Pulmonary Tumor Thrombotic Microangiopathy Caused by Metastatic Ovarian Cancer: An Antemortem Diagnosis with Pulmonary Aspiration Cytopathology

Figures

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  Figure 1.. Chest radiograph and 12-lead electrocardiography findings on admission. A: Chest radiography revealed cardiomegaly with significant enlargement of both the right and left second cardiac arches. B: A 12-lead electrocardiogram showed sinus tachycardia with incomplete right bundle branch block, S wave in I, counterclockwise rotation, and negative T in V2-6.

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  Figure 2.. Images of computed tomography and lung perfusion scintigraphy. A: Although the pulmonary artery was dilated, no apparent pulmonary thromboemboli were detected by contrast-enhanced CT. B: Patchy distribution of ground-glass opacity in the centrilobular lung fields was observed. C: Bilateral multiple wedge-shaped perfusion defects in lung perfusion scintigraphy were observed. D: Contrast-enhanced CT also revealed an irregular huge pelvic mass 8.7×5.8 cm in size (white arrows) suspected of being bilateral malignant ovarian cancer.

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  Figure 3.. Cytopathology of pulmonary wedge aspiration by a Swan-Ganz catheter. Pulmonary artery wedge aspiration cytopathology from the tip of the right heart catheter was carried out for the diagnosis. Cytopathology with Papanicolaou stain revealed a cluster of atypical cells with anisokaryosis, a high nuclear-to-cytoplasmic ratio, and nuclear hyperchromasia.

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  Figure 4.. Diagram depicting the clinical course of the case during hospitalization. ALT: alanine aminotransferase, AST: aspartate aminotransferase, sBP: systolic blood pressure, HR: heart rate, NHF: nasal high flow, PAW: pulmonary artery wedge, RHC: right heart catheterization, UFH: unfractionated heparin

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  Figure 5.. Postmortem pathologic observation of the lung showing PTTM and primary ovarian cancer. A: Low-power image of the lung with Hematoxylin and Eosin (H&E) staining. Multiple nodular lesions of tumor emboli, clot formation, and fibrocellular occlusion in pulmonary arterioles were observed (black arrows). B-I: High-power images of the arteriole showing embolization of cancer cells accompanied by fibrin-rich thrombus (Th). B-H images came from adjacent sections. H&E staining (B), EVG (C), MT (D), as well as IHC for TF (E), PDGF-A (G), CA125 (H), double IF staining for VEGF-A (green), and αSMA (red) [nuclei were counterstained with DAPI (blue)] (F). IHC image for CA125 in primary ovarian cancer (I). J-L: High power images of another lesion for lung arteriole showing fibrocellular occlusion accompanied by embolic cancer cells. Adjacent sections of EVG (J), MT (K) staining, and IHC image for αSMA (L) are presented. The lumen was occupied by αSMA-positive mesenchymal cells. The length of the scale bar indicates 1,000 μm (A) or 100 μm (B-L) in each image. αSMA: alpha smooth muscle actin, CA125: cancer antigen 125, DAPI: 4’,6-diamidino-2-phenylindole, EVG: elastica van Gieson, IF:…