Lung adenocarcinoma - occult in collapsed lung

Case contributed by Dr Bruno Di Muzio

Presentation

Shortness of breath.

Patient Data

Age: 85 years
Gender: Female
X-ray

Chest Radiograph

Large pleural effusion on the left with partial lung collapse. The right lung and pleural space are clear. 

There is a large left pleural effusion with partial collapse of the lung. Within the LLL collapsed lung, there is an ill-defined hypovascular mass that is highlighted in the normal enhancing collapsed lung. 

Macroscopy: Pleural fluid- 700ml of blood-stained fluid.

Microscopy: The preparations show blood, chronic inflammation, histiocytes, mesothelial cells and numerous malignant epithelioid cells presenting in cohesive arrangements and large papilliform fragments. These cells are pleomorphic, exhibiting a high N/C ratio, convoluted nuclei, coarsened chromatin, macronucleoli and moderate amount of vacuolated cytoplasm.

Conclusion: Pleural fluid: Malignant. Features consistent with metastatic adenocarcinoma. 

Diffusely positive for CK7 and TTF1, weak positive GATA3, negative CK20, ER, PAX8, HER-2 – pulmonary origin

X-ray

Chest Radiograph (5 days later)

Small residual left pleural effusion and LLL ill-defined persistent opacity. 

CT

CT Chest (5 days later)

Significant interval reduction in the size of the left pleural effusion which is now small, revealing a spiculate solid mass is present within the left lower lobe anteriorly.  Its exact size is difficult to ascertain as it is continuous anteriorly with a band like opacity which crosses the fissure and extends to the anterior pleural surface of the lingula.  It merges posteriorly with a band like opacity which extends into the medial basal left lower lobe. It tethers the pleural surface laterally.

Patchy ground glass opacity is present within the medial left lower lobe.  Several calcified nodules, scarring and architectural distortion are present in the right lung apex suggestive of previous TB.  Several scattered adjacent 3 mm noncalcified nodules are indeterminate but possibly represent noncalcified granulomas.  Two incidental right upper lobe pneumatoceles.

No mediastinal, hilar or axillary lymphadenopathy.  Calcified unenlarged right hilar lymph nodes.  Moderate hiatus hernia.

No destructive bony lesion.

Case Discussion

This case illustrates how important is to work-up for underlying etiologies when assessing scans of pleural effusion of unknown etiology. Even with the collapsed the lung, the primary tumor can be identified as a non-enhancing area within normal enhancing collapsed lung parenchyma.  

 

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Case information

rID: 60655
Published: 31st Aug 2018
Last edited: 14th Aug 2019
System: Chest
Inclusion in quiz mode: Included

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