Presentation
Cough for a few months. Current smoker. No other past medical history.
Patient Data
Right lower lobe opacity with volume loss. Impression of cavity superiorly. Left lung and pleural space is clear. No bone lesion.
Cavitating right lower lobe mass centered on the superior segment. It extends to the hilum but there is no definite hilar or mediastinal lymphadenopathy.
Cavitating mass demonstrates peripheral FDG avidity. No mediastinal nodal uptake or distant metastases.
MACROSCOPIC DESCRIPTION: The specimen consists of a right lower and middle lung lobe with the lower lobe measuring 140 x 140 x 135 mm. The middle lobe measures 150 x 70 x 50 mm. There are three areas of pleural disruption within the lower lobe with the first lying 27 mm from the hilum and measuring 40 x 10mm. The second area lies antero-inferiorly and measures up to 55mm in extent. The third area of disruption is present laterally and measures up to 25mm in extent. The middle lobe is intact. At the bronchial resection margin, a firm cream tumor is seen partially obstructing the bronchus. The cut surface of the lower lobe shows a centrally located solid cream tumor with patchy hemorrhage measuring 50 x 37 x 55 mm. Distal to this, there is a large cavitating area filled with hemorrhage and purulent exudate and measuring 80 x 43 x 85 mm. The cavity extends to communicate with the lateral and central pleural defects. The tumor appears to expand and distort the visceral pleura but does not clearly invade through it. The tumor does not extend to involve the middle lobe.
MICROSCOPIC DESCRIPTION: Sections from the right lower lung lobe show a 55mm poorly differentiated squamous cell carcinoma centered towards the hilar region. The tumor comprises islands and nests of pleomorphic tumor cells that are supported by a dense desmoplastic stroma. The tumor cells have large, irregularly circumscribed, nuclei with large eosinophilic nucleoli and a moderate amount of eosinophilic cytoplasm. There are scattered foci of intracytoplasmic keratin. Large areas of tumor necrosis are present, together with abundant atypical mitotic figures. Tumor cells are TTF-1 negative and p40 positive by immunohistochemistry. There is perineural invasion. Tumor also invades the wall of elastic arteries. The tumor appears to invade the visceral pleura in one focus and this is confirmed on an elastin stain. There are five hilar lymph nodes, one containing metastatic carcinoma. The adjacent non-neoplastic lung has abscess formation, necrosis and organizing fibrosis. Sections from the middle lobe show a pleuritis but no evidence of malignancy.
Diagnosis: Right lower and middle lung lobes: Poorly differentiated squamous cell carcinoma, right lower lobe:
- 55mm maximum extent
- Perineural invasion
- Invasion through visceral pleura
- 1/5 hilar lymph nodes contain metastatic carcinoma
- Does not extend to right middle lobe
- Adjacent cavitation, abscess and fibrosis
Pathology specimens and report courtesy Department of Pathology, The Royal Melbourne Hospital.
Case Discussion
This case demonstrates a squamous cell lung cancer that caused distal obstruction that has resulted in distal abscess formation that has cavitated. There was single hilar node metastases that was occult on both CT and PET.
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