INTERNATIONAL JOURNAL OF CLINICAL AND MEDICAL CASES (ISSN:2517-7346)

Pulmonary blastoma is one of the rare lung tumors and is considered to be distinct from other lung tumors by its pathological features, clinical course and prognosis [1]. Classic pulmonary blastoma is composed of both malignant mesenchymal stroma and epithelial components resembling emberyonic lung tissue. Surgery is the standard treatment and the efficacy of adjuvant chemotherapy and radiotherapy has not yet been established [2].

Our patient was admitted and managed at Abassia Pulmonary Hospital, Ministry Of Health, Cairo Governorate, and Egypt.

A 37 year-old Egyptian male presented to our hospital after repeated attacks of blood tinged sputum. The first attacks dated about 6 months before admission. The patient had progressive shortness of breath over a period of two years. The patient was a smoker of one pack of cigarettes per day for more than 15 years. There was no significant past history nor family history.

After admission to the Chest Medicine Department at Abbasia Pulmonary Hospital, routine basic investigations were done including complete blood picture with differential count, fasting blood sugar and 2 hours after meal, liver function tests, renal function tests, and coagulation profile. All investigations were within normal. Sputum examinations for AFB for 3 successive days were done and were all negative. Sputum cytology did not show malignant cells.

The P-A view of his chest X-ray showed a well-demarcated right upper and middle lung zones mass. The mass extends to the right lung apex abutting the inner chest wall and medially extended to the mediastinum and the right hilum. The mass has a heterogeneous texture (Figure 1). Chest CT scan (Figure 2 and 3) showed a large well defined, heterogeneous right upper lobe mass. The CT showed no significant meditational lymph nodes enlargement.

Preoperative fiberoptic bronchoscoy showed no endobroncheal pathology. Also the bronchoalveolar lavage was negative for both AFB and malignant cells. Preoperative CT needle guided biopsy revealed a biphasic pulmonary blastoma with both epithelial and mesenchymal components. Preoperative CT abdomen and bone scintigraphy revealed no evidence of distant metastasis.

The patient was referred to the Thoracic Surgery Department at our hospital for resection of the pulmonary blastoma affecting the right upper lung lobe. General anaesthesia was conducted via double lumen endotracheal tube for one lung anaesthesia. The patient was positioned in the lateral decubitus position with his right side up. Standard right posterolateral thoracotomy in the fifth space was done. The tumor mass was seen and felt involving the entire right upper lung lobe and sparing both the middle and lower lung lobes. The mass was well circumscribed, lobulated with firm to hard texture. Classic right upper lobectomy was done. After closure of the bronchial stump with simple interrupted Vicryl 2 zero sutures, the stump was covered using a pedicled intercostal muscle flap as our standard technique in cases of malignancy and TB to guard against Postoperative pathology bronchpleural fistula. Postoperativepathology report confirmed the diagnosis  of high grade biphasic pulmonary blastoma with free bronchial margin, free pleural tissue and negative mediastinal lymph nodes for metastasis. The postoperative course of the patient was uneventful. After removal of the stiches; the patient was referred to the Cancer Institute of Cairo University for evaluation and the possibility of post lobectomy chemotherapy and / or radiotherapy. (Figure 1, Figure 2,Figure 3, Figure 4, Figure 5,)