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Year : 2022  |  Volume : 65  |  Issue : 3  |  Page : 722-723
Transdiaphragmatic spread of lung cancer: A rare cause of Budd--Chiari syndrome

1 Department of GI Surgery, IPGME&R, Kolkata, West Bengal, India
2 Department of GI Radiology, IPGME&R, Kolkata, West Bengal, India
3 Department of Radiology, IPGME&R, Kolkata, West Bengal, India
4 Department of Pathology, IPGME&R, Kolkata, West Bengal, India

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Date of Submission02-Sep-2021
Date of Decision20-Nov-2021
Date of Acceptance25-Nov-2021
Date of Web Publication21-Jul-2022

How to cite this article:
Dhali A, Biswas DN, Parvin S, Ray S, Ghosh R. Transdiaphragmatic spread of lung cancer: A rare cause of Budd--Chiari syndrome. Indian J Pathol Microbiol 2022;65:722-3

How to cite this URL:
Dhali A, Biswas DN, Parvin S, Ray S, Ghosh R. Transdiaphragmatic spread of lung cancer: A rare cause of Budd--Chiari syndrome. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 Aug 15];65:722-3. Available from: https://www.ijpmonline.org/text.asp?2022/65/3/722/351624

Acute Budd--Chiari syndrome secondary to squamous-cell lung cancer has never been reported before. Although other pathological variants of lung cancer are known to cause secondary Budd--Chiari syndrome. This is primarily due to different locations of tumors and their clinicopathological differences. It is caused by occlusion of hepatic vein or inferior vena cava (IVC) and typically presents with the classical triad of pain abdomen, ascites, and hepatomegaly. These atypical clinical features make the diagnosis even harder for this poorly prognosticated disease. We reported a rare case of Budd--Chiari syndrome caused by tumor thrombus in IVC secondary to central lung carcinoma. Moreover, we found a transdiaphragmatic extension of this central tumor which is an extremely rare route of metastasis.

Herein we report a 45-year-old diabetic male, who presented to the emergency department with shortness of breath, abdominal pain and abdominal distension since 15 days. He was a chronic smoker for the last 30 years. There was no history of hemoptysis, chest pain, hematemesis, melena. Past and family history were non-contributary. On physical examination, there was decreased breath sounds in the right hemi-thorax, distended abdomen, hepatomegaly with bilateral pedal oedema. Laboratory investigation showed: total WBC-14,800 cu.mm, total billirubin-2.1 mg/dl, Alkaline phosphatase-171 U/L, SGPT- 600 U/L, SGOT-657 U/L, prothrombin time-20.3 s and INR-1.40. Initial chest X-ray [Figure 1]a revealed “Golden S sign”, suggestive of right-upper-lobe collapse. Ultrasound evaluation of the abdomen showed a heterogeneously hyperechoic lesion in segment VII of the liver with thrombus in the IVC [Figure 1]b. Diaphragmatic deposit [Figure 1]c and adrenal nodule [Figure 1]d was also visualized. Contrast-enhanced computed tomography of the thorax and abdomen was warranted and revealed [Figure 2a] right sided central lung mass with mediastinal lymph node. Heterogeneously enhancing liver with a metastatic deposit in segment VII which was breaching the diaphragm was also noted [Figure 2]a. It also revealed an IVC thrombus which extended up to the right atrium [Figure 2]b. This thrombus was associated with right sided adrenal nodule [Figure 2]c. There was nutmeg appearance of the liver with evidence of ascites and contralateral hyper-inflated lung [Figure 2]c. Overall, this was suggestive of Budd--Chiari syndrome secondary to metastatic lung cancer. Bronchoscopy-guided biopsy from the lung mass revealed sheets of large polygonal malignant cells showing keratin pearls. Intercellular bridges were also noted. The histological features were consistent with non-small cell carcinoma of lung favoring well-defined squamous cell carcinoma [Figure 3]. The patient succumbed within 2-days after diagnosis before initiation of chemotherapy and placement of stent. Although there is a reported case of small cell carcinoma of lung presenting with acute Budd--Chiari syndrome by Huang YW et al.,[1] but there is no literature regarding squamous-cell carcinoma. Moreover, the transdiaphragmatic spread of this tumor was also unique. Although pleural tumors and mediastinal tumors like thymoma may directly invade the muscular diaphragm and enter the abdominal cavity.[2] Clinicians should be aware of the fact that acute Budd--Chiari syndrome could be a presenting feature of an undiagnosed lung carcinoma and aggressive management is required to salvage these group of patients.
Figure 1: (a,b): H&E image showing sheets of large polygonal malignant cells. Intercellular bridges are also noted suggestive of well defined squamous cell carcinoma, (c) IHC positive for p63

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Figure 2: CECT showing- (a): Heterogeneously enhancing mass (blue arrow) in right hilar region causing obstruction of the right main bronchus resulting in complete collapse of right upper lobe. There is right sided lower lobe collapse consolidation with gross pleural effusion (yellow arrow). Multiple large metastatic lymph nodes (red arrow) are seen in the pretrachial and paravascular region, (b): large diaphragmatic deposit seen, which is invading the segment VII of liver (red arrow). There is enhancing retrohepatic IVC thrombus extending up to right atrium (yellow arrow). Hepatic veins have not been opacified, (c): Nutmeg appearance of liver (red *), hyperinflated contralateral lung field (yellow *), adrenal nodule (red arrow), enhancing partial thrombus (purple arrow) and mild ascites noted (yellow arrow)

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Figure 3: (a): Chest X-Ray showing “Golden S sign” (red arrow), Ultrasound evaluation showing- (b): thrombus in the inferior venacava (red arrow), (c): Diaphragmatic deposit (red arrow), (d): adrenal nodule (red arrow)

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Declaration of patient consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical committee approval

Not required in our institution to publish anonymous case reports

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Huang YW, Yang JC, Chang YL, Tsang YM, Wang TH. Acute pancreatitis combined with acute Budd-Chiari syndrome as the initial manifestation of small cell lung cancer. Journal of the Formosan Medical Association. 2005;104:431-5.  Back to cited text no. 1
Maher MM, Shepard JA. Imaging of thymoma. InSeminars in thoracic and cardiovascular surgery WB Saunders. 2005;17;12-9.  Back to cited text no. 2

Correspondence Address:
Arkadeep Dhali
Department of GI Surgery, IPGME&R, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpm.ijpm_885_21

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  [Figure 1], [Figure 2], [Figure 3]


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