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Excavated pulmonary nodules: an unusual clinical presentation of lung metastasis in two cases
© Allam et al; licensee BioMed Central Ltd. 2010
Received: 14 January 2010
Accepted: 24 June 2010
Published: 24 June 2010
Excavated pulmonary metastasis are rare. We present two cases of excavated pulmonary nodules proved to be metastases from osteosarcoma and gallblader lymphoma.
The first one is 39-year-old man in whom cholecystectomy made the diagnosis of primary non-Hodgkin's lymphoma of the gallbladder. He presented in chest CT scan excavated nodules that had been biopsied and confirmed the diagnosis of non hodgkin lymphoma. He underwent 8 courses of chemotherapy CHOP 21 with complete remission. The second one is an 21 years old man who presented a right leg osteoblastic osteosarcoma with only excavated pulmonary nodules in extension assessment. He had 3 courses of polychemotherapy API (doxorubicin, platinum, and ifosfamide) with partial response. Unfortunately, he died following a septic shock.
Review of the literature shows that excavated pulmonary nodules as metastasis are rare but we should consider this diagnosis every time we are in front of a cancer. Chest computed tomography is the best diagnosis imaging that could make this diagnosis. Differential diagnosis between benign and malignant bullous lesions is important because surgical excision affects survival in some malignancies.
Although pulmonary nodules are the most common cancer metastasis, a differential diagnosis of a concurrent primary malignancy should always be considered every time we have excavated lesions, even in patients with known malignant disease. Thorough chest evaluation is important, as multiple primary malignancies may occur concomitantly.
Metastatic causes of excavated pulmonary nodules are rare but must be considered in patients with a history of neoplastic disease.
Excavated metastatic pulmonary lesions are described, but in a country of epidemic tuberculosis, or in front of smokers, it is necessary to raise differential diagnosis. Sometimes, chest scann permitt to elaborate a definite diagnosis, and sometimes, we must resort to a biopsy. We report here two cases of excavated pulmonary metastasis attendant to primary malignancies.
A 21 years old man, with no particular medical history, who presented a right leg painful mass was consulting at our hospital. There was no history of trauma or infection. On examination, a great warm mass measuring 12 × 21 cm was found at the end of the right tibia. Signs of inflammation were observed with a large swelling and oozing. He had no lymphadenopathy and no other mass. He just accused intermittent cough lasting for two months. His blood parameters were correct. An MRI (magnetic resonnance) was performed to establish the nature of this mass and its locoregional reports, it objectived abnormal signal intensities with a cortical destruction. A biopsy was then realised and the histopathological study revealed a chondroblastic osteosarcoma with an hypercellular neoplasm. He underwent an extension assessement by chest CT scan, scintigraphy, that revealed bilateral excavated pulmonary metastasis with different sizes and location. A pulmonary biopsy was performed to eliminate infectious diagnosis or vascularite, and revealed a metastasis of osteosarcoma. He had 3 courses of polychemotherapy API (doxorubicin 60 mg/m2 IV day 1, cis-platinum 75 mg/m2 IV day 1, and ifosfamide 7 g/m2 from day 1 to 5 IV with uromitexan to protect against hemorrhagic cystitis ) with partial response. Unfortunately, he died following a septic shock.
Lung represents a major metastatic site of the body as there's a seat about 30 to 50% of all secondary locations. The occurrence of excavated lung metastases is rarely observed only in 4% of cases (1). We report two cases with rare lymphoma of the gallbladder and osteosarcoma of the leg with pulmonary excavated metastasis emphasizing the role of CT in characterizing these lesions. Primitive tumor corresponds mainly to squamous cell carcinoma of the head and neck or cervix, rarely to colon (2,3). Metastatic sarcomas, especially osteogenic can disseminate as excavated pulmonary nodules with a high risk of pneumothorax. Excavation sometimes occurs after chemo-radiotherapy (4). A review of litterature shows that the primary site that metastasis to lung are excavated are bladder, kidney, breast, and ovary (2,5,6). CT scan is more sensitive than standard chest radiography for the detection of excavated metastatic lesions. It also allows aetiological diagnosis achieved by biopsy guided by the scan, as in our second observation.
In conclusion, we recommend to realise chest CT scan and biopsy each suspected lesions to ensure diagnosis of metastasis.
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