J Gastric Cancer.  2014 Jun;14(2):142-146.

Occult Gastric Cancer Presenting as Hypoxia from Pulmonary Tumor Thrombotic Microangiopathy

• Mandaliya
• Farhat S
• Uprety D
• Balla M
• Gandhi A
• Goldhahn R
• Auerbach H
• Christensen C
• Reed C
• Cohen S

Abstract

Pulmonary tumor thrombotic microangiopathy (PTTM) causing fatal pulmonary hypertension is a rare presentation of malignancy. In general, patients with PTTM rapidly succumb to death due to severe hypoxia. To date, very few cases of PTTM have been reported in the literature; and most of these cases were from gastric cancer and were diagnosed on post mortem autopsy, as it is extremely challenging to make an ante mortem diagnosis. We here report on a case of undiagnosed diffuse gastric cancer, presenting as worsening hypoxia. The clinical, radiographic, and echocardiographic features, and laboratory and pathological results were consistent with PTTM from gastric cancer. The patient was started on anticoagulation therapy, corticosteroids, and high-flow oxygen. However, her hypoxia worsened to the extent that she required ventilator support, and she died soon after intubation due to cardiac arrest. Since diffuse gastric cancer is associated with hereditary diffuse gastric cancer syndrome, cadherin 1 gene mutation analysis was performed to estimate the risk to her daughters. The test came back negative.

Keyword

Stomach neoplasms; Pulmonary tumor thrombotic microangiopathy; Hypertension, pulmonary

MeSH Terms

Adrenal Cortex Hormones
Anoxia*
Ants
Autopsy
Cadherins
Diagnosis
Echocardiography
Heart Arrest
Humans
Hypertension, Pulmonary
Intubation
Nuclear Family
Oxygen
Stomach Neoplasms*
Thrombotic Microangiopathies*
Ventilators, Mechanical
Adrenal Cortex Hormones
Cadherins
Oxygen

Figure

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  Fig. 1 Computed tomography of the chest showed nodular opacities with tree in bud appearance (arrows).

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  Fig. 2 Histopathology of the mediastinal lymph node biopsy. The H & E stain showed signet ring adenocarcinoma cells with poor differentiation (×600).

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  Fig. 3 Mucicarmine stain of the tumor cells. The mucicarmine stain showed mucus-producing signet ring cells stained with pink color (arrow) (×400).

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  Fig. 4 Computed tomography of the abdomen showed a diffusely thickened stomach with mucosal enhancement consistent with linitis plastica (arrow).

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