Intrapulmonary Mass Research Articles

Video Yardımlı Göğüs Cerrahisi Cerrahi Karar Vermenin Neresinde?: 497 Olgunun Değerlendirilmesi

Background: Video-assisted thoracic surgery (VATS) exploration is a frequently performed surgical intervention in thoracic surgery in cases such as pleural biopsy, mediastinal and hilar lymphadenopathy biopsies, hemothorax, air leak control. In this study, 497 patients were reviewed and extended indications of VATS exploration were revealed. Methods: All of the patients with radiologically detected intrathoracic pathology between 2009-2019 were included in the study. Preoperative, intraoperative and postoperative findings were evaluated retrospectively. Results: The clinical indications for VATS exploration were pleural effusion, intrapulmonary mass, cystic lesion, mediastinal lymphadenopathy or mass that has been investigated with a pre-diagnosis of malignancy or developed secondary to previously known malignancy, prolonged air leakage and / or lung expansion problems, mediastinal mass, hemothorax, pleural thickening or pleural nodule, chest wall tumor, pericardial cyst or effusion, chylothorax, and intrathoracic cavitary lesion. All patients with these indications were managed mainly with VATS exploration. Conclusion: Evaluation of operability criteria, and subtype determination for targeted therapies in the diagnosed patient, definitive diagnosis can be made and over-treatments can be prevented due to the precise biopsies can be taken with VATS exploration. We recommend the VATS exploration as a key step for all intrathoracic pathologies.

Primary Rosai-Dorfman disease of the thymus and lung: A clinicopathological and immunohistochemical study of three cases

Three cases of primary Rosai-Dorfman disease of the thymus and lung are presented. The patients are 3 men between the ages of 42 and 47 years who presented with non-specific symptoms including cough, chest pain, and shortness of breath. Clinically, the patients did not have any other pertinent clinical history. Diagnostic imaging revealed in one patient a cystic anterior mediastinal mass, while in two other patients the imaging was that of an intrapulmonary mass, one in the right upper lobe and the other in the left lower lobe. The three patients undergo surgical resection of the mass. In the cases in which the tumor mass was in the lung, both patients had a lobectomy while in the patient with anterior mediastinal mass, surgical resection via thoracotomy was performed. The intrapulmonary tumors were described as soft and yellowish measuring 2.5 and 3.0 cm in greatest diameter, while the mediastinal mass was described as cystic measuring 4.0 cm in diameter. Histologically, all tumors show similar features in terms of a proliferation of large histiocytes admixed with an inflammatory component composed predominantly of plasma cells. Immunohistochemical stains show positive staining for CD68 and S-100 protein, while negative for keratin, CD1a, and langerin. The cases herein presented highlight the ubiquitous distribution of Rosai-Dorfman disease and the importance of keeping this entity in the differential diagnosis of histiocytic proliferation in the thymus or lung.

Primary Warthin’s-like adenocarcinoma of the lung: A clinicopathological, immunohistochemical, and molecular analysis of three cases

Three cases of primary pulmonary adenocarcinoma with prominent lymphoid stroma and papillary features mimicking Warthin’s tumor are presented. The patients are two women and one man ages 52, 62, and 74 years respectively. Clinically, the patients presented with non-specific symptoms of cough, dyspnea, and chest pain. Imaging showed the presence of an intrapulmonary mass in the right lower, right upper and left lower lobe. All patients underwent lobectomy. Histologically, the tumors were characterized by the presence of and oncocytic papillary growth pattern embedded in a lymphoid rich background. Immunohistochemical stains for TTF-1, keratin 7, and beta-catenin were positive in the epithelial component, while CD20 showed strong positive staining in the lymphoid component. In addition, CD4 and CD8 also showed positive staining in a ratio of 3–4:1, EBER was negative. Kras mutations with wild type EGFR were identified in one case. Clinical follow-up ranging from 8 to 24 months was obtained showing that all patients are alive without recurrence. The cases herein presented represent an unusual histological variant of primary lung adenocarcinoma, which closely mimics Warthin’s tumor.

Primary Giant Cell Tumors of the Lung: A Clinicopathologic and Immunohistochemical Study of 3 Cases.

Three cases of primary giant cell tumors of the lung akin to those described in the soft tissues are presented. The patients are 3 men between the ages of 43 and 54 years who presented with nonspecific symptoms of cough, chest pain, and shortness of breath. None of the patients had any prior history of malignancy anywhere else. Diagnostic imaging disclosed the presence of an intrapulmonary mass. All the patients underwent lobectomy. Grossly, the tumors were described as solid, slightly hemorrhagic, and measuring between 1.8 and 2.4 cm in greatest diameter. Histologically, the tumors were characterized by a dual population of multinucleated giant cells admixed with a mononuclear proliferation. Nuclear atypia was mild to moderate, and mitotic activity varied but was under 5 mitotic figures per 10 high power fields. Immunohistochemical stains showed positive staining for vimentin, CD68, and cathepsin K, whereas the tumors were negative for keratin, TTF-1, p40, S-100 protein, and SABT-2. Clinical follow-up was obtained in 2 patients who have remained alive and without evidence of recurrence or metastasis up to 12 months after surgery. One patient was lost to follow-up. The current neoplasms represent a tumor that to the best of our knowledge has not been reported as a primary neoplasm of the lung. The cases herein described represent an unusual occurrence and should be maintained in the differential diagnosis of primary pulmonary tumors rich in multinucleated giant cells.

CT-guided versus ultrasound-guided percutaneous lung puncture biopsy in the diagnosis of peripheral pulmonary masses: a Meta-analysis

Objective To systematically evaluate the efficacy and safety of CT-guided percutaneous lung puncture biopsy versus ultrasound-guided percutaneous lung puncture biopsy. Methods Relevant domestic and foreign related databases such as PubMed, Web of Science, Cochrane Library, OVID, China Biology Medicine, VIP, Wanfang and CNKI databases were searched, the randomized controlled trial about the applications of CT-guided and ultrasound-guided percutaneous lung puncture biopsy were collected. After extracting the relevant data, a Meta-analysis was performed using RevMan 5.2 and Stata softwares. Results Ten studies met the inclusion criteria, with a total sample size of 1 158 cases, of which 635 were CT-guided puncture biopsy and 523 were ultrasound-guided puncture biopsy. Meta-analysis showed that the difference of the success rate between the CT-guided group and the ultrasound-guided group was not statistically significant [97.48% (619/635) vs. 96.56% (505/523), RR= 1.01, 95% CI 0.99-1.03, P= 0.360]; the puncture diagnosis rate in the CT-guided group was lower than in the ultrasound-guided group, and the difference was statistically significant [92.44% (619/635) vs. 96.56% (505/523), RR= 0.97, 95% CI 0.94-0.99, P= 0.007]. The total incidence of complications after puncture in the CT-guided group was higher than that in the ultrasound-guided group, and the difference was statistically significant [14.49% (92/635) vs. 9.56% (50/523), RR= 1.56, 95% CI 1.11-2.19, P= 0.010]; the incidence of pneumothorax after puncture in the CT-guided group was higher than that in the ultrasound-guided group, and the difference was statistically significant [11.50%(73/635) vs. 6.31% (33/523), RR= 1.77, 95% CI 1.17-2.68, P= 0.007]; the difference of the incidence of bleeding after puncture between the CT-guided group and the ultrasound-guided group was not statistically significant [2.99% (19/635) vs. 3.25% (17/523), RR= 1.08, 95% CI 0.59-1.98, P= 0.800]. Conclusions Both CT-guided and ultrasound-guided percutaneous lung puncture biopsy have good clinical diagnostic value. However, for the intrapulmonary masses shown by ultrasound, the ultrasound-guided lung puncture biopsy has a shorter operation time, lower cost, and higher safety. Key words: Biopsy; Punctures; Ultrasonogrophy; Computed tomography; Peripheral pulmonary masses; Meta-analysis

Transthoracic Echocardiography for Evaluation of an Intrapulmonary Artery Mass

Transthoracic Echocardiography for Evaluation of an Intrapulmonary Artery Mass

Osteoclast-like giant cell–rich carcinomas of the lung: a clinicopathological, immunohistochemical, and molecular study of 3 cases

Three cases of primary carcinomas of the lung each with an extensive osteoclast-like giant cell component are presented. The patients are 3 men between the ages of 58 and 67 years (average, 62.5 years) who presented with nonspecific symptoms. A history of malignancy, infectious, or granulomatous disease was negative in all the patients. Diagnostic imaging disclosed the presence of a large intrapulmonary mass; in 1 case in the right upper lobe and in 2 cases in the right lower lobe. Surgical resection via lobectomy was performed in the 3 patients. Grossly, the tumors were described as soft, friable intrapulmonary masses, reddish in color, and measuring from 6 to 13 cm in largest diameter. Histologically, the tumors were each characterized by the extensive presence of a multinucleated osteoclast-like giant cell component, which represented approximately 80% of the tumor mass. The osteoclast-like giant cell component was admixed with a sarcomatoid carcinoma in 2 cases and an adenocarcinoma in 1 case. Immunohistochemistry showed that the osteoclast-like giant cells were positive for CD-68, cathepsin K, and histone H3, whereas the carcinoma component was positive for keratin, thyroid transcription factor-1, and histone H3 (patchy). Molecular studies were performed in 2 patients with negative results. Clinical follow-up was obtained in 2 patients; 1 died 14 months after initial diagnosis, whereas 1 remains alive 6 months after initial diagnosis. One patient was lost to follow-up. The current neoplasms represent an unusual type of lung carcinoma that needs highlighting as a separate type from conventional giant cell carcinoma.

AN INTRAPULMONARY MASS: A RARE PRESENTATION OF CASTLEMAN DISEASE

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Castleman disease (CD) is a lymphoproliferative disease clinically classified as unicentric or multicentric. Histologically, CD has two variants: hyaline vascular and plasma cell type. Unicentric CD (UCD) is commonly found in the mediastinum and is usually of the hyaline vascular subtype. CD presenting as an intrapulmonary mass is very rare with only a few reported cases. We present a patient with intrapulmonary Castleman disease (IPCD). CASE PRESENTATION: 31 year old male, non-smoker, with no past medical history who presented with pleuritic chest pain. Chest radiograph revealed a 7.7 cm right infrahilar mass. CT of the chest revealed a 5.6x4.2x3.3 right infrahilar partially calcified mass complicated by a right lower lung collapse and nodular opacities (see image 1 and 2). Infectious workup and tumor makers HCG/AFP/LD were negative. Subsequent PET/CT showed low to moderate FDG avidity. He underwent two separate bronchoscopies with transbronchial biopsies of the right middle lobe bronchus that were both non diagnostic. He then underwent CT guided biopsy that displayed lymphoid infiltrate, but was non diagnostic for lymphoid malignancy. Lastly, he underwent right thoracotomy with right middle and lower lobe resection. Pathology of the lung parenchyma was consistent with the hyaline vascular variant of CD. DISCUSSION: UCD is a rare disease that most commonly occurs in the thorax with nodal proliferation into any lymphatic tissue including: the hila, axillae, pleural space, chest wall and extrapleural soft tissues. IPCD is even rarer, with only a few reported cases in the literature. Histologically both IPCD and UCD are of the hyaline vascular variant. Further characterization of our patient's pathology also reveals large caliber airways, blood vessels, glandular tissue and cartilage, which suggests that the process originated in the peribronchial or peribronchiolar lymphoid tissue. While the pathogenesis of the disease has yet to be fully elucidated, the hyaline variant is generally less aggressive. The treatment of choice is surgical resection, which is usually curative. CONCLUSIONS: CD remains a diagnostic challenge as clinical presentation is variable, radiographic findings are nonspecific and an adequate sample for biopsy may be difficult to obtain. Surgical resection is typically both diagnostic and therapeutic. Given this complexity, it is essential to include CD in the differential for intrapulmonary masses. Reference #1: Kligerman S, Auerbach A et al. Castleman Disease of the Thorax: Clinical, Radiologic, and Pathologic Correlation: RadioGraphics. 2016;36(5):1309-1332. Reference #2: Liu Y, Chen G, Qiu X, et al. Intrapulmonary unicentric Castleman disease mimicking peripheral pulmonary malignancy. Thoracic Cancer. 2014;5(6):576-580. DISCLOSURES: No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Maralee Kanin, source=Web Response

Diagnostic yield of CT thorax angiography in patients suspected of pulmonary embolism: independent predictors and protocol adherence

ObjectivesTo determine the diagnostic yield of computed tomography scanning of the pulmonary arteries (CTPA) in our centre and factors associated with it. Differences between specialties as well as adherence to protocol were investigated.MethodsAll patients receiving a first CTPA for pulmonary embolism (PE) in 2010 were included. Data about relevant clinical information and the requesting specialty were retrospectively obtained. Differences in diagnostic yield were tested using a chi-squared test. Independent predictors were identified with multivariate logistic regression.ResultsPE on CTPA was found in 224 of the 974 patients (23 %). Between specialties, diagnostic yield varied from 19.5 to 23.9 % (p = 0.20). Independent predictors of diagnostic yield were: age, sex, D-dimer, cough, dyspnea, cardiac history, chronic obstructive pulmonary disease (COPD), atelectasis/consolidation, intrapulmonary mass and/or interstitial pulmonary disease on CT. Wells scores were poorly documented (n = 127, 13.0 %). Poor adherence to protocol was also shown by a high amount of unnecessary D-dimer values with a high Wells-score (35 of 58; 58.6 %).ConclusionsThe diagnostic yield of CTPA in this study was relatively high in comparison with other studies (6.7–31 %). Better adherence to protocol might improve the diagnostic yield further. A prospective study could confirm the independent predictors found in this study.Teaching Points • Pulmonary embolism is potentially life-threatening and requires quick and reliable diagnosis. • Computed tomography of the pulmonary arteries (CTPA) provides this reliable diagnosis. • Several independent predictors of diagnostic yield of CTPA for pulmonary embolism were identified. • Diagnostic yield of CTPA did not differ between requesting specialties in our Hospital. • Better protocol adherence could improve the diagnostic yield of CTPA for pulmonary embolism.

Application of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Management of Mediastinal and Hilar Lymphadenopathy Without Intrapulmonary Mass: Experience from the Largest Cancer Center of Southern China

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is useful for lung cancer diagnosis and lymph node staging. The purpose of this study was to investigate EBUS-TBNA for managing mediastinal and hilar lymphadenopathies without intrapulmonary masses. We retrospectively reviewed our EBUS-TBNA database that was obtained between August 2010 and October 2012. Mediastinal and hilar lymphadenopathies of unknown origin and in the absence of known pulmonary malignancies were included. Final diagnoses were determined by EBUS-TBNA, surgery, and/or clinical follow-up for at least 6 months. Sensitivity, specificity, accuracy, and positive and negative predictive values were determined using standard statistical methods. We identified 128 patients with mediastinal and hilar lymphadenopathies and without intrapulmonary masses. EBUS-TBNA was successfully performed to obtain samples from 161 lymph nodes and mediastinal masses. EBUS-TBNA was diagnostic for 119 of 128 patients (93.0%) for all disease categories. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of EBUS-TBNA were 89.8, 100, 100, 81.6, and 93.0%, respectively. The procedures were uneventful and there were no severe complications. EBUS-TBNA is a safe, minimally invasive approach for diagnosing mediastinal and hilar lymphadenopathies without intrapulmonary masses. It obviates the need for more invasive procedures for tissue sampling of the mediastinum and hilum.

Treatment of pulmonary epithelioid hemangioendothelioma with combination chemotherapy: Report of three cases and review of the literature

No standard therapy for pulmonary epithelioid hemangioendothelioma (PEH) has yet been established due to the rarity of the disease, the lack of clear standards for treatment and the partial-to-complete spontaneous regression. This report describes three cases of PHE manifested as bilateral intrapulmonary masses with an initial diagnosis conducted by thoracoscopic lung biopsy. These patients demonstrated a partial response to combination chemotherapy with carboplatin, paclitaxel, bevacizumab or endostar, and an improvement in clinical status. Furthermore, we reviewed the literature regarding such patients who received chemotherapy and immunotherapy; this indicated that patients with PEH demonstrated a good partial response to chemotherapy with carboplatin, paclitaxel, bevacizumab, thalidomide and α-interferon. Overall, combination chemotherapy regimens may hold therapeutic potential for the treatment of this rare disease.

Endobronchial Ultrasound-guided Biopsy of an Intrapulmonary Arterial Mass

We report a case of endobronchial ultrasound (EBUS)-guided biopsy of an intrapulmonary arterial lung mass. The patient was referred to our center after unsuccessful attempts to get the diagnosis using bronchoscopic-guided (including EBUS) and computed tomography-guided approaches at the referring institution. We attempted to cannulate the upper lobe bronchus with the EBUS scope, but the sharp angle and narrow orifice would not permit the scope to view the mass or surrounding anatomy. We proceeded with biopsy of the mass by traversing the left main pulmonary arterial free wall and obtained diagnostic tissue without complications. The patient was discharged from the procedure unit and followed up with her referring physician.

Febrile complications after endobronchial ultrasound-guided transbronchial needle aspiration for intra-pulmonary mass lesions of lung cancer—a series of 3 cases

Recent case reports have shown that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal lesions is sometimes accompanied by severe infectious complications. Here, we report 3 cases with refractory febrile complications following EBUS-TBNA for intra-pulmonary large mass lesion of lung cancer (squamous cell carcinoma, n=2; adenocarcinoma, n=1). After the EBUS-TBNA, all cases showed prolonged fever and systemic inflammation despite receiving a sufficient dose of broad-spectrum antibiotics. The presence of a low-density area inside the masses upon CT examination, suggesting necrosis, may be a predictive sign of febrile complications associated with EBUS-TBNA.

Primary parosteal osteosarcoma of the rib

Osteosarcoma is a common primary malignant tumour of bones that produces an osteoid matrix. Parosteal osteosarcoma is an uncommon neoplasm and principally affects the long bones, especially in the distal femur, proximal tibia and proximal humerus. Rarely, the tumour may arise in a flat bone, and rib involvement is very infrequent. An unusual case of primary parosteal osteosarcoma of the rib in an asymptomatic 28-year old female is presented here. A chest X-ray film suggested an intrapulmonary homogeneous mass, while a computed tomography scan revealed a broad-based calcified mass attached to the inner cortex of the right fourth anterior rib. The patient underwent a wide excision of the tumour together with adjacent intercostal muscles and chest wall reconstruction. Postoperative histopathological outcome was consistent with primary parosteal osteosarcoma.

A rare case of massive papillary fibroelastoma of the right ventricular free wall

A 51-year-old previously healthy woman was referred to our institution with atypical chest pain. Physical examination and laboratory findings were normal. The electrocardiogram demonstrated sinus rhythm of 70 beats/min with a right bundle branch block. Routine chest X-ray showed calcifications projecting on the heart. Transthoracic echocardiography was hampered by a limited acoustic window. Cardiovascular magnetic resonance revealed a well-demarcated mass in the right ventricle in conjunction with the right ventricular free wall (Fig. 1). Dimensions were 9.5 × 4.5 × 4.5 cm. Computed tomography of the thorax demonstrated a densely calcified mass located in the right ventricle but showed no evidence of pulmonary embolism or intrapulmonary masses (Fig. 2a and b). Finally, transvenous biopsy of the tumour led to the histological diagnosis of papillary fibroelastoma (Fig. 2d). To our knowledge, this is the first well-documented case of a large calcified papillary fibroelastoma of the right ventricular free wall [1, 2]. Fig. 1 Cardiovascular magnetic resonance (CMR) demonstrates a large mass in the right ventricle in conjunction with the right ventricular free wall. On cine-imaging, the mass exhibited a somewhat lower signal than the left ventricular myocardium (a and b). T1 ... Fig 2 Axial (a) and (b) coronal CT image show a large and heavily calcified mass at the right ventricular free wall. Coronary angiography (c) shows a large non vascularised calcified mass. Histological examination (d) in haematoxylin and eosin stain reveals ...

Role of EBUS-TBNA in the diagnosis of bronchogenic carcinoma.

e17534 Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a technique of minimally invasive endoscopic staging and of great interest for the identification and staging of mediastinal and hilar lymph nodes in patients with suspected and/or known bronchopulmonary neoplasm. This study was to evaluate diagnostic yield and the safety of EBUS-TBNA in the diagnosis of bronchogenic carcinoma. Methods: Between July, 2009 and Feb, 2010, 95 patients with mediastinal / hilar lymphadenopathy and /or intrathoracic peritracheal or peribronchial masses previously detected with CT scan underwent EBUS-TBNA. No rapid onsite cytology was performed. Results: In all 95 patients, 60 cases of patients were newly diagnosed lung cancer through the pathological examination and clinical follow-up certification. In 60 lung cancer cases, 112 samples were obtained from lymph nodes (LNs) and 11 samples were obtained from intrapulmonary lesions. 58 cases of patients were diagnosed in 60 lung cancer cases, false negative in 2 cases. Sensitivity and specificity of EBUS-guided TBNA method in distinguishing benign from malignant LNs or thoracic masses was 96.67% and 100%, respectively. In absence of any major complication, the procedure was uneventful. Conclusions: EBUS-TBNA seemed a safe and effective technique in making bronchogenic carcinoma diagnosis for mediastinal/hilar LNs and intrapulmonary masses.

Role of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of bronchogenic carcinoma

背景与目的本研究旨在评价超声支气管镜引导下的经支气管针吸活检（endobronchial ultrasoundguided transbronchial needle aspiration, EBUS-TBNA）对肺癌的诊断价值和安全性。方法于2009年7月-2010年2月，对95例胸部CT检查显示纵隔/肺门淋巴结肿大和/或胸内气管或支气管旁肿块患者进行EBUS-TBNA，并未采取现场细胞学方法进行检测。结果95例患者中，其中经病理学检查和临床随访验证新发肺癌患者60例。60例肺癌患者共穿刺112组淋巴结，肺内肿块11例。60例肺癌患者中通过EBUS-TBNA明确诊断58例，假阴性2例，敏感性为96.67%、特异性100%。EBUS-TBNA过程安全，全部病例无并发症发生。结论EBUS-TBNA是诊断肺癌安全、有效的方法。

Role of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of bronchogenic carcinoma: Experience of a single institution in China.

To evaluate diagnostic yield and the safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal/hilar lymph nodes and intrapulmonary masses. Between July 2009 and February 2010, 95 patients with mediastinal/hilar lymphadenopathy and/or intrathoracic peritracheal or peribronchial masses detected with computed tomography underwent EBUS-TBNA. One hundred and twelve samples were obtained from lymph nodes (LNs) and 11 samples were obtained from intrapulmonary lesions. All patients had cytological evaluation by smears and/or tissue evaluation of aspiration specimens. Out of the 95 patients, 60 had lung cancer, 58 of these patients were diagnosed using EBUS-TBNA without onsite cytology assistance, false negative in 2 cases. Sensitivity the of convex probe EBUS-TBNA method in distinguishing benign from malignant lymph nodes or thoracic mass was 96.67%. In the absence of any major complications the procedure was uneventful. EBUS-TBNA seems a safe and effective technique in the diagnosis making bronchogenic carcinoma for mediastinal/hilar lymph nodes (LNs) and intrapulmonary masses.

Castleman’s disease arising from an intrapulmonary lymph node

A 23-year-old woman was admitted to our hospital because of an intrapulmonary mass that had been observed for 7 years. Chest computed tomography revealed a 3.5-cm well-defined mass with enhancement in the left lower lobe. During the 7 years of observation, she had been asymptomatic and the tumor size was unchanged. She underwent surgical resection for diagnosis and treatment. Histological examination revealed Castleman's disease of the hyaline vascular type. We present this rare case of solitary Castleman's disease arising from an intrapulmonary lymph node.

Large mixed germ cell tumor in a young patient presenting as an intrapulmonary mass

We present the case of a 26-year-old man with a bland medical history, who presented to the general practitioner because of severe cough and dyspnea. The chest X-ray revealed a massive organ-displacing tumor in the right chest not delineable from the mediastinum. The subsequent needle core biopsy was diagnostic for a mixed germ cell tumor comprising immature teratoma and seminoma. After an initially good response to chemotherapy, tumor markers and tumor size were progressive. The right-sided pneumonectomy revealed an intrapulmonary tumor with cystic and solid components, hemorrhage, and necrosis with a tumor diameter of 18 cm. Histology confirmed a teratoma with mature and immature components accompanied by residual seminomatous tumor cells. Despite maximal intensive care, the patient died four weeks after surgery from acute respiratory distress syndrome. We describe this exceptional large intrapulmonary germ cell tumor and discuss the spectrum of such rare tumors.