AD, BAC, and AAH in the case patient might have occurred as a result of second-hit mutations L861Q and L858R in the setting of a germline V843I mutation. However, the effects of the EGFR V843I mutation on EGFR signaling and the molecular importance of the dou- ble mutation on EGFR exon 21 are unknown. The patient’s father and a brother had died of lung cancer. However, another brother and a sister, each of whom had germline EGFR V843I mutation, have not developed lung cancer despite being almost 70 years old. The role of germline EGFR V843I mutation in multifocal lung carcinogenesis and the familial occurrence of lung cancer in the case patient are still unclear. In vitro experiments are needed to clarify the effects of EGFR V843I mutation on EGFR signaling, as is accumulation of clinical cases to determine the role of germline EGFR mutation in lung carcinogenesis. References 1. Zwirewich CV, Miller RR, Muller NL. Multicentric adenocar- cinoma of the lung: CT-pathologic correlation. Radiology 1990;176:185–90. 2. Bell DW, Gore I, Okimoto RA, et al. Inherited susceptibility to lung cancer may be associated with the T790M drug resis- tance mutation in EGFR. Nat Genet 2005;37:1315– 6. 3. Blons H, Côté JF, Le Corre D, et al. Epidermal growth factor receptor mutation in lung cancer is linked to bronchioloal- veolar differentiation. Am J Surg Pathol 2006;30:1309–15. 4. Tang X, Shigematsu H, Bekele N, et al. EGFR tyrosine kinase domain mutations are detected in histologically normal re- spiratory epithelium in lung cancer patients. Cancer Res 2005;65:7568 –72. 5. Ji H, Li D, Chen L, et al. The impact of human EGFR kinase domain mutations on lung tumorigenesis and in vivo sensi- tivity to EGFR-targeted therapies. Cancer Cells 2006;9:485–95. 6. Shih J-Y, Gow C-H, Yu C-J, et al. Epidermal growth factor receptor mutation in needle biopsy/aspiration samples pre- dicts response to gefitinib therapy and survival of patients with advanced non–small cell lung cancer. Int J Cancer 2006;118:963–9. 7. Leone F, Cavalloni G, Pignochino Y, et al. Somatic mutation of epidermal growth factor recepter in bile duct and gallbladder carcinoma. Clin Cancer Res 2006;12:1680 –5. 8. Knudson AG Jr. Overview: genes that predispose to cancer. Mutat Res 1991;247:185–90. Pseudocavitating Bronchioloalveolar Carcinoma Followed Over a Decade Jason P. Shaw, MD, Pablo A. Bejarano, MD, and Richard J. Thurer, MD Department of Surgery, Division of Cardiothoracic Surgery, and Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida A 38-year-old woman with bronchioloalveolar carcinoma (BAC) had a slow-growing cavitary nodule for nearly a decade. When she was hospitalized because of pneumo- nia 9 years earlier, a chest computed tomography scan showed a 1.5-cm cavitary right upper lobe nodule. At 1, 3, and 9 years computed tomography scans showed slow growth of the nodule to 2.4 cm, corresponding to a volume doubling time of 1494 days. Thoracoscopic bi- opsy and lobectomy were performed. Pathologic analysis revealed a well-differentiated mucinous BAC (T1N0M0). Pseudocavitation in solitary BAC is rare. A longer period of surveillance may be required to rule out malignancy in this setting. Surgical resection remains the mainstay of therapy. (Ann Thorac Surg 2008;85:1432– 4) © 2008 by The Society of Thoracic Surgeons W ith more widespread use of computed tomography (CT) of the lung, small bronchioloalveolar carci- nomas (BACs) are being diagnosed with increasing fre- quency. Bronchioloalveolar carcinomas are generally thought to have a more indolent course than other subtypes of adenocarcinoma of the lung. While CT ap- pearance varies, the presence of BAC as a solitary cavi- tary nodule is rare. We report the case of a slow-growing BAC in a young woman that highlights the importance of prolonged surveillance or resection when BAC is in- cluded in the differential diagnosis. A 38-year-old woman with nonpleuritic chest pain and a long-standing right upper lobe cavitary lesion, with a 3 pack-year smoking history, was referred for thoracic surgical evaluation. Nine years previously the patient had been hospitalized because of pneumonia involving the posterior segment of the right upper lobe. Results of tuberculin skin testing were negative. When a chest radiograph at 6-month follow-up showed a persistent mass, a CT scan of the chest was obtained, which re- vealed a 1.5-cm rounded lesion with central lucency (Fig 1A). Bronchoscopy performed 1 year after initial presen- tation was nondiagnostic. A chest CT scan obtained 9 years after initial presentation demonstrated the lesion in the right upper lobe measuring 2.4 cm. A fluorodeoxy- glucose positron emission tomography scan demon- strated no uptake. Thoracoscopic biopsy followed by lobectomy with lymph node dissection was performed. Pathologic analysis revealed a 2.5-cm well-differentiated mucinous BAC (T1N0M0) (Figs 2, 3). The patient had an uneventful hospital course and was discharged on post- operative day 4. During nearly a decade, CT scans had been obtained at various institutions, at 6 months and at 1, 3, and 9 years after initial presentation (Figs 1A-D). Review of the scans revealed a largest tumor diameter of 1.5 cm, 1.5 cm, 1.6 cm, and 2.4 cm, respectively, suggesting tumor stability at 1 year. However, calculation of tumor volume from each CT scan (V =/6  ab 2 , where a is the largest diameter and b is the largest diameter perpendicular to a) showed an increase in tumor volume at each interval, with volumes of 1.3 cm 3 , 1.4 cm 3 , 1.8 cm 3 , and 5.6 cm 3 , respectively. Tumor Accepted for publication Oct 1, 2007. Address correspondence to Dr Shaw, Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, PO Box 016960 (R-114), Miami, FL 33010; e-mail: jason.shaw@mssm.edu. 1432 CASE REPORT SHAW ET AL Ann Thorac Surg PSEUDOCAVITATING BRONCHIOLOALVEOLAR CARCINOMA 2008;85:1432– 4 © 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2007.10.031 FEATURE ARTICLES