Lymphangiopericytoma.Case report of a previously undescribed tumor type

Pulmonary Lymphangioleiomyomatosis: A Case Report in Postmenopausal Woman Treated with Pleurodesis and Progesterone (Medroxyprogesterone Acetate)

The main problem in the treatment of pulmonary lymphangioleiomyomatosis, which frequently occurs in the reproductive age, is the control of chylothorax and disease progression. We herein report a case of a 62-year-old woman who underwent surgery for recurrent chylothorax. Histologic examination of lung and lymph node biopsies demonstrated lymphangioleiomyomatosis. Thirty-six months after tetracycline pleurodesis and high-dose medroxyprogesterone acetate therapy, the disease was stable and chylothorax effectively controlled. It would therefore appear that hormonal treatment with medroxyprogesterone acetate may be beneficial in postmenopausal women.

Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guidelines: Lymphangioleiomyomatosis Diagnosis and Management

BACKGROUND

Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease that primarily affects women. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of LAM.

METHODS

Systematic reviews were performed to summarize evidence pertinent to our questions. The evidence was summarized and discussed by a multidisciplinary panel. Evidence-based recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

After considering the panel's confidence in the estimated effects, the balance of desirable (i.e., benefits) and undesirable (i.e., harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were formulated for or against specific interventions. These included recommendations for sirolimus treatment and vascular endothelial growth factor D testing and recommendations against doxycycline and hormonal therapy.

CONCLUSIONS

Evidence-based recommendations for the diagnosis and treatment of patients with LAM are provided. Frequent reassessment and updating will be needed.

Linfangioleiomiomatose pulmonar

Linfangioleiomiomatose pulmonar (LAM) é uma doença rara, de etiologia desconhecida, que basicamente afeta mulheres jovens no período fértil de sua vida. Clinicamente, manifesta-se através de dispnéia progressiva, pneumotórax de repetição, tosse seca e, menos freqüentemente, por quilotórax e escarros hemoptóicos. Essas alterações surgem devido à proliferação anormal de células de músculo liso no parênquima pulmonar, linfonodos e em outros tecidos. Mais recentemente, estudos citogenéticos verificaram a presença de mutações do gene TSC-2 em células de angiomiolipoma renal e linfonodos abdominais de pacientes com LAM, indicando uma possível origem para as lesões hamartomatosas da doença. Radiologicamente, caracteriza-se pela presença de infiltrado intersticial reticulonodular e sinais de hiperinsuflação ao radiografia de tórax. Na tomografia computadorizada de alta resolução, cistos de paredes finas, localizados centralmente, são visibilizados por todo o parênquima do pulmão. O ultrassom e a tomografia de abdome podem revelar angiomiolipomas renais e linfonodomegalias retroperitoneais. Meningeomas também podem estar associados, porém a sua presença deve sempre levar à pesquisa de esclerose tuberosa. Funcionalmente, a doença caracteriza-se por um distúrbio ventilatório obstrutivo, de caráter progressivo, com hiperinsuflação pulmonar e diminuição da difusão de monóxido de carbono. Apesar da ausência de comprovação quanto à eficácia, o principal tratamento utilizado ainda é o anti-estrogênico e constitui-se de oofarectomia, progesterona contínua, tamoxifeno e análogos de GnRH. Além desse, a realização de transplantes pulmonares tem elevado para além de dez anos a sobrevida média das pacientes.

Chylothorax in lymphangioleiomyomatosis

STUDY OBJECTIVE

Pulmonary lymphangioleiomyomatosis (LAM) is a rare, serious disorder characterized by proliferation of abnormal smooth-muscle cells and affects almost exclusively women of childbearing age. Optimal management of chylothorax, a well-recognized complication of LAM, in these patients has not been defined. This study was performed to characterize the clinical course and identify appropriate management options for chylothorax occurring in patients with LAM.

DESIGN

Identification and retrospective review of available medical records on patients with LAM and chylothorax.

SETTING

Tertiary-referral medical center.

PATIENTS

All patients with LAM seen at Mayo Clinic, Rochester, MN, from January 1, 1976, to December 31, 2000.

INTERVENTION

None.

MEASUREMENT AND RESULTS

Eight of 79 patients (10.1%) with LAM had chylothorax. All were women aged 33 to 51 years, and four patients had underlying tuberous sclerosis complex. These eight women represented 3.5% of the 229 patients with chylothorax seen over this 25-year period at Mayo Clinic Rochester. Six patients had unilateral pleural effusion and two patients had bilateral effusions at initial presentation. The size of the chylothorax varied and was not necessarily progressive. Management of chylothorax ranged from thoracentesis only to thoracotomy with thoracic duct ligation and parietal pleurectomy. When needed, pleurodesis by instillation of sclerosing agents or parietal pleurectomy appeared to be effective in controlling chylothorax.

CONCLUSIONS

Chylothorax occurring in patients with LAM has a variable clinical course. Although pleurodesis with or without thoracic duct ligation appears to be effective in controlling intractable chylothorax, less invasive treatments such as thoracentesis or observation may suffice in some cases. Management of chylothorax in patients with LAM should be individualized depending on the size and clinical effects of the chylous pleural effusion, as well as comorbid factors and local expertise.

Lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM), a rare disorder of unknown cause that occurs almost exclusively in women of childbearing years, is characterized microscopically by abnormal smooth muscle proliferation in the lung, lymphatics, and mediastinal, abdominal and lower cervical lymph nodes. LAM is associated with progressive dyspnea, recurrent pneumothoraces, chylous effusions, abdominal tumors (angiomyolipoma), and chylous ascites. Because of the predilection of this disease for young women, therapies to date have mainly involved hormonal manipulation. Although the efficacy of these therapies has not been established, the clinical course is more favorable in recent studies compared with earlier reports.

Massive low-attenuation mediastinal, retroperitoneal, and pelvic lymphadenopathy on CT from lymphangioleiomyomatosis. Case report

Lymphangioleiomyomatosis (LAM) is a rare disease of women of child-bearing age characterized by the proliferation of smooth muscle throughout the lymph nodes and lymphatic channels of the retroperitoneum, mediastinum, and lungs. Most previous reports of LAM have concentrated on the pulmonary findings. Although mediastinal and retroperitoneal lymphadenopathy is known to be a prominent feature of the disease, it is rarely imaged. We present a case of a young woman with LAM who presented with massive pelvic, retroperitoneal, and mediastinal lymphadenopathy associated with a chylous pleural effusion on the left. On computed tomography (CT) the lymphadenopathy was heterogeneous in nature but was predominantly of low attenuation. We believe that when CT demonstrates low-attenuation lymphadenopathy in the mediastinum or retroperitoneum of a woman of child-bearing age, LAM should be considered as a likely diagnosis.

Characterization of the smooth muscle cell infiltrate and associated connective matrix of lymphangiomyomatosis. Immunohistochemical and ultrastructural study of two cases

Lymphangiomyomatosis (LAM) consists of smooth muscle (SM) cell proliferation of unknown origin involving the lymph nodes and the lung interstitium. From morphological studies showing both SM differentiation of the proliferating cells and lymphatic hyperplasia, hypotheses were suggested concerning the origin of the proliferation. Two cases of LAM were investigated by electron microscopy and immunohistochemistry; tissues were obtained by lymph node and open lung biopsies. Cytoplasmic and matrix protein markers were used in order to clarify the pattern of differentiation of the proliferating cells and to characterize their connective tissue environment. The proliferating cells present ultrastructural characteristics of SM cells; they contain vimentin, desmin, and alpha-SM actin and are devoid of Factor VIII, favouring a parieto-arterial origin. The connective tissue matrix inside the infiltrate is composed of interstitial collagens and basement membrane components. At the late stage of the disease, remodelling of the interstitial matrix accompanies the infiltrate and remains perilesional.

Pulmonary mechanics in lymphangioleiomyomatosis

Standard pulmonary function and mechanics studies were done in eight female patients with lymphangioleiomyomatosis diagnosed by open-lung biopsy. Five patients were studied before hormone treatment. The mean age of the patients was 40 +/- 3 (SEM) years. Two of the eight had a smoking history of 10 pack-years or more, but all had quit smoking several years before evaluation. There was a trend toward increased total lung capacity (114 +/- 7% expressed as mean of percentage predicted +/- SEM) and increased residual volume (207 +/- 24%). Of the eight patients seven had expiratory obstruction as evidenced by the reduced forced expiratory volume in 1 s/forced vital capacity ratio [( FEV1/FVC] 61 +/- 6%). Steady-state diffusing capacity for carbon monoxide was reduced in seven of the patients (57 +/- 12%). Pulmonary mechanics studies performed in a body plethysmograph revealed a modest reduction in retractive force both at total lung capacity and at 90% total lung capacity (67 +/- 10 and 59 +/- 9%, respectively). Static compliance tended to be increased (128 +/- 19%). Pulmonary flow resistance was markedly elevated (266 +/- 46%). Maximal flow-static recoll curves revealed that in the seven patients with expiratory obstruction the cause was predominantly airway narrowing rather than loss of lung elastic forces. We conclude that in this group of patients with lymphangioleiomyomatosis there was no evidence for significant restriction. Although there was some decrease in retractive force consistent with emphysema, expiratory flows were reduced predominantly because of airway narrowing or obstruction rather than loss of pulmonary elastic recoil forces.

Treatment of lymphangioleiomyomatosis. A meta-analysis

Lymphangioleiomyomatosis is a rare disease which afflicts young women of childbearing age. It is sufficiently uncommon that randomization or any other systematic evaluation of regimens of treatment has been difficult. Review of scattered case reports implies that a number of hormonal manipulations may be equally effective. A comprehensive review of the literature revealed 30 cases of LAM treated with eight regimens of treatment. Evaluation with predetermined criteria (meta-analysis) shows that administration of progesterone or oophorectomy or both are the most effective treatments, resulting in improvement or stabilization of the disease in the majority of cases.

Retroperitoneal lymphangioleiomyomatosis. A 36-year benign course in a postmenopausal woman

An 89-year-old asymptomatic white woman was found to have a pelvic mass with retroperitoneal extension. Biopsy of the lesion demonstrated lymphangioleiomyomatosis. Review of her records revealed that 36 years ago a mass in the same location had been found incidentally and biopsy was performed during abdominoperineal resection for rectal carcinoma. Comparison of the old and recent biopsy specimens showed an identical histologic appearance. This case, therefore, represents a benign, localized form of lymphangioleiomyomatosis; the long survival without therapy may be related to the fact that this patient was postmenopausal.

Small lymphangiomas of the eyelids

Three patients are described with focal lymphangiomatous lesions of their eyelids. A child with a partially regressed, congenital lesion presented with evidence of recent hemorrhage, while, of two adults with acquired tumors, one had a blue lesion suggesting a malignant melanoma, and the other had a more obviously cystic lesion, suggesting an epidermal or adnexal cyst. In one case, the lesion was situated entirely within the marginal orbicularis striated muscle, and in the other two cases the lesion was restricted to the dermis of the lid. Abrupt change in the coloration of a lesion in the lid should suggest hemorrhage into a preexistent tumor. Hemorrhage into lymphangiomas is extremely common, and therefore this vascular tumor should be included in the differential diagnosis of previously nondiscolored lesions. Other vascular tumors, such as capillary, cavernous or venous angiomas would be expected to have a longstanding reddish-blue hue.

Multiple pulmonary (hamartomatous?) leiomyomas. Light and electron microscopic study

The light and electron microscopical features of the lung tumors in a case of multiple pulmonary leiomyomas are described. The differential diagnosis of leiomyomatous tumors of the lung is discussed. They have to be differentiated from lymphangio-leiomyomatosis of the lungs. In the literature, multiple pulmonary leiomyomas are generally considered to be metastases from low grade uterine leiomyosarcoma or to be hamartomatous lung tumors. This is suggested by the glandular structures both within the tumor and on the surface. However, our ultrastructural observations showed these epithelia to have features of granular pneumocytes (type II), in particular they contain lamellar bodies and possess microvilli on their surface. Their formation is considered to be a secondary reaction of alveolar lining cells to tumor growth. A possible origin of multiple pulmonary leiomyomas from the contractile system of the lung acini (contractile interstitial cells) is discussed.

Lymphangiosarcoma after filarial infection

A case of lymphangiosarcoma of a lower extremity is described in a patient with chronic lymphedema of that leg from a filarial infection in childhood. Histologically, the neoplasm resembled lymphangiosarcomas that arise in arms that become lymphedematous after mastectomies, but was different in that it also contained areas of calcification consistent with prior filarial infection. Calcifications were also present in muscle uninvolved by the lymphangiosarcoma of this case. The prolonged survival of this patient is unlike that of most patients with lymphangiosarcoma, which is generally shorter. Although lymphedema after filariasis is common, this is the first case of a lymphangiosarcoma arising in chronic lymphedema of filarial origin.

Pulmonary lymphangiomyomatosis

Pulmonary lymphangiomyomatosis is a rare but distinct clinical and pathological entity. It is characterized by hamartomatous proliferation of smooth muscle around the lymphatic vessels of the lung, mediastinum, and retroperitoneum. It occurs only in menstruating women and girls and is manifested by spontaneous pneumothorax and chylous pleural or abdominal effusion. As it progresses, the lungs become increasingly involved with subsequent pulmonary insufficiency and recurrent infection. Eventually death results. This entity has not been reported previously in the surgical literature even though the thoracic surgeon is called on to both establish the diagnosis and aid in palliation. The hypothesis that the disease is estrogen dependent is reviewed and the desirability of estrogen ablation in patients with positive estrogen receptors is suggested.

Lymphangiomyomatosis syndrome with hyperparathyroidism: a case report

A 48-year-old woman presented with the classical clinicopathological features of the lymphangiomyomatosis syndrome. After a three year stable period, there was the onset of a rapidly progressive downhill course unresponsive to dietary, bronchodilator and corticosteroid therapy. Pathological findings were characterized by widespread pulmonary, thoracic duct and lymph node involvement. There was a mediastinal lymphangiomyoma growing within the distal thoracic duct, and a similar lesion within the left kidney which could clinically mimic an angiomyolipoma. Comments are also made on the finding of a parathyroid adenoma. The physiopathology and possible resemblance to "formes frustes" of tuberous sclerosis are discussed.

Lymphangiomyoma of the Thoracic Duct with Previously Undescribed Epithelial Tubules

A case of mediastinal lymphangiomyoma with tubules covered with epithelium is reported. The epithelium of these tubules is morphologically identical to that of the bronchi. It is the first time that epithelial, presumably pulmonary, elements have been described in an extrapulmonary lymphangiomyoma. It is concluded that the present case of a mediastinal lymphangiomyoma suggests a hamartomatous malformation. Whether this applies in general to lymphangiomyomatosis still remains a matter of discussion.

Lymphangiomyoma

A case report is presented of the incidental finding of a lymphangiomyoma in a 50-year-old woman who underwent total hysterectomy for squamous cell carcinoma of the cervix. The condition seems to occur only in women after puberty and so far, has been mainly reported in association with chylothorax or chylous ascites. There is no evidence of any clinical complication more than 2 years after removal of the lesion. The lesion is most likely a hamartoma although the term lymphangiomyoma is acceptable. The term lymphangiomyomatosis is best reserved for the fully developed clinico-pathological syndrome.

Lymphangiomyomatosis: morphogenetic study and ultrastructural confirmation of the histogenesis of the lung lesion

A 34-year old woman underwent a surgical intervention as a result of a retroperitoneal tumor. This tumor was excised and the pathological diagnosis was lymphangiomyoma. Two months later she developed a spontaneous right pneumothorax with a chylous pleural effusion. Roentgenograms showed that the lungs had developed a honeycomb pattern. She was treated surgically and at the same time a biopsy was performed. Sixteen months later she deveoped a left pneumothorax which necessitated additional surgery, and a further biopsy was taken. She died of respiratory insufficiency 2 years after the clinical onset of the symptoms. The pathologic material was studied by both electron and light microscopy in serial sections. The electron-microscopic study proved the muscular nature of this condition. The light microscopic study of the serial sections showed that the lung lesion was due to the proliferation of the muscle cells associated with the lymphatics surrounding the acini.

Hemangiopericytoma. A clinicopathologic study and long-term followup of 60 patients

The clinical courses of 60 patients with hemangiopericytoma of the somatic soft tissues are summarized in this retrospective study. The tumors were subjected to a comparative histologic review and classified as benign (12 lesions), borderline malignant (16 lesions), and malignant (32 lesions). Tumors with 1 mitotic figure per 10 high-power field and moderate cellular anaplasia or 1 mitotic figure per 20 high-power fields and moderate cellular anaplasia may be expected to follow a malignant clinical course. Six of the 16 tumors with these microscopic features (borederline lesions) metastasized (37.5%), and 6 exhibited local recurrences after excision. Of the 32 malignant tumors, 25 (78%) metastasized. Twenty-three patients with malignant tumors were followed for more than 5 years or until death from tumor, and only one patient was alive and free of disease. Fifteen of the 23 patients experienced one of more local recurrences. None of the benign tumors metastasized. Surgical ablation of hemangiopericytioma is, in our experience, the only satisfactory method of treatment. Amputation of an extremity need be done only when the location of the lesion precludes a wide local excision. Local recurrent tumor was experienced by 22 patients after an inadequate local excision. Long-term follow-up is recommended because metastasis became apparent in 11% of patients with malignant tumors and 7% with borderline tumors after 5 "disease-free" years.

Lymphangiomyomatosis: report of a case with ureteral involvement and chyluria

A 54-year-old woman, presenting with chyluria and progressive dyspnea, is reported. Necropsy revealed co-existent lymphangiomyomatosis and pneumoconiosis in the lungs. Retroperitoneal lymphangiomyomas surrounded the distal ureters, and cystoscopy revealed pyelolymphatic backflow into renal lymphatic sinuses. The finding of chyluria with atypical smooth muscle hyperplasia within the ureters is extremely rare. Previously reported cases of lymphangiomyomatosis are discussed and compared with our own. Electron micrographs of involved lymph nodes are presented and the findings briefly evaluated.