Pneumomediastinum and pneumoperitoneum after endobronchial laser therapy and debulking in leiomyosarcoma lung metastasis

C. Da Silva Alves*^a (Dr), A. Fabiano^a (Dr), M. Alves^b (Dr), L. Maia Morais^c (Dr), M. Ferrão Silveira^a (Dr), L. Santos^a (Dr), R. Costa^a (Dr), J. Boléo-Tomé^a (Dr)

^a Pulmonology Department, Hospital Professor Doutor Fernando da Fonseca, Amadora, PORTUGAL ; ^b Pulmonology Department, Centro Hospitalar Lisboa Ocidental, Lisboa, PORTUGAL ; ^c Intensive Care Unit, Centro Hospitalar Lisboa Ocidental, Lisboa, PORTUGAL

* cmdsalves@gmail.com

Background: Rigid bronchoscopy is mainly used for central airway obstruction, and pneumomediastinum and pneumoperitoneum are rare complications. Leiomyosarcoma is a rare solid neoplasic malignancy characterized by aggressive behavior, occasionally metastizing to the lung.

Case Report: A 41-year-old woman presented to the emergency room with hemoptoic cough and a history of progressive weight loss within the previous two months. Chest radiography showed multiple large “cannon ball” pulmonary nodules, confirmed by chest CT, with one mass invading the main left bronchus. The patient underwent a rigid bronchoscopy, revealing a necrotic neoplastic growth occluding the main left bronchus (90% stenosis). Mechanical debulking followed by Laser Nd:YAG photocoagulation were performed, showing occlusion of left upper lobe bronchus and permeability of lower lobe segments. In the recovery room, after coughing, the patient developed sudden subcutaneous emphysema in the neck and face. A chest x-ray showed a left pneumomediastinum. Subcutaneous needles were inserted, with clinical improvement of the emphysema. Chest-Abdomen CT reveled a large, bilateral pneumomediastinum and pneumothorax, pneumoperitoneum, retropneumoperitoneum, a mass in the right kidney and multiple uterine nodules. The patient was managed conservatively and improved.

Biopsy of the lung mass revealed leiomyosarcoma of unknown origin. Three weeks later, rigid bronchoscopy was repeated due to left atelectasis, showing new neoplastic growth occluding the main left bronchus and right B6 segment. Mechanical debulking was performed of both lesions and a Dumon stent was placed in the left main bronchus. Biopsy of the mass of the right kidney confirmed renal leiomyosarcoma stage IV.

Conclusion: We report these rare complications following bronchoscopy and rapid progression of leiomyosarcoma lung metastasis. Although no laceration was detected during the procedure, pneumomediastinum and pneumothorax are possible, and the air can spread to the abdominal cavity through small pleuroperitoneal anatomic defects, resulting in pneumoperitoneum and retropneumoperitoneum.

Disclosure of funding source(s): none