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{{ Infobox diagnosis | {{ Infobox diagnosis | ||
| Name = {{PAGENAME}} | | Name = {{PAGENAME}} | ||
| Image = | | Image = Acinar pattern adenocarcinoma of lung -- low mag.jpg | ||
| Width = | | Width = | ||
| Caption = | | Caption = Invasive adenocarcinoma, acinar pattern (right of image) and benign lung (left of image). [[H&E stain]]. | ||
| Synonyms = | | Synonyms = | ||
| Micro = nuclear atypia, eccentrically placed nuclei, usu. abundant cytoplasm (classically with mucin vacuoles), often conspicuous [[nucleoli]], +/-[[nuclear pseudoinclusions]] | | Micro = +/-nuclear atypia (may be absent in mucinous tumours), eccentrically placed nuclei, usu. abundant cytoplasm (classically with mucin vacuoles), often conspicuous [[nucleoli]], +/-[[nuclear pseudoinclusions]] | ||
| Subtypes = | | Subtypes = | ||
| LMDDx = | | LMDDx = [[atypical adenomatous hyperplasia of the lung]], adenocarcinoma in situ, [[squamous cell carcinoma of the lung]], [[small cell carcinoma of the lung]], [[non-small cell lung carcinoma]], [[malignant mesothelioma]], [[Metastasis|metastatic]] [[adenocarcinoma]] (esp. [[colorectal adenocarcinoma]], breast adenocarcinoma ([[invasive ductal carcinoma of the breast]], [[invasive lobular carcinoma]])) | ||
| Stains = | | Stains = | ||
| IHC = CK7 +ve, TTF-1 +ve, CK20 -ve, p40 -ve, p63 -ve (usually) | | IHC = [[CK7]] +ve, [[TTF-1]] +ve, CK20 -ve, [[p40]] -ve, p63 -ve (usually) | ||
| EM = | | EM = | ||
| Molecular = +/-EGFR mutations, +/-ALK [[chromosomal translocation]] (inv(2)(p21p23) -- EML4-ALK fusion) | | Molecular = +/-KRAS mutations, +/-EGFR mutations, +/-ALK [[chromosomal translocation]] (inv(2)(p21p23) -- EML4-ALK fusion), +/-ROS1 rearrangements, +/-RET rearrangements | ||
| IF = | | IF = | ||
| Gross = | | Gross = | ||
| Grossing = | | Grossing = | ||
| Staging = [[lung cancer staging]] | |||
| Site = [[lung]] - see ''[[lung tumours]]'' | | Site = [[lung]] - see ''[[lung tumours]]'' | ||
| Assdx = | | Assdx = | ||
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| Rads = lung mass - typically peripheral lesion (distant from large airways), may be multifocal | | Rads = lung mass - typically peripheral lesion (distant from large airways), may be multifocal | ||
| Endoscopy = | | Endoscopy = | ||
| Prognosis = moderate | | Prognosis = dependent on stage (minimally invasive and noninvasive: very good; invasive: moderate) | ||
| Other = | | Other = | ||
| ClinDDx = other [[lung tumours]] - primary and metastatic | | ClinDDx = other [[lung tumours]] - primary and metastatic | ||
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*Adenocarcinoma is the most common (primary lung cancer).<ref name=pmid19118313>{{cite journal |author=Lutschg JH |title=Lung cancer |journal=N. Engl. J. Med. |volume=360 |issue=1 |pages=87-8; author reply 88 |year=2009 |month=January |pmid=19118313 |doi=10.1056/NEJMc082208 |url=}}</ref> | *Adenocarcinoma is the most common (primary lung cancer).<ref name=pmid19118313>{{cite journal |author=Lutschg JH |title=Lung cancer |journal=N. Engl. J. Med. |volume=360 |issue=1 |pages=87-8; author reply 88 |year=2009 |month=January |pmid=19118313 |doi=10.1056/NEJMc082208 |url=}}</ref> | ||
*Adenocarcinoma is the non-smoker tumour - [[small cell carcinoma of the lung|SCLC]] and [[squamous cell carcinoma of the lung|squamous]] are more strongly associated with [[smoking]]. | *Adenocarcinoma is the non-smoker tumour - [[small cell carcinoma of the lung|SCLC]] and [[squamous cell carcinoma of the lung|squamous]] are more strongly associated with [[smoking]]. | ||
*Lung adenocarcinoma is the most common brain metastasis.<ref name=pmid22012633>{{Cite journal | last1 = Nayak | first1 = L. | last2 = Lee | first2 = EQ. | last3 = Wen | first3 = PY. | title = Epidemiology of brain metastases. | journal = Curr Oncol Rep | volume = 14 | issue = 1 | pages = 48-54 | month = Feb | year = 2012 | doi = 10.1007/s11912-011-0203-y | PMID = 22012633 }}</ref> | |||
Treatment: | Treatment: | ||
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===Image=== | ===Image=== | ||
<gallery> | <gallery> | ||
Image:Adenocarcinoma (3950819000).jpg | Lung adenocarcinoma. (WC/Rosen) | Image:Adenocarcinoma (3950819000).jpg | Lung adenocarcinoma. (WC/Rosen) | ||
</gallery> | </gallery> | ||
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==Microscopic== | ==Microscopic== | ||
Features: | Features: | ||
*Nuclear atypia. | *+/-Nuclear atypia - '''important'''. | ||
**May be absent in mucinous tumours - may look similar to foveolar epithelium. | |||
*Eccentrically placed nuclei. | *Eccentrically placed nuclei. | ||
*Abundant cytoplasm - classically with mucin vacuoles. | *Abundant cytoplasm - classically with mucin vacuoles. | ||
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Patterns:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref> | Patterns:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref> | ||
*Lepidic - tumour grows long the alveolar wall; means ''scaly covering''.<ref>URL: [http://medical-dictionary.thefreedictionary.com/lepidic http://medical-dictionary.thefreedictionary.com/lepidic]. Accessed on: 8 August 2013.</ref> | *Lepidic - tumour grows long the alveolar wall; means ''scaly covering''.<ref>URL: [http://medical-dictionary.thefreedictionary.com/lepidic http://medical-dictionary.thefreedictionary.com/lepidic]. Accessed on: 8 August 2013.</ref> At lower power, the shapes should still resemble lung acini. | ||
*Acinar - berry-shaped glands. | *Acinar - berry-shaped glands, smaller than lung acini. | ||
*Papillary - fibrovascular cores. | *Papillary - fibrovascular cores. | ||
*Micropapillary - nipple shaped projections without fibrovascular cores. | *Micropapillary - nipple shaped projections without fibrovascular cores. | ||
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DDx: | DDx: | ||
*[[Atypical adenomatous hyperplasia of the lung]] - spaced [[hobnail]] cells, mild-to-moderate nuclear atypia, small lesion (must be <5 mm). | |||
*Adenocarcinoma in situ. | |||
*[[Papillary thyroid carcinoma|Papillary carcinoma of thyroid]]. | |||
*[[Squamous cell carcinoma of the lung]]. | |||
*[[Small cell carcinoma of the lung]]. | |||
*[[Adenoid cystic carcinoma]]. | |||
*[[Non-small cell lung carcinoma]] - diagnosis should be avoided if possible. | |||
*[[Malignant mesothelioma]]. | |||
*[[Metastasis|Metastatic]] adenocarcinoma. | *[[Metastasis|Metastatic]] adenocarcinoma. | ||
**[[Colorectal adenocarcinoma]]. | **[[Colorectal adenocarcinoma]]. | ||
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***[[Invasive ductal carcinoma of the breast]]. | ***[[Invasive ductal carcinoma of the breast]]. | ||
***[[Invasive lobular carcinoma]]. | ***[[Invasive lobular carcinoma]]. | ||
*[[ | ***[[Bronchiolar metaplasia]]. | ||
* | **Other carcinomas. | ||
* | *Carcinomas of the bronchial glands, e.g. [[adenoid cystic carcinoma]]. | ||
===Images=== | ===Images=== | ||
=====Acinar adenocarcinoma===== | |||
<gallery> | |||
Image: Acinar pattern adenocarcinoma of lung -- low mag.jpg | Acinar LA - low mag. | |||
Image: Acinar pattern adenocarcinoma of lung -- intermed mag.jpg | Acinar LA - intermed. mag. | |||
Image: Acinar pattern adenocarcinoma of lung -- high mag.jpg | Acinar LA - high mag. | |||
Image: Acinar pattern adenocarcinoma of lung -- very high mag.jpg | Acinar LA - very high mag. | |||
Image: Acinar pattern adenocarcinoma of lung - alt -- very high mag.jpg | Acinar LA - very high mag. | |||
</gallery> | |||
<gallery> | |||
Image:Adenocarcinoma, acinar subtype (3923397562).jpg | Acinar adenocarcinoma. (WC/Yale Rosen) | |||
Image:Adenocarcinoma,_acinar_subtype_(4420421886).jpg | Acinar adenocarcinoma. (WC/Yale Rosen) | |||
</gallery> | |||
=====Mucinous adenocarcinoma===== | |||
<gallery> | |||
Image: Mucinous adenocarcinoma of the lung -- low mag.jpg | MAL - low mag. | |||
Image: Mucinous adenocarcinoma of the lung -- intermed mag.jpg | MAL - intermed. mag. | |||
Image: Mucinous adenocarcinoma of the lung -- high mag.jpg | MAL - high mag. | |||
Image: Mucinous adenocarcinoma of the lung -- very high mag.jpg | MAL - very high mag. | |||
</gallery> | |||
<gallery> | <gallery> | ||
Image: Mucinous lung adenocarcinoma -- low mag.jpg | MAL - low mag. | |||
Image: Mucinous lung adenocarcinoma -- intermed mag.jpg | MAL - intermed. mag. | |||
Image: Mucinous lung adenocarcinoma -- high mag.jpg | MAL - high mag. | |||
Image: Mucinous lung adenocarcinoma and airway -- intermed mag.jpg | MAL - intermed. mag. | |||
Image: Mucinous lung adenocarcinoma and airway -- high mag.jpg | MAL - high mag. | |||
Image: Mucinous lung adenocarcinoma and airway - alt -- high mag.jpg | MAL - high mag. | |||
</gallery> | |||
<gallery> | |||
Image:Bronchioloalveolar carcinoma, mucinous type 2.jpg |BAC - mucinous type - low mag. (WC/Yale Rosen) | Image:Bronchioloalveolar carcinoma, mucinous type 2.jpg |BAC - mucinous type - low mag. (WC/Yale Rosen) | ||
Image:Bronchioloalveolar carcinoma, mucinous type.jpg | BAC - mucinous type - high mag. (WC/Yale Rosen) | Image:Bronchioloalveolar carcinoma, mucinous type.jpg | BAC - mucinous type - high mag. (WC/Yale Rosen) | ||
</gallery> | </gallery> | ||
www | |||
=====Papillary adenocarcinoma===== | |||
<gallery> | |||
Image: Papillary adenocarcinoma of the lung -- very low mag.jpg | PAL - very low mag. (WC/Nephron) | |||
Image: Papillary adenocarcinoma of the lung -- low mag.jpg | PAL - low mag. (WC/Nephron) | |||
Image: Papillary adenocarcinoma of the lung -- intermed mag.jpg | PAL - intermed. mag. (WC/Nephron) | |||
Image: Papillary adenocarcinoma of the lung -- high mag.jpg | PAL - high mag. (WC/Nephron) | |||
</gallery> | |||
====Fetal adenocarcinoma==== | |||
<gallery> | |||
Image: Fetal adenocarcinoma of the lung -- very low mag.jpg | FAL - very low mag. (WC) | |||
Image: Fetal adenocarcinoma of the lung - alt2 -- very low mag.jpg | FAL - very low mag. (WC) | |||
Image: Fetal adenocarcinoma of the lung -- low mag.jpg | FAL - low mag. (WC) | |||
Image: Fetal adenocarcinoma of the lung -- intermed mag.jpg | FAL - intermed. mag. (WC) | |||
Image: Fetal adenocarcinoma of the lung -- high mag.jpg | FAL - high mag. (WC) | |||
</gallery> | |||
====www==== | |||
*[http://www.pathpedia.com/education/eatlas/histopathology/lung_and_bronchi/bronchioloalveolar_carcinoma_mucinous.aspx BAC mucinous type adjacent to benign (pathpedia.com)]. | *[http://www.pathpedia.com/education/eatlas/histopathology/lung_and_bronchi/bronchioloalveolar_carcinoma_mucinous.aspx BAC mucinous type adjacent to benign (pathpedia.com)]. | ||
*[http://cancergrace.org/wp-content/uploads/2007/05/mucinous-vs-nonmucinous-bac-histology.jpg BAC mucinous and nonmucinous (cancergrace.org)].<ref>URL: [http://cancergrace.org/lung/2007/05/14/bac-mucinous-and-non-mucinous/ http://cancergrace.org/lung/2007/05/14/bac-mucinous-and-non-mucinous/]. Accessed on: 8 August 2013.</ref> | *[http://cancergrace.org/wp-content/uploads/2007/05/mucinous-vs-nonmucinous-bac-histology.jpg BAC mucinous and nonmucinous (cancergrace.org)].<ref>URL: [http://cancergrace.org/lung/2007/05/14/bac-mucinous-and-non-mucinous/ http://cancergrace.org/lung/2007/05/14/bac-mucinous-and-non-mucinous/]. Accessed on: 8 August 2013.</ref> | ||
*[https://www.flickr.com/photos/pulmonary_pathology/7589291672/ Lepidic adenocarcinoma with invasive (flickr.com/Yale Rosen)]. | |||
*[https://www.flickr.com/photos/pulmonary_pathology/7589292214/in/photostream/ Lepidic adenocarcinoma (flickr.com/Yale Rosen)]. | |||
*[http://www.rosaicollection.org/searchresults.cfm/ Lepidic adenocarcinoma (rosaicollection.org/index.cfm)]. | |||
*[http://pathlabmed.typepad.com/surgical_pathology_and_la/2010/09/digital-case-challenge-non-mucinous-bronchioloalveolar-adenocarcinoma.html Mucinous adenocarcinoma (pathlabmed.typepad.com)]. | |||
*[https://www.flickr.com/photos/pulmonary_pathology/7589292780/in/photostream/ Non-mucinous adenocarcinoma in situ (flickr.com/Yale Rosen)]. | |||
*[https://www.flickr.com/photos/pulmonary_pathology/7589292496/in/photostream/ Non-mucinous adenocarcinoma in situ (flickr.com/Yale Rosen)]. | |||
*[https://www.flickr.com/photos/pulmonary_pathology/7589290010/in/photostream/ Acinar adenocarcinoma (flickr.com/Yale Rosen)]. | |||
*[https://www.flickr.com/photos/pulmonary_pathology/7589289274/in/photostream/ Acinar adenocarcinoma (flickr.com/Yale Rosen)]. | |||
===Classification=== | ===Classification=== | ||
Classification based on extent:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref> | Classification based on extent:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref> | ||
#Adenocarcinoma in situ (AIS) - previously known as [[BAC]]. | #Adenocarcinoma in situ (AIS) - previously known as ''bronchioloalveolar carcinoma'' (abbreviated [[BAC]]). | ||
#*Subtypes: nonmucinous, mucinous, mixed mucinous/nonmucinous. | #*Subtypes: nonmucinous, mucinous, mixed mucinous/nonmucinous. | ||
#*Definition: lack of invasion into the stroma, vascular spaces and pleura. | |||
#*Must have a lepidic growth pattern.<ref name=pmid22214965>{{Cite journal | last1 = Borczuk | first1 = AC. | title = Assessment of invasion in lung adenocarcinoma classification, including adenocarcinoma in situ and minimally invasive adenocarcinoma. | journal = Mod Pathol | volume = 25 Suppl 1 | issue = | pages = S1-10 | month = Jan | year = 2012 | doi = 10.1038/modpathol.2011.151 | PMID = 22214965 }}</ref> | |||
#Minimally invasive adenocarcinoma (MIA). | #Minimally invasive adenocarcinoma (MIA). | ||
#*Lepidic growth with up to 5 mm of invasion. | #*Lepidic growth with up to 5 mm of invasion. | ||
#*Subtypes: nonmucinous (most common), mucinous, mixed mucinous/nonmucinous. | #*Subtypes: nonmucinous (most common), mucinous (uncommon), mixed (mucinous/nonmucinous). | ||
#*Should not have [[lymphovascular invasion]].{{fact}} | |||
#Invasive adenocarcinoma: | #Invasive adenocarcinoma: | ||
#*Subtypes: micropapillary, mucinous (previously ''mucinous BAC''), colloid, fetal, enteric. | #*Subtypes: micropapillary, mucinous (previously ''mucinous BAC''), colloid, fetal, enteric. | ||
====Grading==== | |||
Graded G1-G4 - as per CAP protocol (version 3.4.0.0):<ref name=cap_protocol>CAP Lung protocol. Version: 3.4.0.0. URL: [http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution%20Folders/WebContent/pdf/cp-lung-16protocol-3400.pdf http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution%20Folders/WebContent/pdf/cp-lung-16protocol-3400.pdf]. Accessed on: March 23, 2016.</ref> | |||
*G1 = lepidic. | |||
*G2 = acinar, papillary, cribriform. | |||
*G3 = micropapillary, solid, mucinous, colloid. | |||
*G4 = undifferentiated - '''not''' used for lung adenocarcinoma; it used for small cell carcinoma and large cell carcinoma. | |||
Note: | |||
*There is no consensus currently on grading - as per the international consensus guidelines of 2011.<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref> | |||
==Special stains== | |||
*[[Mucicarmine]] +ve, cytoplasmic. | |||
*[[PAS-diastase]] +ve, cytoplasmic. | |||
==IHC== | ==IHC== | ||
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Panel for adenocarcinoma versus SCC: | Panel for adenocarcinoma versus SCC: | ||
*TTF-1 +ve. | *TTF-1 +ve. | ||
*Napsin A +ve. | *[[Napsin]] A +ve. | ||
*p40 -ve.<ref name=pmid22056955>{{Cite journal | last1 = Bishop | first1 = JA. | last2 = Teruya-Feldstein | first2 = J. | last3 = Westra | first3 = WH. | last4 = Pelosi | first4 = G. | last5 = Travis | first5 = WD. | last6 = Rekhtman | first6 = N. | title = p40 (ΔNp63) is superior to p63 for the diagnosis of pulmonary squamous cell carcinoma. | journal = Mod Pathol | volume = 25 | issue = 3 | pages = 405-15 | month = Mar | year = 2012 | doi = 10.1038/modpathol.2011.173 | PMID = 22056955 }}</ref> | *[[p40]] -ve.<ref name=pmid22056955>{{Cite journal | last1 = Bishop | first1 = JA. | last2 = Teruya-Feldstein | first2 = J. | last3 = Westra | first3 = WH. | last4 = Pelosi | first4 = G. | last5 = Travis | first5 = WD. | last6 = Rekhtman | first6 = N. | title = p40 (ΔNp63) is superior to p63 for the diagnosis of pulmonary squamous cell carcinoma. | journal = Mod Pathol | volume = 25 | issue = 3 | pages = 405-15 | month = Mar | year = 2012 | doi = 10.1038/modpathol.2011.173 | PMID = 22056955 }}</ref> | ||
*CK5/6 -ve. | *CK5/6 -ve. | ||
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*Vimentin -ve/+ve (+ve relatively common). | *Vimentin -ve/+ve (+ve relatively common). | ||
**Poor prognosticator.<ref>{{Cite journal | last1 = Dauphin | first1 = M. | last2 = Barbe | first2 = C. | last3 = Lemaire | first3 = S. | last4 = Nawrocki-Raby | first4 = B. | last5 = Lagonotte | first5 = E. | last6 = Delepine | first6 = G. | last7 = Birembaut | first7 = P. | last8 = Gilles | first8 = C. | last9 = Polette | first9 = M. | title = Vimentin expression predicts the occurrence of metastases in non small cell lung carcinomas. | journal = Lung Cancer | volume = 81 | issue = 1 | pages = 117-22 | month = Jul | year = 2013 | doi = 10.1016/j.lungcan.2013.03.011 | PMID = 23562674 }}</ref> | **Poor prognosticator.<ref>{{Cite journal | last1 = Dauphin | first1 = M. | last2 = Barbe | first2 = C. | last3 = Lemaire | first3 = S. | last4 = Nawrocki-Raby | first4 = B. | last5 = Lagonotte | first5 = E. | last6 = Delepine | first6 = G. | last7 = Birembaut | first7 = P. | last8 = Gilles | first8 = C. | last9 = Polette | first9 = M. | title = Vimentin expression predicts the occurrence of metastases in non small cell lung carcinomas. | journal = Lung Cancer | volume = 81 | issue = 1 | pages = 117-22 | month = Jul | year = 2013 | doi = 10.1016/j.lungcan.2013.03.011 | PMID = 23562674 }}</ref> | ||
Note: | |||
*In mucinous adenocarcinoma of the lung TTF-1 is usu. -ve (46% +ve) and napsin is usu. -ve (36% +ve). | |||
**Positive staining is unusual but useful if present, as metastatic disease is uniformily negative for both.<ref name=pmid24651909>{{Cite journal | last1 = Rossi | first1 = G. | last2 = Cavazza | first2 = A. | last3 = Righi | first3 = L. | last4 = Sartori | first4 = G. | last5 = Bisagni | first5 = A. | last6 = Longo | first6 = L. | last7 = Pelosi | first7 = G. | last8 = Papotti | first8 = M. | title = Napsin-A, TTF-1, EGFR, and ALK Status Determination in Lung Primary and Metastatic Mucin-Producing Adenocarcinomas. | journal = Int J Surg Pathol | volume = 22 | issue = 5 | pages = 401-7 | month = Aug | year = 2014 | doi = 10.1177/1066896914527609 | PMID = 24651909 }} | |||
</ref> | |||
==Molecular== | ==Molecular== | ||
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**Exon 21 L858R. | **Exon 21 L858R. | ||
***Natural history of mutation is suspected to have a better prognosis vs. wild-type.<ref>URL: [http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r]. Accessed on: 27 April 2012.</ref> | ***Natural history of mutation is suspected to have a better prognosis vs. wild-type.<ref>URL: [http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r]. Accessed on: 27 April 2012.</ref> | ||
**KRAS mutations are absent, i.e. ''wild-type KRAS''.<ref>{{Cite journal | last1 = Pao | first1 = W. | last2 = Wang | first2 = TY. | last3 = Riely | first3 = GJ. | last4 = Miller | first4 = VA. | last5 = Pan | first5 = Q. | last6 = Ladanyi | first6 = M. | last7 = Zakowski | first7 = MF. | last8 = Heelan | first8 = RT. | last9 = Kris | first9 = MG. | title = KRAS mutations and primary resistance of lung adenocarcinomas to gefitinib or erlotinib. | journal = PLoS Med | volume = 2 | issue = 1 | pages = e17 | month = Jan | year = 2005 | doi = 10.1371/journal.pmed.0020017 | PMID = 15696205 }}</ref> | **[[KRAS mutations]] are absent, i.e. ''wild-type KRAS''.<ref>{{Cite journal | last1 = Pao | first1 = W. | last2 = Wang | first2 = TY. | last3 = Riely | first3 = GJ. | last4 = Miller | first4 = VA. | last5 = Pan | first5 = Q. | last6 = Ladanyi | first6 = M. | last7 = Zakowski | first7 = MF. | last8 = Heelan | first8 = RT. | last9 = Kris | first9 = MG. | title = KRAS mutations and primary resistance of lung adenocarcinomas to gefitinib or erlotinib. | journal = PLoS Med | volume = 2 | issue = 1 | pages = e17 | month = Jan | year = 2005 | doi = 10.1371/journal.pmed.0020017 | PMID = 15696205 }}</ref> | ||
*ALK [[chromosomal translocation]] (inv(2)(p21p23) -- EML4-ALK fusion).<ref name=pmid21245935>{{Cite journal | last1 = Li | first1 = Y. | last2 = Ye | first2 = X. | last3 = Liu | first3 = J. | last4 = Zha | first4 = J. | last5 = Pei | first5 = L. | title = Evaluation of EML4-ALK fusion proteins in non-small cell lung cancer using small molecule inhibitors. | journal = Neoplasia | volume = 13 | issue = 1 | pages = 1-11 | month = Jan | year = 2011 | doi = | PMID = 21245935 }}</ref> | *ALK [[chromosomal translocation]] (inv(2)(p21p23) -- EML4-ALK fusion).<ref name=pmid21245935>{{Cite journal | last1 = Li | first1 = Y. | last2 = Ye | first2 = X. | last3 = Liu | first3 = J. | last4 = Zha | first4 = J. | last5 = Pei | first5 = L. | title = Evaluation of EML4-ALK fusion proteins in non-small cell lung cancer using small molecule inhibitors. | journal = Neoplasia | volume = 13 | issue = 1 | pages = 1-11 | month = Jan | year = 2011 | doi = | PMID = 21245935 }}</ref> | ||
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**See ''[[lung carcinoma with ALK rearrangement]]. | **See ''[[lung carcinoma with ALK rearrangement]]. | ||
**Do ''not'' occur with EGRF mutations ''or'' KRAS mutations.<ref name=pmid23729361>{{Cite journal | last1 = Gainor | first1 = JF. | last2 = Varghese | first2 = AM. | last3 = Ou | first3 = SH. | last4 = Kabraji | first4 = S. | last5 = Awad | first5 = MM. | last6 = Katayama | first6 = R. | last7 = Pawlak | first7 = A. | last8 = Mino-Kenudson | first8 = M. | last9 = Yeap | first9 = BY. | title = ALK rearrangements are mutually exclusive with mutations in EGFR or KRAS: an analysis of 1,683 patients with non-small cell lung cancer. | journal = Clin Cancer Res | volume = 19 | issue = 15 | pages = 4273-81 | month = Aug | year = 2013 | doi = 10.1158/1078-0432.CCR-13-0318 | PMID = 23729361 }}</ref> | **Do ''not'' occur with EGRF mutations ''or'' KRAS mutations.<ref name=pmid23729361>{{Cite journal | last1 = Gainor | first1 = JF. | last2 = Varghese | first2 = AM. | last3 = Ou | first3 = SH. | last4 = Kabraji | first4 = S. | last5 = Awad | first5 = MM. | last6 = Katayama | first6 = R. | last7 = Pawlak | first7 = A. | last8 = Mino-Kenudson | first8 = M. | last9 = Yeap | first9 = BY. | title = ALK rearrangements are mutually exclusive with mutations in EGFR or KRAS: an analysis of 1,683 patients with non-small cell lung cancer. | journal = Clin Cancer Res | volume = 19 | issue = 15 | pages = 4273-81 | month = Aug | year = 2013 | doi = 10.1158/1078-0432.CCR-13-0318 | PMID = 23729361 }}</ref> | ||
*ROS1 - good response to crizotinib.<ref name=pmid25264305>{{Cite journal | last1 = Shaw | first1 = AT. | last2 = Ou | first2 = SH. | last3 = Bang | first3 = YJ. | last4 = Camidge | first4 = DR. | last5 = Solomon | first5 = BJ. | last6 = Salgia | first6 = R. | last7 = Riely | first7 = GJ. | last8 = Varella-Garcia | first8 = M. | last9 = Shapiro | first9 = GI. | title = Crizotinib in ROS1-rearranged non-small-cell lung cancer. | journal = N Engl J Med | volume = 371 | issue = 21 | pages = 1963-71 | month = Nov | year = 2014 | doi = 10.1056/NEJMoa1406766 | PMID = 25264305 }}</ref> | |||
**Approximately 1% of NSCLC.<ref name=pmid25409376>{{Cite journal | last1 = Gold | first1 = KA. | title = ROS1--targeting the one percent in lung cancer. | journal = N Engl J Med | volume = 371 | issue = 21 | pages = 2030-1 | month = Nov | year = 2014 | doi = 10.1056/NEJMe1411319 | PMID = 25409376 }}</ref> | |||
==Sign out== | ==Sign out== | ||
===Biopsy=== | ===Biopsy=== | ||
Consensus recommendations:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref> | |||
*''Adenocarcinoma in situ'' (AIS) and ''minimally invasive adenocarcinoma'' should '''not''' be used in the reporting of small biopsies and cytology. | |||
**Tumours with a non-invasive pattern are referred to by their pattern, e.g. ''lepidic growth'', '''not''' as AIS. | |||
<pre> | |||
Lung, Right Upper Lobe, Core Biopsy: | |||
- INVASIVE ADENOCARCINOMA, NON-MUCINOUS. | |||
Comment: | |||
The adenocarcinoma is positive for TTF-1 and napsin. EGFR/ALK testing was ordered. | |||
</pre> | |||
====Lepidic pattern on biopsy==== | |||
Important note: lesion '''''must''''' be >=5 mm ''and'' <=30 mm. | |||
<pre> | |||
Lung, Left Upper Lobe, Core Biopsy: | |||
- ADENOCARCINOMA, lepidic pattern. | |||
Comment: | |||
The tumour is stains as follows: | |||
POSITIVE: TTF-1, napsin A, CK7. | |||
NEGATIVE: p40. | |||
The findings are in keeping with lepidic pattern adenocarcinoma; the differential diagnosis includes: (1) adenocarcinoma in situ, (2) minimally invasive adenocarcinoma, and (3) invasive adenocarcinoma. | |||
Lung biomarkers (EGFR, ALK, PDL1, ROS1) have been ordered. | |||
</pre> | |||
=====Mucinous adenocarcinoma with noncontributory stains===== | |||
<pre> | |||
Lung, Right Upper Lobe, Core Biopsy: | |||
- ADENOCARCINOMA, MUCINOUS, see comment. | |||
Comment: | |||
The adenocarcinoma is negative for both napsin and TTF-1. EGFR/ALK testing was ordered. | |||
The findings are compatible with a primary or secondary adenocarcinoma; clinical and | |||
radiologic correlation is required. | |||
</pre> | |||
====Block letters==== | |||
<pre> | <pre> | ||
LUNG, LEFT, BIOPSY: | LUNG, LEFT, BIOPSY: | ||
- ADENOCARCINOMA, LEPIDIC GROWTH; INVASION CANNOT BE EXCLUDED IN THIS SMALL SPECIMEN. | - ADENOCARCINOMA, LEPIDIC GROWTH; INVASION CANNOT BE EXCLUDED IN THIS SMALL SPECIMEN. | ||
</pre> | |||
<pre> | |||
LUNG, RIGHT UPPER LOBE, NEEDLE BIOPSY: | |||
- INVASIVE ADENOCARCINOMA, NON-MUCINOUS. | |||
COMMENT: | |||
The tumour stains as follows: | |||
POSITIVE: TTF-1. | |||
NEGATIVE: p40. | |||
The immunoprofile is compatible with lung adenocarcinoma. | |||
</pre> | |||
<pre> | |||
MASS, LEFT LOWER LOBE OF LUNG, BIOPSY: | |||
- INVASIVE ADENOCARCINOMA. | |||
COMMENT: | |||
The tumour is positive for TTF-1. | |||
Tissue will be sent for molecular testing and the results reported as an addendum. | |||
</pre> | </pre> | ||
Line 173: | Line 322: | ||
===Micro=== | ===Micro=== | ||
<pre> | <pre> | ||
Size (tissue): scant tissue (<0.5 cm). | |||
Gland formation: focal, poorly formed. | Gland formation: focal, poorly formed. | ||
Cell size: large. | Cell size: large. | ||
Line 202: | Line 351: | ||
</pre> | </pre> | ||
=== | ====Mucinous==== | ||
The sections show cores with well-formed glands composed of foveolar-like columnar cells with a relatively bland cytomorphology. Mitotic activity is not readily apparent. A small amount of non-lesional lung parenchyma is present. | |||
===Lung cancer staging=== | |||
{{Main|Lung cancer staging}} | |||
==See also== | ==See also== | ||
Line 210: | Line 361: | ||
*[[Adenocarcinoma]]. | *[[Adenocarcinoma]]. | ||
*[[Metastasis]]. | *[[Metastasis]]. | ||
*[[Lung carcinoma with ALK rearrangement]]. | |||
*[[SMARCA4-deficient adenocarcinoma of the lung]]. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
==External links== | |||
*[http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-staging Lung cancer staging (cancer.org)]. | |||
*[http://www.nucmedresource.com/thoracic-nodal-stations.html Thoracic lymph node stations (nucmedresource.com)]. | |||
[[Category:Diagnosis]] | [[Category:Diagnosis]] | ||
[[Category:Lung tumours]] | [[Category:Lung tumours]] |
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