Benign metastasizing leiomyoma presenting as cystic lung disease: a diagnostic pitfall

Diagnosis of cystic lung diseases: a position statement from the UK Cystic Lung Disease Rare Disease Collaborative Network

BACKGROUND

Rare cystic lung diseases are increasingly recognised due the wider application of CT scanning making cystic lung disease management a growing part of respiratory care. Cystic lung diseases tend to have extrapulmonary features that can both be diagnostic but also require surveillance and treatment in their own right. As some of these diseases now have specific treatments, making a precise diagnosis is crucial. While Langerhans cell histiocytosis, Birt-Hogg-Dubé syndrome, lymphoid interstitial pneumonia and lymphangioleiomyomatosis are becoming relatively well-known diseases to respiratory physicians, a targeted and thorough workup improves diagnostic accuracy and may suggest other ultrarare diseases such as light chain deposition disease, cystic pulmonary amyloidosis, low-grade metastatic neoplasms or infections. In many cases, diagnostic information is overlooked leaving uncertainty over the disease course and treatments.

AIMS

This position statement from the Rare Disease Collaborative Network for cystic lung diseases will review how clinical, radiological and physiological features can be used to differentiate between these diseases.

NARRATIVE

We highlight that in many cases a multidisciplinary diagnosis can be made without the need for lung biopsy and discuss where tissue sampling is necessary when non-invasive methods leave diagnostic doubt. We suggest an initial workup focusing on points in the history which identify key disease features, underlying systemic and familial diseases and a clinical examination to search for connective tissue disease and features of genetic causes of lung cysts. All patients should have a CT of the thorax and abdomen to characterise the pattern and burden of lung cysts and extrapulmonary features and also spirometry, gas transfer and a 6 min walk test. Discussion with a rare cystic lung disease centre is suggested before a surgical biopsy is undertaken.

CONCLUSIONS

We suggest that this focused workup should be performed in all people with multiple lung cysts and would streamline referral pathways, help guide early treatment, management decisions, improve patient experience and reduce overall care costs. It could also potentially catalyse a national research database to describe these less well-understood and unidentified diseases, categorise disease phenotypes and outcomes, potentially leading to better prognostic data and generating a stronger platform to understand specific disease biology.

Pulmonary nodular and cystic light chain deposition disease: A retrospective review of 10 cases

INTRODUCTION

Light chain deposition disease (LCDD) rarely involves the lungs. We report clinical and radiologic findings of pulmonary LCDD.

METHODS

We retrospectively identified patients with biopsy-proven pulmonary LCDD seen at Mayo Clinic (Rochester, Minnesota) from January 1997 through December 2018. Demographic, clinical, and imaging features were analyzed.

RESULTS

We identified 10 patients with pulmonary LCDD (median age at diagnosis, 55 years; range, 39-77 years). Eight patients were women and 7 were never-smokers. Dyspnea (n = 3) and chest pain (n = 3) were the most common respiratory symptoms. Associated conditions included Sjögren syndrome (n = 6), sarcoidosis (n = 1), and limited scleroderma (n = 1). Eight patients had mucosa-associated lymphoid tissue (MALT) lymphoma. Among the 9 patients with chest computed tomography (CT) images, 8 (89%) had cysts. Cysts were predominantly distributed in the lower lung and were round or oval. All patients had multiple cysts (5 patients had 1-5 cysts, 3 had >20 cysts). The median diameter of the largest cyst was 18 mm (range, 5-68 mm). All 9 patients had solid nodules (3 had >10 nodules). Five patients had subsolid nodules. The median diameter of the largest solid nodules was 13 mm (range, 6-26 mm). Positron emission tomography-CT images were available for 8 patients. The median maximum standardized uptake value of the most avid pulmonary nodule was 2.2 (range, 1.9-6.0). Two patients died during a median follow-up of 2.3 years (range, 0.5-9.9 years).

CONCLUSIONS

Pulmonary LCDD is characterized by cysts and nodules. The disease is associated with MALT lymphoma, especially in the setting of Sjögren syndrome.

An unusual cause of multiple incidental lung nodules

Cystic or cavitating lung nodules may reflect an additional diagnostic challenge in benign metastasizing leiomyoma. Our case underlines the importance of combining clinical and radiological findings with specific pulmonary pathology consultation.

Benign metastasizing leiomyoma: A review of current literature in respect to the time and type of previous gynecological surgery

INTRODUCTION

Benign metastasizing leiomyoma (BML) is a rare disorder that affects women with a history of uterine leiomyoma, which is found to metastasise within extrauterine sites. The aetiology of BML remains unexplained. Because BML is rare, and most publications contain descriptions of single cases, no statistically determined time relations were found between the primary and secondary surgeries, which may have aetiological implications.

OBJECTIVES

To determine age before BML surgery, age during diagnosis of BML, type of prior surgery, and location of metastasis based on the literature.

METHODS

A systematic review of four databases (Medline/PubMed, Embase, Web of Science, and Cochrane) covering articles published from 1 January 1965 to 10 April 2016. The inclusion criteria were full-text articles in English and articles containing case reports. Articles in languages other than English (39), articles containing incomplete data (14), i.e. no information regarding the time of surgery and/or the site of metastasis, articles bereft of case studies (25), and articles with access only to summaries, without access to the complete text (10) were excluded. Of 321 titles identified, only 126 articles met the aforementioned criteria.

RESULTS AND CONCLUSIONS

The mean age during primary surgery and BML diagnosis was 38.5 years and 47.3 years, respectively. The most common surgery was total hysterectomy. The most frequent site of metastasis was the lungs; other organs were affected less frequently.The site of metastases and their number were not related to the longer time span between the patient's initial surgery and occurrence of metastasis. The analysed data, such as the age during primary surgery, age during BML diagnosis, site and type of metastasis, do not provide us a clear answer. Thus, BML pathogenesis is most probably complex in nature and requires further multidirectional research.

Imaging features of thoracic metastases from gynecologic neoplasms

Gynecologic malignancies are a heterogeneous group of common neoplasms and represent the fourth most common malignancy in women. Thoracic metastases exhibit various imaging patterns and are usually associated with locally invasive primary neoplasms with intra-abdominal spread. However, thoracic involvement may also occur many months to years after initial diagnosis or as an isolated finding in patients without evidence of intra-abdominal neoplastic involvement. Thoracic metastases from endometrial carcinoma typically manifest as pulmonary nodules and lymphadenopathy. Thoracic metastases from ovarian cancer often manifest with small pleural effusions and subtle pleural nodules. Thoracic metastases to the lungs, lymph nodes, and pleura may also exhibit calcification and mimic granulomatous disease. Metastases from fallopian tube carcinomas exhibit imaging features identical to those of ovarian cancers. Most cervical cancers are of squamous histology, and while solid pulmonary metastases are more common, cavitary metastases occur with some frequency. Metastatic choriocarcinoma to the lung characteristically manifests with solid pulmonary nodules. Some pulmonary metastases from gynecologic malignancies exhibit characteristic features such as cavitation (in squamous cell cervical cancer) and the "halo" sign (in hemorrhagic metastatic choriocarcinoma) at computed tomography (CT). However, metastases from common gynecologic malignancies may be subtle and indolent and may mimic benign conditions such as intrapulmonary lymph nodes and remote granulomatous disease. Therefore, radiologists should consider the presence of locoregional disease as well as elevated tumor marker levels when interpreting imaging studies because subtle imaging findings may represent metastatic disease. Positron emission tomography/CT may be helpful in identifying early locoregional and distant tumor spread.

Pulmonary benign metastasizing leiomyoma: report of three cases

Benign metastasizing leiomyoma is very rare and usually occurs in women who undergo hysterectomy and myomectomy for uterine leiomyoma. This is a benign spindle-shaped smooth muscle cell tumor pathologically but metastasizes to the extrauterine organs. Lungs are the most common site of metastasis. We observed three cases of pulmonary benign metastasizing leiomyoma.

Cystic lung disease

This review addresses the pathology of lung disease in which the predominant finding is diffuse cystic change. Although cysts may be found radiologically in a wide variety of disease states, the entities discussed are those most likely to be encountered in biopsies where the underlying aetiology is unclear. These include Langerhans cell histiocytosis, lymphangioleiomyomatosis and Birt-Hogg-Dubé syndrome, and recent advances in the molecular pathology of these entities are reviewed. Conditions in which cyst formation may occur but does not represent the predominant pathology are also considered, including alveolar septal amyloidosis, light chain disease, follicular bronchiolitis and lymphocytic interstitial pneumonia. Cystic metastases may present a differential diagnostic dilemma.

Benign metastasizing leiomyoma of the lung with spontaneous pneumothorax

A 47-year-old woman was admitted with recurrent pneumothorax. Preoperative chest computed tomography (CT) showed multiple lung nodules and cysts bilaterally. She had undergone enucleatic myomectomy 12 years earlier. Video-associated thoracoscopic biopsy was performed. Histopathologically, there were bulla-like dilated cystic changes, the walls of which showed spindle cell proliferation, causing pneumothorax. Hormone therapy was started after benign metastasizing leiomyoma resection; pneumothorax has not recurred in 7 months. Multiple residual lung nodules have decreased or disappeared on CT.