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

Successful chemotherapy management of disseminated intravascular coagulation presenting with metastatic clear cell renal carcinoma: a case report and review of the literature

Background

Disseminated intravascular coagulation is a critical complication of advanced clear cell renal cell carcinoma, despite the rarity of the occurrence of disseminated intravascular coagulation in such tumors. The diagnosis of cancer-related disseminated intravascular coagulation is mostly based on clinical bleeding and laboratory test; available data suggest that treating the primary cancer also treats the disseminated intravascular coagulation. Among three reported cases of renal cell carcinoma-related disseminated intravascular coagulation in the literature, this is the first patient whose disseminated intravascular coagulation was successfully treated, in particular, with chemotherapy without any anti-disseminated intravascular coagulation therapies.

Case presentation

This case is a 66-year-old Vietnamese man who presented disseminated intravascular coagulation 2 weeks after his admission for severe back pain. At admission, his initial laboratory work-up revealed only a mild thrombocytopenia with a platelet count of 93 × 10⁹/L (normal range, 150–450 × 10⁹/L) without clinical bleeding. His past medical history and family history were unremarkable. An open-biopsy was performed and the definitive diagnosis was bone metastatic clear cell renal cell carcinoma based on immunohistochemistry. Two weeks after admission, the diagnosis of disseminated intravascular coagulation was confirmed according to the International Society on Thrombosis and Haemostasis. Immediately, he was treated with a paclitaxel plus carboplatin regimen and disseminated intravascular coagulation completely disappeared after one cycle of systemic chemotherapy. Until recently, 11 months subsequent to the diagnosis of disseminated intravascular coagulation, he had been being undergoing maintenance therapy for metastatic clear cell renal cell carcinoma.

Conclusions

First, an early detection of overt disseminated intravascular coagulation is essential, although disseminated intravascular coagulation in cancer presents as a chronic or even subclinical process with unique thrombocytopenia. Second, making a decision of systemic chemotherapy without delay at the time of disseminated intravascular coagulation diagnosis is the key to successful cancer-related disseminated intravascular coagulation treatment.

Pulmonary tumor thrombotic microangiopathy with cor pulmonale due to desmoplastic small round cell tumor

A 12-year-old boy presented acutely after an episode of syncope with perioral cyanosis. He died 19 hours after admission due to cor pulmonale as a complication of metastatic desmoplastic small round cell tumor in the lungs with associated tumor thrombotic microangiopathy.

Extensive endothelial replacement by tumor cells in the portal system: an autopsy case of intrahepatic cholangiocarcinoma

An autopsy case of intrahepatic cholangiocarcinoma (ICC) with a peculiar form of extensive portal invasion is reported here. A 76-year-old woman presented with anorexia and abdominal discomfort. A high level of serum carbohydrate antigen 19-9 and endoscopically detected esophageal varices were found. Obvious mass lesion was not identified on CT scan and no portal blood flow was found. The patient died 6 months after admission. At autopsy multiple irregular shaped tumors in the liver were found. The size of the largest one was 3 x 2 cm. These tumors were well-differentiated adenocarcinomas with partial mucinous carcinoma morphology. Surprisingly, portal veins contained mucinous fluid and the inner surface was lined with a single layer of tumor cells but not endothelial cells. Invasion of carcinoma into the tissue outside the blood vessels was hardly observed in organs other than the liver. This form of extensive invasion of the tumor, termed intimal carcinoma spreading, caused complete obstruction of the portal system. To our knowledge there has been no report on this type of portal invasion of ICC.

Pulmonary tumor thrombotic microangiopathy resulting from metastatic signet ring cell carcinoma of the stomach

Pulmonary tumor thrombotic microangiopathy is an unusual malignancy-related respiratory complication characterized by multiple microthrombi and intimal myofibroblast proliferation. Its clinical manifestation is subacute respiratory failure with pulmonary hypertension. Herein is reported a case of pulmonary tumor thrombotic microangiopathy associated with gastric signet ring cell carcinoma. A 51-year-old woman with gastric cancer died of subacute respiratory failure. Autopsy showed gastric signet ring cell carcinoma with diffuse metastasis of pulmonary lymphatics and pleurae; every organ examined lacked a space-occupying tumor mass. Histologically, proliferated intimal myofibroblasts obliterated most of the pulmonary vascular lumen, and a few stenosed vascular lumina contained cancer cells. In addition, pulmonary vasculature associated with intimal proliferation contained microthrombi. Most cancer cells in the stomach and pulmonary lymphatics were typical signet ring cells, whereas those in vascular lesions were cells of poorly differentiated adenocarcinoma without mucous production. Consistent with a previous report, the latter expressed vascular endothelial growth factor (VEGF) and tissue factor (TF). The proliferated intimal myofibroblasts also expressed type 2A serotonin receptor (5-HT(2A)). These findings suggest that local expression of VEGF, TF, and 5-HT(2A) may be linked to the pathogenesis of this unusual pulmonary complication.

Solitary cerebral metastasis from transitional cell carcinoma of the urinary tract

We present a patient with a solitary cerebral metastasis from a transitional cell carcinoma of the right renal pelvis in the right occipital lobe with intratumoral hemorrhage. Despite aggressive multimodality management the patient died within 3 months of presentation due to widespread systemic disease.

Annexin 2 and hemorrhagic disorder in vascular intimal carcinomatosis

Vascular intimal carcinomatosis refers to a characteristic tumor proliferation on vascular intima that replaces normal endothelium. This pathological event of unknown cause is quite different from tumor thrombotic microangiopathy due to the absence of thrombi on the tumor cell surfaces. We analyzed renal transitional cell carcinoma cases with metastasis to the main pulmonary arteries and marked hyperfibrino(geno)lysis. The fibrinogen-derived products from patients' plasma were identified as D1A/gamma, D1/gamma, and D1/beta by immunoblotting with the NH2-terminus of the fragment D specific antibody JIF-23. In all cases, the neoplastic cells with vascular intimal carcinomatosis were stained positive for anti-human annexin 2, which is a unique cell surface co-receptor for plasminogen and tissue-type plasminogen activator. In contrast, normal renal pelvic mucosa or renal transitional cell carcinoma without vascular intimal carcinomatosis did not express any annexin 2. The isolated transitional cell carcinoma cells contained annexin 2 mRNA and expressed its protein. Anti-annexin 2 antibody and transfection of annexin 2 small interfering RNA into these carcinoma cells significantly inhibited tissue-type plasminogen activator dependent plasmin generation. These findings suggest that annexin 2 mediated fibrinolysis on the transitional cell carcinoma cells may play a role in inducing hemorrhagic disorder in vascular intimal carcinomatosis.

Tumors of the pulmonary vasculature

Most primary tumors of the pulmonary vasculature are sarcomas arising in the main pulmonary arteries and veins with high mortality rates. Pulmonary artery sarcoma is far more prevalent than its venous counterpart, though both are rare. Pulmonary capillary hemangiomatosis is a rare low-grade tumor or tumor-like lesion of the pulmonary capillaries that causes severe pulmonary hypertension. Secondary involvement of pulmonary vasculature by malignant tumors may rarely mimic a primary vascular tumor or clinically present as unexplained pulmonary hypertension associated with thrombotic microangiopathy.