CT-guided Biopsy for the Diagnosis of Pulmonary Epithelioid Hemangioendothelioma Mimicking Metastatic Lung Cancer

Abstract

A 69-year-old male patient presented with multiple lung nodules revealed by chest-computed tomography (CT) during a preoperative examination for an appendiceal tumor. The nodule diameters ranged from 2-10 mm without either pleural thickening or effusions. A fluorine-18-labeled fluorodeoxyglucose (¹⁸F-FDG)-positron emission tomography (PET)/CT scan showed a high FDG uptake in the appendiceal tumor, but almost normal standardized uptake values in the bilateral lung nodules. A CT-guided biopsy led to a diagnosis of pulmonary epithelioid hemangioendothelioma, a rare vascular tumor with a radiological presentation similar to that of a metastatic lung tumor. The present case is the first to describe successful treatment using a CT-guided biopsy instead of more conventional methods.

Keywords: minimally invasive procedure; multiple lung nodules; thoracoscopic biopsy; vascular tumor.

Figure.

Imaging of the appendiceal tumor and PEH. (A) Colonoscopy revealed a 15-mm Paris class 0-IIa lesion located in the appendiceal orifice. (B) Computed tomography (CT) scan revealed multiple bilateral lung nodules. The nodule diameters ranged from 2 to 10 mm (yellow arrow head points to a 10-mm lesion). (C) ¹⁸F-FDG-PET/CT revealed an appendiceal tumor with a maximum SUV of 2.4 (yellow arrow head). (D) Bilateral lung nodules showed normal SUVs, and the largest nodule (10 mm) showed an SUV of 1.0 (yellow arrow head). (E) A specimen composed of pale eosinophilic nonstructural substances, which contained epithelioid spindle and cubic mid-sized tumor cells (100 HPF). (F) Immunohistopathologic staining showed the tumor cells to be endothelial in origin and immunoreactive for CD34 (100 HPF).