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Complete spontaneous remission of non-small-cell lung cancer: a case report
Lung Cancer (2004) 45, 263—266
CASE REPORT
Complete spontaneous remission of non-small-cell lung cancer: a case report M.A. Cafferata a , M. Chiaramondia b , F. Monetti c , A. Ardizzoni a,* a
Department of Medical Oncology A, Istituto Nazionale per la Ricerca sul Cancro, Largo R. Benzi 10, 16132 Genova, Italy b Department of Pathology, Ospedale S. Martino, Largo R. Benzi 10, 16132 Genova, Italy c Department of Radiology, Istituto Nazionale per la Ricerca sul Cancro, Largo R. Benzi 10, 16132 Genova, Italy Received 3 December 2003; accepted 27 January 2004
KEYWORDS Spontaneous remission (SR); Non-small-cell lung cancer (NSCLC)
Summary Spontaneous remission (SR) of cancer is a rare event, particularly in lung cancer. We report the case of a 68-year-old man, who came to our attention with a diagnosis of poorly differentiated pulmonary adenocarcinoma and, in absence of any active therapy, underwent a durable complete SR. Our case supports the rare occurrence of SR in non-small-cell lung cancer (NSCLC). © 2004 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Spontaneous remission (SR) of cancer, according to a generally accepted definition, is a complete or partial, temporary or permanent disappearance of all or at least some relevant parameters of a soundly diagnosed malignant disease, without any medical treatment or with treatment that is considered inadequate to produce the resulting regression. SR is an extremely rare event. Everson and Cole reported only 176 cases of SR from 1900 to 1964, with an estimated incidence of 1 out of 60,000—100,000 people with cancer [1,2]. Although SR is seen sporadically in any type of cancer, it has been reported especially in a few * Corresponding
author. Tel.: +39-010-5600668; fax: +39-010-5600850. E-mail address: [email protected] (A. Ardizzoni).
types of tumours, where the host immune system is known to play an important role, as malignant melanoma, renal cell cancer, low-grade non-Hodgkins’s lymphoma, chronic lymphocytic leukaemia and neuroblastoma in children. SR is considered to be a particularly rare event in lung cancer [3]. Contemporary with the first observations of SR the interest was raised about the possible biological mechanisms involved in this phenomenon, which unfortunately remains still unexplained.
2. Discussion A 68-year-old Caucasian man was admitted to the hospital in October 1999, because of acute respiratory insufficiency without fever or signs of infection. The patient was a heavy smoker and
0169-5002/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2004.01.026
264
M.A. Cafferata et al.
Fig. 1 (A and B) Chest CT-scan (02-11-99) revealing a large, well-circumscribed, lobulated nodule suggestive for a radiological diagnosis of primary lung cancer.
had a past medical history of hypertension, emphysema, asthma, ischemic heart disease and nephroangiosclerosis. A thoracic computed tomography (CT) revealed the presence of a middle lobe 3 cm mass, with omogeneous contrast en-
hancement and without calcifications or peripheral retraction, suggesting a radiological diagnosis of primary lung cancer (Fig. 1A and B) [4]. A sputum cytology was negative for malignant cells and a fiberoptic bronchoscopy did not show any neo-
Fig. 2 (A and B) Papanicolaou and MGG stains, 400×, suggesting a cytological diagnosis of poorly differentiated pulmonary adenocarcinoma.
Complete spontaneous remission of non-small-cell lung cancer: a case report
Fig. 3 Chest CT-scan (22-02-00) showing a small decrease in size of the lobulated nodule in the middle lobe.
plastic lesion, but only a bilateral hypertrophic bronchitis. Respiratory function tests were consistent with severe chronic obstructive lung disease and pulmonary emphysema controindicating lung resection. A CT-guided fine needle aspiration biopsy was performed by means of 22 G Chiba needle. Six smears were prepared and stained with Papanicolaou and MGG stains. The cytological examination showed a highly cellular smear with loosely choesive clusters of medium-sized epithelial cells. Nuclei were moderately pleomorphic with granular chromatin and prominent central nucleoli. The cytoplasm were tiny, homogeneous or vacuolated. The features were consistent with a cytological diagnosis of poorly differentiated pulmonary adenocarcinoma (Fig. 2A and B) [5]. The patient was discharged from hospital, with a diagnosis of stage I NSCLC, inoperable for medical reasons. In February 2000 the patient was seen in the out-patient clinic with a new thoracic CT scan, confirming the presence of the right pulmonary mass (Fig. 3). A year later, in February 2001, hematology, chemistry, CEA and Cyfra 21-1 were all within normal limits. A CT scan was performed, which exhibited a decrease in size of the pulmonary mass (Fig. 4). The patient was seen again in May 2001 and in January 2002, when a follow-up CT scan showed an almost complete disappearance of the known pulmonary mass (Fig. 5). A positron emission tomography performed in May
265
Fig. 4 Chest CT-scan showing (21-02-01) a decrease in size and in density of the lobulated nodule in the middle lobe.
2002 was negative (Fig. 6). The patient had not received any conventional or unconventional anticancer treatment. At the last in-office visit, in September 2003, no evidence of disease was found.
Fig. 5 Chest CT-scan (12-02-02) showing an almost complete resolution of the nodule.
266
M.A. Cafferata et al.
Fig. 6
FDG-PET-scan (14-05-02) showing no pathologic FDG uptake.
3. Conclusion
References
SR of cancer is the disappearance of a malignant disease, without adequate treatment. SR, occasionally reported in few tumor types, is considered to be an exceptionally rare event in lung cancer, in spite of its global high incidence. Kappauf, in his review of the literature [3], reports only 11 cases of SR in NSCLC. In this series some patients had undergone surgery, with residual non-resectable, or low dose radiotherapy, and obtained a SR, also after developing metastasis. Only three patients had a complete remission by modern imaging techniques documented, without any therapy. In our case a patient with a diagnosis of pulmonary adenocarcinoma underwent a durable complete SR in absence of any active therapy, confirming the possibility of SR, rare and unexplained occurrence in NSCLC.
[1] Everson TC, Cole WH. Spontaneous regression of cancer. Philadelphia: WB Saunders; 1966. [2] Cole WH. Efforts to explain spontaneous regression of cancer. J Surg Oncol 1981;17:201—9. [3] Kappauf H, Gallmeier WM, Wünsch PH. Complete spontaneous remission in a patient with metastatic non-small-cell lung cancer. Case report, review of literature, and discussion of possible biological pathways involved. Ann Oncol 1997;8(10):1031—9. [4] Naidich DP, Webb WR, Müller NL. Computed tomography and magnetic resonance of the thorax. Philadelphia: Lippincott-Raven; 1999. p. 296—331. [5] Johnston WW, Elson CE. Cytology of the respiratory tract. In: Bibbo M, editor. Comprehensive cytopathology. Philadelphia: WB Saunders; 1997. p. 325—401.
CASE REPORT
Complete spontaneous remission of non-small-cell lung cancer: a case report M.A. Cafferata a , M. Chiaramondia b , F. Monetti c , A. Ardizzoni a,* a
Department of Medical Oncology A, Istituto Nazionale per la Ricerca sul Cancro, Largo R. Benzi 10, 16132 Genova, Italy b Department of Pathology, Ospedale S. Martino, Largo R. Benzi 10, 16132 Genova, Italy c Department of Radiology, Istituto Nazionale per la Ricerca sul Cancro, Largo R. Benzi 10, 16132 Genova, Italy Received 3 December 2003; accepted 27 January 2004
KEYWORDS Spontaneous remission (SR); Non-small-cell lung cancer (NSCLC)
Summary Spontaneous remission (SR) of cancer is a rare event, particularly in lung cancer. We report the case of a 68-year-old man, who came to our attention with a diagnosis of poorly differentiated pulmonary adenocarcinoma and, in absence of any active therapy, underwent a durable complete SR. Our case supports the rare occurrence of SR in non-small-cell lung cancer (NSCLC). © 2004 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Spontaneous remission (SR) of cancer, according to a generally accepted definition, is a complete or partial, temporary or permanent disappearance of all or at least some relevant parameters of a soundly diagnosed malignant disease, without any medical treatment or with treatment that is considered inadequate to produce the resulting regression. SR is an extremely rare event. Everson and Cole reported only 176 cases of SR from 1900 to 1964, with an estimated incidence of 1 out of 60,000—100,000 people with cancer [1,2]. Although SR is seen sporadically in any type of cancer, it has been reported especially in a few * Corresponding
author. Tel.: +39-010-5600668; fax: +39-010-5600850. E-mail address: [email protected] (A. Ardizzoni).
types of tumours, where the host immune system is known to play an important role, as malignant melanoma, renal cell cancer, low-grade non-Hodgkins’s lymphoma, chronic lymphocytic leukaemia and neuroblastoma in children. SR is considered to be a particularly rare event in lung cancer [3]. Contemporary with the first observations of SR the interest was raised about the possible biological mechanisms involved in this phenomenon, which unfortunately remains still unexplained.
2. Discussion A 68-year-old Caucasian man was admitted to the hospital in October 1999, because of acute respiratory insufficiency without fever or signs of infection. The patient was a heavy smoker and
0169-5002/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2004.01.026
264
M.A. Cafferata et al.
Fig. 1 (A and B) Chest CT-scan (02-11-99) revealing a large, well-circumscribed, lobulated nodule suggestive for a radiological diagnosis of primary lung cancer.
had a past medical history of hypertension, emphysema, asthma, ischemic heart disease and nephroangiosclerosis. A thoracic computed tomography (CT) revealed the presence of a middle lobe 3 cm mass, with omogeneous contrast en-
hancement and without calcifications or peripheral retraction, suggesting a radiological diagnosis of primary lung cancer (Fig. 1A and B) [4]. A sputum cytology was negative for malignant cells and a fiberoptic bronchoscopy did not show any neo-
Fig. 2 (A and B) Papanicolaou and MGG stains, 400×, suggesting a cytological diagnosis of poorly differentiated pulmonary adenocarcinoma.
Complete spontaneous remission of non-small-cell lung cancer: a case report
Fig. 3 Chest CT-scan (22-02-00) showing a small decrease in size of the lobulated nodule in the middle lobe.
plastic lesion, but only a bilateral hypertrophic bronchitis. Respiratory function tests were consistent with severe chronic obstructive lung disease and pulmonary emphysema controindicating lung resection. A CT-guided fine needle aspiration biopsy was performed by means of 22 G Chiba needle. Six smears were prepared and stained with Papanicolaou and MGG stains. The cytological examination showed a highly cellular smear with loosely choesive clusters of medium-sized epithelial cells. Nuclei were moderately pleomorphic with granular chromatin and prominent central nucleoli. The cytoplasm were tiny, homogeneous or vacuolated. The features were consistent with a cytological diagnosis of poorly differentiated pulmonary adenocarcinoma (Fig. 2A and B) [5]. The patient was discharged from hospital, with a diagnosis of stage I NSCLC, inoperable for medical reasons. In February 2000 the patient was seen in the out-patient clinic with a new thoracic CT scan, confirming the presence of the right pulmonary mass (Fig. 3). A year later, in February 2001, hematology, chemistry, CEA and Cyfra 21-1 were all within normal limits. A CT scan was performed, which exhibited a decrease in size of the pulmonary mass (Fig. 4). The patient was seen again in May 2001 and in January 2002, when a follow-up CT scan showed an almost complete disappearance of the known pulmonary mass (Fig. 5). A positron emission tomography performed in May
265
Fig. 4 Chest CT-scan showing (21-02-01) a decrease in size and in density of the lobulated nodule in the middle lobe.
2002 was negative (Fig. 6). The patient had not received any conventional or unconventional anticancer treatment. At the last in-office visit, in September 2003, no evidence of disease was found.
Fig. 5 Chest CT-scan (12-02-02) showing an almost complete resolution of the nodule.
266
M.A. Cafferata et al.
Fig. 6
FDG-PET-scan (14-05-02) showing no pathologic FDG uptake.
3. Conclusion
References
SR of cancer is the disappearance of a malignant disease, without adequate treatment. SR, occasionally reported in few tumor types, is considered to be an exceptionally rare event in lung cancer, in spite of its global high incidence. Kappauf, in his review of the literature [3], reports only 11 cases of SR in NSCLC. In this series some patients had undergone surgery, with residual non-resectable, or low dose radiotherapy, and obtained a SR, also after developing metastasis. Only three patients had a complete remission by modern imaging techniques documented, without any therapy. In our case a patient with a diagnosis of pulmonary adenocarcinoma underwent a durable complete SR in absence of any active therapy, confirming the possibility of SR, rare and unexplained occurrence in NSCLC.
[1] Everson TC, Cole WH. Spontaneous regression of cancer. Philadelphia: WB Saunders; 1966. [2] Cole WH. Efforts to explain spontaneous regression of cancer. J Surg Oncol 1981;17:201—9. [3] Kappauf H, Gallmeier WM, Wünsch PH. Complete spontaneous remission in a patient with metastatic non-small-cell lung cancer. Case report, review of literature, and discussion of possible biological pathways involved. Ann Oncol 1997;8(10):1031—9. [4] Naidich DP, Webb WR, Müller NL. Computed tomography and magnetic resonance of the thorax. Philadelphia: Lippincott-Raven; 1999. p. 296—331. [5] Johnston WW, Elson CE. Cytology of the respiratory tract. In: Bibbo M, editor. Comprehensive cytopathology. Philadelphia: WB Saunders; 1997. p. 325—401.