Ann Thorac Surg 2008;86:312-313. doi:10.1016/j.athoracsur.2008.01.029
© 2008 The Society of Thoracic Surgeons
Case Reports
Brain Metastases Secondary to Tumor Emboli From Primary Lung Cancer During Lobectomy
Yasushi Cho, MD,
Yasuhiro Hida, MD*,
Kichizo Kaga, MD,
Hiroaki Kato, MD,
Mikiya Iizuka, MD,
Satoshi Kondo, MD
Surgical Oncology, Cancer Medicine, Division of Cancer Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
Accepted for publication January 10, 2008.
* Address correspondence to Dr Hida, Department of Surgical Oncology, Cancer Medicine, Division of Cancer Medicine, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan (Email: yhida{at}med.hokudai.ac.jp).
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Abstract
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It is assumed that dissemination of tumor cells during pulmonary resection may be followed by metastases. A 70-year-old man with pleomorphic carcinoma of the lung had brain metastases develop secondary to brain infarction caused by tumor emboli during lobectomy. This is a rare case that clearly showed brain metastases as a consequence of tumor emboli during pulmonary resection.
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Introduction
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It is assumed that dissemination of tumor cells during pulmonary resection may be followed by metastases, although it has scarcely been proven. We report a case of pleomorphic carcinoma of the lung with brain metastases secondary to brain infarction caused by tumor emboli during lobectomy.
A 70-year-old man with a history of diabetes mellitus presented with a fever for several days. The chest x-ray film showed an abnormal shadow in his right lower lung field. Chest computed tomographic scan showed a 4.5 x 4.2 cm mass lesion with peripheral ground glass opacity in the middle lobe (Fig 1A). There was no sign of direct tumor invasion to the pulmonary veins. Transbronchial biopsy revealed a nonsmall cell carcinoma. He underwent a middle lobectomy with a posterolateral incision. Both lungs were ventilated because of dislocation of the endotracheal tube. There was no pleural dissemination or effusion. The tumor invaded the right lower lobe, which was partially resected simultaneously. The sequence of the vessel interruption was the artery followed by the vein due to technical difficulties, although the vein followed by the artery is more usual. The tumor was white and measured 3.5 x 3.2 x 2.5 cm. The histopathologic diagnosis was a pleomorphic carcinoma with no lymph node metastasis. There was vessel invasion at the periphery of the tumor (Fig 1B). There was no tumor thrombus in the lobar or segmental pulmonary veins. There was no tumor invasion to the stumps of the resected specimen. Postoperatively, the patient experienced motor aphasia and paralysis of his right extremities. Brain magnetic resonance imaging 4 hours after the operation showed low signal intensity in the left temporal lobe and frontal lobe (Fig 2A). These results were diagnosed as cerebral infarctions. He was given edaravone, hyperbaric oxygen therapy, and rehabilitation. His neurologic symptoms improved for 6 weeks until remittance. Brain magnetic resonance imaging showed metastases in the infarcted area (Fig 2B). It was suspected that intraoperative tumor emboli caused brain infarctions resulting in brain metastases in 6 weeks. He died of brain metastases 8 months after surgery, despite radiation therapy. A postmortem examination was not performed.
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Fig 1. (A) Chest computed tomographic scan shows a 4.5 x 4.2 cm mass lesion in the right middle lobe with a ground glass opacity shadow surrounding the tumor. (B) Microscopically, a pleomorphic carcinoma infiltrated the pulmonary vein.
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Fig 2. (A) Diffusion magnetic resonance imaging 4 hours after surgery showed cerebral infarction in the left temporal and frontal lobes (arrows). (B) T2-magnetic resonance imaging scan on postoperative day 43 showed metastases in the same positions as the infarction areas (arrows).
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Comment
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Cerebral infarction and acute myocardial infarction due to tumor emboli during surgery for lung carcinoma have been previously reported [1, 2]. In this case, cerebral infarction occurred during surgery for primary lung carcinoma. Multiple brain metastases appeared 6 weeks after the development of cerebral infarctions at exactly the same locations. It was speculated that cerebral infarction was caused by tumor emboli spread through a pulmonary vein. Pathologic examination revealed that the primary lung tumor was a pleomorphic carcinoma with venous invasion. A pleomorphic carcinoma grows rapidly and is related to poor prognosis. In this case, the tumor-bearing middle lobe was manipulated more than usual during the operation because of a large-sized tumor, unsatisfactory one-lung ventilation, and intrathoracic adhesions. The pulmonary vein was interrupted after the pulmonary artery.
During pulmonary resections for nonsmall cell lung carcinoma, the pulmonary vein is preferentially interrupted first to prevent seeding of malignant cells and consequently to decrease hematogenous metastasis. The importance of early pulmonary venous ligation in lung cancer surgery, first stressed by Aylwin [3] in 1951, is evident, particularly when intravenous tumor progression has been preoperatively diagnosed by echocardiography or computed tomography.
The report by Kurusu and associates [4] evaluated the impact of the sequence of vessel ligation during lobectomy for nonsmall cell lung carcinoma on the amount of circulating cancer cells in peripheral blood. They investigated the presence of the mRNA of carcinoembryonic antigen in peripheral blood before, during, and after lobectomy by reverse-transcriptase polymerase chain reaction. They concluded that ligation of the pulmonary vein before the artery may lessen intraoperative hematogenous dissemination. However, the historical study by Refaely and colleagues [5] did not show the sequence of vessel interruption as a risk factor of recurrence. A prospective randomized control study is necessary to elucidate the role of sequence of vessel interruption.
To reduce the risk of intraoperative systemic dissemination, it is recommended to avoid excess manipulation of the tumor-bearing lobe, especially before ligation of the pulmonary vein if venous invasion is suspected.
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References
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- O'Neill BP, Dinapoli RP, Okazaki H. Cerebral infarction as a result of tumor emboli Cancer 1987;60:90-95.[Medline]
- Spencer DD, de la Garza JL, Walker WA. Multiple tumor emboli after pneumonectomy Ann Thorac Surg 1993;55:169-171.[Abstract]
- Aylwin JA. Avoidable vascular spread in resection for bronchial carcinoma Thorax 1951;6:250-267.[Free Full Text]
- Kurusu Y, Yamashita J, Hayashi N, et al. The sequence of vessel ligation affects tumor release into the circulation J Thorac Cardiovasc Surg 1998;116:107-113.[Abstract/Free Full Text]
- Refaely Y, Sadetzki S, Chetrit A, et al. The sequence of vessel interruption during lobectomy for non-small cell lung cancer: is it indeed important? J Thorac Cardiovasc Surg 2003;125:1313-1320.[Abstract/Free Full Text]
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Abstract
Introduction
