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Lung Mass in a Five-Year-Old Girl
1'OIIIIIIInoaram alibI molllh Lung Mass In a FIve-Year-Qld Glrl* Robert G. WeUs, M.D.; and]ohn R. Sty, M.D.
A five-year-old girl
was evaluated fur recurrent tonsilitis. There was no associated fever, weight loss, night sweats, or family illness. There was no history of foreign-body aspiration, travel to endemic-disease areas, or exposure to pets and birds . Physicalexamination revealed enlarged tonsils and adenoids without cervical or peripheral adenopathy. There was no evidence of hepatosplenomegaly. The following laboratory tests were normal: hemoglobin, ICE, and total
*Milwaukee Children's Hospital, Milwaukee.
FICURE lA,
FICURE
and differential WBC count. Allergy skin tests and a STU purified protein derivative skin test were negative. Routine PAand lateral chest roentgenograms (Fig lA and B)demonstrated a large left upper lobe lung mass. Areas of mottled calcification were faintly visible. Computed tomography (CT) of the chest using intravenous (IV) contrast medium (Fig 2) clearly demonstrated the round lung mass. A thick rim of contrast enhancement was identified at the margin of the mass, and areas of dense calcification were imaged. The lesion was totally excised.
B
2 CHEST I 89 I 5 I MAV, 1986
747
Diagnosis: Left upper lobe pseudotumor ofthe lung Benign lung tumors in children are rare. Probably
the most common benign lung mass in a child is the
infiammatory pseudotumor, a lesion that may reach considerable size, yet is not histologically defined as a true neoplasm.' This lesion has been called plasma cell granuloma, inflammatory pseudotumor; histiocytoma, solitary mast cell granuloma, and xanthogranuloma by various authors. I Inflammatory pseudotunior may be confused radiographically with carcinoma of the lung, blastomycosis, primary pulmonary Hodgkins disease, or hamartoma. The pathogenesis of inflammatory pseudotumor is unclean Electron microscopy typically demonstrates spindle cells with abundant cytoplasmic fibriles containing actin-like protein, suggesting a fibrocytic derivation." This type of spindle cell is sometimes referred to as a "myoflbroblast" and is generally found in granulation tissue and other fibroblastic lesions. The histologic findings therefore suggest that the mass develops as a result of a chronic inflammatory process.3.4 Berardi and coworkers! analyzed 181 instances of Inflammatory pseudotumors in a literature review The majority of patients were asymptomatic (74 percent). The few patients who were symptomatic ~enerally reported nonspecific complaints such as a nonproductive cough, fever, and pain. Hemoptysis and clubbing of the fingers are infrequent signs. In all of the reviewed cases, laboratory findings were noncontributory in establishing a preoperative diagnosis. The radiographic appearance of pulmonary inflammatory pseudotumor is that of a large, sometimes lobulated lung mass. Most are greater than 4 cm in diameter Postinflammatory calcificationis usually visible, particularly with c;r scans. cr with IV contrast material may demonstrate a rim of enhancement at the outer margin of the mass, as shown in Figure 2. This probably represents a thick inflammatory pseudocap-
741
sule. The pattern of calci6cation is helpful in the radiographic differentiation from other large, solitary pulmonary masses. Pseudotumor calcification varies from an amorphous, mixed pattern to dense collections. The calcifications are usually scattered at various locations within the mass. Calcification in a granuloma, which represents another cause of large, solitary masses, is usually visualized as a central "target" density. Hamartomas also frequently contain calcification; howeven the pattern is typically that of cartilaginous calcification, commonly described as upop_ com calcification." Treatment in most cases of inflammatory pseudotumor consists of surgical excision." There have been reports of spontaneous resolution following open biopsy" No cases of malignant degeneration have been documented. Despite these reports, surgical excision is generally recommended in all cases, both to confirm the diagnosis and to prevent potential complications such as compression of major bronchi or other adjacent structures. Percutaneous needle aspiration biopsy has been recommended, although its diagnostic reliability in large benign lesions is questionable. Complete surgical excision is usually possible without sacrifice of normal lung tissue or other adjacent structures. REFERENCES
1 Bahadori M, Liebow M. Plasma cell granulomas of the lung. Cancer 1973; 31:191-208 2 Maple~ MD, Mkins RB Jr, Graham BS, Dao AH, Scott HW Jr. Pseudotumor of the lung. Am Surg 1985; 51:84-88 3 Buell R, Wang NS, Seemayer TA, Ahmed MN. Endobronchial plasma cell granuloma (xanthomatous pse~dotumor); a light and electron microscopic study. Hum Patholl976; 7:411-26 4 Janigan D1: Marrie TJ. An inflammatory pseudotumor of the lung in Q fever pneumonia. N Eng! J Med 1983; 308:86-88 5 Berardi RS, Lee SS, Chen H~ Stines GJ. Inflammatory pseudotumors of the lung. Surg Gynecol Obstet 1983; 156:89-96 6 Mandelbaum I, Brashear RE, Hull Ml: Surgical treatment and course of pulmonary pseudotumor (plasma cell granuloma). J Thorac Cardiovasc Surg 1981; 82:77-82
Roentgenogram of the Month(Wells, Sty)
A five-year-old girl
was evaluated fur recurrent tonsilitis. There was no associated fever, weight loss, night sweats, or family illness. There was no history of foreign-body aspiration, travel to endemic-disease areas, or exposure to pets and birds . Physicalexamination revealed enlarged tonsils and adenoids without cervical or peripheral adenopathy. There was no evidence of hepatosplenomegaly. The following laboratory tests were normal: hemoglobin, ICE, and total
*Milwaukee Children's Hospital, Milwaukee.
FICURE lA,
FICURE
and differential WBC count. Allergy skin tests and a STU purified protein derivative skin test were negative. Routine PAand lateral chest roentgenograms (Fig lA and B)demonstrated a large left upper lobe lung mass. Areas of mottled calcification were faintly visible. Computed tomography (CT) of the chest using intravenous (IV) contrast medium (Fig 2) clearly demonstrated the round lung mass. A thick rim of contrast enhancement was identified at the margin of the mass, and areas of dense calcification were imaged. The lesion was totally excised.
B
2 CHEST I 89 I 5 I MAV, 1986
747
Diagnosis: Left upper lobe pseudotumor ofthe lung Benign lung tumors in children are rare. Probably
the most common benign lung mass in a child is the
infiammatory pseudotumor, a lesion that may reach considerable size, yet is not histologically defined as a true neoplasm.' This lesion has been called plasma cell granuloma, inflammatory pseudotumor; histiocytoma, solitary mast cell granuloma, and xanthogranuloma by various authors. I Inflammatory pseudotunior may be confused radiographically with carcinoma of the lung, blastomycosis, primary pulmonary Hodgkins disease, or hamartoma. The pathogenesis of inflammatory pseudotumor is unclean Electron microscopy typically demonstrates spindle cells with abundant cytoplasmic fibriles containing actin-like protein, suggesting a fibrocytic derivation." This type of spindle cell is sometimes referred to as a "myoflbroblast" and is generally found in granulation tissue and other fibroblastic lesions. The histologic findings therefore suggest that the mass develops as a result of a chronic inflammatory process.3.4 Berardi and coworkers! analyzed 181 instances of Inflammatory pseudotumors in a literature review The majority of patients were asymptomatic (74 percent). The few patients who were symptomatic ~enerally reported nonspecific complaints such as a nonproductive cough, fever, and pain. Hemoptysis and clubbing of the fingers are infrequent signs. In all of the reviewed cases, laboratory findings were noncontributory in establishing a preoperative diagnosis. The radiographic appearance of pulmonary inflammatory pseudotumor is that of a large, sometimes lobulated lung mass. Most are greater than 4 cm in diameter Postinflammatory calcificationis usually visible, particularly with c;r scans. cr with IV contrast material may demonstrate a rim of enhancement at the outer margin of the mass, as shown in Figure 2. This probably represents a thick inflammatory pseudocap-
741
sule. The pattern of calci6cation is helpful in the radiographic differentiation from other large, solitary pulmonary masses. Pseudotumor calcification varies from an amorphous, mixed pattern to dense collections. The calcifications are usually scattered at various locations within the mass. Calcification in a granuloma, which represents another cause of large, solitary masses, is usually visualized as a central "target" density. Hamartomas also frequently contain calcification; howeven the pattern is typically that of cartilaginous calcification, commonly described as upop_ com calcification." Treatment in most cases of inflammatory pseudotumor consists of surgical excision." There have been reports of spontaneous resolution following open biopsy" No cases of malignant degeneration have been documented. Despite these reports, surgical excision is generally recommended in all cases, both to confirm the diagnosis and to prevent potential complications such as compression of major bronchi or other adjacent structures. Percutaneous needle aspiration biopsy has been recommended, although its diagnostic reliability in large benign lesions is questionable. Complete surgical excision is usually possible without sacrifice of normal lung tissue or other adjacent structures. REFERENCES
1 Bahadori M, Liebow M. Plasma cell granulomas of the lung. Cancer 1973; 31:191-208 2 Maple~ MD, Mkins RB Jr, Graham BS, Dao AH, Scott HW Jr. Pseudotumor of the lung. Am Surg 1985; 51:84-88 3 Buell R, Wang NS, Seemayer TA, Ahmed MN. Endobronchial plasma cell granuloma (xanthomatous pse~dotumor); a light and electron microscopic study. Hum Patholl976; 7:411-26 4 Janigan D1: Marrie TJ. An inflammatory pseudotumor of the lung in Q fever pneumonia. N Eng! J Med 1983; 308:86-88 5 Berardi RS, Lee SS, Chen H~ Stines GJ. Inflammatory pseudotumors of the lung. Surg Gynecol Obstet 1983; 156:89-96 6 Mandelbaum I, Brashear RE, Hull Ml: Surgical treatment and course of pulmonary pseudotumor (plasma cell granuloma). J Thorac Cardiovasc Surg 1981; 82:77-82
Roentgenogram of the Month(Wells, Sty)