Spontaneous bilateral pneumothorax in metastatic renal cell carcinoma on sunitinib therapy

Bilateral spontaneous pneumothorax is a rare occurrence in patients with both primary and metastatic lung cancer. Pneumothorax occurring as a complication of vascular endothelial growth factor receptor (VEGFR) inhibitor therapy has not been previously described in the medical literature. Sunitinib malate is a VEGFR inhibitor approved for the treatment of advanced renal cell carcinoma. We present a patient with metastatic renal cell carcinoma manifested as bilateral pulmonary nodules who developed a bilateral spontaneous pneumothorax 3 weeks after initiation of sunitinib therapy. We believe that sunitinib therapy resulted in necrosis of multiple pleural-based pulmonary nodules with central cavernization and ultimately rupture with bronchopleural fistula formation. Based on this experience, we advise that practitioners exercise caution when prescribing anti-VEGFR therapy in patients with pleural-based pulmonary metastases and recognize that the efficacy and toxicity of these agents may be closely linked.     

Pneumothorax as a Complication of Radiation Therapy for Primary Lung Cancer

A case of spontaneous pneumothorax complicating irradiation for bronchogenic carcinoma is presented. Pneumothorax developed in a collapsed lung caused by a central bronchogenic carcinoma. The cause is presumably secondary to either a bronchopleural fistula by tumour or sudden expansion of the lung following irradiation. Various tumours of the lung have been associated with spontaneous pneumothorax, including metastatic osteogenic sarcoma¹², eosinophilic granuloma⁴, teratoma¹¹, other metastatic sarcomas³, lymphoma following radiation therapy⁸, and primary bronchogenic carcinomas^{1,2,3,5,6,7,9,10}. We have encountered a case of spontaneous pneumothorax complicating irradiation for bronchogenic carcinoma. To our knowledge, this is the first report in the English radiologic literature, and the second, in the English literature, of a case of spontaneous pneumothorax following radiation therapy for proven bronchogenic carcinoma.     

^125I放射性粒子植入联合三维适形放疗治疗局部非小细胞肺癌的疗效

目的：探讨^125I放射性粒子（^125I粒子）植入联合三维适形放疗治疗非小细胞肺癌的放射剂量、安全性和近期疗效。方法：对经病理学确诊的16例非小细胞肺癌病人（均为周围型,腺癌9例,鳞癌7例）予外照射（8MV的X线常规放疗）治疗,60-66Gy/（30-33）次。1-2个月左右复查胸部CT,观察肿瘤退缩情况,并开始应用^125I粒子。术前经三维立体定向^125I粒子植入放射治疗计划系统（TPS）制定治疗计划,根据TPS结果计算所需^125I粒子数和布源方法。在CT引导下经皮穿刺组织间植入^125I粒子,内照射剂量为90-120Gy。术后应用TPS进行剂量验证。结果：^125I粒子植入术后每3个月左右复查胸部CT,肺部肿瘤完全消退者4例,部分退缩者12例。16例病人接受植入术中发生少量气胸者2例;4例出现咳血痰,给予止咳和止血药物后1-2d症状消失。结论：^125I粒子植入联合外照射治疗非小细胞肺癌是一种有效的方法,且肺放射性损伤程度低,值得进一步研究。     

Response of Small Cell Carcinoma of Pancreas to a Small Cell Lung Cancer Regimen: A Case Report

Small cell carcinoma of the pancreas is a very rare malignancy with 18 cases reported in the literature, of which only 3 were treated with chemotherapy. A 52-year-old man was diagnosed with small cell carcinoma originating in the head of the pancreas and invading the duodenum. He was treated with a similar approach as for localized small cell lung cancer, with six cycles of combination chemotherapy and local radiotherapy, and went into complete remission. After 3 months, he developed liver metastases along with an enlarged left supraclavicular lymph node. He was treated with two cycles of CVA, but developed lung metastases and was treated with ifosfamide/mesna. However, his overall condition deteriorated and hospice care was instituted until the patient's demise. The patient survived 14 months following diagnosis, significantly longer than the 15 reported patients with small cell pancreatic carcinomas not treated with chemotherapy. Combination chemotherapy and radiation therapy as is utilized for small cell lung cancer appear to be beneficial for small cell carcinoma of the pancreas.     

Acute leukemia secondary to lung cancer. Case report and review of the literature

A case of acute myelomonocytic leukemia following cytotoxic therapy for an oat cell carcinoma of the lung in a 48-year-old man is reported. This case is characterized by a long phase of increasing macrocytosis during cyclophosphamide maintenance therapy. 15 other cases of secondary leukemia to lung cancer from the literature are reviewed. All patients received alkylating agents. Most patients showed peripheral blood changes more than 3 months before the onset of acute leukemia. All leukemia cases, except one, were nonlymphocytic with a high frequency of erythroleukemia. The development of acute leukemia seems to be linked with an unexpected good response to chemotherapy in advanced or poor histologic prognosis cancers. With therapeutic improvement in lung cancer, secondary leukemia could become a major hazard as in other cancers successfully treated with cytotoxic agents.     

集束电极射频治疗肺癌手术并发症及其处理

目的 探讨集束电极射频热凝固治疗肺癌的手术并发症及其发生的原因、处理方法和预防措施。方法 肺癌54例，62个病灶，CT引导下经皮肺穿刺将射频电极插入肺癌病灶行热凝固治疗。术中及术后密切观察，对并发症发生者予以积极处理。结果 54例患者的术中并发症：咳嗽ll例，气胸9例，血压下降7例，贴电极处皮肤灼伤4例，穿刺点持续渗血2例，呃逆2例及寒战l例，经处理后均不需中断手术。术后的常见并发症为发热，l例出现术后气胸。结论 集束电极射频热凝固治疗术中最常见并发症为咳嗽，最严重并发症为气胸：术后常出现发热。应采取积极的防治措施，才能保证手术的顺利进行。     

Cerebral metastases as first symptom of bronchogenic carcinoma. A prospective study of 37 cases

Among the patients showing evidence of cerebral metastases without previously known cancer history, lung cancer has been found 37 times as the primary tumor in our institution. There were 34 men and three women and all but two were heavy smokers. Only one presented at diagnosis with thoracic symptoms but the chest radiograph was abnormal in 34. The histologic type of the primary tumor was obtained in 32 cases as a result of thoracic investigations and in five cases from metastatic tumor tissue. The primary tumor appeared to be non-small cell lung carcinoma in 26 cases and small cell lung carcinoma in 11 cases. These results show that patients treated with surgery (20 cases) have a better survival (median 10 months versus 4.5) than the others, and among surgically treated patients only those treated with bifocal resection (eight patients) are long-term survivors. Also, in four of six patients, objective regression of the neurologic symptoms was seen after radiation therapy alone. Central nervous system relapse was seen in 12 patients, but in none of the patients treated with postoperative radiation therapy. Conventional chemotherapy (11 patients) induced objective responses only in the small cell type and proved to be too toxic when used simultaneously with radiation therapy in inoperable patients.     

肺癌脑转移140例临床资料分析

本文依据140例肺癌脑转移病例的临床资料,着重分析了肺癌病理分型与脑转移出现时间的关系,肺癌治疗方法对脑转移出现时间的影响以及病理类型和治疗方式对预后的影响。结果表明:①肺腺癌最易发生脑转移64/140(46％)。②小细胞癌因分化快、倍增时间短,脑转移出现时间较其它病理类型早。③原发灶经过手术、效疗及化疗后,可延迟脑转移出现时间。④小细胞肺癌脑转移病情进展迅速,平均生存期仅4.8个月。目前应用手术、放疗及化疗子综合疗法,可在一定程度上改善病人的症状,延长病人生存时间。     

Implantation and stability of metallic fiducials within pulmonary lesions

PURPOSE: To report and describe implantation techniques and stability of metallic fiducials in lung lesions to be treated with external beam radiotherapy. METHODS AND MATERIALS: Patients undergoing radiation therapy for small early-stage lung cancer underwent implantation with small metallic markers. Implantation was either transcutaneous under computed tomographic (CT) or fluoroscopic guidance or transbronchial with the superDimension/Bronchus system (radiofrequency signal-based bronchoscopy guidance related to CT images). RESULTS: Implantation was performed transcutaneously in 15 patients and transbronchially in 8 patients. Pneumothorax occurred with eight of the 15 transcutaneous implants, six of which required chest tube placement. None of the patients who underwent transbronchial implantation developed pneumothorax. Successfully inserted markers were all usable during gated image-guided radiotherapy. Marker stability was determined by observing the variation in gross target volume (GTV) centroid relative to the marker on repeated CT scans. Average three-dimensional variation in the GTV center relative to the marker was 2.6 +/- 1.3 (SD) mm, and the largest variation along any anatomic axis for any patient was <5 mm. Average GTV volume decrease during the observation period was 34% +/- 23%. Gross tumor volumes do not appear to shrink uniformly about the center of the tumor, but rather the tumor shapes deform substantially throughout treatment. CONCLUSIONS: Transbronchial marker placement is less invasive than transcutaneous placement, which is associated with high pneumothorax rates. Although marker geometry can be affected by tumor shrinkage, implanted markers are stable within tumors throughout the treatment duration regardless of implantation method.     

Improved survival using multi-modality therapy in patients with lung metastases from colorectal cancer: a preliminary study

This retrospective study was conducted to assess the safety, efficacy, and long-term results of multi-modality therapy including radio-frequency thermal ablation (RFA) and radiotherapy as an additional cytoreductive method for eliciting the marked effects of chemotherapy in treating unresectable lung metastases from colorectal cancer. Total of 21 patients with lung metastasis from colorectal cancer were included. They were treated with modified pharmacokinetic modulating chemotherapy (PMC). Eleven were also treated with RFA and/or radiotherapy (multi-modality group), and 10 were treated with chemotherapy alone (chemotherapy group). Characteristics and survival of patients in the multi-modality group were compared with those of the chemotherapy group. The median survival of all patients was 38.6 months after the initial PMC. The cumulative 3-year survival rate of patients in the multi-modality group was 87.5% compared with 33.3% in the chemotherapy group (p=0.0041). The course of multi-modality therapy was uneventful except for pneumothorax in those who received RFA. Although pneumothorax developed in 4 of 11 patients (36.4%) treated with RFA, all were able to receive chemotherapy within 2 weeks after RFA. In conclusion, multi-modality therapy combined with modified PMC, radiation and RFA is a feasible choice of treatment associated with reasonable morbidity and mortality in patients with inoperable lung metastases from colorectal cancer.     

Bronchogenic carcinoma presenting as spontaneous pneumothorax: case reports with review of literature.

Six months after right-sided spontaneous pneumothorax developed in a 56-year-old man, squamous cell carcinoma was discovered in the ipsilateral lung. Fifteen cases of bronchogenic carcinoma presenting as spontaneous pneumothorax have been reported in the English language literature. Possible pathogenetic mechanisms include: direct tumor invasion of pleura; rupture of a subpleural bleb (in an area of obstructive emphysema) or an emphysematous bulla (in an overexpanded portion of the lung associated with lobar or segmental collapse); or unknown. Patients with spontaneous pneumothorax who fail to achieve complete expansion after three weeks of therapy or who have persistent roentgenographic pulmonary infiltration should undergo further investigation for bronchogenic carcinoma.     

A prospective study of whether radiation pneumonitis is influenced by low-dose irradiated lung volume in primary lung cancer with chronic pulmonary disease

The current study prospectively investigated the optimal dose-volume condition in cases of lung cancer with chronic pulmonary disease compared to those without chronic pulmonary disease. Cases of primary lung cancer treated with intended curative radiation therapy were registered in the current study. Their fraction size was limited to 2-3 Gy, so-called standard fractionation. They were prescribed a total dose of 60 Gy for non-small cell lung cancer (NSCLC; n=17) and a total dose of 54 Gy for small cell lung cancer (SCLC; n=4). Of the 21 patients enrolled in this study, 4 had chronic pulmonary disease (study arm), and the others had no chronic pulmonary disease (control arm). Seven received chemotherapy. Symptomatic radiation pneumonitis occurred in 5. Of the four patients in the study arm, two (50%) experienced symptomatic radiation pneumonitis; only 3 of the 17 patients in the control arm (17.6%) experienced symptomatic radiation pneumonitis. Furthermore, the median V(20) of patients who experienced symptomatic radiation pneumonitis in the study arm was 14%, which was higher than that of patients with no symptomatic radiation pneumonitis in the study arm, 5.8%. On the other hand, in the control arm, the median V(20) of patients with symptomatic radiation pneumonitis was 14.2%, about the same as that of patients with no symptomatic radiation pneumonitis in the control arm, 15.1%. The current study suggested that, as much as 15% of V(20), might play an important role in cases of lung cancer with chronic pulmonary disease.     

Direct current therapy with chemotherapy for the local control of lung cancer

Direct current therapy (DC therapy), consisting of the application of electric current directly to the lesion, with chemotherapy using BLM was performed in 4 advanced inoperable lung cancer patients in whom chemotherapy and radiotherapy were not effective or could not be performed. Fluoroscopically two electrodes were inserted percutaneously into the tumor under local anesthesia. The distance between the two electrodes was about 3-4 cm. About 10 volts of direct current for 1 hour (totally over 40 coulombs) was passed between them using a DC treatment processor model 85 (Inter Nova Co., Ltd.), and simultaneously 15-30 mg of BLM was administered intravenously according to the general condition of the patient. The histologic type was adenocarcinoma in 3 cases and there was 1 large cell carcinoma. This treatment was performed once in 3 cases and twice in another. A reduction of tumor size was recognized in 3 cases (2 adenocarcinomas and 1 large cell carcinoma). In another adenocarcinoma case it was not measurable in size because of infiltrative shadow but histologically tumor destruction was recognized within a short period after DC therapy. The complications were mainly slight fever and light pain during the procedure. There was one small amount of hemoptysis and one pneumothorax but it was not necessary to perform special treatment for these complications. DC therapy with chemotherapy is based on our basic experimental experience that some anticancer agents accumulate around the electrodes in lung tissue when direct current is passed. In addition, current itself has cytocidal effects in some cases. Our clinical experience suggested the usefulness of this therapy to treat lung cancer lesions locally.(ABSTRACT TRUNCATED AT 250 WORDS)     

Combination chemotherapy concurrent with small-dose radiation therapy of small cell carcinoma of the lung

Forty consecutive patients with small cell carcinoma of the lung were treated with chemotherapy, radiotherapy or both. Of 34 patients treated with chemotherapy, 24 were treated with combination chemotherapy, containing cyclophosphamide vincristine methotrexate and procarbazine, concurrent with small dose radiation therapy (500cGy/5 fraction) as a chemosensitizer (COMPrt). The response rate to this regimen was 81% (29% complete) and the 2 year survival rate was 28.6%. These results have been superior to other regimens and the toxicity was not see to be any higher. After completion of COMPrt regimen, 10 patients were treated with intrathoracic radiation therapy (average dose 3000cGy) and 3 received surgical treatment. Radiation therapy improved the 2-year survival rate (42.2%) when compared with those patients who received no radiation therapy (18.2%). Three patients received surgical treatment were considered to be disease-free for 23, 17, and 9 months respectively, after induction of chemotherapy.     

原发性骨肉瘤放化综合治疗的远期疗效

对 37例原发性骨肉瘤进行局部介入和放射治疗后全身化疗 ,按不同治疗方式分 3组总结。A组 :局部介入和放疗后加全身化疗 1 8例 ;B组 :局部介入和放疗后 ,无或不足量全身化疗 1 4例 ;C组 :局部介入和放疗均在半量以下 ,无全身化疗 5例。除C组 5例外 ,余 32例连续随访 2 4～ 95个月。结果 :局部肿瘤控制率达 93.8% ( 30 /32 ) ,患肢活动功能障碍率从 93.8% ( 30 /32 )恢复为 4 0 .6 ( 1 3/32 )。 32例中位生存 (无瘤生存 )期为 38个月。A组病例按年度收治至随访截止时间例数计 2 ,3,5和 7年生存率分别为 :94 .4 % ( 1 7/1 8) ,92 .3% ( 1 2 /1 3) ,72 .7% ( 8/1 1 )和 5 0 % ( 3/6 )。 1 9例死于肺转移病例 ,总中位带瘤生存 1 3 6个月。 3组中位带瘤生存期分别为 :A组 1 8个月 ,B组 1 5个月和C组 6个月。A组病例的远期疗效优于B和C组 (P <0 .0 1 )。本治疗方案能提高原发性骨肉瘤的远期疗效 ,并对肺转移有抑制作用。     

Heimlich翼瓣引流管气胸引流术在肿瘤介入诊疗中的应用(附13例报告)

背景与目的:肿瘤患者在接受介入诊疗操作中(如穿刺活检、经皮穿刺肺癌射频消融治疗等),可能会并发气胸,且这类气胸多为单纯性气胸。传统的处理方法是采用胸腔引流管与水封瓶相连接的胸腔闭式引流术,此术创伤大,患者需要住院接受治疗。Heimlich翼瓣引流管(简称Heimlich管)用于胸腔引流在国外已有多年,但在国内罕有报道。本文通过总结13例肿瘤患者在介入诊疗中并发气胸后应用Heimlich管的经验,探讨这一微创技术的临床价值。方法:1999年3月～2003年2月对13例介入诊疗中并发气胸的肿瘤患者应用Heimlich管微创插管技术方法行气胸引流。患者中6例住院治疗,7例门诊观察。结果:所有气胸患者经Heimlich管引流2～3天后,气胸消失,塌陷的肺组织完全复张,无任何并发症发生。结论:Heimlich管连接置入胸腔的多侧孔猪尾形导管行气胸引流术具有操作简单快捷、安全可靠、疗效好、患者可在门诊接受观察等优点,尤其值得在胸腔肿瘤介入诊疗操作中并发单纯气胸的患者中推广应用。     

Limited small cell lung cancer of the lung treated with combination chemotherapy and radiotherapy: a retrospective analysis.

We assessed the outcome in 65 patients with limited small cell lung cancer (SCLC) treated from 1980 through 1989 with combination chemotherapy and chest and cranial irradiation. Of the 65 patients, 32.3% (21/65) achieved a complete remission (CR) prior to radiation therapy; six additional cases achieved a CR after radiotherapy with an improvement of 10% in the incidence of CR. In our group, 8 patients were alive and free of disease at 30 months (12.3%). We think that a combination of local thoracic irradiation in SCLC limited disease plus chemotherapy yields more CR and improves survival, especially in the group of patients who obtained the CR after initial induction chemotherapy.     

非小细胞肺癌伽玛刀治疗后并发放射性肺不张分析

目的：回顾分析伽玛刀大分割适形放射治疗非小细胞肺癌（non small cell lung cancer,NSCLC）后并发非肿瘤性肺不张的原因,进一步完善大分割适形放射治疗。方法：488例非小细胞肺癌（NSCLC）分为中央型（262例）和周围型（226例）,分别进行了伽玛刀分次治疗,剂量3Gy-8Gy/次,处方剂量50%-70%剂量线,1次/日,5次/周,连续照射,总次数5-16次,总剂量35Gy-60Gy。结果：非小细胞肺癌中央型伽玛刀治疗3-6月后共出现20例放射性肺不张,而周围型未出现放射性肺不张,两组差异明显。结论：放射性肺不张是肺癌大分割适形放射治疗中很少报道的严重并发症,区分中央型和周围型分别实施治疗可能有效减轻治疗的严重并发症,中央型肺癌进行精确放疗时有必要将1,2级支气管作为剂量限制性器官。     

Spontaneous pneumothorax in patients irradiated for Hodgkin's disease and other malignant lymphomas

A retrospective review of patients treated for Hodgkin's disease or other malignant lymphomas between 1953 and 1988 revealed 10 cases of spontaneous pneumothorax. Nine had Hodgkin's disease whereas one had diffuse histiocytic lymphoma. Ages of the 10 patients ranged from 11 to 54 years, although nine were less than 30-years old. Spontaneous pneumothorax was observed only in patients who had received mantle or mini-mantle radiation therapy (RT). Five patients had concurrent severe parenchymal pulmonary disease including chemotherapy-induced interstitial fibrosis, Varicella pneumonia and severe radiation pneumonitis. Pneumothorax in these patients tended to be severe, bilateral and/or recurrent. All five required chest tube placement. Three of the five also required thoracotomy. RT dose ranged from 3000-7500 cGy, exceeding 4700 cGy in three patients who required a second course of RT which included the involved lung apex. In comparison, the five who did not have concurrent severe lung disease had milder episodes of pneumothorax. Only one required chest tube placement, whereas none required thoracotomy. Pulmonary apex RT dose ranged from 3672-4257 cGy. For Hodgkin's disease patients treated by RT, the frequency of spontaneous pneumothorax in the absence of concurrent pulmonary disease was 2.2%. Limiting analysis to patients in the peak age population of 10-30 years raised the frequency to 3.0%. No RT dose-response effect could be demonstrated, although spontaneous pneumothorax was not observed in patients who received less than 3000 cGy. Spontaneous pneumothorax was not more frequent among patients who also received chemotherapy as compared to those treated only by RT. Exploratory thoracotomy in three cases with severe pulmonary disease revealed subpleural apical blebs and/or dense pleural fibrosis. Unusual aspects in the medical histories of other cases suggest the possibility that patients who develop pneumothorax may have unusually dense pulmonary and/or pleural fibrosis compared to the majority of patients who receive RT for Hodgkin's disease or other malignant lymphomas.     

Surgical treatment of locally far-advanced lung carcinoma

It has been our policy to employ radical lung resection as a primary treatment whenever possible in locally far-advanced lung cancer. In order to assess the therapeutic results, a total of 132 patients with locally far-advanced lung cancer who had radical lung resection were reviewed. Postoperative mortality was 10%. A significant difference in survival was seen between those patients receiving no adjuvant therapy, radiation or single agent chemotherapy and those receiving cis-platinum-based polychemotherapy and/or immunotherapy (respective median survivals 14.25 and 25.68 months, P <0.05 Breslow test of failure rates). Aggressive surgery followed by effective adjuvant therapy in locally far-advanced Stage III lung carcinoma appears to produce acceptable survival results.