Pulmonary hyalinizing granuloma

Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT

High-attenuation pulmonary abnormalities are commonly seen on CT. These findings are increasingly encountered with the growing number of CT examinations and the wide availability of thin-slice images. The abnormalities include benign lesions, such as infectious granulomatous diseases and metabolic diseases, and malignant tumors, such as lung cancers and metastatic tumors. Due to the wide spectrum of diseases, the proper diagnosis of high-attenuation abnormalities can be challenging. The assessment of these abnormal findings requires scrutiny, and the treatment is imperative. Our proposed stepwise diagnostic algorithm consists of five steps. Step 1: Establish the presence or absence of metallic artifacts. Step 2: Identify associated nodular or mass-like soft tissue components. Step 3: Establish the presence of solitary or multiple lesions if identified in Step 2. Step 4: Ascertain the predominant distribution in the upper or lower lungs if not identified in Step 2. Step 5: Identify the morphological pattern, such as linear, consolidation, nodular, or micronodular if not identified in Step 4. These five steps to diagnosing high-attenuation abnormalities subdivide the lesions into nine categories. This stepwise radiologic diagnostic approach could help to narrow the differential diagnosis for various pulmonary high-attenuation abnormalities and to achieve a precise diagnosis.Critical relevance statement Our proposed stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities may help to recognize a variety of those high-attenuation findings, to determine whether the associated diseases require further investigation, and to guide appropriate patient management. Key points • To provide a stepwise diagnostic approach to high-attenuation pulmonary abnormalities.• To familiarize radiologists with the varying cause of high-attenuation pulmonary abnormalities.• To recognize which high-attenuation abnormalities require scrutiny and prompt treatment.

Syphilitic Pulmonary Inflammatory Pseudotumor: A Diagnostic Challenge

A 46-year-old man presented with nonproductive cough and lower limb swelling. Chest radiograph showed a left lower lobe lung mass and multiple subpleural nodules. Other investigations revealed that he had nephrotic syndrome. Core biopsies of the left lower lobe lung mass showed features of inflammatory pseudotumor with endarteritis obliterans and a lymphoplasmacytic infiltrate. Immunohistochemical stain for Treponema pallidum was positive. Resolution of the lung mass and nephrotic syndrome was achieved after treatment with intramuscular benzathine benzylpenicillin. The differential diagnosis of pulmonary inflammatory pseudotumor, manifestations of pulmonary syphilis, and a literature review of secondary syphilis of the lung are discussed.

A rare solitary and endobronchial pulmonary hyalinising granuloma requiring bilobectomy

Pulmonary hyalinising granuloma is a very rare disease often presenting as multiple smooth rounded nodules within the lung parenchyma and mimicking metastatic disease. Solitary pulmonary hyalinising granuloma is an even rarer subgroup, and to our knowledge, there have been no endoluminal pulmonary hyalinising granulomas reported. A 36-year-old female non-smoker with no significant past medical history presented with a persistent cough and was found to have a right lower lobe bronchial lesion causing lower lobe obstruction. After multiple failed attempts at tissue diagnosis from both percutaneous and endobronchial biopsies, and with worsening haemoptysis, the patient underwent a right thoracotomy and lower bilobectomy. The histopathology was reported as a solitary endobronchial pulmonary hyalinising granuloma. Although benign in nature, tissue diagnosis can be difficult in these lesions, especially when presenting as a solitary mass in a central location. This report demonstrates that these lesions can also be found endobronchially necessitating parenchymal resection for diagnosis and obstructive symptoms.

Pulmonary Hyalinizing Granuloma Mimicking Primary Lung Cancer

We herein report a case of pulmonary hyalinizing granuloma (PHG), which is a rare pulmonary mass. A 69-year-old man with no symptoms presented to our hospital because of the appearance of an abnormal shadow on chest X-ray. Computed tomography revealed a right middle-lobe mass with spicula and infiltration into the upper lobe. Since a bronchofiberscopic examination showed no malignant cells in the specimen, the patient underwent thoracoscopic surgery, which revealed PHG. Spiculation and interlobar infiltration, which comprise the characteristic features of primary lung cancer, are uncommon presentations of this rare entity.

Pulmonary hyalinizing granuloma: a multicenter study of 5 new cases and review of the 135 cases of the literature

Pulmonary hyalinizing granuloma (PHG) is a rare disease characterized by single or multiple benign lung nodules mimicking lung neoplasma. Histologic analysis reveals homogenous hyaline lamellae, usually surrounded by collection of plasma cells, lymphocytes and histiocytes in a perivascular distribution. The clinical and radiological findings have been described in small series, but the long-term outcomes have rarely been reported. The objectives were to describe the clinical, radiological and outcomes of PHG in new cases and through a literature review. Patients with PHG were found by a multicenter search among French departments of internal medicine, pulmonology and anatomo-pathology. Review of the literature was made through the National Library of Medicine's MEDLINE database using keywords "hyalinizing granuloma." Five news cases and 135 cases of the literature were found. There were 82 men and 57 women, mean age at the diagnosis 44.6 years (15-83). Patients were frequently asymptomatic (n = 39, 27.4 %). The nodule was unique in 37 cases (28.9 %) and multiple in 91 cases (71.1 %). 18FDG PET scan revealed hypermetabolism of the nodule in 9/15 cases (60 %). A systemic disease was associated in 65 cases (mainly mediastinal and retroperitoneal fibrosis, autoimmune, tumoral or infectious disease or thromboembolism). The outcomes were evaluated in 73 patients when follow-up was available: 14 patients had a surgical resection of the nodule. Forty-five patients did not receive any immunosuppressive drug. Among these patients, 2 improved, 29 were stable and 14 worsened. Corticosteroids were used as a monotherapy in 19 patients and led to radiological improvement in 8 cases, stabilization in 8 cases and worsening in 3 cases. Five patients were treated with corticosteroids and at least one immunosuppressive drug and 4 patients improved. PHG is a rare benign disease, mimicking lung neoplasma, frequently associated with systemic diseases.

Radiographic and Pathologic Manifestations of Uncommon and Rare Pulmonary Lesions

Pulmonary opacities/nodules are common findings on computed tomography examinations, which may represent an underlying infections or malignancy. However, not every pulmonary nodule or opacity represents malignancy or infection. We present a pictorial essay illustrating common as well as obscure noninfectious, nonmalignant pulmonary lesions. Lesions discussed include organizing pneumonia, Langerhans cell histiocytosis, pulmonary amyloidosis, hyalinizing granuloma, tumourlet (benign localized neuroendocrine cell proliferations), atypical alveolar hyperplasia, inflammatory myofibroblastic tumour, papillary alveolar adenoma, plasma cell granuloma, juvenile xanthogranuloma, and sclerosing hemangiomas. We discuss the clinical presentation, prevalence, radiographic clues, pathology, and diagnostic pitfalls of these rare lesions.

Pulmonary Hyalinizing Granuloma Mimicking Metastatic Lung Cancer

Pulmonary hyalinizing granuloma is a very rare benign condition, which usually manifests as solitary and sometimes as multiple pulmonary nodules. Deposition of immune complexes in the lung parenchyma due to hypersensitivity reactions is implicated in the etiology of pulmonary hyalinizing granuloma. A 59-year-old female patient who presented to our clinic with complaints of chest pain and cough had bilateral, multiple, and rounded lesions with regular margins suggesting metastatic lung disease. A transthoracic needle biopsy of the nodule was performed in the left pulmonary anterior segment. Biopsy showed no malignancy. Since no diagnosis was made by the biopsy, the patient underwent a video-assisted thoracic surgery. The wedge biopsy reported pulmonary hyalinizing granuloma. We aimed to present the diagnosis and treatment stages of our patient who was diagnosed with pulmonary hyalinizing granuloma in the light of literature review.

A 40-year-old woman with multiple pulmonary nodules. Pulmonary hyalinizing granuloma

A 40-year-old woman (a nonsmoker) with history of idiopathic thrombocytopenic purpura and a platelet count > 90,000 cells/μL without specific medication was referred to pulmonary clinic for evaluation of multiple pulmonary nodules. The patient presented to an outside hospital with fatigue, lack of energy, and dyspnea on exertion for 2 years. She denied fever, cough, chest pain, or weight loss. An initial chest radiograph showed bilateral multiple pulmonary nodules. A chest CT scan revealed multiple nodular lesions, varying in size, in all lobes of both lungs. There was no mediastinal lymphadenopathy or pleural effusion. There was no significant hypermetabolic activity on a subsequent fluorodeoxyglucose PET scan/CT scan, and there had been no significant change. She underwent CT scan-guided percutaneous transthoracic biopsy and bronchoscopy with transbronchial biopsies, all of which were inconclusive. An open lung biopsy was considered.

A comorbid case of multicentric Castleman's disease and pulmonary hyalinising granuloma successfully treated with tocilizumab and corticosteroid

A 49-year-old man with superficial lymphadenopathy presented with symptoms of low-grade fever, general fatigue and weight loss. On examination, multiple superficial lymphadenopathies and brown macules were observed on the trunk. Laboratory studies revealed an elevation of serum C reactive protein and interleukin 6 (IL-6) in addition to polyclonal hyperimmunoglobulinaemia. High-resolution CT of the chest showed bilateral multiple nodules and patchy ground-glass opacities with interstitial thickening. Biopsy of the cervical lymph node and skin biopsy showed numerous perivascular plasma cells, which were characteristic of the plasma cell type of Castleman's disease. Surgical lung biopsy showed hyalinising granuloma, which are hyalinous nodular lesions surrounded by lymphoid cells. He was diagnosed with multicentric Castleman's disease complicated by pulmonary hyalinising granulomas; his symptoms improved by treatment with tocilizumab, which is a humanised antihuman IL-6 receptor monoclonal antibody and corticosteroid. This is the first report of a comorbid case successfully treated with tocilizumab and corticosteroid.

Pulmonary hyalinizing granuloma detected in a family member after confirmation of tuberculosis in his father

Pulmonary hyalinizing granuloma (PHG) is an uncommon lung disease that usually presents as bilateral multiple nodules, and more rarely as a solitary nodule. An exaggerated immune response to antigenic stimuli resulting from infection or an autoimmune process has been suggested as the cause of PHG. Here, we describe a rare case of solitary PHG that was detected in a family member after tuberculosis had been confirmed in his father, without any background of infectious disease or autoimmune abnormality.

Chickenpox-related pulmonary granulomas in immunocompetent adults: clinicopathologic and molecular features of an underrated occurrence

Pulmonary granulomas represent a common inflammatory reaction to several lung infective or noninfective diseases. However, little is known about the histology and clinical presentation of chickenpox-related granulomas in immunocompetent subjects. We collected a series of 8 adult patients (mean age, 40 y; range, 33 to 53 y) with several bilateral pulmonary granulomas incidentally discovered after imaging studies. All patients were asymptomatic and had experienced a varicella-zoster virus (VZV) infection as adults but were clinically suspected to have a metastatic neoplasm of unknown origin. Chest computed tomography scan revealed numerous, tiny (few millimeters to 1 cm in size) nodules randomly dispersed through the lungs. Positron emission tomography scan performed in 4 patients was negative. All patients underwent video-assisted thoracoscopic surgical resection and were still alive and well. At histology, granulomas consisted of well-defined, rounded, small nodules centered by a deeply eosinophilic, acellular necrosis rimmed by lamellar dense collagen and a chronic inflammatory infiltrate with or without multinucleated giant cells. Chickenpox-related granulomas were included in the differential diagnosis along with several other granulomatous diseases. Polymerase chain reaction-based molecular analysis for VZV performed on paraffin sections detected VZV DNA in all 8 cases. By contrast, 85 cases of pulmonary granulomas of different etiologies were simultaneously studied by molecular analysis with negative results. Pathologists should be familiar with the peculiar morphologic appearance of chickenpox-related granulomas. A careful search for a history of VZV infection in adulthood and molecular studies may be very helpful in confirming the diagnosis.

A Unique Case of Pulmonary Hyalinizing Granuloma Associated With FDG-avid PET Scan and Deep Venous Thrombosis

An 83-year-old obese woman with a 60-pack-year smoking history was referred for evaluation of an abnormal chest radiograph [chest x-ray (CXR)]. Her past medical history was significant for recurrent deep venous thrombosis without any predisposing factors. CXR showed a large mass in the right mid lung and another nodule at the right apex, highly suspicious for a neoplastic process. These were not present on a CXR from 2 years earlier. An fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scan revealed that all lesions were strongly FDG-avid. Six CT-guided core-needle lung biopsy specimens were obtained from the lung mass and all contained dense, lamellar, or "ropy" keloid-like collagen bundles arranged in a haphazard pattern. The biopsy specimens lacked significant necrosis and granulomas. Congo red stain with polarization was also negative for amyloid. The diagnosis of pulmonary hyalinizing granuloma (PHG) was made. A complete hypercoagulable workup was performed but no underlying abnormalities were found, including a negative lupus anticoagulant and malignancy workup. The patient was maintained on warfarin and followed with serial CT scans for 1 year, with spontaneous regression in the lung mass. The case is unique as it is the first case that reports an association of PHG with recurrent deep venous thrombosis in the absence of autoimmune or procoagulant factors and emphasizes the need for life-long anticoagulation in such scenarios. Also, we report the FDG-avid PET scan findings here that are novel for this disease in adults and add PHG to the list of diseases causing false-positive PET scans when malignancy is suspected.

Neoplastic and nonneoplastic benign mass lesions of the lung

While most lung neoplasms are malignant, a subset of true neoplasms are benign, the most common of which are pulmonary hamartomas. In addition, a substantial proportion of lung mass lesions are nonneoplastic; granulomas are among the commonly encountered nonneoplastic masses. There is also a group of relatively rare, mainly inflammatory and fibrous tumor-like lesions that are encountered on core biopsy and excisions of lung tissue.

Pulmonary hyalinizing granuloma mimicking multiple lung metastases: report of fluorodeoxyglucose positron emission findings

Pulmonary hyalinizing granuloma (PHG) is a rare disease characterized by multiple bilateral pulmonary nodules of uncertain etiology. We describe a 71-year-old female patient with thyroid papillary carcinoma in whom bilateral pulmonary nodules were found during a routine chest radiography examination. Subsequent fluorodeoxyglucose positron emission tomography/computed tomography scan gave the impression of multiple pulmonary metastases based on high maximum standardized uptake value. She underwent video-assisted thoracoscopic surgery with wedge resection, and PHG was diagnosed on the basis of histopathologic findings. To our knowledge, this is the first report of PHG developing in a patient as a solid cancer, mimicking multiple pulmonary metastases. We also present the first description of positron emission tomography in PHG, according to a Medline search.

Primary sclerosing neuroendocrine carcinomas of the lung: A clinicopathologic and immunohistochemical study of 10 cases

We describe 10 cases of primary well-differentiated neuroendocrine carcinomas (carcinoid tumor) of the lung with extensive sclerotic changes. The patients were 6 women and 4 men from 20 to 69 years of age. Clinically, patients had symptoms of bronchial obstruction such as cough, dyspnea, and chest pain. Surgical resection of the tumors was accomplished in all the cases. Histologically, all tumors corresponded to the well-differentiated type; however, in 4 cases, lymph node metastases were present. Immunohistochemically, all tumors showed positive staining for neuroendocrine markers, including chromogranin, synaptophysin, CD56, and broad-spectrum keratin. Follow-up information showed that 8 patients were alive after a period ranging from 1 to 5 years. The cases presented highlight an important feature of neuroendocrine carcinomas of the lung not previously addressed, one that may pose a problem not only in the diagnosis but also in the grading of these neoplasms.

Pulmonary pseudoneoplasms

CONTEXT

Not uncommonly, a surgical pathologist will be requested to review excised material, with a clinical diagnosis of cancer, in which no malignancy can be identified. Often, sampling may be the issue. However, different nonneoplastic processes may mimic cancer clinically and not be recognized histologically. These are commonly referred to as pseudoneoplasms and can involve the lung, pleura, and mediastinum.

OBJECTIVE

To review the most commonly encountered pseudoneoplasms of the thoracic cavity in surgical pathology and discuss the main differential diagnosis.

DATA SOURCES

Literature and personal review of cases with focus on inflammatory pseudotumors of the lung, organizing pneumonia, nodular lymphoid hyperplasia, apical cap, round atelectasis, and sclerosing mediastinitis with its pulmonary counterpart, hyalinizing granuloma.

CONCLUSIONS

When reviewing specimens that appear nondiagnostic for malignancy, it is important to consider one of these pseudoneoplasms in the differential diagnosis as they may explain the clinical and radiologic information.

Non-diagnosed pulmonary hyalinizing granuloma (PHG) as a cause of sudden unexpected death

Pulmonary hyalinizing granuloma (PHG), a very rare benign tumour of the lungs, was first reported in 1977. We present a PHG of a 32-year-old woman from Yemen who collapsed 1 day after her arrival in Germany. Tuberculosis was suspected and the health authorities nearly closed part of one of the major international airports in Europe. However, this drastic measure was avoided by autopsy and a correct interpretation of the solid-elastic and well-circumscribed lung tumour as not characteristic for tuberculosis. Although the final diagnosis of PHG was only achieved after histology, this case strongly illustrates the necessity of a profound morphological training of forensic physicians.

Benign Tumors and Tumorlike Conditions of the Lung

Context.—Benign tumors and tumorlike conditions of the lung are encountered in the pathologic evaluation of asymptomatic and symptomatic lung nodules. Since many of these lesions are uncommon, they can be diagnostically challenging.

Objective.—To review the current classification of benign lung tumors, with emphasis on histopathology and useful ancillary studies.

Data Sources.—The current World Health Organization classification system for lung neoplasms and review of relevant publications.

Conclusions.—Despite improved imaging techniques, benign lung nodules are encountered in wedge biopsy and resection specimens. Histopathology, immunohistochemistry, and molecular techniques ensure accurate pathologic diagnosis and have shed light on the histogenesis of these unusual lesions.

[Pulmonary hyalinizing granuloma revealed by a pituitary gland diffusion]

INTRODUCTION

Pulmonary hyalinizing granuloma is a rare fibrosing lesion of the lung, characterized by its histological appearance which includes central whorled deposits of lamellar collagen. The extrapulmonary diffusion of the disease is extremely rare, and in our knowledge any case of pituitary diffusion has ever been reported in the literature.

EXEGESIS

We reported an unpublished case of a 31-year-old woman presenting with amenorrhea, galactorrhea, diplopia, headache, polyuria and polydipsia. The diagnosis of pulmonary hyalinizing granuloma revealed by an intracranial localization was based on radiologic and pathologic findings. Clinical course was favourable with corticotherapy.

CONCLUSION

Our report is particular because cerebral localization was the initial manifestation of primary hyalinizing granuloma and because of the favourable outcome with corticotherapy.

Subpleural pulmonary hyalinizing granuloma presenting as a solitary pulmonary nodule

We introduce a case of pulmonary hyalinizing granuloma presented as a solitary pulmonary nodule located subpleurally. The patient was a 57-year-old man who had abnormal chest roentgenograms showing a solitary pulmonary nodule in the right lower lung field. The nodule was resected for definitive diagnosis and histopathologically proved to be pulmonary hyalinizing granuloma. In previously reported cases, most patients had ill-defined margins and usually bilateral, multiple lesions radiographically. In our case, the subpleural location is an uncommon location of this rare entity.

Radiology–Pathology Conference: pulmonary hyalinizing granuloma associated with lupus-like anticoagulant and Morvan's Syndrome

Pulmonary hyalinizing granulomata are rare, noninfectious, fibrosing lesions of the lung, which can mimic metastatic disease radiographically. Their etiology is unknown, but they may be caused by an exaggerated immune response. We report the radiology, long clinical course, and pathology of a patient with pulmonary hyalinizing granuloma who presented with initially asymptomatic pulmonary nodules. Over a 10-year period, the patient developed multiple insidious autoimmune phenomena, including lupus anticoagulant, neuromyotonia, demyelinating sensorimotor polyneuropathy, and eventually, Morvan's syndrome. Such an association has not been previously published to our knowledge.

Pulmonary hyalinizing granuloma and retroperitoneal fibrosis in an adolescent

We describe a 15-year-old boy who developed pulmonary hyalinizing granuloma (PHG) and retroperitoneal fibrosis (RPF). His PHG and RPF were not associated with histoplasmosis or tuberculosis and appeared to represent idiopathic autoimmune phenomena. This is the first reported case of PHG in a pediatric patient and the fourth reported co-occurrence of PHG and RPF. The use of F-18 fluorodeoxyglucose positron emission tomography in the diagnostic and follow-up evaluation of PHG is reported.

Hyper-IgG4 disease: report and characterisation of a new disease

BACKGROUND

We highlight a chronic inflammatory disease we call 'hyper-IgG4 disease', which has many synonyms depending on the organ involved, the country of origin and the year of the report. It is characterized histologically by a lymphoplasmacytic inflammation with IgG4-positive cells and exuberant fibrosis, which leaves dense fibrosis on resolution. A typical example is idiopathic retroperitoneal fibrosis, but the initial report in 2001 was of sclerosing pancreatitis.

METHODS

We report an index case with fever and severe systemic disease. We have also reviewed the histology of 11 further patients with idiopathic retroperitoneal fibrosis for evidence of IgG4-expressing plasma cells, and examined a wide range of other inflammatory conditions and fibrotic diseases as organ-specific controls. We have reviewed the published literature for disease associations with idiopathic, systemic fibrosing conditions and the synonyms: pseudotumour, myofibroblastic tumour, plasma cell granuloma, systemic fibrosis, xanthofibrogranulomatosis, and multifocal fibrosclerosis.

RESULTS

Histology from all 12 patients showed, to varying degrees, fibrosis, intense inflammatory cell infiltration with lymphocytes, plasma cells, scattered neutrophils, and sometimes eosinophilic aggregates, with venulitis and obliterative arteritis. The majority of lymphocytes were T cells that expressed CD8 and CD4, with scattered B-cell-rich small lymphoid follicles. In all cases, there was a significant increase in IgG4-positive plasma cells compared with controls. In two cases, biopsies before and after steroid treatment were available, and only scattered plasma cells were seen after treatment, none of them expressing IgG4. Review of the literature shows that although pathology commonly appears confined to one organ, patients can have systemic symptoms and fever. In the active period, there is an acute phase response with a high serum concentration of IgG, and during this phase, there is a rapid clinical response to glucocorticoid steroid treatment.

CONCLUSION

We believe that hyper-IgG4 disease is an important condition to recognise, as the diagnosis can be readily verified and the outcome with treatment is very good.

Pathology of the Pleura

The pleura and lung are intimately associated and share many pathologic conditions. Nevertheless, they represent two separate organs of different embryonic derivation and with different yet often symbiotic functions. In this article, the authors explore the pathologic manifestations of the many conditions that primarily or secondarily affect the pleura.

[Pulmonary hyalinising granuloma with mediastinal fibrosis: a rare cause of dysphagia]

Pulmonary hyalinising granulomas (PHG) are rare. They are defined by the presence of collagen lamellar fibrosis. One third are associated with retroperitoneal or mediastinal fibrosis. Two cases of PHG are presented. They were revealed by dysphagia due to tight oesophageal stricture from associated mediastinal fibrosis. PHG are considered as a benign and slowly evolving disease, but associated mediastinal fibrosis may evolve on its own. Only steroid therapy may slow down progression. This makes an accurate diagnosis necessary. It relies on large surgical biopsies.

Pulmonary hyalinizing granuloma with laryngeal and subcutaneous involvement: report of a case successfully treated with glucocorticoids

We report a case of pulmonary hyalinizing granuloma (PHG) with laryngeal and subcutaneous involvement. A 43-year-old man was admitted to our hospital for assessment of hoarseness. Cervical and chest computed tomography, respectively, revealed a laryngeal tumor and two pulmonary masses. Specimens obtained from the pulmonary masses were compatible with PHG. The histopathology of biopsy specimens from both the laryngeal tumor and a subcutaneous tumor resembled that of the resected lung masses. Although there is no established treatment for PHG, the laryngeal tumor was diminished and all other lesions disappeared with glucocorticoid treatment.

A Case of Pulmonary Hyalinizing Granuloma Associated with Posterior Uveitis

A 48-year-old male was admitted to our hospital because of abnormal pulmonary shadows and a decrease in visual acuity. He had a history of tuberculosis 20 years ago. The chest roentgenogram showed multiple pulmonary nodules throughout both lung fields. No definitive diagnosis was established either by brushing cytology or biopsy through bronchoscopy or percutaneous needle biopsy. Pathological examination of open lung biopsy specimen revealed that extensive, hyalinized lamellar collagen bundles arranged in whorls, parallel arrays. Plasma cells and lymphocytes were found between the collagen bands and germinal centers were seen at the periphery of the lesion. A definitive diagnosis of pulmonary hyalinizing granuloma was made on the basis of these histopathological findings. Although there is no established treatment for pulmonary hyalinizing granuloma, during 1 month of follow-up, posterior uveitis mildly resolved with glucocorticoid treatment and there had been a slight increase in visual acuity.

AS. Granulomas hialinizantes pulmonares: aspectos na tomografia computadorizada - relato de caso

Granulomas hialinizantes são lesões fibrosantes benignas que em geral se apresentam radiologicamente sob a forma de nódulos múltiplos, freqüentemente escavados e/ou calcificados. Neste trabalho é relatado o caso de uma paciente de 28 anos de idade que apresentou a doença provavelmente secundária a infecção tuberculosa prévia. Ressalta-se a necessidade da inclusão deste diagnóstico diferencial frente ao quadro radiológico de múltiplas lesões nodulares.

Primary pulmonary low-grade marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type with prominent hyalinosis. A case report

We report a case of primary pulmonary low-grade marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT)-type with prominent sclerosis, which morphologically resembled pulmonary hyalinizing granuloma (PHG) or inflammatory pseudotumor (IPT) of the lung. The patient, a 66-year-old Japanese female with a history of Sjögren's syndrome and primary biliary cirrhosis, presented with a lower left lobe mass 6.8 cm in diameter. Histologically, the lesion is characterized by dense bundles of collagen with scattered plasma cells, mature small lymphocytes, and histiocytes among the collagen bundles. Only the peripheral area of the nodule contained dense lymphoplasmacytoid and histiocytoid infiltrates. A few centrocyte-like cells were obscured by the numerous plasma cells and plasmacytoid cells. In addition, lymphoepithelial lesions and colonalized lymphoid follicles were identified by immunohistochemistry alone. Although PHG and IPT are unlikely to be confused with pulmonary MALT-type lymphomas, the present case suggests that MALT-type lymphoma should be added to the list of differential diagnoses for PHG and IPT.

Pulmonary hyalinizing granuloma associated with Aspergillus infection

A 38-year-old immunocompetent man with occupational exposure to Aspergillus presented with dyspnea, pleuritic chest pain, and hemoptysis. Chest roentgenograms and computed tomography scans demonstrated multiple pulmonary nodules bilaterally. An initial set of bronchial washing cultures grew Aspergillus fumigatus, serologic testing showed an elevated anti-Aspergillus titer, and immunodiffusion testing was positive for antibody against A. fumigatus and A. niger. There was no microbiologic or serologic evidence of infection by other pathogens, and no clinical or laboratory evidence of autoimmune disease. An open lung biopsy was diagnostic of pulmonary hyalinizing granuloma. This novel association with Aspergillus infection not only expands the spectrum of pathogens linked to pulmonary hyalinizing granuloma but also documents a new pattern of lung disease that can be caused by Aspergillus.

Pulmonary small lymphocytic lymphoma (mucosa-associated lymphoid tissue type) associated with pulmonary hyalinizing granuloma

A case of pulmonary hyalinizing granuloma (PHG) and concomitant low-grade, small lymphocytic lymphoma of the lung is presented. This is the first occurrence of pulmonary lymphoma in patients with PHG ever reported. The infiltrates around a left lower lobe nodule with left pleural effusion and thickening seen on chest CT were histologically proven to be lymphomatous infiltrates of the lung, pleura, and chest wall muscle. We believe that the lymphoma developed around the nodule and spread to the pleura and muscle in our patient. When infiltrates around the nodules, pleural effusion, or adenopathy are developed in a patient with proven PHG, close follow-up, biopsy, or careful cytology should be seriously considered to rule out a developing lymphoma.

[Pulmonary hyalinising granuloma: report of 2 original cases with cervicofacial and orbital involvement]

INTRODUCTION

Pulmonary hyalinizing granuloma is a rare fibrosing nodular disease of the lung characterized by its histological appearance, which includes at the center of the lesion a dense network of concentric hyalinized collagen lamella surrounded by perivascular lymphoplasmacytic infiltrate that rarefies in the center of the nodule.

EXEGESIS

We report two new cases: the first with laryngeal (endoluminal tumor-like), orbital (subeyelid nodule) and mesenteric (9 x 6 cm mass) location of hyalinizing granuloma; the second with cervical, facial (trismus), orbital (pseudotumor) and limb (ankylosing elbow) fibrosis.

CONCLUSION

The extrapulmonary diffusion of the disease is extremely rare. In one of the cases, with corticosteroids and after a follow-up of 12 months, the pulmonary tumors vanished but the fibrosis resolved only partially.

Pulmonary hyalinising granuloma: a case report and literature review

This is a case of a rare lung disease known as pulmonary hyalinising granuloma, which is usually discovered incidentally on chest radiographs and poses diagnostic difficulties but has an excellent prognosis. In this case a 75-year-old man had a 6-year history of undiagnosed, enlarging, bilateral dense apical infiltrates. The patient died from his tobacco smoke-related emphysema, which led to diagnosis of the lesion. At autopsy both lungs showed well-defined apical, hard, grey-white masses covered by a rind of thickened adherent pleura. Histologically, the lesion was composed of dense, haphazard lamellar, keloid-like collagen concentrically arranged around blood vessels with extension into the pleura and perivascular collections of lymphocytes and plasma cells.

Nodular amyloidoma and primary pulmonary lymphoma with amyloid production: a differential diagnostic problem

Nodular amyloidomas (NA) of the lung are non-neoplastic inflammatory nodules containing eosinophilic amyloid deposits and a lymphoplasmacytic infiltrate. In some instances, the extensive amyloid deposits may obscure an underlying lymphoproliferative disorder. The histologic and immunohistologic features that discriminate these two differential diagnostic possibilities were studied in this series of six cases of NA and five cases of primary low-grade malignant lymphomas of lung with secondary amyloid deposits (ML). Two of lymphoma cases showed histopathologic and immunophenotypic features of B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (B-cell CLL/SLL), and three cases were low-grade B-cell lymphoma derived from mucosa associated lymphoid tissue (MALT lymphoma). Key discriminating morphologic features between NA and ML included lymphatic tracking of the cellular infiltrate (3/5 ML; 1/6 NA), pleural infiltration (3/5 ML; 0/6 NA), sheet-like masses of plasma cells (5/5 ML; 0/6 NA) and reactive follicles (4/5 ML; 1/6 NA). Lesional circumscription, vascular and bronchial destruction, lymphoepithelial lesions, and granulomas were not helpful discriminators. Immunohistochemical features indicating a dominant CD20+, CD79a+ B-cell population (5/5 ML; 0/6 NA), light chain restriction (4/5 ML; 0/6 NA), and aberrant antigen expression of CD20/CD43 (2/5 ML; 0/6 NA) were helpful. Amyloid tumors with a reactive lymphoplasmacytic infiltrate can be separated from low-grade malignant lymphomas utilizing both histologic and immunohistochemical features.

Sclerosing inflammatory myofibroblastic tumour of the tongue: an immunohistochemical and ultrastructural study

A case of inflammatory myofibroblastic tumour (IMT) arising in the tongue of a 27-year-old man is described. The patient presented with a solitary, well-circumscribed submucosal mass of 4 months duration. The tumour showed in its largest part a paucicellular sclerosing lesion resembling a hyalinizing granuloma surrounded by a thin rim of an admixture of myofibroblasts, plasma cells and foamy histiocytes. Myofibroblasts expressed vimentin and alpha-smooth muscle actin positive immunophenotypes. Ultrastructurally the hyaline areas were composed of abundant collagen fibres with sparse myofibroblasts. Extensive scar-like change in this IMT may be related to a traumatic insult.

Is calcifying fibrous pseudotumor a late sclerosing stage of inflammatory myofibroblastic tumor?

Calcifying fibrous pseudotumor is a recently described distinctive lesion, characterized by the presence of abundant hyalinized collagen with psammomatous or dystrophic calcifications and a lymphoplasmacytic infiltrate. The cause and pathogenesis are unclear, but a possible relationship with other pseudotumors, like nodular fasciitis or inflammatory myofibroblastic tumor, has been proposed by some authors. However, cases with overlapping histologic features have not been reported. A 17-year-old girl with multiple peritoneal calcifying fibrous pseudotumors and inflammatory myofibroblastic tumors (inflammatory pseudotumors) is described. Some multinodular lesions showed calcifying fibrous pseudotumors next to inflammatory myofibroblastic tumors. Transitional stages between calcifying fibrous pseudotumor and inflammatory myofibroblastic tumor were also present. This case clearly illustrates a histogenetic relationship between calcifying fibrous pseudotumor and inflammatory myofibroblastic tumor, and it suggests that calcifying fibrous pseudotumor is a late sclerosing stage of inflammatory myofibroblastic tumor, at least in some cases.

Calcifying fibrous pseudotumor of pleura: radiologic features in three cases

PURPOSE

Our goal was to describe the radiologic features of calcifying fibrous pseudotumor (CEPT) of pleura.

METHOD

Chest radiographs and CT images of three patients, aged 23-34 years, with pathologically proven CFPT of pleura were reviewed with regard to lesion size, location, and appearance.

RESULTS

Chest radiographs showed well marginated, noncalcified pleural masses in all cases. Two patients had solitary masses and one had multifocal ipsilateral masses. All masses were located in the inferior aspect of the chest and measured 3-12 cm. All masses were calcified on CT. The calcifications were thick and band-like in two cases and punctate in one. There was no chest wall invasion, pleural effusion, or parenchymal disease.

CONCLUSION

CFPTs of pleura are rare lesions that manifest as calcified pleural masses in young adults.