□ Case Report □
Korean J Thorac Cardiovasc Surg 2016;49:218-220 ISSN: 2233-601X (Print)
http://dx.doi.org/10.5090/kjtcs.2016.49.3.218
ISSN: 2093-6516 (Online)
Primary Pulmonary Amyloidosis with Mediastinal Lymphadenopathy Dohun Kim, M.D.1, Yong-Moon Lee, M.D.2, Si-Wook Kim, M.D.1, Jong-Won Kim, M.D.1, Jong-Myeon Hong, M.D., Ph.D.1
We report a case of inadvertent hoarseness after surgery for primary pulmonary amyloidosis. A 55-year-old male was transferred to our facility due to a lung mass. Chest computed tomography revealed a solitary pulmonary nodule. Positron emission tomography–computed tomography showed fluorodeoxyglucose uptake in the main mass and in the mediastinal lymph nodes. To confirm the pathology of the mass, wedge resection and thorough lymph node dissection were performed via video-assisted thoracic surgery (VATS). No complications except for hoarseness were observed; hoarseness developed soon after surgery and lasted for 3 months. The main mass was diagnosed as amyloidosis, but this was not found in the lymph nodes. In conclusion, VATS wedge resection for peripheral amyloidosis is a feasible and safe procedure. However, mediastinal lymph node dissection is not recommended unless there is evidence of a clear benefit. Key words: 1. Solitary pulmonary nodule 2. Amyloidosis 3. Video-assisted thoracic surgery
ing lung cancer. PET-CT showed subtle fluorodeoxyglucose
CASE REPORT
uptake in the pulmonary nodule, but strong uptake in the mePrimary pulmonary amyloidosis is a rare disease that can
diastinal lymph node (Fig. 1B). A percutaneous lung biopsy
be mistaken for lung cancer [1]. Although percutaneous lung
was performed, but the results were insufficient for diagnosis.
biopsy and other diagnostic modalities including positron
Therefore, video-assisted thoracic surgery (VATS) was
emission tomography–computed tomography (PET-CT) can be
performed. The pulmonary nodule was located in a major fis-
helpful, surgical resection is required to determine the exact
sure and was found easily. Wedge resection was performed
pathologic diagnosis [2]. Subaortic lymph nodes in particular
and the cut edge of the mass showed grayish tan-colored,
are difficult to investigate without surgery. We herein report
firm features. The subaortic lymph node was located deep un-
a case of primary pulmonary amyloidosis with mediastinal
der the aorta, and careful dissection was performed to avoid
lymphadenopathy and inadvertent postoperative complications.
injury to the vagus or recurrent laryngeal nerve (Fig. 2).
A 55-year-old man was transferred to the department of
Electrocautery was also limited in order to avoid thermal
thoracic surgery due to a solitary pulmonary nodule in the
injury. Lymph node sampling was attempted, but thorough
left lower lobe (Fig. 1A). The nodule was found 3 months
dissection was unavoidable because massive bleeding oc-
prior and had increased in size on follow-up chest CT, imply-
curred along the cut edge of the lymph node. There were no
1
2
Departments of Thoracic and Cardiovascular Surgery and Pathology, Chungbuk National University College of Medicine Received: July 24, 2015, Revised: August 22, 2015, Accepted: August 25, 2015, Published online: June 5, 2016 Corresponding author: Jong-Myeon Hong, Department of Thoracic and Cardiovascular Surgery, Chungbuk National University College of Medicine, 1 Chungdae-ro, Seowon-gu, Cheongju 28644, Korea (Tel) 82-43-269-6062 (Fax) 82-43-269-6969 (E-mail)
[email protected] C The Korean Society for Thoracic and Cardiovascular Surgery. 2016. All right reserved. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Unnecessary Lymph Node Dissection in Pulmonary Amyloidoma
Fig. 1. Chest CT and PET-CT of the main mass (*) and mediastinal lymph nodes (!). (A) Solitary pulmonary nodule in the left lower lobe on chest CT. (B) Pulmonary nodule and mediastinal lymphadenopathy on PET-CT. CT, computed tomography; PET, positron emission tomography. pa, beta 2-microglobulin, and protein electrophoresis in serum and urine were within normal limits. However, a brain magnetic resonance imaging was not performed due to patient refusal. The nodule was diagnosed as primary pulmonary amyloidosis, and regular follow-up was planned without additional treatment.
DISCUSSION Fig. 2. Operative view for subaortic lymph node dissection. The subaortic lymph node was dissected completely.
Primary pulmonary amyloidosis is a rare disease characterized by the deposition of immunoglobulin light-chain fragments [3]. Intrathoracic manifestations are broad, including
postoperative complications, with the exception of hoarseness.
tracheobronchial, parenchymal, and pleural involvement in ad-
Although vocal symptoms improved upon follow-up in the
dition to mediastinal lymphadenopathy [2,4]. Pulmonary amy-
outpatient clinic, vocal cord palsy was still observed on post-
loidosis can be associated with lymphoproliferative diseases
operative day 90. In pathologic reports, amorphous eosino-
such as mucosa-associated lymphoid tissue lymphoma or mul-
philia and positive Congo red staining were found in the pul-
tiple myeloma [5]. Percutaneous lung biopsy is typically suf-
monary nodule, consistent with amyloidosis (Fig. 3). Lymph
ficient for pathological diagnosis [1,6], but surgical resection
involvement of amyloidosis was not found, but reactive hy-
is recommended when malignancy is suspected [2,7].
perplasia was observed in all mediastinal lymph nodes.
Excision of the lesion is the treatment of choice due to its
Further diagnostic tests to rule out systemic diseases that
rare recurrence [4]. However, it remains unclear whether
could lead to secondary amyloidosis (e.g., multiple myeloma)
lymph node dissection is necessary. According to this report,
were performed. All blood tests with light chain lambda, kap-
lymph node dissection may be harmful in primary pulmonary
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Dohun Kim, et al
Fig. 3. Amorphous eosinophilia and positive Congo red staining were found in the pulmonary nodule. (A) H&E stain, ×400. (B) Congo red stain, ×400. amyloidosis. Mediastinal lymphadenopathy is not a rare condition in the disease entity, but mediastinal involvement by amyloidosis is rare [8]. Careful subaortic lymph node dissection was performed, but it resulted in hoarseness lasting
2.
for 3 months. Moreover, there was no pathologic evidence that the lymph nodes were involved in amyloidosis. Therefore,
3.
mediastinal sampling or biopsy is recommended over thorough dissection in the case of primary pulmonary amyloidosis.
4.
In conclusion, treating peripheral amyloidosis with VATS wedge resection can be an effective option, but mediastinal 5.
lymph node dissection should be done carefully.
6.
CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported.
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