Surg Today (2000) 30:462–464

Rib Metastasis Appearing 8 Years After Surgery for Lung Cancer:Report of a Case

Shinichiro Kase, Kenji Sugio, Tokujiro Yano, Kenichi Nishioka, Koji Yamazaki, Tatsuro Okamoto,Takaomi Koga, Masafumi Yamaguchi, Kaoru Ondo, and Keizo Sugimachi

Department of Surgery II, Faculty of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan

Case Report

A 39-year old man who was a nonsmoker underwent achest roentgenogram during a regular health examina-tion in December 1987, and an abnormal shadow wasfound in his right lung. He underwent a regular healthexamination once a year but no abnormalities had everbeen pointed out on chest roentgenogram findings.Computed tomography (CT) showed a soft tissue massin the right upper lobe with a pleural indentation andspiculation (Fig. 1) which was diagnosed to be adeno-carcinoma by a transbronchial lung biopsy (TBLB). Aright upper lobectomy and lymph node dissection weretherefore performed on March 7, 1988. The size of thetumor measured 35 3 26 mm in diameter. Histologi-cally, the tumor showed well-differentiated adenocarci-noma (Fig. 2a). All lymph nodes examined were free oftumor cells. The patient was thus considered to havepT2N0M0 stage I disease. After surgery, his follow-upexaminations included a chest roentgenogram with tu-mor markers every 3 months, with chest CT and a sys-temic bone scintillation scan every year. Generally, ourfollow-up period is 10 years after surgery. On October29, 1996, 8 years 7 months after surgery, a bone scintil-lation scan showed an abnormal uptake in the rightfourth rib. To rule out a primary bone tumor, aspirationneedle cytology was performed, and adenocarcinomawas identified with the same histology as the previouslung cancer. Since no other metastasis was recognizedon a CT of the brain, chest, and abdomen, we thusdecided to completely resect the rib.

On admission, a physical examination revealed noabnormal findings. The serum chemistry levels andblood count showed no abnormalities. Tumor markersindicated as follows: carcinoembryonic antigen 4.5ng/ml, squamous cell carcinoma antigen 1.8ng/ml, CYFRA2.4ng/ml (normal levels are ,2.5 ng/ml, ,2.5 ng/ml, and,2.0 ng/ml, respectively). The respiratory function wasnormal. A chest CT showed lytic changes in the right

Abstract: A 39-year-old man underwent a right upper lobec-tomy and lymph node dissection for right lung adenocar-cinoma on March 7, 1988. He was referred for an evaluation ofa systemic bone scintillation scan on October 29, 1996. A hotspot at the right fourth rib was recognized. After performingneedle aspiration cytology, a diagnosis of adenocarcinomawas made. This case was considered to be rib metastasis occur-ring 8 years after surgery for lung cancer. In general, regularfollow-up examinations are performed for at least 5 yearsafter surgery; however, surgeons should also keep such latemetastatic cases in mind.

Key Words: lung cancer, adenocarcinoma, metastasis,recurrence, disease-free interval

Introduction

The overall incidence of recurrence in patients withstage I non-small cell lung cancer ranges from 27% to48%.1–3 Recurrence commonly occurs within 5 yearsafter surgery, and most frequently within 3 years. Therecurrence sites can be divided into three large groupsconsisting of distant, locoregional, and combined(regional and distant) groups, and the incidences of re-currence are about 50%, 30%, and 20%, respectively.4,5

The incidence of bone metastasis ranges from 11% to32%,1,6,7 while it is only 0.5% over 5 years after surgery.However, we sometimes experience cases of recurrencemore than 5 years after surgery. We report herein a caseof rib metastasis which appeared 8 years after surgeryfor lung cancer.

Reprint requests to: S. Kase(Received for publication on May 17, 1999; accepted on Nov.11, 1999)

Fig. 1. Chest computed tomography (CT) reveals an irregularmass with pleural indentation and spiculation in the rightupper lobe

Fig. 2. a Well-differentiated adenocarcinoma of the primarylung cancer resected in 1988 (H&E, 3200). b Metastatic bonetumor. Histologically, bone tissue is largely replaced by a

proliferation of cancer cells in a papillary or cribriform pat-tern. (H&E, 3200)

a b

fourth rib (Fig. 3). A systemic bone scintillation scanshowed a hot spot on the right fourth rib (Fig. 4). Nodistant metastasis was observed except on the rightfourth rib. A resection of the fourth rib was done onDecember 10, 1996.

Histologically, the bone tissue had largely been re-placed by the proliferation of cancer cells in either apapillary or cribriform pattern. In addition, these cellswere also similar to those of the previous lung adeno-carcinoma. Therefore, metastatic carcinoma from lungcancer was indicated (Fig. 2b). The patient made anuneventful recovery and was discharged from our hos-pital on the 14th postoperative day, and had no adjuvantchemotherapy.

The patient was checked regularly since the secondoperation. Unfortunately, bilateral multiple pulmonarymetastases were recognized on October 21, 1998. The

Fig. 3. Chest CT shows lytic change of the right fourth rib

patient is presently alive with recurrent disease as ofJuly 1999.

Discussion

Recurrence over 5 years after curative surgery for lungcancer is relatively rare. Martini reported the overallrecurrence for resected stage I non-small cell lung can-cer to be in 159 (27%) of 598 patients, and 15 (2.5%) ofthese recurred after 5 or more years, while bone me-tastasis occurred in only 3 patients (bone 1 lung, bone1 brain, bone only) and second primary cancers devel-oped in 206 of 598 patients.1 In our department, of the917 patients curatively resected for lung cancer, 378(41.2%) had recurrent disease, and only 5 showedrecurrence over 5 years. The incidences of recurrence

463S. Kase et al.: Rib Metastasis After Lung Cancer Surgery

which occurred in a distant region, local region, anddistant/local region were 70%, 24%, and 6%, respec-tively.8 All 5 cases with recurrent disease occurringmore than 5 years after surgery showed distant metasta-sis; 2 had lung metastasis, 2 had brain metastasis, and 1had bone metastasis. The incidence of recurrence over 5years after surgery is thus about 0.5%, and the incidenceof bone metastasis after more than 5 years is only 0.1%.Therefore, the chance to detect recurrence is consid-ered to be extremely rare even if routine examinationscontinue more than 5 years after surgery.

In general, patients with bone metastasis are not indi-cated for surgery, because the main purpose of bonemetastasis therapy tends to be pain relief and radiationtherapy is usually the initial treatment. Sagawa et al.reported that although bone recurrence tends to dem-onstrate only one local lesion, multiple bone metastaseshave often been recognized after death. It is also diffi-cult for patients who have a single bone metastasis tosurvive longer when the bone is resected.9 The indica-tions for a resection of bone metastasis in the presentcase include: a single lesion restricted to the rib, the

Fig. 4. Systemic bone scintillation scan shows a hot spot onthe right fourth rib

possibility of achieving a complete resection, and nodetection of other distant metastasis. In fact, it has yet tobe determined as to whether a resection was indeed theoptimal treatment modality, and this case was carefullyfollowed up.

In conclusion, regular examinations after a curativeoperation should generally be made for 5 years to checkfor any recurrences. However, we should keep in mindthat some cases may also demonstrate a disease-free-interval which is longer than 5 years.

Acknowledgment. We thank Dr. B.T. Quinn, Kyushu Univer-sity, for his critical comments during the preparation of themanuscript.

References

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2. Harpole DH Jr, Herndon JE, Wolfe WG, Iglehart JD, Marks JR(1995) A prognostic model of recurrence and death in stage I non-small cell lung cancer utilizing presentation, histopathology, andoncoprotein expression. Cancer Res 55:51–56

3. Ramacciato G, Paolini A, Volpino P, Aurello P, Balesh AM,D’Andrea N, Del GE, Passaro U, Tosato F, Fegiz G (1995) Modal-ity of failure following resection of stage I and stage II non-smallcell lung cancer. Int Surg 80:156–161

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7. The Ludwig Lung Cancer Study Group (1987) Patterns of failure inpatients with resected stage I and II non-small-cell carcinoma ofthe lung. Ann Surg 205:67–71

8. Mitsudomi T, Nishioka K, Maruyama R, Saitoh G, Hamatake M,Fukuyama Y, Yaita H, Ishida T, Sugimachi K (1996) Kinetic analy-sis of recurrence and survival after potentially curative resection ofnonsmall cell lung cancer. J Surg Oncol 63:159–165

9. Sagawa M, Saito Y, Takahashi S, Sato M, Kamma K, Usuda K,Endo C, Yan C, Sakurada A, Aikawa K, Okaniwa G, Fujimura S(1994) Significance of surgical treatment for bone metastasis fromlung cancer (in Japanese with English abstract). Kyobu Geka (JpnJ Thorac Surg) 47:1001–1006

464 S. Kase et al.: Rib Metastasis After Lung Cancer Surgery