Ann Thorac Surg 2006;82:1508-1510
© 2006 The Society of Thoracic Surgeons
Case Reports
Multiple Lung Adenocarcinomas Showing Ground-Glass Opacities on Thoracic Computed Tomography
Yukio Tsushima, MD,
Kenji Suzuki, MD*,
Shun-ichi Watanabe, MD,
Masahiko Kusumoto, MD,
Koji Tsuta, MD,
Yoshihiro Matsuno, MD,
Hisao Asamura, MD
Divisions of Thoracic Surgery, Diagnostic Radiology and Clinical Laboratory, National Cancer Center Hospital, Tokyo, Chuo-ku, Japan
Accepted for publication January 23, 2006.
* Address correspondence to Dr Suzuki, Thoracic Surgery Division, National Cancer Center Hospital, 1-1, Tsukiji 5 chome, Chuo-ku, Tokyo, 104-0045 Japan (Email: kjsuzuki{at}ncc.go.jp).
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Abstract
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It is difficult to distinguish multiple primary lung cancers from pulmonary metastasis. We experienced a case of surgically resected lung tumors that showed multiple ground-glass opacities on thoracic computed tomographic scan. There were eight nonsolid and two part-solid ground-glass opacities in the bilateral lungs. Surgical resection was performed because all tumors had a ground-glass opacity appearance on computed tomographic scan, which is compatible with a finding of primary lung adenocarcinoma. The postoperative pathologic diagnoses were two cases of invasive adenocarcinoma, six cases of bronchioloalveolar carcinoma, and eight cases of atypical adenomatous hyperplasia. The patient remains alive without any evidence of recurrence 40 months after surgery. A ground-glass opacity appearance on computed tomographic scan could be interpreted as supportive evidence for multiple primary lung adenocarcinoma rather than pulmonary metastases.
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Introduction
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Introduction of computed tomography into clinical practice led to an increased number of tiny lung nodules that could be detected on computed tomographic (CT) scans. Generally speaking, it is quite difficult to preoperatively distinguish between multiple lung cancers and intrapulmonary metastasis when the histologic diagnosis is the same. We experienced a lung cancer patient who had multiple ground-glass opacities (GGOs) and underwent surgical resection for these lesions. Postoperative pathologic diagnosis revealed the lesions as multiple adenocarcinomas of the lung. We considered that GGO appearance on preoperative CT scan could be interpreted as a sign of multiple lung adenocarcinomas instead of intrapulmonary metastasis.
A 60-year-old woman without a remarkable medical history was admitted to our hospital for an evaluation of lung nodules detected by a screening with a CT scan. She had no smoking history and no family history of any cancers. There were multiple GGOs on the thoracic CT scan in the bilateral lungs (Fig 1). Neither hilar nor mediastinal lymphadenopathy was demonstrated. The serum carcino-embroyonic antigen was within normal limits. There were three lung nodules in the right lung on CT scan; one part solid GGO with a maximum dimension of 1.5 cm in the upper lobe, and one GGO each in the middle and lower lobes, respectively. There were five lung nodules in the left lung; one part solid GGO (1.5 cm in diameter), one GGO in the upper lobe, and three GGOs in the lower lobe. An open-lung biopsy was performed from the right side. A right superior segmentectomy and wide wedge resection of the middle and lower lobes with mediastinal lymph node sampling were performed, resulting in four resected lung nodules. A histopathologic examination revealed multiple lung tumors showing extensive bronchioloalveolar spread, which is a feature of primary neoplasm of peripheral airway epithelium. The four tumors consisted of one well-differentiated invasive adenocarcinoma, two bronchioloalveolar carcinomas in the lower lobe (Fig 2), and one atypical adenomatous hyperplasia (AAH) in the middle lobe (Table 1). No tumor cells were found in the lymph nodes. Thus the pathologic diagnosis was right synchronous triple lung cancers of pT1N0M0 accompanied by one AAH. The postoperative course was uneventful. We performed a second operation on the left side 3 months later. Seven wedge resections of the left upper and left lower lobes were performed. A histopathologic examination showed multiple lung tumors that were similar to the right lung. These tumors consisted of one well-differentiated invasive adenocarcinoma and two AAHs in the upper lobe, and four bronchioloalveolar carcinomas and five AAHs in the lower lobe (Table 1). No lymph node metastasis was found. The diagnosis was left synchronous five primary lung cancers of pathologic stage T1N0M0 and seven AAHs. The postoperative course was uneventful and no evidence of recurrence has been observed for 40 months.
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Comment
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It is often difficult to distinguish between multiple primary lung cancers and intrapulmonary metastasis when we encounter patients with multiple lung nodules by radiology. However the diagnosis is quite critical for deciding on the clinical strategy for lung cancers. We encountered a case of multiple lung tumors that showed multiple GGO on thoracic CT scan. Radiographic findings strongly suggested that multiple lung nodules in the present case were multiple primary adenocarcinomas, which were confirmed by histopathology. After multiple lung resections for these tumors, the patient remains alive without evidence of disease. This case suggests that multiple lung nodules displaying GGO on CT are important for differentiating multiple lung cancers from intrapulmonary metastases.
Recent advances in high-resolution CT scanning have resulted in the more frequent detection of GGO. There is still some controversy regarding how to best manage this lesion. Careful follow-up may be sufficient instead of conventional surgical resection. As for the type of surgery, major lung resection such as pneumonectomy or lobectomy is still the standard approach for primary lung cancer. However, limited resection may be suitable for lung cancer detected by CT, because these lesions tend to be early adenocarcinoma [1]. In this case we basically diagnosed the bilateral lesions as synchronous primary adenocarcinomas based on the criteria of Martini and Melamed [2]. Most of the lesions were accompanied by GGO on thoracic CT scan, and we suspected them to be early lung cancers. As a result, multiple limited surgical resections were performed with curative intent.
There are still various controversies regarding the carcinogenesis of lung cancer. There have been some reports on the adenoma-carcinoma sequence in the lung, and AAH, which is believed to be a precursor lesion, is concomitant with lung adenocarcinoma in more than 20% of the cases [3–5]. Although concomitant AAH has no impact on the prognosis, metachronous multiple lung cancers may be found in this population. Thus intensive follow-up is necessary for this situation. In our case, intensive follow-up with thoracic CT scan was indicated for 40 months. So far there have been no new lesions on thoracic CT scan. Further investigations of multiple lung cancers with precancerous lesions are needed.
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Acknowledgments
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This work was supported in part by a Grant-in-Aid for Cancer Research from the Ministry of Health, Labor, and Welfare.
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References
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- Martini N, Melamed MR. Multiple primary lung cancers J Thorac Cardiovasc Surg 1975;70:606-612.[Abstract]
- Clayton F. The spectrum and significance of bronchioloalveolar carcinomas Pathol Annu 1988;23:361-394.
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- Logan PM, Miller RR, Evans K, Muller NL. Bronchogenic carcinoma and coexistent bronchioloalveolar cell adenomasAssessment of radiologic detection and follow-up in 28 patients. Chest 1996;109:713-717.[Abstract/Free Full Text]
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Abstract
Introduction
