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CASE REPORT Open Access
Uncommon features of surgically resected
ALK-positive cavitary lung adenocarcinoma:
a case report
Shinkichi Takamori, Masafumi Yamaguchi*, Kenichi Taguchi, Makoto Edagawa, Shinichiro Shimamatsu,
Ryo Toyozawa, Kaname Nosaki, Fumihiko Hirai, Takashi Seto, Mitsuhiro Takenoyama and Yukito Ichinose
Abstract
Some features found on chest computed tomography (CT), such as central tumor location, large pleural effusion,
and the absence of a pleural tail, and a patient age of less than 60 years, have been suggested to be useful in
predicting anaplastic lymphoma kinase (ALK) rearrangement in patients with non-small cell lung cancer (NSCLC).
A 68-year-old female patient with a history of gynecological treatment was found to have a cavitary mass in the
right lower lobe on an annual chest roentgenogram. The tumor was located in the peripheral area with a pleural
tail showing no pleural effusion. In addition, two pure ground-glass-opacity nodules (p-GGNs) in the right upper
lobe of the lung were detected on consecutive chest CT scans. The patient underwent right lower lobectomy,
partial resection of the right upper lobe, and hilar mediastinal lymph node dissection for complete resection of
each tumor. The pathological diagnosis was invasive mucinous adenocarcinoma with signet-ring cells for the
cavitary mass in the right lower lobe and invasive adenocarcinoma for the rest of the p-GGNs; subcarinal lymph
node metastasis was also detected. The ALK rearrangement was detected by fluorescence in situ hybridization
from the cavitary mass. The patient underwent four cycles of cisplatin and vinorelbine chemotherapy as standard
adjuvant chemotherapy for pStage III NSCLC. The ALK fusion gene status of NSCLC with atypical CT features should
also be investigated.
Keywords: Anaplastic lymphoma kinase, Cavitary mass, Radiological feature
Background
Several radiological features delineated by chest computed
tomography (CT) of non-small cell lung cancer (NSCLC)
have been reported to be associated with some utility in
detecting the gene mutation status, such as epidermal
growth factor receptor (EGFR) or anaplastic lymphoma
kinase (ALK) rearrangement. Certain features of a tumor
on chest CT, such as convergence, notch, and a pleural
tail, have been reported to have a significant association
with an EGFR or ALK fusion gene mutation [1–5]. With
regard to the mutation of the ALK fusion gene, the com-
bination of certain tumor features on chest CT, such as a
central tumor location, large pleural effusion, and the ab-
sence of a pleural tail, and a younger patient age (<60 years
old), were shown to have a significant relationship with
ALK rearrangement in patients with NSCLC [6]. In gen-
eral, larger squamous cell carcinomas often show cavita-
tion, and cavitary masses have been found in a number of
adenocarcinoma patients who had a poor prognosis [7].
We herein report a case of surgically resected lung
adenocarcinoma that presented as a cavitary mass har-
boring ALK fusion with rare radiological features.
Case presentation
A 68-year-old female was found to have a cavitary mass
on annual chest roentgenography in December 2015. She
had a history of treatment for cervical cancer in the uterus
in 2001 and had been followed up at our hospital without
recurrence. She was a never-smoker and had no signifi-
cant abnormalities on a physical examination except for
an abdominal scar related to the treatment for her cervical
cancer.
* Correspondence: yamaguchi.m@nk-cc.go.jp
Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1
Notame, Minami-ku, Fukuoka 811-1395, Japan
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Takamori et al. Surgical Case Reports  (2017) 3:46 
DOI 10.1186/s40792-017-0322-2
Chest CT revealed a cavitary mass, approximately
4.3 cm in its maximum dimension, in the basal segment
of the right lower lobe of the lung (Fig. 1a). In addition,
we noted 2 pure ground-glass-opacity nodules (p-GGNs),
8 and 12 mm in their maximum dimensions. Retrospect-
ively, abdominal CT performed in 2008 occasionally re-
vealed a tiny nodule in the basal segment of the right
lower lobe adjacent to the visceral pleura on the dia-
phragm (Fig. 1b). No significant hilar or mediastinal
lymph node swelling was observed. fluorodeoxyglucose
positron emission tomography (FDG-PET) showed no ab-
normal accumulation except in the mass in the right lower
lobe. A biopsy of the tumor via fiber optic bronchoscopy
could not distinguish the cavitary mass from a metastatic
or primary tumor. The two p-GGNs were considered to
be multiple primary lung cancers. The patient underwent
video-assisted thoracoscopic right lower lobectomy, partial
resections for the two p-GGNs in the right upper lobe,
and systemic hilar mediastinal lymph node dissection
as curative intent resection. An analysis of the intraop-
erative frozen sections for the three tumors revealed
adenocarcinoma.
A pathological examination revealed the cavitary mass
in the right lower lobe to be invasive mucinous adeno-
carcinoma (60% acinar, 30% micropapillary, 10% papil-
lary growth pattern) with signet-ring cells (Fig. 1c).
Mediastinal lymph node metastasis was found in the
subcarinal lesion. The two p-GGNs were pathologically
different from the cavitary mass in the right lower lobe;
thus, the pathological diagnosis was multiple primary
NSCLC: pT2aN2M0 stage IIIA adenocarcinoma for the
cavitary mass in the right lower lobe and pT1aN0M0
stage IA adenocarcinoma for each p-GGN in the right
upper lobe. The patient received four cycles of cisplatin
and vinorelbine as adjuvant chemotherapy. In addition,
ALK rearrangement was detected by FISH from the
specimen obtained from the cavitary mass on the right
lower lobe. The postoperative course was uneventful,
and the patient is currently disease-free at 5 months post
operation.
Discussion
Previous reports have shown that some CT features are
significantly associated with the ALK fusion gene [2–5].
Yamamoto et al. reported that three CT features, namely
a central tumor location, large pleural effusion, and the
absence of pleural tail, with a patient age of less than
60 years, were good predictors of the presence of the
ALK fusion gene in cases of NSCLC [6]. In addition,
Yamamoto et al. attempted to predict the presence of
the ALK fusion gene using those three CT features and
the age of patients and revealed a sensitivity and specifi-
city of 89.4 and 100.0%, respectively, for the presence of
the ALK fusion gene in certain cohorts of patients. How-
ever, the equation failed to demonstrate the presence of
the ALK fusion gene in our patient in the present report.
Retrospectively, a tiny nodule was occasionally found in
the basal segment adjacent to the visceral pleura (the
peripheral area of the right lung on an abdominal CT
taken 8 years prior as a follow-up of cervical cancer of
the uterus; Fig. 1b). The present case therefore differed
with respect to the predictive factors for the presence of
the ALK gene fusion in the cavity formation in the
tumor, an initial tumor location in a peripheral site
Fig 1 a Chest cross-sectional computed tomography (CT) showing a cavitary mass in the S6 segment in the peripheral area with a pleural tail
and without pleural effusion. b An abdominal CT scan taken in 2008 occasionally showed a tiny nodule on the basal segment of the right lower
lobe adjacent to the visceral pleura on the diaphragm (arrow). c The results of a histological examination. Invasive mucinous adenocarcinoma
with signet-ring cells in an S6 tumor (hematoxylin and eosin staining, original magnification ×400)
Takamori et al. Surgical Case Reports  (2017) 3:46 Page 2 of 3
without pleural tail formation, and a patient age over
60 years old.
With regard to the pathological features of this case, the
permanent specimen showed invasive mucinous adeno-
carcinoma with signet-ring cells (Fig. 1c). Signet-ring cells
are a rare feature of primary lung adenocarcinoma [7]; the
presence of signet-ring-cell elements is significantly more
frequent in ALK+ lung cancer [8]. Given that the ALK
status of the patient was positive, these findings were con-
sistent with those of previous reports.
Conclusions
We report a case of NSCLC harboring ALK rearrangement
with uncommon radiological features. The ALK gene
status of NSCLC with atypical CT features should also
be investigated.
Abbreviations
ALK: Anaplastic lymphoma kinase; CT: Computed tomography;
EGFR: Epidermal growth factor receptor; FDG-PET: Fluorodeoxyglucose
positron emission tomography; NSCLC: Non-small cell lung cancer; p-
GGNs: Pure ground-glass-opacity nodules
Acknowledgements
The authors are grateful for the English language review by Brian Quinn of
Japan Medical Communication.
Funding
This study was not supported by any funding.
Authors’ contributions
ST wrote the manuscript. ME and SS participated in the surgery. KT analyzed
the pathologic specimens. MY supervised the writing of the manuscript. RT, KN,
FH, TS, MT and YI assisted in drafting the manuscript. All authors significantly
contributed to this study. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Informed consent was obtained from the patient for publication of this case
report and the accompanying images.
Ethics approval and consent to participate
This study was carried out in accordance with the principles of the Declaration
of Helsinki.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Received: 1 February 2017 Accepted: 16 March 2017
References
1. Hasegawa M, Sakai F, Ishikawa R, Kimura F, Ishida H, Kobayashi K, et al. CT
features of epidermal growth factor receptor-mutated adenocarcinoma of
the lung: comparison with nonmutated adenocarcinoma. J Thorac Oncol.
2016;11(6):819–26.
2. Kim TJ, Lee CT, Jheon SH, Park JS, Chung JH. Radiologic characteristics of
surgically resected non-small cell lung cancer with ALK rearrangement or
EGFR mutations. Ann Thorac Surg. 2016;101(2):473–80.
3. Halpenny DF, Riely GJ, Hayes S, Yu H, Zheng J, Moskowitz CS, et al. Are
there imaging characteristics associated with lung adenocarcinomas
harboring ALK rearrangements? Lung Cancer. 2014;86(2):190–4.
4. Choi CM, Kim MY, Hwang HJ, Lee JB, Kim WS. Advanced adenocarcinoma of
the lung: comparison of CT characteristics of patients with anaplastic
lymphoma kinase gene rearrangement and those with epidermal growth
factor receptor mutation. Radiology. 2015;275(1):272–9.
5. Rizzo S, Petrella F, Buscarino V, De Maria F, Raimondi S, Barberis M, et al. CT
radiogenomic characterization of EGFR, K-RAS, and ALK mutations in non-
small cell lung cancer. Eur Radiol. 2016;26(1):32–42.
6. Yamamoto S, Korn RL, Oklu R, Migdal C, Gotway MB, Weiss GJ, et al. ALK
molecular phenotype in non-small cell lung cancer: CT radiogenomic
characterization. Radiology. 2014;272(2):568–76.
7. Vallonthaiel AG, Jain D, Madan K, Arava S. Pulmonary adenocarcinoma with
signet ring features: detailed cytomorphologic analysis. Diagn Cytopathol.
2016;44(7):607–11.
8. Rodig SJ, Mino-Kenudson M, Dacic S, Yeap BY, Shaw A, Barletta JA, et al. Unique
clinicopathologic features characterize ALK-rearranged lung adenocarcinoma in
the western population. Clin Cancer Res. 2009;15(16):5216–23.
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