대한흉부영상의학회 Weekly Chest Cases

Case No : 810 Date 2013-05-06

Courtesy of In Hye Chae, Sung Shine Shim, Yookyung Kim / Mokdong Hospital, Ewha Womans University
Age/Sex 62 / F
Chief ComplaintAbnormal finding on chest radiograph, 20 pack year current smoker

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Diagnosis With Brief Discussion

Diagnosis: Atypical carcinoid
Radiologic Findings: Chest radiograph shows increased opacity in inferior right hilum and subcarina area with obliteration of azygoesophageal line. CT images show about 5cm sized, two enlarged soft tissue mass with highly enhancement at carina and subcarina area. Right hilar opacity on simple radiograph appears on CT as a well enhancing nodule with lobulated border and partially internal necrosis. This nodule is located in RML with obstructing the lumen of the right middle lobar bronchus. There is no significantly increased FDG uptake on PET/CT.
Bronchoscopic biopsy was done. Microscopically, the tumor shows less than 5 mitoses per 10HPFs and diffuse, strong positive chromogranin and confirmed as atypical carcinoid tumor.
Brief Review: Bronchopulmonary carcinoid tumors account for over 25% of all carcinoid tumors and for 2% of all pulmonary neoplasms. About 80% of cases are typical carcinoid, which generally are low grade and have a benign course. The remainders (20%) are atypical carcinoid, which are much more aggressive and may have metastasized. Unlike typical carcinoids, atypical carcinoids are associated with a history of cigarette smoking (90% of cases) and occur more often in men (2:1). Typical and atypical bronchial carcinoids have similar radiologic features, mostly arise centrally in the main, lobar, or segmental bronchi and demonstrate no specific lobar distribution. And carcinoids tend to be vascular and may have intense enhancement. Atypical carcinoids have a larger tumor size, a higher rate of hilar or mediastinal nodal metastasis (76%), more peripheral location, and may be locally invasive, while the typical carcinoids are generally small tumors with a lower rate of nodal metastasis (4% or 6%) and more central location. Hence, a more radical approach (lobectomy or pneumonectomy) is justified in case of atypical carcinoid. AT PET/CT, carcinoid tumors do not exhibit increased activity and usually have less FDG uptake than is expected for malignant tumors.
References: 1. Jeung, M.Y., et al., Bronchial carcinoid tumors of the thorax: spectrum of radiologic findings. Radiographics, 2002. 22(2): p. 351-65.
2. Scarsbrook, A.F., et al., Anatomic and functional imaging of metastatic carcinoid tumors. Radiographics, 2007. 27(2): p. 455-77.
3. Thomas, C.F., Jr., H.D. Tazelaar, and J.R. Jett, Typical and atypical pulmonary carcinoids : outcome in patients presenting with regional lymph node involvement. Chest, 2001. 119(4): p. 1143-50.
4. Chong, S., et al., Neuroendocrine tumors of the lung: clinical, pathologic, and imaging findings. Radiographics, 2006. 26(1): p. 41-57; discussion 57-8.
Keywords: Airway, Malignant tumor,

No. of Applicants : 74

▶ Correct Answer : 12/74, 16.2%

- Kyoto University , Japan Akihiko Sakata
- University of British Columbia , Canada Amr Ajlan
- All India Institute of Medical Sciences , India Ashish Gupta
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- IRSA La Rochelle France , France Denis Chabassiere
- NDMVP Nashik , India Imran Jindani
- James Paget Hospital , U.K , United Kingdom nabil mahmood
- Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
- All India Institute of medical sciences , India Justin Moses

▶ Correct Answer as Differential Diagnosis : 10/74, 13.5%

- Oita University, Faculty of Medicine , Japan Fumito Okada
- Chonnam national university hospital , Korea (South) SeungJin Lee
- McGill University Health Center , Canada Alexandre Semionov
- EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) Sang Min Lee
- Kizawa Memorial Hospital , Japan Yo Kaneko
- Myongji hospital , Korea (South) Ji Ye Lee
- IRSA LA ROCHELLE , France, Metropolitan BIGOT
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Kyungpook National University Hospital , Korea (South) Jaekwang Lim
- Eren T캇p Merkezi Istanbul , Turkey Armagan Sarac

▶ Semi-Correct Answer : 2/74, 2.7%

- Konkuk university hospital , Korea (South) Jeong Geun Yi
- GHICL , France manuel toledano

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 810 Date 2013-05-06

Discussion

No. of Applicants : 74