Affiliations: Bon Secours Hospital
Grosse Pointe, MI,
Gifu University School of Medicine
Correspondence to: David M. Wu, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Bon Secours Hospital, 468 Cadieux, Grosse Pointe, MI 48230
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.2–3
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.
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.2–5 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.
Become a CHEST member and receive a FREE subscription as a benefit of membership.
Individuals can purchase this article on ScienceDirect.
Individuals can purchase a subscription to the journal.
Individuals can purchase a subscription to the journal or buy individual articles.
Learn more about membership or Purchase a Full Subscription.
Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited:
Customize your page view by dragging & repositioning the boxes below.
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.