Bilateral Lung Nodules Research Articles

Metastatic Clear Cell Adenocarcinoma of the Urethra in a Male Patient: Report of a Case

A 39-year-old white male presented with urinary hesitancy 2.5 years ago. He was referred to a urologist who performed cystoscopic evaluation and discovered a urethral mass with no abnormalities in the bladder. A staging positron emission tomography (PET) scan revealed fluorine-18 (F) fluorodeoxyglucose (FDG) uptake in a soft tissue prominence in the urethra and bilateral inguinal and iliac FDG-avid lymphadenopathy. Computed tomography (CT) of the hest also demonstrated several bilateral lung nodules. Needle biopsy f a left pelvic lymph node showed adenocarcinoma with micropapllary architecture (Figure 1A). Immunohistochemical analysis howed the carcinoma was positive for CK7 and CAM 5.2 and negtive for CK20, -fetoprotein, CDX-2, and prostate-specific antigen the immunostains are not shown). Sections from the subsequent ransurethral resection specimen of the urethral tumor showed an denocarcinoma with a tubulocystic, micropapillary, and solid archiecture (Figure 1B-D). The tumor had hobnail cells, clear and amhophilic cytoplasm, and high-grade nuclear atypia (Figure 1E). An

Benign metastasizing leiomyoma of the lung with malignant transformation mimicking mediastinal tumor

We report a rare case of benign metastasizing leiomyomas (BMLs) showing malignant transformation in one of them. A 65-year-old woman had a fever. Computed tomography (CT) revealed a mass on the left side of the anterior mediastinum and multiple nodules in bilateral lungs. The masses proved to be leiomyomas and a leiomyosarcoma. The latter showed heterogeneous contrast enhancement on CT and high heterogeneous uptake of 18F-fluorodeoxyglucose (FDG) on positron emission tomography (PET)-CT. This case suggested the potential usefulness of PET-CT for differentiating these entities.

Metastatic endometrial stromal sarcoma of the lung: importance of immunohistochemical staining, clinical history and imaging studies

Proper evaluation of lung nodules is a difficult issue for clinical management of patients. Discriminating metastatic endometrial stromal sarcoma (ESS) from other primary spindle cell neoplasms of the lung using histological analysis can be challenging. This is particularly true when an adequate clinical history is lacking, because ESS metastasis can be delayed by a couple of decades. To emphasize the importance of the correlation of pathological findings with clinical history and imaging studies, we investigated 11 cases of ESS (seven low grade and four high grade) metastatic to the lung. All cases presented with one to multiple unilateral or bilateral lung nodules that were detected by chest computed tomography. Primary ESS was diagnosed from hysterectomy specimens except for one by endometrial biopsy, 0.5 to 23 years prior to metastasis. Immunohistochemical studies showed that all ESS cases were moderately to strongly positive for Bcl-2 and CD10 with > 50% of tumor cells stained, except for one high grade ESS that was negative for CD10. Eight (72.7%) and seven (63.6) of the 11 cases showed positive estrogen and progesterone receptors, respectively, with a majority of positive cases showing diffuse and moderate to strong staining. Strong but patchy staining for CD34 was detected in one (9.1%) case with smooth muscle differentiation. CK7 and TTF-1 were negative in all cases. Two (18.2%) cases exhibited patchy and strong positivity for caldesmon. Two (18.2%) low grade ESS cases showed moderate to strong AE1/AE3 positivity in > 50% of tumor cells, one of which also showed moderate CK19 and Cam 5.2 staining in >30% of tumor cells. One should be cautious when assessing spindle cell neoplasms of the lung in women with a history of hysterectomy. Correlation of clinical history and imaging studies with histological and immunohistochemical findings is essential to diagnosis of metastatic ESS to the lung.

Stromal sarcoma of the breast with lung metastases showing a clinical complete response to doxorubicin plus ifosfamide treatment: Report of a case

A 29-year-old woman presented with a painful right breast tumor, measuring 15 cm in diameter, which had progressed rapidly over 3 months. Core needle biopsy of the tumor revealed a malignant mesenchymal tumor. A mastectomy was performed, and pathological examination of the tumor showed stromal sarcoma. Solitary pleural dissemination in the right lung was suspected, based on the computed tomography image taken before the operation. Two months after surgery, bilateral multiple lung nodules were demonstrated. Systemic chemotherapy with doxorubicin plus ifosfamide was performed, and 3 months later the lung metastases had disappeared. Moreover, there is still no sign of recurrence at 5 months after the initiation of the chemotherapy. Breast stromal sarcoma is very rare, accounting for less than 1% of mammary neoplasms, and the treatment strategy is not well established, especially regarding chemotherapy. This case demonstrates the effectiveness of chemotherapy with doxorubicin plus ifosfamide for lung metastases from breast stromal sarcoma.

Elevated IgG4 Levels in Patients Demonstrating Sarcoidosis-Like Radiologic Findings

One of the radiologic patterns associated with IgG4-related systemic disease was similar to that of pulmonary sarcoidosis. We analyzed whether suspected pulmonary sarcoidosis might include unrecognized IgG4-related systemic disease. The enrolled patients had bilateral hilar lymphadenopathy and/or lung nodules on chest computed tomography, used to diagnose the patients who could either be compatible with or suggested as having pulmonary sarcoidosis. The IgG4 levels were retrospectively measured. Bronchoalveolar lavage (BAL) was analyzed for the presence of IgG subclasses, and specimens were stained by an antibody to IgG4. We compared these data in the suspected sarcoidosis patients, with or without elevated serum IgG4, with the laboratory data and bronchoscopy results in patients with definite sarcoidosis. All enrolled patients were followed for over 5 years. The patients were classified as 49 definite and 44 suspected sarcoidosis patients. Eight patients, including 6 suspected sarcoidosis patients, had elevated abnormal levels of serum IgG4. The suspected sarcoidosis patients had significantly lower percentages of lymphocytes and IgG in the BAL. One suspected sarcoidosis patient had positive IgG4 staining in a lung specimen. The elevated serum IgG4 patients among the patients with suspected sarcoidosis showed significantly higher levels of BAL IgG4, IgG4/IgG, and IgG4/IgG3 compared with the levels of the normal serum IgG4 patients. The follow-up study revealed that 1 patient with elevated serum IgG4 was complicated with other organ failure caused by IgG4-related systemic disease, and Castleman disease was diagnosed in 2 patients. IgG4-related systemic disease was, therefore, identified among the patients with elevated serum IgG4.

Angiosarcoma Arising from Right Atrium: Remarkable Response to Concurrent Chemoradiotherapy with Carboplatin and Paclitaxel

We read with interest the case report by Fehr et al.1Fehr M Kuhn M Mayer K et al.Metastatic angiosarcoma arising from the right atrium: unusual presentation and excellent response to treatment in a young patient.J Thorac Oncol. 2010; 5: 1301-1302Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar and the concise review by Orlandi et al.2Orlandi A Ferlosio A Roselli M et al.Cardiac sarcomas: an update.J Thorac Oncol. 2010; 5: 1483-1489Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar regarding cardiac sarcomas. Concurrent chemoradiotherapy (CRT) to cardiac angiosarcomas has been scarcely documented, and only one case was reported with the benefit from concurrent CRT with docetaxel.3Nakamura-Horigome M Koyama J Eizawa T et al.Successful treatment of primary cardiac angiosarcoma with docetaxel and radiotherapy.Angiology. 2008; 59: 368-371Crossref PubMed Scopus (28) Google Scholar Although efficacy of weekly paclitaxel (PTX) for unresectable angiosarcoma has been demonstrated,4Penel N Bui BN Bay JO et al.Phase II trial of weekly paclitaxel for unresectable angiosarcoma: the ANGIOTAX Study.J Clin Oncol. 2008; 26: 5269-5274Crossref PubMed Scopus (387) Google Scholar CRT with weekly PTX was not reported before the report by Fehr et al. We present herein a case of metastatic angiosarcoma arising from the right atrium, which remarkably responded to concurrent CRT with weekly carboplatin and PTX. A 40-year-old man was referred to our institute, presenting a tumor in the right atrium and multiple bilateral lung nodules with the computed tomography (Figures 1A, B). Histology obtained by wedge resection of a lung nodule revealed a high-grade epithelial angiosarcoma, thus the patient was diagnosed with angiosarcoma from right atrium with multiple lung metastases. We judged it to be unresectable and decided to perform concurrent CRT (30 fractions of 2Gy) with weekly carboplatin (area under the curve = 2) and PTX (60 mg/m2) for 6 consecutive weeks. The radiation field was limited to the primary cardiac tumor. After the therapy, almost all bilateral pulmonary nodules disappeared, and a large tumor in the right atrium was markedly reduced (Figure 2A, B). Although grade 2 esophagitis and neutropenia were observed, the treatment was generally well tolerated. No evidence of progression has been confirmed after more than 5 months of follow-up.FIGURE 2A, Almost all bilateral pulmonary nodules disappeared 3 months after the initiation of chemoradiation therapy. B, The cardiac tumor in the right atrium was remarkably reduced 3 months after the initiation of chemoradiation therapy.View Large Image Figure ViewerDownload (PPT) Multimodality treatment combined with surgery and adjuvant chemotherapy and/or radiotherapy is indicated as the standard care for patients with cardiac angiosarcomas. Nevertheless, the majority of patients with cardiac sarcoma are already unresectable and metastatic disease at their initial diagnosis and have a poor prognosis. CRT is desirable in some cases with cardiac sarcoma to control both the primary cardiac tumor and metastatic lesions. In our case, a combined regimen including PTX was chosen to obtain better response of metastatic lesions, and good response was clearly observed. Moreover, the efficacy and tolerability of concurrent CRT with carboplatin + PTX have been recently demonstrated in locally advanced non-small cell lung cancer.5Yamamoto N Nakagawa K Nishimura Y et al.Phase III study comparing second- and third-generation regimens with concurrent thoracic radiotherapy in patients with unresectable stage III non-small-cell lung cancer: West Japan Thoracic Oncology Group WJTOG0105.J Clin Oncol. 2010; 28: 3739-3745Crossref PubMed Scopus (206) Google Scholar To our knowledge, this is the first report demonstrating the efficacy of concurrent CRT with carboplatin + PTX for cardiac angiosarcoma. Nevertheless, there is no other evidence of CRT with doublet regimens. Future studies to explore usefulness of concurrent CRT for cardiac angiosarcomas are warranted.

Acute Cytomegalovirus Pneumonitis in Patient with Lymphomatoid Granulomatosis

Acute Cytomegalovirus Pneumonitis in Patient with Lymphomatoid Granulomatosis

Three colleagues with sarcoidosis?

To the Editors: Bilateral pulmonary nodules are a relatively common finding in thoracic radiology and hence are an important problem that chest physicians often face. Aetiology can be diverse, ranging from neoplastic conditions to infectious lesions. An accurate and prompt diagnosis is needed in order to target the most appropriate and least harmful treatment. We report the case of a 49-yr-old, Caucasian, otherwise healthy male patient with bilateral lung nodules and an unusual diagnosis. The patient had an unremarkable history and was referred due to asymptomatic bilateral lung nodules. He had stopped smoking 6 months earlier and had a normal chest radiograph a year before referral, taken for follow-up of benign colon polyps. At the time of presentation he was not on any medication. The patient was an engineer working in a Belgian high-tech facility. His job mainly consisted of office work with occasional visits to production sites where coating of medical material was performed. When visiting these sites, he did not systematically wear a protective mask. The problems occurred after a business trip to the USA where he met with three colleagues. He first visited his general practitioner with a flu-like syndrome. Other symptoms included a productive cough, night sweats and loss of weight (5 kg in 2 weeks). He was treated symptomatically with paracetamol. Two of his colleagues developed the same complaints. One never visited a doctor but the other did and was diagnosed with sarcoidosis based on the finding of non-necrotising granulomatous lesions in transbronchial biopsies. He was put on steroids and his condition improved. Oddly, the third colleague who did not visit the doctor had an existing diagnosis of sarcoidosis but remained asymptomatic. Due to persistent cough and low-grade fever, our patient was subsequently referred …

A Case of Fulminant Hepatic Failure of Unusual Etiology

Purpose: Fulminant Hepatic Failure (FHF) often affects young people and has a very high mortality. Incidence approaches around 2,000 cases annually in the United States. Drug toxicity comprises more than 50% of acute liver failure cases. Nearly 15% of cases remain of indeterminate etiology. A 64 yr-old male with history of hypertension presented to emergency room with fever, chills, and right flank pain. Physical exam was unremarkable. Labs revealed AST: 337 u/l, ALT: 215 u/l, Alkphos: 431 u/l. CT scan of the abdomen revealed consolidation of left lung bases with bilateral small calcified lung nodules, hepatomegaly and non-specific abdominal lymphadenopathy. Patient refused hospital admission, thus sent home on levofloxacin and prevacid and asked to follow up with the primary care physician for further evaluation. Ten days later he was admitted to hospital with progressive confusion, dyspnea, lethargy, and abdominal pain. Abdomen was soft, slightly distended, and mildly tender in the right upper quadrant. Bowel sounds were positive. Liver was palpable with a span of 18 cms. Admission labs revealed worsening of liver function. Chest X-ray showed persisting left lower lobe infiltrate. He was started on unasyn and azithromycin. CT of abdomen displayed massive hepatomegaly 30.4 cm along with extensive abdominal lymphadenopathy. On day two, patient became encephalopathic with profound liver and renal failure necessitating ICU transfer and was started on lactulose. Non-contrast CT scan of chest showed a 2.2 cm mass in the left upper lobe with extensive mediastinal lymphadenopathy and airbronchograms involving the left base. Liver biopsy unmasked massive infiltration of hepatic parenchyma with poorly differentiated Small cell Lung Cancer (SCLC) with intrasinusoidal involvement. He was started on high dose steroids, fractionated cytoxan and, transferred to a transplant center but died on the fourth day with advanced Multiorgan dysfunction syndrome. FHF from liver metastases is relatively rare (0.44%). Only 20 cases of FHF from SCLC were reported in literature. The most striking features at presentation of FHF secondary to metastatic disease are massive hepatomegaly, elevated serum LDH, uric acid, and increased serum LDH to ALT ratio. LDH levels are often used as a marker of tumor growth and predictor for impending liver failure in patients with SCLC. Imaging of the liver often fails to demonstrate a well defined lesion. Diffuse involvement of the liver is the norm. Liver biopsy is warranted to eliminate other causes of liver failure. After the onset of FHF prognosis is dismal and, these patients rapidly progress to MODS. Death invariably follows in days.

F-18 FDG PET/CT Findings in Pulmonary Necrotizing Sarcoid Granulomatosis

Necrotizing sarcoid granulomatosis (NSG) is a rare systemic disease that was described by Liebow in 1973. Dyspnea and chest pain may be present, as in our first patient; however, 25% of patients are asymptomatic, as our second patient. The typical radiographic findings are nonspecific: single or multiple lung opacities, with common involvement of the pleura. To the best of our knowledge, fluorodeoxyglucose (FDG) PET has only been reported in one case of NSG, which was atypical as it occurred in an adolescent. We report 2 cases, confirming that the lesions of NSG are FDG positive, showing a typical pattern of multiple bilateral lung nodules (imaged with PET/CT in 1 case). FDG imaging has a potential role when this distribution is observed on CT, to guide the surgical biopsy and show the actual extent of the disease.

Case study documenting the diagnosis of idiopathic CD4+ Lymphocytopenia in a patient with atypical fungal infection (disseminated blastomycosis) by FNA of adrenal mass

Idiopathic CD4+ lymphocytopenia, described in 1992 by the Centers for Disease Control, is characterized by persistent CD4+ lymphocytopenia (less than 300 cells per micro-liter) in nonimmunosuppressed, HIV negative individuals, who present with atypical infections. This rare though likely undiagnosed entity is associated with chronic disseminated forms of either fungal or bacterial infections in otherwise healthy adults. We report a case of a 59-year-old male with ring-enhancing brain lesions, bilateral adrenal masses, lung and vocal cord nodules, where the diagnosis of exclusion was metastatic malignancy. Fine needle aspiration (FNA) of the adrenal mass and a subsequent vocal cord biopsy confirmed chronic widely disseminated blastomycosis. Flow cytometric evaluation of peripheral blood documented persistent selective CD4+ lymphocytopenia with T8 (suppressor) T-Lymphocyte count within normal range. We believe that idiopathic CD4+ lymphocytopenia is an important etiologic factor to be considered for patients who present with mass lesions and are diagnosed by FNA with atypical fungal infections. We relate the diagnostic criteria for idiopathic CD4+ lymphocytopenia and the importance of providing on-site triage for FNA samples for fungal studies and correlation for flow cytometry.

Clinical features of pulmonary malignancies in patients younger than 30 years of age

To analyse the clinical features of young patients with pulmonary malignancies. The clinical data of 58 young (< 30 years) patients with pulmonary malignancies who were treated in our hospital were retrospectively analyzed. Out of these 58 patients, adenocarcinoma was most common (n=23, 39.66%). Accompanied tumors were seen in two patients. Occupational or environmental factors were noted in two patients. Histories of smoking were noted in 10 patients (17.24%), and all of them were patients with epithelial tumor patients. Four patients had family history of tumors. The mean time from the onset of disease to confirmed diagnosis was (5.98+/-8.95) months. The initial misdiagnosis rate was 37.9% (n=23), with pulmonary tuberculosis as the most common misdiagnosis. The proportions of advanced-stage patients (stage III B and IV) and moderate to poor-differentiated tumor accounted for 59.26% (16/27) and 77.8% (14/18), respectively in 27 patients with non-small cell lung cancer. The proportion of tumors in limited stage was 72.73% in 11 patients with small cell lung cancer, and most patients (54.55) were not sensitive to conventional chemotherapy. In 6 patients with carcinoid, 4 patients were central and the other 2 patients were peripheral, and all of them presented as Cushing syndrome; CgA, AE1/AE3, Syn, and NSE were positive in immunohistochemical staining; and surgical operation was the main treatment for them. In 6 patients with carcinomas of salivary gland type, all cases were central; no lymph nodes metastasis was found in the postoperative specimen; and surgical operation was also the main treatment for these patients. In 3 patients with primitive neuroectodermal tumors, the tumors were highly malignant and invasive, and the development of primitive neuroectodermal tumors was closely related with pleura. Immunohistochemical staining showed that the tumor cells were positive for CD99. Multiple nodules in bilateral lungs were presented in 2 patients with anaplastic large cell lymphomas, in which CD30 was positive in tumor cells; chemotherapy was the main therapy for these two patients. In one patient with synovial sarcoma, the tumor was giant and highly malignant and invasive; it was divided into many cavities filled with bloody fluid and white cheese-like substances; immunohistochemical analysis showed positive vimentin and AE1/AE3. The pulmonary malignancies in young patients tend to be complicated. The treatment strategy should be based on the specific conditions of each patient.

CT Characteristics of Lung Nodules Present at Diagnosis of Extrapulmonary Malignancy in Children

The purpose of this study was to evaluate the CT characteristics of lung nodules present at diagnosis of extrapulmonary malignancies in children. We performed a retrospective analysis of CT images of children seen in our oncology service over a 6-year period. We included all children diagnosed with a non-CNS solid extrapulmonary malignancy or lymphoma who had also undergone chest CT at presentation. Images were reviewed for the presence of lung nodules; if present, the following nodular characteristics were recorded: sidedness, number, distribution, CT attenuation, shape, margins, calcification, and size. When available, pathology results were correlated with the nodules found on CT. One hundred eleven infants and children (age range, 14 days-17 years 10 months; median age, 11 years 8 months) had lung nodules on CT. The nodules showed a variety of patterns, but the most common findings were bilateral lung nodules (71 of 111 patients), between two and 10 in number (60 patients), peripheral distribution (98 patients), < or = 5 mm (48 patients), oval shape (45 patients), solid attenuation (74 patients), smoothly marginated (91 patients), and noncalcified (107 patients). Twenty-seven patients underwent biopsy. Seventeen biopsies showed benign lesions and nine, malignant lesions; the results for the remaining biopsy were inconclusive. In the subgroup of lung nodules that underwent biopsy, none of the CT characteristics was able to differentiate benignity from malignancy. Lung nodules in children with extrapulmonary malignancies showed a variety of patterns on CT. In the subgroup of lung nodules that underwent biopsy, none of the nodule features studied on CT reliably differentiated benignity from malignancy.

Thoracic CT findings of Behcet disease

Objective To illustrate the thoracic CT findings of Behcet disease and to assess the CT diagnostic role in patients with Behcet disease. Methods Thoracic CT images and medical records were retrospectively reviewed in 13 patients with thoracic Behcet disease. The diagnosis was based on the criteria set by the international study group for Behcet disease. Results Of 13 patients, subpleural patchy consolidations were showed in 3, bilateral diffuse ground glass opacities in 3, left low lobe collapse with a right small nodule in 1, subpleural solitary pulmonary nodule in 1, bilateral pleural effusion in 2 ,mediastinal lymphoadenopathy in 2, diffuse bilateral miliary lung nodules in 1 during treatment. Thoracic vascular involvement was presented in 8 patients, two with superior vena cava thrombosis, one with left subclavicle artery aneurysm, one with left low pulmonary artery aneurysm and mural thrombosis, one with bilateral low pulmonary arteries and left basilar artery aneurysm, three with right pulmonary artery thrombosis in which there were two with left pulmonary artery occlusion and one with left basilar artery branch aneurysm. Conclusions Thoracic CT findings of Behcet disease are variable and nonspecific. Contrast-enhanced CT scan can be helpful by showing thrombosis of the superior vena cava and pulmonary artery as well aneurysm of the pulmonary artery. Key words: Behcet syndrome; Pulmonary embolism; Aneurysm; Tomography,X-ray computed

Cancer testiculaire et granulomatose nécrosante sarcoid-like

A 35-year-old man with a stage I non-seminomatous germ-cell tumor of the right testis was treated with a simple orchidectomy. Sixty-seven months later, the patient who was on clinical follow-up, has presented five bilateral lung nodules on computed-tomography scan. Additional staging showed no other abnormalities. Lung biopsy of two nodules was performed during a videothoracoscopy and the histologic examination revealed a sarcoidosis-like necrotizing granulomatosis. The coexistence of non-caseating granulomas and testis carcinoma showed an increase during the last two decades. The immunopathogenesis of sarcoid formation in malignant tumours is still unknown. During follow-up of patients with testicular carcinomas, the presence of lung nodules requires a histologic examination and sarcoidosis should be considered as differential diagnosis.

Wegener's granulomatosis in which rheumatoid factor was useful for evaluating the disease status: a case report

IntroductionAccurate evaluation of disease status is very important in treatment of Wegener's granulomatosisCase presentationA 73-year-old Japanese man presented with chronic sinusitis and otitis media. He was admitted to our hospital because of bilateral lung nodules. Cytoplasmic antineutrophil cytoplasmic antibody was negative but his rheumatoid factor was high. He was diagnosed with limited Wegener's granulomatosis and received remission induction therapy. His serum rheumatoid factor level correlated with the Wegener's granulomatosis state when he experienced a severe infection and recurrence due to Wegener's granulomatosis.ConclusionWe describe a case of Wegener's granulomatosis in which rheumatoid factor was helpful for evaluating the therapeutic effect.

Metastasizing dermatofibroma in lung

Benign dermatofibroma is very common skin tumor and can very rarely metastasize. We report a case of metastasizing dermatofibroma on a 36-year-old woman who presented multiple bilateral lung nodules. She underwent incisional biopsy for cellular dermatofibroma of the right shoulder 7 years ago. Chest computed tomographic scanning shows multiple nodules in both lung fields. Segmental and wedge resections were done. Grossly, the masses were hemorrhagic cysts. Microscopically, there were dilated cystic airspaces. The airspaces were lined by respiratory and metaplastic squamous epithelium with underlying layers of fibrohistiocytic spindle cells with storiform and fascicular pattern. The tumor cells stained for CD68 and CD10. The lung mass shows same histologic features with skin lesion.

Pulmonary inflammatory pseudotumor caused by Cryptococcus presenting multiple nodules in bilateral lungs

By now there are a few reports describing a case of pulmonary inflammatory pseudotumor, presenting multiple nodules in bilateral lungs and a pseudotumor caused by fungus infection is also a very rare disease. Here we report a rare case of pulmonary inflammatory pseudotumor with confirmed cause by Cryptococcus infection presenting multiple nodules in bilateral lungs.

Posttransplant Lymphoproliferative Disorder in a Lung Transplant Recipient

The authors describe a case of posttransplant lymphoproliferative disorder (PTLD) in a 38-year-old Japanese male patient who had undergone bilateral lung transplantation. Chest CT performed on day 109 revealed multiple lung nodules measuring approximately 1cm in the left lower lobe. Despite administration of anti-fungal agents, follow-up CT performed on day 138 showed bilateral lung nodules increased in size and number. Transcutaneous lung biopsy was performed, yielding a diagnosis of polymorphic PTLD positive for Epstein-Barr virus (EBV)-encoded RNA (EBER) and CD20. Treatment with rituximab was successful, resulting in decreased size and number of lung nodules. FDG-PET showed no increased metabolic activity in the residual nodules. In this case, CT and FDG-PET were useful for initial diagnosis and evaluation of treatment response. To the best of our knowledge, this is the first report of PTLD in a lung transplant recipient in Japan documented in the English literature.

Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary?

Surgical resection of lung metastases is routine procedure for selected patients with pulmonary nodules and solid tumors. In some cases, patients present with unilateral pulmonary metastases amenable to surgical resection. Surgeons are still divided between unilateral approach directed to the radiologically detected nodules, or bilateral exploratory thoracotomy. This study evaluates the need for bilateral thoracotomy in patients diagnosed with unilateral lung metastases. A retrospective evaluation was made of a prospective database from a single institution (1990-1997) of all consecutive patients (n = 267) diagnosed on admission with unilateral (n = 179) or bilateral (n= 88) lung nodules. Ipsilateral thoracotomy was performed on all patients with unilateral disease. Bilateral thoracotomy was performed on all patients with bilateral lung metastases. adenocarcinoma (25%), osteosarcoma (23%), squamous cell carcinoma (18%), soft-tissue sarcoma (18%), and other (16%). Median follow-up was 17 months. Contralateral disease-free survival and overall survival were determined. Univariate and multivariate analyses were performed to determine prognostic factors for overall and contralateral disease-free survival. The two groups of patients with confirmed bilateral metastases (synchronous or metachronous) were compared. Actuarial overall 5-year survival was 34.9%. Contralateral recurrence-free 6-month, 12-month, and 5-year survival were 95%, 89%, and 78%, respectively. Patients who experienced recurrence in the contralateral lung within 3, 6, or 12 months had an overall 5-year survival rate of 24%, 30%, and 37%, respectively. When patients with recurrence in the contralateral lung were compared to patients with bilateral metastases on admission, there was no significant difference in overall survival. Only histology and the number of pathologically proven metastases significantly (p < 0.05) predicted recurrence in the contralateral lung. Bilateral exploration of unilateral lung metastases is not warranted in all cases. Most patients will have only unilateral disease, and delaying contralateral thoracotomy until disease is detected radiologically does not appear to affect outcome.