Letters to Editor
An unusual presentation of pancreatic cancer: Muscular metastasis
Sir, Muscular metastasis of pancreatic cancer is rare. In fact, the skeletal muscle is a very unusual site of metastasis from any malignancy. In autopsy series, the frequency of microscopic intramuscular metastases is only 16%.[1] Three cases have been reported in the literature. We described here an interesting case of muscular pancreatic metastasis.[1‑3] A 58‑year‑old Caucasian woman was admitted to the Medical Oncology department in Leon Berard Center with epigastralgia, dorsal pain, and continuous weight loss for the past 2 months. Upon initial staging, the Eastern Cooperative Oncology Group (ECOG) performance status was equal to 2. Physical examination showed no abnormalities.
To eliminate a vascular or sarcomatous tumor, other markers were studied (anti‑CD31, anti‑CD34, anti‑factor‑VIII, anti‑CK5/6, calretinin, anti‑desmin). According to the clinical, biological, radiological, and histological elements, we concluded a muscular metastasis from an undifferentiated pancreatic carcinoma. The patient was treated with an association of chemotherapy with 5‑fluorouracil, irinotecan, and oxaliplatin (folfirinox protocol) in a phase II‑III clinical study (ACCORD 11 trial). She died of acute hematemesis from esophageal varix rupture after two cycles. Skeletal muscle is a rare site for metastases, with only 242 cases being reported previously. Primary cancers of the lung, hematological malignancies, gastrointestinal tract, and genitourinary tract were the most frequently involved. Only three cases of muscular metastasis from pancreatic cancer have been reported in the literature.[1‑3]
Neuroendocrine markers, S‑100 protein, anti‑hepatocyte antibody, and anti‑cytokeratin‑20 were negative.
Various theories have been proposed to explain the resistance of the skeletal muscle to both primary and metastatic cancer, and the relative rarity of skeletal muscle metastases, given the fact that the skeletal muscle accounts for a large percentage of total body weight: Variability of blood flow, intermittent muscular contraction, lactic acid metabolism and pH, presence of diffusible proteases, and other inhibitors that may block the enzyme‑dependent processes of invasion or tumor growth. [4] Organs with a high incidence of metastases, such as lungs, liver, and bones of the axial skeleton, have extensive capillary vascularization and a relatively constant blood flow. By contrast, although skeletal muscles have a rich vasculature, the blood flow is extremely variable and under the influence of b‑adrenergic receptors. Irrespective of high blood flow, skeletal muscle tissue may be a poor
Figure 1: Abdominal CT scan showing a caudal pancreatic mass measuring 10/9/7 cm
Figure 2: Abdominal CT scan showing metastatic infiltration of the right lobe and paravertebral muscles
Abdominal computed tomography (CT) scan showed a huge lesion of the caudal pancreas measuring 10 cm infiltrating the left kidney [Figure 1]. This mass was associated with multiple nodules of the liver, peritoneal effusion, portal hypertension, and multiple skeletal lesions of paravertebrals and gluteal muscles [Figures 2 and 3]. CA 19‑9 was elevated (300 UI/l). A scan‑guided biopsy of the muscular mass was performed. Histological and immunohistochemistry studies showed an undifferentiated tumoral process. Most of the tumor cells were positive for anti‑keratin cocktail, anti‑keratin‑7, and anti‑endomysial (anti‑EMA) antibodies.
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
369
Letters to Editor Departments of Medical Oncology, Centre Oncology-Hematology, Cadi Ayad University, Marrakech, 1National Institute of Oncology, Rabat, Morocco, 2Centre Leon Berard, Lyon, France Correspondence to: Dr. Rhizlane Belbaraka, E‑mail: [email protected]
References 1. 2. 3. 4. 5. Figure 3: CT scan showing multiple metastatic lesions in the obturator and gluteal muscles
recipient for tumors, which may be related to lactic acid metabolism. [5] These different factors that inhibit the growth of metastases in the skeletal muscle did not prevent the growth of metastases in our case. Belbarka R, Fadoukheir Z1, Delafouchardiere C2, Desseigne F2, Errihani H2
Primary renal lymphoma: An unusual presentation of non‑Hodgkin’s lymphoma
Sir, Primary renal non‑Hodgkin’s lymphoma (NHL) is a rare disease. Less than 100 of cases of primary renal Lymphoma are described.[1]
Wafflart E, Gibaud H, Lerat F, de Kersaint‑Gilly A, Leborgne J. Muscular metastasis of cancer of the pancreas. A propos of a case. J Chir (Paris) 1996;133:167‑70. Garcia OA, Fernandez FA, Satue EG, Buelta L, Val‑Bernal JF. Metastasis of malignant neoplasms of skeletal muscle. Rev Esp Oncol 1984;31:57‑67. Belloir A, Pujol J, Bruel JM, Rouanet JP, Lamarque JL. Muscular metastases: Uncommon manifestation of cystadenocarcinoma of the pancreas. J Radiol 1986;67:209‑11. Perrin AE, Goichot B, Greget M, Lioure B, Dufour P, Marcellin L, et al. Muscular metastasis as the first manifestation of an adenocarcinoma. Rev Med Interne 1997;18:328‑31. Bar‑Yehuda S, Barer F, Volfsson L, Fishman P. Resistance of muscle to tumor metastases: A role for A3 adenosine receptor agonists. Neoplasia 2001;3:125‑31. Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146714 PMID: *****
with the compressed kidney at the periphery. Sections from the tumor show round cells having hyper‑chromatic nuclei, coarse chromatin, and scant–moderate amount of cytoplasm [Figure 2]. Some of the cells display a plasmacytoid appearance. The tumor cells are arranged in sheets and they tend to fall out from each other and have no definite architecture. Immunohistochemistry revealed CD20 positivity [Figure 3]. A staging bone marrow
It is defined as an NHL arising primarily in the renal parenchyma, not resulting from invasion of an adjacent lymphomatous mass and without evidence of systemic involvement.[1,2] We report a case of a 49‑year‑old male who presented with a history of pain and mass per abdomen since 20 days. General physical examination revealed no lymphadenopathy. Local examination revealed a mass occupying the right hypochondriac, lumbar, and iliac regions, and measuring 13 × 10 cm. Investigations revealed normal peripheral smear and negativity for HIV, hepatitis C virus (HCV), and hepatitis B surface antigen (HBsAg). Ultrasonography revealed a complex mass of mixed echogenicity at the posterior border of the right kidney measuring 14 × 12 cm [Figure 1]. With provisional diagnosis of sarcoma, laparotomy was undertaken and nephrectomy was done. We received a large single nodular, grey‑white soft tissue mass measuring 17 × 13 × 11cm. The external surface was nodular and glistening. The cut section shows a solid, grey‑white, lobular, and well‑circumscribed tumor 370
Figure 1: Pre‑operative radiologic image
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Copyright of Indian Journal of Cancer is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
An unusual presentation of pancreatic cancer: Muscular metastasis
Sir, Muscular metastasis of pancreatic cancer is rare. In fact, the skeletal muscle is a very unusual site of metastasis from any malignancy. In autopsy series, the frequency of microscopic intramuscular metastases is only 16%.[1] Three cases have been reported in the literature. We described here an interesting case of muscular pancreatic metastasis.[1‑3] A 58‑year‑old Caucasian woman was admitted to the Medical Oncology department in Leon Berard Center with epigastralgia, dorsal pain, and continuous weight loss for the past 2 months. Upon initial staging, the Eastern Cooperative Oncology Group (ECOG) performance status was equal to 2. Physical examination showed no abnormalities.
To eliminate a vascular or sarcomatous tumor, other markers were studied (anti‑CD31, anti‑CD34, anti‑factor‑VIII, anti‑CK5/6, calretinin, anti‑desmin). According to the clinical, biological, radiological, and histological elements, we concluded a muscular metastasis from an undifferentiated pancreatic carcinoma. The patient was treated with an association of chemotherapy with 5‑fluorouracil, irinotecan, and oxaliplatin (folfirinox protocol) in a phase II‑III clinical study (ACCORD 11 trial). She died of acute hematemesis from esophageal varix rupture after two cycles. Skeletal muscle is a rare site for metastases, with only 242 cases being reported previously. Primary cancers of the lung, hematological malignancies, gastrointestinal tract, and genitourinary tract were the most frequently involved. Only three cases of muscular metastasis from pancreatic cancer have been reported in the literature.[1‑3]
Neuroendocrine markers, S‑100 protein, anti‑hepatocyte antibody, and anti‑cytokeratin‑20 were negative.
Various theories have been proposed to explain the resistance of the skeletal muscle to both primary and metastatic cancer, and the relative rarity of skeletal muscle metastases, given the fact that the skeletal muscle accounts for a large percentage of total body weight: Variability of blood flow, intermittent muscular contraction, lactic acid metabolism and pH, presence of diffusible proteases, and other inhibitors that may block the enzyme‑dependent processes of invasion or tumor growth. [4] Organs with a high incidence of metastases, such as lungs, liver, and bones of the axial skeleton, have extensive capillary vascularization and a relatively constant blood flow. By contrast, although skeletal muscles have a rich vasculature, the blood flow is extremely variable and under the influence of b‑adrenergic receptors. Irrespective of high blood flow, skeletal muscle tissue may be a poor
Figure 1: Abdominal CT scan showing a caudal pancreatic mass measuring 10/9/7 cm
Figure 2: Abdominal CT scan showing metastatic infiltration of the right lobe and paravertebral muscles
Abdominal computed tomography (CT) scan showed a huge lesion of the caudal pancreas measuring 10 cm infiltrating the left kidney [Figure 1]. This mass was associated with multiple nodules of the liver, peritoneal effusion, portal hypertension, and multiple skeletal lesions of paravertebrals and gluteal muscles [Figures 2 and 3]. CA 19‑9 was elevated (300 UI/l). A scan‑guided biopsy of the muscular mass was performed. Histological and immunohistochemistry studies showed an undifferentiated tumoral process. Most of the tumor cells were positive for anti‑keratin cocktail, anti‑keratin‑7, and anti‑endomysial (anti‑EMA) antibodies.
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
369
Letters to Editor Departments of Medical Oncology, Centre Oncology-Hematology, Cadi Ayad University, Marrakech, 1National Institute of Oncology, Rabat, Morocco, 2Centre Leon Berard, Lyon, France Correspondence to: Dr. Rhizlane Belbaraka, E‑mail: [email protected]
References 1. 2. 3. 4. 5. Figure 3: CT scan showing multiple metastatic lesions in the obturator and gluteal muscles
recipient for tumors, which may be related to lactic acid metabolism. [5] These different factors that inhibit the growth of metastases in the skeletal muscle did not prevent the growth of metastases in our case. Belbarka R, Fadoukheir Z1, Delafouchardiere C2, Desseigne F2, Errihani H2
Primary renal lymphoma: An unusual presentation of non‑Hodgkin’s lymphoma
Sir, Primary renal non‑Hodgkin’s lymphoma (NHL) is a rare disease. Less than 100 of cases of primary renal Lymphoma are described.[1]
Wafflart E, Gibaud H, Lerat F, de Kersaint‑Gilly A, Leborgne J. Muscular metastasis of cancer of the pancreas. A propos of a case. J Chir (Paris) 1996;133:167‑70. Garcia OA, Fernandez FA, Satue EG, Buelta L, Val‑Bernal JF. Metastasis of malignant neoplasms of skeletal muscle. Rev Esp Oncol 1984;31:57‑67. Belloir A, Pujol J, Bruel JM, Rouanet JP, Lamarque JL. Muscular metastases: Uncommon manifestation of cystadenocarcinoma of the pancreas. J Radiol 1986;67:209‑11. Perrin AE, Goichot B, Greget M, Lioure B, Dufour P, Marcellin L, et al. Muscular metastasis as the first manifestation of an adenocarcinoma. Rev Med Interne 1997;18:328‑31. Bar‑Yehuda S, Barer F, Volfsson L, Fishman P. Resistance of muscle to tumor metastases: A role for A3 adenosine receptor agonists. Neoplasia 2001;3:125‑31. Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146714 PMID: *****
with the compressed kidney at the periphery. Sections from the tumor show round cells having hyper‑chromatic nuclei, coarse chromatin, and scant–moderate amount of cytoplasm [Figure 2]. Some of the cells display a plasmacytoid appearance. The tumor cells are arranged in sheets and they tend to fall out from each other and have no definite architecture. Immunohistochemistry revealed CD20 positivity [Figure 3]. A staging bone marrow
It is defined as an NHL arising primarily in the renal parenchyma, not resulting from invasion of an adjacent lymphomatous mass and without evidence of systemic involvement.[1,2] We report a case of a 49‑year‑old male who presented with a history of pain and mass per abdomen since 20 days. General physical examination revealed no lymphadenopathy. Local examination revealed a mass occupying the right hypochondriac, lumbar, and iliac regions, and measuring 13 × 10 cm. Investigations revealed normal peripheral smear and negativity for HIV, hepatitis C virus (HCV), and hepatitis B surface antigen (HBsAg). Ultrasonography revealed a complex mass of mixed echogenicity at the posterior border of the right kidney measuring 14 × 12 cm [Figure 1]. With provisional diagnosis of sarcoma, laparotomy was undertaken and nephrectomy was done. We received a large single nodular, grey‑white soft tissue mass measuring 17 × 13 × 11cm. The external surface was nodular and glistening. The cut section shows a solid, grey‑white, lobular, and well‑circumscribed tumor 370
Figure 1: Pre‑operative radiologic image
Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3
Copyright of Indian Journal of Cancer is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
