Lung Cancer: Fellow Case Report Slide: Lung Cancer |

Pulmonary Tumor Thrombotic Microangiopathy Caused by Metastatic Gastric Carcinoma FREE TO VIEW

Derek Hansen, MD; Geraldo Holguin, MD; Avani Mehta, MD
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University of Mississippi Medical Center, Jackson, MS

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):684A. doi:10.1016/j.chest.2016.08.779
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SESSION TITLE: Fellow Case Report Slide: Lung Cancer

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 23, 2016 at 03:15 PM - 04:15 PM

INTRODUCTION: We present a case of a 31-year-old male who died from right heart failure due to pulmonary tumor thrombotic microangiopathy (PTTM) from diffuse primary gastric adenocarcinoma.

CASE PRESENTATION: A 31-year-old Hispanic male smoker with no significant past medical history presented with persistent bilateral hip and knee pain, fatigue, unintentional 30 pound weight loss, and a productive cough with scant hemoptysis. He had emigrated from Mexico 15 years prior and never returned. He worked in a chicken plant where he built coops and administered vaccinations to the animals. Laboratory data revealed a leukocytosis, normocytic anemia, hyperbilirubinemia, and thrombocytopenia. HIV testing was negative. Physical examination was unremarkable except for jaundice and submandibular lymphadenopathy. Chest x-ray revealed diffuse bilateral interstitial opacities. Computed tomography (CT) of the chest showed no pulmonary emboli, scattered areas of ill-defined ground glass opacities with interlobular septal thickening bilaterally, and hilar lymphadenopathy. He was started on broad-spectrum antibiotic therapy. Transthoracic echocardiogram revealed right heart failure. He was noted to have an increasing oxygen requirement and acutely decompensated requiring intubation for hypoxemic respiratory failure. Very rapidly thereafter, he suffered a cardiac arrest and was unable to be revived. Autopsy found the cause of death to be extensive tumor embolization within the pulmonary vascular circulation from a primary diffuse gastric adenocarcinoma.

DISCUSSION: Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare clinicopathologic entity, most frequently associated with gastric malignancies that can result in severe pulmonary hypertension. Unfortunately, it is rarely diagnosed pre-mortem. Histologic features of PTTM include widespread tumor emboli of the small arteries and arterioles of the lungs resulting in occlusion or stenosis of the pulmonary vasculature; and, often is associated with thrombus formation from activation of the coagulation cascade.

CONCLUSIONS: PTTM should be considered in the differential diagnosis of new onset pulmonary arterial hypertension and in rapidly progressive respiratory distress even in the absence of a previous diagnosis of malignancy.

Reference #1: Yao, D. X., Flieder, D. B., Hoda, S. A. Pulmonary tumor thrombotic microangiopathy: an often missed ante mortem diagnosis. Arch Pathol Lab Med 2001; 125: 304-305.

DISCLOSURE: The following authors have nothing to disclose: Derek Hansen, Geraldo Holguin, Avani Mehta

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