Ann Thorac Surg 2005;79:716
© 2005 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Multiple Pleural Destruction Due to Pleural Dissemination of Pulmonary Carcinoma Originating From Pneumothorax
Tohru Mawatari, MDa,*,
Atsushi Watanabe, MDa,
Hisayoshi Ohsawa, MDa,
Yasuaki Fujisawa, MDa,
Tomio Abe, MDa
a Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
* Address reprint requests to Dr Mawatari, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, 060-8556 Japan
mawatari{at}sapmed.ac.jp
A 48-year-old man was admitted to our hospital complaining of coughing, hemosputum, and dyspnea. Chest roentgenography revealed left pneumothorax and pleural effusion (Fig 1), which was revealed to be malignant by cytologic examination and contained a high level of hyaluronic acid (4,761 mg/mL). Primary lung carcinoma or mesothelioma was suspected. A drainage tube was placed in the left pleural cavity and 10 cmH2O suction was applied for 10 days. Surgery was scheduled because of prolonged air leakage, and the operation was done thoracoscopically. Multiple small nodules were observed on the parietal and visceral pleura through the thoracoscope, and these were partially resected. The pathologic diagnosis was adenocarcinoma. Pulmonary fistulas from which the air leaks had originated were found in segments 2, 6, and 10. The fistulous portions showed destruction of the visceral pleura, and pleural defects were observed through the thoracoscope. The visceral pleura lying over segment 2 was destroyed and showed a crater-like hollow (shown by two arrows in Fig 2). Air leaks were found in this section, and no bullae were observed. The pulmonary fistulas in segments 6 and 10 were resected using a stapling instrument (Endo-GIA; United States Surgical, Norwalk, CT), and pneumonorrhaphy was done using a nylon suture for the fistula in segment 2. Intrapleural chemotherapy was performed with 200 mg of CDDP (Cisplatin) diluted in 2,500 mL sterilized distilled water for 15 minutes. Hyperthermia for the left pleural cavity was performed at 41°C to 42°C for 80 minutes on postoperative day 3 using 200 mg of CDDP diluted in distilled water. Furthermore, the diluent used for the CDDP was infused into the left pleural cavity on postoperative day 8. The chest tube was removed on postoperative day 17, and the patient was discharged. At this time, cytologic examination of the pleural effusion removed through the chest tube was negative for malignancy.
There have been a number of reports [1, 2] of pneumothorax complicated by lung carcinoma, but we are reporting a case in which air leaks were observed in areas of the visceral pleura where tumor cells had disseminated. Pathologic examination of the resected lung specimen, including the portion showing air leakage, indicated that carcinoma cells had invaded the pleura and destroyed the structure of the lung parenchyma. As this case was one of advanced lung carcinoma, the prognosis was thought to be very poor. Currently, 5 months after the surgery, the patient is still alive and frequently visits our outpatient clinic.
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References
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- Laurens RG Jr, Pine JR, Honing EG. Spontaneous pneumothorax in primary cavitating lung carcinoma. Radiology. 1983;146:295–297[Abstract/Free Full Text]
- Steinhauslin CA, Cuttat JF. Spontaneous pneumothorax. A complication of lung cancer? Chest. 1985;88:709–713[Abstract/Free Full Text]
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