Spontaneous Pneumothorax in Small cell Lung Cancer* Brian M. O'Connor, M.D.;t Patricia Ziegler, R.N.t and Monica B. Spaulding, M.D.t

Two patients with extensive small cell lung cancer developed unilateral, spontaneous pneumothoraces while receiving chemotherapy. Both pneumothoraces were asymptomatic, required no special procedure, and resolved with continued chemotherapy. Development of spontaneous pneumothorax during chemotherapy in patients with known small cell lung cancer may represent a response to treatment. (Chest 1992; 102:628-29)

I SCLC =small cell lung cancer I

S

pontaneous pneumothorax is infrequently associated with lung cancer. The estimated rate of joint occurrence is approximately 0.03 percent for primary lung cancers and may be more frequent in childhood sarcomas with pulmonary metastases.1.2 In a comprehensive review of 52 cases reported by Steinhauslin and Cuttat" of spontaneous pneumothorax in lung cancer, only three were associated with small cell lung cancer (SCLC). One of these patients presented six weeks after diagnosis and had received prior radiation to the chest, while in the other two, the pneumothorax and cancer were diagnosed concomitantly. Thus, spontaneous pneumothorax is rare in lung cancer and more unusual in SCLC. We are presently treating two patients with SCLC who developed unilateral spontaneous pneumothoraces while responding to their chemotherapy.

FIGURE 1. Small cell lung cancer in left upper and right middle lobes at presentation. chemotherapy in October and remains in stable (.'ondition. CASE 2 A 67-year-old white woman presented in April 1990 with a four-

CASE REPORTS

CASE 1 A 57-year-old white man presented in May 1989 to our clinic with a four-month history of confusion, tremors, urinary incontinence, and an unsteady gait. He had no respiratory complaints. No focal findings were found except on neurologic examination: he was oriented only to his person, had severe cognitive impairment, intention tremors, and an ataxic gait. Laboratory test results were normal. The chest x-ray film showed total opacification of the left lung field which by CT scan was secondary to complete atelectasis of the lung. A head CT scan revealed multiple brain metastases. He received 3,000 rads of whole brain radiation with improvement, but refused bronchoscopy or any further testing for his lung lesion. He continued to decline study or treatment until December 1989 when he consented to radiation therapy for his left lung that remained collapsed by x-ray film. He received a total of 6,000 rads to the left lung and mediastinum with total reexpansion of the left lung. Late in February 1990, he was noted to have a hard subcutaneous nodule in the left submandibular area and massive hepatomegaly. Biopsy revealed a small cell cancer. Chemotherapy with cisplatin and etoposide was given with resolution of the submandibular mass and hepatomegaly. On May 31, he was noted to have a small asymptomatic left spontaneous pneumothorax. There was also minimal shift of the mediastinum to the left suggesting mediastinal fixation probably secondary to his prior radiation. The pneumothorax was thus observed without treatment. He most recently received ·From the tFrederick Memorial Hospital, Regional Cancer Therapy Center, Frederick, Md; and the tOncology Section (111H), Department of Medicine, State University of New York at Buffalo, Department of Veterans Affairs Medical Center, Buffalo, NY.

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FIGURE 2. Partial response to chemotherapy and small pneumohydrothorax at the base of the left lung. Spontaneous Pneumothorax in SCLC (O'Connor, Ziegler, Spaulding)

month history of ri~ht shoulder pain. On chest x-ray film, she had left upper lobe and right middle lobe masses (Fi~ 1). Bronchoscopy at another institution was nondia~nostic. On transfer to our facility in May 1990, she was asymptomatic. The physical exam and laboratory test results were normal. A cr scan of her chest confirmed the presence of a 3 x 3 cm ri~ht middle lobe mass, a 8 x 9 cm left upper lobe tumor and a small left pleural effusion. Transthoracic needle biopsy was positive fnr small cell cancer. The cr scan of the head revealed a left frontal brain metastasis. She received 3,000 rads of whole brain radiation and was ~iven (·hemotherapy with cisplatin and etoposide. In July, an access port was placed in her left subclavian vein prior to her third wurse of chemotherapy. The procedure was free of immediate complications and a follow up chest x-ray film did not reveal any pneumothorax. She was asymptomatic when she presented Iilr her Iilllrth comse of chemotherapy four weeks later, but her chest x-ray film demonstrated a small left pneumohydrothorax (Fig 2). This condition did not require any additional treatment. By the fifth course of chemotherapy, the pneumohydrothorax had decreased in size, and it completely resolved prior to her sixth course (Fi~ 3). DISCUSSION

The mechanisms presumed responsible for the production of spontaneous pneumothorax associated with lung cancer are many. Most authors postulate that the spontaneous pneumothoraces are either random events or merely reflect the risk afforded by the chronic pulmonary pathology of tobacco ravaged lungs with subpleural blebs or emphysematous bullae that then go on to rupture. 1.3 Others blame progressive cancer either central or peripheral.'" The pleural based tumors can, through invasion, create a bronchopleural fistula and lead to a pneumothorax. A central mass, on the other hand, can cause alveoli distal to a bronchial obstruction to dilate and rupture by functioning as a oneway valve or lead to compensatory distension and rupture of

distant tumor-free alveoli if the involved segment is completely obstructed and atelectatic. Spontaneous pneumothoraces have also been described in association with metastatic sarcomas and germ cell tumors, and in lymphomas with lung involvement, but not generally with other cancers. 2.6 Thus, their occurrence seems to be limited to certain tumor cell types. Treatment of lung metastases from these cancers with chemotherapy, according to Smevik and Klepp2 and Schulman et al," has increased the frequency of spontaneous pneumothorax. They hypothesize that the association between lung metastasis and spontaneous pneumothorax is not fortuitous, but rather is directly attributable to the intensity of the chemotherapy which makes it possible to induce rapid and significant necrosis of neoplasms while interfering with normal repair. Schulman et al" predict spontaneous pneumothoraces will become an ever-increasing problem as more active cytotoxic regimens come into use. This has not occurred, and spontaneous pneumothoraces in chemotherapy-sensitive lung tumors remain anecdotal in spite of routine use of more intensive chemotherapies. There seem to be at least two distinct groups of patients with spontaneous pneumothoraces and lung tumors: the first and larger comprises approximately 75 percent of patients and includes those with spontaneous pneumothorax as the presenting feature of lung involvement." These patients survive as long as similar stage cancer patients without spontaneous pneumothoraces." The second and smaller group is composed of those known to have a lung neoplasm, but who, at some later date, suffer a spontaneous pneumothorax. This group probably has two subcategories: those with progressive malignancy and those responding to treatment. Both our patients were in this latter subgroup, and neither required any special intervention. Also in both instances, the small pneumothoraces were asymptomatic, surprise chest x-ray findings that resolved while continuing systemic chemotherapy, suggesting the repair process can continue in spite of intensive chemotherapy. Spontaneous pneumothorax can occur in lung neoplasms receiving chemotherapy. Patients may be completely asymptomatic and may not require any additional interventions. Spontaneous pneumothorax associated with SCLC could, in some instances, represent an indirect measure of response, particularly if it resolves during continued chemotherapy. REFERENCES

2 3 4 5 6 7 FIGURE 3. Complete response and resolution of left pneumohydrothorax.

Dines DE, Cortese DA, Brennan MD, Hahn RG, Payne WS. Mali~nant pulmonary neoplasms predisposin~ to spontaneous pneumothorax. Mayo Clin Proc 1973; 48:541-44 Smevik B, Klepp 0. The risk of spontaneous pneumothorax in patients with ost~enic sarcoma and testicular cancer. Cancer 1982; 49:1734-37 Steinhauslin CA, Cuttat JF. Spontaneous pneumothnrax: a complication oflung cancer? Chest 1985; 88:709-13 Arnett JC, Hatch HB. Pneumothorax associated "~th bronchogenic carcinoma. Chest 1976; 70:796-97 Hyde L, Hyde CI. Rare occurrence of simultaneous pneumothorax and lun~cancer. JAMA 1978; 239:1421 Yellin A, Benfield JR. Pneumothnrax associated with lymphoma. Am Rev Respir Dis 1986: 134:590-92 Schulman P, Chen~ E, Cvilkovik E, Golhey R. Spontaneous pneumothorax as a result of intensive cytotoxic chemotherapy. Chest 1979; 75:194-96 CHEST I 102 I 2 I AUGUST, 1992

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Spontaneous pneumothorax in small cell lung cancer.

Two patients with extensive small cell lung cancer developed unilateral, spontaneous pneumothoraces while receiving chemotherapy. Both pneumothoraces ...
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