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LETTER TO THE EDITOR
Year : 2012  |  Volume : 8  |  Issue : 1  |  Page : 161-162

Isolated axillary lymph node metastasis at presentation in bronchogenic carcinoma


1 Department of Surgical Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai - 600020, India
2 Department of Molecular Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai - 600020, India

Date of Web Publication19-Apr-2012

Correspondence Address:
Arvind Krishnamurthy
Department of Surgical Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai - 600020, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.95206

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How to cite this article:
Krishnamurthy A, Neelakantan V. Isolated axillary lymph node metastasis at presentation in bronchogenic carcinoma. J Can Res Ther 2012;8:161-2

How to cite this URL:
Krishnamurthy A, Neelakantan V. Isolated axillary lymph node metastasis at presentation in bronchogenic carcinoma. J Can Res Ther [serial online] 2012 [cited 2019 Nov 19];8:161-2. Available from: http://www.cancerjournal.net/text.asp?2012/8/1/161/95206

Sir,

Axillary lymph nodes metastasis (ALNM) from a bronchogenic carcinoma is a rare occurrence, isolated metastasis is even rarer. We recently treated a patient of bronchogenic carcinoma who presented with isolated ipsilateral ALNM (without cervical and supraclavicular nodal metastasis), identified by a PET-CT.

A 68-year-old male, a heavy smoker (40 pack/years), presented to us with a two-month history of cough and right-sided chest pain On evaluation, we found him in Eastern Cooperative Oncology Group (ECOG) performance status 2, examination of the respiratory system revealed decreased air entry in his right upper zone, and a 2 × 1.5 cm significant right axillary lymph node (ALN). A PET-CT scan showed an increased uptake in a 5 × 6 cm pleural-based mass lesion in the right upper lung, increased uptakes were also seen in the right para tracheal nodes and right ALN [Figure 1] and [Figure 2]. The mass was not visualized endobronchially; hence, CT-guided aspiration cytology from the lung mass was done, which revealed malignant cell suggesting the possibility of a non small cell lung cancer. A right ALN biopsy was then performed; [Figure 3] which on microscopic examination revealed a metastatic carcinoma of glandular origin consistent with a primary in the lung. Epidermal growth factor (EGFR) mutation screened for exons 18 to 21 by polymerase chain reaction followed by DNA sequencing revealed only the wild type EGFR sequence in the exons studied. He was clinically staged T3N2M1. A decision was made to administer only oral chemotherapy considering the age and performance status, the patient was started on oral etoposide and continues to live with disease for the past six months.
Figure 1: PET - CT showing uptake in the right upper lobe lesion along with the mediastinal and axillary lymph nodes

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Figure 2: Whole body PET image showing uptake in the upper lobe lung and right axillary node

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Figure 3: Intra operative picture of right axillary lymph node biopsy

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ALN normally receives lymphatic drainage from the upper limbs and chest wall and not from the lungs. Many hypotheses have been put forward to explain the unusual pattern of ALN metastasis from bronchogenic carcinomas. Ochsner and DeBakey [1] in a review of 1298 cases of bronchogenic carcinomas reported a 6.6% incidence of ALNM and added 2 cases of their own; however, the incidence described in subsequent series have been less than 1%. [2],[3] Marcantonio and Libshitz [2] believed that bronchogenic carcinomas involve ipsilateral ALN through either chest wall invasion or retrograde spread from supraclavicular lymph nodes . Another hypothesis suggesting that ALNM occurs through newly formed lymphatic channels arising in chest wall or a pleural adhesion has been described. A third pathway of ALNM is involvement of intercostal lymphatics via the mediastinal lymph nodes. [4] The other suggested mechanism involves the systemic vascular route, considering the fact that there are no channels of lymphatic communication from the lungs to the ALNs. [3]

Non regional LNM is classified as distant metastasis and treatments generally include systemic chemotherapy. The prognosis is expectedly poor, with survivals ranging from 1 to 10 months. [3],[4] In conclusion clinicians should have a high index of suspicion while examining the ALNs in cases of bronchogenic carcinomas with chest wall invasion.

 
 > References Top

1.Ochsner A, DeBakey M. Significance of metastases in primary carcinoma of the lungs: Report of two cases with unusual site of metastasis. J Thorac Surg 1941;11:357-87.   Back to cited text no. 1
    
2.Marcantonio DR, Libshitz HI. Axillary lymph node metastases of bronchogenic carcinoma. Cancer 1995;76:803-6.  Back to cited text no. 2
[PUBMED]    
3.Riquet M, Le Pimpec-Barthes F, Danel C. Axillary lymph node metastases from bronchogenic carcinoma. Ann Thorac Surg 1998;66:920-2.   Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Satoh H, Ishikawa H, Kagohashi K, Kurishima K, Sekizawa K. Axillary lymph node metastasis in lung cancer. Med Oncol 2009;26:147-50.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  


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  [Figure 1], [Figure 2], [Figure 3]



 

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