Bronchioloalveolar carcinoma (BAC) can demonstratemany different radiologic appearances. The common ra-diologic appearances are those of a solitary peripheralpulmonary nodule, multiple nodules and lobar or dif-fuse consolidation (1). The unusual radiologic appear-ances include diffuse disease with minimal or no radio-logic signs, expansive pulmonary consolidation withoutair bronchograms, lobar atelectasis and cavitation (1).

To the best of our knowledge, there are only rare casereports of bronchioloalveolar carcinoma mimicking dif-fuse interstitial lung disease (1-3). We report here on acase of bronchioalveolar carcinoma that presented asmultiple peripheral consolidations with pleural tails,ground-glass opacities and interstitial thickening thatmimicked diffuse interstitial lung disease.

Case Report

A 60-year-old male presented with dyspnea, coughand chills that he had experienced for over one month.He had a smoking history of 30 pack years. He wastreated for pulmonary infection at a local clinic, butthere was no significant improvement of his symptoms.Right flank pain on inspiration developed and thecoughing was aggravated at night, especially when hespoke or was lying down.

The initial chest radiography showed diffusely distrib-uted multiple peripheral patchy consolidations andreticular opacities in both lungs (Fig. 1). Computed to-mography (CT) revealed multiple patchy consolidationswith pleural tails and ground-glass opacities in bothlungs; this was mainly seen in the peripheral portions.The ground-glass opacities were variable sized triangu-lar or rectangular shapes that represented secondarypulmonary lobule involvement. The subpleural linesand pleural thickening were quite prominent. Multiplesmall nodules around the consolidations, mild interlobu-lar septal thickening, a small amount of fluid collection

J Korean Radiol Soc 2006;54:497-501

─ 497 ─

Bronchioloalveolar Carcinoma Mimicking DILD: A Case Report1

Ju Young Lee, M.D., In Jae Lee, M.D., Dong Gyu Kim, M.D.2, Soo Kee Min, M.D.3, Min-Jeong Kim, M.D., Sung Il Hwang, M.D., Yul Lee, M.D., Sang Hoon Bae, M.D.

1Departments of Radiology, 2Internal Medicine and 3Pathology, HallymUniversity College of MedicineReceived December 1, 2005 ; Accepted February 14, 2006Address reprint requests to : In Jae Lee, M.D., Department of Radiology,Hallym University Sacred Heart Hospital, 896 Pyungchon-dong, Dongan-gu, Anyang-city, Kyungki-do 431-070, Korea.Tel. 82-31-380-3885 Fax. 82-31-380-3878

Bronchioloalveolar carcinoma is a disease with an insidious onset and various radio-logic manifestations. A solitary peripheral pulmonary nodule, multiple nodules and lo-bar or diffuse consolidation are the common radiological findings. We report here on acase of bronchioloalveolar carcinoma mimicking DILD (diffuse interstitial lung dis-ease) in a 60 year-old male that manifested as multiple peripheral consolidations,ground-glass opacities, subpleural lines, pleural thickening and interlobular septalthickening on CT.

Index words : LungComputed tomography (CT)Lung neoplasms

at the right major fissure and enlarged precarinal lymphnodes were the associated findings (Fig. 2).

Four days later, the symptoms had persisted and thefollow up chest radiography showed mild aggravationwith increased opacity in the right lower lung and mild-ly increased right pleural effusion, so he was admittedfor further evaluation. On the next day, bronchoscopywas performed and the cytologic examination of bron-chioalveolar lavage (BAL) fluid revealed no evidence ofmalignancy with one percent neutrophils, two percenteosinophils and 87% macrophages. On the fourth day ofadmission, open lung biopsy was done at the posteriorbasal segment of the left lung; this intervention revealedthat the lung was covered with diffuse whitish materialsand small hard plaque about 0.5 cm in diameter thatwere attached to the diaphragm. Multifocal pleural ad-hesions were also noted. The pathology report revealedit was well-to-poorly differentiated multifocal adenocar-cinoma with the mucinous-type features of bronchi-oloalveolar carcinoma showing infiltration into theabortive glands in the vascular wall (Fig. 3). The marginof biopsy specimen was positive with tumor cells. Thepatient underwent PET (positron emission tomography)-CT scan using 2-(F-18)-fluoro-2-deoxy-D-glucose (FDG)

for the metastasis work up. The scan showed multiplenodular lesions with mildly increased FDG uptake inthe right upper and bilateral lower lung fields, and alsoin the lateral and posterior subpleural areas. An associat-ed mild to moderate amount of bilateral pleural effusionwith increased FDG uptake and a mildly increased FDGuptake in the precarinal lymph nodes were also noted.There was a focal area of increased uptake in the firstthoracic vertebral body and it suggested bone metasta-sis. He was then transferred to the oncology departmentfor chemotherapy.

Although the patient was treated with chemotherapy,including IressaⓇ (Gefitinib), the serial follow-up chestradiography showed the disease had progressed with in-creased peripheral reticular nodular opacities and in-creased bilateral pleural effusion (Fig. 4). CT scanningalso showed generally progressed disease with in-creased pleural effusion, more aggravated consolida-tions, ground-glass opacities and interstitial thickeningin both lungs, and progressed mediastinal lym-phadenopathy was also noted.

Discussion

Bronchioloalveolar carcinoma remains one of themost enigmatic and controversial lung cancers and ithas a broad spectrum of radiographic appearances (3, 4).It is a disease with an insidious onset and various radi-ographic manifestations. BAC can be defined as a well-differentiated, peripheral, primary lung neoplasm thatarises beyond the recognizable bronchus, and it has atendency to spread locally into the peripheral air spacesby using the alveolar septa as a stroma (3, 4). The tumorcan spread to other areas of the lung via aerogenous andlymphogenous routes (3). The physician has to makesure there is no other bronchogenic carcinoma presentand no adenocarcinoma involving another organ be-cause metastatic adenocarcinoma from another organcannot always be reliably differentiated from tumorsthat have developed from lung tissue (3). Hill (3) retro-spectively reviewed the radiographic patterns of 136 pa-tients with bronchioloalveolar carcinoma. The lesionsfell into one of three categories: a localized nodule lessthan 4 cm in diameter, a mass or a localized area of con-solidation, or diffuse nodules or areas of consolidation.Lesion growth is characterized by a variable latency pe-riod, with some localized lesions remaining dormant orgrowing slowly over a period of years, and other diffuseor multicentric forms progress rapidly and aggressively

Ju Young Lee, et al : Bronchioloalveolar Carcinoma Mimicking DILD

─ 498 ─

Fig. 1. A 60-year-old male patient with dyspnea. The chest ra-diography shows diffusely distributed multiple peripheralpatchy consolidations and reticular opacities in both lungs.

(5). Aquino et al. (6) compared consolidated BAC withconsolidated infectious pneumonia; this revealed thatcoexisting nodules and a peripheral distribution of con-

solidation were more often seen on CT scans of consoli-dated BAC. The consolidated form of BAC accounts forapproximately 30% of all the BAC tumors and it corre-

J Korean Radiol Soc 2006;54:497-501

─ 499 ─

A B

C

Fig. 2. Computed tomography (CT) reveals multiple patchy con-solidations with pleural tails and ground-glass opacities in bothlungs with a peripheral predominance at the level of the aorticarch (A), the level of the right lower bronchus (B), and the levelof the diaphragm (C). Associated subpleural lines, pleural thick-ening and multiple small nodules are noted in both lungs.

A BFig. 3. A. (H & E, ×15) Open lung biopsy shows the normal alveolar structure (thick arrow) and tumor cells (thin arrow) in thesame section.B. (H & E, ×200) Mucin containing tall columnar cells line the alveolar walls. The nuclei show atypia and they are displaced to thebasement membrane by the mucin vacuoles.

sponds to a mucinous histologic subtype (6). Certainfindings such as multiple cysts, cavities or bubble-likeradiolucencies, an air bronchogram, bulging of the inter-lobar fissure, the CT angiogram sign and uniform, lowattenuation of the pulmonary consolidation on CT mayhelp to identify pulmonary consolidation as BAC. Thefive-year survival rate of patients with the consolidatedform of BAC is 26% (6, 7). The natural course of the dis-ease is bronchogenic dissemination throughout the lungand ultimately death by respiratory failure (6).

Ground-glass opacity is a finding seen on high resolu-tion CT, and it is defined as hazy increased attenuationof the lung with preservation of the bronchial and vas-cular margins. It is caused by the combined effects of di-minished intra-alveolar air and increased cellular densi-ty with alveolar cuboidal cell hyperplasia, thickening ofthe alveolar septa and partial filling of the terminal airspaces. Although ground-glass opacity is a nonspecificfinding, BAC must be considered in the differential diag-nosis when the size of this ground-glass opacity is larger

than 1 cm (8).We experienced a case of the rapidly progressing mul-

tifocal consolidated type of BAC, and it was was con-fused with DILD on chest radiography and CT. Onchest CT, diffusely distributed multiple patchy ground-glass opacities and patchy consolidations with pleuraltails were predominant in the peripheral portion of bothlungs. Associated multiple small nodules, interlobularseptal thickening, subpleural lines, pleural thickeningand several enlarged precarinal lymph nodes were alsonoted. The lesion was confirmed by wedge biopsy of thelung as being adenocarcinoma with a feature of the mu-cinous type of bronchioalveolar carcinoma. The PET-CTscan showed increased uptakes in the lung lesions andmultiple metastases that included pleura and bone. Thelesions were confused with diffuse interstitial lung dis-ease because they presented with multiple consolida-tions, ground-glass opacities, subpleural lines and inter-stitial thickening; these findings were predominantlyobserved in the peripheral portion of both lungs.

If there is no response or there is progression of theconsolidation in the lung disease in spite of antibioticstreatment, the possibility of the consolidated type orDILD-mimicking BAC might be considered and cytolog-ic evaluation could be recommended.

References

1. Weisbrod GL, Towers MJ, Chamberlain DW, Herman SJ,Matzinger FR. Thin-walled cystic lesions in bronchioalveolar carci-noma. Radiology 1992;185:401-405

2. Epstein DM. Bronchioloalveolar carcinoma. Semin Roentgenol1990;25:105-111

3. Hill CA. Bronchioloalveolar carcinoma: a review. Radiology1984;150:15-20

4. Jang HJ, Lee KS, Kwon OJ, Rhee CH, Shim YM, Han J.Bronchioloalveolar carcinoma: focal area of ground-glass attenua-tion at thin-section CT as an early sign. Radiology 1996;199:485-488

5. Kuhlman JE, Fishman EK, Kuhajda FP, Meziane MM, Khouri NF,Zerhouni EA, et al. Solitary bronchioloalveolar carcinoma: CT cri-teria. Radiology 1988; 167:379-382

6. Aquino SL, Chiles C, Halford P. Distinction of consolidative bron-chioloalveolar carcinoma from pneumonia: do CT criteria work?AJR Am J Roentgenol 1998;171:359-363

7. Manning JT Jr, Spjut HJ, Tschen JA. Bronchiolo-alveolar carcino-ma: the significance of two histologic types. Cancer 1984;54:525-534

8. Nakata M, Saeki H, Takata I, Segawa Y, Mogami H, Mandai K, etal. Focal ground-glass opacity detected by low-dose helical CT.Chest 2002;121:1464-1467

Ju Young Lee, et al : Bronchioloalveolar Carcinoma Mimicking DILD

─ 500 ─

Fig. 4. Four months later from the initial chest radiogram, thedisease has progressed with increased peripheral reticularnodular opacities and increased bilateral pleural effusion.

J Korean Radiol Soc 2006;54:497-501

─ 501 ─

대한영상의학회지 2006;54:497-501

미만성 간질성 폐질환을 모방한 세기관지 폐포암: 증례 보고1

1한림대학교 의과대학 방사선과학교실2한림대학교 의과대학 내과학교실3한림대학교 의과대학 병리학교실

이주영·이인재·김동규2·민수기3·김민정·황성일·이 열·배상훈

세기관지 폐포암은 잠행성 발현을 보이는 폐선암의 일종으로 다양한 방사선학적 소견을 나타낸다. 폐 말단부위

에 단일 결절형이나 미만 결절형, 분절대엽 혹은 융합성 대엽성 경화형이 흔한 형이다. 저자들은 60세 남자 환자에

서 CT상 폐 주변부의 폐경화, 간유리 음영, 늑막하 띠음영, 늑막비후, 소엽간 중격비후 등의 소견을 보여 미만성 간

질성 폐질환처럼 나타난 기관지 세포암 1예를 경험하였기에 문헌 고찰과 함께 보고한다.