How can my sister manage her mucinous adenocarcinoma at 64?

Question

Hello doctor,

My sister has recently been diagnosed with a mucinous adenocarcinoma. She is 64, a non-smoker, and on blood pressure medications. A mass was found on her lower right lobe incidentally through an unrelated scan. She then underwent a CT scan.

A bronchoscopy was performed. This resulted in the diagnosis of mucinous adenocarcinoma. She has travelled often to an Island which is endemic for Cryptococcus Gatti. Her surgeon has said that he will need to remove the lower lobe of her lung and possibly the entire right lung because the location of the mass may be traversing the region between the lobes.

My concern is that they are 100 percent sure of the diagnosis. She has had no reports regarding any investigation of the possibility of fungal infection. I understand from literature reviews that Cryptococcus can mimic lung cancer even in histology.

She has been very stressed but is mentally preparing herself for surgery. I do not want to bring up this possibility to her unnecessarily, but I am worried that it may not have been fully explored. She does not have any results regarding biomarkers; it seems they are going to wait until after the surgery.

Can you please advise me if I should be encouraging further investigation?

A 24-mm spiculated mass is present in the right lower lobe with air bronchograms in the superior segment, posterior to the right mainstem bronchus. SUV max is 3.9 (mediastinal blood pool SUV max 2.7). There is no other suspicious thoracic activity or lymphadenopathy. No FDG-avid or non-avid pulmonary nodules are identified. Background activity elsewhere in the region is within expected limits. Minimal LAD calcification is noted. No pleural or pericardial effusion. Impression:

Mildly hypermetabolic right lower lobe spiculated mass measuring 24 mm (SUV max 3.9).
Findings are suspicious for primary lung adenocarcinoma; tissue correlation is recommended.
No evidence of hypermetabolic nodal or distant metastatic disease.

Please advise.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern, and I will do my best to help.

First, I would like to clarify one important point: Was a definite tissue or biopsy diagnosis of mucinous adenocarcinoma made by a pathologist? If so, the pathology report should describe features such as malignant gland-forming cells and, ideally, immunohistochemistry (IHC) markers.

If the biopsy included IHC and markers such as TTF-1 (thyroid transcription factor 1) or CK7 (cytokeratin 7), which were positive, this strongly supports a primary lung adenocarcinoma, and the diagnosis can generally be considered reliable. In such cases, proceeding with the planned surgery would be appropriate. Even if an IHC was not performed, a clear pathology description confirming malignant glandular cells with mucin production usually indicates that the diagnosis is correct.

Physicians in that place are also very familiar with Cryptococcus gattii, and infectious mimics are typically considered when the appearance is not classic for cancer.

However, if a definite tissue diagnosis has not been made, for example, if only imaging or inconclusive cytology is available, it would be reasonable to politely insist on a proper biopsy or pathology confirmation before any major lung surgery.

To summarize, a confident preoperative diagnosis generally includes:

Clear malignant cells on cytology or histology.
IHC markers supporting lung adenocarcinoma (e.g., TTF-1 positive)
Exclusion of infectious mimics if the morphology is not straightforward.

If these elements are documented in her report, the diagnosis can be considered reliable.

I hope this helps clarify things.

Take care.