Lepidic predominant adenocarcinoma of the lung

Case contributed by Dr Bruno Di Muzio

Presentation

Chronic cough.

Patient Data

Age: 70 years
Gender: Female
X-ray

Chest radiograph

There is an ill-defined lung opacity in the right lower zones, the lungs and pleural spaces are otherwise clear. Cardiomediastinal contours are within the normal limits. 

There is a 3.0 cm juxta fissural lesion in the right lower lobe that has a solid nodular and surrounding ground-glass components. Within both upper lobes, there are focal ground-glass opacities measuring less than 5 mm. No lymphadenopathy. 

Nuclear medicine

PET-CT (18F-FDG)

No radiotracer uptake within the RLL lesion. 

The patient underwent a CT-guided core-biopsy and further lobectomy:

Macroscopy:  A. Labelled "Right lung lower lobe". Specimen description: Intact lobectomy. Size: 164 x 110 x 40 mm, 150g

  • inking: Parenchymal - green, Pleura - blue, Bronchial/vascular - Black (4mm stapled margin amputated before inking) 
  • pleural surface: Smooth, glistening tan-violaceous, focal puckering over the medial basal segment
  • tumour location: Peripheral, basal medial segment.  
  • tumour size: 33 x 30 x 12 mm 
  • tumour appearance: Cream-grey, lobulated/infiltrative, firm
  • relationship to pleura: Retraction of pleura, possible invasion.
  • distance from bronchial margin: 70 mm
  • post-obstructive pneumonia: Absent 
  • remaining lung parenchyma: Red/brown and spongy
  • lymph nodes: 4 perihilar lymph nodes.

B. Labelled "Station 7 lymph node (right pleural)".  A violaceous fatty tissue fragment 35 x 17 x 4 mm, containing a single elongate lymph node, 30 mm.  LS ×4.

C. Labelled "Station 9 lymph node right pleural".  A fragment of fatty tissue 20 x 10 x 3 mm, containing 2 dark brown lymph nodes 15 x 8 x 3 mm and 5 x 3 x 1 mm, and a small amount of attached fat.  Largest node bisected.  All in.

D. Labelled "Station 11 lymph node (right pleural)".  4 fragments of dark brown, ragged tissue ranging from 3-10 mm.  Fragments processed whole.

Microscopy: A. The sections taken from the macroscopically described tumour show an invasive adenocarcinoma. The tumour has predominantly lepidic pattern with admixed papillary (20%) and acinar (10%) patterns. The tumour cells show moderate nuclear pleomorphism, nuclear hyperchromasia and small nucleoli. No lymphovascular or perineural invasion is identified. There is a focal extension through the elastic layer of visceral pleural. The tumour is clear of resection margins. Non-neoplastic lung show small foci of organising pneumonia. Three hilar lymph nodes show sinus histiocytosis with no evidence of metastatic malignancy (0/3). 

B. The sections show a lymph node with sinus histiocytosis. There is no evidence of metastatic malignancy (0/1).

C. The sections show 2 lymph nodes with sinus histiocytosis. There is no evidence of metastatic malignancy (0/2).

D. The sections show lymphoid tissue with sinus histiocytosis. There is no evidence of malignancy.

Conclusion: A. Right lower lobe, resection:

  • histological type Moderately differentiated, lepidic predominant adenocarcinoma pT2a N0
  • tumour size 33 mm in maximal dimension
  • visceral pleural invasion     Focally into visceral pleura (PL1)
  • lymphovascular invasion Not identified
  • perineural invasion Not identified
  • bronchial resection margin Not involved
  • vascular resection margin Not involved
  • hilar lymph nodes involvement Absent (0/3)

B. Station 7 lymph node right pleural, excision: No metastatic malignancy in 1 lymph node (0/1).

C. Station 9 lymph node right pleural, excision: No metastatic malignancy in 2 lymph nodes (0/2).

D. Lesion 11 lymph node right pleural, excision: No metastatic malignancy.

Case Discussion

This case illustrates focal lung lesion in the right lower lobe with mixed solid and ground glass components and low or non-measurable metabolic activity on PET. The patient was offered a CT-guided lung biopsy that confirmed a lung adenocarcinoma, with further resection showing a lepidic predominant lung adenocarcinoma (T2a N0 M0). Other tiny ground-glass nodules in the upper lobes, although non-specific, are suspicious for pre-invasive lung tumors and will be followed-up on imaging. 

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Case information

rID: 59779
Published: 11th Aug 2018
Last edited: 14th Aug 2019
System: Chest, Oncology
Inclusion in quiz mode: Included

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