Korean J Leg Med.  2019 Nov;43(4):153-158. 10.7580/kjlm.2019.43.4.153.

Sudden Unexpected Death During Bronchoscopy of a Patient with Pulmonary Lymphangitic Carcinomatosis and Pulmonary Tumor Thrombotic Microangiopathy due to Gastric Cancer

• Park S
• Na JY
• Choi BH

• KMID: 2464493
• DOI: http://doi.org/10.7580/kjlm.2019.43.4.153

Abstract

We present the case of a 48-year-old woman who complained of sustained dyspnea and newly developed dyspnea, who then suddenly and unexpectedly expired during bronchoscopy. On postmortem examination, the deceased had advanced gastric cancer as a primary tumor. Frequent lymphatic tumor emboli were observed with some pulmonary lymphangitic carcinomatosis (PLC), and pulmonary tumor thrombotic microangiopathy (PTMA). PLC and PTMA are lethal forms of pulmonary metastasis, and PTMA can lead to sudden death. The characteristic findings of PLC and PTMA in the deceased were not predominant, however, and the clinical manifestation was not acutely deteriorating. These findings are, therefore, insufficient to explain the deceased's sudden death. Clinically, the deceased manifested hypoxemia, bradycardia and cardiac arrest during bronchoscopy and then soon expired, suggesting the possibility of cardiovascular complication related to bronchoscopy. Despite several limitations, we assumed that the sudden unexpected death might have been induced by cardiovascular complications related to bronchoscopy and due to the underlying pathologic condition by PLC and PTMA.

Keyword

Forensic pathology; Autopsy; Postmortem; Lymphatic carcinomatosis; Stomach neoplasms; Pulmonary tumor thrombotic microangiopathy

MeSH Terms

Anoxia
Autopsy
Bradycardia
Bronchoscopy*
Carcinoma*
Death, Sudden
Dyspnea
Female
Forensic Pathology
Heart Arrest
Humans
Middle Aged
Neoplasm Metastasis
Stomach Neoplasms*
Thrombotic Microangiopathies*

Figure

• 

  Fig. 1 The pleural surfaces of the lungs show prominent fine lymphatic network with mild fibrosis.

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  Fig. 2 (A) There are multifocal tumor emboli in the lymphatics of the pleura, bronchovascular trees and septa (H&E, ×40). (B) The lymphatic vessels with tumor emboli are immunoreactive for D2-40 (×40).

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  Fig. 3 Tumor emboli are observed in the lymphatics of the bronchovascular tree, and tumor cells invade the adjacent connective tissue and bronchial wall with fibrosis (H&E, ×40).

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  Fig. 4 (A) Some pulmonary arterioles show microscopic tumor emboli with thrombi and fibrointimal proliferation (H&E, ×100). (B) Fibrointimal proliferation is observed in some pulmonary arterioles (Masson trichrome, ×100).

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