Lung cancer currently constitutes the most common cause of death owing to malignant disease in the western world, being the primary cause in men, and with a growing tendency in women.1–4 This cancer causes more deaths than the 3 most common cancers combined: colon, breast, and prostate.5 Symptoms generally develop when the tumor is in an advanced stage. The radiologic signs are quite variable, and cavitation occurs only in 10% of cases.6
Endoscopic findings depend on the site and cell type of the tumor, although to a greater or lesser degree, disease of the airway is often observed and bronchial obstruction by the tumor is the most common observation.7
We report a unique case of widespread bronchogenic cancer that presented as a cavitating lesion with a broad communication with the central airways, and to our knowledge, such a presentation is seldom reported.
A 51-year-old male farm worker, with an alcohol consumption of 80 g/d, and smoker of 30 cigarettes/d, with chronic bronchitis was admitted with a 1-month history of asthenia associated with moderate dyspnea on exertion. He had productive cough and streaky hemoptysis. During the 2 previous weeks, he suffered with fever of 40°C, weight loss, and chest pain. Skin pallor was evident on physical examination. Auscultation revealed a generalized decrease in breath sounds, particularly over the bases, and localized rhonchi in the right upper field. Hepatomegaly of 3 cm, with a smooth border, was found on abdominal examination.
At the time of admission, the blood tests showed a raised white cell count (22,130×103/μL) with left deviation (12% band forms), and a microcytic, hypochromic anemia at a level requiring transfusion. The biochemistry showed no changes in renal or liver function despite a prothrombin activity of 56% and an international normalized ratio of 1.3.
Chest x-ray showed a cavitating mass situated in the right upper lobe.
During the admission, Pseudomonas aeruginosa was isolated from the sputum. Serial microscopy and culture in special media (Löwenstein) were negative. The patient was treated with intravenous imipenem (1 g/12 h) and tobramycin (70 mg/8 h), with clinical improvement with resolution of the fever and a decrease in the cough and expectoration. However, no improvement was observed in the radiographic findings. A contrast-enhanced thoracoabdominal computerized tomography scan was performed, showing a cavitating mass of 8×7 cm in the right upper lobe, with thick walls and a nodular internal surface. The mass was attached to the pleura and communicated with the right main bronchus (Fig. 1). A high right paratracheal and a hilar lymph node, up to 1 cm in diameter, were also observed. There were multiple hepatic lesions that, together with the ultrasound study, supported the diagnosis of metastasis.
Flexible bronchoscopy (FB) revealed thickened and irregular right main bronchus mucosa with a large stoma at the site of the upper lobe bronchus that communicated with a very large cavity. Passage of the FB allowed the inspection of the tumor cavity, revealing irregular, convoluted, lobulated and highly vascularized walls (Fig. 2). Samples were obtained using fine needle (4 mm), biopsy forceps, and by scraping of one of the nodular masses; revealing adenocarcinoma.
Adenocarcinoma of the lung is a cancer of variable appearance and histiogenesis, which is classified into 4 histologic subtypes: acinar carcinoma, papillary carcinoma, solid carcinoma with mucin formation, and bronchioloalveolar carcinoma.8 As a group, the adenocarcinomas are one of the most common histologic types of lung cancer, and constitute approximately 30% to 35% of all lung cancers. The majority of these tumors are situated in the peripheral regions of the lung, often in a subpleural situation. The margins are usually smooth, although occasionally may present a spicular or irregular appearance.9
In large bronchogenic cancers, small necrotic foci may be observed. However, their coalescence to form a cavity is uncommon in adenocarcinoma.6,10
In our patient, as may be observed in Figure 1, the communication of the tumor cavity with the airway was very large, allowing passage of the FB and examination of the cavity (Fig. 2). To our knowledge, cavitation with the characteristics found in this case has not been described previously; in addition, the central localization of the tumor with disease of the main airway is very uncommon.3 Cases have been published in which the FB reaches anatomic cavities through a fistula from the bronchial wall to the mediastinum or esophagus, caused by necrosis,11,12 and in a few cases of squamous cell carcinoma after radiation therapy the FB led by the stoma of a bronchus to a tumoral cavity13; however, the endoscopic view of a lung adenocarcinoma cavitation is a unique finding.
The development of a tumor cavity seems to be associated with rapid tumor growth that exceeds blood supply, favoring central necrosis that progresses to the formation of a cavity.6 However, this hypothesis is controversial, and other mechanisms have been proposed to explain cavity formation. It has been postulated that overexpression of epidermal growth factor present in the neoplastic cells6 and infection13,14 may play an important role in the development of a tumor cavity.15 In our patient, P. aeruginosa was isolated; yet its role in the formation of the tumor cavity is uncertain. It is reasonable to assume that visualization of a cavity containing tumor nodules must be because of the tumor causing ulceration of the bronchial wall and communication with the airway. In addition, infection is common in immunodepressed patients and, in some studies; it has been observed that the incidence of in situ infection can reach over 27%.15
A number of cases have been reported of squamous cell carcinoma in which the combination of infection and radiotherapy synergistically produced necrosis, leading to tumor cavitation.13,14
The present case is particularly interesting owing to certain characteristics that are exceptional in this type of tumor. First, as has been stated above, cavitation of an adenocarcinoma is very rare. Second, the large communication of the tumor with the main airway as a result of the natural growth of the tumor permitted endoscopic vision of the tumor cavity. To our knowledge, this finding has been seldom reported.
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