Ovarian Clear Cell Carcinoma Presenting as Non-bacterial Thrombotic Endocarditis and Systemic Embolization

Abstract

Non-bacterial thrombotic endocarditis (NBTE) is a rare manifestation of cancer-induced hypercoaguability. It most commonly occurs in association with mucin-producing adenocarcinomas and has rarely been described with ovarian clear cell carcinoma (OCCC). We report a case of NBTE with multi-organ embolic infarcts occurring in a patient with early stage clear cell ovarian cancer. A 56 years old Caucasian female presented with leg pain, and left flank discomfort. Evaluation revealed multi-organ infarction, extensive deep vein thrombosis (DVT), and the incidental presence of an asymptomatic large ovarian mass with a laboratory picture consistent with disseminated intravascular coagulation (DIC). The diagnosis of NBTE was supported by echocardiogram and multiple negative bacteriological studies. She underwent surgical extirpation of an early stage OCCC and initiation of anticoagulation. Postoperatively, the patient’s hypercoaguability promptly resolved with gradual resolution of vegetations. Subsequent recurrence of the malignancy was heralded by a return of the prothrombotic state. This case shows a rarely reported association between NBTE and OCCC. It illustrates how the clinical picture of NBTE can dominate the initial presentation of an early stage and otherwise asymptomatic malignancy. Late recognition can lead to significant morbidity and a rapidly fatal course. Recurrent thromboembolism may be the first indication of disease recurrence.

Antemortem diagnosis of nonbacterial thrombotic endocarditis in a patient with previously resected pancreatic adenocarcinoma: a case report

“…There have been few reports where replacement of the affected valves has led to the resolution 5 of the disease. In some reports, resecting the cancer 6 or treating them with chemotherapy 6 , 7 have improved the haematological profile and prevented recurrent embolic events. Nonetheless, in the majority, the advanced nature of the underlying malignancy and concomitant comorbidity often precludes definitive surgery as was evident in this patient with an extremely high perioperative risk.…”

A case of multifocal stroke—the first presentation of underlying ovarian malignancy

“…NBTE has been reported as a manifestation of numerous malignancies, such as pancreas, stomach, colon, liver, gallbladder and ovarian [ 3 ]. Clinically, this is seen as valvular lesions composed of platelets and fibrin [ 6 ].…”

Correction of coagulopathy associated with non-bacterial thrombotic endocarditis (NBTE) by surgical debulking in a case of ovarian clear cell carcinoma

“…NBTE has been described previously in association with multiple gynecologic malignancies ( Delgado & Smith, 1975 ), but most often with ovarian cancer. Of four cases of NBTE identified in association with ovarian clear cell carcinoma, two presented during metastatic recurrence ( Devulapalli et al, 2012 Jan , Yilmaz et al, 2015 ), and two during primary presentation of the malignancy ( Oueida and Scola, 2011 Oct 28 , Aryana et al, 2006 Dec ).…”