Ewha Med J.  2014 Sep;37(2):146-151. 10.12771/emj.2014.37.2.146.

Pulmonary Tumor Thrombotic Microangiopathy Associated with Advanced Gastric Cancer Successfully Treated with Chemotherapy

• Yoo SH
• Park K
• Hong JY
• Kim JY
• Park JW
• Park YW
• Lee KH
• Jeon KS

• KMID: 2171300
• DOI: http://doi.org/10.12771/emj.2014.37.2.146

Abstract

Pulmonary tumor thrombotic microangiopathy (PTTM) is an uncommon and fatal malignancy-related pulmonary complication characterized by fibrocellular intimal proliferation of small pulmonary arteries and arterioles. It causes marked pulmonary hypertension, right-side heart failure, and sudden death. Diagnosis of PTTM is extremely difficult while the patient is alive. Here, we report a 44-year-old woman who presented with complaining of progressing dyspnea and pulmonary hypertension but with no history of cancer. She was diagnosed with PTTM caused by advanced gastric cancer ante mortem and was treated effectively with chemotherapy.

Keyword

Pulmonary tumor thrombotic microangiopathy; Stomach neoplasms; Pulmonary hypertension; Chemotherapy

MeSH Terms

Adult
Ants
Arterioles
Death, Sudden
Diagnosis
Drug Therapy*
Dyspnea
Female
Heart Failure
Humans
Hypertension, Pulmonary
Pulmonary Artery
Stomach Neoplasms*
Thrombotic Microangiopathies*

Figure

• 

  Fig. 1 Peripheral blood smear. It shows schistocytes and reticulocytes, consistent with microangiopathic hemolytic anemia (×400).

• 

  Fig. 2 Pulmonary computed tomography angiogram. It shows no abnormalities in the pulmonary artery, but enlargement of the right atrium and ventricle are observed (A). There are no significant abnormalities in the lung parenchyme (B).

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  Fig. 3 The echocardiogram. It shows typical findings of acute pulmonary thromboembolism with a D-shaped left ventricle, right ventricular enlargement without hypokinesia, moderate tricuspid regurgitation, and severe pulmonary hypertension with right ventricular systolic pressure of 79 mmHg.

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  Fig. 4 Abdomino-pelvic computed tomography (CT). It shows diffusely thickened gastric antrum wall and multiple enlarged lymph nodes in celiac, paraaortic, aortocaval, and mesenteric lesions (A). In the lung parenchyme of the abdominopelvic CT, ground-glass opacities and reticulonodular infiltration with tree-in-bud form appeared compared with the initial pulmonary CT (B).

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  Fig. 5 Gastroduodenoscopic finding. (A) Gastroduodenoscopy shows an ulcerofungating mass with folds converging from the low body to the proximal antrum. (B) Microscopically, the stomach biopsy shows poorly differentiated adenocarcinoma (H&E, ×100). (C) Microscopically, the lymph node biopsy shows metastatic adenocarcinoma (H&E, ×100).

• 

  Fig. 6 Lung and perfusion scans. (A) Lung scan shows no defects in the lung ventilation. (B) The perfusion scan shows multiple small wedge-shaped perfusion defects throughout both lungs and the periphery. This finding is compatible with a tumor microembolism. ANT, anterior; POST, posterior; RT-LAT, right lateral; LT-LAT, left lateral; RPO, right posterior oblique; LPO, left posterior oblique.

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