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case_images: Chest CT images. (A, B) A nodule located in the apicoposterior segment of the left upper lobe, approximately 1.3x1.4 cm in size, exhibits spiculation and lobulation, presenting moderate heterogeneous enhancement and causing adjacent pleural traction. (C-F) Multiple nodules of varying sizes are present in the upper and lower lobes of both lungs (indicated by red arrows), with the larger ones measuring approximately 1.0 cm in diameter, showing mild enhancement. the mediastinal lymph nodes were normal.
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case_images: Contrast-enhanced computed tomography (CT) of Chest showed a 1.3x1.2-cm nodule in the apicoposterior segment of the left upper lobe ( Figures 1A, B ), which was highly suspected to be peripheral lung cancer. The number of these nodules is approximately over 30 ( Figures 1C-F ). The hilar and mediastinal lymph nodes were not enlarged ( Figure 1 ).
case_images: PET-CT reveals an irregular nodule subpleurally in the apicoposterior segment of the left upper lobe, measuring approximately 1.4x1.3 cm. The nodule, adorned with minute spiculations, exerts traction on the adjacent pleura and exhibits abnormal radiotracer accumulation, with an SUVmax of 7.1. Multiple variably sized, quasicircular nodules are identified in both lungs, with diameters ranging from approximately 0.2-1.0 cm; these do not exhibit abnormal radiotracer concentrations. No additional abnormal solid changes or radiotracer accumulations are observed. No evident enlargement or abnormal radiotracer uptake was identified in the mediastinal lymph nodes.
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case_images: CT-guided percutaneous needle biopsy. (A) Percutaneous biopsy of the apicoposterior segment nodule in the left upper lobe. (B) Biopsy of the upper left lobe confirming adenocarcinoma of pulmonary origin (HE, x100, scan view). (C) The first needle biopsy of a nodule in the lingular segment of the left upper lobe. (D) The second needle biopsy of the same nodule, with a visible haemorrhagic focus at the biopsy site (within the red circle). (E) The biopsied tissue from the lingular segment of the upper left lobe, revealing haemorrhage and minor fibrous exudation within the alveolar cavity under the microscope. Focal widening of the alveolar septa and reactive hyperplasia of alveolar epithelial cells were noted, with no evident cellular atypia (HE, x100; scan view).
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case_images: To obtain a definitive diagnosis, a CT-guided percutaneous needle biopsy was performed on nodule in the apicoposterior segment of the upper left lobe ( Figure 3A ). Subsequently, hematoxylin-eosin (HE) staining of biopsy specimens confirmed to be primary lung adenocarcinoma ( Figure 3B ), the immunostaining revealed positive results for TTF-1 (+), NapsinA (+), CK7(+). However, to determine whether the nature of other nodules is intrapulmonary metastasis, considering that the nodule in left lingual lobe is close to the adenocarcinoma nodule and the nodule size is relatively large, a subsequent percutaneous lung biopsy was performed on the nodule in left lingual lobe ( Figures 3C, D ) on July 28, 2023. Postoperative pathology showed haemorrhage and a small amount of fibrous exudation in the alveolar cavity, focal widening of the alveolar septum, and reactive hyperplasia of alveolar epithelial cells with no obvious atypia ( Figure 3E ).
case_images: Surgical pathology. (A) The resected left upper lobe. The nodules identified by the two red arrows are atrophic cavernous haemangiomas. (B) This lesions was an invasive adenocarcinoma, predominantly characterised by an acinar growth pattern. The tumour dimensions were 1.8 cm x 1 cm x 0.8 cm, and there was no involvement of the pleura or bronchi or evidence of vascular invasion or perineural invasion. Tumour spread through air space (STAS) is observed. (C) Another examined nodule in the upper left lobe, pathologically diagnosed as a cavernous haemangioma with a diameter of 0.8 cm (HE, x200; scan view). Immunohistochemical staining yielded CD31(+), CD34(+), CK7(-), NapsinA(-), TTF-1(SPT24)(-), D2-40(-), and SMA(+), indicating a vascular origin.
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case_images: D2-40(-), SMA(+)( Figure 4C ). The mass was adjacent to the pleura and did not involve the bronchus ( Figure 4A ).
case_images: Four-months postoperative chest CT. (A, B) The postoperative state following the postoperative state following the lobectomy of the left upper lobe. (C, D) Multiple nodules of varying sizes in both lungs, with the larger ones measuring approximately 1.3 cm in diameter, consistent with previous findings.
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case_images: Osimertinib (80 mg orally once daily) was subsequently administered, and following 4 months of therapy, a chest contrast-enhanced CT revealed multiple nodules in both lungs, which were almost unchanged compared with before ( Figure 5 ).