A 56-year-old white male aircraft mechanic presented to his primary care physician for his annual physical examination. A routine radiographic image of the chest exposed a 4- to 5-cm mass in the lower lobe of his left lung. The primary care physician ordered a computed tomography (CT) scan of the chest, abdomen, and pelvis to evaluate for evidence of metastases. On the CT scan, a mass was noted in the left lung base with no abnormalities present elsewhere. The patient's primary care physician referred him to a consulting cardiothoracic surgeon.
The patient presented to the cardiothoracic surgeon (A.H.O.) 2 weeks after being seen by his primary care physician. He had a 35-year history of tobacco use, smoking one pack of cigarettes per day for 30 years, as well as a history of squamous cell carcinoma on his hand and basal cell carcinoma on his shoulder. His family history was significant for cancers of the bladder, pancreas, liver, and neck. Additional patient risk factors included workplace chemical and fuel exposure. The patient denied any upper respiratory symptoms, exercise limitations, or contact with individuals who had respiratory symptoms.
On physical examination, vital signs were stable. The patient's lungs were clear to auscultation with slightly diminished breath sounds bilaterally. Oxygen saturation was 96% on room air. Pulmonary function tests showed evidence of air trapping and bronchodilator response most likely secondary to reactive airway disease. Forced vital capacity (FVC) was 5.2 L (86% predicted); forced expiratory volume in the first second of expiration (FEV1) was 3.2 L (71% predicted); and FEV1/FVC was 63%.
The CT scan revealed a 3.5 × 2.2–cm bilobulated mass in the anterior basal portion of the left lung lobe abutting the major fissure. Some thickening and fluid in the oblique fissure were also noted. An interventional radiologist performed a CT-guided biopsy, which revealed a mesenchymal lesion consistent with a smooth muscle cell–type lesion. Bundles of spindle-shaped cells with small nuclei and a few large hyperchromatic nuclei were seen. A light scattering of lymphocytes and focal necrosis were evident. Minimal mitotic activity and some nonneoplastic lung tissue were present.
A positron emission tomographic/CT whole body scan was taken to rule out disease involvement in other areas of the body. A 3.7-cm lobulated mass with moderate increased activity was seen in the inferior lingula. There was no evidence of metastatic disease. A repeated chest radiograph, taken 2 months after the initial radiograph, showed a poorly marginated nodular opacity measuring 4.5 cm in the basilar left lower lobe. There was no evidence of infiltrate, mass, or effusion.
The patient underwent a left thoracotomy with a left lower lobectomy. Mediastinal lymphadenectomy of the left upper paratracheal, left lower paratracheal, para-aortic, and subcarinal lymph nodes was negative for metastatic disease. The sarcoma was 4 cm and did not involve the lymphovascular bed or the overlying visceral pleura. The surgical margins of resection were negative for malignancy. The sarcoma was 5.2 cm from the bronchial margin of resection. The remaining lung parenchyma demonstrated focal areas of benign pneumocyte hyperplasia and mild emphysematous-type change.
The surgical pathology report revealed a well-circumscribed malignant spindle cell tumor characterized by spindle cells with blunt nuclear ends and markedly increased areas of mitotic activity. The average mitotic rate was 18 mitotic figures per 10 high-powered fields. Punctuate areas of necrosis were also identified. The presence of hypocellularity areas along with hyalinized fibrosis were noted centrally. The malignant spindle cells tested positive for S100 antigen, smooth muscle actin, and vimentin. Malignant spindle cells tested negative for anticytokeratin 5.2, caldesmon, cytokeratin 5/6, cytokeratin 7, cytokeratin 20, CD34, C-Kit, desmin, epithelial membrane antigen, myogenin, pancytokeratin, and thyroid transcription factor-1. The spindle cell tumor had no epithelial differentiation. Overall morphologic features favored a high-grade sarcoma with evidence of smooth muscle differentiation, making this a leiomyosarcoma.
The lung expanded on the left side postoperatively, and the patient had an uneventful recovery. Osteopathic manipulative treatment (OMT) comprising soft tissue and myofascial release to the upper thoracic and chest wall regions and gentle rib raising techniques was applied postoperatively twice daily. Pedal lymphatic pump technique was also used to augment systemic lymphatic flow.
He was discharged in stable condition on postoperative day 3 with a final diagnosis of high-grade spindle cell sarcoma consistent with leiomyosarcoma. He was instructed to follow up with an oncologist for his leiomyosarcoma diagnosis and with his primary care physician for smoking cessation.