Journal of Cytology
Home About us Ahead of print Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online:960
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size


 
 Table of Contents    
CASE REPORT  
Year : 2014  |  Volume : 31  |  Issue : 2  |  Page : 117-118
Metastatic squamous cell carcinoma of the lung masquerading as a soft tissue tumor


Department of Pathology, Christian Medical College and Hospital, Ludhiana, Punjab, India

Click here for correspondence address and email

Date of Web Publication14-Aug-2014
 

   Abstract 

Carcinoma of lung can metastasize to any organ system; however, metastasis to skeletal muscles is extremely rare. A 63-year-old man, known case of pulmonary tuberculosis on treatment, presented with a painful swelling in his left leg. Examination revealed a 5.0 cm × 3.0 cm calf swelling, which on imaging was suggestive of a soft tissue tumor. Fine-needle aspiration cytology of the swelling revealed it to be squamous cell carcinoma. Further investigations revealed a mass in the left lower lobe of the lung. Biopsies from both the lung lesion and calf swelling confirmed the diagnosis of squamous cell carcinoma of lung with metastasis to the calf muscle. The case is being presented because of its unusual presentation and rarity.

Keywords: Fine-needle aspiration cytology; lung cancer; skeletal muscle metastasis

How to cite this article:
Kaur R, Kwatra KS, Masih K, Calton N. Metastatic squamous cell carcinoma of the lung masquerading as a soft tissue tumor. J Cytol 2014;31:117-8

How to cite this URL:
Kaur R, Kwatra KS, Masih K, Calton N. Metastatic squamous cell carcinoma of the lung masquerading as a soft tissue tumor. J Cytol [serial online] 2014 [cited 2019 Nov 22];31:117-8. Available from: http://www.jcytol.org/text.asp?2014/31/2/117/138693



   Introduction Top


Although skeletal muscles comprise nearly 50% of the total body mass, it is an extremely rare site for metastatic tumors. The prevalence of skeletal muscle metastasis in various autopsy series of patients with any type of cancer ranged from 0.8% to 17.5%, whereby, the most common tumors found to metastasize to the skeletal muscles were from the genitourinary and gastrointestinal tract. [1],[2],[3] The prevalence of lung cancer metastasis to skeletal muscles is very low and ranges between 0.0% and 0.8% [1],[2],[3] Sometimes, these metastatic lesions are the first clinical signs of underlying malignancy. We report one such case of squamous cell carcinoma of the lung who presented with a metastatic swelling in the calf muscle, mimicking a soft tissue tumor.


   Case Report Top


The case we present here is about a 63-year-old man who was referred to our out-patient clinic with a gradually increasing swelling in his left calf since 3 months and associated pain since the last 1 month. He gave a history of loss of appetite and weight. He had been diagnosed to be having pulmonary tuberculosis 5 months ago for which he was receiving treatment regularly. The patient was a nonsmoker.

General physical examination revealed mild pallor and clubbing of his fingers. The left calf swelling was ill-defined and measured 5.0 cm Χ 3.0 cm approximately. It was firm to hard in consistency, tender and showed mobility in the transverse axis. Systemic examination revealed no abnormality except for decreased breath sounds and crepitations in both the lung fields.

Magnetic resonance imaging of the leg swelling showed a 3.2 cm Χ 2.4 cm Χ 2.0 cm mass in the lateral border of the gastrocnemius muscle encasing the peroneal nerve - suggestive of a peripheral nerve sheath tumor. Computed tomography scan of the chest revealed a fibro-cavitatory lesion in the right upper lobe of the lung which was consistent with tuberculosis. In addition, an ill-defined mass was visualized in the left lower lobe, measuring 3.5 cm Χ 2.7 cm, with associated collapse. This lesion was suspected to be neoplastic. Abdominal ultrasound was normal.

Hemogram showed mild iron deficiency anemia. All the biochemical parameters were within normal histological limits.

Based on the above investigations, a presumptive diagnosis of soft tissue tumor of the leg with possible metastasis to the lung and coexistent pulmonary tuberculosis was made.

The calf swelling was first subjected to fine-needle aspiration cytology (FNAC). Cytology revealed loose groups as well as singly placed polygonal and round cells with squamoid appearance [Figure 1]a. The cells had high nuclear-cytoplasmic ratio, hyperchromatic irregular nuclei, small nucleoli and a moderate amount of dense eosinophilic cytoplasm. Few bizarre looking cells were also seen. Possibility of a metastatic squamous cell carcinoma was suggested.

This was followed by core biopsies from the left lung mass as well as the calf swelling. Histopathology from both the sites revealed moderately differentiated squamous cell carcinoma [Figure 1]b and c. A final diagnosis of squamous cell carcinoma of the lung with skeletal muscle metastasis was made.
Figure 1: (a) Fine-needle aspiration cytology of the calf swelling showing malignant squamous cells (H and E, ×400); (b and c) Core biopsies from the lung lesion and calf swelling respectively, showing squamous cell carcinoma (H and E, ×400)

Click here to view



   Discussion Top


Lung carcinomas can metastasize to various organ systems. Local intra-thoracic spread can occur to mediastinal lymph nodes, pleura, diaphragm, chest wall and pericardium. The most common extra thoracic sites are the liver, adrenal glands, brain, bone and kidney. [1] Rarely, metastasis can occur to the skeletal muscles, producing a soft tissue swelling, which can clinically be confused with a soft tissue sarcoma. [4]

In spite of its rich vascularity, skeletal muscles are resistant to hematogenous metastasis from epithelial neoplasms; the reported incidence being less than 1% in various clinical case series. [5],[6] Di Giorgio et al. in their study of 3000 patients treated for lung cancer, described only three cases showing skeletal muscle metastasis. [5]

Various hypotheses viz. mechanical, metabolic, and immunological have been proposed to explain the rarity of metastasis to skeletal muscles. Mechanical hypothesis attributes muscle contraction, increased tissue pressure and variable blood flow to creating an inhospitable tissue environment for seeding of tumor. [7] According to the metabolic hypothesis, presence of lactic acid and protease inhibitors in the muscle inhibit the growth of tumor cells and resist invasion. [8] Immunological hypothesis suggests a role of cellular and humoral immunity. [9] None of these can however, provide a complete explanation.

The present case is interesting due to the fact that the presenting feature of an underlying lung carcinoma was a metastatic lesion in the skeletal muscle, masquerading as a soft tissue tumor. It also highlights the role of FNAC as a convenient tool to correctly diagnose such lesions.

 
   References Top

1.Perisano C, Spinelli MS, Graci C, Scaramuzzo L, Marzetti E, Barone C, et al. Soft tissue metastases in lung cancer: A review of the literature. Eur Rev Med Pharmacol Sci 2012;16:1908-14.  Back to cited text no. 1
    
2.Surov A, Hainz M, Holzhausen HJ, Arnold D, Katzer M, Schmidt J, et al. Skeletal muscle metastases: Primary tumours, prevalence, and radiological features. Eur Radiol 2010;20:649-58.  Back to cited text no. 2
    
3.Pearson CM. Incidence and type of pathologic alterations observed in muscle in a routine autopsy survey. Neurology 1959;9:757-66.  Back to cited text no. 3
[PUBMED]    
4.Sudo A, Ogihara Y, Shiokawa Y, Fujinami S, Sekiguchi S. Intramuscular metastasis of carcinoma. Clin Orthop Relat Res 1993;296:213-7.  Back to cited text no. 4
    
5.Di Giorgio A, Sammartino P, Cardini CL, Al Mansour M, Accarpio F, Sibio S, et al. Lung cancer and skeletal muscle metastases. Ann Thorac Surg 2004;78:709-11.  Back to cited text no. 5
    
6.Ménard O, Parache RM. Muscle metastases of cancers. Ann Med Interne (Paris) 1991;142:423-8.  Back to cited text no. 6
    
7.Weiss L. Biomechanical destruction of cancer cells in skeletal muscle: A rate-regulator for hematogenous metastasis. Clin Exp Metastasis 1989;7:483-91.  Back to cited text no. 7
[PUBMED]    
8.Seely S. Possible reasons for the high resistance of muscle to cancer. Med 1980;6:133-7.  Back to cited text no. 8
    
9.Stein-Werblowsky R. Skeletal muscle and tumour metastasis. Experientia 1974;30:423-4.  Back to cited text no. 9
[PUBMED]    

Top
Correspondence Address:
Kanwardeep Singh Kwatra
Department of Pathology, Christian Medical College, Ludhiana, Punjab - 141 008
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.138693

Rights and Permissions


    Figures

  [Figure 1]

This article has been cited by
1 Tumors Involving Skin, Soft Tissue and Skeletal Muscle: Benign, Primary Malignant or Metastatic?
Chi-Ying Hsieh,Huang-Wen Tsai,Chih-Chun Chang,Tsuo-Wu Lin,Ke-Chung Chang,Yo-Shen Chen
Asian Pacific Journal of Cancer Prevention. 2015; 16(15): 6681
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1514    
    Printed57    
    Emailed0    
    PDF Downloaded70    
    Comments [Add]    
    Cited by others 1    

Recommend this journal