Solitary Atypical Adenomatous Hyperplasia in the Lung of a 17-Year-Old Man with Spontaneous Pneumothorax
Tsuyoshi ShojiNoritaka IsowaSeiki HasegawaMio LiKojiro MorimotoHiroyuki UedaMasanori KitaichiMitsuyoshi HirokawaHiromi Wada
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Abstract:
We report here a case of solitary atypical adenomatous hyperplasia (AAH). A 17-year-old non-smoker man developed spontaneous pneumothorax, and computed tomogram scanning of his chest revealed a ground-glass opacity measuring 5 × 5 mm in the right lung with no change in its size for the next 7 months. To exclude the possibility of pulmonary neoplasia, he underwent partial pulmonary resection. The postoperative pathologic diagnosis was AAH. The present case is very exceptional for AAH because of the patient’s young age and non-association with pulmonary carcinoma. The postoperative 23-month follow-up was uneventful.Keywords:
Atypical adenomatous hyperplasia
Ground-glass opacity
Pulmonary nodules with ground-glass opacity (GGO) are frequently observed and will be increasingly detected. GGO can be observed in both benign and malignant conditions, including lung cancer and its preinvasive lesions. Atypical adenomatous hyperplasia and adenocarcinoma in situ are typically manifested as pure GGOs, whereas more advanced adenocarcinomas may include a larger solid component within the GGO region. The natural history of GGOs has been gradually clarified. Approximately 20% of pure GGOs and 40% of part-solid GGOs gradually grow or increase their solid component, whereas others remain unchanged for years. Therefore, it remains unclear whether all pulmonary lesions with GGO should be surgically resected or whether lesions without changes may not require resection. To distinguish GGOs with growth from those without growth, a 3-year follow-up observation period is a reasonable benchmark based on the data that the volume-doubling time (VDT) of pure GGOs ranges from approximately 600 to 900 days and that of part-solid GGOs ranges from 300 to 450 days. Future studies on the genetic differences between GGOs with growth and those without growth will help establish an appropriate management algorithm.
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Atypical adenomatous hyperplasia
Nodule (geology)
Ground-glass opacity
Solitary pulmonary nodule
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To clarify the high-resolution CT(HRCT) findings of pulmonary atypical adenomatous hyperplasia (AAH) of 5 mm or less in diameter.We evaluated the HRCT findings of 43 histopathologically confirmed AAH of 5 mm or less in diameter in 7 patients who underwent lobectomy for pulmonary adenocarcinoma. For comparison, we also examined the HRCT findings of 13 bronchioloalveolar carcinomas (BAC) of the same size from these patients.We identified 36 of 43 AAH and all 13 BAC on HRCT performed with multidetector-row CT. Thirty-five AAH and 11 BAC showed ground-glass opacity without any high-attenuation component. Margins of 20 AAH were well defined, and 16 were ill defined. In BAC, 11 lesions demonstrated well-defined margins, with only 2 showing ill-defined margins.Most AAH lesions of 5 mm or less in diameter are identified as ground-glass opacity on HRCT. Detection of minute ground-glass opacity is important in locating AAH on HRCT.
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A 75-year-old man with a 50 pack-year smoking history underwent a right upper lobectomy due to an early stage lung adenocarcinoma. Simultaneously, pure ground-glass opacity (GGO) on the left upper lobe measuring 6.7 mm in diameter was detected on computed tomography (CT), which was considered atypical adenomatous hyperplasia, a bronchioloalveolar carcinoma, or focal organizing pneumonia/fibrosis. Eighteen months later, the diameter of the lesion increased to 9.0 mm. The lesion further enlarged to 10.4 mm with a small solid component within the GGO at 28 months after the initial CT scan. At the 33- month follow-up, the lesion had decreased in size and a solid component was prominent. Forty months after the initial CT, the lesion seemed to be a fibrotic scar. To the best of our knowledge, no studies have reported a pure GGO progressing with a solid component that regressed spontaneously over such a long period. Although this case seems rare, physicians should be aware that a lung nodule compatible with progression from in situ carcinoma to invasive carcinoma on CT could resolve over 24 months.
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The introduction of low dose chest computed tomography for health screening in Korea has resulted in increased detection of solitary pulmonary nodules, including nodular ground glass opacity. In contrast to the classic solitary pulmonary nodule, nodular ground glass opacity (GGO) has special characteristics especially in Koreans. More than half of nodular GGOs are transient and they are caused by a pulmonary infiltrate of eosinophils. However, persistent nodular GGO (nGGO) showed a high malignant potential such as atypical adenomatous hyperplasia and bronchioloalveolar cell carcinoma. The increasing use of video assisted thoracoscopic surgery (VATS) for diagnosis and treatment is the current trend for managing nodular GGO. Even though lobectomy is still the standard management for malignant nGGO, limited resection (wide wedge resection or segmentectomy) is widely used for the small malignant GGO (Noguchi types A and B). Multifocal nodular GGOs are mostly of a synchronous origin rather than intrapulmonary metastasis. Therefore, aggressive surgical resection is warranted. This review contains the current concepts for managing nodular GGO and it especially focuses on the Korean data.
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Ground-glass opacity (GGO) nodules noted at thin-section computed tomography (CT) scan have been shown to have a histopathologic relationship with atypical adenomatous hyperplasia, bronchioloalveolar carcinoma (BAC, or adenocarcinoma in situ), and adenocarcinoma with a predominant BAC component (minimally invasive adenocarcinoma). Patients harboring GGO nodules of BAC or adenocarcinoma with a predominant BAC component demonstrate negative results for malignancy at positron emission tomography. In peripheral adenocarcinoma of a part-solid (mixed GGO and solid attenuation) nodular nature, both the degree of disappearance of GGO area, when the lung window is changed to a mediastinal window image at CT scanning, and the maximum standardized uptake value at positron emission tomography correlate well with histopathologic BAC and non-BAC ratios. However, a high non-BAC ratio appears to be the only independent prognosis-determining factor. Epidermal growth factor receptor mutations are positively correlated with the GGO ratio at a thin-section CT scan in lung adenocarcinomas. As patients with a GGO nodule of BAC or adenocarcinoma with a predominant BAC component have a good prognosis, a wedge resection is recommended as a treatment option, in preference to lobectomy. Even for multiple malignant pure GGO nodules, minimally invasive surgery (including multiple resections) with the preservation of lung volume and adequate imaging follow-up studies are the recommended diagnostic and therapeutic measures.
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A 75-year-old man with a 50 pack-year smoking history underwent a right upper lobectomy due to an early stage lung adenocarcinoma. Simultaneously, pure ground-glass opacity (GGO) on the left upper lobe measuring 6.7 mm in diameter was detected on computed tomography (CT), which was considered atypical adenomatous hyperplasia, a bronchioloalveolar carcinoma, or focal organizing pneumonia/fibrosis. Eighteen months later, the diameter of the lesion increased to 9.0 mm. The lesion further enlarged to 10.4 mm with a small solid component within the GGO at 28 months after the initial CT scan. At the 33- month follow-up, the lesion had decreased in size and a solid component was prominent. Forty months after the initial CT, the lesion seemed to be a fibrotic scar. To the best of our knowledge, no studies have reported a pure GGO progressing with a solid component that regressed spontaneously over such a long period. Although this case seems rare, physicians should be aware that a lung nodule compatible with progression from in situ carcinoma to invasive carcinoma on CT could resolve over 24 months.
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Objective: Pulmonary ground glass opacity (GGO) nodules represent a significant dilemma in oncology since its diagnosis in clinical practice has increased because of growing application of low dose computed tomography and screening program. The aim of this study is to analyze the clinical and pathological features, the overall survival (OS) and disease-free interval (DFI) in surgically resected solitary ground glass nodules in order to assess the surgical treatment of choice. Methods: We retrospectively analyzed 49 patients (M/F=25/24) with a mean age of 67.7 (range, 40–81) years who underwent lung resection for solitary GGO nodules among 570 reviewed CT of patients who were treated for lung neoplasms between 2010 and 2016. The cohort included 22 pure GGO nodules and 27 part solid GGOs (also called mixed GGOs). Results: Median maximum diameter of GGOs, defined as the largest axial diameter of the lesion on the lung-window setting, was 17 (range, 5–30) mm. GGO nodules were removed by wedge resection, segmentectomy, or lobectomy in 17 (35%), 9 (18%), and 23 (47%) cases, respectively. Pathologic diagnosis was atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), invasive adenocarcinoma (IA) or multifocal adenocarcinoma (MAC) in 4 (8.2%), 9 (18.4%), 11 (22.4%), 22 (44.9%) and 3 (6.1%) cases, respectively. With a median follow up of 47 months the OS and DFI of the entire cohort was 46.3 and 43 months, respectively. The histotype (P=0.008), the dimension of GGO (P=0.014) and the PET-SUV max (P=0.001) were independent prognostic factors of worse survival. Sex, age, previous lung surgery, type of surgical resection and the mediastinal lymph-node evaluation did not impact on OS and DFI. Analyzing the 22 pure GGO nodules, we found a 3-year OS and DFI of 98% and 100% respectively, significantly different from 80% and 75% respectively of part-solid GGOs (log-rank P=0.043 and P=0.011). Conclusion: Our data suggest an indolent behaviour of tumour presenting as solitary GGO nodules, especially in case of pure GGOs. In our series wedge resections guarantee the same results in terms of OS and DFI when compared to lobectomies. Sublobar resections without mediastinal lymph-nodes evaluation represent the treatment of choice for pure-GGO. More studies are needed to assess its role for part-solid GGO nodules.
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Atypical adenomatous hyperplasia
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