Ann Thorac Surg 2005;79:1415-1417
© 2005 The Society of Thoracic Surgeons
Case report
Multiple Pulmonary Nodules and Underlying Head and Neck Cancer
Fabrice Barlesi, MD*,a,d,
Céline Gimenez, MDa,d,
Christophe Doddoli, MDb,d,
Bruno Chetaille, MDc,d,
Bruno Guelfucci, MDe,d,
Jean-Pierre Kleisbauer, MDa,d,
Pascal Thomas, MDb,d
c University de la Méditerranée (Aix-Marseille II), Faculty of Medicine, Assistance Publique, Hôpitaux de Marseille, Marseille, France
a Department of Thoracic OncologyMarseille, France
b Department of Thoracic SurgeryMarseille, France
d Department of Pathology, Sainte-Marguerite Hospital, Marseille, France
e Department of Head and Neck Surgery, Timone Hospital, Marseille, France
Accepted for publication September 23, 2003.
* Address reprint requests to Dr Barlesi, Service d'Oncologie Thoracique, Département des Maladies Respiratoires, Hôpital Sainte-Marguerite, 270, Bd de Sainte-Marguerite, Marseille Cedex 09 13274, France
fabrice.barlesi{at}mail.ap-hm.fr
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Abstract
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We describe a 66-year-old woman with recently diagnosed cT2N0 mouth cancer and multiple hypo-dense pulmonary nodules discovered on a computed tomographic chest scan. These nodules were located in the anterior part of the right upper and middle lobe and were resected thoracoscopically. Histologic examination of these nodules revealed a lipoid pneumonia. Exogenous lipoid pneumonia is a rare but described pulmonary disease that typically presents as consolidations. An exclusive presentation such as multiple pulmonary nodules is very unusual.
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Introduction
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The diagnosis of multiple pulmonary nodules is generally entrusted to chest physicians or thoracic surgeons. Multiple pulmonary nodules in a context of cancer are frequently synonymous with metastases and thus prognosis is poor. However a final diagnosis can sometimes be unexpected.
A 66-year-old woman with recently diagnosed floor of mouth cancer staged cT2N0 was referred after a computed tomographic chest scan showed two hypo-dense (–59 Hounsfield units) pulmonary nodules in the right upper lobe (Fig 1A, B) and the middle lobe (Fig 1C), as well as in the mediastinal lymph nodes (Fig 1D). Her past medical history was significant for tobacco exposure of 100 pack-years, chronic alcoholic intoxication, hypertension, coronary heart disease, and plastic surgery of the breasts. She had no known occupational exposure. Fiberoptic bronchoscopy was macroscopically normal. Bronchoalveolar lavage fluid also appeared to be normal. Cytologic examination showed alveolar cells without neoplastic cells. Transbronchial biopsy was not done. No microorganism was identified. Abdominal and computed tomographic head scans were normal, as well as a bone scan.
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Fig 1. (A, B) Hypo-dense nodule of the right upper lobe. (C) Nodule of the middle lobe. (D) Mediastinal lymph node (location 4R). (E) Histologic examination showing empty cystic spaces representing droplets of an aspirated exogenous oil.
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The lack of a pathologic diagnosis led to a surgical approach. Axial mediastinoscopy was performed first to sample the right mediastinal lymph node. Pathologic analysis revealed a follicular hyperplasia without tumoral involvement. Video-assisted thoracic surgery was subsequently performed. Minimal pleural effusion was seen macroscopically, which appeared to be consistent with a chylothorax. Intraoperative lung examination revealed two nodules in the middle lobe and one in the right upper lobe. Atypical resections were performed. Gross examination of the three nodules showed firm, gray-white, poorly limited, nonencapsulated lesions. On frozen sections, only fibrosis and inflammation were seen without evidence of tumor. After formalin fixation, pathologic examination of paraffin-embedded tissue revealed alterations of lung parenchyma by numerous round to oval cystic spaces surrounded by fibrosis and histiocytes, some of which displayed a finely vacuolated cytoplasm. These empty cystic spaces represented droplets of an aspirated exogenous oil that washed out during pathologic processing (Fig 1E). Altogether these findings led to a diagnosis of lipoid pneumonia. In addition, chemical analysis of pleural fluid showed cholesterol (3.79 mmol/L; normal value < 1.54 mmol/L), triglycerides (15.88 mmol/L; normal value < 1.24 mmol/L), and chylomicrons. With further questioning of the patient, she admitted to a 30-year exposure to oil (ie, paraffin oil used as a laxative and a petroleum jelly nasal drop).
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Comment
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Diagnosis of exogenous lipoid pneumonia can usually be made after a specific history of aspiration of lipid material (animal, vegetable, or mineral origin) is obtained. Clinical signs of exogenous lipoid pneumonia are unspecific. In the past, diagnosis was usually obtained by pathologic examination of a surgical specimen, but it is now performed using bronchoalveolar lavage (milky or oily fluid appearance, lipid-laden alveolar macrophages) and computed tomographic scan. Radiologic typical aspects are alveolar consolidation [1], ground glass opacities, alveolar nodules, and linear opacities. A network with a smooth linear pattern superimposed on an area of ground-glass opacity leading to the crazy-paving appearance is also classically described [2]. They are usually bilateral, predominantly involving the lower lobes and the dependent parts of the lungs. Density of these lesions is usually low [3]. The presence of isolated pulmonary nodules in the lower and dependent parts of the lung could have intend in making the diagnosis, but this was not seen in our case.
Occurrence of the exogenous lipoid pneumonia for this patient with a 30-year history of oil inhalation could perhaps be explained by a swallowing disorder secondary to her floor of mouth cancer [4]. Furthermore, a history of both oral and nasal oil exposure should have made the diagnosis easier. This emphasizes the difficulty in spontaneously obtaining a lipoid aspiration history. One remaining question in regard to the presence of chylothorax was that it has never been reported as a consequence of oil exposure. This may have resulted from the mediastinoscopy [5] as suggested by its absence on the computed tomographic scan performed 15 days preoperatively.
In conclusion, this report shows that exogenous lipoid pneumonia may have multiple atypical parenchymatous presentations that indicates exogenous oil intoxication must be systematically assessed in patients at risk of aspiration with multiple pulmonary nodules.
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References
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Abstract
Introduction
