Int J Clin Oncol (2000) 5:54–56
CASE REPORT
Tetsuji Yamada · Yoshio Tsunezuka · Shingo Yagi
Kozen Yamamura · Hideo Sato · Susumu Kitagawa
Masaaki Nakagawa · Hiroshi Kurumaya
Pneumothorax caused by metastatic carcinoma of the breast
Received: February 17, 1999 / Accepted: October 4, 1999
Abstract
We report a rare case of pneumothorax caused by meta-
static carcinoma of the breast, in a 69-year-old woman who
was admitted to our hospital with severe chest pain. Four
years previously, she had undergone modified radical mas-
tectomy for a left breast tumor. Chest X-ray examination
and computed tomography (CT) scan on current admission
revealed right pneumothorax and bilateral pulmonary tu-
mors. Although operation is not usually indicated in such
circumstances, the patient had persistent air leakage for 7
days, despite receiving effective closed cather drainage,
making right thoracotomy necessary. During the operation,
an open bronchopleural fistula in the metastatic tumor of
the upper lobe, infiltrating close to the visceral pleura, was
observed. Wedge resection, including the necrotic tumor,
was thus performed. Microscopic examination of the
resected specimen showed poorly differentiated adenocar-
cinoma, consistent with metastasis from breast carcinoma.
This is the second reported case of pneumothorax caused by
metastatic carcinoma of the breast.
Key words Breast cancer · Pneumothorax · Metastatic lung
cancer
Introduction
Pneumothorax is caused by various factors, but is rarely
caused by pulmonary metastasis. Further, such sporadic
cases are most commonly caused by pulmonary metastasis
T. Yamada (*) · Y. Tsunezuka · S. Yagi · K. Yamamura · H. Sato ·
S. Kitagawa · M. Nakagawa
Department of Surgery, Ishikawa Prefectural Central Hospital, 153-
Nu Minamishinbo, Kanazawa, Ishikawa 920-0064, Japan
Tel. 181-76-237-8211; Fax 181-76-237-2337
H. Kurumaya
Department of Pathology, Ishikawa Prefectural Central Hospital,
Ishikawa, Japan
© The Japan Society of Clinical Oncology 2000
from sarcoma, and only very rarely occur as sequelae of
pulmonary metastasis of breast cancer.1,2 We recently en-
countered a patient with pneumothorax caused by a
bronchopleural fistula of pulmonary metastasis, and we re-
port our findings.
Case report
A 65-year-old woman with a left breast tumor (4.5 3 2.5 3
2.0 cm) underwent a modified radical mastectomy on July 8,
1994. Pathological examination of the resected tumor re-
vealed invasive solid-tubular carcinoma without node me-
tastasis (Fig. 1a). Lymphatic or vascular invasion was not
observed. The patient was estrogen receptor-positive and
therefore received postoperative hormonal therapy with
tamoxifen (TAM) at the outpatient clinic. However, in
August 1995, dermal metastasis on the left chest wall and
bilateral pulmonary metastasis were detected. The outpa-
tient treatment was continued by replacing TAM with
medroxyprogesterone acetate (MPA). The pulmonary me-
tastasis gradually enlarged during this period, despite the
patient’s generally good condition. On May 7, 1998, the
patient was hospitalized because of severe chest pain and
shortness of breath. A chest X-ray examination and com-
puted tomography (CT) scan revealed right pneumothorax
and pulmonary tumors with cavitation (Fig. 2a). The pneu-
mothorax was managed by tube thoracotomy. With closed
catheter drainage over a 48-h period, the right lung fully
reexpanded (Fig. 2b). Persistent air leakage, for 7 days,
however, made a right thoracotomy necessary. At the op-
eration, an open bronchopleural fistula in the necrotic pul-
monary tumor in S3 of the right upper lobe, infiltrating the
visceral pleura, was observed. A wedge resection of the
necrotic tumor which had caused the pneumothorax was
therefore performed. The patient made satisfactory postop-
erative progress, and the chest drainage tube was removed
3 days later. Microscopic examination of the specimen
showed poorly differentiated adenocarcinoma, consistent
with metastasis from the breast carcinoma (Fig. 1b). At

a a
b
Fig. 1. a Microscopic view of breast tumor resected in 1994 shows
invasive solid-tubular carcinoma infiltrating the mammary gland. b
Microscopic view of specimen of the pulmonary tumor resected in 1998
shows poorly differentiated papillotubular adenocarcinoma similar to
that in the intially resected breast tumor. a and b H&E, 325
present (October, 1999), the patient is receiving regular
outpatient treatment with MPA.
Discussion
It is well known that primary and secondary lung tumors are
occasionally complicated by pneumothorax.1 The most
common primary lesion of metastatic pulmonary tumors
which cause pneumothorax is reported to be osteosarcoma,
followed by angiosarcoma.1,2 To date, there have been few
reports of pneumothorax caused by metastatic pulmonary
tumors arising from other primary lesions, including renal
cancer,3 rectal cancer,4 uterine cancer,5 and melanoma.6
Only one patient with pneumothorax caused by pulmonary
metastasis of breast cancer has previously been reported in
the English-language literature.7
The possible ways that pneumothorax may be caused by
tumors include: (1) breakage of an existing bulla; (2) expan-
sion of the tumor and tumor embolism; (3) bronchopleural
fistula associated with tumor necrosis, as a result of the
treatment regimen; (4) a check-valve mechanism, caused by
55
b
Fig. 2. a Chest computed tomography scan on admission in 1998 shows
right pneumothorax, and pulmonary tumor with cavitation in S3 of the
right upper lobe (arrow) can be observed infiltrating the pleura. b
Anteroposterior chest roentgenographic film shows bilateral pulmo-
nary metastases (arrows) and full reexpansion of the right lung after
insertion of a catheter
pressure of the tumor on the bronchioles; and (5) direct
infiltration of the pleura by the tumor. In our patient, CT
revealed the tumor that had caused the pneumothorax. In
this patient, the disease was assumed to be caused by the
expanding tumor, which had infiltrated the pleura and then
perforated the necrotic area, resulting in the development
of pneumothorax.
The differential diagnosis between a metastatic pulmo-
nary tumor and a primary pulmonary carcinoma may be
difficult even when diagnostic imaging or pathological diag-
nosis is employed. In the present patient, the lesion was
determined to be pulmonary metastasis of breast cancer
because the microscopic characteristics of the resected
specimen were very similar to those of the primary lesion.
Pulmonary metastasis of breast carcinoma is not usually
treated by surgery, unless there are one or two lesions in
one lobe.8 Our patient’s condition, with multiple bilateral