Lung (2015) 193:443–445 DOI 10.1007/s00408-015-9709-7
Intrapulmonary Mature Teratoma Mimicking a Fungus Ball Miriam Menna Barreto1 • Paulo Marcos Valiante1 • Gla´ucia Zanetti1 Carlos Henrique Ribeiro Boasquevisque1 • Edson Marchiori1
•
Received: 21 February 2015 / Accepted: 2 March 2015 / Published online: 7 March 2015 Ó Springer Science+Business Media New York 2015
Case Report A 22-year-old woman presented with history of cough and hemoptysis. Chest computed tomography (CT) revealed a heterogeneous cavitated mass in the left upper lobe, with solid intracavitary content, mimicking a fungus ball (Fig. 1). Patient was subjected to upper left upper lobectomy. The cut section revealed a solid-cystic mass (Fig. 2). The tumor was composed of skin, sebaceous glands, hair follicles, apocrine glands, smooth muscle, cartilage, fat, and respiratory epithelium (Fig. 3). Given the presence of unaffected pulmonary parenchymal areas adjacent to the mediastinal pleura, the final diagnosis was primary mature pulmonary teratoma. The patient’s postoperative course was uneventful.
Discussion Teratomas are tumors consisting of tissue derived from all three germinal layers: the endoderm, mesoderm, and ectoderm. Almost all intrathoracic teratomas occur in the
mediastinum, but they are rarely found in the lung [1–3]. Hair expectoration (trichoptysis) signifies communication with the tracheobronchial tree [2, 3], and a is strong evidence of an intrapulmonary teratoma [3, 4]. Air within a cavity is also a feature distinguishing intrapulmonary from mediastinal teratomas [3, 4]. Intralesional fat component can help establish the diagnosis, but 15 % of teratomas are purely cystic, with no fat or calcium [3]. Intrapulmonary teratomas are more commonly in the left upper lobe [2, 3]. CT typically revealed a heterogeneous, lobulated mass containing soft tissue, fat, fluid, and/or calcium [1, 3, 4]. However, it may appear as a cavitary lesion, consolidation, peripheral translucency, or, as in our case, an ‘‘air crescent sign’’ mimicking a fungus ball. Typically, a fungus ball presents as a mass separated from the wall of the cavity by an airspace, resulting in the ‘‘air crescent sign’’. Although Aspergillus spp. is the most frequent cause of fungus balls, this finding has been reported in association with a variety of other conditions, including tuberculosis (blood clot or Rasmussen aneurysm), hydatid cyst, lung cancer, bacterial lung abscess,
& Edson Marchiori [email protected] 1
Federal University of Rio de Janeiro, Rua Thomaz Cameron, 438. Valparaiso, Petro´polis, Rio de Janeiro CEP 25685.120, Brazil
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Lung (2015) 193:443–445
Fig. 1 Chest computed tomography revealed a 5 cm mass in the left upper lobe, adjacent to the mediastinum. Axial images at lung window (a) and mediastinal (b) window setting and coronal (c) and sagittal (d) reconstructions. The lesion showed cavitation with thick walls and an intracavitary mass (asterisk) mimicking a fungus ball. Note that the solid content presents focal areas of fat density (arrowheads in b)
other fungal or fungal-like conditions (coccidioidomycosis, actinomycosis, nocardiosis, candidiasis), and intracavitary hematoma [5]. Complete surgical resection is curative and recommended [1, 4]. If untreated, intrapulmonary teratoma may cause significant complications, such as rupture, hemoptysis, airway compression, and malignant transformation [2, 3]. In conclusion, the diagnosis of teratoma is based on radiologic imaging, especially CT, which demonstrates calcification, cavitation, and translucent areas. Trichoptysis is the only clinical feature that can be diagnostic. Due to the potential for rupture or malignancy, surgical removal of an intrapulmonary teratoma is indicated. Teratoma should be considered in the differential diagnosis in cases presenting with the CT finding of the air crescent sign.
Fig. 2 Photograph of the gross specimen showing a large heterogeneous mass in the left upper lobe containing fat and hair (arrow)
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Lung (2015) 193:443–445
445 Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Giunchi F, Segura JJ (2012) Primary malignant teratoma of lung: report of a case and review of the literature. Int J Surg Pathol 20(5):523–527 2. Sawant AC, Kandra A, Narra SR (2012) Intrapulmonary cystic teratoma mimicking malignant pulmonary neoplasm. BMJ Case Rep. doi:10.1136/bcr.02.2012.5770 3. Rana SS, Swami N, Mehta S et al (2007) Intrapulmonary teratoma: an exceptional disease. Ann Thorac Surg 83(3):1194–1196 4. Guibert N, Attias D, Pontier S et al (2011) Mediastinal teratoma and trichoptysis. Ann Thorac Surg 92(1):351–353 5. Gazzoni FF, Severo LC, Marchiori E et al (2014) Pulmonary diseases with imaging findings mimicking aspergilloma. Lung 192(3):347–357
Fig. 3 Photomicrographs (a, b) of the mature pulmonary teratoma show mature adipose tissue (AT), sweat glands (SWG), smooth muscle (SM), hair follicles (HF), cartilage (C), respiratory epithelium (RE), and sebaceous glands (SG) (hematoxylin & eosin stain, 940 magnification)
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Intrapulmonary Mature Teratoma Mimicking a Fungus Ball Miriam Menna Barreto1 • Paulo Marcos Valiante1 • Gla´ucia Zanetti1 Carlos Henrique Ribeiro Boasquevisque1 • Edson Marchiori1
•
Received: 21 February 2015 / Accepted: 2 March 2015 / Published online: 7 March 2015 Ó Springer Science+Business Media New York 2015
Case Report A 22-year-old woman presented with history of cough and hemoptysis. Chest computed tomography (CT) revealed a heterogeneous cavitated mass in the left upper lobe, with solid intracavitary content, mimicking a fungus ball (Fig. 1). Patient was subjected to upper left upper lobectomy. The cut section revealed a solid-cystic mass (Fig. 2). The tumor was composed of skin, sebaceous glands, hair follicles, apocrine glands, smooth muscle, cartilage, fat, and respiratory epithelium (Fig. 3). Given the presence of unaffected pulmonary parenchymal areas adjacent to the mediastinal pleura, the final diagnosis was primary mature pulmonary teratoma. The patient’s postoperative course was uneventful.
Discussion Teratomas are tumors consisting of tissue derived from all three germinal layers: the endoderm, mesoderm, and ectoderm. Almost all intrathoracic teratomas occur in the
mediastinum, but they are rarely found in the lung [1–3]. Hair expectoration (trichoptysis) signifies communication with the tracheobronchial tree [2, 3], and a is strong evidence of an intrapulmonary teratoma [3, 4]. Air within a cavity is also a feature distinguishing intrapulmonary from mediastinal teratomas [3, 4]. Intralesional fat component can help establish the diagnosis, but 15 % of teratomas are purely cystic, with no fat or calcium [3]. Intrapulmonary teratomas are more commonly in the left upper lobe [2, 3]. CT typically revealed a heterogeneous, lobulated mass containing soft tissue, fat, fluid, and/or calcium [1, 3, 4]. However, it may appear as a cavitary lesion, consolidation, peripheral translucency, or, as in our case, an ‘‘air crescent sign’’ mimicking a fungus ball. Typically, a fungus ball presents as a mass separated from the wall of the cavity by an airspace, resulting in the ‘‘air crescent sign’’. Although Aspergillus spp. is the most frequent cause of fungus balls, this finding has been reported in association with a variety of other conditions, including tuberculosis (blood clot or Rasmussen aneurysm), hydatid cyst, lung cancer, bacterial lung abscess,
& Edson Marchiori [email protected] 1
Federal University of Rio de Janeiro, Rua Thomaz Cameron, 438. Valparaiso, Petro´polis, Rio de Janeiro CEP 25685.120, Brazil
123
444
Lung (2015) 193:443–445
Fig. 1 Chest computed tomography revealed a 5 cm mass in the left upper lobe, adjacent to the mediastinum. Axial images at lung window (a) and mediastinal (b) window setting and coronal (c) and sagittal (d) reconstructions. The lesion showed cavitation with thick walls and an intracavitary mass (asterisk) mimicking a fungus ball. Note that the solid content presents focal areas of fat density (arrowheads in b)
other fungal or fungal-like conditions (coccidioidomycosis, actinomycosis, nocardiosis, candidiasis), and intracavitary hematoma [5]. Complete surgical resection is curative and recommended [1, 4]. If untreated, intrapulmonary teratoma may cause significant complications, such as rupture, hemoptysis, airway compression, and malignant transformation [2, 3]. In conclusion, the diagnosis of teratoma is based on radiologic imaging, especially CT, which demonstrates calcification, cavitation, and translucent areas. Trichoptysis is the only clinical feature that can be diagnostic. Due to the potential for rupture or malignancy, surgical removal of an intrapulmonary teratoma is indicated. Teratoma should be considered in the differential diagnosis in cases presenting with the CT finding of the air crescent sign.
Fig. 2 Photograph of the gross specimen showing a large heterogeneous mass in the left upper lobe containing fat and hair (arrow)
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Lung (2015) 193:443–445
445 Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Giunchi F, Segura JJ (2012) Primary malignant teratoma of lung: report of a case and review of the literature. Int J Surg Pathol 20(5):523–527 2. Sawant AC, Kandra A, Narra SR (2012) Intrapulmonary cystic teratoma mimicking malignant pulmonary neoplasm. BMJ Case Rep. doi:10.1136/bcr.02.2012.5770 3. Rana SS, Swami N, Mehta S et al (2007) Intrapulmonary teratoma: an exceptional disease. Ann Thorac Surg 83(3):1194–1196 4. Guibert N, Attias D, Pontier S et al (2011) Mediastinal teratoma and trichoptysis. Ann Thorac Surg 92(1):351–353 5. Gazzoni FF, Severo LC, Marchiori E et al (2014) Pulmonary diseases with imaging findings mimicking aspergilloma. Lung 192(3):347–357
Fig. 3 Photomicrographs (a, b) of the mature pulmonary teratoma show mature adipose tissue (AT), sweat glands (SWG), smooth muscle (SM), hair follicles (HF), cartilage (C), respiratory epithelium (RE), and sebaceous glands (SG) (hematoxylin & eosin stain, 940 magnification)
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