Peripheral Lung Fields Research Articles

Large cell neuroendocrine carcinoma of the lung—Atypical presentation

Large cell neuroendocrine carcinoma is a rare and aggressive neoplasm of the lung with a very poor prognosis. It accounts for approximately 1,6–3,1% of all lung cancers. Most cases present as large primary lung masses in the peripheral lung fields. Patients are less likely to present with pulmonary symptoms. Diagnosis is a difficult task which requires histological analysis, cytological evaluation and immunohistochemistry. To confirm neuroendocrine origin in the tumor cells, at least one immunohistochemical markers, such as cromogranin, synaptophysin or CD56, must be positive.

Discriminative features of thin-slice computed tomography for peripheral intrapulmonary lymph nodes

The use of computed tomography (CT) scans has increased the opportunities to detect small nodular shadows in peripheral lung fields. Intrapulmonary lymph nodes (IPLNs) are sometimes identified among these nodular shadows, and a differential diagnosis is often difficult. However, few descriptions of the CT findings of IPLNs, with regard to their potential for the differential diagnosis of lung cancer, have been published. From 2006 through 2011, 606 patients underwent thoracic surgery for pulmonary nodules. Nine patients (1.5%) had pathologically diagnosed IPLNs. We retrospectively reviewed the clinicopathological features and thin-section CT findings of the patients with IPLNs. We also compared these IPLN patients with 17 patients having small-sized lung cancer. In six cases, the nodules were round, and linear density extending from the IPLNs was visualized in seven nodules. The nodules in IPLNs were located in the lower lobe, and the nodule borders were clearer than those of lung cancers. Six out of nine nodules were round, and linear densities were more easily visualized for the IPLNs. Medical specialists need to be familiar with the discriminative features of thin-slice CT for IPLNs not only to avoid performing unnecessary operations, but also to prevent the mis-staging of lung cancer.

A case of septic pulmonary embolism caused by urinary tract infection

A 56-year-old woman with diabetes mellitus (DM) presented at our department with intermittent low-grade fever, right-side back pain and general fatigue, having taken antibiotics (cefotiam) for the preceding two weeks as prescribed at another healthcare facility. Despite the absence of any cough or sputum production, chest X-ray revealed multiple nodular lesions in the peripheral lung fi elds (Figure-1). These nodules were not observed at the time of initial treatment at the referring hospital. Chest CT indicated multiple nodules with necrotic centers in the peripheral bilateral lung fi elds (Figure-2). Abdominal CT showed a swollen right kidney and diffuse abscesses (Figure-3). A diagnosis of septic pulmonary embolism accompanied by pyelonephrosis was made. Accordingly, an alternative antibiotic (cefotaxime) was administered against sepsis. The multiple nodules in the lung and the diffuse renal abscesses simultaneously disappeared within two months after this course of highly potent anti-bacterial therapy. DM control was also accomplished by insulin therapy.Septic pulmonary embolism has been defi ned as a lung embolism caused by a blood clot infected with any of several bacterial or fungal species. Typically, patients present with high-grade fever, productive cough, general malaise and hemoptysis. The presence of DM has an unfavorable impact on disease progression and prognosis. The most common radiographic fi ndings are bilateral peripheral nodules with feeding vessels and cavity formations less than 3 cm in diameter (1). Septic pulmonary emboli are classifi ed according to their source, i.e.

Reasonable Extent of Lymph Node Dissection in Intentional Segmentectomy for Small-Sized Peripheral Non–Small-Cell Lung Cancer: From the Clinicopathological Findings of Patients Who Underwent Lobectomy with Systematic Lymph Node Dissection

Currently, randomized clinical trials to evaluate segmentectomy compared with lobectomy for peripheral cT1aN0M0 non-small-cell lung cancer (NSCLC) are ongoing. During segmentectomy, some lobar-segmental lymph nodes (LSNs) can be difficult to resect for anatomical reasons. The purpose of this study was to clarify the reasonable extent of dissection during intentional segmentectomy for peripheral cT1aN0M0 NSCLC. We reviewed the records of patients who underwent lobectomies and systematic lymph node dissections for cT1aN0M0 NSCLC from 1992 to 2009. Among them, a total of 307 patients whose primary nodule was located in the outer third peripheral lung field on thin-section computed tomography (TSCT), and who could be candidates for intentional segmentectomy were enrolled in this study. We analyzed the clinical and radiological factors, which may predict nodal metastasis, and the distribution patterns of lymph node metastases. In particular, we set out to evaluate the specific LSNs, which are difficult to resect on segmentectomy (isolated LSNs [iLSNs]). Of all patients, 34 (11%) had lymph node metastases (pN1: 9, pN2: 25). The median tumor sizes and tumor disappearance rates (TDRs) on TSCT were significantly larger and lower, respectively, compared with those of the remaining 273 node-negative patients. All 34 node-positive patients had a solid-dominant component on TSCT (TDR < 0.25). Of these, nine patients (n = 5, station 11, n = 4, station 13) were iLSN positive, but all of them also had metastases to station 12 or mediastinal lymph nodes. No patients had solitary metastasis in iLSNs. The reasonable extent of dissection for intentional segmentectomy for small (≤ 2 cm) peripheral NSCLC includes LSNs in the segments with tumors, and the hilar and mediastinal nodes. It may not be necessary to examine iLSNs. Systematic lymph node dissection might not be necessary for tumors with ground grass opacity on TSCT (TDR ≥ 0.25).

Pulmonary Toxicity After Initiation of Azathioprine for Treatment of Interstitial Pneumonia in a Patient with Rheumatoid Arthritis

To the Editor: Pulmonary involvement of rheumatoid arthritis (RA) includes drug-induced pulmonary toxicity, interstitial pneumonia (IP) due to RA itself, airway lesions, pleural lesions, and pulmonary infections due to the use of immunosuppressants. It is sometimes difficult to differentiate between these conditions. Pulmonary toxicity has been reported to be often induced by methotrexate and leflunomide but rarely by azathioprine (AZA). We describe a patient with RA and IP, in whom AZA induced pulmonary toxicity. The patient was a 72-year-old man diagnosed with RA (Steinbrocker stage III, class 2), treated with 5 mg/day prednisolone (PSL) and with clinically low disease activity. He developed a nonproductive cough 2 years ago. Chest radiograph and high-resolution computed tomography (HRCT) of the chest at that time revealed ground-glass opacities (GGO) in the bilateral peripheral lung fields and honeycomb-like cysts in the dorsal side of both lower lung fields, leading to a diagnosis of IP. Pulmonary function tests showed a vital capacity (VC) of 99.3%, and DLCO 54.2%. After he developed exertional dyspnea (Hugh-Jones Grade II) in March 2006, he was referred to our hospital and was admitted on June 20, 2006. Fine crackles were audible in both lower lung fields. Blood tests showed a white blood cell … Address correspondence to Dr. Ishida; E-mail: t-takeuchi{at}poh.osaka-med.ac.jp

Acute megakaryoblastic leukemia and severe pulmonary fibrosis in a child with down syndrome: Successful treatment with ultra low-dose cytarabine using GATA1 mutation to monitor minimal residual disease

Acute megakaryoblastic leukemia and severe pulmonary fibrosis in a child with down syndrome: Successful treatment with ultra low-dose cytarabine using GATA1 mutation to monitor minimal residual disease

Congenital Bronchial Atresia: Diagnosis and Treatment

This study aimed to retrospectively summarize the clinical signs, diagnosis, and treatment of congenital bronchial atresia (CBA) in 12 patients. Chest radiographs and computed tomographic (CT) images of 12 patients with CBA treated in the Chinese People's Liberation Army General Hospital were reviewed. Analysis of chest radiographs revealed ten patients had hilar mass-like shadows and two had pneumonia-like shadows; most patients (n = 8) showed hyperlucency of the peripheral lung fields. CT revealed a mucocele in all the patients (n = 12); the mucoceles were round in four patients and club-like in eight. In 80% of the cases (n = 10), associated anomalies, including occlusions of the bronchus central to the mucocele, emphysematous changes of the peripheral lung fields, bronchogenic cyst, and anomalous branching of the bronchial tree and vascular structure were observed. CBA was detected in the right lobe in eight patients and the left lobe in the remaining four. No surgical intervention was performed in 5 CBA patients and the remaining 7 patients underwent surgery, including lobectomy in 5 patients and local resection in 2 patients. Among these 7 patients, 3 had a preoperative diagnosis of malignant disease, and the remaining 4 had severe clinical symptoms that could not be effectively treated by medicines. All patients were followed up, and none experienced obvious discomfort. CBA is a relatively rare and benign malformation disease. Chest CT is the procedure of choice for diagnosis. The presence of a bronchocele and surrounding emphysematous changes are typical radiologic findings in CBA. Surgery should be reserved only for patients with serious complications secondary to the atretic bronchus.

Large Cell Neuroendocrine Carcinoma Arising from the Left Main Bronchus

A 67-year-old man was referred to our hospital for a detailed medical examination of a bronchial polyp that was detected during chest computed tomography. Bronchoscopic examination revealed a tumor that almost occluded the main left bronchus. Nd-YAG laser treatment and tumor removal with biopsy forceps were conducted. On the basis of the histopathological and immunohistochemical features, large cell neuroendocrine carcinoma (LCNEC), T2aN0M0, stage IB was diagnosed. After induction chemotherapy with a combination of cisplatin and etoposide, a sleeve resection of the left main bronchus with telescoping bronchial anastomosis was performed. LCNEC typically occurs in the peripheral lung field, but here, we report a rare case of LCNEC arising from the left main bronchus.

Lung cancer associated with idiopathic interstitial pneumonia

Idiopathic interstitial pneumonia (IIP) is known to have a tendency to be associated with lung cancer. Clinical characteristics of lung cancer associated with IIP are discussed in this article. Thirteen cases of lung cancer associated with IIP were examined from 1975 to 1988. A total of 590 cases of lung cancer and 38 cases of IIP were observed during that period. The 13 cases of lung cancer were found to be associated with IIP during the follow-up observation of our patients. Of these 13 patients, 12 men and a woman, the average age was 68.0 years old. All these 13 cases were ex- or present smokers. Five cases of lung cancer had no symptoms, but were detected by abnormal shadows on chest X-ray. Eight cases were detected symptoms. The duration from the onset of IIP to the onset of lung cancer was 36.5 +/- 23.5 months. Primary sites of lung cancer were distributed as follows. Nine cancers were in the left lung (64%) and five cancers were in the right lung (36%). Three cancers were in the hilar region (21%) and 11 cancers were in the peripheral lung field (79%). The numbers of lung cancers were equal in upper and lower lobe. The most common histological type was squamous cell carcinoma, followed by adenocarcinoma. Most cases were in stage III or IV. Three cases were operated, 4 were treated with chemotherapy, 4 were treated with chemotherapy plus irradiation, and 2 cases were treated by BRMs. The frequency of weight loss or finger clubbing in these patients was higher than in IIP patients without lung cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence and clinical features of lung cancer in patients with idiopathic interstitial pneumonia

We studied the incidence of lung cancer in the 599 patients with idiopathic interstitial pneumonia (IIP) who had visited to 37 institutions during 1991. In addition to 89 patients with lung cancer registered initially 29 were found during more than 4 years of follow-up, which indicates that annual incidence of lung cancer in these patients with IIP was a few percent. A total of 118 lung cancers accounted for 19.7% of all the IIP patients registered and also for 27.2% of the 435 IIP patients in whom a definite outcome was certified by this study. Most of the patients with lung cancer were older men who were heavy smokers. The distribution of histological types was not noteworthy. On the chest rentgenogrms, the tumors were found predominantly in the peripheral lung fields even in the patients with squamous cell cancer, but no apparent association with IIP lesion was observed. Surgical resection was done in only 52% of the patients with the disease at stage I or II; chemotherapy and/or radiotherapy were given to 52.4% of the patients with advanced disease, which may have been due to considerations of the adverse effects of anticancer treatment on the prognoses. The mortality in IIP patients with lung cancer was higher than in those without lung cancer, mainly due to progression of the lung cancer, not the IIP. This indicates the importance of lung cancer as a prognostic factor in patients with IIP.

Characteristics and management of patients with lung cancer and idiopathic interstitial pneumonia

Among 102 patients with idiopathic interstitial pneumonia (IIP), 22 with lung cancer who were treated from 1981 to 1994 were studied retrospectively. As controls, 248 patients with lung cancer only who were treated from 1991 to 1992 were also studied. Lung cancer developed in 6 of 85 patients after IIP was diagnosed (7.1%). The time from the onset of IIP to the onset of lung cancer was 7.7 years. In 17 patients both IIP and lung cancer were present on admission. In general, patients with IIP and lung cancer were heavy smokers. In patients with IIP and lung cancer, %VC was higher than in those with IIP alone, and 20 cancers (90.0%) were in peripheral lung fields. Seventeen patients received anticancer chemotherapy, irradiation, or both. Five patients (29.4%) died of respiratory failure due to progression of pneumonitis after the therapy. The prognosis for patients with IIP and lung cancer was very poor.

Chest computed tomography of a patient revealing severe hypoxia due to amniotic fluid embolism: a case report

IntroductionAmniotic fluid embolism is one of the most severe complications in the peripartum period. Because its onset is abrupt and fulminant, it is unlikely that there will be time to examine the condition using thoracic computed tomography (CT). We report a case of life-threatening amniotic fluid embolism, where chest CT in the acute phase was obtained.Case presentationA 22-year-old Asian Japanese primiparous woman was suspected of having an amniotic fluid embolism. After a Cesarean section for cephalopelvic disproportion, her respiratory condition deteriorated. Her chest CT images were examined. CT findings revealed diffuse homogeneous ground-glass shadow in her bilateral peripheral lung fields. She was therefore transferred to our hospital. On admission to our hospital's intensive care unit, she was found to have severe hypoxemia, with SpO2 of 50% with a reservoir mask of 15 L/min oxygen. She was intubated with the support of noninvasive positive pressure ventilation. She was successfully extubated on the sixth day, and discharged from the hospital on the twentieth day.ConclusionThis is the first case report describing amniotic fluid embolism in which CT revealed an acute respiratory distress syndrome-like shadow.

Lymphomatoid granulomatosis with splenomegaly and pancytopenia.

Lymphomatoid granulomatosis (LG) is an angiocentric lymphoproliferative disease. It usually involves lung, skin, and central nervous system, but splenomegaly and pancytopenia are the rare manifestations of the disease. We report a 15-year-old boy presented with fever, dry cough and dyspnea from two months ago, after admission patient had nodular lesions on the left leg and hepatosplenomegaly. Then he manifested neurologic signs such as seizure, aphasia and right-sided hemiplegia. Chest X-ray and CT scan revealed bilateral pulmonary nodules predominantly in lower lobes and peripheral lung fields. Laboratory exams showed pancytopenia. Skin biopsy was done, and histopathological examination and immunohistochemistry evaluation confirmed lymphomatoid granulomatosis. He was treated with steroid and cyclophosphamide but succumbed by neurologic involvement.

Chronic Thromboembolic Pulmonary Hypertension

Since the last World Symposium on Pulmonary Hypertension in 2008, we have witnessed numerous and exciting developments in chronic thromboembolic pulmonary hypertension (CTEPH). Emerging clinical data and advances in technology have led to reinforcing and updated guidance on diagnostic approaches to pulmonary hypertension, guidelines that we hope will lead to better recognition and more timely diagnosis of CTEPH. We have new data on treatment practices across international boundaries as well as long-term outcomes for CTEPH patients treated with or without pulmonary endarterectomy. Furthermore, we have expanded data on alternative treatment options for select CTEPH patients, including data from multiple clinical trials of medical therapy, including 1 recent pivotal trial, and compelling case series of percutaneous pulmonary angioplasty. Lastly, we have garnered more experience, and on a larger international scale, with pulmonary endarterectomy, which is the treatment of choice for operable CTEPH. This report overviews and highlights these important interval developments as deliberated among our task force of CTEPH experts and presented at the 2013 World Symposium on Pulmonary Hypertension in Nice, France.

Intrapulmonary lymph node mimicking a pulmonary metastasis associated with adenocarcinoma on high resolution computed tomography (HR-CT) findings

The widespread use of chest CT has increased the detection of small nodules in lung, and intrapulmonary lymph nodes are identified frequently among them. We report a case of intrapulmonary lymph node mimicking a pulmonary metastasis associated with adenocarcinoma. The patient was a 60-year old woman with a small nodule that was round shaped and existed subpleural portion of left upper lobe distant from primary adenocarcinoma. She underwent surgery, and histological examination of resected material revealed that the small nodule was composed of lymph node without malignant cell. Intrapulmonary lymph nodes (IPLN) should be included in the differential diagnosis of small nodules in the peripheral lung field.

Nine-Year-Old Girl With Lymphangiectasia and Chest Pain

Nine-Year-Old Girl With Lymphangiectasia and Chest Pain

Small Cell Lung Cancer Associated with Systemic Sclerosis

A 51-year-old woman developed small cell lung cancer (SCLC). She was a non-smoker and had interstitial pneumonia associated with systemic sclerosis (SSc). Sixteen additional cases obtained from the literature describing patients with SCLC associated with SSc are reviewed. The majority of patients were women with underlying interstitial pneumonia. In 3 patients who were non-smokers, interstitial pneumonia was complicated and cancer had developed in the peripheral lung field but not in the central lung field. Since SCLC is very rare in non-smokers, these findings suggest a positive association between SCLC and interstitial pneumonia associated with SSc.

Congenital bronchial atresia: radiologic findings in nine patients.

The purpose of this article is to describe the radiologic findings to diagnose congenital bronchial atresia. Chest radiographs, CT scans, and MRI of nine patients with congenital bronchial atresia were reviewed. Six patients (67%) had hilar mass-like shadows and hyperlucency of the peripheral lung field on chest radiographs. On chest CT scans, all patients demonstrated mucocele, occlusion of bronchus central to mucocele, and emphysematous change of the peripheral lung field. On chest MRI, performed in seven patients, all mucoceles demonstrated very high signal intensity on T2-weighted image, indicating that mucoceles were filled with fluid. Diagnosis of congenital bronchial atresia can be confirmed based on the findings of chest CT: mucocele, occlusion of bronchus central to mucocele, and emphysematous change of the peripheral lung field.

Intrapulmonary lymph nodes enlarged after lobectomy for lung cancer

A 62-year-old man, who had had a left upper lobectomy for mucoepidermoid lung carcinoma, was admitted again 3 months later because of enlargement of four small nodules in the left lower lobe. A computed tomography–guided needle aspiration biopsy obtained insufficient material for diagnosis, and because pulmonary metastases were suspected, two of the four tumors were extirpated. Intraoperative frozen section found the nodules to be intrapulmonary lymph nodes. Intrapulmonary lymph nodes should be included in the differential diagnosis of coin lesions in the peripheral lung field.

Expression of carcinoembryonic antigen in peripheral- or central-located small cell lung cancer: its clinical significance.

Small cell lung cancer (SCLC) has a higher percentage of hilar masses than other histological types of lung cancer. The primary site is usually adjacent to the hilum, but we often observe primary sites in the peripheral lung field. In this study, our objectives were to elucidate whether peripheral-located small cell lung cancer (PSCLC) is an independent entity and whether it differs clinically from central-located small cell lung cancer (CSCLC). We reviewed the clinical and pathological features of 52 patients treated at Kagawa Medical University Hospital between 1987 and 1996 with a diagnosis of SCLC. We defined CSCLC as a tumor whose primary site is located in the segmental bronchi or more proximally and PSCLC as a tumor located distal to the subsegmental bronchi. Twenty-one PSCLC patients and 31 CSCLC patients were identified. Kaplan-Meier survival curves were constructed and comparisons were made between PSCLC and CSCLC by the log-rank test. The carcinoembryonic antigen (CEA) level was also evaluated in each group. Although the percentage of limited disease (LD) in the patients with PSCLC was higher than that in the patients with CSCLC, the 3-year survival rate of PSCLC tended to be worse than that of CSCLC (9% for patients with PSCLC and 29% for those with CSCLC). Survival curves of patients with PSCLC also tended to be worse than those of patients with CSCLC, not only in the limited disease group but also in the extensive disease (ED) group. In addition, the mean CEA value in patients with PSCLC was higher than that in patients with CSCLC (p < 0.001), whereas the neuron specific enolase (NSE) level was not significantly different between PSCLC and CSCLC. The median survival of patients with pretherapeutic CEA titers of > or =5 ng/ml was significantly shorter than that in patients with CEA levels <5 ng/ml. These findings suggest that the survival of SCLC patients with a high CEA level was significantly shorter than that of patients with a low CEA level. In addition, CEA levels in PSCLC patients were significantly higher than those in CSCLC patients. However, the survivals of LD or ED patients with PSCLC and CSCLC were not statistically different.