Mass In Left Lower Lobe Research Articles

June 2023 Medical Image of the Month: Solitary Fibrous Tumor of the Pleura

No abstract available. Article truncated after 150 words. An 85-year-old man presented to our institution for a second opinion and for management of a recurrent left-sided pleural effusion. The patient has a history of CLL, which was diagnosed with a chest wall biopsy 4 years prior to presentation. Since that time, he has undergone chemotherapy and had a good response. In the past 18 months, the patient has had their left-sided pleural effusion drained 24 times. The patient also has a history of hypothyroidism and has had a cholecystectomy. The patient brought multiple outside imaging studies with him for review. An image capture from a recent ultrasound-guided left thoracentesis (Figure 1A) demonstrated, in retrospect, a pedunculated left lower lobe mass. An outside PET-CT (Figure 1B) was also available, confirming the presence of this mass, which had relatively uniform, low level FDG uptake such that it evade notice on first interpretation. A CT angiogram (Figure 2) demonstrated a large …

ODP503 Non-Small Cell Lung Cancer Metastatic to the Thyroid Gland

Abstract Introduction Metastatic disease affecting the thyroid gland is an uncommon phenomenon, with the most common primary sites being kidney, breast, lung and gastrointestinal tract. Thyroid metastases frequently occur simultaneously with spread to other sites and are rarely symptomatic. Clinical case: 73-year-old female with remote history of stage IA (T1c, N0, M0) invasive lobular carcinoma of the right breast treated with lumpectomy, radiation and tamoxifen, previous tobacco use, remote exposure to radiation during Chernobyl nuclear accident, developed progressive dyspnea on exertion. She was found to have a large left-sided pleural effusion. Thoracentesis was performed, and the cytology revealed adenocarcinoma with features favoring lung primary. Further imaging showed a left lower lobe mass with central necrosis and left hilar adenopathy, multiple pleural masses, and a small solitary brain lesion. PET-CT also demonstrated, amongst other findings, an FDG avid left lower pole thyroid nodule. Thyroid ultrasound was obtained to further characterize the lesion, which demonstrated a 0.8×1.3×1.3 cm solid hypoechoic nodule in the left mid lobe, which was thought to be corresponding to the PET avid nodule. Two additional nodules, a mixed cystic and solid measuring 1.7×2.1×2.9 cm on the right lobe, and another left-sided solid isoechoic measuring 0.8×0.7×0.9 cm, were noted. Thyroid FNA of the 1.3 cm PET avid nodule revealed rare cells in clusters, with large pale nuclei and prominent nucleoli, some with intracytoplasmic vacuoles, morphologically similar to those seen in the prior pleural fluid. Thin prep was stained with antibody to thyroglobulin, and the malignant cells showed lack of staining, supporting the diagnosis of metastatic lung cancer. Thyroid function tests were normal. Given lack of compressive symptoms, patient was maintained on her primary oncologic treatment with carboplatin and pemetrexed, and stereotactic radiation for the brain metastasis. Repeat PET-CT, performed approximately 8 months after the initial scan, showed mildly decreased focal FDG activity in the thyroid lesion. Discussion In this scenario, a patient with primary lung malignancy was found to have an FDG avid thyroid nodule which on FNA proved to be a metastatic lesion. Per some studies, such lesions can be seen in 1.4%–3% of patients who undergo surgery for suspected malignancy in the thyroid gland. Management of metastatic thyroid cancers depends on multiple factors including the primary malignancy location and staging, patient comorbidities, compressive symptoms, etc. Surgical management may be of benefit in isolated lesions in the thyroid. Conclusion When evaluating thyroid nodules in patients with known history of malignancy, it is important to consider the differential of metastatic lesions and to perform a thorough evaluation including fine-needle aspiration for clinical elucidation and management. Presentation: No date and time listed

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

IGG4-RELATED DISEASE PRESENTING AS A PULMONARY INFLAMMATORY PSEUDOTUMOR

IGG4-RELATED DISEASE PRESENTING AS A PULMONARY INFLAMMATORY PSEUDOTUMOR

Abstract 4121: Durable stable disease with nivolumab, PD-1 inhibitor, and subsequent bevacizumab, Anti-VEGF monoclonal antibody, in long standing recurrent respiratory papillomatosis with lung squamous cell carcinoma

Abstract Background: Recurrent respiratory papillomatosis (RRP) is a human papilloma virus (HPV) associated benign disease, which, in rare cases, can develop into lung squamous cell carcinoma. Treatment options are limited with no approved systemic adjuvant therapy and the disease requires frequent surgical resection to prevent airway obstruction. Therefore, expanding available treatment options remains a highly important, but unmet need in RRP. Herein, we present a case of RRP with squamous cell carcinoma of lung that demonstrated durable stable disease with nivolumab and subsequent bevacizumab. Case presentation: A 48-year-old woman with long standing RRP since teenager, who underwent multiple microsuspension laryngoscopies, debridements including laryngeal lesions, and ultimately, 5 years ago, video assisted thoracic surgery (VATS) resection of right upper lobe mass, confirming squamous cell carcinoma, has been managed with debulking surgery on tracheal lesions by ENT on regular basis. Nivolumab, a programmed death-1 blockade, 3 mg/kg every 2 weeks was started given squamous cell carcinoma of lung. Stable disease (SD) in lung lesions was achieved on nivolumab for one year but she required more frequent debulking of tracheal lesions. After multidisciplinary discussion with Otorhinolaryngology, she was started on bevacizumab, vascular endothelial growth factor inhibitor, 10 mg/kg every 6 weeks. Follow-up CT scans in 10 weeks showed a decrease in size of a left lower lobe mass to 27 mm from 32 mm in the previous image. After one year, administration of bevacizumab was spaced out to every 12 weeks. She requires less debulking surgery and the last debulking surgery was approximately 3 years ago. She maintains SD for over 4 years since starting bevacizumab. Discussion: Our patient with RRP and squamous cell carcinoma of lung demonstrated SD on nivolumab before she was switched to bevacizumab. In addition, her SD on bevacizumab of more than 4 years with 12 weeks of maintenance interval is encouraging as there is no current standard of care treatment for RRP. Despite difficulty in running clinical trials in RRP due to its rareness, additional studies evaluating the efficacy of PD-1 inhibitor or anti-VEGF monoclonal antibody on RRP are warranted. Citation Format: Horyun Choi, Jinah Kim, Yeun Ho Lee, Leeseul Kim, Young Kwang Chae. Durable stable disease with nivolumab, PD-1 inhibitor, and subsequent bevacizumab, Anti-VEGF monoclonal antibody, in long standing recurrent respiratory papillomatosis with lung squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4121.

Lambert-Eaton myasthenic syndrome revealed after surgery of lung adenocarcinoma.

We report a very rare case of cT1N0M0 lung adenocarcinoma reveling Lambert-Eaton myasthenic syndrome (LEMS). A 69-year-old nonsmoking woman, with several comorbidities consulted for cough and dyspnea. Chest radiograph and CT scanning detected a left lower lobe mass; Needle biopsy confirmed differentiated adenocarcinoma; 18FDG-PET scan and Brain MRI eliminated metastatic disease dissemination. Our patient underwent a left lower lobectomy with mediastinal lymphadenectomy (pT1N0M0), no adjuvant chemotherapy was administrated. One month later patient present a muscle weakness in both lower limbs and fatigability followed by an inability to walk. The diagnosis of LEMS was made from the distinctive electromyogram (EMG) findings and a treatment with Amifampridine (3, 4-diaminopyridine phosphate [3, 4-DAP]) was prescribed with evident efficacy for symptoms.

A rare condition masquerading as lung cancer

A 63-year-old woman was referred to the lung cancer clinic after presenting to the emergency department with a 10-day history of fever, chest tightness and breathlessness. Chest X-ray showed a...

All that is Miliary is not tuberculosis

Miliary pattern on radiographs are attributed always to tuberculosis even though the differential diagnoses of miliary pattern is very wide. This pattern is most commonly caused by infectious diseases and rarely by malignancies. Primary lung cancers presenting with miliary shadows is extremely rare. Here we report a case of 50-year old female, presenting with 15 days of symptoms and CXR PA view showing bilateral diffuse miliary nodules. HRCT Chest confirmed the miliary pattern and also showed a mass in left lower lobe. Microbiological tests for tuberculosis and fungal infections were negative. CECT Chest gave impression of left lower lobe suspected malignant lung mass with pulmonary metastasis. Malignancy was confirmed by CT guided FNAC as Adenocarcinoma lung. PET scan didnot reveal metastasis in other organs. CONCLUSION : Miliary pattern does not always indicate tuberculosis and other possibilities should be evaluated.

A DIAGNOSTIC DILEMMA: MULTIPLE BRAIN RING-ENHANCING LESIONS IN A PATIENT WTH UNILATERAL HAND NUMBNESS

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Brain ring-enhancing lesions (RELs) have a broad differential diagnosis including infections, demyelinating disorders and neoplastic conditions. We present a 68-year-old female with unilateral hand numbness, newly diagnosed with metastatic lung adenocarcinoma. CASE PRESENTATION: A 68-year-old Caucasian female presented with left-hand numbness and headaches for 1 month. Her past medical history includes type 2 diabetes, tracheostomy dependence secondary to chronic respiratory failure from motor vehicle accident, 112 pack-year smoking history, and unremarkable family history. CT head without contrast was obtained to evaluate left-hand numbness and no acute intracranial hemorrhage was found. Follow-up MRI brain with and without contrast revealed innumerable subcentimeter RELs throughout both cerebral hemispheres, brainstem, and cerebellum without significant surrounding edema, which was concerning for infection. She also complained of worsening shortness of breath, so CXR was obtained and showed diffuse alveolar opacities. Follow-up CT chest revealed a left lower lobe mass measuring 3.2 x 2.7cm with multiple nodules in the left hemithorax. Bronchoscopy was considered but deferred due to significant tracheal stenosis. Of note, she had a normal CXR nine months prior. Sputum cultures were positive for Nontuberculous Mycobacterium (NTM) and therapy was initiated with azithromycin, ethambutol, ciprofloxacin, and amikacin. Infectious workup was negative for HIV, Toxoplasma, Histoplasma, Blastomyces, Cysticercosis, Coccidioides, and Aspergillus. Lumbar puncture was unremarkable for infection or malignancy. Ultimately, brain biopsy was performed on the RELs for suspected infectious etiology given her lung lesions and NTM infection. Pathology returned positive for metastatic lung adenocarcinoma. DISCUSSION: The differential diagnoses for RELs include infections (bacterial, fungal, parasitic), primary neoplasms, metastatic cancers (lung, breast, skin) and demyelinating disorders (multiple sclerosis). Our patient had RELs in both white and gray matter without significant edema, which are more characteristic of infections. Brain metastasis typically presents as a solid mass with distinct borders and surrounding edema that can become a REL if central necrosis occurs. Therefore, the patient’s RELs in conjunction with her chest images and NTM positive sputum were highly suspicious for infective process. Unfortunately, ten percent of newly diagnosed non-small cell lung cancers present with brain metastases. The median time for brain metastasis to occur is 12 to 16 months. Once metastasis occurs, median survival time is about 6 months. Therefore, prompt and accurate diagnosis is crucial to survival. CONCLUSIONS: Clinicians should consider rapidly progressive lung cancer high in the differential of brain RELs despite concurrent infections. Reference #1: Sharma V, Prabhash K, Noronha V, Tandon N, Joshi A. A systematic approach to diagnosis of cystic brain lesions. South Asian J Cancer 2013;2:98-101. Reference #2: Garg R K, Sinha M K. Multiple ring-enhancing lesions of the brain. J Postgrad Med 2010;56:307-16. Reference #3: Chakraborty S (2013). Multiple Ring Enhancing Lesions in a Patient with Unilateral Limb Jerking. J Clin Case Rep 3: 304. DISCLOSURES: No relevant relationships by Priyatha Garlapati, source=Web Response No relevant relationships by Shreedhar Kulkarni, source=Web Response No relevant relationships by Diana Song, source=Web Response

SUN-487 A Case of Type 2 Anaplastic Spindle Cell Squamous Cancer

Background: Papillary thyroid carcinoma (PTC) is generally considered a relatively slow-growing, indolent cancer; however, an important subset of these cancers known as the tall cell variant (TCV), portend a more aggressive prognosis. TCV PTC is characterized by cells, which are at least twice as tall as they are wide. Patients diagnosed with TCV PTC fare worse than those with the classic variant. A less common thyroid cancer, spindle cell squamous cell carcinoma (SCSC), may arise as a primary tumor, but rarely also alongside or from a previous TCV PTC (1). It may also occur as a component of an anaplastic thyroid cancer, the most aggressive and rarest thyroid malignancy. There are three main types of anaplastic SCSC arising from TCV PTC based on histological characteristics: Type 1 is defined by the presence of both TCV and SCSC within the initial resection; type 2 refers to when the SCSC arises as a recurrence or metastasis in patients with a known history of TCV PTC; type 3 occurs when SCSC presents as a primary laryngeal SCC in patients with or without a known history of TCV. We report a case of type 2 anaplastic SCSC. Clinical Case: A 76 yr old man with hx of invasive TCV PTC (diagnosed 2011) s/p total thyroidectomy with b/l neck dissection and laryngectomy, as well as 200 mci of I-131 (in 2012), returns to clinic in 2019, with worsening unexplained weight loss (> 20 lbs). He had been lost to follow-up since 2015. Now, chest CT showed a new, necrotic, left lower lobe mass obstructing the bronchus, as well as bony erosion of the right clavicle and manubrium. Bronchoscopy of the mass was performed, and pathology was consistent with metastatic anaplastic thyroid cancer with squamous nests. Immunohistochemistry was positive for PAX-8, p40, p63 and negative for TTF-1, Napsin A, TG and PDL-1. The endobronchial tumor tissue was compared to the prior resection specimen from 2011, showing morphologic similarity to the squamoid nests. In retrospect, these nests likely represented small foci of anaplastic thyroid cancer arising in association with TCV PTC. The positive staining for PAX-8 and lack of expression for TTF-1 and Napsin A supports this interpretation and is evidence against a primary pulmonary squamous cell carcinoma. Next Gen Sequencing was positive for BRAF V600E mutation, which allowed us to offer BRAF inhibitor and MEK inhibitor therapy. Unfortunately, due to patient’s non-adherence to therapy and follow-up clinic visits, we are not able to assess his response. Conclusion: This is a case of the rarely described type 2 anaplastic SCSC and is an example of the very poor prognosis associated with TCV PTC. It is a reminder that this variant of PTC should be treated more aggressively from the time it is first identified on biopsy. Reference: (1) Gopal PP et al. The variable presentations of anaplastic spindle cell squamous carcinoma associated with tall cell variant of papillary thyroid carcinoma. Thyroid. 2011;21(5):493–499.

ROUNDED ATELECTASIS: IS IT TRULY BENIGN?

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Rounded Atelactasis (RA) is a special type of peripheral lung collapse associated with focal pleural thickening, typically attributed to asbestos inhalation(1). RA is usually benign, and does not require any intervention, and is often misdiagnosed as a malignant lesion requiring patients to undergo unnecessary interventions. The co-existence of RA and lung cancer has been rarely reported in literature. Here, we present a 67-year-old male with RA, that was subsequently followed with a biopsy ten years later revealing adenocarcinoma. CASE PRESENTATION: 67-year-old male with minimal smoking history and medical history of hypertension, dyslipidemia presented outpatient as referral for an abnormal finding on his Cardiac CT for calcium scoring. Patient denied cough, shortness of breath, weight loss, hemoptysis, pleuritic chest pain and night sweats. All other review of system questions were answered in negative. Occupational history was positive for asbestos exposure but no family history of lung cancer. Physical exam was positive for mild decrease air entry on the left side. No clubbing, or lymphadenopathy was seen. Spirometry showed FVC and FEV1 of 59% and 54% of predicted respectively with FEV1/FVC ratio of 70. Previous CT chest from 2007 revealed bilateral pleural plaques and thickened pleura with 3 cm RA in left lower lobe. Repeat CT chest from 2010 showed stable 3 cm mass-like opacity likely representing RA with no evidence of parenchymal fibrosis. CT chest from 2018 showed interval increase in size of left lower lobe mass to 4.8 cm at the site of previous RA. Subsequent PET-CT showed increased uptake about the lesion, which was subsequently biopsied. Microscopically, tumor cells were positive for Napsin A and TTF-1, and no necrosis was appreciated in the biopsy sample. A histopathologic diagnosis of moderately differentiated adenocarcinoma was established. Patient has since been followed by our team and oncology as outpatient. DISCUSSION: RA results from in-folding of the lung in the presence of pleural fluid and fibrinous pleuritis(2). RA appears as a pleural-based mass-like lesion with a rounded shadow 2.5-5 cm in diameter lying along the lower lobe(3). CT typically shows a sharply marginated and homogeneous subpleural mass and volume loss in the affected lung, associated with adjacent pleural effusion or thickening, incurving vessels and bronchi, acute angles with pleura, and sharp lateral margins(4,5). CONCLUSIONS: Our patient possibly had stable RA initially that was later complicated by an underlying malignant process; a rare presentation with both entities co-existing independently of each other. This case educates us to be more aware of RA masking a potential underlying malignant process making it imperative to have recommended guidelines for follow-up of such lesions. Reference #1: Batra P, Brown K, Hayashi K, Mori M. Rounded atelectasis. Journal of Thorac Imaging. 1996;11(3): 187–197. Reference #2: Fraser RS, Muller NL, Colman N, Pare PD. Diagnosis of diseases of the chest, 4th ed. Philadelphia, PA: W. B. Saunders,1999 : 521–522. Reference #3: Schneider, H., Felson, B., & Gonzalez, L. (1980). Rounded atelectasis. American Journal of Roentgenology,134(2), 225-232. https://doi.org/10.2214/ajr.134.2.225 Doyle TC, Lawler GA. CT features of rounded atelectasis of the lung. AJR 1984; 143:225 –228 O'Donovan PB, Schenk M, Lim K, Obuchowski N, Stoller JK. Evaluation of the reliability of computed tomographic criteria used in the diagnosis of rounded atelectasis. J Thorac Imaging 1997; 12:54 –58. DISCLOSURES: No relevant relationships by Anas Al-khateeb, source=Web Response No relevant relationships by Sharath Bellary, source=Web Response No relevant relationships by Muqueet Kadri, source=Web Response No relevant relationships by Saraswathi Lakkasani, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response No relevant relationships by Hari Sharma, source=Web Response

ENDOBRONCHIAL METASTASIS FROM OSTEOSARCOMA

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Lung is the most frequent site for metastasis from osteosarcoma. Usually, the presentation is with well-defined parenchymal nodules, and unusually with pleural deposits, calcification, or mediastinal nodes. Metastases from osteosarcoma presenting as an isolated endobronchial lesion is discretely rare. CASE PRESENTATION: 36 Y/O man with a diagnosis of osteosarcoma presented with dry cough. The patient CT chest showed a left lower lobe mass with central calcification (figure). The patient underwent bronchoscopy for evaluation left lower lobe mass. The bronchoscopy showed left lower lobe superior segment endobronchial lesion. Hot snare and cryo probe used to debulck the endo bronchial lesion (figure). The lesion was extending deep in the airway and EBUS confirmed the depth of the lesion with the finding for central calcification (figure). Pathology confirmed the diagnosis of metastatic small cell osteosarcoma (figure). DISCUSSION: Airway metastasis of tumors usually rare. The incidence of such metastasis is estimated to be approximately 2%; the most common primary malignancies being renal cell, colorectal, cervical, breast carcinoma, and malignant melanoma.This case presenting an extension of small cell small cell Osteosarcom mass in the left lower lobe into the airway confirmed with EBUS. CONCLUSIONS: Airway inspection is an important test for patient with metastatic tumors to the lung close to a major airways. This will give the chance for a baseline evaluation of the airway for any future progress of disease or future complication of the disease such as hemoptysis. Inexplicable pulmonary manifestations should prompt an early evaluation including bronchoscopy and early institution of local therapy for possible palliation. Reference #1: Mogulkoc N, Goker E, Atasever A, et al. Endobronchial metastasis from osteosarcoma of bone: treatment with intraluminal radiotherapy. Chest. 1999;116:1811–1814 Reference #2: Rubio ER, Chang EE, David O, et al. Pulmonary osteosarcoma: endoscopic management. J Bronchol. 2001;8:277–281 DISCLOSURES: No relevant relationships by Abdul Hamid Alraiyes, source=Web Response No relevant relationships by Mohamed Elrifai, source=Web Response No relevant relationships by Arun Kadamkulam Syriac, source=Web Response

ACQUIRED ICHTHYOSIS: A RARE PRESENTATION OF LUNG CANCER

SESSION TITLE: Lung Cancer 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Acquired ichthyosis (AI) is a skin condition characterized by dry, rough and scaling skin, often described as “fish scale skin”. AI can be either congenital or acquired and can be associated with malignancies, lupus, chronic liver disease, kidney disease, malnutrition, AIDS and certain medications. Cancers associated with AI include but are not limited to: Hodgkin's lymphoma, lung and breast adenocarcinoma. Although AI is associated with underlying malignancy, this skin finding is not always recognized and is often treated independently and thus, a diagnostic evaluation for an underlying malignancy is not always performed. CASE PRESENTATION: A 54-year-old Caucasian male, who is an 80 pack year smoker and type 2 diabetic, presented to the ER with dizziness and syncope. He reported shoulder pain from falling, anorexia and unintentional weight loss. He had no shortness of breath, cough, hemoptysis, night sweats or fatigue. On exam, he was cachectic with severe dry, rough scaling skin especially to the palms and plantar surfaces (Figure1&2). He reported that this skin finding had been present for 2 months. CT of the head showed: a right frontal mass and a second heterogeneous mass within the cerebellum. So, a chest x-ray was obtained to evaluate for a possible primary neoplasm and showed a left peri-hilar mass. CT chest was subsequently completed and showed a left lower lobe mass with mediastinal lymphadenopathy, which CT guided biopsy later confirmed as small cell undifferentiated carcinoma. Podiatry was consulted for his skin findings which were believed to be paraneoplastic acquired ichthyosis and keratolytic therapy with 40% urea cream was ordered. Oncology was consulted and palliative radiation for brain metastasis and chemotherapy were started. Unfortunately, the patient died 4 months after his diagnosis was made. DISCUSSION: Lung cancer is associated with multiple paraneoplastic phenomena, including AI. Early recognition of cancer is very important especially in fast growing small cell lung cancers. As shown in this case, AI presented 2 months before the diagnosis of cancer was confirmed. This diagnosis could have been made earlier if a thorough evaluation by a dermatologist or a podiatrist was obtained. Furthermore review of the current literature and case reports on AI are very limited. Therefore, a high index of suspicion in the appropriate clinical scenario is warranted and can make a difference in the early diagnosis and treatment of associated malignancy. Unfortunately, for our patient his diagnosis of AI was made simultaneously with his diagnosis of metastatic lung cancer and so he lost an opportunity for earlier diagnosis. CONCLUSIONS: Paraneoplastic syndromes might be the first red flag observed with the presentation of cancer. Therefore, it is crucial that rare manifestation such as AI be recognized and investigated to rule underlying malignancy. Reference #1: Okulicz JF, Schwartz RA. Hereditary and acquired ichthyosis vulgaris. Int J Dermatol 2003; 42:95–8. Reference #2: Penven K, Verneuil L, Dompmartin A, Louvet S, Leroy D. An association of paraneoplastic syndromes in a patient. Ann Dermatol Venereol. 2002; 129(8-9):1042-5. Reference #3: Patel N, Spencer LA, English JC, Zirwas MJ. Acquired ichthyosis. J Am Acad Dermatol 2006; 55:647. DISCLOSURES: No relevant relationships by Haytham Adada, source=Web Response No relevant relationships by Mahmoud Amarna, source=Web Response No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by AHMAD HAMMAD, source=Web Response No relevant relationships by Leisa Walker, source=Web Response

Contralateral recurrence of inflammatory myofibroblastic tumour of the lung 10 years after pneumonectomy

Inflammatory myofibroblastic tumour (IMT) is a rare form of inflammatory pseudotumour of the lung. Complete surgical resection is the treatment of choice, with corticosteroid-based medical therapy reserved for cases where...

A rare presentation of pulmonary sarcoidosis as a solitary lung mass: a case report

BackgroundSarcoidosis is a multisystem, chronic granulomatous disease of unknown etiology that predominantly affects the lungs. Pulmonary sarcoidosis classically presents with constitutional symptoms and computed tomographic scan findings of bilateral, symmetric micronodules in a peribronchovascular distribution with upper and middle lung zone predominance accompanied by bilateral, symmetric hilar lymphadenopathy. A solitary lung mass is a rare finding for pulmonary sarcoidosis, and with its associated constitutional symptoms, it strongly mimics a malignancy. We aimed to provide further insight into the broad differential diagnosis of a lung mass by describing our experiences in the care of a patient who presented with clinical and radiographic features of lung cancer who was ultimately found to have an atypical manifestation of stage II pulmonary sarcoidosis.Case presentationA 44-year-old African American woman with a history of childhood asthma and type 2 diabetes mellitus presented with shortness of breath. After being treated for a presumed asthma exacerbation with prednisone, she experienced worsening dyspnea, night sweats, and unintentional weight loss. Further evaluation revealed a large left lower lobe mass and hilar lymphadenopathy. A computed tomography-guided biopsy of the lung mass revealed a multifocal non-necrotizing granuloma with multinucleated giant cells. Although consistent with sarcoidosis, this finding could represent a sarcoid-like reaction secondary to an occult malignancy. A more extensive repeat biopsy via bronchoscopy and mediastinoscopy revealed granulomatous inflammation without evidence of malignancy or infection. These procedures confirmed the diagnosis of pulmonary sarcoidosis, and she was started on treatment with high-dose prednisone. Her treatment course was complicated by hyperglycemia necessitating insulin therapy, but after 3 months of therapy, she reported improvement in her dyspnea, and repeat imaging revealed a significant decrease in the size of the lung mass and lymphadenopathy. Given her clinical and radiographic response, she was continued on a prednisone taper.ConclusionsAtypical manifestations of pulmonary sarcoidosis are diagnostically challenging because the clinical and radiographic features of the disease mimic those of a malignancy. We aimed to illustrate a unique etiology of a lung mass and the importance of maintaining a broad differential diagnosis. Nonetheless, with the possibility of a malignancy, a high index of suspicion is necessary for timely diagnosis and optimal management.

Endobronchial ultrasound-guided transbronchial needle aspiration for staging of non-small cell lung cancer.

Accurate staging for non-small cell lung cancer (NSCLC) is essential to guide therapy. While computed tomography (CT) and positron emission tomography (PET) scan can indicate whether mediastinal lymphadenopathy is present, histologic confirmation is required to complete the staging evaluation. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique associated with similar diagnostic yield and improved postoperative pain and complication rates compared to mediastinoscopy. We share the surgical technique for EBUS-TBNA based on our experience. An 81-year-old man underwent EBUS-TBNA for concurrent tissue diagnosis and mediastinal staging of a hypermetabolic left lower lobe mass and subcarinal lymph node. Our patient had no perioperative complications and was discharged home on the same day. Histologic evaluation demonstrated squamous cell carcinoma in the left lower lobe and subcarinal lymph node. EBUS-TBNA provides histologic confirmation of suspicious mediastinal lymph nodes seen on imaging. Clinicians should consider EBUS-TBNA as a mediastinal staging modality for patients with NSCLC.

P3.01-012 P40 in Metastatic Pulmonary Trophoblastic Tumor: Potential Diagnostic Pitfall with Pulmonary Squamous Cell Carcinoma: Topic: Morphology

p40, one of the two isomers of p63, is nowadays widely used for diagnosis of squamous cell carcinoma, especially in subtyping non-small cell carcinoma on lung biopsies. We describe a case in which lung tumor was misdiagnosed as squamous cell carcinoma due to p40 immunopositivity. A 36-year-old lady presented with cough and left sided chest pain for 2 months duration. Chest imaging revealed a lesion in left lower lobe of lung and biopsy was suggestive of squamous cell carcinoma (Fig 1). However, past history revealed amputation of great toe for non-healing discharging ulcer which on histopathology was diagnosed as choriocarcinoma. She developed similar nodules and ulcers over the left arm, followed by a gradually worsening dry cough and progressive shortness of breath. On imaging, she was found to have a septated left-sided pleural effusion. A positron emission tomography–computed tomography (PET-CT) revealed a large hypermetabolic soft tissue mass in left lower lobe with bilateral lung metastases and multiple liver deposits. On reviewing obstetric history, she also had a history of hysterectomy five years ago, details of which were not available. Post-amputation β-hCG levels were high and she had been treated with multimodality chemotherapy for choriocarcinoma. She had good response to chemotherapy initially, however became resistant later on. Review of lung biopsy in the light of the past history along with extensive literature review led to the final diagnosis of metastatic trophoblastic tumor to lung. Figure 1- The lung biopsy shows an invasive tumor (A) (H&E, 10×); composed of polygonal cells with moderate amount of eosinophilic cytoplasm, round to oval nuclei and inconspicuous nucleoli (B) (H&E, 20×). Hyaline eosinophilic material is seen amid tumor cells with mitotic activity (C) (H&E, 20×). These tumor cells show strong nuclear immunopositivity for p40 in approximately half of the tumor cells (D) (IHC, 20×). Hence, awareness that p40 immunopositivity can be seen in trophoblastic tumors is essential to avoid misdiagnosis, especially in sites like lung where squamous cell carcinoma is common.

Pulmonary Cyst of Uterine Genesis

SESSION TITLE: Fellow Case Report Poster - Imaging SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Benign metastasizing leiomyoma (BML) is a rare disease characterized by well differentiated smooth musle cells of uterine myomatous origin that are present in sites distant from the uterus, most commonly in the lung. Pulmonary BML typically presents as solid discrete nodules of tumor within lung parenchyma in an asymptomatic patient. CASE PRESENTATION: A 65 year old woman presented with episodes of marked diaphoresis for one year. She had history of a hysterectomy for uterine fibroids 17 years prior. Her medical evaluation was unremarkable save for a chest radiograph which identified a left lower lobe mass. Computed tomography of the chest demonstrated a 4.9 cm low density mass along the left major fissure, consistent with a bronchogenic cyst (Figure 1A-B). Also noted were multiple small nodules, 3-6mm in size. The cyst was resected; its cytology was benign and fluid bacterial culture had no growth. The wall of the cyst demonstrated smooth muscle cells staining positive for actin, desmin, as well as estrogen and progesterone receptors, identical to histopathology from her prior hysterectomy. The cyst was also lined by a single layer of cuboidal epithelial cells staining positive for TTF-1 (Figure 2A-F). After cyst removal, the patient reported complete resolution of her symptoms. DISCUSSION: BML lesions are thought to arise as hematogenous metastases from benign tumors, with leiomyomatous smooth muscle cells entering the blood stream during surgical resection. The most well described radiographic presentation is multiple pulmonary nodules with a distribution typical of metastatic lesions. In very rare cases, BML has been reported to present with multiple thin walled pulmonary cysts, invoking the radiographic differential of diffuse cystic lung disease. In these cases,cyst formation is theorized to be due to pulmonary elements entrapped in tumor cells. We believe this case is the first described radiographic presentation of BML consistent with a predominant large fluid filled bronchogenic cyst. While the vast majority of BML nodules are found incidentally in aysmptomatic patients, in this case, the serous filled cyst was associated with pronounced diaphoresis that resolved with cyst resection. CONCLUSIONS: The radiographic differential for localized cystic pulmonary disease should include the rare finding of BML in patients with a history of uterine leiomyomata. Reference #1: Aboualfa K, et al. Benign metastasizing leiomyoma presenting as cystic lung disease: a diagnostic pitfall. Histopathology.2001;59(4):796-799. DISCLOSURE: The following authors have nothing to disclose: Anna Moniodis, Douglas Lin, Paul VanderLaan, Majd Mouded No Product/Research Disclosure Information

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

Unusual aetiology of a hilar mass in a man with history of thyroid cancer

A 39-year-old male non-smoking lumberyard worker from northern Mississippi was referred for evaluation of a left lower lobe mass. He had been treated 4 years earlier for papillary thyroid cancer...