A 60-year-old gentleman, with a history of 6 months on and off blood stained sputum, was admitted for an episode of massive hemoptysis. Urgent computed tomography (CT) bronchial arteriogram was performed to assess the need for bronchial artery embolization. It excluded any dilated bronchial artery. Focal consolidation with multiple small centrilobular nodules and adjacent ground glass changes were found [Figure 1a and b]. Bronchoscopy with biopsy taken was negative for malignancy and infection. Autoimmune workup was negative. Tuberculosis infection (TB) could present with centrilobular nodules and consolidative changes in CT, and relatively common in Asia. The culture sometimes could be false negative in partially treated cases. Combined with the clinical picture, with negative bronchoscopy, fungal, acid-fast bacilli culture and cytology, the case was treated as culture-negative TB. However, his hemoptysis was unresolved. He was followed up with high-resolution CT after a month, showed an enlarged left upper lobe mass surrounding by a ground glass halo [Figure 2a and b] Neoplasm had to be considered. Left thoracotomy and left upper lobe lobectomy were performed. Epithelioid angiosacroma was found in histology. The sections showed an infiltrative hemorrhagic tumor, which eroded the bronchus and was associated with bronchial luminal hemorrhage and diffuse hemorrhage into the adjacent pulmonary parenchyma [Figure 3a]. The tumor comprised sheets of loosely cohesive malignant tumor cells which had eccentric markedly pleomorphic nuclei, prominent nucleoli, vesicular with presence of fine strands of chromatin, and moderate amount of eosinophilic cytoplasm [Figure 3b]. In areas, adenomatoid tumor arrangement, ill-formed ectatic vascular channel formation, and hemorrhagic microcystic arrangement with mitotic figures up to 1.5 per 10 high-power fields. The tumor cells were immunoreactive to vascular markers ERG and CD31 [Figure 3c and d], and are negative to CD34. Some tumor cells showed cytoplasmic staining upon study for epithelial marker CK. Tumor cells were negative to TTF-1. The overall features supported epithelioid angiosarcoma. On review of the intitial CT, there is partial obliteration of the segmental bronchus, these findings would be more suggestive of malignancy than atypical infection such as TB or fungal infection.
(b) Selected coronal image of high resolution computed tomography could appreciate the ground glass halo around the enlarged lung mass (arrow).