Presentation
Chest pain.
Patient Data
Right upper zones rounded lung mass associated with likely prominent lymph nodes in the right paratracheal stripe and right hilum.
18F-FDG PET-CT
Intensively avid 5.5 cm right upper lobe mass associated with avid lymphadenopathy involving the right hilar, subcarinal, right paratracheal, and right supraclavicular chains. No distant metastatic disease.
This patient had chemoradiotherapy and multiple imaging follow-ups. She was upstaged later due to pericardial metastatic deposits and lung nodules (not shown).
Chest (2 years later)
Post-radiation scar in the right upper lobe.
Stable right middle lobe nodule abutting the pericardium. Stable lung nodules within the left upper and superior segment of the left lower lobe, the largest of which in the perihilar region of the left upper lobe, measuring 7mm. No new pulmonary nodules. The lungs and pleural spaces are otherwise clear.
Within the limits of this scan, normal appearance of the mediastinal soft tissue and vascular structures. No mediastinal, hilar, or axillary lymphadenopathy.
Chest (3 years later)
Stable post-radiation fibrosis and complete right upper lobe collapse. Within the region of fibrosis, round low attenuation nodule of 15 mm is identified. Although this may represent necrotic tumor, it is slightly larger compared to previous scans with subtle convex bulging of the right lateral margin. Locoregional tumor recurrence needs to be considered.
Recurrence at radiation portal
Annotated images comparing current CT (right) to one year earlier (left).
18F-FDG PET-CT
Comparative PET images from the time of diagnosis, 2 years, and current recurrence.
Macroscopy: Labeled "Right upper and middle lobe of lung". Perihilar soft tissue is present over a bare area on the medial aspect 55 x 46 mm (inked green). Bronchial and vascular resection margins amputated, resulting surfaces inked blue. Parenchymal staple lines amputated, resulting surfaces inked black. There is a moderately firm lobulated yellow lesion in the lobe, which abuts the does not appear to cross the fissure into the lobe. The lesion has central areas of yellow necrosis. Peritumoral parenchymal changes seen with areas of grey mottling of the parenchyma distal to the tumor site within the lobe.
Microscopy: The sections taken from the macroscopically described tumor show an invasive tumor, composed of irregular fused glands with cribriform formation, papillary structures and numerous nests of atypical epithelial cells. The tumor cells have moderate to abundant pale to eosinophilic cytoplasm, moderate nuclear pleomorphism, irregular nuclear membranes and prominent nucleoli. There is frequent atypical mitosis. Stromal retraction artefact is present. There are foci of necrosis, fibrosis with accompanying active chronic inflammation including foamy macrophages and multinucleated giant cells surrounding cholesterol clefts. Vascular wall changes and atypical stromal cells are seen. These features are in keeping with the treatment effect. There is extensive lymphovascular invasion, including within bronchovascular bundles of an adjacent lobe. No discrete tumor nodule is seen in adjacent lobe. No perineural invasion is seen. Residual tumor cells are seen within peritumoral changes described macroscopically. Estimated tumor size is 43 mm. The tumor is clear of resection margins. Four hilar lymph nodes show sclerosis with chronic inflammation including histiocytes, in keeping with treatment effect. One of the lymph nodes shows a small focus of intravascular adenocarcinoma, 0.05 mm in size.
Conclusion: Right upper and middle lobe of lung:
- Histological type Adenocarcinoma, acinar predominant
- Tumor size 47 mm in maximal dimension
- Visceral pleural invasion Not identified
- Lymphovascular invasion Extensive, into the adjacent lobe
- Perineural invasion Not identified
- Bronchial resection margin Not involved
- Vascular resection margin Not involved
- Response to neoadjuvant therapy >10% residual viable tumor
- Hilar lymph nodes Positive (1/4), treatment effect present
Case Discussion
This case illustrates an advanced lung adenocarcinoma, initially stage IIIC, further progressing to stage IV (images of this progression not shown). The main point here is to demonstrate how important it is to assess the lung radiation field/scar with attention, chasing for any new growth or bulging of the contours (see annotated images).
The images of the last CT scan demonstrate right upper lobe in-field tumor recurrence. The patient was offered further resection, given her response to the disease elsewhere.
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