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Endobronchial metastasis: an anesthetic complication?

Padhar Hospital, Padhar, India, E-mail: neipe{at}yahoo.com

To the Editor:

A 55-yr-old man presented with dyspnea and hemoptysis six months after completion of external radiation to the head and neck. Ten months previously he had undergone radical surgery for carcinoma tongue (T4N0M0). Review of his previous records revealed that he had required an awake fibreoptic intubation. Considerable difficulty was encountered in negotiating the tracheal tube due to posterior extension of the tumour. The intraoperative and postoperative periods were uneventful and he made satisfactory recovery. The patient had no lung pathology (clinically or radiologically) either at the time of surgery or radiation therapy. The plain radiograph of the chest now showed a right hilar opacity. Flexible fibreoptic bronchoscopy revealed a mass in the right main bronchus just beyond the carina, probably an endobronchial metastasis (EBM). Histopathology was confirmed as squamous cell carcinoma. He underwent chemotherapy but subsequently died of pulmonary complications.

EBM from extra-pulmonary solid malignant tumours are rare and virtually unknown in squamous cell carcinoma tongue. The diagnosis of EBM is now increasing because of the regular use of fibreoptic bronchoscopy.¹ Sugarbaker and colleagues² have suggested the tumour cell entrapment hypothesis (dissemination of malignant cells from trauma). Pickhardt and co-workers³ have described the metastatic implantation at the percutaneous endoscopic gastrostomy tract. They further state that evidence points to direct tumour implantation during endoscopic placement as the likely cause rather than hematogenous spread. Airway instrumentation has been known to cause trauma to various soft tissues of the upper airway and aspiration of solid material to the lung has been described.⁴ The right main bronchus is known to be the most common site of aspiration and this was the site of EBM in our patient. Direct tumour implantation during surgical dissection is unlikely to have occurred since the airway was protected with a cuffed tracheal tube.

Our opinion is divided between a second primary (carcinoma lung) and a metastasis (EBM from carcinoma tongue) because it is difficult to distinguish histopathologically or immunohistochemically between these entities. Kawada and others⁵ report a similar case, but they suggested that the single endobronchial lesion was considered to be a second primary tumour. In our patient, a secondary tumour was considered more likely because of the documented trauma to the tumour before surgical excision. We conclude that direct tumour implantation into the lower airways during anesthesia is a possibility that should be investigated and ruled out by further clinical investigations.

Footnotes

Sources of financial support: Padhar Hospital.

Conflicts of interest: none declared.

References

1 Kim YS, Chang J, Kim YS, et al. Endobronchial metastasis of uterine cervix cancer: a two case reports and a review of the literature. Yonsei Med J 2002; 43: 547–52.[Medline]

2 Sugarbaker TA, Chang D, Koslowe P, Sugarbaker PH. Patterns of spread of recurrent intraabdominal sarcoma. Cancer Treat Res 1996; 82: 65–77.[Medline]

3 Pickhardt PJ, Rohrmann CA Jr, Cossentino MJ. Stomal metastases complicating percutaneous endoscopic gastrostomy: CT findings and the argument for radiologic tube placement. AJR Am J Roentgenol 2002; 179: 735–9.[Abstract/Free Full Text]

4 Stone DJ, Gal TJ. Airway management. In: Miller RD (Ed.). Anesthesia, 5th ed. Churchill Livingstone; 2000: 1414–51.

5 Kawada I, Terashima T, Morishita T, et al. A case of primary lung cancer in a young female with tongue cancer (Japanese). Nihon Kokyuki Gakkai Zasshi 2003; 41: 641–5.[Medline]

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