Abstract Background Cases of pulmonary artery masses have only rarely been reported, and the optimal type of the diagnosis and treatment is controversial. Case Presentation An 81-year-old woman was found to have an abnormal shadow on chest X-ray film. Computed tomography showed an irregularly bordered tumor centered in the hilar region extending from segment 6 to the middle lobe of the right lung. Pulmonary angiography showed complete occlusion of the trunk at the periphery proximal to the bifurcation of the posterior ascending branch. Based on bronchoscopic biopsy of the tumor, an adenocarcinoma was diagnosed. Middle and lower lobectomy was performed. Histopathologically, the adenocarcinoma had invaded the tunica intima of the pulmonary artery and also replaced the endothelium in the same region. Although a large thrombus was found at the vessel invasion site of the adenocarcinoma in the pulmonary artery, there were no malignant findings in the thrombus itself. Conclusions This is the first reported case of radical resection of a lung cancer with invasion along the pulmonary artery wherein a benign thrombus had formed. In general, surgery would be the treatment of choice for a pulmonary artery mass.</p

A Chambers

AL Estrera

AO Zurick

Arafumi Maeshima

C Engelke

CW Brecher

HH Lin

JK Pinckard

JM Parish

K Chinen

M Kamigaki

N Kayalar

Ryoichi Kato

T Yamaguchi

Taichiro Goto

English

PubMed

Springer - Publisher Connector

CASE REPORT Open Access
Lung adenocarcinoma with peculiar growth to
the pulmonary artery and thrombus formation:
report of a case
Taichiro Goto1*, Arafumi Maeshima2 and Ryoichi Kato1
Abstract
Background: Cases of pulmonary artery masses have only rarely been reported, and the optimal type of the
diagnosis and treatment is controversial.
Case Presentation: An 81-year-old woman was found to have an abnormal shadow on chest X-ray film.
Computed tomography showed an irregularly bordered tumor centered in the hilar region extending from
segment 6 to the middle lobe of the right lung. Pulmonary angiography showed complete occlusion of the trunk
at the periphery proximal to the bifurcation of the posterior ascending branch. Based on bronchoscopic biopsy of
the tumor, an adenocarcinoma was diagnosed. Middle and lower lobectomy was performed. Histopathologically,
the adenocarcinoma had invaded the tunica intima of the pulmonary artery and also replaced the endothelium in
the same region. Although a large thrombus was found at the vessel invasion site of the adenocarcinoma in the
pulmonary artery, there were no malignant findings in the thrombus itself.
Conclusions: This is the first reported case of radical resection of a lung cancer with invasion along the pulmonary
artery wherein a benign thrombus had formed. In general, surgery would be the treatment of choice for a
pulmonary artery mass.
Background
Tumors growing into the pulmonary arteries include
angiosarcoma and tumor embolizations from other organs
[1-5]. Despite being rare, there are several reports of pri-
mary lung cancers macroscopically growing into pulmon-
ary arteries [6-8]. An intravascular tumor at the pulmonary
artery represents a rare but important differential diagnosis
of pulmonary thromboembolism [1,5,9]. Herein, we
describe a patient with lung cancer that presented as a sus-
pected pulmonary artery mass. The evaluation and treat-
ment of this patient are presented in detail.
Case Presentation
An 81-year-old woman was found to have an abnormal
shadow in the right lower lung field on chest radiography
for a routine health check-up (Figure 1A). Her past medi-
cal history was unremarkable. Her smoking history was 1
pack/day × 50 years, and she had quit smoking at age 70.
Chest computed tomography (CT) showed a tumor with
an irregular border centered in the hilar region extending
from segment 6 (S6) to the middle lobe of the right lung
(Figure 1B, C). Based on stenotic and occlusive findings of
the pulmonary artery on CT scan, the tumor was consid-
ered to have directly invaded the pulmonary trunk (Figure
1B, C). Although positron emission tomography showed
fluorodeoxyglucose uptake with a maximum standard
uptake value of 4.7 in the tumor region (Figure 1D), there
was no fluorodeoxyglucose uptake in mediastinal lymph
nodes or other organs. To closely examine the extent of
proximal intravascular tumor invasion, angiography was
performed, which revealed complete occlusion of the pul-
monary trunk at the periphery proximal to the bifurcation
of the posterior ascending branch, and a filling defect at
the root of this branch (Figure 1E). Although broncho-
scopy showed no mass lesion in the visible range, adeno-
carcinoma was diagnosed by bronchoscopic biopsy of the
tumor. The level of carcinoembryonic antigen was ele-
vated, at 5.7 ng/mL (institutional cutoff value, 5.0 ng/ml);
* Correspondence: taichiro@1997.jukuin.keio.ac.jp
1Department of General Thoracic Surgery, National Hospital Organization
Tokyo Medical Center, Tokyo, Japan
Full list of author information is available at the end of the article
Goto et al. World Journal of Surgical Oncology 2012, 10:16
http://www.wjso.com/content/10/1/16 WORLD JOURNAL OF 
SURGICAL ONCOLOGY 
© 2012 Goto et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
however, no abnormalities were detected in other blood
chemistry or tumor marker levels. The patient was other-
wise healthy and asymptomatic. Her vital capacity was
1.92 liters, and her forced expiratory volume in 1 second
was 1.40 liters. Because right pneumonectomy would be
difficult given her pulmonary function and age, preserva-
tion of the right upper lobe was chosen as the surgical
strategy.
Figure 1 Radiological findings. A: Chest X-ray showed a mass shadow in the right middle lung field. B, C: Chest CT showed a tumor with an
irregular border centered in the hilar region extending from S6 to the middle lobe of the right lung. Stenosis and occlusion of the pulmonary
artery were found on mediastinal window setting. D: Positron emission tomography showed fluorodeoxyglucose uptake in the tumor. E:
Angiography showed complete occlusion of the pulmonary trunk at the periphery proximal to the bifurcation of the posterior ascending branch,
and a filling defect at the root of this branch.
Goto et al. World Journal of Surgical Oncology 2012, 10:16
http://www.wjso.com/content/10/1/16
Page 2 of 5
Intraoperatively, the tumor was found to be located on
the interlobar surface of S6-middle lobe, tending to invade
proximally and distally along the pulmonary trunk. Mas-
sive induration was felt inside the pulmonary artery at the
cancer invasion site (Figure 2A). Cancer invasion was also
observed at the root of the posterior ascending branch,
and induration was felt in the lumen of this branch. Thus,
it was ligated and divided on the peripheral side (Figure
2A). The pulmonary artery was clamped with vascular for-
ceps at a site proximally peripheral to the bifurcation of
the anterior trunk and without internal palpable indura-
tion; then, the artery was divided and sutured. As a result
of these procedures on blood vessels, we were able to pre-
serve the right upper lobe and perform middle and lower
lobectomy (Figure 2A).
Gross examination of the specimen disclosed that the
tumor was mainly centered in the hilar region at S6, mea-
sured 40 mm, and was partially grayish inside (Figure 2B).
The tumor showed continuous invasion into the pulmon-
ary artery, and the pulmonary trunk was occluded with a
massive thrombus. Histopathologically, cuboidal tumor
cells showed acinar, bronchioloalveolar and solid pattern
with central fibrotic scar, leading to the diagnosis of ade-
nocarcinoma with mixed subtypes (Figure 3A, B). Invasion
of adenocarcinoma mainly composed of acinar pattern
was observed in the pulmonary artery wall (Figure 3C, D),
and the endothelium had also been replaced by
adenocarcinoma cells in the same region (Figure 3E, F).
Although a large thrombus was detected at the site of ves-
sel invasion by adenocarcinoma in the pulmonary artery,
there were no malignant findings in the thrombus itself
(Figure 3C-F). No cancer invasion was observed at the sur-
gical margins of either the posterior ascending branch or
the pulmonary trunk (Figure 2A). There was no lymph
node metastasis. The cancer was pathologically diagnosed
as pT4N0M0, stage IIIA.
The patient’s postoperative course was uneventful, and
she has remained in good health since discharge. In con-
sideration of her advanced age, no adjuvant chemotherapy
was performed. For the 14 months to date, since surgery,
the patient has remained free of lung cancer recurrence,
and will continue to be followed-up on an outpatient basis.
Discussion
We experienced a case with lung cancer directly invading
the pulmonary artery and forming a thrombus at the vessel
invasion site. To the best of our knowledge, no similar
cases have been reported previously. The primary etiologies
of pulmonary artery masses include pulmonary throm-
boembolism, angiosarcoma, tumor embolism from cancers
of other organs, and growth of a primary lung cancer into
the intravascular lumen [1-9], but the diagnosis of a pul-
monary mass is seldom made preoperatively. There are
very few reports describing primary lung cancers directly
Figure 2 Surgical findings. A: Intraoperative treatment for blood vessels. The tumor invaded the pulmonary trunk on the interlobar surface and
also at the root of the posterior ascending branch. The branch was ligated and divided on the peripheral side. The pulmonary trunk was
clamped with vascular forceps at the periphery proximal to the bifurcation of the anterior trunk, and the pulmonary trunk was then divided and
sutured. The red area indicates the cancer invasion site. The brown area indicates the thrombus in the pulmonary artery. The double lines
indicate the division sites of blood vessels. B: Macroscopically, the cancer showed continuous invasion of the pulmonary artery, and the
pulmonary trunk was occluded with a massive thrombus.
Goto et al. World Journal of Surgical Oncology 2012, 10:16
http://www.wjso.com/content/10/1/16
Page 3 of 5
invading pulmonary arteries, with polypoidal growth into
the lumens of these blood vessels [6-8]. Although the
pathology of our case may also be regarded as direct inva-
sion of a primary lung cancer to the pulmonary artery, this
case featured temporal and spatial coincidence of vessel
invasion by the lung cancer and a thrombus without malig-
nant findings. The well-known pathologies of cancer-
related thrombus include Trousseau’s syndrome,
Figure 3 Histological findings. A, B: The center of the adenocarcinoma is mainly composed of bronchioloalveolar, solid and acinar pattern. C,
D: Adenocarcinoma invasion was observed in the pulmonary artery wall. Thrombus formation was seen in the blood vessel (C, Hematoxylin and
eosin staining; D, Elastica-van Gieson staining). E, F: Adenocarcinoma mainly composed of acinar pattern invaded the tunica intima of the
pulmonary artery. The endothelium of the same region had been replaced by adenocarcinoma cells.
Goto et al. World Journal of Surgical Oncology 2012, 10:16
http://www.wjso.com/content/10/1/16
Page 4 of 5
pulmonary tumor thrombotic microangiopathy, and disse-
minated intravascular coagulation, which are multiple
microthrombi associated with biochemical changes caused
by vessel invasion of cancer [10,11]. On the other hand, an
intravascular massive thrombus was formed at the vessel
invasion site of the cancer in our present case. One possi-
ble explanation is that peripheral pulmonary arterial occlu-
sion by the tumor disturbed arterial flow at a proximal site,
leading to the formation of a thrombus, but the precise
pathogenesis remains uncertain. Studies of similar cases
and further definition of this condition may shed light on
the complex underlying mechanisms.
The rarity of this tumor growth pattern makes it diffi-
cult to define its prognostic impact and pathological
implications. For example, polypoidal cancer growth in a
pulmonary artery is thought to lead to dissemination into
the pulmonary circulation. However, such pathological
findings are actually quite infrequent. Pulmonary artery
invasion reportedly carries a better prognosis than other
forms of mediastinal structural invasion [12]. Thus, even
when macroscopic cancer invasion to the main pulmon-
ary artery seems likely, complete surgical resection may
offer the only chance for survival.
Conclusions
In conclusion, this is the first reported case of a lung can-
cer mimicking pulmonary artery sarcoma, but which
actually formed a massive thrombus at the vessel invasion
site. This mode of cancer extension is quite rare and its
prognostic significance remains unclear. Although pul-
monary arterial invasion is generally an ominous prog-
nostic sign, presentation as a pulmonary artery mass may
warrant open exploration for diagnosis and possible defi-
nitive treatment.
Consent
Written informed consent was obtained from the patient
for the publication of this case presentation and accom-
panying images. A copy of the written consent is avail-
able for review by the Editor-in-Chief of this journal.
Abbreviations
CT: computed tomography; S: segment.
Author details
1Department of General Thoracic Surgery, National Hospital Organization
Tokyo Medical Center, Tokyo, Japan. 2Department of Pathology, National
Hospital Organization Tokyo Medical Center, Tokyo, Japan.
Authors’ contributions
TG wrote the manuscript. TG and RK performed surgery. AM carried out the
pathological examination. RK was involved in the final editing. All authors
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 30 December 2011 Accepted: 21 January 2012
Published: 21 January 2012
References
1. Brecher CW, Lang EV: Tumor thromboembolism masquerading as bland
pulmonary embolism. J Vasc Interv Radiol 2004, 15:293-296.
2. Kayalar N, Leibovich BC, Orszulak TA, Schaff HV, Sundt TM, Daly RC,
McGregor CG: Concomitant surgery for renal neoplasm with pulmonary
tumor embolism. J Thorac Cardiovasc Surg 2010, 139:320-325.
3. Lin HH, Hsieh CB, Chu HC, Chang WK, Chao YC, Hsieh TY: Acute
pulmonary embolism as the first manifestation of hepatocellular
carcinoma complicated with tumor thrombi in the inferior vena cava:
surgery or not? Dig Dis Sci 2007, 52:1554-1557.
4. Parish JM, Rosenow EC, Swensen SJ, Crotty TB: Pulmonary artery sarcoma.
Clinical features. Chest 1996, 110:1480-1488.
5. Zurick AO, Lenge De Rosen V, Tan CD, Rodriguez ER, Flamm SD,
Schoenhagen P: Pulmonary artery intimal sarcoma masquerading as
pulmonary embolism. Circulation 2011, 124:1180-1181.
6. Estrera AL, Cagle PT, Azizzadeh A, Reardon MJ: Large cell neuroendocrine
carcinoma: an unusual presentation. Ann Thorac Surg 2002, 73:1957-1960.
7. Kamigaki M, Yamazaki K, Tsujino I, Suga M, Sakaue S, Dosaka-Akita H,
Nishimura M: Small cell carcinoma of the lung exclusively localized
within the left descending pulmonary artery. Chest 2005, 127:2273-2276.
8. Yamaguchi T, Suzuki K, Asamura H, Kondo H, Niki T, Yamada T, Tsuchiya R:
Lung carcinoma with polypoid growth in the main pulmonary artery:
report of two cases. Jpn J Clin Oncol 2000, 30:358-361.
9. Engelke C, Riedel M, Rummeny EJ, Marten K: Pulmonary
haemangiosarcoma with main pulmonary artery thrombosis imitating
subacute pulmonary embolism with infarction. Br J Radiol 2004,
77:623-625.
10. Chinen K, Kazumoto T, Ohkura Y, Matsubara O, Tsuchiya E: Pulmonary
tumor thrombotic microangiopathy caused by a gastric carcinoma
expressing vascular endothelial growth factor and tissue factor. Pathol
Int 2005, 55:27-31.
11. Pinckard JK, Wick MR: Tumor-related thrombotic pulmonary
microangiopathy: review of pathologic findings and pathophysiologic
mechanisms. Ann Diagn Pathol 2000, 4:154-157.
12. Chambers A, Routledge T, Bille A, Scarci M: Does surgery have a role in
T4N0 and T4N1 lung cancer? Interact Cardiovasc Thorac Surg 2010,
11:473-479.
doi:10.1186/1477-7819-10-16
Cite this article as: Goto et al.: Lung adenocarcinoma with peculiar
growth to the pulmonary artery and thrombus formation: report of a
case. World Journal of Surgical Oncology 2012 10:16.
Submit your next manuscript to BioMed Central
and take full advantage of: 
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at 
www.biomedcentral.com/submit
Goto et al. World Journal of Surgical Oncology 2012, 10:16
http://www.wjso.com/content/10/1/16
Page 5 of 5


Lung adenocarcinoma with peculiar growth to the pulmonary artery and thrombus formation: report of a case

Crossref

CASE REPORT Open AccessLung adenocarcinoma with peculiar growth tothe pulmonary artery and thrombus formation:report of a caseTaichiro Goto1*, Arafumi Maeshima2 and Ryoichi Kato1AbstractBackground: Cases of pulmonary artery masses have only rarely been reported, and the optimal type of thediagnosis and treatment is controversial.Case Presentation: An 81-year-old woman was found to have an abnormal shadow on chest X-ray film.Computed tomography showed an irregularly bordered tumor centered in the hilar region extending fromsegment 6 to the middle lobe of the right lung. Pulmonary angiography showed complete occlusion of the trunkat the periphery proximal to the bifurcation of the posterior ascending branch. Based on bronchoscopic biopsy ofthe tumor, an adenocarcinoma was diagnosed. Middle and lower lobectomy was performed. Histopathologically,the adenocarcinoma had invaded the tunica intima of the pulmonary artery and also replaced the endothelium inthe same region. Although a large thrombus was found at the vessel invasion site of the adenocarcinoma in thepulmonary artery, there were no malignant findings in the thrombus itself.Conclusions: This is the first reported case of radical resection of a lung cancer with invasion along the pulmonaryartery wherein a benign thrombus had formed. In general, surgery would be the treatment of choice for apulmonary artery mass.BackgroundTumors growing into the pulmonary arteries includeangiosarcoma and tumor embolizations from other organs[1-5]. Despite being rare, there are several reports of pri-mary lung cancers macroscopically growing into pulmon-ary arteries [6-8]. An intravascular tumor at the pulmonaryartery represents a rare but important differential diagnosisof pulmonary thromboembolism [1,5,9]. Herein, wedescribe a patient with lung cancer that presented as a sus-pected pulmonary artery mass. The evaluation and treat-ment of this patient are presented in detail.Case PresentationAn 81-year-old woman was found to have an abnormalshadow in the right lower lung field on chest radiographyfor a routine health check-up (Figure 1A). Her past medi-cal history was unremarkable. Her smoking history was 1pack/day × 50 years, and she had quit smoking at age 70.Chest computed tomography (CT) showed a tumor withan irregular border centered in the hilar region extendingfrom segment 6 (S6) to the middle lobe of the right lung(Figure 1B, C). Based on stenotic and occlusive findings ofthe pulmonary artery on CT scan, the tumor was consid-ered to have directly invaded the pulmonary trunk (Figure1B, C). Although positron emission tomography showedfluorodeoxyglucose uptake with a maximum standarduptake value of 4.7 in the tumor region (Figure 1D), therewas no fluorodeoxyglucose uptake in mediastinal lymphnodes or other organs. To closely examine the extent ofproximal intravascular tumor invasion, angiography wasperformed, which revealed complete occlusion of the pul-monary trunk at the periphery proximal to the bifurcationof the posterior ascending branch, and a filling defect atthe root of this branch (Figure 1E). Although broncho-scopy showed no mass lesion in the visible range, adeno-carcinoma was diagnosed by bronchoscopic biopsy of thetumor. The level of carcinoembryonic antigen was ele-vated, at 5.7 ng/mL (institutional cutoff value, 5.0 ng/ml);* Correspondence: taichiro@1997.jukuin.keio.ac.jp1Department of General Thoracic Surgery, National Hospital OrganizationTokyo Medical Center, Tokyo, JapanFull list of author information is available at the end of the articleGoto et al. World Journal of Surgical Oncology 2012, 10:16http://www.wjso.com/content/10/1/16 WORLD JOURNAL OF SURGICAL ONCOLOGY © 2012 Goto et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.however, no abnormalities were detected in other bloodchemistry or tumor marker levels. The patient was other-wise healthy and asymptomatic. Her vital capacity was1.92 liters, and her forced expiratory volume in 1 secondwas 1.40 liters. Because right pneumonectomy would bedifficult given her pulmonary function and age, preserva-tion of the right upper lobe was chosen as the surgicalstrategy.Figure 1 Radiological findings. A: Chest X-ray showed a mass shadow in the right middle lung field. B, C: Chest CT showed a tumor with anirregular border centered in the hilar region extending from S6 to the middle lobe of the right lung. Stenosis and occlusion of the pulmonaryartery were found on mediastinal window setting. D: Positron emission tomography showed fluorodeoxyglucose uptake in the tumor. E:Angiography showed complete occlusion of the pulmonary trunk at the periphery proximal to the bifurcation of the posterior ascending branch,and a filling defect at the root of this branch.Goto et al. World Journal of Surgical Oncology 2012, 10:16http://www.wjso.com/content/10/1/16Page 2 of 5Intraoperatively, the tumor was found to be located onthe interlobar surface of S6-middle lobe, tending to invadeproximally and distally along the pulmonary trunk. Mas-sive induration was felt inside the pulmonary artery at thecancer invasion site (Figure 2A). Cancer invasion was alsoobserved at the root of the posterior ascending branch,and induration was felt in the lumen of this branch. Thus,it was ligated and divided on the peripheral side (Figure2A). The pulmonary artery was clamped with vascular for-ceps at a site proximally peripheral to the bifurcation ofthe anterior trunk and without internal palpable indura-tion; then, the artery was divided and sutured. As a resultof these procedures on blood vessels, we were able to pre-serve the right upper lobe and perform middle and lowerlobectomy (Figure 2A).Gross examination of the specimen disclosed that thetumor was mainly centered in the hilar region at S6, mea-sured 40 mm, and was partially grayish inside (Figure 2B).The tumor showed continuous invasion into the pulmon-ary artery, and the pulmonary trunk was occluded with amassive thrombus. Histopathologically, cuboidal tumorcells showed acinar, bronchioloalveolar and solid patternwith central fibrotic scar, leading to the diagnosis of ade-nocarcinoma with mixed subtypes (Figure 3A, B). Invasionof adenocarcinoma mainly composed of acinar patternwas observed in the pulmonary artery wall (Figure 3C, D),and the endothelium had also been replaced byadenocarcinoma cells in the same region (Figure 3E, F).Although a large thrombus was detected at the site of ves-sel invasion by adenocarcinoma in the pulmonary artery,there were no malignant findings in the thrombus itself(Figure 3C-F). No cancer invasion was observed at the sur-gical margins of either the posterior ascending branch orthe pulmonary trunk (Figure 2A). There was no lymphnode metastasis. The cancer was pathologically diagnosedas pT4N0M0, stage IIIA.The patient’s postoperative course was uneventful, andshe has remained in good health since discharge. In con-sideration of her advanced age, no adjuvant chemotherapywas performed. For the 14 months to date, since surgery,the patient has remained free of lung cancer recurrence,and will continue to be followed-up on an outpatient basis.DiscussionWe experienced a case with lung cancer directly invadingthe pulmonary artery and forming a thrombus at the vesselinvasion site. To the best of our knowledge, no similarcases have been reported previously. The primary etiologiesof pulmonary artery masses include pulmonary throm-boembolism, angiosarcoma, tumor embolism from cancersof other organs, and growth of a primary lung cancer intothe intravascular lumen [1-9], but the diagnosis of a pul-monary mass is seldom made preoperatively. There arevery few reports describing primary lung cancers directlyFigure 2 Surgical findings. A: Intraoperative treatment for blood vessels. The tumor invaded the pulmonary trunk on the interlobar surface andalso at the root of the posterior ascending branch. The branch was ligated and divided on the peripheral side. The pulmonary trunk wasclamped with vascular forceps at the periphery proximal to the bifurcation of the anterior trunk, and the pulmonary trunk was then divided andsutured. The red area indicates the cancer invasion site. The brown area indicates the thrombus in the pulmonary artery. The double linesindicate the division sites of blood vessels. B: Macroscopically, the cancer showed continuous invasion of the pulmonary artery, and thepulmonary trunk was occluded with a massive thrombus.Goto et al. World Journal of Surgical Oncology 2012, 10:16http://www.wjso.com/content/10/1/16Page 3 of 5invading pulmonary arteries, with polypoidal growth intothe lumens of these blood vessels [6-8]. Although thepathology of our case may also be regarded as direct inva-sion of a primary lung cancer to the pulmonary artery, thiscase featured temporal and spatial coincidence of vesselinvasion by the lung cancer and a thrombus without malig-nant findings. The well-known pathologies of cancer-related thrombus include Trousseau’s syndrome,Figure 3 Histological findings. A, B: The center of the adenocarcinoma is mainly composed of bronchioloalveolar, solid and acinar pattern. C,D: Adenocarcinoma invasion was observed in the pulmonary artery wall. Thrombus formation was seen in the blood vessel (C, Hematoxylin andeosin staining; D, Elastica-van Gieson staining). E, F: Adenocarcinoma mainly composed of acinar pattern invaded the tunica intima of thepulmonary artery. The endothelium of the same region had been replaced by adenocarcinoma cells.Goto et al. World Journal of Surgical Oncology 2012, 10:16http://www.wjso.com/content/10/1/16Page 4 of 5pulmonary tumor thrombotic microangiopathy, and disse-minated intravascular coagulation, which are multiplemicrothrombi associated with biochemical changes causedby vessel invasion of cancer [10,11]. On the other hand, anintravascular massive thrombus was formed at the vesselinvasion site of the cancer in our present case. One possi-ble explanation is that peripheral pulmonary arterial occlu-sion by the tumor disturbed arterial flow at a proximal site,leading to the formation of a thrombus, but the precisepathogenesis remains uncertain. Studies of similar casesand further definition of this condition may shed light onthe complex underlying mechanisms.The rarity of this tumor growth pattern makes it diffi-cult to define its prognostic impact and pathologicalimplications. For example, polypoidal cancer growth in apulmonary artery is thought to lead to dissemination intothe pulmonary circulation. However, such pathologicalfindings are actually quite infrequent. Pulmonary arteryinvasion reportedly carries a better prognosis than otherforms of mediastinal structural invasion [12]. Thus, evenwhen macroscopic cancer invasion to the main pulmon-ary artery seems likely, complete surgical resection mayoffer the only chance for survival.ConclusionsIn conclusion, this is the first reported case of a lung can-cer mimicking pulmonary artery sarcoma, but whichactually formed a massive thrombus at the vessel invasionsite. This mode of cancer extension is quite rare and itsprognostic significance remains unclear. Although pul-monary arterial invasion is generally an ominous prog-nostic sign, presentation as a pulmonary artery mass maywarrant open exploration for diagnosis and possible defi-nitive treatment.ConsentWritten informed consent was obtained from the patientfor the publication of this case presentation and accom-panying images. A copy of the written consent is avail-able for review by the Editor-in-Chief of this journal.AbbreviationsCT: computed tomography; S: segment.Author details1Department of General Thoracic Surgery, National Hospital OrganizationTokyo Medical Center, Tokyo, Japan. 2Department of Pathology, NationalHospital Organization Tokyo Medical Center, Tokyo, Japan.Authors’ contributionsTG wrote the manuscript. TG and RK performed surgery. AM carried out thepathological examination. RK was involved in the final editing. All authorsapproved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 30 December 2011 Accepted: 21 January 2012Published: 21 January 2012References1. Brecher CW, Lang EV: Tumor thromboembolism masquerading as blandpulmonary embolism. J Vasc Interv Radiol 2004, 15:293-296.2. Kayalar N, Leibovich BC, Orszulak TA, Schaff HV, Sundt TM, Daly RC,McGregor CG: Concomitant surgery for renal neoplasm with pulmonarytumor embolism. J Thorac Cardiovasc Surg 2010, 139:320-325.3. Lin HH, Hsieh CB, Chu HC, Chang WK, Chao YC, Hsieh TY: Acutepulmonary embolism as the first manifestation of hepatocellularcarcinoma complicated with tumor thrombi in the inferior vena cava:surgery or not? Dig Dis Sci 2007, 52:1554-1557.4. Parish JM, Rosenow EC, Swensen SJ, Crotty TB: Pulmonary artery sarcoma.Clinical features. Chest 1996, 110:1480-1488.5. Zurick AO, Lenge De Rosen V, Tan CD, Rodriguez ER, Flamm SD,Schoenhagen P: Pulmonary artery intimal sarcoma masquerading aspulmonary embolism. Circulation 2011, 124:1180-1181.6. Estrera AL, Cagle PT, Azizzadeh A, Reardon MJ: Large cell neuroendocrinecarcinoma: an unusual presentation. Ann Thorac Surg 2002, 73:1957-1960.7. Kamigaki M, Yamazaki K, Tsujino I, Suga M, Sakaue S, Dosaka-Akita H,Nishimura M: Small cell carcinoma of the lung exclusively localizedwithin the left descending pulmonary artery. Chest 2005, 127:2273-2276.8. Yamaguchi T, Suzuki K, Asamura H, Kondo H, Niki T, Yamada T, Tsuchiya R:Lung carcinoma with polypoid growth in the main pulmonary artery:report of two cases. Jpn J Clin Oncol 2000, 30:358-361.9. Engelke C, Riedel M, Rummeny EJ, Marten K: Pulmonaryhaemangiosarcoma with main pulmonary artery thrombosis imitatingsubacute pulmonary embolism with infarction. Br J Radiol 2004,77:623-625.10. Chinen K, Kazumoto T, Ohkura Y, Matsubara O, Tsuchiya E: Pulmonarytumor thrombotic microangiopathy caused by a gastric carcinomaexpressing vascular endothelial growth factor and tissue factor. PatholInt 2005, 55:27-31.11. Pinckard JK, Wick MR: Tumor-related thrombotic pulmonarymicroangiopathy: review of pathologic findings and pathophysiologicmechanisms. Ann Diagn Pathol 2000, 4:154-157.12. Chambers A, Routledge T, Bille A, Scarci M: Does surgery have a role inT4N0 and T4N1 lung cancer? Interact Cardiovasc Thorac Surg 2010,11:473-479.doi:10.1186/1477-7819-10-16Cite this article as: Goto et al.: Lung adenocarcinoma with peculiargrowth to the pulmonary artery and thrombus formation: report of acase. World Journal of Surgical Oncology 2012 10:16.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitGoto et al. World Journal of Surgical Oncology 2012, 10:16http://www.wjso.com/content/10/1/16Page 5 of 5

World Journal of Surgical Oncology

Abstract Background Cases of pulmonary artery masses have only rarely been reported, and the optimal type of the diagnosis and treatment is controversial. Case Presentation An 81-year-old woman was found to have an abnormal shadow on chest X-ray film. Computed tomography showed an irregularly bordered tumor centered in the hilar region extending from segment 6 to the middle lobe of the right lung. Pulmonary angiography showed complete occlusion of the trunk at the periphery proximal to the bifurcation of the posterior ascending branch. Based on bronchoscopic biopsy of the tumor, an adenocarcinoma was diagnosed. Middle and lower lobectomy was performed. Histopathologically, the adenocarcinoma had invaded the tunica intima of the pulmonary artery and also replaced the endothelium in the same region. Although a large thrombus was found at the vessel invasion site of the adenocarcinoma in the pulmonary artery, there were no malignant findings in the thrombus itself. Conclusions This is the first reported case of radical resection of a lung cancer with invasion along the pulmonary artery wherein a benign thrombus had formed. In general, surgery would be the treatment of choice for a pulmonary artery mass.</p

Goto Taichiro

Maeshima Arafumi

Kato Ryoichi

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Lung adenocarcinoma with peculiar growth to the pulmonary artery and thrombus formation: report of a case

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Directory of Open Access Journals

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