Metastatic lung adenocarcinoma in a 20-year-old patient

O. Khan, MD, W.P. Tong, MD, and N.J. Karlin, MD

Author information Copyright and License information

Abstract
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1.INTRODUCTION
Lung cancer is the leading cause of death for men and women in the United States, surpassing
deaths from breast, prostate, and colon cancer 1. The age-adjusted incidence for 2006 reveals that
lung cancer is the number one cause of death for men over the age of 40 and for women over the
age of 601. Increasing age and tobacco use constitute the strongest risk factors for lung cancer.
Young patients under 25 years of age without a history of tobacco use, environmental exposures,
or genetic predisposition are only rarely diagnosed with lung cancer. Non-small-cell lung cancer
(NSCLC) typically presents at a more advanced stage and carries a poor prognosis.
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2.CASE DESCRIPTION
A 20-year-old man with no history of tobacco use presented with a several-months history of
cough and lower back pain, and an 11.3-kg weight loss. Because of the persistent cough and
development of hemoptysis, further imaging studies were obtained. A chest radiograph revealed
total opacification of the right lung (Figure 1).

FIGURE 1
Posteroanterior view of the chest demonstrates complete opacification of the right hemithorax.
The patient was diagnosed with pneumonia and was started on antibiotics, but he did not
improve.
Infectious serologies were negative. Computed tomography imaging of the thorax revealed a
778- cm mass in the superior right hilum, total collapse of the right lung with post-obstructive
atelectasis, and mediastinal lymphadenopathy (Figure 2). Further imaging revealed
retroperitoneal lymphadenopathy, renal and pancreatic masses, skeletal metastases in the pelvis
and vertebral bodies, and intraparenchymal brain metastases. Interestingly, both adrenal glands
were spared.

FIGURE 2
Computed tomography imaging of the thorax, with contrast, reveals a poorly defined 778-cm
superior hilar mass.
Placement of a right bronchial stent and mediastinoscopy with biopsy were performed. The
biopsy revealed poorly differentiated epithelioid tumour with desmoplastic stromal reaction,
neutrophil infiltration, and squamous differentiation (Figure 3). The tumour cells stained positive
for epithelial membrane antigen, pancytokeratin, thyroid transcription factor 1, and cytokeratins
8 and 7. Testing for epidermal growth factor receptor mutation and amplification was negative.
Isochrome 12p was not detected. Serum human chorionic gonadotropin was 3.6 IU/L (normal
range: 00.6 IU/L) and alpha fetoprotein was 1.5 ng/mL (normal reading: <6 ng/mL). Testicular
ultrasound was unremarkable. These findings confirmed a primary lung adenocarcinoma.

FIGURE 3
Biopsy of the mediastinal mass shows a poorly differentiated carcinoma, non-small-cell type.
(Courtesy Kevin Leslie, MD, of the Department of Pathology, Mayo Clinic Arizona; with
permission)
The patient was urgently treated with cisplatin and etoposide. Radiotherapy was also initiated to
lung, spine, and pelvis. He improved clinically, but required several hospitalizations throughout
chemotherapy. Ultimately, his disease progressed, and he died within 9 months of the initial
diagnosis.
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3.DISCUSSION
Lung cancer is the leading cause of cancer-related death worldwide, with NSCLC accounting for
85% of all lung cancers 2. Lung adenocarcinoma has the highest incidence among lung cancer
patients, with a sex-specific incidence of about 30% in men and 37% in women in the United
States 3. The strongest risk factors for lung cancer are tobacco use and age, although small-cell
lung cancer and squamous cell lung cancer have a stronger association with tobacco use than
does lung adenocarcinoma 3.
In patients under 25 years of age, NSCLC is exceedingly rare, having an incidence rate for 2002
2006 of 0.3 per 100,0004. The most common types of lung cancer in this group of patients are
pleuropulmonary blastoma, germ-cell tumours (teratocarcinoma), carcinoid, and metastatic

cancer from a non-lung primary 5. In reference to NSCLC occurring in young people, a higher
incidence of adenocarcinoma is seen in female patients, and most cases show no history of
tobacco use 6. This observation suggests that genetic factors may have a greater role in the
development of cancer in this patient population. Genetic factors are known to play a role in the
development of lung adenocarcinoma, and familial genetic clustering of lung cancer has been
found. Common gene mutations in KRAS, EGFR, and TP53 have been associated with a higher
risk for development of lung adenocarcinoma. We do not know the KRAS status for this patients
tumour.
Survival in this group of patients remains highly variable. Mizushima et al. found no difference
in survival between lung adenocarcinoma patients less than and more than 30 years of age 6.
Similarly, a retrospective study of patients younger than 50 years of age compared with those
older than 50 found no difference in survival or in time to disease progression 9. In contrast, two
other studies found a worse prognosis for young patients with lung adenocarcinoma than for their
older counterparts 10.
Because of the dearth of cases, data evaluating the effectiveness of treatment for lung cancer in
patients under 25 years of age are limited. Combined modalities of chemoradiation and surgical
resection have been tried and compared. Bourke et al. studied lung cancer in patients less than 45
years of age, comparing them with patients more than 45 years of age at three different
geographic sites 11. In that study, lung cancer staging was demonstrated to be the factor most
determinant for survival in patients less than 45 years of age 11.
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4.CONCLUSIONS
Metastatic NSCLC is rare in patients under the age of 25 years. Additional malignancies to be
considered for thoracic masses in this age group include germ cell tumours (teratocarcinoma),
lymphoma, carcinoid, and metastases from a non-lung primary cancer. The prognosis of
metastatic NSCLC in young patients remains dismal. Further clinical trials evaluating this group
of patients with metastatic NSCLC are desperately needed.
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5. ACKNOWLEDGMENTS
The authors thank Dr. Helen Ross of Hematology and Oncology and Dr. Kevin Leslie of
Pathology.

CT scan (computer tomography) and PET scan (positron emission

tomography) are different but related imaging techniques. A PET scan
uses nuclear medicine imaging to produce a three-dimensional picture
of functional processes in the body. PET scans provide metabolic
information and are increasingly read alongside CT or MRI (magnetic
resonance imaging) scans, which provide anatomic information.

Comparison chart
CT Scan

PET Scan

Cost CT Scan costs range from $1,200 to $3,200; they

usually cost less than MRIs (about half the price
of MRI).

PET scans cost $3,000 to

$6,000; much higher than
regular CT scans.

Time taken Usually completed within 5 minutes. Actual scan

for complete time usually less than 30 seconds. Therefore, CT
scan is less sensitive to patient movement than MRI.

Usually takes 2 to 4 hours

Radiation The effective radiation dose from CT ranges

exposure from 2 to 10 mSv, which is about the same as the
average person receives from background
radiation in 3 to 5 years. Usually, CT is not
recommended for pregnant women or children
unless absolutely necessary.

Moderate to high radiation

Principle Uses X-rays for imaging

used for
imaging

Effects on the Despite being small, CT can pose the risk of

body irradiation. Painless, noninvasive.
Acronym for Computed (Axial) Tomography
Scope of CT can outline bone inside the body very
application accurately.
History The first commercially viable CT scanner was
invented by Sir Godfrey Hounsfield in Hayes,

Radioactive tracers that emit

positrons are used. The
positrons are tracked by the
system to generate a 3D image
over time.
Radiation risk from the
injection of a radioactive tracer
is about the same as an X-ray
Positron emission tomography
PET scans can image biological
processes within the body.
The compound was first
administered to two normal

CT Scan

PET Scan

United Kingdom. First patient's brain-scan was

done on 1 October 1971.

human volunteers by Abass

Alavi in August 1976 at the
University of Pennsylvania.

Contents: CT Scan vs PET Scan

1 Applications

2 Principle and Procedure

o 2.1 Related Videos

3 Cost Comparison

4 Advantages of PET vs. CT scan

5 Risks

6 References

Applications

PET Scan brain image of a patient with Alzheimer's disease (L).

A CT scan provides good detail about bony structures and some detail of soft
tissues. It answers the question What does it look like?. For example, an
abnormal growth like a tumor can be easily detected using a CT scan. A PET

scan on the other hand is more useful in providing a good detail of functioning
of body parts. It answers the question How is it working?. For example, staging
and monitoring treatment of cancers.
CT Scanning is useful for screening diseases such as coloncancer, detecting
injuries and abnormalities in the head, chest, heart, abdomen and extremities.
This technique is often combined with other techniques such as MRI,
andultrasonography.
PET scanning is used effectively in oncology (study and treatment of cancer),
neurology, cardiology, Cognitive neuroscience, Psychiatry, Pharmacology and
Muscular-Skeletal Imaging.

Principle and Procedure

A CT scan relies on a series of X-rays and is usually completed within 5-10
minutes. On the other hand, a PET scan takes anywhere between 2 to 4 hours.
The basic principle behind a CT scan relies on the reconstruction of a three
dimensional image of an organ, by a computer. During a CT scan, the patient is
moved along the scanning system, during which multiple X-ray images of the
organ being examined are acquired from different angles. These images are
obtained by passing multiple beams of X-rays through the region of interest.
Sophisticated computer algorithms combine all these images to create a view of
the organ, which is available soon after the scan is complete.

Related Videos
This video explains how a CT scan is performed:
During a PET scan, a radioactive substance like fluorine-18 (F18), fluorodeoxyglucose (FDG) or oxygen-15 is injected into the patients body.
This is called a tracer or radiotracer. Each tracer has the ability to get absorbed
by the particular organ or tissue being studied. It takes 30 minutes to an hour for
the tracers to get absorbed. Only then can the patient be moved into the PET
scanner and imaging can start. The tracer is injected into the body on a
biologically active molecule and emits pairs of gamma rays. The PET scan

system detects these gamma rays and thereby determines the movement of the
tracer in the body over time. This movement is then reconstructed via a CT scan.
This video provides a good overview of how PET scans work:

Cost Comparison
CT Scan costs range from $1,200 to $3,200 and the cost of PET scan depends on
the area examined and usually ranges form $3,000 to $6,000. The cost might vary
in different countries.

Advantages of PET vs. CT scan

CT scans have advantages in viewing anatomical structures. Due to the high
contrast resolution of CT scanning, differences between the tissues are more
apparent compared to other techniques. Further, imaging in CT scan removes
the superimposition of structures other than the area of interest. The data from a
single procedure can be viewed in different planes and thus increases diagnostic
ability. This technique is also popular because it can be used to diagnose a
number of conditions. This might eliminate the need for other diagnostic
techniques such as colonoscopy.
Moreover, a U.S. government-financed study showed that annual CT scans of
heavysmokers reduce the risk that they will die from lung cancer by 20 percent.
[1]

PET scans have an advantage over regular CT scans in determining the

functioning of biological processes. In a PET scan the imaging technique gets
down to the cellular level of the body, hence it can detect the early onset of
disease like cancer, before they start showing up in CT scan. It is also very useful
in finding out how effective the treatment is.

Risks
CT scans are associated with the risk of causing cancers, such as lung cancer,
colon cancer and leukemia. This is mainly due to the use of X-rays. There are
other safety concerns associated with the use of contrast agents which are

administered intravenously. However, these disadvantages can be reduced with

the use of lower doses.
There is exposure to ionization radiation in a PET scan. Pregnant or
breastfeeding women should not get this scan done. Some mild allergic reaction
may occur in some people because of the radioactive substance used. Sometimes
abnormal blood sugar and insulin levels may result in an erroneous PET report.

Lung cancer stages

Small cell lung cancer staging
Small cell lung cancer stages are classified in one of two ways:

Limited stage: Cancer is in one lung, sometimes including nearby lymph nodes.
Extensive stage: Cancer has spread to the other lung, the fluid around the lung (the pleura)
or to other organs in the body.
Non-small cell lung cancer staging
Non-small cell lung cancer staging uses the TNM system:

Tumor(T) describes the size of the original tumor.

Lymph node (N) indicates whether the cancer is present in the lymph nodes.

Metastasis (M) refers to whether cancer has spread to other parts of the body, usually the
liver, bones or brain.
A number (0-4) or the letter X is assigned to each factor. A higher number indicates increasing
severity. For instance, a T1 score indicates a smaller tumor than a T2 score. The letter X means the
information could not be assessed.
Once the T, N and M scores have been assigned, an overall stage is assigned.
Stages of non-small cell lung cancer:

Stage I non-small cell lung cancer: Cancer may be present in the underlying lung
tissues, but the lymph nodes remain unaffected.

Stage II non-small cell lung cancer: The cancer may have spread to nearby lymph
nodes or into the chest wall.

Stage III non-small cell lung cancer: The cancer is continuing to spread from the
lungs to the lymph nodes or to nearby structures and organs such as the heart, trachea and
esophagus.

Stage IV non-small cell lung cancer: The cancer has metastasized throughout the
body and may now affect the liver, bones or brain.