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 

May 2019 Imaging Case of the Month: Asymptomatic Pulmonary Nodules and Cysts in a 47-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 47-year-old previously healthy woman presented to her new physician for a routine physical examination. The patient had no complaints. The patient’s physical examination showed normal vital signs and clear lungs; the physical examination was essentially unremarkable. The patient’s past medical history included a brief smoking history, having quit over 20 years earlier, as well as seasonal allergies. Her past surgical history included an appendectomy nearly 20 years earlier and a hysterectomy for bleeding related to uterine leiomyomas approximately 12 years prior to presentation. The patient was not taking any prescription medications.

Basic laboratory data, including a complete blood count, electrolyte panel, and liver function studies were all within the normal range. An electrocardiogram revealed normal findings. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (click on the correct answer to be directed to the second of eleven pages)

1. The chest radiograph shows mediastinal and hilar lymph node enlargement
2. The chest radiograph shows multifocal nodular pulmonary consolidation
3. The chest radiograph shows multiple, bilateral cavitary nodules
4. The chest radiograph shows multiple, bilateral circumscribed nodules
5. The chest radiograph shows nodular interstitial thickening

Cite as: Gotway MB. May 2019 imaging case of the month: Asymptomatic pulmonary nodules and cysts in a 47-year-old woman. Southwest J Pulm Crit Care. 2019;18(5):106-19. doi: https://doi.org/10.13175/swjpcc022-19 PDF 

August 2018 Imaging Case of the Month: Dyspnea in a 55-Year-Old Smoker

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 55–year old woman presented to the emergency room with complaints of shortness of breath and lower extremity swelling. The patient noted her shortness of breath had been worsening over the previous 6 months, especially in the last 3 months. The patient denies cough, fever, chills, and night sweats. The patient admits to some fatigue but has not lost weight recently.

The patient is a current smoker, averaging about 1 pack-per-day for the previous 40 years. Her allergies include penicillin and sulfa drugs, and her prior medical history was remarkable only for hypothyroidism and gastroesophageal reflux. Her only previous surgery was for an ectopic pregnancy. The patient’s mediation list included use of opiates for pain related to a herniated disc in the lower cervical spine following an automobile accident two years earlier.

Her physical examination was unremarkable aside from obesity and mild symmetric lower extremity edema. Her vital signs were within normal limits.

Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to be directed to the second of ten pages)

1. Chest radiography shows a mediastinal mass
2. Chest radiography shows cavitary pulmonary lesions
3. Chest radiography shows miliary nodules
4. Chest radiography shows an interstitial abnormality consisting of reticular and nodular opacities
5. Chest radiography shows basilar fibrotic opacities

Cite as: Gotway MB. August 2018 imaging case of the month: Dyspnea in a 55-year-old smoker. Southwest J Pulm Crit Care. 2018;17(2):59-69. doi: https://doi.org/10.13175/swjpcc099-18 PDF

Medical Image of the Week: Pulmonary Amyloidosis in Primary Sjogren’s Syndrome

Figure 1. Thoracic CT scan showing multiple pulmonary nodules and lung cysts. The lung cysts were located apart from the pulmonary nodules.

Figure 2. Follow up CT scan in one year revealing worsening of the widespread lung cysts.

A 69-year-old woman with past medical history of Sjögren's syndrome presented with pleuritic chest pain and shortness of breath for a month. Review of systems revealed worsening dysphagia and dryness of eyes over the last one year. Physical exam was significant for a palpable left axillary node and mild rhonchi bilaterally in the lower lung bases. Laboratory work was positive for Sjogren’s Syndrome antibodies. Chest x-ray revealed multiple nodules in bilateral lung fields. HRCT showed interlobular septal thickening and multiple cystic areas throughout the lung parenchyma which had progressed over 1 year (Figure 1). Wedge resection and thorough lymph node dissection were performed via video-assisted thoracic surgery (VATS). Biopsy of the lung nodules revealed thickened alveolar septate with acellular eosinophilic homogenous materials, which took up Congo Red stain. Based on these pathological findings, the final diagnosis was - diffuse septal alveolar pulmonary amyloidosis secondary to Sjogren’s Syndrome. bortezomib. However, patient did not want to undergo chemotherapy. She preferred the ‘wait and watch approach’ and wished to be treated with only prednisone, with the intention to switch to azathioprine in future. However, after one year thoracic CT showed worsening of the cysts (Figure 2).

Pulmonary amyloidosis of the lower respiratory tract may represent a significant clinical problem in systemic and organ-limited amyloidosis and can contribute to cardiopulmonary failure. Pulmonary amyloidosis may present as a nodular localized type, diffuse septal alveolar amyloidosis, tracheobronchial amyloidosis and even pleural amyloidosis (1). Each patient requires complete assessment and unequivocal amyloid typing to determine their optimal treatment. Diffuse alveolar-septal amyloidosis is treated according to the underlying systemic amyloidosis, with most chemotherapeutic regimes similar to that of multiple myeloma (2). Patients should be monitored very closely and physicians should frequently asses the efficacy of the chemotherapeutic regime.

Payal Sen, MD and Betty Chang, MDCM, PhD

University of New Mexico

Albuquerque, NM USA

References

1. Milani P, Basset M, Russo F, Foli A, Palladini G, Merlini G. The lung in amyloidosis. Eur Respir Rev. 2017 Sep 6;26(145). [CrossRef] [PubMed]
2. Dispenzieri A, Seenithamby K, Lacy MQ, et al. Patients with immunoglobulin light chain amyloidosis undergoing autologous stem cell transplantation have superior outcomes compared with patients with multiple myeloma: a retrospective review from a tertiary referral center. Bone Marrow Transplant. 2013 Oct;48(10):1302-7. [CrossRef] [PubMed]

Cite as: Sen P, Chang B. Medical image of the week: Pulmonary amyloidosis in primary Sjogren’s syndrome. Southwest J Pulm Crit Care. 2018;16(6):336-7. doi: https://doi.org/10.13175/swjpcc072-18 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 

July 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: An 18-year-old non-smoking man with a previous diagnosis of Ehlers-Danlos syndrome presented with mild shortness of breath and new cough. Physical examination was normal. The patient was afebrile.

Laboratory data were remarkable except for a mildly elevated white blood cell count of 11 x 10⁹ cells/L. Serum chemistries were within normal limits. Oxygen saturation on room air was 97%.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography

A previous comparison chest radiograph from 3 years earlier (Figure 2) is shown as well.

Figure 2. Frontal and lateral chest radiography from 3 years earlier.

 Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven panels)

1. The frontal chest radiograph shows new bilateral small nodular opacities
2. The frontal chest radiograph shows new focal opacity in the lateral right base 
3. The frontal chest radiograph shows new mediastinal lymphadenopathy
4. The frontal chest radiograph shows no focal abnormalities or change from prior
5. The frontal chest radiograph shows pneumothorax

Cite as: Gotway MB. July 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016:13(1):15-26. doi: http://dx.doi.org/10.13175/swjpcc061-16 PDF

December 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 30-year-old man complained of intermittent shortness of breath and recurrent respiratory tract infections. Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph mediastinal lymphadenopathy
2. The chest radiograph shows basal predominant linear opacities suggesting fibrosis
3. The chest radiograph shows large lung volumes with faint, thin-walled cystic lesions bilaterally
4. The chest radiograph shows multifocal ground-glass opacity and consolidation associated with linear and reticular abnormalities
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. December 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(6):339-47. doi: http://dx.doi.org/10.13175/swjpcc172-13 PDF