A case of localized pleural mesothelioma containing a wedge-shaped area of aeration]

A 32-year-old man was admitted to our hospital because of an abnormal shadow on the chest X-ray film, which was detected on mass survey. The chest X-ray film on admission revealed an irregular mass shadow in the pleural layer between the left upper lobe and the lower lobe, and this shadow had a wedge-shaped area of aeration inside it. Needle biopsy under ultrasonography suggested a localized pleural mesothelioma. Surgery to resect the tumor revealed that it was pedunculated and had developed from the pleura of the left S5 segment. The resected specimen showed lung tissue invaginating into the tumor through a concave area of the tumor. The chest X-ray findings of this case are very unusual, and we were unable to find a similar case of localized pleural mesothelioma in the literature.     

A case of lung cancer suspected to be pulmonary mycosis of the fungus ball type

This paper reports a 73-year-old male case of lung cancer presenting as thin-walled cavity which was suspected to be pulmonary mycosis of the fungus ball type. Routine chest X-ray film showed a thin-walled cavity without a round shadow inside it. CR tomogram taken 2 months after the previous plain chest X-ray film showed an irregular thickening of the cavity wall and a round shadow inside it. Pulmonary mycosis of the fungus ball type was suspected based on the CR tomogram. But chest X-ray CT film taken 1 month after the previous CR tomogram revealed that the entire cavity wall was thickened with irregular convexity and no round shadow was seen in the cavity. Cavitary lung cancer was also suspected based on the findings of X-ray CT film. The surgical specimen, obtained by right upper lobectomy, revealed a moderately differentiated squamous cell carcinoma unaccompanied by pulmonary mycosis in the cavity space. Even in cases suggestive of mycosis, aggressive surgical intervention is recommended in those suspected of malignancy.     

A case of M. fortuitum lung disease with small-cell lung cancer]

A 58-year-old man was admitted to our hospital because of an abnormal shadow found on chest radiography. Chest radiographs and chest CT on admission showed a bulla with a niveau and infiltration in the right upper lobe. Smear of sputum and bronchial lavage were negative for acid-fast bacilli. Despite treatment with meropenem and clindamycin, the infiltrating shadow worsened. Since bronchial lavage and sputum culture were positive for M. fortuitum, these drugs were replaced with minocycline and imipenem. Thereafter, the shadow on the chest radiograph improved. After discharge, outpatient treatment with clarithromycin and levofloxacin was continued. After 4 months, the residual tumor shadow in the right upper lobe gradually grew. When a CT-guided transcutaneous needle lung biopsy was undertaken, malignant cells were found. Right upper lobectomy was performed. Pathological examination of the lesion demonstrated small-cell lung cancer. If a lesion does not change after nontuberculous mycobacteria treatment, the physician should consider other lesions such as lung cancer.     

A case report of large cell lung cancer detected in the course of antituberculous therapy after a giant bullectomy

A case of a 60-year-old who male developed lung cancer after surgical resection of a emphysematous giant bulla. At first, he showed a emphysematous giant bulla associated with infected bulla in the right lung on the chest roentgenograph. After a giant bullectomy the resected specimen, suggested possible pulmonary tuberculosis. Thereafter, he was followed for one year with antituberculous therapy. Nevertheless, the chest roentgenograph taken one year after surgery, showed a new tumor density (1.5 x 2.0 cm) in the right lung. Due to the rapid growth of the lung tumor, right upper lobectomy was performed. The histological diagnosis was a large cell lung cancer (giant cell type). The postoperative staging of the tumor proved to be T2N0M0. He was treated with systemic chemotherapy of CDDP 120 mg, VDS 4.5 mg, and MMC 12 mg. Unfortunately, he died of cancer recurrence 5 months after lobectomy. Clinical evaluation of the emphysematous giant bulla associated with lung cancer was performed.     

A case of pulmonary cryptococcosis with lung cancer in a pulmonary lobe

A 63-year old female was admitted because of an abnormal shadow on chest X-ray film. Chest CT showed a nodular shadow in the right S6 and a patchy shadow in the right S10. Right lower lobectomy was performed under a diagnosis of lung cancer made by TBLB in the right S6. Pathological examination of the resected lung revealed papillary adenocarcinoma in the right S6 and numerous cryptococci in the right S10. No cryptococcal infection was found in the resected lymph nodes.     

A case of plasma cell granuloma with good response to steroid therapy

A 46-year-old man was admitted with complaints of fever, cough and anterior chest pain. Chest X-ray examination disclosed an infiltrative shadow in the right upper lung field and chest CT scan strongly suggested invasion of mediastinum and anterior chest wall. Therefore, steroid therapy was selected because biopsy specimen showed proliferation of fibroblasts and mononuclear cells mainly containing plasma cells with no evidence of malignancy. After steroid therapy, chest X-ray examination showed that the infiltrative shadow was greatly reduced. However, since infiltrative shadow was increased again at 3 years after the initiation of steroid therapy, right upper lobectomy was performed. Histopathological analysis of resected tumor demonstrated proliferation of mature plasma cells and fibroblasts in conjunction with minor infiltration of neutrophils and lymphocytes. At 18 months after operation, new shadows appeared in right S8 and S10 which were shown to have almost the same histological findings as the resected tumor. Steroid therapy was restarted, and then the size of shadows decreased. It is conceivable that steroid therapy is an effective therapy for pulmonary plasma cell granuloma, especially multifocal and relapsing cases.     

Two cases of inflammatory pseudotumor of the lung

Two cases of inflammatory pseudotumor of the lung were reported. Case 1. A 68 year-old man was referred to our hospital because of an abnormal shadow on chest X-ray. He had a history of pneumonia in the right upper lobe five months before. The chest X-ray film revealed a coin lesion in the right upper lung field (S1), the same segment as the previous pneumonia. Although RPF and INH were administered for three months, the shadow did not change, and cough and sputum continued. In order to confirm the diagnosis, open thoracotomy was performed and microscopic findings of the resected tumor showed inflammatory pseudotumor; proliferation of fibrous tissue with infiltration by inflammatory cells (plasma cells, lymphocytes and a few neutrophils). Case 2. A 35 year-old man was admitted to our hospital because of an abnormal shadow on chest X-ray, i.e. a coin lesion with vascular indentation in the left lower lung field (S8). A wedge resection including the mass was performed, and histopathologic examination revealed inflammatory pseudotumor, or plasma cell granuloma; proliferation of fibrous connective tissue with infiltration by predominantly mature plasma cells. Both patients have been doing well after the operation. We also reviewed 46 cases reported in the Japanese literature and discussed various aspects of this disease. Of 10 patients who had a history of previous respiratory tract infection, 8 had histopathologic features with various inflammatory cells, including many lymphocytes, as in our Case 1. Although the common etiology of inflammatory pseudotumor is obscure, we suppose that in some cases the lesion may be a result of post-inflammatory repair process.     

A case of asymptomatic paraganglioma diagnosed by abnormal shadow on chest X-ray]

A 65-year-old man was noted to have an abnormal shadow on chest X-ray at mass screening examination, and was seen at Douhoku Byoin National Sanatorium. Chest X-ray showed a homogeneous mass shadow and a lytic lesion of the right 5th rib with extra-pleural tumor sign at the right upper and middle lung fields. Retroperitoneal tumor of 5 cm in diameter was detected in the right adrenal area by ultrasonography. Because of increasing plasma levels of norepinephrine and dopamine, the diagnosis of malignant pheochromocytoma with rib metastasis was made. Histologically, chromogranin staining was positive in each resected specimen. The retroperitoneal tumor was separate from the right adrenal gland. We report a rare case of malignant paraganglioma which was asymptomatic in spite of increasing plasma levels of catecholamines.     

A case of organizing pneumonia which had to be treated with steroids in the early phase of the disease against delayed resolution of severe pneumonia occurring even after antibiotic therapy]

A 58-year-old male was referred to our division because of antibiotic-resistant pneumonia. A chest X-ray film revealed severe pneumonia over the left lung field but laboratory data showed no leukocytosis. Transbronchial lung biopsy findings showed the evidence consistent with organizing pneumonia. One-month prednisolone therapy produced a disappearance of the pneumonia shadow, but a giant bulla was found at the same site. It was considered that it was necessary to treat this case with a combination of effective antibiotics and steroids in the early phase of the disease.     

Extensively calcified hemangioma of the diaphragm with increased 99mTc-hydroxymethylene diphosphonate uptake

A 31-year-old woman visited an out-patient clinic, because of low-grade fever and general fatigue. She was referred to our hospital and admitted for examination of an abnormal shadow which had been found on the chest radiograph. She had experienced faint right lateral chest pain several times on the deep inspirations. Chest radiography showed a mass shadow with calcification in the right lower lung field on the mediastinal side. Chest radiographic computed tomography showed a 6x6 cm tumor in the right lung field. There were low-density areas with septae inside the tumor. Bone scintigraphy showed extremely high uptake of (99m)Tc-HMDP in the tumor. After surgical resection and pathological examination, we concluded that the tumor was an extensively calcified benign hemangioma of the diaphragm.     

A case of subacute necrotizing lymphadenitis with localized interstitial pneumonia

A 16-year-old male was admitted with a history of cervical lymph node swelling, high fever, cough and hemosputum. On admission, bilateral cervical lymph nodes swelling and fine crackles in the right lower lung field were noted. A chest X-ray film showed an infiltrative shadow in the right lower lung field and right hilar enlargement. Cervical lymph node biopsy specimens revealed wide areas of necrosis with nuclear debris. Transbronchial lung biopsy showed infiltration of lymphocytes in the interstitium and bronchoalveolar lavage fluid showed increased T-lymphocytes and a decreased T4/T8 ratio. The patient was diagnosed to have subacute necrotizing lymphadenitis with T-lymphocyte alveolitis. Additionally, antinuclear antibodies were positive, and anti HTLV-I antibody was false positive. These findings suggested an immunological abnormality in this case. His cervical lymph node swelling and infiltrative shadow on chest X-ray film improved with steroid therapy. Our case may be the first case of subacute necrotizing lymphadenitis with T-lymphocyte alveolitis.     

A case of anomalous course of the pulmonary vein with a tracheobronchus]

A 28-year-old man was admitted to our hospital for further evaluation of a loop-like abnormal shadow in the middle lower lung field on chest X-ray film. Pulmonary angiograms demonstrated staining of the abnormal shadow during the venous phase. The abnormal vein descended from the right upper lobe to the middle lobe and then tortuously made a loop upward to drain into the left atrium. A part of the right apical vein was stenosed. The right apical segmental bronchus directly branched from the trachea. These observations indicate that the abnormalities may have originated in the prenatal period. Cases of anomalous course of the pulmonary vein are very rare.     

A case of lung tuberculosis which also incidentally found intestinal tuberculosis by 18F-fluorodeoxyglucose-positron emission tomography]

A 60-year-old women presenting with an abnormal shadow on a chest X-ray film was admitted to our hospital in June 2004. Her CT scan of the chest showed a cavitary mass shadow in the left upper lobe. FDG-PET was performed to examine whether this shadow was the lung cancer or not, and incidentally it showed an additional accumulation of FDG in the ileocecal resion. The colonoscopy was then carried out. Luminal narrowing with circumferential ulcer in the ileocecal resion could be observed, and pathological findings of the biopsy specimen revealed epithelioid cell granulomas. Partial lobectomy of the left upper lung was also performed, and the histological examination revealed typical pulmonary tuberculosis. Since the antituberculosis therapy was effective to the ileocecal lesion, we assert that the ileocecal lesion was intestinal tuberculosis.     

A case of congenital bronchial atresia with obstructive pneumonia accompanied with partial anomalous pulmonary venous drainage

A 25-year-old male was admitted with productive cough and an abnormal shadow on chest X-ray film which showed a cylindrical shadow near the left hilum and consolidation in the markedly hyperlucent left upper lung field. The cylindrical shadow appeared to be located in left S1+2 but bronchographic examination showed independence of the branches of B1+2. Furthermore, pulmonary venography by DSA showed that the left upper pulmonary vein entered the left brachiocephalic vein. The patient underwent left partial lobectomy under a diagnosis of congenital bronchial atresia with partial anomalous pulmonary venous drainage. Pathological examination of the resected lung revealed obstructive pneumonia in the over-inflated lung zone, probably induced through collateral airways.     

Asymptomatic colonic metastases from primary squamous cell carcinoma of the lung with a positive fecal occult blood test

We describe a 74-year-old man with a colonic metastatic squamous cell carcinoma （SCC） from the lung. His chest X-ray revealed an abnormal shadow in the right upper lobe. Computed tomography （CT） of the chest demonstrated a large lung tumor in the right upper lobe obstructing the right upper bronchus. Bronchoscopy revealed an easy-bleeding tumor in the right upper bronchus that was diagnosed as poorly differentiated squamous cell lung carcinoma. He underwent colonoscopy because he had a positive fecal occult blood test. Colonoscopy revealed a large protruding lesion with central ulceration in the descending colon. Histological examination of the biopsy specimen obtained from the colonic lesion revealed SCC. The lesion was diagnosed as metastatic colonic SCC. He had no abdominal symptoms. He underwent chemotherapy with an infusion of cisplatin 130 mg i.v. day 1, and docetaxel hydrate 100 mg i.v. day 1, repeated every 4 wk, followed by 4 courses of chemotherapy. The primary lesion shrank by less than 10% and was judged to be ＂Partial Response＂ （PR） after 3 courses of treatment. The patient still lived 23 wk after the diagnosis of metastatic colonic SCC. Colonic metastasis of primary SCC of the lung is rare.     

A case of lung tuberculosis showing no chest radiograph findings with recurrent hemoptysis

A 59-year-old male was referred to our hospital because of hemoptysis. A chest X-ray film and 7 mm-slice CT scan showed no abnormal finding. Bronchoscopy revealed hemorrhage in the right upper bronchus (B1a) Bronchial lavage of the lesion was performed, but Mycobacterium tuberculosis was not detected. Because of repeated hemoptysis, he was admitted to our hospital. Right bronchial artery angiograph showed vascular hyperplasia in the peripheral part of the upper lobal branch, and this lesion was suggested to be a bleeding point. There were no vascular malformations. Thin slice (0.5 mm-thick) CT scan showed mild infiltrative shadow in the right upper lobe. After admission, sputa smear for mycobacteria and PCR for M. tuberculosis became positive, and he was diagnosed as pulmonary tuberculosis. After starting antituberculous chemotherapy, hemoptysis disappeared, and sputa smear and culture for mycobacteria converted to negative. This case suggests that lung tuberculosis should be suspected in patients having hemoptysis, even though they had no chest X-ray film abnormality.     

Hemilaminectomy for a dumbbell-shaped vertebral hemangioma

We report the case of a dumbbell-shaped vertebral hemangioma mimicking a neurogenic tumor. A 73-year-old male was found on chest X-ray to have an abnormal shadow at the apex of the right upper lung field. Chest computed tomography revealed a 4.0-cm mass in the posterior right paravertebral region, adjacent to the T1 and T2 vertebral bodies. Given the location and shape of the tumor, it was suspected to be a neurogenic tumor. Magnetic resonance imaging revealed that the tumor extended into the spinal canal via the second intervertebral foramen. The tumor was resected successfully via hemilaminectomy with costotranversectomy. On pathological examination, the tumor was found to be a benign hemangioma. The patient is free of recurrence at 10 months post-resection. Vertebral hemangioma should be considered in the differential diagnosis of dumbbell-shaped tumors of the upper or posterior mediastinum.     

A case of pulmonary metastasis from carcinosarcoma of uterus with subcutaneous implantation of tumor cells along the needle tract after percutaneous needle biopsy of lung]

A 68-year-old female who had undergone total hysterectomy for carcinosarcoma five months previously was noted to have a solitary nodular shadow in the right lung on chest X-ray. Percutaneous needle biopsy of the lung was performed via the right anterior chest wall, and the histologic findings showed metastasis from carcinosarcoma of uterus. Two months after needle biopsy, a chest wall mass appeared of the site of puncture of the lung needle biopsy. The mass was resected to relieve the chest wall pain and the specimen showed carcinosarcoma of uterus histologically. We consider that tumor cells were implanted to the chest wall along the needle tract after percutaneous needle biopsy of the lung. The postoperative chest computed tomogram showed the route of tumor implantation from the metastasis of right lung into the right chest wall. Dissemination and chest wall implantation of malignant cells after percutaneous lung needle biopsy have been rarely reported. However there are no reports of tumor implantation of sarcoma. The possibility of implantation of tumor cells along the needle tract after percutaneous lung needle biopsy should be carefully considered in cases of carcinosarcoma.     

A case of diffuse large B-cell lymphoma transformed from immunoglobulin A-producing marginal zone B-cell lymphoma

We present a rare case of diffuse large B-cell lymphoma transformed from immunoglobulin (Ig) A-secreting marginal zone B-cell lymphoma. A 62-year-old woman was admitted to our hospital for examination of a disseminated pulmonary shadow. Gradual swelling of bilateral axilla and right inguinal lymph nodes were noted after admission. Histological examination of the lymph node biopsy specimen revealed the appearance of marginal zone B-cell lymphoma. The surface Ig of lymphoma cells was IgA-kappa, which coincided with the class of monoclonal Ig found in the patient's serum. The lymph node swelling and pulmonary shadow subsided, and the serum IgA level was normalized by 3 courses of systemic chemotherapy. However, after 4 courses of treatment, new tumor lesions at the right chest wall and left arm progressively became apparent. The biopsy specimen of the tumor showed a feature of diffuse large B-cell lymphoma. Despite intensive chemotherapy, the patient died of spreading tumor burden into the central nervous system.     

A case of Recklinghausen's disease associated with multiple emphysematous bullae and lung cancer

A 36-year-old man was admitted with cough and sputum. He had cafe-au-lait spots and multiple subcutaneous neurofibromas. Chest X-ray revealed multiple emphysematous bullae in bilateral upper lobes and a tumor in the bulla of the right upper lobe. Needle aspiration biopsy of the tumor showed small cell carcinoma. Although chemotherapy and radiation resulted in decrease in tumor size, it subsequently increased in size and he died 11 months after admission. Including this case there have been 7 reports of Recklinghausen's disease associated with multiple lung cysts and 8 reports with lung cancer in Japan. However, cases with lung cysts and cancer are very rare. The cancer of this case was considered to be associated with emphysematous bulla rather than Recklinghausen's diseases.