Central Lung Tumor Research Articles

Dosimetric analysis of 17 cardiac Sub-structures, Toxicity, and survival in ultra central lung tumor patients treated with SBRT

•Data on cardiac toxicity after SBRT for ultra-central lung tumors remains limited.•We analyzed the dose to 18 cardiac sub-structures and cardiovascular toxicity.•A SBRT regimen of 45Gy in 8-10 fractions yields good local control and low toxicity.•The highest cardiac doses were observed in the pulmonary artery and left atrium.•Higher doses to the base of the heart seem to be associated with non-cancer deaths.

Comparison of MR-guided radiotherapy accumulated doses for central lung tumors with non-adaptive and online adaptive proton therapy.

Stereotactic body radiation therapy (SBRT) of central lung tumors with photon or proton therapy has a risk of increased toxicity. Treatment planning studies comparing accumulated doses for state-of-the-art treatment techniques, such as MR-guided radiotherapy (MRgRT) and intensity modulated proton therapy (IMPT), are currently lacking. We conducted a comparison of accumulated doses for MRgRT, robustly optimized non-adaptive IMPT, and online adaptive IMPT for central lung tumors. A special focus was set on analyzing the accumulated doses to the bronchial tree, a parameter linked to high-grade toxicities. Data of 18 early-stage central lung tumor patients, treated at a 0.35T MR-linac in eight or five fractions, were analyzed. Three gated treatment scenarios were compared: (S1) online adaptive MRgRT, (S2) non-adaptive IMPT, and (S3) online adaptive IMPT. The treatment plans were recalculated or reoptimized on the daily imaging data acquired during MRgRT, and accumulated over all treatment fractions. Accumulated dose-volume histogram (DVH) parameters of the gross tumor volume (GTV), lung, heart, and organs-at-risk (OARs) within 2cm of the planning target volume (PTV) were extracted for each scenario and compared in Wilcoxon signed-rank tests between S1 & S2, and S1 & S3. The accumulated GTV D98% was above the prescribed dose for all patients and scenarios. Significant reductions (p < 0.05) of the mean ipsilateral lung dose (S2: -8%; S3: -23%) and mean heart dose (S2: -79%; S3: -83%) were observed for both proton scenarios compared to S1. The bronchial tree D0.1cc was significantly lower for S3 (S1: 48.1 Gy; S3: 39.2 Gy; p = 0.005), but not significantly different for S2 (S2: 45.0 Gy; p = 0.094), compared to S1. The D0.1cc for S2 and S3 compared to S1 was significantly (p < 0.05) smaller for OARs within 1-2cm of the PTV (S1: 30.2 Gy; S2: 24.6 Gy; S3: 23.1 Gy), but not significantlydifferent for OARs within 1cm of the PTV. A significant dose sparing potential of non-adaptive and online adaptive proton therapy compared to MRgRT for OARs in close, but not direct proximity of central lung tumors was identified. The near-maximum dose to the bronchial tree was not significantly different for MRgRT and non-adaptive IMPT. Online adaptive IMPT achieved significantly lower doses to the bronchial tree compared to MRgRT.

Трудности диагностики центральной эндофитной опухоли легкого, возникшей на фоне туберкулеза

Актуальность. Проблема раннего выявления рака легких, возникшего на фоне специфического процесса, является чрезвычайно актуальной и сложной. Целью работы стало изучение роли рентгенологических и бронхоскопических методов исследования в диагностике центральной эндофитной опухоли легкого у больных туберкулезом легких. Материалы и методы. Анализ литературы, клинический случай. Результаты. Такие рентгенологические методы исследования, как обзорная рентгенограмма, информативны на поздних стадиях развития эндофитной опухоли легкого. Самым информативным методом на ранних стадиях является многосрезовое спиральное сканирование, особенностью которого является изотропность изображений (равное качество во всех плоскостях). Приведен клинический случай развития центральной эндофитной опухоли легкого у больного мультирезистентным туберкулезом легких. Выводы. Необходимо сочетание таких инструментальных методов исследования, как рентгенологические и фибробронхоскопия (с исследованием аспирата из бронхов), что дает в совокупности значительный объем информации о развитии у больного туберкулезом центральной эндофитной опухоли легкого.

Dosimetric Effects of Differences in Multi-Leaf Collimator Speed on SBRT-VMAT for Central Lung Cancer Patients.

Purpose: We aimed to investigate the effects of different multi-leaf collimator (MLC) speed constraints in volumetric modulated radiotherapy (VMAT) on the robustness of treatment plans for central lung cancer patients. Method and Materials: Twenty patients with central lung tumor who underwent stereotactic body radiotherapy (SBRT) with the VMAT technique at our hospital were included in this retrospective study. The reference plans were created with 3 different MLC speed constraints (Plan A: 0.1 cm/deg., Plan B: 0.3 cm/deg., and Plan C: 0.5 cm/deg.) with a 50-Gy/8Fr, planning target volume (PTV) D95% prescription. In each of these plans, setup errors from 1 to 5 mm were intentionally added in the direction of the central organ at 1-mm intervals (300 plans [20 cases × 3 MLC speeds × 5 error plans] were created in total). Each plan was then calculated by the same beam conditions as each reference plan. The actual average MLC speed and dose difference between the reference plan and the error-added plan were then calculated and compared among the 3 MLC speeds. Results: In the reference plans, the actual average MLC speeds were 0.25 ± 0.04, 0.34 ± 0.07, and 0.39 ± 0.12 cm/deg. for Plan A, Plan B, and Plan C, respectively (P < .05). For PTV and OARs, many dose indices tended to improve as the MLC speed increased, while no significant differences were observed among the 3 MLC speed constraints. However, in assessments of robustness, no significant differences in dose difference were observed among the 3 MLC speed constraints for most of the indices. Conclusions: When necessary, increasing the MLC speed constraint with a priority on improving the quality of the dose distribution is an acceptable approach for central lung cancer patients.

The development and external validation of an overall survival nomogram in medically inoperable centrally located early-stage non-small cell lung carcinoma

Background and purposeCurrent nomograms predicting survival prognosis after stereotactic body radiation therapy (SBRT) in non-small cell lung cancer (NSCLC) are based on peripherally located tumors. However, patients with a central lung tumor tend to be older, the tumor is often larger and fraction-schedules are risk-adapted. Therefore, we developed and externally validated a nomogram to predict overall survival (OS) in patients having centrally located early-stage NSCLC treated with SBRT. Materials and methodsPatients who underwent SBRT for centrally located NSCLC were identified and baseline characteristics were obtained. A nomogram was built to predict 6-month, 1-, 2- and 3-year OS using Cox proportional hazards model. The model building procedure was validated using bootstrap sampling. To determine generalizability, external validation was performed on a cohort of patients with central NSCLC treated with SBRT from another center. Discriminatory ability was measured with the concordance index (C-index) and calibration plots were used to compare Kaplan–Meier-estimated and nomogram-predicted OS. ResultsThe nomogram was built on data of 220 patients and consisted of the following variables: PTV, age, WHO performance status, tumor lobe location and ultracentral location. The C-index of the nomogram (corrected for optimism) was moderate at 0.64 (95% confidence interval (CI) 0.59–0.69). Calibration plots showed favorable predictive accuracy. The external validation showed acceptable validity with a C-index of 0.62 (95% CI 0.61–0.64). DiscussionWe developed and externally validated the first nomogram to estimate the OS-probability in patients with centrally located NSCLC treated with SBRT. This nomogram is based on 5 patient and tumor characteristics and gives an individualized survival prediction.

A bumpy road to the diagnosis of metastatic lung cancer

Cardiac tumors pose the uncommon group of disorders and most of them are metastases. They are generally localized in the left heart and may present with non-specific symptoms. Diagnosis may be often difficult due to the presence other heart diseases. The gold standard in diagnosing is non-invasive imaging. We present a case of a 77-year-old male admitted to our hospital due to flu symptoms, headaches and loss of weight in the last 2–3 weeks. The diagnostic process including computed tomography (CT) and magnetic resonance imaging revealed pathological contrast enhancement in the left parietal lobe, whereas subsequent transthoracic echocardiography disclosed a pathological oval mass 2.5 x 3.5 cm in the left heart suspected of a metastasis. Results of echocardiography turned the diagnostic process around and extended to bronchoscopy and abdominal CT. Finally, central left lung tumor with metastases to lungs, pleura, lymphoid nodes of the right hilar, left ventricle, left suprarenal gland and central nervous system was diagnosed.

Endobronchial masses encountered on fine-needle aspiration biopsy: a focus on unusual entities.

Fine-needle aspiration biopsy (FNAB) is a useful technique in the evaluation of central lung tumors which is commonly encountered in clinical cytology practice. Some of these tumors may show endobronchial, polypoid growth which is readily apparent to the endoscopist. Pulmonary salivary gland-type tumors and carcinoid tumors are overall uncommon in the lung, but these tumors tend to occur centrally and show endobronchial involvement. The prognosis of these tumors is generally better than that of small cell or non-small cell carcinomas of the lung and more conservative surgical resection is often indicated. The identification of salient cytological features and a high index of suspicion when considering the differential diagnosis of a central lung tumor is essential to accurate diagnosis. This review focuses on cytological clues as well as ancillary techniques that may be useful to the practicing cytopathologist.

Predicting High-Grade Esophagus Toxicity After Treating Central Lung Tumors With Stereotactic Radiation Therapy Using a Normal Tissue Complication Probability Model

The treatment of central lung tumors with stereotactic body radiation therapy (SBRT) is challenged by the risk of excessive esophageal toxicity. To improve clinical decision making, we aimed to derive normal tissue complication probability (NTCP) models in a patient cohort with central lung tumors treated with SBRT and to evaluate the currently used esophagus dose constraints. Patients with a central lung tumor who received SBRT (8 fractions of 7.5 Gy or 12 fractions of 5 Gy) were included. Doses were recalculated to an equivalent dose of 2 Gy with an α/β-ratio of 10 Gy for acute and 3 Gy for late toxicity (the cut-off was 3 months). The esophagus was manually delineated. NTCP modeling based on logistic regression was used to relate dose-volume histogram parameters (Dmax, D1cc, D2cc, D5cc) to acute and late toxicity. Parameters with a P < .05 were included in the model. Based on the NTCP models, we determined the probability of toxicity for the currently used dose constraints: D1cc ≤40 Gy for 8 fractions and D1cc ≤48 Gy for 12 fractions. For this study, 188 patients with 203 tumors were eligible. Esophagus toxicity occurred in 33 patients (18%). Late high-grade toxicity consisted of 2 possible treatment-related deaths (grade 5) and 2 patients with grade 3 toxicity. Acute toxicity consisted of only grade 1 (n = 19) and grade 2 toxicity (n = 10). All investigated dose-volume histogram parameters were significantly correlated to acute and late toxicity. The probability of late high-grade toxicity is 1.1% for 8 fractions and 1.4% for 12 fractions when applying the current dose constraints. High-grade esophageal toxicity occurred in 2.1% of the patients, including 2 possible treatment-related deaths. The currently used dose constraints correspond to a low risk of high-grade toxicity.

Esophagus toxicity after stereotactic and hypofractionated radiotherapy for central lung tumors: Normal tissue complication probability modeling

PurposeTo correlate esophagus toxicity and dose-volume histogram (DVH) parameters in order to assess risks, and derive a Normal Tissue Complication Probability (NTCP) model. Methods and materialsPatients with a central lung tumor from 2 centers, who underwent stereotactic or hypofractionated radiotherapy (≤12 fractions), were analyzed. Doses were recalculated to an equivalent dose of 2 Gy with an α/β ratio of 10 (EQD210). The esophagus was manually delineated and DVH-parameters (Dmax,EQD2, D1cc,EQD2, D2cc,EQD2, D5cc,EQD2) were analyzed and used for NTCP modeling based on logistic regression analysis. ResultsTwo-hundred-and-thirty-one patients with 252 tumors were eligible. No acute or late grade 3–5 esophageal toxicity was reported. Acute grade 1–2 esophagus toxicity was recorded in 38 patients (17%). All DVH-parameters were significantly higher in patients with toxicity. NTCP models showed a 50% probability of acute grade 1–2 toxicity at a Dmax of 67 Gy EQD210 and D1cc of 42 Gy EQD210. No difference in overall survival was observed between patients with and without toxicity (p = 0.428). ConclusionAs no grade 3–5 esophageal toxicity was observed in our cohort, a Dmax of 56 Gy EQD210 and a D5cc of 35.5 Gy EQD210 could be delivered without high risks of severe toxicity. The NTCP models of this study might be used as practical guidelines for the treatment of central lung tumors with stereotactic radiotherapy.

Normal Tissue Complication Probability Modeling of Pulmonary Toxicity After Stereotactic and Hypofractionated Radiation Therapy for Central Lung Tumors

Toevaluate clinical pulmonary and radiographic bronchial toxicity after stereotactic ablative radiation therapy and hypofractionated radiation therapy for central lung tumors, and perform normal tissue complication probability modeling and multivariable analyses to identify predictors for toxicity. A pooled analysis was performed of patients with a central lung tumor treated using ≤12 fractions at 2 centers between 2006 and 2015. Airways were manually contoured on planning computed tomography scans, and doses were recalculated to an equivalent dose of 2Gy per fraction with an α/β ratio of 3. Grade ≥3 (≥G3) clinical pulmonary toxicity was evaluated by 2 or more physicians. Radiographic toxicity was defined as a stenosis or an occlusion with or without atelectasis using follow-up computed tomography scans. Logistic regression analyses were used for statistical analyses. A total of 585 bronchial structures were studied in 195 patients who were mainly treated using 5 or 8 fractions (60%). Median patient survival was 27.9months (95% confidence interval 22.3-33.6months). Clinical≥G3 toxicity was observed in 24 patients (12%) and radiographic bronchial toxicity in 55 patients (28%), both mainly manifesting ≤12months after treatment. All analyzed dosimetric parameters correlated with clinical and lobar bronchial radiographic toxicity, with V130Gy,EQD having the highest odds ratio. Normal tissue complication probability modeling showed a volume dependency for the development of both clinical and radiographic toxicity. On multivariate analyses, significant predictors for≥G3 toxicity were a planning target volume overlapping the trachea or main stem bronchus (P = .005), chronic obstructive pulmonary disease (P = .034), and the total V130Gy,EQD (P = .012). Radiographic bronchial toxicity did not significantly correlate with clinical toxicity (P = .663). We identified patient and dosimetric factors associated with clinical and radiographic toxicity after high-dose radiation therapy for central lung tumors. Additional data from prospective studies are needed to validate these findings.

P1.13-007 Is Central Lung Tumor Location Really Predictive for Occult Mediastinal Nodal Disease in (Suspected) NSCLC Staged cN0 on PET-CT?

P1.13-007 Is Central Lung Tumor Location Really Predictive for Occult Mediastinal Nodal Disease in (Suspected) NSCLC Staged cN0 on PET-CT?

Sinoatrial node toxicity after stereotactic ablative radiation therapy to lung tumors

PurposeStereotactic ablative radiation therapy (SABR) is an established treatment for selected lung tumors. Sinoatrial node (SAN) toxicity after thoracic SABR has not been reported in the literature. We sought to understand the risk of SAN toxicity owing to incidental dose to the SAN from SABR. Methods and materialsWe conducted a retrospective review of patients with early-stage lung cancer or limited pulmonary metastases who underwent thoracic SABR to a right-sided central lung tumor (within 2 cm of the mainstem bronchus or other mediastinal structures) between January 2008 and December 2014, analyzed a subset whose treatment imparted dose to the SAN exceeding 10% of the prescription dose, and examined patient and treatment dosimetric characteristics. Mean follow-up interval was 28 months. Time to toxicity was defined from start of SABR. ResultsOf 47 patients with central tumors in the right lung treated with SABR reviewed, 13 met our study criteria. A contouring atlas of regional cardiac anatomy was created. One patient treated with SABR for non-small cell lung cancer at the right hilum developed symptomatic sick sinus syndrome, requiring pacemaker placement 6 months after treatment. Her acute presentation and short interval between SABR and onset of symptoms suggest that SAN toxicity was likely due to radiation-induced injury. Both her age and mean dose to her SAN were the third highest in our cohort. She remained free from cancer progression at 24 months’ follow-up. Twelve additional patients who received significant dose to the SAN from SABR did not develop toxicity. ConclusionWhile uncommon, SAN toxicity from SABR to right-sided central thoracic tumors should be recognized and followed in future studies.

Stereotactic ablative radiotherapy (SABR) for treatment of central and ultra-central lung tumors.

Treatment of central and ultra-central lung tumors with stereotactic ablative radiotherapy (SABR) remains controversial due to risks of treatment-related toxicities compared with peripheral tumors. Here we report our institution's experience in treating central and ultra-central lung tumor patients with SABR. We retrospectively reviewed outcomes in 68 patients with single lung tumors, 34 central and 34 peripheral, all treated with SABR consisting of 50 Gy in 4-5 fractions. Tumor centrality was defined per the RTOG 0813 protocol. We defined "ultra-central" tumors as those with GTV directly abutting the central airway. Median follow-up time was 18.4 months and median overall survival was 38.1 months. Two-year overall survival was similar between ultra-central, central, and peripheral NSCLC (80.0% vs. 63.2% vs. 86.6%, P=0.62), as was 2-year local failure (0% vs. 10.0% vs. 16.3%, P=0.64). Toxicity rates were low and comparable between the three groups, with only two cases of grade 3 toxicity (chest wall pain), and one case of grade 4 toxicity (pneumonitis) observed. Patients with ultra-central tumors experienced no symptomatic toxicities over a median follow-up time of 23.6 months. Dosimetric analysis revealed that RTOG 0813 central airway dose constraints were frequently not achieved in central tumor treatment plans, but this did not correlate with increased toxicity rate. Patients with central and ultra-central lung tumors treated with SABR (50 Gy in 4-5 fractions) experienced few toxicities and good outcomes, similar to patients with peripheral lung tumors.

Increased Rates of Pneumonitis in Patients Receiving Stereotactic Ablative Radiation Therapy for Central Versus Peripheral Lung Tumors: Treatment Toxicity

Recently there has been controversy in the literature regarding treatment of central lung tumors with stereotactic ablative radiation therapy (SABR) from a toxicity standpoint, with RTOG 0813 designed to help address this issue. Here we report our institution’s experience in treating central lung tumor patients with SABR, compared to similarly treated peripheral lung tumors.

Abstract 864: Increased rates of radiation pneumonitis in patients receiving stereotactic ablative radiotherapy for central versus peripheral lung tumors

Abstract Purpose: Treatment of central lung tumors with stereotactic ablative radiotherapy (SABR) has been associated with higher rates of toxicities than patients with peripheral tumors. Here we report our institution's experience in treating central lung tumor patients with SABR, compared to patients treated for peripheral lung tumors. Methods: We retrospectively reviewed outcomes in 82 patients with a total of 96 primary or metastatic lung tumors treated by SABR. The cohort included 47 central and 49 peripheral tumors and all were treated with 50 Gy in 4-5 fractions. Outcomes and radiation-associated toxicities were compared between the two groups, not including patients in whom central and peripheral tumors were concurrently treated (8 such patients). Dosimetric analysis was performed on patients with central tumors to determine max point dose (MPD) and volumetric max dose (Vmax) to central structures. Results: Median follow-up time was 15 months (range 1 to 59 months). Median overall survival was 34 and 40 months (p=0.75) for patients with central and peripheral tumors, respectively. We observed no hemoptysis and no grade 5 toxicities. Rates of symptomatic toxicity were higher in patients with central tumors (grade 2+, 38% vs. 11%, p=0.0056) but were equivalent for severe toxicity (grade 3+, 5.4% vs. 5.4%, p=0.93). The vast majority of toxicities were due to radiation pneumonitis, incidence of which was significantly greater in patients with central tumors (grade 2+, 30% vs. 2.7%, p=0.0021; grade 3+, 5.4% vs. 0%, p=0.15). Dosimetric analysis of 36 central tumor treatment plans revealed that 23 (64%) exceeded at least one of the dose constraints used in RTOG 0813, most commonly for central airway. Rates of grade 2+ pneumonitis were not significantly different between patients exceeding RTOG 0813 central airway dosing constraints vs. those meeting them (24% vs. 20%, p=0.69), but trended towards significance for grade 3+ radiation pneumonitis, with patients exceeding RTOG 0813 central airway dosing constraints experiencing higher rates (0% vs. 13%, p=0.095). Conclusions: Central lung tumor patients treated with SABR appear to have greater risk for symptomatic radiation pneumonitis than patients with peripheral tumors. Exceeding RTOG 0813 dosimetric constraints for central airway may predispose to higher risk for severe radiation pneumonitis. Citation Format: Aadel A. Chaudhuri, Chad Tang, Nicholas Trakul, Jacob Wynne, Billy Loo, Maximilian Diehn. Increased rates of radiation pneumonitis in patients receiving stereotactic ablative radiotherapy for central versus peripheral lung tumors. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 864. doi:10.1158/1538-7445.AM2014-864

Increased Rates of Pneumonitis in Patients Receiving Stereotactic Ablative Radiation Therapy for Central Versus Peripheral Lung Tumors

Recently there has been controversy in the literature regarding treatment of central lung tumors with stereotactic ablative radiation therapy (SABR) from a toxicity standpoint, with RTOG 0813 designed to help address this issue. Here we report our institution’s experience in treating central lung tumor patients with SABR, compared to similarly treated peripheral lung tumors.

Simple Clinical Factors Associated With Radiation-Induced Lung Toxicity After Stereotactic Body Radiation Therapy in Lung Cancer: A Pooled Analysis of 70 Studies

radiation therapy (SABR) from a toxicity standpoint, with RTOG 0813 designed to help address this issue. Here we report our institution’s experience in treating central lung tumor patients with SABR, compared to similarly treated peripheral lung tumors. Materials/Methods: We retrospectively reviewed outcomes in 82 patients with 96 primary or metastatic lung tumors treated by SABR. The cohort included 47 central and 49 peripheral tumors; all were treated with 50 Gy in 4 to 5 fractions. Outcomes, toxicities, and dosimetric parameters were compared between the 2 groups, not including patients in whom central and peripheral tumors were concurrently treated (8 such patients). Results: Median follow-up time was 15 months (range 1 to 59 months). Median overall survival was 34 and 40 months (PZ.75) for patients with central and peripheral tumors, respectively. We observed no hemoptysis, and no grade 5 toxicities. Rates of symptomatic (grade 2+) toxicity were higher in patients with central tumors by both univariate analysis (38% vs 11%, PZ.0056, HRZ3.7) and multivariate analysis (PZ.02, HRZ3.9), but were equivalent for severe (grade 3+) toxicity (5.4% vs 5.4%, PZ.93, HRZ1.1). The vast majority of observed toxicities were due to symptomatic pneumonitis, incidence of which was significantly greater in patients with central tumors by both univariate analysis (30% vs 2.7%, PZ.0021, HRZ6.5) and multivariate analysis (PZ.02, HRZ11.1). These patients also had higher rates of severe pneumonitis that trended towards significance (5.4% vs 0, PZ.15, HRZ7.6). Dosimetric analysis revealed that the central tumor patients in our study experienced significantly greater ipsilateral mean lung doses than their peripheral tumor counterparts (7.33 vs 5.15 Gy, PZ.0058). Total mean lung dose and total lung V20 were not significantly different between the 2 populations. Further analysis of the 35 available central tumor treatment plans revealed that 23 (66%) exceeded at least 1 of the dose constraints used in RTOG 0813, most commonly for central airway. Rates of symptomatic pneumonitis were not significantly different between patients exceeding RTOG 0813 central airway dosing constraints versus those meeting them (25% vs 20%, PZ.64), but trended towards significance for severe pneumonitis, with patients exceeding RTOG 0813 central airway dose constraints experiencing higher rates (0 vs 13%, PZ.10). Conclusions: Central lung tumor patients treated with SABR appear to experience higher rates of symptomatic pneumonitis compared to patients with peripherally located lung tumors, which grossly correlates with increased ipsilateral mean lung dose. Exceeding RTOG 0813 dosimetric constraints for central airway may predispose to higher risk for severe radiation pneumonitis. Author Disclosure: A. Chaudhuri: None. C. Tang: None. N. Trakul: None. J. Wynne: None. B.W. Loo: E. Research Grant; Varian, RaySearch Laboratories. F. Honoraria; Varian. M. Diehn: E. Research Grant; Varian, RaySearch Laboratories. F. Honoraria; Varian. G. Consultant; Varian.

Pulmonary Atelectasis after Stereotactic Ablative Radiotherapy for a Central Lung Tumor

Pulmonary Atelectasis after Stereotactic Ablative Radiotherapy for a Central Lung Tumor

An Atypical Presentation with Diagnostic Challenge of a Large Cell Neuroendocrine Cancer of Lung: A Case Report and Review of the Literature.

Large-cell neuroendocrine carcinomas (LCNECs) are relatively rare and aggressive neoplasms of the lung with very poor prognosis. Even though they are included in the classification of nonsmall cell carcinomas, they have a biological behaviour and physiological response to treatment more like small cell carcinomas of lung. We report an atypical case presentation of LCNEC in a 51-year-old gentleman who presented with diffuse metastases to the thoracic and lumbar spine, brain, and liver, posing a diagnostic challenge. The primary small central lung tumor was in close proximity to major vessels, rendering a biopsy of the primary cancer challenging and nearly impossible. The final diagnosis was established through immunohistochemistry staining and examination of liver biopsy from a metastatic lesion. We also included a review of the current literature pertinent to LCNEC, as well as the important role of tumor markers plus immunohistochemistry profiles in determining the origin of unknown primary tumors in such difficult patient presentations.

Bilious pericardial effusion at initial presentation in a patient with lung cancer

BackgroundCardiac tamponade as the initial manifestation of metastatic cancer is a rare clinical entity. Furthermore, a thoraco-biliary fistula is another rare complication of echinococcosis due to rupture of hydatid cysts located at the upper surface of the liver to the pleural or pericardial cavity. We report a case of non-small cell lung cancer with a coexisting hepatic hydatid cyst presenting as a bilious pericardial effusion.Case reportA 66-year-old patient presented with cardiac tamponade of unknown origin. Chest CT-scan demonstrated a left central lung tumor, a smaller peripheral one, bilateral pleural effusions and a hydatid cyst on the dome of the liver in close contact to the diaphragm and pericardium. Pericardiotomy with drainage was performed, followed by bleomycin pleurodesis. The possible mechanism for the bilious pericardial effusion might be the presence of a pericardio-biliary fistula created by the hepatic hydatid cyst.ConclusionsThis is the first case of a bilious pericardial effusion at initial presentation in a patient with lung cancer with coexisting hepatic hydatid cyst.