1
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Ramakrishnan P, Dahiya G, Lindstrom M, Thenappan T. Pulmonary tumor thrombotic microangiopathy: Exploration into current diagnostic aids and therapeutics. Pulm Circ 2023; 13:e12278. [PMID: 37593090 PMCID: PMC10427771 DOI: 10.1002/pul2.12278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/19/2023] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is an under-recognized cause of pulmonary hypertension and fulminant right ventricle failure. It is associated with a high mortality due to delay in diagnosis. We present two cases of PTTM, both diagnosed postmortem, highlighting the importance of timely identification and initiation of treatment for this near-fatal condition.
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Affiliation(s)
| | - Garima Dahiya
- Cardiovascular Division, Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Meghan Lindstrom
- Department of PathologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Thenappan Thenappan
- Cardiovascular Division, Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
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2
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CARREIRA M, LISBOA-GONÇALVES P, MATOS MI, FLORES L, CUNHA F, VON HAFE P. Relapsing uterine adenosarcoma presenting as pulmonary hypertension. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.21.04574-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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3
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Kamakura M, Okazaki A, Ito K, Kin F, Miyajima K, Takashima Y, Watanabe T, Kawaguchi Y, Wakabayashi Y, Asano M, Maekawa Y. Concomitant Pulmonary and Cerebral Tumor Embolism and Intracardiac Metastasis from Bladder Cancer. Intern Med 2021; 60:3749-3753. [PMID: 34120999 PMCID: PMC8710365 DOI: 10.2169/internalmedicine.6765-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
An 82-year-old woman with a history of bladder cancer presented with dyspnea and loss of consciousness. Contrast-enhanced computed tomography revealed pulmonary embolism, and emergency thrombus aspiration therapy was performed, but the thrombus was not aspirated. Echocardiography showed mobile masses in the heart and a right-to-left shunt due to a patent foramen ovale (PFO). Magnetic resonance imaging showed multiple cerebral infarctions. Surgical thrombectomy and PFO closure were performed, and the patient was diagnosed with intracardiac metastasis of bladder cancer based on intraoperative histopathology. This is a rare case of concomitant pulmonary and cerebral tumor embolism and intracardiac metastasis from bladder cancer.
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Affiliation(s)
| | - Ayako Okazaki
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Kazuki Ito
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Fumihiko Kin
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Keisuke Miyajima
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | - Yasuyo Takashima
- Department of Cardiology, Seirei Mikatahara General Hospital, Japan
| | | | | | | | - Mitsuru Asano
- Department of Cardiac Surgery, Seirei Mikatahara General Hospital, Japan
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
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4
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(Severe pulmonary hypertension as the first manifestation of gastric cancer in a young man). COR ET VASA 2021. [DOI: 10.33678/cor.2021.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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5
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Taniguchi J, Nakashima K, Matsuura T, Yoshikawa A, Honma K, Homma Y, Kubota N, Yoshimi M, Otsuki A, Ito H. Long-term survival of a patient with uterine cancer-induced pulmonary tumor thrombotic microangiopathy following treatment with platinum-based chemotherapy and bevacizumab: A case report. Respir Med Case Rep 2021; 33:101447. [PMID: 34401286 PMCID: PMC8349034 DOI: 10.1016/j.rmcr.2021.101447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 11/30/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare but fatal cancer-related disease. Owing to its non-specific findings, aggressive course, and lack of established treatment guidelines, only a few cases of antemortem diagnosis in long-term survivors have been reported. We aimed to report a case of uterine cervical cancer induced PTTM that was suspected based on pulmonary hypertension and successfully treated using combination chemotherapy despite of delayed diagnose. It is important to be aware that PTTM should be suspected when respiratory failure occurs in patients with unexplained pulmonary hypertension. Multidisciplinary treatments including molecular targeted therapies might be effective treatment options.
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Key Words
- BAL, bronchoalveolar lavage
- Bevacizumab
- CT, computed tomography
- Case report
- EBUS-TBLB, endobronchial ultrasound-guided transbronchial lung biopsy
- FDG, fluorodeoxyglucose (18F)
- GGO, ground glass opacity
- PAP, pulmonary arterial pressure
- PAWP, pulmonary arterial wedge pressure
- PDGF, platelet-derived growth factor
- PET–CT, positron emission tomography–computed tomography
- PTTM, pulmonary tumor thrombotic microangiopathy
- Pulmonary hypertension
- Pulmonary tumor thrombotic microangiopathy
- VEGF, vascular endothelial growth factor
- Vascular endothelial growth factor
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Affiliation(s)
- Jumpei Taniguchi
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Kei Nakashima
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Takuto Matsuura
- Department of Obstetrics and Gynecology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Akira Yoshikawa
- Department of Pathology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Koichi Honma
- Department of Pathology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Yuya Homma
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Norihiko Kubota
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Michinori Yoshimi
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Ayumu Otsuki
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Hiroyuki Ito
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
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6
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Cui N, Wang L, Zhao J. Pulmonary tumour thrombotic microangiopathy presented as gastric signet ring cell carcinoma: A case report. J Int Med Res 2020; 48:300060520910884. [PMID: 32216513 PMCID: PMC7132559 DOI: 10.1177/0300060520910884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pulmonary tumour thrombotic microangiopathy (PTTM) is a rare complication of
cancer characterized by widespread tumour cell emboli in small arteries and
arterioles of the lung and often accompanied by microthrombi. We report a case
of PTTM in a young Chinese woman that presented as gastric signet ring cell
carcinoma. Although rare, PTTM should be considered in cancer patients with a
rapidly progressing dyspnoea, chest computed tomography (CT) scan suggestive of
pulmonary hypertension and diffuse pulmonary interstitial infiltration.
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Affiliation(s)
- Ning Cui
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lijun Wang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jingming Zhao
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
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7
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Kawanaka Y, Kawakami H, Shimizu S, Yoshida T, Hayashi H, Nishio K, Satou T, Nakagawa K. A Case of Pulmonary Tumor Thrombotic Microangiopathy Suggested by the Presence of Tumor Cells in Peripheral Blood. Case Rep Oncol 2020; 13:843-848. [PMID: 32884528 PMCID: PMC7443647 DOI: 10.1159/000508362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 01/09/2023] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is characterized by tumor cell microemboli with occlusive fibrointimal remodeling in small pulmonary vessels. Platelet-derived growth factor (PDGF) has been implicated in the development of PTTM, and fibroblast growth factor (FGF) promotes PDGF signaling via PDGF receptor β. We here describe a cancer patient who presented with dyspnea of uncertain etiology and whose condition worsened rapidly. A 68-year-old man with hypopharyngeal squamous cell carcinoma (cT4aN2bM0, stage IVA) was treated with surgery followed by radiation. Two years later, a lung metastatic lesion was surgically removed on the basis of suspected primary lung cancer. The patient was thereafter monitored without chemotherapy. Two months later, he had third-degree burns and received conservative therapy including debridement and application of trafermin (FGF2) spray. Two weeks later, he was hospitalized with complaints of fever and dyspnea. Pneumonia and pulmonary embolism were ruled out by chest computed tomography with pulmonary arteriography, whereas intravascular lymphoma was excluded by laboratory testing. Malignant cells were detected in his peripheral blood on hospital day 8, and their number increased gradually thereafter. His respiratory symptoms worsened, and the patient died on hospital day 10. We concluded that the cause of death was PTTM, with the clinical course suggesting a possible relation to trafermin. This suggestion was supported by the detection of FGF receptor 2 overexpression in the primary tumor by immunostaining.
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Affiliation(s)
- Yusuke Kawanaka
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Hisato Kawakami
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Shigeki Shimizu
- Department of Pathology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Takeshi Yoshida
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Hidetoshi Hayashi
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kazuto Nishio
- Department of Genome Biology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Takao Satou
- Department of Pathology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kazuhiko Nakagawa
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
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8
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Petnak T, Suwatanapongched T, Klaisuban W, Nitiwarangkul C, Pornsuriyasak P. Initial diagnosis and successful treatment of pulmonary tumor embolism manifesting as the first clinical sign of prostatic adenocarcinoma. Respir Med Case Rep 2020; 31:101163. [PMID: 32714825 PMCID: PMC7378679 DOI: 10.1016/j.rmcr.2020.101163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022] Open
Abstract
Although pulmonary tumor embolism (PTE) is a well-recognized end-stage form of pulmonary metastases at postmortem examination, the entity is rarely the first clinical sign of prostate cancer. Diagnosis of this condition in patients who have no previous history of malignancy is a challenge. Herein, we reported a 79-year-old man presented with progressive, unexplained dyspnea on exertion. Microscopic PTE coinciding with pulmonary lymphangitic carcinomatosis were readily recognized based on the presence of multifocal dilatation and beading of the peripheral pulmonary arteries with thickening of the bronchial walls and interlobular septa on the initial thin-section chest CT images. Pathologic examination of the transbronchial lung biopsy specimen revealed tumor emboli occluding both the small muscular pulmonary arteries and lymphatic vessels. These tumor cells were positive for prostatic specific antigen on immunohistochemical staining. The final diagnosis of prostatic adenocarcinoma was confirmed. Remarkable clinical and radiographic improvement was achieved following bilateral orchiectomies and anti-androgen treatment. Pulmonary tumor embolism (PTE) can be the first clinical sign of advanced prostatic adenocarcinoma. CT findings of dilated, beaded peripheral pulmonary arteries should raise a concern of microscopic PTE. Dilated, beaded pulmonary arteries should not be mistaken for tree-in-bud opacities caused by bronchiolar disease on CT. Prostate cancer should always be considered in the differential diagnosis of adenocarcinoma of unknown origin in men.
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Affiliation(s)
- Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thitiporn Suwatanapongched
- Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Corresponding author. Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University. Address: 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
| | - Wipawi Klaisuban
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chayanin Nitiwarangkul
- Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prapaporn Pornsuriyasak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Imakura T, Tezuka T, Inayama M, Miyamoto R, Abe A, Otsuka K, Yoshida S, Kudo E, Haku T. A Long-term Survival Case of Pulmonary Tumor Thrombotic Microangiopathy due to Gastric Cancer Confirmed by the Early Diagnosis based on a Transbronchial Lung Biopsy. Intern Med 2020; 59:1621-1627. [PMID: 32612065 PMCID: PMC7402956 DOI: 10.2169/internalmedicine.3630-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is an acute, progressive, and fatal disease. PTTM manifests as subacute respiratory failure with pulmonary hypertension, progressive right-sided heart failure, and sudden death. An antemortem diagnosis of PTTM is very difficult to obtain, and many patients die within several weeks. We herein report a case of PTTM diagnosed based on a transbronchial lung biopsy. In this case, we finally diagnosed PTTM due to gastric cancer because of its histological identity. The patient was administered chemotherapy, including angiogenesis inhibitors, against gastric cancer at an early age and survived for a long time.
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Affiliation(s)
- Takeshi Imakura
- Department of Respiratory Medicine, Tokushima Prefectural Central Hospital, Japan
| | - Toshifumi Tezuka
- Department of Respiratory Medicine, Tokushima Prefectural Central Hospital, Japan
| | - Mami Inayama
- Department of Respiratory Medicine, Tokushima Prefectural Central Hospital, Japan
| | - Ryota Miyamoto
- Department of Respiratory Medicine, Tokushima Prefectural Central Hospital, Japan
| | - Akane Abe
- Department of Respiratory Medicine, Tokushima Prefectural Central Hospital, Japan
| | - Kanako Otsuka
- Department of Gastroenterology, Tokushima Prefectural Central Hospital, Japan
| | - Seiji Yoshida
- Department of Respiratory Medicine, Tokushima Prefectural Central Hospital, Japan
| | - Eiji Kudo
- Department of Pathology, Tokushima Prefectural Central Hospital, Japan
| | - Takashi Haku
- Department of Respiratory Medicine, Tokushima Prefectural Central Hospital, Japan
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10
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Yamakawa H, Oba T, Ohta H, Tsukahara Y, Kida G, Tsumiyama E, Nishizawa T, Kawabe R, Sato S, Akasaka K, Amano M, Kuwano K, Matsushima H. A case of pulmonary tumor thrombotic microangiopathy associated with lung cancer diagnosed by cell-block immunohistochemistry of pulmonary microvascular cytology. Respir Med Case Rep 2019; 28:100956. [PMID: 31720205 PMCID: PMC6838463 DOI: 10.1016/j.rmcr.2019.100956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 12/03/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is rare but should be considered as a possible diagnosis in patients with cancer. In this case, PTTM induced by lung cancer was more accurately diagnosed using cell block immunohistochemistry of pulmonary microvascular cytology (PMC) because we could confirm that lung adenocarcinoma was the origin of PTTM by the positive result of TTF-1 for atypical cells in PMC. The PMC procedure was minimally invasive and safer than lung biopsy. We believe that the cell block technique of PMC should be considered as one diagnostic option in PTTM.
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Affiliation(s)
- Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
- Corresponding author. Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan.
| | - Tomohiro Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Hiroki Ohta
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Yuta Tsukahara
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Gen Kida
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Emiri Tsumiyama
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
| | - Tomotaka Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Rie Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Masako Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
| | - Kazuyoshi Kuwano
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Japan
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11
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Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal disease process in
which pulmonary hypertension (PH) develops in the setting of malignancy. The
purpose of this study is to present a detailed analysis of cases of PTTM
reported in literature in the hopes of achieving more ante-mortem diagnoses. We
conducted a systematic review of currently published and available cases of PTTM
by searching the term “pulmonary tumor thrombotic microangiopathy” on the
Pubmed.gov database. Seventy-nine publications were included consisting of 160
unique cases of PTTM. The most commonly reported malignancy was gastric
adenocarcinoma (94 cases, 59%). Cough and dyspnea were reported in 61 (85%) and
102 (94%) cases, respectively. Hypoxemia was reported in 96 cases (95%).
Elevation in D-dimer was noted in 36 cases (95%), presence of anemia in 32 cases
(84%), and thrombocytopenia in 30 cases (77%). Common findings on chest computed
tomography (CT) included ground-glass opacities (GGO) in 28 cases (82%) and
nodules in 24 cases (86%). PH on echocardiography was noted in 59 cases (89%)
with an average right ventricular systolic pressure of 71 mmHg. Common features
of PTTM that are reported across the published literature include presence of
dyspnea and cough, hypoxemia, with abnormal CT findings of GGO, nodules, and
mediastinal/hilar lymphadenopathy, and PH. PTTM is a universally fatal disease
process and this analysis provides a detailed examination of all the available
published data that may help clinicians establish an earlier diagnosis of
PTTM.
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Affiliation(s)
- Rohit H Godbole
- 1 Division of Pulmonary and Critical Care Medicine, University of California, Irvine, CA, USA
| | - Rajan Saggar
- 2 Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles David Geffen School of medicine, Los Angeles, CA, USA
| | - Nader Kamangar
- 3 Division of Pulmonary and Critical Care Medicine, Olive View - UCLA Medical Center, Los Angeles, CA, USA
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Godbole R, Saggar R, Zider A, Betancourt J, Wallace WD, Suh RD, Kamangar N. Insights on pulmonary tumor thrombotic microangiopathy: a seven-patient case series. Pulm Circ 2017; 7:813-820. [PMID: 28782988 PMCID: PMC5703123 DOI: 10.1177/2045893217728072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a disease process wherein tumor cells are thought to embolize to the pulmonary circulation causing pulmonary hypertension (PH) and death from right heart failure. Presented herein are clinical, laboratory, radiographic, and histologic features across seven cases of PTTM. Highlighted in this publication are also involvement of pulmonary venules and clinical features distinguishing PTTM from clinical mimics. We conducted a retrospective chart review of seven cases of PTTM from hospitals in the greater Los Angeles metropolitan area. Patients in this series exhibited: symptoms of cough and progressive dyspnea; PH and/or heart failure on physical exam; laboratory abnormalities of anemia, thrombocytopenia, elevated LDH, and elevated D-dimer; chest computed tomography (CT) showing diffuse septal thickening, mediastinal and hilar lymphadenopathy and nodules; elevated pulmonary artery pressures on transthoracic echocardiogram and/or right heart catheterization; and presence of malignancy. Tumor emboli and fibrocellular intimal proliferation were seen in pulmonary arterioles, while two patients had pulmonary venopathy. PTTM is a devastating disease occurring in patients with metastatic carcinoma. An early diagnosis is challenging. Understanding the clinical presentation of PTTM and distinguishing PTTM from clinical mimics may help achieve an early diagnosis and allow time for initiation of treatment.
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Affiliation(s)
- Rohit Godbole
- 1 Division of Pulmonary and Critical Care Medicine, University of California, Irvine, CA, USA
| | - Rajan Saggar
- 2 Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Alexander Zider
- 2 Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jamie Betancourt
- 3 Division of Pulmonary and Critical Care Medicine, West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA, USA
| | - William D Wallace
- 4 Department of Pathology and Laboratory Medicine, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Robert D Suh
- 5 Department of Radiological Sciences, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Nader Kamangar
- 2 Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA.,6 Division of Pulmonary and Critical Care Medicine, Olive View-UCLA Medical Center
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13
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Banno A, Chiba K, Kasai H, Nagami K. Ante-mortem diagnosis of pulmonary tumour thrombotic microangiopathy in a patient with unrecognised extramammary Paget's disease. BMJ Case Rep 2016; 2016:bcr-2016-216666. [PMID: 27566212 DOI: 10.1136/bcr-2016-216666] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pulmonary tumour thrombotic microangiopathy (PTTM) resulting in fatal pulmonary hypertension is a rare complication of malignancy. Patients with PTTM generally suffer rapid deterioration of hypoxaemia, and a diagnosis is often only made at autopsy. We report a case of extramammary Paget's disease associated with PTTM. An ante-mortem diagnosis was made based on cytology of blood aspirated from a pulmonary artery catheter in a wedged position. Together with a review of the literature, this case highlights the potential diagnostic value of blood cytology in patients with cancer with rapidly progressing pulmonary hypertension.
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Affiliation(s)
- Aya Banno
- Department of Internal Medicine, Ippan Zaidan Hojin Kanagawa-ken Keiyukai, Yokohama, Kanagawa, Japan
| | - Keijiro Chiba
- Department of Internal Medicine, Ippan Zaidan Hojin Kanagawa-ken Keiyukai, Yokohama, Kanagawa, Japan
| | - Hiroko Kasai
- Department of Dermatology, Ippan Zaidan Hojin Kanagawa-ken Keiyukai, Yokohama, Kanagawa, Japan
| | - Keiichi Nagami
- Department of Internal Medicine, Ippan Zaidan Hojin Kanagawa-ken Keiyukai, Yokohama, Kanagawa, Japan
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Takahashi Y, Uruga H, Fujii T, Mochizuki S, Hanada S, Takaya H, Miyamoto A, Morokawa N, Kurosaki A, Kishi K. Antemortem diagnosis of pulmonary tumor thrombotic microangiopathy in a patient with recurrent breast cancer: a case report. BMC Cancer 2016; 16:666. [PMID: 27549622 PMCID: PMC4994171 DOI: 10.1186/s12885-016-2721-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 08/14/2016] [Indexed: 11/30/2022] Open
Abstract
Background Pulmonary tumor thrombotic microangiopathy (PTTM), a rare complication of advanced cancer, is histologically characterized by tumor embolisms and fibrocellular intimal proliferation of small pulmonary arteries and arterioles. PTTM usually has an extremely poor prognosis, and antemortem diagnosis is very difficult. Case presentation A 65-year-old woman with a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months. She had previously received neoadjuvant chemotherapy and left mastectomy. Because the cancer cells were positive for human epidermal growth factor receptor 2 (HER2), four cycles of trastuzumab had been administered as adjuvant chemotherapy. On admission, chest computed tomography (CT) showed peripheral consolidations in both the lower lobes and a mediastinal mass. Specimens obtained on video-assisted thoracoscopic surgical biopsy revealed tumor cell embolism, intimal fibrocellular proliferation of small arteries, fibrin thrombi, recanalization, and infarction in the left lower lobe, as well as metastasis to the mediastinal pleura. Immunohistochemical staining of the tumor cells revealed positivity for HER2, and a diagnosis of recurrent breast cancer with PTTM was made. Four cycles of trastuzumab resulted in rapid improvement of her symptoms and CT findings of peripheral consolidations and the mediastinal mass. Conclusion An antemortem diagnosis of PTTM was made in a patient with HER2-positive recurrent breast cancer. Trastuzumab was effective for not only breast cancer but also PTTM.
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Affiliation(s)
- Yui Takahashi
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
| | - Hironori Uruga
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Takeshi Fujii
- Department of Pathology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Sayaka Mochizuki
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Shigeo Hanada
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Hisashi Takaya
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Atsushi Miyamoto
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Nasa Morokawa
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Atsuko Kurosaki
- Department of Diagnostic Radiology, Fukujuji Hospital, 3-1-24 Matsuyama, Kiyose-shi, Tokyo, 204-8522, Japan
| | - Kazuma Kishi
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hspital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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15
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Carter CA, Browning R, Oronsky BT, Scicinski JJ, Brzezniak C. The Case of a Zebra That Was Misdiagnosed as a Horse: Pulmonary Tumor Thrombotic Microangiopathy, a New Paraneoplastic Syndrome, Mimicking PD-1-Induced Pneumonitis. Case Rep Oncol 2016; 9:68-75. [PMID: 26933422 PMCID: PMC4772616 DOI: 10.1159/000443723] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A case report of a 47-year-old woman with triple-negative breast cancer on a clinical trial called PRIMETIME (NCT02518958) who received the anti-PD-1 inhibitor nivolumab and the experimental anticancer agent RRx-001 is presented. Although initially diagnosed and treated for anti-PD-1-induced pneumonitis, clinical and radiological abnormalities triggered further investigation, leading to the diagnosis of pulmonary tumor thrombotic microangiopathy (PTTM). This example highlights the importance of exercising due diligence in determining immune-related adverse events and suggests that PD-1-induced pneumonitis should be a diagnosis of exclusion rather than a diagnosis by default. A case history and review of the literature are presented for PTTM, which we propose to define as a paraneoplastic syndrome.
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Affiliation(s)
- Corey A Carter
- Walter Reed National Military Medical Center, Bethesda, Md., USA
| | - Robert Browning
- Walter Reed National Military Medical Center, Bethesda, Md., USA
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16
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Endicott-Yazdani T, Ghazi A, Armstrong D, Guileyardo J, Schuller D. Fatal pulmonary tumor thrombotic microangiopathy caused by undiagnosed metastatic gastric adenocarcinoma. Proc AMIA Symp 2015; 28:482-3. [PMID: 26424948 DOI: 10.1080/08998280.2015.11929315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare cause of rapidly progressive dyspnea in a background of metastatic cancer. Gastric adenocarcinoma is the neoplasm most frequently associated with PTTM. Unfortunately, PTTM is difficult to identify clinically and is most commonly a postmortem diagnosis. We present the case of a woman with no previous diagnosis of cancer who presented with rapidly progressive shortness of breath. She was diagnosed with severe pulmonary arterial hypertension and rapidly succumbed to her illness. A postmortem diagnosis of PTTM was established based on autopsy results.
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Affiliation(s)
- Tiana Endicott-Yazdani
- Department of Internal Medicine (Endicott-Yazdani), the Department of Pathology (Ghazi, Armstrong, Guileyardo), and the Division of Pulmonary and Critical Care Medicine (Schuller), Baylor University Medical Center at Dallas
| | - Alexia Ghazi
- Department of Internal Medicine (Endicott-Yazdani), the Department of Pathology (Ghazi, Armstrong, Guileyardo), and the Division of Pulmonary and Critical Care Medicine (Schuller), Baylor University Medical Center at Dallas
| | - Danielle Armstrong
- Department of Internal Medicine (Endicott-Yazdani), the Department of Pathology (Ghazi, Armstrong, Guileyardo), and the Division of Pulmonary and Critical Care Medicine (Schuller), Baylor University Medical Center at Dallas
| | - Joseph Guileyardo
- Department of Internal Medicine (Endicott-Yazdani), the Department of Pathology (Ghazi, Armstrong, Guileyardo), and the Division of Pulmonary and Critical Care Medicine (Schuller), Baylor University Medical Center at Dallas
| | - Dan Schuller
- Department of Internal Medicine (Endicott-Yazdani), the Department of Pathology (Ghazi, Armstrong, Guileyardo), and the Division of Pulmonary and Critical Care Medicine (Schuller), Baylor University Medical Center at Dallas
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17
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Purga SL, Narula N, Horn EM, Karas MG. Pulmonary tumour thrombotic microangiopathy as a cause of new-onset pulmonary hypertension in a patient with metastatic low-grade serous ovarian cancer. BMJ Case Rep 2015; 2015:bcr-2015-211890. [PMID: 26311016 DOI: 10.1136/bcr-2015-211890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 78-year-old woman with metastatic low-grade serous ovarian cancer presented with rapidly progressive exertional dyspnoea and hypoxia, and was found to have new-onset severe pulmonary hypertension (PH) by right heart catheterisation. A diagnosis of pulmonary tumour thrombotic microangiopathy (PTTM) was made at autopsy. PTTM is a rare complication of advanced cancer that often presents as rapidly progressive PH or acute hypoxic respiratory failure. Widespread tumour cell emboli in the pulmonary arteries and arterioles are hypothesised to induce fibrocellular subintimal proliferation and microthrombi, leading to increased pulmonary vascular resistance and PH. PTTM arising from serous ovarian cancer is exceedingly rare, with only two previously reported cases. A discussion of the pathophysiology, diagnosis and management of PTTM is presented.
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Affiliation(s)
- Scott L Purga
- Department of Internal Medicine, NYP/Weill Cornell Medical College, New York, New York, USA
| | - Navneet Narula
- Department of Pathology, Weill Cornell Medical College, New York, New York, USA
| | - Evelyn M Horn
- Department of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Maria G Karas
- Department of Cardiology, Weill Cornell Medical College, New York, New York, USA
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18
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Godbole R, Ghatol A, Betancourt J, Sacoolidge J, Kamangar N. Pulmonary Tumor Thrombotic Microangiopathy: Clinical, Radiologic, and Histologic Correlation. J Clin Imaging Sci 2015; 5:44. [PMID: 26312142 PMCID: PMC4541166 DOI: 10.4103/2156-7514.161978] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/29/2015] [Indexed: 11/04/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a clinicopathologic disease entity in which the tumor cells embolize to the pulmonary vasculature leading to a series of maladaptive reactions including the activation of coagulation and fibrocellular intimal thickening. The resultant stenosis of blood vessels leads to pulmonary hypertension and eventual death from cor pulmonale. In this report, we present a case of PTTM presenting as the initial manifestation of metastatic gastric carcinoma in a young man. Although unusual in its occurrence as the initial manifestation of gastric carcinoma, the case is illustrative in its clinical, radiological and histological presentation.
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Affiliation(s)
- Rohit Godbole
- Department of Medicine, Olive View - UCLA Medical Center, Sylmar, California, USA
| | - Abhijeet Ghatol
- Division of Pulmonary and Critical Care Medicine, Olive View - UCLA Medical Center, Sylmar, California, USA
| | - Jamie Betancourt
- Division of Pulmonary and Critical Care Medicine, West Los Angeles Veterans Affairs Medical Center, Los Angeles, California, USA
| | - John Sacoolidge
- Department of Pathology, Olive View - UCLA Medical Center, Sylmar, California, USA
| | - Nader Kamangar
- Division of Pulmonary and Critical Care Medicine, Olive View - UCLA Medical Center, Sylmar, California, USA
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19
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Yamakawa H, Yoshida M, Yamada M, Ishikawa T, Takagi M, Katagi H, Yoshida J, Kosuga T, Kuwano K. Pulmonary tumor thrombotic microangiopathy associated with urothelial carcinoma of the urinary bladder: antemortem diagnosis by pulmonary microvascular cytology. Clin Case Rep 2015; 3:735-9. [PMID: 26401277 PMCID: PMC4574788 DOI: 10.1002/ccr3.330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 06/24/2015] [Indexed: 01/09/2023] Open
Abstract
PTTM (Pulmonary tumor thrombotic microangiopathy) is very difficult to diagnose before death. We report a case of urothelial carcinoma of the urinary bladder associated with PTTM in which an antemortem diagnosis by PMC (pulmonary microvascular cytology). PMC may represent the only chance for diagnosis and achievement of remission in PTTM.
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Affiliation(s)
- Hideaki Yamakawa
- Division of Respiratory Medicine, Department of Internal Medicine, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Masahiro Yoshida
- Division of Respiratory Medicine, Department of Internal Medicine, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Masami Yamada
- Division of Respiratory Medicine, Department of Internal Medicine, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Takeo Ishikawa
- Division of Respiratory Medicine, Department of Internal Medicine, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Masamichi Takagi
- Division of Respiratory Medicine, Department of Internal Medicine, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Hiroaki Katagi
- Division of Diagnostic Pathology, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Jun Yoshida
- Division of Cardiology, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Tsuneharu Kosuga
- Division of Cardiology, Jikei University School of Medicine, Kashiwa Hospital Chiba, Japan
| | - Kazuyoshi Kuwano
- Division of Respiratory Medicine, Department of Internal Medicine, Jikei University School of Medicine Tokyo, Japan
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20
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The diagnostic challenge of pulmonary tumour thrombotic microangiopathy as a presentation for metastatic gastric cancer: a case report and review of the literature. BMC Cancer 2015; 15:450. [PMID: 26036321 PMCID: PMC4451732 DOI: 10.1186/s12885-015-1467-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/22/2015] [Indexed: 11/26/2022] Open
Abstract
Background Pulmonary tumour thrombotic microangiopathy (PTTM) is a rare complication of metastatic cancer with a distinct histological appearance which presents with dyspnoea and pulmonary arterial hypertension and leads to death in hours to days. It is a challenging diagnosis to make ante mortem, in part due to the rapid clinical decline. Herein, we report a case of a young woman initially felt to have pulmonary sarcoidosis but who then died eight days later from what was found at post mortem to be PTTM. Case presentation A 41 year old Caucasian woman presented with progressive dyspnoea. Computed tomography of her thorax showed diffuse tiny centrilobular nodules in a tree-in-bud appearance along with small volume mediastinal lymphadenopathy. A presumptive diagnosis of pulmonary sarcoidosis was made; bronchoscopy with transbronchial lung biopsy was arranged to confirm the diagnosis. However, she rapidly deteriorated and died eight days later. Post mortem examination revealed metastatic poorly differentiated gastric adenocarcinoma with PTTM being the final cause of death. Conclusion This case demonstrates the diagnostic difficulties in such a rare and rapidly fatal oncological complication; a greater awareness amongst clinicians may help make a positive diagnosis in the short window of time available. Little is known about its pathogenesis, and even less about optimal management strategies. We review the literature to demonstrate the clinical characteristics that might provide clues towards an ante mortem diagnosis, and highlight how imatinib may provide the key to treating PTTM.
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21
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Mandaliya R, Farhat S, Uprety D, Balla M, Gandhi A, Goldhahn R, Auerbach H, Christensen C, Reed C, Cohen S. Occult gastric cancer presenting as hypoxia from pulmonary tumor thrombotic microangiopathy. J Gastric Cancer 2014; 14:142-6. [PMID: 25061544 PMCID: PMC4105381 DOI: 10.5230/jgc.2014.14.2.142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 06/09/2014] [Accepted: 06/16/2014] [Indexed: 02/05/2023] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) causing fatal pulmonary hypertension is a rare presentation of malignancy. In general, patients with PTTM rapidly succumb to death due to severe hypoxia. To date, very few cases of PTTM have been reported in the literature; and most of these cases were from gastric cancer and were diagnosed on post mortem autopsy, as it is extremely challenging to make an ante mortem diagnosis. We here report on a case of undiagnosed diffuse gastric cancer, presenting as worsening hypoxia. The clinical, radiographic, and echocardiographic features, and laboratory and pathological results were consistent with PTTM from gastric cancer. The patient was started on anticoagulation therapy, corticosteroids, and high-flow oxygen. However, her hypoxia worsened to the extent that she required ventilator support, and she died soon after intubation due to cardiac arrest. Since diffuse gastric cancer is associated with hereditary diffuse gastric cancer syndrome, cadherin 1 gene mutation analysis was performed to estimate the risk to her daughters. The test came back negative.
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Affiliation(s)
- Rohan Mandaliya
- Department of Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Salman Farhat
- Department of Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Dipesh Uprety
- Department of Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Mamtha Balla
- Department of Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Apurva Gandhi
- Department of Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Richard Goldhahn
- Department of Anatomy and Pathology, Abington Memorial Hospital, Abington, PA, USA
| | - Herbert Auerbach
- Department of Anatomy and Pathology, Abington Memorial Hospital, Abington, PA, USA
| | - Chris Christensen
- Division of Pulmonary and Critical Care, Abington Memorial Hospital, Abington, PA, USA
| | - Conrad Reed
- Division of Pulmonary and Critical Care, Abington Memorial Hospital, Abington, PA, USA
| | - Sidney Cohen
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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