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Case Report |
1 Service de Radiologie et Imagerie Médicale, CHU Grenoble, BP 217,
Grenoble 38043, CEDEX 9, France.
2 Département de Médecine Aiguë Spécialisée,
CHU Grenoble, France.
3 Service de Chirurgie Thoracique, CHU Grenoble, France.
4 Service de Pathologie Cellulaire, CHU Grenoble, France.
Received August 11, 2003;
accepted after revision November 10, 2003.
Address correspondence to G. R. Ferretti
(gferretti{at}chu-grenoble.fr).
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Macroscopically, the wedge resection contained a subpleural lesion composed of gelatinous and papillary fatty projections that were several millimeters in diameter. No mucus or blood filled this mixed cystic and solid lesion that appeared well demarcated from the normal surrounding lung parenchyma.
Histologically, the lesion consisted of placental or villuslike structures surrounded by hyperinflated air spaces (Fig. 1D). At higher magnification, these villuslike structures corresponded to alveolar walls enlarged by mature adipose tissue and fibroblasts intermixed with thin or dilated capillaries. No smooth-muscle, cartilage, bronchial structures, or mesenchymal or inflammatory cells were present in these papillary structures. These papillary structures were lined either by flattened type I alveolar cells or by hyperplastic type II pneumonocytes. Lipoblasts and atypical epithelial cells were absent. The overlying pleura was normal, and the adjacent lung, which was free of emphysematous changes, was also normal. The final diagnosis was placental transmogrification of the lung.
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The high-resolution CT appearance of the nodule in our patient was surprising in that it contained air, fat, and soft-tissue attenuating components in a well-defined nodular structure. To our knowledge, this report is the first for high-resolution CT features of placental transmogrification of the lung presenting as a pulmonary nodule. The radiologic differential diagnostic of this lesion should include lesions with fatty components and lesions containing air. Fatty tumors of the lung are rare. Fat is present in lipomas and hamartomas [4]. CT shows fat as low-density material (–40 to –120 H), and MRI shows fat as high signal intensity on T1-weighted images and intermediate signal intensity on T2-weighted images. Fat is the only component of lipomas, which appear as well-circumscribed nodules in the periphery of the lung surrounded by normal lung tissue [5]. They represent approximately 0.1% of all pulmonary tumors.
Hamartomas represent the most common benign pulmonary neoplasm of the lung, accounting for approximately 6% of all pulmonary nodules. Its prevalence at autopsy reaches 0.25% [6]. Pulmonary hamartomas consist of a mixture of cartilage, connective tissue, smooth muscle, marrow, bone, and variable amounts of fat. On CT, hamartomas are typically spherical lobulated nodules with well-defined margins surrounded by normal lung tissue. Fat is detected in approximately 50% of hamartomas, and its presence is considered a reliable indicator of hamartoma, precluding a transthoracic biopsy or surgical resection [6]. On CT, air bronchogram in a hamartoma has been reported in one of 30 cases and corresponds pathologically to bronchial epithelium in cartilaginous tissue [7].
The presence of air in a nodule may result from cavitation that can occur in both benign and malignant nodules. Benign cavitary nodules usually have smooth thin walls (< 4 mm), as in our patient, whereas malignant nodules typically have irregular thick walls (> 16 mm) [8]. A significant overlap exists, making wall thickness alone an inaccurate feature for differentiating malignant from benign cavitary nodules.
In summary, we reported the high-resolution CT findings of pulmonary placental transmogrification, an unusual lung tumor that contains air, fat, and soft-tissue. This tumor should be included in the differential diagnosis of benign lung tumors with fatty and air components.
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