogenic sarcoma Adenocarcinoma of the colon

1 1

Bilateral common femoral arteries Aortic bifurcation

3. Tumour of the arterial wall Angiosarcoma Primary aortic tumour

1 3

Right femoral arterNdistal arteries of the leg SMA Renal arteries, celiac artery Small bowel arterioles

4. Other neoplasias Hodgkin's disease of hilar nodes Testicular teratoma

1 1 n =47

SMA Paradoxical embolism

Mesenteric embolisation presents with symptoms of acute mesenteric ischaemia. In the majority of cases reported (Table 1), acute arterial ischaemia of upper extremities 2 or more commonly of lower extremities 2-5 is the main clinical manifestation. Diagnostic evaluation consists primarily of computerised tomography or MRI which confirm the existence of the tumour. Arteriography demonstrates the site of peripheral occlusion and in some cases filling defects caused by tumour invasion of the arterial wall. Urgent embolectomy is the procedure of choice to treat the embolus. Pathological examination of the embolectomy specimen confirms malignancy and can usually reveal the type of tumour, 2 although in some cases this is not possible because of extensive tissue necrosis. Although all patients with advanced malignancy eventually die from their primary disease, peripheral tumour embolisation is a limb threatening complication which should be treated as a surgical emergency.

Eur J Vasc Endovasc Surg Vol 10, July 1995

1 2 1 1 1 1 Total 60

References 1 KHAN MA, MUYAHED MA. Atrial myxoma producing a saddle embolus in a child. Thorax 1970; 25: 634-636. 2 PRIOLEAUPG, KATZENSTEINAL. Major peripheral arterial occlusion due to malignant tumour embolism: histologic recognition and surgical management. Cancer 1978; 42: 2009-2014. 3 STARR DS, LAWl~E GM, MORPaS GC. Unusual presentation of bronchogenic carcinoma: Case report and review of the literature. Cancer 1981; 47: 398401. 4 Vo NM, 8AKURAIH, GAMBARINIAJ. Malignant tumour emboli to the peripheral vessels. J Surg Oncol 1981; 17: 151-157. 5 HARRIS RW, ANDROS G, DULAWA LB, OBLATH RW. Malignant melanoma embolus as a cause of acute aortic occlusion: report of a case. J Vasc Surg 1986; 3: 550-553.

Accepted 21 March 1994