Differentiating bronchioloalveolar carcinoma from adenocarcinoma

The recognition of bronchioloalveolar carcinoma (BAC) as distinct from adenocarcinoma of the lung, is controversial. Using strict pathologic criteria, 43 consecutive patients with BAC were matched by year of diagnosis and compared with a similar number of patients with adenocarcinoma, and for contrast, with those with squamous and oat cell carcinoma of the lung. We demonstrated that BAC is not sex related, and is not as smoking related as the other neoplasms. Unlike epidermoid carcinoma, BAC does not show a predilection for those occupations requiring manual labor. Also, BAC is frequently distinguishable radiologically from the other three by being smaller and peripheral. A pleural tag and an air bronchogram in a mass are rather specific, and BAC is less likely to have large airway involvement and adenopathy. The percentage of patients who were free of tumor after 2 yr was greater in the BAC group than in the others, but the overall survival rate between the BAC group and the adenocarcinoma group was not. Based on inter-observer variability, there is some overlap pathologically between these 2 groups. However, when the overlap between the adenocarcinoma and the BAC groups is compared with that between the adenocarcinoma and the squamous cell carcinoma groups, the difference is not significant. We conclude that BAC should be considered a distinct clinical entity.     

细支气管肺泡癌75例临床分析

目的 总结经病理证实的75例细支气管肺泡癌（BAC）的临床特征和诊断方法.方法 对我院2001年1月～2010年6月收治的75例BAC进行回顾性分析.结果 75例BAC患者男女比例为1∶1.34,平均年龄56.9岁,吸烟者占12％; CT检查58例表现为孤立结节型,8例为弥漫结节型,9例为炎症浸润型;26例患者行CT或超声引导下经皮肺穿刺活检,22例获得确诊,9例行支气管镜检查,仅1例确诊,52例为手术后组织活检确诊.结论 BAC的临床特征不同于其他类型肺癌,CT检查有助于BAC的诊断,而经皮肺穿刺活检则能提高BAC诊断的正确率.     

False-negative PET scan with bronchioloalveolar carcinoma: an important diagnostic caveat

Positron emission tomography (PET) is becoming widely accepted as a powerful diagnostic tool for the diagnosis of lung cancer, but it has very poor sensitivity for the detection of bronchioloalveolar carcinoma (BAC) and adenocarcinoma with BAC pattern, the less common form of pulmonary neoplasia. We present a case of a patient with a negative PET scan who might have been followed by observation but was found to have bronchioloalveolar carcinoma at thoracotomy. PET has a reported sensitivity of over 98% in most series but misses almost two-thirds of BAC lesions, which might delay invasive testing and early diagnosis of this potentially lethal cancer. Although this diagnostic limitation has been well reported in the radiology literature, the high reported sensitivity and sensitivity can give clinicians a false sense of security with negative PET scans of lung nodules. The usual risk factors for bronchogenic carcinoma are less reliable for these subtypes of non-small-cell lung cancer; thus, clinicians need to have a high index of suspicion for BAC and exercise caution when making decisions on the basis of PET.     

Cystic bronchioloalveolar cell carcinoma

Bronchioloalveolar cell carcinomas (BACs), a subset of primary lung adenocarcinomas, are uncommon. Similar to other non-small cell lung cancers, patients with BAC are usually 40-70 years of age. Distinguishing features relative to other non-small cell lung cancers include occurrence in young patients, a higher relative predominance in women, and weaker association with smoking. Histologically, they are a diverse group of malignancies that grow in a lepidic manner. Common radiologic presentations of BAC include a solitary nodule, airspace disease, and multiple nodules. Rare manifestations include cystic and cavitary disease. We report a case of a young woman with BAC that manifested as a chronic cough and bilateral air-containing opacities, initially misinterpreted as infection. Knowledge of the spectrum of radiologic manifestations of BAC and correlation with clinical history are important in suggesting the diagnosis and preventing misinterpretation.     

Abnormal epithelial cells recovered by bronchoalveolar lavage: are they malignant?

The recovery of neoplastic cells by bronchoalveolar lavage is useful in the diagnosis of lung cancer. Abnormal epithelial cells can also be recovered from patients with interstitial lung diseases who do not have cancer, and therefore the usefulness of lavage in the diagnosis of malignancy in this setting is unknown. In this study, we evaluated the diagnostic significance of abnormal lavage cells recovered from patients with diffuse parenchymal abnormalities and compared the usefulness of standard cytologic assessment, correlation with clinical features, and immunocytochemical staining for carcinoembryonic antigen (CEA) in identifying abnormal cells that are truly malignant. Thirty of 2,314 patients had atypical lavage cells, but in only nine was lung cancer demonstrated. Although most patients with clinical suspicion of malignancy had lung carcinoma (six of seven), one such patient did not have cancer, and three were shown to have unsuspected carcinoma. Cytologic criteria identified definitely malignant cells in only four of nine patients with lung cancer, indicating that the approach is not sensitive. Immunostaining of abnormal cells with anti-CEA antibodies proved helpful. All patients with lung malignancy had CEA+ cells (n = 9), and no patient whose abnormal cells were CEA- proved to have cancer (n = 17). Because only nine of 13 patients with CEA+ cells had lung malignancy, the test is not diagnostic, but it appears to limit the need for further evaluation to a smaller group of patients in whom cancer is likely to be present. When used together, cytopathologic findings, detection of CEA by immunocytochemical techniques, and clinical correlates proved useful in diagnosis of lung malignancy, but further improvements are still needed to improve diagnostic accuracy.     

Expression of FAK and PTEN in Bronchioloalveolar Carcinoma and Lung Adenocarcinoma

Bronchioloalveolar carcinoma (BAC) is classified as a subset of lung adenocarcinoma but has a distinct clinical presentation, tumor biology, response to therapy, and prognosis compared with other subtypes of lung adenocarcinoma. This study was designed to investigate the clinicopathological differences between BAC and adenocarcinoma and the expression of focal adhesion kinase (FAK) and phosphatase and tensin homologue (PTEN) and their clinical significance in BAC and adenocarcinoma. A retrospective analysis was performed on 77 patients with BAC and 172 patients with pure adenocarcinoma seen during the period from January 1998 to December 2000. All patients underwent lobectomy or pneumonectomy and systematic lymph node dissection. Paraffin-embedded tissue blocks from these patients were obtained and expressions of PTEN and FAK were evaluated by using immunohistochemical staining. Clinicopathological characteristics and survival outcome were reviewed and compared between patients with BAC and adenocarcinoma. Lymph node status, clinical symptoms, CT appearance and expression of FAK were different between BAC and adenocarcinoma. The overall survival of BAC was better than that of adenocarcinoma. In patients with FAK(−), the overall survival was not different between BAC and adenocarcinoma. In patients with adenocarcinoma, the overall survival was better for FAK(−) compared with FAK(+). Expression of PTEN had a prognostic significance in patients with BAC and adenocarcinoma. BAC and adenocarcinoma have different clinicopathological presentations. Expression of FAK has some effect on such differences and affects survival of lung adenocarcinoma. Expression of PTEN can predict outcome of resected lung adenocarcinoma and BAC.     

Lung cancer in chronic obstructive pulmonary disease: enhancing surgical options and outcomes

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for both the development of primary lung cancer, as well as poor outcome after lung cancer diagnosis and treatment. Because of existing impairments in lung function, patients with COPD often do not meet traditional criteria for tolerance of definitive surgical lung cancer therapy. Emerging information regarding the physiology of lung resection in COPD indicates that postoperative decrements in lung function may be less than anticipated by traditional prediction tools. In patients with COPD, more inclusive consideration for surgical resection with curative intent may be appropriate as limited surgical resections or nonsurgical therapeutic options provide inferior survival. Furthermore, optimizing perioperative COPD medical care according to clinical practice guidelines including smoking cessation can potentially minimize morbidity and improve functional status in this often severely impaired patient population.     

热休克蛋白90在肺癌诊治中的研究进展

肺癌的发病率和病死率在中国居各类肿瘤之首,热休克蛋白90 (heat shock protein 90,Hsp90)作为重要的分子伴侣参与调控和维持细胞内多种肿瘤相关蛋白的构象和功能,通过抑制Hsp90能抑制实体瘤如肺癌、乳腺癌、前列腺癌等的侵袭和转移.因此,Hsp90抑制剂作为治疗晚期非小细胞肺癌的抗肿瘤药物目前已进入美国临床试验,在单药治疗、联合治疗以及对EGFR-TKI/Crizotinib耐药的非小细胞肺癌患者Ⅰ、Ⅱ期临床试验中取得了良好的效果.而血清中的Hsp90α亦可作为肺癌诊断、治疗和判断预后的良好监测指标.本文将对Hsp90在肺癌的诊治方面的现状和研究进展进行综述.     

非小细胞肺癌146例诊断来源分析

目的进一步规范非小细胞肺癌的诊断,为其治疗和判断预后提供依据。方法统计2002年2月至2005年8月沈阳军区总医院接受治疗的146例非小细胞肺癌的诊断结果。结果总体有完整病理诊断的123例,占84·2%。其中经手术获得病理诊断的42例,占28·8%;未手术的104例中,经痰细胞学检查、淋巴结针吸活检、胸腔积液细胞学和支气管镜获得诊断的分别为31例(21·2%)、18例(12·3%)、15例(10·3%)和11例(7·5%)。经临床诊断(无明确病理诊断,依据临床体征和影像学检查)的23例,占15·7%。结论在治疗前对非小细胞肺癌作出明确的病理诊断,会使治疗更准确无误,对判定肿瘤的发展和预后更有帮助。     

Lung cancer in HIV-positive patients

Since 1996, AIDS-related mortality has declined considerably with the introduction of tritherapy (HAART). This decline in mortality has been associated with an increase in the proportion of deaths caused by cancers unrelated to AIDS, particularly lung cancer. The risk of developing lung cancer is higher in the HIV-seropositive population than in the aged-matched general population, undoubtedly because of the high rate of smoking, particularly among drug abusers, but also because of other reasons which remain to be determined. Mean age at the discovery of lung cancer in HIV+ patients is 45 years, and most are symptomatic. The diagnosis is established at a locally advanced or metastatic stage in 75-90% of patients, as in the general population. Adenocarcinoma is the most common histological type. The prognosis is worse in HIV+ patients than in patients with an undetermined HIV status. Evidence on the efficacy and toxicity of chemotherapy is insufficient to draw any conclusions. Surgery remains the treatment of choice for locally advanced disease if allowed by the clinical status and respiratory function. Prospective clinical studies are needed to define a better management strategy for lung cancer in HIV-positive patients.     

细支气管肺泡癌77例临床分析

目的 探讨细支气管肺泡癌的临床症状、诊断、误诊、病理类型、影像学特点、治疗方案及预后.方法 回顾性分析解放军总医院2003年1月至2007年12月期间住院治疗的经病理证实的77例细支气管肺泡癌病例.结果本 组病例占我院同期住院治疗的原发性支气管肺癌患者的4.6%(77/1 665),男女比例为1.66:1;对53例资料完整病例进行统计学分析,中位生存期47.4个月;吸烟、治疗方案的组间生存曲线差异有显著意义(P<0.05).结论 细支气管肺泡癌患者临床表现多样.缺乏特征,咳大量泡沫样痰的症状并不多见.再加上影像学上的多样性.易被溟诊;对细支气管肺泡癌的治疗应采用手术为主,结合化疗、放疗、分子靶向治疗的综合治疗方式;对晚期不能手术的患者采用先化疗后分子靶向治疗的续贯疗法可取得较好的疗效.     

Pancreatic cancer in cystic fibrosis after bilateral lung transplantation

Cystic fibrosis (CF) is the most common lethal genetic disease affecting 1 in 2500 white patients. Chronic obstructive lung disease and pancreatic insufficiency are the main clinical manifestations of CF. Lung transplantation has become a treatment option for advanced pulmonary disease during the last decade. On the other hand, there is evidence from large cohort studies that CF and immunosuppression are risk factors for pancreatic cancer. Here, we report the case of an 18-year-old female patient with CF and bilateral lung transplantation who underwent Whipple procedure for pancreatic adenocarcinoma at the age of 12 years. Because of growth retardation, the patient underwent a 2-year period of growth hormone treatment before the diagnosis of pancreatic cancer. This case should sensitize physicians to be aware of the increased risk for pancreatic cancer in CF patients especially in those after lung transplantation with immunosuppression and prolonged survival.     

Idiopathic acute eosinophilic pneumonia: a study of 22 patients

Idiopathic acute eosinophilic pneumonia (IAEP) is characterized by acute febrile respiratory failure associated with diffuse radiographic infiltrates and pulmonary eosinophilia. We conducted a multicenter retrospective study to characterize this rare clinical entity further and to improve its diagnostic criteria. A total of 13 male and 9 female patients (mean age: 29 +/- 15.8 years) presented with severe hypoxemia (Pa(O2)/fraction of inspired oxygen ratio = 156 +/- 74.1) requiring mechanical ventilation in 14 cases. Bronchoalveolar lavage was performed on all patients and showed 54.4 +/- 19.2% eosinophils on differential cell count, but no open-lung biopsies were done. No clinical differences were found between patients seen at less than 7 days (n = 15) or at 7 to 31 days (n = 7) from the onset of IAEP. A total of 12 patients met the clinical criteria of acute lung injury, and eight of these patients met the criteria for acute respiratory distress syndrome. All patients recovered, either spontaneously (6) or on corticosteroid treatment (16). No relapses occurred. We conclude that: (1) diagnostic criteria of IAEP are compatible with a duration of symptoms for up to 1 month, but the response to corticosteroid treatment is not diagnostic because of possible spontaneous recovery; (2) IAEP should be considered as differential diagnosis of acute lung injury or acute respiratory distress syndrome; (3) bronchoalveolar lavage eosinophilia obviates the need for lung biopsy in IAEP.     

肺炎型细支气管肺泡癌6例临床分析

目的提高对肺炎型细支气管肺泡细胞癌(bronchioloalveolar carcinoma,BAC)的临床及影像学特点的认识。方法对2006年1月至2011年7月在巢湖市第一人民医院确诊的6例肺炎型BAC患者的临床症状、影像学特点、误诊情况等资料进行分析。结果 6例BAC患者男女各3例,年龄为47～78岁。6例中5例以咳嗽、咳痰为首发表现,其中咳大量泡沫痰2例,合并咯血1例,合并胸闷、呼吸困难2例。影像学检查主要表现为肺部实变及磨玻璃样影,位于周边部。2例经手术后标本病理确诊,4例经皮肺穿刺活检病理确诊。结论肺炎型BAC易误诊,咳嗽、咳痰为其主要症状,影像学检查以肺部实变影为主。经皮肺穿刺活检对肺炎型BAC诊断帮助较大。     

细支气管肺泡癌的研究进展

肺癌在全球范围内呈上升状态，仅2005年在美国新发病者就有172000例之多。非小细胞肺癌（non-small cell lung cancer，NSCLC）占肺癌的80．0％以上。其中细支气管肺泡癌（bronchioloalveolar carcinoma，BAC）是肺腺癌的一个重要亚型，近年来BAC的发病率呈逐年上升趋势，治疗方面也取得了新的进展，是一值得重视的问题。本文就该病的流行病学、危险因子、病理学、临床表现和治疗，尤其表皮生长因子-酪氨酸激酶抑制物（epidermalgrowthfactorreceptors—tyrosinekinaseinhibitor，EGFR—TKIs）在BAC治疗方面作一综述。     

Reclassification of cystic bronchioloalveolar carcinomas to adenocarcinomas based on the revised World Health Organization Classification of Lung and Pleural Tumours

The objective of this study was to evaluate the radiologic-pathologic correlation of cystic change in cases of bronchioloalveolar carcinoma (BAC) using the 1999 revised World Health Organization Classification of Lung and Pleural Tumours. A total of 304 cases diagnosed as BAC before 1999 were reviewed retrospectively for radiologic findings of cystic change (n = 31). Of these, 20 had adequate clinical, pathologic, and radiologic material available for review. Patient demographics and history; the method, location, and size of specimen biopsy; and pathology reports were evaluated. A pulmonary pathologist reviewed the microscopic findings to confirm the diagnosis based on the 1999 World Health Organization criteria. Chest radiographs (n = 20) and computed tomographic scans (n = 11) were analyzed for location, size, and multiplicity of pulmonary nodules, masses, consolidations, or characterization of cystic change. Associated findings of lymphadenopathy, pleural effusion, atelectasis, and underlying lung disease were noted. There were 10 men and 10 women (mean age, 49.3 years) who participated in the study. Eleven were symptomatic. Pathologic review, based on the revised World Health Organization classification, yielded the diagnosis of adenocarcinoma (n = 14); adenocarcinoma, possible BAC (n = 4); and BAC (n = 2). Radiologically, adenocarcinoma (n = 14) manifested as a solitary pulmonary nodule/mass (n = 5) or consolidation (n = 6) and as multifocal mixed disease (n = 3) with solitary (n = 8) or multicystic (n = 6) change. Adenocarcinoma, possible BAC (n = 4) manifested as multifocal and multicystic consolidations (n = 2) or mixed disease (n = 1) and as a solitary cystic mass (n = 1). BAC (n = 2) manifested as a cystic mass (n = 1) and as multifocal multicystic mixed disease (n = 1). Most cases of BAC with radiologic cystic change were reclassified as adenocarcinoma. The radiologic features of BAC may need to be redefined in light of the current diagnostic criteria to help identify patients with limited and potentially curable disease.     

肺肉瘤样癌2例并文献复习

目的提高对肺肉瘤样癌（lung sarcomatoid carcinoma,LSC）的诊断、治疗及预后方面的认识。方法通过对2例LSC患者的诊治进行分析,结合相关文献复习。结果患者表现为咳嗽、咯血、胸痛,其症状与其它类型肺癌相似,增强CT示环形强化为其特征。肺组织活检确诊肺肉瘤样癌（病理及免疫组化）。手术联合化/放疗可延长患者生存时间。结论肺肉瘤样癌罕见,较一般肺癌更具侵袭性,预后差。本病缺乏特异性临床表征,增强CT扫描示环形强化为其特征,但诊断主要依靠手术病理。手术是LSC的首选治疗方法。     

19例变态反应性支气管肺曲霉病临床分析

目的总结分析不同类型变态反应性支气管肺曲霉病（allergic bronchopulmonary aspergillosis,ABPA）的临床特点，提高对ABPA的认识，做到早诊断早治疗。方法分析中山医院近5年确诊的19例ABPA患者的临床资料，分为变态反应性支气管肺曲菌病-血清IgE增高型组和变态反应性支气管肺曲菌病-中心支气管扩张型组，比较两组病人的临床症状和实验室特点。结果19例ABPA患者中男11例，女8例，在确诊前被误诊为肺结核的有8例，误诊为肺癌的有3例，其他诊断包括支气管哮喘、过敏性肺炎、Wegener肉芽肿等。两组病人在年龄、性别、症状等方面差别无统计学意义，但ABPA伴中心型支气管扩张组的嗜酸粒细胞和血清总IgE水平比血清IgE增高型的ABPA组升高（P〈0.01），而第一秒用力呼气容积占预计值百分比则降低（P〈0.01）。结论不伴中心型支气管扩张的ABPA可能是疾病的早期或侵袭性较弱的一种形式，为避免肺功能出现不可逆的改变，对气喘、肺部出现游走性浸润影、嗜酸性粒细胞及IgE升高者应进一步查肺CT、烟曲菌特异性IgE和烟曲菌抗原皮内试验，以及早确诊并治疗。     

Pathology of lung cancer

This article reviews current concepts in pathologic classification of lung cancer based on the 2004 World Health Organization classification of lung tumors and the 2011 International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification of lung adenocarcinoma. Preinvasive lesions are discussed. The major changes in lung disease diagnosis affected by the IASLC/ATS/ERS classification are presented. For adenocarcinomas diagnosed in small biopsies, specific terminology and diagnostic criteria are proposed along with recommendations for strategic management of tissue and EGFR mutation testing in patients with advanced adenocarcinoma. Histologic criteria are also presented for other tumors.     

老年肺癌患者的支气管镜表现及临床特点分析

目的 观察老年肺癌患者临床特点及支气管镜表现.方法 分析182例经支气管镜检查确诊肺癌的老年患者（＆gt;60岁）的临床特点及支气管镜下表现、病灶部位、病理学分型等.结果 老年肺癌男女患病比例为3.79：1;病灶主要在右上叶支气管（31.87%）及左上叶支气管（23.08%）;增生型肺癌多见（65.93%）,其中鳞癌最多（65.83%）;其次是浸润型（21.43%）.结论 老年肺癌患者男性发病率高于女性,支气管镜可准确判断病灶部位、病理学类型,在肺癌临床诊治中具有重要价值.