PMC7170120_01
Chest computerized tomography (CT) before any therapy.(A, B) CT slices showed a mass lesion in the upper lobe of right lung and partial of right pleural thickening.(C, D) CT slices showed diffuse ground-glass opacities with interlobular septal thickening called as"crazy-paving"pattern
SVDLD-35-390-g001.jpg
PMC7170120_01_SVDLD-35-390-g001.jpg
F1
Initially, computed tomography (CT) scan of his chest showed a mass lesion in right upper lobe of his lung and partial of right pleural thickening, with diffuse consolidation and ground-glass opacity in bilateral pulmones (Figure 1).
PET/CT of pulmonary alveolar proteinosis complicating with lung adenocarcinom. (A, B) A nodule showing an definate increase in glucose metabolism, with characteristics of lobulation and spiculation in the right lung apex section. (C, D) Diffuse consolidation shadow spreading over both of lungs, considered as diffuse lung cancer with mildly elevated uptake value of (18)F-FDG
SVDLD-35-390-g002.jpg
PMC7170120_01_SVDLD-35-390-g002.jpg
F2
Remaining consolidation was considered as diffuse lung cancer with mildly elevated uptake value of (18)F-FDG (Figure 2).
BALF of right upper lung. (A) HE staining showed a large number of amorphous red-dyed materials, in which scattered in a small number of alveolar macrophages and inflammatory cells. (B) PAS staining showed PAS positive in cytoplasm of some alveolar cells
SVDLD-35-390-g003.jpg
PMC7170120_01_SVDLD-35-390-g003.jpg
F3
BALF showed a large amount of amorphous red-dyed materials and a few alveolar macrophages scattered in endoalveolar space with PAS positive (Figure 3).
Pathology of transbronchial lung biopsy. (A, B) A few cancer cells infiltrated in the right lung apex section. Immunohistochemistry showed TTF-1 (+). (C, D) Large amounts of amorphous red-dyed materials filled the alveolar space with PAS (+)
SVDLD-35-390-g004.jpg
PMC7170120_01_SVDLD-35-390-g004.jpg
F4
Transbronchial lung biopsy (TBLB) found great numbers of unstructured, red-dyed granules with PAS+ and adenocarcinoma with differentiated grade II with immunohistochemical analysis for ALK-D5F3(-), CEA(-), EGFR-E746(-), EGFR-L858(-), Ki-67(5%+), NapsinA(+), TTF-1(+), SPA(+), CD68(+) and CK(+) (Figure 4).
The lesion of wedge resection in upper right lung. (A) Adenocarcinoma differentiated grade II~III, mainly presenting as acinar and solid type, rarely papillary type. (B) Little amorphous eosinophilic scattered over the alveolar space around
SVDLD-35-390-g005.jpg
PMC7170120_01_SVDLD-35-390-g005.jpg
F5
Amorphous eosinophilic substance can be seen in the alveolar of pulmonary tissue around, which was consistent with PAP (Figure 5).
Chest CT after 2 cycles of postoperative chemotherapy. (A) No tumor recurrence in right upper lobe of lung. (B) Diffuse consolidation and ground-glass opacity disappeared after therapy (wedge resection and 2 cycles of adjuvant chemotherapy)
SVDLD-35-390-g006.jpg
PMC7170120_01_SVDLD-35-390-g006.jpg
F6
CT after 2 cycles of postoperative chemotherapy (Figure 6) showed no tumor recurrence and no patchy, ground-glass opacities.
Chest CT of ninth months after therapy. (A) A ground-glass nodule found in the superior segment of lower lobe.(B) A part-solid nodule found in the upper lobe of left lung. (C, D) Multiple subsolid nodules in lower lobe of both lungs
SVDLD-35-390-g007.jpg
PMC7170120_01_SVDLD-35-390-g007.jpg
F7
T8 vertebral bone (Figure 7).SPECT/CT for whole body bone planar imaging showed multiple bone metastasis, considered the recurrence and metastasis of the adenocarcinoma. Then we reassessed as stage IVB (rT4N3M1c) and administered 2cycles of primary chemotherapy (Cisplatin 75 mg/m2 day 1, pemetrexed 500 mg/m2 day 1,every 28 days for 4 cycles) up to now.