Endobronchial Spread of Bronchioloalveolar Carcinoma

case of TSS, even though the patient did not live long enough to exhibit all of the clinical criteria, (namely desquamation). The criteria for TSS diagno sis include the following: temperature >38 .9°C; diffuse macular erythroderma: hypotension (systolic blood pressure <90 mm Hg); desquamation of the palms and soles 2 to 3 week s after the onset of illness; and evidence of multisystem organ failure of at least 3 organ systems. This patient had evidence of renal, respiratory, and hematologic failure . In addition, the patient must have negative blood, throat, or cerebrospinal fluid culture and no rise in titer to Rocky Mountain spotted fever, leptospirosis, or rubella. During the initial week of ICU admission, multiple diagnoses were entertained. These included septic shock with no focus, acetylsalicylic acid overdose, and Korean hemorrhagic fever. In addition, group A Streptococcus pneumonia and sepsis were considered and have been associated with a toxic shock-like syndrome,' but the cultures and antistreptolysin-OT titer were negative . Patients with Al DS have an increased incidence of positive S aureus blood cultures. In a chart review of 22 cases of S au reus bacteremia in 18 patients with AIDS or AIDS-related complex , none had complications ascribed to a toxin (TSSTI) mediated source . In a recent review of five cases, Cone et al"found five patients with a TSS-like picture with positive TSST-l. All these patients had AIDS . In 1982. Davis et al" described possible altered host defense mechanisms in TSS . These included a profound absolute lymphopenia during acute TSS which may result from direct cytotoxicity ofTSSTI. It is impossible to be certain as to the cause of the lymphopenia in this patient for it could be due to either TSS or HIY. However, his lymphocyte count did return to low normal during the first week in the ICU .

Endobronchial Spread of Bronchioloalveolar Carcinoma· William D. Donovan, M .D .• M .P.H.; David F. Yankeleoitz, M.D .; Claudia 1. Henschke , Ph.D .• M.D.; Nasser Altorki, M.D .• F.C.C .P.; and Thomas A. Nash . M .D .

Bronchioloalveolar cell carcinoma is known to have several presentations. We present a case of a patient with a solitary nodule in the upper lobe who had an episode of hemoptysis one week prior to lobectomy. Blood clots were removed from the lower lobe bronchus at surgery. Seven months later, the patient was documented to have recurrence in the lower lobe with computed tomographic scan and pathologic findings consistent with endobronchial spread of tumor. (Chest 1993; 104:951·53)

I BAC = bronchiolalveolar cell carcinoma I cell carcinoma (BAC) is the least B ronchioloalveolar understood and the rarest of the malignant primary

lung neoplasms. It is commonly believed to occur in two forms: a localized lesion usually presenting as a single nodule or mass, and as diffuse . infiltrating lesions associated with a significantly poorer prognosis . Crossover between the two types, or progression from the localized form to the diffuse form , has been suspected in the past , hilt at best this has been documented only circumstantially in the literature . This case demonstrates endobronchial spread of BAC over ·From the Departments of Radiolo~ (Dr s. Donovan. Yankelevitz, and lIenschke), Surgery (Dr. Altorki). and Pulmonary and Critical Care Medicine (Dr. Nash). The New York Hospital-Cornell Medical Center. New YorkCity. Reprint requests: Dr. Yankeleoitz • .52.5 East 68th Street, New ¥lJrk 10021

Our patient presented with the clinical picture of TSS and had a hyperdynamic septic shock pattern on pulmonary artery readings. This case demonstrates the overwhelming nature ofTSS when combined with an HIV-positive patient. Therefore, in the appropriate demographic groups , the HIV status of the patient should be investigated in non menstrual TSS. REFERENCES Sparano J. Ferranti E. The acquired immunodeficiency syndrome and nonrnenstrual toxic shock syndrome. Ann Intern Med 1986; 300:105 2 Kline M. Dunkle L. Toxic shock syndrome and the acquired immunodeficiency syndrome. Pediatr Infect Dis J 1988; 7:736-38 3 Cone L. Woodward D . Byrd R, Schulz K. Kopp S. Schlievert P. A recalcitrant . desqnamating disorder associated with toxin producing stap hylococci in patients with AIDS . J Infect Dis 1992; 165:638-43

4 Reingold A, Hargrett N. Shands K, Dan B. Scmid G, Strickland B, et al. Toxic shock syndrome surveillance in the United States 1980 to 1981. Ann Intern Med 1982; 96(pt 2):875-80 5 Stevens D, Tanner M, Winship J. Swarts R. Ries K. Schlievert P, et aI. Sever e group A streptococcal infection associated with a toxic shock-like syndrome and scarlet fever toxin A. N En~1 J Med 1989; 321 :1-7 6 Davis J. Vergeront J. Chesney J. Possible host-defense mechanism in toxic shock syndrome . Ann Intern Med 1982; 96(pt 2):986-91

FIGURE I. Posteroanterior chest radio~raph obtained three weeks prior to surgery shows a solitary left upper Johe mass. CHEST I 104 I 3 I SEPTEMBER. 1993

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FIGl'R~: 2 . lI iWi·resnllltion computed tomographic scan obtained on week prior tn surgery showing the left upper lohe mass with spiculated margins and retraction of the pleura.

the course of a year, with conversion of a solitary nodule into a diffuse, multinodular lesion. CASf>: REPORT

A 50-year-old woman was admitted to the hospital fnr a dilatatinn and curettage for menometrorrhagia. A 4 x 3-em mass was present

FIGllRt: ,'3 . Posteroanterior chest radiographs obtained one day prior to sur~ery. The left IIpper lohe mass is a~ain identified . There is now evidence of left lower lohe att'lel"lasis ".ith associated findin~s of vol lime loss. Note the posterinr displacement of the mass.

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in the left upper 101... on preoperauv« dl ..st radioltraph (Filt I). Computed tomography (CT) confirmed this findinlt (Fu; 2). TIlt' patient was asymptomatic , hilt had a 75 pack -year smoking histnry. Transbronchial biopsy via fil... roptic bronchoscopy (FOB) 01.tained cells consist.. nt with BAc' On .. w .... k /i,lInwinlt brunchoscopv, the patient experi.. nc..d an isolat ..d .. pisod.. nf h.. moptysis. This was accnmpanied by wh .... zinlt that improv..d when sh .. IIs..d a prr-viouslv prescribed hronchodilator, Th...•.. w.. eks afll -r bronchoscopy, the preoperativ.. chest radiograph (CXR) (Fn; 3) altain demonstrated the left uppe-r lnl... mass, hili now th ..,... was II.. W I..ft lowe-r lnl", atelectasis. At surgery, repeat..d FOB prior In intubation d .. monstrat ..d mature blood dots in till' I,·ft main. left lippeI'. and left lower 101... bronchi. Th..se [ragments w.. re ..xtract ..d hy suctioning during lilt' course of the upper lobectomy The preoperative diagnosis of HAC was confirmed on pathologi« sections. and bronchial and vascular mariti liS were dear. Th e pleura was not involved , and all 21 sampled lymph IH>d.. S were ne ltatis't' for tumor. Postoperat iv.. CXRs demonstrat..d r..expansion of th .. left lower lobe . The pati e nt had all uneventful postoperative cours e-. A follow-up CT sean (Fig 4) obtain..d seven months aft .. r Sllrlt.. ry revealed multiple small ill-defin..d IIIKIIII..s, local ..d anteriorlv in the left lower lobe , The distributlon nf th .. nodules dirt'l'lly corresponded to th .. location nf tilt' hl'KKI clots seeII preopi-rattv..ly. and were in direct re lationship to small bronchi . No lesions wer.. present elsewh.. re in th .. ch ..st and th .. re was no adenopathy, A CT-~lIid ..d fin..-n....dl .. aspiration hiopsy of th .. lesions was positive for malignant (·..lIs consistent with BAC. A I,·ft lowe-r lobectomy was p.. rformed . DISCI'SSI()~

Diffuse, infiltrating BAC was characte-rize-d in H)();3 hy Musser' following earlier descriptions hy Malassez ." Onlv in 1953 was the solitary nodular form of this entity recognized as a different manifestation of the same disease." In 1960. Liehow' defined BAC as well-differentiated adenocarcinomas arising in the peripheral lung " be yond a grossly recognizable bronchus' with local spread through the airspaces; the lung stroma is used as a framework, hut direct invasion or destruction of pulmonary tissue is a late mani-

FI( :l'R~: 4 . High-resolution computed lomoltraphi,' ,,·,m showinlt mllltiple smalllll>dul..s slIrrollndinlt a small hrnnchlls in lilt' r.. maininlt I..ft lower lohe . This pall.. rn sll!tlt..sls .. ndnhronchial spread.

Endobronchial Spread of Bronchioloalveolar Carcinoma (Donovan at al)

festation. This description still applies to date. Bronchioloalveolar cell carcinoma constitutes between 1 and 9 percent of primary pulmonary malignant neoplasms. Unlike other primary lung cancers, BACoccurs as frequently in men as in women, and it has the weakest association with smoking, occupational exposure, or chronic lung disease . The average age at diagnosis is similar to that of adenocarcinoma of the lung, but patients are less likely to complain of constitutional symptoms (such as weight loss, fevers, and malaise) than with other lung rumors. Its myriad manifestations-solitary pulmonary nodule, lobar consolidation, multiple nodules, diffuse infiltratecontinue to intrigue clinicians, radiologists, and pathologists. The solitary and diffuse forms certainly display dichotomous prognoses; recent studies have shown stage I BAC to have a prognosis more favorable than that of stage I adenocarcinoma (with five-year survival of 75 percent and 50 percent, respectively), whereas the survival times of stages II and III BAC are significantly shorter than that for stage III adenocarcinoma.··· When it was realized that BACdemonstrated both solitary and diffuse forms, the natural assumption was that the former was the predecessor of the latter, and that earlier detection of BAC would assure a better prognosis . Thus, speculation as to whether solitary foci of BAC have the capability to spread and implant throughout the bronchial tree, thus giving rise to diffuse involvement, has been a source of discussion for decades but has never led to clear demonstration of such a case . Late development of local and distant metastases due to hematogenous and lymphogenous spread in patients who have undergone resection of a solitary BAC has been clearly documented similar to the typical metastatic spread of adenocarcinoma; but multiple studies following patients over various numbers of years have failed to identify any such patients with focal disease who have progressed to diffuse involvement by BAC in a manner suggesting rapid endobronchial spread ,"> The alternative hypothesis, advanced most notably by Miller et aI,· is that solitary and diffuse BAC may (or may not) share a common histology, but are in reality different clinical entities and should be treated as such , has therefore received favorable support.•.10 A review by Hill in 1984 directly contradicted this theory by asserting that in the absence of "surgical intervention, there was a transition from a solitary lesion to diffuse disease in every patient:' Tracking of 45 patients in their study demonstrated "progression" in these patients from a nodule to a mass, to diffuse nodules, and to localized and diffuse consolidations. Other patients reportedly demonstrated progression from masses to consolidations and to diffuse nodules." The lack of convincing radiographic documentation in the review article hindered resolution of the debate. and there has been a significant lack of corroboration of HiII's" stance in the literature in the years since his report appeared. The current case offers rather convincing evidence of endobronchial spread of BAC from a solitary focus, resulting in diffuse pulmonary involvement. Although the blood aspirated from the left lower lobe bronchus postoperatively was not sent for cytologic study, the short time span between the initial procedure and BAC recurrence in the lower lobe , its radiologic and pathologic appearance, and postoperative

stage I of the patient, make endobronchial spread of BAC the most likely explanation. REFERENCES 1 Musser JH . Primary carcinoma of the lung. Univ Penn Bull 1903; 16:289-96

2 Malassez L. Examen histologique d'un case de cancer eneephaloide du paumon. Arch Physiol Normal Pathol 1876;3:353-56 3 Storey CF, Knudtson KF. Laurence BJ. Bronchiolar ('alveolar cell) carcinoma of the lung. J Thome Surg 1956;26:331-56 4 Liebow AA. Bronchoalveolar cell carcinoma . Adv Intern Med 1960; 10:329-58 5 Grover FL. Piantadosi S. Recurrence and survival following resection ofbronchioloalveolar carcinoma of the lung-the lung cancer study group experience. Ann Surg 1989; 209:779-90 6 Greco RJ. Steiner RM, Goldman S, Cotler H, Patchefsky A. Cohn HE . Bronchoalveolar cell carcinoma of the lung. Ann Thome Surg 1986;41:652-56 7 Epstein DM. Bronchioloalveolar cell carcinoma. Semin Roentgenoll990; 25:105-11 8 Edgerton F, Rao U, Thkita H. Vincent RG. Bronchia-alveolar carcinoma. Oncology 1981;38:269-73 9 Miller wr, Husted J. Freiman D, Atkison B, Pietra GG. Bronchioloalveolar carcinoma: two clinical entities with one pathologic diagnosis. AJR 1978; 130:905-12 10 Clagett (Jr. Allen TH. Payne WS. Woolner LB. The surgical treatment of pulmonary neoplasms: a ten-year experience. J Thome Cardiovasc Surg 1964; 48:391-400 11 Hill CA. Bronchioloalveolar carcinoma: a review. Radiology 1984; 150:15-20

NeedleIWlre Lung Nodule Localization for thoracoscopic Resectlon* Philip A. Templeton, M.D.• F.C.C.P.; and Mark Krasna. M.D.

Small lung nodules undiagnosed by percutaneous needle biopsy have traditionally gone to thoracotomy for diagnosis. We describe a technique using computed tomographic needle/wire lung localization of these nodules, to be resected using video-assisted thoracoscopy. This is less invasive and less painful than thoracotomy and provides for cost-effective definitive diagnosis. (Chen 1993; 104:953-54)

T

horacoscopy is a surgical technique enabling lung resection without thoracotomy and its associated complications. J The lung is collapsed and three small incisions are made in the chest for insertion of a video thoracoscope, biopsy forceps, and a stapling and/or laser device. Peripheral lesions visible on the surface of the lung can be resected under direct vision. A wedge biopsy specimen 3 x 3 em is obtained, and successive applications can be performed to obtain a specimen 9 x 9 cm . To allow resection of lesions deep to the surface of the lung, we report a system for needlelwire lung localization. CASE REPORT A 57-yel1l"Old man with a history of resected bladder carcinoma and an 80 pack-year smoking history had a small left upper lobe

·From the University of Maryland Medical System. Baltimore. Reprint requests: Dr. Thmpleton. Department of RDdlowgy. UnioerBUy ofMaryland Hospital. Baltimore21201 CHEST I 104 I 3 I SEPTEMBER, 1993

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