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LUNG AND PLEURAL MALIGNANCIESLUNG AND PLEURAL MALIGNANCIES

GRAND ROUNDGRAND ROUND

Prof. Metin GORGUNER, MDgorguner@atauni.edu.tr

TURKISH THORACIC SOCIETY 11th Annual Congress

23 – 27 April 2008, Antalya, TURKIYE

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General Characteristics Male, 45 years old Born in the Eleşkirt Living in the Ağrı Goverment official Back pain at left hemithorax Admission; 14 Jan 2008

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Patient’s Brief History Back pain at left side

during the last 2 months

Various nonspesific therapies

Pain relieving with analgesics

Chest X Ray in Nov 2007

Thorax CT in Nov 2007

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Chest X Ray in 29 November 2007

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Thorax CT in 29 November 2007

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Pneumonia in 1985 ? Traffic accident in 1990 Discal hernia operation in 2000 Varicose veins of the left leg Pantoprazol, 40 mg/daily Smoking, 25 packs-year No history of familial disease

Patient’s Former History

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Physical Examination Good performance status A soft, swelling and immobile

lesion on the thoracic wall at the leftside

In percussion; dullness of left lower hemithorax

In auscultation; diminished breath sounds of left lower hemithorax

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A soft, swelling and immobile lesion on the thoracic

wall at the leftside

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Laboratory Findings All of the parameters was normal

except the ESR: 80 mm/hour

Tuberculin skin test was negative

Electrocardigraphy was normal

Mild restriction on PFT

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What is your initial diagnosis ?

A. Organizing hematoma

B. Chest wall cystic lesion

C. Pleural tumor D. Chest wall tumor E. Rib tuberculosis

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Which test should be performed ?

A. Chest X Ray B. Thorax MRI C. Percutaneous Needle Aspiration D. Bronchoscopy E. Surgery

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Which test should be performed ?

A. Chest X Ray B. Thorax MRI C. Percutaneous Needle Aspiration D. Bronchoscopy E. Surgery

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Chest X Ray

29 November 2007

15 January 2008

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Chest X Ray

29 November 2007

15 January 2008

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Multi Detector CTContrast Enhanced Axial Image

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Multi Detector CTContrast Enhanced Axial Image

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Multi Detector CTContrast Enhanced Axial Image

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Multi Detector CTContrast Enhanced Axial Image

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Multi Detector CTContrast Enhanced Axial Image

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Multi Detector CTContrast Enhanced Axial Image

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Multi Detector CTContrast Enhanced Sagittal Image

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Multi Detector CTContrast Enhanced Sagittal Image

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Multi Detector CTContrast Enhanced Sagittal Image

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Multi Detector CTContrast Enhanced Sagittal Image

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Multi Detector CTContrast Enhanced Coronal Image

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Multi Detector CTContrast Enhanced Coronal Image

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Multi Detector CTContrast Enhanced Coronal Image

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Multi Detector CTContrast Enhanced Coronal Image

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Multi Detector CTMulti-plane Reconstructed Coronal Image

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Multi Detector CTMulti-plane Reconstructed Coronal Image

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Multi Detector CTMulti-plane Reconstructed Coronal Image

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Multi Detector CTMulti-plane Reconstructed Coronal Image

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Multi Detector CT Three Dimensional Volume Rendering Image

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What is your diagnosis ? A. Organizing

hematoma B. Chest wall cystic

lesion C. Malignant

mesothelioma D. Chest wall tumor E. Rib tuberculosis

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Which test should be performed ?

A. Thorax MRI B. Percutaneous Needle Aspiration D. Bronchoscopy C. Pleural Biopsy E. Surgery

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Which test should be performed ?

A. Thorax MRI B. Percutaneous Needle Aspiration D. Bronchoscopy C. Pleural Biopsy E. Surgery

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H.E. – 2x10 Magnification

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H.E. – 20x10 Magnification

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H.E. – 40x10 Magnification

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Vimentin Positive

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cd68 Positive

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ki67 Positive

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Desmin Negative

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s100 Negative

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What is your final diagnosis ?

A. Organizing hematoma

B. Chest wall cystic lesion

C. Malignant mesothelioma

D. Chest wall tumor E. Rib tuberculosis

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What is your final diagnosis ?

A. Organizing hematoma

B. Chest wall cystic lesion

C. Malignant mesothelioma

D. Chest wall tumor E. Rib tuberculosis

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FINAL DIAGNOSIS

Mesenchymal Tumor with Mixoid Component

(Mixoid Malignant Fibrous Histiocytoma)

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MALIGNANT FIBROUS HISTIOCYTOMA Clinical Summary – 1

A common soft tissue tumor In late middle age, with a median of 54

yrs Develops frequently in the extremities

and the retroperitoneum. The lungs are the most common site of

metastases. Primary pulmonary MFH is extremely

rare.

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MALIGNANT FIBROUS HISTIOCYTOMA Clinical Summary – 2

Clinical and radiographic features are nonspesific; Cough, chest pain, hemoptysis, dyspnea A solitary mass with a nondescript

appearance and relatively homogeneous density on CT or MR

Tissue examination is absolutely required.

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MALIGNANT FIBROUS HISTIOCYTOMA Pathology

Five histologic subtype; Pleomorphic Mixoid Giant cell Inflammatory Angiomatoid

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MALIGNANT FIBROUS HISTIOCYTOMA Treatment and Prognosis

Surgical resection is recommended if the tumor shows limited extrapulmonary spread to the intrathoracic great vessels or soft tissue.

Adjuvant CT or RT have not proven to be effective.

Mediastinal, chest wall, or carinal involvement, prominent symptoms, incompleteness of excision, and tumor recurrence are the bad prognostic factors.

Survival (2 yrs) approx. 60 %, RR 30 – 60 %

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Jan 1987 – Dec 1995, 13 cases diagnosed as MFH

Only 3 cases with thoracic involvement All of them originated by chest wall One case has lung invasion and

endobronchial tm

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Special thanks to…

Assoc. Prof. Fazli ERDOGAN Department of Pathology

Assoc. Prof. Fatih ALPER Department of Radiology

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Thank you…