A 67-year-old male ex-smoker (>20 years) with a 30 pack-year history was investigated for morning cough and clear sputum with no constitutional symptoms and an active lifestyle. Past medical history included chronic obstructive pulmonary disease and ischaemic heart disease. External physical examination was unremarkable. Chest computed tomography (CT) showed a right middle lobe nodule which increased from 11 mm to 16 mm over six months. A positron emission tomography (PET) scan showed low radiolabeled [18F]-2-fluoro-2-deoxy-D-glucose (FDG) uptake with a standardised uptake value (SUV) max of 2.0 and no evidence of metastatic disease (). CT-guided biopsy identified eosinophilic amorphic material, which was Congo red negative, with no definitive diagnosis reached. Due to the volume increase of the suspicious lesion, a right middle lobe lobectomy was performed.
A 64-year-old man presented with an incidental right lung mass on chest X-ray. Mediastinoscopy and lymph node biopsy confirmed amyloid, remaining asymptomatic until four years later, developing exertional dyspnoea matched by significant increase of the mass by chest radiography. Basic laboratory evaluation and immunohistochemistry was unremarkable. Immunoelectrophoresis revealed a faint immunoglobulin G (IgG) kappa band. No mass spectrometry was performed. Colonic biopsy, bone marrow aspirate, immunophenotyping and trephine were normal. 123I Serum amyloid P-component (SAP) scintigraphy showed abnormal uptake within the mass only. Computerised tomography (CT) revealed mediastinal and hilar lymphadenopathy, with a 9.5 × 6.5 × 10 cm right mediastinal mass containing fat and calcification with a radiological differential diagnosis of a teratoma. F-18 fluorodeoxyglucose (FDG)-Positron Emission Tomography (PET)/CT demonstrated intermediate to high-grade uptake within the soft tissue and low-grade uptake in the fatty component (). Cardiac magnetic resonance imaging excluded cardiac involvement. Repeat core biopsy demonstrated fibrovascular tissue with focal amyloid deposition. The patient proceeded to surgical mass de-bulking for diagnosis and symptom relief and histology confirmed evidence of amyloid. The patient’s postoperative course was uneventful; no evidence of recurrence three months following surgery and marked symptomic improvement, with disappearance of the IGgk paraprotein following resection, currently planned for local consolidation radiotherapy.