A case of primary lung squamous cell carcinoma mimicking malignant mesothelioma producing granulocyte colony stimulating factor with chemotherapy (cisplatin and gemcitabine)-associated thrombotic thrombocytopenic purpura (TTP); An autopsy case report

Our plain-English summary of A case of primary lung squamous cell carcinoma mimicking malignant mesothelioma producing granulocyte colony stimulating factor with chemotherapy (cisplatin and gemcitabine)-associated thrombotic thrombocytopenic purpura (TTP); An autopsy case report, by Y. Suzuki, K. Kanazawa, R. Kanai, et al (Lung Cancer, 2019).

The study

• Authors: Y. Suzuki, K. Kanazawa, R. Kanai, H. Tomita, M. Saito, N. Watanabe, J. Morimoto, T. Umeda, T. Kawamata, M. Rikimaru, T. Koizumi, R. Togawa, Y. Sato, K. Hirai, M. Uematsu, H. Minemura, T. Nikaido, A. Fukuhara, S. Sato, J. Saito, Y. Tanino, K. Mori, Y. Shibata
• Journal: Lung Cancer
• Published: 2019;136:105-108
• Type of article: Case report
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: Thrombotic thrombocytopenic purpura (TTP) is a rare form of thrombotic microangiopathy. In recent years, an extensive variety of drugs, including certain cytotoxic agents, have been reported to be associated with TTP. Additionally, several studies have reported that granulocyte colony-stimulating factor (G-CSF) was produced by lung carcinoma. G-CSF-producing carcinoma also produces various other cytokines, which may cause vascular endothelial damage and trigger TTP development. However, there has been no report describing G-CSF-producing carcinoma combined with TTP. We report a rare case of pseudomesothliomatous squamous cell lung carcinoma producing G-CSF along with chemotherapy associated TTP.

Materials And Methods: A 66-year-old man with pseudomesotheliomatous primary squamous cell lung carcinoma was treated with chemotherapy consisting of cisplatin and gemcitabine as the first line treatment. However, thrombocytopenia, acute renal dysfunction and acute respiratory failure occurred after starting the first chemotherapy cycle. As a result, the patient died, and an autopsy was performed.

Results: According to the autopsy findings, a diagnosis of primary lung squamous cell carcinoma producing G-CSF associated with TTP was made.

Conclusion: Chemotherapy-related TTP should be considered when anemia and thrombocytopenia progress rapidly in patients who are under chemotherapy treatment. Furthermore, the current case may provide a possible link between TTP and G-CSF-producing tumor.

Copyright © 2019 Elsevier B.V. All rights reserved.

In plain English

This autopsy case report, from doctors at Fukushima Medical University in Japan, described one 66-year-old man whose lung cancer spread along the lining of the chest (the pleura) in a way that looked like malignant mesothelioma. He had smoked for 66 pack-years and had no known history of asbestos exposure. A needle biopsy of the thickened left pleura showed squamous cell carcinoma. Two weeks after he started chemotherapy with cisplatin and gemcitabine, his platelet count fell sharply. Sudden kidney problems (acute renal dysfunction) and acute respiratory failure followed. The doctors diagnosed thrombotic thrombocytopenic purpura (TTP), a rare clotting disorder. His ADAMTS13 enzyme activity was 26% (reference range 70 to 120%). His white blood cell count rose from 12,400 to 39,200 per microlitre, and his blood level of a hormone called G-CSF was raised, at 210 pg/ml. He died on day 26 after admission. From the autopsy, the authors concluded that the cancer began in the lung rather than the pleura and produced G-CSF. Tiny platelet clots in the heart and kidney were compatible with TTP. The authors suggested the case may point to a possible link between TTP and G-CSF-producing tumors, and said that more such cases need to be collected.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: autopsy case report (one patient)
• Who was studied: One 66-year-old man with a 66 pack-year smoking history, treated by the authors' department at Fukushima Medical University, Japan
• Exposure: Chemotherapy with cisplatin (80 mg/m2 on day 1) and gemcitabine (1000 mg/m2 on days 1 and 8). The patient had no known history of asbestos exposure.
• Main results:
  • Needle biopsy of the thickened left pleura showed squamous cell carcinoma with carcinomatous pleuritis
  • About 2 weeks after chemotherapy began, the patient's platelet count fell from 25.4 to 2.2 (× 10 to the 4th per microlitre)
  • Acute renal dysfunction and acute respiratory failure occurred 2 days after a platelet transfusion
  • The patient's ADAMTS13 activity was 26% (reference range 70 to 120%), and TTP was diagnosed
  • The patient's white blood cell count rose from 12,400 to 39,200 per microlitre within a week, and serum G-CSF was elevated at 210 pg/ml
  • Serum IL-1 beta was not elevated (less than 10 ng/ml)
  • The patient died on day 26 after admission
  • At autopsy, the tumor cells stained positive for p40 and negative for calretinin and TTF-1, and staining for G-CSF was positive
  • The authors judged that the tumor arose in the lung, not the pleura
  • Multiple tiny platelet clots were found in the small blood vessels of the heart and kidney, compatible with TTP
• The authors' conclusion: The authors concluded that chemotherapy-related TTP should be considered when anemia and low platelets progress rapidly during chemotherapy, and that this case may suggest a possible link between TTP and G-CSF-producing tumors
• Limitations the authors state:
  • The authors did not test for ADAMTS13 gene mutation, so hereditary TTP was judged unlikely on history alone
  • The authors state that further investigation is needed to clarify the relationship between G-CSF-producing carcinoma and TTP

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Squamous Cell Carcinoma, Malignant Mesothelioma, Chemotherapy, Cisplatin, Gemcitabine, Autopsy, Carcinoma, Cytokine.

Related studies

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• Pulmonary acantholytic squamous cell carcinoma with focal signet ring cell morphology mimicking malignant mesothelioma on fine needle aspiration cytology: a case report — S.E. Choi, H.S. Park (2016)
• Assessing Tumor-Infiltrating Lymphocytes in Solid Tumors: A Practical Review for Pathologists and Proposal for a Standardized Method from the International Immuno-Oncology Biomarkers Working Group: Part 2: TILs in Melanoma, Gastrointestinal Tract Carcinomas, Non-Small Cell Lung Carcinoma and Mesothelioma, Endometrial and Ovarian Carcinomas, Squamous Cell Carcinoma of the Head and Neck, Genitourinary Carcinomas, and Primary Brain Tumors — S. Hendry, R. Salgado, et al. (2017)
• Acne inversa complicated by squamous cell carcinoma in association with diffuse malignant peritoneal mesothelioma arising in the absence of predisposing factors: a case report — V. Barresi, E. Vitarelli, et al. (2008)
• Pseudomesotheliomatous carcinoma of the pleura: an autopsy case of metastasis from a G-CSF-producing anaplastic carcinoma of the pancreas — Y. Hattori, K. Sentani, et al. (2018)
• Malignant mesothelioma mimicking squamous carcinoma in a pleural fluid aspirate — J.S. Johnson, J.M. Edwards (2001)

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