ORIGINAL ARTICLE

The Pseudocavitation Sign of Lung Adenocarcinoma

A Distinguishing Feature and Imaging Biomarker of Lepidic Growth
Tina D. Tailor, MD,* Rodney A. Schmidt, MD, PhD,w Keith D. Eaton, MD, PhD,z
Douglas E. Wood, MD,y and Sudhakar N. J. Pipavath, MD*

growth factor receptor (EGFR) inhibitors, offer treatment

Purpose: Our purpose was to evaluate whether pseudocavitation, advantage.4–9
characterized by round or oval areas of low attenuation in a lesion A multidisciplinary approach for distinguishing ade-
on computed tomography (CT), can help distinguish adenocarci- nocarcinoma from SCC is central to the recent adeno-
noma from other types of non–small cell lung cancer (NSCLC). We
also sought to determine whether pseudocavitation is associated
carcinoma classification proposed by the International
with lepidic growth on histopathology. Association for the Study of Lung Cancer (IASLC),
American Thoracic Society (ATS), and European Respi-
Materials and Methods: This retrospective HIPAA-compliant study ratory Society (ERS).10 These criteria also recommend
was approved by our institutional review board. The need for characterizing invasive adenocarcinomas by the predom-
informed consent was waived. CT scans and pathology records inant histologic subtype. Of these subtypes, adenocarcino-
from 158 NSCLCs in 149 patients were retrospectively reviewed.
The frequency of pseudocavitation was compared among types of
mas with lepidic-predominant growth, namely growth
NSCLC, specifically adenocarcinoma versus other types of along alveolar walls, may carry better prognosis.10,11
NSCLC. Subgroup analysis of adenocarcinomas was performed to In light of the IASCL/ATS/ERS recommendations and
identify any difference in the frequency of pseudocavitation the rising use of computed tomography (CT) for lung cancer
between adenocarcinomas with reported lepidic growth and those screening, accurate radiologic assessment of NSCLC is
without lepidic growth. important. Further, as adenocarcinoma is the most common
lung cancer type, and with emerging knowledge that its
Results: There was a significantly greater frequency of pseudoca-
vitation in adenocarcinomas versus other types of NSCLC [19/86 diagnosis potentially implies different treatment and prog-
(22.1%) vs. 4/72 (5.6%), P = 0.007]. The sensitivity and specificity nosis than other NSCLCs, there is an impetus to identify
of the pseudocavitation sign for adenocarcinoma were 0.22 and radiologic features that reflect lesion pathology.3,12 In this
0.94, respectively. Among adenocarcinomas, the pseudocavitation way, quantitative studies correlating imaging features and
sign was more frequent in tumors with lepidic growth versus those histology can improve radiologic characterization.
without lepidic growth [10/24 (41.7%) vs. 9/62 (14.5%), P = 0.015]. Although many radiologic signs have been described
Conclusions: Pseudocavitation at CT is more common in primary in pulmonary adenocarcinoma, few studies quantify fea-
lung adenocarcinoma than in other types of NSCLC. It is also tures distinguishing adenocarcinoma from other NSCLCs.
more common in adenocarcinomas with lepidic growth, suggesting Pseudocavitation is a CT feature characterized by round or
a correlation between the imaging finding of pseudocavitation and oval areas of low attenuation in a pulmonary nodule,
the pathologic finding of lepidic growth. As the subtype of NSCLC consolidation, or mass (Fig. 1).13 In contrast to true cav-
guides treatment, predicting tumor pathology by imaging may itation, which may have an air-fluid level and reflects
improve diagnostic workup for patients with NSCLC. pathologic necrosis, per the Fleischner Criteria Glossary of
Key Words: non–small cell lung cancer, pseudocavitation, lepidic Terms for Thoracic Imaging, pseudocavitation represents
growth, computed tomography, adenocarcinoma spared parenchyma, normal or ectatic bronchi, or focal
emphysema.13–16 Unlike cavitation, which generally implies
(J Thorac Imaging 2015;30:308–313) a single area of low attenuation in a lesion that is usually
centrally located (reflecting a necrotic or hypoxic core),
pseudocavities are often multiple, typically small (< 1 cm in
diameter), and may be scattered throughout a lesion.13,14,17
B ecause of the growth of targeted treatments for lung
cancer, there is increased need to distinguish adeno-
carcinoma from other non–small cell lung cancers (NSCLCs),
Because of these characteristics, pseudocavitation is some-
times referred to as “bubble-like lucencies” or “cystic air
particularly squamous cell carcinoma (SCC).1–3 Unlike spaces” in a lesion.
SCCs, adenocarcinomas undergo routine testing for driver Although pseudocavitation has been described in
mutations for which targeted agents, such as epidermal adenocarcinoma, few quantitative studies have evaluated
this sign as a feature distinguishing adenocarcinoma from
NSCLC types. Our purpose was to evaluate whether
pseudocavitation is a feature distinguishing adenocarci-
From the Departments of *Radiology; wPathology; zMedicine, Divi- noma from other NSCLC types. As a secondary aim, we
sion of Oncology; and yDepartment of Surgery, University of sought to evaluate whether pseudocavitation was asso-
Washington Medical Center, Seattle, WA.
The authors declare no conflicts of interest.
ciated with lepidic growth at histology.
Correspondence to: Sudhakar N. J. Pipavath, MD, Department of
Radiology, University of Washington, 1959 NE Pacific Street, Box MATERIALS AND METHODS
357115, Seattle, WA 98195-7115 (e-mail: [email protected]).
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. This HIPAA-compliant study was approved by our
DOI: 10.1097/RTI.0000000000000168 institutional review board. The requirement for informed

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J Thorac Imaging  Volume 30, Number 5, September 2015 Pseudocavitation in Lung Adenocarcinoma

FIGURE 1. Pseudocavitation and cavitation on CT scan. A, Transaxial CT scan in lung window of a 64-year-old woman with a history of
lung adenocarcinoma shows a mass in the right upper lobe with a large eccentrically located pseudocavity (arrowhead). Adjacent to this
are multiple smaller bubble-like lucencies, consistent with smaller pseudocavities (arrows). Biopsy revealed adenocarcinoma with lepidic
features. The lesion was compatible with the clinical stage IA. B, Transaxial CT scans of an 84-year-old woman with a spiculated left
upper lobe mass shows that the lesion contains multiple subcentimeter-size areas of low attenuation, compatible with pseudocavitation.
Lesion pathology was compatible with stage IIB adenocarcinoma with lepidic features. C, Transaxial CT in lung window of an 82-year-
old woman with a history of SCC of the lung shows a spiculated left upper lobe mass with a large central cavitation (arrow). Biopsy was
compatible with poorly differentiated SCC.

consent was waived because this was a retrospective review. Subjects were excluded if (a) a pathology report was
analysis. not available, (b) a CT scan was not available, or (c) the
tumor was a primary endobronchial lesion, adenocarcinoma
Patients and Lesions of unknown primary, metastatic adenocarcinoma from an
Three hundred thirty-three subjects with a pathologi- extrapulmonary site, or mesothelioma. For subjects having
cally proven diagnosis of NSCLC were randomly selected >1 lesion, only lesions with a pathologic tissue diagnosis
from our institutional tumor board registry of 1648 patients were included. A total of 158 lesions in 149 patients fulfilled
with NSCLC between the dates of January 2000 to April the inclusion criteria (86 adenocarcinomas and 72 NSCLCs
2009. Subjects with all stages (IA to IV) of NSCLC were other than adenocarcinoma).
included, and the medical records and imaging results for
each patient were reviewed by the primary author. Patients Histology
were included only if (a) there was a pathology report in the Pathologic reports from the medical records were retro-
medical record confirming a diagnosis of NSCLC [including spectively reviewed to document the histologic type of NSCLC
adenocarcinoma variants formerly known as bronchioalveo- (ie, adenocarcinoma, SCC, large cell, NSCLC not otherwise
lar cell carcinoma (BAC)], and (b) a CT scan with transaxial specified, etc.). For all cases of adenocarcinoma, the presence
sections <3 mm performed before biopsy or treatment with of lepidic growth (formerly known as bronchioalveolar
surgery, chemotherapy, and/or radiation was available for growth) was documented. Specifically, adenocarcinomas were

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Tailor et al J Thorac Imaging  Volume 30, Number 5, September 2015

considered to have lepidic growth if the presence of lepidic 2-tailed Student t test was used to determine differences in
growth (or bronchioalveolar growth) was explicitly stated in tumor diameter between adenocarcinomas with pseudoca-
the pathology report. Because this was a retrospective study, vitation and those without pseudocavitation, as well as
the pathology reports did not consistently follow the IASLC/ NSCLCs with cavitation and those without cavitation. The
ATS/ERS adenocarcinoma classification, in that dominant statistical methods did not take into account clustering
histologic subtypes were not consistently assigned. Thus, effects of patients with multiple lesions because some
documented lepidic growth in the pathology report was not patients had >1 primary lesion, and other published
taken to imply lepidic-predominant growth. Sixty-three of the studies quantifying imaging features of malignancy have
lesions underwent needle biopsy, 142 had a surgical wedge regarded multiple lesions as independent for the purposes
biopsy with or without surgical resection, and 47 underwent of statistical analysis. Statistical analysis was performed
both. For subjects receiving both needle biopsy and surgical with the use of R version 3.1.1. A P-value of <0.05 was
biopsy and/or resection, the pathology from the surgical considered statistically significant.
specimen was accepted as the final tissue diagnosis.
RESULTS
CT Examinations and Interpretation
Chest CT examinations performed at our institution Patients and Lesions
were obtained with the following parameters: 100 to Table 1 summarizes the clinical and pathologic fea-
120 kVp, 100 to 200 mAs, pitch 1.35 to 1.375, 0.4 to 0.8 tures of lesions included in this study. A total of 158 lesions
seconds/helical rotation, and axial reconstruction thickness in 149 patients fulfilled the inclusion criteria. Of the 158
2.5 mm (GE LightSpeed VCT 64, GE Discovery CT750 NSCLCs, 86 (54%) were pathologically proven adeno-
HD, GE LightSpeed QX/i, GE LightSpeed Ultra 8, GE carcinoma and 72 (46%) were other types of NSCLC. Of
HSA Highspeed; GE Healthcare). For outside CT exami- the 86 adenocarcinomas, 24 had reported lepidic growth at
nations, subjects were included if transaxial CT sections pathology. The average tumor diameter was 3.1 ± 1.9 cm
with a slice thickness of 3 mm or less were available. Eighty- (2.8 ± 1.7 cm for all adenocarcinomas, 3.5 ± 2.0 cm for
eight CT scans were performed at our institution, and 60 NSCLCs other than adenocarcinomas). Forty-five of the
were performed at an outside hospital. Images were viewed lesions were located in the right upper lobe, 6 were in the
with a sharp reconstruction algorithm in standard lung right middle lobe, 26 were in the right lower lobe, 60 were in
windows (window 1500, level 600). The mean interval the left upper lobe, 17 were in the left lower lobe, and 4
time between the chest CT and histologic diagnosis by involved >1 lobe.
needle or surgical biopsy was 34 days (range, 0 to 452 d).
Interpreting radiologists were blinded to the patho- CT Features and Tumor Histology
logic diagnosis at the time of CT interpretation. The first Table 2 demonstrates the CT features of lesions
author, a radiologist in training with 4 years of experience included in the study. Twenty-three of 158 tumors (14.6%)
in chest CT interpretation, recorded lesion size, location, demonstrated pseudocavitation. Of these 23 lesions, 19
and the presence or absence of either a pseudocavitation or were adenocarcinoma and 4 were other types of NSCLC.
cavitation. The senior author, a board-certified chest radi- Eleven of 158 tumors (7.0%) demonstrated cavitation, of
ologist with >15 years of experience in chest CT inter- which 4 were adenocarcinomas and 7 were other types of
pretation, independently read all cases of pseudocavitation NSCLC. The overall interreader concordance for the
or cavitation, as determined by the first reader. For dis- presence of pseudocavitation and cavitation on CT was
cordant cases, a decision was reached by consensus. 87.2% (the second reader was in agreement with 34 of 39
cases deemed by the first reader as having pseudocavitation
Statistical Analysis or cavitation). For the CT finding of cavitation, the con-
The Pearson w2 test was used to evaluate the differ- cordance was 100% (11 of 11 cases). For the CT finding of
ences between CT features, namely pseudocavitation and pseudocavitation, the concordance was 82.1% (23 of 28
cavitation, and type of NSCLC (ie, adenocarcinoma vs. cases).
other types of NSCLC). The 2-tailed Pearson w2 test was There was a statistically significant difference in the
also used to evaluate for differences in the frequency of presence of pseudocavitation between adenocarcinoma and
pseudocavitation between adenocarcinomas with lepidic other types of NSCLC (P = 0.007), with pseudocavitation
growth and those without lepidic growth. The Fisher exact being more likely in adenocarcinomas than in other types of
test was used for the subgroup analysis of clinical stage. The NSCLC (22.1% vs. 5.6%) (Table 2). The sensitivity and

TABLE 1. Tumor Characteristics

Stage
Type of NSCLC IA IB IIA IIB IIIA IIIB IV Total [n (%)]
Adenocarcinoma 16 23 9 13 13 9 3 86 (54.4)
SCC 8 6 4 15 6 5 3 47 (29.7)
NSCLC, NOS 4 2 2 1 2 4 4 19 (12.0)
Adenosquamous 0 1 0 1 0 0 0 2 (1.3)
Large cell 0 1 0 2 0 1 0 4 (2.5)
Total [n (%)] 28 (17.7) 33 (20.9) 15 (9.5) 32 (20.3) 21 (13.3) 19 (12.0) 10 (6.3) 158
Note: all numbers in the second column reflect the number of lesions, not the number of patients.
NOS indicates not otherwise specified.

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J Thorac Imaging  Volume 30, Number 5, September 2015 Pseudocavitation in Lung Adenocarcinoma

TABLE 2. CT Findings of NSCLCs

CT Characteristic Adenocarcinoma [n (%)] Other NSCLCs [n (%)] P Odds Ratio 95% CI
Pseudocavitation 19/86 (22.1) 4/72 (5.6) 0.007 4.82 1.56-14.92
Cavitation 4/86 (4.7) 7/72 (9.7) 0.351 0.44 0.13-1.61
Note: other NSCLCs in the third column refer to all NSCLCs that were not adenocarcinomas. Of the NSCLCs with pseudocavitation, 3 were SCC, and
1 was NSCLC not otherwise specified.
CI indicates confidence interval.

specificity of the pseudocavitation sign for adenocarcinoma platinum-based chemotherapy).22,23 Similarly, treatment
were 0.22 and 0.94, respectively. with targeted TKIs is associated with prolonged PFS in
There was no significant difference in the presence patients with chromosomal rearrangements involving ana-
of cavitation between adenocarcinomas and other NSCLC plastic lymphoma kinase.24,25 As knowledge of molecular
types (Table 2, P = 0.351). There was no significant pathways in adenocarcinoma continues to emerge, targeted
difference in average tumor diameter between NSCLCs therapies will undoubtedly continue to evolve. Thus,
with cavitation and those without cavitation (3.8 ± 2.4 imaging features suggest that pathology may facilitate the
vs. 3.0 ± 1.7 cm, P = 0.288), or adenocarcinomas with pseu- proper biopsy for conventional histology and molecular
docavitation versus those without pseudocavitation (3.3 ± 2 testing and expedite diagnosis and treatment.
vs. 2.7 ± 1.6 cm, P = 0.253). Prior studies, consisting primarily of small retro-
Of the 86 pathologically proven adenocarcinomas spective case series, describe pseudocavitation in 19% to
included in the study, there was no significant relationship 29% of lung adenocarcinomas, similar to its frequency in
between the clinical tumor stage and the presence of pseu- our study.14,26 In adenocarcinoma variants formerly known
docavitation (P = 0.757) (Table 3). Subgroup analysis of as BAC (now considered to be a spectrum of pathologies
clinical stage revealed no significant difference in the from preinvasive lesions to invasive carcinomas), pseudo-
frequency of pseudocavitation between those lesions con- cavitation has been reported with a frequency of
ventionally considered surgically resectable (stages IA-IIIA) >50%.14,18 In a retrospective series of 26 patients with lung
and surgically unresectable (stages IIIB-IV) (P = 0.723). adenocarcinomas having a bubble-like appearance on CT,
At pathology, 27.9% (24 of 86) had lepidic growth. Kojima et al17 reported a 100% 5-year survival after sur-
There was a statistically significant difference in the pres- gical resection, suggesting that adenocarcinomas with this
ence of pseudocavitation between adenocarcinomas dem- CT feature have may have unique and potentially favorable
onstrating lepidic growth and those without lepidic growth, histopathologic features. Our results extend the existing
with pseudocavitation being more likely in adenocarcino- literature by demonstrating that pseudocavitation on CT
mas with lepidic growth [10/24 (41.7%) vs. 9/62 (14.5%), may distinguish adenocarcinoma from other NSCLC types
P = 0.015]. The sensitivity and specificity of the pseudoca- (ie, SCC) and by suggesting a correlation between pseu-
vitation sign for predicting lepidic growth of adenocarci- docavitation and lepidic growth at pathology. The latter is
noma were 0.42 and 0.85, respectively. Figure 2 shows a important because the IASLC/ATS/ERS adenocarcinoma
representative example of pseudocavitation on CT in a classification recommends characterization of invasive
patient with lepidic growth at histology. adenocarcinomas into histologic subtypes.10
At histology, lepidic growth refers to neoplastic
growth along alveolar walls without pleural, stromal, or
DISCUSSION vascular invasion.10 Among invasive adenocarcinomas,
In this study, we demonstrate that pseudocavitation which constitute most resected cases, Warth and colleagues
on CT is more common in lung adenocarcinoma than in
other types of NSCLC. Although pseudocavitation has low
sensitivity for adenocarcinoma, the specificity is >90%.
TABLE 3. The Presence of Pseudocavitation and Lepidic Growth
Thus, the presence of pseudocavitation on CT makes ade- by Clinical Stage of Adenocarcinoma
nocarcinoma likely, but its absence does not rule out ade-
nocarcinoma. Our results also demonstrate that pseudoca- Adenocarcinomas
vitation on CT is associated with lepidic growth at With Adenocarcinomas
histopathology. Adenocarcinoma No. Pseudocavitation With Lepidic
These results are important because it is now known Stage Lesions [n (%)] Growth [n (%)]
that the subtype of NSCLC has implications for patient IA 16 4 (25.0) 11 (68.8)
treatment and prognosis.2 Specifically, distinguishing ade- IB 23 7 (30.4) 6 (26.1)
nocarcinoma from SCC is important because current IIA 9 2 (22.2) 1 (11.1)
guidelines recommend molecular testing for adenocarcino- IIB 13 1 (7.7) 2 (15.4)
mas to match individual therapy to precise genetic muta- IIIA 13 2 (15.4) 1 (7.7)
tions.6,10,18 Certain EGFR mutations expressed in adeno- IIIB 9 2 (22.2) 2 (22.2)
IV 3 1 (33.3) 1 (33.3)
carcinomas, such as exon 19 deletions and point mutations Total 86 19 (22.1) 24 (27.9)*
on exon 21, are considered “sensitizing” because they pre-
dict response to EGFR tyrosine kinase inhibitors (TKIs), *Pseudocavitation was more common in adenocarcinomas with lepidic
such as erlotinib and gefinitib.7,8,19–21 In the presence of growth than in adenocarcinomas without lepidic growth [10/24 (41.7%) vs.
9/62 (14.5%), P = 0.015].
such mutations, EGFR-TKIs are associated with prolonged There was no significant relationship between the stage of adenocarci-
progression-free survival (PFS) (9.7 to 13.1 mo for patients noma and the presence of pseudocavitation (P = 0.757).
receiving erlotinib, 4.6 to 5.2 mo for patients receiving

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Tailor et al J Thorac Imaging  Volume 30, Number 5, September 2015

FIGURE 2. Pseudocavitation on CT scan in an 84-year-old female patient with lung adenocarcinoma demonstrating lepidic growth at
histology. A, Transaxial CT scan in lung window shows a spiculated right upper lobe mass with multiple peripherally located bubble-like
lucencies, compatible with pseudocavitation. B, Representative pathologic slide (stained with hematoxylin and eosin) shows adeno-
carcinoma with lepidic growth (arrows), that is, neoplastic cell growth along the normal alveolar framework. The overall lung archi-
tecture is preserved, and there is lack of angiolymphatic invasion. An asterisk (*) marks an alveolar space.

reported that predominant histologic pattern influences Further, no significant size difference was observed between
overall survival, disease-specific survival, and disease-free cavitary and noncavitary lesions, or between pseudocavi-
survival, with lepidic-predominant adenocarcinoma having tary and nonpseudocavitary lesions.
the most favorable prognosis. Warth et al11 also suggested Our study has limitations. First, the population is
that histologic subtype may affect treatment response. limited to biopsied or resected NSCLCs. Therefore, to
Similarly, Anami et al27 reported that in patients with translate these results to the evaluation of an indeterminate
mixed subtype adenocarcinomas, the presence of lepidic pulmonary nodule or mass with pseudocavitation, the
growth was associated with prolonged overall survival and suspicion for NSCLC must be high before adenocarcinoma
that lepidic growth was a more reliable prognostic indicator can be suggested. In practice, however, the differential
than nodal status. Thus, the ability to suggest histologic diagnosis for lung malignancy and, more specifically, the
features of adenocarcinoma by CT could help predict type of malignancy, depends on a number of consid-
clinical course. erations, such as patient risk factors, other imaging fea-
Although a direct radiologic and pathologic inves- tures, location (ie, central vs. peripheral), and lesion sta-
tigation to correlate the CT finding of pseudocavitation to bility. In this way, the presence of pseudocavitation is
histologic findings was not performed in this study, prior complementary to other imaging features, and in a patient
studies, consisting mainly of retrospective case series, report with high suspicion for NSCLC, our results suggest that it
that pseudocavitation reflects air spaces or air broncho- is a predictor of adenocarcinoma. Further, interreader
grams in a lesion, which may be accentuated by cicatrical concordance for pseudocavitation on CT was high (82.1%),
contraction.15,18,26 Originally described in adenocarcinoma supporting the notion that the sign can be generally agreed
variants formerly known as BAC, it is thought that pseu- upon and is thus useful in suggesting adenocarcinoma. If
docavitation reflects the propensity of tumor cells to grow there is low suspicion for NSCLC, other non-neoplastic
along alveolar walls without disrupting lung archi- differential considerations for lesions with pseudocavitation
tecture.15,26,28 As this type of proliferation is characteristic include inflammatory diseases, such as granulomatosis with
of lepidic growth, our results, which suggest a correlation polyangitis, and infection.14
between pseudocavitation and lepidic growth, support these This study did not quantify the amount of pseudoca-
prior reports. Conversely, because nonlepidic growth is vitation in a lesion or evaluate for relationships between the
thought to compress or obliterate small airways, pseudo- amount of pseudocavitation and pathology. As with other
cavitation in nonlepidic adenocarcinomas is reportedly signs in imaging, in the absence of robust quantitative
rare.18 analysis techniques, quantification is invariably affected by
Unlike pseudocavitation, true cavitation, which as some degree of interpreter subjectively.31 In this same
above reflects necrosis, is rare in lung adenocarcino- regard, in clinical practice, the differentiation between
mas.14,16,29 In a retrospective study of 353 patients with cavitation and pseudocavitation is also subject to some
primary lung cancer, Mouroux et al29 reported that <6% degree of interpreter variability. As above, cavitation and
of cavitary lung cancers were adenocarcinomas and that pseudocavitation imply different pathologic features; how-
cavitary tumors were 1.5 times larger than noncavitary ever, there is some extent of overlap in their definitions that
tumors. Although there is ample evidence supporting that may make differentiation of these 2 signs challenging in
cavitation is more frequent in SCC, our study showed no select cases.13
significant difference in the presence of cavitation between Finally, pathologic specimens of NSCLCs included in
adenocarcinomas and other types of NSCLC.26,29,30 this retrospective study were not directly reevaluated to

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J Thorac Imaging  Volume 30, Number 5, September 2015 Pseudocavitation in Lung Adenocarcinoma

classify lesion histology. Hence, we cannot define a precise 12. Herbst RS, Heymach JV, Lippman SM. Lung cancer. N Engl J
relationship between pseudocavitation on CT and its his- Med. 2008;359:1367–1380.
tologic counterpart, nor can we determine whether pseu- 13. Hansell DM, Bankier AA, MacMahon H, et al. Fleischner
docavitation on CT reflects the same underlying histology Society: glossary of terms for thoracic imaging. Radiology.
2008;246:697–722.
in adenocarcinomas of differing stages. Further, because of 14. Trigaux JP, Gevenois PA, Goncette L, et al. Bronchioloalveo-
the retrospective study design, lesion pathology did not lar carcinoma: computed tomography findings. Eur Respir J.
consistently follow the IASLC/ATS/ERS adenocarcinoma 1996;9:11–16.
classification, in that dominant histologic subtypes were not 15. Weisbrod GL, Chamberlain D, Herman SJ. Cystic change
consistently assigned.10 Therefore, we can only conclude (pseudocavitation) associated with bronchioloalveolar carci-
that pseudocavitation is correlated with lepidic growth and noma: a report of four patients. J Thorac Imaging. 1995;10:
not necessarily lepidic-predominant growth. Future studies 106–111.
may investigate the relationship between pseudocavitation 16. Kim NR, Han J. Pathologic review of cystic and cavitary lung
and the IASLC/ATS/ERS classification, EGFR status, diseases. Korean J Pathol. 2012;46:407–414.
17. Kojima Y, Saito H, Sakuma Y, et al. Correlations of thin-
clinical tumor stage, and patient outcomes. section computed tomographic, histopathological, and clinical
In conclusion, our results suggest that pseudocavita- findings of adenocarcinoma with a bubblelike appearance.
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from other types of NSCLC. The pseudocavitation sign is 18. Nakazono T, Sakao Y, Yamaguchi K, et al. Subtypes of
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NSCLC and is a potential predictor of lepidic growth at section CT. Eur Radiol. 2005;15:1563–1568.
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