A Massive Calcified Mass in the Lung

(CHEST 2003; 124:2010 –2013) A 60-year-old woman was evaluated for a mass lesion shown on a radiograph of the thorax. The patient had been well until 6 weeks before, when progressive shortness of breath, coughing and leftsided chest pain, and pain between her shoulders developed. Her medical history revealed rheumatoid arthritis for 30 years, for which she received prednisolone, 10 mg/d. In 1994, breast-conserving surgery was performed because of a metaplastic carcinoma of the right breast. After surgery, she received adjuvant radiotherapy. No lymph node metastases were found. During follow-up, no signs of metastasis or relapse were observed. There was no history of smoking. Physical examination showed normal vital signs. The right breast showed a scar, but there were no palpable abnormalities in either breast. There was no lymphadenopathy. Percussion and auscultation of the chest were normal. Her extremities showed malformations matching her rheumatoid arthritis. Laboratory examination revealed an erythrocyte sedimentation rate of 52 mm/h, and a microcytic and hypochromic anemia (hemoglobin, 11,4 g/dL; hematocrit, 36%). The alkaline phosphatase level was 1,494 U/L (normal range, 70 to 150 U/L), with an elevated bone fraction. The other liver function test results were normal. The calcium and albumin levels were normal, and the parathyroid hormone was slightly raised (110 pg/L; normal range, 0 to 100 pg/L). Chest radiography showed a widened mediastinal silhouette, especially around the aortic arch, and a shadow at the posterobasal side of the left lung (Fig 1, top, and bottom). A CT scan revealed an abnormal calcified mass in the mediastinum and left lower lobe. The calcified mass in the mediastinum showed encasement of the descending aorta, with displacement of the trachea toward the left hemithorax (Fig 2, top). The calcified consolidated left lower lobe was continuous with the mediastinal mass. Left-sided pleural fluid was also present (Fig 2, bottom). A radionuclide bone scan showed pathologic uptake in the soft tissue of the left hemithorax. There were no signs of any bone metastases. Fiberoptic bronchoscopy revealed a stenotic left main bronchus, narrowed by pathologic tissue. Eventually, CT-guided biopsy was performed to obtain sufficient material for histologic examination.