Abstract Lung cancer is the leading cause of cancer-related death worldwide, with non-small cell lung cancer (NSCLC) accounting for 87% of cases. A rare subtype, lung cancer associated with cystic airspaces (LCCA), represents only 1-4% of NSCLC. Histologically, LCCA often develops along pre-existing cystic structures from emphysema, fibrosis, or airway obstruction. Radiographically, LCCA appears as cystic lesions with wall thickening, mural nodules, or ground-glass opacities. With increased use of CT imaging and lung cancer screening, these lesions are detected more often, though their atypical appearance frequently leads to misdiagnosis as benign cysts or bullae. In major screening trials, up to 22% of missed lung cancers later showed cystic features. When detected early and surgically resected, their outcomes are similar to conventional NSCLC. We present the case of a 59-year-old woman non-smoker with a history of moderate persistent asthma, emphysema, nasal polyps, and a ground-glass pulmonary nodule, who presented with sudden-onset left-sided chest pain, dyspnea, and wheezing. Imaging revealed a large tension pneumothorax which improved following emergent chest tube placement. Her hospital course was complicated by pneumomediastinum and extensive subcutaneous emphysema extending to the neck. She underwent VATS wedge resection with blebectomy, where a firm nodule was noted on the LUL surface near the lingular fissure. The surgical team excised the bleb and nodule and harvested mediastinal lymph nodes. The pneumothorax resolved, and the chest tube was removed. Final pathology revealed lung adenocarcinoma, with negative lymph nodes (T1N0 disease). The patient remains clinically stable and continues follow-up with pulmonary and oncology teams. Roughly 1-4% of lung malignancies usually present with a cystic/bullous morphology, and adenocarcinoma is the commonest subtype presenting in this manner, with a prevalence of 70-80%. Cohort data obtained from a Lung cancer CT screening program of a cohort of 15.762 patients demonstrated that patients who had long-standing pulmonary bullae showed a 10-14% increase in odds of transforming into a cancerous nodule especially cystic lesions associated with certain imaging features like presence of nodular wall thickening of the cyst, solid nodule or combined ground-glass component. Current screening guidelines for solid and subsolid nodules are guided by Fleischer and NCCN guidelines that emphasize screening CT scans based on factors like number and size of lesion, rate of growth, and risk factors but lack consensus in settings of heightened risk like obstructive airway disease. This case underscores the need for heightened vigilance when monitoring cystic pulmonary lesions. This abstract is funded by: None
Santiago et al. (Fri,) studied this question.