Lung Cancer: Student/Resident Case Report Poster - Lung Cancer II |

Squamous Cell Carcinoma of the Lung With Heterotopic Ossification FREE TO VIEW

Humnah Khudayar, MBBS; Omair Tahir, MD; Kamran Manzoor, MD
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Memorial Hospital of Rhode Island, Providence, RI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):757A. doi:10.1016/j.chest.2016.08.852
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SESSION TITLE: Student/Resident Case Report Poster - Lung Cancer II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary ossification is mature bone in the alveolar or interstitial space seen in non-neoplastic processes such as pulmonary infections and interstitial fibrosis. It is also described in renal, gastrointestinal and soft tissues tumors but is rarely reported in primary lung carcinoma. We describe a case of heterotopic ossification associated with squamous cell carcinoma of the lung which was not evident on initial pleural and parenchymal biopsy.

CASE PRESENTATION: A 71 year male was admitted for evaluation of dyspnea and unexplained weight loss. Initial computerized tomography (CT) thorax revealed a loculated left pleural effusion with marked pleural thickening and consolidation of the left lung requiring chest tube placement. Subsequent CT thorax showed residual loculated effusion without interval improvement. The patient underwent bronchoscopy and video-assisted thoracic surgery (VATS) with decortication. No endobronchial lesions were demonstrated on bronchoscopy, however VATS revealed multiple loculated pleural adhesions. A large peel over the lung could not be decorticated via VATS and required limited left thoracotomy. Multiple heavily calcified areas were identified on further exploration. Additionally, a left upper lobe ( LUL) palpable density led to wedge resection. Histopathologically, the pleural peel demonstrated acute and chronic inflammation with necrosis; LUL wedge biopsy demonstrated heterotopic ossification without evidence of malignancy. The patient was readmitted with worsening dyspnea and pleurisy. Repeat CT thorax showed multiple new left rib fractures with osseous invasion of pleura, mediastinal lymphadenopathy, innumerable pulmonary nodules and vertebral bony metastasis. CT guided biopsy of the pleura revealed the diagnosis of squamous cell carcinoma.

DISCUSSION: The pathogenesis of bone formation is unclear. A possible mechanism is production of bone stimulating substances by the tumor cells with identification of bone morphogenic proteins (BMPs) inducing extraskeletal ossification. Primary lung cancer may present with intratumoral heterotopic calcification (IHO) or extratumoral heterotopic calcification (EHO). EHO is associated with squamous cell carcinoma, large cell neuroendocrine carcinoma, adenosquamous carcinoma and less frequently with adenocarcinoma. IHO has a stronger association with adenocarcinoma.

CONCLUSIONS: This case illustrates rarely reported EHO associated with squamous cell carcinoma. Initial diagnostic work up was unrevealing likely due to a markedly inflammatory pleural effusion. Pulmonary hetertrophic ossification suggests the possibility of malignancy and should prompt further investigation.

Reference #1: Markert E, Gruber-Moesenbacher U, Porubsky C, Popper HH. Lung osteoma-a new benign lung lesion. Virchows Arch. 2006 Jul;449(1):117-20.

Reference #2: Kudo H, Narita T, Fukushi A. Spontaneous pulmonary adenocarcinoma cell shows osseous metaplasia in vivo. In Vitro Cell. Dev. Biol. 31:258-259, April 1995.

DISCLOSURE: The following authors have nothing to disclose: Humnah Khudayar, Omair Tahir, Kamran Manzoor

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