Presentation
Cough.
Patient Data
A region of what appears to be atelectasis is seen in the lingular segment of the left upper lobe. It appears smaller than the corresponding lesion seen on CT however this may be due to relatively low density of the periphery of the lesion. Comparison with previous chest x-rays would be helpful to confirm that the lesion is not smaller in size.
Elsewhere the lungs and pleural spaces are clear. The cardiomediastinal contours are normal.
An irregularly shaped somewhat spiculated mass measuring 2.4 x 2.8cm is identified in the lingular segment of the left upper lobe. There is a linear tail which appears to be atelectasis extending to the pleural surface. There is no associated pleural thickening. Centrally within the mass are multiple focal radiolucencies suggesting this may represent an adenocarcinoma.
There is a 1cm subtle rounded area of groundglass opacity in a subpleural position postero-laterally in the left lower lobe. If the larger lesion proves to be an adenocarcinoma, this could represent either in situ disease at all well differentiated adenocarcinoma.
A minor region of atelectasis in the apical segment of the right lower lobe is unchanged. A non-specific opacity inferiorly and anteriorly in the right upper lobe may represent scarring.
In extensive changes of emphysema are seen.
There are no enlarged hilar or mediastinal lymph nodes.
No suspicious bone lesions are seen.
Conclusion:
- at the lingular segment left upper lobe mass has the appearance of a carcinoma, probably adenocarcinoma
- small groundglass focus in the right lower lobe could also represent adenocarcinoma either in situ or low grade
- there are bronchi passing into the lingular segment mass. It would be amenable to bronchoscopic biopsy
Case Discussion
This patient went on to have a left upper lobectomy.
Histology
MICROSCOPIC DESCRIPTION: Sections from the tumor show adenocarcinoma with a predominantly lepidic growth (60%) and a lesser component of acinar growth (40%). Tumor cells are cuboidal to columnar with large hyperchromatic pleomorphic, small nucleoli and clumped chromatin. The stroma appears desmoplastic and contains a dense mononuclear inflamamtory cell infiltrate. There is a large central scar area. Lymphovascular and perineural invasion are not identified. Tumor is close to the pleura. but does not appear to invade the pleura. The sections of the hilar margin structures are clear of tumor. Lung parenchyma away from the tumor is unremarkable. There is some mild subpleural fibrosis and emphysema in one of the sections. Two lymph nodes show no evidence of metastatic carcinoma.
DIAGNOSIS:
- Left upper lobectomy: * Lepidic predominant adenocarcinoma. - Lepidic component 60%, acinar component 40%. - Size - 22mm. - No pleural invasion. - No lymphovascular invasion. - No perineural invasion. - Well clear of margins. - 2 lymph nodes with no evidence of metastatic carcinoma (0/2).
- Station 5, 8, 10, 11: lymph nodes with no evidence of metastatic carcinoma
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