INTRODUCTION: Multiple growing pulmonary nodules raise concern for metastatic disease. We present a patient with a history of cancer found to have an unusual mimic of pulmonary metastases.
CASE PRESENTATION: A 70-year-old female was referred to the pulmonary clinic for evaluation of multiple pulmonary nodules. The patient had been diagnosed with a stage 1 (T1bN0M0) infiltrating breast carcinoma approximately one year prior. The patient was treated with lumpectomy and negative surgical margins were achieved. Radiation therapy was declined and the patient was placed on anastrazole. Computed tomography (CT) was performed for routine cancer screening. It revealed numerous, lower lobe predominant nodules bilaterally which were increased in size and number when compared to a scan from 2 years earlier (See Figure 1). The patient initially deferred intervention, so a repeat CT was obtained six months later. This revealed further increase in size and number of the nodules. (See Figure 2) The patient denies symptoms to include dyspnea, hemoptysis, weight loss, fevers, chills, or night sweats. She did endorse a dry, nonproductive cough. Her past medical history was notable for the previously described breast cancer, hypertension, hyperlipidemia, peripheral vascular disease, and collagenous colitis. Prior surgeries included the recent lumpectomy, an appendectomy, carotid endarterectomy, and a total abdominal hysterectomy. Her medications includes mesalamine, simvastatin, lisinopril, atenolol, clopidogrel, and anastrazole. Her physical exam and laboratory data were unremarkable. Initially a bronchoscopy with bronchoalveolar lavage and transbronchial biopsies was performed. Acid-fast bacilli and fungal smears and cultures were negative. Transbronchial biopsies revealed only chronic inflammation. The patient was referred for open lung biopsy. Biopsies revealed tumor cells which were strongly positive for synaptophysin and chromogranin (Slides available if selected) consistent with multiple carcinoid tumors. An octreotide scan revealed no uptake outside of the lung. A 24-hour urine 5-hydroxyindoleacetate level was normal. The patient was referred to oncology who offered therapy with octreotide, which was declined. The patient continues to do well.
DISCUSSIONS: A spectrum of neuroendocrine cell proliferations have been described. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) refers to a proliferation of cells or small nodules that may remain confined to the bronchiole or bronchiolar epithelium or can proliferates extraluminally in the form of tumorlets or carcinoid tumors. (1) By definition, tumorlets are nodules are less than .5 cm in diameter, with any larger nodules designated carcinoid tumors. (2) Multiple pulmonary carcinoid tumors and tumorlets have a radiographic appearance similar to metastatic disease. In fact, biopsies performed for concern of metastatic disease are the most common scenario in which carcinoid tumorlets are discovered. (1) Multiple pulmonary carcinoids are most commonly found in older women, particularly those with a history of prior malignancy. (1,2) Approximately half of patients are symptomatic, generally with cough. (1) An association between DIPNECH and airflow obstruction has been reported (3), although the majority of patients with tumorlets have no significant obstruction or restriction. (1) The prognosis of carcinoid tumorlets is favorable, with most patients having persistent but stable disease without specific therapy. (1).
CONCLUSION: Multiple pulmonary carcinoids may mimic metastatic disease, particularly in elderly women.
DISCLOSURE: Christopher King, No Financial Disclosure Information; No Product/Research Disclosure Information