Case Report A Rare Case of Diffuse Idiopathic Pulmonary Neuroendocrine …downloads.hindawi.com/journals/cris/2015/318175.pdf · 2019. 7. 31. · of neuroendocrine cell neoplasia

Case ReportA Rare Case of Diffuse Idiopathic PulmonaryNeuroendocrine Cell Hyperplasia

Godwin Ofikwu,1 Vishnu R. Mani,2 Ajai Rajabalan,1 Albert Adu,1

Leaque Ahmed,1 and Dennis Vega3

1Department of Surgery, Columbia University College of Physicians and Surgeons at Harlem Hospital, New York, NY 10037, USA2Department of Surgery, New York University School of Medicine, New York, NY 10016, USA3Department of Cardiothoracic Surgery, Harlem Hospital Center, New York, NY 10037, USA

Correspondence should be addressed to Vishnu R. Mani; [email protected]

Received 4 September 2015; Accepted 8 October 2015

Academic Editor: Francesco Petrella

Copyright © 2015 Godwin Ofikwu et al.This is an open access article distributed under theCreativeCommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare clinical condition with only about 100 casesreported in the literature. It is characterized by primary hyperplasia of pulmonary neuroendocrine cells (PNECs) which arespecialized epithelial cells located throughout the entire respiratory tract, from the trachea to the terminal airways. DIPNECHappears in various forms that include diffuse proliferation of scattered neuroendocrine cells, small nodules, or a linear proliferation.It is usually seen in middle-aged, nonsmoking women with symptoms of cough, dyspnea, and wheezing. We present a 45-year-old, nonsmoking woman who presented with symptoms of DIPNECH associated with bilateral pulmonary nodules and left hilaradenopathy. Of interest, DIPNECH in our patient was associated with metastatic pulmonary carcinoids, papillary carcinoma ofthe left breast, oncocytoma and angiomyolipoma of her left kidney, and cortical nodules suggestive of tuberous sclerosis. She hadvideo assisted thoracoscopic surgery (VATS), modified radical mastectomy with reconstruction, and radical nephrectomy. She iscurrently symptom-free most of the time with over two years of follow-up.

1. Introduction

Diffuse idiopathic pulmonary neuroendocrine cell hyper-plasia (DIPNECH) is a relatively new and rare diseasethat has recently received attention, and it is commonlymisdiagnosed. DIPNECH was first reported by Aguayo etal. [1] in 1992. The World Health Organization (WHO)included DIPNECH in its 1999 lung tumor classificationas a form of preinvasive lung lesion within the spectrumof neuroendocrine cell neoplasia [2]. This included tumor-lets that extended beyond the basement membrane andformed lesions which are <5mm in greatest dimensionand nodules which are >5mm. These were classified aspulmonary neuroendocrine tumors [NETs] and also knownas carcinoids. DIPNECH is regarded as a precursor lesionfor carcinoid tumors. Carcinoid tumors are subdivided intotypical carcinoids, which are low grade tumors and atypicalcarcinoids, which are intermediate grade tumors. DIPNECH

has a predilection for nonsmoking, middle-aged women andis associated with a predominantly obstructive ventilatorypattern on pulmonary function tests seen in obliterativebronchiolar fibrosis [1] or bronchiectasis.Most of the patientspresent with nonproductive cough and exertional dyspneathat are commonly misdiagnosed for bronchial asthma orchronic bronchitis. The treatments included systemic andinhaled corticosteroids, bronchodilators, and lung resection.The clinical outcomes vary from improvement of symptomsto deterioration. We present our experience in the manage-ment of a unique case of a 45-year-old, nonsmoking womanwho presented with bilateral pulmonary nodules and lefthilar adenopathy in association with papillary carcinoma ofthe left breast, oncocytoma, and angiomyolipoma of the leftkidney. She gave a history of several years of a nonproductivecough, dyspnea, and wheezing that were initially thoughtto be due to bronchial asthma. The patient was managedwith video assisted thoracoscopic surgery (VATS)withwedge

Hindawi Publishing CorporationCase Reports in SurgeryVolume 2015, Article ID 318175, 5 pageshttp://dx.doi.org/10.1155/2015/318175

2 Case Reports in Surgery

resections for DIPNECH, left modified radical mastectomyfor breast cancer, and left laparoscopic radical nephrectomyfor oncocytoma. Her symptoms have progressively improvedfollowing the lung surgery, and she is currently asymptomaticmost of the time.This case is unique because, to the best of ourknowledge, it is the first case of DIPNECH with metastaticcarcinoid associated with papillary breast cancer, ductalcarcinoma in situ (DCIS), oncocytoma, and angiomyolipomaof the kidney with possible brain tumors. There may be anunderlying genetic predisposition to development of thesepreinvasive lesions and neoplasms.

2. Case Summary

Our patient is a 46-year-old, nonsmoker, African Americanwoman, who is originally from Barbados. She initially wentto her primary care physician (PCP) four years prior topresenting to us, with several years history of cough, dyspnea,wheezing, and occasional chest pain. She was diagnosedwith allergic rhinitis and asthma with a peak expiratoryflow rate (PEFR) of 145 and 180 before and after albuteroltreatment, respectively.The patient was treated with albuterolinhaler and antihistamines and continued follow-up visitsto her PCP. The purified protein derivative (PPD) skin testwas found to be positive. However, the follow-up chest X-ray was unremarkable. She was later called back to herPCP office for an abnormal result on her annual screeningmammography. Additional views were required and weresubsequently reported as normal, other than the three benigncysts that were found in her right breast.

A year later, she had an emergency room visit for anacute exacerbation of her respiratory symptoms. Due to therecurrent emergency room visits, her PCP established amoreaggressive asthma treatment plan. Several weeks later at herannual visit to the gynecologist, the patient was found tohave a palpable mass on the upper outer quadrant of herleft breast, measuring 2 × 3 cm. There was no associatedaxillary lymphadenopathy. A core needle biopsy of the leftbreast mass showed papillary carcinoma, estrogen receptor(ER) 90–95% positive, progesterone receptor (PR) 65–70%positive, Her2/Neu receptor (HER2) by IHC 1+ negative, andKi-67 < 10% favorable. During preoperative breast MRI andmammogram, multiple grouped micro calcifications wereseen in the right breast at 12 o’clock position, suspicious ofmalignancy, and grouped micro calcifications at 12 and 6o’clock position in left breast. Stereotactic biopsies of theseright breast grouped micro calcifications and left breastgrouped micro calcifications at 12 o’clock position showedfibrocystic changes and ductal hyperplasia in the right breastand carcinoma in the left breast.

A CT scan of the abdomen and pelvis was done as part ofthe workup to determine the extent of her disease. It showed a3.5 cmmass with central necrosis in the upper pole of the leftkidney, a smaller exophytic lesion of the mid-portion of theleft kidney, bone island, or area of sclerosis in left iliac wing,and the limited view of the lung bases demonstrated multiplesubcentimeter nodules in the lung bases. Findings appearedconsistent with primary renal neoplasm with lung nodules of

Figure 1: PET CT of chest.

Figure 2: CT chest. Multiple subcentimeter bilateral lung nodules.

unknown etiology versus metastatic renal carcinoma. A CTguided biopsy of the left renal mass showed oncocytic renalcell neoplasm,whichwas suggestive of oncocytoma.TheCEAwas 1.5 ng/mL (𝑛 < 5 ng/mL); CA-125, 3.7 (𝑛 < 35); and CA-19-9, 27.29 (𝑛 < 39.6). The subsequent chest CT (Figure 2)showed a triangular shaped soft tissue density in the anteriormediastinum and bilateral multiple pulmonary nodules withthe largest nodule located in the right upper lobe, measuring1.5 cm, left hilar adenopathy, and minimal focal pleuralthickening in the left lower hemithorax. A Positron EmissionTomography (PET) scan imaging (Figure 1) showed uptakein these lung nodules as well as in the left hilar region andin the left renal mass. A CT guided transthoracic needlebiopsy (TTNBx) of the largest right pulmonary nodule wasnondiagnostic.

A multidisciplinary review of the PET/CT (Figure 4)raised the possibility that the lung lesion was metastatic renalcell or breast cancer versus unknown primary. It was decidedthat the best way to obtain a diagnosis was to operate andperform wedge resection of the largest lung nodules. She hadbilateral video assisted thoracoscopic surgery (VATS) withresection of the right chest 2 cm hilar lymph node, wedgeresections of right middle lobe (RML), and excision of rightlower lobe (RLL) nodules. The patient did well postopera-tively and was discharged home on postoperative day three.The pathology of the left hilar lymph node was positive forcarcinoid tumor. The right middle and lower lobe nodulesshowed carcinoid tumor as well. Also seen within the lungwere multiple carcinoid tumorlets, diffuse neuroendocrinecell hyperplasia, and bronchiectasis. Microscopically, thetumor in both the lungs and lymph nodes showed organoid

Case Reports in Surgery 3

Brain MRI showingmultiple subcorticalmasses suspicious

for tuberous sclerosis

Figure 3: Brain MRI, showing subcortical masses.

and trabecular growth with salt and pepper chromatin. Thehighest mitotic count was 1 per 10 high power fields (HPF)and no necrosis was seen. These findings are consistent withtypical carcinoid tumors. Given the history of breast cancerand a renal tumor, immunohistochemistry (IHC) studieswere performed. IHC staining was positive for cytokeratin(weak), cytokeratin 7, synaptophysin, chromogranin, andTTF1 (weak) but negative for napsin, PAX8, GFDFP15, ER,PR, mammaglobin, and CDX2.

The patient then underwent a left mastectomy and sen-tinel lymphnode biopsy.Thepathology on the sentinel lymphnode was negative for malignancy. The left breast on pathol-ogy showed florid low grade multifocal DCIS. IHC studieswere similar to her previous breast biopsy result with no focuson invasiveness ofDCIS. She also had laparoscopic radical leftnephrectomy for her left renal tumors. The pathology resultreturned as oncocytoma with two growth patterns. One wasof solid growth with oncocytes and the other with tubularand nested growth of oncocytes. Oncocytes were positive forCK18, CK7, CD10, c-kit, racemase, and PAX8 and negativefor vimentin, thyroid transcription factor 1 (TTF-1), napsin,chromogranin, and synaptophysin. The second tumor isspindle cell predominant, positive for SMA and HMB45 andnegative for CK, representing an angiomyolipoma.

A brain MRI was later done because of the association ofDIPNECHwith MEN1 and tuberous sclerosis with angiomy-olipoma of the kidney. MRI of the brain (Figure 3) showedflair hyperintense lesions in subcortical white matter of theright parietal lobe, which could represent subcortical tubersin the setting of Tuberous Sclerosis Complex (TSC). Thepatient then had a whole body octreotide scan, which, inaddition to the masses discussed thus far, showed bilateralanterior neck masses. Fine needle aspiration biopsy (FNAB)was reported as benign. The patient refused further invasivetesting to get a tissue diagnosis.

In summary, we have a patient with bilateral diffuseidiopathic pulmonary neuroendocrine hyperplasia (DIP-NECH), lung carcinoid tumor with mediastinal metastasisand unrelated left breast cancer with florid multifocal DCIS,left renal tumors, anterior neck tumors, and possible tuberoussclerosis.

3. Discussion

The first formal recognition of DIPNECH was by Aguayoet al., in a series of 6 case reports in 1992, in which theydescribed patients with severe obstructive airway diseaseand progressive dyspnea. These patients were discoveredto have diffuse neuroendocrine cell hyperplasia of the air-ways and obliterative airway fibrosis, in which the three ofthese patients also had carcinoid tumor. Since DIPNECHwas reported in 1992, several other authors have reviewedadditional cases of DIPNECH; some were associated withcarcinoids [1].This recent surge in frequency of the diagnosisof DIPNECH is due to increased use of high resolutionCT (HRCT) scans combined with increased awareness ofthis entity as previously suggested by Davis et al. [3]. It isnoteworthy that only about 100 cases of DIPNECHhave beenreported in the literature. In 1999, DIPNECH was definedby the WHO as a generalized proliferation of scatteredsingle cells, small nodules/neuroendocrine bodies, or linearproliferations of pulmonary neuroendocrine cells that maybe confined to the bronchiolar epithelium, including localextraluminal proliferation in the form of tumorlets, or extendto the development of carcinoid tumors. This WHO defini-tion includes cases of neuroendocrine cell hyperplasia andtumorlet formationwith or without associated airway fibrosisand specifically notes that other pathologies that might beassociated with reactive neuroendocrine cell proliferationare absent [4]. DIPNECH has been associated primarilywith the development of typical carcinoids. In fact, it isgenerally believed that DIPNECH is probably a precursorlesion for typical carcinoid. WHO report indicated this inits 2004 histological classification of tumors. In the seriesby Davies et al., there were three cases associated withatypical carcinoid, one of whom had multiple endocrineneoplasia. To our knowledge, this is the first case of DIP-NECH where the patient is presenting with a classic clinicalpicture of DIPNECH with metastatic carcinoid and multipleunrelated tumors. Our patient has DIPNECH in associationwith papillary carcinoma of the breast, oncocytoma, andangiomyolipoma of the left kidney and a yet-to-be-diagnosedneck mass.

Our patient is a nonsmoking woman who was firstseen by a physician in the United States 4 years prior topresenting to us. The patient complained of many years ofintermittent, nonproductive cough, dyspnea, wheezing, andoccasional chest pain.There was no significant weight loss orphysical findings. The patient appeared to be in good health,otherwise, andwas initiallymisdiagnosed as case of bronchialasthma and treated for it. The patient was later found tohave papillary breast cancer and renal tumors; she was againmisdiagnosed as having metastatic lung disease when herchest CT revealed multiple subcentimeter round nodulesin the lung bases. This presentation is in line with severalcases discussed in the literature. A 6-year electronic literaturesearch of all DIPNECH cases reported in English by Nassaret al. found that 92% of these patients were women with anage range of 36 to 76 years at diagnosis and 67% of themwere nonsmokers. This description applies to our patient.Furthermore, the latter report also found that 71% of the

4 Case Reports in Surgery

(a) (b)

(c)

Figure 4: Multidisciplinary review of PET CT.

patients had cough; 63% had dyspnea; and 25% hadwheezingfor days to years prior to diagnosis. Like our patient, 54% ofthe patients reviewed had pulmonary function tests showingobstructive ventilatory disease and pulmonary nodules werefound in 63% of patients. Grozinsky-Glasberg et al., intheir review of all the 100 reported cases of DIPNECHidentified in the literature published in 2011, found a similarpattern of clinical presentation and most of the patients hadstable disease like our patient who has stable symptoms thathave not progressed since diagnosis. In fact, her symptomsare so stable that she does not want to undergo furtherevaluation for a recently discovered neck mass since fineneedle aspiration returned as benign cells.

After reviewing the PET/CT of our patient, the differen-tial diagnosis includedmetastatic renal cell cancer;metastaticbreast cancer, although unlikely given in this picture; andmetastatic disease of unknown primary. Several reviews inthe literature have alluded to the fact thatmostDIPECHcasesare usually misdiagnosed and these patients often get treatedfor bronchial asthma and other respiratory conditions.Whenpulmonary nodules are encountered in the lungs they arebelieved to bemetastases. A surgical lung biopsywas requiredto make a histological diagnosis of DIPNECH and carcinoidswith bronchiectasis in this patient. 21% of patients reportedin the literature, as reviewed by Nassar et al., had associatedbronchiectasis with DIPNECH and 88% of them requiredsurgical lung biopsy for histological confirmation of disease.

After the histological diagnosis of DIPNECH with meta-static carcinoids, we thought that the other masses including

the breast and kidney masses were metastatic carcinoids.However, immunohistochemical and histological studies, asindicated above, showed the breast mass to be a papillarycarcinoma which is ER+, PR+ HER2/NEU−, and Ki67−. Therenal masses were negative for TTF-1, napsin, chromogranin,and synaptophysin and had no histological appearance ofcarcinoids. In contrast, the neuroendocrine cells in DIP-NECH are positive for neuroendocrine markers such assynaptophysin, chromogranin, and CD56. Davies et al. alsoshowed weak positive staining for TTF-1 in nine cases [3].These findings led us to conclude that the breast and renalmasses were not metastatic carcinoids but were different andseparate tumors. Incidence of multiple cancers in this patientled us to hypothesize that she might have familial or geneticpredisposition to the occurrence of such a conglomerate ofdifferent tumors with benign, preinvasive, and malignantcomponents.The patient denied any family history or similarsymptoms in her immediate or extended family. However,we cannot rule out the presence of similar but subclinicalconditions in her family. It is of interest that she is the onlyone in her family residing in the United States with everyother family member back in Barbados and unavailable forexamination and possible genetic testing.

The management of patients with DIPNECH is predom-inantly close surveillance. The role of surgery is not clearlydefined. However, the treatment principle remains surgicalintervention for early disease and predominantly palliativetherapy in metastatic disease. Treatment strategies includesystemic and inhaled corticosteroids, bronchodilators, and

Case Reports in Surgery 5

lung resection. Of note, the recent demonstration of molecu-lar signaling pathways involved in tumor growth, as demon-strated by Chen et al. [5], showing that carcinoid and otherneuroendocrine tumors have activation of Ras signalingdirectly by mutations in Ras and indirectly by loss of Ras-regulatory proteins, or via constitutive activation of upstreamor downstream effector pathways of Ras, such as growthfactor receptors or PI3-Kinase and Raf/MAP kinases mightlead to new immunomodulating agents for the disease. Inaddition, aberrant activation of Ras signaling sensitizes cellsto apoptosis when the activity of the PKC𝛿 isozyme is sup-pressed and that PKC𝛿 suppression is not toxic to cells withnormal levels of RAS p21 signaling. Furthermore, inhibitionof PKC𝛿 by a number of independent means, includinggenetic mechanisms (shRNA) or small molecule inhibitors,is able to efficiently and selectively repress the growth ofhuman neuroendocrine cell lines derived from bronchopul-monary, foregut, or hindgut tumors. PKC𝛿 inhibition in thesetumors also efficiently induced apoptosis. In line with thesefindings and more recent reports, Sunitinib, a multitargetedtyrosine kinase inhibitor, has been shown to improve thesurvival of pancreatic NETs patients. Similarly, the use of anmTOR inhibitor, everolimus, either alone or in combinationwith somatostatin analogs has demonstrated encouragingefficacy in treating advanced NETs as documented by Leunget al. [6]. The success of these two agents in pancreaticNETS supports the notion that targeting angiogenesis and/orPI3K/AKT/mTOR pathway is an important strategy for mak-ing therapeutic advances in this disease.Themajor drawbackis the differential response to biological agents amongst NETsof different anatomical origins, with pancreatic NETs gen-erally more responsive to both chemotherapy and targetedagents than NETs of other sites. There are currently manyongoing trials in exploring the role of other biological mod-ifiers or agents in treating patients with NETs or carcinoids,especially metastatic disease. From the time our patient wasfirst diagnosed, she has been treatedwith bronchodilators andinhaled steroids. Because of her unique presentation, she hashad left modified radical mastectomy, left nephrectomy andbilateral VATS with removal of left chest 2 cm hilar lymphnode, and right chest wedge resections of right middle lobe(RML) and right lower lobe (RLL) nodules for the lesionsdescribed above. She did well and was discharged homeon postoperative day three. She has been followed up inclinic over a 2-year period postoperatively and reported to beasymptomatic most of the time, developing cough only whenexposed to cold environment. This contributed to her refusalfor any further evaluation and treatment of her condition.Her stable condition compliments the findings of Swigrisand colleagues who presented four patients with 2- to 14-year follow-up with an excellent long-term prognosis. Weanticipate an excellent long-term prognosis for our patienttoo.

4. Conclusion

There is a surge in the number of patients diagnosed withDIPNECH since it was first described in 1992. Patients withthis unique disease are still misdiagnosed. Although most

patients enjoy a relatively stable clinical course, this diseasemay be associatedwith prolongedmorbidity in somepatients.High index of suspicion and close follow-up remain the keyfor early diagnosis and management of patients with morbidsymptoms.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

[1] S. M. Aguayo, Y. E. Miller, J. A. Waldron Jr. et al., “Brief report:Idiopathic diffuse hyperplasia of pulmonary neuroendocrinecells and airways disease,”TheNew England Journal ofMedicine,vol. 327, no. 18, pp. 1285–1288, 1992.

[2] J. Swigris, S. Ghamande, T. W. Rice, and C. Farver, “Diffuseidiopathic neuroendocrine cell hyperplasia: An interstitial lungdisease with airway obstruction,” Journal of Bronchology, vol. 12,no. 1, pp. 62–65, 2005.

[3] S. J. Davies, J. R. Gosney, D. M. Hansell et al., “Diffuse idio-pathic pulmonary neuroendocrine cell hyperplasia: an under-recognised spectrum of disease,”Thorax, vol. 62, no. 3, pp. 248–252, 2007.

[4] W. D. Travis, E. Brambilla, H. K. Muller-Hermelink, and C. C.Harris, World Health Organization Classification of Tumours:Pathology & Genetics: Tumours of the Lung, Pleura,Thymus andHeart, IARC Press, Lyon, France, 2004.

[5] Z. Chen, L. W. Forman, K. A. Miller et al., “Protein kinase C-delta inactivation inhibits cellular proliferation and decreasessurvival in human neuroendocrine tumor,” Endocrine-RelatedCancer, vol. 18, no. 6, pp. 759–771, 2011.

[6] R. Leung, B. Lang, H. Wong et al., “Advances in the systemictreatment of neuroendocrine tumors in the era of moleculartherapy,”Anti-Cancer Agents inMedicinal Chemistry, vol. 13, no.3, pp. 382–388, 2013.

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Case Report A Rare Case of Diffuse Idiopathic Pulmonary Neuroendocrine …downloads.hindawi.com/journals/cris/2015/318175.pdf · 2019. 7. 31. · of neuroendocrine cell neoplasia