PAINFUL FINGERS AND TOES REVEAL A CASE OF NON-SMALL CELL LUNG CANCER

Abstract

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: As a paraneoplastic syndrome, the association of hypercoagulability states (HCS) in cancer patients has been well established and can have an adverse effect on quality of life and survival. (1) The findings of HCS such as venous thromboembolism (VTE), embolic strokes, arterial thromboembolic events (ATE) and nonbacterial thrombotic endocarditis (NBTE) should make the clinician suspicious of an underlying malignancy. The deposition of thrombi on previously undamaged heart valves in the absence of bacterial infection is known as NBTE and is often discovered at time of autopsy or in late-stage cancer. (2) Here we describe a case of lung adenocarcinoma, who presented with multiple HCS at the time of diagnosis, including painful digits caused by ATE propagated by NBTE. CASE PRESENTATION: A 56 year old female with a 30 pack year smoking history presented with a myriad of complaints including dyspnea, fatigue, nausea, hematemesis and headache for one month. Most bothersome were her painful, blue-discolored fingers and toes (Fig. 1) that were cool to touch with palpable pulses. CXR identified a large left upper lobe lung mass and follow-up CT (Fig. 2) identified that the mass involved the pulmonary hilum with bilateral mediastinal lymphadenopathy. A bronchoalveolar lavage confirmed lung adenocarcinoma on cytology. MRI brain was performed which identified multiple infarcts of an embolic source. Lower extremity doppler studies revealed bilateral arterial and venous occlusions. She was treated with apixaban after EGD identified no source of bleed. Transesophageal echocardiography identified severe mitral regurgitation (MR) (Fig. 3) with small vegetations on both mitral valve leaflets consistent with NBTE—the source of her disseminated embolisms. She received mediastinal radiation and a chemotherapy regimen of carboplatin, pemetrexed, and pembrolizumab. For congestive heart failure (CHF) due to severe MR, she was discharged on metoprolol and furosemide. She returned one month later to the ICU in cardiogenic shock due to worsening CHF. She passed away one week later under hospice care. DISCUSSION: Since HCS have first been recognized in gastric cancer by Trousseau in 1865, multiple cancers, including lung cancer, have been associated with HCS. (3) Recommendations are that high-risk cancer patients (4) be offered prophylactic anticoagulation should no significant bleeding risk exist. (5) In general, NBTE and ATE were often reported after cancer diagnosis (6,7,8,9) and acute heart failure caused by NBTE is a rare clinical event reported only in a few case reports. (6,7) Our patient exemplifies the extensive findings of HCS as a manifestation of lung adenocarcinoma. CONCLUSIONS: This case shows a unique clinical presentation of NBTE, VTE, ATE, cerebral embolic infarction, and heart failure at the time of diagnosis of lung adenocarcinoma. Such HCS should be recognized as herald signs in underlying cancer. Reference #1: 1.Connolly GC, Francis CW. Cancer-associated thrombosis. Hematology Am Soc Hematol Educ Program. 2013;2013:684-691. doi:10.1182/asheducation-2013.1.684 2.el-Shami K, Griffiths E, Streiff M. Nonbacterial thrombotic endocarditis in cancer patients: pathogenesis, diagnosis, and treatment. Oncologist. 2007;12(5):518-523. doi:10.1634/theoncologist.12-5-518 3.Connolly GC, Dalal M, Lin J, Khorana AA. Incidence and predictors of venous thromboembolism (VTE) among ambulatory patients with lung cancer. Lung Cancer. 2012;78(3):253-258. doi:10.1016/j.lungcan.2012.09.007 Reference #2: 4.Khorana AA, Kuderer NM, Culakova E, Lyman GH, Francis CW. Development and validation of a predictive model for chemotherapy-associated thrombosis. Blood. 2008;111(10):4902-4907. doi:10.1182/blood-2007-10-116327 5.Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, Wong SL, Balaban EP, Flowers CR, Francis CW, Gates LE, Kakkar AK, Levine MN, Liebman HA, Tempero MA, Lyman GH, Falanga A. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2020 Feb 10;38(5):496-520. doi: 10.1200/JCO.19.01461. Epub 2019 Aug 5. PubMed PMID: 31381464. 6.Lee JM, Lim JH, Kim JS, Park JS, Memon A, Lee SK, Nam HS, Cho JH, Kwak SM, Lee HL, Kim HJ, Hong GJ, Ryu JS. Multiple hypercoagulability disorders at presentation of non-small-cell lung cancer. Tuberc Respir Dis (Seoul). 2014 Jul;77(1):34-7. doi: 10.4046/trd.2014.77.1.34. Epub 2014 Jul 31. PubMed PMID: 25114702; PubMed Central PMCID: PMC4127411. Reference #3: 7.Taniyama D, Yamamoto R, Kawasaki M, Kamata H, Miyamoto K, Mashimo S, et al. Nonbacterial thrombotic endocarditis leading to acute heart failure due to aortic stenosis in a patient with lung cancer. Intern Med 2013;52:1617-20. 8.Lopez JA, Ross RS, Fishbein MC, Siegel RJ. Nonbacterial thrombotic endocarditis: a review. Am Heart J. 1987;113(3):773-784. doi:10.1016/0002-8703(87)90719-8 9.Navi BB, Reiner AS, Kamel H, et al. Risk of Arterial Thromboembolism in Patients With Cancer. J Am Coll Cardiol. 2017;70(8):926-938. doi:10.1016/j.jacc.2017.06.047 DISCLOSURES: No relevant relationships by Milica Antic, source=Web Response No relevant relationships by Jeffrey Bloomer, source=Web Response No relevant relationships by Sara Ruiz Aguinaga, source=Web Response