Ann Thorac Surg 2008;85:333-334. doi:10.1016/j.athoracsur.2007.08.038
© 2008 The Society of Thoracic Surgeons
Case Reports
Squamous Cell Carcinoma in a Postpneumonectomy Cavity
Alpay Orki, MD*,
Senol Urek, MD,
Mehmet Suat Patlakoglu, MD,
Ahmet Erdal Tasci, MD,
Cemal Asim Kutlu, MD, FETCS
Deparment of Thoracic Surgery, Sureyyapasa Chest Diseases and Chest Surgery Research and Training Hospital, Istanbul, Turkey
Accepted for publication August 21, 2007.
* Address correspondence to Dr Orki, Camlica Palmiye Sitesi, D:11-3, NATO Yolu, Izmir Sok, Uskudar-Istanbul, 34692, Turkey (Email: alpayorki{at}yahoo.com).
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Abstract
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A 55-year-old woman was referred to our department with the diagnosis of a bronchopleural fistula and empyema. Her medical history revealed that she had undergone a left pneumonectomy 25 years prior due to a destroyed lung associated with tuberculosis. Open drainage and a biopsy was performed because of the large mass detected on thoracic computed tomography. Postoperative pathology revealed squamous cell carcinoma.
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Introduction
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It has been reported that squamous cell carcinoma may develop in an area of chronic inflammation such as that affected by a chronic ulcer, scar, empyema, or osteomyelitis [1, 2]. However, carcinoma originating from the chest cavity after postpneumonectomy empyema is an extremely uncommon condition in the literature. This article reports a patient who underwent pneumonectomy for a benign condition and presented with a large mass in the chest cavity 25 years after the operation.
A 55-year-old housewife presented to a primary care physician complaining of cough, sputum, weight loss, and weakness for 5 months. Clinical improvement was achieved by antibiotic therapy, and no further investigations were performed. Her condition suddenly deteriorated with cough, expectoration of an excessive amount of smelly sputum, and hemoptysis at 3 weeks after her first admission. She was admitted to an emergency department where a chest x-ray film was obtained (Fig 1). The laboratory results were as follows: hematocrit, 32.3%; hemoglobin, 10.8 g/dL; and white blood count, 14.800/mm3. Her past medical history revealed that she was diagnosed with tuberculosis at the age of 28 years, and she was treated with an anti-tuberculosis regimen for 9 months. Subsequently, her symptoms resolved, and she resumed a normal life. However, she presented with expectoration of smelly sputum at 6 months after the treatment. A chest x-ray film and computed tomographic scan revealed a destroyed lung, and then she underwent a left pneumonectomy. The postoperative course was uneventful and she was discharged on postoperative day 5. Thereafter, she led a normal life for 25 years without any complaints.
She was referred to our department with the diagnosis of bronchopleural fistula and empyema. Physical examination was essentially normal, except for a thoracotomy incision and loss of volume observed in the left hemithorax. The patient lost 10 kg since the onset of symptoms. Prior to attempting insertion of a chest tube, we obtained a computed tomographic thorax scan because of the unusually long interval between the pneumonectomy and the bronchopleural fistula. A computed tomograpic thorax scan revealed a mass occupying most of the thoracic cavity and invading the chest wall (Fig 2). We performed bronchoscopy and open drainage under general anaesthesia. A large fistula was observed at the stump that appeared essentially healthy. Multiple biopsies were obtained along the left bronchus. The thoracic cavity was opened through a small incision that was eventually converted to an open thoracostomy. The cavity was debrided and necrotic material was removed to prevent futher aspiration through the fistula (Fig 3). On inspection, it was observed that the tumor nodules were scattered throughout the pleural surface. The postoperative pathology revealed squamous cell carcinoma, and no tumor was detected in the bronchial biopsies. The condition of the patient improved after the operation and further investigations were planned. Whole-body positron emission tomographic and computed tomographic scans revelaed no tumor foci elsewhere in the body, and a cranial magnetic resonance image was normal. Despite supportive therapy, her condition gradually worsened with time, and she died in postoperative week 7 due to respiratory failure.
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Comment
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It is well known that the risk of carcinoma is increased in areas subjected to chronic irritation [1]. An empyema cavity after pneumonectomy may be considered a risk factor for malignancy. However, such cases are rarely reported in the literature considering the frequency of empyema after pneumonectomy. The mechanism remains to be clarified, but some explanations have been investigated. The long-term inflammation causes metaplasia in the bronchial and pleural epithelium and the epithelium of the skin margins of the tract. Subsequently, metaplastic epithelium extends into the chest cavity where cell proliferation and malignant degeneration occur [2]. The other explanation relies on the observation that patients in whom artificial therapeutic pneumothorax was used for tuberculosis presented with carcinoma many years after the treatment [3–5]. This suggests that exposure of the thoracic cavity to the environment causes degenerative changes resulting in malignancy [3, 4].
The reports indicate that longstanding chronic irritation may result in carcinoma in the range of 11 to 51 years [1–6]. In the present case, the patient had undergone a left pneumonectomy 25 years ago, but no pleural disease was noted in her medical record and no complication occurred postoperatively. The patient underwent a routine follow-up for 8 years postoperatively and survived for 25 years without any complaints. Thus, in this patient, regarding the mechanisms for cancer development, exposure of the cavity seems to be a risk factor rather than a chronic irratation. It seems that onset of the symptoms was caused by the large mass. Initially the mass probably resulted in a microfistula causing an intrapleural infection and subsequently a large fistula developed. It has been reported that bronchopleural fistula occurs many years after pneumonectomy; however, 25 years remains an unusually long interval. Malignancy originating from a bronchial stump may well be a reason for bronchopleural fistula, which can be easily diagnosed with bronchoscopy. Emergency chest tube insertion is a basic approach for empyema and bronchopleural fistula to prevent contralateral aspiration; however, the exceptional history of this patient prompted us to obtain a computed tomographic scan prior to drainage. Further evaluation was performed in the operating room because simple drainage was not considered to be adequate.
In conclusion, surgeons should note that malignant degenerations may develop in the thoracic cavity after pneumonectomy in patients who have a long life expectancy. Postoperative chest x-ray films obtained many years after pneumonectomy must also be reviewed in this regard.
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References
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- Cattaneo SM. Carcinoma of the chest wall complicating chronically draining empyema Chest 1973;64:673-676.
- Deaton WR. Carcinoma arising in chronic empyema cavity: Case report with review of the literature Chest 1962;42:563-566.
- Rena O, Casadio C, Maggi G. Primitive squamous-cell carcinoma after extrapleural pneumothorax for active tuberculosis Eur J Thorac Cardiovasc Surg 2001;19:92-95.
- Gross P, Harley A. Asbestos-induced intrathoracic tissue reactions Arch Pathol 1973;96:245-250.[Medline]
- Prabhakar G, Mitchell IM, Guha T, et al. Squamous cell carcinoma of the pleura following bronchopleural fistula Thorax 1989;44:1053-1054.[Abstract/Free Full Text]
- Ruttner JR, Heinzl S. Squamous cell carcinoma of the pleura Thorax 1977;32:497-500.[Abstract/Free Full Text]
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Abstract
Introduction
