Pulmonary tumor thrombotic microangiopathy of hepatocellular carcinoma: A case report and review of literature

Abstract

BACKGROUNDPulmonary tumor thrombotic microangiopathy (PTTM) is a rare condition in patients with hepatocellular carcinoma (HCC); to date, few cases have been reported. While hepatic dysfunction has been focused on the later stages of HCC, the management of symptoms in PTTM is important for supportive care of the cases. For the better understanding of PTTM in HCC, the information of our recent case and reported cases have been summarized.CASE SUMMARYA patient with HCC exhibited acute and severe respiratory failure. Radiography and computed tomography of the chest revealed the multiple metastatic tumors and a frosted glass–like shadow with no evidence of infectious pneumonia. We diagnosed his condition as acute respiratory distress syndrome caused by the lung metastases and involvement of the pulmonary vessels by tumor thrombus. Administration of prednisolone to alleviate the diffuse alveolar damages including edematous changes of alveolar wall caused by the tumor cell infiltration and ischemia showed mild improvement in his symptoms and imaging findings. An autopsy showed the typical pattern of PTTM in the lung with multiple metastases.CONCLUSIONPTTM is caused by tumor thrombi in the arteries and thickening of the pulmonary arterial endothelium leading to the symptoms of dyspnea in terminal staged patients. Therefore, supportive management of symptoms is necessary in the cases with PTTM and hence we believe that the information presented here is of great significance for the diagnosis and management of symptoms of PTTM with HCC.

Fatal pulmonary tumour thrombotic microangiopathy in patient with ovarian adenocarcinoma: review and a case report

“…It has been previously reported that VEGF is being expressed by tumour cells in PTTM cases, as well as tissue factor (TF) and platelet-derived growth factor (PDGF) [5]. The expression of TF and PDGF can lead to hypercoagulation state causing disseminated intravascular coagulation (DIC) [4,7]. This mechanism provokes PH by inducing the remodelling of pre-capillary and post-capillary pulmonary vessels [8].…”

“…This leads to narrowing and occluding of small pulmonary vessels until pulmonary hypertension, dyspnea, respiratory failure develop [1,6]. A major part here is played by vascular endothelial growth factor (VEGF) [4]. It has been previously reported that VEGF is being expressed by tumour cells in PTTM cases, as well as tissue factor (TF) and platelet-derived growth factor (PDGF) [5].…”

“…PTTM causes pulmonary hypertension (PH), respiratory Neverauskaite-Piliponiene et al BMC Cardiovascular Disorders (2022) 22:1 failure leading to death due to the right heart failure [3]. Pathologically, major role is played by factors expressed by tumour cells-vascular endothelial growth factor (VEGF), tissue factor (TF) and platelet-derived growth factor (PDGF) [4,5]. Most recent systematic review consisting of seventy-nine publications with 160 patients, presents PTTM incidence around 1.4-3.3% in patients with carcinoma [6].…”

Pulmonary Tumor Embolism: A Rare Cause of Acute Pulmonary Hypertension

“…Another mechanism is caused by tumor cells being spread hematogenously, where the cells will lodge into the pulmonary arteries. This is known as pulmonary tumor thrombotic microangiopathy (PTTM), and it results in thrombus formation within the pulmonary arteries, leading to occlusion of the vessels [ 6 ]. Finally, in a primary or secondary lung malignancy, such as in this patient, PTE can be caused by local invasion and occlusion of the pulmonary arteries [ 7 ].…”

Pulmonary Tumor Embolism Complicated by Metastatic Liver Carcinoma in Female With Primary Breast Carcinoma

“…The staging of primary tumors such as liver, breast, stomach, kidney, and prostate carcinoma can assess the risk of developing pulmonary tumor embolism, justifying the higher risk of embolism in advanced-stage cancer. Generally, clinicians correlate the risk of pulmonary tumor embolism with advanced-stage tumors that usually metastasize to the lungs [ 4 ]. PE along with liver metastatic carcinoma is uncommon, and a recent study identified that out of 658 autopsies, 20 patients had pulmonary tumor emboli.…”