Spontaneous Pneumothorax
A Complication of Lung Cancer?*
c. A Steinhauslin, M.D.; and]. F. Cuttat, M.D.
Among338 adults (258men and 80 women)presenting with
spontaneous pneumothorax, there were six men with lung
cancer: five squamous cell carcinoma and one oat cell
carcinoma. Pneumothorax led to the diagnosis in fivecases
and the remaining occurred as a complication of known
neoplastic disease. The average age was 67 years. We
analyze these six cases, along with 46 others from the
literature. In patients less than 40 years old with normal
chest x-ray &1m 6ndings after lung expansion, further
investigationfor neoplastic disease is notjusti6ed. However,
Spontan eous pneumothorax can be divided into
types. Primary spontaneous pneumothorax associ-
two
ated with subpleural bullous dystrophy, including
recurrent spontaneous pneumothorax, is predominant
between the ages of 20 and 40 years.r' Secondary
spontaneous pneumothorax, due to natural evolution
of intrathoracic pathology," becomes more frequent
from the end of the fourth decade, mainly due to
bullous emphysema." A number of rare pulmonary
dystrophies may present as spontaneous pneumotho-
rax. 1-14 Pleuroparenchymatous metastases from sar-
comas in children and adolescents are a rare but classic
etiology of spontaneous pneumothorax. 15-19 They com-
prise less than 1.5 percent of cases. l 6.iO
Spontaneous pneumothorax due to primary lung
cancer, between 0.03 21 and 0.05 percent" of the total,
should also be mentioned. Beside the fact that it occurs
in the same high risk population (smokers, II chronic
bronchitis" and those with emphysemat':"), pneu-
mothorax may reveal a cancel:
We report six cases to illustrate this association and
review 46 cases from the literature.
MATERIAL AND METHODS
From 1959 to 1983,338 adults (258 men and 80 women) presenting
a total of519 pneumothoraces, were treated at CH~ Lausanne. Six
cases were associated with lung cancer (Iable 1), constituting 0.46
percent of aD the cases ofbronchial neoplasm seen during this same
period.
All pneumothoraces were ipsilateral to the tumor.
CASE REPORTS
All patients were men between 61 and 74 years, average age 67
years. Five were heavy smokers with chronic bronchitis (patients 1,
*Service de Chfrurgie A, Prot F: Saegesser, Centre Hospitalier
Universitaire Vaudois, Lausanne, Switzerland.
Manuscript received February 12; revision accepted May 8.
Reprint requut8: Dr. Stelnhiluslin, Seroice de Chirurgie A, CHuv,
1011 Lausanne, Switzerland
heavy smoking, chronic bronchitis, bullous emphysema and
incomplete lung expansion after chest drainage in patients
over 40 years old are indications for cancer screening
through sputum cytologicstudy, bronchoscopicexamination
and surgical exploration. The occurrence of a pneu-
mothorax neither alters the treatment of the underlying
disease nor m0di6es the one-year prognosis. Five-year
survival is nil, suggesting that lung cancers present as
pneumothorax at an advanced stage of disease.
2, 3, 4, 6). One had a history of recurrent bronchopneumonia (patient
5).
Four patients presented with acute thoracic pain followed by
dyspnea, and two patients presented with an aggravation of pre-
existent dyspnea (patients 2 and 5); pneumothorax was found on
chest x-ray examination. Three patients (3, 4, and 6) complained of
hemoptysis.
In three cases pneumothorax disclosed a neoplasm (patient 2, 3,
and 6), and in one it occurred in a patient undergoing radiotherapy
for lung cancer (patient 5). In two cases (patients 1 and 4), the delay
before cancer was diagnosed was six weeks and six months, respec-
tively. One patient (4) had a recurrent pneumothorax before the
diagnosis was made.
A tumor was visible on the initial chest x-ray examination in two
cases (patients 2 and 5). In one (patient 3), no pathology other than
complete pulmonary collapse was seen. Two chest x-ray films showed
segmental infiltrations (patients 2 and 4), and one showed segmental
atelectasis (patient 1). Patient 6 presented pneumothorax associated
with a giant, air-filled cyst (Fig lA); on lung expansion, chest x-ray
film showed left hilar enlargement (Fig IB). Standard lung to-
mographic examination localized a lesion in the apical segment of the
upper lobe stenosing the bronchus proximal to the cyst (Fig lC).
In five cases, bronchoscopic and histologic examination confirmed
the presence of bronchial neoplasm. The remaining case was
diagnosed on sputum cytologic study alone. Indications for bron-
choscopy were: persistent pneumothorax (patients 1, 3); recurrent
ipsilateral pneumothorax (patient 4); post-irradiation pneumothorax
(patient 5); and bronchial stenosis on tomography (patient 6).
Bronchoscopic examination showed three bronchial obstructions,
(patients 1, 3 and 6), one accompanied by a bronchopleural fistula;
and two bronchial stenoses (patients 4 and 5), one post-irradiation.
Five diagnoses were squamous cell carcinomas of all degrees of
differentiation, TNM staging being: three T3 lesions and two T.
lesions. The other was an oat cell carcinoma.
Ofthe patients with squamous cell carcinoma, one hadan inferior
lobectomy and succumbed two months later to local recurrences and
multiple metastases (patient 4); two underwent pneumonectomy,
and one died two months later of pulmonary embolus (patient 1)and
the other survived two years (patient 3). One patient was treated by
chest drainage and radiotherapy (patient 6). He lived for three years,
then died of local spread. Patient 5, with oat cell carcinoma, was
similarly treated by chest drainage followed by radiotherapy; he
succumbed to disseminated metastases four months later. There was
CHEST I 88 I 5 I NOVEMBER. 1985 708
 FIGURE lA (left). Sixty-five-year-old male . Initial chest x-ray examination: total left pneumothorax. Giant air
filled cyst on the collapsed lung. B (center). Control chest x-ray film on lung expansion. Air filled cyst at the
left pulmonary apex. Left hilar enlargement suspicious for lung cancer. C. (right). Standard lung
tomographic study. Giant air filled cyst distal to a stenosis suspicious for cancer, localized on the apical
superior segmental bronchus.
no treatment offerable to patient 2, with extensive disease. Oper- chial cancer may be due to: 1)rupture into the pleural
ative mortality was nil. space of dilated alveoli distal to stenotic bronchial
Overall survival was 33 percent at one year, and average survival cancer (patients 2, 4, 6); 2), rupture into the pleural
was 12.5 months (two months to three years).
space of alveoli that have become distended in com-
DISCUSSION pensation for atelectasis due to obstructive bronchial
Spontaneous pneumothorax associated with bron- cancer (patient 1); 3) bronchopleural fistula secondary
Table I-Summary ofSh Caaa

Treatment
Sequence Radiologic Histologic Survival
Patient Sex Age(yrs) delay evidence diagnosis PNO CA TNM

1 M 61 PNO-CA Poorly diff Drainage 0 pneumonectomy 4 months

6 weeks Segmental squamous cell CA pleurodesis 0 pulmonary
atelectasis bronchoscopy persistent PNO embolus
PNO obstruction T3N) Mo
sup lob br
2 M 74 PNO-CA + Poorlydiff Abstension 6 months
simultaneous Pulmonary squamous cell CA organization pulmonary
infiltrate cytology atelectasis
lymph nodes T3 N. Mo
PNO
3 M 65 PNO-CA Squamous cell CA Drainage 0 pneumonectomy
simultaneous PNO bronchoscopy persistent PNO
obstruction
bronchopleural
fistula
sup lob br
4 M 72 PNO-CA Drainage
2 episodes PNO Non diff
6 months + squamous cell CA Drainage in£. lobectomy
segmental bronchoscopy recurrence
infiltrate inflob br
PNO obstruction
5 M 65 CA-PNO + Oat cell CA Drainage DXR 4 months
6 weeks Lymphatic bronchoscopy
involvement post. DXR Metastasis
PNO stenosis
6 M 65 PNO-CA + Poorly diff Drainage 0 DXR 3 years
simultaneous Gian t squamous cell CA pleurodesis + Local
airfilled cyst bronchoscopy
PNO sup lob br stenosis
main stem inva-
sion

710 Spontaneous Pneumolhorax; Complication 01 LungC8ncer? (Stelnhluslin. CutfIItJ

 Table2-SUtIitJIGfy tf 1M46 Cilia ita ,It. UNrtJlure
Treatment
Sequencel
Author Sex Age delay X-ray Histology PNO CA Survival
Hochberg1C m59 PNO-CA adeno CAithoraco· thoraco
Heimlich33 m45 PNO-CAI3w1c: squamous cell drainage 0 pneumonectomy 2+ yr
m53 PNO-CAI3mo anaplasticlthoraco drainage 0 Smo
mSl PNO-CAInone + adeno CAlbronchos- drainage 1mo
copy
Bariety'1 m47 PNO-CAl6 mo squamous cell drainage lobectomy
2 episodes bronchoscopy drainage 0
Citron- £49 PNO-CAl4 mo squamouscelli 4+ mo
bronchoscopy
£64 PNO-CAInone + squamouscelli
bronchoscopy
mOO PNO-CAl2 mo squamouscelli 2+ mo
bronchoscopy
m63 CA-PNO/3 wIc: + squamouscelli 1+ mo
bronchoscopy
mSS CA-PNO/3 wk + anaplasticlbronchos- pneumonectomy
copy
m72 CA-PNO + carcinoma OXR 2+ mo
RoW' mOO PNO-CAinone + large celllthoraco drainage 0 pneumonectomy
mSS PNO-CAInone + adeno CAithoraco drainage 0 lobectomy
Gautmann31 m60 PNQ-CA squamous celllcytol drainage 0 lobectomy
Seremetis4D m39 PNO-CA13 mo large celllthoraco drainage lobectomy 10mo
2 episodes drainage 0
Williams· m48 PNO-CAl4 mo alveol celllbiopsy drainage 6mo
2 episodes
Dines· m74 PNO-CAInone + adeno CA OXR 2mo
m56 PNO-CAInone + small cell drainage 0 5wk
m60 PNO-CAinone + adeno CA drainage 0 OXR Imo
£55 PNO-CAInone carcinoma/cytology drainage OXR
JCban31 m56 PNO-CAinone + squamouscelllautop drainage 3w1c:
m53 PNO-CAInone + squamouscelllalitop drainage explo thoraco 1- mo
m60 PNO-CAl2 wit squamouscelli drainage 2wk
bronchoscopy
Mabajan- m39 PNO-CAinone + large ceUlbiopsy explo thoraco I mo
chemotherapy
Arnettll m31 PNO-CAl2 mo large celllthoraco drainage lobectomy Iyr
2 episodes drainage 0 OXR
chemotherapy
BaydurJI mM CA-PNO/2 wk + squamous celllcytol drainage 2mo
Wrightlt m69 CA-PNO/1 mo + squamouscelli OXR
bronchoscopy
m 71 CA-PNO/2yr + carcinomalbronchos-
copy
m60 PNO-CAInone + squamous celli
bronchoscopy
CA-PNO +
PNO-CAInone
YeUD~ m50 PNO-CM mo squamouscelli drainage 13+ mo
2 episodes + thoraco drainage 0 pneumonectomy
Doumovc" m57 PNO-CAInone + squamouscelli drainage pneumonectomy
bronchoscopy
Hydell m68 PNO-CAInone + squamouscelli drainage
bronchoscopy
Watt4l m49 PNO-CAII wIc: adeno CAithoraco drainage 0 lobectomy 6+ mo
Ayresta m 71 CA-PNO + small cell drainage
mSS PNO-CA + squamous cell pneumonectomy
m62 PNO-CA + squamous cell drainage OXR
m82 CA-PNO + squamous cell
Lundgren31 m12 PNO-CAInone + squamous celllcytol drainage 0 explo thoraco Smo
chemotherapy
m 71 PNO-CAinone squamous celllcytol drainage 0 chemotherapy SIIlO
De La Oliva30 m53 PNO-CAInone + squamouscelli drainage
bronchosoopy
m53 CA-PNO/10 wk + adeno CAlbronchos- drainage explo thoraco
copy chemotherapy
m61 PNO-CAInone + adeno CAicytology drainage lobectomy
Lauren" £51 PNO-CA13 mo indift'. CAlbronchos- drainage lobectomy 4+ mo
copy
m47 PNO-CAInone + large celllbronchos- drainage OXR 10+ mo
copy

CHEST I 88 I 5 I NOVEMBER, 1985 711

to rapid invasion of a peripheral or pleural neoplasm
(patients 3, 5;·andlor 4) fortuitous association, as most
of these patients have either chronic bronchitis,
asthma or emphysema; emphysematous bullae may
rupture following disturbance of lung architecture due
to bronchial cancel:
The 46 reported cases of spontaneous pneumothorax
and lung cancer13,lS,I9,2l.25-43 show a clear predominance
in men (90 percent) between 31 and 74 years of age,
average 57.1 years (Table 2).
Pneumothorax was the first manifestation of cancer
in 36 of the 46 (78.3 percent). Among these, the
majority of neoplasms, 20 of 36 (56 percent) were
suspected at the first episode of pneumothorax, the
motivation for further investigation being suspicious
chest x-ray film findings, persistent pneumothorax and
suspicious cytologic findings of pleural fluid.
Lung cancer was diagnosed late in 16 of 36 patients
(44 percent), with a mean delay of2. 9 months. Of these
16 cases, there was no suspicion of lung cancer on
initial chest x-ray examination after lung expansion. In
four patients with two episodes of pneumothorax, the
delay was incresed to 4.5 months; these four included
two of the three patients of the series less than 40 years
old. Pneumothorax occurred in known cases of bron-
chial cancer in ten of 46 (21. 7 percent).
All the types of histology are cited, distributed as
follows: squamous cell carcinomas (50 percent), ade-
nocarcinomas (18.2 percent), giant cell carcinomas
(11.4 percent), oat cell carcinomas (4.5 percent),
anaplastic carcinomas (4.5 percent), alveolar cell car-
cinoma (2.3 percent), undifferentiated carcinoma (2.3
percent), and carcinomas of undefined histology (6.8
percent).
Thirty-three of46 (71.7 percent) of the cancers were
treated. All lines oftreatment were followed, including
pneumonectomy, lobectomy, radiotherapy, and
chemotherapy, singly or in conjunction.
The overall survival was 17 percent at one year, with
an average SUrvival of5.2 months (less than one month
to more than two years).
Spontaneous pneumothorax as a complication of
lung cancer is rare, as seen from the literature,
comprising only 0.05 percent of all pneumotho-
races. 13,19.2l.i8,30,37,38,40,43
In our establishment over the past 20 years, 1.13
percent of spontaneous pneumothoraces were due to
lung cancel; occurring in 0.46 percent of the cases of
bronchial neoplasm. All histologic types of lung cancer
have been reported, principally squamous cell car-
cinoma, probably because of its relatively higher
incidence.
Approximately three-fourths of the spontaneous
pneumothoraces preceded the diagnosis of lung cancer
in our series and in the literature.
The occurrence ofspontaneous pneumothorax com-
712
plicating lung cancer does not affect short-term prog-
nosis for the underlying disease. The overall one-year
survival rate for lung cancer in our establishment is
27.7 percent. 44 This figure is statistically comparable
with that of our six patients and the 46 patientsfrom the
literature, 33 percent and 17 percent, respectively.
However, although the overall five-year survival for
lung cancer is 8 to 10 percent," the absence of
survivors at five years in the literature review and in
our own experience suggests that lung cancer present-
ing as a pneumothorax is at an advanced stage. In three
cases of our series, visceral pleura was involved,
suggesting a T3 lesion.
In adults less than 40 years old, lung cancer only
exceptionally underlies a pneumothorax, the most
frequent origin being primary spontaneous pneu-
mothorax (conscripts disease). Despite this, recurrent
pneumothorax in a young adult should be considered
secondary and a cause sought. 5,19.40
Therefore, we conclude that: 1) spontaneous pneu-
mothorax in association with lung cancer is rare; 2)
spontaneous pneumothorax is a complication of lung
cancel; occurring at an advanced stage of disease; 3)
patients less than 40 years old with a recurrent
spontaneous pneumothorax may harbor a neoplasm;
and 4) in patients more than 40 years old with a history
of heavy smoking, chronic bronchitis, bullous emphy-
sema, incomplete lung expansion or a suspicious chest
x-ray film after chest drainage, further investigation
with sputum cytologic study, bronchoscopic examina-
tion and, if need be, exploratory thoracotomy is
warranted.
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