Refer to: Krutchik AN, Tashima CK, Buzdar AU, et al: Endobronchial metastases in breast carcinoma. West J Med 129:177-180, Sep 1978
Endobronchial Metastases in Breast Carcinoma ALLAN N. KRUTCHIK, MD; CHARLES K. TASHIMA, MD; AMAN U. BUZDAR, MD, and GEORGE R. BLUMENSCHEIN, MD, Houston
In a consecutive sertes of 1,628 patients with breast carcinoma, six cases of endobronchial metastases were diagnosed for an incidence of 0.4 percent. The median latent interval from the diagnosis of the primary carcinoma until the time of diagnosis of endobronchial metastases was 21 months. Endobronchial metastases can be the initial manifestation of recurrent cancer and can present with no abnormalities shown on x-ray films of the chest. Because of similar symptomatology, the diagnosis of endobronchial metastases may be confused with a central bronchogenic carcinoma but the histological appearance could differentiate the two entities. Local treatment with radiation therapy is usually inadequate and patients should also be treated with some form of systemic treatment such as chemotherapy. The median survival after the diagnosis of endobronchial metastases was 13 months. ENDOBRONCHIAL METASTASES occur in only 2 percent of patients with solid tumors with renal and colorectal carcinoma being the most common extrathoracic tumors associated with endobronchial metastases.' However, recently breast carcinoma has been proposed as the most common tumor causing endobronchial metastasis.2 During a two-year period, we have encountered six patients with breast carcinoma who had documented endobronchial metastases from breast carcinoma.
Methods and Results From the period of July 1974 to December 1976 a review of 1,628 patients with breast carFrom the Medical Breast Service, Department of Medicine, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston. Submitted February 2, 1978. Reprint requests to: Allan N. Krutchik, MD, Department of Medicine, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, 6723 Bertner Avenue, Houston, TX 77030.
cinoma showed six cases (0.4 percent) of endo-
bronchial metastases from breast carcinoma which were documented by bronchoscopy. Our chart review was limited only to cases in which there were grossly visible (macroscopic) endobronchial metastases. Cases in which bronchial washings (microscopic) alone were used as a basis for the diagnosis of metastatic breast carcinoma were eliminated from this study. The patients' clinical characteristics are summarized in Table 1. There are several salient and important features that are evident in this group of patients. First, in two of six patients, the x-ray studies of the chest at the time of diagnosis of endobronchial metastases showed no abnormalities. Second, in three of six, endobronchial metastases were the initial manifestation of recurrent carcinoma. Third, the median latent interval from the diagnosis of primary carcinoma until the time of diagnosis of THE WESTERN JOURNAL OF MEDICINE
177
BREAST CARCINOMA TABLE 1.-Patient Characteristics
Patient
1 2 3 4 5 6
Age of Patient at Time of EBM
.... .... . ... .... ....
54 36 54 72 33 60
Presenting Signs and Symptoms
Time Interval (months*)
Cough, hemoptysis, dyspnea 20 8 Cough 84 Dyspnea, hoarseness 8 Cough 21 Cough, wheezing 68 Hemoptysis, hoarseness
EBM = endobronchial metastases
Location of EBM
Chest X-ray
LUL bronchus RUL bronchus RUL bronchus RLL bronchus RLL bronchus LUL bronchus
LUL = left upper lobe
Atelectasis,pleural effusion Atelectasis Normal Normal Pleural effusion Loss of lung volume
RLL = right lower lobe
Sites of Survival After Disease Before Diagnosis Diagnosis of EBM of EBM (months)
Soft tissue None Soft Tissue None None Soft tissue
13 36 8t 24 14
lit
RUL = right upper lobe
*Time interval between diagnosis of primary breast carcinoma and the diagnosis of endobronchial metastases.
tAlive at time of this review (November, 1977)
endobronchial metastases was 21 months (range 8 to 84 months). Fourth, localized radiation therapy was attempted in three of six patients with relief of symptoms in one patient. Fifth, the median survival after the diagnosis of endobronchial metastases was 13 months (range 8 to 36 months).
Reports of Cases CASE 1. In a 53-year-old woman a right radical mastectomy was carried out; 11 of 13 lymph nodes contained metastatic breast carcinoma. The patient received postoperative radiation therapy to the peripheral lymphatics. In September 1974, she was again treated with radiation therapy for a right supraclavicular metastasis and received concomitant hormonal therapy. In February 1975 dyspnea and a productive cough developed with occasional hemoptysis; a small pleural effusion on the left was seen on an x-ray film of the chest. Subsequently, complete atelectasis of the left lung developed. Bronchoscopy showed an endobronchial mass occluding the left upper main stem bronchus and biopsy of this lesion showed metastatic breast carcinoma. The patient was treated with combination chemotherapy and within ten days the left lung had completely reexpanded and the pleural effusion disappeared. The pleural effusion reoccurred in eight months with a rightward shift of the mediastinum. Bronchoscopy showed an endobronchial mass in the right main stem bronchus at that time, which was treated with localized radiation therapy without improvement. Four months after bronchoscopy, meningeal carcinomatosis developed and the patient died. CASE 2. A 36-year-old woman had a right radical mastectomy for breast carcinoma in 1969. She was well until February 1974, when a non178
SEPTEMBER 1978 * 129 * 3
productive cough and dyspnea developed. An xray study of the chest shoWed right hilar adenopathy and enlargement of the azygous vein. The patient was given a trial of antibiotics without relief. Subsequently, rhonchi and chest pain over the right hemithorax posteriorly developed. Eight months later a bronchoscopy was carried out and showed stenosis of the right upper lobe bronchus with an endobronchial metastasis present which on biopsy was found to be metastatic breast carcinoma. There was no evidence on bronchoscopy that the endobronchial metastasis represented an extrabronchial tumor arising from the right hilum that was eroding into the bronchus. Shortly after this, liver and bone metastases developed and a bilateral oophorectomy was carried out; a partial remission was obtained. Subsequently the patient was treated with adrenalectomy and combination chemotherapy. The patient died of pulmonary metastases 36 months after the diagnosis of endobronchial metastases was made. CASE 3. In a 54-year-old woman a left mastectomy was carried out. Metastatic breast carcinoma was found in one out of two axillary lymph nodes and postoperative radiation therapy was administered. Five years later a skin recurrence developed and bilateral oophorectomy was done, followed by sequential androgen therapy. Shortly after the skin metastases, metastases to the right breast developed and a simple mastectomy was done. The patient later was treated with combination chemotherapy for soft tissue metasases and a partial remission was obtained. Seven years after the diagnosis of primary breast carcinoma, hoarseness and dyspnea developed. A bronchoscopy showed an endobronchial metastasis in the right main stem bronchus. Indirect laryngoscopy showed left vocal cord paralysis but no tumor was found. The patient was then treated
BREAST CARCINOMA
with combination chemoimmunotherapy: 5-fluorouracil, doxorubicin hydrochloride (Adriamycinm), cyclophosphamide and levamisole with stabilization of disease and is alive at this time. CASE 4. A left radical mastectomy was carried out in a 72-year-old woman. Metastatic breast carcinoma was found in 24 of 46 nodes. Postoperatively radioactive gold seeds were implanted in the chest wall. Eight months later a persistent nonproductive cough developed; an x-ray film of the chest done at that time showed no abnormalities. Bronchoscopy showed an endobronchial metastasis in the right lower lobe bronchus. The patient was then treated with radiation therapy to the involved lung without improvement. Subsequently, she was treated with estrogens followed by combination chemotherapy. There was stabilization of disease until two years later when brain metastases developed along with progressive pulmonary metastases, both unresponsive to further chemotherapy. The patient died two years after the diagnosis of endobronchial metastases was made. CASE 5. In a 33-year-old woman a right modified radical mastectomy was done in March 1974. There were no axillary node metastases. Postoperative radiation therapy was given because of the location of the carcinoma (medial lesion). In May 1974 a prophylatic left simple mastectomy was carried out. In October 1975 a cough, wheezing, a low grade temperature and a right pleural effusion developed. She was treated for pneumonia but the symptoms persisted. Bronchoscopy then was carried out and an endobronchial tumor was found occluding the right lower lobe bronchus; a biopsy of this tumor showed metastatic breast carcinoma. The patient was treated with combination chemotherapy consisting of 5-fluorouracil, doxorubicin hydrochloride (Adriamycin), cyclophosphamide and then methotrexate was substituted when the dose of doxorubicin hydrochloride reached 450 mg per sq meter. In December 1975 a bilateral oophorectomy was done because of recurrent pulmonary metastases. After there was an objective response to oophorectomy in regard to lung metastases, brain metastases developed. This condition was treated with various therapies including radiation therapy. In January 1977 respiratory distress developed and bronchoscopy was done; endobronchial metastases were seen in the area of the carina. The patient then received radiation to the left lung with a good response. However, after this, progressive pumonary disease
developed and the patient died 16 months after the diagnosis of endobronchial metastasis was made. CASE 6. A left radical mastectomy was done in a 60-year-old woman in April 1971 for Paget disease of the breast; axillary lymph node metastases were treated with postoperative radiation therapy. In February 1976 hoarseness developed, followed by supraclavicular metastases. Radiation therapy to the left supraclavicular area and to a mediastinal mass was- administered. In October 1976 dyspnea and hemoptysis developed. Bronchoscopy was carried out and showed endobronchial obstruction of the lingular portion of the left lung with a tumor compatible with breast carcinoma. Treatment was carried out with combination chemoimmunotherapy consisting of 5-fluoro*uracil, doxorubicin hydrochloride (Adriamycin), cyclophosphamide and Corynebacterium parvum. The patient noted subjective improvement after chemotherapy was initiated -and continued to do well until August 1977, when hemoptysis reappeared along with dyspnea. A bronchoscopy was done which showed an endobronchial metastasis obstructing the left upper lobe bronchus. This relapse indicated drug resistance and the patient was treated with a four-day infusion of amphotericin B followed by the same chemotherapy that the patient had received previously with no response. She is currently being treated with vincristine and methotrexate; the disease is stable.
Discussion The symptoms and signs of endobronchial metastases from an extrathoracic tumor may be indistinguishable from central bronchogenic carcinoma; however, histological appearance should readily differentiate the two entities. The presence of carcinoma in situ in adjacent bronchial epithelium clearly indicates primary bronchogenic carcinoma.' Endobronchial metastasis can occur before the clinical appearance of the primary tumor and therefore it can mimic bronchogenic carcinoma. In the absence of common roentgenographic signs of bronchial obstruction such as atelectasis,l there may be a low index of suspicion of endobronchial metastasis. This was the case in two of six patients who presented with normal findings on x-ray studies of the chest at the time of diagnosis of endobronchial metastases. In addition two patients presented with pleural effusions. Although we have no definitive evidence that the THE WESTERN JOURNAL OF MEDICINE
179
BREAST CARCINOMA
pleural effusions that occurred were caused by endobronchial metastasis, there is evidence in the literature that pleural effusions can be produced by endobronchial metastasis.3 In three of the six patients endobronchial metastases developed as the first site of relapsing disease from breast carcinoma; in one of these three patients x-ray films of the chest showed no abnormalities, with the only symptom being a cough. As recently reported, endotracheal metastases from breast carcinoma may present with symptQms of cough and hemoptysis and this could cause difficulty in diagnosing endobronchial metastases. However, tracheal tumors usually do not obstruct a single bronchus and one should not expect to see atelectasis of a lung. With normal findings on an x-ray film of the chest, tomography of the trachea should be obtained to resolve the dilemma.4 The mean survival of our group of patients after the diagnosis of endobronchial metastases was 13 months. Two patients, however, survived 24 and 36 months, respectively; this is considerably less than another small, recently reported group of patients with breast carcinoma whose mean survival was 29 months.2 Because of the small number of patients both in our series and in the literature, it is difficult to make specific recommendations for the treatment of endobronchial metastases. Radiation therapy in our series was unsuccessful even in the one patient who initially benefitted because of the subsequent development of distant metastases. Therefore, while radiation therapy is effective for short-term control of local disease, most patients relapse when this is the only modality of treatment used.2 In view of the excellent response achieved in the patient in case 1 within a short time after the institution of combination chemo-
180
SEPTEMBER 1978 * 129 * 3
therapy and also because of another reported case in which the patient received excellent palliation with hormonal therapy (fluoxy-mesterone) followed by chemotherapy,2 we recommend that systemic therapy should be employed in these patients. It has been shown that following an isolated recurrence in breast cancer, systemic disease is already present in a high percentage of patients or will soon develop. Some 3 to 21 percent of patients have been reported to survive five years following regional therapy-surgical or radiation therapy, or both-after the first evidence of recurrence.5'6 A combination of 5-fluorouracil, doxorubicin hydrochloride (Adriamycin) and cyclophosphamide has significantly prolonged the disease-free interval following regional therapy of isolated recurrence.7 Endobronchial involvement is not necessarily associated with a poor prognosis as noted by mean survival in excess of 12 months, with a few patients surviving beyond two years. Therefore, all of these patients should be treated with systemic therapy in addition to the local therapyradiation or surgical therapy, or both-that is administered for relief of symptomatic obstruction. REFERENCES 1. Braman SS, Whitcomb ME: Endobronchial metastasis. Arch
Intern Med 135:543-547, 1975 2. Fitzgerald RH: Endobronchial metastases. South Med J 70: 440-441, 1977 3. Light RW: Pleural effusions. Med Clin North Am 61:1346, 1977 4. Garces M, Tsai E, Marson RE: Endotracheal metastases. Chest 65:350.351, 1974 5. Spratt JS: Locally recurrent cancer after radical mastectomy. Cancer 20:1051-1053, 1967 6. Dao TL, Nemoto T: The clinical significance of skin recurrence after radical mastectomy in women with cancer of the breast. Surg Gynecol Obstet 117:447453, 1963 7. Blumenschein GR, Buzdar AU, Tashima CK, et al; Adjuvant chemoimmunotherapy of stage IV (NED) breast cancer, In Salmon SE, Jones SE (Eds): Adjuvant Therapy of Cancer. Amsterdam, North Holland Publishing Co, 1977, pp 147-152
Endobronchial Metastases in Breast Carcinoma ALLAN N. KRUTCHIK, MD; CHARLES K. TASHIMA, MD; AMAN U. BUZDAR, MD, and GEORGE R. BLUMENSCHEIN, MD, Houston
In a consecutive sertes of 1,628 patients with breast carcinoma, six cases of endobronchial metastases were diagnosed for an incidence of 0.4 percent. The median latent interval from the diagnosis of the primary carcinoma until the time of diagnosis of endobronchial metastases was 21 months. Endobronchial metastases can be the initial manifestation of recurrent cancer and can present with no abnormalities shown on x-ray films of the chest. Because of similar symptomatology, the diagnosis of endobronchial metastases may be confused with a central bronchogenic carcinoma but the histological appearance could differentiate the two entities. Local treatment with radiation therapy is usually inadequate and patients should also be treated with some form of systemic treatment such as chemotherapy. The median survival after the diagnosis of endobronchial metastases was 13 months. ENDOBRONCHIAL METASTASES occur in only 2 percent of patients with solid tumors with renal and colorectal carcinoma being the most common extrathoracic tumors associated with endobronchial metastases.' However, recently breast carcinoma has been proposed as the most common tumor causing endobronchial metastasis.2 During a two-year period, we have encountered six patients with breast carcinoma who had documented endobronchial metastases from breast carcinoma.
Methods and Results From the period of July 1974 to December 1976 a review of 1,628 patients with breast carFrom the Medical Breast Service, Department of Medicine, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston. Submitted February 2, 1978. Reprint requests to: Allan N. Krutchik, MD, Department of Medicine, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, 6723 Bertner Avenue, Houston, TX 77030.
cinoma showed six cases (0.4 percent) of endo-
bronchial metastases from breast carcinoma which were documented by bronchoscopy. Our chart review was limited only to cases in which there were grossly visible (macroscopic) endobronchial metastases. Cases in which bronchial washings (microscopic) alone were used as a basis for the diagnosis of metastatic breast carcinoma were eliminated from this study. The patients' clinical characteristics are summarized in Table 1. There are several salient and important features that are evident in this group of patients. First, in two of six patients, the x-ray studies of the chest at the time of diagnosis of endobronchial metastases showed no abnormalities. Second, in three of six, endobronchial metastases were the initial manifestation of recurrent carcinoma. Third, the median latent interval from the diagnosis of primary carcinoma until the time of diagnosis of THE WESTERN JOURNAL OF MEDICINE
177
BREAST CARCINOMA TABLE 1.-Patient Characteristics
Patient
1 2 3 4 5 6
Age of Patient at Time of EBM
.... .... . ... .... ....
54 36 54 72 33 60
Presenting Signs and Symptoms
Time Interval (months*)
Cough, hemoptysis, dyspnea 20 8 Cough 84 Dyspnea, hoarseness 8 Cough 21 Cough, wheezing 68 Hemoptysis, hoarseness
EBM = endobronchial metastases
Location of EBM
Chest X-ray
LUL bronchus RUL bronchus RUL bronchus RLL bronchus RLL bronchus LUL bronchus
LUL = left upper lobe
Atelectasis,pleural effusion Atelectasis Normal Normal Pleural effusion Loss of lung volume
RLL = right lower lobe
Sites of Survival After Disease Before Diagnosis Diagnosis of EBM of EBM (months)
Soft tissue None Soft Tissue None None Soft tissue
13 36 8t 24 14
lit
RUL = right upper lobe
*Time interval between diagnosis of primary breast carcinoma and the diagnosis of endobronchial metastases.
tAlive at time of this review (November, 1977)
endobronchial metastases was 21 months (range 8 to 84 months). Fourth, localized radiation therapy was attempted in three of six patients with relief of symptoms in one patient. Fifth, the median survival after the diagnosis of endobronchial metastases was 13 months (range 8 to 36 months).
Reports of Cases CASE 1. In a 53-year-old woman a right radical mastectomy was carried out; 11 of 13 lymph nodes contained metastatic breast carcinoma. The patient received postoperative radiation therapy to the peripheral lymphatics. In September 1974, she was again treated with radiation therapy for a right supraclavicular metastasis and received concomitant hormonal therapy. In February 1975 dyspnea and a productive cough developed with occasional hemoptysis; a small pleural effusion on the left was seen on an x-ray film of the chest. Subsequently, complete atelectasis of the left lung developed. Bronchoscopy showed an endobronchial mass occluding the left upper main stem bronchus and biopsy of this lesion showed metastatic breast carcinoma. The patient was treated with combination chemotherapy and within ten days the left lung had completely reexpanded and the pleural effusion disappeared. The pleural effusion reoccurred in eight months with a rightward shift of the mediastinum. Bronchoscopy showed an endobronchial mass in the right main stem bronchus at that time, which was treated with localized radiation therapy without improvement. Four months after bronchoscopy, meningeal carcinomatosis developed and the patient died. CASE 2. A 36-year-old woman had a right radical mastectomy for breast carcinoma in 1969. She was well until February 1974, when a non178
SEPTEMBER 1978 * 129 * 3
productive cough and dyspnea developed. An xray study of the chest shoWed right hilar adenopathy and enlargement of the azygous vein. The patient was given a trial of antibiotics without relief. Subsequently, rhonchi and chest pain over the right hemithorax posteriorly developed. Eight months later a bronchoscopy was carried out and showed stenosis of the right upper lobe bronchus with an endobronchial metastasis present which on biopsy was found to be metastatic breast carcinoma. There was no evidence on bronchoscopy that the endobronchial metastasis represented an extrabronchial tumor arising from the right hilum that was eroding into the bronchus. Shortly after this, liver and bone metastases developed and a bilateral oophorectomy was carried out; a partial remission was obtained. Subsequently the patient was treated with adrenalectomy and combination chemotherapy. The patient died of pulmonary metastases 36 months after the diagnosis of endobronchial metastases was made. CASE 3. In a 54-year-old woman a left mastectomy was carried out. Metastatic breast carcinoma was found in one out of two axillary lymph nodes and postoperative radiation therapy was administered. Five years later a skin recurrence developed and bilateral oophorectomy was done, followed by sequential androgen therapy. Shortly after the skin metastases, metastases to the right breast developed and a simple mastectomy was done. The patient later was treated with combination chemotherapy for soft tissue metasases and a partial remission was obtained. Seven years after the diagnosis of primary breast carcinoma, hoarseness and dyspnea developed. A bronchoscopy showed an endobronchial metastasis in the right main stem bronchus. Indirect laryngoscopy showed left vocal cord paralysis but no tumor was found. The patient was then treated
BREAST CARCINOMA
with combination chemoimmunotherapy: 5-fluorouracil, doxorubicin hydrochloride (Adriamycinm), cyclophosphamide and levamisole with stabilization of disease and is alive at this time. CASE 4. A left radical mastectomy was carried out in a 72-year-old woman. Metastatic breast carcinoma was found in 24 of 46 nodes. Postoperatively radioactive gold seeds were implanted in the chest wall. Eight months later a persistent nonproductive cough developed; an x-ray film of the chest done at that time showed no abnormalities. Bronchoscopy showed an endobronchial metastasis in the right lower lobe bronchus. The patient was then treated with radiation therapy to the involved lung without improvement. Subsequently, she was treated with estrogens followed by combination chemotherapy. There was stabilization of disease until two years later when brain metastases developed along with progressive pulmonary metastases, both unresponsive to further chemotherapy. The patient died two years after the diagnosis of endobronchial metastases was made. CASE 5. In a 33-year-old woman a right modified radical mastectomy was done in March 1974. There were no axillary node metastases. Postoperative radiation therapy was given because of the location of the carcinoma (medial lesion). In May 1974 a prophylatic left simple mastectomy was carried out. In October 1975 a cough, wheezing, a low grade temperature and a right pleural effusion developed. She was treated for pneumonia but the symptoms persisted. Bronchoscopy then was carried out and an endobronchial tumor was found occluding the right lower lobe bronchus; a biopsy of this tumor showed metastatic breast carcinoma. The patient was treated with combination chemotherapy consisting of 5-fluorouracil, doxorubicin hydrochloride (Adriamycin), cyclophosphamide and then methotrexate was substituted when the dose of doxorubicin hydrochloride reached 450 mg per sq meter. In December 1975 a bilateral oophorectomy was done because of recurrent pulmonary metastases. After there was an objective response to oophorectomy in regard to lung metastases, brain metastases developed. This condition was treated with various therapies including radiation therapy. In January 1977 respiratory distress developed and bronchoscopy was done; endobronchial metastases were seen in the area of the carina. The patient then received radiation to the left lung with a good response. However, after this, progressive pumonary disease
developed and the patient died 16 months after the diagnosis of endobronchial metastasis was made. CASE 6. A left radical mastectomy was done in a 60-year-old woman in April 1971 for Paget disease of the breast; axillary lymph node metastases were treated with postoperative radiation therapy. In February 1976 hoarseness developed, followed by supraclavicular metastases. Radiation therapy to the left supraclavicular area and to a mediastinal mass was- administered. In October 1976 dyspnea and hemoptysis developed. Bronchoscopy was carried out and showed endobronchial obstruction of the lingular portion of the left lung with a tumor compatible with breast carcinoma. Treatment was carried out with combination chemoimmunotherapy consisting of 5-fluoro*uracil, doxorubicin hydrochloride (Adriamycin), cyclophosphamide and Corynebacterium parvum. The patient noted subjective improvement after chemotherapy was initiated -and continued to do well until August 1977, when hemoptysis reappeared along with dyspnea. A bronchoscopy was done which showed an endobronchial metastasis obstructing the left upper lobe bronchus. This relapse indicated drug resistance and the patient was treated with a four-day infusion of amphotericin B followed by the same chemotherapy that the patient had received previously with no response. She is currently being treated with vincristine and methotrexate; the disease is stable.
Discussion The symptoms and signs of endobronchial metastases from an extrathoracic tumor may be indistinguishable from central bronchogenic carcinoma; however, histological appearance should readily differentiate the two entities. The presence of carcinoma in situ in adjacent bronchial epithelium clearly indicates primary bronchogenic carcinoma.' Endobronchial metastasis can occur before the clinical appearance of the primary tumor and therefore it can mimic bronchogenic carcinoma. In the absence of common roentgenographic signs of bronchial obstruction such as atelectasis,l there may be a low index of suspicion of endobronchial metastasis. This was the case in two of six patients who presented with normal findings on x-ray studies of the chest at the time of diagnosis of endobronchial metastases. In addition two patients presented with pleural effusions. Although we have no definitive evidence that the THE WESTERN JOURNAL OF MEDICINE
179
BREAST CARCINOMA
pleural effusions that occurred were caused by endobronchial metastasis, there is evidence in the literature that pleural effusions can be produced by endobronchial metastasis.3 In three of the six patients endobronchial metastases developed as the first site of relapsing disease from breast carcinoma; in one of these three patients x-ray films of the chest showed no abnormalities, with the only symptom being a cough. As recently reported, endotracheal metastases from breast carcinoma may present with symptQms of cough and hemoptysis and this could cause difficulty in diagnosing endobronchial metastases. However, tracheal tumors usually do not obstruct a single bronchus and one should not expect to see atelectasis of a lung. With normal findings on an x-ray film of the chest, tomography of the trachea should be obtained to resolve the dilemma.4 The mean survival of our group of patients after the diagnosis of endobronchial metastases was 13 months. Two patients, however, survived 24 and 36 months, respectively; this is considerably less than another small, recently reported group of patients with breast carcinoma whose mean survival was 29 months.2 Because of the small number of patients both in our series and in the literature, it is difficult to make specific recommendations for the treatment of endobronchial metastases. Radiation therapy in our series was unsuccessful even in the one patient who initially benefitted because of the subsequent development of distant metastases. Therefore, while radiation therapy is effective for short-term control of local disease, most patients relapse when this is the only modality of treatment used.2 In view of the excellent response achieved in the patient in case 1 within a short time after the institution of combination chemo-
180
SEPTEMBER 1978 * 129 * 3
therapy and also because of another reported case in which the patient received excellent palliation with hormonal therapy (fluoxy-mesterone) followed by chemotherapy,2 we recommend that systemic therapy should be employed in these patients. It has been shown that following an isolated recurrence in breast cancer, systemic disease is already present in a high percentage of patients or will soon develop. Some 3 to 21 percent of patients have been reported to survive five years following regional therapy-surgical or radiation therapy, or both-after the first evidence of recurrence.5'6 A combination of 5-fluorouracil, doxorubicin hydrochloride (Adriamycin) and cyclophosphamide has significantly prolonged the disease-free interval following regional therapy of isolated recurrence.7 Endobronchial involvement is not necessarily associated with a poor prognosis as noted by mean survival in excess of 12 months, with a few patients surviving beyond two years. Therefore, all of these patients should be treated with systemic therapy in addition to the local therapyradiation or surgical therapy, or both-that is administered for relief of symptomatic obstruction. REFERENCES 1. Braman SS, Whitcomb ME: Endobronchial metastasis. Arch
Intern Med 135:543-547, 1975 2. Fitzgerald RH: Endobronchial metastases. South Med J 70: 440-441, 1977 3. Light RW: Pleural effusions. Med Clin North Am 61:1346, 1977 4. Garces M, Tsai E, Marson RE: Endotracheal metastases. Chest 65:350.351, 1974 5. Spratt JS: Locally recurrent cancer after radical mastectomy. Cancer 20:1051-1053, 1967 6. Dao TL, Nemoto T: The clinical significance of skin recurrence after radical mastectomy in women with cancer of the breast. Surg Gynecol Obstet 117:447453, 1963 7. Blumenschein GR, Buzdar AU, Tashima CK, et al; Adjuvant chemoimmunotherapy of stage IV (NED) breast cancer, In Salmon SE, Jones SE (Eds): Adjuvant Therapy of Cancer. Amsterdam, North Holland Publishing Co, 1977, pp 147-152
