Subacute Pulmonary Hypertension due to Pulmonary Tumor Microembolism as a Clinical Manifestation of Occult Gallbladder Adenocarcinoma

Abstract

We report a 67-year-old man who developed pulmonary hypertension as an initial clinical manifestation of occult gallbladder adenocarcinoma. He had a 6-week history of persistent dry cough followed by progressive dyspnea on exertion. Physical examination and chest roentgenogram revealed signs of precapillary pulmonary hypertension. He died of shock 1 h after pulmonary angiography, which failed to show any intravascular filling defects. Autopsy disclosed a mucin-producing small adenocarcinoma (2 cm diameter) and a gallstone in the gallbladder with a few small metastases to peri-aortic, peri-bronchial and mediastinal lymph nodes. Macroscopically, there was no gross thrombotic pulmonary embolism or pulmonary metastases. However, microscopically, more than 60% of the small pulmonary arteries less than 1 mm in diameter were occluded with pulmonary tumor microemboli. This case emphasizes the need to include tumor pulmonary embolism in the differential diagnosis of pulmonary hypertension whether or not there is evidence of an underlying malignant tumor.

Pulmonary Tumor Embolism Syndrome from Occult Colonic Adenocarcinoma

“…Pulmonary tumor embolism syndrome (also known as pulmonary tumor thrombotic microangiopathy) has been reported to be found in 3% to 26% of autopsies conducted on patients with solid tumors (1)(2)(3)(4). Numerous case reports have been published (5)(6)(7)(8)(9)(10)(11)(12)(13), and in most cases the diagnosis is not made until after death. Th e incidence is highest in patients with gastric adenocarcinoma, and fewer cases have been reported with adenocarcinoma of the colon (14)(15)(16).…”

Pulmonary Hypertension Caused by Metastatic Breast Cancer and Its Response to Antihormone Therapy and Chemotherapy

“…Pulmonary hypertension caused by tumor cell microembolism is a rare occurrence. Although various solid tumors such as breast (1), colon (2), gall bladder (3), stomach (4), and choriocarcinoma (5) have been reported to cause microembolism to lungs causing pulmonary hypertension, diagnosis is usually made at autopsy and antemortem diagnosis is extremely rare. Furthermore, there is little information on response to therapy of this condition (6,7).…”