Pulmonary nodules in a 34-year-old woman

Introduction: The following is a case report of bilateral pulmonary nodules incidentally found on a preoperative chest radiograph. The patient was referred to the pulmonary service for further evaluation and management prior to hysterectomy to remove a fibroid uterus. Case Presentation: CJ is a 34 year old African American woman who was completely asymptomatic at the time of presentation with no complaints of shortness of breath, cough, chest pain, fever, chills, night sweats, or systemic symptoms. Her past pulmonary history was significant for a 25 PYH of smoking. She had questionable exposure to TB while imprisoned for 18 months 3 years prior to this evaluation. She denied any occupational exposures. She had no pets and her most recent travel was to the Carribean Islands several years ago during which time she visited caves. She had no history of pneumonia, pleurisy, or wheezing. Her past medical history was significant for sickle cell trait. Family history and social history were significant for smoking crack which she had stopped several years ago. She is currently not abusing drugs. She had no history of intravenous drug abuse and was HIV negative. Review of systems was noncontributory. On physical exam, she was a well appearing woman with a normal physical. Of note there was no lacrimal or parotid gland enlargement or adenopathy. The lungs were clear and there was no clubbing, cyanosis, or edema or skin lesions. On pelvic exam she had large fibroids. Laboratory data including an SMA-7, CBC, CEA, CA-125, PT, and PTT were all within normal limits. Pulmonary function tests showed a moderate obstructive ventilatory defect with a FEV1/FVC of 70%. The FEV1 = 1.66 L, Dlco=74%, and her O2 sat=99% on room air. PPD was negative and the anergy panel was nonreactive. CXR showed bilateral pulmonary nodules. There were no mediastinal or pleural abnormalities. The patient underwent video assisted thoroscopic surgery and the diagnosis of benign metastasizing leiomyoma was made. She then underwent total abdominal hysterectomy/bilateral salphingoophrectomy with regression of the pulmonary nodules. Discussion: Benign metastasizing leiomyoma is one of four entities in a special class of smooth muscle tumors called leiomyomatosis. The other three entities in this classification are lymphangiomyomatosis, leiomyomatosis peritonealis disseminata, and intravenous leiomyomatosis. All four occur primarily in women of child bearing age. The primary tumor source for all four is considered a uterine leiomyoma. Clinically, the patients with benign metastasizing leiomyoma are usually asymptomatic from a pulmonary standpoint. As in this case, the radiographic findings are often an incidental finding. The radiographic manifestations are usually well-defined nodules ranging in size from 0.2-8 cm which may be unilateral or bilateral. Histologically, the lesions are whorling bundles of mature smooth muscles that often have admixed epithelial and/or fibrous elements. The lesions are considered benign as they show low mitotic activity, lack of cellular atypia, and no lymphatic involvement. Clinically, however, these lesions can show malignant potential since cells from the primary uterine tumor can metastasize to the lung parenchyma. Treatment for benign metastasizing leiomyoma remains somewhat unclear. Most patients who undergo TAH/BSO show regression or stabilization of their pulmonary lesions. However, there are reports of treatment with antiestrogen agents, progesterone, and medical castration with leutinizing hormone releasing hormone (LHRH) analogues with good results. If left untreated the pulmonary lesions can continue to grow and eventually lead to symptoms. The long term prognosis with treatment is excellent. Conclusion: It is important to include benign metastasizing leiomyoma in the differential diagnosis of a young woman with pulmonary nodules particularly if she has a fibroid uterus. It remains puzzling that although the main criteria for malignancy (mitotic activity) is absent, these lesions are capable of spreading to a distant site.