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      Enhancing survival with early surgical resection of endobronchial metastasis in a follow-up of ovarian carcinoma

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          Abstract

          Dear Editor, A 45 year-old female patient presented with a previous history of abdominal pain whose onset had occurred one year earlier. Pelvic ultrasonography demonstrated a suspiciously malignant left adnexal complex cyst, confirmed by pelvic magnetic resonance imaging. After surgical resection, the histological diagnosis was ovarian endometrioid adenocarcinoma. As lymph nodes were negative and there was no clinical or radiological evidence of distant metastasis, the disease stage was IA and the surgery was considered curative. Chest multidetector computed tomography (CT) performed at six-month follow-up demonstrated an unusual finding of a small endobronchial lesion of 6.7 mm in the left lower lobe causing significant bronchial narrowing (Figure 1). The patient had neither complaints nor symptoms and follow-up positron emission tomography/CT did not reveal any abnormal fluoro-2-deoxy-glucose uptake, including by the endobronchial lesion. Transbronchial biopsy of the lesion confirmed a mucin-producing adenocarcinoma positive for CA-125, compatible with metastasis from the ovarian adenocarcinoma. The patient underwent left lower lobectomy followed by chemotherapy. Five years after treatment completion follow-up exams showed no evidence of disease activity. Figure 1 A: CT image shows an endobronchial nodule (arrows) in the lateral basal bronchus of the left lower lobe. B: This nodule measures 6.7 mm. C: CT coronal reconstruction demonstrating > 50% decrease of the endobronchial lumen (arrow). D: Virtual bronchoscopy confirms the endobronchial narrowing. Endobronchial metastases from ovarian carcinoma are rare, and few cases are described in the literature. Clinical and radiological findings are quite similar to those of endobronchial primary lung cancer, so a histopathological diagnosis is critical in such cases(1). Endobronchial metastasis is defined as primary involvement of the bronchial epithelium, originating from extra-pulmonary malignant tumors(2). Salud et al. showed that breast, colorectal and renal carcinomas were the most common primary sites of endobronchial metastasis(3). None of these studies demonstrated ovarian tumor as the primary site as occurred in the present case. Endobronchial metastases may be asymptomatic without any other signs of dissemination from the primary tumor, as demonstrated in the present case(4). Symptoms may be associated with airway obstruction (dyspnea, wheezing), mucosal irritation and ulceration (cough, hemoptysis), or direct invasion and involvement of adjacent structures (recurrent laryngeal nerve palsy, dysphagia). Currently, multidetector CT is the best imaging modality for the diagnosis and characterization of endobronchial metastases. Multiplanar two-dimensional and three-dimensional image reconstruction techniques, including virtual bronchoscopy, can be easily generated to complement conventional axial CT imaging. In addition, virtual bronchoscopy provides a noninvasive method to evaluate airway lesions and plays an essential role as a complement to conventional bronchoscopy, facilitating planning and guidance of bronchoscopic interventions(5). CT is relatively accurate in the evaluation of bronchial abnormalities, and in patients with endobronchial metastases may be used as a complement to bronchoscopy to evaluate lesion extent(6). Finally, endobronchial metastases are rare and have clinical and radiological findings similar to those of primary endobronchial tumors. Although uncommon, oncologists and radiologists should be alert to the occurrence of endobronchial metastases in early follow-up of patients previously treated for ovarian carcinoma, in order to avoid delay in the diagnosis and to allow for proper therapeutic planning.

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          Most cited references9

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          Endobronchial metastases from extrapulmonary solid tumors.

          Malignancy detected during endobronchial biopsies is usually regarded as proof of lung cancer. It may, however, represent endobronchial metastases from extrapulmonary primary tumors. The literature was reviewed to describe how frequent extrapulmonary tumors have been reported to metastasize to the endobronchial epithelium. English language literature was searched from 1962 through 2002. Primary lung cancer and lymphomas were excluded. Endobronchial metastases were reported in 204 patients, originating from 20 different extrapulmonary primary tumors, usually cancers of the breast, kidney, colorectal, uterine cervix, sarcoma and skin. The mean time from diagnosis of primary tumor was 50 months (range 0-300 months) and mean survival time from diagnosis of endobronchial metastasis was 15.2 months (range 0-150 months). It is important to make a distinction between endobronchial metastases from primary lung cancer, as treatment possibilities may be different. The possibility of endobronchial metastasis should be considered if the patient has a history of malignancy in other organs.
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            Endobronchial metastatic disease: analysis of 32 cases.

            Endobronchial metastasis (EM) from nonpulmonary tumors is uncommon. A 9-year retrospective study at the University Hospital Vall d'Hebron (Barcelona, Spain) identified 32 patients with EM. All but four cases were diagnosed by fiberoptic bronchoscopy with bronchial biopsy. Primary tumors included the following types: breast cancer (20), colorectal cancer (3), melanoma (2), gastric cancer (1), neuroblastoma of the olfactory nerve (1), abdominal leiomyosarcoma (1), hypernephroma (1), endometrial carcinoma (1), papillary thyroid cancer (1), and hepatocarcinoma (1). Median age at diagnosis of EM was 58.7 years and median interval from the diagnosis of the primary tumor to the diagnosis of EM was 50.4 months. Seventeen patients (53%) had evidence of other metastatic sites at endobronchial relapse. The more common clinical manifestations included cough (37.5%), haemoptysis (28%), dyspnea (18.7%), and recurrent pulmonary infections (6.2%). Eight patients (25%) had no symptoms. There appears to be a predilection for metastatic involvement of the right and left upper lobe bronchus. Treatment was instituted in 20 patients, and their median survival was 11 months, in comparison with the 3 months found in 12 patients who received only palliative therapy because of advanced disseminated disease. Breast cancer is the most common tumor causing EM. The prognosis of patients with EM depends on the type of the primary tumor and the presence of other metastatic sites. Treatment must be individualized.
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              Update on multidetector computed tomography imaging of the airways.

              Recent advances in multidetector computed tomography (MDCT) technology have transformed the imaging evaluation of the trachea and bronchi. Multiplanar 2-dimensional and 3-dimensional volume reconstruction techniques, including external rendering and virtual bronchoscopy, can be generated in mere minutes, thereby complementing conventional axial CT imaging in the depiction of various central airway disease processes including airway stenoses, central airway neoplasms, and congenital airway disorders. Paired inspiratory and dynamic expiratory MDCT imaging, along with newer cine CT imaging methods, have enhanced the assessment of tracheobronchomalacia in both adults and the pediatric population. In addition, MDCT imaging plays an essential complementary role to conventional bronchoscopy, facilitating planning and guidance of bronchoscopic interventions, and providing a noninvasive method for postprocedural surveillance.
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                Author and article information

                Journal
                Radiol Bras
                Radiol Bras
                rb
                Radiologia Brasileira
                Colégio Brasileiro de Radiologia e Diagnóstico por Imagem
                0100-3984
                1678-7099
                Mar-Apr 2015
                Mar-Apr 2015
                : 48
                : 2
                : 130
                Affiliations
                [1 ]Hospital Heliópolis, São Paulo, SP, Brazil.
                [2 ]A.C.Camargo Cancer Center, São Paulo, SP, Brazil.
                [3 ]Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
                [4 ]Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.
                Author notes
                Mailing Address: Dr. Rafael Marques Franco. Rua Cônego Xavier, 276, Cidade Nova Heliópolis. São Paulo, SP, Brazil, 04231-030. E-mail: rafaelmarquesfranco@ 123456gmail.com .
                Article
                10.1590/0100-3984.2013.0020
                4433307
                25987757
                a8c20038-74a6-401b-b98f-9971f011ca40
                © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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