Managing multifocal bronchioloalveolar carcinoma/lepidic predominant adenocarcinoma: changing rules for an evolving...

Although the clinical entity of bronchioloalveolar carcinoma (BAC) has been reclassified into adenocarcinoma in situ, lepidic predominant adenocarcinoma, and mucinous adenocarcinoma, it continues to merit special consideration based on its distinct natural history and response to therapy. The clinical behavior of multifocal BAC is highly variable, as is its response to various treatments. This characteristic should encourage latitude for individualized judgment rather than reliance on dogma about how advanced non-small cell lung cancer (NSCLC) should be managed. Specifically, it is worth first questioning whether any of the visible disease is progressing at a clinically significant pace. If clear progression is unlikely to occur over several months or longer, an appropriate option is attentive clinical and radiographic follow-up with no intervention. If significant progression is demonstrated in an isolated area, it is very reasonable to consider local therapy-whether surgery or radiation-in this area alone. If progression is clearly apparent, then optimal systemic therapy should be used based on molecular findings. This is the same approach that is generally recommended for other forms of advanced NSCLC, with the presence or absence of a driver mutation used to guide the selection of an epidermal growth factor receptor inhibitor, an anaplastic lymphoma kinase inhibitor, or conventional platinum-based chemotherapy (with the potential addition of bevacizumab).