Dyspnea with a Slow-Growing Mass in the Breast

Chest radiography showed multiple nodular opacities in both peripheral lung fields. Thin-section CT of the chest revealed multiple tiny nodules and centrilobular branching opacities in the subpleural regions of both lung fields ( fig. 1 a). Wedge-shaped or irregularly shaped nodular opacities suggesting pulmonary infarction were also seen in subpleural distribution ( fig. 1 b). On contrastenhanced CT of the mediastinal window setting, a wellenhanced mass in the left breast, up to 3 cm in diameter, was seen ( fig. 1 c). No mediastinal or hilar lymphadenopathy was identified. There were no pleural effusions. The patient underwent bronchoscopy that showed normal endobronchial mucosa. Bronchoalveolar lavage was not diagnostic; no organisms or malignant cells were seen on lavage fluid stains, and the fluid was sterile. Transbronchial lung biopsy (TBLB) was performed from right B 4 . Pathologically, scattered thrombi involving small pulmonary arteries and arterioles were seen. Simultaneously, a ventilation-perfusion lung scintigram was performed. Multiple minute defects in the peripheral lung fields just under the pleura were seen on the perfusion scintigram, while the ventilation scintigram showed normal ventilation. In view of these findings, what is your diagnosis? A 48-year-old Japanese woman presented with a 6month history of increasing exertional dyspnea and dry cough. She denied fever, night sweats, or weight loss. She was a nonsmoker. Her medical history was unremarkable except for the fact that she had been aware of a mass in her left breast for 1 2 years. On admission, her temperature was 36.7 ° C, her pulse was regular at 70 b.p.m., and her respiratory rate was 16 breaths/min. Her lungs were clear on auscultation, and cardiac examination revealed no murmur or gallops. No edema or varicosities were seen in her lower extremities. A hard mass measuring up to 3 cm in diameter was palpable in her left breast. Oxygen saturation was 94% on room air. Arterial blood gases on room air were pH 7.404, Pa CO 2 5.5 kPa (40.9 mm Hg), Pa O 2 9.3 kPa (69.4 mm Hg), and A-a DO 2 4.2 kPa (31.5 mm Hg). On laboratory examination, the complete blood count and basic chemistries were within the normal ranges. D-dimer was 2.5 (normal value ! 1.0) g/ml, and the thrombin-antithrombin III complex was 7.0 (normal value 3.0) ng/ml. Fibrinogen and fibrinogen degradation products were within their normal ranges. The results of pulmonary function tests were: VC 1.86 liters, %VC 69.1%, FEV 1.0 1.88 liters, FEV 1.0 % 100.0%, DL CO 8.37 ml/mm/mm Hg, and %DL CO 51.4%. Echoand electrocardiograms disclosed no findings of cardiac failure or pulmonary hypertension. Received: January 7, 2009 Accepted after revision: October 5, 2009 Published online: December 3, 2009