CASE REPORT Bronchial Metastases from Ovarian Carcinoma Report of a Case and Review of the Literature FRANCISCOMATEO,* ELI SERUR,~ AND PETER R. SMITH*” *Division
Department of Medicine and TDepartment of Obstetrics and Gynecology, Health Science Center at Brooklyn, Brooklyn, New York 11203
State University of New York,
Received October 28, 1991
was positive for malignant cells. Chemotherapy with Amonafide was begun in July 1989, but the pelvic masses progressed and it was discontinued. She developed thrombosis of the subclavian, axillary, and innominate veins due to an indwelling central line and was treated with heparin and broad spectrum antibiotics. A chest radiograph at this time showed a new lobulated parahilar density in the right upper lobe and a hazy infiltrate in the superior segment of the left lower lobe. On CT scan the right upper lobe bronchus was obliterated INTRODUCTION by a mass and finger-like projections extended distally, suggesting mucoid impaction of the segmental bronchi. Tracheobronchial metastasesfrom extrapulmonary ma- A second lesion surrounded the left lower lobe bronchus. lignancies are most common with carcinomas of the Fiberoptic bronchoscopy showed tumor completely obbreast, kidney, and colon [l-3]. Although pleural and structing the right upper lobe and superior segment of parenchymal lung metastases are frequent with ovarian the left lower lobe. Biopsy showed adenocarcinoma. A carcinomas , tracheobronchial metastases are rare. review of the original pathology material indicated that Three cases have been reported previously [5-71. We the bronchial tumor was consistent with the ovarian pridescribe a case of ovarian carcinoma with bilateral bron- mary. She received seven courses of carboplatin and cychial metastases resulting in respiratory insufficiency. clophosphamide which was followed by serial CA-125 levels and clinical evaluation. The pelvic and thoracic masses CASE REPORT remained stable on this regimen. In July 1990, the patient developed a cough with minA 62-year-old nonsmoking woman para 4014, under- imal sputum production and wheezing that responded went total abdominal hysterectomy and omentectomy in poorly to bronchodilator therapy. In addition, the CA1984 for stage IIIb, grade 3 ovarian serous cystadeno- 125 levels had increased. Since the patient was noted to carcinoma. Eight courses of cisplatin, adriamycin, and have multifocal disease involving both lungs and pelvis, cyclophosphamide were given after surgery. A “second- another attempt at systemic therapy was instituted. Her look” laparotomy showed no residual tumor later that chemotherapy was changed to 5-fluorouracil, cyclophosyear. She was well until 1989 when a CT scan showed phamide, and actinomycin-D and continued for two right pararectal and cul-de-sac masses. A needle aspirate courses. Five months later, (18 months after the lung masses were first noted) she was readmitted with severe dyspnea, ’ To whom reprint requests should be addressed at Long Island College Hospital, 340 Henry Street, Brooklyn, NY 11201. cough, and wheezing. She was in respiratory distress with A patient with ovarian cystadenocarcinoma developed respiratory insufficiency due to bilateral endobronchial metastases,6.5 years after treatment of the primary tumor. Ovarian cancers frequently metastasize to the pleura and lung parenchyma. Clinically significant bronchial metastasesare rare. Only three cases have been reported previously. As in our patient, bronchial metastases tend to occur after a relatively long interval from diagnosis of the primary tumor, and survival may be prolonged after their appearance. 0 1992 Academic press, IX.
235 oo90-825&x/92 $4.00 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
MATEO, SERUR, AND SMITH
FIG. 1. Chest radiograph showing right upper lobe (closed arrow) and left lower lobe (open arrow) infiltrates.
respiratory rate, 32 per minute; pulse, 110 per minute; BP, 100/60. There was loud stridor over the trachea and anterior chest. Inspiratory and expiratory wheezes were heard over both lungs diffusely. Arterial blood gases on room air were pH 7.45; PaCO,, 41 mmHg; and PaO,, 52 mmHg. Chest radiograph (Fig. 1) showed progression of the infiltrates in the right upper and left lower lobes. A CT scan (Fig. 2) showed the right upper lobe mass protruding into the right main bronchus resulting in almost complete obstruction. She was unable to perform pulmonary function tests because of respiratory distress. She was started on 40 mg Solu-Medrol every 6 hr intravenously and radiation therapy to the right upper lobe and left lower lobe. Over the ensuing 2 weeks, her respiratory distress and hypoxemia improved and she was discharged to continue radiation and taper the steroids as an outpatient. A total of 3160 rad was administered to the lungs and mediastinum over a 3.5week period. Persistent thrombocytopenia developed and radiotherapy was discontinued. In February 1991, (22 months after appearance of bronchial metastases), she developed multiple brain metastases, deteriorated rapidly, and expired.
DISCUSSION Thoracic metastases from solid extrathoracic tumors occur frequently. Clinically significant tracheobronchial metastases, however, are uncommon. Lesser degrees of involvement of the tracheobronchial tree including only microscopic deposits, may be seen in 18 to 50% of such neoplasms, but symptomatic or radiographically visible disease occurs in less than 5% . In combining data from three large reviews [l-3], breast and renal malignancies each accounted for about 25% of reported tracheobronchial metastases. Colorectal cancer, sarcomas, uterine and cervical cancers, and melanoma were responsible for another 33%. The remainder included a few cases each of thyroid, testicular, prostatic, pancreatic, choriocarcinoma, and adrenal carcinomas, and three reports of ovarian carcinoma [5-71. Clinically significant tracheobronchial metastases are symptomatic in more than 80% of cases diagnosed antemortem [1,2]. The remainder are identified only on radiographic studies. The clinical picture and radiographic findings are usually indistinguishable from primary bron-