Anjum Jalal, Haider Zaman, C P Forrester.
Solitary Pulmonary Masses: A Diagnostic Dilemma.
J Coll Physicians Surg Pak Jan ;10(6):226-8.

The differential diagnosis of a radiologically discovered isolated pulmonary mass includes both .t benign and malignant conditions. Such lesions occasionally masquerade clinical presentation as well as morphologic appearance of each other putting physicians in diagnostic dilemmas. We report our experience of four cases where clinical diagnosis was completely changed on post operative histological examination. Modern diagnostic techniques including contrast enhancement CT, coloured Doppler studies and Positron Emission Tomography (PET), if available, can provide valuable information for appropriate decision making. However, in the absence of these advanced diagnostic facilities, if the frozen section biopsy remains inconclusive, it is safe as well as prudent to undertake appropriate resection on purely clinical grounds.

CASE REPORTS: Case 1: A 69 years old man presented with several episodes of hemoptysis over a period of six months. The past medical history included ulcerative colitis. He gave up smoking 27 years ago after smoking 15 cigarettes a day for a long time and never had exposure to industrial dusts or fumes. The results of routine hematology and blood biochemistry were within normal range and respiratory function tests were satisfactory. Flexible bronchoscopy demonstrated abnormal endobroncheal lesions. The Chest x-ray showed a small stellate lesion in the periphery of right upper zone and CT scan confirmed a solid lesion in right upper lobe with an area of central cavitation. The hilar and mediastinal areas did not show any lymph node enlargement. In the light of clinical infromation and radiological evidence a provisional diagnosis of bronchogenic carcinoma was made and surgical resection was decided. A posterolateral thoracotomy was performed and the tumour was four to be palpable in the depth of posterior segment of upper with tethering of overlying pleura. A wedge excision was possible and upper lobectomy was, therefore, performed. On gross appearance it was a mass of 3cm with an area` central necrosis. The histology revealed a dense collection` fungal hyphae in the central necrotic area which w surrounded by inflamed granulation tissue and fibrotic I The background lung showed lymphocytic alveolitis occasional poorly formed granulomas, suggesting a hype`, sitivity pneumonitis. Fungal stains confirmed the presence` fungal hyphae with morphology in keeping with aspergillo Immediate postoperative recovery was satisfactory. patient remained in good clinical condition thereafter. No fungal treatment was prescribed as the lesion was enti covered by lung tissue and the margins of resection were clear

Case 2: A 59 years old man presented with a brisk hemoptysis; initial management of hemoptysis further investigations carried out. Routine blood tests were normal and b choscopy was inconclusive. Chest x-ray showed opacity in right lung field which, on CT scan, was confirmed to be irregular mass in the anterior segment of the right upper 1 Over next two weeks, his chest x-ray showed further incre in the size of opacity with a new shadow along the right border of superior mediastinum. He underwent posterolateral thoracotomy and was discovered have a large mass in upper lobe extending on to the right pulmonary artery and surrounding the origin of the upper lobe bronchus. Frozen section biopsy was inconclusive and therefore, pneumonectomy was the only surgical option. this was carried out without any complications. The post-operative recovery was smooth and uneventful.The histology of resected specimen reported a solid mass of consolidated lung with extensive acute and chronic inflammatory changes and scattered areas of fibrosis and micro abscesses. The architecture of lung was badly destroyed and replaced by granulation tissue. The micro abscesses and granulation tissue contained colonies of filamentous organisms consistent with actinomycetes. After confirmation with special stains for actinomycetes, the patient was treated with a short course of benzyl penicillin.

Case 3: A 60 years old lady presented with shortness of breath and was diagnosed to have left sided pneumothorax. She smoked 30 cigarettes a day and did not have any medical illness in past. Her pneumothorax was treated with intercostal tube which re-expanded the lung. After removal of tube she had a satisfactory initial recovery followed by another episode of pneumothorax. This time the x-ray also showed an air-fluid level. She was, therefore, admitted for open drainage and pleurectomy. A limited left posterolateral thoracotomy was performed. The parietal pleura was thickened and there was a thin layer of fibrin on the visceral pleura. The lower lobe showed a thin walled abscess which was de-roofed and multiple biopsies were taken from the abscess wall. The operation remained uncomplicated and the postoperative recovery was satisfactory.The histological examination of biopsy specimens demonstrated that the lung tissue was completely effaced by adenoarcinoma showing a variable pattern of differentiation ranging from well differentiated to almost anaplastic. She, therefore, underwent a re-thoracotomy and left lower lobechtomy. The histology of the cavitating lesion confirmed the previous findings. The postoperative recovery remained unevenful.

Case 4: A 53 years old lady with history of heavy smoking and chronic obstructive lung disease presented with progressive dyspnoea, repeated chest infections and productive cough of six months duration. On radiological examination a mass lesion was discovered in posterior segment of right lower lobe. A needle biopsy was performed under CT guidance which remained inconclusive. Her spirometery showed reasonable volumes to tolerate a lobectomy. Considering her age, history of heavy smoking and CT scan, highly suggestive of carcinoma, she was planned to undergo a lobectomy. This was performed without any complications and she made a quick recovery. The histology demonstrated the presence of cas- granulomas pathognomic of tuberculosis.

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