Lung (2015) 193:439–441 DOI 10.1007/s00408-015-9713-y
LUNG IMAGES
Synchronous Intrapulmonary Schwannoma and Primary Lung Cancer Filippo Lococo1 • Gabriele Carlinfante2 • Cristian Rapicetta1 • Tommaso Ricchetti1 Loris Brandi1 • Massimiliano Paci1 • Cristiano Carbonelli3 • Giorgio Sgarbi1
•
Received: 16 February 2015 / Accepted: 25 February 2015 / Published online: 15 March 2015 Ó Springer Science+Business Media New York 2015
A 67-year-old male underwent radiological examination as a consequence of a persistent cough. Chest X-ray first and computer tomography (CT) scan later showed an area of pulmonary consolidation at the level of lower right lobe (Fig. 1a, yellow arrow) and a round-shape pulmonary nodule in the lower left lobe (Fig. 1a, b, red arrow). The patient underwent bronchoscopy with trans-bronchial biopsy, and the histo/cytological examination showed a primary mucinous adenocarcinoma of the right lower lobe, while fine-needle biopsy of the left lesion was inadequate to achieve a certain diagnosis. Positron emission tomography (PET)/CT scan for staging purpose revealed a moderate uptake at the level of both right (SUVmax = 3.1, Fig. 1c, d, yellow arrow) and left (SUVmax = 3.2, Fig. 1c, d, red arrow) lung lesions, while no uptake was observed in other sites. Institutional Tumor Board interpreted the radiological scenario as a primary adenocarcinoma with single
contralateral lung metastases scheduling sequential surgical lung resections. Thus, the patient underwent right lower lobectomy with mediastinal lymph-nodal dissection (confirming a pT2N0 adenocarcinoma) and, subsequently, a wedge resection of the right upper lobe. Macroscopically, the nodule appeared well defined by thin fibrous capsule (Fig. 2a), while microscopically fascicles of elongated cells with spindle-shaped nuclei (Fig. 2b), walled and ectatic vessels, and hemorrhagic area with perivascular hemosiderin deposition were observed (Fig. 2c). Immunohistochemical staining showed tumor cells positive for S-100 protein (Fig. 2d) and negative for cytokeratin AE1/AE3, smooth muscle actin, desmin, and CD34. A final diagnosis of intrapulmonary schwannoma was done, and no adjuvant chemotherapy was performed. Pulmonary schwannomas are extremely rare neoplasm accounting for \0.2 % of all pulmonary neoplasms [1].
& Filippo Lococo [email protected] 1
Unit of Thoracic Surgery, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
2
Unit of Pathology, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
3
Pulmonology Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
123
440
Lung (2015) 193:439–441
Fig. 1 Radiological evaluation–pre-operative CT scan revealed an area of pulmonary consolidation at the level of right lower lobe (a, yellow arrow) and a roundshape pulmonary lesion in the proximity of a segmental bronchus of the lower left lobe (a, b, red arrow). Radiometabolic evaluation– PET/CT scan for staging purpose showed the presence of moderate uptake (SUVmax = 3.1) at the level of right pulmonary consolidation (c, d, yellow arrow) and, similarly (SUVmax = 3.2) in correspondence of the left lung lesion (c, d, red arrow). No uptake was observed in other sites
Fig. 2 Pathological evaluation: macroscopic examination of left lesion a showed an encapsulated, smooth-surfaced nodule measuring 3 cm in greatest dimension. The nodule appeared well defined by thin fibrous capsule (original magnification 920); Microscopically (b), the tumor showed fascicles of elongated cells with spindle-shaped nuclei, original magnification 9100; c thin-walled and ectatic vessels and hemorrhagic area with perivascular hemosiderin deposition were present, original magnification 9100; d tumor cells showed strong and diffuse staining for S-100 protein, original magnification 940. Moreover, scattered EMA-positive perineurial cells in the capsule were present, whereas the tumor cells resulted in negative (findings not shown)
Generally, such tumors presented as round lesions with well-defined margins [2] and low to mildly increased uptake on PET scan which may mimic low-grade malignancy [3] or NSCLC-metastases as in the present case. Synchronous tumors have still been reported in the lung but, to
123
the best of our knowledge, this is the first report of a patient presenting with these two pathological entities. The physicians should take in mind such challenging diagnosis in the differential diagnosis of round-shape pulmonary lesions.
Lung (2015) 193:439–441 Conflict of interest
None.
References 1. Ohtsuka T, Nomori H, Naruke T, Orikasa H, Yamazaki K, Suemasu K (2005) Intrapulmonary schwannoma. Jpn J Thorac Cardiovasc Surg 53(3):154–156
441 2. Boland JM, Colby TV, Folpe AL (2014) Intrathoracic peripheral nerve sheath tumors—a clinicopathological study of 75 cases. Hum Pathol. doi:10.1016/j.humpath.2014.11.017 3. Gonzalez M, Prior JO, Rotman S, Ris HB, Krueger T (2011) Benign intrapulmonary schwannoma: aspect on F-18 fluorodeoxyglucose PET/CT. Clin Nucl Med 36(6):465–467. doi:10.1097/RLU.0b01 3e31820aa268
123
LUNG IMAGES
Synchronous Intrapulmonary Schwannoma and Primary Lung Cancer Filippo Lococo1 • Gabriele Carlinfante2 • Cristian Rapicetta1 • Tommaso Ricchetti1 Loris Brandi1 • Massimiliano Paci1 • Cristiano Carbonelli3 • Giorgio Sgarbi1
•
Received: 16 February 2015 / Accepted: 25 February 2015 / Published online: 15 March 2015 Ó Springer Science+Business Media New York 2015
A 67-year-old male underwent radiological examination as a consequence of a persistent cough. Chest X-ray first and computer tomography (CT) scan later showed an area of pulmonary consolidation at the level of lower right lobe (Fig. 1a, yellow arrow) and a round-shape pulmonary nodule in the lower left lobe (Fig. 1a, b, red arrow). The patient underwent bronchoscopy with trans-bronchial biopsy, and the histo/cytological examination showed a primary mucinous adenocarcinoma of the right lower lobe, while fine-needle biopsy of the left lesion was inadequate to achieve a certain diagnosis. Positron emission tomography (PET)/CT scan for staging purpose revealed a moderate uptake at the level of both right (SUVmax = 3.1, Fig. 1c, d, yellow arrow) and left (SUVmax = 3.2, Fig. 1c, d, red arrow) lung lesions, while no uptake was observed in other sites. Institutional Tumor Board interpreted the radiological scenario as a primary adenocarcinoma with single
contralateral lung metastases scheduling sequential surgical lung resections. Thus, the patient underwent right lower lobectomy with mediastinal lymph-nodal dissection (confirming a pT2N0 adenocarcinoma) and, subsequently, a wedge resection of the right upper lobe. Macroscopically, the nodule appeared well defined by thin fibrous capsule (Fig. 2a), while microscopically fascicles of elongated cells with spindle-shaped nuclei (Fig. 2b), walled and ectatic vessels, and hemorrhagic area with perivascular hemosiderin deposition were observed (Fig. 2c). Immunohistochemical staining showed tumor cells positive for S-100 protein (Fig. 2d) and negative for cytokeratin AE1/AE3, smooth muscle actin, desmin, and CD34. A final diagnosis of intrapulmonary schwannoma was done, and no adjuvant chemotherapy was performed. Pulmonary schwannomas are extremely rare neoplasm accounting for \0.2 % of all pulmonary neoplasms [1].
& Filippo Lococo [email protected] 1
Unit of Thoracic Surgery, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
2
Unit of Pathology, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
3
Pulmonology Unit, Department of Cardiology, Thoracic and Vascular Surgery and Critical Care Medicine, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
123
440
Lung (2015) 193:439–441
Fig. 1 Radiological evaluation–pre-operative CT scan revealed an area of pulmonary consolidation at the level of right lower lobe (a, yellow arrow) and a roundshape pulmonary lesion in the proximity of a segmental bronchus of the lower left lobe (a, b, red arrow). Radiometabolic evaluation– PET/CT scan for staging purpose showed the presence of moderate uptake (SUVmax = 3.1) at the level of right pulmonary consolidation (c, d, yellow arrow) and, similarly (SUVmax = 3.2) in correspondence of the left lung lesion (c, d, red arrow). No uptake was observed in other sites
Fig. 2 Pathological evaluation: macroscopic examination of left lesion a showed an encapsulated, smooth-surfaced nodule measuring 3 cm in greatest dimension. The nodule appeared well defined by thin fibrous capsule (original magnification 920); Microscopically (b), the tumor showed fascicles of elongated cells with spindle-shaped nuclei, original magnification 9100; c thin-walled and ectatic vessels and hemorrhagic area with perivascular hemosiderin deposition were present, original magnification 9100; d tumor cells showed strong and diffuse staining for S-100 protein, original magnification 940. Moreover, scattered EMA-positive perineurial cells in the capsule were present, whereas the tumor cells resulted in negative (findings not shown)
Generally, such tumors presented as round lesions with well-defined margins [2] and low to mildly increased uptake on PET scan which may mimic low-grade malignancy [3] or NSCLC-metastases as in the present case. Synchronous tumors have still been reported in the lung but, to
123
the best of our knowledge, this is the first report of a patient presenting with these two pathological entities. The physicians should take in mind such challenging diagnosis in the differential diagnosis of round-shape pulmonary lesions.
Lung (2015) 193:439–441 Conflict of interest
None.
References 1. Ohtsuka T, Nomori H, Naruke T, Orikasa H, Yamazaki K, Suemasu K (2005) Intrapulmonary schwannoma. Jpn J Thorac Cardiovasc Surg 53(3):154–156
441 2. Boland JM, Colby TV, Folpe AL (2014) Intrathoracic peripheral nerve sheath tumors—a clinicopathological study of 75 cases. Hum Pathol. doi:10.1016/j.humpath.2014.11.017 3. Gonzalez M, Prior JO, Rotman S, Ris HB, Krueger T (2011) Benign intrapulmonary schwannoma: aspect on F-18 fluorodeoxyglucose PET/CT. Clin Nucl Med 36(6):465–467. doi:10.1097/RLU.0b01 3e31820aa268
123
