B. Hamartoma
Discussion
Hamartomas are the most common benign lung neoplasms and are often
incidentally discovered on imaging. They are generally found in adults,
with a higher male predominance. The most common radiologic pattern of a
hamartoma is a solitary lung nodule that appears like a coin lesion in
the periphery of the lung. Hamartomas are solid, and the majority are
<4 cm, and appear round with smooth, clearly delineated margins.
Endobronchial hamartomas account for 10-25% of cases.
Typical radiographic features of pulmonary hamartomas include popcorn
calcification or intranodular fat (-40 to -120 HU). These features may
be absent approximately 30% of the time, requiring biopsy or resection
for definitive diagnosis. PET/CT findings can be supportive, but
hamartomas (especially those larger in size) can have uptake
characteristics that suggest malignancy. Histologic examination reveals a
mixture of cartilage, fat, smooth muscle, myxomatous connective tissue,
bone, and clefts lined by respiratory epithelium.
The association between pulmonary hamartomas and malignancy is
controversial. There are observational studies describing an increased
risk of bronchial cancer, and case reports of patients with hamartomas
and synchronous malignancy. Most pulmonary hamartomas are non-expanding
or slow-growing. Surveillance is recommended, and surgical resection can
be considered in hamartomas greater than 2.5cm in size, rapidly
expanding nodules, uncertainty in diagnosis or difficulty
differentiating from malignancy, or if patients are symptomatic.
While granulomas can be round, solid and solitary, the patient had no
clinical signs or symptoms of infection (A). Rounded atelectasis (C) is
usually subpleural with a characteristic comet tail sign and adjacent
pleural thickening. Nodules or masses suggestive of granulomatosis with
polyangiitis (D) are often multiple and can appear densely consolidated,
cavitary, or with surrounding ground glass. A carcinoid tumor of the
lung (E) could be considered as these are commonly incidentally found
solitary nodules, but the histopathologic result is not consistent.
References
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Elsayed, H., et al. Is resection necessary in biopsy-proven asymptomatic pulmonary hamartomas? Interactive CardioVascular and Thoracic Surgery 2015; 21: 773-776.