Eur J Cardiothorac Surg 1999;16:384-386
© 1999 Elsevier Science NL
Adenosquamous carcinoma occurring after small cell lung cancer: a 10 year follow-up
Marc Riqueta,
Françoise Le Pimpec Barthesa,
Antoine Chehaba,
Claire Danelb
a Service de Chirurgie Thoracique, Hôpital Laennec, 42 rue de Sèvres, 75007Paris, France
b Laboratoire d'Anatomie Pathologique, Hôpital Laennec, 42 rue de Sèvres, 75007 Paris, France
Corresponding author. Tel.: +33-1-4439-6601; fax: +33-1-4439-6619
e-mail: marc.riquet{at}lnc.ap-hop-paris-fr
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Abstract
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Long term survival in small cell lung cancer is rather rare, and in such instances the risk for secondary malignancy increases. We report the case of an adenosquamous carcinoma occurring after a 6-year disease free period following treatment of an ipsilateral small cell lung cancer. The patient was treated by pneumonectomy and is still alive 4 years after surgery.
Key Words: Small cell carcinoma • Chemotherapy • Radiotherapy • Adenosquamous carcinoma • Surgery
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1. Introduction
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Long term survival in small cell lung cancer (SCLC) rarely exceeds 5 years. The longer the survival, the greater is the risk of development of a second malignant tumour [1,2]. Non-small cell cancer (NSCLC) occurring in the same lung are generally squamous in nature [3,4] and is lethal in most cases [4]. We observed one case of adenosquamous carcinoma successfully cured by pneumonectomy that occurred 6 years after a small cell lung carcinoma treated by chemotherapy and radiotherapy.
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2. Case report
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A 39-year-old man with a 40 pack/year smoking history presented in August 1989 complaining of cough and asthenia. Chest radiography revealed a large right hilar mass and widened mediastinum. Histology was obtained by biopsies under bronchoscopy. Diagnosis was small cell lung cancer. Results of liver and bone scanning, bone marrow aspiration and biopsy and computed cranial tomography were within normal limits. The patient was treated with local chest (60 Gy) and cranial irradiation (24 Gy) as well as combination chemotherapy (cyclophosphamide, Epirubicin, Etoposide and Cisplatin). Treatment was initiated in October 1989 and chemotherapy was completed in April 1990 (six courses); after treatment the tumour had completely resolved. In June 1990 the patient was hospitalized for a pulmonary embolism. There was no sign of cancer recurrence. The patient recovered and had stable chest radiographic findings until 1994. Due to the fact that long-term survival is unusual in small cell lung cancer, biopsy samples initially obtained at bronchoscopy in 1989 were reevaluated at 5 year follow-up. Histology (Fig. 1), and immuno histochemistry (keratin +, neurone specific enolase +, synaptophysin + and chromogranin A +) reconfirmed the diagnosis of small cell neuroendocrine carcinoma.
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Fig. 1. Bronchial biopsy showing an infiltrative neuroendocrine small cell carcinoma (original magnification x400; hematoxylin and eosin stain).
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In October 1995, the patient complained of dyspnea and dorsal pain; an upper lobe image was visible on chest radiography. Bronchoscopy allowed biopsy of a right upper lobe adenocarcinoma. Restaging showed no evidence of distant disease. Respiratory parameter allowing surgery, right pneumonectomy with mediastinal node dissection was performed in December 1995; the bronchial stump was reinforced by a pericardial flap. Post operative stay was uneventful. Histologic examination of the lung revealed right upper lobe bronchus infiltration by an adenosquamous carcinoma (Fig. 2) with major submucosal lymphangitis; Interlobar nodes were invaded but mediastinal nodes were disease- free. Main bronchus resection margin was normal. No additional treatment was administered. The patient did well and was disease free in December 1998, after an overall history of 10 years.
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Fig. 2. Representative region of adenosquamous carcinoma showing both glandular (arrow) and squamous (arrow head) differentiation in the same area. Hematoxylin and eosin staining (x400).
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3. Comments
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Five year and longer survival rates in SCLC average 3.5 [5] to 5.7% [1]. The risk for developing a second primary tumour is 10.3% per person-year [1]. Not all secondary tumours are NSCLC but the cumulative actuarial risk of a second NSCLC at 16 years may be as high as 69% [2]. Most of these NSCLC are ipsilateral but controlateral lung location has been observed once [6]. In the first publication concerning 10 cases, only one had a survival exceeding 5 years with secondary occurrence of a bronchoalveolar carcinoma. The nine other cases observed had shorter survivals [7]. Seven of these case were squamous cell carcinomas [7] which was the most frequent histological type reported in other subsequent series: Sajman (n=3/3) [3] and Soria (n=5/6) [4]. Adenocarcinomas are less frequent and mucoepidermoïd has been observed once [7]. Adenosquamous carcinoma has not yet been reported.
The occurrence 6 years after treated SCLC of a NSCLC, that was successfully managed by surgery with a 4 year disease-free follow-up, encourages to closely follow up such patients and not hesitate to operate them on when possible: few other therapeutic issues are available in such cases and surgery may allow a chance for cure.
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Acknowledgments
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The authors wish to thank Drs. M. Daguerre and G. Wajener for helpful comments on the case.
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References
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Received April 6, 1999;
received in revised form June 21, 1999;
accepted July 13, 1999.
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Abstract
1. Introduction
