What happened, in summary

A 62-year-old man developed worsening shortness of breath about 5 years after treatment for Stage III gastric cancer. His original treatment had included distal gastrectomy followed by 2 years of tegafur plus uracil chemotherapy, and no recurrence had been seen after completing that treatment.

At the new presentation, he had severe pulmonary hypertension, low oxygen levels and abnormal blood counts. CT did not show a conventional pulmonary embolism, but bone imaging was abnormal and a bone-marrow biopsy confirmed recurrent gastric cancer. The combination of metastatic cancer, severe pulmonary hypertension and a negative pulmonary angiogram raised strong concern for pulmonary tumor thrombotic microangiopathy, a rare complication caused by tumor cells in the small lung vessels.

Corticosteroid treatment temporarily improved the lung findings, pulmonary pressure and oxygenation. His condition was still too poor for further chemotherapy, so he transitioned to palliative care. Several weeks later he developed recurrent respiratory failure and died on hospital day 45. Lung examination after death confirmed pulmonary tumor thrombotic microangiopathy. His death occurred about 5 years after the original gastric cancer diagnosis.