|Year : 2019 | Volume
| Issue : 2 | Page : 66-69
Bronchioloalveolar Carcinoma: A Case Series
Saurabh Karmakar1, Ronal Naorem2, Mohd H.G Ansari2, Zafar Neyaz3, Hira Lal3, Alok Nath4
1 Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna, India
2 Department of Pulmonary Medicine, Era’s Lucknow Medical College & Hospital, Lucknow, Uttar Pradesh, India
3 Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||20-Jun-2019|
Dr. Saurabh Karmakar
Department of PulmonaryMedicine, All India Institute ofMedical Sciences, 3rd Floor,
New OPD Building, Phulwari Sharif, Patna 801507
Source of Support: None, Conflict of Interest: None
Bronchioloalveolar carcinoma (BAC) is a rare subtype of adenocarcinoma of lung with distinct features and distinctive characteristics. We present a case series of four patients of BAC who underwent evaluation for nonresolving pneumonia. All the patients were nonsmokers and ranged in age from 25 to 78 years. BAC was suspected because of characteristic clinicoradiological features, and the analysis of fine-needle aspiration biopsy specimen confirmed the diagnosis. Clinicians should be aware of this presentation of BAC, which would lead to early detection and improved outcome.
Keywords: Bronchioloalveolar carcinoma, case series, India, lung cancer
|How to cite this article:|
Karmakar S, Naorem R, Ansari MH, Neyaz Z, Lal H, Nath A. Bronchioloalveolar Carcinoma: A Case Series. J Assoc Chest Physicians 2019;7:66-9
| Introduction|| |
Bronchioloalveolar carcinoma (BAC) is an uncommon subset of lung adenocarcinoma that develops from terminal bronchiolar and acinar epithelia of the lung. BAC typically arises in the periphery of the lung and grows along alveolar walls, without destruction of the underlying parenchyma and without vascular and pleural invasion. It is characterized by unique epidemiology, clinical features, radiological presentation, and cytological characteristics. BAC has long intrigued physicians and oncologists. As BAC becomes a more recognized entity within the pathological continuum of adenocarcinoma, several controversies have emerged regarding this tumor. BAC can serve as a paradigm for understanding lung cancer. Herein, we present four patients from our institution with BAC, and we perform a review of literature of this subtype of lung cancer.
| Case Series|| |
A 70-year-old hypertensive female presented with complaints of cough off and on for 3 months associated with bronchorrhea, loss of appetite since 2 months, and dyspnea on exertion since 1 month. She had a pulse rate of 88/min, respiratory rate of 18/min, and oxygen saturation of 96% in room air. Posteroanterior (PA) view of the chest X-ray [Figure 1] showed dense opacity in the right lower zone. Contrast-enhanced computed tomography (CECT) thorax [Figure 2] showed diffuse ground-glass opacities around nodules and consolidation involving the apical and basal segments of the right lower lobe.
|Figure 1 PA of the chest X-ray showing dense opacity in right lower zone|
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|Figure 2 CECT thorax showing diffuse ground-glass opacities around nodules and consolidation involving the apical and basal segments of right lower lobe|
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A 45-year-old male presented with complaints of cough off and on for 1 year with bronchorrhea since 9 months, hemoptysis off and on, and progressively worsening dyspnea since 6 months. He had a pulse rate of 106/min, respiratory rate of 24/min, and oxygen saturation of 82% in room air. Posteroanterior (PA) view of the chest X-ray [Figure 3] showed dense consolidation of bilateral (right < left) middle and lower zones with nodules and relative sparing of upper zones. CECT thorax [Figure 4] showed bilateral upper lobe centrilobular nodules, with bilateral consolidation with air bronchogram (right lower lobe, basal segment was relatively spared), and ground glassing around nodules.
|Figure 3 PA view of the chest X-ray showing dense consolidation of bilateral (right < left) middle and lower zones with nodules and relative sparing of upper zones|
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|Figure 4 CECT thorax showing bilateral upper lobe centrilobular nodules, with bilateral consolidation with air bronchogram (right lower lobe, basal segment was relatively spared) and ground glassing around nodules|
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A 42-year-old male presented with complaints of cough off and on for 4 months with bronchorrhea since 3 months and progressively worsening dyspnea and chest pain since 2 months. He had pulse rate of 96/min, respiratory rate of 18/min, and oxygen saturation of 86% in room air. Posteroanterior (PA) view of the chest X-ray [Figure 5] showed bilateral consolidation with relative sparing of right upper zone. CECT thorax [Figure 6] showed bilateral dense consolidation with relative sparing of right upper lobe and nodular opacities in the right upper lobe.
|Figure 5 PA view of the chest X-ray showed bilateral consolidation with relative sparing of right upper zone|
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|Figure 6 CECT thorax showing bilateral dense consolidation with relative sparing of right upper lobe and nodular opacities in the right upper lobe|
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A 68-year-old male presented with complaints of cough off and on since 6 months with bronchorrhea since 4 months and chest pain since 3 months. He had a pulse rate of 96/min, respiratory rate of 24/min, and oxygen saturation of 96% in room air. CECT thorax [Figure 7] showed consolidation of the anterior segment of left upper lobe and apical segment of the left lower lobe and nodular opacities in the right upper lobe and apical segment of the left lower lobe.
|Figure 7 CECT thorax showed consolidation of the anterior segment of left upper lobe and apical segment of left lower lobe and nodular opacities in the right upper lobe apical segment of left lower lobe Posteroanterior view of the chest X-ray|
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All the patients were afebrile and hemodynamically stable. All were never smokers and did not have any comorbidity or any significant personal or past history. Case 1 was treated with a course of antibiotics by a local practitioner. Cases 2, 3, and 4 were prescribed antituberculosis therapy by doctors treating them previously and were referred due to progressive worsening. Sputum smear was negative for acid fast bacilli and fungal hyphae in all the patients. As India is a high tuberculosis burden country, to rule out smear negative pulmonary tuberculosis, fiber-optic bronchoscopy for bronchoalveolar lavage (BAL) was performed. To achieve a greater sensitivity and for early results, BAL fluid was subjected to cartridge-based nucleic acid analysis test (CBNAAT). CBNAAT did not yield Mycobacterium tuberculosis in all the patients. We did a CT-guided fine-needle aspiration biopsy (FNAB) from the areas of dense consolidation. A 20-gauge quick core biopsy needle set manufactured by Cook, Bloomington, Indiana, USA, with a 19-gauge coaxial needle, was used for the procedure. No complication occurred in any of the patients. Histopathology of the biopsy samples in the patients revealed tall columnar cells with bland, basally located nuclei, and abundant apical cytoplasmic mucin, and the cells lined the alveoli in a continuous fashion. There was an abrupt transition between the tumor cells and the uninvolved alveoli. There was no stromal, vascular, or pleural invasion. The underlying pulmonary architecture was preserved and no invasive component was seen. On immunohistochemistry (IHC), the cells stained positive for cytokeratin 7 (CK7) and CK20, and negative for thyroid transcription factor-1. We diagnosed the patients as the cases of mucinous BAC and referred them to the Department of Medical Oncology for further management.
| Discussion|| |
Worldwide, lung cancer is the most common malignancy and the most common cause of cancer deaths. Generally, lung cancer is divided into small-cell lung cancer and nonsmall-cell lung cancer (NSCLC). Adenocarcinoma is the most common type of NSCLC, and its incidence is increasing worldwide. The major subtypes of adenocarcinoma are acinar, papillary, bronchioloalveolar, and solid adenocarcinoma with mucin production. BAC, as a subtype, represents only 2% to 3% of all NSCLCs and less than 6.5% of all primary lung neoplasms. However, the incidence of BAC has been steadily increasing over the past decades. This rare subtype of NSCLC is more common in never smokers, females, and Asian ethnicity patients, and will thus impose a disproportionate burden on them in the coming years. In addition, BAC poses issues among researchers, pathologists, and clinicians regarding the definition and classification.
Most of the patients of BAC are between 40 and 70 years of age, as in our series.
The histological subclassification and diagnostic criteria for BAC have changed significantly in the WHO classification of lung tumors of 2015 as compared to 1999 and 2004. The 1999 and 2004 WHO histological classification of lung tumors classified BAC into mucinous, nonmucinous, and indeterminate or mixed. Diagnostic criteria were defined in 1999 and 2004 as adenocarcinoma showing “growth of neoplastic cells along pre-existing alveolar structures (lepidic growth), without evidence of stromal, vascular or pleural invasion.”, The 2015 WHO classification discontinued BAC and classified former BAC into adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), lepidic predominant adenocarcinoma (LPA), adenocarcinoma predominantly invasive with some nonmucinous lepidic component, and invasive mucinous adenocarcinoma (formerly mucinous BAC). AIS represent ≤3 cm solitary adenocarcinomas with pure lepidic growth and are subdivided into mucinous and nonmucinous variants. MIA are ≤3 cm solitary adenocarcinomas with predominant lepidic growth and small foci of invasion measuring ≤0.5 cm, usually nonmucinous. Adenocarcinoma predominantly invasive with some nonmucinous lepidic component is intermediate prognostic group. The term LPA is recommended for the formerly subtype mixed BAC wherein the predominant subtype comprises nonmucinous BAC. Formerly described mucinous BAC are currently classified as mucinous AIS, mucinous MIA, or invasive mucinous adenocarcinoma depending on the extent of the lepidic versus invasive growth.The clinical relevance of the latest WHO classification is limited to patients with resectable disease. The majority of patients with lung cancer have advanced disease, for which biopsy remains the method of sampling. Using conventional criteria, a diagnosis of BAC by FNAB is possible. It is hereby evident in our case series that the presence of progressive, widespread air-space consolidation, bronchorrhea, and biopsy demonstrating mucin-secreting carcinoma cells without evidence of invasion and with IHC led to the diagnosis of bronchoalveolar carcinoma.
To the best of our knowledge, this is the first case series of BAC that we have reported from India and summarized the current concepts regarding this subtype of lung cancer. As clinical experience will build up with BAC in our country, surveillance epidemiology and end results studies will shed further light on this subtype of lung cancer.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]