PULMONARY-EMBOLISM AS THE PRESENTING FEATURE OF HEPATOCELLULAR-CARCINOMA

Primary hepatocellular carcinoma can be revealed by recurrent pulmonar y embolism as observed in this case of a 63-year-old woman initially h ospitalized for abdominal pain and shortness of breath. The clinical d iagnosis was confirmed by laboratory findings, a ventilation perfusion scan and pulmonary angiography which demonstrated peripheral basal ar tery cut-off and slow filling with delayed washout. The patient was tr eated with heparin then with nicoumarol and responded well. One month after discharge the patient again complained of shortness of breath an d was readmitted. Anticoagulation was adequate as evidenced by a proth ombin time of 1.39 INR and the physical examination and laboratory tes ts again suggested pulmonary emboli, confirmed by a ventilation perfus ion scan. Computed tomography of the chest and abdomen revealed multip le 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 thrombophlebit is are extremely rare. Pulmonary embolism has not been described as a presenting feature of hepatocellular carcinoma. In this case, there wa s no evidence of hepatic dysfunction and the pulmonary embolism occurr ed despite adequate anticoagulation. Clinicians should include occult carcinoma among the possible causes of recurrent pulmonary embolism an d when searching for malignancy can include hepatocellular carcinoma a mong the causes of hypercoagulation.