*From the Cardiothoracic Unit (Drs. Luckraz and Butchart), Radiology Department (Dr. Crane), and Pathology Department (Dr. Giggs), University Hospital of Wales, Cardiff, UK.
Correspondence to: Herman Luckraz, FRCS, Cardiothoracic Unit, University Hospital of Wales, Heath Park, Cardiff CF4 4XW, UK; e-mail: HeymanLuckraz@aol.com
A 63-year-old woman presented with a short history (a few months) of persistent cough and mild shortness of breath. On further enquiry, she admitted to having a poor appetite, with an associated weight loss of approximately 4 kg over a period of 6 months. Clinical examination was unremarkable and did not reveal any signs of lung malignancy. A chest roentgenogram showed bilateral multiple pulmonary nodules (Fig 1
). Blood tests for angiotensin-converting enzyme levels, systemic vasculitic screen, antineutrophil cytoplasmic antibody, and rheumatoid factor were normal. The C-reactive protein was mildly elevated at 52 mg/L.
CT with IV contrast enhancement confirmed multiple nodular lesions within both lungs (Fig 2
). The majority of the lesions had an unusual appearance, with a solid rim surrounding necrotic material and a more dense opacity at the center, reminiscent of an archery target. There was a larger cavitating lesion in the left lower lobe suggesting a primary tumor with multiple metastases. CT also revealed a mass in the left ovary. However, oophrectomy and subsequent histology revealed the lesion to be a benign ovarian fibroma.
An open-lung biopsy was carried out to establish the diagnosis of the multiple lung nodules. At surgery, several visceral puckering nodules were identified. Histology of a lingular biopsy revealed multiple well-circumscribed tumors with central necrosis and cavitation. The tumors consisted of pleiomorphic epithelial cells with both glandular and squamous features, each of which comprised approximately 50% of the tumor and in keeping with primary adenosquamous carcinoma of the lung. She made an uneventful recovery from the surgical intervention and was referred for further treatment to her local oncologist.
Primary adenosquamous carcinoma (ASC) of the lung is an uncommon tumor reported in 0.4 to 4% of patients with pulmonary malignancy.1It may arise in damaged lung parenchyma such as in radiation fibrosis and pneumoconiosis. The histologic diagnosis was defined in 1982 through World Health Organization criteria2and recently by the Japanese Lung Cancer Society,3 and is based on microscopic analysis showing at least 10% of both adeno and squamous features within the lesion. It is associated with a poor prognosis. In a review of 1,400 cases of lung cancer, Nagakawa et al1 reported a 6.2% 5-year survival for patients with ASC compared to 42.1% in patients with adenocarcinoma and 42.8% in patients with squamous cell carcinoma, for all stages. They also reported that N status, M status, radicality of resection, age, and sex were significant independent prognostic factors of survival.
The radiologic features of the patient described are rather unusual. A review of the radiologic presentation of patients with ASC was carried out by the radiology department at Massachusetts General Hospital.4 They described ASC to be peripheral lesions in 83% of their cases with sizes ranging from 7 to 65 mm. Cavitation was reported in 14%, with the tumor being more common in the right lung (63%). However, the features of multiple cavitating nodules were not described. The differential diagnosis for these appearances includes metastatic disease from a distal primary particularly adenocarcinoma of gut origin, lymphoma, rheumatoid nodules, and a vasculitic process, eg, Wegener granulomatosis. In immunosuppressed individuals, infective conditions either bacterial or fungal in origin should be considered.
Diagnosis of ASC through percutaneous fine-needle aspiration under radiologic guidance is unreliable with a positive diagnosis in only 10% of cases. Lung biopsy either with video assistance or through minithoracotomy is often necessary to confirm the diagnosis. The theories about the origin of ASC include the collision tumor, arising from two adjacent but originally distinct tumors. Others5 think that ASC is a high-grade mucoepidermoid carcinoma with a high squamous content, or ASC may represent adenocarcinoma that has undergone squamous metaplasia.
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