Arterial embolism with lower limb ischemia is a rare manifestation of paraneoplastic hypercoagulability in cancer patients. We report a unique case of fatal thromboembolism involving both circulations associated with a poorly differentiated neuroendocrine tumor of the lung with rapid progress despite high doses of unfractioned heparin and review the current literature on anticoagulative regimen in tumour patients. 1. Introduction Limb ischemia due to arterial embolism in cancer patients has been reported for phaeochromocytoma, malignant melanoma, angiosarcoma, or cardiac tumour patients [1–3]. Single cases have also been linked to pancreatic adenocarcinoma or carotid body paraganglioma [4, 5]. Tumour associated venous thrombosis with pulmonary embolism on the other hand is much more common. Compared to a normal population, cancer patients bear a thirty times greater risk of deep vein thrombosis [6]. Vascular tumour invasion, metastatic spread, and fragmentation of cardiac masses need to be distinguished from paraneoplastic effects like catecholamine associated vasospasm, protein precipitation, and hypercoagulability [7]. The latter is of largely unknown origin and is responsible for about 10% of cancer-related thromboembolisms [8, 9]. Additionally, catecholamine independent arterial vasospasm leading to limb ischemia has been recently reported in a patient with well-differentiated pulmonary neuroendocrine carcinoma [10]. Embolism suggestive of Trousseau syndrome may occur as initial symptom resulting in tumour diagnosis, as complication alongside disease progression or may be triggered by specific chemotherapy agents [11, 12]. Thromboembolism is the second leading cause of death in cancer patients [13]. Here we report the unique case of a patient diagnosed with a multilocular metastasized neuroendocrine tumour (NET) of the lung suffering from progressive arterial embolisms in both circulations leading to bilateral lower limb ischemia, pulmonary embolism, stroke, and finally death five weeks after the initial bout of chemotherapy despite high doses of unfractioned heparin. 2. Case Report A 58-year-old Caucasian male was admitted to the Oncology Department with polyuria and weight loss of seven kilos in the last two weeks. Risk factors were arterial hypertension and cigarette smoking. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) with hyponatremia was noticed and tumour search detected metastatic liver disease and enlarged hilar lymph nodes. Blood analysis revealed elevated levels for neuron-specific enolase (NSE), carcinoembryonic
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