Muscle metastasis from non-small cell lung cancer: two cases and literature review Y. Tezcan, M. Koc Konya N.E. University Meram Faculty of Medicine, Department of Radiation Oncology, Turkey Non-small cell lung cancers (NSCLC) is the most commonly observed group among lung cancers. Adenocancers are histopathologically more common. Males are more affected than females, an effect which is directly related to smoking. They generally cause distant haematogenous and lymphatic metastasis. Distant haematogenous metastases are often seen in contralateral lung, brain, bone, adrenals, and liver. Muscle metastases from NSCLC are quite rare and male cases are more frequently affected compared to female cases. NSCLC cases with muscle metastasis are at the same time accompanied by distant organ metastases such as bone, brain, and liver. All treatment approaches are considered to be palliative in these cases, which are symptomatologically quite severe. In the present study, we presented the rarely observed cases of two male patients with muscle metastasis from NSCLC together with the related literature. Keywords: Non-small cell lung cancer, Muscle metastasis, Bronchoscopy, Radiotherapy
Introduction Lung cancers are histopathologically classified into two groups as small cell lung cancer and non-small cell lung cancer (NSCLC). NSCLCs, and accordingly adenocancers, are more frequently seen. Their distant metastases occur through haematogenous and lymphatic routes located in the chest wall. Haematogenous and lymphatic dissemination are frequent. Haematogenous metastases are most frequently seen as contralateral lung, brain, bone, adrenals, and liver. Rare muscle metastases are more frequently observed in males (M/F52 : 1) and they are often seen as metastases with primaries that originated from lungs, urinary system, gastrointestinal system, and genitourinary system. Muscle metastases in adenocarcinomas compared to other histopathological types are more common.1 Muscle metastases are localized to the lower extremity at a rate of 46%,2 but according to Haygood et al., the most common site of involvement was the muscles of the trunk.3 Typical clinical findings in muscle metastases are local pain, increased muscular tonus and swelling. Al-Alao et al. reported a rare case of metastasis to the gluteal muscle from NSCLC.4 Hajouji et al. performed MRI, CT scan, and ultrasonography imaging of muscle metastasis for the diagnosis of a series of seven cases from NSCLC
Correspondence to: Y. Tezcan, N.E. University Meram Faculty of Medicine, Department of Radiation Oncology, 42090 Konya, Turkey. Email: [email protected]
ß Acta Clinica Belgica 2014 DOI 10.1179/2295333714Y.0000000035
and pathologically diagnosed all the cases through biopsy.5 In our study, we presented two rare cases with muscle metastasis from NSCLC, in which the diagnoses were confirmed through biopsies. After biopsy, all our patients have palliative radiotherapy.
Methods Case 1 The case was a 48-year-old male patient with a smoking history of 70 packs/year and a history of alcohol use. Blood biochemistry was within normal limits. The examinations performed for complaints of cough and PET/CT imaging revealed the presence of a standardized uptake value (SUV)517.15 mass lesion with increased F-18 fluorodeoxyglucose (FDG) uptake necrotic in the middle and located in the right lung upper lobe (Fig. 1a). As the result of fiberoptic bronchoscopy and biopsy, the case was diagnosed as epidermoid carcinoma. There were complaints of swelling and pain in the quadratus femoris vastus lateralis muscle region of the right femur. The same PET/CT scan showed a second SUV57.27 lesion with increased FDG uptake, necrotic in the middle and located in the quadratus femoris vastus lateralis muscle of the right femur (Fig. 1b). In the MRI of the femur, a 53651684 mm sized contrast enhancing soft tissue mass was observed in the quadratus femoris vastus lateralis muscle in the middle of the right femur. Based on the biopsy performed from this region, the case was diagnosed as epidermoid carcinoma and
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Muscle metastasis from NSCLC
Figure 1 In PET/CT, (a) primary located tumor in the right lung upper lobe lesion, (b) metastatic muscle lesion in the quadratus femoris vastus lateralis muscle of the right femur; (c) right lung hilar lesion; and (d) metastatic muscle lesion in the right gluteus maximus muscle.
staged as stage IV NSCLC from muscle metastasis. The patient had diffuse brain and lung metastases. General condition was bad. Our patient refused surgery due to muscle metastasis, so we did not consider surgery for muscle metastases. According to these findings, a systemic chemotherapy regime with cisplatin and docetaxel and palliative radiotherapy were planned. A total dose of 3600 cGy of palliative radiotherapy was applied in fractions of 300 cGy612 for the metastatic lesion in the right quatratus femoris vastus lateralis. After the radiotherapy, a decrease in the mass size and lessening of the symptoms of pain and swelling were observed. Response to radiotherapy was partial. Our case died within the 5 months following the detection of muscle metastasis.
Case 2 The case was a 50-year-old male patient with a smoking history of 45 packs/year. Blood biochemistry was within normal limits. Mass was detected in the right lung in the posterior–anterior chest radiography performed during routine controls. In the PET/CT imaging, a 35623 mm sized mass lesion with SUV513.6, right hilar and paratrachial lymph nodes were detected in the hilar region of the right
lung (Fig. 1c). Distant organ metastases were not present at the time of diagnosis. As the result of the biopsy, the case was diagnosed as adenocarcinoma. The case was staged as clinical T2bN2M0 (stage IIIA) and neoadjuvant chemoradiotherapy was planned. One month after the completion of the chemoradiotherapy, which included simultaneous cisplatin and vinorelbine, complaint of pain developed in the right femur. PET/CT and MRI examinations were performed for restaging. Pelvic MRI revealed the presence of an approximately 50640 mm sized soft tissue mass necrotic in the middle and located in the right gluteus maximus muscle. In the PET/CT scan, an SUV510.5 mass lesion with increased FDG uptake was detected in the right gluteus maximus muscle (Fig. 1d). Based on the needle biopsy performed from this region, the case was diagnosed as adenocarcinoma. Also, the patient had bone, brain, and adrenal gland metastases. There were multiorgan metastases, and since survival is short for muscle metastases, we did not consider surgery. Palliative radiotherapy was planned. A total dose of 3000 cGy of palliative radiotherapy was applied in fractions of 300 cGy6 10 for the metastatic lesion in the right gluteus
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maximus muscle region. In another clinic, the second line of chemotherapy treatment was continued as palliative cisplatin and docetaxel. Our case died within the 3 months following the detection of muscle metastasis.
Results Today, NSCLCs are types of cancers that cause the most cancer deaths in males and females. The treatment is performed through a multidisciplinary approach. Distant organ metastases are observed through haematogenous and lymphatic routes. Haematogenous metastases are most frequently seen in contralateral lung, brain, bone, adrenals, and liver, whereas muscle metastases are quite rare. The cases which are considered to be muscle metastasis and in which mass and pain are detected in the muscle through physical examination, histopathological diagnosis should also be definitely performed through needle biopsy or excisional biopsy following the radiological imaging of the metastasis through MRI, CT, or ultrasonography.
Conclusion Muscle metastasis from NSCLC is an aggressive cancer and survivals are quite poor and short. NSCLC cases with muscle metastasis are at the same time accompanied by distant organ metastases such as brain, bone, and liver. All treatment approaches are considered to be palliative in these cases, which are symptomatologically quite severe. For this
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reason, an approach specific to each patient and multidisciplinary treatment alternatives need to be offered in selected patients. Local treatments, especially surgical and radiotherapy options, should be considered in the first place. In muscular metastasis, if appropriate for the patient’s performance and anesthesia, surgical removal is recommended. Palliative radiation therapy after surgery may be more appropriate. We presented these two cases together with the related literature because of the fact that NSCLC with muscle metastasis is rarely observed in the literature.
Disclaimer Statements Contributors None. Funding None. Conflicts of interest There is no conflict of interest. Ethics approval Consent was obtained from patients.
References 1 Strauss JB, Shah AP, Chen SS, Gielda BT, Kim AW. Psoas muscle metastases in non-small cell lung cancer. J Thorac Dis. 2012;4:83–7. 2 Mathis S, Fromont-Hankard G, du Boisgue´heneuc F, Godene`che G, Mahieu F, Balaboi I, et al. Muscular metastasis. Rev Neurol. 2010;166(3):295–304. 3 Haygood TM, Wong J, Lin JC, Li S, Matamoros A, Costelloe CM, et al. Skeletal muscle metastases: a three-part study of a not-so-rare entity. Skelet Radiol. 2012;41(8):899–909. 4 Al-Alao BS, Westrup J, Shuhaibar MN. Non-small-cell lung cancer: unusual presentation in the gluteal muscle. Gen Thorac Cardiovasc Surg. 2011;59(5):382–4. 5 Hajouji L, Mennecier B, de la Haye Saint-Hilaire D, Bierry G, Canuet M, Quoix E. Muscular metastasis from primary lung cancer: about seven cases. Rev Pneumol Clin. 2011;67(2):75–81.