A case of bronchioloalveolar cell carcinoma with bilateral diffuse interstitial infiltrative shadow during the treatment of Takatsuki's disease]

A 54-year old man treated with Takatsuki's disease was referred to us complaining of cough and excessive sputum. A chest roentgenogram showed bilateral diffuse interstitial infiltrative shadow. Chest CT showed banding shadows around the bronchioles and lobule-septum thickening in the right middle and both lower lung fields, and many small nodules in both lower lung fields. The histological diagnosis was adenocarcinoma replaced with one layer of bronchiolar epithelium, and partly bronchiolo-alveolar carcinoma. The patient received 3 courses of combination chemotherapy with docetaxel and cisplatin. After chemotherapy, the chest CT showed no change. The clinicopathological characteristics of this rare case included adenocarcinoma mixed with bronchioloalveolar carcinoma, in which radiography showed bilateral diffuse interstitial infiltrative shadow.     

Cavitary pulmonary metastasis from bladder cancer: a case report]

A 69 year-old [correction of 63] man who had had a radical cystectomy for bladder cancer was admitted to our hospital because of hemosputum and right femoral pain. His chest radiograph and computed tomogram showed a mass shadow with a cavity in the left upper lung field. Sputum cytology showed class V squamous cell carcinoma and a bone scintigram showed right femoral metastasis. Despite radiotherapy to the left upper lung and the right femur, the patient's condition worsened, and he died of respiratory failure after hospitalization for about 1 month. At autopsy, pathologic studies of lung cancer revealed mixed-type transitional cell carcinoma, squamous cell carcinoma and adenocarcinoma. A diagnosis of metastatic lung cancer from bladder cancer was made. Cavitating pulmonary metastasis is uncommon. We report a rare case of pulmonary metastasis from bladder cancer, with mixed-type histopathology at both primary and metastatic sites.     

Primary pulmonary combined scar carcinoma composed of adenocarcinoma,squamous cell carcinoma,and small cell carcinoma: An autopsy case and literature review

Primary pulmonary scar carcinoma with triplicate differentiation is very rare. A 66-year-old woman presented with cough, and consulted to a private hospital, where she was pointed out to have abnormal lung shadow by chest X-P. She was admitted to our hospital for scrutiny. Imaging modalities including chest X-P, CT, and MRI revealed a main tumor (35 mm in diameter) in the right lower lobe and multiple small metastases in both lungs. Biopsies and cytology revealed an adenocarcinoma. Metastasis to the liver, iliac bone and tibia bone were also detected. She was diagnosed as stage IV lung adenocarcinoma (T2N3M1), and received chemotherapy. Soon, she complained of right hemiparesis, and brain CT revealed multiple brain metastases. She died of respiratory failure due to bronchopneumonia 7 months after admission. An autopsy revealed a lung tumor (4 × 4 × 3 cm) in the right lower lobe. Miliary micrometastases were recognized in bilateral lungs, brain, bones, pleura, liver, brain, and systemic lymph nodes. The lungs showed bronchopneumonia. The liver was cirrhotic. Microscopically, the primary lung tumor consisted of adenocarcinoma element (70% in area), squamous cell carcinoma element (20%), and small cell carcinoma element (10%), all of which were embedded in a fibroelastic scar with calcification (scar carcinoma). There were gradual merges between the adenocarcinoma and squamous cell carcinoma elements, but the small cell carcinoma element was isolated. The liver metastases were composed only of small cell carcinoma, and other metastatic sites consisted of adenocarcinoma, squamous cell carcinoma, and small cell carcinoma. Other pathologic changes included pulmonary aspergilosis, bronchopneumonia, splenomegaly, emphysema, cardiac hypertrophy, and kidney congestion. The present case shows that a lung scar carcinoma can display triplicate differentiations.     

Bronchioloalveolar carcinoma complicated by a lesion resembling bronchiolitis obliterans organizing pneumonia in the opposite lung]

A 50-year-old woman with abnormal shadows in her chest radiograph was admitted for a more detailed examination in April 2000. A chest CT scan showed infiltrates surrounded by ground-glass opacities in the right upper lobe, and ground-glass opacities with partial infiltrative changes in the left lower lobe. A diagnosis of adenocarcinoma like bronchioloalveolar carcinoma (BAC) was made for the lesion in the right upper lobe by means of a transbronchial biopsy. However, the specimen from the left lower lobe showed nonspecific changes, and bronchiolitis obliterans organizing pneumonia (BOOP) or a metastatic lesion from the BAC was suspected. We prescribed steroids for the short term. Since the lesion in the left lobe disappeared, we performed a right upper lobectomy. In cases of primary lung carcinoma, BOOP in the opposite lung is rare and it was difficult to decide on the operability. We concluded that steroid therapy is useful for distinguishing between inflammatory and tumorous lesions in cases in which a detailed examination is difficult.     

Bronchioloalveolar carcinoma masked by gravity-dependent gradient on computed tomography

A 78-year-old woman was found to have a small bronchioloalveolar carcinoma with ground-glass attenuation in the gravity-dependent gradient in the left lower lobe during a preoperative chest computed tomography (CT) evaluation, which was performed for previously-diagnosed adenocarcinoma of the right upper lobe. To remove the gravitational effect of the CT, the patient underwent a thin section CT in the prone position. Then, a ground-glass attenuation was revealed clearly in the left lower lobe. Postoperative pathological diagnosis was synchronous multiple bronchioloalveolar carcinomas, stage IA. This case suggests that focal areas of ground-glass attenuations on a thin-section CT in patients with BAC would be considered to be multicentric development of BAC. CT with the patient in the prone position helps to exclude the gravitational effect and narrow the differential diagnosis of ground-glass opacity, including localized forms of BAC.     

A case of resected squamous cell carcinoma of the lung complicated with sarcoidosis]

A 64-year-old man with uveitis was admitted to our hospital for detailed investigation of an abnormal shadow on his chest X-ray. Chest radiography and computed tomography of the chest showed mediastinal lymphadenopathy and a tumor shadow in the left hilum. Transbronchial tumor biopsy revealed squamous cell carcinoma. Left upper lobectomy and drainage of bilateral hilar and mediastinal lymph nodes were performed. Histopathological examination revealed the coexistence of squamous cell carcinoma with many non-caseating epithelioid cell granulomas in all hilar and mediastinal drainage lymph nodes, but no metastasis. Non-caseating epithelioid cell granulomas were also seen in the interstitium and alveolar spaces. Coexistence of sarcoidosis and lung cancer in the same patient is not common, and only 29 cases, including ours, have been reported. This case also provides the concept that surgical tumor resection should be considered even if bilateral mediastinal lymphadenopathy is found in a case of lung cancer complicated with sarcoidosis.     

Lung transplantation: bronchogenic carcinoma in the native lung

In lung transplantation, the presence of bronchogenic carcinoma in the native organ is uncommon, but doubtless affects patient survival, independently of the transplantation process itself. We describe 2 cases in which a primary tumor was found in the explanted lung--1 case of adenocarcinoma in a patient with pulmonary emphysema and 1 case of bronchioloalveolar carcinoma in a patient with idiopathic pulmonary fibrosis. Both patients died due to the recurrence of the neoplastic disease. Distant metastasis was the initial manifestation of the recurrence.     

Adenocarcinoma arising in a mediastinal enteric cyst

A 39 year-old male was admitted to our hospital because of relapsing episodes of pneumonia. His chest roentgenogram showed a consolidated shadow and cavity formation in the left lower lobe. During a left lower lobectomy an enteric cyst in the posterior mediastinum involving lung was found. This cyst in the lung contained normal gastric parietal cells and pancreatic tissue, and was surrounded by adenocarcinoma characteristic of gastric cancer. This is a rare case in which an adenocarcinoma arise from an enteric cyst in the mediastinum.     

A case of adenocarcinoma of lung with idiopathic pulmonary fibrosis, showing 1 8-fluorodeoxyglucose uptake in positron emission tomograhy]

A 61-year-old man consulted our hospital because of bloody sputum. Cells of Class V (adenocarcinoma) were found on sputum cytologic examination. Chest computed tomography (CT) showed reticular shadows but no obvious mass was detected. Positron emission tomography with 18-fluorodeoxyglucose (FDG-PET) revealed FDG uptake in both lower lung fields and more increased FDG uptake in a small area of the left lung field. Repeated chest CT, bronchial brushing, bronchial washing, and lung-imaging fluorescence endoscopy were performed, however, resulting in no detection of the primary site of lung cancer. Six months after initial consultation, chest CT showed an enlargement of the shadow in left S6 corresponding to the area of the more increased FDG uptake in PET. On the other hand, the shadow in right S10 did not change in size. Bronchial brushing of the left S6 was performed again, and class IV cells (adenocarcinoma) were found. After left lower lobectomy, diagnoses of well differentiated adenocarcinoma and usual interstitial pneumonia (UIP) were established histologically. There has been no report demonstrating the efficacy of FDG-PET for diagnosis of lung cancer with idiopathic pulmonary fibrosis (IPF).However, combination of lung cancer should be considered if PET shows spots of high FDG uptake in the lung fields of IPF.     

Two cases of lung cancer in the third decade of life]

We report two cases of lung cancer in the third decade of life. One patient was a 27-year-old man complaining of persistent cough and chest pain. He was referred for examination of an abnormal shadow found on chest radiography. A diagnosis of adenocarcinoma consisting of bronchial gland cells was made by bronchial biopsy. The clinical stage was T4N2M1. Although he was treated with cisplatin-based chemotherapy and gefitinib, he died of lung cancer. The other patient was a 26-year-old Chinese woman complaining of hemosputum. Since histologic examination at thoracotomy revealed lung cancer, left lower lobectomy and lymph node dissection were performed. Histological examination of the resected specimen revealed pleomorphic carcinoma. The pathological stage was pT2N2MX. Although the absolute number of young adults with lung cancer has been increasing, the relative incidence among all cases of lung cancer has been decreasing. In some cases, young adults with lung cancer have been misdiagnosed as having bronchial asthma or pulmonary tuberculosis.     

A case of coexistent bronchogenic carcinoma with pulmonary tuberculosis]

A 79-year-old housewife complaining of shortness of breath presented with a LUL mass lesion on chest roentgenogram. Bronchofiberscopic biopsy and curettage revealed adenocarcinoma as well as acid-fast bacilli of Gaffky-4. Further investigations showed increased ESR, CRP levels and positive RF. PPD skin test was positive measuring 55 x 43 mm. A left upper lobectomy with mediastinal lymph node dissection was performed. The mass was in S1+2 and measured 2.7 x 2.5 x 1.5 cm. Histologically caseaous necroses and spotted granulomas of tuberculosis were surrounded by bronchioloalveolar cell carcinoma. Recent discussion concerning the simultaneous occurrence of pulmonary tuberculosis and bronchogenic carcinoma suggests a higher coexistence of both diseases. However, the coexistence of active tuberculosis with carcinoma in the same region, as in our case, is quite rare and suggests an etiological closer relationship between both diseases.     

Synchronus presentation of early-stage small cell carcinoma and adenocarcinoma in the same lung lobe

A 73-year-old man with no symptoms was admitted to our hospital with a nodular shadow (>2 cm) in the left upper lung field on chest X-ray. A histological diagnosis (small cell carcinoma) was obtained by bronchoscopic examination including a transbronchial lung biopsy (TBLB). The preoperative clinical staging was T1N0M0 (StageIA). After preoperative chemotherapy (CDDP + CPT11) was carried out, a nodule in the left S(1+2) diminished remarkably, but a smaller nodule in the left S3 (>8 mm) remained unchanged. While the nodule in the left S(1+2) (small cell carcinoma) had become completely necrotic by the time the final diagnosis was made after resection of the left upper lobe, histological diagnosis of the nodule in the left S3 revealed a well differentiated adenocarcinoma. Synchronous presentation of early-stage lung cancer consisting of small cell carcinoma and adenocarcinoma was identified in the same left upper division of the lung. Because there have been the few previous reports regarding cases of synchronous presentation of early-stage lung cancer in the same lung lobe, we also report on the clinical characteristics, thus adding this case to the five previously reported cases.     

Severe bronchorrhea in a patient with bronchioloalveolar carcinoma

Mucinous bronchioloalveolar carcinoma (BAC) can be associated with significant bronchorrhea. A 46-year-old man presented with BAC with 2,000 mL of sputum production on a daily basis, which prevented him from being extubated. As this condition is rare, there are only case reports outlining the therapy for the associated bronchorrhea. We used azithromycin, scopolamine, and inhaled fluticasone with moderate success. The initiation of an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, gefitinib, resulted in dramatic improvement in the volume of pulmonary secretions produced. The patient's EGFR mutation status was subsequently found to be negative, which supports the hypothesis that the mechanism of reduction of bronchorrhea is independent of the antiproliferative effect of the drug.     

Diagnosis and treatment of bronchioloalveolar carcinoma

PURPOSE OF REVIEW: Bronchioloalveolar carcinoma accounts for 5% of lung cancers, although histologically mixed bronchioloalveolar carcinoma and adenocarcinoma account for up to 20%. Bronchioloalveolar carcinoma histology is present in a majority of tumors found on lung-cancer screening by computed tomography. We review issues surrounding the diagnosis and treatment of bronchioloalveolar carcinoma, which often differs from other types of lung cancer. RECENT FINDINGS: A spectrum of disease from histologically pure bronchioloalveolar carcinoma to adenocarcinoma exists. The approach to treatment of diseases within this spectrum is still evolving. Evidence on the role of sub-lobar resection, resection of multifocal disease, and pulmonary transplantation is reviewed. We also discuss epidermal growth factor receptor tyrosine kinase inhibitors, and their role in patients with bronchioloalveolar carcinoma. SUMMARY: An understanding of recent developments in the diagnosis and treatment of patients with bronchioloalveolar carcinoma histology is important as early detection of lung cancer becomes more common. Ongoing clinical trials will provide important information on the role of limited resection. The use of epidermal growth factor receptor tyrosine kinase inhibitors should currently be limited to patients with advanced or recurrent disease who have failed cytotoxic chemotherapy. New targeted therapies are emerging for patients with bronchioloalveolar carcinoma histology.     

An autopsy case of adenocarcinoma of the lung with signet ring cells, manifesting with aphasia and hemiparesis due to nonbacterial thrombotic endocarditis

A 42-year-old male was admitted to Tokyo University Hospital because of confusion, aphasia and right hemiparesis. Cranial computed tomography and cerebral angiography demonstrated cerebral infarction due to occlusion of the left middle cerebral artery, while chest roentgenography disclosed a nodular shadow in the right upper lobe and swelling of right hilar and paratracheal lymph nodes. These findings suggested carcinoma of pulmonary origin and tumor-associated cerebral thrombosis, but a possibility of gastric cancer was raised by the finding of cervical lymph node biopsy which revealed signet ring cells in metastatic adenocarcinoma. He developed disseminated intravascular coagulation syndrome and died on the 83rd hospital day. Autopsy revealed adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis which appeared to be responsible for the cerebral infarction. The relationship between adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis was discussed.     

Occult papillary carcinoma of the thyroid presenting as a solitary pulmonary metastasis

This is a report of a quite rare case of occult papillary carcinoma of the thyroid in which the initial clinical manifestation was a solitary lung metastasis. A 58-year-old woman was referred to the Fukuoka University Hospital because a coin lesion approximately 5 cm in diameter was detected in the right lower lobe of the lung by routine roentgenographic examination. This abnormal finding by chest X-ray had been pointed out about fifteen years before. Although she did not remember the exact size of the lung tumor, it had grown minimally since that time. Otherwise, she had been in good health all her life. No abnormalities in clinical and laboratory tests were found on admission. The tumor was clinically suspected to be of benign nature (probably sclerosing hemangioma), and pulmonary lobectomy was performed. Microscopic examination of the tumor revealed a papillary carcinoma with focal areas of follicle formation and colloid production, consistent with metastatic thyroid carcinoma. Immunoperoxidase stain for thyroglobulin was strongly positive in the tumor, and this finding confirmed the thyroid origin. Repeated physical examination of the thyroid gland, thyroid scan, and thyroid function tests were all unremarkable, however, she was closely followed up for two years. Then, a thyroid nodule with cystic change was detected on the ultrasonogram. The patient underwent a right hemithyroidectomy, disclosing papillary adenocarcinoma histologically. This case suggests that thyroid cancer should be considered as possible primary site in cases of long-standing coin lesion on chest X-rays in patients without remarkable complaints and in whom the primary site is unknown. A search of the literature has revealed only five cases with occult thyroid carcinoma associated with solitary pulmonary metastasis.     

A patient with lymphoma of mucosa-associated lymphoid tissue (MALT) and adenocarcinoma in the same tumor of the lung]

A 60-year-old woman with no symptoms was found to have a mass shadow in the left lower lobe of the lung on chest radiography. Open lung biopsy and left lower lobectomy were performed. Histopathological study of the specimen revealed two distinct neoplasms. One tumor was a low grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) of the lung, while the other was an adenocarcinoma. The two neoplasms were admixed to form a composite tumor.     

Late onset pulmonary metastasis more than 10 years after primary sigmoid carcinoma

According to current guidelines, follow-up of patients with colorectal cancer is ended after five years. Also, chest X-ray is not part of standard investigation during follow-up. We describe a case of a 74-year-old patient, more than ten years after a sigmoid resection because of carcinoma of the sigmoid. No recurrence was detected during intensive follow-up. However, ten years after resection of the sigmoid adenocarcinoma, complaints of coughing induced further examination with as result the detection of a solitary metastasis in the left lung of the patient. Within half-a-year after metastasectomy of the lung metastasis, she presented herself with thoracic pain and dyspnea resulting in discovering diffuse metastasis on pulmonary, pleural, costal and muscular level. Five year follow-up of colorectal carcinoma without chest X-ray can be questioned to be efficient. The growing knowledge of tumor biology might in future adjust the duration and frequency of diagnostic follow-up to prevent(late) recurrence in patients with colorectal carcinoma.     

An autopsy case of pulmonary metastasis of cholangiocellular carcinoma associated with marked fibrotic change of the lungs]

An autopsy case of pulmonary metastasis of cholangiocellular carcinoma is presented. A 44-year-old woman was admitted to our hospital because of dyspnea, general fatigue and a sense of abdominal fullness on February 5, 1990. In November 1986, at an other hospital, she had been diagnosed as having diffuse metastatic lung tumor and multiple bone metastases, by transbronchial lung biopsy and other examinations. During the clinical course, she was not received chest irradiation and chemotherapy which induced fibrotic change of lungs. Chest X-ray film on December 21, 1986 showed diffuse nodular shadows in both lung fields. Chest X-ray film on February 4, 1990 showed diffuse reticular shadows with marked shrinkage of lung fields. She died two months after admission. The primary site of the carcinoma was not determined clinically, but was revealed by autopsy to be cholangiocellular carcinoma of the liver, with generalized metastasis. Microscopic findings of the autopsied lung showed markedly increased connective tissue around bronchi and blood vessels, in areas where microtubular adenocarcinoma was scattered. This is a very rare case of pulmonary metastasis of cholangiocellular carcinoma, associated with marked fibrotic change of the lungs during about 3.5 years. To our knowledge, this is the first reported case.