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Cystic Degeneration of a Carcinoid Lung Tumor: An Uncommon Cause of an Intrathoracic Cyst
CASE REPORTS
Cystic Degeneration of a Carcinoid Lung Tumor: An Uncommon Cause of an Intrathoracic Cyst Hammad Sheikh, MRCS, MBBS, Chinyelu Menakaya, MRCS, Lazlo Hajdu, FRCS, and Michael Shackcloth, FRCS Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Prenton, United Kingdom
Carcinoid tumor is a rare, slow-growing neuroendocrine tumor that accounts for less than 1% of all lung tumors. It occurs most commonly in the midgut, then the lung, and usually presents as a solid lesion. We report a patient with a typical carcinoid tumor that had undergone cystic degeneration. (Ann Thorac Surg 2011;91:1966 –7) © 2011 by The Society of Thoracic Surgeons
C
arcinoid tumors are neuroendocrine tumors that can be classified by histology into typical and atypical types [1]. Typical carcinoid with central cystic degeneration is exceedingly rare. We present a case of a typical carcinoid tumour with central cystic degeneration.
FEATURE ARTICLES
A 65-year-old woman with learning difficulties presented with increasing shortness of breath and mild dysphagia. She had lost about 8 kg in weight during the previous year and had an occasional cough. She had never smoked. Results of hematologic and biochemical tests were normal, and pulmonary function tests showed a restrictive pattern. A chest roentgenogram showed a lesion occupying the lower left hemithorax (Fig 1A), and a computed tomography scan showed a 15-cm cystic lesion causing mediastinal shift and some calcification (Fig 1B). She underwent a left thoracotomy, and a lesion 15 cm in diameter was found arising from the inferior aspect of the left lower lobe. There were adhesions between the lesion and the diaphragm. To make dissection easier, the lesion was made smaller by aspirating 1 liter of brown fluid from its centre. The adhesions were then divided, and a left lower lobectomy was performed without difficulty. She made an uneventful postoperative recovery. Histopathology showed that the left lower lobe was largely occupied by a degenerate, cystic mass with a diameter of 65 mm. Adherent to its inner wall were masses of friable brown tissue. Microscopically, the cystic mass revealed a largely degenerate epithelial neoplasm, the remaining viable part of which consisted of regular cells with a vaguely nodular pattern of growth in a fine stroma. There was some cellular and nuclear pleomorphism, but there was no necrosis, and just one definite mitotic figure seen in 100 high-power microscopic fields Accepted for publication Nov 12, 2010. Address correspondence to Dr Sheikh, 72 Hampton Chase, Prenton CH43 9HE, UK; e-mail: [email protected].
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. (A) Chest roentgenogram shows a lesion occupying the left lower hemithorax. (B) A computed tomography scan shows a 15-cm cystic lesion with mediastinal shift and some calcification.
(Fig 2). Immunolabeling revealed expression of a range of neuroendocrine antigens. The features were those of a typical carcinoid tumor that had undergone central cystic degeneration and became surrounded by a pseudocapsule of fibrous tissue. The bronchial margin appeared normal and the pleura were not invaded. One lymph node contained metastatic disease. This patient underwent postoperative chemotherapy due to metastatic disease in the lymph node. 0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.11.027
Ann Thorac Surg 2011;91:1967–9
CASE REPORT MYUNG ET AL MEDIASTINAL COELOMIC CYST
1967
References
Fig 2. (A, B) Histology (eosin and hematoxylin, respectively) shows largely degenerate epithelial neoplasm and some cellular and nuclear pleomorphism, but no necrosis.
Comment Carcinoid tumors of the lung are a rare entity, comprising about 1% of all lung cancers. The incidence is equal in men and women, and they all have metastatic potential. Carcinoid tumors can be divided into typical and atypical type according to histology. They can also be divided according to location into central and peripheral [1, 2]. Carcinoid tumors can be asymptomatic, discovered as an incidental finding, or can present with symptoms depending on the location of the tumor. The most frequently presenting symptoms are cough, chest pain, and wheeze. If centrally placed, they may cause hemoptysis. When a large carcinoid tumor causes partial or complete blockage of a large air passage, a lung infection may develop that will not be cured by antibiotics. Ten percent of carcinoids may secrete hormones that produce symptoms such as recent weight gain, facial flushing, and diarrhea [3, 4]. Our patient presented with occasional cough and associated shortness of breath. The tumor is staged by computed tomography, metaiodobenzylguanidine scan, or somatostatin receptor actinography along with bronchial biopsy [4]. Treatment is © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Wick MR, Ritter J. Pathology of Lung Cancer, Thoracic Surgery. 2nd ed. Philadelphia, PA: Churchill Livingstone; 2002:806 –7. 2. Caplin ME, Buscombe JR, Hilson AJ, Jones AL, Watkinson AF, Burroughs AK. Carcinoid tumor. Lancet 1998;352:799 – 805. 3. Jensen RT, Doherty GM. Carcinoid tumours and the carcinoid syndrome. In: DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles and Practice of Oncology. Philadelphia: Lippincott Williams & Wilkins; 2001:1813–33. 4. Kulke MH, Mayer RJ. Carcinoid tumours. N Engl J Med 1999;340:858 – 68. 5. Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumours. Cancer 1997;79:813–29.
Mediastinal Coelomic Cyst Richard J. Myung, MD, Bradley G. Leshnower, MD, and Joseph I. Miller, Jr, MD Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
Coelomic cysts are rare cysts of mesothelial origin. This is a case report of a thoracic coelomic cyst presenting as atypical chest pain. (Ann Thorac Surg 2011;91:1967–9) © 2011 by The Society of Thoracic Surgeons Accepted for publication Nov 9, 2010. Address correspondence to Dr Myung, Division of Cardiothoracic Surgery, 61 Whichter St, Ste 4100, Marietta, GA 30060; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.11.021
FEATURE ARTICLES
by surgical resection and, if needed, chemotherapy or radiotherapy according to the stage of disease. Histologically, the tumor can be typical or atypical, typical being more common, and shows features of trabecular, ribbon-like, nested, and solid sheets. The cytoplasm is relatively abundant, and spindle cell change may also be seen. Mitotic activity is very limited, and no necrosis is present. Atypical carcinoids have pleomorphism with increased mitotic activity. They also have hyperchromic nuclei and a high nucleocytoplasmic ratio. Spontaneous necrosis is also seen [1, 2]. Survival at 5 years is 90% for typical and exceeds 70% for atypical carcinoid. The 10-year survival is 10%, lower than 5-year survival in both types [5]. The cause of the cystic degeneration of carcinoid tumor in our patient is uncertain. It is unusual for a slowgrowing tumor such as a typical carcinoid to outgrow its blood supply, but in the absence of any other possible explanation, we believe this was the probable cause of cystic degeneration. Differential diagnoses that were considered in this patient included pericardial cyst, bronchogenic cyst, thoracic duct cyst, or esophageal duplication cyst. We conclude that cystic degeneration of a carcinoid tumor, although extremely rare, should be considered in the differential diagnosis of any large intrathoracic cyst.
Cystic Degeneration of a Carcinoid Lung Tumor: An Uncommon Cause of an Intrathoracic Cyst Hammad Sheikh, MRCS, MBBS, Chinyelu Menakaya, MRCS, Lazlo Hajdu, FRCS, and Michael Shackcloth, FRCS Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Prenton, United Kingdom
Carcinoid tumor is a rare, slow-growing neuroendocrine tumor that accounts for less than 1% of all lung tumors. It occurs most commonly in the midgut, then the lung, and usually presents as a solid lesion. We report a patient with a typical carcinoid tumor that had undergone cystic degeneration. (Ann Thorac Surg 2011;91:1966 –7) © 2011 by The Society of Thoracic Surgeons
C
arcinoid tumors are neuroendocrine tumors that can be classified by histology into typical and atypical types [1]. Typical carcinoid with central cystic degeneration is exceedingly rare. We present a case of a typical carcinoid tumour with central cystic degeneration.
FEATURE ARTICLES
A 65-year-old woman with learning difficulties presented with increasing shortness of breath and mild dysphagia. She had lost about 8 kg in weight during the previous year and had an occasional cough. She had never smoked. Results of hematologic and biochemical tests were normal, and pulmonary function tests showed a restrictive pattern. A chest roentgenogram showed a lesion occupying the lower left hemithorax (Fig 1A), and a computed tomography scan showed a 15-cm cystic lesion causing mediastinal shift and some calcification (Fig 1B). She underwent a left thoracotomy, and a lesion 15 cm in diameter was found arising from the inferior aspect of the left lower lobe. There were adhesions between the lesion and the diaphragm. To make dissection easier, the lesion was made smaller by aspirating 1 liter of brown fluid from its centre. The adhesions were then divided, and a left lower lobectomy was performed without difficulty. She made an uneventful postoperative recovery. Histopathology showed that the left lower lobe was largely occupied by a degenerate, cystic mass with a diameter of 65 mm. Adherent to its inner wall were masses of friable brown tissue. Microscopically, the cystic mass revealed a largely degenerate epithelial neoplasm, the remaining viable part of which consisted of regular cells with a vaguely nodular pattern of growth in a fine stroma. There was some cellular and nuclear pleomorphism, but there was no necrosis, and just one definite mitotic figure seen in 100 high-power microscopic fields Accepted for publication Nov 12, 2010. Address correspondence to Dr Sheikh, 72 Hampton Chase, Prenton CH43 9HE, UK; e-mail: [email protected].
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. (A) Chest roentgenogram shows a lesion occupying the left lower hemithorax. (B) A computed tomography scan shows a 15-cm cystic lesion with mediastinal shift and some calcification.
(Fig 2). Immunolabeling revealed expression of a range of neuroendocrine antigens. The features were those of a typical carcinoid tumor that had undergone central cystic degeneration and became surrounded by a pseudocapsule of fibrous tissue. The bronchial margin appeared normal and the pleura were not invaded. One lymph node contained metastatic disease. This patient underwent postoperative chemotherapy due to metastatic disease in the lymph node. 0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.11.027
Ann Thorac Surg 2011;91:1967–9
CASE REPORT MYUNG ET AL MEDIASTINAL COELOMIC CYST
1967
References
Fig 2. (A, B) Histology (eosin and hematoxylin, respectively) shows largely degenerate epithelial neoplasm and some cellular and nuclear pleomorphism, but no necrosis.
Comment Carcinoid tumors of the lung are a rare entity, comprising about 1% of all lung cancers. The incidence is equal in men and women, and they all have metastatic potential. Carcinoid tumors can be divided into typical and atypical type according to histology. They can also be divided according to location into central and peripheral [1, 2]. Carcinoid tumors can be asymptomatic, discovered as an incidental finding, or can present with symptoms depending on the location of the tumor. The most frequently presenting symptoms are cough, chest pain, and wheeze. If centrally placed, they may cause hemoptysis. When a large carcinoid tumor causes partial or complete blockage of a large air passage, a lung infection may develop that will not be cured by antibiotics. Ten percent of carcinoids may secrete hormones that produce symptoms such as recent weight gain, facial flushing, and diarrhea [3, 4]. Our patient presented with occasional cough and associated shortness of breath. The tumor is staged by computed tomography, metaiodobenzylguanidine scan, or somatostatin receptor actinography along with bronchial biopsy [4]. Treatment is © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Wick MR, Ritter J. Pathology of Lung Cancer, Thoracic Surgery. 2nd ed. Philadelphia, PA: Churchill Livingstone; 2002:806 –7. 2. Caplin ME, Buscombe JR, Hilson AJ, Jones AL, Watkinson AF, Burroughs AK. Carcinoid tumor. Lancet 1998;352:799 – 805. 3. Jensen RT, Doherty GM. Carcinoid tumours and the carcinoid syndrome. In: DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles and Practice of Oncology. Philadelphia: Lippincott Williams & Wilkins; 2001:1813–33. 4. Kulke MH, Mayer RJ. Carcinoid tumours. N Engl J Med 1999;340:858 – 68. 5. Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumours. Cancer 1997;79:813–29.
Mediastinal Coelomic Cyst Richard J. Myung, MD, Bradley G. Leshnower, MD, and Joseph I. Miller, Jr, MD Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
Coelomic cysts are rare cysts of mesothelial origin. This is a case report of a thoracic coelomic cyst presenting as atypical chest pain. (Ann Thorac Surg 2011;91:1967–9) © 2011 by The Society of Thoracic Surgeons Accepted for publication Nov 9, 2010. Address correspondence to Dr Myung, Division of Cardiothoracic Surgery, 61 Whichter St, Ste 4100, Marietta, GA 30060; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.11.021
FEATURE ARTICLES
by surgical resection and, if needed, chemotherapy or radiotherapy according to the stage of disease. Histologically, the tumor can be typical or atypical, typical being more common, and shows features of trabecular, ribbon-like, nested, and solid sheets. The cytoplasm is relatively abundant, and spindle cell change may also be seen. Mitotic activity is very limited, and no necrosis is present. Atypical carcinoids have pleomorphism with increased mitotic activity. They also have hyperchromic nuclei and a high nucleocytoplasmic ratio. Spontaneous necrosis is also seen [1, 2]. Survival at 5 years is 90% for typical and exceeds 70% for atypical carcinoid. The 10-year survival is 10%, lower than 5-year survival in both types [5]. The cause of the cystic degeneration of carcinoid tumor in our patient is uncertain. It is unusual for a slowgrowing tumor such as a typical carcinoid to outgrow its blood supply, but in the absence of any other possible explanation, we believe this was the probable cause of cystic degeneration. Differential diagnoses that were considered in this patient included pericardial cyst, bronchogenic cyst, thoracic duct cyst, or esophageal duplication cyst. We conclude that cystic degeneration of a carcinoid tumor, although extremely rare, should be considered in the differential diagnosis of any large intrathoracic cyst.