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J Thorac Cardiovasc Surg 2008;135:704-705
© 2008 The American Association for Thoracic Surgery

Brief Communication

Visualization of bronchoalveolar fistula as the presenting sign of lung cancer

Francesco Givigliano, MD, Antonello La Rocca, MD, Michele Salati, MD, Luigi Busiello, MD, Carmine La Manna, MD, Francesco Scognamiglio, MD, Gaetano Rocco, MD, FRCS (Ed), FECTS*

Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy

Received for publication August 22, 2007; accepted for publication October 17, 2007.

* Address for reprints: Gaetano Rocco, MD, FRCS (Ed), FECTS, Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Via M. Semmola, 81, 80131, Naples, Italy. (Email: Gaetano.Rocco{at}btopenworld.com).

The incidence of pneumothorax resulting from bronchoalveolar fistula complicating primary or secondary lung cancer ranges between 1% and 4%.1Go Because of the rarity of this condition (4 cases out of 663 admissions for lung cancer [0.4%] during a 2-year period in our institution), preventing the accumulation of large numbered series, and the anecdotal nature of the reported cases, it has not been possible to investigate the pathophysiology and codify the possible therapeutic pathways indicated in the management of this particular type of pneumothorax.

Clinical Summary

An asymptomatic 52-year-old woman was referred to our attention for the detection on a chest radiogram of a total collapse of the right lung. After chest drain insertion, a computed tomographic scan showed a 5-cm right upper lesion with no obvious mediastinal nodal enlargement. The surgical approach entailed a right video-assisted thoracoscopy to rule out pleural dissemination; a subpleural tear in the pulmonary mass in the upper lobe was identified (Go Figure 1). During the same session, a right upper lobectomy with complete mediastinal nodal dissection was performed via a right totally muscle-sparing hybrid (video-assisted/open) approach. The final pathologic report showed a pT2 N0 adenocarcinoma.


Figure 1
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  		Figure 1. Radiologic evidence of the total collapse of the right lung (A), computed tomographic demonstration of the right upper lobe cancer (B), and the thoracoscopic view of the subpleural parenchymal tear (C).

 
Both non–small cell and small–cell lung cancers have been associated with pneumothorax either as a presenting sign or as a treatment-related complication. When primary lung cancer manifests itself in young patients with a spontaneous pneumothorax, the prognostic outlook is considered acceptable because an early diagnosis often leads to early treatment.2Go Conversely, if the pneumothorax appears late in the course of the disease, it generally portends an ominous prognosis.3,4Go

Extrathoracic malignant tumors can equally metastasize to the lung and virtually all histotypes have been associated with the onset of a pneumothorax. The etiopathogenesis of the pneumothorax can be multifactorial,1,2Go and the same side as the cancer or the contralateral side can be affected depending on whether the actual tumor is the direct cause of the pneumothorax.

The treatment of this condition depends on the patient's age and performance status, cardiorespiratory functional reserve, and life expectancy. The ideal situation is to radically treat the cancer by a formal resection or by lung volume reduction surgery as per recent reports.3-5Go However, when this is not feasible, alternative management aimed primarily at achieving pleurodesis3Go should be considered after an adequate, but not prolonged, observation period (up to 2 weeks).

References

  1. Srinivas S, Varadhachary G. Spontaneous pneumothorax in malignancy: a case report and review of the literature. Ann Oncol 2000;11:887-889.[Abstract/Free Full Text]
  2. Pohl D, Herse B, Criee CP, Dalichau H. Spontaneous pneumothorax as the initial symptom of bronchial cancer. Pneumologie 1993;47:69-72.[Medline]
  3. Suter M, Bettschart V, Vandoni RE, Cuttat JF. Thoracoscopic pleurodesis for prolonged (or intractable) air leak after lung resection. Eur J Cardiothorac Surg 1997;12:160-161.[Abstract/Free Full Text]
  4. Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:924-926.[Abstract/Free Full Text]
  5. Nakamura H, Takamori S, Miwa K, Fukunaga M, Maeshiro K, Matsuo T, et al. Rapid-growth lung cancer associated with a pulmonary giant bulla: a case report. Kurume Med J 2003;50:147-150.[Medline]




This Article
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Antonello La Rocca
Michele Salati
Carmine La Manna
Francesco Scognamiglio
Gaetano Rocco
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