Japanese Journal of Clinical Oncology 30:358-361 (2000)
© 2000 Foundation for Promotion of Cancer Research
Lung Carcinoma with Polypoid Growth in the Main Pulmonary Artery: Report of Two Cases
,+ 1Thoracic Surgery Division, National Cancer Center Hospital, Tokyo and 2Pathology Division, National Cancer Center Research Institute, Tokyo, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTSDISCUSSIONAcknowledgmentREFERENCES |
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Invasion into the lumen of the main pulmonary artery is an uncommon mode of extension in lung carcinoma and its prognostic significance remains unclear. We describe here two resected cases of lung carcinoma that showed such a rare tumor spread. Although a preoperative evaluation, such as angiography or perfusion scan of the lung, had shown a significant decrease in circulation, we could not diagnose the intraluminal tumor growth preoperatively. Pneumonectomy was finally needed to perform a curative operation. The tumors were centrally located and showed polypoid growth in the main pulmonary artery. Postoperative pathological examination revealed the tumors to be adenosquamous carcinoma of the lung in both cases. No intrapulmonary metastases were detected. One patient is doing well with no signs of recurrence after a follow-up period of 10 years. Although intra-arterial polypoid growth of lung carcinoma is extremely rare, such tumor extension should be considered preoperatively to perform a curative surgical resection, especially when the tumor is centrally located. While arterial invasion is generally an ominous prognostic factor, curative surgical resection would offer a good prognosis, even for lung carcinoma invading the main pulmonary arterial trunk.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTSDISCUSSIONAcknowledgmentREFERENCES |
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Whereas microscopic vascular invasion by lung carcinoma is frequently observed, polypoid growth into the lumen of the main pulmonary vessels is quite rare. Several authors have reported that lung carcinoma could extend through the major pulmonary vein and up to the left atrium (1,2). However, such tumor growth into the lumen of the pulmonary artery has been documented infrequently (3–5). In this paper, we describe two resected lung carcinoma cases that showed such a rare growth pattern.
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CASE REPORTS |
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TOPABSTRACTINTRODUCTIONCASE REPORTSDISCUSSIONAcknowledgmentREFERENCES |
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Case 1
A 66-year-old man, complaining of dry cough, was referred to our hospital with a diagnosis of lung carcinoma. He had smoked five cigarettes per day for 40 years. On physical examination, no abnormality was detected. Chest X-ray revealed an irregular shadow in the middle lobe, measuring 6 cm maximum tumor dimension. A computed axial tomographic (CAT) scan showed a centrally located lung tumor and significantly decreased circulation to the middle and right lower lobe was noted on pulmonary angiogram (Fig. 1). Preoperative evaluation revealed no distant metastases and surgical resection of the tumor was planned. On thoracotomy, right middle and lower lobectomy was initially intended because the tumor was centrally located in the middle lobe and appeared to invade the basal trunk of the pulmonary artery. However, intraluminal tumor growth was found when we divided the intermediate trunk of the pulmonary artery and therefore we selected intrapericardial pneumonectomy for complete resection. Macroscopically, the tumor invaded the intermediate trunk of the pulmonary artery and extended into its lumen proximally up to the right main trunk (Fig. 2). Although the tumor was divided once at the level of the intermediate trunk, the surgical margin was finally free from cancer invasion. Histologically, the tumor was diagnosed to be adenosquamous carcinoma of the lung with small foci of a spindle cell component. The spindle cell component was mainly observed in the polypoid part of the tumor which extended into the trunk of the pulmonary artery. The dominant histology was squamous cell carcinoma. Pathological stage was T2N1M0, stage IIB. The postoperative course was uneventful and the patient is doing well with no signs of recurrence 10 years after the operation.
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Case 2
A 55-year-old woman with a complaint of dry cough was referred to our institute. She had a 26-year smoking history. Chest X-ray and a CAT scan showed an irregular mass centrally located in the left upper lobe, which measured about 5 cm maximum tumor dimension. The tumor was suspected to have invaded the superior segment of the lower lobe. Preoperative work-up revealed the tumor to be non-small cell lung carcinoma with no distant metastases. Perfusion lung scan suggested a severe decrease in circulation to the lower lobe and only 17% of the total circulation was supplied to the left lung (Fig. 3). First, we tried to perform a left upper lobectomy; however, pneumonectomy was necessary for complete resection because of tumor invasion to the pulmonary arterial trunk. Postoperative macroscopic investigation revealed a polypoid tumor growth in the main pulmonary artery (Fig. 4). The surgical margin was cancer-negative. Histologically, the tumor had directly invaded the hilar lymph nodes and extended to the pulmonary arterial trunk through them (Fig. 5). Histological typing was adenosquamous carcinoma of the lung and it also had small foci of a spindle cell component. The dominant histology was adenocarcinoma (Fig. 6). Pathological stage was T2N1M0, stage IIB. The patient had been free from any recurrent signs for 8 months, but she complained of a partial seizure of her right hand due to multiple brain metastases which was diagnosed by magnetic resonance imaging. She is now undergoing whole brain irradiation.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTSDISCUSSIONAcknowledgmentREFERENCES |
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Lung carcinoma frequently invades pulmonary vessels histologically and such vascular invasion has been reported to be an ominous prognostic factor (6–9). On the other hand, macroscopic tumor growth into the lumen of the major pulmonary vessels is relatively rare (1,2). In the case of the major pulmonary artery, such intraluminal polypoid tumor extension is extremely rare and very few cases have been reported (3–5). In both of the cases reported here, the tumor had not only invaded the pulmonary artery, but also extended proximally up to the main pulmonary artery against the bloodstream. Even such a rare pattern of tumor growth should be considered whenever lung cancer is centrally located and reduced circulation to the diseased lung is suspected; otherwise, incomplete resection and a subsequent fatal thromboembolic event might occur during the operation. Intraoperative ultrasonography could be useful for preventing such a disastrous event (10,11).
In the present cases, the histological typing of the tumor was adenosquamous carcinoma. This lung cancer subtype has been reported to be more aggressive than adenocarcinoma or squamous cell carcinoma of the lung (12). The characteristics of this tumor might be associated with intraluminal polypoid growth. The resistance of the main pulmonary artery, which is a strong barrier against other histological types of lung cancer, may not be strong enough to oppose adenosquamous carcinoma of the lung. However, since we present only two such cases, the relationship between adenosquamous histology and polypoid tumor growth in the main pulmonary artery remains to be clarified. Although the prognosis of adenosquamous carcinoma of the lung is reportedly worse than that of other types of lung carcinoma, one of our cases has survived for more than 10 years. Thus, even when macroscopic tumor invasion to the main pulmonary artery is observed, complete surgical resection of the tumor may offer an excellent prognosis.
The rarity of this tumor growth pattern makes it difficult to define its prognostic impact and pathological implications. For example, polypoid tumor growth in the pulmonary artery is thought to lead to dissemination of the tumor in the pulmonary circulation, resulting in multiple intrapulmonary metastases. However, in our two cases, such pathological findings were not observed. Peripheral pulmonary infarction or embolization might have occurred, but was not found in our cases.
In summary, we have presented two cases of lung carcinoma with polypoid growth into the lumen of the main pulmonary artery. This mode of tumor extension is rare and its prognostic significance remains unclear. Such tumor extension should be considered preoperatively to perform a curative surgical resection, especially when the tumor is centrally located. Although arterial invasion is generally an ominous prognostic factor, curative surgical resection should offer a good prognosis, even for lung carcinoma invading the main pulmonary arterial trunk.
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Acknowledgment |
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TOPABSTRACTINTRODUCTIONCASE REPORTSDISCUSSIONAcknowledgmentREFERENCES |
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This work was supported in part by a Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare
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FOOTNOTES |
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+ For reprints and all correspondence: Kenji Suzuki, Thoracic Surgery Division, National Cancer Center Hospital, 1–1, Tsukiji 5-chome, Chuo-ku, Tokyo 104–0045, Japan. E-mail: kjsuzuki@ncc.go.jp
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Received March 27, 2000; accepted May 16, 2000.
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