Presentation
Smoker, chest discomfort and increasing shortness of breath for 2 months.
Patient Data
Frontal and lateral radiographs demonstrate a large soft tissue mass in the right lower zone. The mass has a calcified rim, there is no cavitation , no bone erosion or destruction seen. It lies adjacent to the heart and deviates it to the left. The precise anatomical location is unclear, it may lie in the middle lobe, be a mediastinal abnormality or potentially arise from the heart.
A small right basal pleural effusion is also suspected.
The curvilinear calcification in this location is unusual, benign and malignant lung tumors, mediastinal masses with calcification, calcified neurogenic tumors merit consideration. A vascular lesion such as a right coronary artery aneurysm also enters the differential.These aneurysms are usually seen post CABG surgery. Mycotic coronary artery aneurysms rarely calcify. Pulmonary hydatid rarely calcifies, mediastinal hydatid does calcify.
The CT study reveals a mass lesion in the lower right chest. There is calcification in the wall of this mass. It lies adjacent to the right heart border, it deviates the heart to the left. There is no rib destruction seen.There is a small pleural effusion or pleural thickening present at the right base.
No mediastinal lymphadenopathy.
On CT the lesion does not appear to arise from the coronary circulation, pleura or an adjacent rib.
CLINICAL NOTES:
Large cystic lesion. Intrathoracic sample from lesion wall.
MACROSCOPIC DESCRIPTION:
1. "Mediastinal tissue": A piece of soft red tissue 8x6x4mm. Bisected for frozen section. FS DIAGNOSIS: SCC. (AET) 2. "Mass wall": A sheet of firm tissue 50x40x5mm. The inner surface is covered by friable brown material. Representative sections for frozen section. FS DIAGNOSIS: SCC. (AET). P2. 3. "Cyst content": Multiple fragments of soft cream colored material measuring in aggregate 30x30x25mm. P1. 4. "Mediastinal mass": The specimen comprised of a collapsed pale tan cyst 125x120x90mm. The external surface of the cyst is focally fibrotic. The cyst wall is focally calcified. The internal surface of the cyst contains friable pale tan material. P5. Digital photo taken. (MAS)
MICROSCOPIC DESCRIPTION:
1. Vascular fibrous tissue containing focally keratinizing well differentiated squamous cell carcinoma.
2. Vascular fibrous tissue containing focally keratinizing well differentiated squamous cell carcinoma.
3. Acellular debris.
4. Focally calcified fibrous tissue containing multiple foci of squamous cell carcinoma. Lymphovascular is identified. No luminal lining epithelium is identified.
DIAGNOSIS:
1. Mediastinal tissue: Well differentiated squamous cell carcinoma.
2. Mass wall: Well differentiated squamous cell carcinoma.
3. Cyst contents: Amorphous material.
4. Mediastinal mass: Well differentiated squamous cell carcinoma within calcified fibrous cyst wall. Lymphovascular invasion identified.
Case Discussion
Calcified cancers of the mediastinum and lung are uncommon.
The majority of mediastinal masses that contain calcification are usually teratomata, calcifications in mediastinal metastases or following radiotherapy for lymphoma.
Calcification maybe seen in cystic thymic tumors and has been described in mediastinal hydatid although very rare.
When calcification occurs in lung malignancies it is rarely curvilinear , it more commonly presents as an amorphous mass within a cancer.
This SCC most likely had its origin with a thymic cyst or some other congenital cystic structure of the mediastinum
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