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NEUROENDOCRINE CARCINOMA (PERFUSION SCINTIGRAPHY)
Authored By: Andrew Homb and Henry Royal.
Patient: 28 year old female
History:

28 year-old woman with progressively worsening cough and intermittent hemoptysis over the last several months.

 

 

Figure 1

Figure 2

Figure 3

 

 

What is your interpretation of this study?

 

Is this a good pattern for pulmonary embolism?

 

 

CT Angiography:

 

Figure 4

Figure 5

Figure 6

 

 

Findings and interpretation? 

Image Size:[small][as-submitted]

Fig. 1
Perfusion Images

Fig. 2
Perfusion Quantification

Fig. 3
PA and Lateral Chest Radiographs (two days prior to the perfusion study)

Fig. 4
CT Soft Tissue Windows (same day as the perfusion study)

Fig. 5
CT Lung Windows (same day as the perfusion study)

Fig. 6
CT Oblique Reconstruction (same day as the perfusion study)
Image Size:[small][as-submitted]

Findings:

Chest Radiographs:

 

Bilateral lower lobe linear atelectasis.

 

Blunting of the left costophrenic angle, which may represent a small layering effusion.

 

Staple line from a prior biopsy in the left lung.

 

Left lung midlung hazy opacity is noted and may represent changes of prior biopsy

 

 

Quantatative Lung Perfusion Scintigraphy:

 

RADIOPHARMACEUTICAL: 4.5 mCi Tc-99m MAA i.v.

 

Diffusely decreased perfusion to the left lung with absence of the superior segment of the left lower lobe.

 

The right lung receives 75% and the left lung receives 25% of total pulmonary perfusion.

 

 

CT Chest Angiogram:

 

Bulky non-calcific soft tissue in the left hilar region and around the left pulmonary veins. The main, left, and right pulmonary arteries are normal. The left lateral basal segmental artery has a moderate stenosis approximately 3 cm away from the origin with post stenotic dilatation. The rest of the pulmonary segmental arteries are unremarkable.

 

Approximately 1 cm from the origin of left inferior pulmonary vein, there is a 40% stenosis caused by the adjacent lymphadenopathy. Approximately 2.0 cm from the origin of the left superior pulmonary vein, there is a moderate stenosis, most notable in the sagittal and axial planes, and not well seen in the coronal plane. Prominent bronchial vessels identified around the left mains stem bronchus.

 

An irregular, infiltrating left mediastinal opacity emanates into the left hilar region causing stenosis of the left inferior and superior pulmonary veins and lateral basal segmental artery, the lesion compresses the left lower lobe bronchus, superior segmental bronchus, and lateral basal segmental bronchus.

 

Postobstructive, patchy pulmonary opacities are identified in the periphery, most notable in the mid and lower lung zones. A small left pleural effusion is present. The right lung is normal.

DDx:

DDX (Decreased Perfusion to one lung) 

Mettler page 171 table 7-2

 

Centrally obstructing tumor

 

Mediastinal fibrosis

 

Pulmonary agenesis or stemosis

 

Sweyer-James syndrome

 

Massive effusion

 

Aortic dissection

 

Pneumothorax

 

Pulmonary Embolism much less likely

Diagnosis: High grade neuroendocrine carcinoma in the left lower lobe with peribronchial, left hilar, and mediastinal lymph node metastasis (Surigical Pathology)
General Discussion:

Full History:

 

28 year-old woman with fibrosing mediastinitis presenting with progressively worsening cough and intermittent hemoptysis over the last several months.

 

Discussion:

 

"Neuroendrocine proliferations of the lung encompass a spectrum of nonneoplastic lesions and low, intermediate, and high grade tumors." 

 

Nonneoplastic:

 

 

Diffuse neuroendocrine cell hyperplasia

 

carcinoid tumorlets

 

 

Neoplastic (listed from lowest to highest grade):

 

 

Typical carcinoid tumor (10 year survival 90%)

 

Atypical carcinoid tumor (10 year survival 50%)

 

large cell neuroendocrince carcinoma (10 year survival 9%)

 

small cell neuroendocrine carcinoma (10 year survival 5%)

 

 

Low and intermediate grades are usually treated surgically.  High grade neoplasms are treated with chemotherapy or combined modality treatment.

References: Aslan et al. "KI-67 IN NEUROENDOCRINE TUMORS WITH CRUSH ARTIFACT" Am J Clin Pathol 123:874-878. 2005
Comments:
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Additional Details:

Case Number: 245532Owner(s): Andrew Homb and Henry RoyalLast Updated: 02-07-2013
Anatomy: Cardiopulmonary   Pathology: Neoplasm
Modality: CT, Conventional Radiograph, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: penmACR: 60000.32000

Case has been viewed 34 times.
Certified by Henry Royal on 10-10-2010

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