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Prognosis of Residual Invasive Cancer At the Margin of Bronchial Resection
Prognosis of Residual Invasive Cancer At the Margin of Bronchial Resection Richard K. Hughes, M.D., and Toussaint T. Tildon, M.D.
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ancer left at the bronchial margin in resection of the lung is synonymous with palliative resection. T h e poor prognosis for long-term survival following such a resection is well known [2]. It may be less well known that postoperative bronchopleural fistula and empyema do not necessarily follow closure of a bronchial stump which contains invasive cancer. Groves and McCormack reported a case in which invasive squamous-cell carcinoma was present at the margin of bronchial resection [ll. Although death resulted six years after right pneumonectomy from residual tumor at the bronchial stump and adjacent structures, postoperative complications did not occur. Habein, McDonald, and Clagett discussed five cases of squamous-cell carcinoma at the proximal end of the resected main bronchus in which bronchopleural fistula and empyema were not reported to follow pneumonectomy [2]. Our experience also suggests that a bronchial stump which contains invasive residual carcinoma may heal satisfactorily. From 1953 to 1964, 288 pulmonary resections were performed at Wadsworth Veterans Administration Hospital for cancer of the lung. Eighteen of these resections transected invasive carcinoma at the point of bronchial division. Tumor was confined to the submucosal lymphatic vessels in 4 of the 18. Fourteen of these “palliative” resections were pneumonectomies and 4 were lobectomies. Lobectomy rather than pneumonectomy was performed in 3 patients because of inadequate cardiopulmonary status and in 1 patient because of definitive evidence that pneumonectomy would not result in cure. In the 18 patients who had palliative resections, a total of 4 deaths occurred within the first 30 postoperative days. Three were due to heart failure, 1 of which resulted from coronary artery occlusion. Four of the From the Department of Thoracic Surgery, Wadsworth Hospital, Veterans Administration Center, Los Angeles, and the Department of Surgery, The University of California at Los Angeles School of Medicine, Los Angeles, Calif. Supported in part by Grant CA 07414-05. from the National Institutes of Health, US.Public Health Service. Accepted for publication Aug. 12, 1965.
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remaining 15 necessarily inadequate resections were followed by bronchopleural fistula and empyema 6 days, 11 days, and four months after pneumonectomy, and 1 occurred 30 days after left lower lobectomy. T h e late occurrence (after four months) followed a tuberculous empyema which developed in spite of adequate antituberculosis chemotherapy administered postoperatively. All 3 of the early postoperative fistulas followed difficult and unsatisfactory closures of the bronchial stumps. One stump was fused to the esophagus by tumor. Another, which had been irradiated preoperatively with 4,500 rads, was surrounded by fibrotic, calcified, and caseating lymph nodes. In 1 of these patients regional extension of the tumor had occurred, and in all 3, tumor-containing mediastinal or hilar lymph nodes were found. Two of the 3 early fistulas caused death after resection, 1 at 23 days and the other at 58 days. Death occurred one year after resection in the third. T h e patient who had the tuberculous empyema and fistula survived for 42 months after pulmonary resection. T h e 4 patients with bronchial stumps which contained tumor limited to submucosal lymphatic vessels healed satisfactorily. Although 3 early fistulas and 1 late fistula following 15 pulmonary resections is a very high incidence of this complication, it is interesting that 11 of the 15 bronchial stumps which probably contained residual invasive carcinoma healed. Eleven palliative resections were followed by death due to residual lung cancer, 5 within the first year, 5 during the second year, and 1 at 42 months.
FZG. 1. Section at margin of bronchial resection in patient surviving five years. Znvasive, poorly differentiated squamous-cell carcinoma is seen in nests extending from the bronchial lumen (upper left), through the full thickness of the bronchial wall. Bronchial glands and calcified bronchial cartilage are seen in the lower left-hand corner. (H&E; ~ 4 0 before , 25% reduction.)
HUGHES AND TILDON
FIG. 2. Section at margin of tracheal resection in patient suruiving 18 months. Ulceration of tracheal mucosa is present. Poorly diflerentiated adenocarcinoma, which shows effects of radiation, is seen adjacent to the lumen. T h e tumor extended in nests throu h the tracheal wall; tracheal cartilage is seen at the , 25% reduction.) periphery. (H&E; ~ 4 0%efore
It is remarkable that there have been 2 possible “cures.” One man is without evidence of cancer five years after a “palliative” right lower lobectomy for squamous-cell carcinoma which was found to have invaded the bronchial mucosa at the margin of resection (Fig. 1). Chemotherapy of 23 mg. of nitrogen mustard was administered to him during the early postoperative period. Bronchoscopy performed three years after resection did not reveal evidence of cancer, and thoracic roentgenograms continue to show no evidence of residual tumor. The other man is without evidence of lung cancer 18 months after “palliative” right pneumonectomy for adenocarcinoma, which was irradiated preoperatively with 4,524 rads (Fig. 2). In addition to invasive radiated carcinoma at the tracheal margin of resection, microscopic vascular invasion was found. No evidence of cancer was found on bronchoscopy performed 5 and 18 months after resection; biopsies taken from the benign-appearing site of tracheal closure were unremarkable. Thoracic roentgenograms show no evidence of residual tumor. DZSCUSSZON
Pulmonary resection which crosses through known invasive carcinoma of the bronchus is undesirable but occasionally necessary. More often, the pathologist’s final report will describe previously unsuspected invasive cancer at the bronchial margin of resection. Further resection may not be feasible. Development of postoperative bronchopleural fistula is not inevitable, though its incidence may be higher than after 104
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resection through a normal bronchus. Blood supply to the bronchial stump and to tumor within the bronchial stump may be an important determining factor. Three of four palliative resections which were followed by bronchopleural fistula appear to have resulted from inadequate blood supply at the site of bronchial closure. T h e fourth is believed to have resulted from a tuberculous empyema. Explanation for the two possible cures following bronchial transection through invasive carcinoma is difficult. T h e proximal margin of the specimens may have contained all the tumor. It is doubtful that postoperative nitrogen mustard chemotherapy effected a permanent cure of one of the patients. T h e other underwent a palliative resection only 18 months ago and is likely to manifest residual cancer in the future. Preoperative irradiation may have retarded clinical expression of residual cancer. SUMMARY
Bronchopleural fistula will not inevitably follow pulmonary resection which transects invasive carcinoma at the bronchial margin. Eleven of the authors’ cases and six reported in the literature support this statement. REFERENCES
1. Groves, L. K., and McCormack, L. J. Long-term survival with persistent carcinoma at the bronchial stump: Report of two cases. J . Thorac. Cardiov. Surg. 44:385, 1962. 2. Habein, H. C., Jr., McDonald, J. R., and Clagett, 0. T. Recurrent carcinoma in the bronchial stump. J . Thorac. Surg. 31:703, 1956.
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C
ancer left at the bronchial margin in resection of the lung is synonymous with palliative resection. T h e poor prognosis for long-term survival following such a resection is well known [2]. It may be less well known that postoperative bronchopleural fistula and empyema do not necessarily follow closure of a bronchial stump which contains invasive cancer. Groves and McCormack reported a case in which invasive squamous-cell carcinoma was present at the margin of bronchial resection [ll. Although death resulted six years after right pneumonectomy from residual tumor at the bronchial stump and adjacent structures, postoperative complications did not occur. Habein, McDonald, and Clagett discussed five cases of squamous-cell carcinoma at the proximal end of the resected main bronchus in which bronchopleural fistula and empyema were not reported to follow pneumonectomy [2]. Our experience also suggests that a bronchial stump which contains invasive residual carcinoma may heal satisfactorily. From 1953 to 1964, 288 pulmonary resections were performed at Wadsworth Veterans Administration Hospital for cancer of the lung. Eighteen of these resections transected invasive carcinoma at the point of bronchial division. Tumor was confined to the submucosal lymphatic vessels in 4 of the 18. Fourteen of these “palliative” resections were pneumonectomies and 4 were lobectomies. Lobectomy rather than pneumonectomy was performed in 3 patients because of inadequate cardiopulmonary status and in 1 patient because of definitive evidence that pneumonectomy would not result in cure. In the 18 patients who had palliative resections, a total of 4 deaths occurred within the first 30 postoperative days. Three were due to heart failure, 1 of which resulted from coronary artery occlusion. Four of the From the Department of Thoracic Surgery, Wadsworth Hospital, Veterans Administration Center, Los Angeles, and the Department of Surgery, The University of California at Los Angeles School of Medicine, Los Angeles, Calif. Supported in part by Grant CA 07414-05. from the National Institutes of Health, US.Public Health Service. Accepted for publication Aug. 12, 1965.
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Residual Cancer at Bronchial Margin
remaining 15 necessarily inadequate resections were followed by bronchopleural fistula and empyema 6 days, 11 days, and four months after pneumonectomy, and 1 occurred 30 days after left lower lobectomy. T h e late occurrence (after four months) followed a tuberculous empyema which developed in spite of adequate antituberculosis chemotherapy administered postoperatively. All 3 of the early postoperative fistulas followed difficult and unsatisfactory closures of the bronchial stumps. One stump was fused to the esophagus by tumor. Another, which had been irradiated preoperatively with 4,500 rads, was surrounded by fibrotic, calcified, and caseating lymph nodes. In 1 of these patients regional extension of the tumor had occurred, and in all 3, tumor-containing mediastinal or hilar lymph nodes were found. Two of the 3 early fistulas caused death after resection, 1 at 23 days and the other at 58 days. Death occurred one year after resection in the third. T h e patient who had the tuberculous empyema and fistula survived for 42 months after pulmonary resection. T h e 4 patients with bronchial stumps which contained tumor limited to submucosal lymphatic vessels healed satisfactorily. Although 3 early fistulas and 1 late fistula following 15 pulmonary resections is a very high incidence of this complication, it is interesting that 11 of the 15 bronchial stumps which probably contained residual invasive carcinoma healed. Eleven palliative resections were followed by death due to residual lung cancer, 5 within the first year, 5 during the second year, and 1 at 42 months.
FZG. 1. Section at margin of bronchial resection in patient surviving five years. Znvasive, poorly differentiated squamous-cell carcinoma is seen in nests extending from the bronchial lumen (upper left), through the full thickness of the bronchial wall. Bronchial glands and calcified bronchial cartilage are seen in the lower left-hand corner. (H&E; ~ 4 0 before , 25% reduction.)
HUGHES AND TILDON
FIG. 2. Section at margin of tracheal resection in patient suruiving 18 months. Ulceration of tracheal mucosa is present. Poorly diflerentiated adenocarcinoma, which shows effects of radiation, is seen adjacent to the lumen. T h e tumor extended in nests throu h the tracheal wall; tracheal cartilage is seen at the , 25% reduction.) periphery. (H&E; ~ 4 0%efore
It is remarkable that there have been 2 possible “cures.” One man is without evidence of cancer five years after a “palliative” right lower lobectomy for squamous-cell carcinoma which was found to have invaded the bronchial mucosa at the margin of resection (Fig. 1). Chemotherapy of 23 mg. of nitrogen mustard was administered to him during the early postoperative period. Bronchoscopy performed three years after resection did not reveal evidence of cancer, and thoracic roentgenograms continue to show no evidence of residual tumor. The other man is without evidence of lung cancer 18 months after “palliative” right pneumonectomy for adenocarcinoma, which was irradiated preoperatively with 4,524 rads (Fig. 2). In addition to invasive radiated carcinoma at the tracheal margin of resection, microscopic vascular invasion was found. No evidence of cancer was found on bronchoscopy performed 5 and 18 months after resection; biopsies taken from the benign-appearing site of tracheal closure were unremarkable. Thoracic roentgenograms show no evidence of residual tumor. DZSCUSSZON
Pulmonary resection which crosses through known invasive carcinoma of the bronchus is undesirable but occasionally necessary. More often, the pathologist’s final report will describe previously unsuspected invasive cancer at the bronchial margin of resection. Further resection may not be feasible. Development of postoperative bronchopleural fistula is not inevitable, though its incidence may be higher than after 104
THE ANNALS OF THORACIC SURGERY
NOTE:
Residual Cancer at Bronchial Margin
resection through a normal bronchus. Blood supply to the bronchial stump and to tumor within the bronchial stump may be an important determining factor. Three of four palliative resections which were followed by bronchopleural fistula appear to have resulted from inadequate blood supply at the site of bronchial closure. T h e fourth is believed to have resulted from a tuberculous empyema. Explanation for the two possible cures following bronchial transection through invasive carcinoma is difficult. T h e proximal margin of the specimens may have contained all the tumor. It is doubtful that postoperative nitrogen mustard chemotherapy effected a permanent cure of one of the patients. T h e other underwent a palliative resection only 18 months ago and is likely to manifest residual cancer in the future. Preoperative irradiation may have retarded clinical expression of residual cancer. SUMMARY
Bronchopleural fistula will not inevitably follow pulmonary resection which transects invasive carcinoma at the bronchial margin. Eleven of the authors’ cases and six reported in the literature support this statement. REFERENCES
1. Groves, L. K., and McCormack, L. J. Long-term survival with persistent carcinoma at the bronchial stump: Report of two cases. J . Thorac. Cardiov. Surg. 44:385, 1962. 2. Habein, H. C., Jr., McDonald, J. R., and Clagett, 0. T. Recurrent carcinoma in the bronchial stump. J . Thorac. Surg. 31:703, 1956.
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1966
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