Japanese Journal of Clinical Oncology 31:35-38 (2001)
© 2001 Foundation for Promotion of Cancer Research
A 7 mm Lung Adenocarcinoma with Mediastinal Involvement and Lymphangiosis Carcinomatosa: A Case Report
1Division of Thoracic Oncology, National Cancer Center Hospital East, Kashiwa, Chiba and 2Pathology Division, National Cancer Center Research Institute East, Kashiwa, Chiba, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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We report a case of a 46-year-old man with a 7 mm lung adenocarcinoma with mediastinal nodal involvement and lymphangiosis carcinomatosa. The resected right middle lobe contained a 7 mm well-differentiated papillary adenocarcinoma and lymphatic vessels towards the hilum were severely involved. The disease was pathologically diagnosed as T1N2M0. Six months after the operation, malignant pleural effusion and multiple bone metastases developed and he died 21 months after the operation. This case indicates that even a very small-sized lung cancer, 1 cm or smaller, could be biologically highly malignant.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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In Japan, with the introduction of computed tomography (CT) in lung cancer screening programs, small-sized peripheral lung cancers have increasingly been found (1,2). Most of these cases result in a good prognosis following surgical resection (2). However, there are rare cases with poor prognosis. In this paper, we describe a rare case of a 7 mm lung cancer with mediastinal involvement and lymphangiosis carcinomatosa.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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A 46-year-old man had been suffering from fever and frequent cough for 2 weeks and was admitted to a community hospital in September 1996. A chest roentgenogram showed an infiltrative shadow in the right lung field, which was diagnosed as pneumonia, and antibiotic treatment was initiated. After his pneumonia improved, an abnormal small nodular shadow in the right lung field was detected on a chest roentgenogram. He was referred to our institute for further examinations in November 1996.
Past and family histories were unremarkable. He reported smoking 20 cigarettes per day for the past 20 years. Physical examination revealed no abnormalities and no lymphadenopathy. Routine laboratory tests yielded no abnormal results. A chest roentgenogram showed an ill-defined tumor, 7 mm in diameter, in the right middle lung field. Conventional CT and high-resolution CT at 2 mm section intervals revealed an ill-circumscribed consolidated tumor, 7 mm in diameter, in the right middle lobe (Fig. 1). The tumor had an irregular surface, spicula formation, vascular convergence and pleural indentation. These features were suggestive of malignancy. CT-guided aspiration biopsy failed to obtain sufficient histological material.
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On January 17, 1997, we performed video-assisted thoracoscopic surgery to obtain a definitive diagnosis of the tumor. There was neither pleural effusion nor adhesion in the right thorax. Part of the middle lobe including the tumor was resected and immediate frozen section revealed adenocarcinoma of the lung. We proceeded to perform right middle lobectomy and mediastinal node dissection. There was no lymphadenopathy in the pulmonary hilum or mediastinum.
Macroscopically, the tumor was gray–whitish in color, ill-circumscribed with pleural indentations and measured 7 x 6 mm. Microscopically, it was composed of atypical epithelial cells growing in a papillary pattern arranged in a single layer along the thickened alveolar septa (Fig. 2). Cytologically, the tumor cells showed striking nuclear pleomorphism with marked nuclear atypia (Fig. 3). Fibrotic scar formation was observed in the center. Histological examination revealed well differentiated papillary adenocarcinoma. Lymphatic vessels toward the hilum were severely involved (Fig. 4) and lymphangiosis carcinomatosa was diagnosed. A pretracheal lymph node was also involved. The disease was pathologically diagnosed as T1N2M0 (3).
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The postoperative course was uneventful. He was discharged on the fourteenth postoperative day. Six months after the operation, pleural effusion in the right thorax and multiple bone metastases developed. Pleural effusion drainage and topical bone irradiation palliated his symptoms. He died on October 1, 1998. His family refused an autopsy.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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With the introduction of CT to mass screening for lung cancer, patients with a peripheral small-sized lung cancer have been increasingly identified in Japan (1,2). Most of these cases result in a good outcome following surgical resection (2). However, there are rare cases with a poor outcome even in this cohort. We have described here a very small-sized lung cancer with a dismal outcome. Even though the tumor was only 7 mm in diameter, severe lymphatic permeation and mediastinal lymph node involvement were observed. He died 21 months after surgical intervention.
Nodal involvement is known to be a strongly poor prognostic factor in resected lung cancer patients (4,5). The incidence of lymph node involvement in clinically N0 non-small cell lung cancers 3 cm or smaller has been reported to be 21–30% (6–8). Even in tumors 2, 1.5 and 1 cm or smaller, the incidence of nodal involvement has been reported as 15–20% (7–9), 14% (10) and 0% (10), respectively. Although the incidence of lymph node involvement appears to decrease with decreasing tumor size, physicians should note that even a very small-sized lung cancer can involve mediastinal nodes.
Vascular invasion by the primary tumor has also been reported to be a poor prognostic factor for lung cancer patients (11,12), even in node-negative diseases (13). Shimosato et al. (14) first reported the central fibrotic focus as a prognostic factor in peripheral adenocarcinoma patients. They also indicated that the grade of central fibrosis was related to the degree of vascular invasion and lymph node involvement. Kurokawa et al. (15) and Noguchi et al. (16) confirmed that the grade of central fibrosis is one of the most important prognostic factors in small adenocarcinomas. Noguchi et al. (16) classified small peripheral adenocarcinomas into six categories and concluded that type A (localized bronchioloalveolar carcinoma) (LBAC) and type B (LBAC with foci of structural collapse of alveoli) tumors were in situ carcinomas whereas type C (LBAC with foci of active fibroblastic proliferation]) appeared to be an advanced stage of types A and B. Yoshida et al. (17) reported that five of 10 peripheral adenocarcinomas 1 cm or smaller showed an invasive nature. These reports indicate that even a very small-sized lung cancer could be biologically highly malignant.
In our case, even though the tumor was only 7 mm in diameter, severe lymphatic permeation and mediastinal lymph node involvement were noted. Histologically, the tumor was characterized not only by a bronchioloalveolar component in the form of single layer of atypical epithelial cells along the thickened alveolar septa, but also by a papillary component. The papillary component was predominantly continuous with the central fibrosis and the papillary component had invaded the lymphatic vessels. Silver et al. (18) reported a higher incidence of nodal involvement and lymphatic permeation in adenocarcinomas with the morphological features of papillary structures than without such features and they suggested that the natural history of adenocarcinomas with these features is different from that reported for similar-stage solitary bronchioloalveolar carcinomas. Yokose et al. (19) confirmed that the tumors with a papillary growth component >25% have an unfavorable outcome. The histological findings in this case closely reflected the characteristics reported.
In conclusion, we have described a rare case of a 7 mm lung cancer with mediastinal involvement, lymphangiosis carcinomatosa and a dismal outcome. Although we do not have accurate methods to predict the detailed prognosis of a lung cancer patient, especially in those with very small tumors, this case indicated that the tumor size alone cannot be a predictor of prognosis. It is therefore necessary to establish predictors of prognosis using diagnositc modalities, such as high-resolution CT scans. In the future, molecular and genetic analysis of preoperative histological specimens may provide more precise predictive information (20,21).
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Acknowledgment |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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This work was supported in part by a Grant-in-Aid (No. P11-19) for Cancer Research from the Ministry of Health and Welfare, Japan.
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FOOTNOTES |
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+ For reprints and all correspondence: Hidenori Kawasaki, Division of Thoracic Surgery, National Okinawa Hospital, 3–20–14, Ganeko, Ginowann, Okinawa 901-2214, Japan. E-mail: hkawasak@sub-tky.hosp. go.jp
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REFERENCES |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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Received July 24, 2000; accepted October 31, 2000.
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