CHEST Guidelines-Curious-Case-of-Unexplained-Dyspnea-With-Malignanc

Curious-Case-of-Unexplained-Dyspnea-With-Malignanc

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The case study discusses a 48-year-old woman with unexplained dyspnea and recent diagnosis of stage IV triple-negative adenocarcinoma of the breast, who had yet to begin chemotherapy. Initial assessments including chest X-ray, CT scans, and pulmonary V/Q scans were unremarkable, yet right heart catheterization indicated elevated pulmonary artery pressures. Cytologic analysis of her pulmonary artery blood revealed malignant adenocarcinoma cells, leading to a diagnosis of dyspnea secondary to pulmonary tumor microemboli (PTME). PTME involves tumor cells entering the pulmonary microvasculature, causing perfusion defects due to occlusion slightly larger than capillaries, a rare and often postmortem diagnosis. <br /><br />The study highlights the difficulties in diagnosing PTME due to nonspecific symptoms and lack of sensitive imaging techniques. Clinically, PTME is indicated by unexplained progressive dyspnea, elevated right ventricular systolic pressure, and stability despite normal imaging in the context of cancer. PTME often progresses to conditions like pulmonary tumor thrombotic microangiopathy (PTMA), which involves systemic coagulation abnormalities and lymphangitic carcinomatosis (LC), where cancer cells invade the lymphatics.<br /><br />Since traditional imaging is mostly unremarkable for PTME, histopathological examination through invasive lung biopsy has been the standard for definitive diagnosis, though now cytologic analysis of pulmonary microvascular blood provides a less invasive alternative. Unfortunately, PTME and PTMA have poor prognoses, with average survival after diagnosis being around 9.5 weeks, and necessitate focusing on managing the underlying malignancy alongside symptomatic support. Newer therapies in case reports and anti-inflammatory drugs show promise in extending survival.

Keywords

pulmonary tumor microemboli

dyspnea

adenocarcinoma

pulmonary artery pressures

cytologic analysis

right heart catheterization

pulmonary microvasculature

diagnosis challenges

histopathological examination

anti-inflammatory drugs