Lung Cancer: Well differentiated mixed acinar and bronchoalveolar adenocarcinoma (BAC) of the lung (T1 N0).
Short summary
74-year-old women with thickening in the left lung. The tumor was typified as non-small cell lung cancer (NSCLC) with millimetric parenchymal nodules suspected as secondary. She underwent a lingular segmental resection.
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
74 year old female.
Arterial hypertension
Diverticular disease of the colon
Radical hysteroannessiectomy performed 27 years ago.
Patient recently (November 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 hospital in her city 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.
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 January, 2008, the patient 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 February 2008 and returned for a check-up with the chest surgical ward on February 2008. 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 March 2008, reporting as follows:
Diagnosis: lung neoplasia Histotype: Adenocarcinoma
T 1 N 0 M 0
Stage IA grading 1
In 0/5
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.
Medical 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 the patient 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 this case 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 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.
