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Weekly Chest CasesArchive of Old Cases

Case No : 1329 Date 2023-04-10

  • Courtesy of Jung Han Woo, Tae Jung Kim / Samsung Medical Center
  • Age/Sex 67 / M
  • Chief Complaintdyspnea, edema on feet and face On CTx for lung adenocarcinoma
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Pulmonary Tumor Thrombotic Microangiopathy
Radiologic Findings
Fig 1. Chest PA shows prominent bilateral interstitial markings with cardiomegaly.
Fig 2-3. CT scans reveal diffuse bronchovascular and interlobular thickening, centrilobular ground glass nodules, and multiple areas of branching centrilobular nodules in the periphery.
Fig 4. Enlarged right ventricle, inducing interventricular septum bowing
Brief Review
Pulmonary tumor thrombotic microangiopathy (PTTM)
: Fatal disease process in which pulmonary hypertension (PH) develops in the setting of malignancy

Tumor embolism in the small and medium pulmonary arteries, leading to rapid progressive pulmonary hypertension

Pathology
extensive pulmonary vascular fibrocellular hyperplasia
concomitant with tumor emboli

Commonly associated with adenocarcinoma
Gastric cancer(m/c, 59%), breast cancer, lung cancer

Image findings
Interlobular septal thickening
Centrilobular ground-glass nodules
Tree-in-bud sign

Pulmonary hypertension
Enlarged pulmonary artery and right ventricle
Increased main pulmonary artery (pulmonary trunk) to ascending aorta ratio.
References
European Journal of Radiology Open Volume 7, 2020, 100212
Ewha Med J 2014;37(2):146-151
Clinical Nuclear Medicine: March 2009 - Volume 34 - Issue 3 - p 175-177
Pulm Circ. 2019 Apr-Jun; 9(2): 2045894019851000.
SAGE Volume: 7 issue: 4, page(s): 813-820
Keywords

No. of Applicants : 96

▶ Correct Answer : 43/96,  44.8%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - , Japan HIROAKI ARAKAWA
  • - Jichi Medical University Hospital , Japan JUN KANZAWA
  • - , Japan KYOKO NAGAI
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Chonnam National University Hwasun Hospital , Korea (South) SEONGWOO CHO
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
  • - Chonnam National University Hwasun Hospital , Korea (South) DONGHUN HAN
  • - Secomedic Hospital , Japan FUMINORI MIYOSHI
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Inje University Pusan Paik Hospital , Korea (South) GANGWON JEONG
  • - Seoul Medical Center , Korea (South) HYUK GI HONG
  • - Osaka University , Japan AKINORI HATA
  • - , Japan HIKARI FUKUI
  • - , Japan YUKIKO USUI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Yamanashi Prefectural Central Hospital , Japan HIROAKI WATANABE
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - , Korea (South) JUN GU KANG
  • - Presbyterian Medical Center , Korea (South) SOOYEON JEONG
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Wonkwang University Hospital , Korea (South) SERI KANG
  • - Hukuda memorial hospital , Japan SHINTARO KANO
  • - , Japan KENTARO KOTANI
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Seoul National University Hospital , Korea (South) SUNGHO HONG
  • - , China MING LU
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Kyoto University , Japan SHO KOYASU
  • - Seoul National University Hospital , Korea (South) HYE SOO CHO
  • - Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - Yonsei University,Gangnam Severance Hospital , Korea (South) SEUNGHYUN SONG
  • - Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
  • - Toyota Kosei Hospital , Japan YUKI HAYASHI
  • - , Korea (South) HM PARK
  • - Chonnam National University Hospital , Korea (South) EUN JU KIM
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 8/96,  8.3%
  • - , Japan SUZUNE TSUKAMOTO
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - The University of Tokyo Hospital , Japan WATARU GONOI
  • - Soonchunhyang University Hospital Bucheon , Korea (South) HYEJOO PARK
  • - Kantou Rousai Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
  • - Shiga University of Medical Science , Japan RYO UEMURA
▶ Semi-Correct Answer : 2/96,  2.1%
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Chonnam National University Hospital , Korea (South) SOMIN LEE
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