Ann Thorac Surg 1996;61:530-532
© 1996 The Society of Thoracic Surgeons
Original Article: General Thoracic
Should Cavitated Bronchopulmonary Cancers Be Considered a Separate Entity?
Jérôme Mouroux, MD,
Bernard Padovani, MD,
Dan Elkaïm, MD,
Henri Richelme, MD
Departments of Abdominal and Thoracic Surgery and Radiology, Hôpital Pasteur, Nice, France
Accepted for publication October 9, 1995.
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Abstract
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Background. This study was designed to identify any clinical, histologic, and prognostic features specific to cavitated bronchopulmonary tumors.
Methods. A total of 353 patients with lung cancer were categorized in two groups on the basis of chest radiograph and computed tomographic findings: 35 patients with cavitated cancers (group I) and 318 patients with noncavitated neoplasms (group II). Cavitation was defined as the presence of air in the tumor at the time of diagnosis and before any treatment or aspiration biopsy. The two groups were compared.
Results. There was no significant difference between the two groups concerning age, smoking history, or the interval to diagnosis, but diabetes (14.3% versus 5%) and fever (28.6% versus 13.5%) were significantly more frequent in group I than in group II. No statistically significant difference was observed between the two groups in tumor site or endoscopic appearance. Cavitated tumors were 1.5 times larger than the noncavitated lesions. Squamous cell carcinoma was significantly more frequent in group I than in group II (82.8% versus 61%). Survival at 1, 3, and 5 years was, respectively, 58.6%, 36.1%, and 22.2% in group I versus 48.2%, 35%, and 23.8% in group II.
Conclusions. Despite several specific features, there appears to be no justification for considering cavitated neoplasms separately from other forms of lung cancer.
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Introduction
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A lung cavity is defined as an abnormal hollow space within the lung parenchyma. In his 1973 review covering 100 cavitated cancers, Chaudhuri [1] defined the main causes of cavitation. Since this extensive work, few clinical investigations have been conducted on this form of cancer. This study was designed to identify any clinical, histologic, and prognostic features specific to cavitated bronchopulmonary tumors.
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Patients and Methods
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The chest roentgenograms and computed tomographic scans of 353 patients hospitalized for bronchopulmonary cancer between January 1988 and December 1992 were reviewed for tumor cavitation, defined as the presence of air in the tumor at the time of diagnosis and before aspiration biopsy or treatment (Figs 1 and 2
). Films were interpreted by two surgeons (J.M., D.E.) and a radiologist (B.P.). Tumors that had developed in preexisting emphysema bullae or cysts were excluded whenever radiographs taken before diagnosis of the cancer were available for comparison. Patients were divided into two categories depending on whether the tumor was cavitated (group I) or not (group II).
Records were reviewed for age, sex, smoking history in packs/year, past history, clinical presenting features, and interval to diagnosis (estimated from the date of the first symptoms to initiation of treatment). The site and appearance of all tumors at fiberoptic bronchoscopy were recorded. Tumor size, mediastinal node enlargement (for nodes more than 10 mm in diameter) and parietal invasion (bone lysis and/or soft tissue infiltration) were determined from chest computed tomographic scans. Tumors were staged by the TNM classification [2] as a function of clinical evaluation before any treatment. The histologic type was obtained by histopathologic examination of material from bronchoscopy, transthoracic needle aspiration, or surgical specimens.
Statistical Analysis
Values are expressed as the mean ± standard deviation. Disease variables were analyzed using the 
2 test or, when appropriate, Fischer's exact test. A p value of less than 0.05 was considered significant. Survival probabilities were estimated by the actuarial method using the date of surgical treatment as the starting time.
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Results
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Group I consisted of 35 patients (9.9%; 8 women, 27 men) with a mean age of 62.9 ± 10.2 years; group II was composed of 318 patients (33 women, 285 men) with a mean age of 63.8 ± 22 years. The tumor was discovered radiologically in 14.3% of the patients in group I versus 14.5% in group II, and the intervals from the date of the first symptoms to initiation of treatment were, respectively, 3.1 ± 2.7 months and 2.7 ± 2.2 months. Thirty-three (94.2%) of the group I patients were smokers (45 ± 29.83 packs/year) versus 288 (90.5%) of the group II patients (48 ± 32.67 packs/year). Among clinical features, diabetes (14.3% versus 5%; p = 0.028) and fever (28.6% versus 13.5%; p = 0.017) were significantly more frequent in group I than in group II. No statistically significant difference was observed between the two groups in tumor site or endoscopic appearance. Cavitated tumors were significantly larger than noncavitated lesions: 6 ± 2.69 cm in group I versus 4.16 ± 2.40 cm in group II. Mediastinal node involvement was noted in 16 patients in group I (46%) and 121 patients in group II (38%); this difference is not significant. There was no significant difference in the preoperative TNM stages between the two groups (Table 1). Squamous cell carcinoma was significantly more frequent in group I than in group II (82.6% versus 61%) (Table 2).
Thirty-nine patients in group II were treated preoperatively: chemotherapy (n = 18), radiotherapy (n = 9), or radiochemotherapy (n = 12). None of the group I patients was given any therapy before operation. Thirty-two patients in group I and 257 patients in group II underwent operation. Three group I patients were not surgical candidates (2 for oncologic reasons, 1 because of a contraindication for anesthesia); 44 group II patients did not undergo operation for oncologic reasons and 17 because anesthesia was contraindicated. There was one exploratory thoracotomy in group I and five in group II, corresponding to resectability rates of 88.5% and 79.2%. There were more lobectomies in group I (71.8% versus 52.14%); the difference is significant. Extension of resection to the chest wall (parietal pleura or ribs) was necessary for 8 group I patients (25%) and 15 group II patients (6.2%); this difference is also significant. The postoperative course was uneventful in 84.4% of the patients in group I and 79.7% in group II. There were 2 deaths in group I versus 5 in group II (respective mortality rates, 6.25% and 5.8%). Postoperative complications occurred in 6 patients (18.75%) in group I and 52 patients (20.2%) in group II (not significant). Postoperatively, 17 group I patients (53.2%) and 82 group II patients (31.9%) required complementary treatment. Survival at 1, 3, and 5 years was, respectively, 58.6%, 36.1%, and 22.2% in group I versus 48.2%, 35%, and 23.8% in group II.
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Comment
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The frequency of cavitated tumors in this series was close to 10% versus 2% to 25% in the literature [1]. These variations can be explained by the differences in methods of selection [1, 3]. In our series, chest computed tomographic scans detected seven cavitated lesions not seen on chest roentgenograms. This study confirms the large sizes of cavitated tumors (1.5 times larger than noncavitated lesions) [4]. Squamous cell carcinoma was the most frequent histologic type in our series, probably due to the high percentage of smokers (90.9%). This histologic type was significantly more common for cavitated carcinomas (82.8% versus 61%). These figures are comparable with those reported by other investigators [1, 3–7].
The relatively high number of women with cavitated tumors in our study (22.8% in group I) is unusual, and we do not have any explanation; in the literature, the frequency of female involvement varies from 0% to 10% [1, 4, 7]. No correlation was observed between cavitated tumors and patient age or smoking. Diabetes, the only risk factor that was more common in group I, may increase the risk of cavitation by favoring infection. Fever was the presenting feature found more often in patients with cavitated tumors. We did not observe any case of pneumothorax secondary to rupture of the cavity [8, 9] or to a bronchoesophageal fistula [6].
The elevated resectability rate in group I can be explained by the finding that certain stage III or IV cavitated tumors that are classically considered inoperable were operated on owing to chest pain or because of infection. Although we agree with the oncologists at our institution that chemotherapy or radiotherapy for large cavitated tumors can lead to serious, difficult-to-treat infectious complications, there has been little objective evaluation of the true risks of such treatments. These stage III and IV tumors were often managed by a limited procedure, with lobectomy being performed rather than pneumonectomy whenever technically possible.
No postoperative complication appears specific to cavitated bronchopulmonary carcinoma. Postoperative morbidity, mortality, and survival were similar in both groups.
Despite several specific features (frequency of diabetes and fever), there appear to be no valid arguments for considering cavitated tumors separately from other forms of bronchopulmonary cancer.
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Footnotes
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Address reprint requests to Dr Mouroux, Department of Abdominal and Thoracic Surgery, Hôpital Pasteur, B.P. 69, 06002 Nice Cedex 1, France.
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References
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- Chaudhuri MR. Primary pulmonary cavitating carcinomas. Thorax 1973;28:354–66.[Abstract/Free Full Text]
- Lung tumors. In: Hermanek P, Sobin LH, eds. TNM classification of malignant tumours, 4th ed. Heidelberg-New York: Springer, 1987:69–73.
- Strang C, Simpson JA. Carcinomatous abscess of the lung. Thorax 1953;8:11–28.[Free Full Text]
- Good CA, Holman CB. Cavitary carcinoma of the lung: roentgenologic features in 19 cases. Dis Chest 1960;37:289–93.
- Berger M, Thompson JR. Cavitary carcinomatosis of the lungs. Report of a case. Dis Chest 1967;52:106–11.[Medline]
- Chiu FTS. Cavitation in lung cancers. Aust NZ J Med 1975;5:523–30.[Medline]
- Zorini AO. Primary carcinomatous cavities of the lung; possible role of neoplastic cell autophagism. Dis Chest 1967;52:329–37.[Medline]
- Laurens R, Pine J. Spontaneous pneumothorax in primary excavating lung carcinoma. Radiology 1983;146:295–7.[Abstract/Free Full Text]
- Lundgren R, Stjernberg N. Spontaneous pneumothorax as first symptom in bronchial carcinoma. Acta Med Scand 1980;207:329–30.[Medline]
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Abstract
Introduction
