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History :

Case of the Month 43 January 2019. History : A 64-year-old woman presented with shortness of breath, ECG signs of right overload, and tendency to hypotension. She had no remarkable previous history. CT-angiography was performed to rule out pulmonary embolism. Case of the Month 43.

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History :

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  1. Case of the Month 43 January 2019 History: A 64-year-old woman presented with shortness of breath, ECG signs of right overload, and tendency to hypotension. She had no remarkable previous history. CT-angiography was performed to rule out pulmonary embolism.

  2. Case of the Month 43

  3. Case of the Month 43 MIP reconstructions

  4. Case of the Month 43 What is your diagnosis ?

  5. Case of the Month 43 January 2019 History: A 64-year-old woman presented with shortness of breath, ECG signs of right overload, and tendency to hypotension. She had no remarkable previous history. CT-angiography was performed to rule out pulmonary embolism. Question: What are the key findings on the CTA?

  6. Case of the Month 43

  7. Case of the Month 43 MIP reconstructions

  8. Case of the Month 43 • Signs of pulmonary hypertension with cardiac repercussion (dilatation of the pulmonary trunk) • Dilatation of right cardiac chambers • (incidental, hiatal hernia)

  9. Case of the Month 43 • Mediastinal lymphadenopathy • sign of malignancy • Centrilobular nodules due to diffuse • vascular tree-in-bud

  10. Case of the Month 43 What is your diagnosis ?

  11. Case of the Month 43 The patient died 3 days after admission and the CTA. An autopsy was performed.

  12. Case of the Month 43 • Histopathological findings of the lung specimens obtained at autopsy showed: • Tumour embolism (black arrow) in the pulmonary arterioles with fibrocellular intimal proliferation (blue arrows). Neoplastic intravascular cells (asterisk). A gastriccancerwasdiscovered.

  13. Case of the Month 43 Diagnosis Pulmonary tumour thrombotic microangiopathy PTTM Authors: M. Costilla, E. Castañer

  14. Case of the Month 43 Discussion • PTTM can occur in patients with widespread cancer, a history of malignant disease, or occasionally as the first symptom of occult malignancy(as is in our case). • Usually considered rare, intravascular pulmonary metastases are commonly seen at autopsy, particularly in patients with breast, stomach, liver, kidney, lung, or prostate cancer or choriocarcinoma. • PTTM causes increased pulmonary vascular resistance, resulting in severe clinical manifestations: • -new onset or worsening of dyspnoea • -pulmonary hypertension • -right-sided heart failure with cor pulmonale • -sudden death • The radiologic diagnosis of PTTM is difficult because the findings are often minimal or nonspecific.

  15. Case of the Month 43 Discussion • PTTM causes a vascular tree-in-bud sign in the CT; MIP reconstructions are essential to show dilations of the distal pulmonary arteries. A feature that helps in the differential diagnosis with tree-in-bud due to bronchial disease is the lack of changes in the bronchi. • The presence of signs of malignancy and signs of pulmonary hypertension (dilation of central pulmonary arteries and repercussion in the right heart chambers) associated with the vascular tree-in-bud sign are the key for the diagnosis.

  16. Case of the Month 43 Discussion • PTTM should be considered in the differential diagnosis of acute/subacute cor pulmonale, and PH in patients with known cancer and in those without. • MIP reformations are essential to visualize the vascular tree-in-bud. • The accompanying signs of malignancy provide a clue to the diagnosis. • Differential Diagnosis • Bronchial causes of the tree-in-bud pattern • Other vascular causes of tree-in-bud: • Excipient lung disease, related to intravenous injection of substances containing filler material (insoluble excipients such as starch, cellulose, or talc). • Other causes of pulmonary hypertension

  17. Case of the Month 43 Further Reading PULMONARY TUMOUR THROMBOTIC MICROANGIOPATHY 1) Franquet T, Giménez A, Prats R et al. ThromboticMicroangiopathyofPulmonaryTumors: A Vascular Cause of Tree-In-Bud Pattern on CT. AJR 2002;179:897-899. 2) S.Miyano, S. Izumi, Y. Takeda et al. Pulmonary tumor thromboticmicroangiopathy. J. Clin. Oncol. 2007; 25: 597-599. 3) Chinen K, Tokuda Y, Fujiwara M et al. Pulmonary tumor thromboticmicroangiopathyin patients with gastric carcinoma: An analysis of 6 autopsy cases and review of the literature. Pathology - Research and Practice 2010; 206: 682-689. 4) Price LC, Wells AU, Wort SJ. Pulmonary tumour thrombotic microangiopathy. CurrOpinPulm Med. 2016 Sep;22(5):421-8.

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