Medical Image of the Month: Metastatic Spindle Cell Carcinoma of the Breast

Figure 1. A coronal reconstruction of the patient’s CT of the chest with contrast in lung windows demonstrates extensive, bilateral metastatic disease, with the greatest burden of disease situated in the right lower lobe. Areas of cystic change (blue arrows) and cavitary disease (red arrow) are present.

Clinical Scenario: A 71-year-old woman with primary malignancy of the breast in remission post bilateral mastectomy in 2005 and 2008, presented to the emergency room with progressive shortness of breath for the past 6 months. Upon arrival to the emergency room, she described localized sharp chest pain along the right thoracic wall which had gradually worsened over the past three months. The pain was exacerbated with movement and with deep inspiration. She also endorsed significant hemoptysis, expectorating approximately 500 ml of bloody sputum on the morning of her presentation. Pertinent vitals revealed that she was both tachycardic and tachypneic, saturating 94% on room air with an increased work of breathing. Physical examination was significant for coarse breath sounds and diminished right sided lung sounds. Initial labs demonstrated a normal troponin and an unremarkable EKG. A chest radiograph demonstrated a large left mediastinal and hilar mass with numerous parenchymal nodules bilaterally. A CT of the chest with contrast (Figure 1) demonstrated widespread lung nodules, most notably in the right lung with a confluent mass in the right base. No significant focal lesions were seen in the chest wall or breast regions. A biopsy of the left mediastinal mass was performed and confirmed metastatic spindle cell carcinoma originating from her primary breast cancer.

Discussion: Spindle cell carcinoma of the breast, a variant classified under metaplastic carcinoma, is a rare entity occurring in less than 1% of all incidences of primary breast cancer, and most commonly seen in postmenopausal women (2,5). Treatment is primarily surgical resection. The role of radiation and chemotherapy is unclear and varies per patient treatment plan. Tumors are typically triple-negative, limiting therapeutic options (1,2,5). Primary tumor diameter and grade may be the most important prognostic factors, although prognosis regarding spindle cell carcinoma is generally poor. At the time of diagnosis, incidence of axillary lymph node metastasis was 40 – 56% with a high grade of recurrence at 57% - 63% (1,4,5). Most common extra nodal metastasis was to the lungs. In addition to the poor prognosis of spindle cell carcinomas and high rates of local recurrence, metastatic disease is also frequently seeing in patients, such as the metastatic disease seen with our patient (2-4).

Our patient’s primary breast cancer was treated with a bilateral mastectomy followed by neither chemotherapy nor radiation therapy based on patient’s preference and discussion with her oncology team. The primary tumor was in the left breast with recurrence to the right breast and metastasis to bilateral lungs. Like other cases, a biopsy revealed a triple-negative tumor. She was discharged on supplemental oxygen and is expected to receive P13K inhibitor therapy for targeted palliative treatment.

Vinita Kusupati MD, MBA and Stefano Natali DO

Department of Internal Medicine,

Banner University Medical Center-Tucson Campus

Tucson, AZ USA

References

1. Adem C, Reynolds C, Ingle JN, Nascimento AG. Primary breast sarcoma: clinicopathologic series from the Mayo Clinic and review of the literature. Br J Cancer. 2004 Jul 19;91(2):237-41. [CrossRef] [PubMed]
2. Alaoui M'hamdi H, Abbad F, Rais H, Asmouki H, Soumani A, Khouchani M, Belbaraka R. Rare variant of metaplastic carcinoma of the breast: a case report and review of the literature. J Med Case Rep. 2018 Feb 21;12(1):43. [CrossRef] [PubMed]
3. Carter MR, Hornick JL, Lester S, Fletcher CD. Spindle cell (sarcomatoid) carcinoma of the breast: a clinicopathologic and immunohistochemical analysis of 29 cases. Am J Surg Pathol. 2006 Mar;30(3):300-9. [CrossRef] [PubMed]
4. Khan HN, Wyld L, Dunne B, Lee AH, Pinder SE, Evans AJ, Robertson JF. Spindle cell carcinoma of the breast: a case series of a rare histological subtype. Eur J Surg Oncol. 2003 Sep;29(7):600-3. [CrossRef] [PubMed]
5. Tse GM, Tan PH, Putti TC, Lui PC, Chaiwun B, Law BK. Metaplastic carcinoma of the breast: a clinicopathological review. J Clin Pathol. 2006 Oct;59(10):1079-83. [CrossRef] [PubMed]
6. Tse GM, Tan PH, Lui PC, Putti TC. Spindle cell lesions of the breast--the pathologic differential diagnosis. Breast Cancer Res Treat. 2008 May;109(2):199-207. [CrossRef] [PubMed]

Cite as: Kusupati V, Natali S. Medical image of the month: metastatic spindle cell carcinoma of the breast. Southwest J Pulm Crit Care. 2021;22(6):114-5. doi: https://doi.org/10.13175/swjpcc021-21 PDF 

Medical Image of The Week: Urothelial Carcinoma with Pulmonary Metastases Presenting with Shoulder Pain

Figure 1. AP view of the left shoulder demonstrated multiple pulmonary nodules.

Figure 2. Coronal view of chest CT demonstrating innumerable pulmonary nodules with thick walled cavitations.

Figure 3. Axial view of chest CT demonstrating innumerable pulmonary nodules with thick walled cavitations.

A 68 year old man with a past medical history significant only for mild hyperlipidemia and distant cigar smoking presented to this primary physician’s office with a chief complaint of left sided shoulder pain for more than 6 months duration. His only other complaint was a hacking morning cough that was attributed to GERD after resolution with omperazole therapy. He was without any other complaints such as weight loss, fevers, chills, night sweats, shortness of breath, or dyspnea on exertion. His physical exam was without any abnormality. An initial radiograph of the rileft shoudler was obtained which was without any obvious bony abnormality but demonstrated numerous potential pulmonary nodules (Figure 1).  He was then referred to pulmonology for further assessment. A chest CT scan peformed with contrast again demonstrated numerous pulmonary nodules with thick walled central cavitations throughout the lung parenchyma bilaterally (Figures 2 & 3). Additional testing performed included Coccidioides serologies, c-ANCA, p-ANCA, Quantiferon Gold, PSA, and rheumatoid arthritis serology (RF/CCP) all of which were negative. He was taken for a CT guided lung biopsy of one of the nodules and the biopsy result demonstrated a poorly-differentiated carcinoma with focal squamous differential; nuclear “salt and pepper” features; along with immunostaining consistent with poorly differentiated urothelial cell carcinoma. The patient was referred to oncology but refused potential palliative chemotherapy.

The differential diagnoses for cystic and cavitary lung disease is very broad, therefore it is of utmost importance to differentiate between cystic and cavitary diseases. Typically, cystic lung diseases are round parenchymal lucencies with a thin wall, typically <2mm in thickness, whereas cavitary lung disease are round luciencies typically with a wall >4mm in thickness, but overlapp between cystic and cavitary lung disease does exist (1,2). Without evidence or symptomology to suggest malignancy, initial differential diagnosis must include infectious causes of cystic/cavitating lung disease. In regions such as the Southwestern United States where diseases such as Coccidioidomycosis is endemic, this must be included in the differential diagnosis, as does other potential infectious cystic/cavitating lung disease such as M. tuberculosis, Pneumocystis infection, or Klebsiella infection (2). Granulomatosis with polyangiitis (Wegener’s granulomatosis), as well as other rheumatologic conditions must also be included in the initial differential diagnosis. In this case, infectious and rheumatologic testing was negative. Biopsy was then necessary to determine etiology which was consistent with a metastatic urothelial carcinoma. A CT urogram was performed which was without evidence of primary tumor. Literature review suggests that approximately 65% of metastatic urothelial cancers metastasize to the lung, and often form nodules with central necrosing cavitations (3).

Benjamin Jarrett MD, MPH¹, Huthayfa Ateeli, MBBS², Harbhajan Singh, MD²

¹Department of Internal Medicine and ²Department of Pulmonary and Critical Care Medicine

University of Arizona College of Medicine and Southern Arizona VA Healthcare System

Tucson, Arizona USA

References

1. Raoof S, Bondalapati P, Vydyula R, et al. Cystic lung diseases: algorithmic approach. Chest. 2016 Oct;150(4):945-65. [CrossRef] [PubMed]
2. Gadkowski LB, Stout JE. Cavitary pulmonary disease. Clin Microbiol Rev. 2008 Apr;21(2):305-33. [CrossRef] [PubMed]
3. Shinagare AB, Fennessy FM, Ramaiya NH, Jagannathan JP, Taplin ME, Van den Abbeele AD. Urothelial cancers of the upper urinary tract: metastatic pattern and its correlation with tumor histopathology and location. J Comput Assist Tomogr. 2011 Mar-Apr;35(2):217-22. [CrossRef] [PubMed]

Cite as: Jarrett B, Ateeli H, Singh H. Medical image of the week: urothelial carcinoma with pulmonary metastases presenting with shoulder pain. Southwest J Pulm Crit Care. 2017;14(6):315-7. doi: https://doi.org/10.13175/swjpcc067-17 PDF 

Medical Image of the Week: Staphylococcal Pneumonia in a Patient with Influenza

Figure 1. Thoracic CT scan axial view demonstrating bilateral cavitary infiltrates.

A 63-year-old, obese diabetic man presented to his primary care physician with complaints of fever, headache, myalgias, and cough. A nasal swab specimen was positive for influenza A by fluorescent immunoassay. Therapy with oseltamivir was initiated. The patient’s symptoms progressed and he was transported to the emergency department , where he was found to have a room air oxygen saturation of 74%, bilateral basilar infiltrates on chest radiograph, a white blood count of 24.2 K/uL and a procalcitonin level of 12.66 ng/ml. He was placed on BIPAP with high flow supplemental oxygen,  started on empiric intravenous antibiotic therapy with vancomycin and piperacillin/tazobactam, and admitted to the intensive care unit.  Blood and sputum cultures were eventually positive for methicillin-sensitive Staphylococcus aureus, and the patient’s antibiotic therapy was de-escalated to nafcillin. On hospital day 5, a CT of the chest obtained to evaluate pleuritic pain revealed extensive bilateral cavitary infiltrates (Figure 1). The patient’s discomfort resolved without further intervention, he continued to improve, and was uneventfully transitioned to oral therapy. 

S. aureus pneumonia is characterized by high fever, productive cough, and a radiographic pattern of patchy, often multilobar, infiltrates which may exhibit cavitary change.  In the USA, approximately 2% of patients admitted to the hospital for treatment of community-acquired pneumonia demonstrate microbiologic evidence of S. aureus infection (1). There is a slight predominance of methicillin sensitive species (MSSA) compared to methicillin resistant species (MRSA).  Morbidity and mortality are both high, with over 80% of patients requiring care in the ICU, and a fatality rate of 13% (2).

Among patients admitted to the intensive care unit with a primary diagnosis of influenza, there is a 15% incidence of S. aureus pneumonia. Risk factors for co-infection in this setting  include obesity, HIV infection, and immunosuppressive medication. There is a robust association between bacteremia and mortality (3).  Early empiric antibiotic therapy with an agent active against S. aureus should be strongly considered for patients admitted to the ICU with influenza complicated by pneumonia, pending the return of blood and respiratory cultures.

¹Charles VanHook, ²Kristin Dahlem, and ¹Angela Taylor

¹Longmont United Hospital, Longmont, Colorado USA

²Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts USA

References

1. Jain S, Self WH, Wunderink R, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015 Jul 30;373(5):415-27. [CrossRef] [PubMed]
2. Self WH, Wunderink RG, Williams DJ, et al. Staphylococcus aureus community-acquired pneumonia: prevalence, clinical characteristics, and outcomes. Clin Infect Dis. 2016 Aug 1;63(3):300-9. [CrossRef] [PubMed]
3. Martin-Loeches I, J Schultz M, et al. Increased incidence of co-infection in critically ill patients with influenza. Intensive Care Med. 2017 Jan;43(1):48-58. [CrossRef] [PubMed]

Cite as: VanHook C, Dahlem K, Taylor A. Medical image of the week: staphylococcal pneumonia in a patient with influenza. Southwest J Pulm Crit Care 2017:14(4):170-1. doi: https://doi.org/10.13175/swjpcc045-17 PDF

Medical Image of the week: Chronic Pulmonary Histoplasmosis

Figure 1. Chest radiography showing upper lobe fibrosis and cavitation secondary to chronic histoplasmosis.

Histoplasmosis is endemic to the Midwest US and commonly causes an acute infection that presents as a subacute pneumonia.  In patients with underlying lung disease, particularly COPD, a subacute pneumonia can evolve into chronic pulmonary histoplasmosis and is characterized by persistent or recurrent pulmonary symptoms, progressive lung infiltrates, fibrosis, and cavitation. Upper lobe infiltrates and cavities are characteristic, resembling the findings in tuberculosis (Figure 1). Progression is manifested by cavity enlargement, increased fibrosis and bronchopleural fistulae.  Misdiagnosis delays therapy and can be catastrophic.  Histoplasmosis titers and sputum cultures are useful tests.  Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy for culture may be needed when diagnosis remains elusive.

Kenneth S. Knox, MD¹ and Veronica A. Arteaga, MD²

¹Professor of Medicine

University of Arizona College of Medicine- Phoenix

Phoenix, AZ USA

²Associate Professor of Medicine

Medical Imaging

University of Arizona College of Medicine- Tucson

Tucson, AZ USA

Cite as: Knox KS, Artega VA. Medical image of the week: chronic pulmonary histoplasmosis. Southwest J Pulm Crit Care. 2017;14(3):88. doi: https://doi.org/10.13175/swjpcc022-17 PDF