The role of surgery in the management of solitary pulmonary nodule in breast cancer patients

doi:10.1016/j.ejso.2006.12.015

European Journal of Surgical Oncology (EJSO)

Volume 33, Issue 5, June 2007, Pages 546-550

https://doi.org/10.1016/j.ejso.2006.12.015 Get rights and content

Abstract

Aims

To assess the role of surgery in the diagnosis and treatment of a solitary pulmonary nodule (SPN) in patients who had received previous surgery for breast cancer.

Methods

A series of 79 consecutive patients who underwent surgery for an SPN between 1990 and 2003 after a curative resection for breast cancer were reviewed.

Results

Surgical diagnosis was obtained by open procedure before 1996 (37 cases), and by video-assisted thoracoscopic surgery (VATS) after 1996 (33 out of 42 cases, 9 open procedures) and intraoperative evaluation. Histology of SPN was primary lung cancer in 38 patients, pulmonary metastasis of breast cancer in 27, and benign condition in 14. VATS was converted to open procedure for anatomical resection in primary lung cancer and for the palpation of the lung in metastatic disease. Average disease-free interval from the initial mastectomy was significantly longer in primary lung cancer than in metastatic patients (179 ± 107 vs 51 ± 27 moths). Manual palpation identified multiple pulmonary nodules in 3 out of 27 metastatic patients. Five-year survival rate after pulmonary metastasectomy was 38% and was significantly influenced by disease-free interval; 5-year survival rate after resection of primary lung cancer was 43% and was significantly influenced by the pathological stage.

Conclusions

VATS is a good procedure for diagnostic management of peripheral SPN. As SPN in breast cancer patients is primary lung cancer in half cases, it deserves confirmation of pathological diagnosis and appropriate surgical treatment. When breast cancer metastasis is demonstrated, open procedure must be performed to palpate the entire lung to exclude previously unknown nodules.

Introduction

The solitary pulmonary nodule (SPN) is radiologically defined as an intraparenchymal lung lesion that is less than 3 cm in diameter and is not associated with atelectasis or adenopathy.¹

More than 150,000 patients/year in the United States present their physicians with the diagnostic dilemma of an SPN.² This number increased even further due to incidental findings of lung nodules on chest computed tomography (CT).³

Pulmonary metastases are common features in patients with breast cancer.⁴ An SPN appearing in a patient with documented breast cancer, either past or present provides a diagnostic challenge. The traditional reaction of most physicians is that such a pulmonary lesion represents a metastasis from the known breast malignancy. In the case of multiple pulmonary lesions this may be more reasonable, but the evidence indicates that an SPN in a patient with breast cancer, more likely represents a primary lung tumour deserving accurate evaluation for diagnosis and an appropriate treatment.

We conducted a retrospective review to analyse the nature of SPN in breast cancer patients as well as the role of surgery in its management.

Section snippets

Patient population, inclusions and exclusions

From January 1990, through December 2003, 79 patients who previously underwent curative surgery for breast cancer were referred to our institutions because affected by a solitary pulmonary nodule (SPN).

All patients were female, the mean age was 63 (range 42–82) years. Preoperative evaluation by chest X-ray, total body CT-scan, fiberoptic bronchoscopy, isotopic bone scanning, cardio-pulmonary function test and, after 1999, by total body FDG-PET, was carried out. Peripheral lesions were

Patient groups

Among 79 patients submitted to surgery during the entire period, 55 patients underwent wedge-resection (22 by muscle-sparing thoracotomy and 33 by VATS). Before 1996, 15 patients required segmentectomy or lobectomy for diagnosis of intraparenchymal located nodules (all by muscle-sparing thoracotomy). After 1996, in 9 cases VATS has been converted to open procedure to allow segmentectomy or lobectomy for deep intraparenchymal located nodules.

In 14 cases the absence of malignant cells was proved

Discussion

Solitary pulmonary nodule is not rarely identified in patients submitted to chest X-ray or CT-scan. As reported in the international literature, SPNs are malignant tumours in half cases and quite 15–30% of patients have an advanced stage disease at diagnosis.² These concepts, during the last decade, have inducted the maximal attention to the SPN, because of the relative importance of each aspect: if benign, surgical resection with open procedure may appear an over-treatment, if malignant it

Conclusions

The solitary pulmonary nodule in breast cancer patients remains a surgical challenge. Radiological or DFI criteria are not useful in indicating the proper therapeutic approach. Although less invasive sampling technique such as fine-needle aspiration biopsy associated with the use of immunohistochemistry has improved the diagnostic possibilities in these patients, surgery remains the diagnostic procedure in the great part of cases. At today, when the lesion is located in the peripheral lung,

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^☆: The study was performed within the Research Fellowship Program “Dottorato di Ricerca in Tecnologie e Terapie Avanzate in Chirurgia”, appointed by “Tor Vergata” University, Roma, Italy.

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The role of surgery in the management of solitary pulmonary nodule in breast cancer patients☆

Abstract

Aims

Methods

Results

Conclusions

Introduction

Section snippets

Patient population, inclusions and exclusions

Patient groups

Discussion

Conclusions

Radiol Clin North Am

Ann Thorac Surg

Glossary of terms of thoracic radiology: recommendations of the Nomenclature Committee of the Fleisher Society

AJR Am J Roentgenol

The solitary pulmonary nodule

Chest

Malignant tumours of the breast

HER2 expression in breast cancer primary tumours and corresponding metastases. Original data and literature review

Br J Cancer