|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 1 | Page : 216-217
Metastatic soft tissue squamous cell carcinoma: Unusual presentation of lung cancer
Shirish S Chandanwale, Sukanya S Pal
Department of Pathology, Padmashree Dr. D Y Patil Medical College, Dr. D Y Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||23-Apr-2014|
Shirish S Chandanwale
75/1+2/1 Krishna Appt., Behind Indraprashta BLD New Sangvi, Pune - 411 027, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandanwale SS, Pal SS. Metastatic soft tissue squamous cell carcinoma: Unusual presentation of lung cancer. J Can Res Ther 2014;10:216-7
Distant metastasis to soft tissues including skeletal muscle, subcutaneous tissue, and skin are rarely reported in the literature. Autopsy series reported soft tissue metastasis in 0.75-9% of patients who died from metastatic carcinomas. Metastasis of squamous cell carcinoma of the lung to soft tissue is extremely rare. , We report soft tissue metastasis as a presenting symptom of squamous cell carcinoma of the lung.
A 60-year-old man, a chronic smoker presented with complaints of three small painful nodules on the lower abdomen since 20 days, fever on and off, dry cough, breathlessness on exertion of 1 month duration. There was no other significant medical history. Three firm small painful subcutaneous nodules measuring 1.4 × 0.6 cm, 1.2 × 0.5 cm, and 1 × 0.5 cm each were palpable on the lower abdomen below the umbilicus. Overlying skin was normal. Chest X-ray suggested a diagnosis of collapse/consolidation in the left upper zone of the lung [Figure 1]a. Routine hematological investigations were normal except hemoglobin was 7 g/dl. Histopathological examination of excised subcutaneous nodule showed sheets of tumor cells showing squamous differentiation and infiltrating subcutaneous fibrofatty tissue [Figure 1]b. Nuclei showed moderate nuclear pleomorphism, prominent nucleoli, and mitotic figures [Figure 1]c. Tumor emboli were seen in occasional blood vessel [[Figure 1]c, inset]. A diagnosis of metastatic squamous cell carcinoma to anterior abdominal wall was made. Computed tomography (CT) scan showed left lung upper lobe collapse/consolidation with heterogeneous enhancement and left segmental bronchial narrowing [Figure 1]d. A diagnosis of lung carcinoma was suggested. CT guided transthoracic fine needle aspiration (FNA) confirmed the diagnosis of squamous cell carcinoma of the lung.
|Figure 1: (a) Chest radiograph showing homogenous opacity in the left upper zone of the lung. (b) Subcutaneous nodule show sheets of squamoid tumor cells infiltrating subcutaneous fibro fatty tissue (hematoxylin and eosin, ×100). (c) Tumor cells showed moderate nuclear pleomorphism, prominent nucleoli and mitotic figures, and tumor emboli in vessel (inset, H and E, ×400). (d) Computed tomography scan showed left lung upper lobe collapse/consolidation with left segmental bronchial narrowing|
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Lung cancers are known to spread early throughout the body. The most common type is adenocarcinoma. Squamous cell carcinoma spread late outside thorax. Major sites of metastasis include liver, adrenal glands, brain, bone, kidney, and abdominal lymph nodes. Spread occurs through hematogenous, lymphatic, and perineural spread.  In our case, arterial emboli were seen [[Figure 1]c, inset].
Soft tissue metastasis including skeletal muscle, subcutaneous tissue, and skin are rarely reported and they usually appear when the lung cancer is advanced. In our case, soft tissue metastasis was the presenting symptom. Most frequent symptom of soft tissue metastasis of lung cancer is palpable painful mass. It can be painless or even asymptomatic.  Most frequently reported locations of soft tissue metastasis include back, chest wall, neck, posterior abdominal wall, thigh muscles, iliopsoas muscles, and paraspinous muscles. ,, In our case, small painful subcutaneous nodules were on anterior abdominal wall.
Detection of soft tissue metastasis may affect the staging and prognosis and is important for therapeutic decision making. Early diagnosis and treatment are important for better prognosis.
Treatment of soft tissue metastasis depends on their localization, clinical presentation, and prognosis of primary tumor. Therapeutic options include observation, radiotherapy, chemotherapy, and surgery. For multiple soft tissue metastatic lesions, palliative treatment with surgical debulking is indicated if pain and neurovascular damage is clinically significant.  Metastatic lung cancer is treated with chemotherapy. Survival of patients with soft tissue metastasis range from less than 9 months to not more than 3 years after diagnosis, although in some cases survival up to 5 years is reported.  Patient was started chemotherapy and is under close observation. We conclude, presence of multiple painful subcutaneous nodules on the anterior abdomen in elderly male with history of chronic smoking, carcinoma of the lung should be ruled out.
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