A case of bronchiolo-alveolar carcinoma presenting as miliary mottling.
CASE REPORT: A 62 year old non addict male farmer by occupation presented to the emergency with complaints of progressively increasing breathlessness over three months. It had progressed to difficulty in speaking sentences at the time of presentation. He had low grade fever and also complained of continuous hacking cough that was non-productive. On examination, he was afebrile with a respiratory rate of 48/min, pulse rate 140/min and blood pressure was 130/80 mm of mercury. On general examination, patient had a single supra-clavicular lymph node measuring 3x2x1 cm. On auscultation he had bilateral crackles. The patient's baseline oxygen saturation was 60% on room air, which improved to 90% on Fi02 of 60% with venturi mask.
A chest radiograph was done prior to his visit to our hospital which showed bilateral extensive nodular shadows in both the lung fields with dense distribution in the hilar areas. (FIG 1) The previous hospital had started the patient on anti-tuberculosis treatment based on the chest radiograph and clinical findings for one month. At our hospital, induced sputum was negative for Acid Fast Bacilli.
CT thorax and CT abdomen with contrast was done for further evaluation of the patient CT thorax showed bilateral extensive nodular shadows in both lung fields with interlobular septal thickening. Three differential diagnoses were given by the radiologist-l) Acute respiratory distress syndrome 2) Bronchiolo-Alveolar carcinoma with lymphangitis carcinomatosa 3) Extensive pulmonary tuberculosis (FIG 2, 3). CT abdomen did not show any abnormality.
Fine needle aspiration of the lymph node was done. Cytology was suggestive of metastasis from the epithelial malignancy. Later a lymph node biopsy was done. Histopathological evaluation showed metastases from Bronchiolo-Alveolar carcinoma-non mucinous type. (FIG. 4). Immunohistochemistry on lymph node biopsy was positive for Thyroid Transcription Factor 1 (FIG 5) and cytokeratin 7 (FIG. 6).
Based on these investigations a diagnosis of bronchiolo-alveolar cell carcinoma, nonmucinous type was made. In view of poor performance status and stage IV malignancy it was decided by the Oncologist to give the patient a trial of Gefitinib, a tyrosine kinase inhibitor. Patient has been on treatment for 4 months now and is able to perform daily activities and maintains a saturation of 93% on room air.
DISCUSSION: Bronchiolo-Alveolar carcinoma, now termed as lepidic predominant adenocarcinoma is a slow growing malignancy which can have varied presentations. The diagnosis of bronchioloalveolar carcinoma can often pose a challenge to physicians. Due to its slow growth and subtle symptomatology, diagnosis is often delayed. It is important to maintain a high index of suspicion to diagnose bronchiolo-alveolar carcinoma as early as possible. Bronchiolo-alveolar carcinoma is known to present with widely varying patterns on Computed Tomography (CT) such as (i) bubblelike lucencies of pseudocavitation associated with nodules of varying density, (ii) unifocal or multifocal ground-glass opacities, (iii) crazy paving, (iv) nodules and airspace opacities with unaffected vessels coursing through them and (v) lobar or multilobar consolidation and cavitating nodules, (vi) solitary or multiple pulmonary nodules, with and without air bronchograms. Isolated cases of BAC masquerading as tuberculosis have been reported in the literature previously also., The nodules of BAC often have a centrilobular or bronchocentric location. While bronchogenic spread of tuberculosis can mimic multinodular BAC, miliary tuberculosis usually has a more random distribution of nodules.,
In our case, the patient presented with severe hypoxemic respiratory failure and chest X-ray and CT chest showed miliary mottling without any evidence of a primary lung mass. We arrived at the diagnosis of bronchiolo-alveolar cell carcinoma by histopathology and immunohistochemistry done on lymph node biopsy. Diffuse and multi-centric growth pattern is a prominent feature of mucinous tumor, however it can also be seen in the non- mucinous type as seen in this case. 7 Significantly, this patient with stage IV lung malignancy responded dramatically to tyrosine kinase inhibitor and was able to pursue his activities of daily living after discharge.
CONCLUSION: In countries with a high prevalence of tuberculosis, it is not uncommon to start patients on anti- tuberculosis treatment based on chest X-ray findings alone. However, the rising prevalence of lung cancer and recent advances in its treatment point towards a need to diagnose lung cancer as early as possible.
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1. Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y et al. International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J ThoracOncol. 2011;6(2):244-85.
2. Patsios D, Roberts HC, Paul NS, Chung T, Herman SJ, Pereira A et al. Pictorial review of the many faces of bronchioloalveolar cell carcinoma. Br J Radiol. 2007;80:1015-23.
3. S. R. S Mandrekar, R .G. W Pinto, J .A Vernekar. Bronchioloalveolar Carcinoma Mimicking Tuberculosis-A Case Report With Autopsy Findings. Lung India. 1995;13(4):114-6.
4. Chandrasekhar HR, Shashikala P, Murthy BN, Vidyasagar B, Rao HL.Bronchioloalveolar carcinoma mimicking miliary tuberculosis.J Assoc Physicians India. 2001;49:281-2.
5. Akira M, Atagi S, Kawahara M, Iuchi K, Johkoh T. High-resolution CT findings of diffuse bronchioloalveolar carcinoma in 38 patients. AJR Am Journal of Roentgenology. 1999;173: 1623-9.
6. Oh YW, Kim YH, Lee NJ, Kim JH, Chung KB, Suh WH, Yoo SW.High-resolution CT appearance of miliary tuberculosis. J Comput Assist Tomogr. 1994;18(6):862-6.
7. Travis WD, Garg K, Franklin WA et al. Evolving concepts in the pathology and computed tomography imaging of lung adenocarcinoma and bronchioloalveolar carcinoma. J Clin Oncol 2005;23:3279-87.
(1.) Pujari Vishwanath V.
(2.) Bhagwat Shraddha V.
(3.) Rajurkar Sourabh B.
(4.) Bhaskaran Divya
PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Pulmonary Medicine, BJ Government Medical College and Sassoon General Hospital, Pune.
2. Assistant Professor, Department of Pulmonary Medicine, BJ Government Medical College and Sassoon General Hospital, Pune.
3. Third Year Resident, Department of Pulmonary Medicine, BJ Government Medical College and Sassoon General Hospital, Pune.
4. Third Year Resident, Department of Pulmonary Medicine, BJ Government Medical College and Sassoon General Hospital, Pune.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Pujari Vishwanath V, Riddhi Siddhi Apartment, Opposite Vidyaniketan High School, Canara Bank Lane, Bibwewadi, Pune-411037. Email: email@example.com
Date of Submission: 18/07/2014.
Date of Peer Review: 19/07/2014.
Date of Acceptance: 30/07/2014.
Date of Publishing: 02/08/2014.
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|Title Annotation:||CASE REPORT|
|Author:||V., Pujari Vishwanath; V., Bhagwat Shraddha; B., Rajurkar Sourabh; Divya, Bhaskaran|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Article Type:||Clinical report|
|Date:||Aug 4, 2014|
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