Scientific letter
Alveolar adenoma: Atypical radiological presentation of a rare neoplasm
Adenoma alveolar: presentación radiológica atípica de una neoplasia infrecuente
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Sección teñida con HE (100×) B). Cavidades quísticas ocupadas por denso material extracelular eosinófilo con histiocitos. El estudio inmunohistoquímico pone de manifiesto células positivas para actina de músculo liso en el interior de los tabiques (recuadro con asterisco).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. García-Abellás, J. Alarcón-Rodríguez" "autores" => array:2 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "García-Abellás" ] 1 => array:2 [ "nombre" => "J." 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Un diagnóstico alternativo ante la presencia de adenopatías axilares" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1409 "Ancho" => 2925 "Tamanyo" => 265118 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0085" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Positron emission tomography-computed tomography (PET-CT) showing right axillary lymphadenopathy (yellow arrow) with abnormal uptake of <span class="elsevierStyleSup">18</span>F-FDG (SUVmax<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.7). B) Axial CT showing the lymphadenopathy in the right axilla (orange arrow), rounded in shape and of increased size (the largest node with short axis of 14<span class="elsevierStyleHsp" style=""></span>mm). In addition, inflammatory changes can be observed in the right axilla, close to the most anterior enlarged lymph node, secondary to a recent fine-needle aspiration puncture. C) <span class="elsevierStyleSup">18</span>F-FDG PET-CT where, in addition to uptake of the lymphadenopathy in the right axilla (blue arrow), a diffuse increase in activity is observed in the soft tissues of the anterior mediastinum (blue arrowhead), probably related to thymic remnants. No lymphadenopathy can be identified in the lateral/cervical area or in other locations. D) Coronal CT scan of the chest and upper abdomen showing some of the enlarged lymph nodes in the right axilla (green arrow), with no other lymphadenopathy in either the left axilla or other locations.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Joral del Hoyo, M. Gallego Verdejo, M.S. González Fuentes" "autores" => array:3 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Joral del Hoyo" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Gallego Verdejo" ] 2 => array:2 [ "nombre" => "M.S." "apellidos" => "González Fuentes" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833821001272" "doi" => "10.1016/j.rx.2021.08.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833821001272?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510722001203?idApp=UINPBA00004N" "url" => "/21735107/0000006400000006/v1_202211170607/S2173510722001203/v1_202211170607/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Alveolar adenoma: Atypical radiological presentation of a rare neoplasm" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "589" "paginaFinal" => "590" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. García-Abellás, J. Alarcón-Rodríguez" "autores" => array:2 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "García-Abellás" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "J." "apellidos" => "Alarcón-Rodríguez" "email" => array:1 [ 0 => "josejavier.alarcon@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Adenoma alveolar: presentación radiológica atípica de una neoplasia infrecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 561 "Ancho" => 2341 "Tamanyo" => 188318 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography with intravenous contrast. Lung parenchyma window in axial (A) and coronal (B) planes. In the posterior segment of the right lower lobe, a nodular formation can be seen with components of both lobulated and aerial soft tissue density (black arrow). Mediastinal window in the axial plane (C), where the attenuation values of the soft tissue component in the arterial (left) and portal phase (right) are compared, showing that there is no significant variation in the density of the lesion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Alveolar adenoma is a rare lung neoplasm initially described by Yousem and Hochholzer in 1986<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. In most cases, they are described incidentally in radiological studies on middle-aged, asymptomatic women<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Although their course is benign, surgical resection and histological study are required for the definitive diagnosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 48-year-old woman with a history of pneumonia associated with environmental dust, treated with antibiotics and bronchodilators. During the investigations related to this episode, a computed tomography (CT) scan conducted after the administration of intravenous contrast (IVC) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) identified a nodular formation in the posterior segment of her right lower lobe (RLL), 30<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mm in size. It had an aerial component and a lobulated soft tissue density component (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B), with mean attenuation values of around 45 Hounsfield units (HU) and no significant variations between the arterial and portal phases (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">As this was an indeterminate pulmonary nodule not accessible to transthoracic biopsy, an atypical segmental resection of the RLL was performed using video-assisted thoracoscopic surgery. There were no complications in the immediate postoperative period. The CT scan performed six months after surgery showed no radiological data of recurrence.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The macroscopic examination of the surgical specimen found a well-defined polypoid subpleural mass with a maximum diameter of about 3<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A), comprised of multiple cystic cavities filled with a dense gelatinous material.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Histopathological examination (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B) identified it as a cystic tumour, made up of cavities lined by cuboidal epithelial cells without atypia. The cavities were separated by connective tissue septa, consisting of mesenchymal cells arranged in a fibromyxoid matrix. Inside the cysts was an eosinophilic protein material with histiocytes. In the immunohistochemical analysis, the epithelial cells were positive for TTF-1, pan-CK and napsin, and the mesenchymal cells focally expressed smooth muscle actin.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The lack of an invasive growth pattern and atypia are helpful in the differential diagnosis of adenocarcinoma. It can be distinguished from a lymphangioma by the fact that the cells lining the cystic cavities are positive for epithelial markers and negative for endothelial markers. Stromal cells negative for TTF-1 rule out a cystic pneumocytoma. These factors then lead to the diagnosis of alveolar adenoma.</p><p id="par0035" class="elsevierStylePara elsevierViewall">From a radiological standpoint, alveolar adenomas appear as subpleural nodules with well-defined borders, with a mean diameter of 2.2<span class="elsevierStyleHsp" style=""></span>cm, relatively low attenuation values (around 25 HU) and no enhancement after administration of IVC<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. The lack of enhancement is an important factor in the differential diagnosis with pneumocytoma, which also presents as a subpleural nodule in middle-aged women, but which does usually show marked enhancement<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. Although one case in the literature had punctiform enhancement areas inside the nodule, this finding was related to the presence of stromal vessels in the interstitium<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. There is also a report of a multiseptate, cavitated mass with well-defined borders<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. However, we found no imaging descriptions like that of our patient, associating both soft tissue density and air cystic components, and we believe that the interest of our case lies in this distinctive feature.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Lesions studied with positron emission tomography did not show significant avidity for 18FDG<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the few cases assessed with magnetic resonance imaging<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> showed a behaviour consistent with a cystic lesion (signal hypointensity in T1-weighted sequences and marked hyperintensity in T2-weighted sequences), with wall ring enhancement after gadolinium administration.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, alveolar adenoma is a rare neoplasm, but one that should be included in the differential diagnosis of incidental pulmonary nodules, especially in middle-aged women. Radiologically, they can be both homogeneous lesions and mixed lesions (as in our case) with a soft tissue and air component. After reviewing the histology of our case, we believe that the dense eosinophilic proteinaceous alveolar content may correspond to the soft tissue density reported in the radiological examination.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any type of funding.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 561 "Ancho" => 2341 "Tamanyo" => 188318 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography with intravenous contrast. Lung parenchyma window in axial (A) and coronal (B) planes. In the posterior segment of the right lower lobe, a nodular formation can be seen with components of both lobulated and aerial soft tissue density (black arrow). Mediastinal window in the axial plane (C), where the attenuation values of the soft tissue component in the arterial (left) and portal phase (right) are compared, showing that there is no significant variation in the density of the lesion.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 902 "Ancho" => 755 "Tamanyo" => 159496 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Macroscopic examination reveals a well-defined subpleural lesion of the adjacent lung parenchyma, consisting of multiple cystic cavities filled with a dense gelatinous material. Section stained with HE (100×) B). Cystic cavities filled with dense eosinophilic extracellular material with histiocytes. Immunohistochemistry reveals smooth muscle actin-positive cells within the septa (box with asterisk).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alveolar adenoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.A. Yousem" 1 => "L. Hochholzer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0046-8177(86)80092-2" "Revista" => array:6 [ "tituloSerie" => "Hum Pathol" "fecha" => "1986" "volumen" => "17" "paginaInicial" => "1066" "paginaFinal" => "1071" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3759064" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alveolar adenoma of the lung: multidisciplinary case discussion and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Roshkovan" 1 => "J.C. Thompson" 2 => "S.I. Katz" 3 => "C. Deshpande" 4 => "T. Jenkins" 5 => "A.K. Nowak" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/jtd-20-1831" "Revista" => array:6 [ "tituloSerie" => "J Thorac Dis" "fecha" => "2020" "volumen" => "12" "paginaInicial" => "6847" "paginaFinal" => "6853" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33282386" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alveolar adenoma of the lung: computed tomography and magnetic resonance imaging findings" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Fujimoto" 1 => "N.L. Müller" 2 => "J. Sadohara" 3 => "H. Harada" 4 => "A. Hayashi" 5 => "N. Hayabuchi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00005382-200204000-00011" "Revista" => array:6 [ "tituloSerie" => "J Thorac Imaging" "fecha" => "2002" "volumen" => "17" "paginaInicial" => "163" "paginaFinal" => "166" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11956369" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Computed tomography findings of alveolar adenoma of the lung with histopathologic comparison: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.Y. Kim" 1 => "D.S. Ryu" 2 => "G.H. Gang" 3 => "M.S. Park" 4 => "S.-J. Choi" 5 => "J.H. Ahn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3348/jksr.2014.70.5.347" "Revista" => array:5 [ "tituloSerie" => "J Korean Soc Radiol" "fecha" => "2014" "volumen" => "70" "paginaInicial" => "347" "itemHostRev" => array:3 [ "pii" => "S2352301819303388" "estado" => "S300" "issn" => "23523018" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Giant alveolar adenoma causing severe dyspnoea" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Petrella" 1 => "S. Rizzo" 2 => "G. Pelosi" 3 => "A. Borri" 4 => "D. Galetta" 5 => "R. Gasparri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/JTO.0b013e3181d95ca5" "Revista" => array:7 [ "tituloSerie" => "J Thorac Oncol" "fecha" => "2010" "volumen" => "5" "paginaInicial" => "1088" "paginaFinal" => "1090" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20581577" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109717390502" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735107/0000006400000006/v1_202211170607/S2173510722001264/v1_202211170607/en/main.assets" "Apartado" => array:4 [ "identificador" => "77332" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735107/0000006400000006/v1_202211170607/S2173510722001264/v1_202211170607/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510722001264?idApp=UINPBA00004N" ]
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