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Fig. 1 Chest radiograph showing a nodular lesion with an irregular margin located in the right middle field.
Fig. 2 Chest CT scan showing a 35-mm nodular lesion at the periphery of the right S4 extending to the upper and lower lobes with an irregular margin, spiculation and pleural indentation. The inside of the nodular lesion was heterogeneously enhanced.
病理組織所見:切除腫瘤は 4.5×3.0×2.0 cm 大で,多数の壊死性肉芽腫が葉間胸膜を越えて上中下葉に分布していた(Fig. 5).壊死物質は細気管支内腔に充満しており,弾性線維染色でみると壊死性肉芽腫は肺動脈周囲に形成されていた(Fig. 6A,B).また,壊死性肉芽腫の周囲には巨細胞を伴った壊死のない肉芽腫形成もあり,前医での CT ガイド下肺生検の組織像と一致していた
(Fig. 6C,D).よって,本症例は組織学的には細気管支
日呼吸会誌 49(12),2011.972
Fig. 3 A PET-CT scan shows an abnormal amount of FDG accumulation in the nodular lesion (SUV max; 6.63 in the early phase, 8.87 in the late phase).
Fig. 4 The CT-guided lung biopsy specimen obtained by the referring physician histopathologically showed that small non-necrotic epithelioid cell gran-ulomas were dispersed in the lung tissue and were associated with Langhan giant cells. (hematoxylin-eo-sin [HE] stain, ×10)
Fig. 5 Histology of the resected nodular lesion shows epithelioid cell granulomas with necrosis spreading beyond the interlobar pleura. (RUL: right upper lobe, RML: right middle lobe, PL: pleura, HE stain ×1)
ited angitis and granulomatosis of the Wegener type(LWG),lymphomatoid granulomatosis(LYG),necrotiz-ing sarcoid angitis(NSG),bronchocentric granulomato-sis(BCG)に分類したが,このうち BCG に関しては病理組織学的概念が先行し,頻度も少なく,その病態がアレルギー反応なのか,感染症の一側面なのか,低悪性度の腫瘍性病変なのか不明であり,臨床医にとって理解し難い疾患概念となっている.Liebow によれば,BCG は壁破壊を伴う気管支や細気管支周囲の非特異的な壊死性肉芽腫性病変を特徴とするが,血管炎所見が軽いことがWegener 肉芽腫などといった他の肉芽腫性血管炎と異なるとされる.その後の検討で,BCG の約半数はアレルギー性気管支肺アスペルギルス症(allergic bron-chopulmonary aspergillosis:以下 ABPA)に伴うことがわかってきた2).一方,ABPA を伴わない群では,
気管支中心性肉芽腫症の 1 例 973
Fig. 6 (A) Epithelioid cell granuloma with necrosis centered on the bronchioles. (Br: bronchiole, PA: pul-monary artery, HE stain ×2) (B) This necrotizing granuloma was formed around the pulmonary artery (Elastica van Gieson stain ×2). (C) (D) These granulomas ( → ) were surrounded by other non-necrotic granulomas with giant cells. (HE stain ×10)
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8)Den Hertog RW, Wagenaar SS, Wastermann CJ.Bronchocentric granulomatosis and pulmonary
echinococcosis. Am Rev Respir Dis 1982 ; 126 : 344-347.
9)Houser SL, Mark EJ. Bronchocentric granulomato-sis with mucus impaction due to bronchogenic carci-noma. An association with clinical relevance. ArchPathol Lab Med 2000 ; 124 : 1168-1171.
10)Warren J, Pitchenik AE, Saldana MJ. Bronchocen-tric granulomatosis with glomerulonephritis. Chest1985 ; 87 : 832-834.
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1)Department of RespiratoryMedicine, National Hospital Organization Himeji Medical Center2)Department of Pathology, National Hospital Organization Himeji Medical Center
3)Department of Pathology, Tenri Yorozu Hospital
A 51-year-old man visited a local physician because of a chest radiographic abnormality which had beenpointed out in October 2009 and March 2010. His chest CT images revealed a nodular lesion in the right middlelobe. Since the nodular lesion showed abnormal FDG accumulation on FDG-PET, the physician suspected lungcancer, but was unable to make a definitive diagnosis by CT-guided lung biopsy. The patient was thus referred toour hospital for detailed investigations. A nodular lesion with spiculation and pleural indentation was recognizedin the S4 region on chest CT scans which was strongly suspected to be lung cancer. Since various examinationsdid not provide a definitive diagnosis, we performed surgery. The histological findings of the extirpated tumorwere considered to be bronchocentric granulomatosis (BCG), because necrotic granulomatous lesions with epithe-lioid cells centered on the bronchioles and there was no evidence of fungus or acid-fast bacterium infection.