Endobronchial metastases from extrapulmonary solid tumors

Therapeutic bronchoscopy for malignant central airway obstructions caused by non-bronchogenic cancers: Results from the EpiGETIF registry

BACKGROUND AND OBJECTIVE

Little is known about malignant central airway obstruction (MCAO) complicating the metastatic spread of non-bronchogenic solid cancers (NBC) and their bronchoscopic management. This study aimed to describe the epidemiology of this population and determine prognostic factors before therapeutic bronchoscopy (TB).

METHODS

In this multicenter study using the EpiGETIF registry, we analysed patients treated with TB for MCAO caused by NBC between January 2019 and December 2022.

RESULTS

From a database of 2389 patients, 436 patients (18%) with MCAO and NBC were identified. After excluding patients with direct local invasion, 214 patients (8.9%) were analysed. The main primaries involved were kidney (17.8%), colon (16.4%), sarcoma (15.4%), thyroid (8.9%) and head and neck (7.9%) cancers. Most patients (63.8%) had already received one or more lines of systemic treatment. Obstructions were purely intrinsic in 58.2%, extrinsic in 11.1% and mixed in 30.8%. Mechanical debulking was used in 73.4% of cases, combined with thermal techniques in 25.6% of cases. Airway stenting was required in 38.4% of patients. Median survival after TB was 11.2 months, influenced by histology (p = 0.002), performance status (p = 0.019), initial hypoxia (HR 1.45 [1.01-2.18]), prior oncologic treatment received (HR 1.82 [1.28-2.56], p < 0.001) and assessment of success at the end of the procedure (HR 0.66 [0.44-0.99], p < 0.001). Complications rate was 8.8%, mostly mild, with no procedure-related mortality.

CONCLUSION

TB for MCAO caused by a NBC metastasis provides rapid improvement of symptoms and prolonged survival. Patients should be promptly referred by medical oncologists for bronchoscopic management based on the prognostic factors identified.

Current diagnosis and treatment of salivary gland-type tumors of the lung

Salivary gland-type tumors of the lung are thought to originate from the submucosal exocrine glands of the large airways. Due to their rare occurrence, reports of their study are limited to small-scale or case reports. Therefore, daily clinical practices often require a search for previous reports. In the last 20 years, several genetic rearrangements have been identified, such as MYB::NF1B rearrangements in adenoid cystic carcinoma, CRTC1::MAML2 rearrangements in mucoepidermoid carcinoma, EWSR1::ATF1 rearrangements in hyalinizing clear cell carcinoma and rearrangements of the EWSR1 locus or FUS (TLS) locus in myoepithelioma and myoepithelial carcinoma. These molecular alterations have been useful in diagnosing these tumors, although they have not yet been linked to molecularly targeted therapies. The morphologic, immunophenotypic, and molecular characteristics of these tumors are similar to those of their counterparts of extrapulmonary origin, so clinical and radiologic differential diagnosis is required to distinguish between primary and metastatic disease of other primary sites. However, these molecular alterations can be useful in differentiating them from other primary lung cancer histologic types. The management of these tumors requires broad knowledge of the latest diagnostics, surgery, radiotherapy, bronchoscopic interventions, chemotherapy, immunotherapy as well as therapeutic agents in development, including molecularly targeted agents. This review provides a comprehensive overview of the current diagnosis and treatment of pulmonary salivary gland tumors, with a focus on adenoid cystic carcinoma and mucoepidermoid carcinoma, which are the two most common subtypes.

Primary endobronchial melanoma: a case report and clinical management indications

BACKGROUND

While cutaneous melanomas are well-documented, primary melanoma of the lung (PMML), particularly with endobronchial origin, remains rare and poorly characterized. This case report addresses gaps in understanding by presenting a comprehensive case of a 71-year-old male with primary endobronchial melanoma and conducting a systematic review of PMML cases.

CASE PRESENTATION

The patient, a former smoker, presented with dyspnea, cough, and hemoptysis. Imaging revealed left lung atelectasis and a suspicious nodule. Bronchoscopy identified an endobronchial mass, subsequently treated with argon plasma coagulation and resection. Biopsy confirmed melanoma. Extensive examinations ruled out a primary skin lesion. Despite initial treatment, recurrence led to pneumonectomy. Histopathology confirmed melanoma. The patient received treatment with pembrolizumab and ipilimumab, but with poor clinical benefit.

CONCLUSIONS

Primary endobronchial melanoma is a rare entity, comprising 0.01% of lung tumors. This case underscores diagnostic challenges and emphasizes histological criteria to distinguish primary from metastatic lesions. The pathogenesis remains unclear, with theories proposing foetal melanocyte migration or squamous metaplasia. Prognosis varies, necessitating radical surgical extirpation. A systematic review revealed diverse outcomes, supporting the need for further research. In conclusion, endobronchial melanoma involves an endoscopic and surgical management, but evolving therapies, such as immunotherapy, may reshape treatment paradigms. This case contributes to our understanding of PMML, guiding future research and clinical management. As therapeutic options evolve, continued research is crucial to refine our understanding and improve outcomes for this rare malignancy.

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.

Malignant and Benign Tracheobronchial Neoplasms: Comprehensive Review with Radiologic, Bronchoscopic, and Pathologic Correlation

Tracheobronchial neoplasms are much less common than lung parenchymal neoplasms but can be associated with significant morbidity and mortality. They include a broad differential of both malignant and benign entities, extending far beyond more commonly known pathologic conditions such as squamous cell carcinoma and carcinoid tumor. Airway lesions may be incidental findings at imaging or manifest with symptoms related to airway narrowing or mucosal irritation, invasion of adjacent structures, or distant metastatic disease. While there is considerable overlap in clinical manifestation, imaging features, and bronchoscopic appearances, an awareness of potential distinguishing factors may help narrow the differential diagnosis. The authors review the epidemiology, imaging characteristics, typical anatomic distributions, bronchoscopic appearances, and histopathologic findings of a wide range of neoplastic entities involving the tracheobronchial tree. Malignant neoplasms discussed include squamous cell carcinoma, malignant salivary gland tumors (adenoid cystic carcinoma and mucoepidermoid carcinoma), carcinoid tumor, sarcomas, primary tracheobronchial lymphoma, and inflammatory myofibroblastic tumor. Benign neoplasms discussed include hamartoma, chondroma, lipoma, papilloma, amyloidoma, leiomyoma, neurogenic lesions, and benign salivary gland tumors (pleomorphic adenoma and mucous gland adenoma). Familiarity with the range of potential entities and any distinguishing features should prove valuable to thoracic radiologists, pulmonologists, and cardiothoracic surgeons when encountering the myriad of tracheobronchial neoplasms in clinical practice. Attention is paid to any features that may help render a more specific diagnosis before pathologic confirmation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Life-threatening hemoptysis in patients with metastatic kidney cancer

Hemoptysis is a complication of intrathoracic tumors, both primary and metastatic, and the risk may be increased by procedural interventions as well as Stereotactic Ablative Radiation (SAbR). The risk of hemoptysis with SAbR for lung cancer is well characterized, but there is a paucity of data about intrathoracic metastases. Here, we sought to evaluate the incidence of life-threatening/fatal hemoptysis (LTH) in patients with renal cell carcinoma (RCC) chest metastases with a focus on SAbR. We systematically evaluated patients with RCC at UT Southwestern Medical Center (UTSW) Kidney Cancer Program (KCP) from July 2005 to March 2020. We queried Kidney Cancer Explorer (KCE), a data portal with clinical, pathological, and experimental genomic data. Patients were included in the study based on mention of "hemoptysis" in clinical documentation, if they had a previous bronchoscopy, or had undergone SAbR to any site within the chest. Two hundred and thirty four patients met query criteria and their records were individually reviewed. We identified 10 patients who developed LTH. Of these, 4 had LTH as an immediate procedural complication whilst the remaining 6 had prior SAbR to ultra-central (UC; abutting the central bronchial tree) metastases. These 6 patients had a total of 10 lung lesions irradiated (UC, 8; central 1, peripheral 1), with a median total cumulative SAbR dose of 38 Gray (Gy/ lesion) (range: 25-50 Gy). Other risk factors included intrathoracic disease progression (n = 4, 67%), concurrent anticoagulant therapy (n = 1, 17%) and concurrent systemic therapy (n = 4, 67%). Median time to LTH from first SAbR was 26 months (range: 8-61 months). Considering that 130 patients received SAbR to a chest lesion during the study period, the overall incidence of LTH following SAbR was 4.6% (6/130). The patient population that received SAbR (n = 130) was at particularly high risk for complications, with 67 (52%) having two or more chest metastaes treated, and 29 (22%) receiving SAbR to three or more lesions. Overall, the risk of LTH following SAbR to a central or UC lesion was 10.5% (6/57). In conclusion, SAbR of RCC metastases located near the central bronchial tree may increase the risk of LTH.

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.

Hot Gloved Finger Sign in Endobronchial Metastasis From Hepatocellular Carcinoma on FDG PET/CT

ABSTRACT

Endobronchial metastasis from hepatocellular carcinoma is exceedingly rare. We describe FDG PET/CT findings in a case with isolated endobronchial metastasis from hepatocellular carcinoma 13 years after hepatectomy. The endobronchial metastasis appeared as hypermetabolic branching tubular opacities, producing a hot gloved finger sign on FDG PET/CT. This case indicates that the hot gloved finger sign may be suggestive of extensive endobronchial growing of a malignant condition but not endobronchial mucoid plug.

The prognosis of non-small cell lung cancer patients according to endobronchial metastatic lesion

To evaluate the prognosis of non-small cell lung cancer (NSCLC) patients according to endobronchial metastatic lesion (EML), especially those not identified on positron emission tomography or computed tomography. We evaluated progression-free survival (PFS) and overall survival (OS) according to the presence of EML in patients with NSCLC who were diagnosed at a tertiary hospital between January 2010 and December 2019. A total of 364 patients were enrolled in this study. EML was found in 69 (19.0%) patients with NSCLC. In the patients with EML versus the patients without EML, median PFS was 7.0 (3.5–13.5) and 9.5 (5.5–17.5) months (P = 0.011), and median OS was 12.0 (6.0–30.0) versus 20.0 (10.0–39.0) months (P = 0.016), respectively. Median PFS and OS rates were highest in epidermal growth factor receptor (EGFR) (+) and EML (−) patients and lowest in EGFR (−) and EML (+) patients (P < 0.001). By multivariate cox regression analysis, PFS in overall patients with NSCLC was significantly associated with EML, EGFR mutation, performance status, and pleural effusion. NSCLC patients with EML had worse prognoses of PFS and OS than patients without EML.

Carcinoma male breast with tracheal and endobronchial metastasis, masquerading as nonsmall-cell lung cancer, presenting with superior vena cava obstruction - A rare case report

Cancer male breast is not very common. It comprises <1% of all breast cancers. Primary sites of metastasis are bone, brain, lung, and liver. Endobronchial and tracheal metastasis is very rare. To the best of our information, this is the first case of male breast carcinoma with upfront tracheal and endobronchial metastasis which presented as Superior vena cava obstruction (SVCO), initially evaluated on the lines of metastatic nonsmall-cell lung cancer. A 60-year-old gentleman presented with shortness of breath and features of SVCO. On primary evaluation, he was thought to be a case of nonsmall-cell lung cancer. Later on, it was confirmed to be carcinoma male breast with endobronchial and tracheal metastasis, which was reconfirmed with biopsy. The case we came across had symptoms associated with endobronchial metastases from primary extrapulmonary tumor and which was later found out to be breast. Treatment options are very different from lung primary and thus, we should be aware of the unusual disease presentation.

Endobronchial Metastasis From Endometrial Carcinoma: A Case Report and Review of Literature

Primary endometrial carcinoma presenting with endobronchial metastasis is quite rare. Little is known about predisposing risk factors, and the exact pathophysiologic mechanism remains unclear. The clinical presentation is non-specific, and symptoms likely vary depending on the disease burden. Proper tissue acquisition is necessary in order to differentiate between primary pulmonary malignancy and extra-thoracic malignancy presenting as metastatic disease. Although no formal guidelines regarding a standard diagnostic approach exist, flexible bronchoscopy with biopsy is generally regarded as having a high diagnostic yield depending on the extent of disease burden.

A case of metastatic endobronchial tumor from uterine leiomyosarcoma

A 54-year-old woman presented with persistent productive cough, found to have an endobronchial tumor which obstructed the left upper lobe bronchus. Histopathological examination of a transbronchial biopsy of the endobronchial tumor suggested leiomyosarcoma. A positron emission tomography (PET)-CT revealed uterus tumor with moderate uptake of ¹⁸F-fluorodeoxyglucose, suggesting uterine malignancies. From the results of histological findings of the resected uterus and the biopsied bronchial specimen, she was diagnosed with uterine leiomyosarcoma and endobronchial metastasis. The systematic use of PET-CT could be useful for patients presenting with tumors that cause endobronchial metastasis of leiomyosarcomas.

The Role of Cytology in the Diagnosis of Metastatic Hepatocellular Carcinoma

The diagnosis of primary hepatocellular carcinoma (HCC) in high risk patients, such as those with chronic hepatitis B or C with/without cirrhosis of the liver, can be made with relevant image studies alone; however, morphologic confirmation by cytology or histopathology is essential to the diagnosis of metastatic HCC because the treatment of the latter differs from that of primary extrahepatic malignancy. Although both cytology and histopathology are important tools in the diagnosis of malignancy, histopathology almost always plays a confirmatory and pivotal role, and also a gold standard in cyto-histological correlation. We present two patients of metastatic HCC to rare sites; endobronchus in one, and neck lymph nodes, face and the abdominal wall in the other. Repeated bronchial biopsy in the first patient and excisional biopsy from the metastatic sites of the second patient failed to make a conclusive diagnosis of metastatic HCC. However, bronchial brushing in the first patient and fine needle aspiration cytology from the respective metastatic sites of the second patient consistently showed characteristic HCC features and provided clinicians with the rationale for ongoing treatment. The diagnostic issues and possible pitfalls are discussed. Cytology and histopathology appear equipollent; sometimes cytology can play a diagnostic role when histopathology fails its expected role in this scenario.

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.

A Well-Defined Endobronchial Tumor in a 26-Year-Old Man

CASE PRESENTATION

A 26-year-old man presented with a 2-week history of productive cough and a 1-year history of effort-related dyspnea. His medical history was significant for hay fever and exertion-triggered asthma. He was not taking medicines regularly but was using inhaled salbutamol as needed. He was an ex-smoker, with a previous history of 2-pack years.

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.

Undifferentiated Pleomorphic Sarcoma of the Small Intestine with Distant Endobronchial Metastasis Presenting as Intussusception: A Case Report

미분화성 다형성 육종은 중간엽조직에서 기원하는 고등급의 연조직 육종이다. 소장에서 기원한 미분화성 다형성 육종은 매우 드물며 산발적인 증례 보고가 대부분이다. 소장 미분화성 다형성 육종의 증상은 대개는 비특이적이며, 일부에서는 장중첩증으로 발현되어 간헐적 복통을 일으키기도 한다. 미분화성 다형성 육종은 공격적인 성장을 보이는 종양으로 진단 당시에 원격 전이를 동반한 경우가 많다. 가장 흔한 원격 전이 부위는 복막이며, 그 외에도 임파선, 복강 내 고형 장기, 폐나 뇌 등으로 전이할 수 있다. 저자들이 아는 한도에서는, 기관지 내 전이는 현재까지 보고된 바 없다. 저자들은 장중첩증으로 발현한 소장의 미분화성 다형성 육종이 기관지 내로 전이한 드문 증례를 경험하였기에 이를 보고하고자 한다.

Incidental Finding of Endobronchial Metastasis by 18F-FDG PET/CT Leads to Change in Management in a Patient With Rectal Adenocarcinoma

A 58-year-old man with history of resected rectal adenocarcinoma and synchronous unifocal pulmonary metastasis showed a solitary pulmonary relapse in follow-up CT after 3 years of complete remission. Resection was planned. Preoperative F-FDG PET/CT detected a high focal F-FDG uptake in the left main bronchus. Bronchoscopy showed a papillary endobronchial lesion that was biopsied. Histology confirmed distant colorectal metastasis. The initial treatment plan changed, and the recommendation for systemic therapy was made by a multidisciplinary oncology team. Endobronchial metastases are rare and difficult to detect in conventional CT. PET/CT is useful to uncover endobronchial metastasis, which may change patient management.

Endobronchial Malignant Melanoma: An Exceedingly Rare Occurrence

Malignant melanoma is rarely observed to metastasize to endobronchial tissue. We present a case of endobronchial malignant melanoma in a 36-year-old male smoker with a regressed cutaneous lesion. Due to the limited number of cases and poor survival rate, no definitive treatment options are available to improve survival in patients with this rare disease presentation. Immunotherapy and surgical removal of locally aggressive tumor have been described, but the definitive role for these therapeutic modalities in the setting of endobronchial metastases remains largely unknown.

Endobronchial metastasis of ovarian cancer rescued by tumor ablation and a self-expanding hybrid stent: A case report and review of the literature

Tracheal stenosis caused by malignancy is a life-threatening complication. Herein, we performed tumor ablation and airway stenting using a hybrid stent on a patient with upper tracheal stenosis caused by endobronchial metastasis of ovarian cancer. To date, only 9 cases of endobronchial metastasis of ovarian cancer have been reported. This is the first reported case of endobronchial metastasis in the upper part of the trachea, which had a favorable outcome after tumor ablation as a sequential treatment and use of a hybrid stent. In addition, 10 cases of endobronchial metastasis of ovarian cancer, including ours and other case reports, were reviewed.

Endobronchial metastasis as an uncommon pattern of metastatic dissemination from small cell osteosarcoma

Endobronchial metastasis (EBM) from extrapulmonary primary malignancy is a rare entity. Although the most common site of metastasis of osteosarcoma is the lungs, EBM remains a rare occurrence. Cough and dyspnea are the most common symptoms. A significant number of patients are asymptomatic, making the diagnosis without any radiographic imaging challenging. CT scan of the lung, along with bronchoscopy and biopsy, is the mainstay of diagnosis and staging. A 36-year-old man presented with small cell osteosarcoma of the left maxillary region and was treated with surgery and adjuvant chemotherapy. The patient presented 8 years later with axillary metastasis and was found to have lung metastasis on further workup. Bronchoscopy and biopsy proved an EBM that was debulked by hot snare technique. The patient was then started on chemotherapy for recurrent small cell osteosarcoma.

A Rare Case of Endobronchial Metastasis in a Case of Carcinoma Tongue

Cancer of the tongue and other parts of the oral cavity are a leading cause of death in the worldwide population. The common sites of metastasis from oral cavity cancers are lung and bone. Endobronchial metastasis of an extra-thoracic malignancy is a rare phenomenon and such metastases from a malignancy of the tongue are almost unheard of. We present a case of carcinoma oral cavity with subsite tongue that after radical therapy of local site had an unusual site of distant metastasis in the right main bronchus, along with metastases to the lung parenchyma and right third rib.

Endobronchial metastases 20 years after prostate cancer excision

A 78-year-old Japanese man who had undergone total prostatectomy for prostate cancer (pT3cN1M0, Gleason score 3 + 3) 20 years previously was referred to the Respiratory Medicine Department of our institution because of a 1-week history of chest pain and cough. Computed tomography showed multiple small nodules and mediastinal lymph node enlargement. Bronchoscopy revealed multiple soft polypoid masses and obstruction of the lingular segment. Prostate-specific antigen (PSA) concentrations had increased markedly from 0.48 ng/mL in 2014 to 741 ng/mL in 2018. The diagnosis of prostatic cancer metastases was confirmed by revealing the presence of PSA via immunohistological staining of a bronchoscopically obtained biopsy of one of the masses. The patient had not been attending scheduled follow-up visits for the past 4 years. Treatment with degarelix (a gonadotropin-releasing hormone) was started, and the PSA concentration decreased dramatically (29 ng/mL). Metastases from prostate cancer are rarely first diagnosed two decades after radical prostatectomy. This patient illustrates the importance of obtaining a complete medical history.

Argon plasma coagulation for management of hemoptysis in endobronchial metastasis from soft-tissue sarcoma

Hemoptysis is a manifestation of a wide variety of diseases. Endobronchial metastases from nonpulmonary neoplasms are unusual. Among these causes, soft-tissue sarcoma is also discretely rare and scarcely documented. Argon plasma coagulation is a useful tool for the interventional pulmonologist that can allow control of bleeding from these lesions. Here we report a case of hemoptysis from an endobronchial metastasis of soft-tissue sarcoma. Argon plasma coagulation of the bleeding lesion was performed successfully.

Late distant recurrence of breast carcinoma and metastasis to the main bronchus and choroid: A case report

RATIONALE

Metastases of breast carcinoma to the main bronchus and choroid are rare, but have been reported in relevant literature. Late distant recurrence of breast carcinoma after more than 20 years is extremely rare. Herein, we report a 57-year-old woman with late distant recurrence and metastasis to the main bronchus and choroid almost 28 years after surgery.

PATIENT CONCERNS

At the age of 29, the patient underwent chemotherapy and endocrine treatment after a right side mastectomy to remove breast carcinoma. The patient was hospitalized for a cough with blood-tinged sputum, dysphagia, and blurred vision in the left eye at the age of 57.

DIAGNOSES

On evaluation, laboratory findings detected the elevated serum tumor markers of CA12-5, CA15-3, NSE, and Cyfra21-1. The imaging showed left lung metastase, multiple lymph node metastases, and small suspected metastases in the both sides of parietal lobes. Fundus fluorescein angiography showed choroidal occupying lesion of the left side which indicates secondary metastasis and retinal detachment. Combined with the pathological finding via fiberoptic bronchoscopic biopsy, the patient was clinically diagnosed with a late distant recurrence of breast carcinoma.

INTERVENTIONS

The patient received oral endocrine therapy of letrozole, but she refused chemotherapy, radiotherapy and other topical treatments.

OUTCOMES

At the 3-month follow-up visit, the multiple lesions of the left lung and lymph nodes had partially regressed, and the lesion of right parietal lobe had disappeared. The patient's clinical symptoms, such as blood-tinged sputum and dysphagia, had significantly improved.

LESSONS

We have described this case and reviewed the relevant literature concerning late distant recurrence of breast carcinoma. Importantly, this case indicates that patients with HR positive breast carcinoma are more likely to develop late distant recurrence and clinicians should not ignore the follow-up examinations even more than 20 years after the surgery.

Secondary tracheal tumors: a systematic review

BACKGROUND

Secondary tracheal tumors arise from mural invasion by primary tumors in adjacent organs, metastatic lymph nodes or blood-born metastasis from distant sites. This systematic review aims to assess the presentation, management options, and clinical outcomes of these uncommon non-tracheal malignancies.

METHODS

Electronic searches of the MEDLINE database were performed to identify case series and individual case reports of tracheal invasion by primary non-tracheal tumors or metastatic disease. All English-language studies with available abstracts or articles containing primary data were included.

RESULTS

From 1978 to 2017, a total of 160 case reports or case series identified 2,242 patients with invasion of the trachea by tumors of adjacent organs (n=1,853) or by metastatic lymph nodes or hematogenous spread (n=389). Common primary sites of origin were thyroid, esophagus, and lung, and the most common presentation was metachronous (range of interval: 0 to 564 months) with dyspnea, neck mass, voice change and/or hemoptysis. A majority of patients in case reports (77.9%) and case series (66.0%) underwent resection and the most common reported operation was segmental tracheal resection. Fewer patients underwent bronchoscopic intervention (21.7%) and radiation was used in 32.2% of patients. Complications after bronchoscopic treatment included bleeding, granulation tissue, and retained secretions, while anastomotic leak, unplanned tracheostomy, and new recurrent laryngeal nerve paralysis were observed after surgical resection. The rate of 30-day mortality was low (0.01-1.80%). Median survival was higher in patients with thyroid malignancy and in patients who underwent surgical management. Follow-up time ranged from 0.03 to 183 months.

CONCLUSIONS

Patients with tracheal invasion by metastatic or primary non-tracheal malignancies should be assessed for symptoms, tumor grade, tumor recurrence and concurrent metastases to decide on optimal surgical, bronchoscopic or noninterventional therapy. Clinical experience suggests that palliative endoscopic intervention for tracheal obstruction by metastasis-bearing lymph nodes is underreported.

[Report of Successful Treatment of A Rectal Cancer Patient with Endobronchial Metastasis by Bronchial Stent Implantation Combined with Chemotherapy and Apatinib]

The lungs are the most common sites of metastases from non-pulmonary malignancies. On the other hand, endobronchial metastases are rare. Various tumors have been associated with endobronchial metastasis, most commonly renal, breast and colorectal cancer. Advanced rectal cancerwith lung metastasis is common. However, endobronchial metastasis without lung metastasis of rectal cancer is rare, and easily misdiagnosed. We report one case of postoperative rectal cancer with endobronchial, pleuralcavity, pericardial cavitymetastasis, giving the comprehensive treatment of bronchial stentimplantation, chemotherapy, targeted drugs and remission. The process of diagnosis and treatmentis relatively complex, therefore it has a certain clinical reference value.

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.

Endobronchial brachytherapy for metastasis from extrapulmonary malignancies as an effective treatment for palliation of symptoms

PURPOSE

Endobronchial metastasis (EBM) originating from primary cancers outside the lung is rare. External beam radiotherapy is often attempted for control of symptoms with variable effectiveness and retreatment is challenging if symptoms recur. There is limited documentation of high-dose-rate brachytherapy for EBM in the literature.

METHODS AND MATERIALS

A prospective database was created from 2006 to 2015. Patients with EBM who received high-dose-rate brachytherapy were included. Cough, dyspnea, chest pain, and hemoptysis were assessed and graded (0-4) at the time of initial consult and in followup. Symptom-free survival and re-expansion were assessed.

RESULTS

Thirty-five patients with EBM were identified. Most patients received three fractions of 700 cGy, and 17 patients had prior external beam radiotherapy. Median symptom-free and overall survival were 67 and 117 days. After brachytherapy, improvement in cough was documented in 75.0%, hemoptysis in 76.4%, dyspnea in 60.0% for a median of 3-6 months. Of the 22 patients who had subsequent chest imaging, re-expansion was documented in 32%. There were no significant toxicities reported.

CONCLUSIONS

Brachytherapy appears effective in achieving durable symptom control of cough hemoptysis, and dyspnea in patients with EBM and should be considered routinely for palliation where available. Further studies are required to better characterize expected symptom improvement, lung re-expansion rates, and efficacy in comparison with other local treatments.

Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation

Objectives

To describe the imaging features of the central airway pathology, correlating the findings with those in pathology and virtual endoscopy. To propose a schematic and practical approach to reach diagnoses, placing strong emphasis on multidetector computed tomography (MDCT) findings.

Methods

We reviewed our thoracic pathology database and the central airway pathology-related literature. Best cases were selected to illustrate the main features of each disease. MDCT was performed in all cases. Multiplanar and volume-rendering reconstructions were obtained when necessary. Virtual endoscopy was obtained from the CT with dedicated software.

Results

Pathological conditions affecting the central airways are a heterogeneous group of diseases. Focal alterations include benign neoplasms, malignant neoplasms, and non-neoplastic conditions. Diffuse abnormalities are divided into those that produce dilation and those that produce stenosis and tracheobronchomalacia. Direct bronchoscopy (DB) visualises the mucosal layer and is an important diagnostic and therapeutic weapon. However, assessing the deep layers or the adjacent tissue is not possible. MDCT and post-processing techniques such as virtual bronchoscopy (VB) provide an excellent evaluation of the airway wall.

Conclusion

This review presents the complete spectrum of the central airway pathology with its clinical, pathological and radiological features.

Teaching points

• Dividing diseases into diffuse and focal lesions helps narrow the differential diagnosis.

• Focal lesions with nodularity are more likely to correspond to tumours.

• Focal lesions with stenosis are more likely to correspond to inflammatory disease.

• Posterior wall involvement is the main feature in diffuse lesions with stenosis.

Endobronchial metastases from melanoma: a survival analysis

BACKGROUND

Metastatic spread to the tracheobronchial tree from other than bronchopulmonary tumors is a common clinical problem. However, malignant melanoma, a highly metastatic potential tumor, is rarely metastasing in the airways. Therefore little is known about survival of patients with endobronchial metastasis from melanoma.

OBJECTIVES

The aim of our study was to assess survival of patients with endobronchial metastasis of melanomas according to clinical and radiological features, to determine any possible factor affecting survival.

METHODS

This retrospective study included 19 patients who underwent a bronchoscopy from 11 different hospitals. Data about patients' demographics, symptoms, radiographic, endoscopic findings and treatment were investigated to evaluate any possible impact on survival.

RESULTS

Endobronchial metastases occurred at a median of 48 months (range 0-120) following the diagnosis of the primary tumor. About 73.7% of patients had other proven metastases when the endobronchial involvement was diagnosed. Symptoms are not specific as well as radiological features. Median overall survival of the studied population was 6 months (range 1-46). Factors of poor survival were multiple metastatic sites (P = 0.019), pleural (P = 0.0014) and soft tissue metastasis (P = 0.024). Different treatment modalities applied in our patients showed no effect on survival.

CONCLUSION

Patients with endobronchial metastasis have overall poor survival, affected by multiple organ involvement, the presence of pleural and soft tissue disease, while no impact on survival has been shown by any treatment applied.

Pulmonary resection and systemic lymph node dissection in a patient with breast cancer who had a 33-year disease-free interval

Objective

Breast cancer metastasis to the lung is common. The resection of lung metastases in patients with breast cancer has been controversial. Here, we present a very rare case of pulmonary and mediastinal lymph node metastases in a patient with breast cancer who had a disease-free interval (DFI) of more than 33 years.

Methods

An involved lobectomy and systematic mediastinal lymph node dissection were performed.

Results

The histological examination confirmed pulmonary metastasis from the breast cancer associated with mediastinal lymph nodes metastasis.

Conclusions

To our knowledge, this is the first case reported of a patient with a 33-year DFI after a radical mastectomy for breast cancer who presented with pulmonary metastasis with mediastinal lymph node involvement. This case indicates that a long-term follow-up of breast cancer patients is necessary. Systematic mediastinal lymph node dissection should be considered as a prognostic study during pulmonary metastasectomy for breast cancer.

Rare Endobronchial metastasis from uterine leiomyosarcoma

Uterine sarcomas are rare and represent approximately 3.2% of all invasive uterine cancers. The annual incidence rate is less than two per 100,000 women. The median age at which uterine sarcoma diagnosed is 56 years. The most common histologic pattern is leiomyosarcoma (LMS) which originates from the myometrium or myometrial vessels. Uterine LMSs are aggressive tumors with high rates of recurrence. The most common mode of spread is hematogenous, with lymphatic spread being rare. Recurrences of up to 70% are reported in stage I and II disease with the site of recurrence being distal, most commonly the lungs or the upper abdomen. But the intra bronchial spread is extremely rare. Here we are reporting a case of uterine LMS with endobronchial metastasis causing whole lung collapse.

[Surgical therapy of lung metastases]

Surgical treatment of lung metastases from extrathoracic malignancies is an established procedure. Pulmonary metastases are common. Generally, lung metastases are located peripherally and are asymptomatic. Involvement of the bronchial system or infiltration of the chest wall can be symptomatic. The indications for resection are an interdisciplinary decision. Metastasectomy can be with curative or palliative intent. Prerequisitess for pulmonary metastasectomy are primary tumor under control, the absence of extrathoracic metastases, the lack of other promising treatment options, the possibility for complete resection and low perioperative risk. Extra-anatomic resections are common. Perioperative morbidity and mortality is low. A cure is possible in selected patients.

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.

Gastric and endobronchial metastases in a case of lobular breast cancer

Background

Invasive lobular carcinoma (ILC) is the second most common histological type of invasive breast carcinoma, preceded only by infiltrating ductal carcinoma, which has clinical, biological and molecular distinctions. These distinctions imply a different metastatic behavior between the histology of these 2 types of breast cancer.

Case Presentation

We report the case of a 51-year-old woman with breast cancer with ILC histology, diagnosed at an early stage. In the course of her disease, recurrences in the gastric mucosa and endobronchial area occurred. The treatment she received is described herein.

Conclusion

This is a case of ILC with unusual metastases. The absence of E-cadherin is related to the carcinogenesis of ILC and probably to these patterns of metastasis as well.

Endobronchial metastasis from primary anorectal melanoma

Patient: Male, 64

Final Diagnosis: Metastatic anorectal melanoma with endotracheal metastasis

Symptoms: Fatigue • weight loss • hematochezia • cough

Medication: None

Clinical Procedure: Biopsy of anal mass • rigid bronchoscopy

Specialty: Internal medicine • oncology • pulmonology

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.

"Black bronchoscopy"-a case of endobronchial metastases from melanoma

The presence of black pigmentation in the airways during flexible bronchoscopy is uncommon. We report an unusual case of "black bronchoscopy" as a result of endobronchial metastases in a 77-year-old Chinese man, who presented with hemoptysis and postobstructive pneumonia 3 years after initial excision of a skin melanoma. Chest radiograph showed right lower lobe consolidation and collapse. Bronchoscopy showed narrowed airways with black pigmentation involving the lower trachea and right main bronchus. Biopsy confirmed metastatic melanoma. The patient received palliative radiation and died 6 months later. We review the causes of black airway pigmentation. We also briefly review the prevalence, clinical presentation, and prognosis of endobronchial metastases.