case‑3
Correspondence
Spontaneous pneumothorax as the initial manifestation of stage IB primary pulmonary carcinoma: Really early stage cancer? ABSTRACT Spontaneous pneumothorax (SP) is a rare manifestation of lung cancers, especially as the first sign. The mechanism producing pneumothorax from pulmonary cancer has three main reasons, One is that the cancer necrosis directly ruptured into the pleural space. Another is that endobronchial neoplasm acts as a check valve, leading to dilation and eventual rupture of distal alveolar spaces. The third is that the rupture of small subpleural blebs accidentally causes SP. However, the prognosis of lung cancer patients with initial manifestation of SP is very poor, SP seems to be an ominous sign for the primary cavity lung cancer patients, even in an early stage. KEY WORDS: Spontaneous pneumothorax, lung cancer, prognosis
INTRODUCTION Spontaneous pneumothorax (SP) is a rare manifestation of lung cancers, especially as the first sign. When pneumothorax happened, most cancers were already at an advanced stage. And SP as the first manifestation of primary lung cancer in early stage has been few reported. Here, we present a case in which SP occurred as an initial clinical manifestation in a patient with a primary cavitating lung carcinoma in IB stage. We discuss the possible mechanism and the clinical significance of the development of pneumothorax in such patients. CASE REPORT A 55‑year‑old man was admitted to the local hospital for SP in right thorax. The intercostal chest tube drainage was performed. After expansion of the right lung, the chest computed tomography (CT) scan showed a peripheral thick‑wall cavity lesion in the right upper lobe. The cavity wall was partially attached to the pleura and the right lung was slightly collapsed [Figure 1]. Bronchoscopy was performed, there was no neoplasm and compression invasion observed in bronchial lumen. Both mycobacterium tuberculosis and malignant cell were not detected by cytology. The diagnosis was considered to be lung cancer firstly. However, the advancing diagnosis and treatment did not proceed for personal reason of the patient. When air leaks stopped, the chest drainage tube was removed and S118
the patient was discharged. The recurrence of SP happened in 1 month and the patient was referred to our hospital on July 19, 2012 after chest tube was inserted again. The patient with a heavy smoking history had no fever, dyspnea, hemoptysis, purulent sputum and chest pain. Physical examination showed breath sounds was lower on the right lung than the left. Blood tumor markers were within the normal range. The functions of heart, lung, liver and kidney were normal. The distant metastases in brain, bone, liver and adrenal glands were not found. Enlarged mediastinal lymph nodes were not identified from CT scan. Patient was diagnosed with stage IB (T2aN0M0) primary lung cancer. There was no evidence of contraindication to resection. A right thoracotomy was performed. A lesion with a diameter of 3 cm was found in post segment of right upper lobe, with a small pore at the surface of the lung, which caused the communication between the lung and pleural cavity. Metastatic nodule on pleura was not observed. The right upper lobe was resected anatomically. The histological examination of frozen section of lesion showed squamous cell carcinoma and systemic lymph node dissection was finished. Cytologic examination of pleural fluid revealed no malignant cells. Post‑operative histological examination showed that the diameter of the carcinoma was 3 cm, the visceral pleura were infiltrated and there was no lymph node metastasis. The pTNM stage was IB (T2aN0M0). Patient received adjuvant chemotherapy with four
Hua Jiang*, Wei Ma*, Jing‑Ping Zhang1, Lin Zhang Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021, 1 Department of Internal Medicine, Yantai Municipal Laiyang Central Hospital, Yantai, 265200, China *Co-authors: Hua Jiang and Wei Ma have the equal work For correspondence: Prof. Lin Zhang, Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021, China. E‑mail: zhanglindocter@163. com
Access this article online Website: www.cancerjournal.net DOI: 10.4103/0973-1482.119125 PMID: *** Quick Response Code:
Journal of Cancer Research and Therapeutics - Supplement 2 - 2013 - Volume 9
Jiang, et al.: Spontaneous pneumothorax
Figure 1: A peripheral thick‑wall cavity lesion in the right upper lobe. The cavity seems to communicate with pleural space and the right lung was slightly collapsed
cycles of paclitaxel and carboplatin. The latest follow‑up found multiple metastasis in lung and bone in July, 2013. DISCUSSION Usually, SP is caused by rupture of bullae of lung. However, it is quite rarely seen in pulmonary cancer. There is one possibility that SP and pulmonary cancer are two independent and incidental processes. Another possibility is that SP is a manifestation of pulmonary cancer.[1] Both primary and metastatic cancers of lung can cause SP in a very low incidence. Vencevicius reported that 3% of all SP was coexist with pulmonary cancer, either primary or secondary.[2] In most of the cases, SP in pulmonary cancer was mostly treatment‑related, which happens as a complication of radiotherapy [3‑7] or chemotherapy.[8‑11] In addition, SP may appear as a natural progress of pulmonary cancer development. However, it still can be the first clinical manifestation of pulmonary cancers in few case.[2,12‑15] The mechanism producing pneumothorax from pulmonary cancer is not well elucidated, but several theories have been advanced. One is that necrosis of the cancer directly ruptured into the pleural space. This may be the main reason. Vencevicius reported that 21 of 37 patients with pulmonary cancer happened SP in this way.[2] Another is that endobronchial neoplasm acts as a check valve, leading to dilation and eventual rupture of distal alveolar spaces.[16] The third is that the rupture of small subpleural blebs accidentally causes SP. In the present case, we considered the pneumothorax was caused by direct rupture of the peripheral cavity carcinoma into the pleural space and creating a bronchopleural fistula. Penetration of the visceral pleura by the cavity was observed during the operation. In the literature, the prognosis of patients with pneumothorax due to lung cancer is very poor. Once SP develops, majority of patients live no longer than 3 months.[17] It may be attributed to the advanced stage of lung cancer, the extensive lung damage caused by the tumor itself and/or the anti‑tumor therapy, the bronchopleural fistulas caused by the persistent rupture and the deleterious effect of the pneumothorax on the pulmonary function reserve.[17‑19] Journal of Cancer Research and Therapeutics - Supplement 2 - 2013 - Volume 9
As is all known, an early stage primary lung cancer has a better prognosis. In this article, Although this stage IB primary lung cancer patient received operation and four cycles of adjuvant chemotherapy, the prognosis was not as well as we expected. The metastasis in lung and bone was found 1 year later after the operation, but pleural dissemination was not observed. It revealed that the blood metastasis happened in this patient instead of pleural metastasis. We presumed that the carcinoma had invaded blood vessel and formed tumor embolus, which caused vascular embolism and led to necrosis of carcinoma and formation of a cavity. At the same time, the malignant cells from tumor embolus were carried to other organs by blood and caused the distant metastasis. The vascular invasion mechanism had been mentioned in Laurens report.[20] From this experience, we conclude that SP seems to be an ominous sign for the primary cavity lung cancer patients, even in an early stage. REFERENCES 1. Pototskii V, Kolyarzh M. Spontaneous pneumothorax as a manifestation of lung cancer and pulmonary metastases. Probl Oncol 1961;7:1582‑8. 2. Vencevicius V, Cicenas S. Spontaneous pneumothorax as a first sign of pulmonary carcinoma. World J Surg Oncol 2009;7:57. 3. Ren SX, Zhou SW, Zhang L, Zhou CC. Erlotinib treatment for persistent spontaneous pneumothorax in non‑small cell lung cancer: A case report. Chin Med J (Engl) 2010;123:3501‑3. 4. Ohnishi K, Shioyama Y, Nomoto S, Sasaki T, Ohga S, Yoshitake T, et al. Spontaneous pneumothorax after stereotactic radiotherapy for non‑small‑cell lung cancer. Jpn J Radiol 2009;27:269‑74. 5. Okada M, Ebe K, Matsumoto T, Karino Y, Kawamura M, Tokuda O, et al. Ipsilateral spontaneous pneumothorax after rapid development of large thin‑walled cavities in two patients who had undergone radiation therapy for lung cancer. AJR Am J Roentgenol 1998;170:932‑4. 6. Furrer M, Althaus U, Ris HB. Spontaneous pneumothorax from radiographically occult metastatic sarcoma. Eur J Cardiothorac Surg 1997;11:1171‑3. 7. O’Connor BM, Ziegler P, Spaulding MB. Spontaneous pneumothorax in small cell lung cancer. Chest 1992;102:628‑9. 8. Mori M, Nakagawa M, Fujikawa T, Iwasaki T, Kawamura T, Namba Y, et al. Simultaneous bilateral spontaneous pneumothorax observed during the administration of gefitinib for lung adenocarcinoma with multiple lung metastases. Intern Med 2005;44:862‑4. 9. Ozet A, Yavuz AA, Oztürk B, Kömürcü S, Arpaci F, Tuvay E, et al. Recurrent spontaneous pneumothorax following high‑dose chemotherapy in a patient with non‑seminomatous testicular cancer with pulmonary metastases. Tumori 2000;86:253‑5. 10. Bini A, Zompatori M, Ansaloni L, Grazia M, Stella F, Bazzocchi R. Bilateral recurrent pneumothorax complicating chemotherapy for pulmonary metastatic breast ductal carcinoma: Report of a case. Surg Today 2000;30:469‑72. 11. Vicente P, Garciá del Muro X, Cardenal F. Spontaneous pneumothorax in response to chemotherapy of metastatic germinal tumor. An Med Interna 1995;12:307‑8. 12. Moreno Merino S, Gallardo Valera G, Congregado Loscertales M. Spontaneous pneumothorax as the initial manifestation of medullary thyroid carcinoma. Arch Bronconeumol 2011;47:615‑6. 13. Galbis Caravajal JM, Mafé Madueño JJ, Baschwitz Gómez B, Pérez Carbonell A, Rodríguez Paniagua JM. Spontaneous pneumothorax
S119
Jiang, et al.: Spontaneous pneumothorax
as the first sign of pulmonary carcinoma. Arch Bronconeumol 2001;37:397‑400. 14. Lundgren R, Stjernberg N. Spontaneous pneumothorax as first symptom in bronchial carcinoma. Acta Med Scand 1980;207:329‑30. 15. Guznov GI, Kuleshov SE. Spontaneous pneumothorax as the first manifestation of lung cancer. Grudn Khir 1979;1:89‑90. 16. Minami H, Sakai S, Watanabe A, Shimokata K. Check‑valve mechanism as a cause of bilateral spontaneous pneumothorax complicating bronchioloalveolar cell carcinoma. Chest 1991;100:853‑5. 17. Bouros D, Andrianopoulos E. Spontaneous pneumothorax. A complication of lung cancer? Chest 1986;90:926. 18. Lai RS, Perng RP, Chang SC. Primary lung cancer complicated with
S120
pneumothorax. Jpn J Clin Oncol 1992;22:194‑7. 19. Lois M, Noppen M. Bronchopleural fistulas: An overview of the problem with special focus on endoscopic management. Chest 2005;128:3955‑65. 20. Laurens RG Jr, Pine JR, Honig EG. Spontaneous pneumothorax in primary cavitating lung carcinoma. Radiology 1983;146:295‑7. Cite this article as: Jiang H, Ma W, Zhang J, Zhang L. Spontaneous pneumothorax as the initial manifestation of stage I B primary pulmonary carcinoma: Really early stage cancer?. J Can Res Ther 2013;9:118-20. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Cancer Research and Therapeutics - Supplement 2 - 2013 - Volume 9
Copyright of Journal of Cancer Research & Therapeutics is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Correspondence
Spontaneous pneumothorax as the initial manifestation of stage IB primary pulmonary carcinoma: Really early stage cancer? ABSTRACT Spontaneous pneumothorax (SP) is a rare manifestation of lung cancers, especially as the first sign. The mechanism producing pneumothorax from pulmonary cancer has three main reasons, One is that the cancer necrosis directly ruptured into the pleural space. Another is that endobronchial neoplasm acts as a check valve, leading to dilation and eventual rupture of distal alveolar spaces. The third is that the rupture of small subpleural blebs accidentally causes SP. However, the prognosis of lung cancer patients with initial manifestation of SP is very poor, SP seems to be an ominous sign for the primary cavity lung cancer patients, even in an early stage. KEY WORDS: Spontaneous pneumothorax, lung cancer, prognosis
INTRODUCTION Spontaneous pneumothorax (SP) is a rare manifestation of lung cancers, especially as the first sign. When pneumothorax happened, most cancers were already at an advanced stage. And SP as the first manifestation of primary lung cancer in early stage has been few reported. Here, we present a case in which SP occurred as an initial clinical manifestation in a patient with a primary cavitating lung carcinoma in IB stage. We discuss the possible mechanism and the clinical significance of the development of pneumothorax in such patients. CASE REPORT A 55‑year‑old man was admitted to the local hospital for SP in right thorax. The intercostal chest tube drainage was performed. After expansion of the right lung, the chest computed tomography (CT) scan showed a peripheral thick‑wall cavity lesion in the right upper lobe. The cavity wall was partially attached to the pleura and the right lung was slightly collapsed [Figure 1]. Bronchoscopy was performed, there was no neoplasm and compression invasion observed in bronchial lumen. Both mycobacterium tuberculosis and malignant cell were not detected by cytology. The diagnosis was considered to be lung cancer firstly. However, the advancing diagnosis and treatment did not proceed for personal reason of the patient. When air leaks stopped, the chest drainage tube was removed and S118
the patient was discharged. The recurrence of SP happened in 1 month and the patient was referred to our hospital on July 19, 2012 after chest tube was inserted again. The patient with a heavy smoking history had no fever, dyspnea, hemoptysis, purulent sputum and chest pain. Physical examination showed breath sounds was lower on the right lung than the left. Blood tumor markers were within the normal range. The functions of heart, lung, liver and kidney were normal. The distant metastases in brain, bone, liver and adrenal glands were not found. Enlarged mediastinal lymph nodes were not identified from CT scan. Patient was diagnosed with stage IB (T2aN0M0) primary lung cancer. There was no evidence of contraindication to resection. A right thoracotomy was performed. A lesion with a diameter of 3 cm was found in post segment of right upper lobe, with a small pore at the surface of the lung, which caused the communication between the lung and pleural cavity. Metastatic nodule on pleura was not observed. The right upper lobe was resected anatomically. The histological examination of frozen section of lesion showed squamous cell carcinoma and systemic lymph node dissection was finished. Cytologic examination of pleural fluid revealed no malignant cells. Post‑operative histological examination showed that the diameter of the carcinoma was 3 cm, the visceral pleura were infiltrated and there was no lymph node metastasis. The pTNM stage was IB (T2aN0M0). Patient received adjuvant chemotherapy with four
Hua Jiang*, Wei Ma*, Jing‑Ping Zhang1, Lin Zhang Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021, 1 Department of Internal Medicine, Yantai Municipal Laiyang Central Hospital, Yantai, 265200, China *Co-authors: Hua Jiang and Wei Ma have the equal work For correspondence: Prof. Lin Zhang, Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021, China. E‑mail: zhanglindocter@163. com
Access this article online Website: www.cancerjournal.net DOI: 10.4103/0973-1482.119125 PMID: *** Quick Response Code:
Journal of Cancer Research and Therapeutics - Supplement 2 - 2013 - Volume 9
Jiang, et al.: Spontaneous pneumothorax
Figure 1: A peripheral thick‑wall cavity lesion in the right upper lobe. The cavity seems to communicate with pleural space and the right lung was slightly collapsed
cycles of paclitaxel and carboplatin. The latest follow‑up found multiple metastasis in lung and bone in July, 2013. DISCUSSION Usually, SP is caused by rupture of bullae of lung. However, it is quite rarely seen in pulmonary cancer. There is one possibility that SP and pulmonary cancer are two independent and incidental processes. Another possibility is that SP is a manifestation of pulmonary cancer.[1] Both primary and metastatic cancers of lung can cause SP in a very low incidence. Vencevicius reported that 3% of all SP was coexist with pulmonary cancer, either primary or secondary.[2] In most of the cases, SP in pulmonary cancer was mostly treatment‑related, which happens as a complication of radiotherapy [3‑7] or chemotherapy.[8‑11] In addition, SP may appear as a natural progress of pulmonary cancer development. However, it still can be the first clinical manifestation of pulmonary cancers in few case.[2,12‑15] The mechanism producing pneumothorax from pulmonary cancer is not well elucidated, but several theories have been advanced. One is that necrosis of the cancer directly ruptured into the pleural space. This may be the main reason. Vencevicius reported that 21 of 37 patients with pulmonary cancer happened SP in this way.[2] Another is that endobronchial neoplasm acts as a check valve, leading to dilation and eventual rupture of distal alveolar spaces.[16] The third is that the rupture of small subpleural blebs accidentally causes SP. In the present case, we considered the pneumothorax was caused by direct rupture of the peripheral cavity carcinoma into the pleural space and creating a bronchopleural fistula. Penetration of the visceral pleura by the cavity was observed during the operation. In the literature, the prognosis of patients with pneumothorax due to lung cancer is very poor. Once SP develops, majority of patients live no longer than 3 months.[17] It may be attributed to the advanced stage of lung cancer, the extensive lung damage caused by the tumor itself and/or the anti‑tumor therapy, the bronchopleural fistulas caused by the persistent rupture and the deleterious effect of the pneumothorax on the pulmonary function reserve.[17‑19] Journal of Cancer Research and Therapeutics - Supplement 2 - 2013 - Volume 9
As is all known, an early stage primary lung cancer has a better prognosis. In this article, Although this stage IB primary lung cancer patient received operation and four cycles of adjuvant chemotherapy, the prognosis was not as well as we expected. The metastasis in lung and bone was found 1 year later after the operation, but pleural dissemination was not observed. It revealed that the blood metastasis happened in this patient instead of pleural metastasis. We presumed that the carcinoma had invaded blood vessel and formed tumor embolus, which caused vascular embolism and led to necrosis of carcinoma and formation of a cavity. At the same time, the malignant cells from tumor embolus were carried to other organs by blood and caused the distant metastasis. The vascular invasion mechanism had been mentioned in Laurens report.[20] From this experience, we conclude that SP seems to be an ominous sign for the primary cavity lung cancer patients, even in an early stage. REFERENCES 1. Pototskii V, Kolyarzh M. Spontaneous pneumothorax as a manifestation of lung cancer and pulmonary metastases. Probl Oncol 1961;7:1582‑8. 2. Vencevicius V, Cicenas S. Spontaneous pneumothorax as a first sign of pulmonary carcinoma. World J Surg Oncol 2009;7:57. 3. Ren SX, Zhou SW, Zhang L, Zhou CC. Erlotinib treatment for persistent spontaneous pneumothorax in non‑small cell lung cancer: A case report. Chin Med J (Engl) 2010;123:3501‑3. 4. Ohnishi K, Shioyama Y, Nomoto S, Sasaki T, Ohga S, Yoshitake T, et al. Spontaneous pneumothorax after stereotactic radiotherapy for non‑small‑cell lung cancer. Jpn J Radiol 2009;27:269‑74. 5. Okada M, Ebe K, Matsumoto T, Karino Y, Kawamura M, Tokuda O, et al. Ipsilateral spontaneous pneumothorax after rapid development of large thin‑walled cavities in two patients who had undergone radiation therapy for lung cancer. AJR Am J Roentgenol 1998;170:932‑4. 6. Furrer M, Althaus U, Ris HB. Spontaneous pneumothorax from radiographically occult metastatic sarcoma. Eur J Cardiothorac Surg 1997;11:1171‑3. 7. O’Connor BM, Ziegler P, Spaulding MB. Spontaneous pneumothorax in small cell lung cancer. Chest 1992;102:628‑9. 8. Mori M, Nakagawa M, Fujikawa T, Iwasaki T, Kawamura T, Namba Y, et al. Simultaneous bilateral spontaneous pneumothorax observed during the administration of gefitinib for lung adenocarcinoma with multiple lung metastases. Intern Med 2005;44:862‑4. 9. Ozet A, Yavuz AA, Oztürk B, Kömürcü S, Arpaci F, Tuvay E, et al. Recurrent spontaneous pneumothorax following high‑dose chemotherapy in a patient with non‑seminomatous testicular cancer with pulmonary metastases. Tumori 2000;86:253‑5. 10. Bini A, Zompatori M, Ansaloni L, Grazia M, Stella F, Bazzocchi R. Bilateral recurrent pneumothorax complicating chemotherapy for pulmonary metastatic breast ductal carcinoma: Report of a case. Surg Today 2000;30:469‑72. 11. Vicente P, Garciá del Muro X, Cardenal F. Spontaneous pneumothorax in response to chemotherapy of metastatic germinal tumor. An Med Interna 1995;12:307‑8. 12. Moreno Merino S, Gallardo Valera G, Congregado Loscertales M. Spontaneous pneumothorax as the initial manifestation of medullary thyroid carcinoma. Arch Bronconeumol 2011;47:615‑6. 13. Galbis Caravajal JM, Mafé Madueño JJ, Baschwitz Gómez B, Pérez Carbonell A, Rodríguez Paniagua JM. Spontaneous pneumothorax
S119
Jiang, et al.: Spontaneous pneumothorax
as the first sign of pulmonary carcinoma. Arch Bronconeumol 2001;37:397‑400. 14. Lundgren R, Stjernberg N. Spontaneous pneumothorax as first symptom in bronchial carcinoma. Acta Med Scand 1980;207:329‑30. 15. Guznov GI, Kuleshov SE. Spontaneous pneumothorax as the first manifestation of lung cancer. Grudn Khir 1979;1:89‑90. 16. Minami H, Sakai S, Watanabe A, Shimokata K. Check‑valve mechanism as a cause of bilateral spontaneous pneumothorax complicating bronchioloalveolar cell carcinoma. Chest 1991;100:853‑5. 17. Bouros D, Andrianopoulos E. Spontaneous pneumothorax. A complication of lung cancer? Chest 1986;90:926. 18. Lai RS, Perng RP, Chang SC. Primary lung cancer complicated with
S120
pneumothorax. Jpn J Clin Oncol 1992;22:194‑7. 19. Lois M, Noppen M. Bronchopleural fistulas: An overview of the problem with special focus on endoscopic management. Chest 2005;128:3955‑65. 20. Laurens RG Jr, Pine JR, Honig EG. Spontaneous pneumothorax in primary cavitating lung carcinoma. Radiology 1983;146:295‑7. Cite this article as: Jiang H, Ma W, Zhang J, Zhang L. Spontaneous pneumothorax as the initial manifestation of stage I B primary pulmonary carcinoma: Really early stage cancer?. J Can Res Ther 2013;9:118-20. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Cancer Research and Therapeutics - Supplement 2 - 2013 - Volume 9
Copyright of Journal of Cancer Research & Therapeutics is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
![[Spontaneous pneumothorax: unusual manifestation of pulmonary hamartochondroma].](/assets/img/hold.png)
