Total atelectasis of the right lung due to bronchogenic carcinoma

Elevated levels of “lung” markers – CYFRA and Ca-125.

The chest X ray: lung parenchyma without nodular shadows or infiltrates, hilar accentuation, vascular rarefaction, diaphragm decreased, diaphragmatic angles free without pathologic filling (Figure 1).

CT of the chest: centrally in the right hilum located tumorous mass invading right main bronchus and part of trachea, spreading intraluminal with invasion to the right hilar vessels, enlargement of ipsilateral and contralateral hilar nodes, lymphangitic carcinomatosis.
Lung function testing: obstructive ventilatory impairment with moderate obstruction (FEV1 = 1,54 l...48% predicted).
Abdominal ultrasonography: without signs of metastatic spreading in abdominal cavity.
The bronchoscopy was performed and a neoplasm in the right main bronchus with total obturation of lumen and infiltration of trachea was found. The pathologic diagnosis of biopsy under bronchoscopy was squamous cell carcinoma (histological type of non-small-cell lung carcinoma, NSCLC) and the histologic type of carcinoma was assessed by imunohistochemistry analysis including p63+, CK5/6+, without expression of TTF1, napsinA.

According to TNM classification (Figure 2), the patient appeared to have a T4N3M0 stage IIIB primary lung neoplasm. Bone scan and MRI of brain were not realized because the patient had no clinical symptoms indicating injury of those systems. 

Stage IIIB non-small cell lung cancer is considered advanced lung cancer along with stage IV, and though it is not usually curable, it is treatable. Stage IIIB is considered inoperable, for those that are relatively healthy, a combination of chemotherapy or chemotherapy and radiation therapy is often recommended. Our patient was referred to oncological department and chemotherapy was conducted.
After more than 2 years (June 2015) since the diagnosis was set and with ongoing oncological treatment, the patient presented to our department with hemoptysis. The patient stated he had small amounts of blood-streaked sputum for the past couple of days. We performed new chest X ray, which proved progression of the tumour mass in right hilum presenting as non homogenous spiculated infiltration (Figure 3). The patient received hemostatic agent intravenously after which hemoptysis resolved completely, there were no signs of anemia, the patient was discharged with the recommendation to continue in oncological treatment.
One year later (March and April 2017) the patient was repeatedly admitted to our department due to worsening of dysnoea with tachypnea and persistent severe hemoptysis. The patient stated he had coughed up approximately “a small cup” of bright red blood. Chest X ray showed extreme progression with homogenous opacification of the entire right hemithorax with the shift of trachea and mediastinal structures to the right side. The finding was suggestive of total atelectasis of the right lung due to bronchial obstruction caused by bronchogenic carcinoma in progression. Initially, the condition was temporarily better due to intravenous hemostatic medication but few days later he had massive hemoptysis and died.

Bronchogenic carcinoma, squamous-cell histological type
Obstructive atelectasis of the right lung
Hemoptysis

Atelectasis refers to a partial or complete collapse of the lungs. Atelectasis is a radio-pathological sign and can be classified in many ways depending on the underlying cause. Physiologically it is divided into obstructive and nonobstructive causes.
Obstructive atelectasis is the most common type which occurs as a result of complete obstruction of an airway. No new air can enter the portion of the lung distal to the obstruction and any air that is already there is eventually absorbed into the pulmonary capillary system, leaving a collapsed section of the affected lung. Causes of obstructive atelectasis include foreign body, tumour, and mucous plugging. The rate at which atelectasis develops and the extent of atelectasis depend on several factors, including the extent of collateral ventilation that is present and the composition of inspired gas. The obstruction can occur at the level of the larger or smaller bronchus. Obstructive atelectasis of an entire lung ("collapsed lung") can result from complete obstruction of the right or left main bronchus. X-ray manifestation of an entire lung atelectasis is characterized by a presence of opacification of the entire hemithorax and mediastinal shift toward the side of collapse (Figure 4). The mediastinal shift separates atelectasis from a massive pleural effusion.

In many cases, the cause of the obstruction can be seen in a chest x-ray. However, a computed tomography (CT) scan is usually considered to be a superior diagnostic tool as it can provide valuable information such as the exact location and the extent of the blockage.
Treatment for obstructive atelectasis aims to re-expand the collapsed portion of the lung and depends on the cause. The treatment options include chest physiotherapy, body positioning, oxygen therapy, bronchodilatation medication, surgery with the removal of the cause of blockage from the bronchial airways if possible or radiation and chemotherapy in case of lung tumours. Indeed, in patients with lung carcinoma, atelectasis is accepted as a negative prognostic sign. In case of malignant central airway obstruction with respiratory failure, urgent therapeutic bronchoscopy may be performed. Bronchoscopic options for treatment include short-term endotracheal intubation, tumour debulking, balloon dilation, laser therapy, electrocautery, cryotherapy, photodynamic therapy, argon plasma coagulation and airway stent placement.
Nonobstructive atelectasis can be caused by loss of contact between the parietal and visceral pleurae, compression, loss of surfactant, and replacement of parenchymal tissue by scarring or infiltrative disease. Possible causes of nonobstructive atelectasis include injury, pleural effusion, pneumonia, pneumothorax and scarring of lung tissue.