A case of Bronchoalveolar carcinoma (BAC) Dr. Samuel D. Yoo Health Tutors’ College Mulago World Friends Korea

History J.K. was a 60 years old man transferred for bronchoscopy. His chief complaint was progressive difficulty in breathing for 3 years. Was health until 3 years prior to presentation when he developed dry cough and difficulty in breathing on exertion, but no fever. Visited local clinics and took some unknown medicine  His symptoms were worsening. A year prior to bronchoscopic exam, he noted some fluid came out whenever he coughed. Had lost 9 Kg of body weight over 3 years.

An owner of a pub and drank alcohol frequently. Smoked cigarette ½ pack daily for 10 years (quitted 10 years prior to visiting us) A doctor requested chest CT scan and started him on anti-TB medicine. Another doctor stopped the medicine and sent him for bronchoscopy under impression of interstitial lung disease.

Examination No cyanosis, lymphadenopathy, finger clubbing or oedema Respiratory rate : 24/minute Auscultation : markedly decreased on both infrascapular area. Pulse rate : 90/minutes JVP : not raised No murmur

Laboratory tests HIV serology : negative His serial chest X-rays : progressive worsening of lung infiltrates in both lung fields.

Sep 2003

Nov 2003

Feb 2004

Sep 2004

Bronchoscopic findings Foamy secretion that looked like saliva was noted. After suction, the secretion continued to come out. Left lower lobe bronchi

Without washing

Cytology

Acinar or papillary clumps of cells Acinar or papillary clumps of cells. The nucleus was located in the base of the cell. Cytoplasm was abundant and clear and columnar in shape.

Bronchoalveolar carcinoma a distinctive subtype of adenocarcinoma of the lung with variable clinical, radiographic, and histologic presentations. Because of its relative rarity and atypical clinical presentation, diagnosis may be delayed. Though there is causal linkage with cigarette smoking, up to 25 to 50 percent of patients may be nonsmokers.

It can be separated into mucinous and non- mucinous types based upon the cytologic characteristics of individual tumor cells. The mucinous form is probably derived from respiratory goblet cells, while the non- mucinous variants can show ultrastructural and immunophenotypic features of either Clara cells or type II pneumocytes.

usually located peripherally, and can be localized, multinodular, or diffuse (pneumonic). This patient has diffuse BAC

Lobar consolidation Extensive lobar consolidation may simulate bacterial pneumonia or idiopathic pulmonary fibrosis. BAC and lymphoma are the most common causes of an alveolar infiltrate mimicking pneumonia among neoplastic diseases.

may be misdiagnosed as pulmonary tuberculosis or Pneumocystis pneumonia (PCP). This patient was also on anti-TB medicine with no improvement. Bronchorrhea– patients with mucinous BAC may produce more than 100 mL/day of watery sputum. In addition to respiratory symptoms, bronchorrhea may cause electrolyte imbalances

Effective treatment for bronchorrhea in these patients has not been established EGFR TKI (epidermal growth factor receptor- tyrosine kinase inhibitor) has shown good responses in some studies.

Thank you!