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A 76-year-old man with hepatocellular carcinoma (HCC) was admitted to our hospital suffering from rapidly progressing dyspnea. Chest computed tomography on admission merely showed ground-glass pattern...s in both lung fields without thrombi in the pulmonary trunk. On the third day, pulmonary blood flow scintigraphy was performed because of progression of his dyspnea, and showed multiple defects indicating widespread thrombi in the peripheral pulmonary arteries. He died of respiratory failure on day 13. A needle necropsy revealed the presence of multiple foci of adenocarcinoma nests in the lungs, suggesting venous thrombi from the poorly differentiated HCC. Although HCC frequently metastasizes to the lung, patients with lung metastasis rarely result in respiratory failure. It is well known that some patients with adenocarcinoma including HCC can develop respiratory failure owing to pulmonary tumor thrombotic microangiopathy (PTTM). In our case, however, pathological examination showed widespread tumor microemboli in the lung, but no stenosis or fibrocellular intimal proliferation in the small arteries and arterioles, which are essential findings of PTTM. Although we concluded that the respiratory failure in this case was mainly caused by widespread tumor microemboli, it remains unclear why such dissemination rapidly developed.
肝細胞癌の肝外転移臓器として，肺は最も頻度の高い臓器である．CT やMR などの画像検査機器の発達により，肺転移巣の同定は容易となり，その診断に苦慮することは希である．また，肝細胞癌からの肺転移は高頻度であるにもかかわらず，呼吸不全に至る症例は少なく，多くの場合，肺転移巣が拡大して呼吸機能に影響を与えるようになる前に，原発の肝病変が進行して，肝不全に至る．今回我々は，肝細胞癌の経過観察中に，原因不明の呼吸不全が急速に進行した症例を経験した．入院時の画像検査で，肺の腫瘍性病変などの呼吸不全を来たす所見を認めず，酸素化が障害されている原因が不明であったが，死後の肺組織検査により，広範な微小腫瘍塞栓が認められた．肺の腫瘍塞栓によって，急速な呼吸不全を来たす病態として，Pulmonary tumor thrombotic microangiopathy（PTTM）があるが，本症例の病理所見では，PTTM は否定的であった．本症例の呼吸不全に関して若干の文献的考察を加えて報告する．続きを見る
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