대한흉부영상의학회 Weekly Chest Cases

Case No : 134 Date 2000-05-20

Courtesy of Young Hi Choi, M.D. / Dankook University Hospital, Cheonan, Choongnam, Korea
Age/Sex 70 / M
Chief Complaintchest discomfort, cough, dyspnea, fever and chill for 30 days.

Figure 1
Figure 2

Diagnosis With Brief Discussion

Diagnosis: Endogenous lipoid pneumonia
Radiologic Findings: History
A 70-year-old man presented with chest discomfort, cough, dyspnea, fever and chill for 30 days. He had a history of pulmonary tuberculosis. Physical examination revealed asymmetric expansion of thoracic cage and decreased breathing sound in left lower lung zone. Laboratory findings revealed elevated WBC count, and negative for AFB staining. Bronchoscopic examination revealed a protruding mass in the left lower lobar bronchus covered with necrotic materials. Transbronchial and percutaneous needle biopsy were performed in left lower lobar mass and a diagnosis of small cell lung cancer was made.

Frontal chest radiograph shows prominent left hilum, and a large increased density in left lower lung zone with volume decrease without obliteration of left cardiac border. Left lateral chest radiograph shows consolidation of left lower lobe with mild volume decrease. Contrast-enhanced chest CT scans show 1cm sized low-density mass in left lower lobar bronchus and consolidations of left lower lobe with mucus-bronchogram. These findings suggest endogenous lipoid pneumonia of left lower lobe due to endobronchial mass.
Brief Review: Endogenous lipoid pneumonia (ELP), which is also called as postobstructive pneumonitis occurs distal to major airway obstruction. ELP results from a variety of causes including neoplasm and infection. Pathologically it is a combination of atelectasis, bronchiectasis with mucous plugging, and parenchymal inflammation and fibrosis. The lobes often have yellowish or golden hue, which is thought to be produced by the liberation of lipid material from alveolar pneumocytes secondary to the inflammatory reaction. This appearance has given rise to the term golden pneumonia; this abnormality is also known as cholesterol pneumonia. In the vast majority of the cases the inflammation is not caused by bacterial infection. In involved parenchyma that has been recently obstructed, the principal histologic finding is filling of alveolar air space by proteinaceous fluid containing scattered macrophages and cultures are usually sterile. In later stages fluid is replaced by macrophages containing foamy and vacuolated cytoplasm, which is different from the large vacuoles in exogenous lipoid pneumonia. Etiologies of ELP include malignant neoplasms, such as bronchogenic squamous or small cell carcinoma, carcinoid, mucoepidermoid carcinoma; metastatic carcinoma from kidney, colorectum, breast or melanoma; benign rare bronchial tumors such as endobronchial hamartoma, lipoma or schwanoma; other occluding lesions such as mucus plug, foreign body or bronchial fracture; infection such as endobronchial tuberculosis, endobronchial actinomycosis; inflammatory lesions such as antracofibrosis or broncholithiasis; or middle lobe syndrome.

This case was due to small cell lung cancer. Small cell carcinoma is typically located in relation to proximal airways, particularly lobar and main bronchi. Centrally located tumors tend to spread in the submucosa and peribronchovascular connective tissue, and then extend into adjacent lung parenchyma to become a more circumscribed mass that obliterates underlying airways and vessels. Endobronchial growth is seen much less frequently than in squamous cell carcinoma; in fact when airway obstruction occurs, it is usually as a result of compression by the expanding tumor rather than intraluminal growth. CT can better depict the extent of the mass as well as the nature of it.
References: 1. Burke M, Fraser R. Obstructive pneumonitis: a pathologic and pathogenetic reappraisal. Radiology 1988;166:699-704
2. Spencer P. Pathology of the lung. 3rd ed, Pergamon Press Inc, New York, 1977
3. Genereux GP. Lipids in the lungs: radiologic-pathologic correlation, J Canad Assoc Radiol 1970;21:2-15
4. Carter D. Small cell carcinoma of the lung. Am J Surg Pathol 1983;7:775-785
Keywords: Lung, Non-infectious inflammation,

No. of Applicants : 55

▶ Correct Answer : 45/55, 81.8%

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- Asan Medical Center Jeong Hyun Lee
- Gachon Medical School Gil Medical Center Seo Joon Beom
- Hospital General Universitario de Alicante, Spain Juan Arenas
- Ospedale di Fabriano, Italy Giancarlo Passarini
- Samsung Medical Center Kyung Soo Lee
- Seoul national university hospital Choi Hyuck Jae
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- Hospital de Guipuzcoa / San Sebastian / Spain Gonzalo Vega - Hazas Porrua

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 134 Date 2000-05-20

Discussion

No. of Applicants : 55