Mass In Lower Lobe Research Articles

Synchronous Primary Pulmonary Marginal Zone B-Cell Lymphoma and Large B-Cell Lymphoma

SESSION TYPE: Pleural Case Report Posters

Primary intrapulmonary thymoma associated with myasthenia gravis

Primary intrapulmonary thymomas are very rare. So far, research in the field has identified only 31 cases. In all databases, a total of two published articles describing primary intrapulmonary thymoma with myasthenia gravis were encountered between 1950 and 2010. We admitted a 58-year-old male patient with a mass in the right lower lobe of his lung. The tumor was excised, and histological findings were found to be consistent with Type AB thymoma. The patient was intubated due to respiratory distress during the postoperative period, and his acetylcholine receptor antibody was determined positive. He was diagnosed with myasthenia gravis. Pyridostigmine therapy and plasmapheresis were scheduled; yet, we could not begin therapy because of rapid deterioration of the patient's respiratory status due to myasthenia gravis and subsequently resulting in intubation-associated pneumonia. The patient's health rapidly worsened, and he died.

Primary pulmonary Ewing’s sarcoma: report of a case

The Ewing's sarcoma family of tumors has been reported to originate in a variety of sites, most commonly in the extremities. We herein describe a rare case of primary pulmonary Ewing's sarcoma in a patient with a family history of sarcoma. The patient was a 42-year-old male, who presented with hemoptysis. Chest radiographs revealed a pulmonary mass in the right lower lobe. Clinical and radiological examinations (computed tomography and positron emission tomography) revealed that the lesion was a primary lesion. The lesion was resected by right lower lobectomy. The tumor was located in the pulmonary parenchyma, and there was no evidence of an extrapulmonary involvement by the tumor. Histologically, the tumor was composed of uniform cells with round nuclei and scant cytoplasm which were arranged in cohesive lobules with rare pseudorosette formation. Immunohistochemically, the tumor cells were positive for CD99, and negative for epithelial markers, neuroendocrine markers, myogenic markers and lymphoma markers. This diagnosis was further supported by the cytogenic and reverse transcriptase-polymerase chain reaction findings of EWS/FLI-1 fusion transcripts. This demonstrated the presence of a very rare primary pulmonary Ewing's sarcoma. The patient was treated with chemotherapy after the operation because Ewing's sarcoma is an aggressive neoplasm. The patient has had no recurrent disease for 6 months after the operation.

Gallbladder metastasis of non-small cell lung cancer presenting as acute cholecystitis

Although non-small cell lung cancer (NSCLC) can metastasize to almost any organ, metastasis to the gallbladder with significant clinical manifestation is relatively rare. Here, we report a case of gallbladder metastasis of NSCLC presenting as acute cholecystitis. A 79-year-old man presented with pain in the right upper quadrant and fever. A computed tomography (CT) scan of the chest and abdomen showed a cavitary mass in the right lower lobe of the lung and irregular wall thickening of the gallbladder. Open cholecystectomy and needle biopsy of the lung mass were performed. Histological examination of the gallbladder revealed a moderately-differentiated squamous cell carcinoma displaying the same morphology as the lung mass assessed by needle biopsy. Subsequent immunohistochemical examination of the gallbladder and lung tissue showed that the tumor cells were positive for P63 but negative for cytokeratin 7, cytokeratin 20 and thyroid transcription factor-1. A second primary tumor of the gallbladder was excluded by immunohistochemical methods, and the final pathological diagnosis was gallbladder metastasis of NSCLC. Although the incidence is extremely rare, acute cholecystitis can occur in association with lung cancer metastasis to the gallbladder.

Syndrome of Inappropriate Antidiuretic Hormone Secretion in a Patient with Large Cell Neuroendocrine Carcinoma

The syndrome of inappropriate antidiuretic hormone secretion has only been reported in a few patients with large cell neuroendocrine carcinoma (LCNEC); however, it has never been reported in a patient with LCNEC of the lung, whose serum sodium levels were normalized after surgical resection of the mass. A 63-year-old male presented with a two-day history of dizziness and recent memory loss. On admission, his serum sodium level was 113 mEq/L with a serum osmolality of 236 mosm/kg, a urine osmolality of 441 mosm/kg, and a urine sodium level of 65 mEq/L. His chest computed tomography revealed a 2.7×2.3 cm-sized mass in the left lower lobe. After surgical removal of the mass, his serum sodium concentrations were normalized, and histopathology of the mass revealed LCNEC.

A Case of Multi-Organ Macronodular Tuberculosis

A 37 year old female presented with epigastric pain and weight loss over a period of 3 months. Her abdominal CT finding showed a 4.5 cm size hepatic mass and 4.3 cm size pancreatic head mass with multiple macronodules in the liver. At the same time, her chest CT revealed a 5 cm si ze necrotic mass in the left lower lobe of the lung with multiple bilateral pulmonary nodules. We diagnosed these lesions as tuberculosis through multiple biopsies. She was treated with anti-tuberculous medication. After taking the medications, her symptoms were improved. Twelve months later, imaging studies indicated an improvement in the patient's health. Here we report a case report of multi-organ macronodular tuberculosis in lung, liver and pancreas.

A Case of Primary Endobronchial Neurilemmoma Without Intraspinal Extension

Neurilemmoma is a benign and slowly growing neurogenic tumor. Intrathoracic neurilemmoma often develops in the chest wall and posterior mediastinum, but endobronchial neurilemmoma is extremely rare. The diagnosis of endobronchial neurilemmoma with preoperative imaging findings is challenging and is usually made via postoperative pathological examination. These authors encountered a case of primary endobronchial neurilemmoma in a 52year-old woman who had no symptoms. A 3.0 × 2.6 cm mass in the right lower lobe projecting into the mediobasal segmental bronchus was shown in the results of the contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the chest. Benign neurilemmoma was confirmed via bronchoscopic biopsy, and surgical resection (sleeve bronchial excision and end-to-end anastomosis) was performed.

2. A rare primary lung MPNST exhibiting peculiar ‘small cell’ features diagnosed through fna with tissue correlation

Background We report a case of primary intraparenchymal lung malignant peripheral nerve sheath tumour (MPNST) originally diagnosed through fine needle aspiration biopsy (FNAB) incidentally presenting with a peculiar feature in an adult female without NF-1. Aim To present, document and describe the cytomorphological features and tissue correlation of a case of primary lung MPNST with ‘small cell’ features. Case history The patient was an adult female with hemoptysis. CT scan revealed a left lower lobe mass. CT-guided FNAB was performed and MPNST was considered. One month later, she was eventually admitted for dyspnoea. She was subsequently scheduled for thoracotomy with frozen section. Wedge biopsy was done and submitted for histopathological examination. Results FNA cytology showed loose clusters atypical epithelioid cells and spindle cells as singles. The cellblock revealed interlacing fascicles of spindle cells with plump hyperchromatic nuclei and tapered cytoplasm. Some fragments showed epithelioid cells with rosette-like formation. Epithelioid and spindle cells were negative for cytokeratin, desmin and SMA. NSE was positive in >50% of the tumour cells. Frozen section diagnosis favoured small cell carcinoma. The mass appeared hypercellular in the preserved areas and was composed of epithelioid to spindle-shaped cells. Extensive areas of necrosis were noted. Mitotic count was high at 8–12 per 10 HPF. The lesional cells showed positivity against vimentin and weak focal positivity against S-100, while synatophysin, SMA, desmin and TTF-I all showed negative reactions. Conclusion We have documented and described a case of primary MPNST of the lung in an adult female without NF-1 with peculiar ‘small cell’ features. With careful attention to the cytomorpholo-gical details of MPNST, it could be confidently considered through FNA with the aid of immunohistochemistry.

Case 31-2011

A 55-year-old man was seen at this hospital because of headaches, weakness of the left side of the body, and a mass in the brain. Chest CT showed a mass in the right lower lobe of the lung; biopsy revealed adenocarcinoma. Additional diagnostic testing was performed.

Video-assisted thoracic resection for intralobar pulmonary sequestration

We present a case in which video-assisted thoracic resection for intralobar pulmonary sequestration (ILPS) was successfully performed. A 36-year-old woman had repeated pneumonia. Chest computed tomography (CT) showed a round mass in the right lower lobe of the lung. Subsequent three-dimensional CT revealed that a large anomalous artery arising from the descending thoracic aorta was distributing to the posterior basal segment containing the lesion and was draining into the inferior pulmonary vein. The patient was diagnosed with ILPS and underwent surgery. The anomalous artery was divided, and the sequestered segment was completely resected by video-assisted thoracic surgery (VATS). We think that VATS resection for ILPS is feasible and is a major therapeutic option as noninvasive surgery.

Pulmonary malakoplakia: a rare presentation mimicking extensive stage IV lung cancer

To the Editors: Herein, we report a 74-yr-old female who presented with several weeks history of persistent cough productive of mucoid phlegm with specks of haemoptysis. This was associated with fatigue and poor appetite. She also reported a minor episode of nosebleed. She denied any shortness of breath, chest pain, weight loss or any alteration of bowel habit. She complained of some intermittent left-sided pleuritic-type chest pain, which prompted a chest radiograph and urgent referral to the chest clinic thereafter. Her past medical history included left breast surgery 11 yrs ago for ductal carcinoma in situ , atrial fibrillation, essential hypertension, sciatica and psoriasis. She was an ex-smoker with a 37-pack-yr history. Initial blood tests showed a haemoglobin level of 107 g·L−1, a white cell count of 18.6×109 cells·L−1 (lymphocyte count 1.89×109 cells·L−1) and a platelet count of 128×109 cells·L−1. Liver function tests were normal and she was HIV negative. A chest radiograph revealed the presence of a posteriorly located left lower lobe mass. A computed tomography (CT) scan (fig. 1) confirmed the presence of a pleural-based mass posteriorly in the left lower lobe measuring 3.7×3.2 cm with spiculated margin in contiguity with the dome of the left hemidiaphragm and extending into the abdomen. The mass appeared to be infiltrating the …

Late pulmonary metastases of a giant-cell tumour of the spine

A 31-year-old woman presented with sudden onset of hemoptysis. Radiologic imaging revealed a large pulmonary mass in the right lower lobe (∼8 cm in diameter) and additional small bilateral nodules. The computed tomography showed small calcifications within the …

Bronchus-associated lymphoid tissue lymphoma stage IV with subsequent histologic transformation to an aggressive lymphoma: A case report

IntroductionExtranodal marginal B-cell lymphoma of bronchus-associated lymphoid tissue is a rare entity accounting for less than 1% of all lymphomas. We report a case of a low-grade bronchus-associated lymphoid tissue lymphoma stage IV with transformation to an aggressive large B-cell lymphoma.Case presentationA 59-year-old African-American man was incidentally found to have a bronchus-associated lymphoid tissue lymphoma involving the bilateral lower lobes of his lungs. In addition, bone marrow involvement was discovered. His course was indolent with only some mild respiratory symptoms. He received single agent treatment with rituximab. No evidence of progression was seen at the end of receiving this regimen. Two years after treatment our patient presented with B symptoms. Imaging now showed significant increase in the size of the lung masses with cavitation of the right lower lobe mass. A repeat transbronchial biopsy suggested transformation to an aggressive diffuse large B-cell lymphoma.ConclusionThis case illustrates a rare bronchus-associated lymphoid tissue lymphoma stage IV with histologic transformation to an aggressive lymphoma. In addition, this rare case of transformation presented as a cavitary lesion.

Bronchogenic Squamous Cell Carcinoma Mass with Central Photopenia on FDG-PET Scan

A 77-year-old man underwent chest imaging with a hybrid fluoro-deoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan. The study demonstrated a 5 cm mass on standard CT images (figure 1). The FDG-PET images demonstrated a thick-walled mass characterized by intense FDG uptake with a maximum standardized uptake value of 15.9 (figure 2). A large central region of the mass demonstrated photopenia (ie, normal FDG uptake). Volumetric analysis revealed 30% of the mass showed normal FDG uptake, or photophenia. Biopsy of the mass showed squamous cell carcinoma. The findings were consistent with carcinoma that had outgrown its vascular supply resulting in central tumor necrosis. Figure 1 Thoracic computed tomography image showing right lower lobe mass. Figure 2 Hybrid fluoro-deoxyglucose (FDG) positron emission tomography/computed tomography image showing a thick-walled mass characterized by FDG uptake with a maximum standardized uptake value of 15.9 in the wall of the mass and central photopenia, consistent ... Central necrosis is most commonly observed in primary bronchogenic carcinomas of squamous cell origin, with one series reporting squamous cell origin in 82% of cases of necrotizing lung cancer.1 In an analysis of patterns of FDG uptake in lung cancer based on histologic classification, both large cell and squamous cell carcinomas were significantly more likely to demonstrate central cavitation compared with adenocarcinoma.2 The pathogenesis of cavitary malignancies has not been fully elucidated. It has been postulated that cavity formation in tumors is a consequence of rapid tumor growth which exceeds the supporting blood supply resulting in tumor necrosis and cavitation.3 This hypothesis is supported by reports that have shown tumor-associated vasculature inhibition by antiangiogenesis agents causing central necrosis and cavity formation in patients with squamous cell carcinoma of the lung.4, 5 The development of cavitation may have clinically significant consequences. Cavitating lung tumors may initially simulate an infectious process leading to delayed work up, late diagnosis, and presentation with advanced disease. In previous analyses of patient populations with heterogeneous stages of bronchogenic carcinoma, no difference in survival or response to therapy was found between lung cancers with cavitation and those without cavitation.1,6 However, in a more recent analysis of 72 patients with stage I non-small cell lung cancer, cavitation within the primary tumor was associated with significantly shorter disease-free survival time and overall survival time.7 In this analysis, cavitary lesions were significantly more common in squamous cell carcinomas than in adenocarcinomas and in epidermal growth factor receptor (EGFR)-overexpressing tumors than in tumors that did not overexpress EGFR. Accordingly, the presence of cavitation may have therapeutic implications in helping identify patients likely to benefit from targeted treatment with an anti-EGFR agent. In summary, clinicians should be aware that large bronchogenic carcinomas may develop central cavitation and necrosis, likely resulting from compromised vascular supply, resulting in central photopenia on FDG-PET imaging. This finding may have prognostic and therapeutic implications.

Detection of the EGFR mutation in exhaled breath condensate from a heavy smoker with squamous cell carcinoma of the lung

A 61-year-old male smoker (40 pack-years) presented with right chest pain. Computed tomography of the chest revealed a cavitary mass in the right lower lobe. A transbronchial biopsy showed squamous cell carcinoma. We examined epidermal growth factor receptor (EGFR) mutations in exhaled breath condensate (EBC). The DNA extracted from his EBC showed a deletion mutation in exon 19. Subsequently, the del E746-A750 mutation in exon 19 in a transbronchial tissue specimen was confirmed. Although he underwent whole-brain irradiation against multiple brain metastases, he had paralysis of the left side of the body and his performance status was 3. The patient was treated with gefitinib. He had marked tumor regression and no symptoms. Although only a small percentage of heavy smokers with squamous cell carcinoma harbor EGFR mutations, they probably benefit from EGFR-tyrosine kinase inhibitors. EGFR mutation status in the patients having such clinical features might be examined.

Synchronous double primary lung cancers with different response to pemetrexed

We describe the case of a 74-year-old male patient with synchronous double primary lung cancers: adenocarcinoma in the right lower lobe and squamous cell carcinoma in the left upper lobe (LUL). These tumors were difficult to differentiate radiographically from a single metastatic primary cancer, but their eventual diagnoses were triggered by their responses to chemotherapy, which included pemetrexed. After two courses of chemotherapy with pemetrexed and carboplatin, the right lower lobe mass had partially resolved; however, the LUL mass had increased. When S-1 was used as fourth-line chemotherapy, the size of the LUL mass decreased. Pemetrexed is a potentially useful drug for treating nonsquamous cell carcinoma, but may not be appropriate in cases with a coexisting squamous cell carcinoma. Our experience with this interesting case leads us to propose that S-1 monotherapy may provide a treatment option in pemetrexed-refractory cases.

Malignant Pericardial Effusion

A 48-year-old man with a history of alcohol and tobacco abuse presented to the emergency department with a 2-month history of progressive dyspnea. Physical examination revealed distention of the jugular vein and an enlarged left cervical lymph node. An anteroposterior chest radiograph showed cardiomegaly (Panel A). Computed tomographic imaging of the chest (Panel B) revealed a large pericardial effusion (asterisk), a lung mass in the left lower lobe, and necrotic-appearing left supraclavicular lymphadenopathy. Echocardiography confirmed the presence of a circumferential pericardial effusion (Panels C and D and video; asterisk). Diastolic collapse of the right ventricular (RV) free wall (Panel C, . . .

Pulmonary sclerosing hemangioma with pleural dissemination: Report of a case

Pulmonary sclerosing hemangioma is relatively rare and is usually considered a benign tumor. There have been no reports of pulmonary sclerosing hemangioma with pleural dissemination. This report presents an extremely rare case of pulmonary sclerosing hemangioma with pulmonary dissemination. A 57-year-old woman was found to have an abnormal shadow in the right lower lung field on chest X-ray. Chest computed tomography (CT) indicated a 2.5-cm mass in the right lower lobe. A bronchoscopic biopsy failed to identify malignant cells, which led to the patient undergoing an excisional lung biopsy. Intraoperative findings showed a tumor in the right lower lobe with multiple small nodules in the pleura. The pathological findings revealed that the tumor was sclerosing hemangioma with pleural dissemination. Annual follow-up CT showed irregular pleural thickness, which suggested progressive dissemination 3 years after the operation. Although pulmonary sclerosing hemangioma is regarded as a benign tumor, the potential for malignancy may be a consideration in this setting.

A case of pulmonary malignant epithelioid hemangioendothelioma misdiagnosed as adenocarcinoma by fine needle aspiration cytology

Malignant epithelioid hemangioendothelioma (MEHE) is a rare vascular tumor with a biological behavior that lies between those of classical epithelioid hemangioendothelioma and angiosarcoma. Furthermore, MEHE is rarely diagnosed by fine needle aspiration cytology. The authors describe the cytological features of MEHE in a 41-year-old man who presented with increasing dyspnea over a period of 1 month before admission. Computed tomography of the chest showed a 3 cm poorly defined mass in the right lower lobe. Fine needle aspiration cytology demonstrated cellular smears of loosely cohesive clusters of epithelioid cells with numerous intracytoplasmic lumens in a necrotic background. Cellular features included fine chromatin and vesicular or slightly hyperchromatic nuclei with inconspicuous nucleoli and intranuclear inclusions. Nuclear membranes were relatively irregular with indentation. Mean N/C ratio was not increased, presumably due to a moderate amount of cytoplasm. The histologic examination displayed epithelioid and spindle cell proliferation with necrosis accompanying a classical epithelioid hemangioendotheliomatous area. The immunohistochemical evaluation was confirmatory and showed immunoreactivity for vascular markers. The authors also reviewed FNAB findings of epithelioid angiosarcoma, primary adenocarcinoma, and bronchioloalveolar carcinoma of the lung to identify cytomorphologic differences by literature bases. MEHE of the lung is difficult to diagnose cytologically because of its rarity and its cytomorphologic similarities with other malignant epithelial and mesenchymal tumors. However, it may be possible to distinguish it from other entities when the possibility of this unusual vascular neoplasm is suspected and ancillary studies are supportive.

Intrapulmonary Cellular Schwannoma

A 75-year-old asymptomatic woman was admitted to our hospital after an abnormal shadow was found on a chest roentgenogram. Chest computed tomography showed a round mass in the right lower lobe. Magnetic resonance imaging showed the mass with high signal intensity on T2-weighted images and intermediate signal intensity on T1-weighted images. Fluorine-18-fluorodeoxyglucose-positron emission tomography showed high fluorine-18-fluorodeoxyglucose accumulation in the mass. A lobectomy was performed thoracoscopically. The pathologic diagnosis was cellular schwannoma. Immunohistochemical staining demonstrated the presence of S-100 protein, and the Ki67 labeling index was 12%. We present this case of intrapulmonary cellular schwannoma, which is extremely rare.