Sudden Development of Fatal Pulmonary due to Suspected Pulmonary Tumoral Thrombotic Microangiopathy among Patients with Cancer: Case Series of Clinical and CT Features in 10 Patients

Figures

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  Fig. 1. A 55-year-old female presented with neck mass and biopsy from supraclavicular lymphadenopathy confirmed papillary carcinoma of unknown origin. A, B. Initial CT scan shows metastatic mediastinal lymphadenopathy and right pleural effusion. C, D. Five days later, the patient complained of sudden aggravation of dyspnea with hypoxemia (PaO2 = 52 mmHg) and markedly elevated D-dimer levels. CT reveals severe enlargement of the right atrium and ventricle with pulmonary trunk dilatation. The patient died on following day.

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  Fig. 2. A 59-year-old female who visited ER due to dyspnea and was then diagnosed with breast cancer. A, B. Contrast-enhanced CT scans obtained in the ER show marked dilatation of the right ventricle, suggestive of severe pulmonary hypertension. The pulmonary trunk is also slightly enlarged compared with the ascending aorta. C-F. CT images of the lung window setting demonstrate a small nodule with a surrounding GGO halo (white arrows in C and E), focal dilatation of subpleural or peripheral pulmonary vessels with perivascular GGO (circles in D and F), focal subpleural consolidations or GGO (black arrows in E and F), and minimal interlobular septal thickening (arrowhead in F). The patient died 1 week after the CT was performed. ER = emergency room, GGO = ground-glass opacity

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  Fig. 3. A 66-year-old female with bladder cancer and axillary lymph node and bone metastasis had sudden onset of dyspnea and showed hypoxemia (PaO2 79 mmHg). A. Non-contrast-enhanced CT demonstrates deviation of the anterior interventricular groove to the left (arrow), suggestive of right ventricular dilatation. B. Axial lung window image shows ill-defined perivascular and subpleural GGO in the right lung (black arrows), a small nodule with surrounding GGO halo in the left upper lobe (white arrow), and interlobular septal thickening in both lungs (arrowheads). C, D. Coronal images demonstrate focal dilatation of the peripheral pulmonary vessels surrounded by GGO in both upper lobes (circles), diffuse perivascular GGO, and consolidation in the right lung (arrows). With the aggravation of dyspnea, the patient died the following day. GGO = ground-glass opacity

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  Fig. 4. A 71- year-old female, who had left mastectomy due to breast cancer 3 months ago with no known metastasis, visited ER due to intermittent cough and sudden aggravation of dyspnea. The patient showed elevation of D-dimer and hypoxemia (PaO2 63 mmHg). A, B. Contrast-enhanced CT shows severe right atrial and ventricular dilatation without significant enlargement of the pulmonary trunk, suggestive of severe acute pulmonary hypertension. C, D. Lung window images demonstrate focal subpleural (arrows) and extensive perivascular (arrowheads, D) GGO in both lower lobes. A pulmonary vessel connected to the subpleural focal GGO was noted in the right lower lobe (arrowhead, C). The patient died the following day. GGO = ground-glass opacity

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  Fig. 5. A 45-year-old female, who had undergone left mastectomy due to breast cancer and was on palliative chemotherapy due to chest wall and skin metastasis. A. Contrast-enhanced CT scan obtained 8 days prior in an outpatient care center shows diffuse chest wall metastasis at the left mastectomy site. B. CT performed at the ER reveals newly developed severe right ventricular dilatation. C, D. Coronal lung window images show dilatation of small peripheral vessels with perivascular ground-glass opacities in subpleural lung of the left upper lobe (circles). The patient showed rapid improvement in dyspnea and right ventricular dilatation after extensive treatment with chemotherapy combined with corticosteroids and diuretics and was discharged. However, she revisited ER because of severe dyspnea and died 75 days after the initial ER visit. ER = emergency room