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Benign Lymphoid Hyperplasia (Castleman's Tumor) Mimicking a Posterior Mediastinal Neurogenic Tumor
516
CULVER AND CHOf
Benign Lymphoid Hyperplasia (Castleman' 5 Tumor) Mimicking a Posterior Mediastinal Neurogenic Turner" Gordon]. Culver, M.D.·· and Byung-Koo Choi, M.D.t
A mass in the parietal pleura in paravertebral location with rib erosions diagnosed as a neurogenic tumor is reported. The pathologic diagnosis was benign mediastinal lymphoid hyperplasia. This is the ninth reported case of a Castleman's tumor occurring in the posterior mediastinum.
S
ince Cas tleman's 1 original description of benign lymphoid hyperplasia in 1954, 65 cases have been reported occurring in multiple locations. In addition to lymphoid follicle hyperplasia, some have shown capillary proliferation with endothelial hyperplasia and germinal center formation. Descriptive names have been used which include angiofollicular lymph node hyperplasiaand angiomatous lymphoid hamartoma. These tumors have not been associated with any specific symptoms. It would seem that the variable clinical findings are not related to the local pathology. The disease has mainly been discovered on roentgenograms which were obtained as routine studies or for symptoms of respiratory disease such as frequent colds, cough or an acute chest problem. The benign character of the disease is confirmed by the unchanging size of the lesions over many years and by no evidence of recurrence after local excision. Also, there are no reported cases of metastatic lesions. There is no sex predominance. The age range is mainly between 20 and 40 years, with a few below and above. The reported cases indicate that the majority of these tumors are mediastinal or intrathoracic in position. However, they can occur in lymphoid tissue in other locations. The pathology of these tumors is variable, but there is a rather consistent vascular proliferation associated with the lymphoid follicular hyperplasia. Eight cases of Castleman's tumor have been reported in the posterior mediastinum.sf All these cases were treated surgically and there was no recurrence.
FIGURE 1. Posteroanterior chest x-ray fihn showing the paravertebral location of the well circumscribed mass. atypical pneumonia. She received erythromycin. The symptoms subsided and in a week the right upper lobe infiltrates had resolved. She was admitted to the hospital for evaluation of her mediastinal mass. Her admission physical exam was unrevealing and past
CASE REPORT
A 20-year-old white woman was seen by her private physician because she had developed fever, sweating, headache and productive cough. Her chest x-ray fihn revealed a right upper lobe interstitial in61trate and a left posterior mediastinal mass. Her acute condition was diagnosed as ·From the Department of Diagnostic Radiology, Buffalo General Hospital and the School of Medicine, State University of New York at Buffalo. ··Clinical Professor of Radiology. tResident in Diagnostic RadiololQ'. Reprint requests: Dr. Culver, Buy-alo General Hospital, Buf-
falo
14203
FIGURE 2. Lateral view places the tumor against the posterior chest wall.
CHEST, VOL. 62, NO.4, OCTOBER, 1972
VARIABLE PERFUSION OF LUNG
517 ACKNOWLEDGMENTS: The authors thank Dr. Owen Bossman for referring the case and Drs. Richard Adler and James C. Brennan for furnishing the surgical and pathologic descriptions. REFERENCES
4
5
FIGURE 3. Coronal tomogram through the posterior chest wall shows the erosions of the inferior margins of the fourth and fifth ribs. history was unremarkable. Radiographic studies including tomograms were carried out. (Fig 1-3). The posterior mediastinal mass produced erosions at the inferior margins of the fourth and fifth ribs (Fig 3). There was no vertebral erosion. The interpretation was that the tumor was neural in origin, probably arising from an intercostal nerve. This opinion was shared by all consultants. At surgery, the tumor was adherent to the fourth and fifth ribs and transverse processes of the adjacent vertebrae. A block dissection of the tumor and the attached structures was accomplished without breaking into the tumor. The postoperative diagnosis was neurogenic tumor which was probably benign. The pathology report was benign mediastinal lymphoid hyperplasia apparently occurring within the parietal pleura and attached by parietal pleura connective tissues to the overlying ribs and muscle mass. However, there is no direct involvement of the bone or muscle. DISCUSSION
This is the ninth reported case of a Castleman's tumor occurring in the posterior mediastinum. Two other reports have described rib erosions and reactive sclerosls.s-" This is important as it indicates that the position of a tumor in relation to bone determines the secondary osseous change rather than the histology of the neoplasm. As now recorded, three of nine posterior mediastinal Castleman's tumors have produced rib erosions as is commonly associated with tumors of neural origin. Because of the rarity of these tumors, they are usually mistaken for another benign tumor which more commonly arises in a similar location. Hence, anterior mediastinal involvement may be called thymoma while posterior mediastinal masses are called neural tumors.
CHEST, VOL. 62, NO.4, OCTOBER, 1972
1 Castleman B, et al: Case #40011. Hyperplasia of mediastinallymph node. New Eng J Med 250:26-30, 1954 2 Fitzpatrick PJ, Brown TC: Angiofollicular lymph node hyperplasia. Can Med Ass J 99:1259-1262,1968 3 Castleman B, Iverson L, Menendez VP: Localized mediastinal lymph node hyperplasia resembling thymoma. Cancer 9:822-830, 1956 4 Griff LC, Griff RE: Mediastinal lymph node hyperplasia. Br J RadioI40:68-69, 1968 5 Harrison E, Bernatz P: Angiofollicular mediastinal lymph node hyperplasia resembling thymoma. Arch. Path 75:284290, 1963 6 Katz I, Dziadiw R: Localized mediastinal lymph node hyperplasia. Am J Roent 84:206-212, 1960 7 Lattes R, Pachter MR: Benign lymphoid masses of probable hamartomatous nature. Cancer 15:197-214,1962 8 Tung KSK, McCormack LJ: Angiomatous lymphoid hamartoma (Report of 5 Cases). Cancer 20: 525-536, 1967
Variable Perfusion of the Lung in Bronchogenic Carcinoma as Measured by 133 Xenon* Scott R. Inkley, M.D., F.C.C.P and WiUiam ]. MacIntyre, Ph.D.
A case of bronchogenic carcinoma is reported in which the left IUDg was essentially nonperfused at resting levels of lung volume and became relatively well perfused at maximum inspiration. Air-eontaining alveoU in the involved lung were not in communication with major airways based on distribution of inhaled I33xenon and clearance of perfused I33xenon.
C
a rcinoma of the lung frequ~ntly obs.tru~ts ventilati?n to portions of the lung distal to Its Intrabronchial location. Somewhat less well known is the reduction of perfusion to the lung or to its lobes as a consequence of either obliteration of the vascular channels by tumor':" or reduced perfusion by homeostatic mechanisms secondary to reduced ventilation. We have recently observed a patient with biopsy-proved carcinoma who showed reduced ventilation of the left lung and absence of perfusion of that lung at resting levels of ventilation. This patient developed significant perfusion of the affected lung when breath was held at total lung capacity. Although there appeared to be ventilation of the left lung by inhaled 133xenon, the gas apparently was not in the perfused alveoli, but rather in conducting airways as ·From the Department of Medicine, University Hospitals of Cleveland and Case Western Reserve University, Cleveland, Ohio. Supported by contributions from the Joseph H. Thompson Foundation. Reprint requests: Dr. Inkley, 2065 Adelbert Road, Cleveland 44106
CULVER AND CHOf
Benign Lymphoid Hyperplasia (Castleman' 5 Tumor) Mimicking a Posterior Mediastinal Neurogenic Turner" Gordon]. Culver, M.D.·· and Byung-Koo Choi, M.D.t
A mass in the parietal pleura in paravertebral location with rib erosions diagnosed as a neurogenic tumor is reported. The pathologic diagnosis was benign mediastinal lymphoid hyperplasia. This is the ninth reported case of a Castleman's tumor occurring in the posterior mediastinum.
S
ince Cas tleman's 1 original description of benign lymphoid hyperplasia in 1954, 65 cases have been reported occurring in multiple locations. In addition to lymphoid follicle hyperplasia, some have shown capillary proliferation with endothelial hyperplasia and germinal center formation. Descriptive names have been used which include angiofollicular lymph node hyperplasiaand angiomatous lymphoid hamartoma. These tumors have not been associated with any specific symptoms. It would seem that the variable clinical findings are not related to the local pathology. The disease has mainly been discovered on roentgenograms which were obtained as routine studies or for symptoms of respiratory disease such as frequent colds, cough or an acute chest problem. The benign character of the disease is confirmed by the unchanging size of the lesions over many years and by no evidence of recurrence after local excision. Also, there are no reported cases of metastatic lesions. There is no sex predominance. The age range is mainly between 20 and 40 years, with a few below and above. The reported cases indicate that the majority of these tumors are mediastinal or intrathoracic in position. However, they can occur in lymphoid tissue in other locations. The pathology of these tumors is variable, but there is a rather consistent vascular proliferation associated with the lymphoid follicular hyperplasia. Eight cases of Castleman's tumor have been reported in the posterior mediastinum.sf All these cases were treated surgically and there was no recurrence.
FIGURE 1. Posteroanterior chest x-ray fihn showing the paravertebral location of the well circumscribed mass. atypical pneumonia. She received erythromycin. The symptoms subsided and in a week the right upper lobe infiltrates had resolved. She was admitted to the hospital for evaluation of her mediastinal mass. Her admission physical exam was unrevealing and past
CASE REPORT
A 20-year-old white woman was seen by her private physician because she had developed fever, sweating, headache and productive cough. Her chest x-ray fihn revealed a right upper lobe interstitial in61trate and a left posterior mediastinal mass. Her acute condition was diagnosed as ·From the Department of Diagnostic Radiology, Buffalo General Hospital and the School of Medicine, State University of New York at Buffalo. ··Clinical Professor of Radiology. tResident in Diagnostic RadiololQ'. Reprint requests: Dr. Culver, Buy-alo General Hospital, Buf-
falo
14203
FIGURE 2. Lateral view places the tumor against the posterior chest wall.
CHEST, VOL. 62, NO.4, OCTOBER, 1972
VARIABLE PERFUSION OF LUNG
517 ACKNOWLEDGMENTS: The authors thank Dr. Owen Bossman for referring the case and Drs. Richard Adler and James C. Brennan for furnishing the surgical and pathologic descriptions. REFERENCES
4
5
FIGURE 3. Coronal tomogram through the posterior chest wall shows the erosions of the inferior margins of the fourth and fifth ribs. history was unremarkable. Radiographic studies including tomograms were carried out. (Fig 1-3). The posterior mediastinal mass produced erosions at the inferior margins of the fourth and fifth ribs (Fig 3). There was no vertebral erosion. The interpretation was that the tumor was neural in origin, probably arising from an intercostal nerve. This opinion was shared by all consultants. At surgery, the tumor was adherent to the fourth and fifth ribs and transverse processes of the adjacent vertebrae. A block dissection of the tumor and the attached structures was accomplished without breaking into the tumor. The postoperative diagnosis was neurogenic tumor which was probably benign. The pathology report was benign mediastinal lymphoid hyperplasia apparently occurring within the parietal pleura and attached by parietal pleura connective tissues to the overlying ribs and muscle mass. However, there is no direct involvement of the bone or muscle. DISCUSSION
This is the ninth reported case of a Castleman's tumor occurring in the posterior mediastinum. Two other reports have described rib erosions and reactive sclerosls.s-" This is important as it indicates that the position of a tumor in relation to bone determines the secondary osseous change rather than the histology of the neoplasm. As now recorded, three of nine posterior mediastinal Castleman's tumors have produced rib erosions as is commonly associated with tumors of neural origin. Because of the rarity of these tumors, they are usually mistaken for another benign tumor which more commonly arises in a similar location. Hence, anterior mediastinal involvement may be called thymoma while posterior mediastinal masses are called neural tumors.
CHEST, VOL. 62, NO.4, OCTOBER, 1972
1 Castleman B, et al: Case #40011. Hyperplasia of mediastinallymph node. New Eng J Med 250:26-30, 1954 2 Fitzpatrick PJ, Brown TC: Angiofollicular lymph node hyperplasia. Can Med Ass J 99:1259-1262,1968 3 Castleman B, Iverson L, Menendez VP: Localized mediastinal lymph node hyperplasia resembling thymoma. Cancer 9:822-830, 1956 4 Griff LC, Griff RE: Mediastinal lymph node hyperplasia. Br J RadioI40:68-69, 1968 5 Harrison E, Bernatz P: Angiofollicular mediastinal lymph node hyperplasia resembling thymoma. Arch. Path 75:284290, 1963 6 Katz I, Dziadiw R: Localized mediastinal lymph node hyperplasia. Am J Roent 84:206-212, 1960 7 Lattes R, Pachter MR: Benign lymphoid masses of probable hamartomatous nature. Cancer 15:197-214,1962 8 Tung KSK, McCormack LJ: Angiomatous lymphoid hamartoma (Report of 5 Cases). Cancer 20: 525-536, 1967
Variable Perfusion of the Lung in Bronchogenic Carcinoma as Measured by 133 Xenon* Scott R. Inkley, M.D., F.C.C.P and WiUiam ]. MacIntyre, Ph.D.
A case of bronchogenic carcinoma is reported in which the left IUDg was essentially nonperfused at resting levels of lung volume and became relatively well perfused at maximum inspiration. Air-eontaining alveoU in the involved lung were not in communication with major airways based on distribution of inhaled I33xenon and clearance of perfused I33xenon.
C
a rcinoma of the lung frequ~ntly obs.tru~ts ventilati?n to portions of the lung distal to Its Intrabronchial location. Somewhat less well known is the reduction of perfusion to the lung or to its lobes as a consequence of either obliteration of the vascular channels by tumor':" or reduced perfusion by homeostatic mechanisms secondary to reduced ventilation. We have recently observed a patient with biopsy-proved carcinoma who showed reduced ventilation of the left lung and absence of perfusion of that lung at resting levels of ventilation. This patient developed significant perfusion of the affected lung when breath was held at total lung capacity. Although there appeared to be ventilation of the left lung by inhaled 133xenon, the gas apparently was not in the perfused alveoli, but rather in conducting airways as ·From the Department of Medicine, University Hospitals of Cleveland and Case Western Reserve University, Cleveland, Ohio. Supported by contributions from the Joseph H. Thompson Foundation. Reprint requests: Dr. Inkley, 2065 Adelbert Road, Cleveland 44106