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Weekly Chest CasesArchive of Old Cases

Case No : 489 Date 2007-03-12

  • Courtesy of Byoung Wook Choi, M.D., Jin Hur, M.D., Ji Eun Nam, M.D. / Sinchon Severance Hospital, Yonsei University, Seoul, Korea
  • Age/Sex 27 / M
  • Chief ComplaintBlood tinged sputum for 8months with recurrent pneumonia in RLL
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Pulmonary Inflammatory Pseudotumor
Radiologic Findings
CT shows an endobronchial polypoid mass in the posterior basal segmental bronchus of right lower lobe, which is enhanced after contrast administration. Mucoid impaction of subsegmental bronchi of the posterior basal segment is associated with the lesion.
Brief Review
Inflammatory pseudotumor is a quasineoplastic lesion consisting of inflammatory cells and myofibroblastic spindle cells. Inflammatory pseudotumor most commonly involves the lung and the orbit, but it has been reported to occur in nearly every site in the body, from the central nervous system to the gastrointestinal tract.
Inflammatory pseudotumor is the most common primary lung mass seen in children, constituting approximately 50% of benign intrapulmonary tumors seen in pediatric patients. These tumors have no sex predilection, and their peak prevalence is in the second decade of life. Cough, fever, dyspnea, and hemoptysis are the usual presenting symptoms.
On the basis of the predominant histopathologic features, the lesions can be divided into three histologic types: (a) organizing pneumonia pattern, characterized by airways filled with plump fibroblasts and foamy histiocytes and parenchyma replaced with a mixture of histiocytes, mononuclear cells, and fibroblasts; (b) fibrous histiocytic pattern, which is the most common, and is characterized by spindle-shaped myofibroblasts arranged in whorls; and (c) lymphohistiocytic pattern, which is the least common and is characterized by a mixture of lymphocytes and plasma cells with only minimal fibrous connective tissue.
On radiographs, inflammatory pseudotumor typically appears as a solitary, peripheral, sharply circumscribed, lobulated mass with an anatomic bias for the lower lobes. On CT scans, inflammatory pseudotumors have a variable and nonspecific appearance, but most commonly they appear with heterogeneous attenuation and enhancement. Calcification within the lesion occurs more frequently in children than in adults. The calcification pattern ranges from an amorphous, mixed, or fine fleck-like pattern to heavy mineralization. Cavitation and lymphadenopathy are rare. Atelectasis and pleural effusion may occur.
When inflammatory pseudotumor are endobronchial in location, they are typically polypoid and may or may not extend beyond the bronchial wall. Endoluminal airway involvement has been known to occur in 10-12% in previous reports. Recently Kim et al. observed that 5 (50%) of 10 patients with inflammatory pseudotumor had major airway involvement. They concluded that inflammatory pseudotumor should be included in the differential diagnosis when a well-defined, polypoid, endotracheal/endobronchial nodule is seen on CT.
The radiologic differential diagnosis for inflammatory pseudotumor occurring as a solitary pulmonary nodule includes primary or secondary neoplasm, hamartoma, chondroma, hemangioma, granuloma, and pulmonary sequestration. Inflammatory pseudotumor may resemble pulmonary intralobar sequestration in that its blood supply is derived from the systemic arteries. As a endobronchial tumor, inflammatory pseudotumor should be included in differential diagnosis with squamous cell carcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, carcinoid tumor, leiomyoma, neurogenic tumor, and hamartoma.
References
1. Kim TS, Han J, Kim GY, Lee KS, Kim H, Kim J. Pulmonary inflammatory pseudotumor (inflammatory myofibroblastic tumor): CT features with pathologic correlation. J Comput Assist Tomogr 2005;29 :633-639.
2. Hedlund GL, Navoy JF, Galliani CA, Johnson WH. Aggressive manifestations of inflammatory pulmonary pseudotumor in children. Pediatr Radiol 1999; 29:112?16.
3. Agrons GA, Rosado-de-Christenson ML, Kirejczyk WM, Conran RM, Stocker JT. Pulmonary inflammatory pseudotumor: radiologic features. Radiology 1998; 206:511?18.
4. Narla LD, Newman B, Spottswood SS, Narla S, Kolli R. Inflammatory pseudotumor. Radiographics. 2003; 719-729.
Keywords
Lung, Benign tumor, Pulmonary Inflammatory Pseudotumor

No. of Applicants : 49

▶ Correct Answer : 2/49,  4.1%
  • - Shinchon Severance Hospital, Korea Ho-Joon Lee
  • - Severance Hospital, Korea Jung-Ho Kang
▶ Correct Answer as Differential Diagnosis : 7/49,  14.3%
  • - China Medical University Hospital,Taiwan Jun-Jun Yeh
  • - Monaldi Hospital,Naples, Italy Gaetano Rea
  • - IRSA La Rochelle, France Denis Chabassiere
  • - ASCS, Safwa , Saudi Arabia Kalari Adinarayana
  • - Homs National Hospital, Homs - Syria Rami Abou Zalaf
  • - Doctors Hospital, Nassau, Bahamas N.B.S.Mani
  • - St. Mary's hospital,The Catholic University of Korea, Korea Soo Kyung Yoon
▶ Semi-Correct Answer : 28/49,  57.1%
  • - Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
  • - Jikei University, Japan Shigeki Misumi
  • - NTUH, Taiwan Chang You-Lung
  • - SCTIMST, trivandrum, Kerala, India Santho shkumar
  • - Changi General Hospital, Singapore Angeline Poh
  • - E-Da hospital, Taiwan Yu-Feng Wei
  • - Deptt. Of Radiodiagnosis and Imaging PGIMER, Chandigarh, India Ram Prakash Galwa
  • - Ewha Womans University MokDong Hospital, Korea Yoo kyung Kim
  • - NIRMAN HI-TECH DIAGNOSTIC CENTRE, MUMBAI, India MINAL SETH
  • - Samcheonpo jeil hospital, Korea Su Jin Kang
  • - Inha University Hospital, Korea SeungU Choe
  • - KAUMS< Kashan, Iran Ebrahim Razi
  • - Ulsan University Hospital, Ulsan, Korea Jong-Chang, Jang
  • - Mackay Memorial Hospital, Taipei, Taiwan Chia-Fu Tsai
  • - Samsung Medical Center, Korea DaeKun Oh
  • - Hornu, Belgium Delhaye Damien
  • - Vital Imaging centre, Mumbai, India Ganesh Agrawal
  • - Hangang Sacred Heart Hospital, Korea Eil Seong Lee
  • - IRSA LA ROCHELLE, France Jean-Luc BIGOT
  • - Osaka University, Japan Osamu Honda
  • - Kyunghee University Medical Center, Korea Su Youn Sim
  • - Hospital Sotiria, Athens, Greece Vasilios Tzilas
  • - ANNEMASSE, Polyclinique de SAVOIE, France Gay-Depassier Philippe
  • - Chru lille hopital calmette, France Toledano manuel
  • - Regional Imaging - Riverina, Australia Rashid Hashmi
  • - PGIMER Chandigarh India Praveen Kumar
  • - Annecy hospital, FRANCE Gilles genin
  • - Ultra Care , Coimbatore , India Debabrata Das
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