Primary myoepithelial carcinoma of the lung: a rare entity treated with parenchymal sparing resection

  • Inderpal S Sarkaria1Email author,

    Affiliated with

    • Deborah DeLair2,

      Affiliated with

      • William D Travis2 and

        Affiliated with

        • Raja M Flores3

          Affiliated with

          Journal of Cardiothoracic Surgery20116:27

          DOI: 10.1186/1749-8090-6-27

          Received: 21 October 2010

          Accepted: 8 March 2011

          Published: 8 March 2011

          Abstract

          Primary lung myoepithelial carcinomas are rare neoplasms arising from the salivary glands of the respiratory epithelium. Given the rare occurrences and reports of these tumors, appropriate recommendations for resection are difficult to formulate. Although classified as low-grade neoplasms, these tumors have a significant rate of recurrence and distant metastasis.

          Introduction

          Primary salivary gland-type tumors of the lung are rare and include mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, oncocytoma, epithelial-myoepithelial carcinoma, benign myoepithelioma, and mixed tumors of both benign and malignant nature [116]. Primary pulmonary myoepithelial carcinomas are exceedingly rare, with only five known prior cases reported in the English literature to date [1720]. We report a case of primary myoepithelial carcinoma of the lung and a review of the literature.

          Case Report

          A 63-year-old woman presented to the clinic with a history of increasing pulmonary congestion, difficulty expectorating, and low-grade hemoptysis. Her past medical history was significant for diet-controlled insulin-dependent diabetes mellitus. There was no history of cigarette or other tobacco use. Her mother had died of breast cancer in her fifties. A chest radiograph showed a large mass in the right lower lung fields, and computed tomography scanning revealed a 12.4 × 8.3 centimeter smoothly circumscribed heterogeneous mass arising in the right minor fissure and impinging upon the right atrium (Figure 1A). A fine needle aspiration was performed which yielded a diagnosis initially suspicious for schwannoma, as reviewed at an outside institution. At the time of thoracotomy, dense adhesions were dissected free of the upper and middle lobes with no evidence of tumor invasion, and the mass was resected en-bloc with pericardium and a wedge resection of the lower lobe. An additional separate lower lobe nodule was also excised and presumed to be a metastatic focus of tumor. The patient had an uneventful recovery and was discharged home on post-operative day number three.
          http://static-content.springer.com/image/art%3A10.1186%2F1749-8090-6-27/MediaObjects/13019_2010_390_Fig1_HTML.jpg
          Figure 1

          Radiographic and gross pathologic appearance of primary pulmonary myoepithelial carcinoma. A. Computed tomography of right-sided chest mass with compression of right atrium. B. Gross pathologic appearance of right visceral pleural mass.

          The patient developed a biopsy proven solitary liver/diaphragmatic metastasis diagnosed on routine follow-up at 36 months post-resection.

          Pathologic Findings

          Gross pathologic examination revealed the mass to be a 13 × 8 × 8 centimeter lower lobe carcinoma of myoepithelial origin involving the visceral pleura (Figure 1B).

          Histologically, the mass was consistent with a malignant myoepithelial neoplasm with a fibrous capsule and 20% necrosis. The mass was thought to arise from the right lower lobe and involved the visceral pleura. The margin was focally within 0.1 cm of the tumor, but otherwise grossly free of invasion. The separate nodule was 1 cm in size and histologically similar to the primary tumor.

          Immunohistochemical stains were performed and were focally positive for AE1/AE3, Bcl2, Cam5.2, S100p, GFAP, 4A4, SMA, and CD99. Stains for EMA, desmin, CD34, calponin, FLI1, myogenin, and synaptophysin were negative.

          Discussion

          Myoepithelial carcinomas primarily arise from the salivary glands, the parotid, or the breast [21]. Rarely, they may arise in soft tissues, most often in the lower and upper limbs, occurring equally in men and women [22]. These soft-tissue tumors, distinguished from benign myoepitheliomas by their moderate or severe cytologic atypia or invasive growth pattern, recur locally in 42% of patients and metastasize to distant sites in 32%.

          Primary myoepithelial carcinomas of the lung are exceedingly rare, with only 6 patients reported in the English literature, including the present report [1720]. Clinical data from these reports are summarized in Table 1. Very limited information was available for one patient [20]. Most patients were male, in their fifth or sixth decade of life at diagnosis, and smoked tobacco. Most patients presented with primarily endobronchial disease, had preoperative biopsies of their tumors, and underwent anatomic resections of these malignancies. There were no local recurrences. Almost all patients had metastatic disease, either synchronous at time of resection, or presenting as metachronous recurrence. Follow-up was less than two years for all but one patient, who died of metastatic disease to the liver five years postoperatively. One other patient died at fourteen months from synchronous metastatic adenocarcinoma. One patient was alive with disease, and two others were free of disease at relatively short follow-up intervals.
          Table 1

          Clinical characteristics of reported cases of myoepithelial carcinoma of the lung.

          AUTHOR

          Age/Sex

          Smoking

          Location

          Pre-op Bx Diagnosis

          Size (cm)

          Resection Type

          Local Recurrence

          Metastasis

          Outcome

          Present case

          63F

          No

          RLL, Pleural & parenchymal

          Low grade spindle cell neoplasm

          13.0

          Wedge/Local excision

          No

          Yes, same lobe/pleura at time of resection, liver at 36 months

          AWD at 36 months

          Masuya 2005

          48M

          Yes

          LLL, Parenchymal & Endobronchial

          Sarcoma, sarcomatoid carcinoma, carcinosarcoma

          1.5

          Lobectomy

          No

          No

          NED 15 months

          Miura 2000

          46M

          NA

          Right hilum, Right Main Stem, Endobronchial

          No atypical cells

          6.5

          Pneumonectomy

          No

          Yes, LLL

          AWD at 7 months

          Higashiyama

          58M

          Yes

          RUL, Endobronchial

          NA

          3.8

          Sleeve bilobectomy (RUL/RML)

          No

          Yes, soft tissue left arm and hip

          DOC at 14 months (metastatic synchronous adenocarcinoma)

          Higashiyama 1998

          58M

          Yes

          LUL, Endobronchial

          Squamous cell carcinoma

          6.0

          Sleeve lobectomy (LUL)

          No

          Yes, liver

          DOD, 60 months

          Sekine 1998

          NA

          NA

          NA

          NA

          NA

          NA

          NA

          Yes

          NA

          RLL - right lower lobe; LLL - left lower lobe; RUL - right upper lobe; LUL - left upper lobe; RML - right middle lobe; Bx - biopsy; NED - no evidence of disease; AWD - alive with disease; DOC - dead of other causes; DOD - dead of disease

          Given the available reported data, there are a number of unique characteristics of the current case when compared to the previous five. This case represents the eldest and only female patient, as well as the only known never-smoker. This patient's tumor is also the greatest in size within this series, more than doubling the previous known largest of these tumors. All other patients in the series presented with a major component of endobronchial disease, whereas the current tumor was primarily pleural/parenchymal based. Finally, the current case represents the only patient treated with a limited sub-anatomic resection.

          Given the relatively high rates of recurrence, low-grade malignant status, and the propensity for recurrence at distant sites, it is reasonable to consider limited sub-anatomic, parenchymal sparing resections for these patients, especially if pneumonectomy is contemplated. While this may not be adequate for endobronchial lesions involving major pulmonary segments, it is feasible for lesions presenting with primarily parenchymal or pleural based disease, as in the current case. Given the rarity of these tumors, recommendations regarding chemotherapy or radiation, either pre- or postoperatively, are difficult to formulate.

          Consent

          Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

          Declarations

          Authors’ Affiliations

          (1)
          Department of Surgery, Thoracic Service, Memorial Sloan-Kettering Cancer Center
          (2)
          Department of Pathology, Memorial Sloan-Kettering Cancer Center
          (3)
          Division of Thoracic Surgery, Mount Sinai Medical Center

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          Copyright

          © Sarkaria et al; licensee BioMed Central Ltd. 2011

          This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.