대한흉부영상의학회 Weekly Chest Cases

Case No : 361 Date 2004-09-25

Courtesy of Jung Im Jung, M.D. / St. Mary's Hospital, Catholic Univeristy, Seoul, Korea
Age/Sex 34 / F
Chief ComplaintSolitary pulmonary nodule (PHx: right breast conserving surgery for invasive ductal cancer, 25 months ago)

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Diagnosis With Brief Discussion

Diagnosis: Solitary pulmonary metastasis
Radiologic Findings: Chest PA shows an about 1.5cm sized, round nodule in L hilar region (Fig.A). Post contrast CT scan shows a solitary pulmonary nodule in the lingular segment of the left upper lobe. The nodule is mildly enhanced (23 HU) (Fig. B). The lung window setting demonstrates outer lobuation and irregular border of the nodule (Fig. C). Wedge resection of the nodule revealed metastatic breast cancer.
Brief Review: When a solitary nodule is detected in a known case of malignancy, the possibility of its being a metastasis is 25% [1]. Usually metastatic pulmonary nodules are well-circumscribed with smooth margin. Because tumor cells hematogeneously transferred to the lung proliferate into the perivascular interstitium, they appear interstitial lesions having clear, smooth margins. However metastatic tumors can actually grow out the vessels into the adjacent interstitium and alveolar air-space and then proliferate, destroying the lung parenchyma. Metastatic nodules with irregular margins can the expected to be relatively common. In one study regarding CT of pulmonary metastasis with pathologic correlation [2], well defined, smooth margins on HRCT corresponded histopathologically to an expanding type and to an alveolar space-filling type; those with poorly defined margins, to an alveolar cell type, and those with irregular margins, to an interstitial proliferating type.

A solitary metastatic nodule with irregular margin may be difficult to differentiate from a primary lung cancer. Actually development of a solitary pulmonary nodule in patients previously treated for breast cancer may represent something other than recurrent disease. Casey et al [3] found that 52% of breast cancer patients presenting with a solitary pulmonary nodule had primary lung cancer, 43% proved to have metastatic breast cancer, and 5% proved to have benign lesions.

Histologic confirmation is necessary for appropriate staging and treatment.
References: 1.Cahan WG, Shah JP, Castro EB. Benign solitary lung lesions in patients with cancer. Ann Surg 1978; 187: 241-4.

2. Hirakata K, Nakata H, Nakagawa T. CT of pulmonary metastases with pathological correlation. Semin Ultrasound CT MR. 1995; 16: 379-94.

3. Casey JJ, Stempel BG, Scanlon EF, Fry WA. The solitary pulmonary nodule in the patient with breast cancer. Surgery 1984; 96: 801-5.
Keywords: Lung, Malignant tumor,

No. of Applicants : 23

▶ Correct Answer : 15/23, 65.2%

- Al Swaidaa National Hospital, Syria Marwan Al Chami
- Annecy Hospital, France Gilles Genin
- Asan Medical Center, Korea Eun Jin Chae
- Centre d'imagerie Jacques Callot, Nancy, France Lionel Cannard
- CHU Grenoble, France Mathieu Rodiere
- CHU Mustapha, Algers Y Berrah
- CHU Nancy-Brabois, France Denis Regent
- CIM Saint Dizier, France JC Leclerc
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee
- Hanyang University Hospital, Seoul, Korea Yo Won Choi
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Jikei University of Medicine, Japan Shigeki Misumi
- Ohio State University Medical Center, Ohio, USA Haricharan Reddy
- Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
- Social Security Hospital, Ankara, Turkey Meric Tuzun

▶ Semi-Correct Answer : 4/23, 17.4%

- Chonnam National University Hospital, Korea Yong-Ju Moon
- Mallinckrodt Institute of Radiology, USA Jin Mo Goo
- Marien Hospital, Hamm, Germany Davis Chiramel
- Ulsan GoodMorning Hospital, Korea Sang Hoo Joo

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 361 Date 2004-09-25

Discussion

No. of Applicants : 23