PMC6838523_01
Non-contrast chest CT imaging findings associated with PTTM. (a) Axial view at the level of the left atrium showing no abnormalities. This CT was part of a PET-CT scan performed 6 months prior to the CT pulmonary angiogram. (b) Axial view below the carina, showing multiple centrilobular nodules with discrete peripheral GGO opacities (arrows). (c) Coronal reconstruction view, through the anterior aspect of the thoracic spine, demonstrating multiple centrilobular nodules with peripheral prominent confluent GGO (discontinuous line) and peripheral wedge-shaped opacities (dashed arrow). (d) Axial view of a CT scan performed during the fourth hospitalization week revealing worsening GGO. All slices are shown in the lung window view.
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Pulmonary thromboembolism was ruled out by a CT pulmonary angiogram, which showed multifocal ill-defined GGO and small pulmonary nodularities with scattered peripheral WSAC, absent in the CT scan performed 6 month ago (Fig. 1). Of note, the GGO tracking along bronchovascular bundles worsened when compared to the admission chest CT scan (Fig. 1d).
Radiologic findings and histopathology of metastatic carcinoma to the spine and left iliac bone. (a, b) Technetium-99m NM bone images of the thoracolumbar spine and pelvis showing enhancing lesions in a lumbar vertebra and left iliac bone. (c) Bone marrow replaced by carcinoma, H&E (100x). (d) AE1/AE3 pancytokeratin immunohistochemistry highlighting the carcinoma cells (100x).
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T11 and in the left iliac bone. These lesions also exhibited enhancing in contrast MRI and nuclear medicine (NM) bone joint imaging (Fig. 2). Additional findings included metastatic breast cancer to the thoracolumbar spine (Fig. 2) and liver.
Lung histopathology corresponding to ground glass opacities on imaging. (a) Sagittal non-contrast chest CT, lung window. Multiple centrilobular nodules with ground glass opacities in both the upper and lower lobes (arrows). (b) Alveolar wall thickening and tumor emboli (arrow, 50x). (c) Interstitial chronic inflammation (higher magnification 200x, dashed square in b). (d) Obliteration of a small-sized artery by intimal proliferation and carcinoma cells (400x). (e) CAM 5.2 cytokeratin highlighting carcinoma cells in the obliterated artery (400x). (f) Fibrointimal proliferation and tumor emboli in a medium-sized artery (200x). (g) Lymphangitic carcinomatosis (200x). b-d, f, and g: H&E staining.
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Additionally, the obliteration of pulmonary arterioles was associated with cellular interstitial fibrosis, intra-alveolar hemorrhage and early infarction, explaining the lung CT abnormalities identified premortem (Fig. 3, Fig. 4).