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PULMONARY EMBOLISM IN MALIGNANCYESSENCE OF THE POSTERIs 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 IntroductionIncidenceRisk factorsTypes of tumoral embolismManagementPrognosisTake home points

TROUSSEAUS SYNDROMECancer 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.

INCIDENCECancer 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 FACTORSThrombophiliaAlteration in blood flow, damage of endothelial cells, and elaboration of procoagulants.ChemotherapyIncreases risk of thromboembolic disease. i.e Tamoxifen and L Asparaginase.Indwelling central linesIncreased risk for DVT of the ipsilateral upper extremityTumor invasion into a large veinRelatively high for tumor present in liver or kidney.

TYPES OF TUMOR EMBOLISMMacroscopic tumor embolismTumor 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 defect, Non resolution at follow-up examinationMicroscopic tumor embolismImaging 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 EMBOLISMTIMING BOLUSAP scoutTiming bolus below carina ROI in PAHelical acquisition at timing bolusPeak + 5 secContrast - Omnipaque 350Caudal-cranial scan direction from diaphragm to lung apicesTiming bolus: 15 cc contrast (5 cc/s) + 15 cc saline (5cc/s)Primary bolus: 85 cc contrast (5 cc/s) + 30 cc saline (5 cc/s)

AN ELDERLY MALE, CHRONIC ALCOHOLIC PRESENTED WITH H/O ABDOMINAL DISTENSION. USG ABDOMEN REVEALED HETEROECHOIC MASS LESION IN RIGHT LOBE OF LIVER WITHPORTAL VEIN THROMBOSIS HEPATOCELLULAR CARCINOMAFIG 1.1 ARTERIAL PHASE SHOWING ILL DEFINED ENHANCING MASS IN RIGHT LOBE. ASCITES +FIG 1.2 SHOWS WASH OUT IN VENOUS PHASEFIG 1.3 VENOUS PHASE SHOWING BLAND PORTAL THROMBOSISFIG 1.4 MASS EXTENDING INTO MIDDLE HEPATIC VEIN

FIG 1.1FIG 1.2FIG 1.3FIG 1.4

FIG 1.8FIG 1.7FIG 1.6FIG 1.5FIG 1.5 FURTHER EXTENSION INTO INFERIOR VENACAVA (IVC) IS SEEN WITH EXPANSION OF IVCFIG 1.6 THROMBOEMBOLISM INVOLVING RIGHT MIDDLE AND LOWER LOBE PULMONARY ARTFIG 1.7 INVOLVEMENT OF RIGHT LOWER LOBE SEGMENTAL ARTERYFIG 1.8 LUNG WINDOW APPEARS NORMAL

FIG 2.1FIG 2.2FIG 2.3FIG 2.4AN ELDERLY MALE,PRESENTED WITHH/O SWELLING OF LOWER LIMBS,BONE PAIN. USGABDOMENREVEALED HETEROECHOICMASS IN RIGHTKIDNEY WITHEXTENSION INTO INFERIORVENACAVA RENAL CELL CAFIG 2.1 ARTERIAL PHASE SHOWING HETEROGENOUSLY ENHANCING MASS IN RIGHT KIDNEY WITH IVC EXTENSION.FIG 2.2 SHOWS EXTENSION INTO IVC WITH EXPANSIONFIG 2.3, 2.4 MULTIPLE HYPERDENSE LIVER METASTASIS WITH ENHANCEMENT IN ARTERIAL PHASE

FIG 2.8FIG 2.7FIG 2.6FIG 2.5FIG 2.5 RIGHT LOWER PARATRACHEAL, PARA AORTIC ADENOPATHYFIG 2.6 BILATERAL LOWER LOBE PULMONARY ENHANCING THROMBUS MALIGNANT THROMBUSFIG 2.7 NODULES DIFFUSELY INVOLVING LUNG PARENCHYMA HEMATOGENOUS METASTASISFIG 2.8 LYTIC METASTASIS INVOLVING RIGHT SACRAL ALA

FIG 3.1FIG 3.2FIG 3.3FIG 3.4AN ELDERLYWOMANPRESENTED WITHBREATHLESSNESS, ALTEREDCONSCIOUSNESS.CA 125 600U/mlOVARIAN CARCINOMAFIG 3.1 T1W IMAGE WITH THICKENING OF SIGMOID MESOCOLONFIG 3.2 T2W IMAGE SHOWS ADNEXAL COMPLEX CYSTIC LESION WITH FREE FLUIDFIG 3.3 T1W PC IMAGE SHOWING ENHANCEMENT OF MESENTERYFIG 3.4 T2W CORONAL IMAGE WITH NODULAR DEPOSITS ALONG RIGHT HEMIDIAPHRAGM AND PORTA HEPATIS WITH ASCITES

FIG 3.8FIG 3.7FIG 3.6FIG 3.5FIG 3.5 DWI SHOWS RESTRICTED DIFFUSION OF DEPOSITS ALONG RIGHT HEMIDIAPHRAGMFIG 3.6 LUNG WINDOW SHOWING INFARCTS IN RT BASAL SEGMENTSFIG 3.7 BILATERAL LOWER LOBE PULMONARY EMBOLISM WITH LEFT PLEURAL EFFUSIONFIG 3.8 FOCAL AREA OF DWI RESTRICTION IN MIDBRAIN ON RT SIDEMANAGEMENT Idiopathic pulmonary embolism Anticoagulation for 3 months.Tumoral embolismLimited 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 - OncologicalDVT in such patients needs IVC filter placement.

PROGNOSISUp 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 MESSAGESInvestigation 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.REFERENCESNon thrombotic pulmonary embolism Alla Khashper, Federico Discepola, John Kosiuk AJR 2012; 198:W152W159Cancer, Coagulation, and Anticoagulation Anthony Letai, David J. kutera The Oncologist 1999;4:443-449Cancer and clots: All cases of venous thromboembolism are not treated the same Benson Babu, Teresa L. Carman Clev clin journal of med Vol 76 2009Thrombotic And Nonthrombotic Pulmonary Arterial Embolism: Spectrum Of Imaging Findings Daehee Han, Kyung Soo Lee Radiographics Nov 03,23,1521-1539Cancer and Pulmonary embolism Thrombotic embolism, Tumor embolism, and Tumor invasion into a large vein Circulation Journal Vol.70, June 2006