Presentation
Ex-smoker. Cough.
Patient Data
There is a ground-glass nodule within the posterior segment of the right upper lobe, measuring up to 14 x 11 ml in size. An additional 4 mm nodule is noted in the anterior segment of the same lobe. There are two small calcified granulomas in the right lung. The lungs and pleural space are otherwise clear, the airways are normal. The mediastinal structures are unremarkable, no lymphadenopathy. No suspicious bone lesions. The imaged superior abdomen demonstrates diffuse hepatic steatosis.
Marked FDG uptake within the larger RUL ground-glass lesion. Smaller lesion in the same lobe is too small for characterization on PET. No nodal or metastatic disease.
Macroscopy: A. Labeled "Right upper lobe". Right upper lobe weighing 334 g (post inflation) measuring 145 x 111 x 68 mm. Within the peripheral aspect of the lobe, there is an ill-defined pale cream mildly firm lesion measuring 13 x 10 x 8 mm. This is 2 mm clear of the pleural surface and 32 mm clear of the hilar resection margin. The remainder of parenchyma appears tan and unremarkable. Inked green at the hilum, blue stapled resection margin. 4 potential hilar lymph nodes ranging from 3–14 mm. B. Labeled "Station 11 lymph node". 2 pieces of lymph node 10 and 3 mm.
Microscopy: A. The sections show a 13 mm lesion within which atypical epithelial cells are arranged in a predominantly papillary (75%) and lepidic (20%) growth patterns. An occasional micropapillary arrangement of tumor cells is also seen (5%). Tumor cells have enlarged, pleomorphic nuclei with prominent round nucleoli and moderate amounts of eosinophilic finely granular to vacuolated cytoplasm. Angiolymphatic and perineural invasion are not identified. Tumor appears clear of resection margins. Four neuroendocrine tumorlets and at least two foci of flat neuroendocrine hyperplasia are identified within the surrounding lung parenchyma. 5 lymph nodes show no evidence of metastatic malignancy. B. The sections show anthracotic lymph node parenchyma. There is no evidence of metastatic malignancy.
Conclusion: A-B. Right upper lobectomy specimen with Station 11 lymph node, showing:
- specimen type: Right upper lobectomy specimen
- histological tumor type: Invasive adenocarcinoma of the lung pT1b N0
- primary architectural pattern Papillary (75%)
- secondary architectural pattern Lepidic (20%)
- tertiary architectural pattern Micropapillary (5%)
- histological grade: Moderately differentiated
- tumor location: Peripheral right upper lobe
- size 13 mm
- visceral pleural invasion: Not identified
- lymphovascular invasion: Not identified
- perineural invasion: Not identified
- surgical margin status: Not involved
- direct invasion of adjacent structures: Not identified
- In-situ carcinoma: Not identified
- lymph nodes within main resection specimen
- number of lymph nodes 5
- number of involved lymph nodes 0
- other coexistent pathological abnormalities Neuroendocrine tumorlets (x 4)
- Intramucosal neuroendocrine hyperplasia (2 foci)
Case Discussion
The opacities in the right upper lobe have differentials made between inflammatory/infective changed, particularly in the new onset of cough, and pre-invasive or minimally invasive lung adenocarcinomas. Follow-up imaging was proposed with a repeat scan in 3 months, which showed the lesions to be stable. A PET-CT was then organized and confirmed intense uptake within the larger lesion.
Resection was proposed and confirmed a papillary predominant adenocarcinoma of the lung (T1b N0 M0).
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