A 59-year-old man who was a current smoker (30 packyears) was referred to the outpatient department of our hospital for evaluation of a huge left hilar mass with bilateral diffuse opacification of the lung fields on the chest x-ray. Although the patient had no symptoms at his first visit to our clinic, he soon developed progressive dyspnea of acute onset with hypoxemia necessitating oxygen supplementation and continuous bronchorrhea (Ͼ300 mL/d). Moreover, he could not lie on his back because of

more »

... the bronchorrhea flooding out of the nose in this position. The results of arterial blood gas analysis on room air were as follows: pH, 7.422; PaO 2 , 60.3 torr; PaCO 2 , 35.6 torr; HCO 3 , 23.2 mEq/L; BE, Ϫ0.6; O 2 Sat, 91.7%. Fiberoptic bronchoscopy and transbronchial lung biopsy revealed the diagnosis of adenocarcinoma in specimens obtained from the apical segment of the left lower lobe; no malignant cells were identified in the bronchoscopic aspirates obtained from the other lobes. Although repeat sputum cytology did not reveal any malignant cells, the carcinoembryonic antigen level in the sputum was 128 mg/dL as compared with that of 4.2 mg/dL in the serum. High-resolution computed tomography (CT) revealed bilateral diffuse groundglass attenuation (GGA) of the pulmonary parenchyma, in addition to a huge round area of consolidation in the apical segment of the left lower lobe (Figure 1 ). Positron emission tomography with fluorine-18 fluorodeoxyglucose showed a high standardized uptake value of 7.4 in the pulmonary tumor and regional hilar lymph nodes, with no evidence of any metastatic disease (Figure 2 ). We obtained informed consent from the patient for surgery after explaining to him that the surgical procedure to be undertaken may not be curative, but palliative in terms of providing relief from the disabling symptoms of bronchorrhea and dyspnea and improving the arterial oxygen saturation, and performed a left lower lobectomy with systematic radical lymph node dissection. Although a lingular segment obtained by wedge resection did not reveal any evidence of metastasis, multiple small intrapulmonary metastases were evident in the resected left lower lobe. Histopathological examination revealed adenocarcinoma with mucinous bronchioloalveolar adenocarcinoma (BAC) features ( Figure 3 ) and hilar lymph node metastases; pT3N1M0, stage IIIA. Epidermal growth factor receptor direct sequencing of exons 18 to 22 revealed the wild type. The postoperative course was uneventful. The symptoms of bronchorrhea and dyspnea disappeared rapidly, and by the end of day 2 postoperatively, the patient no longer needed oxygen supplementation; arterial blood gas analysis at this time showed a PaO 2 of 88.1 torr on room air. A postoperative CT obtained 3 weeks after the surgery (Figure 4 ) revealed complete disappearance of the diffuse GGA in the residual pulmonary parenchyma. Although he has taken adjuvant chemotherapy with paclitaxel and carboplatin and been well without any pulmonary symptom, a postoperative CT obtained 4 months after surgery revealed difuuse GGA in bilateral lungs suggesting intrapulmonary recurrence.