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Ma H, Gao JM, Wang J, Huang LY, Tian XC, Tian ZG, Wang SJ, Ma G, Tan H, Zhang SX. Pulmonary tumor thrombotic microangiopathy: Two case reports and literature review. Medicine (Baltimore) 2024; 103:e38618. [PMID: 38941435 DOI: 10.1097/md.0000000000038618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Abstract
RATIONALE Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare but serious complication in patients with malignancy; its main manifestation includes acute pulmonary hypertension with severe respiratory distress. More than 200 cases have been reported since it was first identified in 1990. PTTM accounts for approximately 0.9% to 3.3% of deaths due to malignancy, but only a minority of patients are diagnosed ante-mortem, with most patients having a definitive diagnosis after autopsy. PATIENT CONCERNS Two middle-aged women both died within a short period of time due to progressive dyspnea and severe pulmonary hypertension. DIAGNOSES One patient was definitively confirmed as a gastrointestinal malignant tumor by liver puncture biopsy pathology. Ultimately, the clinical diagnosis was pulmonary tumor thrombotic microangiopathy. INTERVENTIONS The patient was treated symptomatically with oxygen, diuresis, and anticoagulation, while a liver puncture was perfected to clarify the cause. OUTCOMES Two cases of middle-aged female patients with rapidly progressive pulmonary hypertension and respiratory failure resulted in death with malignant neoplasm. LESSONS PTTM has a rapid onset and a high morbidity and mortality rate. Our clinicians need to be more aware of the need for timely diagnosis through a targeted clinical approach, leading to more targeted treatment and a better prognosis.
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Affiliation(s)
- Hua Ma
- Clinical Medical College, Ningxia Medical University, Yinchuan, China
| | - Jian-Mei Gao
- Department of Respiratory and Critical Care Medicine, Ningxia Medical University General Hospital, Yinchuan, China
| | - Jing Wang
- Clinical Medical College, Ningxia Medical University, Yinchuan, China
| | - Ling-Yan Huang
- Department of Pathology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xing-Cang Tian
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhi-Gang Tian
- Department of Respiratory and Critical Care Medicine, Ningxia Medical University General Hospital, Yinchuan, China
| | - Shao-Jin Wang
- Department of Respiratory and Critical Care Medicine, Ningxia Medical University General Hospital, Yinchuan, China
| | - Gang Ma
- Department of Respiratory and Critical Care Medicine, Ningxia Medical University General Hospital, Yinchuan, China
| | - Hai Tan
- Department of Respiratory and Critical Care Medicine, Ningxia Medical University General Hospital, Yinchuan, China
| | - Shu-Xiang Zhang
- Department of Respiratory and Critical Care Medicine, Ningxia Medical University General Hospital, Yinchuan, China
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2
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Lichtblau M, Mayer L, Gopalan D, Dorfmüller P, Ulrich S. Clinical-radiological-pathological correlation in pulmonary hypertension with unclear and/or multifactorial mechanisms. Eur Respir Rev 2023; 32:230119. [PMID: 38123234 PMCID: PMC10731469 DOI: 10.1183/16000617.0119-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/16/2023] [Indexed: 12/23/2023] Open
Abstract
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.
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Affiliation(s)
- Mona Lichtblau
- University and University Hospital of Zurich, Zurich, Switzerland
| | - Laura Mayer
- University and University Hospital of Zurich, Zurich, Switzerland
| | - Deepa Gopalan
- Imperial College London, London, UK
- Cambridge University Hospital, Cambridge, UK
| | - Peter Dorfmüller
- Universitätsklinikum Gießen und Marburg GmbH, Pathology Department, Giessen, Germany
| | - Silvia Ulrich
- University and University Hospital of Zurich, Zurich, Switzerland
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3
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Unno K, Ohtani H, Sakamoto A, Murakami H, Yagi H, Ito H, Baba S, Iwashita T, Kosugi I, Maekawa Y. Pulmonary Tumor Thrombotic Microangiopathy Caused by Metastatic Ovarian Cancer: An Antemortem Diagnosis with Pulmonary Aspiration Cytopathology. Intern Med 2023; 62:3649-3655. [PMID: 37121751 PMCID: PMC10781541 DOI: 10.2169/internalmedicine.1641-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/19/2023] [Indexed: 05/02/2023] Open
Abstract
A 48-year-old woman with advanced ovarian cancer was diagnosed with pulmonary tumor thrombotic microangiopathy (PTTM) by antemortem pulmonary wedge aspiration cytopathology. Despite the initiation of anti-cancer treatment, she unfortunately died due to progressive respiratory failure. Histopathology of the autopsied lung revealed multiple tumor embolization with fibrin-rich clot and fibro-cellular intimal proliferation at the pulmonary arteriole. The embolized tumor showed strong immune-positivity for pro-thrombotic and fibrotic factors (tissue factor and vascular endothelial growth factor), suggesting the underlying mechanisms of PTTM development. This case suggests that a quick antemortem diagnosis and the early induction of specific treatments might ensure a better prognosis of PTTM.
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Affiliation(s)
- Kyoko Unno
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Hayato Ohtani
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Atsushi Sakamoto
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Hirotake Murakami
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Japan
| | - Haruna Yagi
- Department of Regenerative & Infectious Pathology, Hamamatsu University School of Medicine, Japan
| | - Hiroaki Ito
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Japan
| | - Satoshi Baba
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, Japan
| | - Toshihide Iwashita
- Department of Regenerative & Infectious Pathology, Hamamatsu University School of Medicine, Japan
| | - Isao Kosugi
- Department of Regenerative & Infectious Pathology, Hamamatsu University School of Medicine, Japan
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
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4
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Kimura A, Yamada A, Oshi M, Nakayama M, Komura N, Sugano T, Yamamoto S, Narui K, Endo I. Dramatic Improvement of Pulmonary Tumor Thrombotic Microangiopathy in a Breast Cancer Patient Treated With Bevacizumab. World J Oncol 2023; 14:575-579. [PMID: 38022402 PMCID: PMC10681781 DOI: 10.14740/wjon1691] [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: 08/17/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023] Open
Abstract
A 47-year-old woman diagnosed with stage IV left-sided breast cancer (T3N3aM1; OSS, HEP, LYM) 6 months back presented with respiratory distress. On admission, she developed respiratory failure, requiring 4 L of oxygen support. Pulmonary embolism was ruled out because computed tomography revealed no obvious pulmonary artery thrombus. Transthoracic echocardiography revealed a significant enlargement of the right ventricle and atrium. Pulmonary hypertension was confirmed via right heart catheterization. Pulmonary artery wedge aspiration cytology revealed adenocarcinoma cells. Based on these findings, we diagnosed the patient with pulmonary tumor thrombotic microangiopathy (PTTM) caused by breast cancer. Immediate chemotherapy (paclitaxel and bevacizumab) for breast cancer and concurrent treatment for pulmonary hypertension and disseminated intravascular coagulation were initiated. We could successfully control her condition with paclitaxel and bevacizumab for a year, and the patient survived for 1 year and 8 months. PTTM is a rare disease characterized by pulmonary hypertension and hypoxemia arising due to tumor embolization of the peripheral pulmonary arteries. PTTM is a rapidly progressing condition with no established treatment guidelines; its pathogenesis involves vascular endothelial growth factor (VEGF). This report highlighted the potential of bevacizumab, known for its anti-VEGF effect, in improving the pathological condition of patients with PTTM caused by breast cancer.
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Affiliation(s)
- Aki Kimura
- Department of Breast Surgery, Yokohama City University Hospital, Yokohama, Japan
| | - Akimitsu Yamada
- Department of Breast Surgery, Yokohama City University Hospital, Yokohama, Japan
| | - Masanori Oshi
- Department of Breast Surgery, Yokohama City University Hospital, Yokohama, Japan
| | - Mina Nakayama
- Department of Cardiology, Yokohama City University Hospital, Yokohama, Japan
| | - Naohiro Komura
- Department of Cardiology, Yokohama City University Hospital, Yokohama, Japan
| | - Teruyasu Sugano
- Department of Cardiology, Yokohama City University Hospital, Yokohama, Japan
| | - Shinya Yamamoto
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center Hospital, Yokohama, Japan
| | - Kazutaka Narui
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center Hospital, Yokohama, Japan
| | - Itaru Endo
- Department of Breast Surgery, Yokohama City University Hospital, Yokohama, Japan
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Aeberhard J, Lichtblau M, Arenja N. An unexpected cause of pulmonary hypertension in a young woman: a case report. Eur Heart J Case Rep 2023; 7:ytad474. [PMID: 37850218 PMCID: PMC10577277 DOI: 10.1093/ehjcr/ytad474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/12/2023] [Accepted: 09/27/2023] [Indexed: 10/19/2023]
Abstract
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.
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Affiliation(s)
- Judith Aeberhard
- Department of Cardiology, Kantonsspital Olten, 4600 Olten, Switzerland
| | - Mona Lichtblau
- Clinic of Pulmonology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Nisha Arenja
- Department of Cardiology, Kantonsspital Olten, 4600 Olten, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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6
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McKenzie H, Scott D, Bateman AC, De La Pena Gomez H. Pulmonary tumour thrombotic microangiopathy mimicking immunotherapy-associated pneumonitis. BMJ Case Rep 2023; 16:e252695. [PMID: 37770234 PMCID: PMC10546101 DOI: 10.1136/bcr-2022-252695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
We present a case of pulmonary tumour thrombotic microangiopathy (PTTM) in a patient on adjuvant immunotherapy for resected triple negative breast cancer. The patient presented with deranged liver function tests and subsequently developed severe hypoxia and thrombocytopaenia, with right heart failure. The primary differential diagnosis considered was immunotherapy-associated hepatitis and pneumonitis. Despite organ support, the patient deteriorated rapidly and died of respiratory failure. As is often the case with PTTM, the diagnosis was only found at postmortem. PTTM should be considered in patients with a background of cancer (and may be more common in certain subtypes) who present with this unusual combination of clinical features. While the condition carries an extremely poor prognosis, prompter recognition for future patients may allow consideration of novel treatments.
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Affiliation(s)
- Hayley McKenzie
- Oncology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Deborah Scott
- Oncology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Adrian C Bateman
- Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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7
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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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8
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Tran H, Kamangar N. Improvement of Breast Cancer-Associated Pulmonary Tumor Thrombotic Microangiopathy With Carboplatin and Gemcitabine. Cureus 2023; 15:e38600. [PMID: 37284356 PMCID: PMC10239657 DOI: 10.7759/cureus.38600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
We present the case of a 50-year-old woman with stage IV invasive ER+/PR-/HER2-ductal breast carcinoma who was admitted to the intensive care unit (ICU) with obstructive shock and hypoxic respiratory failure due to pulmonary tumor thrombotic microangiopathy (PTTM), which significantly improved with chemotherapy. Upon presentation, her heart rate was 145 beats/min, her blood pressure was 86/47 mmHg, her respiratory rate was 25 breaths/min, and her oxygen saturation was 80% in room air. She underwent a broad non-diagnostic infectious evaluation, received fluid resuscitation, and was placed on broad-spectrum antibiotics. Transthoracic echocardiography showed evidence of severe pulmonary hypertension with a pulmonary arterial systolic pressure (PASP) of 77 mmHg. She initially required oxygen via a high-flow nasal cannula (HFNC) at 40 liters/minute and 80% FiO2 and was subsequently placed on inhaled nitric oxide (iNO) at 40 parts per million (PPM) as well as norepinephrine and vasopressin drips for acute decompensated right heart failure. Despite her poor performance status, she was started on chemotherapy with carboplatin and gemcitabine. Over the ensuing week, she was weaned off supplemental oxygen, vasoactive agents, and iNO and discharged home. Repeat echocardiography performed 10 days after the initiation of chemotherapy demonstrated marked improvement in her pulmonary hypertension with a PASP of 34 mmHg. This case highlights the potential role of chemotherapy in altering the course of PTTM in select patients with metastatic breast cancer.
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Affiliation(s)
- Helen Tran
- Internal Medicine, Olive View University of California Los Angeles Medical Center, Sylmar, USA
- Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, USA
| | - Nader Kamangar
- Medicine/Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, USA
- Pulmonary and Critical Care Medicine, Olive View University of California Los Angeles Medical Center, Sylmar, USA
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9
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Kim KA, Jung MH. Pulmonary Tumor Thrombotic Microangiopathy: An Under-Recognized Potentially Fatal Cause of Pulmonary Hypertension. Korean Circ J 2023; 53:185-188. [PMID: 36914607 PMCID: PMC10011223 DOI: 10.4070/kcj.2023.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 03/02/2023] Open
Affiliation(s)
- Kyung An Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Catholic Research Institute for Intractable Cardiovascular Disease (CRID), College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mi-Hyang Jung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Catholic Research Institute for Intractable Cardiovascular Disease (CRID), College of Medicine, The Catholic University of Korea, Seoul, Korea.
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10
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Fujita J, Hummel K, Xu Y. Pulmonary tumor thrombotic microangiopathy caused by metastatic ovarian high-grade serous carcinoma: a case report and literature review. Cardiovasc Pathol 2023:107526. [PMID: 36781067 DOI: 10.1016/j.carpath.2023.107526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare entity with poor prognosis, and often diagnosed postmortem. PTTM is resulting from tumor emboli induced activation of coagulation cascade, fibrin clot formation and fibrocellular intimal proliferation in pulmonary microvasculature. CASE The patient was a 65-year-old female, with past medical history of ovarian high-grade serous carcinoma, presented with chest pain and shortness of breath. The chest computed tomography (CT) revealed innumerable new lung nodules as well as small hazy and patchy opacities compared to the chest CT 2 months before current presentation. She developed progressive respiratory failure and expired. A lung-restricted autopsy showed diffuse subcentimetric nodules in bilateral lungs grossly. Microscopic examination revealed the lung parenchyma demonstrated numerous tumor emboli consisting of pleomorphic tumor cells with varying degrees of fibrin deposition and fibrocellular intimal proliferation in the pulmonary arterioles, small arteries, and capillaries in the alveolar septa. Immunohistochemistry confirmed the ovarian origin of the tumor cells. The findings were consistent with PTTM secondary to metastasis of ovarian high-grade serous carcinoma. Literature review of PTTM caused by ovarian cancer was conducted. CONCLUSION PTTM is a fatal entity with rare association with primary ovarian malignancy. This case study demonstrates the clinicopathological features of PTTM associated with high-grade serous carcinoma, and it will be the second case of PTTM with this association in the literature.
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Affiliation(s)
- Jun Fujita
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Kelsey Hummel
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Ya Xu
- Department of Pathology & Immunology, Baylor College of Medicine, Department of Pathology, Ben Taub General Hospital, Harris Health System, Houston, TX, USA.
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Fujita K, Omori T, Hara H, Shinno N, Yamamoto M, Kanemura T, Takeoka T, Sugase T, Miyata H, Ohue M, Sakon M. Antemortem diagnosis of pulmonary tumor thrombotic microangiopathy associated with gastric cancer and response to immediate chemotherapy. Int Cancer Conf J 2022; 12:1-6. [PMID: 36605835 PMCID: PMC9807729 DOI: 10.1007/s13691-022-00566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023] Open
Abstract
Pulmonary tumor thrombotic microangiopathy is a rare and fatal complication of cancer that features widespread tumor cell-derived embolisms in the small arteries and arterioles of the lung and is often associated with thrombus formation. We describe the case of a 43-year-old woman who was hospitalized with cough and respiratory distress that lasted for 2 months. Computed tomography findings demonstrated multiple areas of interlobular septal thickening and ground-glass opacities in both lungs. Transthoracic echocardiography demonstrated a D-shaped left ventricle suggesting right heart overload, and pulmonary blood flow scintigraphy revealed multiple small, peripheral, and patchy areas of reduced blood flow. Upper gastrointestinal endoscopy revealed a signet-ring carcinoma. The patient was diagnosed with pulmonary tumor thrombotic microangiopathy based on her clinical presentation and treatment with tegafur, gimeracil oteracil potassium, oxaliplatin, and an anticoagulant was initiated on the 3rd day after admission. The symptoms improved rapidly after treatment initiation. The patient was discharged 28 days after initiation of chemotherapy without the need for supplemental oxygen. This case suggests that the immediate use of chemotherapy and anticoagulants for treating pulmonary tumor thrombotic microangiopathy may improve patient survival.
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Affiliation(s)
- Kohei Fujita
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan ,Department of Gastroenterological Surgery, Kariya Toyota General Hospital, 5-15 Sumiyoshicho, Kariyashi, Aichi Japan
| | - Takeshi Omori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Hisashi Hara
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Naoki Shinno
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Masaaki Yamamoto
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Takashi Kanemura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Tomohira Takeoka
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Takahito Sugase
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
| | - Masato Sakon
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567 Japan
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12
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Ma G, Wang D, Xu X, Liang L, Xu L. Case report: apatinib plus selexipag as a novel therapy for pulmonary tumor thrombotic microangiopathy accompanied by pulmonary hypertension associated with gastric carcinoma. Medicine (Baltimore) 2022; 101:e29412. [PMID: 35839042 PMCID: PMC11132349 DOI: 10.1097/md.0000000000029412] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/15/2022] [Indexed: 11/26/2022] Open
Abstract
RATIONALE PTTM is a rare but fatal disease, characterized by endothelial intimal proliferation and pulmonary hypertension due to micro-vascular remodeling. In view of the poor prognosis, new effective strategies are urgently required. PATIENT CONCERNS AND DIAGNOSIS A 51-year-old woman was admitted to hospital for acute progressive dyspnea and dry cough. Clinical tests revealed hypercoagulable state and signs of severe pulmonary hypertension, without evidence of pulmonary embolism on contrast-enhanced CT. CT showed interlobular septal thickening and diffuse ground-glass opacity. Lung perfusion scan indicated multiple segment defect. Further right heart catherization proved a significant increase in pulmonary vascular resistance. INTERVENTIONS A combination therapy of apatinib and selexipag was administered for treatment of PTTM. The conventional therapies of ventilation, anticoagulation and diuretic medicines were initiated after admission. OUTCOMES Symptoms of PTTM were ameliorated with a reduction in pulmonary artery pressure. The resolution of interlobular septal thickening and ground-glass opacity on CT constituted the clinical benefits from treatment. LESSONS Patient with PTTM will benefit from the combination strategy of apatinib, a VEGF-receptor antagonist, and selexipag, an oral prostacyclin receptor agonist.
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Affiliation(s)
- Guofeng Ma
- Regional medical center for National institute of respiratory diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan Wang
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoling Xu
- Regional medical center for National institute of respiratory diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Liang
- Regional medical center for National institute of respiratory diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Xu
- Regional medical center for National institute of respiratory diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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13
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Mitsui Y, Yagi M, Muraki S, Matsuura T, Bando Y, Fujimoto S, Kitamura S, Okamoto K, Muguruma N, Sata M, Takayama T. Pulmonary Tumor Thrombotic Microangiopathy Due to Gastric Cancer Diagnosed Antemortem by a Cytological Examination of Aspirated Pulmonary Artery Blood. Intern Med 2022; 61:1491-1495. [PMID: 34670901 PMCID: PMC9177363 DOI: 10.2169/internalmedicine.8313-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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
A 66-year-old Japanese man receiving systemic chemotherapy for advanced gastric cancer presented with exertional dyspnea. D-dimer was elevated in the blood. Echocardiography revealed pulmonary hypertension, and a ventilation-perfusion scan indicated decreased perfusion in the bilateral lungs. Cardiac catheterization showed no evidence of pulmonary artery embolization and revealed cytologically confirmed adenocarcinoma. Thus, pulmonary tumor thrombotic microangiopathy (PTTM) was diagnosed. The patient died of respiratory failure on the 17th hospitalization day despite systemic chemotherapy. Retrospective serological testing revealed increased vascular endothelial growth factor in the pulmonary artery blood. This is a rare case with antemortem cytologically proven PTTM mediated by VEGF.
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Affiliation(s)
- Yasuhiro Mitsui
- Department of Gastroenterology and Oncology, Tokushima University Hospital, Japan
| | - Mai Yagi
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Japan
- Department of Gastroenterology, Tokushima Prefectural Central Hospital, Japan
| | - Sho Muraki
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Japan
- Department of Gastroenterology, Shikoku Medical Center for Children and Adults, Japan
| | - Tomomi Matsuura
- Department of Cardiovascular Medicine, Tokushima University Hospital, Japan
| | - Yoshimi Bando
- Division of Pathology, Tokushima University Hospital, Japan
| | - Shota Fujimoto
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Japan
| | - Shinji Kitamura
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Japan
| | - Koichi Okamoto
- Department of Gastroenterology and Oncology, Tokushima University Hospital, Japan
| | - Naoki Muguruma
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Japan
| | - Tetsuji Takayama
- Department of Gastroenterology and Oncology, Tokushima University Graduate School of Biomedical Sciences, Japan
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14
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Aoyama D, Fukui S, Hirata H, Ohta‐Ogo K, Matama H, Tateishi E, Nishii T, Asaumi Y, Toyofuku M, Ikeue T, Ogo T, Ishibashi‐Ueda H, Yasuda S. Crizotinib for ROS1‐rearranged Lung Cancer and Pulmonary Tumor Thrombotic Microangiopathy under Veno‐Arterial Extracorporeal Membrane Oxygenation. Pulm Circ 2022; 12:e12047. [PMID: 35506104 PMCID: PMC9052980 DOI: 10.1002/pul2.12047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/16/2021] [Accepted: 01/26/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a rapidly progressive subtype of pulmonary hypertension (PH) associated with impaired right ventricular adaptation and very poor prognosis in cancer, and its rapid progression makes antemortem diagnosis and treatment extremely difficult. We describe the case of a 35‐year‐old woman who developed severe PH with subsequent circulatory collapse. The patient was clinically diagnosed with PTTM induced by lung adenocarcinoma harboring the c‐ros oncogene 1 (ROS1) rearrangement within 1–2 weeks, while hemodynamics were stabilized by rescue venoarterial extracorporeal membrane oxygenation support. Crizotinib, an oral tyrosine kinase inhibitor targeting anaplastic lymphoma kinase, MET, and ROS1 kinase domains dramatically resolved PH, resulting in more than 3 years of survival. Targeted gene‐tailored therapy with mechanical support can improve survival in PTTM.
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Affiliation(s)
- Daisetsu Aoyama
- Department of Cardiovascular Medicine
- Department of Cardiovascular Medicine University of Fukui Fukui Japan
| | - Shigefumi Fukui
- Department of Cardiovascular Medicine
- Department of Cardiovascular Medicine, Tohoku Medical and Pharmaceutical University Hospital Sendai Japan
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology Osaka University Graduate School of Medicine , Suita Japan
| | | | | | - Emi Tateishi
- Department of Radiology, National Cerebral and Cardiovascular Center Suita Japan
| | - Tatsuya Nishii
- Department of Radiology, National Cerebral and Cardiovascular Center Suita Japan
| | | | | | - Tatsuyoshi Ikeue
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center Wakayama Japan
| | | | - Hatsue Ishibashi‐Ueda
- Department of Pathology
- the Department of Diagnostic Pathology, Hokusetsu General Hospital Takatsuki Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine
- the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai Japan
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15
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Kawakami N, Moriya T, Kato R, Nakamura K, Saito H, Wakai Y, Saito K, Sakashita M. Pulmonary tumor thrombotic microangiopathy in occult early gastric cancer that was undetectable on upper endoscopy: a case report and review of similar cases. BMC Gastroenterol 2021; 21:423. [PMID: 34758740 PMCID: PMC8579618 DOI: 10.1186/s12876-021-02009-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/02/2021] [Indexed: 01/04/2023] Open
Abstract
Background Pulmonary tumor thrombotic microangiopathy (PTTM), a rare manifestation of metastatic cancer with poor prognosis, is characterized by subacute/acute fatal pulmonary hypertension. The main cause of PTTM is gastric cancer, and cases of early gastric cancer confirmed using autopsy have been reported. Moreover, several cases of early gastric cancer that are undetectable on endoscopy or macroscopic postmortem examination have been reported. Case presentation A previously healthy 50-year-old man presented with progressive dyspnea and cough for 1 month. Echocardiography suggested pulmonary hypertension. Computed tomography revealed diffuse lymphadenopathy, whereas blood work revealed an elevation in several serum tumor marker levels. Despite normal upper endoscopic findings, a presumptive diagnosis of PTTM due to gastric cancer was made based on pathological findings of cervical lymph node biopsy, which indicated signet ring cell carcinoma. Imatinib and tegafur/gimeracil/oteracil plus oxaliplatin therapy were started on day 7. The patient’s condition was initially stable. However, his symptoms suddenly progressed, and the patient died on day 8. Macroscopic postmortem examination revealed no abnormal gastric wall findings. Microscopically, PTTM was confirmed, and multiple serial sections of the stomach revealed early gastric cancer. Conclusions Despite normal endoscopic findings, micro-occult gastric cancer can lead to PTTM. Physicians should be aware of this disease presentation. Taking prompt action is needed when PTTM is suspected, even if the patient appears stable. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-02009-8.
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Affiliation(s)
- Naoki Kawakami
- Department of Respiratory Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan.
| | - Tomohiro Moriya
- Department of Respiratory Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Rina Kato
- Department of Respiratory Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Kentaro Nakamura
- Department of Respiratory Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Hiroaki Saito
- Department of Respiratory Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Yoko Wakai
- Department of Respiratory Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Kazuhito Saito
- Department of Respiratory Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Mai Sakashita
- Department of Pathology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan
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16
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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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17
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Kamidani R, Kumada K, Okada H, Yoshimura G, Kanayama T, Tomita H, Miura T, Oiwa H, Mizuno Y, Kitagawa Y, Yasuda R, Fukuta T, Miyake T, Doi T, Yoshida T, Yoshida S, Hara A, Ogura S. Postmortem diagnosis of pulmonary tumor thrombotic microangiopathy with rapid exacerbation in a patient with gastric cancer: a case report. Int J Emerg Med 2021; 14:53. [PMID: 34525938 PMCID: PMC8444540 DOI: 10.1186/s12245-021-00377-2] [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: 07/28/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background Pulmonary tumor thrombotic microangiopathy (PTTM) is a condition that involves the development of pulmonary hypertension due to the presence of microscopic tumor emboli of the peripheral pulmonary arteries. Here, we report a case of rapidly exacerbating PTTM associated with gastric cancer that was identified postmortem through pathological autopsy. Case presentation A 52-year-old Asian woman who experienced anterior chest pain while coughing visited the orthopedic department of the Gifu University Hospital. She was diagnosed as having multiple osteolytic bone metastases throughout her body and was subsequently scheduled to undergo combined positron emission tomography and computed tomography (CT) to search for a primary lesion. However, 4 days after her visit to the orthopedic department, she was unable to stand up and thus visited the emergency department. At the time of admission, physical examination results revealed that she had a percutaneous oxygen saturation level of 90% (on room air) and cyanosis and that she was in a state of hemodynamic shock. Laboratory test results revealed elevated levels of fibrin degradation products and D-dimer in her blood. Chest CT results were normal. She was admitted to the hospital’s general ward for follow-up but soon entered a gradually worsening state of shock and respiratory failure. Electrocardiography revealed findings associated with right heart strain; however, contrast-enhanced CT did not reveal the presence of pulmonary embolism. She was admitted to the intensive care unit and was treated for pulmonary hypertension; however, 45 h after her arrival at the hospital, she died of respiratory failure. A pathological autopsy revealed the presence of gastric cancer, tumor microemboli, and fibrous intimal thickening of the peripheral arteries of both lungs; thus, a diagnosis of PTTM was made. Conclusions In patients with carcinoma of unknown primary site and pulmonary hypertension with pulmonary embolism ruled out by CT, emergency physicians and intensivists must consider the possibility of PTTM, which represents an oncologic emergency, and initiate chemotherapy administration as soon as possible.
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Affiliation(s)
- Ryo Kamidani
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Keisuke Kumada
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hideshi Okada
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Genki Yoshimura
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tomohiro Kanayama
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tomotaka Miura
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hideaki Oiwa
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.,Abuse Prevention Center, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yosuke Mizuno
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuichiro Kitagawa
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Ryu Yasuda
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tetsuya Fukuta
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takahito Miyake
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tomoaki Doi
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takahiro Yoshida
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shozo Yoshida
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.,Abuse Prevention Center, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akira Hara
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
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18
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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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19
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Raimondi F, Conti C, Novelli L, Tarantini F, Ciaravino G, Scuri P, Grosu A, Chinaglia D, Grazioli LSC, Gianatti A, Lorini FL, Senni M, Di Marco F. A 57-year-old man with rapidly progressive pulmonary hypertension. Monaldi Arch Chest Dis 2021; 92. [PMID: 34461706 DOI: 10.4081/monaldi.2021.1930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
Pulmonary Tumor Thrombotic Microangiopathy (PTTM) is a rare condition associated with neoplastic disorders, predominantly gastric cancer, leading to pre-capillary Pulmonary Hypertension (PH). The pathologic mechanism involved is a fibrocellular intimal proliferation of small pulmonary vessels sustained by nests of carcinomatous cells lodged in pulmonary vasculature. Clinical presentation is nonspecific, including progressive dyspnea and dry cough. Diagnosis of PTTM is extremely challenging ante-mortem and prognosis is poor. Here we describe the case of a middle-aged man, without known previous cancer history. The clinical course was rapidly unfavorable, with progressive dyspnea and PH associated with hemodynamic instability, eventually culminating in patient's death. PTTM diagnosis was made post-mortem. PTTM should be considered in any patient presenting with unexplained PH, especially if it is rapidly progressive, poorly responsive to standard approaches or there is suspected history of malignancy. A prompt diagnosis of PTTM could help in bringing light into this still under-recognized condition.
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Affiliation(s)
- Federico Raimondi
- Pulmonary Medicine Unit, ASST Papa Giovanni XXIII Hospital, Bergamo; University of Milan.
| | - Caterina Conti
- Pulmonary Medicine Unit, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Luca Novelli
- Pulmonary Medicine Unit, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | | | | | - Piermario Scuri
- Cardiology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Aurelia Grosu
- Cardiology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Daniela Chinaglia
- Department of Pathology, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Lorenzo S C Grazioli
- Anesthesiology Intensive Care Unit 3, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Andrea Gianatti
- Department of Pathology, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Ferdinando L Lorini
- Anesthesiology Intensive Care Unit 3, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Michele Senni
- Cardiology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo.
| | - Fabiano Di Marco
- Pulmonary Medicine Unit, ASST Papa Giovanni XXIII Hospital, Bergamo; University of Milan.
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20
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Stern KM, Ries S, Beltran A, Youssef FA. A 51-Year-Old Woman With Rapidly Progressive Dyspnea. Chest 2021; 159:e251-e255. [PMID: 34022028 DOI: 10.1016/j.chest.2020.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 10/03/2020] [Accepted: 11/06/2020] [Indexed: 11/24/2022] Open
Abstract
CASE PRESENTATION A 51-year-old woman with a history of diabetes mellitus and anemia sought treatment at the emergency room for a 2-month history of dry cough and shortness of breath and a 1-week history of substernal chest tightness. One month before her presentation, she was seen at a separate hospital for dyspnea and was found to be anemic. She underwent chest radiography and CT scanning of the chest that was unrevealing to the cause of dyspnea. She received a blood transfusion, although no cause of the anemia was found. One week before presentation, she started experiencing dyspnea on exertion with associated chest pressure, prompting her to seek treatment at the emergency room. On presentation, she reported no fevers, night sweats, joint pain, paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, lightheadedness, or syncope. She noted a 10- to 20-pound involuntary weight loss over 5 to 6 months. Of note, she had never undergone esophagogastroduodenoscopy or colonoscopy. Medications included an oral diabetic medication. She had no significant family history. She never smoked and had no history of illicit drug or alcohol use.
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Affiliation(s)
- Ken M Stern
- Pulmonary and Critical Care Medicine, University of California - Irvine, CA; East Bay Regional Critical Care and Pulmonary Medicine, Oakland, CA
| | - Savita Ries
- Department of Pathology, MemorialCare - Long Beach Medical Center, Long Beach, CA
| | - Antonio Beltran
- Division of Pulmonary and Critical Care Medicine, Long Beach Memorial Medical Center, Long Beach, CA
| | - Fady A Youssef
- Pulmonary and Critical Care Medicine, University of California - Irvine, CA; Division of Pulmonary and Critical Care Medicine, Long Beach Memorial Medical Center, Long Beach, CA.
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21
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Shah AT, Bernardo RJ, Berry GJ, Kudelko K, Wakelee HA. Two Cases of Pulmonary Tumor Thrombotic Microangiopathy Associated with ROS1-Rearranged Non-Small-Cell Lung Cancer. Clin Lung Cancer 2020; 22:e153-e156. [PMID: 33153897 DOI: 10.1016/j.cllc.2020.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Arpeet T Shah
- Division of Oncology, Stanford University, Stanford, CA
| | - Roberto J Bernardo
- Division of Pulmonary, Allergy and Critical Care, Stanford University, Stanford, CA
| | - Gerald J Berry
- Department of Pathology, Stanford University, Stanford, CA
| | - Kristina Kudelko
- Division of Pulmonary, Allergy and Critical Care, Stanford University, Stanford, CA
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22
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Abstract
Cardiogenic shock (CS) is increasingly recognized in patients with malignancies, while cancer is independently associated with worse prognosis in CS. A number of conditions may lead to CS in cancer, including acute coronary syndromes, cardiomyopathy, takotsubo syndrome, myocarditis, pulmonary embolism, tamponade, and cardiac herniation. In these conditions, CS may be related to cancer itself or to cancer therapy, including surgery, chemotherapy, or radiotherapy. Given the significantly improved overall survival of patients with malignancies, the early recognition and proper management of CS in cancer become increasingly important. In the present paper, we review the available evidence on CS in patients with malignancies and highlight issues related to its management.
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23
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Uncommon thoracic manifestations from extrapulmonary tumors: Computed tomography evaluation - Pictorial review. Respir Med 2020; 168:105986. [PMID: 32469707 DOI: 10.1016/j.rmed.2020.105986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/04/2020] [Accepted: 04/19/2020] [Indexed: 11/23/2022]
Abstract
Although metastasis can occur at a variety of sites, pulmonary involvement is common in patients with cancer. Depending on the source and type of tumor, pulmonary metastases present with a wide range of radiologic appearances. Hematogenous dissemination through the pulmonary arteries to the pulmonary capillary network is the most common form of spread in pulmonary metastases. However, they may also reach the lung via lymphatic dissemination, secondary airway involvement, vessel tumor embolism, and direct chest invasion. In the evaluation of patients with known extrathoracic tumors, CT is the state-of-the-art imaging modality for detecting and characterize pulmonary metastases as well as to predict resectability. Although CT limitations are well known, knowledge of growth rates of various tumors and understanding the pattern of spread may be helpful clues in suggesting and even establish the specific diagnosis. The purpose of this pictorial review is to discuss the imaging appearances of different patterns of intrathoracic tumoral dissemination.
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24
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Onoda H, Imamura T, Inao K, Kinugawa K. How to Diagnose and Treat Pulmonary Tumor Thrombotic Microangiopathy. Int Heart J 2020; 61:409-412. [PMID: 32173712 DOI: 10.1536/ihj.19-549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report here a 70-year-old female patient with a history of breast cancer who presented with dyspnea that had lasted for 2 weeks following a long-distance trip by bus. She was at first suspected of having a pulmonary embolism given the typical presentation, elevated D-dimer level, and enlargement of the right-side heart. However, her systemic condition deteriorated despite the initiation of anti-coagulation therapy. Given the absence of a major thrombus in the pulmonary major arteries but multiple low perfusion lesions in the periphery of the lungs, refractoriness to conventional therapy, an increase in tumor markers, and anaplastic cells demonstrated by aspiration cytology from the pulmonary artery, we diagnosed her as pulmonary tumor thrombotic microangiopathy (PTTM). She died on day 23 due to respiratory failure despite administration of inotropes and prostaglandin I2. The patient had an obvious history of malignancy, but we should emphasize that PTTM can develop even in patients with early-stage or completely cured malignancies. Although an early and definite diagnosis of PTTM is currently challenging, an optimal diagnostic and therapeutic strategy is warranted.
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Affiliation(s)
- Hiroshi Onoda
- The Second Department of Internal Medicine, University of Toyama.,Division of Cardiology, Niigata Prefectural Central Hospital
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama
| | - Kyoko Inao
- The Second Department of Internal Medicine, University of Toyama
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25
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Morin-Thibault LV, Wiseman D, Joubert P, Paulin R, Bonnet S, Provencher S. Pulmonary tumor thrombotic microangiopathy: A systematic review of the literature. CANADIAN JOURNAL OF RESPIRATORY, CRITICAL CARE, AND SLEEP MEDICINE 2020. [DOI: 10.1080/24745332.2020.1724061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- L. V. Morin-Thibault
- Pulmonary Hypertension Research Group, Laval University, Québec City, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Québec, Canada
| | - D. Wiseman
- Faculty of Medicine, McGill University, Montreal, Québec, Canada
| | - P. Joubert
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Québec, Canada
| | - R. Paulin
- Pulmonary Hypertension Research Group, Laval University, Québec City, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Québec, Canada
- Department of Medicine, Laval University, Québec City, Québec, Canada
| | - S. Bonnet
- Pulmonary Hypertension Research Group, Laval University, Québec City, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Québec, Canada
- Department of Medicine, Laval University, Québec City, Québec, Canada
| | - S. Provencher
- Pulmonary Hypertension Research Group, Laval University, Québec City, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Québec, Canada
- Department of Medicine, Laval University, Québec City, Québec, Canada
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26
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Abstract
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.
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Affiliation(s)
- Kristin D'Silva
- From the Departments of Medicine (K.D., B.C., A.L.M., J.L.) and Pathology (W.J.A.), Brigham and Women's Hospital, Boston
| | - Barbara Cockrill
- From the Departments of Medicine (K.D., B.C., A.L.M., J.L.) and Pathology (W.J.A.), Brigham and Women's Hospital, Boston
| | - William J Anderson
- From the Departments of Medicine (K.D., B.C., A.L.M., J.L.) and Pathology (W.J.A.), Brigham and Women's Hospital, Boston
| | - Amy L Miller
- From the Departments of Medicine (K.D., B.C., A.L.M., J.L.) and Pathology (W.J.A.), Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (K.D., B.C., A.L.M., J.L.) and Pathology (W.J.A.), Brigham and Women's Hospital, Boston
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27
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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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28
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Yamauchi Y, Nakano K, Miyagawa I, Inaba Y, Nawata A, Sato N, Kumei S, Kawanami T, Yatera K, Tanaka Y. An autopsy case of a patient with systemic sclerosis who developed marked pulmonary hypertension because of pulmonary tumor thrombotic microangiopathy caused by gastric carcinoma. Mod Rheumatol Case Rep 2019; 4:56-62. [PMID: 33086979 DOI: 10.1080/24725625.2019.1690767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We performed an autopsy on a patient with systemic sclerosis who developed uncontrollable pulmonary hypertension due to pulmonary tumour thrombotic microangiopathy (PTTM) caused by gastric carcinoma. The case was of a 62-year-old woman with systemic sclerosis who was admitted to the intensive care unit (ICU) with severe pulmonary hypertension accompanied by respiratory insufficiency. Pulmonary hypertension could not be controlled despite aggressive medical treatment including vasodilators. Approximately 10 days after admission, a unilateral pleural effusion developed. Thoracentesis was performed, and cytology examination of the pleural fluid revealed carcinomatous pleurisy. Because of the presence of a known gastric carcinoma, PTTM was clinically diagnosed. Although chemotherapy was administered, she died 33 days after ICU admission. An autopsy revealed diffuse fibrocellular intimal thickening of the peripheral pulmonary arterioles, which indicated PTTM. In patients with connective tissue disease complicated with pulmonary hypertension, it is necessary to differentiate not only pulmonary arterial hypertension but also other pathological conditions such as PTTM.
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Affiliation(s)
- Yusuke Yamauchi
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Ippei Miyagawa
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Yuna Inaba
- The Department of Pathology and Oncology, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Aya Nawata
- The Department of Pathology, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Naoko Sato
- The Department of Pathology, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan.,Department of Diagnostic Pathology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shinsuke Kumei
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Toshinori Kawanami
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
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29
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Tran LK, Gross LM, Hagley P, Minkin R. Pulmonary hypertension in metastatic breast cancer: a case of pulmonary tumour thrombotic microangiopathy. BMJ Case Rep 2019; 12:12/9/e229715. [DOI: 10.1136/bcr-2019-229715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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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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Tateishi A, Nakashima K, Hoshi K, Oyama Y, Ebisudani T, Misawa M, Aoshima M. Pulmonary Tumor Thrombotic Microangiopathy Mimicking Inhalation Lung Injury. Intern Med 2019; 58:1311-1314. [PMID: 30626821 PMCID: PMC6543225 DOI: 10.2169/internalmedicine.1796-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a complication characterized by dyspnea, pulmonary hypertension, and occasionally sudden death. We encountered a man who developed PTTM and had an inhalation history of chemical herbicides and abnormal findings on chest computed tomography, mimicking chemical inhalation lung injury. He was diagnosed with PTTM with adenocarcinoma by a transbronchial lung biopsy and received chemotherapy and anticoagulant therapy. He survived for one month. An autopsy revealed primary gastric cancer with PTTM that can have a presentation similar to diffuse pulmonary diseases, including chemical inhalation lung injury. The examination of a biopsy specimen is crucial in such patients.
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Affiliation(s)
| | - Kei Nakashima
- Department of Pulmonology, Kameda Medical Center, Japan
| | - Kazuei Hoshi
- Department of Pathology, Kameda Medical Center, Japan
| | - Yu Oyama
- Department of Oncology Medicine, Kameda Medical Center, Japan
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32
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Price LC, Seckl MJ, Dorfmüller P, Wort SJ. Tumoral pulmonary hypertension. Eur Respir Rev 2019; 28:28/151/180065. [DOI: 10.1183/16000617.0065-2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/23/2018] [Indexed: 12/15/2022] Open
Abstract
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.
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Ohguchi H, Imaeda K, Hotta A, Kakoi S, Yasuda S, Shimizu Y, Hayakawa A, Mishina H, Hasegawa C, Ito S, Ogawa K, Yagi T, Koyama H, Tanaka T, Kato H, Takahashi S, Joh T. An Autopsy Case of Pulmonary Tumor Thrombotic Microangiopathy Due to Rapidly Progressing Colon Cancer in a Patient with Type 2 Diabetes. Intern Med 2018; 57:2533-2539. [PMID: 29607944 PMCID: PMC6172551 DOI: 10.2169/internalmedicine.0204-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
We herein describe a case of pulmonary tumor thrombotic microangiopathy (PTTM) with rapidly progressing colon cancer. A 61-year-old man who had been receiving treatment for type 2 diabetes mellitus for 3 years was hospitalized due to critical hypoxemia. Computed tomography, which had not shown any abnormalities 3 months previously, revealed a tumor in the ascending colon, multiple nodules in the liver, and the absence of any lung abnormalities. On day 3 of hospitalization, a sudden onset of severe dyspnea and tachycardia occurred, followed by death. Autopsy revealed microscopic metastatic tumor emboli in multiple pulmonary vessels with fibrin thrombus and intimal proliferation, which led to a diagnosis of PTTM.
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Affiliation(s)
- Hideomi Ohguchi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Kenro Imaeda
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Asami Hotta
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Shouta Kakoi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Satoshi Yasuda
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Yuki Shimizu
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Akiko Hayakawa
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Haruka Mishina
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Chie Hasegawa
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Shunsuke Ito
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Kento Ogawa
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Takashi Yagi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Hiroyuki Koyama
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Tomohiro Tanaka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Hiroyuki Kato
- Department of Experimental Pathology and Tumor Biology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Satoru Takahashi
- Department of Experimental Pathology and Tumor Biology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Japan
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34
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Iwashita Y, Hiramoto T, Suzuki K, Hashizume R, Maruyama K, Imai H. Possibility of venoarterial extracorporeal membranous oxygenator being a bridging therapy for hemodynamic deterioration of pulmonary tumor thrombotic microangiopathy prior to initiating chemotherapy: A case report. Medicine (Baltimore) 2018; 97:e12169. [PMID: 30212945 PMCID: PMC6155969 DOI: 10.1097/md.0000000000012169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare but lethal complication of carcinoma, defined as non-occlusive pulmonary tumor embolism complicated by fibrocellular intimal proliferation of the small pulmonary arteries, with eventual occlusion of the pulmonary arteries. Hemodynamic deterioration caused by this condition leads to high mortality. PATIENT CONCERNS A 46-year-old woman who had undergone radiation therapy for anaplastic oligoastrocytoma and who was taking temozolomide presented with cough and palpitations. DIAGNOSES A 12-lead electrocardiogram showed sinus tachycardia and SIQIII TIII, with negative T in V1-3. Ultrasound cardiography showed a distended right ventricle. Enhanced chest computed tomography showed no significant thrombus in the major pulmonary artery. The patient's condition deteriorated the next morning, with her blood pressure decreasing to 40 mmHg and her SpO2 unmeasurable. She suffered cardiac arrest. INTERVENTIONS We initiated venoarterial extracorporeal membranous oxygenation (VA-ECMO) and her blood pressure increased to 80 mmHg. Her hemodynamic status stabilized and she was weaned off VA-ECMO on intensive care unit (ICU) day 3. OUTCOMES Gastroesophageal endoscopy on ICU day 4 revealed gastric cancer (Borrman type IV), and she arrested again and died on ICU day 5. Autopsy confirmed gastric cancer and PTTM. LESSONS VA-ECMO rapidly stabilized the hemodynamic status of this patient with PTTM, and may thus be a possible bridging therapy for deterioration of PTTM prior to initiating imatinib.
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Affiliation(s)
- Yoshiaki Iwashita
- Emergency and Critical Care Center, Mie University Hospital
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Mie University
| | | | - Kei Suzuki
- Emergency and Critical Care Center, Mie University Hospital
| | - Ryotaro Hashizume
- Department of Pathology and Matrix Biology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kazuo Maruyama
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Mie University
| | - Hiroshi Imai
- Emergency and Critical Care Center, Mie University Hospital
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35
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Chen CK. Pulmonary Tumor Thrombotic Microangiopathy: Case Report and Literature Review. J Acute Med 2018; 8:127-131. [PMID: 32995214 PMCID: PMC7517918 DOI: 10.6705/j.jacme.201809_8(3).0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 12/19/2017] [Accepted: 01/04/2018] [Indexed: 06/11/2023]
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a rapidly progressive pulmonary disease complicated by malignancy. It manifests clinically as respiratory distress with pulmonary hypertension, progressive right sided heart failure, and sudden death. We describe a case of PTTM associated with metastatic gastric carcinoma. This case demonstrates the diagnostic diffi culties in such a rare and rapidly fatal oncological complication. More awareness among clinicians may help make a right diagnosis in the short time available. We also review the literatures to demonstrate the clinical characteristics that might provide clues towards an antemortem diagnosis, and may provide the key in treating PTTM.
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Affiliation(s)
- Chien-Kuang Chen
- Linkou Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
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36
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Merad M, Alibay A, Ammari S, Antoun S, Bouguerba A, Ayed S, Vincent F. [Pulmonary tumor thrombotic microangiopathy]. Rev Mal Respir 2017; 34:1045-1057. [PMID: 29153757 DOI: 10.1016/j.rmr.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 02/08/2017] [Indexed: 12/25/2022]
Abstract
Pulmonary tumor thrombotic microangiopathy syndrome is a rare clinicopathological entity in which tumor cell micro-emboli in the pulmonary microcirculation induced thrombotic microangiopathy. This can cause respiratory failure, and acute or sub-acute right heart failure. Histological features include micro tumor emboli in the small arteries and arterioles of the lung associated with thrombus formation and fibro-cellular and fibro-muscular intimal proliferation. The diagnosis is however extremely difficult to make before death. Thus, most of the observations reported are based on autopsy data. Very rare diagnostic observations made before death suggest the potential effectiveness of chemotherapy. Many details remain to be elucidated, interdisciplinary research is a priority with close collaboration between pathologists and clinicians to better understand this, often fatal, syndrome. It may be that the use of targeted therapies will improve the very poor prognosis allowing survival of several weeks or months after diagnosis.
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Affiliation(s)
- M Merad
- Service d'urgence en oncologie médicale, Gustave-Roussy Cancer Campus Grand Paris, Villejuif, 94805 Villejuif cedex, France
| | - A Alibay
- Service d'urgence en oncologie médicale, Gustave-Roussy Cancer Campus Grand Paris, Villejuif, 94805 Villejuif cedex, France
| | - S Ammari
- Service de radiologie, Gustave-Roussy Cancer Campus Grand Paris, Villejuif, 94805 Villejuif cedex, France
| | - S Antoun
- Service d'urgence en oncologie médicale, Gustave-Roussy Cancer Campus Grand Paris, Villejuif, 94805 Villejuif cedex, France
| | - A Bouguerba
- Réanimation polyvalente, GHIC Le-Raincy Montfermeil, 93370 Montfermeil, France
| | - S Ayed
- Réanimation polyvalente, GHIC Le-Raincy Montfermeil, 93370 Montfermeil, France
| | - F Vincent
- Réanimation polyvalente, GHIC Le-Raincy Montfermeil, 93370 Montfermeil, France.
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Abstract
PURPOSE OF REVIEW Pulmonary tumour thrombotic microangiopathy (PTTM) describes tumour cell microemboli with occlusive fibrointimal remodelling in small pulmonary arteries, veins and lymphatics. Progressive vessel occlusion ultimately results in pulmonary hypertension, which is often severe and rapid in onset. PTTM is associated with carcinomas, notably gastric carcinoma, with vascular endothelial growth factor and platelet-derived growth factor (PDGF) signalling implicated in driving the intimal remodelling. PTTM is a rare cause of pulmonary hypertension, but given that up to a quarter of autopsy specimens from patients dying of carcinoma show evidence for PTTM, it is probably underdiagnosed. RECENT FINDINGS Until recently, prognosis in PTTM was universally abysmal from weeks to a few months. Diagnostic utilities include aspiration of tumour cells at wedged right heart catheterization, high-resolution computed tomography (HRCT) findings and computed tomography-positron emission tomography (CT-PET), although definitive diagnosis requires histological analysis. Reports of PTTM treated with a combination of targeted pulmonary vasodilator therapies, anticoagulation, specific chemotherapy and PDGF inhibition, for example using imatinib, suggest that these approaches can prolong survival. SUMMARY PTTM is increasingly recognized as an important cause of pulmonary hypertension, often in patients presenting with new-onset pulmonary hypertension and as yet undiagnosed malignancy. Prospects of survival are improving with targeted combination therapy, and early recognition and diagnosis are likely to be the key factors to improve outcome.
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38
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Kubota K, Shinozaki T, Imai Y, Kario K. Imatinib dramatically alleviates pulmonary tumour thrombotic microangiopathy induced by gastric cancer. BMJ Case Rep 2017; 2017:bcr-2017-221032. [PMID: 28882938 PMCID: PMC5589033 DOI: 10.1136/bcr-2017-221032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pulmonary tumour thrombotic microangiopathy (PTTM) is a rare complication of cancer, which can be lethal due to progressive pulmonary hypertension (PH). Several case reports have demonstrated that imatinib, a platelet-derived growth factor receptor–tyrosine kinase inhibitor, can improve severe PH in patients with PTTM. We describe the case of a 56-year-old woman. Her mean pulmonary arterial pressure (mPAP) was 47 mm Hg, and her dyspnoea worsened rapidly over several days. Although pulmonary embolism was not observed on CT, enlargement of the para-aortic lymph nodes was detected. Gastro-oesophageal endoscopy revealed signet-ring cell carcinoma. We diagnosed her as having PTTM based on her clinical course, and started treatment with imatinib. Five days after its administration, her mPAP decreased dramatically. She was discharged and lived without symptoms of PH until her death due to systemic metastasis of carcinoma. In some cases of PTTM, imatinib may be an effective therapeutic option for PH.
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Affiliation(s)
- Kana Kubota
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Taro Shinozaki
- Division of Cardiovascular Medicine, Sano-kosei General Hospital, Sano, Tochigi, Japan
| | - Yasushi Imai
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan.,Division of Clinical Pharmacology, Department of Pharmacology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Fuchigami S, Tsunoda R, Shimizu H, Takae M, Usuku H, Yoshimura H, Ikemoto T, Nagamine M, Ito T, Izumiya Y, Kaikita K, Hokimoto S, Tsujita K. Pulmonary Tumor Thrombotic Microangiopathy ― Antemortem Diagnosis With Pulmonary Artery Wedge Blood Cell Sampling in a Recurrent Breast Cancer Patient ―. Circ J 2017; 81:1959-1960. [DOI: 10.1253/circj.cj-17-0228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Ryusuke Tsunoda
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital
| | - Hiroshi Shimizu
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital
| | - Masafumi Takae
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital
| | - Hiromi Yoshimura
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital
| | - Tomokazu Ikemoto
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital
| | | | - Teruhiko Ito
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
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40
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Toyonaga H, Tsuchiya M, Sakaguchi C, Ajimizu H, Nakanishi Y, Nishiyama S, Morikawa N, Hayashi Y, Nagasaka Y, Yasui H. Pulmonary Tumor Thrombotic Microangiopathy Caused by a Parotid Tumor: Early Antemortem Diagnosis and Long-term Survival. Intern Med 2017; 56:67-71. [PMID: 28050002 PMCID: PMC5313427 DOI: 10.2169/internalmedicine.56.7439] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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
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.
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41
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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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Merad M, Savale L, Antoun S, Vincent F. Is there hope of improving the prognosis of pulmonary tumour thrombotic microangiopathy? Eur Respir J 2016; 47:688-90. [PMID: 26828060 DOI: 10.1183/13993003.01276-2015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Mansouria Merad
- Service de Urgences et de Permanence des Soins, Gustave Roussy Cancer Campus Grand Paris, Villejuif, France
| | - Laurent Savale
- AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sami Antoun
- Service de Urgences et de Permanence des Soins, Gustave Roussy Cancer Campus Grand Paris, Villejuif, France
| | - François Vincent
- Réanimation Polyvalente, GHIC Le Raincy-Montfermeil, Montfermeil, France
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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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Gorospe Sarasúa L, Ureña-Vacas A, García-Santana E. Radiological diagnosis of pulmonary tumor thrombotic microangiopathy: A non-bronchial cause of «tree-in-bud» pattern on computed tomography. Arch Bronconeumol 2016; 52:621-622. [PMID: 27242249 DOI: 10.1016/j.arbres.2016.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/21/2016] [Accepted: 04/24/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Luis Gorospe Sarasúa
- Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - Almudena Ureña-Vacas
- Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, España
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Price LC, Wort SJ. Earlier diagnosis and international registries may improve outcomes in pulmonary tumour thrombotic microangiopathy. Eur Respir J 2016; 47:690-1. [DOI: 10.1183/13993003.01736-2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ishiguro T, Takayanagi N, Baba Y, Kagiyama N, Miyamoto T, Mutoh M, Shimizu Y, Sugita Y. Case Series of Pulmonary Tumor Embolism and Intravascular Lymphoma: Evaluation of the Usefulness of Pulmonary Microvascular Cytology. Intern Med 2016; 55:2679-84. [PMID: 27629967 DOI: 10.2169/internalmedicine.55.6855] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pulmonary tumor embolism (PTE) and intravascular lymphoma cause rapidly progressive deterioration and an antemortem diagnosis is difficult. The usefulness of pulmonary microvascular cytology (PMC) in the diagnosis of these disorders has been reported in sporadic case reports. We retrospectively evaluated the records of 7 patients with tumor cells in the pulmonary microvasculature (4 with PTE and 3 with malignant lymphoma) who underwent pulmonary microvascular cytology. Two of the 4 patients with PTE and 2 of the 3 patients with malignant lymphoma (all 3 had intravascular metastasis) had positive PMC results. These findings suggested that PMC may be useful in the diagnosis of these disorders.
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Affiliation(s)
- Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
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Wakabayashi Y, Iwaya M, Akita M, Takeuchi W, Yamazaki K, Iijima A. Pulmonary Tumor Thrombotic Microangiopathy Caused by Urothelial Carcinoma Expressing Vascular Endothelial Growth Factor, Platelet-derived Growth Factor, and Osteopontin. Intern Med 2016; 55:651-6. [PMID: 26984085 DOI: 10.2169/internalmedicine.55.5758] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal cancer-related pulmonary complication. It is generally caused by gastric adenocarcinoma, and several molecules produced by tumor cells are reported to play important roles in its pathogenesis. We herein report an autopsy case of PTTM caused by urothelial carcinoma. Vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and osteopontin were found to be expressed in both the primary tumor cells and metastatic cells in the PTTM lesions. These findings implicate the possible involvement of VEGF, PDGF, and osteopontin in the pathogenesis of PTTM caused by urothelial carcinoma.
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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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