Pulmonary hypertension attributable to neoplastic emboli: An autopsy study of 20 cases and a review of literature

Percutaneous transcatheter aspiration of pulmonary embolism leading to diagnosis of hepatocellular carcinoma tumor embolus and change in systemic chemotherapy

The management of metastatic hepatocellular carcinoma (HCC) is complex, particularly when complicated by pulmonary embolism. In these cases, atezolizumab-bevacizumab therapy is contraindicated due to an elevated risk of thromboembolic events. Differentiating pulmonary tumor embolism from thromboembolic disease is diagnostically challenging. This report outlines the benefit of transcatheter aspiration to obtain pathological evidence of pulmonary artery tumor embolus in an HCC patient. The intervention enabled a significant shift in the management strategy, leading to an escalation of systemic HCC therapy. This case underscores the importance of precise diagnostic techniques such as transcatheter aspiration in guiding treatment decisions, particularly in cases where pulmonary embolism may signify an underlying malignancy-driven process.

Clinical-radiological-pathological correlation in pulmonary hypertension with unclear and/or multifactorial mechanisms

Ever since the second world symposium on pulmonary hypertension (PH) held in Evian, France, in 1998, PH has been classified into five major clinical groups. Group 5 PH includes a variety of distinct conditions with unclear and/or multifactorial underlying pathologies. Management of these patients is challenging as the number of patients within these groups is often small, not all individuals with certain underlying conditions are affected by PH and patients exhibit distinct symptoms due to different underlying diseases. Studies and clinical trials in these groups are largely lacking and mostly restricted to case series and registry reports. Nonetheless, the worldwide burden of group 5 PH is estimated to be significant in terms of the prevalence of some associated diseases. Group 5 PH encompasses six subgroups, including haematological disorders (inherited and acquired chronic haemolytic anaemia and chronic myeloproliferative disorders), systemic disorders (sarcoidosis, pulmonary Langerhans's cell histiocytosis and neurofibromatosis type 1), metabolic disorders (glycogen storage diseases and Gaucher disease), chronic renal failure with or without haemodialysis, pulmonary tumour thrombotic microangiopathy and fibrosing mediastinitis.

Pulmonary tumor embolism secondary to urothelial carcinoma of urinary bladder: case report and literature review

BACKGROUND

Tumor embolism is the least well-described cause of pulmonary embolism, taking into account the non-specificity of radiographic and nuclear imaging results, the necessity of anatomopathological evidence and the frequency of deep venous thrombosis in the course of solid tumors, suggesting thus thromboembolism.

CASE PRESENTATION

We report a rare case of urothelial carcinoma of the urinary bladder associated with persistent pulmonary embolism despite being on different anticoagulation regimens, the patient was ultimately found to have tumor thrombus in the pulmonary trunk secondary to tumoral extension. We provide a literature review as well about the diagnosis, evaluation and prognosis and of this rare clinical entity.

CONCLUSIONS

Our case highlights the importance of keeping this unusual etiology in mind, particularly when faced with pulmonary embolism occurring in the context of a solid tumor and the ineffectiveness of various anticoagulation protocols. Furthermore, it emphasizes the pivotal role of cytology in confirming diagnosis and guiding therapy.

An unexpected cause of pulmonary hypertension in a young woman: a case report

Background

Pulmonary hypertension (PH) is defined as a progressive disease that leads to right heart failure and death if untreated. This case report presents a young woman with reversible precapillary PH in the setting of a gastric cancer.

Case summary

A 37-year-old woman presented with exertional dyspnoea and syncope. The transthoracic echocardiographic findings were consistent with a cor pulmonale. Right heart catheterization (RHC) proved a precapillary PH. Specific PH therapy with macitentan and tadalafil was initiated. Shortly thereafter, a gastric carcinoma was diagnosed, and oncologic treatment with neoadjuvant chemotherapy and subsequent gastrectomy was promptly initiated. Retrospectively, we considered a pulmonary tumour thrombotic microangiopathy the most probable cause of PH. Follow-up after successful oncologic treatment and cumulative 10 months of specific PH medication showed an excellent clinical response with complete remission of PH confirmed by RHC at rest.

Discussion

Tumour-related PH is very rare and might be largely underdiagnosed as the clinical course often results in a rapid deterioration and fatal outcome before diagnostics are completed. Post mortem studies have documented tumoural emboli in pulmonary microcirculation in ∼26% of patients with a solid tumour, markedly associated with adenocarcinoma. Prompt initiation of cancer treatment on tumoural PH is essential. To our knowledge, this report documents the first full recovery of tumoural PH at rest after successful cancer treatment and temporary specific PH medication. We therefore conclude that a multidisciplinary approach with an initially combined oncologic and PH therapy may be most beneficial with the potential of complete remission of PH.

Beyond Clots in the Pulmonary Circulation: Pulmonary Artery Tumors Mimicking Pulmonary Embolism

Pulmonary embolism (PE) is the most common filling defect seen on CT scan pulmonary angiography. Pulmonary artery (PA) tumors can mimic PE on imaging and clinical presentation. One classic feature of tumors is failure to improve on anticoagulation. PA tumors, particularly malignant ones, have radically different treatments and usually have a grim prognosis. Thus, it is essential that PA tumors, when suspected, receive an expedited confirmatory diagnosis followed by multidisciplinary treatment at an expert center. In this review, we present clinical, imaging, and histopathologic features of benign and malignant PA tumors, emphasizing differentiating features from PE. We also describe available diagnostic and treatment methods for PA tumors.

Pulmonary tumour embolism and lymphangitis carcinomatosa: a case report and review of the literature

Background

Pulmonary tumour embolism and lymphangitis carcinomatosa are complications of malignancy that may mimic the clinical presentation of pulmonary embolism.

Case presentation

We present the case of a 52-year-old male patient with acute-onset right ventricular strain and dyspnoea with elevated D-dimer and without signs of pulmonary embolism on computed tomography pulmonary angiogram (CTPA) and ventilation/perfusion scintigraphy. The patient died eleven days after initial presentation. The diagnosis of pulmonary tumour embolism and lymphangitis carcinomatosa due to carcinoma of unknown origin was made post-mortem by immunohistochemical examination.

Conclusion

Pulmonary tumour embolism and lymphangitis carcinomaosa are complications of malignancy and potential causes of acute right ventricular strain. Radiological signs are unspecific and the clinical course usually fatal. These differential diagnoses should be considered in patients with acute right ventricular strain, dyspnoea and positive D-dimer if there are no signs of pulmonary embolism on CTPA.

A Rapid Change in Pressure

A 74-year-old woman presented with a 6-week history of progressive dyspnea on exertion. Eight weeks before this presentation, she had been traveling in Italy and had been walking up to 4 miles per day. Progressive dyspnea on exertion had developed after she returned to the United States. She also noted a nonproductive cough, fatigue, loss of appetite, and an unintentional weight loss of 9 kg over the previous 6 months. She had no fevers, chills, night sweats, hemoptysis, wheezing, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, swelling of the legs or feet, abdominal pain, nausea, vomiting, melena, or hematochezia. Four weeks before this presentation, she had presented to an emergency department at another institution, where imaging was performed. Chest radiography showed no pneumonia, and venous ultrasonography of both legs showed no deep venous thrombosis. A 5-day course of prednisone and azithromycin was prescribed; however, her symptoms continued to worsen, and she began to have dyspnea when she was at rest.

Occult malignancy underlying a case of "hyperacute" onset of severe pulmonary hypertension

“Tumoral pulmonary hypertension (PH)” includes several subtypes of conditions leading to abnormal levels of pulmonary artery or venous pressure occurring in patients with a current or previous malignancy. Pulmonary tumour “microvascular disease” includes both pulmonary tumour microembolism (PTE) and pulmonary tumour thrombotic microangiopathy (PTTM) that are likely to be part of the same spectrum disease [1]. PTE was described in early studies, and was defined as the occlusion of the pulmonary microvasculature by tumour cells and associated thrombi. Tumour thrombi are frequently formed by malignant cells, platelets and fibrin, and are highly resistant to recanalisation and lead to an irreversible obstruction. In many cases, they are associated with vascular tissue reaction characterised by extensive fibrocellular intimal hyperplasia of small pulmonary arteries initiated by tumour microemboli known as PTTM [1, 2]. Most reported cases of PTE occur in association with adenocarcinomas, including liver [3, 4], kidney, breast [5, 6], stomach [4, 7], bladder and choriocarcinoma [8]. In a handful of cases of PTE, estimated at 5% [9], the primary cancer is unknown. Ante mortem diagnosis of PTE is often challenging and the majorities of cases are identified as results of post mortem studies. This is especially true for a subset of patients with occult malignancy and acute onset of severe PH.

Investigations in a patient with new-onset pulmonary hypertension should include screening for undiagnosed malignancyhttp://bit.ly/2mrLmGM

Pulmonary hypertension in metastatic breast cancer: a case of pulmonary tumour thrombotic microangiopathy

Pulmonary tumour thrombotic microangiopathy (PTTM) and pulmonary tumour emboli (PTE) are distinct but related complications of malignancy. The incidence of each is exceedingly rare, unfortunately often being diagnosed postmortem. Patients with PTTM and PTE typically present with dyspnoea associated with a rapid onset of hypoxia due to pulmonary hypertension (PH), and respiratory failure that is almost certain to be fatal. The prognosis is grim due to the rapidity of the clinical decline and difficulty in establishing an ante-mortem diagnosis. We present a case of new-onset severe PH in a young woman with a recently discovered breast mass. She presented with shortness of breath and experienced rapid deterioration of her cardiopulmonary status which we attributed to PTTM. With early initiation of chemotherapy, systemic steroids and sildenafil, the patient dramatically improved. Case reports have identified early use of steroids, phosphodiesterase inhibitors and other alternative therapies as providing possible benefit in PTTM.

Tumoral pulmonary hypertension

Tumoral pulmonary hypertension (PH) comprises a variety of subtypes in patients with a current or previous malignancy. Tumoral PH principally includes the tumour-related pulmonary microvascular conditions pulmonary tumour microembolism and pulmonary tumour thrombotic microangiopathy. These inter-related conditions are frequently found inpost mortemspecimens but are notoriously difficult to diagnoseante mortem. The outlook for patients remains extremely poor although there is some emerging evidence that pulmonary vasodilators and anti-inflammatory approaches may improve survival. Tumoral PH also includes pulmonary macroembolism and tumours that involve the proximal pulmonary vasculature, such as angiosarcoma; both may mimic pulmonary embolism and chronic thromboembolic PH. Finally, tumoral PH may develop in response to treatments of an underlying malignancy. There is increasing interest in pulmonary arterial hypertension induced by tyrosine kinase inhibitors, such as dasatanib. In addition, radiotherapy and chemotherapeutic agents such as mitomycin-C can cause pulmonary veno-occlusive disease. Tumoral PH should be considered in any patient presenting with unexplained PH, especially if it is poorly responsive to standard approaches or there is a history of malignancy. This article will describe subtypes of tumoral PH, their pathophysiology, investigation and management options in turn.

Neoplastic embolization to systemic and pulmonary arteries

OBJECTIVE

Arterial neoplastic emboli are uncommon, accounting for <1% of thromboemboli in the current literature. Nonetheless, this event may be associated with significant morbidity and mortality. Herein, we report a series of 11 cases of arterial neoplastic emboli from a single tertiary care center along with a comprehensive review of the literature to date. The aim of this study was to document the incidence, clinical presentations, and complications of arterial neoplastic emboli as well as to highlight the importance of routine histologic examination of thrombectomy specimens.

METHODS

Pathology archives from a single tertiary care institution were queried to identify cases of surgically resected arterial emboli containing neoplasm (1998-2014). Histopathology was reviewed for confirmation of diagnosis. Patient demographics and oncologic history were abstracted from the medical record. Comprehensive literature review documented 332 patients in 275 reports (1930-2016).

RESULTS

Eleven patients (six men) with a median age of 63 years (interquartile range, 42-71 years) were identified through institutional archives. Embolism was the primary form of diagnosis in seven (64%) cases. Cardiac involvement (primary or metastasis) was present in more than half of the cohort. Comprehensive literature review revealed that pulmonary primaries were the most common anatomic origin of arterial neoplastic emboli, followed by gastrointestinal neoplasia. Cardiac involvement was present in 18% of patients, and sentinel identification of neoplasia occurred in 30% of cases. Postmortem evaluation was the primary means of diagnosis in 27%.

CONCLUSIONS

This study highlights the importance of routine histopathologic evaluation of embolectomy specimens in patients with and without documented neoplasia.

Pulmonary tumor thrombotic microangiopathy successfully treated with corticosteroids: a case report

BACKGROUND

Pulmonary tumor thrombotic microangiopathy is a special type of tumor thromboembolism. We report the case of a patient who developed pulmonary tumor thrombotic microangiopathy with alveolar hemorrhage. Almost all patients with pulmonary tumor thrombotic microangiopathy die within 1 week of the onset of dyspnea; however, the prognosis in this case was better, with 10 weeks of survival from presentation.

CASE PRESENTATION

A 62-year-old Japanese man was referred to our hospital with a 4-week history of dyspnea on exertion and severe pulmonary hypertension. Five years previously, he had undergone distal gastrectomy for gastric cancer. He was afebrile, normotensive, and hypoxemic. A physical examination was unremarkable except for purpura on his upper extremities and trunk. Blood tests showed anemia and disseminated intravascular coagulation. Chest computed tomography revealed diffuse ground-glass opacities with emphysema in his upper lungs, moderate pleural effusions, mediastinal lymphadenopathy, and enlargement of the right ventricle and main pulmonary artery. A computed tomography pulmonary angiogram showed no evidence of pulmonary embolism. Lung perfusion scintigraphy showed multiple segmental defects. Although recurrence of gastric cancer was confirmed from the results of bone marrow biopsy, bronchoscopy was not performed due to bleeding diathesis. He was treated with corticosteroids, antibiotics, and platelet transfusion, following which resolution of the abnormal lung shadows and right ventricular pressure overload along with partial alleviation of respiratory failure was observed. Because of his poor performance status, he was eventually transited to palliative care and died 6 weeks after admission. Necropsy of the lung confirmed the diagnosis of pulmonary tumor thrombotic microangiopathy with alveolar hemorrhage.

CONCLUSIONS

Pulmonary tumor thrombotic microangiopathy should be considered in the differential diagnosis of patients with cancer who present with severe pulmonary hypertension. In pulmonary tumor thrombotic microangiopathy, local inflammation in pulmonary microvasculature may contribute to pulmonary hypertension, and regulation of inflammation using corticosteroids may help improve the prognosis.

Pulmonary tumor embolism secondary to soft tissue and bone sarcomas: a case report and literature review

Background

Tumor embolisms (TE) are an underappreciated source of pulmonary embolisms in sarcoma. Most evidence in the literature is limited to case reports and none have described the presence of TE secondary to myxofibrosarcoma. We report the first case of myxofibrosarcoma TE and perform a review of the literature for TE secondary to bone and soft tissue sarcomas (STS).

Case presentation

A 36-year-old female presented with debilitating pain of the right upper extremity secondary to a recurrent soft tissue sarcoma. She had distant metastasis to the lung. An MRI revealed a 25-cm shoulder mass involving the proximal arm muscles with encasement of the axillary artery, vein, and brachial plexus. A palliative forequarter amputation was performed and tumor thrombus was evident within the axillary artery and vein. Postoperatively, she developed an acute onset of dyspnea and hypoxia. A computed tomography scan revealed a pulmonary saddle embolism. A bilateral lower extremity venous duplex was negative. She became hemodynamically unstable despite resuscitation and was placed on vasopressor support. A transthoracic echocardiogram revealed elevated pulmonary artery pressure, tricuspid regurgitation, right heart dilation, and reduced right heart systolic function consistent with acute cor pulmonale. The patient did not want to pursue a median sternotomy with pulmonary artery embolectomy and expired from cardiopulmonary arrest within 24 h of the operation. The final pathology revealed a 25 × 16 × 13 cm high-grade myxofibrosarcoma with invasion into the bone, skin, and neurovascular bundle as well as evidence of tumor thrombus.

Conclusion

TE is a rare but deadly cause of pulmonary embolism in sarcoma. A high index of suspicion is necessary in individuals who present with respiratory-related symptoms, especially dyspnea. Diagnostic confirmation with a computed tomography scan of the chest and echocardiogram should be rapid. Unlike venous thromboembolism, pulmonary embolectomy remains the preferred therapeutic approach.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-017-1223-3) contains supplementary material, which is available to authorized users.

Extracorporeal Lung Support as a Bridge to Diagnosis of Pulmonary Tumor Embolism

Bridging to diagnosis is an emerging technique used in end-stage cardiorespiratory failure that prolongs a patient's life using various modalities of extracorporeal lung support (ECLS) to achieve antemortem diagnosis. Pulmonary tumor embolism occurs when cell clusters travel from primary malignancies through venous circulation to the lungs, causing respiratory failure through inflammatory and venoocclusive pathways. Due to its nonspecific symptomatology, pulmonary tumor embolism remains an elusive diagnosis antemortem. Herein, we bridge a patient who presented in acute respiratory failure to the diagnosis of pulmonary tumor embolism from a gastric signet-ring cell carcinoma using ECLS modalities including venoarterial extracorporeal membrane oxygenation and centrally cannulated Novalung pumpless extracorporeal lung assist. We demonstrate the utility of this approach in diagnostically uncertain cases in unstable patients who are potentially acceptable ECLS and transplant candidates.

Pulmonary Tumor Thrombotic Microangiopathy Caused by a Parotid Tumor: Early Antemortem Diagnosis and Long-term Survival

Pulmonary tumor thrombotic microangiopathy (PTTM) is a high-mortality disease that is difficult to diagnose clinically. Our patient was an 80-year-old woman who came to us due to symptoms of increasing dyspnea. A clinical evaluation showed that she had hypoxemia and pulmonary arterial hypertension without any abnormalities in the major pulmonary arteries, bronchi, or alveoli. A lung perfusion scan showed multiple wedge-shaped perfusion defects. Further examination revealed adenocarcinoma in her right parotid gland with metastasis to the submandibular lymph nodes. We diagnosed her to have PTTM caused by a parotid tumor. The patient survived for 11 months with chemotherapy. An early antemortem diagnosis by minimally invasive examinations will help PTTM patients to survive longer.

Unusual Development of Pulmonary Tumor Embolism from Controlled Liver Metastases of Transitional Cell Carcinoma: An Autopsy Case

Clinicians generally suspect pulmonary tumor embolism (PTE) with uncontrolled carcinomas which often spread to lungs. We, however, experienced an autopsy case of diffuse microscopic PTE despite controlled liver metastases of transitional cell carcinoma (TCC). A 66-year-old man with progressing respiratory symptoms showed almost normal chest findings on computed tomography. Although liver metastases were successfully shrunk by chemotherapy, the patient died from aggressive respiratory failure. An autopsy revealed small pulmonary vessels showing diffuse tumor emboli. TCC can cause PTE even if liver metastases are controlled. We must therefore be aware that PTE can manifest as respiratory symptoms without any computed tomography findings.

Progressive diffuse pulmonary interstitial opacities due to complications of pulmonary tumor emboli: an autopsy case report

A 76-year-old man complaining of exertional dyspnea was admitted to our hospital. Chest computed tomography revealed bilateral diffuse ground-glass opacities and small nodules. A transbronchial lung biopsy revealed tumor cell emboli in the pulmonary arteries. The patient was diagnosed with gastric adenocarcinoma using an endoscopic stomach biopsy; however, the interstitial opacities progressively worsened and he died of acute respiratory failure. An autopsy revealed extensive pulmonary tumor embolisms (PTE) with associated ischemic damages, e.g., infarctions, alveolar wall thickening with cuboidal metaplasia, hemorrhage, and diffuse alveolar damage. The ground-glass opacities in the chest computed tomography findings appear to correlate with the pathological ischemic changes associated with PTE.

Sudden unexpected death in a patient with tumour associated pulmonary embolism

Tumour embolisms are rare and in most cases sudden causes of death. Diagnosing this rare condition is still very challenging in the daily clinical routine. In this report we present a case of a lethal sudden pulmonary tumour embolism in a 71-year-old male patient, who was admitted for elective invasive coronary angiography due to suspected coronary artery disease. The patient had suspected Ormond's disease and no previous history of tumour burden. Possible diagnostic and treatment options are discussed herein and an overview of the current literature is also presented.

Tumors of the pulmonary artery and veins

The pulmonary vasculature may be involved by different primary and secondary tumors. Poorly differentiated and undifferentiated sarcomas are the most common primary tumors of the pulmonary arteries. They tend to affect the large caliber pulmonary vessels and present with predominantly intraluminal growth. Pulmonary and mediastinal metastasis are common, and prognosis is poor. Clinical and imaging manifestations may mimic those of pulmonary embolism. Dyspnea, chest pain, cough, and hemoptysis are the most common presenting symptoms. Primary sarcomas arising from the central pulmonary veins are less common than their arterial counterpart. Secondary involvement of the pulmonary arteries and veins by primary and metastatic pulmonary malignancies is more common. Tumoral embolism may also affect the pulmonary arteries. They may develop from different intrathoracic and extrathoracic malignancies and may be indistinguishable from venous thromboembolism. It may manifest as cor pulmonale with right cardiac strain and dilated pulmonary arteries. Computed tomography, magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography may help in the differentiation between these 2 conditions.

Chondrosarcoma presenting as dyspnea in a 19-year-old man: a case report

Introduction

Acute pulmonary embolism has varied presentations ranging from asymptomatic, incidentally discovered emboli to massive embolism, causing immediate death. Tumor embolism is a rare but unique complication of malignancies. This uncommon catastrophe of a malignant tumor in a young patient, culminating as a pulmonary embolism, is being reported for the first time.

Case presentation

A 19-year-old Asian man presented to the emergency service at our hospital with acute onset dyspnea. His clinical examination led to the suspicion of an acute pulmonary embolism with a lower lumbosacral radiculopathy. A magnetic resonance imaging scan of the pelvis demonstrated a chondrosarcoma arising from the right iliac wing, eroding into the common iliac vein and creeping up the inferior vena cava to lodge in the pulmonary artery, thus producing a saddle embolus.

Conclusion

The importance of exploring for malignancies in the event of an idiopathic pulmonary embolism is highlighted. Early detection of such malignancies can substantially affect the outcome in young patients.

Metastatic osteosarcoma presenting as a single pulmonary microembolus

There are only a few published reports of tumor emboli from osteosarcoma. We are reporting a 17-year-old adolescent boy with a history of localized osteosarcoma who developed a symptomatic pulmonary artery tumor embolus. He was initially diagnosed with a pulmonary thromboembolism. This is the first reported case of a single tumor embolus developing after surgical resection of a tumor with 100% necrosis after chemotherapy and no evidence of metastatic disease at the time of surgery. Pulmonary tumor embolism should be considered in the differential diagnosis in patients with cancer who present with dyspnea. The differentiation of tumor embolus from other causes of dyspnea is important for treatment plan.

Avoiding underdiagnosis, overdiagnosis, and misdiagnosis of lung carcinoma

CONTEXT

Given the magnitude of the therapeutic and prognostic implications, it is critical that pathologists diagnose lung cancer accurately. This can sometimes be a formidable challenge, as a number of benign entities mimic lung carcinoma and vice versa.

OBJECTIVE

To present strategies for recognizing benign entities likely to be confused with lung carcinoma, malignancies of the lung prone to misinterpretation as benign, and commonly misclassified pulmonary neoplasms.

DATA SOURCES

The medical literature and experience from consultative and surgical practice.

CONCLUSIONS

In addition to understanding the clinical context in which a lung biopsy is procured and the radiographic findings, appreciating the histologic distribution of disease and what, if any, pathologic features are present in the background can go a long way toward averting a misdiagnosis of lung cancer. Recognizing the limitations posed by small samples and communicating clearly to clinicians the level of diagnostic uncertainty are equally as important for establishing an accurate diagnosis of lung cancer.

Pulmonary tumor thrombotic microangiopathy from metastatic gallbladder carcinoma: an unusual cause of severe pulmonary hypertension

Pulmonary hypertension and cor pulmonale due to tumor emboli causing pulmonary tumor thrombotic microangiopathy (PTTM) is rare and extremely difficult diagnosis to make prior to death. Pulmonary hypertension due to metastatic tumor emboli should be included in the differential diagnosis of various causes of dyspnea in patients with a history of cancer or more common causes, including infection, thromboembolism, metastasis, adverse effects of drugs, and recurrent effusions. We describe a patient with gallbladder carcinoma who presented with progressive dyspnea and severe pulmonary hypertension. The etiology was tumor emboli and PTTM from gallbladder carcinoma, which remained elusive prior to her death despite appropriate clinical investigations and was established on autopsy. To the best of our knowledge, this is likely the second reported case of PTTM from metastatic gallbladder carcinoma.

Fatal cor pulmonale caused by pulmonary tumor microembolism in a patient with occult gastric cancer

BACKGROUND

A fatal pulmonary tumor microembolism is rarely caused by an occult gastric cancer.

METHODS AND RESULTS

We report the case of a 40-year-old woman who died after 3 days of progressive dyspnea, cough, and pulmonary hypertension. Postmortem examination demonstrated the presence of an occult diffuse-type gastric carcinoma, which had caused emboli in about 80% of small pulmonary arteries and arterioles. Despite an interatrial defect in the fossa ovalis, no parenchymal metastases were documented.

CONCLUSION

Pulmonary tumor microembolism may be suspected in patients complaining of unexplained progressive dyspnea and who develop acute or subacute cor pulmonale.

Cancer presenting as fatal pulmonary tumour embolism

Rapidly fatal pulmonary tumour embolism is a rare complication of malignancy, and often presents as progressive dyspnea without obvious cause. We describe two cases presenting with a dramatic clinical picture of lactic acidosis and cardiopulmonary arrest soon after admission on ICU. The first patient was a 29-year old woman with a breast cancer seeming in remission who was admitted with rapidly increasing dyspnea since two weeks. The second patient was a 46-year old woman with HIV and no history of malignancy, who developed dyspnea and lactic acidosis over the course of a few days while she was investigated for an occipital brain lesion. Both patients died soon after admission and massive tumour emboli were found on autopsy. Breast cancer was the origin of the emboli in both cases. Symptoms were out of proportion to the initial physical cardiopulmonary findings and radiographic features. Clinical signs of pulmonary tumour embolism are non-specific and subacute. Prognosis is poor and definite diagnosis is usually made post-mortem. Solid malignancies such as breast cancer account for most of the cases. Pulmonary tumour embolism should be considered in critically ill patients with unexplained hypoxemia and lactic acidosis, mild or no radiological abnormalities and fast clinical deterioration. It may occur in young patients and in patients without history of malignancy.

Surgical pathology of pulmonary thromboendarterectomy: a study of 54 cases from 1990 to 2001

Thromboendarterectomy is performed to treat chronic thromboembolic pulmonary hypertension with obstruction of main, lobar, or segmental pulmonary arteries. The present study evaluated surgical specimens removed between 1990 and 2001. Medical histories and microscopic slides were reviewed in each case. Study slides were stained with hematoxylin and eosin and Verhoeff-van Gieson and evaluated for thrombus, collagen, elastin, atherosclerosis, hemosiderin, calcification, and inflammation. The study group comprised 54 patients (30 women and 24 men), ranging in age from 33 to 77 years (mean, 58 years). Clinically, 28 (52%) had a history of deep leg vein thrombosis and 42 (78%) had a history of pulmonary embolism; 24 (44%) had both events. Coagulation abnormalities were documented in 15 (28%); autoimmune or hematologic disorders, in 8 (15%). Pulmonary thromboendarterectomy was bilateral in 52 patients (96%) and right-sided in 2. Six patients also had obstructions resected from the main pulmonary arteries. Obstruction limited to segmental arteries occurred only in women. Grossly, right-sided specimens were larger than left-sided ones (P = 0.003). Microscopically, ages of thrombi were uniform in 72% and variable in 28%. Intima was thickened in all patients and consisted of collagen (100%), elastin (67%), hemosiderin (56%), inflammation (53%), atherosclerosis (32%), and calcification (15%). We determined that pulmonary thromboendarterectomy was performed most often in middle-aged and elderly patients with a history of deep venous thrombosis or pulmonary embolism. Less than 50% of the patients had an identifiable coagulation, autoimmune, or hematologic abnormality. Most patients had bilateral disease and resections. Right-sided specimens were significantly larger than left-sided specimens, and lower lobe involvement was more common than involvement elsewhere. Resected tissues most commonly exhibited old organized thrombus.

Pulmonary tumor embolism: a review of the literature

Dyspnea in a patient with cancer may have several causes, including infection, thromboembolism, metastases, and therapeutically induced cardiopulmonary disease. Pulmonary tumor embolism is an uncommon cause. Occlusion of the pulmonary microvasculature by tumor cells and associated thrombi can produce a subacute and progressive clinical picture that resembles thromboembolic disease. Unfortunately, microscopic tumor embolism is recognized rarely before death because of difficulty in establishing the diagnosis. We provide a review of the literature about the evaluation and diagnosis of this rare clinical entity.

Vascular intimal carcinomatosis: an autopsy case of unusual form of pulmonary metastasis of transitional cell carcinoma

A 44-year-old woman with an unusual form of pulmonary metastasis is described. She presented with pulmonary thrombosis and clinical signs of disseminated intravascular coagulation (DIC) and died of cerebral hemorrhage. The autopsy study revealed transitional cell carcinoma of the left renal pelvis with pulmonary thrombosis in the large arteries. The intima of the vessels were intact on gross inspection except where the thrombi adhered to. The thrombi contained no tumor cells. However, microscopic examination identified that the metastatic carcinoma diffusely replaced the endothelium and proliferated on to the intimal surface without invasion of the wall and metastatic nodules in the parenchyma. Other examined organs had neither primary nor metastatic tumors, except for microscopic metastasis to the inferior vena cava. To date, this pattern of metastasis has not been noted in previous literature. This condition was designated as being vascular intimal carcinomatosis because of its characteristic manner of tumor proliferation on vascular intima.