A case of primary anterior mediastinal choriocarcinoma

A 25-year-old man was admitted to our hospital because of hemosputum and abnormal shadows on chest X-ray film. The chest film showed a mass shadow located in the right hilum and multiple coin lesions in bilateral lung fields. The chest CT scan showed a bulky mass sized 7 cm X 6 cm at the anterior mediastinum. This case was suspected to be choriocarcinoma because he was young, it was rapidly progressive and also because serum LDH and beta-HCG values were raised. The specimens obtained by surgical biopsy showed HCG-stain positive syncytiotrophoblasts. Cancer chemotherapy was started with CDDP and other anti-cancer drugs, but he succumbed about 3 months after admission. Autopsy findings showed no scar formation of his testes, and the primary lesion was finally diagnosed to be in the anterior mediastinum. Extra-gonadal choriocarcinoma is rare, and beta-HCG is very useful for its diagnosis and the follow-up of the clinical course.     

Pulmonary alveolar proteinosis noted in a patient with thymoma

A 74-year-old woman had general fatigue and mild fever in August 2004. Her chest X-ray showed slight ground glass opacities in the upper and middle lung fields of both lungs. Though she was prescribed antibacterial drugs, the abnormal shadows on chest X-ray did not improve. The chest CT showed ground glass opacities and reticular shadows with thickened alveolar septa (crazy-paving appearance) in both lungs, and a clearly defined mass in the anterior mediastinum. She underwent thymo-thymectomy with wedge resection of the upper lobe of the left lung. Anterior mediastinum tumor was pathologically diagnosed as thymoma. Lung biopsy demonstrated alveoli filled with SP-A positive granular materials, and we diagnosed pulmonary alveolar proteinosis. About 1 month after operation, the shadows on chest CT showed improvement. We think there might be some relationship between thymoma and pulmonary alveolar proteinosis.     

A case of arc welder's lung with ground-glass opacities and progressive massive fibrosis]

A 62-year-old man who had worked as a welder for 35 years was admitted with abnormal chest radiograph shadows. Chest CT scan showed ground-glass opacities (GGO) and nodular shadows (progressive massive fibrosis: PMF) with spiculation in both lung fields. Transbronchial lung biopsy (TBLB) findings of a nodule (left segment 8) revealed many iron particles in the alveoli and positive staining for Fe (Berlin blue stain). Moreover, bronchoalveolar lavage (BAL) fluid of a GGO (left segment 4) revealed many iron particles and positive staining for Fe (Berlin blue stain) in macrophages. Serum ferritin was extremely high (6.352 ng/ml) and ferritin in the BAL fluid was 210 ng/ml. Taking the clinical course and pathological findings together, pneumoconiosis (arc welder's lung) was diagnosed. The most common chest CT pattern in arc welder's lung is ill-defined micronodules diffusely distributed in the lung like hypersensitivity pneumonitis. Arc welder's lung rarely presents as PMF. We report a case of arc welder's lung accompanied with PMF.     

A case of adenocarcinoma of lung with idiopathic pulmonary fibrosis, showing 1 8-fluorodeoxyglucose uptake in positron emission tomograhy]

A 61-year-old man consulted our hospital because of bloody sputum. Cells of Class V (adenocarcinoma) were found on sputum cytologic examination. Chest computed tomography (CT) showed reticular shadows but no obvious mass was detected. Positron emission tomography with 18-fluorodeoxyglucose (FDG-PET) revealed FDG uptake in both lower lung fields and more increased FDG uptake in a small area of the left lung field. Repeated chest CT, bronchial brushing, bronchial washing, and lung-imaging fluorescence endoscopy were performed, however, resulting in no detection of the primary site of lung cancer. Six months after initial consultation, chest CT showed an enlargement of the shadow in left S6 corresponding to the area of the more increased FDG uptake in PET. On the other hand, the shadow in right S10 did not change in size. Bronchial brushing of the left S6 was performed again, and class IV cells (adenocarcinoma) were found. After left lower lobectomy, diagnoses of well differentiated adenocarcinoma and usual interstitial pneumonia (UIP) were established histologically. There has been no report demonstrating the efficacy of FDG-PET for diagnosis of lung cancer with idiopathic pulmonary fibrosis (IPF).However, combination of lung cancer should be considered if PET shows spots of high FDG uptake in the lung fields of IPF.     

A case of thymic cyst with elevated CEA in the cystic fluid

A 66 year-old male was admitted on October 31, 1987 because his chest X-ray film revealed a well-defined round shadow in the right inferior mediastinum. Chest CT showed a large homogenous mass in the right anterior mediastinum. The mass was identified as a cyst on echogram. Surgical removal of the cyst was done with right thoracotomy. The cyst was 15 cm in size and contained about 500 ml of grayish white fluid. Pathological examination showed a thymic cyst and no malignancy. Biochemical analysis of the cystic fluid revealed increased CEA value of 223.2 ng/dl in spite of normal CEA level in serum. CEA was demonstrated in the epithelium of the surface and Hassall's corpuscles by PAP stain. It is conceivable that this elevated CEA observed in the cystic fluid might be correlated with CEA-like antigens such as NCA, NFA and BGP.     

A case of occult breast carcinoma with micronodular shadows on chest x-ray film]

A 57-year-old woman was admitted to our hospital for the evaluation of roentgenological micronodular shadows of the bilateral middle and lower lung fields. Physical findings were normal except for left axillary lymph adenopathy. The level of tumor marker NCC-ST-439 was markedly elevated (2800 U/ml). Histological examination of the transbronchial biopsy and the swollen lymph node biopsy specimens showed proliferation of identical tumor cells. Breast or lung carcinoma was suspected as the primary site. Echogram of the left breast showed microcalcification without a mass. The biopsy specimen obtained from the calcified lesion indicated occult breast carcinoma. From these findings the diffuse micronodular shadows on the chest roentgenogram were considered to be the metastatic lesions of occult breast carcinoma. This case indicates that occult breast carcinoma should be considered as a possible primary site for diffuse pulmonary metastatic lesions.     

A case of angioimmunoblastic T-cell lymphoma with interstitial shadow which disappeared after injection of hydrocortisone]

A case of angioimmunoblastic T-cell lymphoma (AITL) was reported. A 56-year-old woman was admitted because of high fever and systemic lymphademopathy. Her chest X-ray on admission showed mediastinal and bilateral hilar lymphademopathy (BHL) and interstitial shadows in both lower lung fields. Chest CT scan revealed thickening of interlobular septum and bronchovascular bundles. There was a remarkable elevation in serum soluble interleukin-2 receptor. A biopsy of cervical lymph nodes for histopathological examination revealed AITL. After intravenous injection of 200mg of hydrocortisone for 7 days, the interstitial shadows and BHL disappeared. It was suspected that interstitial shadow was caused by pulmonary infiltration of AITL.     

Multiple hepatic metastases due to germ cell tumor on initial clinical presentation]

A 31-year-old man presented with abdominal pain. Abdominal computed tomography (CT) demonstrated heterogeneously enhanced liver masses and chest CT revealed an anterior abnormal mass. He was admitted for further examination and treatment. The patient's serum beta-HCG level was markedly elevated (2,300ng/ml) and liver biopsy revealed the presence of choriocarcinoma and positive immunostaining for HCG. The patient was suspected to have combined germ cell tumor in the mediastinum with multiple liver metastases. He was treated with 8 cycles of BEP therapy (cisplatin. etoposide, bleomycin) and the beta-HCG level was normalized. We report a case of germ cell tumor with multiple and diffuse hypervascular masses in the liver as the initial clinical manifestation.     

A case of pulmonary actinomycosis marked by diagnostic difficulty]

A 59-year-old man was admitted to our hospital for evaluation of an abnormal lung shadow. Chest X-ray and computed tomographic (CT) films showed a mass shadow in the left lower lobe. The shadow decreased in size after the administration of imipenem/cirastatin and clindamycine. Although a transbronchial lung biopsy failed to confirm the diagnosis, histologic examination of percutaneous aspiration biopsy specimens revealed sulfur granules. Actinomycosis was diagnosed but we did not rule out the possibility of coexistent carcinoma. A left lower lobectomy was performed, and the patient has been well without any complaints or recurrence of actinomycosis for 6 months after surgery. We concluded that pulmonary actinomycosis should be considered another candidate for the differential diagnosis of mass shadows from lung cancer.     

Isolated pulmonary choriocarcinoma]

The author report a case of isolated choriocarcinoma of the lung revealed in a young woman by a tumoral syndrome of the right base with haematoma. The diagnosis of isolated pulmonary choriocarcinoma was based on the lack of previous gynaecological history and tumour, on the singleness of the lung tumour at CT, and on the high initial beta-CGH level (3,300 ng/ml) in the absence of pregnancy. Surgical resection confirmed the diagnosis and lowered the beta-CGH level to 7 ng/ml. The various aetiopathogenic theories put forward and their relations with the prognosis disparity found in the literature are reviewed. The authors compare the prognosis of isolated pulmonary choriocarcinoma in a non-nulliparous woman to that of placental choriocarcinoma.     

Three cases of Mycobacterium avium lung disease in an iron foundry]

We report three cases of M. avium lung disease, all occurring in the same iron foundry over a 5-year period. Case 1: A 38-year-old man was admitted to our hospital because of abnormal chest x-ray shadows observed during a routine checkup. M. avium complex was isolated from the sputum and a CT scan showed multiple nodular shadows with cavities. Case 2: A 63-year-old man presented with dyspnea. Chest CT showed nodular shadows in both upper lobes. M. avium complex was isolated from his sputum. Case 3: A 62-year-old man was hospitalized for treatment of diabetes mellitus. A nodular cavitary shadow* OK?* in the right upper lobe was observed in the radiograph. CT scanning demonstrated a nodular shadow with thick pleural indentation. M. avium was isolated from the sputum and gastric juices. There were similarities in the radiographic findings in all cases: nodular shadows with cavities in the upper lung fields. These findings differed from those in another M. avium infection in the lung which occurred in a middle-aged woman. We suspected inhalation of an aerosol contaminated by M. avium complex. There have hitherto been no reports of group infections in healthy persons. We suspected the same environmental source for the infection.     

Intralobar pulmonary sequestration presenting increased serum CEA, CA 19-9, and CA 125, and associated with asymptomatic pulmonary aspergillosis]

A 44-year-old woman was admitted to our hospital for further evaluation of a consolidated shadow in the left lower lobe and the evaluation of serum tumor markers (CEA 46.3 ng/ml, CA 19-9 1911 U/ml, and CA 125 103 U/ml). Chest computed tomography revealed an irregular shaped, low density mass shadow in the left S10 region, suggesting the diagnosis of pulmonary sequestration or bronchial atresia. However digital subtraction angiography failed to demonstrate an anomalous feeding artery. We could not rule out the possibility that a malignant lesion was included in the consolidated shadow. A left thoracotomy revealed an intralobar pulmonary sequestration of the left lower lobe. Hyphae of aspergillus were found in the lumen of the cystic bronchus of the resected lung. Immunohistochemical studies showed strong expression of CEA, CA 19-9, and CA 125 by bronchial epithelia in the pulmonary sequenstration. The serum values of tumor markers returned to their normal ranges after surgery.     

A case of combined squamous cell carcinoma and aspergilloma arising in a cyst wall]

A 76-year-old man in whom interstitial pneumonia and diabetes mellitus had been diagnosed complained of bloody sputum in August, 1998. Chest radiography disclosed irregular shadows in the left lower lung field. Chest computed tomography (CT) scans revealed a cyst and a small nodular lesion in the left S6 segment. Although primary lung cancer was suspected, we did not detect any malignant cells in the transbronchial lung biopsy specimen. CT scans in January 2000 showed a ball-like shadow in the thick-walled cyst in the left S6 segment. Cytologic examination of the sputum and the bronchial lavage fluid from the left B6 revealed squamous cell carcinoma. Left lower lobectomy and mediastinal lymph node dissection were performed. Pathological examination revealed that moderately differentiated squamous cell carcinoma had extensively invaded the wall of the cyst in the left S6 and S10 segments, and was accompanied with aspergilloma. Abnormal thickening of a cyst wall may in some cases suggest the presence of lung cancer.     

Japanese spotted fever complicated by acute respiratory failure

A 66-year-old male was admitted to our hospital, presenting a high fever and generalized erythema on June 9, 1999. Physical examination revealed many eschars on his legs. Laboratory examinations were as follows: platelet counts, 5.5 x 10(4)/microliter: FDP, 25 micrograms/ml: TAT, 70.9 ng/ml: GOT, 177 IU/l, GPT, 174 IU/l: CRP, 32.3 mg/dl. Based on these findings, he was diagnosed as having rickettsiosis with DIC, and minocycline (200 mg/day) and heparin were started immediately, but had no clinical effect for 3 days. Blood gas analysis showed severe hypoxia and the chest CT scan revealed increased CT value in all lung fields with reticular shadows in the lower fields and pleural effusion, suggested interstitial pneumonia. Methyl-prednisolone pulse therapy was started on June 12, after which he completely recovered. Anti-Rikettia japonica IgM antibody was found to be x8,192 by immunofluorescent test, establishing the diagnosis of Japanese spotted fever. Acute respiratory failure with interstitial pneumonia shadows should be emphasized as a complication of severe rickettsiosis.     

A case of rapidly progressing pulmonary aspergillosis presenting various forms of shadow]

A 66-year-old woman who had a history of bullous pemphigoid was admitted to our hospital with abnormal shadows on chest radiography. She was being treated with prednisolone, which suggested that she might be in an immunosuppressed state. The chest radiograph and CT scan disclosed an infiltrative opacity, rapidly progressive cavitation, subsequent mycetoma formation, and a nodular shadow with a clear margin. Histological examination revealed a fungus ball in the cavitary lesion and a small mass of hyphae in necrotic tissue. After transbronchoscopic infusion of fluconazole, the cavitary lesion showed a marked resolution on the chest CT scan, and the infiltrative shadow and the nodule disappeared. It is said that aspergillosis is a spectrum of conditions whose precise manifestation is determined by the state of the lung tissue and by the patient's immune status. We report this rare case of pulmonary aspergillosis presenting various forms of shadow.     

Anaplastic thyroid carcinoma with lung metastasis producing CA 19-9 and GM-CSF]

A 68-year-old Japanese woman was admitted to our hospital because of hoarseness, dysphagia and a mass on the right side of her neck. Chest radiographs showed multiple nodular shadows in both lung fields. Detailed investigations resulted in a diagnosis of multiple lung metastasis of anaplastic thyroid carcinoma transformed from papillary adenocarcinoma. Both serum CA 19-9 and GM-CSF levels were elevated, to 70.5 U/ml (normal range: 0-37 U/ml) and 343.4 pg/ml (normal range: 0-8 pg/ml), respectively. Immunostaining disclosed that the primary and metastatic tumors were positive for CA 19-9, but not for GM-CSF antigens. Serum levels of these two parameters slowly decreased after chemo-radiotherapy, suggesting that the tumor may have produced GM-CSF as well as CA 19-9. Recent studies have indicated that the prognosis is poor for non-small cell lung cancers that produce G-CSF or CA 19-9. To our knowledge, this is the first case report of anaplastic thyroid carcinoma characterized by high serum levels of both CA 19-9 and GM-CSF, with metastasis to the lung and other organs.     

A case of multicentric Castleman's disease with multiple pulmonary nodules]

A 55-year-old woman visited our hospital for further examination of abnormal shadows on chest radiographs. Her routine chest radiograph showed two nodular shadows in the right lower lung field. A chest CT scan revealed other nodules, small patchy shadows in both lung fields, and enlargement of the mediastinal lymphnodes (#2, 3). Laboratory data showed polyclonal hyperimmunoglobulinemia. This case was initially considered on the basis of a transbronchial lung biopsy to be a plasma cell granuloma. However, serum gammaglobulin levels gradually increased, and video-assisted thoracoscopic surgery was performed to aid in making a definite diagnosis. Biopsy specimens revealed lymphoid follicles with plasma cells which were stained with both anti-kappa chain and anti-lambda chain antibodies. The patient was treated with prednisolone (50 mg/day), and the serum gammaglobulin level and the shadows on the chest CT were temporarily slightly improved. During the clinical course, her laboratory data and histological specimens were re-examined, and the final diagnosis was multicentric Castleman's disease.     

Intrathoracic neurofibroma originating in the left vagus nerve]

A 20-year-old man was admitted because of an abnormal mass shadow on chest X-ray film. Computed tomography (CT) and magnetic resonance imaging (MRI) disclosed a mass lesion in the superior portion of the left mediastinum. CT scans showed a well-defined mass with low density. Axial MRI rendered the mass lesion with intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. The preoperative diagnosis was bronchogenic cyst. Video-assisted thoracic surgery revealed that the tumor originated in the truncus of the left vagus nerve. The resected tumor was 90 x 24 x 18 mm in size. The postoperative course was uneventful and hoarseness did not develop. The pathologic diagnosis was benign mediastinal neurofibroma without von Recklinghausen's disease. Such cases are extremely rare in the Japanese literature.     

A case of primary mediastinal choriocarcinoma]

A 30-year-old man presented with cough and bloody sputum. He brought a chest radiogram showing abnormal findings. His chest computed tomography revealed a large mediastinal mass and multiple nodular shadows in both lungs. The serum beta-HCG level was remarkably elevated, and physical examination revealed bilateral gynecomastia and right supraclavicular lymph node swelling. His lymph node was biopsied and choriocarcinoma was diagnosed. After 3 cycles of BEP therapy (cisplatin, etoposide, bleomycin), the tumors regressed and the serum beta-HCG level decreased. Although there were residual tumors and serum beta-HCG was mildly elevated, he refused additional therapy. The choriocarcinoma progessed rapidly again and he died seven months after his first visit. Primary mediastinal germ cell tumors are rare, and in particular the pure type of choriocarcinoma arising in the mediastinum is even rarer. Patients with mediastinal choriocarcinoma are mostly young men. The prognosis of primary mediastinal choriocarcinoma is still very poor despite the introduction of combination chemotheraphy including cisplatin. We report a case of primary mediastinum pure choriocarcinoma. Chemotherapy was effective for the patient, but he died because of recurrence after refusal of future treatment. Establishment of more effective treatment is necessary.     

A case of primary pulmonary MALT lymphoma as a nodular shadow on CT scan, and relapsed with diffuse micronodular shadows after surgical resection at 7 years ago]

A 76-year-old man without symptoms was admitted to our hospital for investigation of an abnormal chest shadow in 1994. His chest radiograph showed a nodular shadow in the lingual lobe. Segmentectomy was performed and the histological diagnosis was MALT (mucosa-associated lymphoid tissue) lymphoma. In June 2001, there were no abnormal shadows on the chest radiograph or in 10 mm slice CT. However, high-resolution CT with 2-mm slice thickness revealed diffuse micronodular shadows in both lungs. A relapse of MALT lymphoma was diagnosed by immunohistochemical analysis of tissue specimens obtained by transbronchial lung biopsy. It was observed that the patterns of radiological findings in primary pulmonary MALT lymphoma cases may differ between the initial state and a relapse.