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Weekly Chest CasesArchive of Old Cases

Case No : 667 Date 2010-08-08

  • Courtesy of Ki-Nam Lee, Eun Ju Kang, Bo Sung Kim / Department of Radiology, Dong-A University Hospital.
  • Age/Sex 42 / F
  • Chief ComplaintIncidentally discovered nodules on chest radiograph and CT as part of an annual physical examination.
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7

Diagnosis With Brief Discussion

Diagnosis
Benign metastasizing leiomyomatosis in the lung
Radiologic Findings
Figure 1. Conventional radiograph demonstrates a well defined mass measuring 3 cm in diameter in right infrahilar area and a small nodule in right upper lung zone.

Figure 2, 3, 4, 5. CT scans depict multiple well circumscribed nodules with homogeneous enhancement.

Figure 6. Pelvic CT scan depicts the surgical clips and the uterus is not found where it should be.

Figure 7. FDG PET-CT. Axial PET image shows a nodule without hypermetabolism.
Brief Review
Benign metastasizing leiomyoma is a rare condition characterized by numerous well-differentiated leiomyomas at sites distant from the uterus.
Metastases most often affect the lungs, whereas the heart, brain, lymph nodes,
bone, and skin are more rarely affected. The condition usually manifests as multiple incidentally detected pulmonary nodules in middle-aged women. A history of hysterectomy for uterine leiomyoma may be indicative, with the mean reported interval between hysterectomy and the appearance of pulmonary nodules ranging from 3 months to 20 years.
Symptoms of chest pain, shortness of breath, and cough have been described.
Although the clinical course is usually indolent, a more rapid progression to severe respiratory symptoms also has been reported.
It is now largely accepted that the lesions arise as hematogenous metastases from benign tumors.
The radiologic imaging appearance of pulmonary nodules in benign metastasizing leiomyomas varies from solitary subcentimeter lesions to multiple lesions mimicking pulmonary metastases from malignant tumors. Cavitation of lesions occasionally take place and rarely may be accompanied by pneumothorax. Calcification is rare. Occasional cases with a military pattern and a pattern simulating interstitial lung disease have been documented. Both CT and MR imaging may be used to depict the pulmonary nodules in benign metastasizing leiomyoma, which have a nonspecific appearance and usually enhance homogeneously. The inclusion of particular entities in the differential diagnosis depends on the size of the nodules, but the most commonly included are metastases from malignant tumors.
The absent FDG uptake of the pulmonary lesions on PET imaging can help to rule out metastasis from extrathoracic tumors or uterine sarcoma. However, nodular lung lesions without FDG uptake and malignant behavior have been described, so we should keep in mind that the differential diagnosis also includes well-differentiated neoplasms, metastasis of tumors with a mucinous component (breast, renal, and gastrointestinal), neuroendocrine tumors, multifocal bronchioloalveolar carcinoma, and carcinoid tumors.
References
1. Fasih N, Prasad Shanbhogue AK, Macdonald DB et al. Leiomyomas
beyond the uterus: unusual locations, rare manifestations. Radiographics 2008; 28(7):1931?948.
2. Abramson S, Gilkeson RC, Goldstein JD, Woodard PK, Eisenberg R, Abramson N. Benign metastasizing leiomyoma: clinical, imaging, and pathologic correlation. AJR Am J Roentgenol 2001;176(6):1409?413.
3. di Scioscio V, Feraco P, Miglio L. Benign Metastasizing Leiomyoma of the Lung
PET Findings: J Thorac Imaging 2009;24:41?4.
Keywords
Lung, Benign tumor,

No. of Applicants : 108

▶ Correct Answer : 48/108,  44.4%
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - SMG-SNU boramae medical center , Korea (South) Kwang Nam Jin
  • - McGill University , Canada Ben Smith
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - University of British Columbia , Canada Amr Ajlan
  • - Shinchon Severance hospital , Korea (South) Hye Mi Kim
  • - Fukuyama daiichi Hospital , Japan Mototsugu Saeki
  • - McGill University Health Center , Canada Alexandre Semionov
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Hopital de Pau , France Mathieu Cannella
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Yonsei university Shinchon Severance hospital , Korea (South) Na-young Shin
  • - Song-do Hospital , Korea (South) Ji-young Yun
  • - radiologist, aditya imaging centre , India vivek patel
  • - Osaka University , Japan Osamu Honda
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - CHRU lille , France manuel toledano
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Uzunkopru Devlet Hastanesi , Turkey Armagan Sarac
  • - Assam Medical college , India samudra borah
  • - care hospital , India Chary D
  • - korea university hospital, ansan , Korea (South) kihwan kim
  • - Chonbuk National University Hospital , Korea (South) Jisoo Song
  • - All India Institute of medical sciences , India Justin Moses
  • - chonnam university hospital , Korea (South) shin hyun
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - ROYAL MELBOURNE HOSPITAL , Australia kimchi kings
  • - Catholic medical center , Korea (South) hyuna kim
  • - SoonChunHyang univ. hospital , Korea (South) Kim Jae Hyun
  • - catholic medical center , Korea (South) eunmi ryu
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Onomichi municipal hospital , Japan Ryotaro Kishi
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - seoul national university hospital , Korea (South) Ijin Joo
  • - Matto Central Hospital , Japan Manabu Akimoto
  • - Seoul Nationial University Bundang Hospital , Korea (South) Hee Seok Choi
  • - Hospital M de Deus , Brazil Thiago Bento da Silva
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - IRSA , France jean-luc BIGOT
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - PITTWATER RADIOLOGY , Australia Saurabh Khandelwal
  • - PITTWATER RADIOLOGY , Australia Julie Arora
  • - NMC Speciality hospital Dubai , United Arab Emirates Vickrant Malhotra
▶ Correct Answer as Differential Diagnosis : 7/108,  6.5%
  • - NTUH , Taiwan Kuei-pin Chung
  • - CHRU Lille , France guillaume lefebvre
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - okayama university , Japan t yamamoto
  • - Goa Medical College , India Paresh Desai
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - NASA SCANS , India RAKESH BHATIA
▶ Semi-Correct Answer : 1/108,  0.9%
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
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