INTRODUCTION: While cancers of the breast, colon and kidney commonly metastasize to the lungs and airways, endobronchial metastasis of ovarian cancer is extremely rare. In this report, we present a case of metastatic endobronchial ovarian carcinoma and describe the clinical challenges associated with its management.
CASE PRESENTATION: A 42 year-old Hispanic female was diagnosed with metastatic poorly differentiated papillary serous carcinoma of the ovary after presenting with abdominal pain and anorexia. She was initially treated with surgical debulking and chemotherapy resulting in symptomatic improvement. However, on surveillance CT imaging eleven months after diagnosis, she was noted to have right paratracheal, right hilar and subcarinal lymphadenopathy, which persisted despite additional chemotherapy. Eighteen months after initial diagnosis, she underwent bronchoscopy with endobronchial ultrasound which revealed normal airways, but cytology from fine needle aspiration of the enlarged lymph nodes was positive for metastatic ovarian cancer. She subsequently underwent additional chemotherapy and external beam radiation to the chest. Twenty-six months after initial diagnosis she was admitted with fever and hemoptysis. Chest imaging showed persistent mediastinal lymphadenopathy with partial collapse of the right middle lobe and a post-obstructive infiltrate. The patient underwent a second bronchoscopy which revealed an obstructive endobronchial lesion in the right middle lobe, as well as exophytic friable endobronchial lesions in the right and left mainstem bronchi. Based on their location, the endobronchial lesions likely represented extrinsic airway invasion from the malignant lymph nodes that were seen on Chest CT. As such, no additional biopsies were performed. The patient was treated with antibiotics for post-obstructive pneumonia, and external radiation was continued. Interventional pulmonary therapies including laser debridement, airway stenting and endobronchial brachytherapy were discussed in a multi-disciplinary conference. Given the location of the lesions, we felt that no intervention would provide a palliative benefit for the patient. Ultimately no further pulmonary interventions were performed, and the patient’s pneumonia resolved with antibiotics. The patient was discharged home with continued outpatient radiation and chemotherapy. The patient remained stable clinically through April 2011 with no further pulmonary complications or infections.
DISCUSSION: Although parenchymal and pleural lung metastases are often seen with ovarian carcinoma, endobronchial metastases are rare. To our knowledge, only six cases of endobronchial metastasis from ovarian carcinoma have been reported in the medical literature in the past 22 years. In these reports, the treatments of the endobronchial metastases were aggressive and heterogeneous; three patients were treated with surgery, one with laser therapy and one with a combination of radiation, chemotherapy and corticosteroids. One patient's treatment was not reported. Despite recent advances in interventional bronchoscopy and the development of new modalities to treat malignant airway obstruction, the optimal management of endobronchial metastases remains challenging. In our patient, the location and multifocal nature of the airway lesions made her a poor candidate for aggressive airway interventions. Moreover, the integration of palliative care into clinical practice over the last two decades has led to less invasive treatment approaches that prioritize symptom management over the reduction of disease burden in patients with widely metastatic cancer. Consistent with these principles of palliative care, we practiced a less invasive treatment strategy in our patient. This report represents the first case of ovarian cancer with endobronchial metastasis since 1995; the management decisions reflect the advances seen in both interventional pulmonology and palliative care over the last 16 years.
CONCLUSIONS: This case provides a rare example of endobronchial ovarian cancer, likely spread through direct invasion from mediastinal lymph nodes into the airway. Palliative management of metastatic cancer with endobronchial involvement demands thoughtful consideration to determine what treatments will truly benefit the patient.
Reference #1 Mateo F, Serur E, Smith PR. Bronchial metastases from ovarian carcinoma. Report of a case and review of the literature. Gynecol Oncol. 1992 Aug;46(2):235-8
Reference #2 Merimsky O, Greif J, Chaitchik S, Inbar M. Endobronchial metastasis of ovarian cancer. A case report. Tumori. 1990 Dec 31;76(6):614-5.
Reference #3 Wholey MH, Meyerrose GE, McGuire WP, Reinhardt MJ, Sostre S. Endobronchial lesion from metastatic ovarian carcinoma resulting in partial right mainstem obstruction demonstrated by lung scintigraphy. Clin Nucl Med. 1995 May;20(5):465-6.
DISCLOSURE: The following authors have nothing to disclose: Annie Harrington, Thomas Mahrer, Dong Chang
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