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Case Report

No.1Respiratory Ward

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General

Patient : Weiwei

Female 53ys Han nationality

Profession : Retired chemical plant worker

chief complaint : Cough, hemoptysis for 1

month

Height: 163cm Weight: 97KG

HPC (history of present illness)

Onset: A month ago, the patient coughed up bright red bloody sputum

in the morning, several times a day; sometimes it happened in the

afternoon. She had no fever or shivering, no chest distress or dyspnea,

no night sweat, no emaciation, no hypodynamia, no hematuria or any

other discomfort. Then she turned to Changhai Hosptial, the chest CT

showed ： two-lung multiple nodules shadow, but she did not receive

any treatment at that time. In order to seek further diagnosis and

treatment, she was admitted to our ward on 2011-07-18 .

Past history

hypertension history for 10 years

diabetes mellitus history for 10 years.

Denied the clear previous medical history like: coronary heart

disease,tuberculosis and so on.

Surgical history: operation for lumbar disc protrusion

Drug allergy history: Penicillin allergy

Personal history: Denied smoking and drinking, father died of lung

cancer, mother died of pancreatic cancer

Physical examination on Admission

T:36.6 ,P:82b/m,R:20b/m,BP:155/90mmhg,℃

Obesity

Superficial lymph nodes were impalpable

No skin rash or petechia

Coarse breath sounds in both lungs,and no significant dry and wet

rales

Rhythm of the heart :82b/m, tidy, heart sounded low, P2<A2,no

pathological murmur.

extremities activity, no clubbed finger

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routine blood test :WBC:9.0*10^9/L N50.20% EOS 0.13*10 ^9/L

PLT 278*10^9L

Dung conventional test :negative ； routine urine test ： WBC3+

quantity 71/u, erythrocyte 20/ul

Blood coagulation :PT:9.4S INR:0.88R FIB:5.0g/l DDimer :200ng/ml

Blood biochemical tests:normal 、 SACE(-)

GLU 6.5mmol/L ， 2H blood sugar 12.1mmol/L after meal

HIV/syphilis 、 Two pairs of semi-hepatitis B :negative

Tumor Marker :normal

Laboratory test(7-19):

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Laboratory test(7-19): Mycoplasma, chlamydia, legionella antibody: negative ；

G test:negative ； ESR:24mm/h ;CD4/CD8:1.98

Blood allergy screening:total IgE 100-200Iu/L, MX1 1.09IU/L

Full rheumatic antibody test 、 Rheumatoid factor 、 O

antibody 、 Tuberculosis antibody: negative

Arterial blood gas analysis ： PaO2-93mmHg PaCO2-39mmHg;

Sputum bacteria 、 Fungal culture:negative; sputum tuberculosis

smear ： negative *2 ；

Sputum Liquid-based cytology test:negative *3

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auxiliary examination

electrocardiogram ： normal

Pulmonary function test ： pulmonary ventilation function 、 Pulmonary

residual volume and Total ratio 、 diffusion function is normal ； Airway

Resistance increased ；

Abdominal ultrasound ： fatty liver

Breast ultrasound ： noamal

Neck by color Doppler ultrasound ： the lymph nodes were seen on the

right side of the neck, about 12*4mm; Left

neck 、 Thyroid 、 Parathyroid glands showed no significant abnormality

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auxiliary examination

Chest enhanced CT: Two nodular masses were seen in the lower lobe of the

left lung ， and a small nodules were found in the right upper lobe posterior

segment ， some inflammation of the right lung lower lobe was found.

lung MIBI ： Abnormal uptake lesions in the Right lung Ueno

bone ECT ： negative ； Brain CT ： Both sides of the basal ganglia lacunars infarction ； abdominal CT ： Ingot into the lumbar ， the rest is not seen obvious

abnormality ； Electronic bronchoscope:negative ； Bronchial brushing cancer cells 、 Liquid-based ： negative ；

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Chest CT film

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Chest CT film

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Chest CT film

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Chest CT film

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Chest CT film

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Chest CT film

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Admission diagnosis:

Lung nodules: Lung Cancer? Metastasis ？

Pulmonary infection

Type 2 Diabetes Mellitus

Hypertension

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Diagnosis?

The Purpose of Discuss

Differential Diagnosis

Sarcoidosis ： Multi-system organ involvement granuloma disease.

Often violated lung,Bilateral pulmonary hilar lymph nodes or

meditational lymph nodes ,skin,eyes and superficial lymph nodes

Tuberculosis ： More symptoms of TB ， imaging of plaques,

nodules cord shadow, sputum TB smear or culture, PPD can be positive

Fungal infections: there are many defects in host immune function,

imaging can also be expressed as nodules, but the sputum fungal

culture, GM experiments and other tests to help diagnose

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Follow-up

2011-07-28 Change to Surgical ward ；

2011-08-02 Perform partial resection of the left

lung lower lobe by VATS;

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Pathology

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Pathology

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The Final Diagnosis

Lung nodules: Pulmonary Sclerosing

Hemangioma

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Pulmonary Sclerosing Hemangioma

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Background of Name

PSH is a kind of rare benign tumor of lung, which was firstly named by

Liebow and Hubbell in 1956. There have been a lot of arguments about

its histogenesis and clinical behavior. With the development of

immunohistochemisty,more and more new antibody to be used, The

hypothesis is that PSH cells originate from pulmonary epithelial instead

of vascular endothelial, mesothelial and neuroendocrine cells. The PSH

was categorized as a miscellaneous tumors in 1999 WHO classification

of lung tumors.

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Origin of Tissue

Analysis the immunohistochemical performance of 100 cases of PSH,

Devouassoux-Shisheboran and his colleagues found that the

expression of the characteristic antigen EMA and CK in epithelial

cells, was high, especially the TTF-1 (thyroid transcription factor-1)

and SPB(surfactant protein). The expression of CEA and SAM

(smooth muscle actin) is negative.These results prove that PSH cells

originate from alveolar epithelial . A variety of epithelial cells develop

these different levels, different directions of differentiation,

accompanied by the proliferation or reaction of a variety of other

ingredients.

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Clinical characteristics (1)

13 ～ 76 ys, the median age 46 ys

Male and female ratio is about 1: 5 ， female easily Suffer

from PSH is perhaps related to progesterone receptor

The patients are found in a routine medical examination

without obvious discomfort symptoms.

Clinical characteristics （ 2）

The PSH patients haven’t positive signs, probably because of tumor’s

shorter diameter and it’s position(lobar peripheral), seldom involved in

 bronchus and blood vessels.

PSH can occur in any lobar,but most in right lung and in the middle or

lower lobar.

PSH is usually diagnoed as a single nodule,but sometimes as multiple

lesions unilateral or bilateral lung.

Treatment and prognosis

Surgery is the only effective treatment.

The choice of surgery :pulmonary wedge resection ,  segmentectomy

of lung .if it’s hard to use wedge resection ,you would choose

lobectomy.

Lymph node metastasis are rare and it’s  metastasis does not affect the

prognosis. So lymph node dissection is not recommend.

PSH’s prognosis is good,There are the majority of patients with

disease-free survival after operation.

Summary

 Pulmonary Sclerosing Hemangioma (PSH) has no obvious specificity

in clinical symptoms and imaging findings. It's hard to diagnose

before surgery. Make a definite diagnosis relying on pathology .

Surgery is the only effective treatment. The choices of surgery have

two: pulmonary wedge resection and  segmentectomy of lung. lymph

node dissection is not recommended.

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Thank you ！