Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 28, 2019; 25(48): 6949-6958
Published online Dec 28, 2019. doi: 10.3748/wjg.v25.i48.6949
Pulmonary tumor thrombotic microangiopathy of hepatocellular carcinoma: A case report and review of literature
Shinichi Morita, Kenya Kamimura, Hiroyuki Abe, Yukari Watanabe-Mori, Chiyumi Oda, Takamasa Kobayashi, Yoshihisa Arao, Yusuke Tani, Riuko Ohashi, Yoichi Ajioka, Shuji Terai
Shinichi Morita, Kenya Kamimura, Hiroyuki Abe, Yukari Watanabe-Mori, Chiyumi Oda, Takamasa Kobayashi, Yoshihisa Arao, Shuji Terai, Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
Yusuke Tani, Riuko Ohashi, Yoichi Ajioka, Division of Molecular and Diagnostic Pathology, Niigata University Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
Riuko Ohashi, Histopathology Core Facility, Niigata University Faculty of Medicine, Niigata University, Niigata 951-8510, Japan
Author contributions: Morita S, Abe H, Mori Y, Oda C, Kobayashi T, Arao Y, Tani Y, Ohashi R, and Ajioka Y acquired data; Kamimura K and Terai S analyzed data and drafted the article; Kamimura K and Terai S made final approval of the article.
Informed consent statement: A study participant provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: the authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Kenya Kamimura, MD, PhD, Lecturer, Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan. kenya-k@med.niigata-u.ac.jp
Received: October 8, 2019
Peer-review started: October 8, 2019
First decision: November 27, 2019
Revised: December 6, 2019
Accepted: December 21, 2019
Article in press: December 22, 2019
Published online: December 28, 2019
Abstract
BACKGROUND

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare condition in patients with hepatocellular carcinoma (HCC); to date, few cases have been reported. While hepatic dysfunction has been focused on the later stages of HCC, the management of symptoms in PTTM is important for supportive care of the cases. For the better understanding of PTTM in HCC, the information of our recent case and reported cases have been summarized.

CASE SUMMARY

A patient with HCC exhibited acute and severe respiratory failure. Radiography and computed tomography of the chest revealed the multiple metastatic tumors and a frosted glass–like shadow with no evidence of infectious pneumonia. We diagnosed his condition as acute respiratory distress syndrome caused by the lung metastases and involvement of the pulmonary vessels by tumor thrombus. Administration of prednisolone to alleviate the diffuse alveolar damages including edematous changes of alveolar wall caused by the tumor cell infiltration and ischemia showed mild improvement in his symptoms and imaging findings. An autopsy showed the typical pattern of PTTM in the lung with multiple metastases.

CONCLUSION

PTTM is caused by tumor thrombi in the arteries and thickening of the pulmonary arterial endothelium leading to the symptoms of dyspnea in terminal staged patients. Therefore, supportive management of symptoms is necessary in the cases with PTTM and hence we believe that the information presented here is of great significance for the diagnosis and management of symptoms of PTTM with HCC.

Keywords: Pulmonary tumor thrombotic microangiopathy, Hepatocellular carcinoma, Respiratory dysfunction, Prednisolone, Supportive care, Case report

Core tip: Pulmonary tumor thrombotic microangiopathy is caused by tumor thrombi in the arteries and thickening of the pulmonary arterial endothelium leading to the symptoms of dyspnea in terminal staged patients. Therefore, supportive management of symptoms is necessary in the cases with pulmonary tumor thrombotic microangiopathy, however, as the hepatic failure, bleeding, and encephalopathy have been focused in these cases with hepatocellular carcinoma and it is rare condition in the cases with hepatocellular carcinoma, only few cases have been reported. Therefore, we have reported the minute clinical and pathological information of our recent case and reviewed literatures of reported cases to date in this paper.