Pulmonary Microvascular Cytology in the Diagnosis of Lymphangitic Carcinomatosis

Masson, R; Krikorian, John G.; Lukl, P; Evans, Gerald L.; J, McGrath

doi:10.1056/nejm198907133210202

Cited by 103 publications

(41 citation statements)

References 22 publications

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“…Blood is subsequently either filtered or spun down, and the remaining cells stained with the Papanicolaou method. The interpretation of such samples proves to be challenging, as megakaryocytes and endothelial cells may mimic malignancy [162].…”

Section: Diagnosismentioning

confidence: 99%

Nonthrombotic pulmonary embolism

Jorens¹,

Marck²,

Snoeckx³

et al. 2009

Eur Respir J

162

127

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Nonthrombotic pulmonary embolism (NTPE) is defined as embolisation to the pulmonary circulation of different cell types (adipocytes, haematopoietic, amniotic, trophoblastic or tumour), bacteria, fungi, foreign material or gas. The purpose of this article is to describe the clinical signs, pathogenesis, diagnosis and treatment of the different NTPE subtypes.The complex and diverse pathogenesis of different subtypes of emboli is subject to continuing speculation and is certainly far more complex than ''simple'' mechanical obstruction after embolisation of vascular thrombi. Nonthrombotic emboli may also lead to a severe inflammatory reaction both in the systemic and pulmonary circulation, as well as in the lung.NTPE presents a formidable diagnostic challenge, as the condition often presents with very unusual and peculiar clinical signs that are frequently overlooked. They range from very dramatic acute presentations such as acute respiratory distress syndrome to signs observed late in the disease course. Pathological observations play a key role in the exact diagnosis, and sometimes carefully aspirated blood from the pulmonary artery or specific staining of cells recovered from bronchoalveolar lavage fluid may be helpful. Frequently, lung biopsies revealing severe granulomatous reaction or unfortunate post-mortem pathological investigations of pulmonary tissue are necessary to confirm the diagnosis. Here, we also aim to familiarise the reader with the atypical radiological features of NTPE. Thin-section computed tomography of the lungs showing peculiar radiographic findings, such as a feeding vessel, the so-called tree-in-bud pattern or the appearance of micronodules distributed at the termination of bronchovascular bundles, may be observed in certain forms of NTPE.Increased awareness of NTPE as an underestimated cause of acute and chronic embolism, which may result in acute and chronic pulmonary hypertension, is needed. Despite the fact that detailed descriptions of several forms of NTPE have existed for nearly 100 years, well-designed trials have never been performed to evaluate therapy in the different subsets of these patients.

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Section: Diagnosismentioning

confidence: 99%

Nonthrombotic pulmonary embolism

Jorens¹,

Marck²,

Snoeckx³

et al. 2009

Eur Respir J

162

127

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“…Cytology of pulmonary microvascular blood drawn from a wedged pulmonary artery catheter has a reported sensitivity of 80% to 88% and specificity of 82% to 94% for the diagnosis of PTTM, but such testing can be challenging to perform and is rarely done without very high suspicion of the diagnosis. 8,9 As such, the diagnosis of PTTM is often revealed postmortem, if at all. 10 Autopsy studies report tumor microemboli were present in 2% to 4% of patients with known solid tumors at the time of death, but, of those cases, only half had manifest symptoms of PH or right heart failure before death.…”

Section: Discussionmentioning

confidence: 99%

Running From Her Past

et al. 2011

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A 51-year-old woman presented to the emergency room with progressive dyspnea on exertion. She was an avid runner, and had completed a half-marathon 2 months before presentation. Since then, she had experienced a rapid decline in exercise capacity such that, on presentation, she was unable to climb a flight of stairs without stopping to catch her breath. She had recently completed a course of azithromycin prescribed by her primary care physician without benefit. She denied chest pain, lower extremity swelling, fevers, chills, or cough. She had had stage II left breast adenocarcinoma successfully treated 2 years before with Adriamycin-containing chemotherapy, radiation to the left chest, and bilateral mastectomy. Her only medication was fexofenadine for seasonal allergies. She had no previous heart disease or cardiovascular risk factors, with the exception of a distant 10 -pack-year smoking history. She had no family history of premature cardiovascular disease. There was no history of illicit substance abuse. Dr John R. Teerlink:The differential diagnosis for rapidly progressive dyspnea on exertion includes cardiac, pulmonary, rheumatologic, and hematologic disorders. The notable aspects of the patient's history include her dyspnea on exertion in the absence of any other symptoms and her previous vigorous exercise capacity, which suggests a rapidly progressive process. Her previous breast cancer and associated treatment raises the possibility of Adriamycin-induced cardiomyopathy, radiation-induced coronary artery disease or constrictive pericarditis, or pulmonary embolus.On examination, the patient was comfortable but tachypneic. Her temperature was 36.6°C and her blood pressure was 112/73 mm Hg. Her heart rate was 100 bpm with a respiratory rate of 22 breaths per minute and an oxygen saturation of 94% while breathing 5 L/min oxygen via nasal cannula. The jugular venous pressure was Ͼ15 cm H 2 O with prominent V-waves. The Kussmaul sign was present. Her heart sounds were tachycardic with an accentuated P2 and a 2/6 early systolic murmur most prominent at the left lower sternal border with radiation to the left upper sternal border. There was a mild left parasternal heave. Breath sounds were slightly diminished at both lung bases. There was hepatomegaly to 1 cm below the costal margin, and the liver was softly pulsatile. Abdominal tenderness was noted in the right upper quadrant. Trace bilateral lower extremity edema was present. Dr John R. Teerlink:The elevated jugular venous pressure suggests volume overload. More specifically, a positive Kussmaul sign-paradoxically increasing plethora and elevation of the jugular pulse during inspiration-is suggestive of diminished right ventricular compliance. The most common etiologies for this finding are right ventricular (RV) infarction, constrictive pericarditis, and restrictive cardiomyopathy. The systolic murmur is consistent with tricuspid regurgitation, which would explain the prominent V waves noted in the jugular pulsation. Tricuspid regurgitation, in association wit...

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“…The patient's poor condition would not have allowed bronchoalveolar lavage or lung biopsy. Right heart catheterization with cytological examinations of blood samples taken from the peripheral pulmonary circulation by means of a Swan-Ganz-catheter placed in wedged position may be diagnostic in lymphangitic carcinomatosis and pulmonary tumour microembolism [6,8]. Would this diagnosis have changed the prognosis?…”

Section: Discussionmentioning

confidence: 99%

Lethal pulmonary hypertension in a young woman caused by unrecognized haemangiosis carcinomatosa

Canova

Kuhn²,

Allemann³

et al. 1998

Journal of Internal Medicine

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Abstract. Canova CR, Kuhn M, Allemann J, Reinhart WH (Kantonsspital, Chur, Switzerland). Lethal pulmonary hypertension in a young woman caused by unrecognized haemangiosis carcinomatosa (Case Report). J Intern Med 1998; 243: 255-57.A 38-year-old female is described, who was admitted with increasing respiratory distress, cough and visible blood stasis in the jugular veins. The most likely diagnosis in this young women taking oral contraceptives was pulmonary embolism, however, a ventilation-perfusion lung scan was normal. Echocardiography showed a dilated right ventricle and increased systolic pulmonary pressure. Despite administration of oxygen and intravenous heparin the patient died in circulatory collapse before further investigations could be initiated. Post-mortem examination revealed diffuse adenocarcinoma of the stomach (linitis plastica) with metastasis to local lymphnodes, lymphangiosis carcinomatosa of the liver, pancreas and spleen and tumour cell masses within the lumen of small pulmonary arteries leading to variable occlusions of the vessels. Fibrocellular intimal proliferation was found, leading to further obstruction and increased resistance to flow through the pulmonary vascular bed and to subacute cor pulmonale.

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Pulmonary Microvascular Cytology in the Diagnosis of Lymphangitic Carcinomatosis

Cited by 103 publications

References 22 publications

Nonthrombotic pulmonary embolism

Nonthrombotic pulmonary embolism

Running From Her Past

Lethal pulmonary hypertension in a young woman caused by unrecognized haemangiosis carcinomatosa

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