Presentation
Chronic cough.
Patient Data
There is an ill-defined lung opacity in the right lower zones, the lungs and pleural spaces are otherwise clear. Cardiomediastinal contours are within the normal limits.
There is a 3.0 cm juxta fissural lesion in the right lower lobe that has a solid nodular and surrounding ground-glass components. Within both upper lobes, there are focal ground-glass opacities measuring less than 5 mm. No lymphadenopathy.
No radiotracer uptake within the RLL lesion.
The patient underwent a CT-guided core-biopsy and further lobectomy:
Macroscopy: A. Labeled "Right lung lower lobe". Specimen description: Intact lobectomy. Size: 164 x 110 x 40 mm, 150g
- inking: Parenchymal - green, Pleura - blue, Bronchial/vascular - Black (4mm stapled margin amputated before inking)
- pleural surface: Smooth, glistening tan-violaceous, focal puckering over the medial basal segment
- tumor location: Peripheral, basal medial segment.
- tumor size: 33 x 30 x 12 mm
- tumor appearance: Cream-grey, lobulated/infiltrative, firm
- relationship to pleura: Retraction of pleura, possible invasion.
- distance from bronchial margin: 70 mm
- post-obstructive pneumonia: Absent
- remaining lung parenchyma: Red/brown and spongy
- lymph nodes: 4 perihilar lymph nodes.
B. Labeled "Station 7 lymph node (right pleural)". A violaceous fatty tissue fragment 35 x 17 x 4 mm, containing a single elongate lymph node, 30 mm. LS ×4.
C. Labeled "Station 9 lymph node right pleural". A fragment of fatty tissue 20 x 10 x 3 mm, containing 2 dark brown lymph nodes 15 x 8 x 3 mm and 5 x 3 x 1 mm, and a small amount of attached fat. Largest node bisected. All in.
D. Labeled "Station 11 lymph node (right pleural)". 4 fragments of dark brown, ragged tissue ranging from 3-10 mm. Fragments processed whole.
Microscopy: A. The sections taken from the macroscopically described tumor show an invasive adenocarcinoma. The tumor has predominantly lepidic pattern with admixed papillary (20%) and acinar (10%) patterns. The tumor cells show moderate nuclear pleomorphism, nuclear hyperchromasia and small nucleoli. No lymphovascular or perineural invasion is identified. There is a focal extension through the elastic layer of visceral pleural. The tumor is clear of resection margins. Non-neoplastic lung show small foci of organizing pneumonia. Three hilar lymph nodes show sinus histiocytosis with no evidence of metastatic malignancy (0/3).
B. The sections show a lymph node with sinus histiocytosis. There is no evidence of metastatic malignancy (0/1).
C. The sections show 2 lymph nodes with sinus histiocytosis. There is no evidence of metastatic malignancy (0/2).
D. The sections show lymphoid tissue with sinus histiocytosis. There is no evidence of malignancy.
Conclusion: A. Right lower lobe, resection:
- histological type Moderately differentiated, lepidic predominant adenocarcinoma pT2a N0
- tumor size 33 mm in maximal dimension
- visceral pleural invasion Focally into visceral pleura (PL1)
- lymphovascular invasion Not identified
- perineural invasion Not identified
- bronchial resection margin Not involved
- vascular resection margin Not involved
- hilar lymph nodes involvement Absent (0/3)
B. Station 7 lymph node right pleural, excision: No metastatic malignancy in 1 lymph node (0/1).
C. Station 9 lymph node right pleural, excision: No metastatic malignancy in 2 lymph nodes (0/2).
D. Lesion 11 lymph node right pleural, excision: No metastatic malignancy.
Case Discussion
This case illustrates focal lung lesion in the right lower lobe with mixed solid and ground glass components and low or non-measurable metabolic activity on PET. The patient was offered a CT-guided lung biopsy that confirmed a lung adenocarcinoma, with further resection showing a lepidic predominant lung adenocarcinoma (T2a N0 M0). Other tiny ground-glass nodules in the upper lobes, although non-specific, are suspicious for pre-invasive lung tumors and will be followed-up on imaging.
Unable to process the form. Check for errors and try again.