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━━ Background. Lepidic predominant adenocarcinoma was previously termed non-mucinous bronchioalveolar carcinoma prior to the reclassification of adenocarcinomas proposed by the International Association for the Study of Lung Cancer (IASLC) American Thoracic Society (ATS) European Respiratory Society (ERS) in 2011. Most lepidic predominant adenocarcinomas present as peripheral localized forms on computed tomography imaging; however, various features may be observed. Case. A 70-year-old male with a seven-month history of a wet cough visited our hospital due to the exacerbation of dyspnea on effort for one month. Chest computed tomography (CT) revealed an extensive crazy-paving appearance, consolidation with an air bronchogram and areas of partially centrilobular ground-glass opacity; these findings suggested an advanced stage of aerogenous spread. Lepidic predominant adenocarcinoma (cT4N3M1a, stage IV and exon 21 point mutated: L858R) was diagnosed based on the findings of a transbronchial lung biopsy and imaging studies. The patient’s bronchorrhea and hypoxemia, confirmed on the day of admission, were rapidly ameliorated following the administration of an epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI), gefitinib, as the first-line therapy. A partial response was achieved; however, the underlying lung adenocarcinoma gradually worsened. Although secondand third-line chemotherapies were administered, the patient died 26 months after diagnosis. Conclusions. It is important to pay attention to lesions with light abnormalities when interpreting the features of diffuse shadows on chest CT images and pathological examinations in order to estimate the distribution of lesions in lobular units. Furthermore, EGFR-TKI is effective in patients presenting with lung adenocarcinoma and bronchorrhea, due to its anti-tumor effect and the potential for a direct reduction in the level of mucus production. (JJLC. 2014;54:212-217) KEY WORDS━━ Aerogenous, Centrilobular, Epidermal growth factor receptor tyrosine kinase inhibitor, Lepidic predominant adenocarcinoma, Crazy-paving appearance Reprints : Makoto Hibino, Department of Respiratory Medicine, Shonan Fujisawa Tokushukai Hospital, 1-5-1 Tsujido Kandai, Fujisawa, Kanagawa 251-0041, Japan (e-mail: m-hibino@ctmc.jp). Received March 30, 2014; accepted June 25, 2014. 要旨━━背景.置換性増殖優位型浸潤性腺癌は,以前は 粘液非産生性細気管支肺胞上皮癌と呼ばれており,多彩 な画像所見を呈する.症例.70 歳の男性.7か月間の湿 性咳嗽と 1か月前からの労作時呼吸困難感を認めて受診 した.胸部CTで広範囲に気管支透亮像を伴う浸潤影と メロンの皮様網目状陰影を認め,一部分に小葉中心性の すりガラス陰影を認めた.以上より経気道散布する病変 が進行している状態が考えられ,経気管支肺生検の結果, 置換性増殖優位型浸潤性腺癌,cT4N3M1a,IV期と診断 した.気管支漏,低酸素血症を認めたが,エクソン 21 1湘南藤沢徳洲会病院呼吸器内科;2瀬戸内徳洲会病院総合内科. 別刷請求先:日比野真,湘南藤沢徳洲会病院呼吸器内科,〒2510041 神奈川県藤沢市辻堂神台 1-5-1(e-mail: m-hibino@ctmc.jp). 受付日:2014 年 3 月 30 日,採択日:2014 年 6 月 25 日. (肺癌.2014;54:212-217) 2014 The Japan Lung Cancer Society Computed Tomographic Findings Suggesting the Progress Pattern of Lung Adenocarcinoma―Hibino et al Japanese Journal of Lung Cancer―Vol 54, No 4, Aug 20, 2014―www.haigan.gr.jp 213 Figure 1. Chest roentgenogram showing infiltration in the middle and lower lung fields in both lungs. の点突然変異(L858R)を確認した後にゲフィチニブを投 与したところ,症状は迅速に改善し酸素療法を離脱でき た.一旦は改善したが,原病の悪化があり 2次,3次治療 を行ったが治療開始後 26 か月で死亡した.結論.胸部 CT読影や病理学的検索の際,小葉単位における病変分 布の推定を行うためには,病変の程度が軽い部分で行う ことが重要である.また,気管支漏を呈する肺腺癌に対 する上皮成長因子受容体チロシンキナーゼ阻害剤の有用 性は,抗腫瘍効果に加え,同薬剤による直接的な粘液産 生抑制が関与している可能性が考えられた. 索引用語━━経気道散布,小葉中心性,上皮成長因子受 容体チロシンキナーゼ阻害剤,置換性増殖優位型浸潤性

Computed Tomographic Findings Suggesting a Progressive Pattern of Lepidic Predominant Adenocarcinoma