Survival of biphasic pulmonary blastoma

Survival of biphasic pulmonary blastoma

ARTICLE IN PRESS Respiratory Medicine (2006) 100, 1174–1179 Survival of biphasic pulmonary blastoma Serife Tuba Limana,, Tamer Altinokb, Salih Topcu...

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ARTICLE IN PRESS Respiratory Medicine (2006) 100, 1174–1179

Survival of biphasic pulmonary blastoma Serife Tuba Limana,, Tamer Altinokb, Salih Topcua, Abdullah Irfan Tastepeb, Ali Uzarc, Sedat Demircand, Funda Demirage a

Thoracic Surgery Department, The Faculty of Medicine, Kocaeli University, Kocaeli, Turkey Thoracic Surgery Department, Ataturk Chest Disease and Thoracic Surgery Center, Ankara, Turkey c Thoracic Surgery Department, Alanya State Hospital, Antalya, Turkey d Thoracic Surgery Department, The Faculty of Medicine, Gazi University, Ankara, Turkey e Pathology Department, Ataturk Chest Disease and Thoracic Surgery Center, Ankara, Turkey b

Received 8 June 2005; accepted 25 October 2005

It was presented at the 14th European Respiratory Society Annual Congress in Glasgow, UK, September 4–8, 2004.

KEYWORDS Pulmonary blastoma; Thoracic surgery; Survival

Summary Pulmonary blastoma is a rare malignant lung tumor with a poor prognosis. It is composed of immature mesenchymal and epithelial components that resemble fetal lung tissue. We aimed to share our treatment results in biphasic pulmonary blastoma. In Ataturk Chest Disease and Thoracic Surgery Center, five patients with biphasic pulmonary blastoma (four men, one woman, aged between 27 and 61—mean 39.4) were treated between 1987 and 2000 (0.3% of operated NSCC). Hemoptysis, cough, chest pain and dyspnea were the symptoms. Anemia and high erythrocyte sedimentation rate were determined in two patients. Radiological examinations revealed a mass in four patients and massive pleural effusion in one. None of the patients were diagnosed preoperatively and hence all patients underwent exploratory thoracotomy. Three lobectomy, one pneumonectomy and one wedge resection were performed. Histopathological examinations revealed biphasic pulmonary blastoma in all the patients. Pathological stagings were as follows: 1 patient in T1N0M0 and 1 patient in T2N0M0 (198 and 112 months survival, respectively), three patients in T2N1M0 (9,10,17 months survival). In follow up period, prostate carcinoma and rectum carcinoma were detected as second primary tumors in the patient in stage T2N0M0. In patients who have small size tumors without nodal involvement, long-term survival can be obtained with radical surgery; even in biphasic pulmonary blastomas.

Corresponding author. +90 262 3037 407; fax: +90 262 3038 003.

E-mail address: [email protected] (S.T. Liman). 0954-6111/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2005.10.026

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1175 According to our limited experiences, N1 nodal involvement shows very poor prognosis. & 2005 Elsevier Ltd. All rights reserved.

Introduction Pulmonary blastomas (PB) are malignant tumors of uncertain histogenesis that histologically resembles the developing in early fetal life. It was hypotesized that it originated from immature pulmonary ‘‘blastema’’ pleuropotential tissue capable of differentiating into both mesenchymal and epithelial portions of the peripheral lungs.1 There are seen very rarely, 0.5% of all primary lung tumors.2 PB are divided into three sub-groups: biphasic pulmonary blastoma (PB), well differentiated fetal adenocarcinoma (WDFA) and pleuropulmonary blastoma (PPB). WDFA are tumors which contains epithelial malignant component without mesenchymal malignancy. PPB indicates tumors with mesenchymal malignancy but without epithelial malignant component. PB are chacterized by a dual or biphasic immature cellular component both are malignant (epithelial and mesenchymal). Here we presented five biphasic pulmonary blastoma and the results of our treatment.

Patients Between 1987 and 2000, we operated 1411 cases with NSCLC in Ataturk Chest Disease and Thoracic Surgery Center. Five of them were biphasic PB (0.3%). There was a male predominance in the patients with PB. Their ages ranged between 27 and 61 years. Three of them were smokers. Patients’ characteristics were summarized in Table 1. The most frequently seen complaints were cough, hemoptysis and chest pain. Anemia and high erythrocyte sedimentation rates were detected in two patients with big tumors. Chest X-ray and thorax tomography were performed in all patients (Figs. 1 and 2). In four patients, radiological examinations revealed solitary pulmonary mass. In one patient, first examinations showed massive pleural effusion and empyema was detected via thoracentesis. After chest tube drainage, solitary big pulmonary mass was observed in his chest X-ray. Tumors were located in lower lobes in three patients, in upper lobe in one and in middle lobe in one patient.

Bronchoscopy was performed in all patients and endobronchial tumor was observed in three. But bronchoscopic biopsy was not diagnostic in those patients. Diagnosis could not be obtained in all of the patients preoperatively and they all underwent thoracotomy. Wedge resection was performed in one patient, lobectomy in three and pneumonectomy in one patient. Wedge resection was performed since frozen section examination could not be performed. He was advised to have a second operation, but he refused. When recurrences was detected in his 3 months follow up after surgery, he accepted the operation and lobectomy was performed. Staging was defined in accordance with the lung cancer staging system. Survivals were measured from the time of diagnosis.

Results All patients were diagnosed as biphasic pulmonary blastoma after histopathological examination of the specimens. Lymph node involvement were detected in three cases with larger tumors (Table 1). There were one patient in T1N0M0, one pateint in T2N0M0 and three patients in T2N1M0. Bronchopleural fistula was occured in the patient who underwent pnemonectomy (T2N1M0). Thoracomyoplasty was performed as a second operation in that case. In his follow up period local recurrence was developed. Esophageal and cardiac involvement were detected. He had 4000 rad radiotherapy. But treatment was unsuccessful and he died in his 9th month of follow up period. In two patients (T2N1M0) systemic metastasis were detected in follow up and chemotherapy was given. But there was no response to chemotherapy and they died. Survivals of those patients were were 10, 17 months. Two patients with tumors 3 cm (T1N0M0) and 3.6 cm (T2N0M0) in size had long-term survivals, 198 and 112, respectively. First patient is still alive. Two different carcinoma were occurred in the second patient while follow up. He was given treatment for prostate carcinoma and

28, m Cough, chest pain 27, f Cough, chest pain, hemoptysis

Ii

54, m Hemoptysis

V

No positive finding

Diminished respiratory sounds

No positive finding

Anemia, high ERS, leucocytosis, empyema

+

Right lower lobe, — 6.5 cm

Right middle lobe, 17 cm

No positive Left lower lobe, + finding 3 cm Anemia, high ERS Right upper lobe, — 6 cm

No positive finding No positive finding

Rll

Rp tmp

Rul

Wedge LLL

Rll

Endobronchial Operation lesion

Right lower lobe, + 3.6 cm

Localization, diameter

No positive finding

Laboratory examinations

No positive finding

Physical examination

T2n1m0

T2n1m0

T2n1m0

T1n0m0

T2n0m0

Tnm



Vincristine+cyclophosphamide, 3 — cures

4000 rad RT

Survival (month)

17 died Bone, liver, brain metastatis (nasocomial pneumonia) 9 died (local recurrence, esophagial and cardiac involvement) 10 died (bone metastasis)

Prostat ca, 112 died dilated rectal cardiomyopathia carcinoma — 198 alive

Additional disease

Vincristine+Cyclophosphamide, 3 — cures, I˙fosphamid+Etoposite, 2 cures





Additional treatment

M: male, F: female, ERS: erythrocyte sedimentation rate, RLL: right lower lobectomy, LLL: left lower lobectomy, RUL: right upper lobectomy, RP: right pneumonectomy, TMP: thoracomyoplastia.

27, m Cough, hemoptysis, fever, dyspnea

Iv

Iii

61, m Cough, chest pain

I

Symptoms

Characteristics of the patients.

Number Age, sex

Table 1

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1176 S.T. Liman et al.

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Figure 1 Posteroanterior and CT scan appearance of lobulated circumscribed large mass with heterogenous enhancement in the middle lobe of the right lung.

rectal carcinoma and he died because of the complications of chemotherapy for rectal carcinoma in his 112th months.

Conclusion Pulmonary blastomas (PB) are rarely seen tumors. They are composed of both mesenchymal and epithelial components which resemble fetal lung tissue morphologically with a frequency of only 0.5% of all primary lung tumors.2 It has been shown that the tumor arises from the endodermal tissue or that it originates in pleuropotential stem cells.3,4 Some authors consider pulmonary blastoma to represent a variant of carcinosarcoma.5 There were three types of PB. Biphasic PB have two malignant components; epithelial and mesenchymal. The prognosis of biphasic blastoma is much worse than the others.

1177

Figure 2 Posteroanterior and CT scan appearance of a solitary mass in the right lower lobe.

The etiology and predisposing factors are not still fully understood. In the literature, there is strong evidence showing the correlation between cigarette smoking and PB.6,7 They may occur at all ages but predominantly common in adults (the peak incidence in the fourth decade of life). There is a male predominance.2 When compared to the operated nonsmall cell lung carcinomas, PB are rare, large and symptomatic tumors which affect younger age groups and have poor prognosis.8 Approximately 60% of the patients are symptomatic.9–11 All of our patients were symptomatic. We detected anemia in two patients who had larger tumors and nodal involvements. Biphasic blastomas are usually located in the periphery of the lung.12 Only 25% exhibit endobronchial growth.13,14 Three of our patients had endobronchial tumor but bronchoscopic biopsies

ARTICLE IN PRESS 1178 were not diagnostic. Pleural effusions occur in a minority of cases. It sometimes may be infected causing empyema like in one of our patients. Considerable immunoreactivity for alpha-fetoprotein (AFP) was reported in the literature.15,16 It was pointed out that the epithelial cells of PB might occasionally de-differentiate into cells functionally resembling fetal hepatic, foregut and yolk sac cells expressing AFP.15 Unfortunately AFP levels were not measured in our patients. In radiological examinations, PB manifest as a solitary pulmonary nodule or mass with a smooth margin because of the desmoplastic change surrounding the mass. Generally, the tumor has massive necrosis.17 The tumor rarely appear to be cavitated, calcified or multiple. Despite bronchoscopy, mediastinoscopy, thoracoscopy, percutaneous and transbronchial biopsies, PB cannot be diagnosed preoperatively due to the lack of cellular material and extensive necrosis of the lesions.18 We also could not diagnose pulmonary blastoma preoperatively. The best treatment of pulmonary blastoma is surgery in the early stages of the disease. Adjunctive therapy is still controversial because of lack of data. Rare cases, which have good responds to chemotherapy and radiotherapy, have been reported in the literature whereas in the majority of cases recurrences are seen.19–21 Cutler et al. treated and reviewed the chemotherapy literature for PB and recommended cisplatin and etoposide treatment as effective regimes.15 Neoadjuvant chemotherapy for downstaging advanced tumors can be used before surgical resections.7 Recurrences are mostly seen with the incidence of 43%, 1–11 months after surgery.18 Recurrences most commonly occur in the brain, mediastinum, pleura, liver, diaphragm, heart and soft tissues of extremities.18 Nodal involvement is almost always associated with the tumor size and also poor prognosis in biphasic PB.6 Based on our limited experience, resection of small tumors, which do not have any lymph node involvement, can provide better survival without any additional treatment. Wedge resection should not be performed in PB. In one of our patient, there was a recurrence due to the inadequate surgical procedure (wedge resection). That patient underwent second operation, he did not have any nodal involvement and he has the best survival time in this small serie. In our cases adjuvant chemotherapies were not effective. Finally, in the patients with small size tumors, which do not have nodal involvement, long-term survival can be obtained with surgery even if it is

S.T. Liman et al. biphasic pulmonary blastoma. According to our limited experiences, N1 nodal involvement shows very poor prognosis even tumor is resected completely. Unfortunately, we still do not know the efficiency of the adjuvant chemotherapy and radiotherapy treatment. Multi-institutional treatment protocols in a sufficient number of patients should be performed.

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