Detection of pulmonary metastases in a patient with synovial cell sarcoma using In-111 labeled monoclonal antibody 19-24

A 35-year-old man was diagnosed in 1984 as having a synovial cell sarcoma of his right wrist without evidence of metastatic spread. The patient underwent regional hyperthermic chemoperfusion, wide-field excision, post-operative radiation therapy and systemic adjuvant chemotherapy. In 1986 and in 1987, because of new lesions found on chest radiographs, the patient underwent bilateral staging thoracotomies with resection of pulmonary metastases, followed by chemotherapy and radiotherapy. Later in 1987, a chest radiograph showed a large left hilar mass and multiple bilateral pulmonary nodules. Computerized tomography of the chest demonstrated a left hilar mass and two nodules in the right lower lung, raising the possibility of recurrent pulmonary metastatic cancer. As a diagnostic procedure, In-111 labeled monoclonal antibody (Mab) 19-24, produced against a human malignant fibrous histiocytoma, was infused intravenously, and 48-hour images revealed focal areas of increased uptake corresponding to the lesions seen on CT. At surgery, the lesions were confirmed to be synovial cell sarcoma. Imaging with Mabs specific for sarcoma may be particularly useful in sarcoma patients in whom there is clinical uncertainty regarding the nature of pulmonary lesions. In this case, the Mab was useful in distinguishing tumor deposits from postsurgical scarring and helped to guide subsequent surgery and treatment.     

卵巢颗粒细胞瘤的临床特点和CT诊断分析

目的分析卵巢颗粒细胞瘤的临床资料及CT资料,提高对该疾病的诊断能力。方法回顾性分析13例经手术病理证实的卵巢颗粒细胞瘤的临床及CT资料。结果13例患者中11例初发,且均为单个病灶,左侧卵巢5例,右侧卵巢6例,呈圆形或椭圆形。2例患者为复发,1例单发病灶,呈不规则形,1例3个病灶,呈圆形或椭圆形。CT表现初发病例与复发病例相似,多数肿块边缘光滑,与周围组织分界清楚,11个病灶表现为囊实性肿块,2个病灶以实性为主肿块,2个病灶以囊性为主肿块。增强扫描实性部分、囊壁及分隔不同程度强化,3例呈轻度强化,8例呈中度强化,2例呈明显强化。8例患者伴有不同程度子宫体积增大、子宫内膜增厚,3例患者伴有子宫肌瘤,6例患者伴有腹水。结论卵巢颗粒细胞瘤的临床特点及CT表现具有一定的特征性,但缺乏特异性,综合分析有助于提高该疾病的正确诊断率。     

CT of pulmonary dirofilariasis--differential diagnosis from lung cancer]

We present here four cases of pulmonary dirofilariasis in which histological examination of the surgical specimen showed occlusion of the peripheral pulmonary artery by filariae and formation of a necrotic mass surrounded by reactive inflammation and hemorrhage. Radiological examination showed a solitary pulmonary nodule in three cases and a wedge-shaped consolidation in one case. Although pulmonary nodules in dirofilariasis closely mimic bronchogenic carcinoma on radiographs , it is possible to distinguish them from bronchogenic carcinoma on the basis of the following findings: (1) coexistence of subtle satellite lesions, (2) absence of pleural involvement, (3) fine marginal speculations, and (4) lack of concentric marginal speculations (eccentric speculation). In each case of dirofilariasis, CT showed the peripheral pulmonary artery entering the mass. This finding differentiates this disease from metastatic lung tumor, because in tumor metastasis via the pulmonary arteries, visible vessels are not usually involved.     

A case of pulmonary synovial sarcoma diagnosed with detection of chimera gene: imaging findings

Pulmonary synovial sarcoma is a rare disease, and reports detailing clinicians' radiological findings are few. We report a case of a primary pulmonary synovial sarcoma in a 68-year-old woman. Chest CT revealed a well-defined and homogeneous oval mass measuring 3x2.5 cm in the left lower lobe in contact with the visceral pleura. No pleural effusion was evident. No calcification or fat component was detected. The tumor showed homogeneous hypointensity on both T1- and T2-weighted MR imaging. In this case, a lung metastasis could be excluded with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET), and the final diagnosis was histopathologically confirmed by the chimeric gene detection.     

Increased FDG uptake in pulmonary epitheloid hemangioendothelioma

A 40 year-old female was examined for complaints of left arm pain and restriction of movement in the left upper extremity for 3 months. Chest X-ray showed a mass in the left upper lung and the patient was evaluated with computed tomography that confirmed the significant mass in the left paratracheal region and also showed small nodules in both of the lungs. A whole-body FDG-PET scan was performed for the suspicion of malignancy. FDG-PET indicated high FDG accumulation in the lung lesions mainly in the left paratracheal region. FDG-PET findings were highly suspicious of malignancy so the patient had thoracoscopic biopsy of the lesion. The histological findings and immunohistochemistry tests were consistent with pulmonary epitheloid hemangioendothelioma (PEH). Epitheloid hemangioendothelioma (EH) is a systemic name that represents a rare type of malignant tumor of vascular endothelial origin, which can arise in bone, liver, soft-tissue, or lung. PEH is currently known as the lung form of EH. Consequently, our patient had resection of the left paratracheal mass. This report presents a rare case of histologically confirmed PEH, which showed increased FDG accumulation on FDG-PET study. PEH should be added to the other causes of increased FDG uptake.     

Pulmonary embolism—the initial manifestation of renal cell carcinoma in a young woman

We report a case of massive pulmonary embolus demonstrated on CT in a young woman presenting with dyspnea, with no known risk factors for embolism. Abdominal CT on further investigation showed a renal tumor invading the left renal vein and the inferior vena cava as the cause of the pulmonary embolus. In a patient presenting with pulmonary artery embolism without venous thrombosis, the differential diagnosis should include an occult tumor as the cause of the embolus. Electronic Publication     

Medullary carcinoma of the breast: a malignant lesion mimicking a benign one

Medullary carcinoma of the breast is an unfrequent type of tumor. We present a case of medullary carcinoma of the breast. The patient presented with a palpable breast mass, corresponding on mammography to an obscured mass, which showed a cystic appearance with thick wall on sonography. We review the radiological findings of this type of tumor which should be considered in the differential diagnosis of lesions with well-circumscribed margins.     

Pulmonary vein tumor thrombosis and left atrial extension in lung carcinoma

A case of lung carcinoma extending into left atrium through a pulmonary vein and mimicking left atrial myxoma is presented. The localized enlargement of a pulmonary vein is seen as a possible CT sign of pulmonary vein tumor thrombosis. Computed tomography (CT) and echocardiography are complementary in the correct diagnosis of this condition.     

Giant cell tumor of bone in a patient with diagnosis of primary hyperparathyroidism: a challenge in differential diagnosis with brown tumor

Giant cell lesions of bone share similar clinical, radiological, and histological features. The most challenging differential diagnosis is between giant cell tumor (GCT) and brown tumor (BT) secondary to hyperparathyroidism. Differential diagnosis is based on determining serum calcium concentration and other markers of calcium metabolism. The authors present the unusual case of a 37-year-old Caucasian woman affected by a GCT of the proximal left tibia and concomitant asymptomatic primary hyperparathyroidism (PHPT) due to a parathyroid adenoma. The presence of two concurrent diseases complicated diagnosis and relative treatment. The patient was first treated for the adenoma, then after 9 months, she underwent curettage of tibial GCT. Denosumab treatment was administered for 12 months to control a relapse occurring at 15 months post-curettage. At 32-month follow-up from primary tibial surgery, the patient was free from tumor disease. To our knowledge, this is the first case in the literature reporting the concomitant presence of asymptomatic PHPT and GCT. The possibility of concomitant finding these two diseases has to be considered during the decision-making process.     

Case report of death from falling: Did heart tumor cause syncope?

A healthy man in his 30s was working on the balustrade of stairs on the second floor. He suddenly fell downstairs without saying anything. On emergency hospitalization, chest echogram showed left hemothorax. Cardiac echogram showed a floating mass from the mitral valve in the left ventricle and severe mitral regurgitation. Surgery for hemothorax and pulmonary contusion was immediately undertaken. However, bleeding from pulmonary contusion could not be controlled and he underwent cardiopulmonary arrest. Autopsy showed a white, elastic, pendulous mass in the left atrium and a white mass in the lower lobe of the left lung. Tumor histology showed a reticular pattern, Schiller-Duval bodies, eosinophilic hyaline globules, and positive staining for α-fetoprotein. We diagnosed primary lung yolk sac tumor with metastatic intracardiac yolk sac tumor, a rare and highly malignant germ cell tumor. It usually arises in the ovaries and testes, and intracardiac yolk sac tumor is rare. Intracavitary tumors induce obstruction of inflow into and outflow from the ventricular cavity. The most common clinical presentation is dyspnea and syncope. In the present case, metastatic cardiac yolk sac tumor might have disturbed cardiac outflow and affected hemodynamics, probably causing syncope. Unfortunately, he was in a high place at that time and fell to receive pulmonary contusion that led to death. Autopsy may sometimes reveal latent diseases which might be related to the cause of death. We should perform autopsy thoroughly to diagnose not only the cause of death but also the factors leading to death.     

A first described chest wall metastasis from colon cancer demonstrated with (18)F-FDG PET/CT

It is well known that, haematogenous colon cancer metastases are most commonly found in the liver, less likely in the lungs through the paravertebral venous system and rarely in other organs. Sporadic clinical cases of colon cancer metastases to the abdominal wall, the thyroid or the adrenal glands have been reported. Here, we present an uncommon case of chest wall metastasis from colon cancer demonstrated with 2-fluoro [fluorine-18]-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT). A 52 years old female patient was examined after she felt a swelling mass above her left breast. Tumor makers, such as serum cancer embryonic antigen (CEA) 146.22kU/L (normal range:0.00~37.0kU/L) and CA19-9 (258.16μg/L (normal range:0.00~10.0μg/L) and neuron-specific enolase (NSE) 78.2 (normal range: 0.00~17.00) were abnormally high. Chest CT revealed the soft tissue density mass on the left anterior chest wall with invasion of left 4th rib, and CT-guided biopsy showed a poorly differentiated adenocarcinoma of unkown origin. The patient was then referred for the (18)F-FDG-PET scan which was performed one hour after the intravenous injection of 370MBq of (18)F-FDG (Discovery Camera, VCT, GE, USA) and showed in addition to the chest mass, abnormal (18)F-FDG accumulation in both lungs, left supraclavicular and peritoneal lymph nodes. Furthermore, high (18)F-FDG uptake was detected in the sigmoid. Pathology findings from colonoscopy confirmed that this was a sigmoid colon adenocarcinoma. So far, chest wall metastasis from colon cancer as an initial finding has not been reported. Usually, an initial chest wall mass is hardly suspected to be a colon cancer metastasis. Abnormal serum tumor markers such as CEA and CA19-9 supported the diagnosis of a gastrointestinal adenocarcinoma. In our case, we found high serum NSE and normal findings of bowel wall on the CT scan, thus without the positive (18)F-FDG findings, one would probably consider as first diagnosis: chest wall metastasis from lung cancer, or a neuroendocrine tumor. The unusual finding in this case was that on the CT images there was no obvious local density of the intestine, no bowel wall thickening, or suspicious nodular lesions. Segmental (18)F-FDG accumulation seen in the sigmoid colon had early maximum standardized uptake value (SUV(max)) 7.3 and in 1h delayed estimation, 8.1. Colonoscopy showed that the (18)F-FDG-avid area at the colon was circular and thickened. "Hot" lesions found in both lungs, the supraclavicular and retroperitoneal lymph nodes by (18)F-FDG PET/CT scan were considered to be most probably metastases from colon adenocarcinoma. In conclusion, PET as a rather simple procedure and less dependent on bowel preparation diagnosed the primary colon cancer, its metastases and specifically a first described chest wall metastasis, while CT alone did not show the primary tumor.     

周围型肺癌阻塞性病变的CT表现(附18例分析)

目的:确定深呼吸时相CT扫描对周围型肺癌诊断敏感性。材料与方法:18例周围型肺癌(13例经病理证实,5例由其它方法证实)和12例良性肺肿块对照者(炎性假瘤和结核球等)均经常规CT扫描,除2例炎性假瘤患者外,其余所有病人并经肿块部位及其上下一层的深呼吸时相CT扫描。结果:周围型肺癌深呼吸时相CT扫描所见的阻塞性病变计有4例肺不张,12例阻塞性肺炎(按其帮位进而可分为远离肿块的和邻近肿块的阻塞性肺炎),1例阻塞性肺气肿,以及1例肺静脉癌栓。周围型肺癌的这些CT表现,在良性肺肿块对照者中不复被看到。结论:深呼吸时相CT扫描所见的远离肿块的阻塞性肺炎及肿块外侧的阻塞性肺气肿,可被看作是周围型肺癌的特有表现而且是其早期诊断的依据。     

A case of sclerosing hemangioma surrounded by emphysematous change

A 44-year-old woman presented with high-grade fever. Chest radiography showed a 30 mm solitary pulmonary mass in the left lower lobe. Chest CT revealed a well-defined solid mass in the left lower lobe. On contrast-enhanced CT, the mass showed homogeneity and mild enhancement. There was an emphysematous portion in the surrounding lung parenchyma. The patient underwent partial lobectomy of the left lower lobe. The final diagnosis of sclerosing hemangioma with abundant vasculature was confirmed pathologically. Pulmonary sclerosing hemangioma is a rare benign neoplasm. Some cases have been reported in which sclerosing hemangioma is surrounded by air spaces. We suggest that the air spaces around the tumor were formed by not only peritumoral bleeding but also a check-valve effect of the compressed bronchus.     

A case of septic pulmonary embolism associated with renal abscess mimicking pulmonary metastases of renal malignancy

We report the case of a 46-year-old woman with acute febrile symptom who had multiple pulmonary nodules and a renal mass. She underwent ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to find a hidden malignancy and the cause of her fever. FDG PET/CT images demonstrated a renal mass and multiple lung nodules with intense FDG uptake, which was suspicious of a renal malignancy with multiple pulmonary metastatic lesions. CT-guided biopsies of the pulmonary and renal lesions only showed chronic inflammatory infiltrates without evidence of malignancy. She was diagnosed with septic pulmonary embolism from a renal abscess. One month after antibiotic treatment, the follow-up chest and abdomen CT showed improvement of the lung and renal lesions. This is the first case demonstrating the FDG PET/CT finding of septic pulmonary embolism associated with renal abscess in the published literature.     

MRI of angiomatoid fibrous histiocytoma

Angiomatoid fibrous histiocytoma is a rare soft tissue tumor of low-grade malignancy. We present the case of a 32-year-old man who complained of soreness and numbness over his left arm and hand over the previous 2 months and of having a palpable mass over his left upper back for 4 years. Magnetic resonance imaging (MRI) showed an intramuscular soft tissue mass in the left scapular region. The tumor mass was seen to have multiple cystic components with fluid-fluid levels. Histological examination showed multiple cystic spaces filled with blood lakes and hemosiderin deposits in the solid part of the tumor. After the initial surgery, the patient had local recurrences over 2.5 years. The immunohistochemical study at the second surgery showed that the recurrent tumor was strongly positive for the histiocytic marker CD68, and the myoid trait desmin. Histological diagnosis was compatible with angiomatoid fibrous histiocytoma.     

Gastrointestinal stromal tumor of the small intestine with lung metastasis

Gastrointestinal stromal tumours (GISTs) represent 1% of primary gastrointestinal cancers. These tumors most frequently metastasise to the liver and peritoneum and rarely to the lungs. We report the case of a 79-year-old woman with gastrointestinal stromal tumor of the small intestine and pulmonary metastases. Contrast-enhanced computed tomography (CT) revealed a focal mass centered around the last intestinal loop associated with pulmonary bilateral masses. The diagnosis of gist of the small bowel was confirmed by histopathological and immunohistochemical analyses of bioptic material obtained from CT guided biopsy of pulmonary lesions. To the best of our knowledge, only few cases had been reported in medical literature as This mode of presentation is unusual, with computed tomography (CT) playing a significant role in the diagnosis and management.     

Diagnostic Radiation Oncology:¶Malignant Cystosarcoma Phylloides

BACKGROUND: Cystosarcoma phylloides is a rare, mostly benign tumor of the breast. In most cases curative treatment is possible with complete surgical excision of the lesions. However, there is a high local recurrence rate up to 46%. There are only few reported successful treatments with radiotherapy in cystosarcoma phylloides. Radiotherapy is indicated in patients with locoregional recurrent disease and those with symptomatic metastases. PATIENT: We present a case of a 54-year-old woman with a painless mass in the right breast. Clinical examination showed a large, firm tumor and axillary lymph node metastases. The patient underwent mastectomy and axillary lymph node dissection. Histopathology showed a cystosarcoma phylloides measuring 30 x 25 x 19 cm as well as lymph node metastases measuring 9.5 cm. Despite a R0 resection the patient developed 4 thoracic wall recurrences within 2 years. At 18 months there were additional multiple pulmonary and pleural lesions with a maximum diameter of 6.5 cm. Subsequently the patient received polychemotherapy. There was a significant response of the thoracic wall disease as well as of the pulmonary and pleural lesions. Six months later there was further progress of the thoracic wall disease and the pulmonary lesions. Following this the patient underwent radiation therapy of her right thoracic wall with 50 Gy which lead clinically to a quick response. For the past 5 months there has been no evidence of thoracic wall disease recurrence. CONCLUSION: This is an unusual case of cystosarcoma phylloides and response to different therapeutic modalities. Cystosarcoma phylloides showed to be a radiosensitive tumor. Thus postopertive radiation therapy is indicated to prevent local recurrences.     

Well differentiated fetal adenocarcinoma of the lung in a 38-year-old woman: dynamic computed tomography findings

We report a case of well-differentiated fetal adenocarcinoma (WDFA) of the lung, with emphasis on dynamic CT (computed tomography) findings. The patient was a 38-year-old woman who was found to have a mass in the left upper lung field in chest radiograph screening. Chest radiograph showed a 5.5 cm well-defined mass in the left upper lung field. CT revealed a well-circumscribed mass measuring 5.5 × 5.5 × 5.0 cm with a lobulated margin in the left upper lobe. Intratumoral enhancing vasculature was noted in the early phase of dynamic CT. In the delayed phase, persistent and plateau enhancement was seen. The tumor also had consistently unenhanced areas, suggesting the presence of necrosis. Left upper lobectomy with mediastinal lymph node dissection was performed. The pathology specimen contained tubular glands consisting of non-ciliated columnar cells with areas of solid nests of epithelial cells with weakly eosinophilic cytoplasm (morule) mimicking fetal lung tissue. The tumor was moderately vascularized with areas of comedo necrosis; the stroma was relatively scanty. Final pathological diagnosis was WDFA with left hilar lymph node metastasis (stage T2bN1M0). This is the first report of dynamic CT findings of WDFA, a rare lung tumor. Although these findings are non-specific, they well reflected the pathological characteristics of this tumor.     

Extraskeletal Ewing sarcoma of the buccal space

Extraskeletal Ewing sarcoma (EES) is a rare soft tissue tumor, and EES of the head and neck is particularly rare. Radiographic imaging of these lesions is crucial given their anatomical complexity and infrequent incidence. Conventional EES imaging features include a large, hyperintense, heterogeneously enhancing lesion, with frequent invasion of local structures. In this case report, a 19-year old male presented with left facial swelling and pain. He underwent sclerotherapy and bleomycin treatment for a presumed lymphatic malformation. Initial imaging demonstrated a rim-enhancing lesion within the left buccal space with no muscle invasion or bony erosion present. Two years later, imaging identified an enlarging buccal mass with destruction of the zygomatic arch and inferolateral orbital wall. The patient underwent surgical resection of the mass. Pathology confirmed the mass to be a small round blue cell tumor and FISH testing confirmed the presence of the EWSR1 gene arrangement that is consistent with EES. The patient tolerated the procedure well and underwent chemoradiation therapy. At three years postoperatively, the patient remains disease free. The presented case demonstrates an unusual presentation of a buccal space EES as a rim-enhancing, centrally hypointense mass with no bony erosion or muscular invasion. The location and atypical imaging appearance of this case offer insight for future diagnosis of EES.