Coexistence of pulmonary sclerosing hemangioma and primary adenocarcinoma in the same nodule of lung

Revisiting Pulmonary Sclerosing Pneumocytoma

Pulmonary sclerosing pneumocytoma (PSP) is a quite rare tumor outside Eastern countries. This rarity, together with a wide histological appearance, makes its correct identification a diagnostic challenge for pathologists under the microscope. Historically, PSP was considered a vascular-derived neoplasm (sclerosing hemangioma), but its immunohistochemical profile clearly supports its epithelial origin. No specific molecular fingerprint has been detected so far. This short narrative revisits the clinical, histological, immunohistochemical, and molecular aspects of this tumor, paying special attention to some controversial points still not well clarified, i.e., clinical aggressiveness and metastatic spread, multifocality, the supposed development of sarcomatoid change in a subset of cases, and tumor associations with lung adenocarcinoma and/or well-differentiated neuroendocrine hyperplasia/tumors. The specific diagnostic difficulties on fine-needle aspiration cytology/biopsy and perioperative frozen sections are also highlighted. Finally, a teaching case of tumor concurrence of lung adenocarcinoma, neuroendocrine lesions, and PSP, paradigmatic of tumor association in this context, is also presented.

Correlation Between Pulmonary Sclerosing Pneumocytoma Features and MSCT Imaging Manifestations in 34 Patients: Implications for Precision Medicine

Objective: To identify and analyze the multi-slice computed tomography (MSCT) imaging manifestations and clinicopathological features of PSP to improve the preoperative and intraoperative diagnosis of the disease. Method: This was a retrospective study conducted on the imaging and clinicopathological data of the PSP patients treated in two major hospitals in China from October 2001 to December 2019. The locations of lung lesions, clinical symptoms, surgical complications, MSCT imaging features, and the corresponding relationship with clinicopathological features were assessed. Then, a new diagnostic approach was defined and used to train imaging and pathological doctors (experimental group). Then, the diagnostic accuracy of the experimental group was evaluated in preoperative and intraoperative diagnosis of PSP. Results: Thirty-four PSP cases were analyzed (mean: 51.42; range: 39-69 years old). The peripheral type was more common, while 92% of the lesions located in the middle lobe of the right lung and the lower lobe of bilateral lungs. The shortest lesion edge-pleura distance ranged 0 to 30 mm and 46% of the lesions (16/34) were attached to the pleura, 62% (21/34) located at 0-5 mm, 92% (31/34) within 20 mm from the pleura. Diameters of the lesions ranged 8.58 to 68.41 mm, while most of them were 20-40 mm. All lesions showed enhancement, and 97% (33/34) were unevenly enhanced. PSP volume was negatively correlated with the total degree of enhancement (r = -0.587, p < 0.01), and the volume difference between the obvious enhancement zone and the slight enhancement zone (r = -0.795, p < 0.01). Welt vessel sign was observed in 61.7% (21/34) of cases, and none of welt vessels entered into the lesions. Vascular-like enhancement area inside the lesion showed no significant correlation with the welt vessels outside the lesion, and no case showed entrance of bronchus into the lesion. The trained experimental group showed significantly greater diagnostic accuracy than the control group. In particular, the accuracy rate of intraoperative frozen section diagnosis was 60% higher in the experimental group than the control group. Conclusion: PSP has characteristic imaging manifestations, which can be utilized to improve the preoperative and intraoperative diagnostic coincidence rate of PSP.

[Analysis of Clinical Characteristics of 35 Cases of Pulmonary Sclerosing Pneumocytoma]

BACKGROUND

Pulmonary sclerosing pneumocytoma (PSP) is rare benign lung tumor which usually develops in middle-aged women without typical clinical and imaging findings. PSP consists of two basic cell types (surface cubic epithelial cells and round mesenchymal cells) and four histological types (hemorrhagic, sclerotic, solid and papillary). It grows slowly, but it can metastasize to distant organs. The pathology before surgery is easily misdiagnosed. This study aims to improve clinicians' understanding of PSP by discussing the clinical characteristics of the disease.

METHODS

This represents a retrospective study of thirty-five patients diagnosed with pulmonary sclerosing pneumocytoma by pathological examination from January 2011 to December 2019.

RESULTS

A total of 35 patients in this study, 12 cases were male and 23 cases were female, the average age is 51 years old. 7 cases were discovered accidentally by physical examination or routine chest computed tomography (CT), and 28 cases were found due to symptoms such as cough, sputum, hemoptysis and chest pain. The imaging changes is mainly featured with isolated or clear circular or round-like single nodule and lump in the lungs. In this group, 12 cases underwent percutaneous lung biopsy, only 7 cases were diagnosed with PSP. A total of 28 patients underwent surgery, 24 cases underwent rapid frozen pathological biopsy, only 5 cases diagnosed with PSP. Postoperative pathological examination results shows that 1 case was diagnosed with keratotic squamous cell carcinoma with partial PSP, and the rest were diagnosed with PSP. The surgical and non-surgical patients were followed up for 1 to 8 years after discharge, and the overall recovery was good. The patients were no recurrence and metastasis on chest CT review.

CONCLUSIONS

PSP is a clinically rare benign lung tumor, which is more common in middle-aged women. The clinical manifestations and imaging features are lack of significance. Percutaneous lung puncture pathological examination and intraoperative rapid frozen pathological sections often leads to misdiagnosis. Final diagnosis relies on postoperative pathological work-up for most cases.

Sclerosing pneumocytoma mixed with a columnar clear cell adenoma and a typical carcinoid: case report and review of literature

Sclerosing pneumocytoma (SP) is a rare and benign tumor predominantly occurring in Asian women, easily misdiagnosed by imaging and pathologic frozen diagnosis during surgery because of its diverse histomorphology (4 structures, 2 types of cells). It may form multiple tumors. When SP is combined with carcinoid, adenoma, or other tumors (although rare), diagnosis is more complicated. SP mixed with carcinoid tumor is rare. At present, only 4 cases have been reported in English literature. Here, we report a case of sclerosing pneumocytoma combined not only with carcinoid, but also with clear cell adenoma of the lung. The patient was a 52-year-old female and CT found a nodule in the middle lobe of the right lung. SP was not excluded by intraoperative frozen section diagnosis. The above 3 components formed a 1.4 cm nodule. The related literature is reviewed to strengthen the understanding of SP, and aid clinicopathological diagnosis.

Expression of ALDH and SOX-2 in Pulmonary Sclerosing Pnemocytoma (PSP) of the Lung: Is There a Meaning Behind?

Background: Pulmonary sclerosing pneumocytoma (PSP) is a rare benign pulmonary tumor that derives from primitive respiratory epithelium of the pulmonary alveolus. The etiology and pathogenesis are still unclear. Histopathological diagnosis focuses on cells that are positive for TTF1, EMA, cytokeratin-7, and CAM 5.2. The aim of our study is to highlight the elevated expression of ALDH and the presence of SOX-2 in pulmonary sclerosing pneumocytoma.

Methods: We report five cases of pulmonary sclerosing pneumocytoma undergone surgery at our Division of Thoracic Surgery, during a period between 1994 and 2011. ALDH and SOX-2 markers were also tested for positivity in all the patients.

Results: Patients showed elevated expression of ALDH during immunohistochemistry and mild expression of SOX-2, although in two cases in which SOX-2 was highly expressed. Among these two patients, one presented with lymph node recurrence while the other had no recurrence with a PET-positive nodule. In particular, the patient who had developed recurrence had an ALDH score of 4 and a SOX-2 score of 3, whereas the patient with the PET-positive nodule showed an ALDH score of 4 with a mild SOX-2 expression of score 1.

Conclusions: This is the first attempt demonstrating the elevated expression of ALDH in this disease. SOX-2 expression was noted in both the patient who developed recurrence and the patient with a PET-positive nodule. We believe that further investigation may be highly useful to better characterize these two markers as well as understand their function.

First report of pulmonary sclerosing pneomucytoma with malignant transformation in both cuboidal surface cells and stromal round cells: a case report

BACKGROUND

Pulmonary sclerosing pneumocytoma (PSP) is a rare benign tumor. Although lymph node metastasis has been reported, it is still considered benign. No malignant transformation has been reported. This is the first case of malignant transformation of both cuboidal surface cells and stromal round cells.

CASE PRESENTATION

A 64-year-old male had been complaining of intermittent hemoptysis several times per day for eight months. Chest computed tomography scan showed parenchymal infiltration with cystic lesion in the right lower lobe accompanied by enlarged right hilar lymph nodes. Lobectomy and systemic lymph node dissection was performed. On grossly pathological examination, the lesion was 50 mm from the bronchial stump. It was a mixture of both cystic and solid components and 30 mm * 20 mm in size with unclear border. Microscopically, the cuboidal surface cells transformed to adenocarcinoma. The stromal round cells also had a malignant transformation. The Ki-67 proliferation index in malignant cuboidal surface cells and stromal round cells were 70 and 55%, respectively. Furthermore, E-cadherin was negative in primary tumor but positive in metastatic lymph node, which suggested that the mesenchymal to epithelial transition may play an important role in lymph node metastasis.

CONCLUSIONS

To our knowledge, we present the first case of malignant transformation of both cuboidal surface cells and stromal round cells in PSP. The process of mesenchymal to epithelial transition may play an important role in lymph node metastasis.

Sclerosing pneumocytoma mixed with a typical carcinoid tumor: A case report and review of literature

RATIONALE

Sclerosing pneumocytoma accompanied with other type of tumor in one patient is very rare. Here, we report a case of a sclerosing pneumocytoma mixed with a typical carcinoid tumor in a same neoplasm.

PATIENT CONCERNS

A 55-year-old woman incidentally detected a space-occupying lesion of right lung in routine health examination. The patient was asymptomatic and there were no positive findings in routine laboratory examination, physical examination, and pulmonary function test. Computed tomography revealed a solitary round mass in the middle lobe of the right lung.

DIAGNOSIS

The lesion was diagnosed as a sclerosing pneumocytoma accompanied with a typical carcinoid tumor of the right lung.

INTERVENTION

The patient underwent thoracoscopic lobectomy in our hospital.

OUTCOMES

The postoperative course was uneventful.

LESSONS

This case is rare and noteworthy for a lesion containing two different types of neoplasms, which may cause diagnostic difficulties.

Case of sclerosing pneumocytoma combined with a typical carcinoid and pulmonary adenocarcinoma in different lobes

We report the first case of a 62‐year‐old man with a sclerosing pneumocytoma (SP) combined with a typical carcinoid (TC) and pulmonary adenocarcinoma in different lung lobes. Computed tomography revealed two nodules. The radiological diagnosis was primary lung cancer and a metastatic nodule; however, no enlarged lymph nodes were observed. Histological and immunohistochemical analyses defined the 1.7 cm nodule in the right upper lobe as adenocarcinoma and the 1.3 cm nodule in the left lower lobe as SP combined with TC. This case is noteworthy because of the rarity of SP combined with TC, the comprehensive examination of frozen and permanent sections, and the clinical implications of the differential diagnosis of lung nodules.

Pulmonary Hilar Tumor: An Unusual Presentation of Sclerosing Hemangioma

Pulmonary sclerosing hemangioma is an uncommon benign tumor of the lung; however, on rare occasions it can arise from the pulmonary hilar region. Herein, we report a 53-year-old female patient who presented with a round opacity in the right upper lung field on a radiograph. Chest computed tomography scanning revealed a 3.1 cm mass in the right pulmonary hilum. Thoracoscopic tumor excision was subsequently performed. On pathohistologic study, the tumor was well defined and composed of round stromal cells and surface cells arranged in a papillary, sclerotic, solid, and hemorrhagic pattern. In immunochemical study, the round cells were positive for thyroid transcription factor-1 (TTF-1) and epithelial membrane antigen (EMA) and negative for cytokeratin. The surface cells were positive for TTF-1, EMA, and cytokeratin. Therefore, a final diagnosis of sclerosing hemangioma was confirmed. In conclusion, pulmonary sclerosing hemangioma is uncommon and rare in the pulmonary hilar region. CT scanning is useful to determine its benignity, although imaging features are not specific for a definite differential diagnosis from other pulmonary tumors. Therefore, tissue diagnosis is usually necessary, and pulmonary sclerosing hemangioma should be listed in the differential diagnoses of pulmonary hilar tumors.

Pulmonary sclerosing pneumocytoma of the lung: CT characteristics in a large series of a tertiary referral center

The purpose of this study is to describe the detailed clinical, chest computed tomography (CT), and F-fluorodeoxyglucose positron emission tomography (FDG PET) characteristics of the tumor boundary for the diagnosis and investigate the outcome of pulmonary sclerosing pneumocytoma (PSP) using confirmed large data of a tertiary referral center. Confirmed 76 patients were included. We evaluated the findings of CT including 4 CT signs, FDG PET, and histopathology. Most patients had a single lesion (92.1%), smooth boundary (65.8%), and oval shape (65.8%) and the mean diameter was 22.7 mm. The CT signs included marginal pseudocapsule (50%), overlying vessel (26.3%), air gap (2.6%), and halo sign (17.1%). A predominantly solid was the most common histopathologic type. The mean maximum standardized uptake value on FDG PET of 17 patients was 1.8 (range, near 0 or normal tissue metabolism ∼2.9). PSP should be considered in middle-aged women whose CT features show incidental nodule(s), commonly with surrounding ground-glass opacity and characteristic CT signs of the tumor boundary, and hypometabolic uptake on FDG PET. Outcome of patients is excellent.

Clinicopathological and EBV analysis of respiratory epithelial adenomatoid hamartoma

Background

To investigate the clinicopathological characteristics of respiratory epithelial adenomatoid hamartoma (REAH) in residents of Southern China and to study the correlation between REAH and Epstein-Barr virus (EBV).

Methods

Clinicopathological data of 53 cases of REAH were retrospectively analyzed. The immunoreactivity for CK 7, CK20, CEA, p53, and Ki-67, Alcian blue–periodic acid-Schiff (AB-PAS) staining and in situ hybridization for EBV-encoded RNA (EBER) were carried out.

Results

REAH lesions were covered with ciliated columnar epithelium and proliferation of subepithelial glands, which were positive for CK7, and negative for CK20, CEA, and p53. Goblet cell metaplasia was stained blue by AB-PAS. The frequency of EBER positive cases in REAH located in nasopharynx was 27.78%, compared with that in the nasal cavity (15.79%) and paranasal sinuses (12.50%), there were no statistical differences.

Conclusions

REAH is an uncommon entity with distinctive morphologic features and EBV may have nothing to do with REAH.

Virtual slides

The virtual slide(s) for this article can be found here:

http://www.diagnosticpathology.diagnomx.eu/vs/5875687401178748

Multiple peripheral typical carcinoid tumors of the lung: associated with sclerosing hemangiomas

Abstract

This study presents a first case of multiple peripheral typical carcinoid tumors associated with sclerosing hemangiomas in the lung. A 52-year-old male presented with incidentally detected multiple pulmonary nodules on a simple chest X-ray during routine health check-up. A computed tomography (CT) scan of the chest showed multiple nodular lesions in the middle and lower lobes of the right lung. These were initially suspected as inflammatory lesions due to miliary tuberculosis. However, possibility of malignancy could not be excluded and right lower lobe lobectomy was performed. Histopathologically, some nodules including two largest nodules were composed of small round to spindle shaped cells with fine chromatin pattern, whereas the rest of the sclerotic nodules were composed of two epithelial cell types- surface cells and round cells. The final diagnosis of this case was multiple peripheral typical carcinoid tumors associated with sclerosing hemangiomas of the lung. For past three years of post-surgery follow up period, no new lesions or changes in the right middle lobe have been identified.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1511610609725790.

Pulmonary sclerosing hemangioma presenting with dense spindle stroma cells: a potential diagnostic pitfall

Pulmonary sclerosing hemangioma (PSH) is an uncommon pulmonary tumor. Histologically, PSH typically consists of two types of cells, surface cuboidal cells and polygonal cells, four architectural patterns including papillary, sclerotic, solid, and hemorrhagic. Herein, we present a case of PSH in a 59-year-old Chinese female. The tumor was predominantly composed of solid area presenting with diffuse spindle cells rather than polygonal cells. Focally, classical papillary and sclerotic area could be seen. Immunohistochemical staining showed that the spindle cells were positive for TTF-1, EMA, Actin(SM) and Vimentin, and negative for cytokeratin, cytokeratin7, cytokeratin5/6, surfactant apoprotein A, surfactant apoprotein B, CD34, CD99, S-100, HMB45, Desmin, Synaptophysin, CD56, ALK and Calretinin. The immunophenotype of the dense spindle cells in this case was similar to that of the polygonal cells, and thus the spindle cells may be the variants of polygonal cells. Based on morphologic features and the immunohistochemical profile, the tumor was diagnosed as a PSH. The significance of spindle cells change is unclear for us. To our knowledge, this is the first reported case of PSH showing dense spindle cells in solid area. This case represents a potential diagnostic pitfall, as it may be misdiagnosed as a mesenchymal tumor such as inflammatory myofibroblastic tumor, synovial sarcoma, solitary fibrous tumor, leiomyoma, or even mesothelioma, especially if the specimen is limited or from fine- needle aspiration.

Pulmonary sclerosing hemangioma: report of two cases

Pulmonary sclerosing hemangioma (PSH) is a rare benign tumor of the lungs. These tumors are composed of cuboidal surface cells and polygonal stromal cells and show four histological manifestations: hemorrhagic, papillary, solid, and sclerotic. PSH predominantly affects asymptomatic middle-aged women. The tumor often occurs at the intralobar site, and less commonly in the bronchus and mediastinum. PSH is easy to be misdiagnosed preoperatively. In this study, we present in detail the treatment procedures followed for two atypical cases of PSH. Case 1 was a 62-year-old woman bearing a tumor for 15 years. The tumor lesion was found to be located in the oblique fissure of the left lung. PSH was confirmed by surgical resection and postoperative pathological diagnosis. There was no sign of recurrence and metastasis 1.5 years after surgery. Case 2 was a 54-year-old woman diagnosed with bilateral multiple nodules by physical examination. This patient was diagnosed with definite PSH through computed tomography-guided percutaneous lung biopsy. Surgical resection was not performed. The patient also showed no sign of enlarged tumor and metastasis after 2 years of follow-up. Although PSH can be cured by surgical resection, the findings in our cases indicate that surgical resection need not be considered the preferred course of treatment. If PSH is diagnosed before surgery, the patients may survive while bearing the tumor.

In pulmonary sclerosing hemangioma expression of β-catenin, Axin, and C-myc differs between the two cell types

Previous studies have shown that pulmonary sclerosing hemangioma is a tumor derived from primitive respiratory epithelium, but its character and the differentiation status of the two cell types (polygonal and cuboidal) composing the lesion are still controversial. We hypothesize that the polygonal cells are immature compared with cuboidal cells and have higher proliferative activity. To further study this question, we examined the expression of β-catenin, Axin, and C-myc by immunostaining in 45 primary sclerosing hemangioma (PSH) specimens. The two cell types were captured by laser capture microdissection from 28 PSH specimens, and total RNA was extracted. Messenger RNA (mRNA) expression of Axin and C-myc was examined by reverse transcription polymerase chain reaction (RT-PCR). By immunostaining, β-catenin was predominantly strongly expressed on the cell membrane of cuboidal cells, while in polygonal cells, β-catenin was predominantly expressed in the cytoplasm and significantly decreased on cell membranes. Axin was expressed in cuboidal cells in 93 % of our 45 cases, but only expressed in 18 % of these in polygonal cells. C-myc expression in polygonal cells was significantly stronger than in cuboidal cells (P < 0.05). RT-PCR showed that the expression level of Axin mRNA in cuboidal cells was significantly higher than in polygonal cells (P < 0.05), and expression level of C-myc mRNA in polygonal cells was significantly higher than in cuboidal cells (P < 0.05).The two PHS cell types have distinct expression of β-catenin, Axin, and C-myc, suggesting that their differentiation status may be different. The higher expression of C-myc in polygonal cells suggests that these cells might have higher proliferative activity.