Contributed by Raniah Al Amri, MD, Samer Khader, MD
A man in his forties with a history of basal cell carcinoma of the nose and a benign neoplasm of the jaw, status post resection with mandibular reconstruction, presented for routine follow-up. On chest x-ray workup, he was found to have numerous bilateral pulmonary nodules that were highly suspicious for a metastatic disease. A follow-up CT scan of the chest with contrast showed eight small round pulmonary nodules measuring few millimeters in size and a larger left lower lobe pulmonary mass measuring 3.0 x 3.1 cm in size. There was no evidence of hilar or mediastinal lymphadenopathy and no pleural nodularity or effusion on imaging.
Subsequent staging imaging with an MRI of the brain and CT scan of the abdomen and pelvis were negative for metastatic disease including absence of intracranial abnormality and retroperitoneal lymphadenopathy.
CT-guided fine needle aspiration (FNA) biopsy of the left lower lung lobe was performed and the results were positive for neoplastic cells.
The patient was started on chemotherapy with Carboplatin and Taxol followed by observation only with serial CT scans. Six months later, his chest CT showed a slight increase in six out of the eight pulmonary nodules, including an increase of 4mm in the left lower lung nodule; consistent with progression of his metastatic disease. The patient was referred for a possible focal radiotherapy which was deemed unnecessary in the setting of slight change of the lesions and the lack of symptoms, thus the patient was continued on close observation and monitoring.
FINE NEEDLE CYTOLOGY
Cytologic preparations showed compact and cohesive clusters of epithelioid neoplastic cells. These cells demonstrate round to oval, hyperchromatic nuclei, inconspicuous nucleoli, moderate amount of delicate cytoplasm and fine chromatin. The cells are minimally pleomorphic and focally demonstrate peripheral palisading.
A. Diff-Quik stain
B. Papanicolaou (PAP) Stain
C. Hematoxylin and Eosin (H&E) Stain
DIAGNOSIS and DISCUSSION