Programmed Death Ligand 1 Expression in Lung Adenocarcinoma: An Analysis of the Histomorphological Features

Background

Immunotherapy is now a vital target therapy in the advanced cases of lung adenocarcinoma. The outstanding result of therapies with medications that inhibit the interaction of programmed death ligand 1 with programmed death protein 1 has revolutionarized prognostic treatment regimes.

Aims

The study was undertaken with the objectives to analyze the detailed histomorphological features of adenocarcinoma lung with programmed death ligand-1 (PD-L1) expression in tumor cells and to compare the histomorphological features with PD-L1 negative group.

Materials and Methods

The present study is a retrospective case series with 100 cases of non-small cell lung cancer-adenocarcinoma phenotype in which testing for PD-L1 had been done using immunohistochemistry. Detailed histomorphological analysis and comparison was performed for both the PD-L1 positive and negative phenotype.

Results

Histomorphological features of 25 cases with positive PD-L1 positivity in the tumor cells and 75 cases that were negative for PD-L1 were analyzed. The most frequent pattern in the category that was PD-L1 positive was singly scattered cells or loose clusters present in 84% cases followed by solid nests that was identified in 60% cases. The presence of solid nests in the PD-L1 positive category was statistically significant (P = 0.018). Mucin was identified in 24% cases, and tumor necrosis was documented in 60% cases with PD-L1 positivity. In the cluster that was PD-L1 positive, 92% cases had moderate-to-severe nuclear pleomorphism.

Conclusion

The identification of histomorphological patterns and characteristics may aid in triaging cases that have the likelihood to harbor PD-L1-positive phenotype, which has predictive and prognostic outcome.

Programmed Death Ligand-1 Testing in Adenocarcinoma Lung: A Comparative Study of Cell Block versus Biopsy

Background

Immunotherapy currently stands as a novel treatment option, specifically in cases of advanced non-small cell lung carcinoma (NSCLC). Expression of programmed death ligand-1 (PD-L1) in tumor cells forms the mainstay for the use of anti-PD-L1 monoclonal antibodies in the treatment of NSCLC.

Aims

The objectives of the study were to assess utility of cell blocks for testing of PD-L1 in adenocarcinoma lung and to compare the expression of PD-L1 in cell blocks and the corresponding biopsy specimens.

Materials and Methods

The current study was a prospective case series that included 20 cases of NSCLC-adenocarcinoma lung. Cases included in the study had biopsies performed from lung masses, along with which cell blocks were prepared from fine needle aspiration cytology (FNAC) samples. Testing for PD-L1 was done using the monoclonal PD-L1 antibody, SP-263 clone on the Ventana Benchmark XT system. PD-L1 expression was assessed only in the tumor cells, and cases with >1% expression, cytoplasmic or membranous, in tumor cells were categorized as positive.

Results

PD-L1 expression was identified in the biopsy samples of tumor cells of 20% of cases (n = 4/20). In the corresponding cell blocks, PD-L1 expression was identified in the tumor cells of 15% of cases (n = 3/20). Sensitivity and specificity of cell blocks were 75% and 100%, respectively. Positive and negative predictive values were 100% and 94.12%, respectively.

Conclusion

PD-L1 testing has both predictive and prognostic implications. PD-L1 testing in cell block samples is a potential alternative, specifically in cases where biopsy tissue is minimal or unavailable.

Delftia acidovorans: An Unusual Pathogen from an Adenocarcinoma Lung Patient with Pleural Effusion

Delftia acidovorans (D. acidovorans) is an aerobic, nonfermentative Gram-negative bacillus infrequently isolated from clinical specimens. The pathogenicity and clinical significance of the organism has not been ascertained due to uncommon clinical isolation and suspected low virulence. The organism has been reported to be inherently resistant to aminoglycoside group of drugs which remain as a widely used first-line drug of choice for febrile neutropenic patients. Hereby, we report a case of D. acidovorans-associated pleural effusion in a patient of metastatic adenocarcinoma diagnosed and treated timely and successfully with appropriate antibiotics.

Different pulmonary adenocarcinoma growth patterns significantly affect survival

OBJECTIVE

Adenocarcinoma (AC) is the number one pathological entity of lung cancer with approximately 30-40% of cases. It is known to be heterogeneous and has 5 histopathological growth patterns. We evaluated the long-term survival rates of patients with predominant subtypes.

METHODS

290 patients with AC underwent pulmonary resection between 2012 and 2017 at our institution. We excluded all patients with lymph node involvement and distant metastases. Hence, 163 patients were included for further analysis. Predominant growth pattern was defined if more than 10% of cells showed a growth pattern. 1, 3, and 5-year survival rates were evaluated. Survival was assessed by Kaplan-Meier curves and the Cox proportional hazards model was used to identify prognostic factors for overall survival.

RESULTS

Predominant growth patterns >10% were compared to <10% growth patterns of the same subtype. 1-year, 3-year, and 5-year overall survival rates of patients with predominant solid tumor growth >10% differed significantly from patients with <10% (88.4% vs. 97.6%, p = 0.04; 65.8% vs. 87.4% p = 0.001, 36.4% vs. 65.9% p = 0.01). Survival rates did not differ between >10% papillary and acinar growth compared to <10%. Kaplan-Meier curves showed reduced overall survival for patients with solid tumor growth >10% (log-rank 0.002). Solid tumor growth >10% was an independent prognostic factor for worse long-term survival (Hazard ratio: 3.05, p = 0.01).

CONCLUSION

Our study demonstrates that the presence of a predominant solid pattern in pulmonary adenocarcinoma is a factor for an unfavorable prognosis. This should be kept in mind in daily clinical practice.

An Unusual Presentation of Aggressive Primary Invasive Adenocarcinoma of Lung

Bilateral diffuse infiltrates on chest imaging can present a diagnostic challenge due to a broader differential diagnosis which includes pulmonary and non-pulmonary causes. Malignancy is generally not considered under differential diagnosis at the time of initial presentation. Here we present a case of primary adenocarcinoma of lung manifesting as diffuse bilateral infiltrates on imaging. Our case is unique in regards to its acute presentation, rapid progression to respiratory failure, ultimately leading to the demise of the patient. This indicates the aggressive nature of this malignancy and its variable presentation, like male gender and young age, thus emphasizing the importance of entertaining malignancy in such presentations, especially if there is no response to conventional antibiotic therapy.

Appreciation of Pattern in Diagnosis of Lung Adenocarcinoma from Cytology Specimen: Our Experience with Fine Needle Aspiration Cytology and Cell Block in a Resource Constraint Setup

Background and Aims:

Advent of personalised treatment needs correct diagnosis of lung adenocarcinoma with its molecular subtyping. Minimal use of special stain or immunohistochemistry (IHC) in small specimens save material for molecular testing. Various histologic patterns in adenocarcinoma (ADC) subtypes have different prognostic implications and current recommendation is to describe these patterns in small specimens. Aim of this study was to diagnose adenocarcinoma from cytology specimens depending on adenocarcinoma pattern on fine needle aspiration smears and cell blocks. We also studied the additional role of cell blocks as a platform for special stain and IHC.

Materials and Methods:

Conventional smears and cell block (CB) preparation were examined from transthoracic CT guided FNA samples of suspicious lung malignancy cases. Clear defining architectural pattern and cytomorphological features in favour of adenocarcinoma were evaluated and mucin stain and IHC were used as and when required.

Results:

A total of 86 cases were included in this study, of which 83 cases were diagnosed as adenocarcinoma, 52 (62.5%) showed clear cut evidence of adenocarcinoma from smears and CBs. CB morphology alone aided the diagnosis in 12. Various ADC patterns in combination or alone were appreciated in these 64 cases. Sixteen needed mucin stain and 3 needed IHC for diagnosis. Forty one were ADC with solid pattern of which 39 showed high nuclear grade.

Conclusion:

Adequately cellular FNA smears and corresponding cell blocks of optimal quality can aid effectively in diagnosing adenocarcinoma and appreciating its pattern. Therefore, it would minimize the need for special stain and/or IHC with preservation of more material for molecular testing.

Nonthyroidal metastatic lesion in thyroid: A missed diagnosis and a lesson learnt

Background

Blood supply to the thyroid is relatively high when compared to that of liver. Despite this documented metastatic deposit in thyroid remains a rarity. Synchronous nonthyroidal metastatic deposit in thyroid from a lung primary is relatively rare. Metastasis to thyroid portends to poor prognosis, and hence a metastatic deposit has to be excluded in any suspicious lesion of thyroid.

Materials and Methods

Details of a rare presentation of a malignant thyroid lesion, a secondary deposit from an asymptomatic primary papillary adenocarcinoma of lung, who had presented to this tertiary care center was retrieved and analyzed.

Results

Patient with an initial diagnosis of papillary carcinoma on FNA was taken up for total thyroidectomy and cervical lmphadenectomy. HPR was mucinous carcinoma of thyroid with high lymph nodal metastasis. In view of the exrathyroidal disease an adjuvant external beam radiotherapy was considered for him. Unfortunately, the radiotherapy planning CT scan revealed left sided lung lesions with pleural effusion which was proved to be papillary adenocarcinoma of lung on biopsy, with metastases to thyroid. He was treated with chemotherapy but he succumbed to his illness 9 months from the date of diagnosis.

Conclusion

Although encountered rarely, metastatic lesions in thyroid from nonthyroidal primaries need to be excluded while evaluating thyroid lesions.

Epidermal growth factor receptor mutation in adenocarcinoma lung in a North Indian population: Prevalence and relation with different clinical variables

Introduction:

Lung cancer is one of the most common causes of cancer deaths worldwide. Adenocarcinoma is taking over squamous cell lung cancer as the predominant histological subtype. Several cytotoxic drugs are available for the treatment of lung cancer, but side effects limit their use. Recently, targeted therapies for cancers have come into clinical practice.

Aims and Objectives:

To determine the prevalence of epidermal growth factor receptor (EGFR) mutation in adenocarcinoma lung in a North Indian population and its relation with different clinical variables.

Materials and Methods:

A total of 57 patients who met inclusion criteria were recruited into the study. Relevant history, clinical examination and investigations were done. EGFR mutation was done in all patients.

Results:

A total of twenty patients tested positive for EGFR mutation. EGFR was more frequently detected in female patients (53.8%), while as only 19.4% of the male patients expressed EGFR mutation, which was statistically very significant (P = 0.007). EGFR mutation was more frequently detected in nonsmokers (52%) as compared to smokers (21.9%) which also was statistically significant (P value of 0.018). EGFR mutation was more common in Stage III and IV adenocarcinomas (48%) as compared to Stage I and II (21.4%) which was statistically significant (P value 0.034).

Conclusion:

EGFR mutation should be routinely done in all patients of adenocarcinoma lung particularly non-smoker females with Stage III and IV disease.

Orbital and infratemporal fossa metastasis: An unusual initial presentation of adenocarcinoma of lung

Orbital metastasis as initial presentation of adenocarcinoma of lung is an extremely rare phenomenon. Here, we report a 46-year-old non-smoker Asian woman, who presented with right eye proptosis due to right orbital and infratemporal fossa metastasis, as the first presentation of adenocarcinoma of right lung.

A rare case of non-small cell carcinoma of lung presenting as miliary mottling

Miliary mottling on chest radiography is seen in miliary tuberculosis, certain fungal infections, sarcoidosis, coal miner's pneumoconiosis, silicosis, hemosiderosis, fibrosing alveolitis, acute extrinsic allergic alveolitis, pulmonary eosinophilic syndrome, pulmonary alveolar proteinosis, and rarely in hematogenous metastases from the primary cancers of the thyroid, kidney, trophoblasts, and some sarcomas. Although very infrequent, miliary mottling can be seen in primary lung cancers. Herein, we report the case of a 28-year-old female with chest X-ray showing miliary mottling. Thoracic computed tomography (CT) features were suggestive of tuberculoma with miliary tuberculosis. CT-guided fine needle aspiration cytology confirmed the diagnosis as lower-lobe, left lung non-small cell carcinoma (adenocarcinoma). It is rare for the non-small cell carcinoma of the lung to present as miliary mottling. The rarity of our case lies in the fact that a young, non-smoking female with miliary mottling was diagnosed with non-small cell carcinoma of the lung.

Case report: Biphasic presentation of multicystic haemorrhagic metastatic adenocarconoma of the lung

Lung cancer is the one of the leading causes of death worldwide. Adenocarcinoma of the lung makes up over a quarter of all incidence of lung cancer. Multiple case reports describe haemorrhage resulting from primary or metastatic lesions affecting different organs. This case report describes an unusual presentation of a benign lung lesion that later progressed to multiple metastases with a characteristic radiological appearance. A review of prior similar reported cases is also included.

Non-small cell lung carcinoma presenting as carcinomatous meningitis

Meningeal carcinomatosis is a diffuse infiltration of leptomeninges and sub arachnoid space by malignant cells metastasizing from systemic cancer. Primary bronchogenic carcinoma presenting as carcinomatous meningitis is a very rare occurrence in clinical practice, often occurring during the treatment course of the underlying malignancy. We present this rare presentation in a young non-smoker male.