Well differentiated mixed acinar and bronchoalveolar adenocarcinoma of the lung
Short Summary

An occasion chest X-ray of a 74-year-old female revealed a thickening in her left lung, and the tumor was latter typified as non-small cell lung cancer. Her staging chest CAT scan was consistent with a primary tumor in the lingular sub-segment together with millimetric parenchymal nodules suspected as secondary. She underwent a lingular segmental resection of the left lung. The histological report described a mixed acinar and non-mucinous bronchoalveolar adenocarcinoma of the lung.

Patient's Questions
1)            Do you agree with the surgical treatment carried out?

2)            Would you consider any further oncological therapies such as chemotherapy or radiotherapy to be of use?

3)            What is the expected prognosis?
Medical Background

Sex:F, Age:74 years old

 
Diagnosis: Well differentiated mixed acinar and bronchoalveolar adenocarcinoma of the lung (T1 N0).
 
Medical history:
Arterial hypertension
Diverticular disease of the colon
Radical hysteroannessiectomy performed 28 years ago.
Patient recently (December 2007) underwent PTCA and Stent on left anterior descending coronary artery and circumflex artery for three-vessel coronary disease with proximal occlusion of the descending coronary artery.
History:
On January 2008, the patient was admitted to the San Paolo Hospital of Milan for thickening of the left lung, already typified by means of fine-needle aspiration, as non-small cell lung cancer (NSCLC). The patient was already in possession of the following documentation:
-       Chest CAT scan: nodule with spiculated margins of possible hyperplastic nature in the lingular sub-segment. Millimetric parenchymal nodules suspected as secondary in the ventral segment of the upper right lobe, in the segments of the basal pyramid of the upper right lobe and lower left lobe.
-       PET SCAN: pathological accumulation of the radioactive marked glucose analogue at the level of the lingula.
-       Fibre bronchoscopy: no pathological findings within visibility limits of endoscopy.
-       Brain CAT scan: no secondary lesions.
-       CT guided lung needle biopsy: non-small cell lung cancer (NSCLC).
-        
Whilst in hospital, routine diagnostic tests and examinations were carried out (blood chemistry tests, chest radiogram in 2 projections, respiratory function tests) to complete the documentation provided by the patient: given the fact that the clinical condition is marked by being positive for lung neoplasia to the lingular segment, after careful cardiological and pneumological evaluation, a surgical approach was decided on.
As such, on 01/2008, Mrs. X underwent a lingular segmental resection of the left lung.
Immediate post-operative progress was normal in intensive care, where the patient was kept for approximately 24 hours as a cautionary measure, given her cardiological history.
The final histological report showed a well-differentiated mixed acinar and bronchoalveolar adenocarcinoma (T1 N0).
She was discharged on 11/02/2008 and returned for a check-up with the chest surgical ward a week later. At this time, the following was reported upon objective examination:
“Patient currently eupnoeic, presence of vesicular murmur diffused bilaterally. She complains of persistent pain to the chest starting from the wound radiating anterior to the chest. Recommended treatment with the following painkillers: Contramal 20 drops twice a day, and Lixidol 1 tablet a day”. An oncological evaluation of the surgical results was also requested, which was carried out on 03/2008, reporting as follows:
Diagnosis:lung neoplasia              Histotype:Adenocarcinoma
T 1 N 0 M 0
Stage IA                                                                     grading 1
                                                                                    In 0/5
Case history 
11/07: lung fine-needle aspiration. Histology test results: non-small cell lung cancer (NSCLC).
Chest CT scan: nodule with spiculate margins at the level of the lingula. Millimetric parenchymal nodules to the right suspected as secondary.
Brain CT scan (12/07): negative
PET scan (06/12/07): pathological hypercaptation of the lingula (max. SUV 6.8)
01/2008: left lingular segmental resection. Histology test results: mixed acinar and non-mucinous bronchoalveolar adenocarcinoma of the lung.
Chest X-Ray (06/03/2008): negative.
Co-morbidity
Arterial hypertension
PTCA + stent on left anterior descending coronary artery and circumflex artery
Diverticular disease of the colon
Radical hysteroannessiectomy performed 28 years ago.
Therapy
No instruction to carry out any specific oncological therapy.
The patient currently keeps to the following home treatment:
Blopresid 1 tablet
Cardura 2 mg 1 tablet
Cardioaspirin 100 mg 1 tablet
Losec 20 mg 1 tablet
Zyloric 300 mg 1 tablet.

Expert's Opinion

1)    Do you agree with the surgical treatment carried out?  
     Yes, I agree with the surgical approach.
It is true that her chest CAT scan revealed millimetre parenchymal nodules suspected as secondary in the ventral segment of the upper right lobe, in the segments of the basal pyramid of the upper right lobe and lower left lobe. However, so far as the chest CAT was not conclusive and the pathological accumulation by PET SCAN was limited to the level of the lingula, I approve the benefit of doubt that she was given with a calculated risk in favour of surgery. I hope that the successful removal of the primary tumour with free margins and with all examined lymph nodes being negative, will prove to represent a radical and curative operation. This is the only treatment modality which offers significant chances for cure from a Non Small Cell Carcinoma of the lung. It is therefore a pleasure to confirm that Mrs. X successfully underwent that procedure in spite of her cardiac co-morbidity.
 
2) Would you consider any further oncological therapies such as chemotherapy or radiotherapy to be of use?
No, I would not suggest any further oncological therapies such as chemotherapy or radiotherapy.
a. Radiotherapy is not indicated since the tumour has been removed with free margins.
b. Adjuvant chemotherapy is currently advised for non small cell lung cancers solely in stage >II, while the present case had a pathological stage limited to Ia.
 
3)   What is the expected prognosis?
The expected prognosis in the case of Mrs. X should be considered in view of several / different factors:
    a. The stage was Ia. This is consistent with above 60% 5yr survival following surgery.
    b. The grade was I (well differentiated), thus in the best level among patients in the above mentioned stage.
    c. The histologic type was mixed acinar bronchoalveolar adenocarcinoma of the lung. This is a relatively rare subtype within the adenocarcinoma group. Although there are no pure series of this subtype to rely upon for defining its specific clinical characteristics, and it is probably not as good as that of the pure brochoalveolar type, it still seems to promise a better prognosis then that of mucinous type adenocarcinomas.
 
Taken together, the three prognostic factors in the case of Mrs. X seem to offer a good prognosis following surgery.
 
           Note: The preoperative CAT scan revealed millimetric parenchymal nodules suspected as secondary in the ventral segment of the upper right lobe, in the segments of the basal pyramid of the upper right lobe and lower left lobe. These could be true tiny metastases consistent with the clinical behaviour characteristic to adenocarcinomas of the lung. They could have been "missed" by the PET/FDG being too small and with low metabolic activity, thus below the detection capacity of the test. Therefore this patient should be re-evaluated by CAT scans. I hope no metastases will be eventually proven. However, in case of disease activity the prognosis would be dictated by the natural behaviour of the disease which can be very much indolent. In addition, her prognosis could probably be further improved by administration of the TKI erlotinib if and when the disease becomes symptomatic, especially so if she has not been a smoker.

 

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