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Eur Respir J 2005; 26:748-749
Copyright ©ERS Journals Ltd 2005

Cystic lesions of the lung: a forgotten menace

C. S. H. Ng, S. Wan, T. W. Lee and A. P. C. Yim

The Chinese University of Hong Kong, Hong Kong

To the Editors:

We read with interest the article by Battistini et al. 1 concerning a young female with spontaneous pneumothorax as the presenting feature of pulmonary lymphangioleiomyoma, which appeared in a previous issue of the European Respiratory Journal. The differential diagnoses, which included lymphangioleiomyoma, tuberous sclerosis and Langerhans cell histiocytosis or eosinophilic granuloma, were based on bilateral cystic pulmonary lesions on high-resolution computed tomography, which were slow to progress, as well as the relatively normal pulmonary function tests 2.

We recall a 46-yr-old male who presented to us with left spontaneous pneumothorax, followed 2 days later by the development of contralateral pneumothorax. A computed tomography scan revealed bilateral multiple cystic lesions with thin smooth walls of varying sizes. However, the male sex prompted us to exclude a more sinister cause for the lesions 2, and upon further questioning the patient had complained of right thigh pain for several weeks. Examination revealed a fixed soft tissue mass in the mid-thigh. Histology from the thigh mass biopsy and bilateral video-assisted thoracic surgery bullectomy 3 confirmed pulmonary epithelioid sarcoma metastases. Subsequent investigations showed no other organ was involved. The pulmonary lesions progressed over a 5-yr period, eventually leading to respiratory failure.

Pulmonary cysts as the sole metastatic manifestation of sarcomas are rare, with <20 cases reported 4. The cysts are usually thin walled, without debris and slow growing (fig. 1Go).



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  		Fig. 1— Computed tomography scan of the patient showing: a) an emerging thin-walled cystic lesion in the right lower lobe; and b) a slight increase in size of the original right lesion and a new development in the contralateral side at 2-yr follow-up.

 
Typically, the cystic lesions are not evident on chest radiographs, but are well visualised on computed tomography scans, where they may mimic benign bullous disease. The diagnosis may not be established until patients present with pneumothorax necessitating surgical intervention and biopsy 3, 5.

Clinicians should be aware of this important differential diagnosis of bilateral pulmonary cystic lesions, and exclude metastatic sarcoma in the assessment of their patients.

REFERENCES

  1. Battistini E, Gambini C, Rossi UG, et al. Spontaneous pneumothorax in a 24-year-old female. Eur Respir J 2005;25:575–580.[Free Full Text]
  2. Johnson SR, Whale CI, Hubbard RB, Lewis SA, Tattersfield AE. Survival and disease progression in UK patients with lymphangioleiomyomatosis. Thorax 2004;59:800–803.[Abstract/Free Full Text]
  3. Yim APC, Ng CSH. Thoracoscopic management of spontaneous pneumothorax. Curr Opin Pulm Med 2001;7:210–214.[Medline] [Order article via Infotrieve]
  4. Hasegawa S, Inui K, Kamakari K, Kotoura Y, Suzuki K, Fukumoto M. Pulmonary cysts as the sole metastatic manifestation of soft tissue sarcoma. Chest 1999;116:263–265.[Abstract/Free Full Text]
  5. Traweek T, Rotter AJ, Swartz W, Azumi N. Cystic pulmonary metastatic sarcoma. Cancer 1990;65:1805–1811.[Medline] [Order article via Infotrieve]



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