malignant glands within a comparatively less-malignant stroma. 7 Nineteen of these tumors have been reported, including a review of the literature by Cox and associates." I have had the opportunity of seeing the patient reported by Cox and examining him by fluoroscopy. Approximately one year later, an additional patient was seen by me which prompted a review of the previously reported cases to see if any roentgen manifestations were common among those cases reported. A case history of the 20th diagnosis of pulmonary blastoma is included.
Roentgen Manifestation~ of Pulmonary Blastoma Thomas T. Thompson, M.D.·
Pulmonary blastomas manifest as weU-demarcated lesions with occasional lobulation and cavitation. These lesions vary in size and are generally found in the periphery of the lung. The tumors pathologically contain malignant glands within a comparatively less malignant stroma and are differentiated from carcinosarcomas. Nineteen previous examples have been reported, and the case history of the twentieth follows.
The patient was a 72-year-old white man with a threemonth history of "weakness" following a flu-like syndrome. He had a cough productive of blood-streaked sputum and had lost ten pounds of body weight attributable to a loss of appetite. He had developed a dull, aching sensation in the left chest not associated with exertion. Past history revealed that he had smoked approximately one pack of cigarettes per day for the past 60 years. Physical examination revealed an alert, elderly white man in no distress. The left lower lip demonstrated a small hyperkeratotic lesion. A grade II/IV systolic murmur was present at the base and transmitted to the apex. His fingers showed clubbing. The rest of the physical examination was essentially normal. Chest x-ray picture (Fig 1) revealed an elongated, welldemarcated, peripheral lung lesion in the superior segment of the left lower lobe adjacent to the aorta. The lesion was not pulsatile. Planigrams revealed narrowing of the segmental bronchus to the superior segment of the lower lobe.
ulmonary blastoma is a relatively new clinical entity, originally described by Barnard in 1952. ' This malignant tumor is thought to arise from bipotential pulmonary blastema formed during embryologic development of the lung and, hence, may develop either mesenchymal or epithelial elements or both. '- 11 Pathologically, it resembles fetal lung tissue and is considered to be distinct from carcinosarcoma or "collision" carcinosarcoma. Carcinosarcomas are composed of squamous cell carcinomas within a sarcomatous stroma and are usually associated with a major bronchus; whereas, pulmonary blastomas are peripheral in location and contain o Assistant
Professor of Radiology and Chief of Radiology, Veterans Administration Hospital, Durham. Reprint requests: Dr. Thompson, VA Hospital, Durham 27705
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FIGURE 1. Admission chest fllms. Note the well-demarcated, lobulated mass adjacent to the descending aorta.
CATHETER PERFORATION OF PULMONARY ARTERY Table I-X-ray Appearance 01 Pulmonary Bla.coma. Reference
R midlung Bilateral LUL RUL RUL Sup seg, LLL Ant seg, LUL Hilium L LUL
Circumscribed, homogeneous Well-demarcated nodules Nodular Homogeneous Well-demarcated, homogeneous Well-circumscribed Cavitating Well-circumscribed Sharply demarcated, lobulated, homogeneous mass Well-demarcated, homogeneous Hard, oval mass, circumscribed Clearly demarcated, oval Well-demarcated
3 4 5
6 7 8 9 10
LUL Sup Seg, LLL RUL LLL LUL, Lingula LUL R midlung RML
Bronchial washings were negative for fungi or malignant cells. Bronchography demonstrated stenosis of the left lower lobe bronchus with obstruction of the superior segment of the lower lobe. A left lateral thoracotomy revealed an irresectable tumor involving the hilum, pleura, and adjacent chest wall. Postoperatively, the patient developed respiratory distress with septicemia and died two weeks following surgery. Pathologic description revealed the tumor to be in the superior portion of the left lower lobe, measuring 6 X 8 X 4 em and extending to the hilum and its bronchi. The mass was soft yellow-brown, with areas of necrosis and hemorrhage into its substance. Microscopically, the tumor consisted of malignant stroma and malignant glands. ROENTGEN MANIFESTATIONS
In reviewing previously reported cases, a roentgen pattern of the tumor is well demonstrated. A composite of the cases reported (Table 1) shows a well-demarcated peripheral lesion which may be somewhat lobulated. There is occasional cavitation," and the lesions vary in size. Although there is no statistical significance, the lesions have been found more commonly on the left. Pulmonary blastomas occur both in men and women and are indolent, with survival times recorded which vary from two to fifteen years." Although the case reports do not present sufficient information, pleural effusion was not present in the case reported by Dr. Cox or in the presently reported case. From the pathologic reports it appears that the well-demarcated lesions are "encapsulated" by compressed or atelectatic lung tissue.l''- 5 Differential diagnoses include hydatid pulmonary cysts, carcinosarcomas, bronchial adenomata, bronchogenic carcinomas, and metastatic tumors.
1 Barnard WG: Embryoma of lung. Thorax 7:299,1952 2 Bauermeister DE, Jennings ER, Beland AH, et al: Pulmonary blastoma, a form of carcinosarcoma. Amer J Clin Path 46:322, 1966 3 Campesi G, Sommariva V: Rarissima neoformazione polmonare di tipo adeno-sarcomatoso. Arch De Vecchi Anat Pat 36: 109. 1961 4 Chitamhar TA, Gujral JS, Aikat BK: Embryonal sarcoma of the lung. J Thorac Cardiovasc Surg 57 :657, 1969 5 Cox JL, Fuson RL, Daly JT: Pulmonary hlastoma. Ann Thor Surg 9:364. 1970 6 Minken SL, Craver WL, Adams JT: Pulmonary blastoma. Arch Path (Chicago) 86:442, 1968 7 Parker JC, jr, Payne WS, Woolner LB: Pulmonary blastoma (embryoma). J Thorac Cardiovasc Surg .'51:694, 1966 8 Peabody CN: Carcinosarcoma of lung of peripheral origin. J Thorac Cardiovasc Surg 37 :766, 1959 9 Souza RC, Peasley ED, Takaro T: Pulmonary blastomas: A distinctive group of carcinosarcomas of the lung. Ann Thorac Surg 1:259, 1965 10 Spencer H: Pulmonary blastomas. J Path Bact 82: 161, 1961 11 Stackhouse EM, Harrison EG, Jr, Ellis HF, Jr: Primary mixed malignancies of lung: Carcinosarcoma and blastoma. J Thorac Cardiovasc Surg 57: 385, 1969
Catheter Perforation of the Pulmonary Artery with Resultant Cardiac Tamponade Edward 1. Greenbaum, M.D.,· and Harold S. Marcus, M.D.··
A case of pulmonary artery perforation secondary to direct penetration of a NIH catheter at the time of pulmonary angiography is described. The patient immediately went into cardiac tamponade, which was successfully treated via pericardiocentesis without subsequent surgical intervention. erforation of the pulmonary artery secondary to right P heart catheterization has not been reported thus far
in the American literature. Teramoto! describes puncture of the pulmonary artery as a complication of transseptal cardiac catheterization with the use of the method described by Ross. Davidson and colleagues," in 80 pulmonary artery injections with the use of catheters with closed tip and side openings, describes one instance of a small subintimal deposit of contrast in the pulmonary artery without effect.
A 20th case of pulmonary blastoma is reported. Roentgen manifestations indicate that this is a well-demarcated lesion seen in the periphery of the lung. There is a tendency to occasional lobulation and cavitation. The lesions vary in size and tend to be indolent pathologically.
• Associate Radiologist, Cedars-Sinai Medical Center, Los Angeles; Assistant Clinical Professor, University of California, Irvine. ··Director, Cardiac Catheterization Laboratory, Cedars-Sinai Medical Center. Reprint requests: Dr. Greenbaum, 584 Lorna Lane, Los Angeles 90049
CHEST, VOL. 62, NO.1, JULY, 1972