Finger Clubbing and a Lung Mass

John D. Urschel, Timothy M. Anderson and Brian P. Whooley

Chest 1999;115;1735-1737
DOI 10.1378/chest.115.6.1735

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roentgenogram of the month

Finger Clubbing and a Lung Mass*
John D. Urschel, MD, FCCP; Timothy M. Anderson, MD; and
Brian P. Whooley, MD

(CHEST 1999; 115:17351737)

71-year old man complained of enlargement of

his distal phalanges. He did not have any other
musculoskeletal complaints, and he denied pulmonary symptoms. He was a heavy smoker. Medical
history was unremarkable. He did not have symptoms of cardiac or liver disease. Physical examination
showed obvious clubbing of his fingers. Chest examination revealed dullness to percussion and decreased air entry at the right base. There was no
lymphadenopathy. Results of cardiac examination
were normal. The liver was not enlarged.
CBC and chemistry were normal. Fasting blood
glucose level was also normal. Chest radiography
showed a mass in the right inferior-posterior hemithorax (Fig 1) that was best seen on the lateral
radiograph (Fig 2). Chest CT scan showed a 12-cm
mass arising from either the pleura or the right lower
lobe (Fig 3). There was no lymphadenopathy. CTguided needle biopsy specimen showed benign fibrous tissue.
Bronchoscopy, done just prior to thoracotomy, was
normal. Right lateral muscle-sparing thoracotomy
revealed a 12-cm mass within the lower lobe. Right
lower lobectomy and mediastinal lymph node sampling were performed. The patient was discharged
*From the Department of Thoracic Surgical Oncology, Roswell
Park Cancer Institute, Buffalo, NY.
Manuscript received September 14, 1998; revision accepted
November 3, 1998.
Correspondence to: John D. Urschel, MD, FCCP, Thoracic
Surgical Oncology, Roswell Park Cancer Institute, Elm and
Carlton Streets, Buffalo, NY 14263-0001

Figure 1. Chest radiograph shows mass in right inferiorposterior hemithorax.

home from the hospital on the second postoperative

day. His finger clubbing completely resolved over
the ensuing 6 months.
What is the diagnosis?

CHEST / 115 / 6 / JUNE, 1999

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1735

Figure 3. Chest CT scan shows 12-cm mass arising from either

the pleura or the right lower lobe.

Figure 2. Lateral radiograph.

1736

Roentgenogram of the Month

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Diagnosis: Solitary fibrous tumor of the pleura

Primary tumors of the pleura can be divided into
two major categories: diffuse and solitary.1 Diffuse
pleural tumors are mesotheliomas. They are more
common than solitary pleural tumors, arise from
mesothelial tissue, are associated with asbestos exposure, and almost always have a fatal course.2 Solitary
tumors have been known by a variety of names that
are indicative of their clinical course and controversies surrounding histogenesis. Previous terminology
included benign mesothelioma, localized mesothelioma, subpleural fibroma, and localized fibrous tumor
of the pleura.1,3,4 These tumors are now known to be
of mesenchymal, as opposed to mesothelial, origin;
the preferred term is solitary fibrous tumor.5 They
are not related to asbestos exposure, and they follow
a benign course in . 80% of cases.1 There is no
relationship between solitary fibrous tumors and
mesotheliomas.1,5 The pleural space is the usual
location for solitary fibrous tumors, but they may
arise in a wide range of tissues.5 This is not surprising
considering their mesenchymal histogenesis.
Patients with solitary fibrous tumors of the pleura
may present with cough, shortness of breath, chest
pain, sensation of a mass moving within the chest,
hypoglycemia, hypertrophic pulmonary osteoarthropathy, digital clubbing, fever, or an asymptomatic radiographic abnormality.1,3,4 Both benign and malignant
solitary fibrous tumors can grow to massive proportions
and cause life-threatening compression of intrathoracic
structures. Clubbing, hypertrophic osteoarthropathy,
and hypoglycemia are not typically seen with mesothelioma, so the combination of a large pleural mass and
one of these paraneoplastic syndromes should suggest a
diagnosis of solitary fibrous tumor.1 Hypoglycemia is
caused by tumor production of insulin-like growth
factor II.6 Hypoglycemic coma and death have been
caused by unrecognized solitary fibrous tumors.1,7 Clinicians usually think of lung cancer with brain metastases when presented with a patient with a large chest
tumor and altered mental status; solitary fibrous tumor
should be kept in mind in this clinical situation. Similarly, the combination of finger clubbing and a chest
mass is suggestive of lung cancer, but solitary fibrous
tumor is also possible. Paraneoplastic syndromes resolve with surgical resection of the solitary fibrous
tumor.3
Solitary fibrous tumors arise from the visceral
pleura more often than the parietal pleura.1 They are
typically well circumscribed, pedunculated masses,
with large vessels within the tumor pedicle. They
can, however, be largely within the lung parenchyma, as was the case in our patient. Radiologically,
it is often difficult to tell if the mass is pleural or
pulmonary in nature. Bronchoscopy is useful to
exclude endobronchial tumors, such as lung cancer.
A transthoracic fine-needle aspiration biopsy specimen usually shows benign-appearing spindle cells.

Ultimately, thoracotomy and tumor resection are

usually required for diagnosis. Histologic examination of benign solitary fibrous tumors shows spindle
cells with minimal nuclear pleomorphism and infrequent mitoses. When malignancy occurs in a solitary
tumor of the pleura, it is characterized by pleomorphism, necrosis, and a high mitotic rate (. 4 per 10
high-power fields).5,8 10 The morphologic appearances of benign and malignant solitary fibrous tumors are variable, and they may simulate a variety of
soft-tissue tumors.5,7,8,11 In addition, there are no
specific ultrastructural characteristics to separate
solitary fibrous tumors from some other soft-tissue
tumors, such as fibrosarcoma. Until recently, immunohistochemical characteristics (keratin negative, vimentin positive, S-100 negative) were helpful, but
not diagnostic.8 The diagnosis of solitary fibrous
tumor has become more precise since CD34 antibody staining was found to be positive in these
tumors; it is now an essential pathologic feature for
the diagnosis of solitary fibrous tumors.5,11
Surgical resection of benign solitary fibrous tumors is usually curative, but local recurrences can
occur years after seemingly adequate surgical treatment.1,3,5,7 Malignant solitary fibrous tumors generally have a poor prognosis.1,3,7,9 Clinical follow-up
and radiologic follow-up are indicated for both benign and malignant solitary fibrous tumors.

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CHEST / 115 / 6 / JUNE, 1999

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Finger Clubbing and a Lung Mass

John D. Urschel, Timothy M. Anderson and Brian P. Whooley
Chest 1999;115;1735-1737
DOI 10.1378/chest.115.6.1735
This information is current as of September 30, 2007
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