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Multifocal lung adenocarcinoma

Case contributed by Bruno Di Muzio
Diagnosis certain

Presentation

Incidental finding on CT performed for other reason.

Patient Data

Age: 50 years
Gender: Female

Chest

ct

Centrilobular emphysema. There are a few thin-walled lung cysts which would support the diagnosis of pulmonary Langerhans cell histiocytosis.

Multiple pulmonary nodules:

  • subsolid, well-circumscribed ground-glass opacity in the right upper lobe measures 14 x 10 mm. Central 2 mm solid nodule adjacent to small dilated bronchiole.  Findings are suspicious for adenocarcinoma in situ
  • solid spiculated nodule posterior segment left upper lobe measuring 12 x 10 mm.  No central cavitation
  • 4 mm subtle ground-glass opacity adjacent to the oblique fissure in the superior segment left lower lobe.
  • 6 mm round ground-glass opacity posterior basal segment right lower lobe

Pleural spaces clear.

Sub centimeter mediastinal lymph nodes.

Macroscopy: Labeled "Left upper lobe of the lung". Left upper lobe weighing 204 g measuring 153 x 125 x 55 mm. Pleura appears dark brown/tan with scattered black pigment, with focal puckering at the posterior aspect. Hilar margins are clear with mucus plugs seen within vessels on sectioning. In the posterior aspect of the lobe, there is a firm pale cream/tan lesion which abuts the pleura measuring 16 x 14 x 10 mm. The lesion is 10 mm from the hilum, and blood appears to invade into vasculature or airway. The remainder of parenchyma appears tan with a spongy texture. There is a focal area of subpleural hemorrhage. No further lesions are identified. Inked blue hilum, black stapled margin and yellow at the area of puckering pleural surface.

Microscopy: Sections show a 16 mm invasive adenocarcinoma that is entire of the acinar (cribriform) pattern. No convincing micropapillary or other patterns are identified. The tumor infiltrates within a desmoplastic inflamed stroma. The entire tumor is strongly positive for CK 7 and TTF-1. The tumor is subpleural in a location with a focal invasion of the visceral pleura identified. Focal lymphovascular space invasion is identified. No perineural invasion is seen. Some free-floating adenocarcinoma tumor fragments are present in the pulmonary parenchyma surrounding the tumor. The tumor is clear of the bronchovascular hilar resection margin and trimmed stapled margin. 

Metastatic adenocarcinoma is identified in one of 5 peribronchial lymph nodes.

The background pulmonary parenchyma shows focal atypical adenomatous hyperplasia, emphysematous change and prominent alveolar macrophages.

Conclusion: 

 

  • specimen type: Left upper lobectomy.
  • histological tumor type: Adenocarcinoma
  • histological grade: Moderately differentiated - acinar pattern
  • tumor location: Subpleural
  • tumor size: 16 mm
  • visceral pleural invasion: Present, PL1 tumor focally invades beyond the elastic layer of the visceral pleura but is not exposed on the pleural surface.
  • lymphovascular invasion: Present
  • perineural invasion: Absent
  • Surgical margins status
  • bronchial resection margin: Clear
  • vascular resection margin: Clear
  • other margins: Stapled hilar margin macroscopically clear.
  • direct invasion of adjacent structures: Absent.
  • in situ carcinoma: Not identified
  • lymph nodes within the main resection specimen:
    • Number of lymph nodes: 5
    • Number of involved lymph nodes: 1
    • Separately received lymph nodes:
    • Number of lymph nodes: 6
    • Number of involved lymph nodes: 0
  • other coexistent pathological abnormalities: Focal atypical adenomatous hyperplasia. Emphysematous change

Pathological staging (AJCC 8th addition):  pT2a N1 MX

Annotated image

1 - confirmed lung invasive adenocarcinoma - acinar pattern 

2 - suspected lung adenocarcinoma in situ

3 - suspected lung adenocarcinoma in situ vs atypical adenomatous hyperplasia 

Case Discussion

Case of multifocal lung adenocarcinoma in multiple degrees of invasiveness: 

The patient had an FDG PET-CT showing mild avidity within the RUL mixed ground glass/solid nodule and more prominent uptake within the LUL solid nodule. MDM discussion was for an LUL wedge resection (further converted into a left upper lobectomy) and further monitoring of the other low-grade lesions. 

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