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Evolving Concepts in the Pathology and Computed Tomography Imaging of Lung Adenocarcinoma and Bronchioloalveolar Carcinoma

William D. Travis, Kavita Garg, Wilbur A. Franklin, Ignacio I. Wistuba, Bradley Sabloff, Masayuki Noguchi, Ryutaro Kakinuma, Maureen Zakowski, Michelle Ginsberg, Robert Padera, Francine Jacobson, Bruce E. Johnson, Fred Hirsch, Elizabeth Brambilla, Douglas B. Flieder, Kim R. Geisinger, Frederik Thunnisen, Keith Kerr, David Yankelevitz, Teri J. Franks, Jeffrey R. Galvin, Douglas W. Henderson, Andrew G. Nicholson, Philip S. Hasleton, Victor Roggli, Ming-Sound Tsao, Federico Cappuzzo, Madeline Vazquez

From the Departments of Pathology and Radiology, Memorial Sloan-Kettering Cancer Center; Departments of Radiology and Pathology, New York Hospital/Cornell UMC, New York, NY; Departments of Radiology, Pathology, and Oncology, University of Colorado Health Sciences Center, Denver, CO; Departments of Pathology and Radiology, M. D. Anderson Cancer Center, Houston, TX; Department of Pathology, Institute of Basic Medical Sciences, University of Tsukuba, Tsukuba-shi, Ibaraki; Cancer Screening Technology Division, Research Center for Cancer Prevention and Screening National Cancer Center, Tokyo, Japan; Departments of Pathology and Radiology, Brigham and Women's Hospital; Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Pathology, Centre Hospitalier Universitaire de Grenoble, Grenoble, France; Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA; Department of Pathology, Wake Forest University, Winston-Salem; Department of Pathology, Duke University, Durham, NC; Department of Pathology, Canisius Wihelmina Ziekenhuis, Nijmigen, the Netherlands; Department of Pathology, Aberdeen University Medical School, Aberdeen, Scotland; Department of Pulmonary & Mediastinal Pathology, Armed Forces Institute of Pathology, Washington DC; Department of Radiology, University of Maryland, Baltimore, MD; Department of Pathology, Flinders Medical Centre, Bedford Park, Australia; Department of Pathology, Brompton Hospital, London; Department of Pathology, Wythenshawe Hospital, University of Manchester, Manchester, England; Department of Pathology, University Health Network/Princess Margaret Hospital, Toronto, Ontario, Canada; and Bellaria Hospital Medical Oncology, Bologna, Italy

Address reprint requests to William D. Travis, MD, Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY, 10021; travisw{at}mskcc.org.

PURPOSE: To review recent advances in pathology and computed tomography (CT) of lung adenocarcinoma and bronchioloalveolar carcinoma (BAC).

METHODS: A pathology/CT review panel of pathologists and radiologists met during a November 2004 International Association for the Study of Lung Cancer/American Society of Clinical Oncology consensus workshop in New York. The purpose was to determine if existing data was sufficient to propose modification of criteria for adenocarcinoma and BAC as newly published in the 2004 WHO Classification of Lung Tumors, and to address the pathologic/radiologic concept of diffuse/multicentric BAC.

RESULTS: Solitary small, peripheral BACs have an excellent prognosis. Most lung adenocarcinomas with a BAC pattern are not pure BAC, but rather adenocarcinoma, mixed subtype with invasive patterns. This applies to tumors presenting with a diffuse/multinodular as well as solitary nodule pattern. The percent of BAC versus invasive components in lung adenocarcinomas appears to be prognostically important. However, a consensus definition of "minimally invasive" BAC with a favorable prognosis could not be achieved. While recognition of a BAC component is possible, the diagnosis of BAC with exclusion of invasive adenocarcinoma cannot be made by small biopsy or cytology specimens.

CONCLUSION: There is a need to work toward a mutual understanding and consensus between pathologists, clinicians, and researchers with the use of the term BAC versus adenocarcinoma. Future studies should make some attempt to quantitate these components and/or other features such as size of scar, size of invasive component, or pattern of invasion. Hopefully, this work will allow definition of a category of adenocarcinoma, mixed subtype with predominant BAC/minimal invasion and a favorable prognosis.

Supported by the International Association for the Study of Lung Cancer and the American Society of Clinical Oncology.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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