Page 62 - ARNM-1-2

Advances in Radiotherapy
& Nuclear Medicine A case of primary pulmonary FDCS

2. Case presentation K = 0.0007/min) of the normal lung were much smaller
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(Figure 1E and F).
A 66-year-old woman, who presented with weight loss
and intermittent cough with sputum for nearly half a The presence of extrapulmonary metastasis of lung
year, underwent a routine physical examination in our cancer is a substantial prognostic determinant with a
hospital. Chest high-resolution computed tomography direct impact on survival because of a variance in the
[3]
revealed an irregular and lobulated pulmonary mass in TNM classification, clinical management, and outcome .
the apical segment of the right superior lobe (longest However, only hilar and mediastinal lymph node
diameter = 3.8 cm) with bronchial occlusion of the apical metastases of primary lung cancer still have a chance of
segment of the right superior lobe. The mass showed slight surgery and a good prognosis. Because malignancy was
enhancement on enhanced computed tomography (CT) strongly suspected, considering there was no absolute
scans. The paratracheal lymph nodes (stations 2 and 4) surgical contraindication (normal cardiopulmonary
and right hilar lymph nodes (station 10) were significantly function and no extrapulmonary metastases), aggressive
enlarged. Abdominal CT and brain magnetic resonance surgical resection was suggested after discussion. The
imaging scans showed no obvious abnormalities. patient underwent surgical sleeve resection of the right
Blood routine test showed normal red blood cell count superior lobe for the lesion with hilar and mediastinal
(4.09 × 10 /L), low hemoglobin (111.0 g/L), high blood lymph node dissection by removing lymph nodes from the
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platelet count (351.0 × 10 /L), high white blood cell count upper paratracheal, lower paratracheal, subcarinal, hilar,
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(12.99 × 10 /L), high neutrophil count (10.10 × 10 /L), interlobar, and lobar regions (stations 2, 4, 7, 10, 11 and
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high neutrophil percentage (77.70%), normal lymphocyte 12). Photomicrograph revealed ovoid and spindle tumor
count (1.83 × 10 /L), and low lymphocyte percentage cells with a diffuse growth pattern (Figure 2A, hematoxylin
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(14.10%). Tumor markers examination showed normal and eosin [H&E] staining). The cell nucleus was vesicular,
levels for progastrin-releasing peptide, cytokeratin 19 and small nucleoli were observed. Cells appeared with
fragment, carcinoembryonic antigen, neuron-specific plenty of cytoplasm with rare mitotic phases. Infiltration
enolase, cancer antigen 15-3, and squamous cell carcinoma of scattered tumor giant cells, lymphocytes, and plasma
antigen. cells was observed. The tumor cells were positive for
To clarify the diagnosis, the patient received a CT-guide vimentin (Figure 2B) and multifocal positive for CD21
percutaneous lung puncture biopsy; cytology of the and CD23. Ki-67 staining showed that the proportion
punctured tissue showed a few atypical cells with scattered of positive tumor cells was about 15% (Figure 2C). The
lymphocytes, plasma cells, and eosinophils. Due to high tumor cells were negative for SMA, desmin, calponin,
suspicion of malignancy, the patient received fluorine-18 CD34, CD68, S-100, LCA, ALK, CK, CK7, CK5/6,
fluorodeoxyglucose positron emission tomography/CT P40, P63, CD56, CgA, and Syn. In situ hybridization
( F-FDG PET/CT) scan for further systemic evaluation was negative for Epstein–Barr virus. Moreover, only
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for distant metastases. The PET maximum intensity hilar (station 10) and lobar (station 12) lymph node
projection images (Figure 1A) revealed that there was an metastases were found according to the histopathology
avid lesion in the right lung (arrow) with several avid hilar of all removed lymph node tissue. Histopathology of
and mediastinal lymph nodes (arrowhead) without distant other lymph nodes (marked stations 2, 4, 7, and 11) only
metastases of other organs. Transversal lung CT, PET, and showed the presence of lung tissue. Neither lymph nodes
PET/CT (Figure 1B-D) images showed an irregular-shaped, nor tumor tissue was found. These pathological findings
lobulated, well-defined solitary pulmonary nodule (arrow) (H&E staining, immunohistochemistry, and in situ
measuring 3.8 × 3.6 cm in the right superior lobe. The hybridization) were consistent with the manifestations
[1]
tumor demonstrated intense FDG uptake (SUV mean = 7.19). in primary pulmonary FDCS . It was reported that
For this case, due to involvement in a clinical trial, the localized FDCS patients who underwent surgery had
patient received a 60-min dynamic F-FDG PET/CT scan, significantly better overall survival (OS) compared to
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and the influx rate constant (K) was calculated by applying those who had other treatment modalities, and there
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the F-FDG PET dynamic modeling approach known as was no significant difference between OS of early-staged
Patlak graphical analysis . The K value of the pulmonary patients who received adjuvant radiotherapy and surgery
[2]
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tumor was 0.0428/min (Figure 1F). SUV mean and K values alone . In this case, the patient received surgery alone.
[1]
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of the most avid mediastinal lymph node (arrowhead, However, 1 year after surgery, follow-up plain chest CT
station 4) of the same sectional axial PET/CT (Figure 1B-D) indicated recurrence with multiple metastases of the
were 6.84 and 0.0392/min (Figure 1E and F), respectively. liver, ribs, and mediastinal lymph nodes (Figure 3). The
In contrast, the SUV mean and K values (SUV mean = 0.45, patient declined further therapy and was lost follow-up.
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Volume 1 Issue 2 (2023) 2 https://doi.org/10.36922/arnm.0824