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A Case Report: Cavitary Infarction Caused by Pulmonary Tumor Thrombotic Microangiopathy in a Patient with Pancreatic Intraductal Papillary Mucinous Neoplasm.

Bae K, Kwon WJ, Choi SH, Lee JH, Cha HJ - Korean J Radiol (2015)

Bottom Line: Here, we present a 52-year-old male with tumor thrombotic microangiopathy and pulmonary infarction, which might have originated from intraductal papillary mucinous tumor of the pancreas.Multiple wedge-shaped consolidations were found initially and aggravated with cavitation.These CT features of pulmonary infarction were pathologically confirmed to result from pulmonary tumor thrombotic microangiopathy.

View Article: PubMed Central - PubMed

Affiliation: Department of Diagnostic Radiology, Ulsan University Hospital, University of Ulsan School of Medicine, Ulsan 682-714, Korea.

ABSTRACT
Pulmonary tumor embolism is commonly discovered at autopsy, but is rarely suspected ante-mortem. Microangiopathy is an uncommon and distinct form of simple tumor pulmonary embolism. Here, we present a 52-year-old male with tumor thrombotic microangiopathy and pulmonary infarction, which might have originated from intraductal papillary mucinous tumor of the pancreas. Multiple wedge-shaped consolidations were found initially and aggravated with cavitation. These CT features of pulmonary infarction were pathologically confirmed to result from pulmonary tumor thrombotic microangiopathy.

No MeSH data available.


Related in: MedlinePlus

52-year-old man with cavitary infarction caused by pulmonary tumor thrombotic microangiopathy originated from pancreatic intraductal papillary mucinous neoplasm.A. Chest radiograph demonstrates bilateral multifocal consolidations in peripheral portions of both upper lungs. Axial computed tomography images (lung window setting; window width, 1500 Hounsfield unit [HU]; window level, -700 HU) show ill-defined wedge-shaped consolidations and ground glass opacities in peripheral portion of both upper lobes (B, C). Cavitation was present in some consolidations (B, arrows). D. Contiguous contrast-enhanced axial CT images show multiple cystic lesions (black arrows with white border) with minimal disproportional pancreatic duct dilatation (branch ducts, white arrowheads) in body and tail of pancreas. Ill-defined soft tissue lesion is present in one cyst (white arrow), which is presumed to be mural nodule of malignant intraductal papillary mucinous neoplasm. E. Lymphadenopathy in peripancreatic space (arrow) and ascites are also seen. F, G. Follow-up axial CT images (lung window setting: window width, 1500 Hounsfield unit [HU]; window level, -700 HU) 3 weeks after initial CT scan demonstrate that wedge-shape consolidations are extended or newly developed. Additionally, cavities in consolidations are newly developed or changed, predominantly in peripheral portion of lungs. H. Photomicrograph of histopathological specimen shows tumor emboli (black arrowheads) and intimal hyperplasia (white asterisks) in vasculature. These tumor emboli and intimal hyperplasia may obstruct vascular lumen and cause irregular vascular shape. Distal lung parenchyma of obstructed vascular lumen is necrotic (black asterisk) (hematoxylin-eosin, original magnification, × 40). I. Photomicrograph of histopathological specimen shows tumor cells, columnar mucin-producing glands (black arrowheads) in pulmonary vasculature, and marked fibrocellular intimal hyperplasia (white asterisk) (hematoxylin-eosin, original magnification, × 100). There is little fibrin thrombosis in vascular lumen. J. Immunohistochemical stain for MUC5ac (× 100), to which metastatic adenocarcinomas demonstrate positive reaction (brown color) but bronchial epithelium and alveolar pneumocytes are negative. In contrast to MUC5ac, basal cells of bronchial epithelium and alveolar pneumocytes demonstrate positive reaction (brown color) to immunohistochemical stain for TTF-1 (× 100), but metastatic adenocarcinomas are negative.
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Figure 1: 52-year-old man with cavitary infarction caused by pulmonary tumor thrombotic microangiopathy originated from pancreatic intraductal papillary mucinous neoplasm.A. Chest radiograph demonstrates bilateral multifocal consolidations in peripheral portions of both upper lungs. Axial computed tomography images (lung window setting; window width, 1500 Hounsfield unit [HU]; window level, -700 HU) show ill-defined wedge-shaped consolidations and ground glass opacities in peripheral portion of both upper lobes (B, C). Cavitation was present in some consolidations (B, arrows). D. Contiguous contrast-enhanced axial CT images show multiple cystic lesions (black arrows with white border) with minimal disproportional pancreatic duct dilatation (branch ducts, white arrowheads) in body and tail of pancreas. Ill-defined soft tissue lesion is present in one cyst (white arrow), which is presumed to be mural nodule of malignant intraductal papillary mucinous neoplasm. E. Lymphadenopathy in peripancreatic space (arrow) and ascites are also seen. F, G. Follow-up axial CT images (lung window setting: window width, 1500 Hounsfield unit [HU]; window level, -700 HU) 3 weeks after initial CT scan demonstrate that wedge-shape consolidations are extended or newly developed. Additionally, cavities in consolidations are newly developed or changed, predominantly in peripheral portion of lungs. H. Photomicrograph of histopathological specimen shows tumor emboli (black arrowheads) and intimal hyperplasia (white asterisks) in vasculature. These tumor emboli and intimal hyperplasia may obstruct vascular lumen and cause irregular vascular shape. Distal lung parenchyma of obstructed vascular lumen is necrotic (black asterisk) (hematoxylin-eosin, original magnification, × 40). I. Photomicrograph of histopathological specimen shows tumor cells, columnar mucin-producing glands (black arrowheads) in pulmonary vasculature, and marked fibrocellular intimal hyperplasia (white asterisk) (hematoxylin-eosin, original magnification, × 100). There is little fibrin thrombosis in vascular lumen. J. Immunohistochemical stain for MUC5ac (× 100), to which metastatic adenocarcinomas demonstrate positive reaction (brown color) but bronchial epithelium and alveolar pneumocytes are negative. In contrast to MUC5ac, basal cells of bronchial epithelium and alveolar pneumocytes demonstrate positive reaction (brown color) to immunohistochemical stain for TTF-1 (× 100), but metastatic adenocarcinomas are negative.

Mentions: Chest radiographs showed bilateral multifocal consolidations, which were predominantly in both upper lung fields and particularly prevalent close to the pleura (Fig. 1A). Chest computed tomography (CT) images (lung window setting: window width, 1500 Hounsfield unit [HU]; window level, -700 HU) revealed ill-defined wedge-shaped consolidations and ground glass opacities predominantly in the peripheral portions of the lungs. There was cavitation in some of the consolidations (Fig. 1B, C). Enhanced abdominal CT scans showed multiple cystic lesions suggesting IPMN in the remnant pancreas and peripancreatic lymphadenopathy (Fig. 1D, E). However, pathological evaluation of the pancreatic lesion and complete oncological evaluation were not performed at that time. We started empirical antibiotics and antifungal agents under the working diagnosis of septic emboli or fungal infection. However, chest CT images 3 weeks later demonstrated that the wedge-shaped consolidations had rapidly become aggravated, and cavitation had progressively developed in the consolidations, despite antibiotic and antifungal therapy (Fig. 1F, G). Furthermore, subjective symptoms of dyspnea and chest radiograph findings had deteriorated. Therefore, we obtained specimens from the cavitary consolidations by percutaneous transthoracic needle biopsy. However, the biopsy specimens only showed numerous neutrophils and necrosis without any organisms such as bacteria or fungus. The patient then underwent a video-assisted thoracoscopic lung biopsy for an accurate pathological diagnosis. Two weeks after the operative biopsy, the patient died despite intensive supportive care.


A Case Report: Cavitary Infarction Caused by Pulmonary Tumor Thrombotic Microangiopathy in a Patient with Pancreatic Intraductal Papillary Mucinous Neoplasm.

Bae K, Kwon WJ, Choi SH, Lee JH, Cha HJ - Korean J Radiol (2015)

52-year-old man with cavitary infarction caused by pulmonary tumor thrombotic microangiopathy originated from pancreatic intraductal papillary mucinous neoplasm.A. Chest radiograph demonstrates bilateral multifocal consolidations in peripheral portions of both upper lungs. Axial computed tomography images (lung window setting; window width, 1500 Hounsfield unit [HU]; window level, -700 HU) show ill-defined wedge-shaped consolidations and ground glass opacities in peripheral portion of both upper lobes (B, C). Cavitation was present in some consolidations (B, arrows). D. Contiguous contrast-enhanced axial CT images show multiple cystic lesions (black arrows with white border) with minimal disproportional pancreatic duct dilatation (branch ducts, white arrowheads) in body and tail of pancreas. Ill-defined soft tissue lesion is present in one cyst (white arrow), which is presumed to be mural nodule of malignant intraductal papillary mucinous neoplasm. E. Lymphadenopathy in peripancreatic space (arrow) and ascites are also seen. F, G. Follow-up axial CT images (lung window setting: window width, 1500 Hounsfield unit [HU]; window level, -700 HU) 3 weeks after initial CT scan demonstrate that wedge-shape consolidations are extended or newly developed. Additionally, cavities in consolidations are newly developed or changed, predominantly in peripheral portion of lungs. H. Photomicrograph of histopathological specimen shows tumor emboli (black arrowheads) and intimal hyperplasia (white asterisks) in vasculature. These tumor emboli and intimal hyperplasia may obstruct vascular lumen and cause irregular vascular shape. Distal lung parenchyma of obstructed vascular lumen is necrotic (black asterisk) (hematoxylin-eosin, original magnification, × 40). I. Photomicrograph of histopathological specimen shows tumor cells, columnar mucin-producing glands (black arrowheads) in pulmonary vasculature, and marked fibrocellular intimal hyperplasia (white asterisk) (hematoxylin-eosin, original magnification, × 100). There is little fibrin thrombosis in vascular lumen. J. Immunohistochemical stain for MUC5ac (× 100), to which metastatic adenocarcinomas demonstrate positive reaction (brown color) but bronchial epithelium and alveolar pneumocytes are negative. In contrast to MUC5ac, basal cells of bronchial epithelium and alveolar pneumocytes demonstrate positive reaction (brown color) to immunohistochemical stain for TTF-1 (× 100), but metastatic adenocarcinomas are negative.
© Copyright Policy - open-access
Related In: Results  -  Collection

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Show All Figures
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Figure 1: 52-year-old man with cavitary infarction caused by pulmonary tumor thrombotic microangiopathy originated from pancreatic intraductal papillary mucinous neoplasm.A. Chest radiograph demonstrates bilateral multifocal consolidations in peripheral portions of both upper lungs. Axial computed tomography images (lung window setting; window width, 1500 Hounsfield unit [HU]; window level, -700 HU) show ill-defined wedge-shaped consolidations and ground glass opacities in peripheral portion of both upper lobes (B, C). Cavitation was present in some consolidations (B, arrows). D. Contiguous contrast-enhanced axial CT images show multiple cystic lesions (black arrows with white border) with minimal disproportional pancreatic duct dilatation (branch ducts, white arrowheads) in body and tail of pancreas. Ill-defined soft tissue lesion is present in one cyst (white arrow), which is presumed to be mural nodule of malignant intraductal papillary mucinous neoplasm. E. Lymphadenopathy in peripancreatic space (arrow) and ascites are also seen. F, G. Follow-up axial CT images (lung window setting: window width, 1500 Hounsfield unit [HU]; window level, -700 HU) 3 weeks after initial CT scan demonstrate that wedge-shape consolidations are extended or newly developed. Additionally, cavities in consolidations are newly developed or changed, predominantly in peripheral portion of lungs. H. Photomicrograph of histopathological specimen shows tumor emboli (black arrowheads) and intimal hyperplasia (white asterisks) in vasculature. These tumor emboli and intimal hyperplasia may obstruct vascular lumen and cause irregular vascular shape. Distal lung parenchyma of obstructed vascular lumen is necrotic (black asterisk) (hematoxylin-eosin, original magnification, × 40). I. Photomicrograph of histopathological specimen shows tumor cells, columnar mucin-producing glands (black arrowheads) in pulmonary vasculature, and marked fibrocellular intimal hyperplasia (white asterisk) (hematoxylin-eosin, original magnification, × 100). There is little fibrin thrombosis in vascular lumen. J. Immunohistochemical stain for MUC5ac (× 100), to which metastatic adenocarcinomas demonstrate positive reaction (brown color) but bronchial epithelium and alveolar pneumocytes are negative. In contrast to MUC5ac, basal cells of bronchial epithelium and alveolar pneumocytes demonstrate positive reaction (brown color) to immunohistochemical stain for TTF-1 (× 100), but metastatic adenocarcinomas are negative.
Mentions: Chest radiographs showed bilateral multifocal consolidations, which were predominantly in both upper lung fields and particularly prevalent close to the pleura (Fig. 1A). Chest computed tomography (CT) images (lung window setting: window width, 1500 Hounsfield unit [HU]; window level, -700 HU) revealed ill-defined wedge-shaped consolidations and ground glass opacities predominantly in the peripheral portions of the lungs. There was cavitation in some of the consolidations (Fig. 1B, C). Enhanced abdominal CT scans showed multiple cystic lesions suggesting IPMN in the remnant pancreas and peripancreatic lymphadenopathy (Fig. 1D, E). However, pathological evaluation of the pancreatic lesion and complete oncological evaluation were not performed at that time. We started empirical antibiotics and antifungal agents under the working diagnosis of septic emboli or fungal infection. However, chest CT images 3 weeks later demonstrated that the wedge-shaped consolidations had rapidly become aggravated, and cavitation had progressively developed in the consolidations, despite antibiotic and antifungal therapy (Fig. 1F, G). Furthermore, subjective symptoms of dyspnea and chest radiograph findings had deteriorated. Therefore, we obtained specimens from the cavitary consolidations by percutaneous transthoracic needle biopsy. However, the biopsy specimens only showed numerous neutrophils and necrosis without any organisms such as bacteria or fungus. The patient then underwent a video-assisted thoracoscopic lung biopsy for an accurate pathological diagnosis. Two weeks after the operative biopsy, the patient died despite intensive supportive care.

Bottom Line: Here, we present a 52-year-old male with tumor thrombotic microangiopathy and pulmonary infarction, which might have originated from intraductal papillary mucinous tumor of the pancreas.Multiple wedge-shaped consolidations were found initially and aggravated with cavitation.These CT features of pulmonary infarction were pathologically confirmed to result from pulmonary tumor thrombotic microangiopathy.

View Article: PubMed Central - PubMed

Affiliation: Department of Diagnostic Radiology, Ulsan University Hospital, University of Ulsan School of Medicine, Ulsan 682-714, Korea.

ABSTRACT
Pulmonary tumor embolism is commonly discovered at autopsy, but is rarely suspected ante-mortem. Microangiopathy is an uncommon and distinct form of simple tumor pulmonary embolism. Here, we present a 52-year-old male with tumor thrombotic microangiopathy and pulmonary infarction, which might have originated from intraductal papillary mucinous tumor of the pancreas. Multiple wedge-shaped consolidations were found initially and aggravated with cavitation. These CT features of pulmonary infarction were pathologically confirmed to result from pulmonary tumor thrombotic microangiopathy.

No MeSH data available.


Related in: MedlinePlus