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Communications to the Editor |

Endobronchial Spread of Parenchymal Metastases FREE TO VIEW

Ranganath Muniyappa, MD, PhD; Rekha Nugaram, MD; Suresh Gehani, MD; David M. Wu, MD, FCCP
Author and Funding Information

Affiliations: Bon Secours Hospital Grosse Pointe, MI,  Gifu University School of Medicine Gifu, Japan

Correspondence to: David M. Wu, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Bon Secours Hospital, 468 Cadieux, Grosse Pointe, MI 48230



Chest. 2002;121(2):664-665. doi:10.1378/chest.121.2.664-a
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To the Editor:

We read with interest the recent article in CHEST by Kiryu et al (March 2001).1 The authors classified endobronchial metastases (EM) on the basis of developmental mechanisms and attempted to correlate patient survival times with the different developmental modes. We applaud the authors’ efforts to define and morphologically classify EM; however, conclusions based on such a small number of patients are tenuous. The authors reported that the type II mode of EM is rare. We describe here the case of a patient with EM from a soft-tissue sarcoma that could be categorized as type II based on the proposed criteria.1Soft-tissue sarcoma is a rare neoplasm. Pulmonary metastases are a common manifestation but rarely present as the initial finding. Although parenchymal metastases are a frequent occurrence, endobronchial spread is extremely rare.23

We present the case of a 36-year-old man with no significant medical problems but with a history of progressive dyspnea and right-sided diffuse chest pain for 2 months. A physical examination revealed dullness to percussion and decreased breath sounds over the right lung base. A chest radiograph showed multiple lung nodules bilaterally with a large right-sided pleural effusion. Pleural fluid was serosanguinous, exudative, and negative for malignant cells. A video-assisted thoracoscopic biopsy of the nodules showed features that were consistent with low-grade sarcoma. A bronchoscopic examination revealed a submucosal lesion obstructing the right bronchus intermedius. A thorough medical history and a physical examination subsequently revealed a 6-month-old swelling in the right thigh that was pathologically similar to the lung lesions. The pulmonary lesions were deemed unresectable, and chemotherapy (doxorubicin [Adriamycin; Pharmacia & Upjohn; Peapack, NJ] and ifosfamide) was initiated.

Unresectable lung disease, the number of nodules, shorter doubling time, and the histologic type (ie, spindle cell) were poor prognostic factors in our patient. Although arising from a low-grade primary sarcoma, the aggressive behavior seen is similar to metastases from high-grade lesions. Our case clearly illustrates the difficulty in the management of endobronchial and pulmonary metastatic disease and the various factors that affect prognosis.

References

Kiryu, T, Hoshi, H, Matsui, E, et al (2001) Endotracheal/endobronchial metastases: clinicopathologic study with special reference to developmental modes.Chest119,768-775. [CrossRef]
 
Udelsman, R, Roth, JA, Lees, D, et al Endobronchial metastases from soft tissue sarcoma.J Surg Oncol1986;32,145-149. [CrossRef]
 
Greelish, JP, Friedberg, JS Secondary pulmonary malignancy.Surg Clin North Am2000;80,633-657. [CrossRef]
 
To the Editor:

We appreciate the interest in our article. Our article, classifying endotracheal/endobronchial metastases (EEM) into four types, was intended to elucidate the developmental modes of bronchoscopically visible EEM and to correlate patient survival times with the different types.1

As Muniyappa et al mentioned, EEM from sarcomas are rare, and there have been only a few reports.25 In our series, EEM from sarcomas were found in only 2 of 16 cases (12.5%); both were osteosarcoma of the bone. However, King and Castleman6 reported that, of 11 patients with sarcoma accompanied by intrathoracic metastatic lesions, 6 patients had endobronchial metastases on the basis of pathologic study, for an incidence of 55.6%. As stated in our earlier discussion, it is important to recognize that the frequencies of EEM vary by definition.

Of the four types of EEM we proposed, we consider that type II is a rare condition because only 1 of 16 subjects demonstrated this type in our series. Although it is difficult to differentiate type II lesions from type IV lesions (type IV being the most common type) using clinical findings and chest imagings alone, it is possible to differentiate these two types by the depth of lesions, and by whether there is mucosal or submucosal invasion. Because of the difference in pathogenesis and the clinical significance, we think that types II and IV should be strictly separated.

Surprisingly, the incident of type II EEM reported by Muniyappa et al showed markedly aggressive behavior despite low-grade primary sarcoma. We encountered one patient with type II EEM who had maxillar carcinoma with histologically adenoid cystic carcinoma. The recurrence interval and survival time were 196 months and 40 months, respectively. This discrepancy is rather interesting.

We thank the authors for bringing to our attention the existence of an aggressive case of type II and for providing the additional reference by Greelish et al, and we certainly agree that, because of the small number of patients evaluated in our series, further evaluation with larger numbers of patients is essential.

References
Kiryu, T, Hoshi, H, Matsui, E, et al Endotracheal/endobronchial metastases: clinicopathologic study with special reference to developmental modes.Chest2001;119,768-775. [CrossRef]
 
Udelsman, R, Roth, J, Lees, D, et al Endobronchial metastases from soft tissue sarcoma.J Surg Oncol1986;32,145-149. [CrossRef]
 
Akiba, T, Ujiie, H, Takasaki, N, et al Endobronchial metastasis from a primary uterine osteosarcoma in a patient with multiple myeloma: report of a case.Surg Today1994;24,179-182. [CrossRef]
 
Flynn, KJ, Kim, HS Endobronchial metastasis of uterine leiomyosarcoma. JAMA. 1978;;240 ,.:2080. [CrossRef]
 
Kiryu, T, Kawaguchi, S, Matsui, E, et al Endobronchial metastasis of osteosarcoma of the bone.J Bronchol2000;7,236-239. [CrossRef]
 
King, DS, Castleman, B Bronchial involvement in metastatic pulmonary malignancy.J Thorac Surg1943;12,305-315
 

Figures

Tables

References

Kiryu, T, Hoshi, H, Matsui, E, et al (2001) Endotracheal/endobronchial metastases: clinicopathologic study with special reference to developmental modes.Chest119,768-775. [CrossRef]
 
Udelsman, R, Roth, JA, Lees, D, et al Endobronchial metastases from soft tissue sarcoma.J Surg Oncol1986;32,145-149. [CrossRef]
 
Greelish, JP, Friedberg, JS Secondary pulmonary malignancy.Surg Clin North Am2000;80,633-657. [CrossRef]
 
Kiryu, T, Hoshi, H, Matsui, E, et al Endotracheal/endobronchial metastases: clinicopathologic study with special reference to developmental modes.Chest2001;119,768-775. [CrossRef]
 
Udelsman, R, Roth, J, Lees, D, et al Endobronchial metastases from soft tissue sarcoma.J Surg Oncol1986;32,145-149. [CrossRef]
 
Akiba, T, Ujiie, H, Takasaki, N, et al Endobronchial metastasis from a primary uterine osteosarcoma in a patient with multiple myeloma: report of a case.Surg Today1994;24,179-182. [CrossRef]
 
Flynn, KJ, Kim, HS Endobronchial metastasis of uterine leiomyosarcoma. JAMA. 1978;;240 ,.:2080. [CrossRef]
 
Kiryu, T, Kawaguchi, S, Matsui, E, et al Endobronchial metastasis of osteosarcoma of the bone.J Bronchol2000;7,236-239. [CrossRef]
 
King, DS, Castleman, B Bronchial involvement in metastatic pulmonary malignancy.J Thorac Surg1943;12,305-315
 
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