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Weekly Chest CasesArchive of Old Cases

Case No : 932 Date 2015-09-07

  • Courtesy of Inyoung Song, Jeong Geun Yi, Jeong Hee Park / Konkuk University Medical Center, Konkuk University School of Medicine
  • Age/Sex 70 / F
  • Chief ComplaintIncidental lung nodules detected on CT
  • Figure 1
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Initial

Diagnosis With Brief Discussion

Diagnosis
Epithelioid hemangioendothelioma
Radiologic Findings
Multiple well-defined small (less than 1cm) nodules are seen in both lungs. Most of the nodules were located in the peripheral portion of the lung. Some of the nodules grew 1~2mm in 5 months. The maximum standardized uptake value (SUVmax) of the lung nodule was 1.2 on FDG PET CT scan. The patient underwent VATS biopsy for diagnosis and the resected nodule was confirmed as epithelioid hemangioendothelioma.
Brief Review
Pulmonary epithelioid hemangioendothelioma (EH) is a rare neoplasm of vascular origin with an epithelioid appearance, initially referred to as an intravascular bronchioloalveolar tumor. Being considered as a low- to intermediate-grade sarcoma, the tumor predominantly involves the liver and lungs, and rarely, bones, and can be aggressive and multicentric, even resulting in systemic metastases.
Pulmonary EHs are four times more common in women than men and are often detected incidentally, as patients are usually asymptomatic. The tumors have variable prognosis; life expectancy may range from less than one year up to 30 years. There are no established standard treatment of choice. Surgery and/or chemoradiation therapy could be considered depending on intrathoracic tumor spread and systemic metastases.
There are three different patterns of CT findings of thoracic EHs: multiple pulmonary nodules; multiple pulmonary reticulonodular opacities; and diffuse infiltrative pleural thickening. PET/CT findings have been reported for a few patients with thoracic epithelioid hemangioendothelioma (EH) with variable increased FDG-uptakes. Because 18-flurine-fluorodeoxyglucose (18F-FDG) is incorporated into rapidly growing, aggressive tumors, 18F-FDG-PET/CT would be valuable for patients with thoracic EHs in the evaluation of the metabolic activity of the multiple pulmonary nodules and in search for other foci of EHs throughout the body. The standardized uptake value (SUV) of EHs on 18F-FDG-PET/CT might also be used as an indicator for therapeutic decision making. However, when deciding surgical resection of small EH nodules less than 2 cm in diameter, it should be considered that the measurement of the SUVs could be of a limited value because of the partial volume averaging effect, which is one of many factors affecting the SUV and would underestimate the real hypermetabolic activity of EH nodules.

Please refer to
Case 691, Case 762, Case 772,
References
1. Eun Young Kim, Tae Sung Kim, Joungho Han, Joon Young Choi, O Jung Kwon and Jhingook Kim : Thoracic epithelioid hemangioendothelioma. Acta Radiologica 2011; 52: 161–166
2. Fagen K, Silverman ED, Cole RL. Detection of a pulmonary epithelioid hemangioendothelioma by FDG PET scan. Clin Nucl Med 2004;29:758–9
3. Watanabe S, Yano F, Kita T, et al. 18F-FDG-PET/CT as an indicator for resection of pulmonary epithelioid hemangioendothelioma. Ann Nucl Med 2008;22:521–4
Keywords
Lung, Malignant tumor,

No. of Applicants : 90

▶ Correct Answer : 11/90,  12.2%
  • - Daejin Medical Center Bundang Jesaeng General Hospital , Korea (South) Donghwan Kim
  • - Juntendo University Hospital , Japan Akifumi Hagiwara
  • - Myongji hospital , Korea (South) Ji Ye Lee
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Gachon Gil hospital , Korea (South) junhyung Ann
  • - DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
  • - National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Niigata University , Japan Atsushi Uehara
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - the first affiliatited hospital of nanjing medical univercity , China Hai Xu
▶ Correct Answer as Differential Diagnosis : 17/90,  18.9%
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - Seoul university hospital , Korea (South) Youngjin Ryu
  • - GHICL , France manuel toledano
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Samsung Medical Center , Korea (South) Jeonghyun Lee
  • - Asan , Korea (South) Sania ALBlushi
  • - Wuhan Union Hospital , China Qiguang Cheng
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - CNUH , Korea (South) Noh Hoon
  • - Armed Forces Seoul Hospital , Korea (South) Eui Jin Hwang
  • - CHU Poitiers , France CHAN paul
  • - CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
  • - The University of Tokyo Hospital , Japan Takeyuki Watadani
  • - Asan Medical Center , Korea (South) , Korea (South) Han Na Lee
  • - Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
  • - Gifu Central Hospital , Japan Haruo Watanabe
  • - Medicheck health care , Korea (South) Chae Lim
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