Lung carcinoma within a lung bulla wall: literature review and case report

Pulmonary emphysema is a common pulmonary disease encountered in daily medical practice. Its management follows specific guidelines but lacks standardized screening for the development of lung cancer. The precancerous theory of emphysematous bulla/cyst is not well described in the literature, with only a few reports of malignancy within an emphysematous bulla wall. We report the case of a 46-year-old man with productive cough and hemoptysis. A chest radiograph showed multiple irregular radiolucencies in both lung apices. Computed tomography revealed bilateral emphysema with a left apical emphysematous bulla that showed a thickened wall and accumulation of fluid within the bullous cavity. Due to life-threatening hemoptysis, a left upper lobectomy and mediastinal lymph node sampling were performed. The pathology report showed pleomorphic carcinoma within the emphysematous cystic wall. Postoperative computed tomography of the abdomen and pelvis showed focal thickening in the left adrenal gland, and adrenal metastatic carcinoma was confirmed. Brain magnetic resonance imaging also showed metastasis. The patient was started on chemotherapy. He died 2 years postoperatively. Twenty-three cases have been reported from 1989 to 2016, but there was no case of metastatic disease within the wall of an emphysematous bulla. Lung emphysema is not routinely screened for cancer development because it is not cost-effective and does not seem to improve patient outcome, but should this practice be reviewed?