Pulmonary Staple-Stump Granuloma After Segmentectomy: Two Case Reports and Comparison with Cases of Stump Recurrence

Abstract

Case series Patient: Male, 70 • Female, 60 Final Diagnosis: Staple stump granuloma Symptoms: Abnormal shadow on computed tomography Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare disease Background: Correctly diagnosing a staple-line mass after pulmonary resection for lung malignant tumor can be difficult. Differential diagnoses of recurrence, infectious mass, granuloma, and so on must be considered, despite their rarity. We report two cases of pulmonary staple-stump granuloma after segmentectomy for lung cancer. Case Reports: Case 1 involved a 70-year-old man with small nodule in the left upper lobe identified on computed tomography (CT). Video-assisted thoracoscopic (VATS) left upper division segmentectomy was performed. Histopathological examination revealed squamous carcinoma. Follow-up CT 1 year postoperatively showed a shadow at the staple-stump, with growth evident later. CT-guided biopsy found no malignancy. However, complete left upper lobectomy was performed because of the gradually enlarging lesion. Histopathological examination revealed epithelioid granuloma. Case 2 involved a 60-year-old with suspected lung cancer in the right upper lobe. VATS right upper division segmentectomy (S2) was performed. CT at 30 months postoperatively showed a shadow at the staple line, with subsequent growth. VATS right upper lobectomy was performed. Intraoperative rapid diagnosis revealed epithelioid granuloma. These two cases were compared with five cases of staple-stump recurrence in our institution. All cases of recurrence grew concentrically or radially from the staple line with the mass surrounding the staple line. On the other hand, cases of granuloma extended along the long axis of the staple line, and 3-dimensional CT (3DCT) may help to understand the morphology. Conclusions: Although preoperative differentiation of staple-line granuloma is difficult and pathological diagnosis is important, characteristic radiologic features and 3DCT may facilitate diagnosis.

Differentiation between suture recurrence and suture granuloma after pulmonary resection for lung cancer by diffusion-weighted magnetic resonance imaging or FDG-PET / CT

“…Diagnosis of suture lesion after pulmonary resection for lung cancer was reported to be difficult [14] . Although much progress has been made in imaging techniques, especially in the promising field of FDG-PET/CT, these procedures should be still investigated in order to rule out suture granulomas and avoid unnecessary surgery [15] .…”

A case of epithelioid cell granulomas arising at the margin of lung resection, with high accumulation on 18F‐fluorodeoxyglucose‐positron emission tomography

“…However, it was suggested that foreign body reaction to staple material, anatomical tissue changes caused by stapling and impairment of ventilation and blood flow might cause granuloma formation. 3 In this case, the suture granuloma was discontinuous with the epithelioid cell granuloma; thus, we assumed that the anatomical changes and the impairment of ventilation and blood flow might have solely influenced the formation of the epithelioid cell granulomas.…”

“…In recent years, granuloma formation at the stump of lung resection that was performed via stapling has been reported. 3 , 4 Differences in the shape of shadows arising from the staple line 3 and evaluation using diffusion‐weighted magnetic resonance imaging (DWI) 4 have been considered helpful for differentiating tumour recurrence from surgery‐related granulomas. DWI may be useful for differentiating masses arising from margins of resection when stapling was not performed, as in this case.…”

Differentiation between staple line granuloma and recurrence after sublobar resection for primary lung cancer

“…Usuda et al (16) reported the usefulness of diffusionweighted magnetic resonance imaging (DWI) for differentiation of suture recurrence and suture granuloma after resection for lung cancer. Mizukami et al (6) and Mizuno et al (17) reported differences in morphology. Staple line granuloma shows a smooth marginated mass in contact with the staple line.…”

“…The sensitivity of PET-CT for lung cancer is reported to be 83-96% and the specificity is reported to be 78-91% (12,13). However, inflammatory diseases and infectious diseases may also show relatively high abnormal accumulation (14), so it is reported that PET-CT cannot differentiate a granuloma from staple line recurrence (6,9,11). In the present study, the SUV-max values on PET-CT in cancer recurrent cases were 1.7 to 12.3; in particular, 5 of the cases had a high accumulation of 5 or more.…”