Left Lung Mass Research Articles

Emergency department diagnosis of critical aortic stenosis using bedside ultrasonography

Abstract Introduction An 88-year-old woman with a history of coronary artery disease, hypertension, and a history of a large left upper lobe lung mass presented to the Emergency Department (ED) from a nursing home with rapidly progressive shortness of breath and chest pain over 1 day with a rapid decline in mental status. Bedside color Doppler ultrasound para-sternal long-axis examination of the heart revealed severe aortic stenosis. Bedside pulsed-wave and continuous-wave Doppler ultrasound in the apical 5-chamber view revealed critical aortic stenosis using the simplified continuity equation. Conclusion Bedside ED cardiac color Doppler, pulsed Doppler evaluation of the left ventricular outflow tract, and continuous-wave Doppler of the aortic valve were used to assist in the diagnosis of critical aortic stenosis.

Ectopic growth hormone-releasing hormone secretion by a bronchial carcinoid tumor: clinical experience following tumor resection and long-acting octreotide therapy

Acromegaly resulting from the ectopic secretion of growth hormone-releasing hormone (GHRH) is rare. We present a case of acromegaly secondary to proven GHRH-secretion by a bronchial carcinoid tumor in a type 1 diabetic subject and document the clinical course pre- and post-resection of the tumor and of subsequent octreotide therapy. A 54-year-old Caucasian man was referred for evaluation of acromegalic symptoms and significantly increased insulin requirements. He had a history of left lung surgery 20 years prior for hemoptysis. Initial laboratory results indicated acromegaly. Fasting serum growth hormone (GH): 26.1 ng/mL (0-5 ng/mL), insulin-like growth factor 1 (IGF-1): 635 ng/mL (87-283 ng/mL), GH at 60 min post-ingestion of 75 grams of oral glucose during a glucose tolerance test: 8.3 ng/mL (normal <1 ng/mL). Pituitary magnetic resonance imaging (MRI) revealed diffuse pituitary enlargement without adenoma. A 4.4 cm left hilar mass was noted on chest computed tomography (CT) scan. Further evaluation for a suspected GHRH-secreting neuroendocrine tumor was pursued. Plasma GHRH level was elevated: 198 pg/mL (<50 pg/mL). Octreoscan showed radiolabelled-octreotide uptake in the left lung mass and pituitary gland. Surgical resection of the lung mass was performed. Immunohistochemical study of the tumor tissue indicated a neuroendocrine tumor secreting GHRH. Postoperatively, serum GHRH, GH and IGF-1 levels fell precipitously. At 10 months, IGF-1 levels were mildly elevated and 7 months of 10 mg long-acting octreotide therapy (Sandostatin(®) LAR(®)) was trialed. At 20 months, off octreotide, serum IGF-1 levels had normalized, acromegalic features were receding, and the patient's daily insulin requirements had decreased by 57%.

アメーバ性肺膿瘍の2 例

CASE 1: A 74-year-old man having a week's fever and diagnosed with a liver abscess was treated with several antibiotics and percutaneous liver drainage. His respiration gradually worsened and chest computed tomography (CT) showed right pleural effusion and a left-lung mass. Percutaneous fine needle aspiration of the pulmonary mass detected Entamoeba histolytica. CASE 2: A 44-year old, zoo office worker admitted for fever and right chest pain was found in CT to have right pleural effusion and a mass with a liver abscess necessitating abscess drainage. Injected contrast medium detected a fistula connected to the right. Following surgical drainage, E. histolytica was detected from the resected lung. Both cases responded well to metronidazole.

Hypertrophic Pulmonary Osteoarthropathy Diagnosed by FDG PET-CT in a Patient With Lung Adenocarcinoma

A 52-year-old man had a positron emission tomography computed tomography (PET-CT) scan for staging of a biopsy proven lung adenocarcinoma. An additional acquisition of the lower extremities was performed as the patient complained of bilateral leg pain. The PET-CT scan showed a 6.5 x 5.0 cm left upper lobe lung mass invading the mediastinum with maximal standardized uptake value of 10.7, compatible with primary lung cancer. The CT portion of the PET-CT of the legs showed extensive irregular bilateral periosteal new bone formation in the long bones. The PET images showed diffuse moderately increased FDG uptake in the periostea of the long bones of the legs, with some focal sites of more intense FDG uptake in the thicker portions of the periosteum. A bone scan showed mild hyperemia surrounding the long bones of the legs and intense Tc-99m MDP uptake in the periostea. The patient was diagnosed with hypertrophic pulmonary osteoarthropathy.

Lung Mass Appearing as a Dilated Left Ventricle on Tc-99m Tetrofosmin Myocardial Perfusion Scintigraphy

Tc-99m tetrofosmin is a common tracer used in myocardial perfusion scintigraphy. Several benign and malignant tumors also take up tetrofosmin. We present a case of a 60-year-old woman with a history of a left lung mass awaiting resection. The patient was referred for a myocardial perfusion scan for preoperative risk assessment. The myocardial perfusion scan revealed a large cavitated lesion mimicking a dilated left ventricle and the CT scan revealed a large mass in the left lung with central necrosis displacing the heart and mediastinum. The patient underwent thoracotomy with resection of the mass and the histology confirmed atypical carcinoid. This case highlights noncardiac uptake of Tc-99m tetrofosmin in an atypical carcinoid.

Myocardial Metastasis or Benign Brown Fat?

Noninvasive positron emission tomography (PET) imaging of cell glucose metabolism has become an essential tool for assessing tissue viability in cardiac (hibernating myocardium) and malignant disease (tumor regression or recurrence). However, PET studies alone provide information regarding tissue and organ metabolism but may not provide enough spatial resolution for accurate assessment of critical structural changes that are the cause or consequence of metabolic perturbations. The following case illustrates the pitfalls of relying on a single cardiac imaging modality and demonstrates how integration of metabolic data from PET with structural data from echocardiography, computed tomography (CT), or MRI studies can be used to correctly identify and manage a diagnostic dilemma. A 63-year-old woman with a medical history of chronic obstructive pulmonary disease and tobacco use was diagnosed with a left lung mass on a chest x-ray examination. A combined CT/fluorodeoxyglucose (FDG)-PET scan at another institution revealed the left lung mass (Figure 1) as well as a cardiac mass with increased uptake of radiotracer concerning for a cardiac metastasis (Figure 2). The CT Hounsfield unit (HU) density in the cardiac mass was −57 HU. She was referred for transesophageal echocardiography to further assess the cardiac mass (Figure 3). She had marked thickening of the interatrial septum with sparing of the fossa ovalis. A cardiac MRI (Figure …

Simultaneous FDG PET+/Glut1+ lung and FDG PET−/Glut1− subcarinal lymph node metastases from prostate cancer

A 78-year-old man with a history of prostate cancer and a rise in PSA presented with a new left lung mass, detected on computed tomography (CT). Positron emission tomography (PET)-CT (PET-CT) scan with 18-F fluorodeoxyglucose glucose revealed intense uptake in the lung mass without any other areas of abnormal uptake. Surgical resection of the mass and mediastinal lymph node dissection revealed metastatic adenocarcinoma from prostate cancer in the left lung mass (tumor size 5 cm) as well as in a subcarinal lymph node (tumor size 1.9 cm), which were identical on hematoxylin and eosin stains with a Gleason score of 8. The size of the subcarinal lymph node metastasis could not explain its non-visualization on PET. Glut1 stains of the lung mass were positive with moderate (2+ out of maximum 3+) reactivity in 95% of the carcinoma cells, whereas Glut1 stains of the subcarinal lymph node were negative with faint (1+ out of maximum 3+) reactivity in ca. 30% of the carcinoma cells. The low Glut1 expression in the subcarinal lymph node is the most likely explanation for its non-visualization on PET.

Lung Sequestration and Pott Disease Masquerading as Primary Lung Cancer With Bone Metastases on FDG PET/CT

The chest x-ray from a 37-year-old man with a history of back pain showed a mass in the left lower lung, which prompted an FDG PET/CT study to evaluate the nature of the mass and possible metastases. The images revealed peripherally increased FDG activity in the left lower lung mass. In addition, there was intense FDG activity in 2 adjacent thoracic vertebrae on PET images corresponding to the regions of bone destruction on the concurrent CT. Therefore, a possible diagnosis of lung carcinoma with bone metastases was suggested. However, subsequent tests demonstrated that the left lung mass was in fact a lung sequestration, whereas the spinal lesions were due to Pott disease (tuberculous spondylitis).

Lung Parasite Ova Granuloma Mimicking Lung Malignancy on FDG PET-CT

A 60-year-old lady with mild fever, blood tinged sputum, and a left upper lung mass had whole body F-18 2-deoxy-D-glucose (FDG) positron emission tomography (PET)-computer tomography (CT) for cancer staging. The PET-CT imaging revealed FDG accumulation in the left upper lung lesion. The histopathology of the left upper lobe lung resection showed a parasite tunnel with necrosis, parasite ova, and foreign body giant cells. After surgery, eosinophiles in the peripheral blood dropped from 20% of white cell counts before operation to 5.5% at 7 weeks postoperation.

A large saphenous vein graft aneurysm one year after coronary artery bypass graft surgery presenting as a left lung mass

Aneurysm of a saphenous vein graft (SVG) is a rare but fatal complication of coronary artery bypass graft (CABG) surgery. The development of SVG aneurysms appears usually about 10-20 years after the operation at an estimated rate of <1%. A 68-year-old male was referred to the emergency department after frequent episodes of dyspnea, chest pain and hemoptysis. He previously had CABG surgery one year before. The physical examination was normal. Chest radiogram showed a left pulmonary midzone mass. CT-angiogram demonstrated a large aortic pseudoaneurysm (6.36 x 6.06 cm) in the middle part of the ascending aorta. After sternotomy, the ascending aorta above sinotubular junction near the origin of brachiocephalic artery was resected and replaced with a tube graft. The patient was transferred to ICU with stable hemodynamic status. SVG aneurysm should be considered while encountering mediastinal mass or undiagnosed cardiopulmonary symptoms in patients with a previous history of CABG because of its rarity and overlap of symptoms with other thoracic, pulmonary, and cardiac diseases. Surgery seems to be the treatment of choice to reduce the risk of rupture and embolism.

Abundant cartilage formation of congenital pulmonary airway malformation – A case report

Congenital pulmonary airway malformation (CPAM) of the lung is an uncommon developmental anomaly. We report an unusual case of type 1 CPAM with abundant cartilage in a 5-year-old boy. On chest radiography, a left lung mass was detected incidentally, and tumor resection was performed under the impression of a benign tumor. The pathological examination of the mass revealed abundant cartilage in the walls of malformed bronchioles with partially cystic dilatation. We think that this case represents a cartilaginous variant of CPAM. The cartilaginous variant of CPAM should be differentiated pathologically from other pulmonary neoplasms containing abundant cartilage, such as chondroid hamartoma.

Adrenocortical oncocytic carcinoma with recurrent metastases: a case report and review of the literature

BackgroundAdrenal cortex oncocytic carcinoma (AOC) represents an exceptional pathological entity, since only 22 cases have been documented in the literature so far.Case presentationOur case concerns a 54-year-old man with past medical history of right adrenal excision with partial hepatectomy, due to an adrenocortical carcinoma. The patient was admitted in our hospital to undergo surgical resection of a left lung mass newly detected on chest Computed Tomography scan. The histological and immunohistochemical study revealed a metastatic AOC. Although the patient was given mitotane orally in adjuvant basis, he experienced relapse with multiple metastases in the thorax twice in the next year and was treated with consecutive resections. Two and a half years later, a right hip joint metastasis was found and concurrent chemoradiation was given. Finally, approximately five years post disease onset, the patient died due to massive metastatic disease. A thorough review of AOC and particularly all diagnostic difficulties are extensively stated.ConclusionHistological classification of adrenocortical oncocytic tumours has been so far a matter of debate. There is no officially established histological scoring system regarding these rare neoplasms and therefore many diagnostic difficulties occur for pathologists.

Lung Images: Primary Pulmonary Hemangiopericytoma

A 43-year-old woman presented with cough and a 6.5 9 5cm homogeneous left lung mass on a chest roentgenogram (Fig. 1). Computed tomography of the thorax revealed a 5.5 9 5.5-cm heterogeneous mass located between the upper and lower lobe bronchi of the left lung (Fig. 2). We performed thoracotomy and a 8 9 4-cm mass between the upper and lower lobes of left lung was detected. The mass was solid and noncystic. A diagnosis of hamartoma was made by frozen section. It was removed with its capsule. Severe bleeding occurred during resection. Ligation of the bleeding artery branch stopped the bleeding. She has remained asymptomatic during the 15 months of followup. On histopathologic examination, the tumor was macroscopically defined as grey-white tissue with a lobulated surface, 6.5 9 5.5 9 4.5 cm in size. Microscopically, in the stroma between the veins there was spindle cell proliferation that did not show distinctive cytologic atypicality. These spindle cells were positively stained with CD34 and C-KIT. The vein structures were CD31-positive. Vein walls were stained with actin upon which characteristic vascular structures with stag horn configuration diagnosed the mass as primary pulmonary hemangiopericytoma (Fig. 3). Hemangiopericytoma is a rare form of sarcoma that originates from the pericytes that surround the capillary membrane [1]. The age range is wide and there is an equal distribution among males and females. The symptoms are usually cough, hemoptysis, and chest pain. The preoperative diagnosis is difficult because of the lack of specific clinical symptoms and radiologic findings. However, paraneoplastic syndromes such as osteoarthropathy and hypoglycemia may appear in relation to primary pulmonary hemangiopericytoma. During surgery a frozen section will be useful in determining the existence of malignancy. The histologic findings consist of multiple mesenchymal tumors, including hemangiopericytoma. Hemangiopericytoma is surrounded by capsules or pseudocapsules and radiologic investigation of the mass reveals clear-cut borders. Also, immunohistochemical studies can be helpful for the accurate diagnosis. Malignancy is usually manifested as

Palpable lung cancer: Unusual manifestation of Lung Cancer

A 37 year old gentleman who had noted an anterior chest wall mass which had gradually increased over the past year. He had some discomfort at the site but no complaints of shortness of breath, cough, hemoptysis or wheeze. He had a weight loss of 20 lbs over the past year. He was a smoker. The mass was palpable on physical examination as a hard indurated structure fixed to skin and underlying muscle. There was no palpable axillary lymphadenopathy. The rest of his exam was normal. A diagnosis of non small cell lung cancer (NSCLC) had been made 6 months earlier by transthoracic needle biopsy. The pathology was consistent with poorly differentiated carcinoma. He was treated with local radiation therapy and dual agent chemotherapy including paclitaxel and carboplatin. Unfortunately his tumour did not respond to any of these treatments. Below is a non contrast chest computed tomography scan image (Figure 1). The image shows obvious erosion of the NSCLC through the anterior chest wall into the subcutaneous tissue mimicking actinomycosis. Figure 1 Figure 1: Noncontrast CT scan of chest showing an infiltrative left lung mass with erosion through the anterior chest wall into the subcutaneous tissue. CORRESPONDENCE TO Bobbak Vahid, MD 700 Fredrick Street Suite 203 Santa Cruz, CA 95062 Tel: 831 4251908 Email: bobbak_vahid@yahoo.com References Palpable lung cancer: Unusual manifestation of Lung Cancer 2 of 2 Author Information Tuhina Raman, MD Department of pulmonary and critical care medicine, Thomas Jefferson University Hospital Bobbak Vahid, MD Department of pulmonary and critical care medicine, Thomas Jefferson University Hospital

Large Natural Killer Cell Lymphoma Arising From an Indolent Natural Killer Cell Large Granular Lymphocyte Proliferation

Natural killer cell large granular lymphocyte proliferation is a relatively rare disorder that typically runs a chronic, indolent course. We present a patient with a 3 1/2-year history of natural killer cell large granular lymphocyte proliferation terminating in large cell lymphoma with natural killer cell features. The diagnosis of natural killer cell large granular lymphocyte proliferation was based on flow cytometric demonstration of an expanded population of CD3- CD16+/CD56+ lymphocytes in the peripheral blood. The patient experienced various rheumatologic symptoms, but was hematologically stable for 3 1/2 years. He then developed fevers, night sweats, weight loss, and a left lower lobe lung mass. Resection of the mass showed a large cell lymphoma with immunohistochemical positivity for CD2, CD7, CD56, and T-cell intracellular antigen-1, compatible with natural killer cell origin. In situ hybridization for Epstein-Barr virus and polymerase chain reaction analysis for T-cell receptor gene rearrangement were negative. To our knowledge, this is the second documented report of chronic natural killer cell large granular lymphocyte proliferation terminating in an aggressive large natural killer cell lymphoma.

Synchronous multiple primary lung cancers with different response to gefitinib

Synchronous bronchiolo-alveolar cell carcinoma (BAC) in both lungs and squamous cell carcinoma in left lung were found in a 66-year-old male smoker. After two courses of chemotherapy with gemcitabine and carboplatin, the left lung mass had partially resolved, however, the extent of BAC had been increased. When gefitinib was used as a second-line chemotherapy, the consolidation lesions of BAC was improved while the mass of squamous cell carcinoma was aggravated. The analysis of epidermal growth factor receptor-tyrosine kinase (EGFR-TK) mutations showed that BAC had the deletion, delE746-A750 in exon 19, however, squamous cell carcinoma had no mutations. These synchronous tumors with different location, histology, status of EGFR-TK mutations and response to chemotherapy might be caused by different molecular pathogenesis.

Massive Adrenal Metastasis

A 66-year-old female former smoker of 40 pack/years presented with a cough accompanied by fever. Chest radiographs demonstrated a left lung mass. Computerized tomography of the chest and abdomen (Figure 1A) demonstrated a cavitated left lower lobe mass measuring 5.5 cm as well as bilateral adrenal masses each 5 cm in size (Figure 1B). Percutaneous needle biopsy of the right adrenal mass was positive for metastatic large-cell carcinoma of the lung. Serum cortisol level was normal. The patient was then referred to medical oncology and began treatment with carboplatin and taxol. Approximately 5 to 10% of patients have evidence of adrenal lesion(s) at the time of lung cancer presentation.1 In most cases, one adrenal lesion is found, but occasionally two or more are also evident. Other etiologies besides metastatic disease include adrenal adenomas, cystic changes, or adrenal hyperplasia. Previous population studies have shown that the overall incidence of benign adrenal lesions varies from 2 to 9%.2 Massive adrenal lesions are uncommon but have been reported. At the time of death, autopsy studies have shown that 25 to 40% of patients with lung cancer have findings of adrenal metastasis.

Rupture of aorta arch aneurysm into the lung with formation of pseudoaneurysm

To improve the early diagnosis and avoid preoperative misdiagnosis, we discuss some of the diagnostic problems related to thoracic saccular aneurysm rupture into the lung. A case report is presented. We report on a patient with rupture of aorta arch aneurysm into the lung with formation of pseudoaneurysm accompanied with left upper lobe atelectasis, who simultaneously underwent a left upper lobectomy, aneurysmectomy and aorta arch neoplasty. The few cases described in the literature are reviewed to discuss the difficulties of differential diagnosis of left lung mass. The diagnosis methods and operation treatment of the aorta aneurysm are discussed. Angiography and CT are effective diagnostic methods of aorta aneurysm. These data suggest that it is an effective method of aneurysmectomy with/without left pneumonectomy or lobectomy to treat aneurysm of thoracic aorta.

Percutaneous Lung Biopsy in a Patient with a Cavitating Lung Mass: Indications, Technique, and Complications

2Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, MA. Case History A 75-year-old man was admitted to the hospital with an acute myocardial infarction. The patient was a former heavy smoker. A chest radiograph revealed a left apical lung mass (Fig. 1). A CT scan showed a cavitary left upper lobe lung mass measuring 3.5 × 4 cm (Fig. 2A) with an additional 3 × 2 cm mass at the left hilum (Fig. 2B). A wholebody PET scan showed the left upper lobe mass and at the left hilum, increased 18F-FDG uptake that was suggestive of lung neoplasm metastatic to the left hilum (Fig. 3). Therefore, a thoracic radiologist was consulted for biopsy of the left upper lobe lung mass. Dr. Titton. It is interesting to note that a PET scan was obtained for this patient. What is the role of 18F-FDG PET in the evaluation of patients with a pulmonary nodule or lung cancer? Dr. Kalra. In the evaluation of patients with a solitary pulmonary nodule, 18F-FDG PET improves characterization of the nodule by estimating the probability of malignancy. The high positive predictive value for malignancy in nodules greater than 1 cm in diameter suggests that those with positive scan results should undergo either percutaneous biopsy or surgical resection. Histologic examination of PET-positive lesions is necessary because false-positive PET findings can be encountered with granulomatous lesions secondary to sarcoidosis, tuberculosis, or infection [1]. False-negative PET findings are seen in patients with small lesions (< 1 cm) and in selected malignancies, such as bronchioalveolar cell carcinoma or well-differentiated adenocarcinoma or carcinoid tumor. For this reason, regardless of PET findings,

Difficult Ventilation with a Double-Lumen Endotracheal Tube: An Unusual Manufacturing Defect

We report an unexpected difficult ventilation with a double-lumen endotracheal tube in a patient receiving left upper lobe lung mass resection. The manufacturing defect in both limbs of the Opti-Port Right Angle Double Swivel Connector of the double-lumen tube resulted in this problem. This defect is difficult to localize by the usual recommended methods. We discuss a modified algorithm for difficult ventilation with a double-lumen endotracheal tube. Difficult ventilation occurred during general anesthesia as the result of a manufacturing defect in both limbs of the connector of the double-lumen endotracheal tube. The problem was resolved with a careful approach, and there were no serious consequences.