A 26 year old male was admitted with fever, chills and worsening cough for 2 weeks. He had a chronic cough which started 2 years prior to presentation and became progressively worse 2 weeks prior to presentation. He reported purulent sputum production with occasional streaks of blood in the sputum. There was no history of tuberculosis or tuberculosis exposure. He was tested tuberculin negative. His past medical history was not significant and his family history was noncontributory. His physical exam was remarkable for reduced air entry in the left upper lung field. Laboratory studies showed leukocytosis of 18,300 cells/ul. Sputum and blood cultures were negative. Sputum smear and culture for acid fast bacilli (AFB) were negative.
The mass is separated medially from the vessels by the mediastinal fat plane and is posteriorly outlined by the major fissure
Presence of endobronchial lesion and dilated cystic spaces suggest a bronchus filled with mucous.
Chest radiograph (CXR) (Fig. 1A) demonstrates luftsichel sign, which signifies left upper lobe collapse with an area of lucency around the aortic arch created by the hyperinflated left lower lobe, a portion of which wraps around the medial side of the collapsed left upper lobe. However, overall there is no significant volume loss of left upper lobe due to the presence of an expansive underlying mass. Lateral Chest radiograph (Fig. 1B) showed major fissure pulled anteriorly with hyper-inflated left lower lobe. Computed Tomography (CT) (Fig. 2A and B) of chest showed a large heterogenous mass with an endobronchial component and dilated cystic spaces. These cystic spaces demonstrate a branching pattern and appear to be the dilated bronchus filled with mucous secretions. There are signs on CT chest which helped to distinguish it as a lung mass
Pulmonary function test was consistent with mild obstructive airway disease with FEV1 of 2.87 L (76% predicted). Lung volumes were normal. Positron emission tomography (PET) scan with 18F-flurodeoxyglucose showed increased uptake only over left hemi-thorax with no other areas of uptake indicating metastasis. Flexible bronchoscopy was performed for further evaluation of this mass. There was a large pinkish polypoidal mass obstructing the left upper lobe bronchus with thick purulent secretions (Fig. 3). Endobronchial biopsy showed (Fig. 4A and B) malignant epithelial neoplasm infiltrating the fibrous hyaline stroma. The neoplasm is composed of multiple glandular structures lined by mucous secreting cells with interspersed stroma which has squamoid and clear cells with minimal mitosis which is consistent with the diagnosis of low grade primary salivary type lung cancer: mucoepidermoid carcinoma. Thoracic surgery was consulted for left upper sleeve lobectomy. Unfortunately there were extensive adhesions which limited the separation of vascular planes between the left upper and lower lobe and thus complete pneumonectomy was performed. Extensive lymph node sampling did not reveal any regional spread. His postoperative course was uneventful and did not require any adjuvant therapy.
A - CT chest cross sectional view: Large heterogenous left upper lobe mass (white arrow) with endobronchial lesion (black arrow).