Primary Lung Cancer Presenting Research Articles

A simple and safe surgical technique for nonpalpable lung tumors: One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH).

When performing thoracoscopic partial resections of nonpalpable lung tumors such as ground-glass opacities (GGOs) and small tumors, detecting the location of the lesion and assessing the resection margins can be challenging. We have developed a novel method to ease this difficulty, the One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH), which uses a hybrid operating room wherein the operating table is seamlessly integrated with cone-beam computed tomography (CBCT). We performed the OS-MRCH method on 62 nodules including primary lung cancer presenting with GGO. Identification of the lesion and confirmation of the margin were performed in 58 of the cases, while nodules were detected in all. The frequency of computed tomography (CT) scans performed prior to resection was one time in 51 cases, two times in eight cases, and ≥3 times in three cases. Additional resection was performed in two cases. The median operative time was 85.0 minutes, and the median pathological margin was 11.0 mm. The key advantages of this method are that all surgical processes can be completed in a single session, specialized skill sets are not required, and it is feasible to perform in any facility equipped with a hybrid operating room. To overcome its disadvantages, such as longer operating time and limited patient positioning, we devised various methods for positioning patients and for CT imaging of the resected specimens. OS-MRCH is a simple, useful, and practical method for performing thoracoscopic partial resection of nonpalpable lung tumors.

PRIMARY LUNG ADENOCARCINOMA PRESENTING AS CARDIAC TAMPONADE

PRIMARY LUNG ADENOCARCINOMA PRESENTING AS CARDIAC TAMPONADE

Metachronous, Ipsilateral Primary Lung Cancer: A Case Report

Lung cancer is the most common malignant tumor in men worldwide. It has been documented that patients can develop multiple primary lung cancer, with a 5% annual risk of a second primary (metachronous) cancer occurring after prior curative treatment. Moreover, there has been an increase in the incidence of metachronous primary lung cancer reflecting a longer survival after curative resection of the primary cancer and improvements in patient surveillance methods. Herein, we present a case of a patient diagnosed with a metachronous primary lung cancer presenting 1 year after treatment of a primary lung cancer at National Chest Hospital, Kingston, Jamaica. Through strict adherence to surveillance guidelines, this metachronous cancer was detected, enabling the patient to be promptly treated.

Tailing effect of PD-1 antibody results in the eradication of unresectable multiple primary lung cancer presenting as ground-glass opacities: a case report

There is currently no standard treatment for multiple primary lung cancer (MPLC). We report a case of synchronous MPLC presenting as one ground-glass opacity (GGO) with predominant consolidation accompanied by at least parietal pleura involvement, and another with >30 GGOs distributed across bilateral lungs, which was ineligible for complete resection. CT-guided percutaneous biopsy of the nearly pure-solid mass showed invasive lung adenocarcinoma mainly composed of acinar type. Capture-based, ultra-deep targeted sequencing (Burning Rock, Guangzhou, China) was performed on the tumor tissue biopsy. The result revealed no druggable mutations according to the guideline and a high TMB of 34.1 Mb. Immunohistochemical staining (22C3; Dako, Denmark) was positive for PD-L1 expression with a tumor expression level of 30%. Based on the clinical information and patient's decision, he received 3 cycles of pemetrexed plus pembrolizumab and was subsequently forced to withdraw due to acquired immune-related pneumonitis. After discontinuation of corticosteroids, he was subjected to wedge resection for the nearly pure-solid lesion, and then refused further treatment for the other tumors. After a follow-up of 12 months from termination of immunotherapy, almost all GGOs achieved radiographically complete remission, attributed to the tailing effect of the programmed cell death protein 1 (PD-1) antibody of pembrolizumab. Through the case study we found that unresectable synchronous MPLC presenting as GGOs may respond well to immunotherapy.

S3050 Gastric Mass as a Rare Presentation of Primary Lung Carcinoma

INTRODUCTION: Symptomatic gastrointestinal metastases are a rare initial presentation of primary lung cancer. The most common sites of lung cancer metastasis are lymph nodes, liver, adrenal glands, bone, and brain. Gastric metastases are often asymptomatic. We report a case of a gastric mass as the initial clinical manifestation of primary small cell lung cancer (SCLC). CASE DESCRIPTION/METHODS: An 82 year old woman with past medical history of hypertension and asthma presented with a complaint of abdominal pain, abdominal distention, and associated shortness of breath for one month. She also endorsed nausea and weight loss (∼25 lbs). She is a former smoker, quitting 19 years prior. Physical exam was notable for moderate abdominal distention with positive fluid wave. CT abdomen showed large volume ascites and an ill-defined mass of the stomach originating from the lesser curvature and extending into the liver hilum, with extensive peritoneal metastatic implants. Paracentesis revealed red-tinged ascitic fluid, with cytology studies suggestive of metastatic cancer of likely gastric origin. Esophagogastroduodenoscopy (EGD) demonstrated external compression of the stomach along the lesser curvature > 5 cm, and two large gastric ulcers >2 cm each with raised edges along the greater curve. Endoscopic ultrasound (EUS) revealed a mixed echogenic gastric mass along the lesser curvature to the antrum abutting the portal vein ( >8 cm longitudinally, and >5 cm vertically), with an area of necrosis (1 cm × 1.5 cm) within the lesion. No vascular flow was identified within the lesion. Additionally, hypoechoic lesions typical of lymph nodes were seen in the mediastinum, celiac axis, and porta hepatis. Pathology report of the tissue biopsy revealed small cell carcinoma, and immunohistochemistry analysis was positive for CD56, TTF-1, and CAM5.2, suggestive of gastric metastasis from primary small cell lung carcinoma. The patient was started on carboplatin/etoposide chemotherapy. DISCUSSION: Small cell lung carcinoma initially presenting with gastrointestinal symptomatology is a rare occurrence. In our patient, the ascitic fluid cytology and the radiologic finding of a large gastric mass were initially suggestive of a primary gastric carcinoma. However, on further staging efforts with EGD/EUS and gastric tissue biopsy, the true primary lesion was revealed to be of lung origin, demonstrating the importance of gastroscopy and detailed immunohistochemistry studies in establishing an accurate diagnosis.

CARDIAC TEMPONADE AS INITIAL PRESENTATION OF ADENOCARCINOMA OF LUNG

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary cardiac tumors are extremely uncommon and mostly cardiac tumors are associated with metastases from secondary tumors. Here we describe a case of a patient with primary lung cancer presenting with cardiac tamponade on initial presentation. CASE PRESENTATION: 70 years old male active smoker who presented to the emergency room for the complain of shortness of breath (SOB).He had Chest x-ray done which showed possible lower lobe infiltrates and was given antibiotics and sent home. He again presented to hospital four days later for worsening SOB. A CTA chest was done to rule out pulmonary embolism (PE) which was negative for PE but showed large pericardial effusion and left upper lobe small nodule. Patient had urgent ECHO done which showed very large effusion with tamponade physiology and also showed masses on free wall of left and right ventricles concerning for metastases. Cardiothoracic surgery was consulted and patient underwent pericardial window procedure. He also underwent CT guided biopsy of lung nodule which was consistent with moderately differentiate adenocarcinoma. His pericardial fluid cytology was also consistent with Metastatic adenocarcinoma. Post operatively patient did well and oncology service was consulted for cancer management. DISCUSSION: Metastatic tumors to heart are rare, although the lung cancer is the most common malignant tumor, review of literature showed only few cases of cardiac metastases associated with lung cancer. Various studies have shown the incidence of cardiac metastases ranging between 2.3% to 18.3% 1. Lung Cancer, melanoma and mediastinal primary tumors are the most common cancers associated with cardiac metastases. Bussani and etal reported adenocarcinoma as the most common lung cancer metastasizes to the heart in 26% of cases, followed by squamous cell carcinoma in 23.4% cases. One study showed Epicardium (88%) and pericardium (5-11%) are the most common site of cardiac metastasis and endocardium (< 3%) is the least involve site. 2 Metastases to heart occurs by direct extension, via blood stream, lymphatics and intracavitary diffusion through either the inferior vena cava or the pulmonary veins. Coronary arteries evaluation is recommended as they get compressed by metastatic tumor.3 Chemotherapy, radiotherapy, and surgery are the treatment options but usually prognosis is poor. CONCLUSIONS: Cardiac metastases are rare and high index of suspicion is required as variety of complications may occur due to metastasis including cardiac tamponade needing urgent pericardiocentesis. In patients with cardiac metastases a thorough evaluation should be performed to find secondary cancers. Reference #1: Bussani R, De-Giorgio F, Abbate A. Cardiac metastases. J Clin Pathol 60: 27-34, 2007. Reference #2: Abe S, Watanabe N, Ogura S. Myocardial metastasis from primary lung cancer: myocardial infarction-like ECG change and pathologic findings. Jpn J Med 30: 213-218, 1991. Reference #3: Butany J, Nair V, Naseemuddin A. Cardiac tumours: diagnosis and management. Lancet Oncol 6: 219-228, 2005. DISCLOSURES: No relevant relationships by Michael Caniglia, source=Web Response No relevant relationships by Adnan Khan, source=Web Response No relevant relationships by Sana Khan, source=Web Response No relevant relationships by Ramsha Zafar, source=Web Response

Impact of preoperative pathological confirmation on surgical and postoperative outcomes of lung resection for early stage lung cancer.

The frequency of detection of peripheral pulmonary lesion (PPL) in suspected early lung cancer has been increasing, and whether preoperative pathological diagnosis (PPD) for small PPLs should always be established before their surgical resection can become a worrisome problem for physicians. The aim of the study was to clarify the impact of obtaining PPD on surgical and postoperative outcomes of lung resection for early stage lung cancer. This was a retrospective review of cases that underwent surgical resection for known or suspected primary lung cancer presenting pathological stage 0 or I, enrolled from June 2006 to May 2016. The patients divided into two groups according to PPD group (n = 57) and non-PPD group (n = 157) were compared. The procedure, node dissection, operation time, amount of bleeding, postoperative complications, postoperative length of stay, and postoperative recurrences were analyzed. Among the 214 patients, no significant differences in operation time (248.5 ± 88.6 versus 257.6 ± 89.0, min, mean ± SD, p = 0.328), amount of bleeding (195.3 ± 176.5 vs 188.1 ± 236.1, ml, p = 0.460), postoperative complication (5.2% vs 4.5%, p = 0.728), postoperative length of stay (10.6 ± 6.3 vs 10.4 ± 5.3, days, p = 0.827), or postoperative recurrences (21.0% vs 17.2%, p = 0.550) were seen between PPD and non-PPD groups. Therefore, PPD had less impact on surgical and postoperative outcomes of pathological stage 0 or I lung cancer; direct surgical resection without non-surgical biopsy would be acceptable with careful selection of cases.

P3.04-045 Primary Lung Cancer Presenting as Pneumothorax: Topic: Miscellaneous II

Analysis of our patients with primary lung cancer presenting as pneumothorax. Between 2010 -2015 we treated in our clinic among 338 adults (258 men and 80 women) presenting with spontaneous pneumothorax, there were nine men and two woman with lung cancer: Seven squamous cell carcinoma, three adenocarcinoma and one oat cell carcinoma. Pneumothorax led to the diagnosis in 11 cases and the remaining occurred as a complication of known neoplastic disease. The average age was 60 years from (32-72 years old). We analyze these 11 cases treated in our hospital. In patients with normal chest x-ray film findings after lung expansion, further investigation for neoplastic disease is not justified. But we need to perform and chest CT and other investigation in patients with, heavy smoking, chronic bronchitis, bullous emphysema and incomplete lung expansion after chest drainage also patients with age over 50 years old. The occurrence of a pneumothorax in patients with lung cancer, worsening prognosis. Five-year survival is poor, suggesting that lung cancers present as pneumothorax at an advanced stage of disease.

Duodenal Metastases from Primary Large Cell Carcinoma of the Lung Presenting with Melena

Introduction: Duodenal metastases from primary lung cancer is very rare and does not usually cause symptoms. We report a case of duodenal metastatic lesions of primary lung origin presenting with melena. Case Report: A 76 year-old male smoker with atrial fibrillation on anticoagulation and chronic obstructive pulmonary disease presented to the emergency department with cough, weight loss and melanotic stools for 1 week. Laboratory studies revealed a hemoglobin (Hb) of 7.7g/dL. Upper and lower endoscopy did not reveal an obvious source of bleeding and the patient was discharged in stable condition. On investigation for progressive cough and shortness of breath, a CT scan was performed and identified a 3cm right hilar mass, precarinal and subcarinal lymphadenopathy, and a 2.4cm soft tissue mass adjacent to the distal duodenum. Bronchoscopy did not show evidence of malignancy and the patient was scheduled for an endobronchial ultrasound (EBUS) with mediastinoscopy. However, due to recurrent episodes of melena with a Hb of 6.6g/dL, EBUS was postponed. Repeat CT scan showed mesenteric lymphadenopathy and thickening of the distal duodenum. An upper endoscopy with push enteroscopy was performed and identifed multiple, large ulcerations in the third and fourth portions of the duodenum without active bleeding. Biopsies were taken and pathology revealed large cell carcinoma consistent with metastases of pulmonary origin. Subsequent EBUS with fine needle aspiration of the lymph nodes confirmed the diagnosis.Figure 1Discussion: Duodenal metastases from primary lung cancer presenting with melena is exceedingly rare and usually indicates terminal stage with poor prognosis. Of the few studies reported to date, the prevalence of small bowel involvement ranges from 0.5% to 10.6%, including results from autopsies. Small bowel metastases have been reported to occur in the setting of gynecologic malignancies (ie. uterine) with jejunal and ileal involvement being the most common. Symptoms from duodenal metastases are infrequent and rarely present at or prior to the time of the cancer diagnosis. Depending on the size and location of the lesions, however, clinical features may include melena with a microcytic anemia, malabsorption, obstruction, and more commonly, perforation. Therefore, metastatic small bowel disease should be included in the differential diagnosis of gastrointestinal bleeding in a patient presenting with constitutional features suggestive of an underlying malignancy.

P1.32: Primary Lung Cancer Presenting as Pneumothorax

P1.32: Primary Lung Cancer Presenting as Pneumothorax

Clinical features of primary lung cancer presenting as pulmonary consolidation mimicking pneumonia

Clinical features of primary lung cancer presenting as pulmonary consolidation mimicking pneumonia

A case of synchronous isolated thyroid metastasis from a primary lung cancer presenting as thyroid primary: Diagnostic challenge!

The thyroid metastasis from any primary is rare, and usually is a late event and presents as a thyroid swelling. Further, the diagnosis of a metastatic lesion in a patient with no antecedent history of any malignancy can be very challenging. Recently, a patient presented to us with a history of diagnostic evaluation suggesting a primary thyroid malignancy with a synchronous lung primary. After surgery for the thyroid swelling, final histopathology revealed a metastatic lesion from a lung primary. Here, we discuss this rare case of isolated synchronous thyroid metastasis from a lung primary and review the relevant literature.

難治性血胸で発症した小細胞肺癌の1例

難治性血胸で発症した小細胞肺癌の1例

Thin-walled cystic lung cancer: an analysis of 24 cases and review of literatures

背景与目的英国学者Anderson和Pierce于1954年首先报道了表现为囊性病变的肺癌。作为少见的肺癌特殊表现类型，薄壁囊性肺癌在临床中经常被误诊。本研究旨在探讨薄壁空洞性肺癌的临床特点、影像学特点，诊断及治疗。方法自2007年3月-2013年12月，解放军总医院胸外科共收治4, 897例原发性肺癌患者，其中24例影像学表现为薄壁空洞型肺癌。我们将影像学上表现为囊性且75%以上囊壁厚度小于4 mm的肺癌定义为薄壁空洞性肺癌。回顾性总结24例病例的临床资料、病理结果及随访情况。结果薄壁空洞型肺癌在我科同期接受手术的肺癌中比例为0.49%（24/4, 897）。其中男性19例，女性5例，平均年龄56.5岁。14例无临床症状，于查体时发现。10例有呼吸道症状。24例患者中18例为腺癌（包括原位腺癌及微浸润腺癌），3例鳞癌，1例大细胞癌，1例小细胞癌，1例腺鳞癌。平均随访时间28个月，3例因肺癌死亡，其余21例未见复发。结论薄壁空洞型肺癌是肺癌少见的影像学表现类型，临床中应避免误诊。其具体形成机制并不明确，可能是肺癌形成的某一阶段。薄壁空洞型肺癌如能早期诊断，可获得较好预后。

Lung cancer presenting as thin‐walled cysts: An analysis of 15 cases and review of literature

Lung cancer presenting as cysts is a rare entity in clinical practice. Differential diagnosis is difficult in the benign-like cyst. We conducted a retrospective analysis of the clinical records of 15 patients who underwent surgery for primary lung cancer presenting as cysts (wall thickness <5 mm) in our department between 2007 and 2012. The whole group underwent postoperative follow-up. The subjects' age ranged from 18 to 80 years with a median age of 58.3 years. Eight cases presented with respiratory symptoms while seven showed abnormal shadows on a chest computed tomography without symptoms. Histological analysis showed that 10 cases were of adenocarcinoma, two of squamous cell carcinoma and one of large cell carcinoma. Two patients died at 13 and 26 months and the remaining 13 patients are alive and disease free at 3-38 months. Cystic lung cancer should be considered in the differential diagnosis of focal benign cyst. Cystic lung cancer could achieve a good outcome if early diagnosis can be obtained.

A Case of Synchronous Presentation of Primary Non-Small Cell Lung Carcinoma and Pheochromocytoma

We report a rare synchronous presentation of primary lung cancer and adrenal pheochromocytoma. A 59-year-old woman was diagnosed with right upper lobe non-small cell lung carcinoma measuring 2.8 cm and a right adrenal gland mass measuring 3.5 cm, which displayed increased metabolic activity on 18F-fluorodeoxyglucose positron emission tomography-computed tomography. The adrenal lesion was revealed to be asymptomatic. The patient underwent right adrenalectomy and histological examination revealed a pheochromocytoma. Ten days later, right upper lobectomy was performed for lung cancer. This case indicates that incidental adrenal lesions found in cases of resectable primary lung cancer should be investigated.

Skeletal muscle metastases as the initial manifestation of an unknown primary lung cancer detected on F-18 fluorodeoxyglucose positron emission tomography/computed tomography

Skeletal muscle metastasis as the initial presentation of the unknown primary lung cancer is unusual. A 65-year-old male patient presented with pain and swelling of the right forearm. Fine needle aspiration of the swelling revealed metastatic squamous cell carcinoma. The patient underwent whole body F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to identify the site of the primary malignancy. The authors present PET/CT images showing FDG-avid metastases to the skeletal muscles along with a previously unknown primary tumor in the right lung, in a patient presenting with initial muscular symptoms without any pulmonary manifestations.

Primary lung cancer presenting with metastasis to the colon: a case report

Although about 50% of lung cancers have distant metastasis at the time of initial diagnosis, colonic metastases are extremely rare. This report presents a rare clinical case of colonic metastasis from primary squamous cell carcinoma of the lung.A 60-year-old female with anorexia and fatigue was referred to the department of pulmonary surgery in our hospital. The patient was diagnosed with primary squamous cell carcinoma of the lung, T2b N3 M1b Stage IV, and chemoradiotherapy was initiated. This treatment led to a good partial response in the primary lung lesion without any new metastatic lesions.The patient developed left abdominal pain due to a bulky sigmoid colon tumor 6 months later, and was preoperatively diagnosed with primary colon cancer. She underwent colonic resection, and the pathology specimen demonstrated poorly differentiated squamous cell carcinoma that was suspected to be colonic metastasis from the primary lung cancer. The postoperative course was uneventful, and she was discharged. Chemotherapy for the lung cancer was scheduled in the department of pulmonary surgery.This report presented a rare case of colonic metastasis from lung cancer. When patients with advanced primary lung cancer complain of abdominal symptoms, we should consider gastrointestinal tract metastasis from lung cancer.

Primary lung cancer presenting as metastasis to the big toe.

A 62-year-old man presented with a 6-week history of shortness of breath, weight loss and painful swelling of the great toe. Examination elicited an ulcerated swelling of the right great toe, thought to be an ingrowing toenail. Chest ‘crackles’ and an enlarged supraclavicular lymph node were detected. Biopsies of the toe swelling and bronchi both showed squamous cell carcinoma, confirmed radiologically as stage IV lung cancer. The patient was referred for palliative amputation of the toe. Cancer metastases to the digits may arise in bone, before enlarging to invade skin, or arise in skin first. 20-60% of cutaneous metastases present before or at the same time as the primary lung tumour. Cutaneous metastases and those in the digits indicate very poor prognosis. Their prompt diagnosis and management can dramatically improve a patient’s quality of life and should be strived for.

Abstract P6-03-05: An Approach for the Differential Diagnosis of Primary Lung Cancer and Breast Cancer Relapse Presenting as a Solitary Pulmonary Nodule in Patients after Breast Surgery

Abstract Background: The distinction of primary lung cancer from metastatic breast cancer is crucial in patients presenting with a solitary pulmonary nodule after breast surgery. However definitive diagnosis of these nodules is often difficult due to similar radiological and pathological features in primary lung and metastatic breast cancer nodules. We assessed the feasibility of our diagnostic approach for these nodules by morphopathological and immunohistochemical examination, and estimated the frequency of primary lung cancer occurrence in breast cancer patients. Material and Methods: We evaluated solitary pulmonary nodules appearing in 24 patients (0.62% : 24/3851) after breast surgery between 1994 and 2006. Patients with metastases to organs other than lungs were not included. For histological examination, CT-guided core needle biopsy (CT-CNB), trans-bronchial lung biopsy (TBLB), or surgical resection was performed. Besides conventional morphopathological examination using HE staining, differential diagnosis was performed by immunohistochemical examination (thyroid transcription factor-1: TTF-1, surfactant pro-protein B: SPPB, estrogen receptor: ER, mammaglobin1: MGB1). The immunopositive results for TTF-1 and SPPB support the specimen diagnosis of primary lung cancer. The immunopositive and immunonegative results for ER and both TTF-1 and SPPB, respectively, suggest that the specimen has a high probability of being metastatic breast cancer. And for cases in which differential diagnosis failed in the morpopathological and TTF-1, SPPB, and ER examination, MGB1 examination was conducted. Several patient and tumor characteristics were evaluated according to the definitive diagnosis of pulmonary nodules in both metastatic breast and primary lung cancer groups, which were then compared using Student's t-test. Results: Biopsy specimens were obtained using minimally invasive methods (CT-CNB and TBLB) in 21 patients (87.5%). Surgical resection was performed for diagnosis and treatment in three patients. Differential diagnosis was obtained by morphopathological methods alone in 18 patients (75.0%, primary lung cancer: 6 cases, metastaic breast cancer: 12 cases) and by immunohistochemical examination in the remaining 6 (25.0%, primary lung cancer: 1 case, metastaic breast cancer: 5 cases). Final diagnosis was metastatic breast and primary lung cancer in 17 (70. 8%) and 7 patients (29.2%), respectively. The mean age was significantly higher in the primary lung than metastatic breast cancer patients group (67 years vs. 57 years: p=0.036). No significant difference in the average diameter of pulmonary nodules was observed between metastatic breast and primary lung cancer patients (2.32cm vs. 2.29 cm). Furthermore, there were no clinical findings between metastatic breast cancer patients group and primary lung cancer group. Conclusions: Our results show the clinical feasibility of our approach to the differential diagnosis of breast cancer relapse and primary lung cancer presenting as a solitary nodule in patients after breast surgery. Further, replication of our findings under independent setting is recommended. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-03-05.