Imaging Considerations for the Diagnosis and Management of Bronchioloalveolar Carcinoma. Sara Alcorn, HMS-4 Dr. Gillian Lieberman March 2010

Transcription

1 Imaging Considerations for the Diagnosis and Management of Bronchioloalveolar Carcinoma Sara Alcorn, HMS-4 Dr. Gillian Lieberman March 2010

2 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

3 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

4 Our Patient: History of Present Illness 81 year old female with a history of CAD, admitted to BIDMC 12/09/09 for anterior STEMI Underwent cardiac catheterization for 3-vessel disease Was found to be hypoxic following this procedure, prompting imaging

5 Our Patient: Review of Systems ROS positive for: 2 months of chronic cough productive of white sputum, refractory to treatment with courses of Ciprofloxacin and Azithromycin 20 pound unintentional weight loss over 3 months Otherwise negative, including no fevers, night sweats, hemoptysis, changes to bowel habits, sick contacts, or recent travel

6 Our Patient: Additional Background PMH: CAD s/p MI and CABG in 1978 Small CVA in 12/2008 Meds: clopidogrel, simvastatin Family history: Mother with h/o colorectal cancer and bone cancer Social history: Married, retired. Independent in ADLs Habits: ~60 pack-years of tobacco. Quit in 2008.

7 Our Patient: Physical Exam Vital signs: HR: 77, BP: 101/46, RR: 16, T: 98.8, O2 Sat: 91% on 4L at rest General: Looks younger than stated age. In NAD. Chest: Decreased breath sounds at right lung base, with crackles extending to mid-right lung field Cardiac, abdominal, extremities, and neurological exams within normal limits

8 Our Patient: Hypoxia Work Up Labs CBC and complete metabolic panel within normal limits ABG with respiratory acidosis and hypoxemia CXR ordered CXR from 1 year prior to presentation reviewed Performed in the setting of productive cough

9 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

10 Our Patient: Chest CXR from One Year Prior to Presentation Upright PA and lateral chest X-ray From PACS, BIDMC

11 Please evaluate our patient s CXR from one year prior to presentation for abnormalities.

12 Our Patient: CXR with RLL Opacity Upright PA and lateral chest X-ray read as RLL opacity consistent with pneumonia. From PACS, BIDMC

13 Our Patient: CXR at Presentation Supine AP chest X-ray From PACS, BIDMC

14 Please evaluate our patient s CXR at presentation for abnormalities.

15 Our Patient: CXR with Basilar Opacity Supine AP CXR read as: New right basilar opacity as compared with 1 year prior Consistent with PNA No other focal opacities suggestive of infection identified at the time From PACS, BIDMC

16 Given the findings of persistent RLL on CXR from (a) one year prior and (b) at the time of presentation, a chest CT was performed.

17 Our Patient: Anatomic Landmarks Right major fissure on Chest CT Left major fissure Axial C- Chest CT (lung window) From PACS, BIDMC

18 Our Patient: Multiple Nodules and Multiple nodules in LUL, LLL, RML, and RLL Ground Glass Opacities Varying sizes from 1-4 mm Associated ground glass opacities (GGO): Hazy increased lung opacity with preservation of underlying bronchial and vascular margins Axial C- Chest CT (lung window) From PACS, BIDMC

19 Our Patient: Multiple Nodules, GGO, and Consolidation Moving inferiorly on CT: Multiple nodules and GGO, especially in RML Consolidation in RLL Axial C- Chest CT (lung window) From PACS, BIDMC

20 Continuing to move inferiorly on CT: Our Patient: Dense RLL Consolidation Dense consolidation of RLL with absence of aerated lung Air bronchograms: Low attenuation, air-filled bronchi in the setting of a higher attenuation background Suggest evacuation or replacement of alveolar air Axial C- Chest CT (lung window) From PACS, BIDMC

21 Our Patient: Aerated Portion of RLL What is this aerated space on our patient s chest CT? Axial C- Chest CT, Lung Window From PACS, BIDMC

22 To clarify what comprises the aerated lung space on axial CT, let s compare this with the corresponding coronal CT view and with CXR

23 Our Patient: Comparing Aerated Lung Space on Axial and Coronal CT Axial C- Chest CT (lung window) Coronal C- Chest CT (lung window) From PACS, BIDMC

24 Our Patient: Comparing Aerated Lung Space on CT and CXR Coronal C- Chest CT (lung window) at presentation Supine AP CXR, 4 days after presentation From PACS, BIDMC

25 Unknown Aerated Space in RLL: Conclusions from CT and CXR Comparisons Sharp borders between the consolidated and aerated spaces suggest that the consolidation follows an anatomic border. To further understand the involved and uninvolved spaces of the RLL, let s review the segmental anatomy of the RLL

26 RLL Segmental Anatomy The 5 segments of the RLL follow branching of the RLL bronchus Superior (S) Anterior basal (AB) Lateral basal (LB) Posterior basal (PB) Medial basal (MB) Adapted from:

27 Our Patient: Aerated Space in RLL Identified RUL bronchus Bronchus intermedius RML Anterior basal segmental bronchus in the anterior basal lung segment Coronal C- Chest CT (lung window) From PACS, BIDMC MEDIAL BASAL LUNG SEGMENT

28 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

29 Differential Diagnostic Dilemma Are the radiologic findings of both consolidation and multiple nodules consistent with: One unifying diagnosis? Two or more concurrent processes leading to the mixed radiologic picture?

30 Differential Diagnosis: Multiple Pulmonary Nodules Neoplasm Primary lung Metastases (breast, colon) Disseminated mycoses Septic emboli Sarcoidosis Mycobacterial disease

31 Narrowed Ddx for Multiple Pulmonary Nodules In Our Patient Large number of nodules in close proximity, with sparing of intervening parenchyma Makes inflammatory etiologies (mycoses, sarcoid) that would cause destruction and/or infiltration of surrounding parenchyma less likely Makes neoplasm more likely Lack of systemic signs of infection Makes extensive septic embolic disease and infection less likely

32 Differential Diagnosis: Lobar Consolidation Infection Edema Pulmonary hemorrhage Atelectasis Tumor

33 Narrowed Ddx for Consolidations in Our Patient Probable long-standing consolidation Lipoid PNA Chronic aspiration Pseudolymphoma (lymphoid hyperplasia) Bronchioloalveolar carcinoma

34 Our Patient: Presumed Diagnosis Sputum cytology positive for adenocarcinoma Specific tumor markers initially pending Tissue sample not possible to obtain due to: Ongoing anticoagulation therapy Low respiratory performance status Pending specific identification of etiology, chemotherapy with premetrexed started Based on radiologic appearance of presumed cause: bronchioloalveolar carcinoma

35 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

36 Bronchioloalveolar Carcinoma (BAC): General Information Histology Subtype of adenocarcinoma Mucinous and non-mucinous histologies Spreads mainly though lepidic growth (using lung architecture as stroma) without destruction of underlying structure Epidemiology Up to 7% of all primary lung neoplasms 25-50% of patients with a history tobacco use Clinical features Often incidentally diagnosed and asymptomatic Symptoms: cough, sputum, SOB, weight loss, fever, bronchorrhea

37 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

38 Roles of Radiology in Diagnosis and Management of BAC To characterize the disease Unique radiologic findings of BAC Exclusion of other etiologies To identify patterns that correlate with specific BAC histologies (and thus prognosis) To further help establish prognosis and treatment by determining extent of disease To monitor treatment response

39 First, let s discuss the radiologic characteristics that help identify BAC

40 Radiologic Patterns of BAC Single nodule, part-nodule, mass, or ground glass opacity (GGO) 43% of cases Multifocal or diffuse 27% of cases Focal consolidation 30% of cases

41 Companion Patient 1: BAC as a Solitary Nodule or Mass Solid nodule or mass Usually peripheral May be lobulated or illmarginated Axial C+ Chest CT (lung window) From PACS, BIDMC May have heterogeneous CT attenuation, CT pseudocavitation, and/or air bronchograms

42 Companion Patient 2: BAC as Focal GGO Focal isolated GGO Especially with heterogeneous attenuation Axial C+ Chest CT (lung window) From PACS, BIDMC Can also be a partnodule: Partly solid opacity with an associated area of GGO

43 Pathophysiology of CT Features in Nodular BAC Heterogeneous attenuation of nodules, masses and GGO Due to non-destructive lepidic growth of tumors along alveolar walls without disruption of the underlying architecture Small patent airways or alveolar spaces left Pseudocavitations and bubble -like areas of low attenuation Favors BAC versus other causes of nodules and/or GGO Air bronchograms: Due to filling of alveoli adjacent to patent bronchi with tumor and mucin GGO: Due to lepidic growth pattern of malignant cells and/or mucin production

44 Our Patient: BAC as Multiple Multiple nodules of varying size Nodules Seen bilaterally With and without GGO Associated with lymphatic spread Axial C- Chest CT (lung window) From PACS, BIDMC

45 Our Patient: Consolidative (Pneumonic) BAC Filling of the airspace with mucus Low-attenuation consolidation on CT due to mucin content Air bronchograms CT angiogram sign on C+ images: Clearer visibility of vessels due to low attenuation of surrounding tumor Axial C+ Chest CT (bone window) From PACS, BIDMC Delayed diagnosis common due to radiologic similarity to pneumonia

46 Our Patient: Consolidative BAC CT changes of the airfilled bronchus in a consolidation that favor BAC to PNA: Stretching Squeezing Sweeping Widening of the branching angle versus PNA BAC is more chronic and with fewer systemic symptoms of infection Axial C- Chest CT (lung window) From PACS, BIDMC

47 Next, let s discuss how radiologic findings correlate with histology and prognosis in BAC

48 Radiologic Findings, Histology, and Prognosis in BAC Radiologic pattern Typical histology 5-year survival s/p resection <1 cm pure GGO or part nodule Non-mucinous 100% <1 cm solid nodule Non-mucinous 94% Multifocal Mucinous 40% Consolidative Mucinous 0%

49 Last, let s discuss radiologic considerations for staging BAC

50 TNM Staging in Lung Cancer: Imaging considerations Assessing tumor size (T) Look for involvement of the main bronchus, pleura, hilum, chest wall, diaphragm, pericardium vertebral bodies, mediastinum Assessing lymph nodes (N) Look for peribronchial, ipsilateral hilar, mediastinal, subarcinal nodes Consider ipsilateral versus contralateral involvement Assessing distant metastases (M) Consider whole body CT and/or PET

51 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

52 Our Patient: Diagnosis and Prognosis BAC confirmed with specific tumor markers General prognosis for BAC with multifocal and consolidative features: Almost 0% survival at 5 years However, she is responding well after 4 courses of chemotherapy.

53 Our Patient: CT after 4 Cycles of Chemotherapy Fewer nodules and GGO in RML Decreased extent of consolidation and more aerated space in RLL Axial C- Chest CT (lung window), at presentation From PACS, BIDMC Axial C+ Chest CT (lung window), after 4 cycles of chemotherapy

54 Overview Presentation of index patient History of present illness Radiologic findings Review of differential diagnoses Discussion of bronchioloalveolar carcinoma General information Roles of radiology in diagnosis and management Follow-up of index patient Summary

55 Summary Radiologic findings of BAC Patterns of growth Non-resolving singular nodule, mass or ground glass opacity Multiple nodules or masses Consolidations Heterogeneous attenuation on CT, with CT-angiogram sign, pseudocavitations, and air bronchograms Radiologic findings have implications for diagnosis, staging, prognosis, and treatment

56 Acknowledgements Dr. Paul Spirn Dr. Ammar Sarwar Dr. Prachi Dubey Dr. Gillian Lieberman Maria Levantakis

57 Select references Akira M, Atagi S, Kawahara M, et al High resolution CT findings of diffuse bronchioloalveolar carcinoma in 38 patients. Am J Roentgenol. 172 (6): Hansell DM, Bankier AA, MacMahon H, et al Fleischner Society: Glossary of terms for thoracic imaging. Radiology. 246: Jung, JI, Kim H, Park SH, et al CT differentiation of pneumonic-type bronchioloalveolar cell carcinoma and infectious pneumonia. Br J Radiol. 74: Lee KS, Kim Y, Ko EJ, et al Bronchioloalveolar carcinoma: clinical, histopathologic, and radiologic findings. RadioGraphics. 17: Lung Segments. Korea Critical Care. Accessed 3/15/10. Available online at: Maldonado RL The CT angiogram sign. Radiology. 210: Mirtcheva RM, Vazquez M, Yankelevitz, DF, Henschke CI Bronchioloalveolar carcinoma and adenocarcinoma with bronchioloalveolar features presenting as groundglass opacities on CT. Clin Imgaing. 26 (2) Patsios D, Roberts HC, Paul NS, et. al Pictorial review of the many faces of bronchioloalveolar cell carcinoma. Br J Radiol. 80 (960): Travis ED, Garg K, Franklin WA, et al Evolving concepts in the pathology and CT imaging of lung adenocarcinoma and bronchioloalveolar carcinoma. J of Clin Onc. 23 (14):