CASE 11766 Published on 04.07.2014

Adenocarcinoma in an intralobar pulmonary sequestration infiltrating the diaphragm

Section

Chest imaging

Case Type

Clinical Cases

Authors

Salvan-Schaschl CV1, Lutfi A1, Steiner J1, Deutschmann H2, Gstettner C3, Fuchsjäger M1

1. Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
2. Division of Interventional and Vascular Radiology, Department of Radiology, Medical University of Graz, Austria
3. Division of Nuclear Medicine, Department of Radiology, Medical University of Graz, Austria
Patient

46 years, female

Categories
Area of Interest Lung, Thorax, Arteries / Aorta ; Imaging Technique CT, Conventional radiography, Catheter arteriography
Clinical History
A 46-year-old female non-smoker presented with intermittent fever for the past 2 months and night sweat, without cough or any other symptoms.
Imaging Findings
The chest X-ray showed an opacity in the right lower lobe with a rounded mass. The CT detected a well-defined, inhomogeneous, 4 x 3, 8 cm lesion mainly in an intradiaphragmatic location, without pathological lymph nodes. This lesion showed arterial vascular supply originating from the abdominal aorta, with deformation of the liver surface, without infiltrating the liver. This raised the radiological suspicion of a tumour within an intralobar pulmonary sequestration infiltrating the diaphragm, with abscess as differential diagnosis.
Due to the clinical presentation and uncertainty a PET-CT was performed, showing an abscess formation. An angiography was subsequently performed for better characterization of the blood supply. In the same session preoperative embolization of the feeding artery originating from the abdominal aorta close to the coeliac trunk was done. The pathology result, after wedge resection of the lower pulmonary lobe and diaphragm, confirmed the intralobar sequestration associated with both adenocarcinoma and abscess.
Discussion
Pulmonary sequestration is a rare condition [1, 2], accounting for 0.15% to 6.4% [3] of congenital pulmonary malformations. Intralobar pulmonary sequestration is more frequent [1, 3], however, it is usually detected in the early years of life [3, 4, 5, 6]. Frequently it is asymptomatic, but commonly associated with infection or pneumonia [3, 7, 8], as in our adult patient presenting with symptoms of infection. The association with lung cancer, especially adenocarcinoma, is rare; just a few cases having been reported [8, 9, 10, 11, 12, 13]. An association with both, cancer and infection, is even less frequently detected [8, 12]. The particular aspect of infiltration of the diaphragm is also an uncommon aspect of lung sequestration. Classically, the pulmonary sequestration is defined as "a congenital mass of aberrant pulmonary tissue that has no normal connection with the bronchial tree or with the pulmonary arteries" [14], reported as intralobar and extralobar sequestration. The chest radiograph can be used as a first diagnostic tool. However, for diagnosis in the adult population, CT is needed for identification, localization and characterization of the pulmonary sequestration and in most cases enables the identification of the aberrant arterial supply [1, 3, 10, 14]. The CT [1, 3, 10, 14] together with angiography [14] supports the diagnosis. Angiography clearly demonstrates the vascular supply and together with CT helps to plan the surgical approach as part of the therapy. The pathology confirms the diagnosis, as in our case. The possibility of pulmonary sequestration - associated or not with other pathologies - should be kept in the differential diagnosis list even in the adult population when evaluating mass-like opacities of the diaphragmatic lung regions.
Differential Diagnosis List
Adenocarcinoma in an intralobar pulmonary sequestration infiltrating the diaphragm
Pneumonia
Abscess
Bronchiectasis
Tumour
Hernia
Final Diagnosis
Adenocarcinoma in an intralobar pulmonary sequestration infiltrating the diaphragm
Case information
URL: https://www.eurorad.org/case/11766
DOI: 10.1594/EURORAD/CASE.11766
ISSN: 1563-4086

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