Clotting Factors: An Unusual Cascade of Events

Abstract

Patients with cirrhosis are at risk for developing thrombus within the porto-venous circulation. Although most are due to bland thrombi, patients with hepatocellular carcinoma (HCC) are at risk for tumor thrombus. In rare instances, tumor thrombus within the porto-venous circulation can result from non-HCC related malignancy. We present a rare case of gastroesophageal (GE)/gastric adenocarcinoma (moderate to poorly differentiated) with extensive tumor thrombus burden resulting in occlusion of main portal vein, extending to right and left portal veins and superior mesenteric vein (SMV). A 46 year old Vietnamese male with alcoholic cirrhosis presented with recurrent melena and iron deficiency anemia. A computed tomography scan of the abdomen and pelvis revealed GE junction mass extending into the fundus. Subsequent esophagogastroduodenoscopy (EGD) revealed a friable non-obstructing medium sized mass at the GE junction and a large ulcerated mass in the gastric fundus. The biopsies were consistent with poorly differentiated gastric adenocarcinoma and a follow up endoscopic ultrasound with biopsies confirmed lymph node involvement. Immunohistochemical stains failed to show mismatch repair protein abnormalities. Positron emission tomography (PET) scan done as part of the staging work up showed uptake on the thrombus previously identified in the main portal vein and SMV. Patient underwent multiple therapies with radiation therapy, FOLFOX (with increase in tumor thrombus) and irinotecan/docetaxel. Unfortunately, the tumor thrombus and gastric cardia masses continued to increase and the patient developed mass effect with biliary dilatation and hyperbilirubinemia. He underwent multiple ERCP guided placements of palliative biliary stents. However, with further progression of the cancer, he developed recalcitrant upper gastrointestinal bleed complicated by multi-organ failure (liver, encephalopathy, lungs and kidneys). The patient passed away after electing to discontinue on going care and being terminally extubated. Various neoplasms can metastasize as portal tumor thrombus such as HCC, non Hodgkin lymphoma, colo-rectal and neuroendocrine tumors. As this case illustrates, a porto-venous thrombus in a patient with cirrhosis and cancer should be investigated and the possibility of a tumor thrombus ruled out as it has significant impact on management and prognosis.Figure: Ulcerated Gastric Mass in Cardia.Figure: Tumor thrombus removed from biliary stent.Figure: Gastric Mass and Tumor Thrombus on PET CT.