CASE REPORT
The Clinical Respiratory Journal
Squamous cell carcinoma presenting as a refilled thin-walled cavity in lung: a case report Ming Lu1, Xiang Zhu1,2, Chen Liu3, Baoshan Cao4, Wanzhen Yao1 and Yahong Chen1 1 Department 2 Department 3 Department 4 Department
of of of of
Respiratory Medicine, Peking University Third Hospital, Beijing, China Pathology, Peking University Health Science Center, Beijing, China Radiology, Peking University Third Hospital, Beijing, China Oncology, Peking University Third Hospital, Beijing, China
Abstract Thin-walled cavity with air-fluid level is often considered radiographically benignlooking lesion. We recently encountered a patient with a rare lung cavity. A 58-yearold male presented with intermittent fever, chest pain and hemoptysis. A large thin-walled cavity, with a smooth inner surface and a clear air-fluid level, occupied the left upper lobe on the chest computerized tomography (CT) scan. After intravenous antibiotics was administrated, the air-fluid level in the cavity disappeared, and the cavity was gradually fluid refilled unexpectedly. However, the cavitary lesion kept the previous contour. Then CT-guided percutaneous needle lung biopsy was performed, revealing a squamous cell carcinoma of the lung. Although it is rare, a refilled thin-walled cavity in lung may be malignant, which should be kept in mind by clinician. Please cite this paper as: Lu M, Zhu X, Liu C, Cao B, Yao W and Chen Y. Squamous cell carcinoma presenting as a refilled thin-walled cavity in lung: a case report. Clin Respir J 2015; ••: ••–••. DOI:10.1111/crj.12246.
Key words air-fluid level – cavity – lung cancer – thin-walled Correspondence Yahong Chen, MD, Department of Respiratory Medicine, Peking University Third Hospital, No.49, North Garden Road, Haidian District, 100191 Beijing, China. Tel: +86 13910232918 Fax: +86 01064821910 email: [email protected] Received: 23 September 2014 Revision requested: 01 January 2015 Accepted: 08 December 2014 DOI:10.1111/crj.12246 Authorship and contributorship Ming Lu, writing of the manuscript. Xiang Zhu, pathological data collection. Chen Liu, computerized tomography-guided lung biopsy and radiological data collection. Baoshan Cao, clinical data collection. Wanzhen Yao and Yahong Chen, study design and manuscript review. Ethics No ethic conflict and patient has agreed to publication. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Introduction Cavitary pulmonary lesions are commonly encountered during chest radiography, and their differential diagnoses include diverse benign and malignant diseases (1). Most cavitary lung cancers usually present
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
typical radiographic findings such as wall thickness, speculated or irregular inner and outer margin (2). Presence of air-fluid level in a thin-walled lung cavity always conveys benign diagnostic possibilities to clinicians. We present a case of lung squamous cell carcinoma with an unusual and interesting cavity.
1
A refilled thin-walled cavity in lung
Lu et al.
Figure 1. (A) Chest X-ray: a large cavitary mass with air-fluid level in left lung. (B) Chest computerized tomography (CT) scan: A large thin-walled cavitary mass with half fluid filling occupying the left upper lobe. (C) Follow-up chest CT scan after antibiotics: the original airfluid level in the cavity disappeared, and the cavity was entirely filled with fluid. (D) Follow-up chest CT scan after lung biopsy and fluid aspiration: the air-fluid level was easily recognizable again.
Case presentation A 58-year-old male, who worked as a field farmer, presented with intermittent fever, anterior chest pain and hemoptysis for 2 months. He had no night sweat, exertional dyspnea, loss of appetite and loss of weight. The patient had a 40-pack-year cigarette smoking history. He was diagnosed human brucellosis 10 years before. He had no family history of cancer. Blood test were as follows: white blood cell count 11 500/μL, neutrophil percentage 77%, eosinophil percentage 0.3%, hemoglobin 16.5 g/dL and platelet count 290 000/μL. A chest radiograph demonstrated a welldemarcated mass with air-fluid level located in the left lung (Fig. 1A). Chest CT revealed a large thin-walled cavity (4.5 cm × 4.6 cm) in the left upper lobe, and half of the cavity was filled with fluid attenuation (Fig. 1B). He was diagnosed as lung abscess and treated with penicillin for 2 weeks; fever and hemoptysis did not recur. However, no obvious improvement in the chest X-ray was observed. Then intravenous administration of cefatriaxone was given for 2 weeks. Surprisingly, follow-up chest CT showed the original air-fluid level in the cavity disappeared, and the cavity was entirely filled with fluid (attenuation values 11 HU) (Fig. 1C). On admission, he was asymptomatic, and the physical examination and routine laboratory tests were
2
unremarkable. The serum values of carcinoembryonic antigen, neuron-specific enolase and squamous cell carcinoma-associated antigen were all within normal range. The concentration of 1,3-β-D-glucan and galactomannan were normal. Echinococcus antigen assay was negative. Bronchoscopy revealed a normal bronchial tree. Then the patient underwent a CT-guided percutaneous needle lung biopsy. Strawcolored fluid about 10 mL were aspirated from the center of the mass. Microorganisms cultured in the aspirated fluid were all negative. The air-fluid level on chest CT was easily recognizable again after fluid aspiration (Fig. 1D). The pathological diagnosis of the lung biopsy revealed moderately differentiated squamous cell carcinoma (Fig. 2). The positive immunohistochemistry staining of cytokine 5/6 and P63 confirmed this diagnosis. Then, the patient received left lower lobectomy and further chemotherapy.
Discussion Cavitation in primary lung cancer is not rare. Squamous cell carcinoma is the most common histological type of lung cancer to cavitate, followed by adenocarcinoma and large cell carcinoma (3). Most of the malignant lung cavity has a thick wall; however,
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
Lu et al.
Figure 2. Histopathological specimen images: lung biopsy specimen revealed moderate differentiated squamous cell carcinoma. Hematoxylin-Eosin staining (×100).
thin-walled cavity lung cancer has been a special form of lung cancer and reported in recent years (4–10). The incidence of this disease was about 8% (2). Moreover, the incidence has increased with the progression of diagnostic techniques, such as percutaneous cavitary lavage or percutaneous needle washing (11, 12). Most of the pathological type of thin-walled cavity lung cancer were reported as adenocarcinoma (5, 6, 9) or bronchoalveolar cell carcinoma (4). Squamous cell carcinoma (7) were also reported in succession. Although it is not fully clear, possible mechanisms forming thin-walled cavitary lung cancer were supposed to be involved (5, 8, 13). (i) A check-valve mechanism of responsible bronchus formed by inflammatory or neoplastic stenosis leads to formation of the lesion. (ii) Liquidized necrotic content is excreted through the responsible bronchus from ischemic centric necrosis of the tumor. (iii) A tumor arising in the preexisting cyst or bullae is infiltrating alongside the cystic wall. In our present case, the patient had no bullous disease observed in the previous period. Neither there were emphysematous lesions in other lung fields. So the check valve mechanism is considered as the most likely mechanism. Air-fluid level is less common in cancerous cavity, only when it is concurrent with infection or hemorrhage. In our patient, what is unique about is that the air-fluid level in the cavity disappeared after antibiotics treatment, and the cavity was gradually fluid refilled unexpectedly. However, the cavitary lesion kept the previous contour. No cases with such images have been reported. Usually, the check valve may cause a cavity become larger and larger; that is, more air can
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
A refilled thin-walled cavity in lung
enter the cavity during inspiration than can escape during expiration. In our case, we speculate that the check valve was disrupted or occluded as a consequence of tumor infiltration or infection plug, and air cannot enter the cavity during inspiration. As the inner lining of cavities continues to deliquesce because of infection, the air in the cavity was squeezed out and evacuated gradually. Finally, the cavity in the tumor was unexpected ‘refilled’. The rarity of this case and its possible implications may help us to further understand the mechanism of thin-walled cancerous cavity of the lung. So imaging cannot be reliably used to differentiate a cavitary tumor from carcinomatous abscess and a benign abscess. This case shows Malignancy should also be taken into consideration in patients with unusual cavities; otherwise the diagnosis may be missed or delayed.
References 1. Honda O, Tsubamoto M, Inoue A, Johkoh T, Tomiyama N, Hamada S, Mihara N, Sumikawa H, Natsag J, Nakamura H. Pulmonary cavitary nodules on computed tomography: differentiation of malignancy and benignancy. J Comput Assist Tomogr. 2007;31: 943–9. 2. Woodring JH, Fried AM, Chuang VP. Solitary cavities of the lung: diagnostic implications of cavity wall thickness. Am J Roentgenol. 1980;135: 1269–71. 3. Chaudhuri MR. Primary pulmonary cavitating carcinomas. Thorax. 1973;28: 354–66. 4. Morimoto T, Sakamoto H, Ohnishi H, Fujiyama R, Tomioka H, Sakurai T, Tada K, Iwasaki H, Hashimoto K. A case of bronchioloalveolar carcinoma with multiple cystic shadows on chest CT. Nihon Kokyuki Gakkai Zasshi. 2001;39: 186–9. 5. Xue X, Wang P, Xue Q, Wang N, Zhang L, Sun J, Wang K, Yang B, Wang J. Comparative study of solitary thin-walled cavity lung cancer with computed tomography and pathological findings. Lung Cancer. 2012;78: 45–50. 6. Sekine A, Hagiwara E, Ogura T, et al. A case of lung adenocarcinoma with gradual enlargement of thin-walled cavity causing pneumothorax. Nihon Kokyuki Gakkai Zasshi. 2008;46: 552–7. 7. Iwata T, Nishiyama N, Nagano K, Izumi N, Tsukioka T, Hanada S, Kimura T, Kudoh S, Hirata K, Suehiro S. Squamous cell carcinoma presenting as a solitary growing cyst in lung: a diagnostic pitfall in daily clinical practice. Ann Thorac Cardiovasc Surg. 2009;15: 174–7. 8. Sugimoto Y, Semba H, Fujii S, Furukawa E, Kurano R. Clinical analysis of primary lung cancer with a thin-walled cavity to explain the mechanism of thin-walled cavity formation. Nihon Kokyuki Gakkai Zasshi. 2007;45: 460–4.
3
A refilled thin-walled cavity in lung
9. Yoshida T, Harada T, Fuke S, et al. Lung adenocarcinoma presenting with enlarged and multiloculated cystic lesions over 2 years. Respir Care. 2004;49: 1522–4. 10. Nakahara Y, Mochiduki Y, Miyamoto Y. Percutaneous needle washing for the diagnosis of pulmonary thin-walled cavitary lesions filled with air. Intern Med. 2007;46: 1089–94. 11. Belet U, Findik S, Ozmen Z, Atici AG, Akan H. Percutaneous cavitary lavage in the diagnosis of pulmonary cavities. J Thorac Dis. 2013;5: 440–5.
4
Lu et al.
12. Hsieh MS, Wu CT, Chang YL. Unusual presentation of lymphoepithelioma-like carcinoma of lung as a thin-walled cavity. Ann Thorac Surg. 2013;96: 1857–9. 13. Kim TS, Koh WJ, Han J, Chung MJ, Lee JH, Lee KS, Kwon OJ. Hypothesis on the evolution of cavitary lesions in nontuberculous mycobacterial pulmonary infection: thin-section CT and histopathologic correlation. Am J Roentgenol. 2005;184: 1247–52.
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
The Clinical Respiratory Journal
Squamous cell carcinoma presenting as a refilled thin-walled cavity in lung: a case report Ming Lu1, Xiang Zhu1,2, Chen Liu3, Baoshan Cao4, Wanzhen Yao1 and Yahong Chen1 1 Department 2 Department 3 Department 4 Department
of of of of
Respiratory Medicine, Peking University Third Hospital, Beijing, China Pathology, Peking University Health Science Center, Beijing, China Radiology, Peking University Third Hospital, Beijing, China Oncology, Peking University Third Hospital, Beijing, China
Abstract Thin-walled cavity with air-fluid level is often considered radiographically benignlooking lesion. We recently encountered a patient with a rare lung cavity. A 58-yearold male presented with intermittent fever, chest pain and hemoptysis. A large thin-walled cavity, with a smooth inner surface and a clear air-fluid level, occupied the left upper lobe on the chest computerized tomography (CT) scan. After intravenous antibiotics was administrated, the air-fluid level in the cavity disappeared, and the cavity was gradually fluid refilled unexpectedly. However, the cavitary lesion kept the previous contour. Then CT-guided percutaneous needle lung biopsy was performed, revealing a squamous cell carcinoma of the lung. Although it is rare, a refilled thin-walled cavity in lung may be malignant, which should be kept in mind by clinician. Please cite this paper as: Lu M, Zhu X, Liu C, Cao B, Yao W and Chen Y. Squamous cell carcinoma presenting as a refilled thin-walled cavity in lung: a case report. Clin Respir J 2015; ••: ••–••. DOI:10.1111/crj.12246.
Key words air-fluid level – cavity – lung cancer – thin-walled Correspondence Yahong Chen, MD, Department of Respiratory Medicine, Peking University Third Hospital, No.49, North Garden Road, Haidian District, 100191 Beijing, China. Tel: +86 13910232918 Fax: +86 01064821910 email: [email protected] Received: 23 September 2014 Revision requested: 01 January 2015 Accepted: 08 December 2014 DOI:10.1111/crj.12246 Authorship and contributorship Ming Lu, writing of the manuscript. Xiang Zhu, pathological data collection. Chen Liu, computerized tomography-guided lung biopsy and radiological data collection. Baoshan Cao, clinical data collection. Wanzhen Yao and Yahong Chen, study design and manuscript review. Ethics No ethic conflict and patient has agreed to publication. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Introduction Cavitary pulmonary lesions are commonly encountered during chest radiography, and their differential diagnoses include diverse benign and malignant diseases (1). Most cavitary lung cancers usually present
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
typical radiographic findings such as wall thickness, speculated or irregular inner and outer margin (2). Presence of air-fluid level in a thin-walled lung cavity always conveys benign diagnostic possibilities to clinicians. We present a case of lung squamous cell carcinoma with an unusual and interesting cavity.
1
A refilled thin-walled cavity in lung
Lu et al.
Figure 1. (A) Chest X-ray: a large cavitary mass with air-fluid level in left lung. (B) Chest computerized tomography (CT) scan: A large thin-walled cavitary mass with half fluid filling occupying the left upper lobe. (C) Follow-up chest CT scan after antibiotics: the original airfluid level in the cavity disappeared, and the cavity was entirely filled with fluid. (D) Follow-up chest CT scan after lung biopsy and fluid aspiration: the air-fluid level was easily recognizable again.
Case presentation A 58-year-old male, who worked as a field farmer, presented with intermittent fever, anterior chest pain and hemoptysis for 2 months. He had no night sweat, exertional dyspnea, loss of appetite and loss of weight. The patient had a 40-pack-year cigarette smoking history. He was diagnosed human brucellosis 10 years before. He had no family history of cancer. Blood test were as follows: white blood cell count 11 500/μL, neutrophil percentage 77%, eosinophil percentage 0.3%, hemoglobin 16.5 g/dL and platelet count 290 000/μL. A chest radiograph demonstrated a welldemarcated mass with air-fluid level located in the left lung (Fig. 1A). Chest CT revealed a large thin-walled cavity (4.5 cm × 4.6 cm) in the left upper lobe, and half of the cavity was filled with fluid attenuation (Fig. 1B). He was diagnosed as lung abscess and treated with penicillin for 2 weeks; fever and hemoptysis did not recur. However, no obvious improvement in the chest X-ray was observed. Then intravenous administration of cefatriaxone was given for 2 weeks. Surprisingly, follow-up chest CT showed the original air-fluid level in the cavity disappeared, and the cavity was entirely filled with fluid (attenuation values 11 HU) (Fig. 1C). On admission, he was asymptomatic, and the physical examination and routine laboratory tests were
2
unremarkable. The serum values of carcinoembryonic antigen, neuron-specific enolase and squamous cell carcinoma-associated antigen were all within normal range. The concentration of 1,3-β-D-glucan and galactomannan were normal. Echinococcus antigen assay was negative. Bronchoscopy revealed a normal bronchial tree. Then the patient underwent a CT-guided percutaneous needle lung biopsy. Strawcolored fluid about 10 mL were aspirated from the center of the mass. Microorganisms cultured in the aspirated fluid were all negative. The air-fluid level on chest CT was easily recognizable again after fluid aspiration (Fig. 1D). The pathological diagnosis of the lung biopsy revealed moderately differentiated squamous cell carcinoma (Fig. 2). The positive immunohistochemistry staining of cytokine 5/6 and P63 confirmed this diagnosis. Then, the patient received left lower lobectomy and further chemotherapy.
Discussion Cavitation in primary lung cancer is not rare. Squamous cell carcinoma is the most common histological type of lung cancer to cavitate, followed by adenocarcinoma and large cell carcinoma (3). Most of the malignant lung cavity has a thick wall; however,
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
Lu et al.
Figure 2. Histopathological specimen images: lung biopsy specimen revealed moderate differentiated squamous cell carcinoma. Hematoxylin-Eosin staining (×100).
thin-walled cavity lung cancer has been a special form of lung cancer and reported in recent years (4–10). The incidence of this disease was about 8% (2). Moreover, the incidence has increased with the progression of diagnostic techniques, such as percutaneous cavitary lavage or percutaneous needle washing (11, 12). Most of the pathological type of thin-walled cavity lung cancer were reported as adenocarcinoma (5, 6, 9) or bronchoalveolar cell carcinoma (4). Squamous cell carcinoma (7) were also reported in succession. Although it is not fully clear, possible mechanisms forming thin-walled cavitary lung cancer were supposed to be involved (5, 8, 13). (i) A check-valve mechanism of responsible bronchus formed by inflammatory or neoplastic stenosis leads to formation of the lesion. (ii) Liquidized necrotic content is excreted through the responsible bronchus from ischemic centric necrosis of the tumor. (iii) A tumor arising in the preexisting cyst or bullae is infiltrating alongside the cystic wall. In our present case, the patient had no bullous disease observed in the previous period. Neither there were emphysematous lesions in other lung fields. So the check valve mechanism is considered as the most likely mechanism. Air-fluid level is less common in cancerous cavity, only when it is concurrent with infection or hemorrhage. In our patient, what is unique about is that the air-fluid level in the cavity disappeared after antibiotics treatment, and the cavity was gradually fluid refilled unexpectedly. However, the cavitary lesion kept the previous contour. No cases with such images have been reported. Usually, the check valve may cause a cavity become larger and larger; that is, more air can
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
A refilled thin-walled cavity in lung
enter the cavity during inspiration than can escape during expiration. In our case, we speculate that the check valve was disrupted or occluded as a consequence of tumor infiltration or infection plug, and air cannot enter the cavity during inspiration. As the inner lining of cavities continues to deliquesce because of infection, the air in the cavity was squeezed out and evacuated gradually. Finally, the cavity in the tumor was unexpected ‘refilled’. The rarity of this case and its possible implications may help us to further understand the mechanism of thin-walled cancerous cavity of the lung. So imaging cannot be reliably used to differentiate a cavitary tumor from carcinomatous abscess and a benign abscess. This case shows Malignancy should also be taken into consideration in patients with unusual cavities; otherwise the diagnosis may be missed or delayed.
References 1. Honda O, Tsubamoto M, Inoue A, Johkoh T, Tomiyama N, Hamada S, Mihara N, Sumikawa H, Natsag J, Nakamura H. Pulmonary cavitary nodules on computed tomography: differentiation of malignancy and benignancy. J Comput Assist Tomogr. 2007;31: 943–9. 2. Woodring JH, Fried AM, Chuang VP. Solitary cavities of the lung: diagnostic implications of cavity wall thickness. Am J Roentgenol. 1980;135: 1269–71. 3. Chaudhuri MR. Primary pulmonary cavitating carcinomas. Thorax. 1973;28: 354–66. 4. Morimoto T, Sakamoto H, Ohnishi H, Fujiyama R, Tomioka H, Sakurai T, Tada K, Iwasaki H, Hashimoto K. A case of bronchioloalveolar carcinoma with multiple cystic shadows on chest CT. Nihon Kokyuki Gakkai Zasshi. 2001;39: 186–9. 5. Xue X, Wang P, Xue Q, Wang N, Zhang L, Sun J, Wang K, Yang B, Wang J. Comparative study of solitary thin-walled cavity lung cancer with computed tomography and pathological findings. Lung Cancer. 2012;78: 45–50. 6. Sekine A, Hagiwara E, Ogura T, et al. A case of lung adenocarcinoma with gradual enlargement of thin-walled cavity causing pneumothorax. Nihon Kokyuki Gakkai Zasshi. 2008;46: 552–7. 7. Iwata T, Nishiyama N, Nagano K, Izumi N, Tsukioka T, Hanada S, Kimura T, Kudoh S, Hirata K, Suehiro S. Squamous cell carcinoma presenting as a solitary growing cyst in lung: a diagnostic pitfall in daily clinical practice. Ann Thorac Cardiovasc Surg. 2009;15: 174–7. 8. Sugimoto Y, Semba H, Fujii S, Furukawa E, Kurano R. Clinical analysis of primary lung cancer with a thin-walled cavity to explain the mechanism of thin-walled cavity formation. Nihon Kokyuki Gakkai Zasshi. 2007;45: 460–4.
3
A refilled thin-walled cavity in lung
9. Yoshida T, Harada T, Fuke S, et al. Lung adenocarcinoma presenting with enlarged and multiloculated cystic lesions over 2 years. Respir Care. 2004;49: 1522–4. 10. Nakahara Y, Mochiduki Y, Miyamoto Y. Percutaneous needle washing for the diagnosis of pulmonary thin-walled cavitary lesions filled with air. Intern Med. 2007;46: 1089–94. 11. Belet U, Findik S, Ozmen Z, Atici AG, Akan H. Percutaneous cavitary lavage in the diagnosis of pulmonary cavities. J Thorac Dis. 2013;5: 440–5.
4
Lu et al.
12. Hsieh MS, Wu CT, Chang YL. Unusual presentation of lymphoepithelioma-like carcinoma of lung as a thin-walled cavity. Ann Thorac Surg. 2013;96: 1857–9. 13. Kim TS, Koh WJ, Han J, Chung MJ, Lee JH, Lee KS, Kwon OJ. Hypothesis on the evolution of cavitary lesions in nontuberculous mycobacterial pulmonary infection: thin-section CT and histopathologic correlation. Am J Roentgenol. 2005;184: 1247–52.
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd
