Imaging Considerations for the Diagnosis and Management of Bronchioloalveolar Carcinoma Sara Alcorn, HMS-4 Dr. Gillian Lieberman March 2010
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
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
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
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
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.
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
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
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
Our Patient: Chest CXR from One Year Prior to Presentation Upright PA and lateral chest X-ray From PACS, BIDMC
Please evaluate our patient s CXR from one year prior to presentation for abnormalities.
Our Patient: CXR with RLL Opacity Upright PA and lateral chest X-ray read as RLL opacity consistent with pneumonia. From PACS, BIDMC
Our Patient: CXR at Presentation Supine AP chest X-ray From PACS, BIDMC
Please evaluate our patient s CXR at presentation for abnormalities.
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
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.
Our Patient: Anatomic Landmarks Right major fissure on Chest CT Left major fissure Axial C- Chest CT (lung window) From PACS, BIDMC
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
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
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
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
To clarify what comprises the aerated lung space on axial CT, let s compare this with the corresponding coronal CT view and with CXR
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
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
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
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: http://koreacritcare.com/www/lung_segment.jpg
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
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
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?
Differential Diagnosis: Multiple Pulmonary Nodules Neoplasm Primary lung Metastases (breast, colon) Disseminated mycoses Septic emboli Sarcoidosis Mycobacterial disease
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
Differential Diagnosis: Lobar Consolidation Infection Edema Pulmonary hemorrhage Atelectasis Tumor
Narrowed Ddx for Consolidations in Our Patient Probable long-standing consolidation Lipoid PNA Chronic aspiration Pseudolymphoma (lymphoid hyperplasia) Bronchioloalveolar carcinoma
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
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
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
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
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
First, let s discuss the radiologic characteristics that help identify BAC
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
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
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
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
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
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
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
Next, let s discuss how radiologic findings correlate with histology and prognosis in BAC
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%
Last, let s discuss radiologic considerations for staging BAC
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
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
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.
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
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
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
Acknowledgements Dr. Paul Spirn Dr. Ammar Sarwar Dr. Prachi Dubey Dr. Gillian Lieberman Maria Levantakis
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