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Weekly Chest CasesArchive of Old Cases

Case No : 592 Date 2009-02-28

  • Courtesy of Choong-Ki Park, MD, Jung Nam Heo, MD / Hanyang University Guri Hospital, Korea
  • Age/Sex 74 / M
  • Chief ComplaintC/C Hemoptysis for 6months
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Large Cell Neuroendocrine Carcinoma
Radiologic Findings
Chest radiograph shows about 6 cm sized, well-defined mass in the left upper lobe and another small spiculated nodule below the main mass (Fig. 1). Contrast-enhanced coronal CT scan shows upper mass and lower nodule with marginal spiculation (Fig. 2). Contrast-enhanced axial CT scan obtained with mediastinal setting shows inhomogenous contrast enhancement with vascular invasion (Fig. 3).

Pathology: The core biopsy shows solid tumor with central necrosis (H&E, x200) (Fig. 4). The tumor shows pleomorphic & hyperchromatic nuclei with prominent nucleoli & variable amount of cytoplasm. There are frequent mitoses (H&E, x400) (Fig. 5). Immunohistochemistry(Immunostain) shows positive reaction for synaptophysin (x200) (Fig. 6).

Brief Review
Large cell neuroendocrine carcinoma is the most common variant of large cell carcinoma, accounting for approximately 3% of surgically resected lung cancers. It fits into the spectrum of neuroendocrine lung neoplasm and is a high-grade non-small cell neuroendocrine carcinoma that differs from atypical carcinoid and small cell carcinoma [1]. Large cell neuroendocrine carcinoma of the lung is defined as a poorly differentiated and high-grade neuroendocrine tumor that morphologically and biologically may be placed between atypical carcinoid tumor and small cell carcinoma [2].

Radiologic findings of large cell neuroendocrine carcinoma usually appears as a well-defined and lobulated tumor with no air bronchograms or calcification. The inhomogeneous enhancement (caused by necrosis) seen in large cell neuroendocrine carcinomas with large diameters is not necessarily apparent in small-diameter (< 33 mm) large cell neuroendocrine carcinomas, even if the tumor contains necrosis. However, infrequently tumor margin may appear to be spiculated. Those spiculated margins appeared as fibrotic strands because of paracicatricial emphysema or linear opacities made more pronounced by preexisting emphysema. CT findings of large cell neuroendocrine carcinomas were similar to those of other expansively growing tumors, such as peripheral small cell carcinomas, poorly differentiated adenocarcinomas, and squamous cell carcinomas [3].
Patients with large cell neuroendocrine carcinomas have a significantly worse survival after resection than patients with large cell carcinomas, even in stage I disease. Accurate differentiation of large cell neuroendocrine carcinoma from large cell carcinoma is important because it identifies those patients at highest risk for the development of recurrent lung cancer.
References
1. Travis WD. Lung cancer: overview and classification. Chap 22 In M?ler NL, Silva CIS. Imaging of the chest. Saunders: 2008;479-480
2. Jiang SX, Kameya T, Shoji M, Dobashi Y, Shinada J, Yoshimura H. Large cell neuroendocrine carcinoma of the lung: a histologic and immunohistochemical study of 22 cases. Am J Surg Pathol 1998;22:526 ?37
3. Oshiro Y, Kusumoto M, Matsuno Y, et al. CT Findings of Surgically Resected Large Cell Neuroendocrine Carcinoma of the Lung in 38 Patients. AJR 2004; 182:87-91
4. Battafarano RJ, Fernandez FG, Ritter J, et al. Large cell neuroendocrine carcinoma: an aggressive form of non-small cell lung cancer. J Thorac Cardiovasc Surg. 2005; 130(1):166-72.

Keywords
Lung, Malignant tumor,

No. of Applicants : 86

▶ Correct Answer : 37/86,  43.0%
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - CH Macon , France sebastien LARIVE
  • - Trakya Univercity School of Medicine , Turkey Armagan Sarac
  • - MD SKNMC & GH,Pune,Maharashtra, INDIA , India Sushant Bhadane
  • - Institute of Chest Diseases,Calicut , India sijith raghavan
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - National Taiwan University Hospital, Yun-Lin Branch , Taiwan Chin-Chung Shu
  • - chp st martin , France Mariotte benoit
  • - taiwn , Taiwan liuchun ww
  • - xi , China qiu zhang
  • - Das Allgemeine Krankenhaus Celle , Germany Davis Chiramel
  • - apollo hospitals , India harish bhambore
  • - CHRU lille , France manuel toledano
  • - Yashoda Super Speciality hospital , India Ramesh Pandey
  • - Cairo University , Egypt Mamdouh Eissa
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - Ruby Hall Clinic , India john joseph
  • - CHRU Lille , France Benjamin Damarey
  • - Asian Heart Institute, Nirman Hitech & Apollo clinic , India Jeshil Shah
  • - McGill University Health Center , Canada Alexandre Semionov
  • - chungbuk uni. hospital , Korea (South) Ahn ypung
  • - fortis hospital vasant kunj new delhi , India dr suman singhal
  • - DCA, , India Rajesh Gothi
  • - Saga University , Japan Ryoko Egashira
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - Trakya University School of Medicine , Turkey Umut Ugur
  • - Bundang CHA hospital , Korea (South) Jung Young
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - kims,narkatpally , India k bhaskar
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - UZ GASTHUISBERG , Belgium Johan COOLEN
  • - PITTWATER RADIOLOGY , Australia Julie Arora
  • - PITTWATER RADIOLOGY , Australia Saurabh Khandelwal
  • - E-DA Hospital / I-Shou University , Taiwan Yu-Feng Wei
▶ Correct Answer as Differential Diagnosis : 18/86,  20.9%
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
  • - Seoul National University Hospital , Korea (South) Kwang Nam Jin
  • - McGill University Health Centre , Canada Amr Ajlan
  • - McGill University Health Center , Canada Faiza Al Kindi
  • - hospital Sao Paulo , Brazil israel missrie
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - EKH-Berlin , Germany Michael Weber
  • - Kashan University of Medical Sciences, kashan , Iran Ebrahim Razi
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - CH Sud Rnion , Reunion jean-baptiste Noel
  • - CHU Grenoble , France Fabrice Bing
  • - AIIMS , India srini jaganathan
  • - NASA SCANS , India RAKESH BHATIA
  • - IRSA , France jean BIGOT
  • - Saiseikai Ibaraki Hospital , Japan Taizo Hiraoka
▶ Semi-Correct Answer : 10/86,  11.6%
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - yashodha hospital , India pravin mahadevappa
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - Hospital Procardiaco , Brazil Mauro Oliveira
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Freelancer , India Kalari Narayana
  • - SNUH , Korea (South) Youkyung Lee
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - ROHINI Scan Center. Ambattur, Chennai , India Umapathi Mahesh
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
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