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clarithromicin and ethambutol&#44; while keeping IV cyclophosphamide&#46; Progressive disease was observed&#44; with posterior development of nephrotic syndrome and renal failure&#46; Implemented rescue therapy with plasmaferesis and rituximab&#44; continuing with cyclophosphamide and IV immunoglobulins&#46; Despite all the different approaches the patient did not survive&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">GPA is a vasculitis of unknown etiology first recognized as a separate entity by Friedrich Wegener in 1930&#44; it is a granulomatous inflammation involving the respiratory tract&#44; and necrotizing vasculitis affecting predominantly the small-sized vessels&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">It affects a wide age range&#44; with peak incidence between 6th and 7th decades&#46; Sex-specific incidence rates do not provide a clear indication for uneven gender distribution&#46; Its reported annual incidence ranges between 2&#46;1 and 15 per million&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> cANCA reacting to PR3 is very &#40;but not totally&#41; specific of GPA&#44; it is found in approximately 90&#37; of patients with active generalized GPA and 60&#37; of active limited GPA&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">A definite histological diagnosis of GPA requires coexistence of vasculitis&#44; granuloma and necrosis although these features are only found in a minority of specimens&#46; Only 1 or 2 of these features may be found&#44; rendering a suggestive biopsy&#44; in which the diagnosis is then supported by clinical criteria&#46; Histopathologic documentation of granulomatous involvement of the respiratory tract is not explicitly required&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Therefore&#44; the diagnosis of GPA depends on a combination of clinical&#44; pathologic&#44; and serologic features&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our case reports a probable localized GPA&#44; interpreted as stage IV NSCLC&#46; Since the patient only had pulmonary disease and the lesions were suggestive of metastatic lesions&#44; ANCA were not initially tested&#46; However&#44; it is well known that cANCA sensitivity is as low as 60&#8211;70&#37; in limited GPA&#44; making its diagnosis more difficult&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Lung nodules are the most common pulmonary manifestation of Wegener&#39;s granulomatosis and occur in approximately 40&#8211;70&#37; of patients&#46; Nodules are usually multiple and bilateral and occur without a zonal predilection&#46; The size of Wegener&#39;s granulomatosis nodules varies&#44; most commonly measuring between 2 and 4<span class="elsevierStyleHsp" style=""></span>cm but ranging from a few millimeters to 10<span class="elsevierStyleHsp" style=""></span>cm&#46; The spectrum of chest CT findings is broad&#44; ranging from nodules and masses to ground glass opacity and lung consolidation&#46; When presented in the form of nodules&#44; it can be easily mistaken for primary or metastatic malignancies&#44; lung abscesses&#44; or septic infarcts&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Solitary or multifocal involvement of the lung by GPA without evidence of extrapulmonary disease is sometimes a difficult diagnosis due to its histopathological variability and possible misinterpretation as lung cancer&#46; Acute inflammation&#44; necrotic debris&#44; reactive epithelial cells and histiocytes and atypical bronchial cells&#44; often present in GPA&#44; can be misinterpreted as adenocarcinoma or even as squamous cells cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Awasthi et al&#46; report six cases of suspected GPA who underwent TNFA&#59; four of them were wrongly diagnosed&#44; one of which was a misdiagnosed squamous cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Because the positive predictive value of lung FNA ranges from 96&#37; to 100&#37;&#44; a patient with a lung fine-needle aspirate diagnosed as malignant has a high probability of harboring a malignancy&#46; However&#44; as with any other diagnostic tests&#44; lung FNA is subject to diagnostic pitfalls that can lead to occasional false-positive diagnoses&#59; the false-positive rate of lung FNA has been cited as being less than 1&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Its diagnostic yield is worse than other methods which provide bigger samples&#44; such as core needle biopsy&#44; bronchial biopsy or surgical lung biopsy&#46; Although core needle biopsy &#40;CNB&#41; has been shown to be an accurate means of diagnosing lung malignancies&#44; there is relatively little information in the literature about its utility in diagnosing non-malignant conditions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our case&#44; although lung cancer could not be completely excluded as a possible diagnosis&#44; complete remission of a stage IV NSCLC made this diagnosis more unlikely&#46; When complete remission was observed&#44; the diagnosis of NSCLC was questioned and ANCA were performed&#44; which were negative&#46; Revision of TFNA cytology was also requested&#44; as well as when generalized form of GPA was evident&#59; giant multinucleated cells&#44; increased nuclear&#47;cytoplasmic ratios and irregular chromatin and irregular cell outlines were still suggestive of poorly differentiated carcinoma&#46; In the lung cancer setting giant multinucleated cells can be present in a variable frequency&#59; although unusual in typical adenocarcinoma these are characteristic of giant cell carcinoma and pleomorphic sarcomatoid carcinoma&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Epidermal growth factor receptor &#40;EGFR&#41; mutation of the cytologic sample was negative&#44; still not helping in differential diagnosis&#46; It was only when the disease relapsed that histologic samples could be collected and the diagnosis of GPA could be established&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">GPA can emerge as a paraneoplastic syndrome&#44; most frequently renal cell carcinoma&#46; There is only one reported case of GPA and lung cancer&#44; but there is no mention of whether therapy for lung cancer induced remission of GPA&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Assuming ad initium the diagnosis of GPA&#44; the cytotoxic agents used in lung cancer chemotherapy curiously led to complete remission of lesions&#44; as well as remission maintenance for 15 months&#46; As far as we know this is the first case reported in the literature&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The recurrence of the generalized form of GPA&#44; although initially responsive to preconized therapy&#44; was complicated by several infectious events and progressive respiratory failure that led to the death of the patient&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our case describes a probable GPA in which presentation was clinically indistinguishable from lung cancer and where cytology showed&#44; even after exhaustive review&#44; features of undifferentiated carcinoma&#46; It exemplifies the importance of considering alternative diagnoses&#44; even when a particular one seems obvious&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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            0 => "Vasculite sist&#233;mica"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Granulomatosis with Polyangiitis &#40;GPA&#41;&#44; which was formerly named Wegener&#39;s Granulomatosis &#40;WG&#41; is a systemic disease characterized by necrotizing granulomatous inflammation and vasculitis that primarily involves upper and lower respiratory tract&#44; as well as kidneys&#46; Diagnosing GPA on the basis of transthoracic fine needle aspiration &#40;TFNA&#41; may be problematic&#44; as it can be misdiagnosed as cancer&#46; We describe a patient with a probable GPA which was originally diagnosed as malignancy&#44; but who responded to lung cancer chemotherapy&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A granulomatose com poliange&#237;te &#40;GPA&#41;&#44; previamente denominada granulomatose de Wegener&#44; &#233; uma doen&#231;a sist&#233;mica caracterizada por inflama&#231;&#227;o granulomatosa necrotizante e vasculite que envolve principalmente o trato respirat&#243;rio superior e inferior&#44; bem como os rins&#46; O diagn&#243;stico de GPA com base em bi&#243;psia por agulha fina &#40;BAF&#41; transtor&#225;cica pode ser problem&#225;tico&#44; levando ao diagn&#243;stico incorreto de cancro&#46; Os autores descrevem o caso de um paciente com prov&#225;vel GPA&#44; inicialmente diagnosticado como cancro do pulm&#227;o&#44; que curiosamente respondeu &#224; quimioterapia para cancro do pulm&#227;o&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; S&#46; Campainha&#44; et al&#46;&#44; Granulomatose com Poliange&#237;te inicialmente diagnosticada como Cancro do Pulm&#227;o&#46; Rev Port Pneumol&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2012.04.002">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;rppneu&#46;2012&#46;04&#46;002</span>&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest CT at the time of diagnosis &#40;A&#41; and 3 months after chemotherapy &#40;B&#41;&#46; &#40;A&#41; Multiple nodular lesions in both lungs&#46; The bigger lesions present in the apices&#46; &#40;B&#41; Resolution of the nodular lesions after 3 cycles of chemotherapy&#46; Some fibrotic sequelar changes can be seen in both apical regions&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; and &#40;B&#41; Chest radiograph &#40;A&#41; and CT &#40;B&#41; at the time of symptom relapse &#40;15 months after chemotherapy&#41;&#44; show multiple irregularly shaped nodules and masses&#44; some of which exhibiting cavitation&#46; &#40;C&#41; Bronchoscopic features evidencing multiple ulcerating lesions and superficial vascularization&#44; along the whole tracheobronchial tree&#46;</p>"
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Case report
Granulomatosis with Polyangiitis initially misdiagnosed as lung cancer
Granulomatose com poliangeíte inicialmente diagnosticada como cancro do pulmão
S. Campainhaa,
Corresponding author
scampainha@gmail.com

Corresponding author.
, M. Gonçalvesb, V. Tavaresb, P. Castelõesb, A. Marinhoc, S. Nevesa
a Serviço de Pneumologia, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
b Unidade de Cuidados Intensivos Polivalente, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
c Departamento de Doenças Auto-imunes do Serviço de Medicina Interna, Centro Hospitalar do Porto, Porto, Portugal
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20 pack-year smoker&#44; diagnosed with stage IV non-small cell lung cancer &#40;NSCLC&#41;&#44; by TFNA&#44; underwent 6 cycles of chemotherapy with carboplatinum and gemcitabin&#44; and complete remission was observed after 3 cycles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; At that time the cytological studies were reviewed&#44; the diagnosis of NSCLC was maintained and antineutrophil cytoplasmic antibodies &#40;ANCA&#41; performed were negative&#46; He was kept under surveillance by his Pulmonary Oncology team&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After an asymptomatic period of 15 months&#44; with no signs of recurrence&#44; he started having exertional dyspnea&#44; dry cough&#44; anorexia and weight loss &#40;3<span class="elsevierStyleHsp" style=""></span>kg over a month&#41;&#46; Physical examination was unremarkable&#46; Chest X-ray showed multiple nodules and masses in both lungs some of which exhibited cavitation&#44; as confirmed by Chest CT &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">At this time a TFNA of a nodular lesion was repeated&#44; which showed cellular debris&#44; compatible with tumoral necrosis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">One week later&#44; the patient developed oral ulcers and purpuric rash of lower limbs and external ear&#44; as well as petechiae in the soft palate&#46; Immunologic study revealed anti-neutrophilic cytoplasm antibody &#40;cANCA&#41; of 1&#47;300 for proteinase 3 &#40;PR3&#41;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>200&#46; Urinalysis revealed active sediment with proteinuria and eritrocituria&#46; Rigid bronchoscopy showed ulcerated lesions along the tracheobronchial tree &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Bronchial biopsies proved extensive necrosis and vasculitis&#44; and there were no features of a neoplastic nature&#46; A skin biopsy was also performed&#44; revealing leucocytoclastic vasculitis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was started on methylprednisolone 1<span class="elsevierStyleHsp" style=""></span>g IV od 3 days&#44; followed by cyclofosfamide 100<span class="elsevierStyleHsp" style=""></span>mg PO od and prednisolone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">After a period of clinical and radiological improvement&#44; respiratory failure developed requiring invasive mechanical ventilation and transfer to ICU unit&#46; Repeated bronchoalveolar lavage revealed <span class="elsevierStyleItalic">Klebsiella pneumonia</span> and <span class="elsevierStyleItalic">Mycobacterium intracellulare</span> infection requiring therapy with imipenem and rifampin&#44; clarithromicin and ethambutol&#44; while keeping IV cyclophosphamide&#46; Progressive disease was observed&#44; with posterior development of nephrotic syndrome and renal failure&#46; Implemented rescue therapy with plasmaferesis and rituximab&#44; continuing with cyclophosphamide and IV immunoglobulins&#46; Despite all the different approaches the patient did not survive&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">GPA is a vasculitis of unknown etiology first recognized as a separate entity by Friedrich Wegener in 1930&#44; it is a granulomatous inflammation involving the respiratory tract&#44; and necrotizing vasculitis affecting predominantly the small-sized vessels&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">It affects a wide age range&#44; with peak incidence between 6th and 7th decades&#46; Sex-specific incidence rates do not provide a clear indication for uneven gender distribution&#46; Its reported annual incidence ranges between 2&#46;1 and 15 per million&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> cANCA reacting to PR3 is very &#40;but not totally&#41; specific of GPA&#44; it is found in approximately 90&#37; of patients with active generalized GPA and 60&#37; of active limited GPA&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">A definite histological diagnosis of GPA requires coexistence of vasculitis&#44; granuloma and necrosis although these features are only found in a minority of specimens&#46; Only 1 or 2 of these features may be found&#44; rendering a suggestive biopsy&#44; in which the diagnosis is then supported by clinical criteria&#46; Histopathologic documentation of granulomatous involvement of the respiratory tract is not explicitly required&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Therefore&#44; the diagnosis of GPA depends on a combination of clinical&#44; pathologic&#44; and serologic features&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our case reports a probable localized GPA&#44; interpreted as stage IV NSCLC&#46; Since the patient only had pulmonary disease and the lesions were suggestive of metastatic lesions&#44; ANCA were not initially tested&#46; However&#44; it is well known that cANCA sensitivity is as low as 60&#8211;70&#37; in limited GPA&#44; making its diagnosis more difficult&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Lung nodules are the most common pulmonary manifestation of Wegener&#39;s granulomatosis and occur in approximately 40&#8211;70&#37; of patients&#46; Nodules are usually multiple and bilateral and occur without a zonal predilection&#46; The size of Wegener&#39;s granulomatosis nodules varies&#44; most commonly measuring between 2 and 4<span class="elsevierStyleHsp" style=""></span>cm but ranging from a few millimeters to 10<span class="elsevierStyleHsp" style=""></span>cm&#46; The spectrum of chest CT findings is broad&#44; ranging from nodules and masses to ground glass opacity and lung consolidation&#46; When presented in the form of nodules&#44; it can be easily mistaken for primary or metastatic malignancies&#44; lung abscesses&#44; or septic infarcts&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Solitary or multifocal involvement of the lung by GPA without evidence of extrapulmonary disease is sometimes a difficult diagnosis due to its histopathological variability and possible misinterpretation as lung cancer&#46; Acute inflammation&#44; necrotic debris&#44; reactive epithelial cells and histiocytes and atypical bronchial cells&#44; often present in GPA&#44; can be misinterpreted as adenocarcinoma or even as squamous cells cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Awasthi et al&#46; report six cases of suspected GPA who underwent TNFA&#59; four of them were wrongly diagnosed&#44; one of which was a misdiagnosed squamous cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Because the positive predictive value of lung FNA ranges from 96&#37; to 100&#37;&#44; a patient with a lung fine-needle aspirate diagnosed as malignant has a high probability of harboring a malignancy&#46; However&#44; as with any other diagnostic tests&#44; lung FNA is subject to diagnostic pitfalls that can lead to occasional false-positive diagnoses&#59; the false-positive rate of lung FNA has been cited as being less than 1&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Its diagnostic yield is worse than other methods which provide bigger samples&#44; such as core needle biopsy&#44; bronchial biopsy or surgical lung biopsy&#46; Although core needle biopsy &#40;CNB&#41; has been shown to be an accurate means of diagnosing lung malignancies&#44; there is relatively little information in the literature about its utility in diagnosing non-malignant conditions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our case&#44; although lung cancer could not be completely excluded as a possible diagnosis&#44; complete remission of a stage IV NSCLC made this diagnosis more unlikely&#46; When complete remission was observed&#44; the diagnosis of NSCLC was questioned and ANCA were performed&#44; which were negative&#46; Revision of TFNA cytology was also requested&#44; as well as when generalized form of GPA was evident&#59; giant multinucleated cells&#44; increased nuclear&#47;cytoplasmic ratios and irregular chromatin and irregular cell outlines were still suggestive of poorly differentiated carcinoma&#46; In the lung cancer setting giant multinucleated cells can be present in a variable frequency&#59; although unusual in typical adenocarcinoma these are characteristic of giant cell carcinoma and pleomorphic sarcomatoid carcinoma&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Epidermal growth factor receptor &#40;EGFR&#41; mutation of the cytologic sample was negative&#44; still not helping in differential diagnosis&#46; It was only when the disease relapsed that histologic samples could be collected and the diagnosis of GPA could be established&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">GPA can emerge as a paraneoplastic syndrome&#44; most frequently renal cell carcinoma&#46; There is only one reported case of GPA and lung cancer&#44; but there is no mention of whether therapy for lung cancer induced remission of GPA&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Assuming ad initium the diagnosis of GPA&#44; the cytotoxic agents used in lung cancer chemotherapy curiously led to complete remission of lesions&#44; as well as remission maintenance for 15 months&#46; As far as we know this is the first case reported in the literature&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The recurrence of the generalized form of GPA&#44; although initially responsive to preconized therapy&#44; was complicated by several infectious events and progressive respiratory failure that led to the death of the patient&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our case describes a probable GPA in which presentation was clinically indistinguishable from lung cancer and where cytology showed&#44; even after exhaustive review&#44; features of undifferentiated carcinoma&#46; It exemplifies the importance of considering alternative diagnoses&#44; even when a particular one seems obvious&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Granulomatosis with Polyangiitis &#40;GPA&#41;&#44; which was formerly named Wegener&#39;s Granulomatosis &#40;WG&#41; is a systemic disease characterized by necrotizing granulomatous inflammation and vasculitis that primarily involves upper and lower respiratory tract&#44; as well as kidneys&#46; Diagnosing GPA on the basis of transthoracic fine needle aspiration &#40;TFNA&#41; may be problematic&#44; as it can be misdiagnosed as cancer&#46; We describe a patient with a probable GPA which was originally diagnosed as malignancy&#44; but who responded to lung cancer chemotherapy&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A granulomatose com poliange&#237;te &#40;GPA&#41;&#44; previamente denominada granulomatose de Wegener&#44; &#233; uma doen&#231;a sist&#233;mica caracterizada por inflama&#231;&#227;o granulomatosa necrotizante e vasculite que envolve principalmente o trato respirat&#243;rio superior e inferior&#44; bem como os rins&#46; O diagn&#243;stico de GPA com base em bi&#243;psia por agulha fina &#40;BAF&#41; transtor&#225;cica pode ser problem&#225;tico&#44; levando ao diagn&#243;stico incorreto de cancro&#46; Os autores descrevem o caso de um paciente com prov&#225;vel GPA&#44; inicialmente diagnosticado como cancro do pulm&#227;o&#44; que curiosamente respondeu &#224; quimioterapia para cancro do pulm&#227;o&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; S&#46; Campainha&#44; et al&#46;&#44; Granulomatose com Poliange&#237;te inicialmente diagnosticada como Cancro do Pulm&#227;o&#46; Rev Port Pneumol&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2012.04.002">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;rppneu&#46;2012&#46;04&#46;002</span>&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest CT at the time of diagnosis &#40;A&#41; and 3 months after chemotherapy &#40;B&#41;&#46; &#40;A&#41; Multiple nodular lesions in both lungs&#46; The bigger lesions present in the apices&#46; &#40;B&#41; Resolution of the nodular lesions after 3 cycles of chemotherapy&#46; Some fibrotic sequelar changes can be seen in both apical regions&#46;</p>"
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                      "autores" => array:1 [
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                          "etal" => false
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ISSN: 21735115
Original language: English
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