Yonago Acta medica 2008;51:17–20

An Autopsy Case of Acute Pulmonary Embolism after Lung
Cancer Surgery
Hiroshige Nakamura, Kenichiro Miyoshi, Yoshin Adachi, Shinji Fujioka, Ken Miwa,Yuji Taniguchi, Yukisato Kitamura* and Kazuhiko Hayashi*
Division of General Thoracic Surgery, Tottori University Hospital, Yonago 683-8504 and *Divisionof Molecular Pathology, Department of Microbiology and Pathology, School of Medicine, Tottori
University Faculty of Medicine, Yonago, 683-8503 Japan

The patient was a 77-year-old female who had difficulty breathing at 48 h after undergoing a right upper lobectomy for lung cancer and experienced sudden cardiopulmonaryarrest. Emergency resuscitation was performed, and she was therefore put under artificial respiration, but she died 15 h after resuscitation. A pathological autopsy was performed upon obtaining informed consent from the family. An examination of the lungs
in which the right upper lobectomy was performed detected multiple embolisms blocking the bilateral main pulmonary arteries to the periphery, and the cause of death wasestablished as acute pulmonary embolism. The rate of occurrence of fatal pulmonaryembolism after surgery is assumed to be 0.08%, but the rate of occurrence after thoracic surgery shows a high rate of 0.34%. It is important to implement early detection
and the early treatment of pulmonary embolism that occurred by misfortune while also
reviewing all risk assessments and preventive measures established under the medical
guidelines in order to prevent such cases from becoming fatal.
Key words: autopsy; lung cancer operation; pulmonary embolism

In Japan, the rate of occurrence of acute pulmo-for the purpose of surgery. She was 157-cm tall,weighed 62 kg and had a body mass index of 24.9.
Her medical history included surgery for thyroid
cancer 10 years earlier. She had no past historyof smoking habit or diabetes mellitus and was aonly regular user of antihypertensive and thyroid
hormones (Thyroxine). Her blood pressure was
130/85 mmHg and there were no abnormal findings in the thyroid function, blood coagulative
test and cardiopulmonary examination. So, weand the anesthesiologists judged this patient low
risk for pulmonary embolism and did not performthe ultrasound examination on the veins in both
lower limbs and intrapelvic area. A 3-cm tumor
on the right upper lobe was detected in the chest
CT scan (Fig. 1), and the patient was diagnosed

nary embolism has been increasing gradually inrecent years as our daily lifestyle becomes more
Westernized. We experienced a patient who suffered a fatal acute pulmonary embolism after surgery for lung cancer, and we performed an autopsy.
We herein present our results with a brief discussion regarding the prevention and treatment of postoperative pulmonary embolism.

Patient Report
The patient was a 77-year-old female in whom
an abnormal shadow was detected by chest computed tomography (CT) during medical examination, resulting in hospitalization in October 2007
Abbreviation: CT, computed tomo-gram, -graphic, -graphy17

H. Nakamura et al.

with pulmonary adenocarcinoma. She therefore
underwent a thoracoscopic right upper lobectomy
and a mediastinal lymph node dissection. The
operation took 240 min to complete with 170 gof bleeding and an intraoperative massage using
intermittent pneumatic compression applied to herlower limbs as her progress continued to improve.
Postoperative pathological findings showed awell-differentiated adenocarcinoma without
lymph node metastases, and we concluded the IA
disease of tumor-node-metastasis staging. The
patient’s postoperative vital signs were stable, andshe started taking meals in a seated position at 18
h after surgery. She had difficulty breathing at 48
h after surgery when she was moved to a generalward, but her condition recovered immediately
after oxygen was administered. After dinner, anurse discovered that the patient was experiencing
respiratory arrest, so cardiopulmonary resuscitation was immediately applied, and the patient wasmoved to the Intensive Care Unit, where she wasput on artificial respiration. Echocardiography
findings indicated a suspected collapse of the left
ventricle and embolisms within the pulmonary
arteries, so it was assumed to be a case of pulmonary embolism, and therefore the intravenous
administration of 48,000 units of urokinase and5,000 units of heparin was carried out. However,A

Fig. 1. In the preoperative chest computed tomogram,a 3-cm tumor with irregular margin on the right upper
lobe was detected. We suspected lung adenocarinoma.

we observed pupil dilation and a loss of light reflex, and the patient was pronounced dead 15 hafter resuscitation. A pathological autopsy wasperformed after obtaining the informed consent
from the family. Upon examining her lungs after the right upper lobectomy, we detected many
embolisms blocking the bilateral main pulmonary
arteries to the periphery (Figs. 2A and B). The resected embolisms were fresh red embolisms thatwere 55 7 mm in size on the right side and 60BFig. 2. Autopsy findings show many embolisms (arrows) blocking bilateral main pulmonary arteries to the periphery.
A: Right lung. B: Left lung.

18

An autopsy case of pulmonary embolism

Fig. 3. The resected were fresh red embolisms 55 7 mm in size on the rightside and 60 13 mm on the left. PA, pulmonary artery.

pancreatic cancers, 3.22% for esophageal cancers,
2.94% for lung cancers, 1.64% for rectal cancers
and 1.28% for stomach cancers, and a correlation
with surgical stress has also been observed (Sakon,2005). According to one large-scale multicenter
survey, the rate of occurrence of fatal postoperative pulmonary embolism, such as that seen inthis patient, was 0.08%, with a high rate of 0.34%
for thoracic surgeries and a low rate of 0.04% forabdominal surgeries (Sakon et al., 2004). Prevention is important for postoperative pulmonary embolism. The recommended actions described in
the medical guidelines include the assessment ofrisk factors, which are age, body type (body massindex), diabetes, underlying diseases such as lower-limb varicosity, a history of embolism and surgical stress before surgery: preventive measurescorresponding to the risk levels should be taken
during and after surgery (Geerts et al., 2004). In
operations for lung cancer, intermittent pneumatic
compression or the administration of heparin arerecommended. Perioperative intermittent pneumatic compression was performed in this patient
as well. There is no way to guarantee prevention,
but the addition of elastic stockings can further
enhance the efficacy of intermittent compression

13 mm on the left side in length. An autopsy forthe brain and both lower limbs was not performedby the refusal from her family. No significant
abnormalities were observed in the other organs,including intracardiac thrombus and vein thrombuses in the intrapelvic area. The cause of death
was determined to be acute pulmonary embolism.

Discussion
It is said that 600,000 people per year experiencepulmonary embolism in Europe and the UnitedStates, and that 16% to 25% of these cases result
in death (Benotti and Dalen, 1984). In Japan,
there has been an increasing tendency of occurrences of pulmonary embolism in recent years as
the general life style becomes more Westernized:
80% to 90% of the causes are attributed to embolisms in the deep veins of the lower limbs (Saitoet al., 2007). Embolism occurs easily througha congestion of blood flow and an increase inclotting function due to bed rest, particularly
after surgery. The risk increases with surgery
for cancer, which is prone to induce coagulation
abnormalities: reported rates were 3.85% for19

H. Nakamura et al.

and the additional administration of heparin is themost effective preventive method known at present. On the other hand, it is a well-known factthat the administration of heparin increases therisk of perioperative and postoperative bleeding(Clagett and Reisch, 1988), thus indicating the difficulty of preventing pulmonary embolism in anyand all cases. Based on our experience with thispatient, we have verified the need to assess risks
in detail before surgery according to the medicalguidelines, as well as the need to ensure the useof elastic stockings and intermittent pneumatic
compression until postoperative ambulation, andto administer heparin to patients with a historyof deep venous thrombus, and we have compiled
these guidelines into a manual.
In diagnosing pulmonary embolism, key
signs include sudden difficulty in breathing anda rapid decrease in saturation of percutaneous O2
that occurs with the first body movement. So,
the common occurrence period of pulmonary
embolism was usually considered to be at the 2nd
or 3rd day after the surgery (Sakon, 2005). As
medical workers, we are required to pay especial
attentions to the patient in this dangerous period
and accurately predict a diagnosis from suchslight symptoms (Saito et al., 2007). By taking acontrast chest CT, embolisms can be detected by
the filling in of defects within the pulmonary arteries, and a diagnosis can thus be determined. It
has been reported that 32% of cases of acute pulmonary embolism result in death of the patient, as
was the case with this patient, and of these cases,
43% died within 1 h of onset (Ota et al., 2002).
Clearly, it is better for treatment to be administered earlier: that is, success or failure depends
on how early thrombolytic therapy and anticoagulation therapy are initiated (Arcasoy and Kreit,1999; Konstantinides et al., 2002). Because thispatient complained of difficulty in breathing when
she was being moved to the general ward at 48 h
after the surgery, and although it was only temporary, it is predicted that acute pulmonary embolism had already occurred by that time. Postop-erative pulmonary embolism occurs even in theless invasive thoracoscopic surgery. This was avaluable case that further reinforced the need forall medical workers to have an increased awareness regarding this disease, and we believe that itis important to ensure the prevention of any reoccurrences by making use of the lessons learned
from this case.

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Received December 21, 2007; accepted January 9, 2008
Corresponding author: Hiroshige Nakamura, MD20