Chest
Volume 132, Issue 3, Supplement, September 2007, Pages 306S-313S
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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Bronchioloalveolar Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

https://doi.org/10.1378/chest.07-1383Get rights and content

Objectives

To review the current evidence on special issues relating to the diagnosis, imaging, prognosis, and treatment of bronchioloalveolar carcinoma (BAC).

Methods

This guideline focuses on aspects of BAC that are unique and ways in which BAC differs importantly from other forms of non-small cell lung cancer (NSCLC). The author reviewed published literature reporting on BAC using key words “histology,” “CT scans,” “fluorodeoxyglucose positron emission tomography scan,” “sensitivity,” “specificity,” “surgical resection,” “sublobar resection,” and “epidermal growth factor receptor tyrosine kinase inhibitor” and selected references from published review articles. Also included was a review of the 1999 World Health Organization (WHO) revised classification system for lung tumors, which established a more restrictive definition of BAC to tumors with a pure lepidic spreading pattern and no evidence of stromal, vascular, or pleural invasion.

Results

With the notable exception of a lower likelihood of a positive positron emission tomography finding in the presence of BAC, staging, diagnosis, and treatment are the same as for other histologic subtypes of NSCLC, but additional treatment options that may prove to be equivalent, if not more effective, for more patients exist (eg, epidermal growth factor receptor tyrosine kinase inhibitor therapy, sublobar resection).

Conclusions

BAC is a form of adenocarcinoma with unique clinical, radiologic, and epidemiologic features. The diagnosis of BAC should be reserved for tumors that meet the WHO criteria. Additional clinical trials are needed on this population of patients, using strict definitions and enrollment criteria to allow the results to be applied to appropriate patient populations.

Section snippets

Materials and Methods

The diagnosis, staging, physiologic evaluation, and treatment of NSCLC are thoroughly covered in other guideline chapters. Therefore, the clinical questions in this guideline were chosen to focus on areas in which there are important differences between BAC and other forms of NSCLC.

These guidelines are restricted to patients with known or suspected “pure BAC” as defined in the 1999 WHO revised classification for lung tumors. This classification system requires that the term bronchioloalveolar

Are There Distinctive Clinical and Epidemiologic Features of Patients With BAC? Are There Prognostic Differences Between BAC and Other NSCLC Histologic Subtypes?

Compared with patients who have other forms of lung cancer, patients with BAC are more likely to be nonsmokers (although smokers are at increased risk for all forms of lung cancer, regardless of histology) or have a minimal smoking history. The proportion of patients who have BAC and are female is closer to 50% and is higher than in other histologic types of lung cancer, and the occurrence of nodal spread and extrathoracic metastasis is much less than in other forms of NSCLC.5

The pathologic

Recommendations

1. We recommend that the use of the term bronchioloalveolar carcinoma be reserved for lung cancers that meet the criteria established in the revised WHO classification system for lung tumors. Grade of recommendation, 1B

2. For patients with suspected BAC, we recommend that a surgical biopsy be used to establish a histopathologic diagnosis. Grade of recommendation, 1C

Recommendation

3. For patients who are unable to undergo surgical biopsy, the diagnosis of BAC should be made only with compatible histopathologic pattern on transbronchial or core needle biopsy and a CT demonstrating a pure ground-glass or pneumonic appearance. Grade of recommendation, 1C

Recommendation

4. For patients whose CT scans show ground-glass attenuation or pneumonic consolidation (suggesting BAC), PET scans often show false-negative results, and therefore we recommend that a PET scan with negative results be followed by additional diagnostic testing to exclude the presence of cancer. Grade of recommendation, 1C

Recommendation

5. In patients who have suspected BAC and are good surgical candidates, a sublobar resection may be appropriate, provided that the CT scan shows a pure ground-glass appearance, intraoperative pathologic consultation confirms pure BAC without evidence of invasion, and surgical margins are free of disease. Grade of recommendation, 1B

Recommendation

6. For patients with good PS and unresectable BAC, we recommend the use of standard chemotherapy. The use of first-line EGFR-targeted agents should be reserved for patients with poor PS or those who are enrolled in clinical trials. Grade of recommendation, 2C

Conclusions

BAC is a form of adenocarcinoma with unique clinical, radiologic, and epidemiologic features. Hints that the presence of BAC should be considered frequently come from findings of a pure ground-glass nodule or nodules on a CT scan. Alternatively, the presence of a pneumonic consolidation that does not respond to pneumonia therapy should raise BAC in the differential diagnosis. With the notable exception of a lower likelihood of positive PET scan results in the presence of BAC, staging,

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    The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml)

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