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Ground-glass opacity of the lung in a patient with melanoma: “The radiological seed of doubt”
Opacidad pulmonar en vidrio esmerilado en un paciente con antecedente de melanoma: “la semilla radiológica de la duda”
G. Dalpiaza, K. Kawamukaib, A.M. Parisib, L. La Torrec, D. Forcellad, G. Leuzzid,
Corresponding author
gio.leuzzi@yahoo.it

Corresponding author.
a Department of Radiology, Bellaria Hospital, Bologna, Italy
b Department of Thoracic Surgery, Maggiore and Bellaria Hospitals, Bologna, Italy
c Department of Oncology, Imola, Italy
d Department of Surgical Oncology, Thoracic Surgery Unit, Regina Elena National Cancer Institute – IFO, Rome, Italy
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Microscopic findings &#40;Haematoxylin and Eosin&#44; original magnification &#215;5&#41;&#58; tumor cells spreading along the alveolar walls and organized in lepidic pattern&#46; No necrotic foci were evidenced&#46; &#40;B&#41; The tumor cells were diffusely stained for antibody anti-S100&#46; Based on these findings&#44; the final pathology was consistent with lung metastasis from melanoma&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 51-year-old Caucasian woman referred to our Department for radiological evidence of ground-glass opacity &#40;GGO&#41; of the left lung&#46; She was an active smoker&#59; her medical history was unremarkable with the exception of the surgical excision 2 years before of a malignant melanoma localized in the left hand and with metastases of axillary nodes &#40;staged as pT3bN0M1b&#41;&#46; A contrast-enhanced computed tomography scan &#40;CT&#41; revealed a non-solid nodule &#40;measuring 2<span class="elsevierStyleHsp" style=""></span>cm&#41; of the left upper lobe &#40;LUL&#41; along with some subcentimetric GGOs bilaterally &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; After the admission&#44; an <span class="elsevierStyleSup">18</span>FDG PET-CT &#40;PET-CT&#41; highlighted an increase of its solid component associated to a slight uptake &#40;SUVmax 2&#46;1&#41; of the LUL lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; No signs of pathologic mediastinal nodes or extra-thoracic disease were disclosed&#46; Given the subsolid nature of the nodule&#44; bronchoscopy or CT-guided biopsy were not performed&#44; thus&#44; after a multidisciplinary meeting&#44; the patient underwent a thoracoscopic LUL wedge resection&#46; Frozen section disclosed atypical cells with lepidic growth only&#44; making a proper pathological diagnosis unfeasible&#58; hence&#44; an uneventful left upper lobectomy plus systematic lymphadectomy was performed&#46; Interestingly&#44; final pathology evidenced intra-pulmonary metastasis from melanoma expressing c-kit mutation &#40;B-Raf wild-type&#41; without nodal involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; so the patient started chemo and immuno-therapy&#46; One year after surgery&#44; oncological follow-up evidenced a stable disease&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">So far&#44; the management of nonsolid&#47;subsolid pulmonary nodules is an extremely challenging issue&#46; As advocated by the Fleischner Society&#44; persistent nonsolid&#47;subsolid nodules usually represent part of the pathologic spectrum of lung adenocarcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Moreover&#44; lung metastasis from adenocarcinoma of thoracic or extra-thoracic origin &#40;gastrointestinal tract&#44; pancreas&#44; kidney&#41; and atypical adenomatous hyperplasia may present with such radiological features and lepidic growth&#46; On the other hand&#44; benign lesions arising from lymphoproliferative disorders&#44; organizing pneumonia and focal interstitial fibrosis may mimic sometimes lung neoplasms given the high rate of GGOs related to these diseases&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Pulmonary metastases from melanoma commonly present as one or multiple solid nodules at standard imaging while GGOs are very rarely reported in literature&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> In this setting&#44; PET-CT may play a role in the case of subsolid metastasis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> In fact&#44; in our patient nuclear images &#40;along with CT&#41; were useful&#58; &#40;i&#41; to evaluate the increase of nodule density&#59; &#40;ii&#41; to assess the <span class="elsevierStyleSup">18</span>FDG uptake of the solid component &#40;as reported for nodules exhibiting a solid part measuring more than 10<span class="elsevierStyleHsp" style=""></span>mm&#41;&#59; &#40;iii&#41; to exclude nodal or extra-thoracic disease&#46; Unfortunately&#44; this uncommon radiological behavior reflects the pathological one related to lepidic growth &#40;resulting from cancer spreading along alveolar walls&#41;&#44; thus leading in difficult pathological diagnosis and&#44; sometimes&#44; overtreatment&#46; In fact&#44; due to the adenocarcinoma-like pathologic pattern&#44; the patient underwent lobectomy rather than lung-sparing surgery&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; in case of radiological evidence of GGOs after surgery for melanoma&#44; follow-up through CT scan and growth rate evaluation are well-recognized options to further analyze such nodules&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> When non-solid nodules acquire partially solid pattern&#44; PET-CT may be useful to better characterize the solid component and to accurately stage the disease&#46; Furthermore&#44; in the suspect of primary or secondary lesions&#44; surgery is usually indicated in order to obtain final diagnosis and oncological treatment simultaneously&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 2253654X
Original language: English
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