GYNECOLOGIC ONCOLOGY 46, 235-238 (1992)

CASE REPORT Bronchial Metastases from Ovarian Carcinoma

Report of a Case and Review of the Literature

FRANCISCO MATEO,* ELI SERUR,~ AND PETER R. SMITH*”

*Division of Pulmonary Medicine, Department of Medicine and TDepartment of Obstetrics and Gynecology, State University of New York, Health Science Center at Brooklyn, Brooklyn, New York 11203

Received October 28, 1991

A patient with ovarian cystadenocarcinoma developed respi- ratory insufficiency due to bilateral endobronchial metastases, 6.5 years after treatment of the primary tumor. Ovarian cancers frequently metastasize to the pleura and lung parenchyma. Clin- ically significant bronchial metastases are rare. Only three cases have been reported previously. As in our patient, bronchial me- tastases tend to occur after a relatively long interval from di- agnosis of the primary tumor, and survival may be prolonged after their appearance. 0 1992 Academic press, IX.

INTRODUCTION

Tracheobronchial metastases from extrapulmonary ma- lignancies are most common with carcinomas of the breast, kidney, and colon [l-3]. Although pleural and parenchymal lung metastases are frequent with ovarian carcinomas [4], tracheobronchial metastases are rare. Three cases have been reported previously [5-71. We describe a case of ovarian carcinoma with bilateral bron- chial metastases resulting in respiratory insufficiency.

CASE REPORT

A 62-year-old nonsmoking woman para 4014, under- went total abdominal hysterectomy and omentectomy in 1984 for stage IIIb, grade 3 ovarian serous cystadeno- carcinoma. Eight courses of cisplatin, adriamycin, and cyclophosphamide were given after surgery. A “second- look” laparotomy showed no residual tumor later that year. She was well until 1989 when a CT scan showed right pararectal and cul-de-sac masses. A needle aspirate

’ To whom reprint requests should be addressed at Long Island Col- lege Hospital, 340 Henry Street, Brooklyn, NY 11201.

was positive for malignant cells. Chemotherapy with Amonafide was begun in July 1989, but the pelvic masses progressed and it was discontinued. She developed throm- bosis of the subclavian, axillary, and innominate veins due to an indwelling central line and was treated with heparin and broad spectrum antibiotics.

A chest radiograph at this time showed a new lobulated parahilar density in the right upper lobe and a hazy in- filtrate in the superior segment of the left lower lobe. On CT scan the right upper lobe bronchus was obliterated by a mass and finger-like projections extended distally, suggesting mucoid impaction of the segmental bronchi. A second lesion surrounded the left lower lobe bronchus.

Fiberoptic bronchoscopy showed tumor completely ob- structing the right upper lobe and superior segment of the left lower lobe. Biopsy showed adenocarcinoma. A review of the original pathology material indicated that the bronchial tumor was consistent with the ovarian pri- mary. She received seven courses of carboplatin and cy- clophosphamide which was followed by serial CA-125 lev- els and clinical evaluation. The pelvic and thoracic masses remained stable on this regimen.

In July 1990, the patient developed a cough with min- imal sputum production and wheezing that responded poorly to bronchodilator therapy. In addition, the CA- 125 levels had increased. Since the patient was noted to have multifocal disease involving both lungs and pelvis, another attempt at systemic therapy was instituted. Her chemotherapy was changed to 5-fluorouracil, cyclophos- phamide, and actinomycin-D and continued for two courses.

Five months later, (18 months after the lung masses were first noted) she was readmitted with severe dyspnea, cough, and wheezing. She was in respiratory distress with

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236 MATEO, SERUR, AND SMITH

FIG. 1. Chest radiograph showing right upper lobe (closed arrow) and left lower lobe (open arrow) infiltrates.

respiratory rate, 32 per minute; pulse, 110 per minute; BP, 100/60. There was loud stridor over the trachea and anterior chest. Inspiratory and expiratory wheezes were heard over both lungs diffusely. Arterial blood gases on room air were pH 7.45; PaCO,, 41 mmHg; and PaO,, 52 mmHg. Chest radiograph (Fig. 1) showed progression of the infiltrates in the right upper and left lower lobes. A CT scan (Fig. 2) showed the right upper lobe mass pro- truding into the right main bronchus resulting in almost complete obstruction. She was unable to perform pul- monary function tests because of respiratory distress.

She was started on 40 mg Solu-Medrol every 6 hr in- travenously and radiation therapy to the right upper lobe and left lower lobe. Over the ensuing 2 weeks, her res- piratory distress and hypoxemia improved and she was discharged to continue radiation and taper the steroids as an outpatient. A total of 3160 rad was administered to the lungs and mediastinum over a 3.5week period. Persistent thrombocytopenia developed and radiotherapy was discontinued. In February 1991, (22 months after appearance of bronchial metastases), she developed mul- tiple brain metastases, deteriorated rapidly, and expired.

DISCUSSION

Thoracic metastases from solid extrathoracic tumors occur frequently. Clinically significant tracheobronchial metastases, however, are uncommon. Lesser degrees of involvement of the tracheobronchial tree including only microscopic deposits, may be seen in 18 to 50% of such neoplasms, but symptomatic or radiographically visible disease occurs in less than 5% [2]. In combining data from three large reviews [l-3], breast and renal malig- nancies each accounted for about 25% of reported tra- cheobronchial metastases. Colorectal cancer, sarcomas, uterine and cervical cancers, and melanoma were re- sponsible for another 33%. The remainder included a few cases each of thyroid, testicular, prostatic, pancreatic, choriocarcinoma, and adrenal carcinomas, and three re- ports of ovarian carcinoma [5-71.

Clinically significant tracheobronchial metastases are symptomatic in more than 80% of cases diagnosed an- temortem [1,2]. The remainder are identified only on radiographic studies. The clinical picture and radiographic findings are usually indistinguishable from primary bron-

CASE REPORT 237

Fl< ;. 2. CT scan showing endobronchial tumor mass (closed arrow) protruding into the right main bronchus from the right upper lobe with distal mucoid impactions (open arrows).

chogenic tumors. Cough and hemoptysis are the most common symptoms. Dyspnea and wheezing are some- times present [l-3]. In two patients reported by Baum- gartner and Mark [3], tracheal involvement resulted in stridor and respiratory distress. In our patient, cough was a troublesome symptom for months. As her disease pro- gressed, she developed severe respiratory distress, es- pecially on exertion. Due to the location and extent of her airway lesion, stridor and wheezing became promi- nent, simulating upper airway obstruction.

Segmental or lobar atelectasis are the most frequent radiographic findings of bronchial metastases [l-3]. Par- tial collapse of the left lower lobe was found in our pa- tient. In addition, the right upper lobe lesion resulted in changes consistent with multiple mucoid impactions.

Tracheobronchial metastases not infrequently appear after a long interval from the primary diagnosis. The mean duration was 5 years in Baumgartner and Mark’s series [3], with a maximum interval up to 14 years in the cases collected by Fitzgerald [2]. This relatively indolent bio- logical behavior may support a more optimistic approach

to treatment [3]. In our case bronchial involvement be- came apparent 5 years after treatment of the primary. There was slow progression over the ensuing 1.5 years, while she was receiving a variety of chemotherapeutic agents.

The lungs and pleura together are the most frequent sites of distant spread of ovarian carcinoma in postmortem [4] and clinical series [8]. Prognosis after the appearance of most types of thoracic metastases is generally poor, with a median survival of 6 to 7 months [8]. By contrast, patients with bronchial metastases may have a better prognosis. Patient characteristics and survival data for our case and the three previously reported cases of bronchial metastases are shown in Table 1. The interval from initial diagnosis to the appearance of bronchial metastases was long in three of four patients (4-12 years). As noted above, this long latency has been observed with bronchial metastases from other primary sites [l-3].

Survival after diagnosis of bronchial metastases from ovarian cancer may also be prolonged. Two of the pre- viously reported patients were well 6 and 24 months fol-

238 MATEO, SERUR, AND SMITH

TABLE 1 Summary of Cases of Ovarian Carcinoma with Bronchial Metastases

Case (ref.)

1 (5) 2 (6)

3 (7)

4 (Present)

Age at primary diagnosis

44 47

4.5

62

Histology

Granulosa cell Papillary colloid

adenocarcinoma Serous cyst-

adenocarcinoma Serous cyst-

adenocarcinoma

Interval to bronchial

metastases (yea=)

Simultaneous 4

12

5

Survival after diagnosis of

Site Treatment bronchial metastases

Right middle lobe Pneumonectomy Well at 6 months Right lower lobe Lobectomy Well at 24 months

Right lower lobe Lobectomy Not reported

Right upper lobe Left lower lobe

Chemotherapy, Expired at 22 months corticosteroids, from brain radiotherapy metastases

lowing resection of the metastases. Our patient lived 22 months after the appearance of bronchial metastases, with rather indolent disease. High-grade bronchial obstruction and respiratory insufficiency developed only toward the end of her illness and then responded quite promptly to corticosteroids and radiotherapy.

REFERENCES

1. Braman, S. S., and Whitcomb, M. E. Endobronchial metastases, Arch. Intern. Med. l35, 543-547 (1975).

2. Fitzgerald, R. H. Endobronchial metastases, South. Med. J. 70,440- 441 (1977).

3. Baumgartner, W. A., and Mark, J. B. D. Metastatic malignancies

4.

5.

6.

7.

8.

from distant sites to the tracheobronchial tree, J. Thorac. Cardiovmc. Surg. 79, 499-503 (1980).

Kerr, V. E., and Cadman, E. Pulmonary metastases in ovarian can- cer: Analysis of 357 patients, Cancer 56, 1209-1213 (1985).

Freedlander, S. S., and Greenfield, J. Hemoptysis in metastatic tu- mors of the lung simulating bronchogenic carcinoma, 1. Thoruc. Surg. 12, 109-116 (1942).

Seiler, H. H., Clagett, D. T., and McDonald, J. R. Pulmonary re- section for metastatic malignant lesions, J. Thorac. Surg. 19, 655- 675 (1950).

Merrill, C. R., and Hopkirk, J. A. C. Late endobronchial metastasis from ovarian tumor, Br. J. Div. Chest 76, 253-254 (1982).

Danplat, J., Hacker, N. F., Nieberg, R. K., Berek, J. S., Rose, T. P., and Sagae, S. Distant metastases in epithelial ovarian carci- noma, Cancer 60, 1561-1566 (1987).