Clinicopathological observation of primary lung enteric adenocarcinoma and its response to chemotherapy: A case report and review of the literature

Abstract

Primary lung enteric adenocarcinoma is a rare type of invasive lung carcinoma. Its morphology and immunohistochemistry are those of colorectal carcinoma, but there is no associated primary colorectal carcinoma. The present study describes the case of a 53-year-old female who presented with an irritating cough and a mass around the right sternoclavicular joint. Comprehensive evaluation revealed involvement of the mediastinum, lungs, right sternoclavicular joint and right kidney. Biopsies from the mediastinal and right sternoclavicular joint tumors showed features of adenocarcinoma. Immunohistochemistry was positive for cytokeratin (CK)20 and caudal type homeobox transcription factor 2, and negative for CK7, thyroid transcription factor-1 and napsin A. Genotypic analysis identified the expression of wild-type epidermal growth factor receptor, Kirsten rat sarcoma viral oncogene homolog, serine/threonine-protein kinase B-Raf and UDP-glucuronosyltransferase 1-1. There was no expression of echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase and a moderate expression of excision repair cross-complementation group 1, ribonucleoside-diphosphate reductase large subunit and tubulin β-3 chain. A strong expression of thymidylate synthase and 677TC genotype expression of methylenetetrahydrofolate reductase was observed. Gastroscopy, enteroscopy, colorectal colonoscopy and positron emission tomography-computed tomography failed to find evidence of a gastrointestinal malignancy and primary lung enteric adenocarcinoma was diagnosed. The presence of multiple metastases did not permit curative surgery. The patient was treated with 3 monthly cycles of the XELOX chemotherapy regimen; the response was poor with progression of supraclavicular lesions. Treatment was switched to the TP regimen for 4 monthly cycles, which resulted in a significant reduction in the size of the lung lesions; however, the supraclavicular lesion responded poorly to the treatment. The patient then received 2 cycles of the FOLFIRI regimen; however, the lung and right supraclavicular lesions progressed, causing increased right upper limb pain. The pain was alleviated by palliative surgery. Following surgery, the DP regimen was employed. Follow-up of the patient remains ongoing. The present findings suggest that the early diagnosis and treatment of primary lung enteric adenocarcinoma is likely to improve patient outcome.

Keywords: chemotherapy; clinicopathogical; diagnosis; primary lung intestinal adenocarcinoma.

Figure 1.

Hematoxylin and eosin staining and immunohistochemistry with CDX2, CEA, CK20 and villin. (A) Histological examination showed a moderately differentiated adenocarcinoma infiltrating fibrous connective tissues (magnification, ×200); (B-E) Immunohistochemical staining for the expression of CDX2, CEA, CK20 and villin in the neoplastic cells, observed using anti-CDX2, anti-CEA, anti-CK20 with slight hematoxylin counterstain (magnification, ×400). CDX2, caudal type homeobox transcription factor 2; CEA, carcinoembryonic antigen; CK, cytokeratin.

Figure 2.

Treatment of lung enteric adenocarcinoma with different chemotherapy regimens and results of monitoring of the CEA levels. The color-coded boxes to the left of each panel explain the relevant data. (A-E) Lung CT scans from (A) February, (B) May, (C) August, (D) September and (E) November 2014. (F-J) CT scans of the mediastinum from (F) February, (G) May, (H) August, (I) September and (J) November 2014. (K and L) Supraclavicular neoplasm (K) preoperatively and (L) postoperatively. CEA, carcinoembryonic antigen; CT, computed tomography; C, cycle.