77 Apollo Medicine, Vol.1 September 2004

Case Reports

NODULAR amyloidosis of the lung is an uncommon form oflocalized amyloidosis. It is also known as amyloid tumor as itforms an asymptomatic mass that is discovered by chanceradiographically and is suspected of being malignant. It is abenign condition of unknown etiology and recurrence isuncommon.

We report a case of pulmonary nodular amyloidosis withcoexisting carcinoma prostate.

CASE REPORT

A 51-year-old male, during a periodic health check-up inJune 2002, was found to have two nodular lesions in the rightlung (Fig. 1). CT scan revealed two well defined, nodular softtissue masses in the right middle lobe and right lower lobe,measuring 3.5 and 4.3 cm respectively. The patient had twoepisodes of hemoptysis in November 2002 and December2003, while remaining asymptomatic in the interveningperiod. CT guided aspiration biopsy done elsewhere wasinconclusive. The patient was advised thoracotomy/lobectomy for which he presented at Apollo in March 2004.Preoperative workup revealed raised PSA (31.42). CAprostate was diagnosed on needle biopsy. Colonoscopy

revealed multiple hyperplastic colonic polyps.

CT scan showed two coin-sized lesions in the right lung(Fig. 2), more or less the same size since June 2002 and twosimple cysts in the liver. Bone scan was normal. A wedgeresection of the lung lesions was done with a clinicaldifferential diagnosis of metastatic disease or hamartoma.

On gross examination, wedge biopsy of the lung weighed250 g. On slicing, two well defined lesions measuring6.5 × 6 × 4.5 cm and 3 × 3.5 × 2.5 cm were seen. The cutsurface was yellow to white and cartilagenous in consistency(Fig. 3).

Histological examination revealed two well circum-scribed nodules (Fig. 4) composed entirely of homogenous,eosinophilic, hyaline material which stained positively withCongo Red (Fig. 5) and showed apple green birefringencewhen viewed under polarised light. The lung parenchymaimmediately adjacent to the nodules showed deposits ofsimilar nature within the alveolar septae and the vessel walls.

DISCUSSION

Primary pulmonary amyloidosis is a rare disorder[1-4]

NODULAR AMYLOIDOSIS OF LUNG

Noopur Gupta#, K.G.J. Prassana*, S. Chatterjee @, Ajay Lall+ and D.S. Arora #

From the Departments of Histopathology #, Cardiothoracic Surgery *, Internal Medicine @ and Respiratory Medicine+,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi -110 044, India.Correspondence to: Dr. D.S. Arora, Senior Consultant Histopathology, Department of Histopathology and Cytopathology,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 044, India.E-mail: deepshikhaarora@apollohospitalsdelhi.com

Key words : Nodular, Amyloidosis, Lung.

Fig. 1. X-ray - two nodules in right lung base. Fig. 2. CT - Nodular mass in posterior part of right lung.

Apollo Medicine, Vol.1 September 2004 78

Case Reports

Fig. 3. Cut surface - sharply circumscribed pale nodule. Fig. 5. Congo red - contrast staining of amyloid and collagen.

amyloidosis which may mimic metastatic disease radio-logically. These lesions are difficult to biopsy making itdifficult to exclude malignancy or confirm benign disease.Thus reliable diagnostic methods are required to avoidunnecessary surgical resection.

REFERENCES

1. Breitenfelder M, Kusch E, Leichsenring M, et al. Pulmonarynodular amyloidosis mimicking multiple pulmonarymetastases of carcinoma of the corpus uteri. Chirurg 2001Sep;72(9):1062-1066.

2. Kirchner J, Jacobi V, Kardos P, et al. CT findings in extensivetracheobronchial amyloidosis. Eur Radiol 1998;8(3):352-354.

3. Antolin Garcia MT, Abad Hernandez MM, Gomez Gomez F,et al. Primary pulmonary nodular amyloidosis. ArchBronchopneumol 1997 May;33(5):251-253.

4. Yoshino I, Katsuda Y, Yokoyama H, et al. Solitary amyloidnodule in the lung. Scand Cardiovasc J 1997; 31(2):121-122.

5. Okabe H, Tomita K, Ogsawara T, et al. A case of solitarynodular pulmonary amyloidosis. Nihon Kokyuki GakkaiZasshi 2003 May; 41(5): 341-346.

6. Tamura K, Nakajima N, Makino S, et al. Primary pulmonaryamyloidosis with multiple nodules. Eur J Radiol 1988 May;8(2):128-130.

7. Hiroshima K, Ohwada H, Ishibashi M, et al. Nodularpulmonary amyloidosis associated with asbestos exposure.Pathol Int 1996 Jan; 46(1): 66-70.

8. Miyamoto K, Kobayashi T, Makiyama M, et al. Monoclonalityof infiltrating plasma cells in primary pulmonary nodularamyloidosis detection with PCR. J Clin Pathol 1999 Jun;52(6): 464-467.

9. Domiguez Juncal LM, Ruanova Saurez S, Tabara RodriquezJ, et al. Multiple nodular pulmonary AA amyloidosis. A casereport. An Med Interna 1999 May;16(5): 244-246.

that appears in three forms - tracheobronchial, nodularparenchymal and diffuse parenchymal [2]. Pulmonarynodular amyloidosis (PNA) is also known as amyloid tumoras it forms an asymptomatic mass that is discovered by chanceradiographically and is suspected of being malignant[1,4-6]as in our case with coexisting carcinoma prostate.

It is a benign condition of unknown etiology and is notrelated to smoking. The possibility of asbestos fibres as one ofthe etiologic factors has been suggested [7].

The amyloid in PNA is of AL type. It involves localaccumulation of monoclonal plasma cells and their secretedproducts [8,9].

Most patients of PNA are middle aged. There is no sexpredilection. Recurrence after resection is unusual.

CONCLUSION

Pulmonary nodular amyloidosis is a rare form of localized

Fig. 4. H & E, x 20, sharp demarcation.