A 42-year-old female presented for pre-operative clearance for a Roux-en-Y gastric bypass. Review of symptoms was negative. Her medical history was significant for morbid obesity, hyperlipidemia, and Type 2 diabetes mellitus. Her surgical history included a hysterectomy performed in another city (for unknown reason at the time of imaging). The patient denied personal or family history of cancer. Pre-operative workup including electrocardiogram and laboratory work (complete blood count, basic metabolic panel, and prothrombin time/international normalized ratio) were unremarkable.
Pre-operative chest radiographs revealed numerous small bilateral lung nodules [Figure 1]. Subsequent chest computed tomography (CT) confirmed numerous, well-circumscribed solid nodules throughout bilateral lungs measuring up to 1.2 cm [Figure 2]. At this point, the leading consideration was metastatic disease from an unknown primary site. Pulmonology was consulted. Positron emission tomography (PET)/CT using 18-F fluorodeoxyglucose (FDG) was ordered to assess for metabolic activity in the nodules and to survey for a primary site of disease. No abnormal hypermetabolic foci were present on the PET/CT [Figure 3]. There was no evidence of a hypermetabolic primary neoplasm, and the solid pulmonary nodules demonstrated a maximum standardized uptake value of 1.3 (below mediastinal blood pool activity). Note was made of a prior hysterectomy on the PET/CT and the possibility of BML was suggested. Additional nonhypermetabolic metastatic etiologies were posed, included benign metastasizing meningioma, giant cell tumor of bone (GCTB), and thyroid adenoma.
Additional history from the patient revealed, she had obtained the hysterectomy for uterine fibroids. There was a multidisciplinary consensus to biopsy the nodules. The patient underwent video-assisted thoracoscopic surgery with wedge resection of all three lobes of the right lung. Histopathological examination revealed estrogen receptor positive bland spindle cell proliferation with entrapped Type II pneumocytes, consistent with BML [Figure 4]. The patient was referred to gynecologic oncology for further management. A 3-month follow-up CT demonstrated stability of existing nodules, and the patient was started on monthly leuprorelin injections. After an additional 3-months, the patient endorsed minimal side effects from treatment and CT redemonstrated nodule stability. She remains asymptomatic and continues to follow with gynecologic oncology for monthly injections and disease monitoring.
A 42-year-old asymptomatic female with numerous solid pulmonary nodules. (a) 18-fluorodeoxyglucose (FGD) Positron Emission Tomography (PET)/Computed Tomography (CT) maximum intensity projection does not reveal any abnormal hypermetabolic activity.