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EBUS Diagnosis of Granular Cell Tumor After Negative Mediastinoscopy FREE TO VIEW

Ellen Marciniak, MD; Julia Choi, MD; Ashutosh Sachdeva, MBBS; Janaki Deepak, MBBS
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University of Maryland School of Medicine, Baltimore, MD

Chest. 2013;144(4_MeetingAbstracts):14A. doi:10.1378/chest.1704789
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SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Granular Cell Tumors (GCT) are rare tumors of Schwann cell origin mostly found in skin, mouth, and tongue. GCT of the lung account for 6-10% of all GCT. This case illustrates the value of careful review of radiologic characteristics, utility of endobronchial ultrasound (EBUS), and limitations of mediastinoscopy in establishing the diagnosis of paratracheal lesions.

CASE PRESENTATION: A 36-year-old nonsmoking woman with asthma presented for evaluation of a right paratracheal mass found on CT scan obtained in 2008. She underwent mediastinoscopy revealing benign lymphoid tissue. There was no follow up of the mass as it was assumed the mediastinoscopy was definitive. Four years later she had a repeat CT chest for evaluation of right shoulder pain. The mass had increased by 1 cm from her previous CT scan. She was otherwise asymptomatic, including resolution of the shoulder pain. Her physical exam was normal. PET/CT revealed the mass to have a SUVmax: 4.8, increased from SUVmax: 2.5 in 2008. No other lesions were noted on PET/CT. She underwent bronchoscopy showing no endobronchial lesions. EBUS-TBNA sampling of the mass revealed sheets/nests of mesenchymal cells with abundant granular cytoplasm that stained s-100 positive, consistent with a GCT.

DISCUSSION: GCT are often benign, slow growing tumors that can infiltrate locally. Presenting symptoms include hemoptysis, chest pain, and post-obstructive pneumonia. GCT can be difficult to differentiate from other tumors. Pathologic staining differentiates them, with GCT staining positive for s-100 and vimentin. Surgical resection is the current treatment of choice although localized therapy including Nd: YAG Laser and Argon Plasma Coagulation (APC) have been used successfully for endobronchial lesions. Given our patient’s young age, tumor proximity to trachea, and growth pattern, she was advised to undergo surgical resection.

CONCLUSIONS: This is a case of right paratracheal mass diagnosed as a GCT via EBUS-TBNA after negative sampling by mediastinoscopy. Since the mass was intra-parenchymal, mediastinoscopy was unable to access it through the tissue planes resulting in removal of a benign lymph node instead. The mass was better characterized with EBUS. This case demonstrates the importance of multi-disciplinary approach and appropriate selection of diagnostic modality for paratracheal lesions. A normal lymph node sampling, as in our case, via mediastinoscopy does not necessarily rule out tumor. In fact, follow up imaging in conjunction with use of a different diagnostic modality may improve diagnostic yield.

Reference #1: Deavers M, et al. Granular Cell Tumors of the Lung. Clinicopathologic Study of 20 cases. Am J Surg Pathol 1995; 19: 627-35.

Reference #2: Van Der Maten J, et al. Granular Cell Tumors of the Tracheobronchial Tree. J Thorac Cardiovasc Surg 2003; 126: 740-3.

DISCLOSURE: The following authors have nothing to disclose: Ellen Marciniak, Julia Choi, Ashutosh Sachdeva, Janaki Deepak

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