IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Cavitary Lung Nodules in a Patient with Prior Squamous Cell Carcinoma of the Submandibular Gland Hrishikesh S. Kulkarni and Daniel B. Rosenbluth Division of Pulmonary and Critical Care, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
Case A 65-year-old man with a 20 pack-year smoking history was referred to our clinic for hemoptysis and lung nodules. Two years before, he had been treated for squamous cell carcinoma of the left submandibular gland with resection, radical neck dissection, radiation, and chemotherapy with cisplatin and bleomycin. His hemoptysis was intermittent and productive of quartersized amounts of bright red blood. He denied any fevers, chills, chest pain, or dyspnea. Bronchoscopic cultures and cytology were unrevealing. His HIV screen, antinuclear antibody, and antineutrophil cytoplasmic antibody were negative. He had undergone a thoracotomy; however, when his right lung was collapsed, the surgeons failed to appreciate any nodules Figure 1. Coronal section of computerized tomographic images of the chest showing bilateral by palpation. Hilar lymph node excision cavitary nodules with ground-glass borders, measuring 29 3 27 mm in the left lower lobe and 43 3 revealed noncaseating granulomas. Repeat 35 mm in the right lower lobe. computerized tomographic images showed an increase in size of the previously noted cavitary nodules within a year (Figures 1 and 2). After a nondiagnostic transbronchial needle aspiration of the right-sided lesion, the patient underwent a right lower lobectomy. The surgical pathology showed a high-grade angiosarcoma measuring 4 cm, with negative margins (Figure 3).
Discussion Primary pulmonary angiosarcomas are rare, as most malignant pulmonary vascular tumors are metastatic from the skin, breast, liver, or heart (1). They can occur as either solitary or multifocal lesions or bilateral infiltrates and can be mistaken for vasculitis or fungal infections (2). They grow insidiously, but local invasion and hematogenous metastases often occur before diagnosis. They are often radiosensitive, although surgical resection has been shown to prolong median survival time (1). Antiangiogenic agents such as paclitaxel, sorafenib, and recombinant IL-2 have been used with some success (3, 4). The prognosis is variable, but those with unresected lesions often survive for less than a year after diagnosis (1). n
Author Contributions: Both H.S.K. and D.B.R. have made substantial contributions to the conception or design of the work and the acquisition, analysis, or interpretation of data for the work; have been involved in drafting the work and revising it critically for important intellectual content; have provided final approval of the version to be published; and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Am J Respir Crit Care Med Vol 190, Iss 12, pp 1447–1448, Dec 15, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201408-1493IM Internet address: www.atsjournals.org
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Figure 2. Transverse section of computerized tomographic images of the chest showing the cavitary nodule in the right lower lobe measuring 43 3 35 mm (left panel) that increased in size over the course of 4 months to 59 3 39 mm (right panel).
Figure 3. Low-power (left panel) and high-power (right panel) microscopy showing atypical vascular spaces lined by endothelial cells with cytologic atypia (white solid arrow, left panel). There is multilayering (black solid arrow, right panel), brisk mitotic activity (white dotted arrow, right panel), and necrosis (transparent dotted arrow, right panel). Stains are positive for CD31 and negative for thyroid transcription factor 1, all of which are highly suggestive of a high-grade angiosarcoma.
Author disclosures are available with the text of this article at www.atsjournals.org. Acknowledgment: The authors thank Reza Alaghehbandan, M.D., M.Sc., for providing them with pathology slides for this case.
References 1. Kojima K, Okamoto I, Ushijima S, Yoshinaga T, Kitaoka M, Suga M, Sasaki Y. Successful treatment of primary pulmonary angiosarcoma. Chest 2003;124:2397–2400. 2. Atasoy C, Fitoz S, Yiğit H, Atasoy P, Erden I, Akyar S. Radiographic, CT, and MRI findings in primary pulmonary angiosarcoma. Clin Imaging 2001;25:337–340.
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3. Penel N, Bui BN, Bay JO, Cupissol D, Ray-Coquard I, PipernoNeumann S, Kerbrat P, Fournier C, Taieb S, Jimenez M, et al. Phase II trial of weekly paclitaxel for unresectable angiosarcoma: the ANGIOTAX Study. J Clin Oncol 2008;26: 5269–5274. 4. Chen YB, Guo LC, Yang L, Feng W, Zhang XQ, Ling CH, Ji C, Huang JA. Angiosarcoma of the lung: 2 cases report and literature reviewed. Lung Cancer 2010;70:352–356.
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 12 | December 15 2014
Case A 65-year-old man with a 20 pack-year smoking history was referred to our clinic for hemoptysis and lung nodules. Two years before, he had been treated for squamous cell carcinoma of the left submandibular gland with resection, radical neck dissection, radiation, and chemotherapy with cisplatin and bleomycin. His hemoptysis was intermittent and productive of quartersized amounts of bright red blood. He denied any fevers, chills, chest pain, or dyspnea. Bronchoscopic cultures and cytology were unrevealing. His HIV screen, antinuclear antibody, and antineutrophil cytoplasmic antibody were negative. He had undergone a thoracotomy; however, when his right lung was collapsed, the surgeons failed to appreciate any nodules Figure 1. Coronal section of computerized tomographic images of the chest showing bilateral by palpation. Hilar lymph node excision cavitary nodules with ground-glass borders, measuring 29 3 27 mm in the left lower lobe and 43 3 revealed noncaseating granulomas. Repeat 35 mm in the right lower lobe. computerized tomographic images showed an increase in size of the previously noted cavitary nodules within a year (Figures 1 and 2). After a nondiagnostic transbronchial needle aspiration of the right-sided lesion, the patient underwent a right lower lobectomy. The surgical pathology showed a high-grade angiosarcoma measuring 4 cm, with negative margins (Figure 3).
Discussion Primary pulmonary angiosarcomas are rare, as most malignant pulmonary vascular tumors are metastatic from the skin, breast, liver, or heart (1). They can occur as either solitary or multifocal lesions or bilateral infiltrates and can be mistaken for vasculitis or fungal infections (2). They grow insidiously, but local invasion and hematogenous metastases often occur before diagnosis. They are often radiosensitive, although surgical resection has been shown to prolong median survival time (1). Antiangiogenic agents such as paclitaxel, sorafenib, and recombinant IL-2 have been used with some success (3, 4). The prognosis is variable, but those with unresected lesions often survive for less than a year after diagnosis (1). n
Author Contributions: Both H.S.K. and D.B.R. have made substantial contributions to the conception or design of the work and the acquisition, analysis, or interpretation of data for the work; have been involved in drafting the work and revising it critically for important intellectual content; have provided final approval of the version to be published; and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Am J Respir Crit Care Med Vol 190, Iss 12, pp 1447–1448, Dec 15, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201408-1493IM Internet address: www.atsjournals.org
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 2. Transverse section of computerized tomographic images of the chest showing the cavitary nodule in the right lower lobe measuring 43 3 35 mm (left panel) that increased in size over the course of 4 months to 59 3 39 mm (right panel).
Figure 3. Low-power (left panel) and high-power (right panel) microscopy showing atypical vascular spaces lined by endothelial cells with cytologic atypia (white solid arrow, left panel). There is multilayering (black solid arrow, right panel), brisk mitotic activity (white dotted arrow, right panel), and necrosis (transparent dotted arrow, right panel). Stains are positive for CD31 and negative for thyroid transcription factor 1, all of which are highly suggestive of a high-grade angiosarcoma.
Author disclosures are available with the text of this article at www.atsjournals.org. Acknowledgment: The authors thank Reza Alaghehbandan, M.D., M.Sc., for providing them with pathology slides for this case.
References 1. Kojima K, Okamoto I, Ushijima S, Yoshinaga T, Kitaoka M, Suga M, Sasaki Y. Successful treatment of primary pulmonary angiosarcoma. Chest 2003;124:2397–2400. 2. Atasoy C, Fitoz S, Yiğit H, Atasoy P, Erden I, Akyar S. Radiographic, CT, and MRI findings in primary pulmonary angiosarcoma. Clin Imaging 2001;25:337–340.
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3. Penel N, Bui BN, Bay JO, Cupissol D, Ray-Coquard I, PipernoNeumann S, Kerbrat P, Fournier C, Taieb S, Jimenez M, et al. Phase II trial of weekly paclitaxel for unresectable angiosarcoma: the ANGIOTAX Study. J Clin Oncol 2008;26: 5269–5274. 4. Chen YB, Guo LC, Yang L, Feng W, Zhang XQ, Ling CH, Ji C, Huang JA. Angiosarcoma of the lung: 2 cases report and literature reviewed. Lung Cancer 2010;70:352–356.
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 12 | December 15 2014
