245 Arguments for pulmonary AIS larger than 7 cm Case 1 A 75-year-old male showed a persistent lobar consolidation in the left lower lobe with extensive ground-glass and small cystic changes on CT-imaging. A differential diagnosis of localized interstitial lung disease or malignancy was made, and a biopsy confirmed the presence of adenocarcinoma with a lepidic growth pattern, without invasive features. He underwent a left lower lobectomy. The gross pathology examination did not show tumor nodules, and confirmed focal bullous cysts (Figure 1). The initial histology identified several areas of non-mucinous lepidic adenocarcinoma without invasion, with an estimated diameter of 16 cm. In search for possible invasive areas, comprehensive histopathological examination was performed and nearly the entire lobe was sampled, resulting in over 300 formalin fixed and paraffin embedded blocks and corresponding slides. The cystic formations observed on imaging could be attributed to areas of bullous emphysema covered by the lepidic growth of tumor cells. Histology showed extensive AIS. The patient successfully recovered from surgery without any major complications. However, 18 months after the resection, he was infected by COVID-19 and required intubation. In a few days, he died due to complications. His status was classified as “death, no evidence of disease” (DND). Case 2 A 77-year-old female showed in the left lower lobe extensive parenchymal consolidations and ground glass areas on CT-imaging. An initial diagnosis in favor of infection was made, but despite antibiotic therapy. A second CT after six months revealed more extensive parenchymal consolidation and ground glass areas. Subsequent bronchoalveolar lavage that showed presence of adenocarcinoma. PET was negative. She recently (2023) underwent left lower lobectomy. The gross pathology examination did not show tumor nodules. The initial histology identified several areas of non-mucinous lepidic adenocarcinoma without invasion, with an estimated diameter of 16 cm. In search for possible invasive areas, comprehensive histopathological examination was performed and nearly the entire lobe was sampled, resulting in additional 130 formalin fixed and paraffin embedded blocks and corresponding slides. Histology showed extensive AIS. The patient successfully recovered from surgery without any major complications. Case 3 In 2010, a woman aged 72, with a history of diabetes mellitus and related vascular disease, underwent a left upper lobectomy for pneumonia-like tumor, with multiple surrounding semisolid nodules. The lobe (diameter 18 cm) showed confluent areas of non-mucinous lepidic adenocarcinoma without invasion. Resection was complete, and uneventful. Six years later, she experienced severe weight loss (20 kg), and was found to have 2 intrapulmonary ground glass opacities in the left lower lobe with diffuse pulmonary nodules on PET-CT imaging. In the differential diagnosis of a second primary lung 16
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