Massive Ossified Lung Masses - medIND

4 downloads 36 Views 52KB Size Report
earlier suffered from osteosarcoma of the left proximal tibia and had undergone an above knee surgical amputation with adjuvant chemotherapy two years back.
Radiology Forum

Massive Ossified Lung Masses Veenu Singla 1, Vivek Virmani1, Rakesh Kapoor2, Ritesh Agarwal3 and Niranjan Khandelwal1 Departments of Radiodiagnosis and Imaging 1, Radiotherapy2 and Pulmonary Medicine3, Postgraduate Institute of Medical Education and Research, Chandigarh, India [Indian J Chest Dis Allied Sci 2009;51:233-235]

CLINICAL SUMMARY A 14-year-old male presented with chest pain, fever and worsening dyspnoea for a period of two months. There was no history of cough. The patient complained of anorexia and significant weight loss (approximately 40%) in the last six months. He had earlier suffered from osteosarcoma of the left proximal tibia and had undergone an above knee surgical amputation with adjuvant chemotherapy two years back. The search for metastases at that time, including computed tomography (CT) of thorax and abdomen, and bone scan was negative. Presently, apart from his chest symptoms the patient also had a large painless swelling at his operation site. There was no redness or ulceration of the overlying skin. Physical examination revealed a 7cm × 8cm mass in the left distal thigh. On examination of the chest, there was dullness to percussion over the left hemithorax with reduced intensity of breath sounds.

Figure 1. Chest radiograph (postero-anterior view) showing multiple large ossified nodules involving bilateral lung fields, the largest of which is seen in the left hemithorax (black arrows).

INVESTIGATIONS Radiograph of the chest revealed bilateral pleural effusion with multiple radio-opaque parenchymal and pleural-based nodules of varying sizes, with the largest one causing near complete opacification of left upper hemithorax (Figure 1). Radiograph of the left proximal femur showed a lytic permeative destruction of the bone with cortical destruction and an associated large soft tissue mass showing osteoid matrix, consistent with recurrent osteosarcoma (Figure 2). Non-contrast CT of the thorax confirmed the multiple large parenchymal and pleural-based soft tissue nodules showing patchy heterogeneous calcification and also demonstrated mediastinal lymphadenopathy, with some of the nodes showing diffuse chunky calcification (Figure 3A and 3B). Pleural effusion was also seen on both sides. However, there was no evidence of cavitation of nodules or pneumothorax on either side. The CT abdomen and the bone scan of the patient were

Figure 2. Radiograph of the left femur, post above knee amputation, showing lytic permeative destruction of the femur with large soft tissue mass with osteoid matrix within it.

[Received: July 17, 2008; accepted after revision: April 1, 2009] Correspondence and reprint requests: Dr Veenu Singla, Assistant Professor, Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, India; Phone: 91-172-2756381; Fax: 91-1722745768; E-mail: [email protected]

234

Radiology Forum

Figure 3A. Non-contrast CT axial image showing large ossified pulmonary (large arrow), pleural (white arrow) and lymph nodal (small arrow) deposits.

Figure 3B. Non-contrast CT coronal reformatted images better illustrating the large ossified parenchymal deposit in the left lung (large black arrow), the ossified pleural (white arrow) and the lymph nodal deposits (small black arrow).

normal, thereby confirming lung to be the sole site of the metastases.

DIAGNOSIS Ossified pulmonary and pleural metastases from recurrent osteosarcoma of the left lower limb with calcified mediastinal lymphadenopathy.

DISCUSSION Pulmonary metastases are seen in 80% of relapse cases of osteosarcoma and in 10% of the cases, these metastases may be the primary presenting feature of osteosarcoma.1 Calcification in metastatic pulmonary

Veenu Singla et al

nodules, though unusual, may be seen in osteosarcoma and chondrosarcoma due to bone formation within the nodules. Rarely, dystrophic calcification may be seen in pulmonary metastases from giant cell tumours, papillary carcinoma of thyroid, synovial sarcomas or treated metastatic disease. Mucinous adenocarcinomas of gastrointestinal tract and breast may also show calcified pulmonary metastases due to mucoid calcification. 2 Various findings have been reported in the metastatic disease of the lung in osteosarcoma including solitary or multiple ossified parenchymal masses, ossified mediastinal lymph nodes, pleural calcifications, diaphragmatic deposits, pneumothorax, esophageal-mediastinal fistula, lymphangitis carcinomatosis and pulmonary artery tumour emboli.3 However, the concurrent occurrence of first four of these findings in the index case made it an interesting radiological picture. Pleural deposits have been infrequently reported in the literature and can occur either due to direct contiguous extension of the lung lesions or by hematogenous spread.3 Moreover, as hematogenous spread is the usual route of dissemination in osteosarcoma, metastatic lymph node involvement is uncommon with a reported incidence of less than three percent.4 Ossifying nodal metastases to the mediastinal lymph nodes are rare with only a few case reports in the literature and are less common as compared to ossifying metastases to the femoral, inguinal and axillary nodes.3,5 Cavitation of metastatic nodules has also been described in osteosarcoma and necrosis of subpleural metastases may lead to formation of bronchopleural fistula and pneumothorax in five percent to seven percent of cases.4 This was, however, not seen in our case. Although aggressive approach is advocated in the treatment of osteosarcoma with lung metastases, resection of these metastases is a relatively uncommon procedure with no uniformity of opinion on surgical management. Patients with metastatic disease limited to the lung who are able to have complete resection of the pulmonary disease have been reported to have a long-term (five-year) survival rate of 30% to 40% as compared to a survival rate of 2.6% in patients who do not undergo resection. 6 The prognosis is influenced by factors, like metastatic tumour burden including the number and size of lung nodules and unilateral versus bilateral disease, the biology of the metastases including the diseasefree interval, extent of primary tumour necrosis and the primary tumour site with axial tumours having worse prognosis than extremity tumours. Pulmonary metastectomy is recommended in bilateral extensive disease, provided the primary lesion is controlled, there is no evidence of metastatic disease outside the lung and if complete resection of all metastases can be obtained with sufficient (at least 50%) post-operative pulmonary reserve.6 The index patient did not have

2009;Vol.51

The Indian Journal of Chest Diseases & Allied Sciences

metastatic disease outside the lung. However, as the primary lesion had relapsed and complete resection of pulmonary metastases was not possible due to the extensive pulmonary and pleural metastases, he was offered neo-adjuvant chemotherapy for control of primary tumour and regression of pulmonary lesions. The treatment strategy included subsequent surgical resection of pulmonary metastases in case of adequate response of the primary tumour and the pulmonary metastases to chemotherapy. However, the family refused treatment despite extensive counselling. To the best of our knowledge, the constellation of simultaneous findings of ossified metastatic parenchymal, pleural, mediastinal nodal and diaphragmatic deposits from osteosarcoma in a single living patient have not been reported previously. These findings present an interesting radiological picture and are unique in the literature as incidence of ossifying pleural and intrathoracic

235

lymphnodal deposits is higher in autopsy series. 3

REFERENCES 1. 2.

3.

4.

5.

6.

Crow J, Slavin G, Kreel L. Pulmonary metastasis: a pathologic and radiologic study. Cancer 1981;47:2595-602. Maile CW, Rodan BA, Godwin JD, Chen JT, Ravin CE. Calcification in pulmonary metastases. Br J Radiol 1982;55:108-13. Rastogi R, Garg R, Thulkar S, Bakhshi S, Gupta A. Unusual thoracic CT manifestations of osteosarcoma: review of 16 cases. Pediatr Radiol 2008;38:551-8. Caceres E, Zaharia M, Calderon R. Incidence of regional lymph node metastases in operable osteogenic sarcoma. Semin Surg Oncol 1990;6:231-3. van Zanten TE, Golding RP, Taets ven Amerongen AH. Osteosarcoma with calcific mediastinal lymphadenopathy. Pediatr Radiol 1987;17:258. Harting MT, Blakely ML. Management of osteosarcoma pulmonary metastases. Semin Pediatr Surg 2006;15:25-9.