Lung Cancer |

Pulmonary Adenocarcinoma In Situ: A Transformation of Terms and Tissue FREE TO VIEW

Tomer Pelleg, BA; Moises Cossio, DO; A. Lukas Loschner, MD
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Philadelphia College of Osteopathic Medicine, Philadelphia, PA

Chest. 2013;144(4_MeetingAbstracts):638A. doi:10.1378/chest.1679817
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SESSION TITLE: Cancer Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchioloalveolar carcinoma (BAC) has historically been characterized by its lack of stromal invasion, preserving the underlying architecture of the lung; however, evidence has shown that a wide variety of neoplasms, from readily curable precursor lesions to metastatic invasive tumors, have been mislabeled as BAC. The 2011 IASLC/ATS/ERS guidelines have dismissed the classic term in favor of 5 distinct entities along the morphologic continuum, from atypical adenomatous hyperplasia to invasive adenocarcinoma. Although adenocarcinoma in situ (AIS) represents the preferred naming convention historically occupied by BAC, AIS has the propensity to progress towards invasive adenocarcinoma.

CASE PRESENTATION: A 51-year-old Caucasian, female never-smoker without significant PMH, presented to her primary physician with a 3-week history of progressive dry cough and SOB. Initial treatment with Azithromycin/Prednisone offered no relief and a CXR showed prominent interstitial markings with bilateral diffuse patchy alveolar opacifications. She was then admitted via the ED for atypical pneumonia; she was initially treated with IV antibiotics. An HRCT was performed showing diffuse ground glass nodular opacifications with mild interlobular septal thickening and multiple ~1cm lymph nodes. Bronchoscopy was performed. The airways appeared hyperemic without gross abnormalities. BAL, brushings and trans-bronchial biopsy specimens were collected. BAL showed atypical glandular cells consistent with AIS. Pathology from subsequent mediastinoscopy demonstrated well-differentiated adenocarcinoma (TTF-1, CK-7, napscin positive). The patient was started on Carboplatin/Paclitaxel while awaiting genetic analysis. Genetic analysis revealed the presence of ALK/EML4 fusion genes without EGFR or k-Ras mutations; she was referred to an ongoing crizotinib clinical trial center.

DISCUSSION: AIS radiologically presents in a multitude of distinct patterns though most commonly as a solitary, peripheral ill-marginated pulmonary nodule. Additional CT findings include pseudocavitation, heterogeneous attenuation, pleural tags and especially intratumoral air bronchograms. Radiologically AIS may be distinguished from other cell types by the demonstration of multifocal disease. Approximately 30% of AIS lesions demonstrate multifocal and lobar consolidations. Extensive ground glass opacifications and septal thickening with so called “crazy paving” may be early indications of invasive transformation.

CONCLUSIONS: AIS may demonstrate diffuse bilateral disease with invasive transformation in previous asymptomatic patients at presentation.

Reference #1: Brambilla, E., “The Histological Reclassification of Adenocarcinoma of the Lung: Implications for Diagnosis and Therapy” American Society of Clinical Oncology. 2011: 279-284.

Reference #2: Patsios D., et. al. “Pictorial review of the many faces of bronchioloalveolar cell carcinoma.” The British Journal of Radiology. 2007 December; 80: 1015-1023.

DISCLOSURE: The following authors have nothing to disclose: Tomer Pelleg, Moises Cossio, A. Lukas Loschner

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