Multifocal lung adenocarcinoma - slow growth

Case contributed by Bruno Di Muzio

Presentation

Smoker with a complex medical history, including previous prostate cancer.

Patient Data

Age: 70 years
Gender: Male

Solitary small (8mm) but spiculated nodule within the anterior segment right upper lobe. There are changes consistent with emphysema placing this patient in a high-risk category for lung carcinoma. Small central lucency/bronchogram suggests adenocarcinoma. Right lower lobe superior segment focal ground-glass opacity. No pleural or pericardial effusions.  No axillary or intrathoracic lymphadenopathy. Limited views of the upper abdomen unremarkable.

No suspicious bony abnormality.  Deformity of the left distal clavicle tip is clearly longstanding.

At that time, the option for imaging follow-up was taken due to other comorbidities. 

Chest (3 years later)

ct

Although there are no significant changes in the RUL solid suspicious lesions and RLL ground glass area, there are new smaller and ill-defined ground glass foci in both lower lobes, RML, and LUL. 

Chest (7 years later)

ct

Jumping to 4 years later, the RLL ground-glass opacity has transformed into a large spiculated solid mass and the RUL solid nodule has increased with new speculation. The middle lobe ground glass focus adjacent to the fissure has increased. Multiple other foci of ground-glass opacities scattered bilaterally and suggestive of pre-invasive adenocarcinoma. 

18FDG PET-CT

Nuclear medicine

Selected images of FDG PET-CT confirms mild metabolic activity with most of the sizable lung lesions, but marked avidity in the RLL new mass. Also, activity within the subcarinal enlarged lymph node. 

Annotated image

1 - RLL lesion progression over a long interval: note to a dilated airway seen since the first identification of the ground glass opacity

2 - RUL lesion with irregular contours/spiculation and associated focally dilated airway 

EBUS was performed to approach the station 7 lymph node: 

Macroscopy: Endobronchial ultrasound-guided TBNA of lymph node station 7R - 5 passes: 8 air-dried smears,  7 alcohol-fixed smears & cell block prepared. Cytologist in attendance.

Microscopy: The smears show a population of atypical epithelioid cells with enlarged, pleomorphic nuclei, irregular nuclear membranes, small nucleoli and delicate, vacuolated cytoplasm arranged in scattered small groups.  Rare clusters of atypical cells are identified within the cell block, together with fragments of the reactive stroma.  Chronic inflammatory cells, anthracosis histiocytes and abundant blood are present within the background.
Conclusion: EBUS-TBNA Station 7 lymph node:  Malignant - Features consistent with non-small cell carcinoma and favoring adenocarcinoma. 

 A limited immunopanel has been requested on the cell block, within which malignant cells are present in only small numbers.  A supplementary report will follow.  There is insufficient material for molecular testing.mmunohistochemistry has been performed on the cell block.  The atypical cell population shows immunoreactivity with antibodies against TTF1 and is negative with antibodies against p40. The immune profile is consistent with adenocarcinoma of primary pulmonary origin.

Case Discussion

Case showing the natural history of slow-growing multifocal/synchronous lung adenocarcinoma. Note the evolution of the persistent ground-glass foci over time, as well as the dilated bronchi associated with the malignant lesions. 

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