Benign Solitary Lung Lesions in Patients with Cancer WILLIAM G. CAHAN, M.D.,* JATIN P. SHAH, M.D.,t EL. B. CASTRO, M.D.t
The appearance of a lung opacity on a chest film of a patient with known cancer may present a diagnostic dilemma. From 1940 through 1975, over 800 patients with this problem underwent thoracotomy for confirmation of diagnosis. In some 500 of these patients, the lesion proved to be primary cancer of the lung; in 1% they were solitary metastases and in 11 patients the lesions were benign. -There were six additional patients in whom multiple opacities were found which proved to be benign conditions. An approach to the investigation, diagnosis, and surgical management of such solitary pulmonary lesions is presented. It is emphasized that the appearance of a solitary pulmonary shadow in a patient with a history of cancer should not be assumed to be a metastasis. Appropriate investigations should be performed without delay in an effort to define the nature of the lesion by microscopic analysis permitting definitive therapy to be administered and a more accurate prognosis provided.
A SOLITARY LUNG OPACITY found on a chest x-ray
Alwith
a known extrathoracic cancer is a diagnostic dilemma. For years, such shadows were assumed to be a metastasis and either the harbinger of many that would subsequently appear or merely the visible evidence of others more cryptically placed. Based upon that premise, therapeutic programs aimed at palliation were initiated. As thoracic surgery matured, it seemed justifiable to try to resect such lesions, particularly as nonsurgical measures often proved to be unrewarding. As a result, although some were indeed metastases, others proved instead to be primary lung cancers or benign conditions.
Clinical Material From 1940 through 1975 at Memorial SloanKettering Cancer Center, more than 800 patients were seen with extrathoracic cancer associated with a solitary pulmonary shadow. In all instances, the diagnosis was microscopically confirmed from specimens obtained by biopsy, resection or autopsy. Of * Attending Surgeon, Thoracic Service t Assistant Attending Surgeon, Head and Neck Service t By Invitation Reprint requests: William G. Cahan, M.D., 1275 York Avenue, New York, N.Y. 10021. Submitted for publication: July 1, 1977.
From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
these, approximately 500 proved to be primary lung cancers (Fig. 1); 196 were solitary metastases (Fig. 2) and 11 were benign lesions. The last group is analyzed in this report and although relatively few cases are included, they are felt to have broad implications.
Site of Cancer The sites of primary cancers were: breast (five), colon (one), stomach (one), larynx (one), melanoma (one), liposarcoma (one), and lung (one). Although 11 patients had solitary pulmonary opacities, there were six others whose chest x-rays revealed more than one shadow. These ranged from two or three to multiple and bilateral shadows, and are discussed as a separate group because of their potential significance. Nine patients were asymptomatic, their shadows having been discovered on routine follow-up examination or workup for a primary cancer: two had nonproductive coughs. Sex and Age There were five males and six females whose ages ranged from 53 to 63 years.
Synchronous and Metachronous Shadows Two lesions were synchronous and eight were metachronous with the primary cancer. In the remaining patient, the shadow was synchronous with a squamous carcinoma of the lung. Preoperative Diagnosis In six patients, a roentgenographic diagnosis of the lesion was not mentioned: in five, the radiologists designated it as a metastasis or a new primary cancer. In one, a tomogram described the shadow as having a calcific rim suggestive of a benign tumor. Six patients were bronchoscoped because their
0003-4932-78-0300-0241-0060 X J. B. Lippincott Company
241
CAHAN, SHAH AND CASTRO
242
Ann. Surg.
o
March 1978
of disease. In no instance was there any significant delay in treatment or modification of the accepted standard procedures of therapy for the cancer because of the presence of the opacity.
51 Basal cell ca's plus the following (not shown): Triple ca's 104 4 separate ca's 6 5 separate ca's 2 6 separate ca's 1
FIG. 1. Multiple primary cancers, one of which was lung (19401972).
opacities seemed to be centrally-located, or if peripheral, were larger than 2 cm. Four showed negative cytology; one was reported as having "suspicious cells and marked bronchial atypia; the sixth showed cancer cells reflecting a stage 0 lung cancer concurrent with a hamartoma. Treatment All 11 patients had an exploratory thoracotomy. The seven intrapulmonic lesions were peripheral to the second division of the bronchi. Their benign nature was often suggested by gross examination; e.g., hamartomas were very firm and well circumscribed and those that lay just beneath the visceral pleura produced a surface convexity instead of umbilicating its surface as do most carcinomas. The other four extrapulmonic lesions were readily identifiable as being benign and were excised. There was no postoperative morbidity or mortality in this series.
Multiple Lung Shadows Although this study has concentrated on solitary shadows, it is relevant to include six patients who had more than one opacity with a known cancer. In three, there were two opacities; in one, there were three; and in two, there were many bilateral densities. Of the three having two densities, two were associated with breast cancers, one of whom had synchronous primary cancers of the breast and lung. The third patient had a synchronous leiomyoblastoma of the stomach. In all three instances, the benign lesions were hamartomas.10'13 Of the two patients who had many lung lesions, one was associated with a primary cancer of the uterus and one of the breast. The shadows proved to be multifocal fibrosis and inflammation and amyloid nodules respectively.8 Three patients had shadows synchronous with their primary cancers: lung and stomach and the third had had simultaneous primaries of breast and lung. Three lesions were initially believed to be solitary but tomography revealed additional densities. In four patients who had two or three shadows, the radiologic diagnosis was either "bronchogenic carcinoma" or "metastases." Of the two patients with many opacities, one was designated as "not entirely characteristic of
Hed and Nec 1(
Colon and Recum
Pathology
There were five hamartomas, the remaining six cases included two granulomas of the lung, one neurilemmoma, one fat pad, one bronchogenic cyst and one dermoid cyst.
7
Results
Survival reflected the course of the primary cancer; four patients are alive from three to 11 years after excision of their primary cancer and show no evidence
FIG. 2. Sources of 1% excised solitary metastases to lung
(1940-1972).
Vol. 187.9 No. 3
BENIGN SOLITARY LUNG LESIONS
metastasis: could be chronic changes" and in the other, only descriptive terms were used.
Discussion Lung metastases from an extrathoracic cancer usually appear from the onset as multiple shadows. Hence, when a single opacity is found insteador at the most two or three-either synchronous or metachronous with the cancer, it is an ambiguous and unique phenomenon that warrants immediate efforts to obtain a histologic diagnosis. This clarification is essential in order to avoid presuming it to be a metastasis for which an inappropriate therapeutic program may be launched and an inaccurate prognosis given. Such a regimen can be debilitating, involving such measures as radiation and/or chemotherapy or even ablative therapy. It can also cause considerable psychological trauma to the patient and his family because of the implications a metastasis carries with it. The necessity for a microscopic diagnosis is graphically demonstrated in this series as most patients had cancers notorious for their strong tendencies to metastasize to lung, and occasionally as a solitary deposit. In fact, in three other studies, the opacity proved to be a single metastasis from 23 breast cancers,3 25 colon cancers2 and 18 melanomas.I In addition, in 43 breast cancers, 29 colon cancers and five melanoma patients, the opacity proved to be a new lung primary. The roentgenographic interpretation of the shadow in this clinical setting is often unreliable and in this group, five were incorrectly diagnosed. Now, at this institution, radiologists list several possibilities, recognizing that no matter how suggestive the size and shape may be or the position of the opacity, it can only hint at certain diagnoses. The presence of calcium either in the vicinity of, or within, the lesion may suggest a benign process but is not, of itself, an entirely reliable clue as cancers can occur in juxtaposition with such deposits. Multiple shadows are usually considered to be unequivocal evidence of metastases and there is compelling evidence for this belief. However, on occasion, doubt may result from the lesion's appearance which may be uncharacteristic for metastasis. Suspicion also arises if the extent of the "metastases" would seem to be inconsistent with the patient's good general condition. Management The management of solitary pulmonary opacities with a known cancer elsewhere has been amply described.7,9"114"5 However, two principles should
243
be emphasized: 1) a shadow is not a histologic diagnosis-a premise that has received additional documentation in this series; 2) all cancer patients should have strict periodic and life-long vigilance. This last subscribes to the tenet that the earlier a cancer or a metastasis is detected and treated, the better the chance for control. The scheduled intervals for post-therapeutic follow-up care in cancer patients are arbitrary. However, as recurrences usually appear within 18 months, it is recommended that patients be seen every two months for the first year; every three months the second year, and then three to four times a year until the fifth anniversary. Thereafter, unless symptoms necessitate an earlier examination, the visits can be spaced at 6 month intervals for the rest of their lives. It is important to continue follow-up care after five years have elapsed as it is now known that this arbitrary "milestone" provides no assurance of "cure," of "control" or of being "free of disease" since metastases or new primary cancers have frequently appeared long after that period of time. At these visits, proper surveillance requires a history and physical examination. Chest roentgenograms, both anteroposterior and lateral views, should be taken at least every six months. This interval should be shorter (every four months) for the first year for those who have had a melanoma or osteogenic sarcoma or a highly anaplastic carcinoma because of the increased probability of pulmonary metastases. Once a pulmonary shadow is found, some bias for its being a primary lung cancer is introduced in patients over 35 who give a history of heavy cigarette smoking. Attempts should be made to obtain previous chest x-rays as quickly as possible for comparison. Tomograms of the lungs are essential and may reveal other opacities or delineate equivocal shadows.'2 In searching for evidence of spread of cancer, laboratory tests are of help. However, although some clues are afforded by blood chemistries and scans (liver, bone and brain), these must be interpreted in the clinical context as they are not, of themselves, infallible indices of the presence or absence of metastases, having often been misleading in both directions. Bronchoscopy to obtain washings and/or a biopsy is recommended especially for centrally-placed lesions or peripheral shadows that are 2 cm or larger. Cytologic studies obtained by sputum or bronchial washings are valuable only when positive. At this institution, scalene lymph node biopsy is not routine but is done when a mass is palpable in the area or if there is suggestive clinical evidence that a diagnostic problem can be resolved by this method, i.e., Boeck's sarcoid, histoplasmosis or a lymphoma.
244
CAHAN, SHAH AND CASTRO
Ann. Surg. * March 1978
Mediastinoscopy is performed in selected clinical situations, particularly when there is a strong suggestion of mediastinal adenopathy. Neither procedure was performed in this series. A negative cytology may warrant preoperative aspiration biopsy (percutaneous) if the pulmonary lesion is large enough to be a target (greater than 2 cm). It is of particular value if the shadow is synchronous with the known cancer, for a benign report might permit a delay of the pulmonary phase until after the extrathoracic cancer has been treated. Aspiration biopsy is of value if there are medical contraindications to thoracic surgery and no other diagnostic measures have succeeded. When properly performed and analyzed, it can be tantamount to a frank biopsy. This procedure is inadvisable when there is a possibility of a melanoma for, as in no other cancers, melanoma metastases are readily transplantable and may be either tracked along the aspirating needle's path or disseminated by its traumatization.
have been managed in various ways: if they are ipsilateral, both an exploratory thoracotomy and a definitive breast operation can be staged or performed simultaneously. If the two lesions are contralateral, it may be more logical to explore the lung lesion first, for should it prove to be a solitary metastasis or one of many radiologically undetected metastases, this might modify the procedure for the breast tumor. If one takes into consideration that a primary lung cancer is present, it should be given priority as it has a more serious prognosis than breast cancer. When melanoma is present, it should receive definitive treatment as if it existed alone. Then, after a short convalescence, attention should be directed to the pulmonary shadow. In summary, a solitary lung shadow with a known cancer elsewhere is a unique and ambiguous phenomenon. Efforts should be made to resolve this ambiguity as soon as possible by microscopic analysis. By so doing, appropriate therapy can be administered and a more accurate prognosis given.
Surgical Management In these ambiguous clinical settings, if the patient's condition permits, an exploratory thoracotomy should be performed. This relatively safe procedure may be the only means of diagnosis if all preoperative tests are negative. The extent of resection is often dictated by the lesion's location and histology: if peripheral, a wedge excision or a segmentectomy is considered adequate for benign lesions. However, malignant neoplasms, either a lung primary or a metastasis, usually require more extensive resection. For centrally-located tumors, an incisional or aspiration biopsy helps plan the extent of the resection. If benign, local extirpation should be attempted in order to spare pulmonary parenchyma. For extrapulmonic benign lesions, a local excision is adequate. When pulmonary lesions occur metachronously with a cancer (eight patients), the sequence of management is simple. However, in this group, three pulmonary shadows were synchronous with their extrapulmonic cancer and the priority of management can be difficult to resolve. By and large, common sense should prevail. If, for example, previous chest x-rays show a shadow unchanged through the years, a more conservative approach to the lung lesion is justified; or (as another example), if a synchronous carcinoma of the colon threatens to obstruct, this would of necessity require prior attention. Concurrent breast cancers and solitary shadows
References 1. Cahan, W. G.: Excision of Melanoma Metastases to Lung: Problems in Diagnosis and Management. Ann. Surg., 178: 703, 1973. 2. Cahan, W. G., Castro, E. B. and Hajdu, S. I.: Significance of a Solitary Lung Shadow in Patients with Colon Carcinoma. Cancer, 33:414, 1974. 3. Cahan, W. G. and Castro, E. B.: Significance of a Solitary Lung Shadow in Patients with Breast Cancer. Ann. Surg., 181:137, 1975. 4. Cahan, W. G., Butler, F., Watson, W. L. and Pool, J. L.: Multiple Cancers: Primary in the Lung and Other Sites. J. Thorac. Cardiovasc. Surg., 20:335, 1950. 5. Cahan, W. G.: Lung Cancer Associated with Cancer Primary in other Sites. Am. J. Surg., 89:494, 1955. 6. Cahan, W. G.: Multiple Primary Cancers One of Which is Lung. Surg. Clin. North Am., 49:323, 1969. 7. Cahan, W. G.: The Management of a Lung Opacity with a Primary Cancer at Another Site. Cancer Management. A Special Graduate Course on Cancer. Philadelphia. J. B. Lippincott. 475-483, 1968. 8. Cotton, R. E. and Jackson, J. W.: Amyloid Tumors of the Lung. Thorax, 19:97, 1964. 9. Davis, E. W., Peabody, J. W. and Katz, S.: The Solitary Pulmonary Nodule. J. Thorac. Cardiovasc. Surg., 32:728, 1956. 10. Koutras, P., Urschel, H. C. and Paulson, D. L.: Hamartoma of the Lung. J. Thorac. Cardiovasc. Surg., 61:768, 1971. 11. Mitchell, R. S. and Taylor, R. R.: The Solitary Circumscribed Pulmonary Nodule. Arch. Intern. Med., 100:780, 1957. 12. Neifeld, J. P., Michaelis, L. L. and Doppman, J. L.: Suspected Pulmonary Metastases. Correlation of Chest X-ray, Whole Lung Tomograms, and Operative findings. Cancer, 39:383, 1977. 13. Shah, J. P., Choudhry, K. U., Huvos, A. G., et al.: Hamartomas of the Lung. Surg., Gynecol. Obstet., 136: 406, 1973. 14. Steele, J. D.: The Solitary Pulmonary Nodule. J. Thorac. Cardiovasc. Surg., 46:21, 1963. 15. Stone, F. J. and Churg, A. M.: The Ultrastructure of Pulmonary Hamartoma. Cancer, 39:1064, 1977.
The appearance of a lung opacity on a chest film of a patient with known cancer may present a diagnostic dilemma. From 1940 through 1975, over 800 patients with this problem underwent thoracotomy for confirmation of diagnosis. In some 500 of these patients, the lesion proved to be primary cancer of the lung; in 1% they were solitary metastases and in 11 patients the lesions were benign. -There were six additional patients in whom multiple opacities were found which proved to be benign conditions. An approach to the investigation, diagnosis, and surgical management of such solitary pulmonary lesions is presented. It is emphasized that the appearance of a solitary pulmonary shadow in a patient with a history of cancer should not be assumed to be a metastasis. Appropriate investigations should be performed without delay in an effort to define the nature of the lesion by microscopic analysis permitting definitive therapy to be administered and a more accurate prognosis provided.
A SOLITARY LUNG OPACITY found on a chest x-ray
Alwith
a known extrathoracic cancer is a diagnostic dilemma. For years, such shadows were assumed to be a metastasis and either the harbinger of many that would subsequently appear or merely the visible evidence of others more cryptically placed. Based upon that premise, therapeutic programs aimed at palliation were initiated. As thoracic surgery matured, it seemed justifiable to try to resect such lesions, particularly as nonsurgical measures often proved to be unrewarding. As a result, although some were indeed metastases, others proved instead to be primary lung cancers or benign conditions.
Clinical Material From 1940 through 1975 at Memorial SloanKettering Cancer Center, more than 800 patients were seen with extrathoracic cancer associated with a solitary pulmonary shadow. In all instances, the diagnosis was microscopically confirmed from specimens obtained by biopsy, resection or autopsy. Of * Attending Surgeon, Thoracic Service t Assistant Attending Surgeon, Head and Neck Service t By Invitation Reprint requests: William G. Cahan, M.D., 1275 York Avenue, New York, N.Y. 10021. Submitted for publication: July 1, 1977.
From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
these, approximately 500 proved to be primary lung cancers (Fig. 1); 196 were solitary metastases (Fig. 2) and 11 were benign lesions. The last group is analyzed in this report and although relatively few cases are included, they are felt to have broad implications.
Site of Cancer The sites of primary cancers were: breast (five), colon (one), stomach (one), larynx (one), melanoma (one), liposarcoma (one), and lung (one). Although 11 patients had solitary pulmonary opacities, there were six others whose chest x-rays revealed more than one shadow. These ranged from two or three to multiple and bilateral shadows, and are discussed as a separate group because of their potential significance. Nine patients were asymptomatic, their shadows having been discovered on routine follow-up examination or workup for a primary cancer: two had nonproductive coughs. Sex and Age There were five males and six females whose ages ranged from 53 to 63 years.
Synchronous and Metachronous Shadows Two lesions were synchronous and eight were metachronous with the primary cancer. In the remaining patient, the shadow was synchronous with a squamous carcinoma of the lung. Preoperative Diagnosis In six patients, a roentgenographic diagnosis of the lesion was not mentioned: in five, the radiologists designated it as a metastasis or a new primary cancer. In one, a tomogram described the shadow as having a calcific rim suggestive of a benign tumor. Six patients were bronchoscoped because their
0003-4932-78-0300-0241-0060 X J. B. Lippincott Company
241
CAHAN, SHAH AND CASTRO
242
Ann. Surg.
o
March 1978
of disease. In no instance was there any significant delay in treatment or modification of the accepted standard procedures of therapy for the cancer because of the presence of the opacity.
51 Basal cell ca's plus the following (not shown): Triple ca's 104 4 separate ca's 6 5 separate ca's 2 6 separate ca's 1
FIG. 1. Multiple primary cancers, one of which was lung (19401972).
opacities seemed to be centrally-located, or if peripheral, were larger than 2 cm. Four showed negative cytology; one was reported as having "suspicious cells and marked bronchial atypia; the sixth showed cancer cells reflecting a stage 0 lung cancer concurrent with a hamartoma. Treatment All 11 patients had an exploratory thoracotomy. The seven intrapulmonic lesions were peripheral to the second division of the bronchi. Their benign nature was often suggested by gross examination; e.g., hamartomas were very firm and well circumscribed and those that lay just beneath the visceral pleura produced a surface convexity instead of umbilicating its surface as do most carcinomas. The other four extrapulmonic lesions were readily identifiable as being benign and were excised. There was no postoperative morbidity or mortality in this series.
Multiple Lung Shadows Although this study has concentrated on solitary shadows, it is relevant to include six patients who had more than one opacity with a known cancer. In three, there were two opacities; in one, there were three; and in two, there were many bilateral densities. Of the three having two densities, two were associated with breast cancers, one of whom had synchronous primary cancers of the breast and lung. The third patient had a synchronous leiomyoblastoma of the stomach. In all three instances, the benign lesions were hamartomas.10'13 Of the two patients who had many lung lesions, one was associated with a primary cancer of the uterus and one of the breast. The shadows proved to be multifocal fibrosis and inflammation and amyloid nodules respectively.8 Three patients had shadows synchronous with their primary cancers: lung and stomach and the third had had simultaneous primaries of breast and lung. Three lesions were initially believed to be solitary but tomography revealed additional densities. In four patients who had two or three shadows, the radiologic diagnosis was either "bronchogenic carcinoma" or "metastases." Of the two patients with many opacities, one was designated as "not entirely characteristic of
Hed and Nec 1(
Colon and Recum
Pathology
There were five hamartomas, the remaining six cases included two granulomas of the lung, one neurilemmoma, one fat pad, one bronchogenic cyst and one dermoid cyst.
7
Results
Survival reflected the course of the primary cancer; four patients are alive from three to 11 years after excision of their primary cancer and show no evidence
FIG. 2. Sources of 1% excised solitary metastases to lung
(1940-1972).
Vol. 187.9 No. 3
BENIGN SOLITARY LUNG LESIONS
metastasis: could be chronic changes" and in the other, only descriptive terms were used.
Discussion Lung metastases from an extrathoracic cancer usually appear from the onset as multiple shadows. Hence, when a single opacity is found insteador at the most two or three-either synchronous or metachronous with the cancer, it is an ambiguous and unique phenomenon that warrants immediate efforts to obtain a histologic diagnosis. This clarification is essential in order to avoid presuming it to be a metastasis for which an inappropriate therapeutic program may be launched and an inaccurate prognosis given. Such a regimen can be debilitating, involving such measures as radiation and/or chemotherapy or even ablative therapy. It can also cause considerable psychological trauma to the patient and his family because of the implications a metastasis carries with it. The necessity for a microscopic diagnosis is graphically demonstrated in this series as most patients had cancers notorious for their strong tendencies to metastasize to lung, and occasionally as a solitary deposit. In fact, in three other studies, the opacity proved to be a single metastasis from 23 breast cancers,3 25 colon cancers2 and 18 melanomas.I In addition, in 43 breast cancers, 29 colon cancers and five melanoma patients, the opacity proved to be a new lung primary. The roentgenographic interpretation of the shadow in this clinical setting is often unreliable and in this group, five were incorrectly diagnosed. Now, at this institution, radiologists list several possibilities, recognizing that no matter how suggestive the size and shape may be or the position of the opacity, it can only hint at certain diagnoses. The presence of calcium either in the vicinity of, or within, the lesion may suggest a benign process but is not, of itself, an entirely reliable clue as cancers can occur in juxtaposition with such deposits. Multiple shadows are usually considered to be unequivocal evidence of metastases and there is compelling evidence for this belief. However, on occasion, doubt may result from the lesion's appearance which may be uncharacteristic for metastasis. Suspicion also arises if the extent of the "metastases" would seem to be inconsistent with the patient's good general condition. Management The management of solitary pulmonary opacities with a known cancer elsewhere has been amply described.7,9"114"5 However, two principles should
243
be emphasized: 1) a shadow is not a histologic diagnosis-a premise that has received additional documentation in this series; 2) all cancer patients should have strict periodic and life-long vigilance. This last subscribes to the tenet that the earlier a cancer or a metastasis is detected and treated, the better the chance for control. The scheduled intervals for post-therapeutic follow-up care in cancer patients are arbitrary. However, as recurrences usually appear within 18 months, it is recommended that patients be seen every two months for the first year; every three months the second year, and then three to four times a year until the fifth anniversary. Thereafter, unless symptoms necessitate an earlier examination, the visits can be spaced at 6 month intervals for the rest of their lives. It is important to continue follow-up care after five years have elapsed as it is now known that this arbitrary "milestone" provides no assurance of "cure," of "control" or of being "free of disease" since metastases or new primary cancers have frequently appeared long after that period of time. At these visits, proper surveillance requires a history and physical examination. Chest roentgenograms, both anteroposterior and lateral views, should be taken at least every six months. This interval should be shorter (every four months) for the first year for those who have had a melanoma or osteogenic sarcoma or a highly anaplastic carcinoma because of the increased probability of pulmonary metastases. Once a pulmonary shadow is found, some bias for its being a primary lung cancer is introduced in patients over 35 who give a history of heavy cigarette smoking. Attempts should be made to obtain previous chest x-rays as quickly as possible for comparison. Tomograms of the lungs are essential and may reveal other opacities or delineate equivocal shadows.'2 In searching for evidence of spread of cancer, laboratory tests are of help. However, although some clues are afforded by blood chemistries and scans (liver, bone and brain), these must be interpreted in the clinical context as they are not, of themselves, infallible indices of the presence or absence of metastases, having often been misleading in both directions. Bronchoscopy to obtain washings and/or a biopsy is recommended especially for centrally-placed lesions or peripheral shadows that are 2 cm or larger. Cytologic studies obtained by sputum or bronchial washings are valuable only when positive. At this institution, scalene lymph node biopsy is not routine but is done when a mass is palpable in the area or if there is suggestive clinical evidence that a diagnostic problem can be resolved by this method, i.e., Boeck's sarcoid, histoplasmosis or a lymphoma.
244
CAHAN, SHAH AND CASTRO
Ann. Surg. * March 1978
Mediastinoscopy is performed in selected clinical situations, particularly when there is a strong suggestion of mediastinal adenopathy. Neither procedure was performed in this series. A negative cytology may warrant preoperative aspiration biopsy (percutaneous) if the pulmonary lesion is large enough to be a target (greater than 2 cm). It is of particular value if the shadow is synchronous with the known cancer, for a benign report might permit a delay of the pulmonary phase until after the extrathoracic cancer has been treated. Aspiration biopsy is of value if there are medical contraindications to thoracic surgery and no other diagnostic measures have succeeded. When properly performed and analyzed, it can be tantamount to a frank biopsy. This procedure is inadvisable when there is a possibility of a melanoma for, as in no other cancers, melanoma metastases are readily transplantable and may be either tracked along the aspirating needle's path or disseminated by its traumatization.
have been managed in various ways: if they are ipsilateral, both an exploratory thoracotomy and a definitive breast operation can be staged or performed simultaneously. If the two lesions are contralateral, it may be more logical to explore the lung lesion first, for should it prove to be a solitary metastasis or one of many radiologically undetected metastases, this might modify the procedure for the breast tumor. If one takes into consideration that a primary lung cancer is present, it should be given priority as it has a more serious prognosis than breast cancer. When melanoma is present, it should receive definitive treatment as if it existed alone. Then, after a short convalescence, attention should be directed to the pulmonary shadow. In summary, a solitary lung shadow with a known cancer elsewhere is a unique and ambiguous phenomenon. Efforts should be made to resolve this ambiguity as soon as possible by microscopic analysis. By so doing, appropriate therapy can be administered and a more accurate prognosis given.
Surgical Management In these ambiguous clinical settings, if the patient's condition permits, an exploratory thoracotomy should be performed. This relatively safe procedure may be the only means of diagnosis if all preoperative tests are negative. The extent of resection is often dictated by the lesion's location and histology: if peripheral, a wedge excision or a segmentectomy is considered adequate for benign lesions. However, malignant neoplasms, either a lung primary or a metastasis, usually require more extensive resection. For centrally-located tumors, an incisional or aspiration biopsy helps plan the extent of the resection. If benign, local extirpation should be attempted in order to spare pulmonary parenchyma. For extrapulmonic benign lesions, a local excision is adequate. When pulmonary lesions occur metachronously with a cancer (eight patients), the sequence of management is simple. However, in this group, three pulmonary shadows were synchronous with their extrapulmonic cancer and the priority of management can be difficult to resolve. By and large, common sense should prevail. If, for example, previous chest x-rays show a shadow unchanged through the years, a more conservative approach to the lung lesion is justified; or (as another example), if a synchronous carcinoma of the colon threatens to obstruct, this would of necessity require prior attention. Concurrent breast cancers and solitary shadows
References 1. Cahan, W. G.: Excision of Melanoma Metastases to Lung: Problems in Diagnosis and Management. Ann. Surg., 178: 703, 1973. 2. Cahan, W. G., Castro, E. B. and Hajdu, S. I.: Significance of a Solitary Lung Shadow in Patients with Colon Carcinoma. Cancer, 33:414, 1974. 3. Cahan, W. G. and Castro, E. B.: Significance of a Solitary Lung Shadow in Patients with Breast Cancer. Ann. Surg., 181:137, 1975. 4. Cahan, W. G., Butler, F., Watson, W. L. and Pool, J. L.: Multiple Cancers: Primary in the Lung and Other Sites. J. Thorac. Cardiovasc. Surg., 20:335, 1950. 5. Cahan, W. G.: Lung Cancer Associated with Cancer Primary in other Sites. Am. J. Surg., 89:494, 1955. 6. Cahan, W. G.: Multiple Primary Cancers One of Which is Lung. Surg. Clin. North Am., 49:323, 1969. 7. Cahan, W. G.: The Management of a Lung Opacity with a Primary Cancer at Another Site. Cancer Management. A Special Graduate Course on Cancer. Philadelphia. J. B. Lippincott. 475-483, 1968. 8. Cotton, R. E. and Jackson, J. W.: Amyloid Tumors of the Lung. Thorax, 19:97, 1964. 9. Davis, E. W., Peabody, J. W. and Katz, S.: The Solitary Pulmonary Nodule. J. Thorac. Cardiovasc. Surg., 32:728, 1956. 10. Koutras, P., Urschel, H. C. and Paulson, D. L.: Hamartoma of the Lung. J. Thorac. Cardiovasc. Surg., 61:768, 1971. 11. Mitchell, R. S. and Taylor, R. R.: The Solitary Circumscribed Pulmonary Nodule. Arch. Intern. Med., 100:780, 1957. 12. Neifeld, J. P., Michaelis, L. L. and Doppman, J. L.: Suspected Pulmonary Metastases. Correlation of Chest X-ray, Whole Lung Tomograms, and Operative findings. Cancer, 39:383, 1977. 13. Shah, J. P., Choudhry, K. U., Huvos, A. G., et al.: Hamartomas of the Lung. Surg., Gynecol. Obstet., 136: 406, 1973. 14. Steele, J. D.: The Solitary Pulmonary Nodule. J. Thorac. Cardiovasc. Surg., 46:21, 1963. 15. Stone, F. J. and Churg, A. M.: The Ultrastructure of Pulmonary Hamartoma. Cancer, 39:1064, 1977.
