PMC7378679_01
A-D: Initial chest CT images with a lung-window setting (A and B) showing mosaic perfusion with multifocal dilatation and beading of the peripheral pulmonary vessels and thickening of bronchial walls and/or interlobular septa in all pulmonary lobes. Note nodular dilatation of the subsegmental pulmonary arterial branch mimicking a pulmonary parenchymal nodule (arrow in A) in the left upper lobe. The post-processing Hounsfield unit (HU)-based color maps of the axial (C) and coronal (D) contrast-enhanced CT images show marked heterogeneity of lung attenuation due to uneven perfusion, coded with different colors. As defined in the color bar in D, the multiple purple and blue-colored areas, most pronounced in the left upper lobe distal to the occluded artery (arrows in C and D), represent areas with low HU due to diminished perfusion. The green, yellow, orange and red-colored areas represent areas with higher HU or perfusion. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
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It revealed multifocal dilatation and beading of the segmental, subsegmental, and centrilobular pulmonary arteries with smooth or irregular thickening of either bronchial walls or interlobular septa in all pulmonary lobes (Fig. 1A and B). Multifocal areas of diminished perfusion were demonstrated on the post-processing CT color maps (Fig. 1C and D), automatically generated by pulmonary artery analysis application of Philips IntelliSpace Portal 7.0.
A-D: Histologic examinations of lung tissues obtained by transbronchial lung biopsy with hematoxylin-eosin staining show a linear distribution of lymphangitic carcinomatosis (A, original magnification x20) and clusters of tumor cells occluding small muscular pulmonary arteries (arrows) and lymphatic channels (arrowheads) (B, original magnification x200). Immunohistochemical staining shows numerous neoplastic cells marked with PSA (C, original magnification x200) and negative staining of neoplastic cells for VEGF (D, original magnification x400).
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Pathological examination of the biopsied lung tissues confirmed the presence of clusters of adenocarcinoma within the small muscular pulmonary arteries and lymphatic vessels (Fig. 2A and B). Subsequent immunohistochemical staining showed that these tumor cells were positive for prostatic specific antigen (PSA) (Fig. 2C) but were negative for an antibody against vascular endothelial growth factor (VEGF) (Fig. 2D).
A-B: Follow-up CT obtained 4 months after the treatment with a lung-window setting shows near-complete resolution of all previous abnormalities, including the previously dilated subsegmental pulmonary artery (arrow in A) in the left upper lobe.
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Following bilateral orchiectomy and anti-androgen (flutamide) treatment, the patient showed remarkable clinical and radiographic improvement (Fig. 3).