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Necrosis of Bronchus in Lung Cancer

Antunes, Ana MD; Gomes, Joana MD; Neves, Sofia MD; Oliveira, Ana MD; Almeida, José MD; e Sá, João Moura MD

Journal of Bronchology & Interventional Pulmonology: October 2011 - Volume 18 - Issue 4 - p 348–351
doi: 10.1097/LBR.0b013e318235d805
Case Reports
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Bronchial necrosis with wall destruction and direct visualization into the cavity is seldom described in the context of lung cancer, except after radiation therapy. We describe 5 cases of cavitating lung cancer with direct communication with the airways, large enough to allow the passage of a flexible bronchoscope. We encountered all of these cases between May 2009 and January 2010. None of the patients had received radiation previously. During bronchoscopy, necrosis of the bronchus was evident with replacement of the involved lung by a large cavity lined by tumor tissue.

Department of Pulmonology, Respiratory Endoscopy Unit, Centro Hospitalar Vila Nova de Gaia/Espinho, EPE, Portugal

Disclosure: There is no conflict of interest or other disclosures.

Reprints: Ana Antunes, MD, Serviço de Pneumologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Unidade 1, Rua Conceição Fernandes s/n, 4434-502 Vila Nova de Gaia (e-mail: ana.oliveirinha2@gmail.com).

Received May 19, 2011

Accepted July 26, 2011

The incidence of cavitating lung tumors in the literature is about 10%. Squamous cell carcinoma, over expression of epidermal growth factor receptor, and infection have been found to be associated with such cavitation.1–3 Fever is the most common presenting feature.1

However, the description of bronchial necrosis with bronchoscopic visualization of pulmonary parenchyma is rare in the absence of previous radiation therapy.4 We report on 5 cases, 3 of them presenting with cavitating forms of lung cancer and bronchial necrosis and with a communication between the cavity and the airways.

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CASE REPORTS

Case 1

A 55-year-old man, a former smoker, was diagnosed with stage IV squamous cell carcinoma of the lung in March 2009. He underwent chemotherapy with carboplatin and paclitaxel. In January 2010 he was hospitalized because of a clinical and radiologic worsening of his condition. His chest computed tomographic (CT) scan showed evidence of a cavitating mass involving the left upper lobe. He underwent a flexible bronchoscopy (FB), which revealed the left main bronchus and secondary carina displaying irregularities of the mucous membrane suggestive of tumor infiltration. After entry into the apical segment of the left upper lobe, a necrotic cavity was observed, with total distortion of the bronchial architecture. It was only possible to guess the orifices of entry of its respective subsegments because of areas with tumor infiltration (Fig. 1). The patient died a week later of respiratory insufficiency.

FIGURE 1

FIGURE 1

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Case 2

A 65-year-old man, a former smoker, was diagnosed with stage IV poorly differentiated non-small-cell lung carcinoma in June 2009. He received chemotherapy using 4 cycles of carboplatin and gemcitabine without much response. He also received docetaxel as a 2nd line treatment during October of that same year. He was hospitalized during the course of the chemotherapy because of moderate hemoptysis. It was in this context that he underwent an FB, which revealed a right upper lobe (RUL) bronchus of reduced caliber, which was permeable. Truncus intermedius showed a total anatomic distortion, in which no bronchial structures were identified; only extensive cavitation with underlying pulmonary parenchyma was observed. There were no signs of active bleeding or old blood clots (Fig. 2). After the stabilization of his clinical condition, he was discharged; he died approximately 2 months later of an unknown cause.

FIGURE 2

FIGURE 2

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Case 3

A 73-year-old man, a former smoker, was under clinical investigation for hemoptysis of 1-month duration, along with a homogenous opacity of the RUL as detected on chest x-ray. Chest CT revealed a tumor mass of 7×7.5 cm in diameter involving the RUL with mediastinal invasion. He underwent an FB, which exhibited a blunted carina. There was extrinsic compression involving the medial wall of the right main bronchus (RMB), along with findings suggestive of tumor infiltration. Distal to the RMB, we observed marked destruction of the bronchial architecture with a swollen, congestive, hemorrhagic mucous membrane and areas of necrosis, with only the outline of some bronchial orifices and direct visualization of pulmonary parenchyma (Fig. 3). Cytologic examination of the bronchoalveolar lavage fluid revealed squamous cell carcinoma. The patient died of exsanguination 4 weeks later.

FIGURE 3

FIGURE 3

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Case 4

A 78-year-old man, an active smoker, presented in May 2009 with hemoptysis and failure to thrive. FB revealed stenosis of the RUL bronchus. Truncus intermedius and middle lobe (ML) and right lower lobe bronchi showed an appearance compatible with tumor infiltration. The right lower lobe exhibited a marked necrosis at the level of the basal segments, obscuring their definition (Fig. 4). Endobronchial biopsy revealed squamous cell carcinoma of the lung. The patient died during the course of hospitalization because of exsanguination.

FIGURE 4

FIGURE 4

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Case 5

A 65-year-old man, a smoker, was hospitalized in November 2009 with a history of massive hemoptysis. His chest x-ray showed the presence of a cavity with a thick and irregular wall involving the lower half of the right hemithorax that was later confirmed by chest CT. He underwent an FB, which exhibited the presence of a large amount of clots occupying the RMB, which were aspirated. There were also clots present at the RUL and ML bronchi and at basal segments of the lower lobe bronchus (LLB). After the removal of clots, the ML bronchus, B6 (superior segment of the LLB), B8 (anterior segment of the LLB), and B10 (posterobasal segment of LLB) were found to be patent. At the level of the entry of the basal pyramid, there was a fungating endobronchial lesion obstructing the lateral basal segment. Excisional biopsy of the lesion proved it to be a squamous cell carcinoma. Bronchus beyond the orifice of B9 (lateral basal segment of the LLB) opened into a large cavity exhibiting lung parenchyma (Fig. 5). The patient underwent a right pneumonectomy, followed by chemotherapy, and was still alive 14 months later.

FIGURE 5

FIGURE 5

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DISCUSSION

In the 5 observed cases there was no history of a previous radiotherapy treatment, a fact commonly described in previous reported cases.4 In our series, hemoptysis was the main presenting symptom rather than fever. Hemoptysis may have been as a result of erosion of the bronchial arterioles and the vessels of the cavity walls. Most patients were smokers and had a diagnosis of squamous cell carcinoma of the lung. We would like to stress the dissociation between the radiologic and bronchoscopic findings; in 3 of our patients neither chest x-ray nor CT revealed any cavitation. We also feel that unless the cavity is surgically resected the prognosis is poor, with most patients dying in a matter of months because of exsanguination.

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REFERENCES

1. Mouroux J, Padovani B, Elkaim D, et al. Should cavitated bronchopulmonary cancers be considered a separate entity? Ann Thorac Surg. 1996;61:530–532
2. Chaudhuri MR. Primary pulmonary cavitating carcinomas. Thorax. 1973;28:354–366
3. Onn A, Choe DH, Herbsi RS, et al. Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome. Radiology. 2005;237:342–347
4. Mehta AC, Dweik RA. Necrosis of the bronchus: role of radiation. Chest. 1995;108:1462–1466
Keywords:

lung cancer; lung cavity; flexible bronchoscopy

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