Interact CardioVasc Thorac Surg 2009;9:379-381. doi:10.1510/icvts.2009.207555
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Thoracic oncologic |
Endobronchial colorectal metastasis versus primary lung cancer: a tale of two sleeve right upper lobectomies
Anthony W. Kima,*,
Michael J. Liptaya,
Theodore J. Saclaridesb and
William H. Warrena
a Division of Thoracic Surgery, Rush University Medical Center, Chicago, IL, USA
b Department of General Surgery, Rush University Medical Center, Chicago, IL, USA
Received 23 March 2009;
received in revised form 20 April 2009;
accepted 20 April 2009
*Corresponding author. 1725 W. Harrison St., Suite 774, Chicago, IL 60612, USA. Tel.: +1 312 738 3732; fax: +1 312 738 9763.
E-mail address: Anthony_Kim{at}rush.edu (A.W. Kim).
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Abstract
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Endobronchial metastasis from colorectal carcinoma is relatively uncommon whereas primary bronchogenic carcinoma is more common. These two disease entities can both appear to be similar clinically and radiographically. Palliative treatment rather than a curative-intent anatomic resection is typically employed in the setting of endobronchial metastatic disease. We compare two cases of patients with a history of colorectal carcinoma with endobronchial lesions of which one was truly a metastatic lesion.
Key Words: Metastasis; Endobronchial; Lung cancer; Colorectal cancer
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1. Introduction
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We present two patients who had a colorectal cancer, but were found to have obstructing right upper lobe lesions of the lung. Both were treated by sleeve lobectomy, but one was for a primary non-small cell lung cancer, while the other one was for an endobronchial metastasis from his previous rectal adenocarcinoma. We present these cases to compare and contrast these two disease entities.
1.1. Case 1
The patient is a 53-year-old male current smoker who was diagnosed with adenocarcinoma of the colon. He underwent a staging CT-scan of the chest, abdomen, and pelvis that demonstrated the presence of right upper lobe consolidation. Although the right upper lobe bronchus was occluded and it was felt that his radiologic findings were consistent with a post-obstructive picture (Fig. 1). Therefore, he was treated for a presumed pneumonia and then underwent an uneventful laparoscopic colectomy. Postoperatively, he underwent an interval chest CT-scan that demonstrated improvement, but persistence of his post-obstructive pneumonia. At this time the thoracic surgery service was asked to perform a flexible bronchoscopy that revealed the presence of an exophytic lesion obstructing the right upper lobe bronchus. Biopsies of this lesion were obtained and these eventually demonstrated the presence of a squamous cell carcinoma. Immunostaining suggested that this lesion was consistent with a primary non-small cell lung carcinoma. Imaging by PET-scanning and CT of the brain did not suggest distant disease. He subsequently underwent staging with a cervical mediastinoscopy that was negative for mediastinal nodal involvement. Ultimately, he underwent a right upper lobe sleeve lobectomy and mediastinal lymphadenectomy without event. Pathology confirmed the presence of a 1.7 cm squamous cell carcinoma that was completely obstructing the bronchus. All of the lymph nodes were negative for disease. He is currently one year removed from surgery and is without evidence of recurrence of either malignancy.
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Fig. 1. Chest CT-scan (lung window) demonstrating large area of consolidation involving entire right upper lobe posterior segment. Within the consolidation, there is a more confluent area which is due to a central mass.
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1.2. Case 2
The patient is a 49-year-old male former smoker who was diagnosed with adenocarcinoma of the sigmoid colon approximately 7 years earlier. He underwent a low anterior resection with colorectostomy for Duke's Collier B2 lesion. He was treated with postoperative chemoradiation therapy. Approximately 10 months after this operation he was found to have two metastatic lesions in the liver for which he underwent wedge resections. He now presented with complaints of a chronic cough that warranted a flexible bronchoscopy. This revealed an exophytic lesion obstructing the right upper lobe orifice. Biopsies of this lesion were obtained and eventually demonstrated the presence of an adenocarcinoma. Immunostaining suggested that this lesion was consistent with endobronchial metastases from his colon cancer. A chest CT-scan was also obtained (Fig. 2). PET-scan demonstrated increased metabolic activity in the right upper lobe (maximum standard uptake value: 11.1) with minimal paratracheal activity and no other activity elsewhere. A CEA level was not checked as the tissue diagnosis was known. He subsequently underwent a right upper lobe sleeve lobectomy with mediastinal lymphadenectomy without event. Pathology confirmed the presence 4 cm metastases in the right upper lobe with infiltration into the bronchus. All of the lymph nodes were negative for disease. He is currently three months removed from surgery and is doing well.
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Fig. 2. Chest CT-scan (lung window) demonstrating an endobronchial lesion within the right upper lobe bronchus with an abrupt cut-off and associated post-obstructive atelectasis in the anterior segment.
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2. Discussion
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Endobronchial metastasis from colorectal carcinoma has been described previously [1, 2]. It is estimated that colorectal carcinomas account for 12–26% of all endobronchial metastases [3] and are one of the more common causes of central airway involvement by metastatic disease [2]. Typically, they present in the context of widely metastatic disease so that the treatment is usually palliative [4–7]. In fact, it is not uncommon for patients to also have pulmonary nodules separate from their endobronchial lesion [5]. Due to its association with other foci of disease, the presence of endobronchial metastasis is generally associated with a poor survival [5, 6]. However, there are reports of anatomic resections, such as sleeve lobectomy, that have been performed with curative intent [5, 8]. Although the occurrence of endobronchial metastasis from a primary colorectal carcinoma may not be uncommon, its presentation as an isolated metastasis amenable to resection is relatively rare. Furthermore, reports describing sleeve lobectomy to resect the type of lesion reported in this manuscript is even rarer. A search on frequently used medical and bioresearch databases such as Pubmed or Medline using different permutations of the terms ‘sleeve lobectomy’, ‘metastasis’, ‘endobronchial metastasis’, ‘colon carcinoma’, ‘rectal carcinoma’, ‘colorectal carcinoma’ reveals that isolated endobronchial colorectal metastasis resected by sleeve lobectomy is an exceedingly rare occurrence. We understand, however, that this may because it is more frequently practiced than described in the published literature.
In general, patients who are eligible for pulmonary metastatectomy are those who have met selective criteria that include being able to tolerate a resection, having resectable metastatic disease, having their primary colorectal carcinoma controlled, and being without distant disease elsewhere except for hepatic metastasis. By meeting these criteria, successful resection of isolated disease can be achieved with 5-year survivals ranging from 38.3 to 63.7% [9].
The patient with endobronchial colorectal metastasis presented in this case report presented many years after the resection of both his primary tumor and liver metastases. A review of the literature indicates that a prolonged interval between the primary tumor and endobronchial metastases is typical [5–7]. The long interval between the initial colorectal resection and the presentation of endobronchial metastasis is a diagnostic clue for the clinician. As the first patient in this case report exemplified, the synchronous presentation of endobronchial disease with a primary colorectal carcinoma is more consistent with a primary bronchogenic carcinoma. It is not uncommon to identify an endobronchial metastasis only after the clinical and radiographic features of a primary colorectal carcinoma that has metastasized [2, 7]. Interestingly, the type of original colorectal resection does not appear to predict the development of endobronchial metastasis [5]. Another clue that can suggest an endobronchial metastasis when there is a delayed presentation is an associated rise in the CEA levels without any other foci of disease (although CEAs were not routinely checked prior to resection in both cases reported in this manuscript).
Given the relative rarity of endobronchial metastasis and in the context of tobacco use, the vast majority of endo bronchial tumors are primary lung cancers. Bronchoscopy typically is not in the armamentarium of the colorectal surgeon, but in the setting of lobar atelectasis it is extremely useful in obtaining tissue for pathologic diagnosis. This diagnostic tool is important to distinguish between endobronchial metastasis and primary lung cancer.
The purpose of this paper was simply to highlight the similarities and differences in the presentation and management of endobronchial metastasis from colorectal carcinoma and primary lung cancers. In both cases, the patients underwent an intent-to-cure procedure that for the former is rare. Simple diagnostic tools, already in the armamentarium of the thoracic surgeon, may help distinguish one disease entity from the other and thereby allow the colorectal and thoracic surgeons to make appropriate staging and operative decisions.
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Abstract
1. Introduction