Canadian Health&Care Mall: Pulmonary Nodule


December 26, 2015 Category: Canadian Health&Care Mall

CT screeningA 65-year-old white woman was evaluated for a solitary pulmonary nodule. While undergoing a commercial whole-body CT screening examination 1.5 years earlier, she was found to have a 9-mm poorly marginated lesion in the right lower lobe of her lung. A short-term follow-up and/or diagnostic evaluation was strongly recommended, but the patient deferred. During the current evaluation, a follow-up chest CT scan demonstrated the presence of a 16-mm nodule in the right lower lobe with irregular margins (Fig 1). The patient denied dyspnea, fever, cough, hemoptysis, or weight loss. Her medical history was only pertinent for type II diabetes mellitus, hypertension, and hypercholesterolemia. Two years earlier, she had undergone a total abdominal hysterectomy with bilateral salpingo-oophrectomy for treatment of a borderline stage IA ovarian tumor. The patient had a remote cumulative 25-pack-year smoking history. Her family history was negative for cancer or lung disease.

Her physical examination showed normal vital signs. The chest, lung, cardiac, and abdominal examinations were unremarkable. She had no palpable lymphadenopathy. The results of her musculoskeletal examination were normal, and her neurologic examination did not reveal any deficits. The parameters of her laboratory test results were normal and included a CBC count, a blood chemistry profile, liver function tests, and measurement of serum calcium level. There are a lot of interesting and thought – provoking information. To read something interesting you may here Canadian HealthCare Mall healthcaremall4you.com.

A whole-body positron emission tomography (PET) study showed an isolated focus of abnormal, increased 18-fluorodeoxyglucose (FDG) activity (standardized uptake ratio, 4.8) corresponding to the location of the pulmonary nodule visualized on the chest CT scan (Fig 2). A bronchogenic carcinoma was strongly suspected based on the history, the results of the imaging studies, and the doubling time of the nodule. The patient was scheduled for a bronchoscopy followed by a wedge resection of the nodule. The treatment plan was to proceed with a right lower lobe lobectomy and systematic lymph node dissection in the same operative setting if the intraoperative histologic examination confirmed a diagnosis of non-small cell lung cancer.

What is the diagnosis?

Diagnosis: Solitary pulmonary papilloma, glandular type

Discussion

Our patient had a solitary, pulmonary glandular papilloma (Fig 3). In adults, a solitary pulmonary papilloma represents a rare benign neoplasm, which accounts for only 0.38% of all lung tumors and 7 to 8% of all benign lung tumors.-2 Little is known about their clinical and pathologic features. Unlike multiple papillomatosis, which is seen in young people, and frequently in children, the solitary pulmonary papilloma commonly appears in the fifth and sixth decades of life. The clinical manifestations of patients with solitary pulmonary papillomas are as follows: hemoptysis, dyspnea, wheezing, postobstructive pneumonia, or clinically asymptomatic radiographic abnormalities.Pulmonary glandular papilloma

The following three histologic types have been recognized: squamous papillomas, glandular papillomas; and mixed squamous and glandular papillomas. Squamous papillomas and mixed squamous and glandular papillomas are predominantly seen in male smokers. Squamous papillomas are the most common type of solitary pulmonary papillomas. Squamous papillomas have been shown to be strongly associated with human papilloma virus infections, an association that has never been documented for glandular or mixed papillomas. Squamous papillomas demonstrate a high rate of malignant transformation, ranging from 8 to 40%.> The risk of transformation increases with exposure to tobacco products,” age > 40 years, and infections with human papillomavirus serotype 16 or 18.

The glandular papilloma, as seen in our patient, represents a very rare subtype of pulmonary papillomas. We performed a MEDLINE search, restricted to the English language from 1954 to the present, and found only 13 case reports of pulmonary glandular papillomas.’ The mean age (± SD) of patients was 60 ± 13 years, with eight pulmonary glandular papillomas found in men, and five in women. Eleven of the 13 patients (84.6%) presented with endobronchial disease and had associated clinical symptoms, such as hemoptysis, wheezing, and recurrent pneumonia. Only one patient (7.7%) presented with an incidental peripheral pulmonary nodule. The patient in the remaining case had no information on the location of the lesion. As opposed to the squamous and mixed papillomas, the glandular papilloma tends to occur in nonsmokers and in an older patient population. Basheda and colleagues initially reported a right-sided predominance for glandular papillomas as demonstrated in our case, but a later study by Flieder and colleagues could not confirm this observation. Our review revealed five cases of left-sided lesions and eight cases of right-sided lesions, including our case. Seven of the eight right-sided solitary glandular papillomas were found in the lower lobe. Little is known about the growth rate of papillomas. The calculated doubling time for our patient’s tumor was 220 days, a growth rate that is commonly observed for malignant disease (50 to 500 days). As opposed to the stated literature on squamous papillomas, there have been no reports of the malignant transformation of glandular papillomas, although the number of reported cases remains limited. Six patients in the previously reported cases of glandular papilloma underwent lobectomy, and four glandular papillomas were removed through endobronchial interventions. No recurrence was reported after either treatment modality, with follow-up periods ranging between 1 year and 11 years.

None of the patients in the previously reported cases underwent a PET scan with FDG. FDG-PET scanning has shown excellent performance characteristics for the diagnosis of malignancy of solitary pulmonary nodules > 1 cm in diameter. A metaanalysis of 40 studies showed a sensitivity of 96.8% and a specificity of 77.8% for detecting malignancy. False-positive results may occur for infectious or inflammatory lesions due to mononuclear cell infiltrates, such as tuberculosis, histoplasmosis, or rheumatoid nodules.

In summary, solitary pulmonary papillomas are rare benign neoplasms. Among the papillomas, the glandular subtype is even rarer. Patients usually present with endobronchial lesions. A peripheral location, as seen in our case, is uncommon. In contrast to squamous papillomas, malignant transformation has not been reported for glandular papillomas. Endoscopic ablation for endobronchial locations and limited surgical resection of peripheral lesions seem to be justified based on the current evidence in the medical literature.

Fig1

Figure 1. A 1.6-cm pulmonary nodule growing in the right lower lobe with ill-defined margins.

Fig2

Figure 2. Corresponding increased FDG uptake at the location of the right lower lobe pulmonary nodule (standardized uptake ratio, 4.8).

Fig3

Figure 3. Pulmonary glandular papilloma. Broad papillary fronds lined by pseudostratified ciliated columnar epithelium with occasional mucin-producing cells and focally hyalinized stroma are seen. No necrosis, mitoses, or atypia are present (hematoxylin-eosin, original X 20)

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