High Clinical Suspicion Of Malignancy Research Articles

A Rare Presentation of Adrenal Leiomyoma Arising in a Ganglioneuroma: A Case Report

Leiomyomas are benign tumours of smooth muscle origin and can occur in any part of the body with adrenal gland being an uncommon site. Ganglioneuromas of adrenal gland are benign neural crest-derived tumours. Both of these tumours are usually detected incidentally. Hereby, the authors report an unusual case of a 31-year-old woman, who presented with paroxysmal attacks of headache, palpitations and flushing pointing towards a hormone secreting adrenal tumour. However, functional adrenal markers were normal. Radiological investigations revealed 8×3 cm heterogeneously enhancing left suprarenal mass with calcification and extension to left renal vein. Patient underwent left nephrectomy and adrenalectomy with a high clinical suspicion of malignancy because of tumour extension to the renal vein. The histopathological examination revealed a leiomyoma arising in a background of ganglioneuroma which was later on confirmed using immunohistochemistry. Authors have presented the present case because of atypical presentation as a hormone secreting adrenal tumour with radiological features of malignancy and the unique histomorphology of the combined occurrence of leiomyoma and ganglioneuromatous area in the adrenal gland. To the best of author’s knowledge, this is the first case report of such an occurrence in the adrenal gland.

S2417 A Diagnosis That Is Difficult to Swallow: Digging Deeper for Answers

Introduction: Esophageal parakeratosis (EP) is an uncommon finding with largely unknown clinical implications and malignant potential. Here, we report a case of severe esophageal parakeratosis. Case Description/Methods: Patient is a 69-year-old African American male with history significant alcohol and cocaine abuse, prior tobacco abuse, keloids, gastroesophageal reflux, food impaction, and progressive dysphagia for 20 years with 40-pound weight loss. Patient’s first esophagogastroduodenoscopy (EGD) in 2000 revealed moderate esophagitis and a distal esophageal stricture with 9 mm lumen bougie dilated to 12 mm, but dysphagia persisted. Repeat EGDs between 2006 and 2016 showed whitish plaques with no evidence of fungal organisms. Given classic appearance of EOE, he was trialed on empiric fluticasone and budesonide with no improvement in dysphagia. In September 2021, he was hospitalized with severe dysphagia. EGD (Figure) at this time showed gray, yellow frondlike lesion replacing esophageal lumen from mid to distal esophagus with mucosal friability. His dysphagia transiently responded to repeat dilations, but continued to recur and worsen. Unfortunately, patient continued to have weight loss and dysphagia unresponsive to dilations. The patient was then started on gastric tube feedings. He was offered surgery due to the severity of his symptoms, but he declined. Most recently, the patient underwent endoscopic mucosal resection with deeper tissue samples revealing superficial fragments of laterally spreading squamous cell carcinoma of the esophagus. Discussion: In this case, there was a high clinical suspicion for malignancy, leading the endoscopist to obtain deeper tissue samples via endoscopic mucosal resection as superficial fragments of the esophagus only revealed parakeratosis. It is important to trust clinical judgment, especially if there is a high suspicion for malignancy. Tylosis also has a known association with EP and often presents with areas of thickened skin plaques on palms and feet. Tylosis has a strong association with head, neck, and esophageal squamous cell carcinoma. The patient had no family history of tylosis and no cutaneous features. Despite this, a careful inspection of the entire EP area with targeted biopsies should be obtained to evaluate for dysplasia. This case represents EP with years of no evidence of squamous cell cancer despite aggressively searching for it, which at least anecdotally suggests a precancerous potential for EP.Figure 1.: A. Initial EGD B. Recent EGD.

Parotid Gland Tumour Presenting in Primary Care: The Importance of Histological Confirmation

This is a report of a patient presenting to a primary care clinic with slow growing parotid gland swelling which was initially suspected as benign from ultrasound findings. A referral to the ORL (otorhinolaryngology) team was made and FNAC (Fine Needle Aspiration Cytology) results confirmed the swelling to be Acinic Cell Carcinoma. The patient subsequently underwent surgical resection. This case highlights the importance of a high clinical suspicion of malignancy in those presenting with slow growing salivary gland tumours due to its indolent nature and imaging difficulties. Histological confirmation is warranted.

Clinical suspicion of pancreatic cancer despite negative endoscopic ultrasound-guided fine-needle aspiration biopsy.

The early and accurate diagnosis of pancreatic ductal adenocarcinoma is vital for improving the efficacy of therapeutic interventions and to provide patients with the best chance of survival. While endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been demonstrated to be a reliable and accurate diagnostic tool for solid pancreatic neoplasms, the ongoing management of patients with a high clinical suspicion for malignancy but with a negative EUS-FNA biopsy result can prove a challenge. We describe five patients from a single centre who presented for further work-up of a pancreatic mass and/or imaging features concerning for a periampullary malignancy. All patients had at least one EUS-FNA biopsy performed which returned no malignant cells on cytology. Despite these negative cytology results, all patients underwent further invasive investigation through upfront resection (pancreaticoduodenectomy) or extra-pancreatic biopsy (laparoscopic biopsy of peritoneal nodule) due to worrisome features on imaging, biochemical factors and clinical presentation culminating in a high degree of suspicion for malignancy. The final tissue histopathological diagnosis in all patients was pancreatic ductal adenocarcinoma. This case series highlights the important clinical findings, imaging and biochemical features which need to be considered in patients who have high suspicion for malignancy despite having a negative EUS-FNA cytology result. In these patients with a high index of suspicion, surgical intervention through an upfront resection or further invasive investigation should not be delayed.

Rare Case of Intestinal-Type Adenocarcinoma Arising in Cervical Oesophageal Heterotopic Gastric Mucosa

Heterotopic Gastric Mucosa (HGM) also termed gastric inlet patch or inlet patch, is a rare and benign phenomenon in cervical oesophagus and can be missed during endoscopy. It has an average incidence of 2.5%. Adenocarcinoma arising in the background of gastric heterotopia is very rare and uncommon in the upper oesophagus. A 46-year-old male presented with hoarseness and progressive dysphagia for solids for the past one month. Upper Gastrointestinal Endoscopy (UGIE) revealed a tight stricture at 19-20 cm from the incisors. Initial mucosal biopsies were not conclusive. With high clinical suspicion of malignancy, patient underwent bougie dilation of oesophageal stricture followed by repeat biopsy. Histology revealed an intestinal type of adenocarcinoma, arising in a background of gastric heterotopia of the cervical oesophagus. Alcian Blue/Periodic Acid Schiff (AB/PAS) staining was positive in both the heterotopic glands and in the cancer, indicating the presence of intestinal metaplasia. Tumour cells were immunopositive for cytokeratin-7. A Positron Emission Tomography – Computed Tomography scan revealed a metabolically active lesion located in the upper third of the oesophagus along with uptake in right supraclavicular node. This case report describes a patient with primary intestinal type adenocarcinoma of the cervical oesophagus in the background of HGM not related to Barrett’s oesophagus.

SPINDLE CELL CARCINOMA OF THE LUNG: A RARE, AGGRESSIVE TUMOR ELUSIVE TO TYPICAL DIAGNOSTIC METHODS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Spindle cell carcinoma is a subtype of sarcomatoid carcinoma, which encompasses a rare group of non-small cell lung carcinomas (NSCLC) that contain true sarcoma or sarcoma-like elements. Less than one percent of all lung cancers are sarcomatoid carcinomas. Here we present a case of spindle cell carcinoma that proved difficult to diagnose in the absence of surgical lobectomy. CASE PRESENTATION: A previously healthy 73-year-old female non-smoker presented to her primary care physician for a persistent non-productive cough. A chest radiograph revealed a large left upper lobe (LUL) mass. A computed tomography (CT) scan of the chest was performed, which demonstrated a 7.5cm LUL mass with a necrotic-appearing center and mediastinal lymphadenopathy. A subsequent positron emission tomography (PET)-CT scan showed uptake around the rim of the mass, sparing the center. She underwent bronchoscopy with endobronchial ultrasound-transbronchial needle aspirations of the mediastinal lymph nodes as well as radial probe ultrasound-guided transbronchial biopsies of the mass, with pathology showing inflammation and no evidence of malignancy. Shortly after the bronchoscopy, she became febrile with shaking chills. She was started on amoxicillin-clavulanate for possible lung abscess. A three-week follow-up CT scan showed no improvement in the size of the mass, so she underwent a CT-guided core biopsy, the pathology from which revealed extensive necrosis but was again negative for malignancy. A thoracentesis was also performed for a small left pleural effusion, during which 470ml of hemorrhagic fluid was drained. Fluid cytology and cultures were negative. Antibiotics were discontinued and she was referred for a lobectomy for definitive diagnosis. She underwent a left upper lobectomy, with pathology revealing an 8.5cm spindle cell carcinoma with visceral pleural invasion and involvement of the internal mammary and levels 5 and 6 lymph nodes, consistent with stage IV disease. A PET-CT performed three weeks post-operatively was highly concerning for residual or recurrent neoplasm in the left anterior chest wall. Radiation therapy was initiated. Genetic testing revealed a MET exon 14 deletion as well as a high expression of PD-L1. The patient is planning to start chemotherapy with pembrolizumab and crizotinib in the near future. DISCUSSION: This case highlights a rare form of lung cancer that was very difficult to diagnose, with false negative bronchoscopic biopsies and CT-guided percutaneous core needle biopsy. Such biopsy methods may not be capable of detecting epithelial and sarcomatous components, which could lead to a missed diagnosis. CONCLUSIONS: Given the high clinical suspicion for malignancy in this patient with a persistent and enlarging lung mass, a surgical biopsy was necessary to obtain a definitive diagnosis. Reference #1: Franks TJ, Galvin JR. Sarcomatoid carcinoma of the lung: histologic criteria and common lesions in the differential diagnosis. Arch Pathol Lab Med. 2010;134(1):49-54. Reference #2: Girard N, Cadranel J, Brambilla E, Cordier J-F. Rare primary lung tumors. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. United States: Elsevier; 2016:965-980. Reference #3: Tazelaar, HD. Pathology of lung malignancies. UpToDate. https://www.uptodate.com/contents/pathology-of-lung-malignancies?search=sarcomatoid%20carcinoma&source=search_result&selectedTitle=1∼29&usage_type=default&display_rank=1. Updated November 16, 2018. Accessed March 13, 2019. DISCLOSURES: No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by Leah Lande, source=Web Response No relevant relationships by Kriti Pathak, source=Web Response

The Second Greatest Masquerader? Sarcoidosis Presenting as a Nodular Lung Mass Mimicking Malignancy

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcoidosis is a systemic granulomatous disease that involves the lungs in 90% of cases. Pulmonary Sarcoidosis can present with the classic pattern of hilar adenopathy and parenchymal ground glass opacities, but also with a wide range of more unusual patterns. We present the case of a young female patient with a lung mass on CT scan that was initially concerning for malignancy but was ultimately found to be Sarcoidosis. CASE PRESENTATION: A 44 year old African American woman with a past medical history of diabetes, obesity, and asthma presented with shortness of breath for one month. She had been treated with Prednisone for a presumed asthma exacerbation; her breathing improved initially but deteriorated after being tapered off Prednisone. She ultimately came to our facility as her respiratory status worsened and she developed night sweats and unintentional weight loss. Chest radiograph revealed a mass-like opacity in the left lower lobe. CT Chest revealed a left lower lobe mass and diffuse hilar lymphadenopathy, which was concerning for malignancy. Initial CT-guided biopsy of the lung mass revealed granulomatous disease consistent with Sarcoidosis and without evidence of malignancy, fungal infection, or infection with acid fast bacilli. However, given the atypical presentation and ongoing concern for malignancy, bronchoscopy and then mediastinoscopy were performed. These both confirmed the diagnosis of Sarcoidosis. Prednisone was initiated but management has been challenging due to frequent episodes of hyperglycemia requiring insulin therapy. Given her robust response, Prednisone has been continued despite poor glucose control. Repeat imaging after 3 months shows a significant decrease in the size of the left lower lobe lung mass. DISCUSSION: Sarcoidosis is known to mimic neoplastic, infectious, or other granulomatous conditions, but dominant nodular mass-like lesions resembling neoplasm are a rare manifestation. Such an atypical presentation requires thorough investigation to rule out other causes. Repeated biopsy on two non-contiguous sites is recommended. In our patient there was initially a high clinical suspicion for malignancy, so the team did not feel comfortable relying on a single biopsy result. After two additional biopsies of other sites the diagnosis of Sarcoidosis was confirmed. Because Sarcoidosis can masquerade as so many conditions, it may be overlooked or disregarded in the search for alternative diagnoses. It is therefore imperative for physicians to keep a high clinical suspicion for Sarcoidosis to prevent delay in diagnosis and treatment. Steroid-sparing agents such as Rituximab can also be considered if patients are intolerant to first-line steroid therapy. CONCLUSIONS: Sarcoidosis can present with a wide range of unusual patterns and a high clinical suspicion is important to prevent delay in management. Reference #1: Baughman RP, Culver DA, Judson MA. A Concise Review of Pulmonary Sarcoidosis, Am J Respir Crit Care Med.2011;183:573-81 DISCLOSURE: The following authors have nothing to disclose: Wing-Tai Kong, Changwan Ryu, Afshin Ahoubim, Christopher Erb No Product/Research Disclosure Information

Implication of suspicious cytology in endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become a preferred technique to evaluate pancreatic masses. The clinical management of a "suspicious for adenocarcinoma" cytological diagnosis is unclear in unresectable cases. We sought to determine whether a suspicious diagnosis in the setting of a high clinical suspicion of malignancy could be sufficient for initiating non-operative therapy, such as chemotherapy, in unresectable patients. Twenty-nine solid pancreatic mass cytology specimens obtained by EUS-FNA with a diagnosis of suspicious for adenocarcinoma were identified from 2000 to 2012. Pathology, clinical, and radiologic data were analyzed. Additional procedures were performed in 21 of the 29 patients. Sixteen of the 21 patients had confirmation of malignancy on further tissue sampling and an additional 2 had confirmed unresectable cancers during surgical exploration. Three of the 21 patients had benign diagnoses on subsequent tissue sampling. Of the remaining eight patients who did not undergo additional diagnostic procedures, six were deemed clinically malignant and treated, one died within a year of the EUS-FNA, and one was lost to follow-up. Consideration of a suspicious diagnosis on EUS-FNA of solid pancreatic masses as sufficient for initiating non-operative therapy is reasonable in the setting of a high clinical suspicion of malignancy.

The value of mutational profiling of the cytocentrifugation supernatant fluid from fine-needle aspiration of pancreatic solid mass lesions

Fine-needle aspiration (FNA) of pancreatic solid masses can be significantly impacted by sampling variation. Molecular analysis of tumor DNA can be an aid for more definitive diagnosis. The aim of this study was to evaluate how molecular analysis of the cell-free cytocentrifugation supernatant DNA can help reduce sampling variability and increase diagnostic yield. Twenty-three FNA smears from pancreatic solid masses were performed. Remaining aspirates were rinsed for preparation of cytocentrifuged slides or cell blocks. DNA was extracted from supernatant fluid and assessed for DNA quantity spectrophotometrically and for amplifiability by quantitative PCR (qPCR). Supernatants with adequate DNA were analyzed for mutations using PCR/capillary electrophoresis for a broad panel of markers (KRAS point mutation by sequencing, microsatellite fragment analysis for loss of heterozygosity (LOH) of 16 markers at 1p, 3p, 5q, 9p, 10q, 17p, 17q, 21q, and 22q). In selected cases, microdissection of stained cytology smears and/or cytocentrifugation cellular slides were analyzed and compared. In all, 5/23 samples cytologically confirmed as adenocarcinoma showed detectable mutations both in the microdissected slide-based cytology cells and in the cytocentrifugation supernatant. While most mutations detected were present in both microdissected slides and supernatant fluid specimens, the latter showed additional mutations supporting greater sensitivity for detecting relevant DNA damage. Clonality for individual marker mutations was higher in the supernatant fluid than in microdissected cells. Cytocentrifugation supernatant fluid contains levels of amplifiable DNA suitable for mutation detection and characterization. The finding of additional detectable mutations at higher clonality indicates that supernatant fluid may be enriched with tumor DNA. Molecular analysis of the supernatant fluid could serve as an adjunct method to reduce sampling variability and increase diagnostic yield, especially in cases with a high clinical suspicion for malignancy and limited number of atypical cells in the smears.

PWE-070 Outcomes following local excision of benign rectal lesions—network MDT results

IntroductionA regional Small and Early Rectal Cancer (SERC) MDT was established in 2008. In line with NICE guidance, all patients with stage 1 rectal cancer are referred, as well as...

Performance Characteristics of Semirigid Thoracoscopy in Pleural Effusions of Undetermined Etiology

The utility of the recently introduced semirigid thoracoscopy in undiagnosed pleural effusions is still unclear. A single-center, 4-year retrospective analysis of all semirigid medical thoracoscopy procedures was done. The diagnostic accuracy of thoracoscopy was calculated as the number of positive diagnoses achieved by thoracoscopy in relation to the end-diagnosis achieved in the patient group by any means. One hundred fifty procedures were analyzed. Ninety-two patients (62.3%) were diagnosed as having a malignant disorder, of which mesothelioma was the most common (26%). Pleural thickening and nodularity were the most common abnormalities noted. The combined presence of nodules and hemorrhagic fluid increased the likelihood of malignancy 9-fold. Thirteen patients with a high clinical suspicion of malignancy but negative by thoracoscopy underwent mediastinoscopy, computed tomography-guided biopsy, or open thoracotomy. A malignant etiology was confirmed in all of them. Overall, thoracoscopy provided a diagnostic accuracy of 91.3%, sensitivity of 87%, and specificity of 100%. The addition of a second procedure in selected patients improved the diagnostic accuracy for malignancy by 8.7%. The procedures were well tolerated and only 6 patients developed minor and transient complications such as pain, hypoxia, and bradycardia. Semirigid thoracoscopy is a safe, well-tolerated, and efficacious procedure for establishing the diagnosis in pleural effusions of undetermined etiology.

The value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in carcinoma of an unknown primary: diagnosis and follow-up

The management of the patients with carcinoma of an unknown primary represents a difficult challenge in oncology. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has provided new insights in the diagnosis, staging, and follow-up of oncological patients. This study aimed to investigate the value of FDG PET/CT in clarifying the primary site in our patients with histologically proven tumor metastasis (HPM) or with a high clinical suspicion of malignancy, and the clinical impact of this technique on the management of these patients. In total 94 patients from two centers underwent FDG PET/CT imaging; 78 patients with HPM and 16 patients with a clinical suspicion of malignancy. The histology and/or follow-up data were used as the gold standard. Hypermetabolic findings at the site of the pathological CT changes or at physiological FDG uptake sites were the criteria for malignancy. PET/CT findings were analyzed for the identification of the primary tumor site, for the relationship with survival, and also for the effect in chemotherapy monitoring. Primary malignancy was discovered in 53 of 90 patients (59%) histologically and 37 (41%) patients' primary tumor sites were not found during the study period. Amongst 90 patients, five (6%) were normal on FDG PET/CT. Of 85 patients (94%) with pathological findings on FDG PET/CT, 27 patients (32%) had solitary and 58 (68%) patients had multiple organs affected. Regarding the whole study population, a sensitivity of 74% and a specificity of 78% were calculated for FDG PET/CT imaging. Regarding the patients with HPM, the sensitivity and specificity values were 84 and 81%, respectively. The mean survival time of the patients with disseminated disease was significantly shorter than those of the patients with single or no lesion (13.44+/-1.61, 20.98+/-2.0 and 26.67+/-2.73 months, respectively, P=0.014). In seven of eight patients, follow-up FDG PET/CT scans effectively monitored the patients' therapies. Whole-body FDG PET/CT has to be considered a useful method, especially in an early phase of the diagnostic workup of patients with carcinoma of an unknown primary syndrome, to optimize the management.

Adenocarcinoma Masquerading as Neurofibroma in a Patient With von Recklinghausen Disease

Lung malignancies reported in association with neurofibromatosis are rare. We present a patient with history of neurofibromatosis and a lung mass. Transbronchial biopsy was consistent with neurofibroma of the lung. Because of high clinical suspicion for malignancy, the patient underwent an open lung biopsy which revealed adenocarcinoma of the lung.

Clinical Significance of the Detection of the Homozygous Deletion of P16 Gene in Malignant Pleural Effusion

To assess the role of the p16 gene exon 2 homozygous deletion in malignant pleural effusions. The homozygous deletion of p16 gene was determined in 34 pleural effusions due to non-small cell lung cancer (NSCLC) and in 21 cases with tuberculous pleuritis by polymerase chain reaction (PCR), compared with the determination of exfoliated cytology in the same specimens. The PCR analysis showed that the homozygous deletion of p16 exon 2 was identified in 15 of 34 malignant pleural effusions (44.11%), including 8 negative cytology and it was not found any tuberculous pleural effusions. The exfoliated cytology of pleural effusion was positive in 19 of 34 malignant cases (55.88%). By combining two methods, the diagnostic sensitivity was enhanced, from 55.88% (19/34) to 79.41% (27/34), whose positive rate was higher than only determination of p16 exon2 homozygous deletion or exfoliated cytology in malignant pleural effusions (p<0.001, p<0.05 respectively). Our data suggested that combining the examination of exfoliated cytology and homozygous deletion of p16 gene exon2 in pleural effusion can recruit and enhance the diagnostic value of pleural effusion cytology. The detection of the homozygous deletion of the p16 gene in pleural effusion may be a useful adjunct to the cytological and histological examinations of pleural effusion. In cases of undiagnosed exudative pleural effusion with a high clinical suspicion for malignancy, it is reasonable to examine the homozygous deletion of pleural fluid p16 gene. With p16 gene homozygous deletion in pleural effusion, it may be strongly highly likely to be malignant and have a higher metastatic potential.

Recto‐urethral fistula following brachytherapy for localized prostate cancer

The use of prostate brachytherapy (BT) in the management of prostate cancer is increasing. BT is often chosen because of its perceived lower toxicity when compared with other radical therapy options. Rarely however serious complications can occur. One such complication is recto-urethral fistula (RUF). We report the incidence of RUF following BT at our centre and review the potential factors in fistula development. A prospectively collected database was used to identify cases of RUF among 1455 patients treated with prostate BT at a single UK centre with at least 2 years of follow up. This included patients treated with BT monotherapy, as well as those treated with BT combined with external beam radiotherapy and BT used as salvage as all these groups have a higher incidence of RUF. Implant dose and volume characteristics for those patients, their co-morbidities and history of endoscopic procedures were recorded. Recto-urethral fistula was identified in three (0.2%) patients, occurring at 19-27 months following BT. All these patients had BT monotherapy. All three patients had rectal symptoms after their BT and had been investigated with endoscopy and low rectal biopsy. Subsequent surgical management with faecal and/or urinary diversion was required. On review of patients' BT details, radiation dose and volume parameters were higher on the postprocedure CT calculations than had been suggested by the preimplant plan. No other predisposing risk factors for RUF were identified. The incidence of RUF in our population is low. RUF following BT has been associated with rectal biopsy in previous series and this is confirmed in our report. Gastrointestinal specialists should not perform biopsy of the anterior rectum in patients who have had BT unless there is a very high clinical suspicion of malignancy.

Evaluation of Imaging-Guided Core Biopsy of Pancreatic Masses

The purpose of this study was to determine the sensitivity and accuracy of imaging-guided core biopsy in the diagnosis of pancreatic masses. Imaging-guided core biopsy is sensitive, safe, and accurate in the diagnosis of malignant lesions of the pancreas. Benign biopsy findings cannot be used to exclude the presence of a neoplasm, and repetition of a biopsy should be considered if there is high clinical suspicion of malignancy.

Inflammatory Sarcomatoid Carcinoma: A Case Report and Discussion of a Malignant Tumor With Benign Appearance

Inflammatory sarcomatoid carcinoma is an aggressive tumor with an unusually benign appearance. We report the case of a 65-year-old man with a history of inoperable poorly differentiated carcinoma of the right lung, for which he had received chemoradiotherapy. A new solitary mass was discovered 4 years later in the left lung on surveillance computed tomography. The patient underwent thoracotomy with a wedge biopsy on which frozen section was performed. The nodule was vaguely granulomatous and associated with a mixed inflammatory infiltrate and a deceptively bland spindle cell proliferation. Results of immunoperoxidase studies, however, showed that the nodule contained neoplastic cells with an epithelial phenotype that were invading the pulmonary vessels. These are features of the rare inflammatory sarcomatoid carcinoma. In contrast to sarcomatoid carcinomas, this case highlights the deceptively benign appearance of inflammatory sarcomatoid carcinoma. This leads us to concur with the recommendation to exercise caution when attempting the diagnosis of apparently benign lesions on intraoperative frozen section in patients with high clinical suspicion of malignancy.

Differentiation of benign vs. malignant mass in a postirradiation cerebral arteriovenous malformation by 2-deoxy-2-[ 18F] fluoro-D-glucose positron emission tomography

This report demonstrates the findings on two 2-deoxy-2-[ 18F]fluoro-D-glucose positron emission tomography (FDG-PET) brain scans of a 16-year-old girl with previous radiation therapy for an arteriovenous malformation (AVM) that was transformed by radiation therapy to a mass in a deep and relatively inaccessible cerebral location. Clinical neurologic examination, brain CT without and with contrast, 1.5 T MRI of the brain without and with contrast, magnetic resonance angiography (MRA), 1H magnetic resonance spectroscopic imaging (MRSI) of the brain, and two FDG brain PET scans were performed to characterize the lesion. Magnetic resonance imaging (MRI) and 1H MR spectroscopic findings showed a mass and surrounding vasogenic edema in the deep left parietal lobe suggestive of malignant angiosarcoma. However, an FDG-PET scan of the brain identified a large area of hypometabolism involving the left parietal lobe. The PET findings were unchanged compared to a FDG-PET scan performed one year prior, suggesting that the lesion was benign. In addition, an MRI performed six months after the second PET scan was also consistent with a benign lesion, and was unchanged from the MRI performed two years prior. We present the first detailed imaging characteristics of a mass of high clinical suspicion for malignancy resulting from transformation of an arteriovenous malformation after radiosurgery treatment. Two FDG-PET scans performed for a one-year time interval provided a noninvasive method to establish that the lesion had nonmalignant characteristics.

Percutaneous Transthoracic Needle Aspiration Biopsy: A Comprehensive Review of Its Current Role in the Diagnosis and Treatment of Lung Tumors

The purpose of this study is to examine the accuracy and complications of transthoracic needle aspiration biopsy (TTNA) to determine its optimal role in the evaluation of patients with lung tumors. The charts of 130 consecutive patients who had undergone CT-guided TTNA were reviewed retrospectively. Thirty-two (25%) of these patients had subsequent surgery and 5 had subsequent transbronchial biopsy (TBB). Using the final surgical and TBB diagnosis as a reference, the accuracy, sensitivity, specificity, and prevalence of malignancy were calculated. Each case was also examined to determine the presence or absence of complications. Of the 130 biopsy results, 95 (73%) were malignant, 33 (25%) were nonspecific, and only 2 (2%) had a specific benign diagnosis. Thirty-two patients subsequently underwent surgical resection. The overall prevalence of malignancy after surgical diagnosis was 91%. The overall diagnostic accuracy of TTNA was 76%. The sensitivity of TTNA for the detection of malignancy was 74% and its specificity was 100%. When comparing TTNA results of small (<3 cm) and large (> or = 3 cm) tumors, the occurrence of nonspecific results was 36% and 16%, respectively. Fifty-six (43%) patients had a pneumothorax subsequent to TTNA. Twenty-four (43%) of these patients required a chest tube and remained hospitalized for a mean of 6 days. Patients who are surgical candidates and have a high clinical suspicion for malignancy should undergo surgical biopsy and resection of their lung tumors if indicated. Information gained from TTNAs performed on this patient population will rarely result in a change in their clinical management.

The value of negative needle biopsy in suspected operable lung cancer

The value of needle biopsy (NB) of pulmonary masses in patients unsuitable for surgery is well established. The presence of malignant cells confirms the diagnosis and thus aids management. We have reviewed 196 patients aged over 40 years with a solitary pulmonary mass suspected of being operable lung cancer to assess the effect of a negative NB result on the management. Malignant cells were discovered in 148 patients and diagnoses of infection were made in a further 10. In 38 patients no malignant cells were identified. Nineteen patients proceeded to thoracotomy and 13 of these had malignant disease. Nine others had further needle biopsies and eight of these had malignancy. Ten patients were followed up without any further intervention and four of these eventually proved to have malignancy. Thus of the 38 patients with no malignant cells on NB but no definite benign diagnosis, 25 had malignancy, six had benign disease and seven had presumed benign disease. In this series NB provided a definite benign diagnosis in 5.1% of patients. From this study it may be concluded that if a solitary pulmonary nodule has a high clinical suspicion of malignancy and the patient is a candidate for surgery, NB is of limited value in management.