SESSION TITLE: Cancer Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 04:30 PM - 05:30 PM
INTRODUCTION: Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare but lethal diagnosis. It is a rapidly progressing disease associated with metastasizing tumor cells that cause sudden dyspnea and ultimately death.
CASE PRESENTATION: A 40yr old female patient with no medical history presented after a brief syncopal episode that was preceded by chest pain. Initial evaluation revealed a modestly elevated troponin that prompted a workup to rule out acute coronary syndrome and pulmonary embolism. Cardiac catheterization and echo were unrevealing. Chest CTA showed no PE, but did show concerning axillary lymph nodes, which were confirmed by needle biopsy to be metastatic breast cancer. Patient was stable and awaiting chemo-port placement when she had sudden hemodynamic collapse requiring intubation and vasopressors. Bedside echo showed severely dilated right ventricle and right heart failure. Repeat CTA again showed no PE so presumptive diagnosis of PTTM in light of confirmed malignancy was made. PA catheter was placed in addition to starting nitric oxide. Unfortunately, despite best efforts, our patient had progressive right heart failure and passed after PEA arrest. Post mortem autopsy confirmed the diagnosis of PTTM in the setting of metastatic breast ca.
DISCUSSION: PTTM is a devastating disease in which tumor cells invade the pulmonary vasculature and trigger the coagulation and inflammatory cascades. The pathophysiology, however, is not clearly understood. The clinical scenario is rapidly progressing dyspnea and chest pain that can progress to hemodynamic compromise and ultimately death. Diagnosis is usually clinical but VQ scan may show a peripheral mismatch that CTA will typically not demonstrate as the affected vessels are generally the fourth and fifth generation. Echo will typically show right heart strain. Depending on progression of symptoms, PET scan may also help with diagnosis. Anticoagulation and pulmonary vasodilators are of uncertain benefit at this time. The malignancies that have the highest potential of PTTM are breast cancer, gastric cancer and lymphangiosis carcinamotosa. Several case reports have reported more indolent progression than with our patient, but the overall mortality still remains high.
CONCLUSIONS: By increasing awareness of PTTM, more cases will be recognized and more antemortem diagnoses will be made which is the first step toward fully understanding this deadly disease.
Reference #1: Hotta M, Ishida M, Kojima F, Iwai Y, Okabe H. PTTM caused by lung adenocarcinoma: case report with review of the literature. Oncology Letters. 2011;2(3):435-437
Reference #2: Seol SH, Park BM, Jin HY, Kim DI. Fatal acute right heart failure in gastric cancer patients. Heart Views 2013;14:179-81
Reference #3: Kitamura, Atsushi, Naoki Nishimura, Torahiko Jinta, Rika Suda, Yasuhiko Yamano, Genta Ishikawa, . "A Case of PTTM Diagnosed by Lung Biopsy." National Center for Biotechnology Information. U.S. National Library of Medicine, 29 Aug. 2013. Web. 25 Mar. 2014.
DISCLOSURE: The following authors have nothing to disclose: Akash Sethi, Badrish Patel
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