Pulmonary Vascular Disease: Rare Pulmonary Disorders |

Pulmonary Nodules Post Hysterectomy FREE TO VIEW

Cheah Hooi Ken Lee, MBBS; Kah Weng Lau, PhD
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Singapore General Hospital, Singapore, Singapore

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

Chest. 2016;150(4_S):1201A. doi:10.1016/j.chest.2016.08.1310
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SESSION TITLE: Rare Pulmonary Disorders

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Monday, October 24, 2016 at 11:00 AM - 12:00 PM

INTRODUCTION: Benign metastasizing leiomyoma (BML) is a rare condition characterised by the unusual growth of leiomyomatous lung lesions, typically found in premenopausal women with a history of uterine fibroids. Most patients are asymptomatic but some rapidly progress to respiratory failure and death. The pathogenesis for BML includes hormone-sensitive in-situ proliferation of smooth muscle bundles, or the transport of smooth muscle cells from a uterine leiomyoma to distant sites in the lung, particularly after surgical procedures involving manipulation of pre-existing uterine leiomyoma.

CASE PRESENTATION: A 54-year-old non-smoking lady underwent a cardiac computed tomography scan for coronary calcium for evaluation of chest pain, which found mutiple sub-centimeter pulmonary nodules present in both lungs. She underwent total hysterectomy 15 years ago for menorrhagia secondary to fibroids. Physical examination was unremarkable. Computed tomography of the chest (Panel A), abdomen and pelvis showed no evidence of a primary malignant neoplasm. The patient underwent a video-assisted thoracoscopic wedge resection of the right middle and lower lobes, which showed multiple small circumscribed firm whitish nodules (Panel B). Histologic findings showed proliferation of interlacing fascicles of bland spindle cells (Panel C), accompanied by a few entrapped tubules. Immunohistochemical staining was positive for smooth muscle marker caldesmon and estrogen receptors (Panels D, E). Other differentials including leiomyosarcoma and lymphangioleiomyomatosis were excluded and she was diagnosed with BML. No further treatment was given but the patient remained on surveillance for disease progression.

DISCUSSION: Previous hysterectomy is a risk factor BML, with a mean time interval of 15 years between surgery and the development of lung lesions. Standard treatment for this condition has not been established. Given the hormone-sensitive nature of BML, therapy options including hormonal manipulation with surgical or medical oophorectomy have been proposed, but outcomes vary. Patients with solitary enlarging lung lesions should be considered for surgical excision. In other cases spontaneous regression of lesions have been reported where estrogen levels fall significantly especially after menopause.

CONCLUSIONS: Benign metastasizing leiomyoma as a differential should be considered for patients with previous hysterectomy presenting with multiple pulmonary nodules. Although most cases follow an indolent course of progression, there is potential for some to develop progressive respiratory failure especially in premenopausal patients. The approach to treatment remains controversial and should be considered on an individual basis.

Reference #1: Jacobson TZ, Rainey EJ, Turton CW. Pulmonary metastasizing leiomyoma: response to treatment with goserelin. Thorax 1995, 50: 1225-1226

Reference #2: Arai T, Yasuda Y, Takay T, Shibayama M. Natural decrease of benign metastasizing leiomyoma. Chest. 2000; 117:921-922

DISCLOSURE: The following authors have nothing to disclose: Cheah Hooi Ken Lee, Kah Weng Lau

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