The patient was a 63-year-old male smoker (40 pack-years). He presented with symptoms of cough, hemoptysis, fever, and weight loss for 2 months. The patient was admitted to the local hospital in 2016-03-21. The chest CT scan showed a soft tissue shadow of 2.8*3.5 cm with large patchy shadows around the upper lobe of the right lung (Fig. 1 A). A PET-CT scan revealed a mass of 2.5*3.5 cm near the right hilar and a patchy shadow of 4.9*3.3 cm in the upper lobe of the right lung. The mean FDG metabolism of the mass near the right hilar was 4.9 (the highest was 9.6). The mean FDG metabolism of the patchy shadow was 4.7 (the highest was 6.0). The CT scan-guided percutaneous biopsy in the right pulmonary apex and right upper lobe (area indicated by the white arrow in Fig. 1 A) was performed twice in 2016-03-25 and 2016-03-30, and pathology results showed chronic pneumonia and OP with local necrosis. The TBLB pathobiology in 2016-04-05 showed chronic inflammation of some bronchial mucosa in the right upper lobe. Community-acquired pneumonia was diagnosed. Cefotiam and Clindamycin were given as anti-infection therapies, and his body temperature dropped to normal, but cough and bloody sputum had not been well improved. A chest CT scan in 2016-04-11 showed that lesions in the upper lobe of the right lung had shrunk, but other lesions enlarged, and the lymph nodes in the right hilum and mediastinum were still swollen (Fig. 1 B).
The patient was admitted to Zhongshan Hospital, Fudan University in 2016-05-10 for further diagnosis and treatment. Physical examination showed that he was well developed and nourished. The sounds in both lungs are clear and regular, with no abnormal changes in the heart or abdomen. Bilateral supraclavicular and cervical lymph nodes were not enlarged. Blood routine and blood biochemistry showed the following: white cell count 10.81*109/l with 65.6% granulocytes and 16.4% lymphocytes, hemoglobin 119 g/l, platelet count 246*109/l, erythrocyte sedimentation rate 73 mm/H and C reactive protein 52.2 mg/l. T-spot test: antigen-A 1, antigen-B 0. Arterial blood gas analysis showed PO2 69.0 mmHg and PCO2 40 mmHg. Tumor marker: CA125 68.3 U/ml and Cyfra211 3.7 ng/ml were slightly elevated, and other markers, such as CEA, CA199, NSE, SCC and proGRP, were all normal. Antinuclear antibody (cytoplasmic pattern) 1:100 and other autoantibody or rheumatoid factors were all negative. The pathological sections from the local hospital were rechecked by our pathology department, considering OP with eosinophil infiltration and scattered hemosiderin deposition (Fig. 2 A).
Initial diagnosis of OP was made, and intravenous corticosteroid therapy was started for 2 weeks. Most symptoms disappeared, except for occasional hemoptysis. However, the follow-up chest CT scan in 2016-05-18 showed that lesions in the puncture site of the right lung were significantly reduced, but other lesions expanded, and the lymph nodes remained swollen (Fig. 1 C, D). We persuaded the patient to receive EBUS in 2016-05-20, and the examination showed slightly swollen mucosa and narrow lumen in the right upper bronchial. The lower segment of the right middle bronchial was external compressive stenosis with congestive mucosa. TBLB was performed under the guidance of ultrasound in the shadow of the posterior segment of the right upper lobe, and pathobiology showed alveolar septal fibrous tissue hyperplasia, with organizing pneumonia lesions in some areas (Fig. 2 B). TBNA from 4R mediastinal lymph nodes showed atypical cells (Fig. 2 C). The immunohistochemical results were CD1a(-), CD21(-), CD23(-), CD30(-), CD33(-), CD68(+), CKpan(++), D2-40(-), EMA(+++), Langerin(-), S-100(+), Vim(+++), CD10(+), CD15(+), CD79a(+), ALK-1(-), PAX-5(-), P63(-), SPA(-), NapsinA(+), TTF-1(+), suggesting poorly differentiated carcinoma (sarcomatoid carcinoma is more likely) which arose from the alveolar epithelium. Bronchial aspiration cultures were negative for bacteria, mycobacteria and fungi. The final diagnosis was lung cancer and secondary organizing pneumonia. The patient received one cycle of chemotherapy (gemcitabine 2.0 d1, cisplatin 120 mg d1) and then lost follow-up.
Pathology of lung and lymph node from March 2016 to May 2016. . (A) Pathology of CT scan-guided percutaneous lung biopsy in the apical segment of the right lung's upper lobe. HE staining of the lung biopsy showed organizing pneumonia lesions (white arrow).