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Journal of Clinical Oncology, Vol 25, No 18 (June 20), 2007: pp. 2616-2618 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.11.0130
Spontaneous Pneumothorax in Metastatic Thyroid Papillary CarcinomaYonsei University College of Medicine, Seoul, Korea An 18-year-old man, suffering from chest pain and dyspnea for 2 days, was admitted to our emergency room. The patient had experienced similar symptoms three or four times during the previous 2 years. Chest x-ray revealed right pneumothorax with no other abnormality (Fig 1; arrows). The patient was evaluated by a thoracic surgeon and the first impression was the presence of a primary spontaneous pneumothorax. Thus, bullectomy was planned due to the recurrent symptom. During the procedure, however, no definite bulla was found, and only a mild emphysematous lesion was observed at the apex. Lung wedge biopsy was performed. The lung tissue showed that the blood vessel contained papillary structured tumor cell clusters on high power view (hemoxylin and eosin x400; Fig 2). Immunohistochemical stain for thyroglobulin revealed cytoplasmic immunoreactivity (Fig 3; original magnification x400). A computed tomography (CT) scan of the chest revealed numerous tiny nodules scattered in both lungs, suggesting hematogeneous lung metastasis (Fig 4). An ill-defined, low-density lesion was also noted in the right thyroid gland on this chest CT. Neck ultrasonography detected an ill-defined heterogenous hypoechoic mass (Fig 5; arrow) with suspicious microcalcification in the right thyroid with multiple cervical lymphadenopathies on the right side (Fig 5). Fine needle aspiration biopsy and subsequent total thyroidectomy confirmed papillary carcinoma with neck node metastasis. The final diagnosis was thyroid papillary carcinoma with hematogenous lung metastasis presenting as spontaneous pneumothorax.
Spontaneous pneumothorax is divided into primary and secondary types. Primary spontaneous pneumothorax most commonly afflicts the young and healthy.1 The secondary type can develop with airflow obstruction, infection, infarction, neoplasm, and diffuse lung disease.2 Spontaneous pneumothorax in primary pulmonary neoplasm or lung metastasis is very rare.3 The authors4 reported that 10 of 1,143 cases with a spontaneous pneumothorax have been attributed to a malignancy in the general population. As a matter of course, the possibility of occult pulmonary metastases presenting as secondary pneumothorax should be considered in patients with malignancy. The mechanism of secondary pneumothorax from lung metastasis is not well understood, but several theories have been advanced. One concept is that it may be the result of tumor necrosis.5 Rupture of a necrotic tumor nodule or necrosis of subpleural metastases is thought to cause communication between the bronchus and the pleural cavity, producing a bronchopleural fistula that results in a pneumothorax.3,6 Another theory concerns the check valve mechanism.7 Tumor nodules at the lung periphery can obstruct bronchioles and create a ball valve-type effect leading to local overdistention and subsequent rupturing of the lung. Yet another theory is explained by tumor embolus with resultant tumor infarction, necrosis, and air leak.8 Pneumothorax caused by pulmonary metastasis occurs frequently with an osteosarcoma, with a reported frequency as high as 5% to 7%.9 But it also has been described in other sarcomatous tumors and in tumors with a necrotic nature after chemotherapy or radiation therapy.10-16 However, our review of the literature found few reports about pneumothorax with pulmonary metastasis from thyroid cancer.17,18 In our case, the initial chest x-ray did not provide any information suggesting lung metastasis. However, considering that the metastatic nodules were so small, it is not surprising that these lesions could hardly be detected in chest radiography. It is known that a pneumothorax associated with metastasis can occur before the deposits are radiologically detectable on a plain radiograph.8 In conclusion, the possibility of lung metastasis should be considered in cases of recurrent pneumothorax, even if it is undetectable on chest radiography. In addition, chest CT may be useful in detecting occult metastatic nodules in such cases. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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