324
Gynaecology Case Reports
González CH, Vargas FR, Álvarez-Pérez AB, Kim CA, Brunoni D, MarquesDias MJ et al. 1993. Limb deficiency with or without Möbius sequence in seven Brazilian children associated with misoprostol use in the first trimester of pregnancy. American Journal of Medical Genetics 47: 59–64. Orioli IM, Castilla EE. 2000. Epidemiological assessment of misoprostol teratogenicity. British Journal of Obstetrics and Gynaecology 107: 519–523. Schüler L, Pastuszak A, Sanseverino MT, Orioli IM, Brunoni D, Koren G. 1997. Pregnancy outcome after abortion attempt with misoprostol. Teratology 55:36.
Primary fallopian tube transitional cell carcinoma J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
A. Keepanasseril1, R. Bagga1, S. C. Saha1, P. Dey2, S. Gainder1 & L. K. Dhaliwal1 Departments of 1Obstetrics and Gynecology and 2Cytology and Gynecologic Pathology, Postgraduate Institute of Medical education and Research (PGIMER), Chandigarh, India DOI: 10.3109/01443615.2014.952223 Correspondence: R. Bagga, Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India. E-mail: [email protected]
Introduction Carcinoma of the fallopian tube is one of the rarest gynaecological tumours accounting for only 0.18–1.6% of gynaecological malignancies (Nordin 1994). Preoperative diagnosis of fallopian tube carcinoma is difficult, most signs and symptoms are non-characteristic. The most frequent clinical symptom at presentation is included in the Latkzo’s triad, which comprises of vaginal discharge or bleeding, lower abdominal pain and pelvic mass (Piura and Rabinovich 2000). However, a correct preoperative diagnosis is achieved in fewer than 5% of cases and, in many cases, tubal carcinoma is an incidental finding during surgery for an unrelated condition (Alvarado-Cabrero et al. 1999). Although pelvic mass or bloody discharge is one of the common presenting symptoms (Ben-Hur et al. 1999), tubal carci-
noma is not usually considered in the differential diagnosis. Here, we report two cases of transitional cell carcinoma of the fallopian tube, which had atypical presentations: one with pyrexia of unknown origin and the other, a cervical malignancy.
Case report 1 A 59-year-old postmenopausal woman presented with lower abdominal pain and high-grade fever of 1-month duration. Ultrasound examination was normal, except for low-level echoes in the cavity, suggestive of pyometra. Cultures were sterile. She was given antibiotics and dilatation and drainage was done. Endometrium was atrophic on evaluation. She continued to have a fever and collection in the endometrial cavity. At 6 months after follow-up, she was suspected to have a right ovarian mass (4.6 ⫻ 2.3 cm) with CA125; 12 IU/ml (normal ⬍ 35 IU/ml). On staging laparotomy, she was found to have a tumour in the right fallopian tube, with no other deposits. She underwent total hysterectomy with bilateral salpingo-oophorectomy, multiple peritoneal biopsies and infracolic omentectomy. Histopathological examination revealed it to be a transitional cell carcinoma. Peritoneal biopsy revealed granulomatous inflammation but no evidence of malignancy. She was diagnosed as FIGO stage I. As she continued to have fever and peritoneal biopsy showing granulomatous inflammation, she was given anti-tubercular treatment. However, the fever did not respond to this and subsided only after initiating chemotherapy. She received six courses of adjuvant chemotherapy once every 3 weeks with carboplatin (AUC ⫽ 6) and paclitaxel (175 mg/m2). She is in remission at 18-months follow-up.
Case report 2 A 55-year-old woman presented with a history of postmenopausal bleeding and foul smelling vaginal discharge. She had undergone a mastectomy for infiltrating ductal carcinoma and had received postoperative radiotherapy and tamoxifen, 25 years previously. Pap smear was inflammatory. Endocervical tissue of the fractional curettage was suggestive of cervical squamous cell carcinoma. Type II radical hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy was performed. Intraoperatively, the uterus was found to be of normal size and mobile. The left fallopian tube revealed a grey–white circumscribed tumour filling the lumen of the tube. Examination of the surgical specimen revealed two nodules in the endocervical area. Histopathological examination revealed a poorly-differentiated transitional cell carcinoma of the left fallopian tube with metastatic involvement in the cervix; the lymph nodes were
Figure 1. Photomicrograph of the peritoneal biopsy showing multiple epithelioid cell granulomas (a) and transitional cell carcinoma of the fallopian tube showing ribbon of tumour cells (c);(b) shows the presence of metastasis in the cervix (H&E, ⫻ 200).
Gynaecology Case Reports 325 free of the tumour (Figure 1). Diagnosis of FIGO stage II fallopian tube carcinoma was made. She received chemotherapy of carboplatin (AUC ⫽ 6) and paclitaxel (175 mg/m2), every 3 weeks for six courses. She is in remission at 20 months follow-up.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Discussion Primary carcinoma of the fallopian tube most frequently occurs after the 4th decade of life (Pectasides et al. 2009; Wethington et al. 2008), with a median age of occurrence of 64 years (range 17–88 years). The majority of the malignant tumours of the fallopian tube are adenocarcinoma. Transitional cell carcinoma of the fallopian tube is very rare (0.2–0.5%) and was first described by Federman and Toker (1973). Fewer than 25 cases have been reported in the literature. The origin of primary transitional cell carcinoma of the fallopian tube has been ascribed to transitional cell metaplasia of the tubal serosa or from mucosal epithelium (Chin 1998). Most patients present with non-characteristic signs and symptoms, which comprise of a triad of pelvic pain, a pelvic mass and serosanguineous vaginal discharge (hydrops tubae profluens) (‘Latzko’s triad’); or vaginal bleeding, vaginal discharge and lower abdominal pain (Nordin 1994; Piura and Rabinovich 2000). Fallopian tube tumours spread the same way as ovarian cancer, proximally by direct extension along the mucosal surface into the uterine cavity, or disseminating to the ovaries and peritoneum with the intraperitoneal route being the most frequently encountered (Pectasides 2009). The rarity of primary fallopian tube carcinoma constitutes a problem in diagnosis and almost invariably, true diagnosis is unknown prior to laparotomy (Nordin 1994; Pectasides et al. 2009; Wethington et al. 2008). In Case report 2, the difficulty was more pronounced due to the fact that the primary lesion did not extend locally to the uterine cavity or the peritoneum, but had a skip lesion, i.e. secondary metastasis, to the cervical canal. As a result, preoperative examination led to the false diagnosis of primary squamous cell carcinoma of the cervical canal. Histopathological examination after surgery led to the correct diagnosis of a fallopian tube tumour. Ultrasonography is useful for detecting a tubal mass; but once a mass is seen, further imaging may not help in establishing diagnosis and surgery is almost always indicated. In the majority of the cases, CA125 is elevated in ⬎ 80%, especially in advanced disease. CA125 levels are independent prognostic markers and have a correlation with disease-free survival in women with fallopian tube carcinoma. It can also be used as a tool in monitoring disease progression. In Case report 1, the CA125 levels were normal (Babu 2009; Takeuchi 1999). Surgery is the mainstay for treatment of these tumours, i.e. total abdominal hysterectomy with bilateral salpingo-oophorectomy, tumour debulking and full staging. Survival rates are better with complete removal of the tumour and with pelvic and para-aortic lymphadenectomy as compared with lymph node sampling (Babu 2009; Kim 1999). Surgical staging proposed by FIGO is used for these tumours (Wheeler 2011).
Conclusion Carcinoma of the fallopian tube are rarely considered preoperatively and it should be considered in the differential diagnosis in a postmenopausal women with atypical presentation who failed to respond to initial conventional therapy. The treatment approach is similar to ovarian carcinoma, primarily surgical. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Alvarado-Cabrero I, Young RH, Vamvakas EC et al. 1999. Carcinoma of the fallopian tube. A clinicopathological study of 105 cases with observations on staging and prognostic factors. Gynecologic Oncology 72:367–379. Babu MR, Haji AG, Chitrathara K et al. 2009. Primary transitional cell carcinoma of the fallopian tube in a premenopausal woman: A case report and review of literature. Indian Journal of Medical and Paediatric Oncology 30:35–38. Ben-Hur H, Dgani R, Ben-Arie A et al. 1999. Diagnostic dilemmas and current therapy of Fallopian tube cancer. European Journal of Gynaecological Oncology 20:108–109.
Chin H, Matsui H, Mitsuhashi A et al. 1998. Primary transitional cell carcinoma of the fallopian tube: a case report and review of the literature. Gynecologic Oncology 71:469–475. Federman Q, Toker C. 1973. Primary transitional cell tumor of the uterine adnexa. American Journal of Obstetrics and Gynecology 115:863–864. Kim JW, Cho EM, Kim YT et al. 1999. A case of primary transitional cell carcinoma of the fallopian tube. Journal of Obstetrics and Gynaecology Research 25:321–326. Nordin AJ. 1994. Primary carcinoma of the fallopian tube: a 20-year literature review. Obstetrical and Gynecological Survey 49:349–361. Pectasides D, Pectasides E, Papaxoinis G et al. 2009. Primary fallopian tube carcinoma: results of a retrospective analysis of 64 patients. Gynecologic Oncology 115:97–101. Piura B, Rabinovich A. 2000. Primary carcinoma of the fallopian tube: study of 11 cases. European Journal of Obstetrics, Gynecology, and Reproductive Biology 91:169–175. Takeuchi S, Hirano H, Ichio T et al. 1999. A case report: rare case of primary transitional cell carcinoma of the fallopian tube. Journal of Obstetrics and Gynaecology Research 25:29–32. Wethington SL, Herzog TJ, Seshan VE et al. 2008. Improved survival for fallopian tube cancer: a comparison of clinical characteristics and outcome for primary fallopian tube and ovarian cancer. Cancer 113:3298–3306. Wheeler JE. 2011. Diseases of the fallopian tube. In: Kurman RB, editor. Blaustein’s pathology of the female genital tract. 6th ed. New York: Springer-Verlag. p 427–429.
Benign metastasising leiomyoma mistaken for pulmonary metastasis from an ovarian carcinoma J. J. Kim1, J. K. Park2, Y. P. Wang2 & S. W. Moon3 Department of Thoracic and Cardiovascular Surgery,1Uijeongbu St. Mary’s Hospital, 2Seoul St. Mary’s Hospital and 3St. Paul Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea DOI: 10.3109/01443615.2014.954097 Correspondence: J. K. Park, Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, Catholic Cancer Center, 222, Banpo-Daero, Seocho-gu, Seoul 137–701, Korea. E-mail: [email protected]
Introduction Benign metastasising leiomyoma is the existence of histologically benign smooth muscle tumours in extrauterine sites, and is a very rare disease in women with a history of benign uterine leiomyoma (Kang et al. 2011; Kim and Han 2012). We report a case in which benign metastasising leiomyoma was mistaken for pulmonary metastasis from an ovarian carcinoma.
Case report A 52-year-old woman visited the department of gynaecology for urinary frequency and abdominal pain. There was a huge abdominopelvic mass that was soft and non-tender on physical examination. Transvaginal ultrasonography findings showed a 9 ⫻ 10 cm cystic ovarian mass. An abdomino-pelvic MRI showed a ∼10 cm sized predominantly cystic mass, with a solid portion in the right adnexa suggesting a right ovary carcinoma, and a few intramural and subserosal myomas in the uterus. |A chest CT showed two small nodules in the left upper lobe, suggesting pulmonary metastases from ovarian cancer (Figure 1). First, the woman underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for the right ovarian mass. The pathological results showed a well-differentiated endometrial adenocarcinoma in the right ovary without lymph node involvement (stage 1A), and a few uterine leiomyomas. Three days later, she was referred to our department for pathological confirmation of the pulmonary nodules. Because of the small size of the lesions, we localised the pulmonary nodules with a chest CT-guided hook wire. We performed a thoracoscopic wedge resection for the pulmonary nodules. The pathology results showed benign metastasising
Gynaecology Case Reports
González CH, Vargas FR, Álvarez-Pérez AB, Kim CA, Brunoni D, MarquesDias MJ et al. 1993. Limb deficiency with or without Möbius sequence in seven Brazilian children associated with misoprostol use in the first trimester of pregnancy. American Journal of Medical Genetics 47: 59–64. Orioli IM, Castilla EE. 2000. Epidemiological assessment of misoprostol teratogenicity. British Journal of Obstetrics and Gynaecology 107: 519–523. Schüler L, Pastuszak A, Sanseverino MT, Orioli IM, Brunoni D, Koren G. 1997. Pregnancy outcome after abortion attempt with misoprostol. Teratology 55:36.
Primary fallopian tube transitional cell carcinoma J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
A. Keepanasseril1, R. Bagga1, S. C. Saha1, P. Dey2, S. Gainder1 & L. K. Dhaliwal1 Departments of 1Obstetrics and Gynecology and 2Cytology and Gynecologic Pathology, Postgraduate Institute of Medical education and Research (PGIMER), Chandigarh, India DOI: 10.3109/01443615.2014.952223 Correspondence: R. Bagga, Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India. E-mail: [email protected]
Introduction Carcinoma of the fallopian tube is one of the rarest gynaecological tumours accounting for only 0.18–1.6% of gynaecological malignancies (Nordin 1994). Preoperative diagnosis of fallopian tube carcinoma is difficult, most signs and symptoms are non-characteristic. The most frequent clinical symptom at presentation is included in the Latkzo’s triad, which comprises of vaginal discharge or bleeding, lower abdominal pain and pelvic mass (Piura and Rabinovich 2000). However, a correct preoperative diagnosis is achieved in fewer than 5% of cases and, in many cases, tubal carcinoma is an incidental finding during surgery for an unrelated condition (Alvarado-Cabrero et al. 1999). Although pelvic mass or bloody discharge is one of the common presenting symptoms (Ben-Hur et al. 1999), tubal carci-
noma is not usually considered in the differential diagnosis. Here, we report two cases of transitional cell carcinoma of the fallopian tube, which had atypical presentations: one with pyrexia of unknown origin and the other, a cervical malignancy.
Case report 1 A 59-year-old postmenopausal woman presented with lower abdominal pain and high-grade fever of 1-month duration. Ultrasound examination was normal, except for low-level echoes in the cavity, suggestive of pyometra. Cultures were sterile. She was given antibiotics and dilatation and drainage was done. Endometrium was atrophic on evaluation. She continued to have a fever and collection in the endometrial cavity. At 6 months after follow-up, she was suspected to have a right ovarian mass (4.6 ⫻ 2.3 cm) with CA125; 12 IU/ml (normal ⬍ 35 IU/ml). On staging laparotomy, she was found to have a tumour in the right fallopian tube, with no other deposits. She underwent total hysterectomy with bilateral salpingo-oophorectomy, multiple peritoneal biopsies and infracolic omentectomy. Histopathological examination revealed it to be a transitional cell carcinoma. Peritoneal biopsy revealed granulomatous inflammation but no evidence of malignancy. She was diagnosed as FIGO stage I. As she continued to have fever and peritoneal biopsy showing granulomatous inflammation, she was given anti-tubercular treatment. However, the fever did not respond to this and subsided only after initiating chemotherapy. She received six courses of adjuvant chemotherapy once every 3 weeks with carboplatin (AUC ⫽ 6) and paclitaxel (175 mg/m2). She is in remission at 18-months follow-up.
Case report 2 A 55-year-old woman presented with a history of postmenopausal bleeding and foul smelling vaginal discharge. She had undergone a mastectomy for infiltrating ductal carcinoma and had received postoperative radiotherapy and tamoxifen, 25 years previously. Pap smear was inflammatory. Endocervical tissue of the fractional curettage was suggestive of cervical squamous cell carcinoma. Type II radical hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy was performed. Intraoperatively, the uterus was found to be of normal size and mobile. The left fallopian tube revealed a grey–white circumscribed tumour filling the lumen of the tube. Examination of the surgical specimen revealed two nodules in the endocervical area. Histopathological examination revealed a poorly-differentiated transitional cell carcinoma of the left fallopian tube with metastatic involvement in the cervix; the lymph nodes were
Figure 1. Photomicrograph of the peritoneal biopsy showing multiple epithelioid cell granulomas (a) and transitional cell carcinoma of the fallopian tube showing ribbon of tumour cells (c);(b) shows the presence of metastasis in the cervix (H&E, ⫻ 200).
Gynaecology Case Reports 325 free of the tumour (Figure 1). Diagnosis of FIGO stage II fallopian tube carcinoma was made. She received chemotherapy of carboplatin (AUC ⫽ 6) and paclitaxel (175 mg/m2), every 3 weeks for six courses. She is in remission at 20 months follow-up.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 05/19/15 For personal use only.
Discussion Primary carcinoma of the fallopian tube most frequently occurs after the 4th decade of life (Pectasides et al. 2009; Wethington et al. 2008), with a median age of occurrence of 64 years (range 17–88 years). The majority of the malignant tumours of the fallopian tube are adenocarcinoma. Transitional cell carcinoma of the fallopian tube is very rare (0.2–0.5%) and was first described by Federman and Toker (1973). Fewer than 25 cases have been reported in the literature. The origin of primary transitional cell carcinoma of the fallopian tube has been ascribed to transitional cell metaplasia of the tubal serosa or from mucosal epithelium (Chin 1998). Most patients present with non-characteristic signs and symptoms, which comprise of a triad of pelvic pain, a pelvic mass and serosanguineous vaginal discharge (hydrops tubae profluens) (‘Latzko’s triad’); or vaginal bleeding, vaginal discharge and lower abdominal pain (Nordin 1994; Piura and Rabinovich 2000). Fallopian tube tumours spread the same way as ovarian cancer, proximally by direct extension along the mucosal surface into the uterine cavity, or disseminating to the ovaries and peritoneum with the intraperitoneal route being the most frequently encountered (Pectasides 2009). The rarity of primary fallopian tube carcinoma constitutes a problem in diagnosis and almost invariably, true diagnosis is unknown prior to laparotomy (Nordin 1994; Pectasides et al. 2009; Wethington et al. 2008). In Case report 2, the difficulty was more pronounced due to the fact that the primary lesion did not extend locally to the uterine cavity or the peritoneum, but had a skip lesion, i.e. secondary metastasis, to the cervical canal. As a result, preoperative examination led to the false diagnosis of primary squamous cell carcinoma of the cervical canal. Histopathological examination after surgery led to the correct diagnosis of a fallopian tube tumour. Ultrasonography is useful for detecting a tubal mass; but once a mass is seen, further imaging may not help in establishing diagnosis and surgery is almost always indicated. In the majority of the cases, CA125 is elevated in ⬎ 80%, especially in advanced disease. CA125 levels are independent prognostic markers and have a correlation with disease-free survival in women with fallopian tube carcinoma. It can also be used as a tool in monitoring disease progression. In Case report 1, the CA125 levels were normal (Babu 2009; Takeuchi 1999). Surgery is the mainstay for treatment of these tumours, i.e. total abdominal hysterectomy with bilateral salpingo-oophorectomy, tumour debulking and full staging. Survival rates are better with complete removal of the tumour and with pelvic and para-aortic lymphadenectomy as compared with lymph node sampling (Babu 2009; Kim 1999). Surgical staging proposed by FIGO is used for these tumours (Wheeler 2011).
Conclusion Carcinoma of the fallopian tube are rarely considered preoperatively and it should be considered in the differential diagnosis in a postmenopausal women with atypical presentation who failed to respond to initial conventional therapy. The treatment approach is similar to ovarian carcinoma, primarily surgical. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Alvarado-Cabrero I, Young RH, Vamvakas EC et al. 1999. Carcinoma of the fallopian tube. A clinicopathological study of 105 cases with observations on staging and prognostic factors. Gynecologic Oncology 72:367–379. Babu MR, Haji AG, Chitrathara K et al. 2009. Primary transitional cell carcinoma of the fallopian tube in a premenopausal woman: A case report and review of literature. Indian Journal of Medical and Paediatric Oncology 30:35–38. Ben-Hur H, Dgani R, Ben-Arie A et al. 1999. Diagnostic dilemmas and current therapy of Fallopian tube cancer. European Journal of Gynaecological Oncology 20:108–109.
Chin H, Matsui H, Mitsuhashi A et al. 1998. Primary transitional cell carcinoma of the fallopian tube: a case report and review of the literature. Gynecologic Oncology 71:469–475. Federman Q, Toker C. 1973. Primary transitional cell tumor of the uterine adnexa. American Journal of Obstetrics and Gynecology 115:863–864. Kim JW, Cho EM, Kim YT et al. 1999. A case of primary transitional cell carcinoma of the fallopian tube. Journal of Obstetrics and Gynaecology Research 25:321–326. Nordin AJ. 1994. Primary carcinoma of the fallopian tube: a 20-year literature review. Obstetrical and Gynecological Survey 49:349–361. Pectasides D, Pectasides E, Papaxoinis G et al. 2009. Primary fallopian tube carcinoma: results of a retrospective analysis of 64 patients. Gynecologic Oncology 115:97–101. Piura B, Rabinovich A. 2000. Primary carcinoma of the fallopian tube: study of 11 cases. European Journal of Obstetrics, Gynecology, and Reproductive Biology 91:169–175. Takeuchi S, Hirano H, Ichio T et al. 1999. A case report: rare case of primary transitional cell carcinoma of the fallopian tube. Journal of Obstetrics and Gynaecology Research 25:29–32. Wethington SL, Herzog TJ, Seshan VE et al. 2008. Improved survival for fallopian tube cancer: a comparison of clinical characteristics and outcome for primary fallopian tube and ovarian cancer. Cancer 113:3298–3306. Wheeler JE. 2011. Diseases of the fallopian tube. In: Kurman RB, editor. Blaustein’s pathology of the female genital tract. 6th ed. New York: Springer-Verlag. p 427–429.
Benign metastasising leiomyoma mistaken for pulmonary metastasis from an ovarian carcinoma J. J. Kim1, J. K. Park2, Y. P. Wang2 & S. W. Moon3 Department of Thoracic and Cardiovascular Surgery,1Uijeongbu St. Mary’s Hospital, 2Seoul St. Mary’s Hospital and 3St. Paul Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea DOI: 10.3109/01443615.2014.954097 Correspondence: J. K. Park, Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, Catholic Cancer Center, 222, Banpo-Daero, Seocho-gu, Seoul 137–701, Korea. E-mail: [email protected]
Introduction Benign metastasising leiomyoma is the existence of histologically benign smooth muscle tumours in extrauterine sites, and is a very rare disease in women with a history of benign uterine leiomyoma (Kang et al. 2011; Kim and Han 2012). We report a case in which benign metastasising leiomyoma was mistaken for pulmonary metastasis from an ovarian carcinoma.
Case report A 52-year-old woman visited the department of gynaecology for urinary frequency and abdominal pain. There was a huge abdominopelvic mass that was soft and non-tender on physical examination. Transvaginal ultrasonography findings showed a 9 ⫻ 10 cm cystic ovarian mass. An abdomino-pelvic MRI showed a ∼10 cm sized predominantly cystic mass, with a solid portion in the right adnexa suggesting a right ovary carcinoma, and a few intramural and subserosal myomas in the uterus. |A chest CT showed two small nodules in the left upper lobe, suggesting pulmonary metastases from ovarian cancer (Figure 1). First, the woman underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for the right ovarian mass. The pathological results showed a well-differentiated endometrial adenocarcinoma in the right ovary without lymph node involvement (stage 1A), and a few uterine leiomyomas. Three days later, she was referred to our department for pathological confirmation of the pulmonary nodules. Because of the small size of the lesions, we localised the pulmonary nodules with a chest CT-guided hook wire. We performed a thoracoscopic wedge resection for the pulmonary nodules. The pathology results showed benign metastasising
