Comparison of the use of antibodies to alpha smooth muscle actin and desmin in pulmonary lymphangioleiomyomatosis

To establish if antibodies to alpha smooth muscle actin (ASMA) are better than desmin as a tumour marker in pulmonary lymphangioleiomyomatosis both antisera were applied to five cases. ASMA strongly stained the muscle in all cases but desmin was negative. Five cases of cryptogenic fibrosing alveolitis showed that mature smooth muscle embedded in fibrous tissue surrounding cysts was positively stained with ASMA but the interstitial fibrous tissue was negative. ASMA is a consistent and better marker than desmin for the detection of immature smooth muscle in pulmonary lymphangioleiomyomatosis.

[Lymphangiomyomatosis involving the kidney: a case report]

A 58-year-old female was admitted with a chief complaint of gross hematuria. A diagnosis of carcinoma of the left kidney with lymphnode metastasis was made on the basis of computerized tomography and angiography. Left nephrectomy and lymphnode dissection were performed. Histological examination revealed lymphangiomyoma, and the final clinical diagnosis was changed to lymphangiomyomatosis with pulmonary, retroperitoneal, and left renal lesions. Lymphangiomyomatosis with renal lesions is extremely rare, and differentiation from renal carcinoma is important, though difficult.

Early chylopneumothorax in a patient with pulmonary lymphangioleiomyomatosis

A 50-year-old woman was admitted with the complaint of cough and dyspnea on exertion for the previous two months. A radiograph of the chest showed a right-sided hydropneumothorax, which was proven to be a chylous effusion by lipoprotein electrophoresis and was very refractory to tetracycline-pleurodesis. The chylopneumothorax was cured by ligation of the thoracic duct and surgical pleurodesis. After an open lung biopsy, lymphangioleiomyomatosis (LAM) was diagnosed histopathologically with smooth muscle nodules scattered throughout the lungs, obstructing the small airways, venules and lymphatics. An immunohistochemistry study using the avidin biotin complex method with monoclonal antibodies for actin and desmin showed the small nodules to be of muscle origin. During the past two years, the patient has remained stable both in respiratory status and roentgenographically without hormonal manipulation or oophorectomy. We present this case to illustrate the heterogeneous nature of this condition. While our patient's initial presentation was acute and associated with chylothorax, her postoperative course has shown no progression despite withholding of hormonal therapy.

Restrictive lung disease in pregnancy

Restrictive ventilatory defects characterized by a reduction in lung volumes and an increase in the ratio of forced expiratory volume in 1 second to forced vital capacity occur when lung expansion is limited because of alterations in the lung parenchyma or because of abnormalities in the pleura, chest wall, or neuromuscular apparatus. Few studies have examined pregnant women with carefully defined restrictive lung disorders. The majority of pulmonary diseases have their onset after the childbearing years. When present, most do not alter fertility. Further, these disorders are only a relative contraindication to pregnancy because both the fetus and mother are able to survive without a high risk of increased morbidity or mortality. The clinical course of sarcoidosis is generally not altered by pregnancy. Factors indicative of a poor prognosis in sarcoidosis and pregnancy include parenchymal lesions on chest radiography, advanced roentgenologic staging, advanced maternal age, low inflammatory activity, requirement for drugs other than corticosteroids, and the presence of extrapulmonary sarcoidosis. Pregnancy seldom has a significant effect on the course of the connective tissue diseases. In PSS with significant renal involvement, pregnancy has the potential for poor fetal prognosis and the risk of maternal death due to a lethal progression of renal failure. Worsening of SLE is uncommon in pregnancy, and prophylactic therapy is generally not necessary. Most women with LAM are advised to avoid pregnancy or the use of estrogens because of the concern that it will lead to worsening of their disease. The incidence of kyphoscoliosis in pregnancy is relatively high. Premature birth rates are higher than that in the normal population. The risk of progression of the abnormal curve in a scoliotic patient appears low. However, women with unstable scolioses at the time of pregnancy can demonstrate progression of the curve with the pregnancy. Respiratory complications during pregnancy in patients with kyphoscoliosis have been reported but in general are not serious if appropriately managed. As a rule, patients with severe restrictive lung disease (i.e., vital capacity < 1 L) should be advised to avoid pregnancy or consider therapeutic abortion. If such a patient decides to continue the pregnancy she should be provided with optimal medical management of her underlying disease and should consider delivery by cesarean section.

Pulmonary lymphangiomyomatosis. Follow-up and long-term outcome with antiestrogen therapy; a report of eight cases

Lymphangiomyomatosis is a rare disease which affects young women of childbearing age. Eight women with pulmonary LAM were treated with antiestrogen therapy and were monitored by blood estrogen measurements along with clinical hypoestrogenic symptoms. Treatment ranged from three to nine years. The response to therapy was evaluated by the clinical course, chest x-ray films, pulmonary function tests and overall long-term outcome. Three patients died of respiratory failure after three, five and nine years of treatment. Of the five patients remaining alive, respiratory function deteriorated in four cases, after a transient period of mild improvement lasting three years in two cases. The last patient appeared stable after three years of follow-up. Time course ranged from 4 to 17 years. However, without a control group, we cannot determine whether or not the apparent improvement of the natural time course was due to the hormonal treatment.

[Pulmonary lymphangioleiomyomatosis. Presentation of a new case]

A 48-year-old woman hospitalized because of spontaneous pneumothorax. She suffered dyspnea since three years before. Diffuse reticulonodular interstitial pattern was observed in the radiography. The transbronchial biopsy suggested lymphangioleiomyomatosis, the diagnosis being supported by open pulmonary biopsy. Usefulness of transbronchial biopsy is discussed and several treatment modalities are described.

Lymphangiomyomatosis: hormonal implications in etiology and therapy

When a 34-year-old woman had dyspnea and chylothorax 8 months postpartum, lymphangiomyomatosis was diagnosed by open-lung biopsy. Baseline laboratory studies to evaluate infertility had revealed normal hormonal levels. She was subsequently treated with various hormones to aid in conception and in sustaining pregnancy. Her condition has improved with progesterone therapy. This case raises concern about the possible adverse consequences of hormonal manipulation in treating infertility. The need for open-lung biopsy in patients with classic manifestations of LAM is also questioned, especially with the advent of high-resolution CT scanning, the nonspecificity of hormonal receptors with regard to response to therapy, and the possible need for subsequent lung transplantation.

Lymphangioleiomyomatosis--treatment with progesterone

Lymphangioleiomyomatosis is a rare devastating disease affecting women mostly of child-bearing age. It presents with spontaneous pneumothorax, chylous effusions, hemoptysis and progressive breathlessness. Most patients die from respiratory failure within 10 years. There are no controlled studies on the efficacy of various treatment regimens. We report our experience with progesterone therapy in three patients. Two failed to respond, one died about 11 years after presentation and another after 5 1/2 years. The third patient has survived 11 years after onset of disease.

[A rare interstitial lung disease]

Pulmonary lymphangioleiomyomatosis (p.l.) is a rare disease of unknown etiology, and restricted to fertile women. It is characterized by a nodular proliferation of smooth muscle cells in the peribronchial, perivascular and perilymphatic lung tissue, accompanied by cystic dilations of the alveoles, rupture of the alveolar wall, lymphangiectasis, and septal collagen fiber deposition. Radiological-alterations range from enhanced interstitial shadowing to honey comb lung. Common clinical symptoms are progressive dyspnea, pneumothorax, chylous pleural effusion and hemoptysis. Here we present the case of a 43 years old woman, undergoing nephrectomy because of hamartoma of the left kidney, with recurrent pneumothorax and progressive dyspnea, verifying the diagnosis of p.l. by open lung biopsy. Pathogenesis of the disease, differential diagnosis and possible therapeutic approaches are discussed.

Acute abdominal pain as presenting symptom in lymphangiomyomatosis. Case report

A case of lymphangiomyomatosis presenting with acute abdominal pain is described. Laparotomy revealed a multiloculated cystic mass on the posterior abdominal wall with typical histological pattern. In the ensuing 3 years the respiratory manifestations of this rare disorder have slowly progressed. Possible causal factors and management are discussed.

[Tuberous sclerosis associated with pulmonary lymphangioleiomyomatosis]

Lymphangioleiomyomatosis (LAM) is a rare disease of women of childbearing age in which there is hyperplasia of atypical smooth muscle along lymphatics in the lung, thorax, and abdomen. Since Lautenbacher's first description in 1918, less than 100 cases of Bourneville's tuberous sclerosis (BTS) with involvement of the lungs have been reported. Their clinical, radiologic and pathologic manifestations are so strikingly similar to those of pulmonary lymphangioleiomyomatosis (PLM) that some authors have considered PLM to be a form fruste of BTS. We present a case of PLM with clinical pictures of dermatologic stigmata and kidney angiomyolipoma of tuberous sclerosis but free of neurologic symptoms. After the development of a recurring spontaneous pneumothorax, she had a downhill course and progressive pulmonary functional defect.

Lymphangiomyomatosis--newer concepts in pathogenesis and management--case reports

Lymphangiomyomatosis was first reported more than forty years ago. Although its incidence is rare, its occurrence is being increasingly recognized and has been the subject of a growing number of cases reports in recent years. This study adds 2 more cases to the file. Both cases involved young women with the characteristic symptoms of dyspnea, cough, abdominal discomfort and swelling, chest pain, and hemoptysis, with abundant formation of refractory chylous, serous ascites. Although the progression of the disease differed in each case, pulmonary function was affected in a similar way by the presence of obstructive and restrictive defects and a decrease in diffusing capacity. Underlying abnormalities were dilated lymphatics, thickened lymphatic walls, and muscular proliferation of leiomyomatous origin, leading to bronchial restriction. The authors point to the subtlety required in arriving at a differentiated diagnosis of lymphangiomyomatosis lymphangioleiomyomatosis and the difference between the two conditions. They also make particular recommendations in respect to the importance of preliminary hormone receptor tests and to the wisdom to be exercised in ligating a main lymphatic duct in the chest to control the formation of ascites. Pneumothorax, a frequent manifestation of lymphangiomyomatosis, is found to be the result of chronic air trapping due to a combination of narrowing of conducting airways and disruption of normal lung parenchyma.

[Diagnostic reflections on lung lymphangioleiomyomatosis]

Two cases of histologically proven pulmonary lymphangiomyomatosis were studied by means of an adequate combination of the current imaging modalities. After an anatomical survey of the secondary pulmonary lobule, the authors discuss the pathologic appearance, the pathogenetic factors (mainly hormones), and the diagnostic problems concerning this pathologic condition. Finally, the authors emphasize the decisive role of high-resolution CT (HRCT) in the evaluation of pulmonary lymphangioleiomyomatosis.

Intrathoracic lymphangiomatosis mimicking lymphangioleiomyomatosis in a young woman

In this report, we describe a case of lymphangiomatosis that mimicked lymphangioleiomyomatosis in a 20-year-old woman. Lung biopsy specimens showed proliferation of anastomosing lymphatic channels in the visceral pleura and dilated peribronchiolar and septal lymphatic channels. During 8 years of follow-up, this process behaved like lymphangioleiomyomatosis with reticulonodular infiltrates and worsening obstructive and restrictive changes evident on pulmonary function tests.

Pulmonary lymphangiomyomatosis in childhood? Marked smooth muscle cell proliferation of the lung in a preadolescent girl with repeated pneumothorax and progressive dyspnea

A 13-year-old girl with repeated spontaneous pneumothorax and progressive dyspnea is described. The biopsy specimen of the lung showed marked proliferation of smooth muscle cells in the thickened bullous wall and alveolar septa, which was similar to the findings of the pulmonary lymphangiomyomatosis. Pulmonary lymphangiomyomatosis is one of the diseases which should be considered when children have progressive dyspnea, chylous effusions and repeated spontaneous pneumothorax.

Pulmonary lymphangioleiomyomatosis: CT and pathologic findings

We present two cases that illustrate the appearance of pulmonary lymphangioleiomyomatosis on high resolution CT. Both patients had numerous thin-walled cystic airspaces of varying sizes distributed diffusely throughout the lungs. Most of the lung parenchyma surrounding the cystic spaces was normal. This pattern correlated closely with the surgical and pathologic findings and is distinct from other diffuse lung diseases.

Cystic disease of the lungs

Cystic disease of the lung should be considered in the differential diagnosis of any patient presenting with respiratory symptoms. The most important aids available to the thoracic surgeon for the evaluation of cystic disease are history, physical examination, and chest radiograph. Confirmation of diagnosis often requires computed tomography, pulmonary and thoracic aortic angiography, and upper gastrointestinal barium series.