case 5 answer Routine Screening Radiograph in a 60-Year-Old Smoker

Routine Screening Radiograph in a 60-Year-Old Smoker

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Answer
Pulmonary hamartoma: A hamartoma is a benign neoplasm in an organ
composed of tissue elements normally found at that site but that are
growing in a disorganized mass. Pulmonary hamartomas are usually
solitary, though multiple tumors have been reported in the Carney
triad of pulmonary chondromas, gastric epithelioid leiomyoblastoma,
and functioning extra-adrenal paraganglioma.

Found in 0.25% of general population, pulmonary hamartoma is the
third most common cause of solitary pulmonary nodules and the most
common benign tumor of the lung. Pulmonary hamartomas account for
6-8% of all solitary pulmonary lesions and 75% of all benign lung
tumors. The tumors most frequently occur in men and are usually found
in the fifth to sixth decades of life. No racial predilection is
observed. Most individuals with hamartomas are smokers.

Suggested theories for the etiology of these lesions include
congenital malformation of a displaced bronchial anlage, hyperplasia
of normal lung tissues, cartilaginous benign neoplasia, and responses
to inflammation.

About 15% of the pulmonary hamartomas are calcified. Characteristic
punctate, or popcorn, calcifications are found on plain films in
about 10% of cases. This popcorn appearance is almost pathognomonic;
other patterns of calcification include curvilinear and stippled. On
CT, the following findings are considered diagnostic of a hamartoma:
solitary lesion; diameter smaller than 2.5 cm; circumscribed,
lobulated, and smooth wall; and fat content in about 50%,
calcification in about 15%, or both. The detection of fat is aided by
using 2-mm slice thickness CT. During follow-up, most tumors grow
slowly at a mean rate of 3 mm/year.

Malignant transformation of pulmonary hamartomas is probably
nonexistent, but the literature does show a higher-than-expected
incidence of lung cancer in patients with these lesions. Most
patients with hamartomas are usually asymptomatic, especially when
the lesion is peripheral (as in up to 90% of cases). However, central
or endobronchial lesions are frequently associated with symptoms or
signs of obstruction (eg, hemoptysis, coughing, wheezing,
expectoration, leukocytosis). Peripheral lesions have no lobar predilection.

Histologic diagnosis can be obtained by means of fine-needle
aspiration of peripheral lesions. The results are diagnostic if
cartilage or fibromyxoid fragments are recognized. The differential
diagnosis of pulmonary hamartomas includes bronchogenic carcinoma,
solitary pulmonary metastasis, granuloma, carcinoid tumor and rarely
papilloma, lymphoma, and pulmonary leiomyoma, among other conditions.

Treatment of symptomatic or rapidly growing masses or those larger
than 2.5 cm in diameter consists of wedge resection or enucleation of
peripheral tumors and bronchoscopic removal of endobronchial lesions.
Lesions that show minimal growth or that do not produce symptoms can
be followed up conservatively.

For more information on pulmonary hamartoma, see the eMedicine
articles
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/radio/topic316.htm%5Etarget=%5E_blank%5E>Hamartoma,
Lung and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/radio/topic782.htm%5Etarget=%5E_blank%5E>Solitary
Pulmonary Nodule (within the Radiology specialty) and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/med/topic3559.htm%5Etarget=%5E_blank%5E>Solitary
Pulmonary Nodule (within the Internal Medicine specialty).

References
* Armstrong P, Wilson AG, Dee P, Hansell DM. Imaging of Diseases
of the Chest. St Louis, Mo: C.V. Mosby; 2000.
* Siegelman SS, Khouri NF, Scott WW Jr, et al. Pulmonary
hamartoma: CT findings. Radiology 1986;160(2):313-7.
BACKGROUND
A 60-year-old man presents to the emergency department after
accidentally falling when he tripped over a sidewalk curb. On the
review of systems, the patient reports occasionally having a dry
cough. He states that he has had the cough "for quite some time" and
attributes it to his 40-pack-year history of smoking cigarettes. On
further questioning, he denies having weight loss, hemoptysis, or
shortness of breath.

On physical examination, the patient is a man of moderate build, in
no apparent distress. His blood pressure, heart rate, and respiratory
rate are within normal limits. He has normal breath sounds and no
respiratory distress. Findings on chest, abdominal, and the rest of
his physical examination are unremarkable. A chest radiograph is
obtained. When the results are reviewed, a CBC and chemistry panel
are ordered and deemed noncontributory. Contrast-enhanced chest CT
scanning is performed.

What is the diagnosis?
Hint
The diagnosis is the most common benign tumor of the lung.
Author: Gautam Dehadrai, MD, Staff Radiologist, Department of
Radiology, Veterans Affairs Medical Center, Albuquerque, NM
eMedicine Editor: Rick G. Kulkarni, MD, Assistant Professor, Yale
School of Medicine, Section of Emergency Medicine, Department of
Surgery, Attending Physician, Medical Director, Department of
Emergency Services, Yale-New Haven Hospital, Conn

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