Radiology/Pathology Correlation

Unknown 4

A 48-year-old black woman presented to the emergency room with acute thoracoabdominal pain. The nature of her pain suggested the possibility of aortic dissection, for which a multidetector-row helical CT examination of the chest, abdomen, and pelvis was obtained. This study demonstrated a large, protruding thrombus in the distal thoracic aorta, but also incidentally revealed the presence of a lesion along the right lateral tracheal wall. The patient denied respiratory complaints.

Radiology

Imaging Findings:

Image A: Axial CT cephalic to Image B

 

 

Image B: Axial CT caudal to Image A

tumor

 

The two axial CT images show asymmetric, plaque-like thickening of the right lateral wall of the trachea, without evidence of tracheal cartilage destruction. The abnormal tissue is not calcified.

In image A, find the lesion. Click on the structure in the image to get verification.

In image B, 1) outline and name the vascular structure just anterior to the trachea, 2) find the left brachiocephalic vein.

 

aortabrachv

aortapulmartlatriumtumor

Other Imaging

This contrast-enhanced, coronal maximum intensity-projected image demonstrates the contiguous nature and plaque-like morphology of the tracheal abnormality to advantage.

Outline the lesion.

Find the aorta.

Find the pulmonary artery. Note the aortico-pulmonary window.

Outline the left atrium. Note the pulmonary veins.

 

Bronchoscopy

A virtual bronchoscopic image (left) shows multiple sessile polyps protruding from the right lateral tracheal wall into the airway lumen. These findings correlate with the bronchoscopic image (right).

Give a differential diagnosis for the lesion. Answer

 


Pathology

Histology--Overview

This section from another patient shows tumor infiltrating bronchial glands and growing on both sides of the cartilage, challenging bronchoscopic removal.

Histology--Low Power

This biopsy from the current patient shows tumor infiltrating the subepithelial tissue. Tumor cells are round to spindled and show mild variation in nuclear size. Mitoses are absent.

The homogeneous, extracellular, pink material beneath the epithelium and forming nests in the tumor represents thickening of the basement membrane (most likely the same collagenosis of the tissue beneath the basement membrane as seen in asthma). This finding, when present, is more pronounced in these tumors than in asthma and helps to suggest the diagnosis.

bm1bm2

Outline 2 examples of this "basement membrane" material.

What other type of extracellular deposit resembles this material? What special stain would identify it? Answer

Histology--High Power

 

At high power, the tumor cells have ill-defined cell borders and abundant, granular pink cytoplasm. Nuclei are mostly dark and small.

What is the histologic differential diagnosis? Answer

What is the most likely diagnosis?

Answer

 

Scroll down after answering the questions.

 

 

 

 

 

 

 

Giant cell tumors (GCTs) (formerly called Abrikossoff tumor and granular cell myoblastoma (now thought to show Schwann cell differentiation, not muscle differentiation)) occur in most parts of the body, especially the skin, mucous membranes, and breast. Rarely, malignant variants occur. About 10% of GCT arise in the larynx [1], trachea (about 30 cases reported up to 2002) [2,3], bronchial tree (about 100 cases reported up to 1995 [4]) or, even more rarely, in lung parenchyma. Malignant pulmonary variants have not been described although metastatic GCT can occur in the lung. Tumors occur in adults of both sexes (median age 45 in adults [4]) and sometimes in children [2]. There appears to be a preference for African-Americans [4]. One half of patients are asymptomatic and one half have symptoms related to obstruction [4]. Tumors may be multiple in the lung or associated with extrapulmonary GCTs. GCT may coexist with bronchogenic carcinoma [5]. Endoscopic removal or surgical resection is used depending on the extent of the tumor and lung damage. Recurrences have been reported when excision has not been complete.

Comments on the radiographic findings in tracheobronchial disease

Comments on the pathologic findings of granular cell tumor [4]

Final Diagnosis: Granular cell tumor. Because the patient was asymptomatic, no further treatment was given. The plan is to follow her with spirometry and CT scans and to consider endobronchial laser therapy.

References

1. Mukherji SK, Castillo M, Rao V, Weissler M. Granular cell tumors of the subglottic region of the larynx: CT and MR findings. AJR Am J Roentgenol 1995;164:1492-1494.

2. Amar YG, Nguyen LH, Manoukian JJ, Nguyen VH, O'Gorman A, Shapiro R. Granular cell tumor of the trachea in a child. Int J Pediatr Otorhinolaryngol 2002; 62:75-80. abstract

3. Thaller S, Fried MP, Goodman ML. Symptomatic solitary granular cell tumor of the trachea. Chest 1985;88:925-928. abstract

4. Deavers M, Guinee D, Koss M, Travis W. Granular cell tumors of the lung. Clinicopathologic study of 20 cases. Am J Surg Pathol 1995; 19:627-635. abstract

5. Muhammad A, Sikka P, Dhillon R, Gibbons W, Ahmed A. Co-existing granular cell tumor and adenocarcinoma of the lung: a case report and review of the literature. Respir Care 2001; 46:702-704. abstract

TOP----------Rad/Path Home Page

Last modified 7/7/02

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lesion

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Radiographic Differential Diagnosis: The differential diagnosis of fixed lesions of the trachea that result in focal narrowing include malignant neoplasms (particularly squamous carcinoma, but also adenoid cystic carcinoma, mucoepidermoid carcinoma, carcinoid tumor, metastases, and local airway invasion from adjacent neoplasms), numerous benign mesenchymal tumors including lipoma (bookmark this page before going to this extended site), post-intubation stenoses, infections (particularly tuberculosis and aspergillosis), and non-infectious inflammatory conditions, such as Wegener's granulomatosis and amyloidosis. These entities are difficult to differentiate from one another on the basis of imaging findings alone, and bronchoscopy with biopsy is usually required.

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Aorta

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Left brachiocephalic vein

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Aorta

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Pulmonary artery

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Left atrium

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What other type of extracellular deposit resembles this material? Amyloid

What special stain would identify it? Congo red stain showing apple green birefringence with polarized light. The stain was negative in this case.

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"Basement membrane" material

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Histologic Differential Diagnosis: Granular cell tumor (S-100 positive), carcinoid tumor (oncocytic variant) (chromogranin positive), squamous carcinoma (keratin positive), metastasis of granular cell variants of renal cell carcinoma, metastasis of granular cell tumor arising elsewhere, and the inflammatory condition malakoplakia.

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