Introduction
Expectoration of tumor tissue is a rare presentation in patients with cancer. Thirty cases of various types of tumor, including primary or metastatic lung cancer, have been reported. Endobronchial metastases from various organs are most common, although 9 primary lung cancer cases have been described, including 4 squamous cell carcinomas, 2 bronchogenic carcinoids, one small cell lung carcinoma, one large cell carcinoma, and one mixed type carcinoma.1–9 Adenocarcinoma of the lung has never been reported. We describe a case of spontaneous expectoration of a piece of lung adenocarcinoma, which enabled a definitive diagnosis of a local recurrence, and led to substantial relief from dyspnea.
Case Summary
A 56-year-old man with a 30-pack-year smoking history presented with respiratory distress. Recurrence of lung cancer was suspected because he had undergone a left upper lobectomy for lung adenocarcinoma (pT1N0M0, stage IA) 18 months earlier. The physical examination revealed no breath sounds on the left side. Bronchoscopy revealed protrusion of a tumor into the trachea from the left main bronchus (Fig. 1A); however, the biopsy specimen yielded only necrotic tissue. Two weeks after bronchofiberscopy he was confined to bed due to severe dyspnea and a forceful productive cough. When he presented to our department, stridor was heard in the anterior neck region, and chest computed tomography revealed a huge mass on the left hilum obstructing the left main bronchus and constricting the trachea (Fig. 2A and 2B). SpO2 was 85% on room air, and the SpO2 increased to 95% while receiving oxygen at 5 L/min via an oxygen mask with a reservoir bag. When he had a paroxysmal cough, he expectorated tumor tissue (18 × 20 × 5 mm, see Fig. 1B) with some bloody sputum. This relieved his dyspnea and forceful cough. The expectorated tumor specimen was pathologically compatible with a recurrence of the previously resected lung adenocarcinoma (see Fig. 1C and D). The stenosis of the trachea was improved on chest computed tomography (see Fig. 2C and D).
Bronchoscopy revealed protrusion of the tumor into the trachea from the left main bronchus (A). Black-and-white arrowheads indicate the inlet of the left main bronchus obstructed by the tumor and the right main bronchus, respectively. The macroscopic finding of the expectorated tumor tissue (B). The pathological findings of the resected primary tumor (C) and expectorated tumor tissue (D). Adenocarcinoma cells were found in both specimens.
Computed tomography showed a huge mass on the left hilum, obstructing the left main bronchus and constricting the trachea (A and B). The arrow indicates the airway obstruction caused by the tumor growing into the trachea. The stenosis of the trachea improved after the tumor tissue was expectorated (C and D).
Discussion
Tumor expectoration is a rare presentation in patients with various tumors. Since Walshe et al described expectorated tumor fragments in sputum in 1843,1 30 cases have been reported (Table). The most frequent tumor was renal cell carcinoma (8 cases, 26.7%),10–13,15 followed by primary lung cancer and sarcoma (7 cases each, 23.3% each).1–4,6–8,16–21 Twenty-four cases (80.0%) were observed in men. Tumor expectoration occurred at either the initial presentation (36.7%) or at the time of recurrence (46.7%). It was observed immediately after bronchofiberscopy3,7,26 in 3 cases, while it occurred spontaneously in the other cases.
Characteristics of Cases of Tumor Expectoration
Tumors showing endobronchial growth are prone to exfoliate into the airway.9,16,17,21 As seen in our case, tumor expectoration might lead to pathological information and could relieve the respiratory symptoms. Histologically, adenocarcinoma accounts for a large proportion of cases in non-small-cell lung cancer worldwide; however, there has been no report of tumor expectoration in a patient with adenocarcinoma of the lung. One explanation for the phenomenon may be the characteristics of the disease: the primary site is usually located in the peripheral lung and would be unlikely to involve a central airway, leading to tumor expectoration. Conversely, squamous cell carcinoma of the lung often involves central lesions.
In conclusion, we experienced spontaneous expectoration of a piece of lung adenocarcinoma. Kelly et al stated that physicians might ignore such specimens, presuming them to be phlegm or blood clots.9 We should be aware that the expectorated tissue might lead to a pathological diagnosis, even in adenocarcinoma of the lung.
Teaching Points
Tumor expectoration is a rare presentation in patients with various tumors. To date, 30 cases have been reported. The most frequent tumor was renal cell carcinoma, followed by primary lung cancer and sarcoma. The patient's spontaneously expectorated material should not be discarded, and should be fixed and examined by a pathologist, since it can provide diagnostic information.
Footnotes
- Correspondence: Nagio Takigawa MD PhD, Department of General Internal Medicine 4, Kawasaki Hospital, Kawasaki Medical School, 2-1-80, Nakasange, Kita-ku, Okayama, 700-8505, Japan. E-mail: ntakigaw{at}med.kawasaki-m.ac.jp.
The authors have disclosed no conflicts of interest.
- Copyright © 2012 by Daedalus Enterprises Inc.
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