Download Metastatic Cancer to the Lung Endotracheal / Endobronchial

ΣΥΝΕΧΙΖΟΜΕΝΗ ΙΑΤΡΙΚΗ ΕΚΠΑΙΔΕΥΣΗ ΣΤΗΝ ΠΝΕΥΜΟΝΟΛΟΓΙΑ
ΜΕΤΑΠΤΥΧΙΑΚΑ ΣΕΜΙΝΑΡΙΑ
METASTATIC CANCER TO THE LUNG
Endotracheal / Endobronchial Metastases
ΝΙΚΟΣ Α. ΚΑΤΙΡΤΖΟΓΛΟΥ, MD
Παθολόγος - Ογκολόγος
Ειδ.Συνεργάτης Ογκολογικής Μονάδας
Γ’ Παθολογική Κλινική Πανεπιστημίου Αθηνών
ΓΝΝΘΑ «Η Σωτηρία»
Endobronchial metastases
EBM : ‘….bronchoscopically visible lesions,
histopathologically identical to the primary tumor
associated with or without parenchymal or
mediastinal lesions in patients with extrapulmonary
malignancies…’
Kiryu et al, CHEST 2002;119:768-775
Endobronchial metastases
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1890: first report of endobronchial metastatic disease by
Zenker et al
1943:
1975:
1980:
1982:
King and Castleman
Braman and Whitcomb
Baumgartner and Mark
Shepherd MP
Endobronchial metastases
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well – documented, but rare condition
Frequency varies according to definition (from 2% to 28%)1
but less frequent than other types of intrathoracic
metastases2
Vast majority of EBT: primary LC with only 1.1% metastatic3
Produce air obstruction indistinguishable from
Bronchogenic Carcinoma
1. Braman & Whitcomb,Arch Intern Med 1975;135:543-7
Shepherd MP,Thorax 1982;37:362-5
2. Pass & Donigtom. In: De Vita et al. Cancer Principles and Practice of Oncology 1997
3. Kreissman et al,Thorax 1983;38:175-9
Endobronchial metastases
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BREAST
COLORECTAL
RENAL
bone > lung
liver > lung
lung > liver,bones
Gynecologic (cervix > endometrium > ovary)
Thyroid (follicular)
Testicular
H&N (Nasopharynx,Larynx)
Prostate
Adrenal
Sarcomas (OST,STS,childhood)
Melanomas
1. Pass & Donigtom.In:De Vita et al.Cancer principles and Practice of Oncology, 1997:2536-50
2.Kreissman et al. Thorax 1983;38:175-9
Endobronchial metastases
Extrapulmonary neoplasm
Pulmonary nodule
SYNCHRONOUS
OR
METACHRONOUS
HNSCC primary: PLC > solitary meta (16:1)
#
Melanoma, OST, testis: solitary meta > PLC
COMMON MAJOR ETIOLOGIC FACTOR
SMOKING: LC, but also: HNSCC, bladder, esophageal
Endobronchial metastases
cough 65%
haemoptysis 35%
dyspnoea 80%
effusion rare
hilar/med LN
EBM
primary LC
35%/rare
atelectasis 25%
multiple PN 40%
single PN 15%
mass 35%
Endobronchial metastases
Akoglu et al, 2005
Endobronchial metastases
Akoglu et al, 2005
Endobronchial metastases
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Bronchoscopy: a valuable tool1
CT: other pulmonary meta or hilar mediastinal L/N2
EBM: usually late manifestation of solid tumors but
reports for diagnosis few months after or before
detection of primary tumor3,4
Survival: poor (1 – 2 years)5
0-300
Months
Mean:
50 m
1. Heitmiller et al, J Thorac Cardiovasc Surg 1993;106:537-42
2. Ikezoe et al, Acta Radiol 1991;32:455-60
3. Carlin et al, Chest 1989;96:1110-4
4. Sorensen et al, Acta Oncol 2004;43(1):73-9
5. Baumgartner & Mark, J Thorac Cardiovasc Surg 1980;79:499-503
Endobronchial metastases
Type I: direct metastasis
to the bronchus
Type II: bronchial invasion by
a parenchymal lesion
Type III: bronchial invasion by
Mediastinal/hilar lymph
node metastasis
Type IV: peripheral lesion extended
along proximal bronchus
Kiryu et al, Chest 2001;119:768-775
Endobronchial metastases
Most common solid tumours complicated by EBM
Katsimbri et al, Lung Cancer 2000;28:163-70
Endobronchial metastases / Literature review of pts with EBM
Katsimbri et al, Lung Cancer 2000;28:163-70
Endobronchial metastases
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A 66 yo man with COLON
CANCER (well-differentiated
adenocarcinoma). Type IV.
A.Fiberoptic bronchoscopy
reveals a polypoid lesion partially
obstructing the main bronchus.
B.Biopsy specimen of the lesion
(CXR: left lower lobe
atelectasis)
Endobronchial metastases
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A 53 yo woman with UTERINE
CERVICAL CANCER (adenosquamous
carcinoma). Type III.
A. Chest CT scan of the truncus
intermedius level shows bulky
mediastinal lymphadenopathy located
in the carina
B. Fiberoptic bronchoscopy reveals a
sessile, lobulated nodule in the
truncus intermedius
C. biopsy specimen reveals a
neoplastic solid nest in the
submucosal layer
Endobronchial metastases
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A 50 yo man with MAXILLARY
CANCER (adenoid cystic carcinoma).
Type II.
A. Chest CT scan of the truncus
intermedius level reveals a nodule
located in contact with the bronchial
posterior wall
B. Fiberoptic bronchoscopy shows a
submucosal nodule in the distal
truncus intermedius
C. biopsy specimen reveals cribiform
growth by neoplastic cells in the
submucosal layer
Endobronchial metastases
TREATMENT & MANAGEMENT
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Biologic behavior
Histology of primary tumor
Anatomic location of lesions
Other metastatic sites
Pt’s PS
- Localized
disease ?
- Mediastinoscopy
1.
SURGICAL EXCISION
2.
LOCAL RADIOTHERAPY
3.
CHEMOTHERAPY
4.
TRANSBRONCHIAL
ENDOSCOPIC
PROCEDURES
Endobronchial metastases
CRITERIA FOR RESECTION OF PULMONARY METASTASIS
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Pulmonary parenchymal nodules or changes consistent with metastasis
Absence of uncontrolled extrathoracic metastases
Control of pt’s primary tumor
Potential for complete resection
Sufficient pulmonary parenchymal reserve after resection
Provide diagnosis
Evaluation of effects of ct on residual disease
Obtain tumor for markers, IHC
Decrease tumor burden
De Vita et al, Cancer Principles & Practice of Oncology, 7th Edition
Endobronchial metastases
PROGNOSTIC INDICATORS
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Resectable pts
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Disease – Free Interval (DFI)
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Type / Location / Stage of PT
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Number of PN preoperatively
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Number of metastasis resected
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Tumor Doubling Time (DT)
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Lesion to the main bronchus ?
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Absence of mediastinal LN spread (renal)
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CEA preoperatively / liver meta (colorectal)
AGE
GENDER
LATERALITY
Endobronchial metastases
SQUAMOUS CELL CARCINOMA [ DD ]
Primary SCC outside the Lungs ( e.g. known HNSCC)
Solitary metastasis
primary bronchogenic Ca
Benign process
Bronchoscopy thoracic
Exploration
Solitary nodule
treated
as
Excisional biopsy
SCC identified Lobectomy +
mediastinal LN
dissection
Indeterminate lesion
primary
Resection of multiple PM from HNSCC:
Benefits ??
Endobronchial metastases
ADENOCARCINOMA
Solitary pulmonary nodule (SPN) in BREAST CANCER pt who had
received previous surgery and Ct : PRIMARY LUNG CANCER in
half cases
VATS: the best procedure for diagnostic management of
peripheral SPN