CASE REPORT
Surgically Resected Isolated Hepatic Metastasis from Non-small Cell Lung Cancer: A Case Report Kyu-Sik Kim,*† Kook-Joo Na,*‡ Yun-Hyeon Kim,*§ Sung-Ja Ahn,*兩兩 Hee-Seung Bom,*¶ Chol-Kyoon Cho,** Hyun-Jong Kim,** Yu-Il Kim,† Sung-Chul Lim,† Soo-Ock Kim,† In-Jae Oh,† Sang-Yun Song,*‡ Chan Choi,*†† and Young-Chul Kim*†
We treated a patient with non-small cell lung cancer (NSCLC) and an isolated hepatic metastasis. He was a 56-year-old male who underwent right pneumonectomy after concurrent chemoradiation therapy (etoposide⫹cisplatin) with the diagnosis of stage IIIA squamous cell lung carcinoma. Seven months later, an isolated hepatic metastasis was found on a PET–CT scan. Hepatic segmentectomy was performed, and the pathology showed squamous cell carcinoma. Adjuvant chemotherapy with five cycles of gemcitabine and cisplatin was also given. The patient has been followed with PET–CT and CT scanning every 6 months, and there is no evidence of relapse at more than 5 years after the diagnosis of NSCLC. This shows that the surgical resection of an isolated hepatic metastasis may be an option in carefully selected patients with NSCLC without evidence of disease outside the liver. (J Thorac Oncol. 2006;1: 494–496)
L
ung cancer has been the leading cause of cancer death in South Korea, as in many other parts of the world, since the year 2000.1 The global burden of lung cancer continues to rise,2 and at least 30% of lung cancer patients are diagnosed with stage IV disease.3 Furthermore, even after treatment with curative intent, many patients relapse with disease in distant organs, such as the brain, liver, adrenals, and bone. Conventional treatment of relapsed non-small cell lung cancer (NSCLC) with metastases in distant organs is palliative in most patients. The surgical resection of an isolated metastasis to the brain followed by whole-brain radiation therapy (WBRT) is superior to WBRT alone,4 but there is insufficient evidence to support resection of solitary adrenal or liver metastasis from lung cancer. In addition, surgery is *Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital; and Departments of †Pulmonology and Critical Care Medicine; ‡Thoracic and Cardiovascular Surgery; §Diagnostic Radiology; 兩兩Radiation Oncology; ¶Nuclear Medicine; **Hepatobiliary Surgery; ††Pathology, Chonnam National University Medical School, South Korea Address for correspondence: Young-Chul Kim, M.D., Lung and Esophageal Cancer Clinic, Department of Pulmonology and Critical Care Medicine, Chonnam National University Hwasun Hospital, Jeollanamdo, Hwasun, Ilsim-ri 160, 519-809. E-mail:
[email protected] Copyright © 2006 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/06/0105-0494
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contraindicated in the majority of patients with metastasis to the liver because of the number or distribution of metastases or the presence of extrahepatic disease. Recently, we experienced a case of NSCLC with an isolated liver metastasis that has been disease-free for more than 5 years after the diagnosis of NSCLC.
CASE REPORT A 55-year-old man presented to us with a 1-year history of exertional dyspnea and a 1-month history of hemoptysis. He was a 37 pack-years ex-smoker who had quit smoking 2 years earlier and had an otherwise unremarkable past medical history. Physical examination revealed decreased breath sounds in the right upper lung field with no superficial lymphadenopathy. A chest radiograph and computed tomography (CT) showed a mass measuring 6.5 ⫻ 4 cm in the right upper lobe with atelectasis and encasement of the superior vena cava (Fig. 1). The right lower paratracheal, tracheobronchial, and aortopulmonary lymph nodes were grossly enlarged. There was no metastasis to any intra-abdominal organ. Fiberoptic bronchoscopy showed a stenotic lesion at the opening of the right upper lobe bronchus. Bronchoscopic biopsy on 19 December 2000 confirmed the diagnosis of squamous carcinoma. A routine metastatic workup revealed normal liver, spleen, adrenals, and bone with no bony metastases. His clinical stage was T3N2M0 (stage IIIA), without PET scan and mediastinoscopy. Two cycles of chemotherapy with oral etoposide (50 mg/m2/day from day 1 to 14) and cisplatin (60 mg/m2) every 3 weeks with concurrent radiation therapy (6000 cGy) were given. A repeat CT scan taken after chemoradiation therapy showed regression of the disease with a decrease in the size of the tumor and mediastinal lymphadenopathy. On 7 March 2001, right pneumonectomy and mediastinal lymph nodes dissection confirmed the pathologic stage as IA (pT1N0M0). Seven months later, an isolated hepatic metastasis was found on a PET–CT scan (Fig. 2). A right caudate lobe segmentectomy was performed on 15 October 2001. The pathologic diagnosis of the resected liver was metastatic squamous cell carcinoma with the same histology as the lung cancer. Subsequently, adjuvant chemotherapy with five cycles of three weekly gemcitabine treatments (1250 mg/m2 days 1 and 8) and cisplatin (70 mg/m2) was given. Another Journal of Thoracic Oncology • Volume 1, Number 5, June 2006
Journal of Thoracic Oncology • Volume 1, Number 5, June 2006
Surgical Resection of Isolated Hepatic NSCLC Metastasis
FIGURE 1. Initial chest CT scan at diagnosis showing a 6.5 ⫻ 4.0-cm, lobulated, contoured mass in the right upper lobe with atelectasis and encasement of the superior vena cava.
FIGURE 3. Chest (A) and abdominal (B) CT scans taken on 2 January 2006 showing no evidence of tumor recurrence at the sites of the right pneumonectomy or liver segmentectomy.
DISCUSSION
FIGURE 2. Positron emission tomography (A) and abdominal CT (B) scans showing an isolated hypermetabolic lesion (arrow) in the caudate lobe of the liver.
PET–CT scan on 13 December 2004 showed no evidence of residual malignancy. The patient has been followed with CT scanning every 6 months, and there is no evidence of relapse more than 5 years after the diagnosis of NSCLC (Fig. 3A and 3B).
The routine use of spiral and multi-slice CT scanning has increased the ability to identify distant metastases of the liver and adrenal glands. Metastasis of lung cancer to the liver has a poor prognosis, and the majority of patients with metastatic disease to the liver are not candidates for surgery because of the number or distribution of metastases or the presence of extrahepatic disease. There are some rules for the resection of distant metastasis in non-small cell lung cancer (NSCLC). According to the revised guidelines of the American Society of Clinical Oncology for unresectable NSCLC,4 the resection of isolated cerebral metastasis followed by WBRT is superior to WBRT alone in patients with controlled disease outside the brain.5,6 Although feasible in selected patients, there is insufficient evidence to support routine resection of solitary adrenal metastasis.7,8 Currently, there are no published guidelines concerning the surgical resection of isolated hepatic metastasis from lung cancer. We found one case report by Nagashima et al. of long-term survival (5 years and 2 months) after surgical resection of a liver metastasis from lung cancer in a 71-yearold male (stage IB, adenocarcinoma).9
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Kim et al.
Our result confirms that surgical resection of an isolated hepatic metastasis may be an option in carefully selected patients with lung cancer and with no evidence of disease outside the liver.
5. 6.
REFERENCES 1. Seo JH, Jeong CS. Death rate statistics of Korea, 2003. Korea National Statistical Office, 2004. 2. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990 –2020: Global Burden of Disease Study. Lancet 1997;349:1498–1504. 3. Korean Academy of Tuberculosis and Respiratory Diseases. The National Survey of Lung Cancer in Korea: tuberculosis and respiratory diseases. 1999;46:455–465. 4. Pfister DG, Johnson DH, Azzoli CG, et al American Society of Clinical
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7. 8. 9.
Oncology treatment of unresectable non-small-cell lung cancer guideline: update 2003. J Clin Oncol 2004;22:330–353. Billing PS, Miller DL, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Surgical treatment of primary lung cancer with synchronous brain metastases. J Thorac Cardiovasc Surg 2001;122:548–553. Bonnette P, Puyo P, Gabriel C, et al Surgical management of non-small cell lung cancer with synchronous brain metastases. Chest 2001;119: 1469–1475. Motta G, Nahum MA, Spinelli E, et al. Adrenalectomy in metastasis of primary pulmonary carcinoma: an emerging issue. Ann Ital Chir 1996; 67:661–667. Sarela AI, Murphy I, Coit DG, Conlon KC. Metastasis to the adrenal gland: the emerging role of laparoscopic surgery. Ann Surg Oncol 2003;10:1191–1196. Nagashima A, Abe Y, Yamada S, Nakagawa M, Yoshimatsu T. Longterm survival after surgical resection of liver metastasis from lung cancer. Jpn J Thorac Cardiovasc Surg 2004;52:311–313.
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