Putterman D, Safadi R, Ilan Y, Rivkind A I, Ben-Chetrit E
Department of Medicine, Hadassah University Hospital, Ein-Kerem, Jerusalem, Israel.
Presse Med. 1994 Mar 12;23(10):474-6.
Primary hepatocellular carcinoma can be revealed by recurrent pulmonary embolism as observed in this case of a 63-year-old woman initially hospitalized for abdominal pain and shortness of breath. The clinical diagnosis was confirmed by laboratory findings, a ventilation perfusion scan and pulmonary angiography which demonstrated peripheral basal artery cut-off and slow filling with delayed washout. The patient was treated with heparin then with nicoumarol and responded well. One month after discharge the patient again complained of shortness of breath and was readmitted. Anticoagulation was adequate as evidenced by a prothrombin time of 1.39 INR and the physical examination and laboratory tests again suggested pulmonary emboli, confirmed by a ventilation perfusion scan. Computed tomography of the chest and abdomen revealed multiple hypodense masses filling half of the liver volume and needle biopsy led to the diagnosis of hepatocellular carcinoma. Hypercoagulability in malignancy is well-known although cases of migratory thrombophlebitis are extremely rare. Pulmonary embolism has not been described as a presenting feature of hepatocellular carcinoma. In this case, there was no evidence of hepatic dysfunction and the pulmonary embolism occurred despite adequate anticoagulation. Clinicians should include occult carcinoma among the possible causes of recurrent pulmonary embolism and when searching for malignancy can include hepatocellular carcinoma among the causes of hypercoagulation.
原发性肝细胞癌可表现为反复发生的肺栓塞，如本例63岁女性患者，最初因腹痛和呼吸急促入院。临床诊断通过实验室检查结果、通气灌注扫描和肺血管造影得以证实，这些检查显示外周基底动脉截断、充盈缓慢且洗脱延迟。患者先接受肝素治疗，后使用双香豆素，反应良好。出院后一个月，患者再次出现呼吸急促并再次入院。凝血酶原时间为1.39国际标准化比值，表明抗凝治疗充分，体格检查和实验室检查再次提示肺栓塞，通气灌注扫描证实了这一点。胸部和腹部计算机断层扫描显示多个低密度肿块占据肝脏体积的一半，经针吸活检诊断为肝细胞癌。恶性肿瘤中的高凝状态众所周知，尽管迁徙性血栓性静脉炎病例极为罕见。肺栓塞尚未被描述为肝细胞癌的首发特征。在本例中，没有肝功能障碍的证据，尽管抗凝治疗充分，仍发生了肺栓塞。临床医生应将隐匿性癌症列为反复发生肺栓塞的可能原因之一，在寻找恶性肿瘤时，应将肝细胞癌列为高凝状态的原因之一。
