CASE REPORT. Abstract. Introduction. Case Report

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1 CASE REPORT Pulmonry Tumor Thromotic Microngiopthy Cused y Urothelil Crcinom Expressing Vsculr Endothelil Growth Fctor, Pltelet-derived Growth Fctor, nd Osteopontin Ysushi Wkyshi 1, Mi Iwy 2, Myo Akit 1, Wtru Tkeuchi 1, Kyohei Ymzki 1 nd Akihiro Iijim 1 Astrct Pulmonry tumor thromotic microngiopthy (PTTM) is ftl cncer-relted pulmonry compliction. It is generlly cused y gstric denocrcinom, nd severl molecules produced y tumor cells re reported to ply importnt roles in its pthogenesis. We herein report n utopsy cse of PTTM cused y urothelil crcinom. Vsculr endothelil growth fctor (VEGF), pltelet-derived growth fctor (PDGF), nd osteopontin were found to e expressed in oth the primry tumor cells nd metsttic cells in the PTTM lesions. These findings implicte the possile involvement of VEGF, PDGF, nd osteopontin in the pthogenesis of PTTM cused y urothelil crcinom. Key words: pulmonry tumor thromotic microngiopthy, urothelil crcinom, vsculr endothelil growth fctor, pltelet-derived growth fctor, osteopontin (Intern Med 55: , 2016) () Introduction Pulmonry tumor thromotic microngiopthy (PTTM) is known to e rre nd ftl pulmonry compliction chrcterized y progressive dyspne nd pulmonry hypertension in ptients with metsttic crcinom. According to the first report y von Hrvey et l., PTTM ws oserved in 3.3% (21/630) of the utopsy cses with mlignnt tumors (1). With respect to the underlying mlignncy, the most frequent orgn nd histologicl type re reported to e the stomch nd denocrcinom, respectively (1, 2), nd only 3 cses of PTTM ssocited with urothelil crcinom hve een reported in the English literture (1, 3, 4). We herein present cse of PTTM ssocited with urothelil crcinom, including n immunohistochemicl nlysis tht reveled importnt clues for the pthogenesis of PTTM cused y urothelil crcinom. Cse Report A 77-yer-old mn ws dignosed with ureterl crcinom of the left ureter nd underwent totl nephroureterectomy with prtil cystectomy. The pthologicl findings of the surgicl specimens indicted urothelil crcinom with squmous differentition (G3) tht hd invded into the suseros (pt3) with lymphtic involvement. Moreover, crcinom in situ ws detected on the surgicl mrgin of the urinry ldder. Although dditionl therpy ws recommended, the ptient chose to forgo dditionl tretment. Five yers fter the surgery, he ws dmitted to our hospitl due to dyspne on exertion. At this dmission, the ptient s lood pressure ws 160/ 90 mmhg nd his hert rte ws 82 ets per minute. His percutneous oxygen sturtion ws 92% on room ir. Lortory tests reveled decrese in the pltelet count (111,000/μL) nd n increse in lctte dehydrogense (522 Deprtment of Internl Medicine, Ngno Prefecturl Kiso Hospitl, Jpn nd Deprtment of Lortory Medicine, Shinshu University Hospitl, Jpn Received for puliction My 12, 2015; Accepted for puliction June 25, 2015 Correspondence to Dr. Ysushi Wkyshi, 99098yw@jichi.c.jp 651

2 Distole phse Erly distole Figure 1. Electrocrdiogrphy nd trnsthorcic echocrdiogrphy. ) Electrocrdiogrphy showed right xis devition nd negtive T wves in V1, V2, V3, nd V4. ) Trnsthorcic echocrdiogrphy reveled D-shpe ppernce of the left ventriculr chmer in erly distole. IU/L), firin degrdtion product (18.2 μg/ml), nd D dimer (6.5 μg/ml). His rin ntriuretic peptide level ws pg/ml. The results did not suggest ny collgen diseses tht would led to pulmonry hypertension. His rteril lood gs exmintion when rething room ir showed hypoxi with respirtory lklosis (ph, 7.47; rteril cron dioxide prtil pressure, 29.0 mmhg; rteril oxygen prtil pressure, 56.0 mmhg; nd icronte, 20.8 meq/l). Chest rdiogrphy showed dilted pulmonry rteries without congestion. Electrocrdiogrphy showed right xis devition nd negtive T wve in V1, V2, V3, nd V4, suggesting right ventriculr overlod (Fig. 1). Trnsthorcic echocrdiogrphy demonstrted dilted right trium nd ventricle, nd D-shpe of the left ventriculr chmer in erly distole (Fig. 1). The tricuspid regurgittion pressure grdient ws 110 mmhg, suggesting pulmonry hypertension. Contrstenhnced computed tomogrphy showed no thromi or tumor emoli in the pulmonry rteries. However, lymphdenopthy of the left suprclviculr, pr-ortic, nd left pelvic lymph nodes ws oserved, suggesting multiple lymph node metstses (Fig. 2). A suprclviculr lymph node iopsy ws performed nd urothelil crcinom with squmous differentition ws found. Thus, the ptient ws dignosed with recurrent ureterl cncer with lymph node metstsis. Although we suspected PTTM, we could not mke definitive dignosis ecuse the ptient refused n invsive lung iopsy procedure. He lso refused intensive chemotherpy nd ws dischrged fter 28 dys, using home oxygen therpy. Twenty-nine dys fter he ws dischrged, he ws redmitted due to generl ftigue nd progressive dyspne, nd multiple orgn filure ws confirmed. Respirtory filure progressed rpidly nd he died severl hours fter dmission. With the pprovl of the ptient s fmily, postmortem utopsy ws performed. No mcroscopic thromi or tumor emoli were detected in the pulmonry rteries or their min rnches, lthough the right ventricle ws dilted. Furthermore, we could not find tumor formtion in the lung prenchym. However, microscopic exmintion of the lungs reveled multiple tumor emoli of the urothelil crcinom with squmous differentition in the smll pulmonry rteries. Mrked intiml firocellulr prolifertion nd clot formtion were lso oserved in the smll pulmonry rteries, nd these findings were consistent with the typicl fetures of PTTM (Fig. 3). A numer of metstses were detected in the left suprclviculr, pr-ortic, nd left pelvic lymph nodes. The finl dignosis fter the utopsy ws PTTM cused y urothelil crcinom of recurrent ureterl cncer. We performed immunohistochemicl stining of the primry tumor cells resected 5 yers previously nd metsttic cells in the PTTM lesions using ntiodies ginst vsculr endothelil growth fctor (VEGF) (JH121; dilution 1:500, EMD Millipore, Billeric, USA), pltelet-derived growth fctor (PDGF) (P-GF.44C; dilution 1:800, Novocstr, Newcstle-upon-Tyne, UK), pltelet-derived growth fctor 652

3 Intern Med 55: , 2016 Figure 2. Contrst-enhnced computed tomogrphy. ) Thromi or tumor emoli were not found in the pulmonry rteries. Intct pulmonry rteries re indicted y yellow rrowheds. ) Lymphdenopthy of the suprclviculr, pr-ortic, nd left pelvic lymph nodes ws oserved, suggesting multiple lymph node metstses. Lymphdenopthy is indicted y the yellow rrows. Figure 3. Histopthologicl findings in the smll pulmonry rteries. ) Hemtoxylin nd Eosin stining (originl mgnifiction 40 ). ) Elstic vn Gieson stining (originl mgnifiction 40 ). Tumor emoli of urothelil crcinom with squmous differentition were oserved in the smll pulmonry rteries. Mrked intiml firocellulr prolifertion nd clot formtion were lso oserved. These findings were consistent with pulmonry tumor thromotic microngiopthy. 653

4 c d e f Figure 4. Immunohistochemicl findings of the primry tumor cells. ) Hemtoxylin nd Eosin stining (originl mgnifiction 100 ). ) Stining for vsculr endothelil growth fctor (VEGF) (originl mgnifiction 100 ). c) Stining for pltelet-derived growth fctor (PDGF) (originl mgnifiction 100 ). d) Stining for pltelet-derived growth fctor receptor β (PDGFRβ) (originl mgnifiction 100 ). e) Stining for osteopontin (originl mgnifiction 100 ). f) Stining for firolst growth fctor 2 (FGF2) (originl mgnifiction 100 ). Focl expression of VEGF, PDGF nd FGF2, nd diffuse expression of osteopontin were found in the primry tumor cells. However, PDGFRβ ws not expressed. receptor β (PDGFRβ) (rit polyclonl; dilution 1:1,000, Snt Crus Biotechnology, Snt Crus, USA), firolst growth fctor 2 (FGF2) (rit polyclonl; dilution 1:100, Snt Crus Biotechnology), nd osteopontin (OP3N, dilution 1:1,000, Novocstr). In the primry tumor cells, the focl expression of VEGF, PDGF nd FGF2 ws oserved. Diffuse expression of osteopontin ws lso detected, lthough PDGFRβ ws not expressed in the primry tumor cells (Fig. 4). In the metsttic cells, the focl expression of VEGF nd PDGF, s well s the diffuse expression of osteopontin, ws oserved. VEGF expression ws stronger in the metsttic cells thn in the primry tumor cells. PDGF nd osteopontin were lso expressed in the proliferting intiml nd vsculr smooth muscle cells in the PTTM lesions. However, PDGFRβ nd FGF2 were not expressed in the metsttic cells (Fig. 5). Discussion PTTM is thought to rise from the direct ttchment of tumor cells to the endothelium of the pulmonry vsculr system nd the development of locl thromosis t the surfce of tumor emoli, cusing the relese of inflmmtory meditors. These meditors induce firocellulr intiml prolifertion of smll pulmonry rteries nd rterioles, leding to diffuse nrrowing of the pulmonry rtery nd n increse in vsculr resistnce (1). For these resons, ptients with PTTM often present with progressive dyspne, severe pulmonry hypertension, nd right crdic filure (5). Previous studies hve suggested the development of PTTM to e ssocited with certin molecules produced y tumor cells, including VEGF, PDGF, nd osteopontin. VEGF is known s n endothelil cell-specific ngiogenic mitogen involved in the prolifertion of endothelil cells (6), nd severl PTTM cses tht showed VEGF expression in tumor cells hve een reported (6-8). PDGF is key meditor of prolifertion nd migrtion of smooth muscle cells nd firolsts (9), nd osteopontin is known to promote the dhesion, migrtion, nd prolifertion of firolsts, vsculr endothelil cells, nd smooth muscle cells (10). Tkhshi et l. reported cse of PTTM cused y gstric crcinom tht showed immunorectivity to PDGF nd osteopontin in tumor cells nd firomusculr intiml cells in the PTTM lesions. They suggested tht n interreltionship etween PDGF nd osteopontin my e involved in the pthogenesis of PTTM (11). With respect to PTTM ssocited with urothelil crcinom, single cse tht included n investigtion of these molecules ws pulished; VEGF nd PDGF were expressed in the primry tumor cells wheres PDGFRα nd PDGFRβ were not expressed. Moreover, VEGF, PDGF, PDGFRα, nd PDGFRβ were not expressed in the metsttic cells in the PTTM lesions, lthough the uthors reported the proility of diminished ntigen ctivity cused y the period of formlin fixtion (3). Therefore, ours is the first cse of PTTM ssocited with urothelil crcinom tht showed immunorectivity to VEGF, PDGF, nd 654

5 c d e f Figure 5. Immunohistochemicl findings of the metsttic cells in the smll pulmonry rteries. ) Hemtoxylin nd Eosin stining (originl mgnifiction 100 ). ) Stining for vsculr endothelil growth fctor (VEGF) (originl mgnifiction 100 ). c) Stining for pltelet-derived growth fctor (PDGF) (originl mgnifiction 100 ). d) Stining for pltelet-derived growth fctor receptor β (PDGFRβ) (originl mgnifiction 100 ). e) Stining for osteopontin (originl mgnifiction 100 ). f) Stining for firolst growth fctor 2 (FGF2) (originl mgnifiction 600 ). Focl expression of VEGF nd PDGF, nd diffuse expression of osteopontin, were oserved in the metsttic cells. PDGF nd osteopontin were lso expressed in the proliferting intiml cells nd vsculr smooth muscle cells. However, PDGFRβ nd FGF2 were not expressed in the metsttic cells. osteopontin in oth the primry nd metsttic tumor cells. We therefore postulte tht VEGF, PDGF, nd osteopontin my e relted to the onset or development of PTTM cused y urothelil crcinom. With respect to PDGFR, two previous cses of PTTM cused y gstric crcinom were reported to show expression of PDGFRα nd PDGFRβ in the PTTM lesions (12, 13). Additionlly, Ae et l. reported eight cses of PTTM cused y gstric crcinom tht showed FGF2 expression (14). In the present cse, neither PDGFRβ nor FGF2 ws detected in the PTTM lesions. Given the previously descried precedence (3), we suspect tht the ntigenic ctivities of these proteins my hve een diminished ecuse of the extended period of formlin fixtion. An ntemortem dignosis nd successful tretment of PTTM is extremely difficult. However, cse of PTTM cused y colorectl denocrcinom ws previously reported to hve een successfully treted with comintion of imtini ( PDGFR ntgonist) nd evcizum ( VEGF receptor inhiitor) (15). In the present cse, the expression of VEGF, PDGF, nd osteopontin suggests tht ptients with PTTM cused y urothelil crcinom lso hve the potentil to e treted effectively with these moleculrtrgeted gents, despite the fct tht PDGFRβ ws not detected nd PDGFRα expression ws not investigted. Furthermore, in cses of PTTM, the vrious molecules tht re expressed in tumor cells should e exmined, s this my offer dditionl clues regrding the mechnism of PTTM development nd susequently led to successful tretment with moleculr-trgeted gents. The uthors stte tht they hve no Conflict of Interest (COI). References 1. von Hery A, Illes A, Wldherr R, Otto HF. Pulmonry tumor thromotic microngiopthy with pulmonry hypertension. Cncer 66: , Urug H, Fujii T, Kuroski A, et l. Pulmonry tumor thromotic microngiopthy: clinicl nlysis of 30 utopsy cses. Intern Med 52: , Hirno H, Ichiori H, Kizki T, et l. Pulmonry tumor thromotic microngiopthy showing ggressive course fter trnsurethrl resection of urinry ldder: n utopsy cse report. Med Mol Morphol 45: , Mrumo S, Skguchi M, Ternishi T, Higmi Y, Koshimo Y, Kto M. Pulmonry tumor thromotic microngiopthy induced y ureterl crcinom: necropsy cse report. Cse Rep Oncol 7: , Okuo Y, Wkym M, Kithr K, et l. Pulmonry tumor thromotic microngiopthy induced y gstric crcinom: morphometric nd immunohistochemicl nlysis of six utopsy cses. Dign Pthol 6: 27, Chinen K, Tokud Y, Fujiwr M, Fujiok Y. Pulmonry tumor thromotic microngiopthy in ptients with gstric crcinom: n nlysis of 6 utopsy cses nd review of the literture. Pthol Res Prct 206: ,

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