Lung Pathology: Fellow Case Report Slide: Lung Pathology |

Granulomatous Lung Mass After Radiotherapy for Non-Small Cell Lung Carcinoma FREE TO VIEW

Lauren Blackwell, MD; Jin Choe, MD; Donghong Cai, MD; Jenny Kim, MD
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Rutgers, New Jersey Medical School, Bloomfield, NJ

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

Chest. 2016;150(4_S):787A. doi:10.1016/j.chest.2016.08.883
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SESSION TITLE: Fellow Case Report Slide: Lung Pathology

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Monday, October 24, 2016 at 03:15 PM - 04:15 PM

INTRODUCTION: Radiation-induced lung injury usually results in fibrosis. An uncommon hypersensitivity-like pneumonitis has also been described. Development of a focal granulomatous inflammation is not a known complication of lung radiation. We report a case of a focal hypersensitivity pneumonitis appearing after radiotherapy for non-small cell lung carcinoma.

CASE PRESENTATION: The patient is a 64 year old man with history of a right upper lobe T2N2 squamous cell carcinoma treated with chemotherapy and radiation therapy (6000 cGy) two years ago, bladder cancer treated surgically, HTN, CKD, and prior tobacco dependence presenting with recurrence of a right upper lobe mass. He denied weight loss, fever, dyspnea, cough, or hemoptysis. A surveillance CT chest revealed a growing 3.3 x 2.7cm mass in the right upper lobe that was not present on post-radiation imaging. PET/CT revealed the mass to have an SUV of 5.6 without uptake in lymph nodes. A BAL was negative for malignancy, fungal, and mycobacterial infection. A wedge resection of the mass revealed small, non-caseating granulomas and modest lymphocytic infiltration. Stains for acid-fast bacilli and fungi were negative and there was no evidence of malignancy. The post-operative course was complicated by pneumothorax that resolved with chest tube drainage.

DISCUSSION: Recurrence of an enlarging mass in the field of radiation is highly suspicious for a radio-resistant tumor. Biopsy in this case demonstrated a benign granulomatous mass, which is rare. Radiation-induced lung injury results from direct cytotoxicity and fibrosis is mediated by various cytokines or from lymphocytic alveolitis in the case of hypersensitivity pneumonitis1. Hypersensitivity pneumonitis is typically seen outside radiation ports and is an early development after irradiation. Post-radiation nasopharyngeal granulomas have also been reported, though they are a rare complication occurring in 1% of cases2. Scattered giant cells and poorly formed granulomas, as seen in this patient’s biopsy, are more typically seen in hypersensitivity pneumonitis than in sarcoidosis.

CONCLUSIONS: Focal hypersensitivity pneumonitis is a rare late finding after lung irradiation and has not been reported in lung parenchyma following radiation.

Reference #1: Abratt and Morgan. Lung toxicity following chest irradiation in patients with lung cancer. Lung Cancer. 2002 Feb;35(2):103-9. Review.

Reference #2: Yang, L. et al. Nasopharyngeal granulomatous mass after radiotherapy for nasopharyngeal carcinoma. Auris Nasus Larynx. 2016 Jan 11.

DISCLOSURE: The following authors have nothing to disclose: Lauren Blackwell, Jin Choe, Donghong Cai, Jenny Kim

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