Lung Cancer During Pregnancy - 1

Letters Lung Cancer During Pregnancy To the Editor: We would like to describe an additional case oflung cancer complicating pregnancy, which is similar to the one reported by Dr. Van Winter and colleagues in the April 1995 issue of the Mayo Clinic Proceedings (pages 384 to 387). A 43-year-old woman (gravida 4, para 3) sought medical assessment during the third trimester of pregnancy because of onset of severe dyspnea. She had a 60-pack-year history of smoking but no prior medical problems. Echocardiography revealed pericardial and left pleural effusion. Thoracentesis demonstrated an exudate with cytologic findings positive for adenocarcinoma. A month before medical assessment, the patient noticed a reddish, raised coinlike lesion. A biopsy revealed metastatic adenocarcinoma. Bronchoscopy also disclosed adenocarcinoma. Computed tomography of the abdomen showed a shadow in the left hepatic lobe, consistent with metastatic involvement. At 37 weeks' gestation, the patient was delivered of a healthy female neonate. No placental lesions were found. The patient died 1 month after diagnosis. Her infant has remained healthy. Whether pregnancy alters the course of lung cancer remains unresolved. The maternal outcome of the previous patients suggests that the combination of young age, adenocarcinoma, and pregnancy is associated with aggressive tumors. The increased incidence of smoking in the female population seems to account for the increase in lung tumors. Remberto J. Bitar, M.D. Nicholas Melillo, M.D. Jeffrey L. Pesin, M.D. JohnF. Kennedy Medical Center Edison, New Jersey To the Editor: Dr. Van Winter and colleagues described a case and provided a comprehensive literature review of lung cancer complicating pregnancy. Survival of 10 of the 12 patients in whom it was reported ranged from 2'1z to 42 months (mean, 9.1). The mean age of the patients was 36.4 years. Five of the patients had small-cell cancers, three had adenocarcinomas, two had large-cell cancers, and one had a squamous cell cancer (this patient lived 42 months after diagnosis). In January 1990, we treated a nonsmoking 29-year-old woman (gravida 3, para 2, aborta 1) who was hospitalized during the third month of pregnancy because of multiple lung masses. A biopsy revealed bronchoalveolar carcinoma. After a therapeutic abortion, the patient received three courses of combination chemotherapy with cisplatin and etoposide. The patient did not seek medical care again until February 1995, when she experienced a cough, fever, weight loss, and anterior chest pain. Bipulmonary basilar infiltrates and cavitary subpleural masses were evident on chest roentgenography and computed tomography. Sputum cultures grew Streptococcus pneumoniae, and a lung biopsy by videothoracoscopy yielded evidence of pneumonitis and bronchoalveolar carcinoma. Intravenous administration of penicillin led to abatement of fever and disappearance of Mayo Clin Proc 1995; 70: 1130

the infiltrates in the lower lobes of the lung, but the subpleural masses persisted. Bronchoalveolar carcinoma of the lung is considered by many pathologists to be a distinct adenocarcinoma! that arises in the bronchial glands. These tumors are multifocal in 25% of cases, occur equally in men and women, may be monoclonal, have an associated 5-year survival rate, and occur often in nonsmokers. A recent report described an increase in bronchoalveolar lung cancer in women,' and this histologic type now constitutes 26% of all pulmonary neoplasms in women and 8% of those in men. To our knowledge, our patient is the first to have a bronchoalveolar carcinoma that occurred during pregnancy. She is still alive 62 months after diagnosis. With the changing patterns of lung cancer, additional instances of this type of tumor will certainly be encountered during pregnancy. In light of the good prognosis associated with bronchoalveolar carcinomas, clinical decisions about treatment and fetal preservation must be carefully considered. Lawrence A. Cone, M.D., D.Sc. April C. Dawson, M.D., M.P.H. Abigail M. Mata, R.N. Eisenhower Medical Center Rancho Mirage, California and Riverside County Health Department Palm Springs, California REFERENCES I. Hirata H, Noguchi M, Shimosato Y, Dei Y, Goya T. Clinicopathologic and immunohistochemical characteristics of bronchial gland cell type adenocarcinoma of the lung. Am J Clin Pathol 1990; 93:20-25 2. Barsky SH, Cameron R, Osann KE, Tomita D, Holmes EC. Rising incidence of bronchioloalveolar lung carcinoma and its unique clinicopathologic features. Cancer 1994; 73:1163-1170

In response: The letter from Dr. Remberto Bitar and colleagues presents another example of a lung cancer diagnosed during pregnancy that progressed rapidly and resulted in a fatal outcome. Although pregnancy may delay the diagnosis of lung cancer, its effect on the course of the cancer is unknown. As long as smoking continues to increase among female adolescents, the incidence of lung cancer in women of reproductive age can also be expected to increase. The case described by Dr. Lawrence Cone and coauthors is an excellent example of a subtype of lung cancer that has an associated good prognosis. This situation contrasts that of our patient, who experienced a rapidly progressive and fatal outcome. My colleagues and I assume that the term "therapeutic abortion" refers to facilitating the start of chemotherapy, inasmuch as abortion per se does not seem to improve the prognosis associated with lung cancer.

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Jo T. Van Winter, M.D. Mayo Clinic Rochester Rochester, Minnesota © 1995 Mayo Foundation for Medical Education and Research

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