Severe Hypoxemia Due to Intrapulmonary Shunting Requiring Surgery for Bronchioloalveolar Carcinoma

Successful pulmonary arterial embolization followed by curative surgery for a lepidic predominant lung adenocarcinoma with severe hypoxemia

Background

Lepidic predominant adenocarcinoma is characterized by frequent refractory hypoxemia due to intrapulmonary shunting. Severe hypoxemia can induce perioperative complications in case of thoracic surgery.

Case presentation

We report a case of a 67 year-old woman with localized lepidic adenocarcinoma in the right lower lobe with severe hypoxemia. A selective arterial lung embolization allowed an instantaneous correction of the hypoxemia, and a curative lobectomy was safely performed 1 week after without any complication. The staging was pT3N0M0, and the patient received adjuvant chemotherapy.

Conclusions

This is the first case-report of successful endovascular embolization before curative surgery for a lepidic predominant lung adenocarcinoma.

Palliative embolisation for intrapulmonary shunting in lepidic predominant adenocarcinoma of the lung

Lepidic predominant adenocarcinoma (LPA) (formerly known as bronchioalveolar carcinoma) has rarely been reported to cause refractory hypoxia with intrapulmonary shunting [1–7]. We describe a case who underwent the palliative strategy of intravascular right lower pulmonary artery embolisation with an 18 mm Amplatzer II vascular plug to reduce intrapulmonary shunting. This is the first report we are aware of using this minimally invasive procedure to treat this condition.

[Bronchiolar-alveolar carcinoma: From concept to innovative therapeutic strategies]

Bronchioloalveolar carcinoma (BAC) is a primary pulmonary adenocarcinoma (ADC) developped from the terminal respiratory unit. Its restrictive definition adopted by the 1999 WHO pathological classification needs a complete tumor resection to exclude any signs of histological invasion. Although IIIB-IV tumors were excluded from the strict WHO definition of BAC, the first international workshop on BAC in 2004 had focussed on the need to include in the same spectrum of disease pure BAC and ADC with BAC feature (ADC-WBF). BAC and ADC-WBF affect more frequently women, non-smokers and Asian people than other non-small cell carcinoma. Their predominant lepidic and aerogenous tumor progression results in a frequent pneumonic, multifocal or diffuse presentation and explains why death is more frequently related to bilateral pulmonary involvement than extrathoracic metastasis. Natural history is slower and prognosis better than for other ADC. Within this entity, there are different cytological subtypes: mucinous, non-mucinous and mixed and according to them different clinical and biological phenotypes, with different sensitivity to therapeutic agents. At present, the diagnosis, the staging and the therapeutic strategy does not differ from that of non-small lung carcinoma cells. In localized forms, surgical resection remains the best therapeutic option for localized tumors. In diffuse forms, high frequency of epidermal growth factor receptor (EGFR) expression on tumor cells and its gene amplification and/or mutation as well as a particular sensitivity of this entity to EGFR tyrosine kinase inhibitors offer new strategy of therapeutical management in patients with non-resectable tumor. However, the place of chemotherapy has recently been revisited in this entity known until now as chemoresistant tumors. The results are being evaluated. It is necessary to continue therapeutic trials to determine criteria for choosing a first-line TKI or conventional chemotherapy in that entity. Cytological subtype will probably have an important role to play in this choice.