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Slide Seminar 17 - Pulmonary Tumors
Wednesday, September 20, 2006 08:00 - 12:00
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Moderators:
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Dr. Elizabeth Brambilla, Dr. John English and Dr. Donald Guinee
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Disclosure:
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In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. Faculty members for this Symposium have indicated they have no disclosures to make.
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Clinical histories are displayed below.
Click on the case numbers to display the text and references for each case.
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- Bronchioloalveolar Carcinoma
Submitted by: Dr. Maureen Zakowski
The patient is a 67 year old white man who presented to his local emergency room with shortness of breath. His past medical history was non-contributory and he had a remote 10 pack year history of smoking; he stopped 32 years ago. He was found to have a left upper lobe lung mass on chest X ray and follow up CT demonstrated a 2 cm lobulated left upper lobe mass and a right upper lobe ground glass opacity. PET can revealed uptake in the left upper lobe with SUV of 3.9 and negative uptake in the right upper lobe opacity.
He underwent a right upper lung lobectomy which found two similar appearing lung adenocarcinomas, both with acinar and non-mucinous bronchioloalveolar patterns. BAC made up 30 and 50% of the tumor types.
A month later he underwent a left upper lobectomy where two adenocarcinomas both with BAC growth patterns in addition to acinar growth. Both tumors had approximately 10% BAC.
Material from both sides of the lung was found to have a EGFR mutation consisting of an exon 19 deletion.
This slide is taken from the right upper lobectomy.
Case 1 - Slide 1
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- Atypical Carcinoid Tumour Associated with Adenocarcinoma
Submitted by: Dr. Philip S. Hasleton
68-year-old male, ex smoker, presented with hemoptysis. On CT scan, a mass was identified in the lingula and on bronchoscopy, there was a mass obliterating the left lingular bronchus. A left upper lobectomy was performed with a tumour protruding through the inferior bronchial resection margin, within 2 mm of the cut edge. The tumour was well demarcated, cream coloured and measures 6.0x3.5x3.5 cm. the uninvolved lung was unremarkable apart from emphysema at the apex.
Case 2 - Slide 1
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- Lymphoepithelioma-like Carcinoma of Lung
Submitted by: Dr. Claudio Y. Castro
49 year old Hispanic male who complained of cough for 2 months. His past medical history was significant only for heavy smoking (2 pack of cigarettes /day/ 15 years). A chest radiograph showed a well-circumscribed nodule in the periphery of the right upper lobe. Patient underwent wedge resection. After frozen section diagnosis, a completion of the lobectomy was performed.
Gross finding: The specimen consisted if a wedge biopsy of lung (4.8 x 2.3 x 2.2 cms) containing a relative well circumscribed 1.4 cms subpleural nodule. The cut surface was white, firm and focally necrotic. The nodule was located at 1.0 cms from the staple surgical resection margin.
Case 3 - Slide 1
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- Metastatic Versus Primary Carcinoma of the Lung
Submitted by: Dr. Keith Kerr
A 46 year old male Caucasian was referred to his local district general hospital with a history of cough productive of purulent sputum and pain over the right side of his chest. He was a life-long cigarette smoker.
On examination he had finger clubbing. Chest CT scan showed a 7cm right lower hilar mass apparently indenting the right atrium. A 1.8 cm nodule was also noted in the left lower lobe. Extensive mediastinal lymphadenopathy was reported. Bronchoscopy, including biopsy and cytology was negative but percutaneous trans-thoracic fine needle aspiration cytology of the left lower lobe mass shower unequivocal malignancy reported as squamous cell carcinoma. He was deemed inoperable and given chemotherapy with apparent response.
Five years later he re-presented to hospital after being lost to follow-up with recurrence of right-sided chest pain. Chest CT again showed the right hilar mass lesion, the left lower lobe lesion measured 1.2 cm and there was no evidence of mediastinal lymphadenopathy. He was reviewed at the regional cardiothoracic surgery centre. Detailed work-up showed no evidence of disease outside the lungs and the patient underwent wedge biopsy of the left lower lobe nodule and later, right pneumonectomy. The tumour was adherent to the pericardium and oesophagus but there was no mediastinal lymphadenopathy.
Postoperatively he received radiotherapy and had over three symptom-free years before death from myocardial infarction 3 years after surgery. At necropsy recurrent tumour was evident in the mediastinum.
Case 4 - Slide 1
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- Squamous Cell Carcinoma Arising in Idiopathic Pulmonary Fibrosis
Submitted by: Dr. Sylvie Lantuejoul
70 year-old smoker (40 pack-years) with a past history of lung fibrosis with honeycombing diagnosed three years ago. The patient's pulmonary function tests showed a severe restrictive defect and CT scan showed honeycombing predominating in both bases. He was found to have a left lower lobe mass which was increasing in size. A lobectomy was performed. (Slide A: mass; Slide B: non-tumoural lung).
Case 5 - Slide 1
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Case 5 - Slide 2
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- Pulmonary Synovial Sarcoma
Submitted by: Dr. Thomas Colby
A 34-year-old man presented at age 30 with a 5.5x4.5x4.0 cm mass in the left lung that was resected. Resection was followed by radiation and chemotherapy with VP16 and cisplatin. Fours years later, at age 34, he was found to have two nodules in the left lung and these were excised and both were similar. Your slide comes from one of these nodules of recurrent neoplasm.
Case 6 - Slide 1
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- Bronchioloalveolar Carcinoma (BAC) Arising in a Type 1 Congenital Cystic Adenomatoid Malformation (CCAM)
Submitted by: Dr. Andrew Nicholson
Male patient presented with an infected intrapulmonary cyst in 1995, aged 11, and reported as an infected bronchogenic cyst. He subsequently presented, aged 19, with further chest sepsis and underwent lobectomy. The representative slide is from the lobectomy. The patient is alive and symptom free at 3 years.
Case 7 - Slide 1
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- Pulmonary Langerhans Cell Histiocytosis
Submitted by: Dr. Andras Khoor
A 45-year-old male cigarette smoker presented with an asymptomatic solitary pulmonary nodule in the left upper lobe. He underwent thoracotomy and wedge excision of the lesion. After the operation, he continued to smoke. Twenty-one years later, at the age of 66 years, he presented with a new asymptomatic solitary nodule in the right upper lobe. CT showed only a single pulmonary nodule with no evidence of interstitial lung disease. Since the second lesion was benign by radiographic criteria, no biopsy was performed. However, the original wedge excision was re-reviewed.
Case 8 - Slide 1
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