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Pulmonary ‘alveolar cell’ (bronchiolar) carcinoma report of three cases in Thailand
268
Tubercle, Lond., (1960), 41, 268
Pulmonary 'Alveolar Cell' (Bronchiolar) Carcinoma Report of Three Cases in Thailand By S. BOVORNKITTI, P. KANGSADAL, S. KARNCHANAKUNCHORN and
S. TANDHANAND from The Departments of Medicine and Pathology, Siriraj Hospital Medical School, Dhonburi, Thailand
This is the first record of pulmonary 'alveolar cell ' (bronchiolar) carcinoma in Thailand. Three cases are here reported.
Case Reports CASE I
A farmer of 4-1, of pure Thai race, was admitted to hospital on 7.12.56. He had smoked 10 cigarettes daily for 20 years. He complained of chest pain and dyspnoea with slight evening fever for 2 months. He was thin but did not look ill. The chest x-ray showed diffuse fine mottling throughout the right lung field with a large left pleural effusion (Fig. 1) . No tubercle bacilli or malignant cells were found in the sputum. The pleural fluid was blood-stained and many large 'atypical' cells were seen in the deposit.Biopsy of a right axillary node showed chronic inflamatory changes only. He died of asphyxia 35 days after admission. Post-mortem Examination Both lungs contained many small, nodular tumours, with the characteristic histological appearances of 'alveolar cell' carcinoma (Fig. 2) . There were metastases in the liver, spleen and mediastinal lymph nodes .
2 A male hotel worker, 54 years old, of pure Thai race, living in a town, was admitted on 28.8.57. He had smoked 10 cigarettes a day for 20 years. For 6 weeks he had been short of breath and complaining of pain in the left shoulder, chest and flank. He was thin, but did not look ill. There was no fever. There was a t em . node above the left clavicle. The chest x-ray showed diffuse fine mottling in the right lung field and a moderate left pleural effusion. The sputum was negative for tubercle bacilli and malignant cells. The pleural fluid was slightly blood stained-'smoky' pale yellow-and the sediment contained 'cancer cells'. Biopsy of the suprac1avic1ar node showed inflamatory changes only. Liver biopsy showed only cloudy swelling. Treatment with nitrogen mustard gave no benefit and he died of asphyxia 78 days after admission. CASE
Post-mortem Examination Both lungs contained many small nodules of tumour. The histological appearances were characteristic of 'alveolar cell' carcinoma (Fig. 3). There were metastases in the liver and greater omentum.
PULMONARY 'ALVEOLAR CELL' CARCINOMA
FIG. I, Case I. - Diffuse fine mottling in right lung field.
269
Fig. 2, Case I. - Columnar cells lining alveolar spaces, heaped up in places into papillary folds.
FIG. 3, Case 2. - Alveoli packed with solid masses of malignant cells.
270
TUBERCLE
3 A chief engineer of 61, resident in a town and of pure Thai race was admitted on 12.12.58. He had smoked 20-30 cigarettes a day for 20 years, but ceased smoking al together 20 years ago. For 2 months he had complained of oppression in the chest, 'jerky' breathing, and slight evening fever with loss of weight. He did not look ill. There was a t em. node above the left clavicle. Chest x-ray showed diffuse, fairly well defined fine mottling in the right lung field and a large left pleural effusion Sputum was negative for tubercle bacilli and malignant cells. The pleural fluid was slightly blood-stained and the sediment contained 'cancer cells'. Biopsy of the supraclaviclar node showed inflamatory changes only. Liver biopsy showed no malignant tissue. He was treated with a nitrogen mustard preparation (methylbis(chloroethyl)amine-N-oxide hydrochloride) and there was impressive improvement in his general condition, lasting for nearly 4 months. But he then deteriorated and died of asphyxia 143 days after admission. CASE
Post-mortem Examination There were diffuse, small nodular tumours in both lungs with metastases in the liver, mesentery and left kidney. The histological appearances were characteristic of pulmonary 'alveolar cell' carcinoma (Fig. 4).
FIG 4, Case 3. - Less differentiation of the 'alveolar cells' with many mitotic
figures.
PULMONARY 'ALVEOLAR CELL' CARCINOMA
271
Comment In each year from 1956 to 1958 a single case of this uncommon carcinoma of the lung was observed in the Medical Service of Siriraj Hospital. In the first case a malignant condition was suspected from the clinical and radiographic picture, confirmed by withdrawal of pleural fluid and the histological diagnosis obtained by necropsy. With the first case in mind, the subsequent two were provisionally diagnosed on admission as having 'alveolar cell' cancers. In all three the presenting symptoms and the progress were similar and in keeping with the published descriptions of the condition. The patients sought treatment because of difficulty of breathing and chest oppression or pain. Dyspnoea increased as a result of increasing alveolar block by diffuse intra-alveolar tumour masses. Before death there was hypoxia and cyanosis. The first x-rays showed only discrete, fine mottling. As the disease progressed the fine shadows got bigger, more compact and radio-opaque. Later they coalesced and finally appeared as large areas of consolidation. The early, diffuse, radiographic changes in these three cases support the hypothesis of multicentric origin. The results of treatment with nitrogen mustard in case 2 were as disappointing as has been reported by others (Smith, Knudson and Watson, 1949; McCoy, 1951; Decker, 1955). In case 3 there was an impressive improvement in general condition with methyl-bis(chloroethyl)amine-N-oxide hydrochloride; and it may have prolonged the course of the disease. But there was no improvement radiographically. The mode of origin and nomenclature of the condition are still topics for discussion. Some consider that they arise from the bronchioles ('bronchiolar carcinoma') and others from the lining of the alveoli ('alveolar-cell carcinoma'). We favour the term 'pulmonary alveolar cell carcinoma'. It has been claimed that some of the tumours are benign, and they have been called 'pulmonary adenomatosis' or 'pre-cancerous pulmonary adenomatosis', when they have metastasized. The two main types described, multiple nodular (Malassez, 1876) and diffuse (ascribed to Musser, 1903) have repeatedly been shown to be merely stages of the same disease. (Delarue and Graham, 1949; Good and others, 1950; Hutchison, 1952; Decker, 1955); and Hutchison (1952) pointed out that Musser's original description is really of a multiple nodular type which has been wrongly quoted as diffuse. Summary Three cases of pulmonary. 'alveolar cell' carcinoma are reported for the first time in Thailand. All had diffuse opacities in the lung fields with a pleural effusion, the fluid containing malignant cells. All died from suffocations and the diagnosis was confirmed by post-mortem examination. References Decker, H. R. (1955) J. thorac. Surg., 30, 230. Delarue, N. c., and Graham, E. A. (1949) J. thorae. Surg., 18, 237. Good, C. A., McDonald,]. R., Clagett, O. T., and Griffith, E. R. (1950) Amer. J. Roentgeno!.. 64, I. Hutchison, H. E. (1952) Cancer, Philad., 5,884. McCoy, H. 1. (1951) Ann. intern. Med., 34, 968. Malassez, L. (1876) Arch. physiol. norm. path. Paris, 3, 353. Mussel',]. H. (1903) Trans. Ass. Amer. Phycns., 18, 625. Smith, R. S., Knudtson, K. P., and Watson, W. L. (1949) Cancer" Philad. 2,972.
Tubercle, Lond., (1960), 41, 268
Pulmonary 'Alveolar Cell' (Bronchiolar) Carcinoma Report of Three Cases in Thailand By S. BOVORNKITTI, P. KANGSADAL, S. KARNCHANAKUNCHORN and
S. TANDHANAND from The Departments of Medicine and Pathology, Siriraj Hospital Medical School, Dhonburi, Thailand
This is the first record of pulmonary 'alveolar cell ' (bronchiolar) carcinoma in Thailand. Three cases are here reported.
Case Reports CASE I
A farmer of 4-1, of pure Thai race, was admitted to hospital on 7.12.56. He had smoked 10 cigarettes daily for 20 years. He complained of chest pain and dyspnoea with slight evening fever for 2 months. He was thin but did not look ill. The chest x-ray showed diffuse fine mottling throughout the right lung field with a large left pleural effusion (Fig. 1) . No tubercle bacilli or malignant cells were found in the sputum. The pleural fluid was blood-stained and many large 'atypical' cells were seen in the deposit.Biopsy of a right axillary node showed chronic inflamatory changes only. He died of asphyxia 35 days after admission. Post-mortem Examination Both lungs contained many small, nodular tumours, with the characteristic histological appearances of 'alveolar cell' carcinoma (Fig. 2) . There were metastases in the liver, spleen and mediastinal lymph nodes .
2 A male hotel worker, 54 years old, of pure Thai race, living in a town, was admitted on 28.8.57. He had smoked 10 cigarettes a day for 20 years. For 6 weeks he had been short of breath and complaining of pain in the left shoulder, chest and flank. He was thin, but did not look ill. There was no fever. There was a t em . node above the left clavicle. The chest x-ray showed diffuse fine mottling in the right lung field and a moderate left pleural effusion. The sputum was negative for tubercle bacilli and malignant cells. The pleural fluid was slightly blood stained-'smoky' pale yellow-and the sediment contained 'cancer cells'. Biopsy of the suprac1avic1ar node showed inflamatory changes only. Liver biopsy showed only cloudy swelling. Treatment with nitrogen mustard gave no benefit and he died of asphyxia 78 days after admission. CASE
Post-mortem Examination Both lungs contained many small nodules of tumour. The histological appearances were characteristic of 'alveolar cell' carcinoma (Fig. 3). There were metastases in the liver and greater omentum.
PULMONARY 'ALVEOLAR CELL' CARCINOMA
FIG. I, Case I. - Diffuse fine mottling in right lung field.
269
Fig. 2, Case I. - Columnar cells lining alveolar spaces, heaped up in places into papillary folds.
FIG. 3, Case 2. - Alveoli packed with solid masses of malignant cells.
270
TUBERCLE
3 A chief engineer of 61, resident in a town and of pure Thai race was admitted on 12.12.58. He had smoked 20-30 cigarettes a day for 20 years, but ceased smoking al together 20 years ago. For 2 months he had complained of oppression in the chest, 'jerky' breathing, and slight evening fever with loss of weight. He did not look ill. There was a t em. node above the left clavicle. Chest x-ray showed diffuse, fairly well defined fine mottling in the right lung field and a large left pleural effusion Sputum was negative for tubercle bacilli and malignant cells. The pleural fluid was slightly blood-stained and the sediment contained 'cancer cells'. Biopsy of the supraclaviclar node showed inflamatory changes only. Liver biopsy showed no malignant tissue. He was treated with a nitrogen mustard preparation (methylbis(chloroethyl)amine-N-oxide hydrochloride) and there was impressive improvement in his general condition, lasting for nearly 4 months. But he then deteriorated and died of asphyxia 143 days after admission. CASE
Post-mortem Examination There were diffuse, small nodular tumours in both lungs with metastases in the liver, mesentery and left kidney. The histological appearances were characteristic of pulmonary 'alveolar cell' carcinoma (Fig. 4).
FIG 4, Case 3. - Less differentiation of the 'alveolar cells' with many mitotic
figures.
PULMONARY 'ALVEOLAR CELL' CARCINOMA
271
Comment In each year from 1956 to 1958 a single case of this uncommon carcinoma of the lung was observed in the Medical Service of Siriraj Hospital. In the first case a malignant condition was suspected from the clinical and radiographic picture, confirmed by withdrawal of pleural fluid and the histological diagnosis obtained by necropsy. With the first case in mind, the subsequent two were provisionally diagnosed on admission as having 'alveolar cell' cancers. In all three the presenting symptoms and the progress were similar and in keeping with the published descriptions of the condition. The patients sought treatment because of difficulty of breathing and chest oppression or pain. Dyspnoea increased as a result of increasing alveolar block by diffuse intra-alveolar tumour masses. Before death there was hypoxia and cyanosis. The first x-rays showed only discrete, fine mottling. As the disease progressed the fine shadows got bigger, more compact and radio-opaque. Later they coalesced and finally appeared as large areas of consolidation. The early, diffuse, radiographic changes in these three cases support the hypothesis of multicentric origin. The results of treatment with nitrogen mustard in case 2 were as disappointing as has been reported by others (Smith, Knudson and Watson, 1949; McCoy, 1951; Decker, 1955). In case 3 there was an impressive improvement in general condition with methyl-bis(chloroethyl)amine-N-oxide hydrochloride; and it may have prolonged the course of the disease. But there was no improvement radiographically. The mode of origin and nomenclature of the condition are still topics for discussion. Some consider that they arise from the bronchioles ('bronchiolar carcinoma') and others from the lining of the alveoli ('alveolar-cell carcinoma'). We favour the term 'pulmonary alveolar cell carcinoma'. It has been claimed that some of the tumours are benign, and they have been called 'pulmonary adenomatosis' or 'pre-cancerous pulmonary adenomatosis', when they have metastasized. The two main types described, multiple nodular (Malassez, 1876) and diffuse (ascribed to Musser, 1903) have repeatedly been shown to be merely stages of the same disease. (Delarue and Graham, 1949; Good and others, 1950; Hutchison, 1952; Decker, 1955); and Hutchison (1952) pointed out that Musser's original description is really of a multiple nodular type which has been wrongly quoted as diffuse. Summary Three cases of pulmonary. 'alveolar cell' carcinoma are reported for the first time in Thailand. All had diffuse opacities in the lung fields with a pleural effusion, the fluid containing malignant cells. All died from suffocations and the diagnosis was confirmed by post-mortem examination. References Decker, H. R. (1955) J. thorac. Surg., 30, 230. Delarue, N. c., and Graham, E. A. (1949) J. thorae. Surg., 18, 237. Good, C. A., McDonald,]. R., Clagett, O. T., and Griffith, E. R. (1950) Amer. J. Roentgeno!.. 64, I. Hutchison, H. E. (1952) Cancer, Philad., 5,884. McCoy, H. 1. (1951) Ann. intern. Med., 34, 968. Malassez, L. (1876) Arch. physiol. norm. path. Paris, 3, 353. Mussel',]. H. (1903) Trans. Ass. Amer. Phycns., 18, 625. Smith, R. S., Knudtson, K. P., and Watson, W. L. (1949) Cancer" Philad. 2,972.