Endobronchial metastasis

Endobronchial metastasis secondary to renal clear cell carcinoma: A case report

BACKGROUND

Endobronchial metastases (EBMs) are tumours that metastasise from a malignant tumour outside the lungs to the central and subsegmental bronchi, and are visible under a bronchofibrescope. Most EBMs are formed by direct invasion or metastasis of intrathoracic malignant tumours, such as lung cancer, oesophageal cancer or mediastinum tumours. Renal cell carcinoma (RCC), accounting for 2% to 3% of all tumours, is a common malignant tumour of the urinary system. Renal clear cell carcinoma (RCCC) constitutes the predominant pathological subtype of RCC, comprising approximately 70% to 80% of all RCC cases. RCCC can spread and metastasise through arterial, venous and lymphatic circulation to almost all organs of the body. Moreover, lung, bone, liver, brain and local recurrence are the most common metastatic neoplasms of RCCC. However, EBM from RCCC has a low complication rate and is often misdiagnosed as primary lung cancer.

CASE SUMMARY

A 71-year-old male patient who had undergone radical left nephrectomy 7 years prior due to RCCC was referred to our hospital due to a 1-mo history of productive cough. The results of an enhanced chest CT scan indicated the presence of a soft tissue nodule in the upper lobe of the left lung, and flexible bronchoscopy revealed a hypervascular lesion in the bronchus of the left lung's superior lobe. Therefore, the patient underwent thoracoscopic left superior lobe wedge resection, and pathology confirmed EBM from the RCCC.

CONCLUSION

EBM from RCCC has a low incidence and no characteristic clinical manifestations in the early stage. If a bronchial tumour is found in a patient with RCCC, the possibility of bronchial metastatic cancer should be considered.

Isolated Endobronchial Metastasis of Breast Cancer Successfully Managed With Multimodal Treatment

Isolated endobronchial metastases of breast cancers, without other visceral metastatic involvement, are exceptional. We report here an observation of isolated endobronchial metastasis discovered 18 months after complete treatment of breast carcinoma. The endobronchial metastasis was revealed by an incoercible cough and hemoptysis. A bronchoscopy revealed a budding tumor process obstructing the right stem bronchus and a biopsy was performed. The anatomopathological and immunohistochemical analysis confirmed the metastatic nature of the endobronchial tumor. The patient received treatment with palbociclib and aromatase inhibitors. Two years after radiotherapy and under hormone treatment, the patient is in complete remission of her breast cancer and endobronchial metastasis. Emerging research suggests that oligometastatic breast cancer carries a superior prognosis. We believe that patients with oligometastatic breast cancer should be treated with curative intent, including ablative therapy to all sites of disease if it can be safely accomplished. This approach may offer an additional chance for prolonged survival.

A case of endobronchial metastasis of colon cancer mimics sarcoidosis, and a review of related literature

PURPOSE

Endobronchial metastases (EBM) are defined as bronchoscopically visible lesions histopathologically identical to extrapulmonary tumors. We summarized the literature on endobronchial metastasis of colorectal cancer and give a brief review.

METHOD

We present a rare case with an episode mistaken for sarcoidosis and unexpectedly identified as colon cancer by bronchoscopic biopsy. A 53-year-old man with dry cough and dyspnea had diffuse micro lung nodules and lymphadenopathy on CT and PET/CT. He was diagnosed with sarcoidosis and took steroid therapy, but the symptoms could not be alleviated. Bronchoscopy was suggested. He was finally identified with colon cancer by bronchoscopic biopsy, which was confirmed by endoscopic biopsy. We summarise the clinical manifestations, imaging, prognosis of EMB of colorectal cancer.

RESULT

EBM are rare. Colorectal cancer is common in EBM and the frequency is increasing.

CONCLUSION

EBM should be distinguished from primary lung cancer, sarcoidosis.

Endobronchial metastasis secondary to occulting renal cell carcinoma: literature review and a rare case report

BACKGROUND

Endobronchial Metastasis from extrathoracic tumors is a rare neoplasm that accounts for approximately 1.1% of total endobronchial malignancies. The most common primary tumors associated with EBM are from the colorectal, breast, and kidney regions. Although it represents a late manifestation in the context of tumor progression, it can rarely antedate the diagnosis of the primary tumor.

CASE PRESENTATION

A 67-years-old male was referred from another city hospital to our thoracic surgery department due to a 4-months history of hemoptysis and productive cough. A chest X-ray and computed tomography scan showed a soft-tissue mass within the left main bronchus and atelectasis of the anterior segment of the left upper lobe. Furthermore, a flexible bronchoscopy revealed a hypervascular lesion occluding completely the left upper lobe bronchus. The patient underwent lobectomy and pathological examination suggested endobronchial metastasis from clear cell renal cell carcinoma. A second computed tomography scan of the abdomen and pelvis showed a well-defined mass arising from the lateral aspect of the right kidney; therefore, the patient underwent right radical nephrectomy three weeks later and pathology confirmed the diagnosis of clear renal cell carcinoma with endobronchial metastasis.

CONCLUSION

Despite its rarity, physicians should consider the possibility of endobronchial metastases in the setting of endobronchial lesions. Proper diagnostic approaches should also be considered to rule out the potential of asymptomatic extrathoracic neoplasms. In this manuscript, we aimed to report a rare case -the first from Syria to our knowledge- of an endobronchial metastasis that preceded the diagnosis of renal cell carcinoma. Importantly, we reviewed the existing literature and discussed the diagnostic and treatment approaches.

Endobronchial Metastasis of Renal Carcinoma: A Case Report and Review of Previous Literature

The definition of endobronchial metastasis (EBM) lacks clarity because it is currently based on the judgments of surgeons; it is rare in patients with nonpulmonary malignancies. Although EBM represents an advanced stage of malignancy, it does not necessarily indicate a poorer prognosis than that for its primary tumors. The present study defines EBM as bronchoscopy-visible lesions with histologically confirmed primary extrapulmonary tumors, excluding those primary lung tumors with involvement of the bronchial lumen. A bronchoscopy and biopsy provide strong proof for diagnosis. Complete surgical resection is the best choice for patients with EBM. This study analyzed the case of a 69-year-old male patient who had undergone a radical left nephrectomy several years previously after the identification of a bronchoscopy-visible lesion in the left main bronchus. The lesion was initially diagnosed as an angiogenic tumor but was eventually confirmed by surgical biopsy as EBM from the left kidney. After diagnosis, the patient underwent a left pneumonectomy. The analysis of this case focused on diagnosis, symptoms, radiographic findings, treatment, and prognosis. A review of the previous literature relating to EBM was also conducted.

Endobronchial metastases secondary to prostate cancer: A case report and literature review

Metastatic disease from solid extrapulmonary tumours affects the lungs frequently. Endobronchial metastases (EM) however are very rare. Most commonly breast, colorectal and renal carcinomas can result in endobronchial metastases. EM secondary to a prostate primary are even more uncommon. We present an unusual case of a synchronous diagnosis of EM and primary prostate cancer. The diagnosis was confirmed on bronchoscopic endobronchial biopsies and immunohistochemical examination. Just 3 such cases have been reported to the best of our knowledge in the last 15 years. We discuss frequencies, similarities with previously reported cases, possible developmental modes and the diagnosis of EM. We conclude that patients with a current or previous diagnosis of an extrapulmonary malignancy with apparently trivial respiratory symptoms and/or unexplained weight loss should be considered for a bronchoscopy. Bronchoscopy and immunohistochemical profiling is the gold standard for diagnosing EM, as they may not be visible on cross sectional imaging.

Diffuse endobronchial metastasis from sigmoid carcinoma presenting as wheezing and respiratory failure

A 66‐year‐old Thai man with underlying asthma, history of traumatic right haemothorax, and sigmoid carcinoma with bladder invasion developed productive cough, whitish sputum, dyspnoea, and wheezing for 2 months. Physical examination showed generalized expiratory wheezing in both lungs. Computed tomography scan of the chest revealed diffuse thickening of bronchial wall, predominantly at lower lobes; several various sizes of pulmonary nodules; diffuse interlobular septal thickening; multiple enlarged mediastinal lymph nodes and hilar lymph nodes; and right pleural effusion. The patient was intubated for respiratory failure with persistent wheezing and, subsequently, with difficulty weaning from mechanical ventilation. Bronchoscopy was performed, which revealed diffuse multiple small mucosal nodules in both lungs. Pathology of the nodules showed foci of adenocarcinoma. Positive immunochemical staining with CDX2 confirmed the diagnosis of endobronchial metastasis of sigmoid carcinoma. This case highlighted a rare presentation of endobronchial metastasis from sigmoid carcinoma with persistent wheezing, respiratory failure, and difficulty in weaning from mechanical ventilation.

Endobronchial Metastasis from Extrapulmonary Neoplasms: Analysis of Clinicopathologic Features and Cytological Evaluation by Bronchial Brushing

PURPOSE

Bronchial brushings (BB) commonly aid in the diagnosis of primary lung cancer. However, the utility of this method in diagnosing endobronchial metastases (EBM) from extrapulmonic malignancies has not been thoroughly evaluated. The purpose of this study is to evaluate the sensitivity of BB in diagnosing EBM.

METHODS

An institutional database was queried for all patients with cytologically or histologically confirmed extrapulmonary EBM identified by endobronchial biopsy between 1978 and 2013. Data were collected on patient demographics, histologic and cytologic diagnoses, time from primary malignancy to identification of EBM, and location of EBM. The sensitivity of BB for the diagnosis of EBM and the clinicopathologic features of extrapulmonary EBM were assessed.

RESULTS

Fifty-six patients (33 females, 23 males; mean age 53 years) were identified with EBM. Diagnoses included lymphoma (21), breast adenocarcinoma (11), colonic adenocarcinoma (7), melanoma (6), renal cell carcinoma (RCC, 5), embryonal carcinoma (2), and 1 case each of tonsillar squamous cell carcinoma, thymic carcinoma, leiomyosarcoma, and sarcoma, not otherwise specified. The sensitivity of BB for identifying EBM was 85% overall and 94% for non-hematologic malignancies. The mean interval between primary diagnosis and EBM was 59 months (range 0-264 months). Excluding ten patients who had EBM at their initial presentation, lymphoma had the shortest (10 months) and RCC had the longest (264 months) mean interval between primary diagnosis and EBM. The mean time between EBM identification and death was 22.4 months (n = 24).

CONCLUSION

Bronchial brushing is a sensitive technique for diagnosing non-hematologic extrapulmonic endobronchial metastases.

Unusual Patterns of Thoracic Metastasis of Urinary Bladder Carcinoma

Urinary bladder carcinoma (UBC) is the ninth most common malignancy and the second most common urological malignancy after prostate cancer in men. Thoracic metastases occur in more than half of those with muscle-invasive disease, and these generally assume the form of multiple solid parenchymal lesions characteristic of hematogenous seeding of the lung. Unusual patterns of thoracic spread of UBC have also been described albeit sporadically in the form of case reports and series. The aim of our case series is to provide illustrations of several atypical patterns of thoracic involvement by UBC such as isolated mediastinal lymphadenopathy, cavitary lung metastases, malignant pleural effusion, endobronchial disease, and pulmonary tumor embolism. This review is meant to highlight the intersection of the fields of urological oncology and thoracic radiology in the care of patients with UBC.

Fibrobronchoscopic cryosurgery for secondary malignant tumors of the trachea and main bronchi

Background

Patients with secondary malignant tracheal and main bronchial tumors may suffer severe symptoms as a result of major airway obstruction. Curative surgical resection is usually not suitable because of the presence of metastatic disease and poor performance status. In this study, the use of bronchoscopic cryosurgery to reopen the airway is analyzed.

Methods

The clinical records of 37 patients who experienced secondary maglinancies from December 2001 to January 2013 were retrospectively reviewed. Low temperature cryotherapy (−50°C to −70°C) was delivered to the central part of the tumor by cryoprobe for four to six minutes causing destruction of the tumor mass (Cryo‐melt method). Subsequently, the edge of the tumor was frozen for 30 seconds to two minutes, followed by piecemeal removal of the frozen tumor tissue (Cryo‐resection method).

Results

The endpoints of the study were degree of symptomatic improvement and survival. The rates of dramatic and partial symptomatic alleviation were 57.1% and 28.6%, respectively, there were no intraoperative deaths, and median survival was 16.0 months. Prolonged survival was significantly correlated to age (under 60 years of age 22.2% vs. over 60 100%, P = 0.011), tumor location (main bronchi 0% vs. trachea 77.8%, P = 0.003), and cryorecanalization times (once 33.3% vs. twice or more 80.0%, P = 0.037).

Conclusion

Bronchoscopic cryorecanalization is a safe, effective, non‐invasive choice for improving the symptoms of malignant airway obstruction. In addition to achieving local‐regional control, the technique may also contribute to improved survival.

Bronchoscopic palliation to treat endobronchial metastasis of the tracheobronchial tree

BACKGROUND

Endobronchial metastases (EBM) are rarely observed, but they are caused by a number of different tumors. Bronchoscopy is the main approach for both differential diagnosis and to maintain endoluminal palliation. In this study, consecutive EBM cases that had been diagnosed and treated were evaluated in a retrospective cohort.

METHODS

In total, 18 pathologically verified patients with EBM originating from extrathoracic tumors who were referred to our interventional pulmonology unit with respiratory symptoms were retrospectively evaluated. Tumor type, metastasis location, treatment method and frequency, and complications were evaluated.

RESULTS

In total, there were 18 patients (13 women) with EBM enrolled in this study. All were diagnosed by a bronchial biopsy. The mean age of the patients was 48±15.24 years (range: 24-76 years). The most frequent sites of origin of the metastases were the bone (5) and kidney. Obstructions were observed in the tracheas of 12 patients, in the right main bronchi of 10, and in the left main bronchi of 11. Twelve airway stents were placed in nine patients. The removal of the obstruction was effective in the remaining patients. The mean number of treatment applications was 1.47 (range: 1-3). Hemorrhage, mucostasis, and granulation were observed. The median follow-up duration was 528 days (range: 62-1177 days). The median survival time for the patients who died was 122 days (range: 2-885 days).

CONCLUSIONS

EBM is rare, and bronchoscopy is the primary method of diagnosis, followed by palliation, if necessary.

Stereotactic body radiotherapy (SBRT) for high-risk central pulmonary metastases

Background and purpose

Radiotherapy of central lung tumors carries a higher risk of treatment-related toxicity and local failure. In the era of aggressive oligometastic management the exploration of the proper dose-fractionation for metastatic central lung tumors is essential.

Materials and methods

Patients diagnosed with high-risk metastatic lesions of the central pulmonary tree comprised this single-institutional retrospective analysis. “High-risk” central pulmonary lesions were defined as those with abutment and/or invasion of the mainstem bronchus. All patients were treated using the CyberKnife SBRT system in 5 fractions to a total dose of 35 or 40 Gy.

Results

Twenty patients were treated from 2008 to 2011 at Georgetown University Hospital. At a median follow up of 19 months, 1-year Kaplan-Meier local control and overall survival was 70 and 75 %, respectively. Late grade 2 or higher atelectasis was the most common treatment-related toxicity and was significantly associated with maximum dose to the mainstem bronchus. Gross endobronchial involvement was associated with significantly lower overall survival.

Conclusions

Five-fraction SBRT to a total dose of 35 or 40 Gy appears to be a safe and effective management strategy for high-risk central pulmonary metastatic lesions, though care should be taken to limit the maximum point dose to the mainstem bronchus.

Endobronchial metastasis: an epidemiologic and clinicopathologic study of 174 consecutive cases

PURPOSE

Endobronchial metastases from extrapulmonary solid tumors are a rare event and currently available epidemiological and clinico-pathological data mainly derive from anecdotal case reports.

METHODS

A series of 174 consecutive cases of endobronchial metastases from extrathoracic solid tumors were collected over a period of 18 years. Immunohistochemistry was performed in 115 cases. Complete imaging features were available in 81 patients, and analysis of the latency period between primitive tumor diagnosis and occurrence of endobronchial metastasis was obtained.

RESULTS

Among all bronchoscopic examinations performed in the same period for malignancy, a mean of 5.6 cases per year consisted of endobronchial metastases (range 2-17 cases), with a statistically significant increase when comparing the periods 1992-2000 (65 cases, 37%) and 2001-2009 (109 cases, 63%) (p = 0.05). Overall, 4% of endobronchial biopsies for suspected malignancy disclosed an endobronchial metastasis from extrapulmonary tumor. Breast (52 cases, 30%), colorectal (42 cases, 24%), renal (14%), gastric (6%) and prostate (4.5%) cancers and melanoma (4.5%) were the most common metastatic neoplasms presenting as endobronchial mass. One-hundred fifty-four cases were identified after the primitive tumor diagnosis (metachronous cases, 89%), 11 cases were simultaneously evidenced in extrapulmonary and endobronchial sites (synchronous cases, 6%), while 9 occult metastatic cases (5%) first presented as endobronchial mass (anachronous cases). Overall, mean latency from extrapulmonary tumor diagnosis and endobronchial metastasis was 136 months (range, 1-300 months). The most frequent symptoms were dyspnea (23%), cough (15%) and haemoptysis (12%), while 26% of patients were totally asymptomatic. At radiology, 53% presented as multiple pulmonary nodules, while other cases presented as hilar and mediastinal mass, single peripheral nodule, atelectasis or pleural effusion.

CONCLUSIONS

Endobronchial metastases from extrapulmonary tumors account for about 4% of all bronchoscopic biopsies performed for suspected malignancy and in 5% of the cases the metastasis is the first manifestation of the neoplasm.

Endobronchial metastases from extrathoracic malignancies: recent 10 years' experience in a single university hospital

BACKGROUND

Although the lung is a common site of metastasis, endobronchial metastases (EBM) from extrathoracic malignancies are rare. Previous studies were retrospective reviews of the cases from each single institute, and the last one was performed between 1992 and 2002. We evaluated the characteristics of patients with EBM who had been diagnosed in recent 10 years in our hospital.

METHODS

We retrospectively reviewed 1,275 patients who had undergone diagnostic bronchoscopic procedures between 2001 and 2011. An EBM was defined as bronchoscopically notable lesion, which was histopathologically identical to the primary tumor.

RESULTS

A total of 18 cases of EBM were identified. The mean age was 53 years, and 12 cases of the 18 patients were female. The most common primary malignancies were colorectal cancer and breast cancer (4 cases each), followed by cervix cancer (3 cases) and renal cell carcinoma (2 cases). Cough was the most common symptom. The most common radiologic finding was atelectasis, which was identified in 27.7% of the cases. The median interval from the diagnosis of primary malignancy to the diagnosis of EBM was 14 months (range, 0-112 months). The median survival time from the diagnosis of EBM was 10 months (range, 1-39 months).

CONCLUSION

EBM from extrathoracic malignancies were rare. Colorectal cancer and breast cancer were common as primary malignancies. Fiberoptic bronchoscopy should be performed in all patients, who are suspected of having EBM. If atypical clinical and pathological features are present, appropriate diagnostic studies should be undertaken.

Endobronchial metastases from extrathoracic malignancy

PURPOSE

Endobronchial metastasis is defined as documented extrathoracic malignancies metastatic to the endobronchus within a bronchoscopically visible range. Although the clinical and radiologic findings of endobronchial metastasis are similar to primary lung cancer, treatment and prognosis may be different. We hereby investigated the clinical, radiologic and bronchoscopic aspects of endobronchial metastases (EBM) in Korean patients.

MATERIALS AND METHODS

A total of 43 patients with EBM who underwent bronchoscopic biopsies from June 1991 to December 2009 at Severance Hospital, Yonsei University College of Medicine in Seoul, Korea, were analyzed retrospectively. We evaluated clinical, radiologic and bronchoscopic characteristics of EBM.

RESULTS

The patients consisted of 27 males and 16 females and their ages ranged from 18 to 77 years. The common primary cancers related to EBM were rectal (16.3%), colon (11.6%), breast (9.3%) and uterine (9.3%) cancers. The mean interval from diagnosis of primary cancer to EBM was 36 months, and the mean survival duration from diagnosis of EBM was 16.1 months in 33 deceased patients.

CONCLUSION

EBM develop in various types of malignancies at various times with unremarkable manifestations. Therefore, physicians should consider the possibility of EBM, especially if a patient has a history of any malignancy, regardless of respiratory symptoms. Respiratory symptoms related with EBM can be treated by various safe procedures.

Endobronchial metastases of anal canal carcinoma

Endobronchial metastases (EBM) secondary to extrapulmonary primary tumours are rare. The most common solid malignant tumours associated with EBM are breast, renal and colorectal carcinomas. This case report describes the first documented case of EBM from anal canal carcinoma. This neoplasm constitutes less than 1% of colorectal tumours. The clinical presentation of this entity is variable, being asymptomatic in more than 50% of cases. Generally, EBM are diagnosed in advanced stages and the survival after the diagnosis is poor. It is therefore an exceptional clinical manifestation in which bronchoscopy has an important role in the diagnosis and the treatment.

Tracheal metastasis of small cell lung cancer

Endotracheal metastases of primary lung cancer are rare. Only one case of tracheal metastasis from small cell lung cancer has been reported in literature. Here, we report a rare case of a 45-year-old woman who was admitted for sudden-onset breathlessness with respiratory failure and required ventilatory support. Endotracheal growth was identified during bronchoscopy, and biopsy revealed endotracheal metastasis of small cell lung cancer.

Endobronchial metastatic breast cancer with pagetoid histology mimicking bronchial pagetoid squamous cell carcinoma in situ

We report a case of a 56-year-old woman with endobronchial breast cancer metastasis of unusual histology. The patient presented with persistent cough, and a lesion was noted in the left mainstem bronchus on bronchoscopic examination. Biopsy revealed extensive squamous metaplasia of bronchial epithelium along with large, atypical cells exhibiting pagetoid intraepithelial spread within squamous mucosa. Immunohistochemical stains were compatible with a diagnosis of metastatic breast adenocarcinoma with pagetoid spread. To our knowledge, this is the first reported case of endobronchial breast cancer metastasis with this histologic presentation. In this report, we describe the clinical, radiographic, bronchoscopic, histologic, and immunohistochemical characteristics of this case. We provide a brief review of existing literature on endobronchial breast cancer metastasis. In addition, we discuss the principal differential diagnosis of bronchial pagetoid lesions. This report raises awareness of this uncommon manifestation of metastatic breast cancer.

Endobronchial metastasis from adenocarcinoma of gastric cardia 7 years after potentially curable resection

Endobronchial metastasis (EBM) is a rare form of metastasis from extrapulmonary malignant tumors, although there are few reports of EBM from gastric cancer specifically. We report the case of a 51-year-old woman who had undergone gastrectomy for advanced gastric cancer seven years previously but was diagnosed with a solitary lung tumor by follow-up computed tomography. On diagnosis of primary lung cancer, she underwent pulmonary lobectomy, but immunohistochemical examination confirmed the resected tumor to be an EBM from the gastric cancer. Six months later, she was diagnosed with peritoneal metastases and underwent chemotherapy with gastric cancer regimen. She is still alive at 33 mo after the lobectomy. Generally, the prognosis for EBM is poor although multidisciplinary treatment can lead to long-term survival. Precise diagnosis on the basis of detailed pathological and immunohistochemical evaluation can contribute to deciding the most effective treatment and improving prognosis.

Endobronchial metastases from extrapulmonary solid tumors

Malignancy detected during endobronchial biopsies is usually regarded as proof of lung cancer. It may, however, represent endobronchial metastases from extrapulmonary primary tumors. The literature was reviewed to describe how frequent extrapulmonary tumors have been reported to metastasize to the endobronchial epithelium. English language literature was searched from 1962 through 2002. Primary lung cancer and lymphomas were excluded. Endobronchial metastases were reported in 204 patients, originating from 20 different extrapulmonary primary tumors, usually cancers of the breast, kidney, colorectal, uterine cervix, sarcoma and skin. The mean time from diagnosis of primary tumor was 50 months (range 0-300 months) and mean survival time from diagnosis of endobronchial metastasis was 15.2 months (range 0-150 months). It is important to make a distinction between endobronchial metastases from primary lung cancer, as treatment possibilities may be different. The possibility of endobronchial metastasis should be considered if the patient has a history of malignancy in other organs.

Endobronchial metastasis from adrenocortical carcinoma

Lung parenchymal metastases are common manifestations; however, endobronchial metastasis is rare. We present herein a case of endobronchial metastasis from adrenocortical carcinoma. In the English language literature, this is the first case with such rare metastasis from adrenocortical carcinoma diagnosed antemortem. Although very rare, physicians should keep in mind the possibility of endobronchial metastasis in patients with a history of extrapulmonary malignancy including adrenocortical carcinoma.

Mucoid impaction secondary to mucin-producing metastatic adenocarcinoma of the cervix

Endobronchial metastases are an uncommon complication of malignant tumours. The vast majority are secondary to carcinoma of the breast, colorectum and kidney, or to melanoma. Occasionally, endobronchial tumours can result in partial or complete bronchial obstruction. Here, we describe an uncommon case of endobronchial metastasis of adenocarcinoma of the cervix causing mucoid impaction owing to mucous production by the tumour cells.

Endobronchial metastases from colorectal adenocarcinomas: clinical and endoscopic characteristics and patient prognosis

BACKGROUND

Endobronchial metastases (EBM) secondary to extrapulmonary solid malignant tumours are rare but may occur. The most common extrathoracic malignancies associated with EBM are breast, renal and colorectal carcinomas. This study aimed to evaluate the clinical and bronchoscopic aspects of EBM from colorectal carcinomas and the prognosis of the patients.

METHODS

EBM were diagnosed in 7 patients with colorectal carcinomas between 2004 and 2005. All patients underwent colorectal resection at the time of primary tumour diagnosis. Bronchial involvement was proved by bronchoscopy, and the metastatic nature of the lesions was confirmed histopathologically in all patients. EBM patients were compared with a control group of 7 patients with pulmonary metastases from colorectal cancer.

RESULTS

Median age at time of colorectal carcinoma was 55 years in EBM patients and 57 years in controls. Distressing airway symptoms caused by EBM were relieved by use of newer intrabronchial therapies: radiotherapy, brachytherapy and cryotherapy. One patient underwent metastasis resection. The median survival after diagnosis of EBM was 18.9 months. All patients had pulmonary metastases. The median survival after diagnosis of pulmonary metastasis from colorectal carcinoma was 55.7 months in EBM patients and 12.7 months in controls (p < 0.005).

DISCUSSION

EBM are generally underdiagnosed in patients with colorectal carcinoma. Bronchoscopy is not part of the standard evaluation of these patients. Physicians must be more attentive to pulmonary symptoms, even when patients' pulmonary metastases are known. Various management options are available for localized endobronchial tumours.

CONCLUSION

On average, EBM are diagnosed about 5 years after the diagnosis of the primary tumour, which is a relatively long lead time. Although this metastatic location usually implies a very negative prognosis regarding life expectancy, it did not seem to significantly reduce survival in our patients. Local treatments allow substantial improvement of pulmonary symptoms.

Endobronchial metastasis from prostate cancer

We report a case of endobronchial metastasis from prostate adenocarcinoma. A patient with a history of prostate cancer under complete androgen blockade presented to the respiratory department complaining of dyspnea and dry coughing. Flexible bronchoscopy showed multiple polypoid lesions in the tracheobronchial tree and the immunohistochemical studies on the biopsy specimen determined the diagnosis. The patient was treated with paclitaxel, estramustine phosphate and carboplatine, and experienced symptoms suppression. To our knowledge, this is the first case of endobronchial metastasis of a patient with androgen refractory prostate cancer without any evidence of extrathoracic metastasis. The current report also emphasises the need for a multidisciplinary approach for cases of endobronchial metastases, with the collaboration of pneumologists, urologists, pathologists and oncologists.

Endotracheal metastases in renal cell carcinoma: A life-threatening but treatable complication

Endotracheal obstruction, by primary bronchogenic carcinoma or by metastases from extrapulmonary tumors, is a rare and life-threatening complication in cancer patients. The trachea is an extremely rare location for metastases from non-pulmonary tumors. We report a patient with metastatic renal cell carcinoma who developed almost complete obstruction of the trachea and who was successfully managed with bronchoscopic resection of endotracheal metastases.

Tracheal metastasis of lung cancer: CT findings in six patients

OBJECTIVE

Our objective was to assess CT findings of tracheal metastasis of lung cancer.

CONCLUSION

Tracheal metastasis of primary non-small cell lung cancer manifested as an endotracheal nodule or eccentric wall thickening of the trachea, showing contrast enhancement with a predilection for the upper trachea on CT. During postoperative evaluation of patients with surgically resected lung cancer, the possibility of tracheal metastasis of lung cancer should be suggested when an endotracheal nodule or eccentric wall thickening is present on CT.

Endobronchial metastases from extrathoracic malignancies

Endobronchial metastases (EBM) from extrapulmonary malignant tumors are rare. The most common extrathoracic malignancies associated with EBM are breast, renal and colorectal carcinomas. In this study, we aimed to evaluate the clinical, radiographic and bronchoscopic aspects of patients with EBM who were diagnosed between 1992 and 2002. Data about patients' clinical conditions, symptoms, radiographic and endoscopic findings, and histopathological examination results were investigated. EBM was defined as bronchoscopically visible lesions histopathologically identical to the primary tumor in patients with extrapulmonary malignancies. We found 15 cases with EBM. Primary tumors included breast (3), colorectal (3), and renal (2) carcinomas; Malignant Melanoma (2); synovial sarcoma (1), ampulla of Vater adenocarcinoma (1), pheochromocytoma (1), hypernephroma (1), and Hodgkin's Disease (1). The most common symptoms were dyspnea (80%), cough (66.6%) and hemoptysis (33.3%). Multiple (40%) or single (13.3%) pulmonary nodules, mediastinal or hilar lymphadenopathy (40%), and effusion (40%) were the most common radiographic findings. The mean interval from initial diagnosis to diagnosis of EBM was 32.8 months (range, 0-96 months) and median survival time was 18 months (range, 4-84). As a conclusion, various extrapulmonary tumors can metastasize to the bronchus. Symptoms and radiographic findings are similar with those in primary lung cancer. Therefore, EBM should be discriminated from primary lung cancer histopathologically. Although mean survival time is usually short, long-term survivors were reported. Consequently, treatment must be planned according to the histology of the primary tumor, evidence of metastasis to other sites and medical status of the patient.

Endobronchial metastases: a clinicopathological analysis

OBJECTIVE

It is important to distinguish endobronchial metastases (EBM) from both primary lung cancers and benign lesions, as treatment will differ. The clinicopathological characteristics of EBM cases were documented to see whether any distinguishing features exist.

METHODOLOGY

Histological cases diagnosed as EBM in the pathology laboratory of a tertiary hospital were re-evaluated. Symptoms, primary tumour sites, recurrence interval, radiological and bronchoscopic features, and histopathological properties were assessed.

RESULTS

There were 18 cases (eight female, 10 male) with EBM. All were diagnosed by bronchoscopic bronchial biopsy. The primary tumour sites were: colorectal (4), breast (3), renal (3), lymphoma (3), rhabdomyosarcoma (2), bladder (1), thyroid (1) and malignant melanoma (1). The mean time from the diagnosis of the primary tumour to their presentation was 3.89+/-1.09 (range, 0--19) years. In five patients, EBM was diagnosed synchronously with their extra pulmonary primary tumour. Two had other metastatic sites. Haemoptysis and cough were the more common symptoms. Interestingly, three patients were asymptomatic. There was no predilection for a particular airway segment to be involved but a predilection for the upper lobe existed. Endoscopic appearance was polypoid in 10 cases and mucosal infiltration in the remainder. Histopathological examination revealed epithelial tissue at the surface of the tumour in nine cases and four of these were metaplastic. In all but one there was inflammation, mainly lymphocytic. Necrosis was present in 10 cases and bleeding was seen in four. There were no statistically significant differences between the level of lymphocytic inflammation and other clinicopathological parameters.

CONCLUSION

EBM is a rare condition that can be synchronous or occur late. Surprisingly, it can be asymptomatic. It is usually found in the upper lobes. Lymphocytic inflammation is a common histopathological finding. There is need for further studies to clarify the clinical importance of EBM.

A rare case of Hurthle cell carcinoma with endobronchial metastasis

Endobronchial metastases (EBM) are frequently seen in breast, renal and colon carcinomas. However, to our knowledge, only one case has ever been reported as EBM secondary to Hurthle cell carcinoma (HCC) in the literature. A 57-year-old woman had a bilateral total thyroidectomy for thyroid mass in 1990 that was diagnosed as HCC. She was admitted to our outpatient clinic in August 1999, with symptoms of cough, sputum, and right-sided pleuritic pain for the last seven months. In the bronchoscopic examination, two endobronchial lesions were seen. Pathological evaluation of the bronchoscopic samples was diagnosed as "Hurthle cell carcinoma" of thyroid. We suggest that, although rare, HCC should be considered in the differential diagnosis of the endobronchial metastasis.

Photodynamic therapy for endobronchial metastases from nonbronchogenic primaries

BACKGROUND

Endobronchial metastases (EBM) occur in 2% of nonbronchogenic malignancies and frequently present with hemoptysis or dyspnea. This report summarizes our recent experience with photodynamic therapy (PDT) for EBM.

METHODS

All patients who have undergone PDT for the treatment of symptomatic EBM from nonbronchogenic primaries were identified in the Division of Thoracic Surgery database to determine number of treatments, frequency of symptom relief, and patient survival.

RESULTS

Endobronchial PDT was administered to 27 patients from April 1997 through December 2000. The predominant primary tumor was renal cell (44%). Endobronchial metastases presented metachronously in 74% of patients. Patients underwent a median of two PDT treatments. Local anesthesia with sedation was used in 76% of treatments. Four patients (15%) developed immediate postoperative respiratory distress. Follow-up bronchoscopy 24 to 48 hours after initial treatment demonstrated tumor necrosis in all cases. Acute relief of hemoptysis and dyspnea was achieved in 85% of patients. Seven patients died within 6 weeks of treatment. Median survival time after PDT was 4 months (range 0.2 to 30 months).

CONCLUSIONS

Patients with EBM treated with PDT had a median survival of 4 months and patients with limited metastatic disease survived up to 30 months. Photodynamic therapy was effective in palliating hemoptysis or dyspnea from EBM with an acceptable morbidity, although the 30-day mortality was 22%.

Epithelial and soft tissue tumors of the tracheobronchial tree

This article provides a broad overview of tumors that can involve the tracheobronchial tree. For the most part, the clinical, radiographic, and endoscopic presentation of these rare tumors does not differ significantly from the more common tumors of the lung. Appropriate classification of many tracheobronchial tumors ultimately requires complete sampling and a thorough microscopic evaluation. The introduction of ancillary diagnostic techniques such as immunohistochemistry and molecular analysis will continue to refine tumor classification.

Yield of bronchoscopy in the diagnosis of neoplasm metastatic to lung

The yield of fiberoptic bronchoscopy (FB) in the diagnosis of pulmonary metastases has not been conveniently analyzed. With the advances in the surgery of pulmonary metastases, there is a need to evaluate the diagnostic yield and the usefulness of FB to exclude other diseases with similar radiological patterns. To determine the value of FB in the diagnosis of pulmonary metastases we have retrospectively analyzed our experience in 113 patients with proven pulmonary metastases. An endobronchial lesion was identified in 57/113 (50.4%). The most frequent tumors with endobronchial lesions were thyroid (100%), head-neck (67%) and breast carcinomas (59%). The highest diagnostic yield was obtained combining techniques of brushing, washing and biopsy (72.6%); in cases with endobronchial lesions (84.2%) and with certain histological types (head-neck 100%; breast 90.9% and colon 84.6%). The most frequent radiological findings were single or multiple nodules (77.9%). Atelectasis were associated with endobronchial lesions. In conclusion, bronchoscopy is a valuable diagnostic procedure in selected patients with metastatic lung disease.

Endotracheal/endobronchial metastases : clinicopathologic study with special reference to developmental modes

BACKGROUND

Endotracheal/endobronchial metastases (EEMs) from nonpulmonary neoplasms are rare. However, their definition and developmental modes have not yet been fully elucidated.

METHODS

EEMs were defined as documented nonpulmonary neoplasms metastatic to the subsegmental or more proximal central bronchus, in a bronchoscopically visible range. The clinical and pathologic features of 16 cases were reviewed, with special emphasis on the developmental modes based on five criteria: location in the tracheobronchial tree, number of lesions, laterality of lesions, depth of lesions, and relationship with the associated bronchus.

RESULTS

The developmental modes were proposed on the basis of the above five criteria as follows: type I, direct metastasis to the bronchus; type II, bronchial invasion by a parenchymal lesion; type III, bronchial invasion by mediastinal or hilar lymph node metastasis; and type IV, peripheral lesions extended along the proximal bronchus. Primary tumors included colorectal in six patients, breast in three patients, uterus in two patients, osteosarcoma of the bone in two patients, and maxillary, larynx, and parotid carcinoma in one patient each, respectively. The mean recurrence interval was 65.3 months. The developmental modes were as follows: type I, five patients; type II, one patient; type III, four patients; and type IV, nine patients. Three patients underwent surgical resection. One patient has remained well for 5 years after operation. Median and mean survival times were 9 months and 15.5 months, respectively.

CONCLUSION

The mean recurrence interval was long at 65.3 months, but the mean survival time was short at 15.5 months. Type I accounted for only 5 of 16 patients. Type II was found in only one patient. It is thought that this type is a rare form. Type IV affected nine patients. Treatment plans must be individualized, because in some cases, long-term survival can be expected.

Survival after photodynamic therapy to non-pulmonary metastatic endobronchial tumors

BACKGROUND

For the past 15 years we have used photodynamic therapy (PDT) to treat endobronchial tumors. Unfortunately patients who have non-primary lung cancer metastatic to bronchi and who have failed other treatment regimens may not be offered endobronchial tumor management. Thirteen patients with endobronchial tumors metastatic from non-pulmonary primaries were treated with PDT. We: 1) evaluated the effects of PDT on the tumor, the quality of life, and the length of survival; and 2) compared their survival after PDT to that of 27 patients with stage IV primary endobronchial tumors treated with PDT after they failed all other treatment regimens.

MATERIALS AND METHODS

Photodynamic therapy was performed using 630-nm light delivered through cylinder diffusing tip quartz fibers passed through the biopsy channel of a flexible bronchoscope after intravenous injection of the photosensitizer dihematoporphyrin ether. One to two days after PDT bronchoscopy was repeated and necrotic tissue was mechanically removed and, if necessary, that site or other new sites were treated. Two days after this another bronchoscopy was performed and the necrotic tissue was mechanically removed. Bronchoscopy was repeated one month after PDT and periodically thereafter as needed to re-treat symptomatic residual tumor. The percent obstruction of the bronchus due to tumor was estimated before and at the end of each bronchoscopy. Clinical effects were evaluated using Wilcoxon signed rank tests for scaled parameters of dyspnea, cough, hemoptysis, and Karnofsky Performance Status (KPS) before and one month after PDT. All patients were followed until their death.

RESULTS

The mean percent obstruction due to metastatic non-pulmonary tumors at 38 different endobronchial treated sites decreased from 85% to 13% at discharge after PDT. The 72% mean decrease of obstruction was statistically significant using the Wilcoxon signed rank test (P < .0001). There was a statistically significant improvement in the level of dyspnea (P = .012), hemoptysis (P = .028), cough (P = .027), and KPS (P = .020). Kaplan-Meier survival curves and Mann-Whitney U rank tests showed the median survival of stage IV primary tumor patients (4 months) vs. metastatic tumor patients (14 months) was statistically significant (P = .008).

CONCLUSION

PDT of endobronchial metastatic tumors effectively decreased the amount of endobronchial obstruction, and improved the quality of life.

Treatment of endobronchial metastases with intraluminal radiotherapy

Metastasis to the lung occurs quite commonly from certain types of extrapulmonary primary carcinoma. Spread to the bronchial lumen is relatively rare. When this does occur, symptoms resembling those of primary bronchial carcinoma are often present, in association with partial or complete obstruction of the bronchial lumen. Palliation of such symptoms is possible with the use of intraluminal radiotherapy (ILT). Between 1990 and 1998, 37 patients with endobronchial metastases were treated using this modality; a single fraction of radiation was delivered by the remote afterloading high dose rate microSelectron system. Data regarding these patients' characteristics and outcome are presented, following a retrospective review of case notes. The commonest symptoms were dyspnoea, cough and haemoptysis; the commonest primary tumour sites were breast, colorectum, oesophagus and kidney. Twenty-four (64.9%) patients had some improvement in symptoms following treatment. Mean overall survival was 280 days, range 9-1145 days. No serious adverse effects occurred. ILT is a relatively simple, safe and effective treatment in the palliation of symptoms due to endobronchial metastases.

Endobronchial metastasis from osteosarcoma of bone: treatment with intraluminal radiotherapy

Lung parenchymal metastases are common manifestations in patients with osteosarcoma; however, spread to the major airway itself is extremely rare. We present a young man who had been previously treated with surgical resection following preoperative chemotherapy and immediate postsurgical adjuvant chemotherapy for proximal tibial osteosarcoma. He developed metastasis to the major airways. The patient was treated with intraluminal radiotherapy (ILT) for the endobronchial metastasis. This is the first report of an endobronchial osteosarcoma that was treated with ILT with a complete endoscopic response. ILT provided excellent palliation in this particular case.

Endobronchial metastasis from stomach cancer

A young woman presented with a dry cough present during the previous 4 weeks. A chest radiograph demonstrated diffuse interstitial infiltration in both lower lung fields. Fibreoptic bronchoscopic examination revealed multiple 2-3 mm elevated nodules on the bronchial surface and a mucosal biopsy showed extensive subepithelial infiltration of poorly differentiated adenocarcinoma without definite precancerous alteration in the overlying epithelium. Studies for the evaluation of primary tumour focus were performed. Oesophagogastroduodenoscopy showed advanced gastric cancer of Borrmann type III, and mucosal biopsy of the stomach showed poorly differentiated adenocarcinoma. The patient was treated three times with systemic chemotherapy, but her condition deteriorated. Three months after diagnosis, she died of complicated pneumonia. This is a rare case of endobronchial metastasis from stomach cancer. The stomach is an unusual site of endobronchial metastasis from extrathoracic primary malignancy.