Case Author(s): J. Philip Moyers, M.D. and Farrokh Dehdashti, M.D. , 10/1/95 . Rating: #D3, #Q4

Diagnosis: Metastatic bronchoalveolar carcinoma

Brief history:

Status post right upper lobectomy for bronchoalveolar carcinoma.


Images from a whole body PET scan

View main image(pt) in a separate image viewer

View second image(xr). PA chest radiograph

View third image(ct). Single image from chest CT

Full history/Diagnosis is available below

Diagnosis: Metastatic bronchoalveolar carcinoma

Full history:

66-year old man status post right upper lobectomy for bronchalveolar carcinoma. The patient presents with worsening cough and persistent right lung infiltrate. The patient was being evaluated for complete right pneumonectomy. This examination is obtained to evaluate for mediastinal disease, as well as left lung disease.


14.8 mCi F-18 fluorodeoxyglucose i.v.


PET images demonstrated increased FDG accumulation diffusely throughout the right lung consistent with the radiographic and CT abnormalities demonstrated diffusely throughout the right lung. These findings are consistent with metastatic bronchoalveolar carcinoma to the right middle and lower lobes. However, no activity is demonstrated in the left lobe and mediastinum.


Bronchoalveolar carcinoma accounts for between 1-20% of pulmonary neoplasms. The population most affected is middle-aged, with no predilection for either sex. Interestingly, there is an increased incidence in patients with scleroderma or other diseases causing localized parenchymal scarring or diffuse interstitial fibrosis. Diffuse bilateral involvement in bronchoalveolar cell carcinoma occurs late in the disease and is usually spread by the bronchial tree. Manifestations include both local and diffuse forms. The local form may grow very slowly changing little for several years. The diffuse form simulates an airspace filling disease with air bronchograms and air broncholograms. A pleural effusion develops in 8-10% of cases. Uncommon manifestations are mediastinal adenopathy, spontaneous pneumothorax, or atelectasis. cavitation also is uncommon. This disease has part of the differential of chronic air space disease for which the following pneumonic may be helpful. TBALLS, T- tuberculosis. B-bronchalveolar. A-alveolar proteinosis. L-lipoid pneumonia. L-lymphoma. S- sarcoidosis. Although computed tomography and magnetic resonance imaging have played an important role in the diagnosis, staging and treatment response of lung tumors, recent studies have shown limitations with both techniques. These modalities provide excellent anatomic information, but not metabolic or pathophysiologic information of the lesion. For example, the prospective data from the Multi- institutional Radiologic Diagnostic Oncology Group Trial, sponsored by the National Cancer Institute, showed that in staging non-small cell lung cancer, CT was only 52% sensitive and 69% specific, whereas MR imaging was 48% sensitive and 64% specific. PET imaging with F-18-fluorodeoxyglucose (FDG) has been shown to be useful for assessing solitary nodules, mediastinal staging, and assessment of reponse to therapy on the basis of the differential uptake in non- neoplastic and malignant lesions. The measurement of FDG uptake provides an index of glucose metabolism in tumors, which, in turn, is used to assist in diagnostic work-up and evaluation of treatment options.

References: 1) Pare, Fraser. Synopsysis of disease of the chest. WB Saunders. 2) Abe Y, Matsuzawa T, Fujiwara T, Itoh M, Fukuda H, Yamaguchi K, Kubota K, Hatazawa J, Tada M, Ido T, Watanuki S. Clinical assessment of the therapeutic effects on cancer using 18F-2- fluoro-2-deoxy-D-glucose and positron emission tomography: preliminary study of lung cancer. Int J Radiation Oncology Biol Phys 1990; 19:1005-1010. 3) McLoud TC, Bourgouin PM, Greenberg RW, Kosiuk JP, Templeton PA, Shepard JO, Moore EH, Wain JC, Mathisen DJ, Grillo HC. Bronchogenic carcinoma: analysis of staging in the mediastinum with CT by correlative lymph node mapping and sampling. Radiology 1992; 182:319-323. 4) Wahl RL, Quint LE, Greenough RL, Meyer CR, White RI, Orringer MB. Staging of mediastinal non-small cell lung cancer with FDG PET, CT, and fusion images: preliminary prospective evaluation. Radiology 1994; 191:371-377. 5) Minn H, Zasadny KR, Quint LE, Wahl RL. Lung cancer: reproducibility of quantitative measurements for evaluating 2


The patient had a sputum cytology positive for bronchoalveolar carcinoma and at this time was awaiting right pneumonectomy for symptomatic relief.

Major teaching point(s):

Abnormal areas of FDG uptake suggest areas of increased metabolism. These can be seen in carcinoma such as bronchoalveolar carcinoma. In this case, diffuse activity throughout the right lung suggest diffuse involvement by tumor. The patientıs previous history of right upper lobectomy for bronchoalveolar carcinoma as well as the hazy infiltrates demonstrated throughout the right lung suggests metastatic bronchoalveolar carcinoma. These findings are confirmed on the PET study.

ACR Codes and Keywords:

References and General Discussion of PET Tumor Imaging Studies (Anatomic field:Lung, Mediastinum, and Pleura, Category:Neoplasm, Neoplastic-like condition)

Search for similar cases.

Edit this case

Add comments about this case

Read comments about this case

Return to the Teaching File home page.

Case number: pt005

Copyright by Wash U MO