IMAGES
IN THE
MEDICAL SCIENCES
Sternal Mass Presenting as a First Manifestation of Lung Cancer Pedro J. Marcos, MD* and Andrés Rodríguez-Lorenzo, MD, PhD *
Servicio de Neumología, Complejo Hospitalario Universitario A Coruña, Xubias de arriba 84, 15006 A Coruña, Spain (E-mail: [email protected])
FIGURE 2
FIGURE 1
B
one metastases although frequently present in the form of lung cancer, a sternal metastasis has rarely been described in the literature. In this clinical case study, we discuss a 61-year-old male patient who presented with a sternal mass as the first manifestation of lung cancer. A 61-year-old man, with a history of smoking 60 packs per year, presented at our clinic for a consultation due to the appearance of a growing centrothoracic mass during the past 4 months with local pain. The patient described that he was feeling unwell and had lost 10 kg during the past month, but he did not complain of dyspnea, fever, or hemoptysis. The patient’s sternum had a 10-cm-diameter erythematous mass with petrous consistency that was painful upon palpation (Figure 1). Computed tomography (CT) showed a destructive lesion affecting the sternal manubrium and sternal body associated with big soft tissue tumefaction, and a 4-cm mass localized near the left hilum with hilar and mediastinal adenopathies (Figure 2). A fine needle puncture aspiration showed malignant cellularity, but bacterial and mycobacterial results were negative. A biopsy of the mass was diagnostic for adenocarcinoma. An immunohistochemical analysis of the tissue mass showed focal positivity with epithelial membrane positivity and a positive nuclear focal result for the thyroid transcription factor-1 marker, suggesting a primary lung-originating cancer. Because of the deteriorating status of the patient, radiotherapy treatment over the sternal lesion commenced immediately. The patient died 3 weeks after the diagnosis. Bones are one of the most frequent localizations for lung cancer metastases. In a review of patients who underwent surgical resection for tumors involving the sternum, only 3.8% of cases were due to lung cancer metastases.1 Unique, large mass-volume, sternal metastasis, as in the present case, is uncommon. Some published data have described unique sternal metastases of the breast, liver, thyroid, kidney, and laryngeal
420
cancer. A unique sternal metastasis from a lung cancer is infrequent and is usually localized on the sternal body. Confirmation of the presence of a destructive sternal and lung mass was performed initially by chest x-ray and later with a CT. Use of a fine needle puncture aspiration for diagnosing lung lesions is controversial because of an important number of false negatives related with the technique; however, when immunohistochemical analyses are performed, the diagnostic yield could be higher. In this present case, the definite diagnosis came from performing an incisional biopsy of the lesion. The puncture procedure was helpful to rule out other causes such as infection, which could manifest itself in similar ways. Although treatment is not completely standardized, a therapeutic approach must be combined with radiotherapy, chemotherapy, and surgery. External radiotherapy can control bone pain to a significant extent. Good results have been achieved with sternal resectional surgery in cases that required reconstruction, such as primary sternal tumors and breast metastases.2 Surgical experience is more limited with other types of tumors, and it is possible that the approach should be on a case-by-case basis. In this case, the deteriorated state of the patient persuaded the authors to choose palliative treatment, which resulted in radiotherapy of the lesion. In conclusion, although the presentation of a lung cancer as a sternal mass is rare, it should be considered when presented with a chest wall tumor, particularly in a high-risk population. Early diagnosis and rapid intervention could lead to a better outcome. REFERENCES 1. Incarbone M, Nava M, Lequaglie C, et al. Sternal resection for primary or secondary tumors. J Thorac Cardiovasc Surg 1997;114:93–9. 2. Lequaglie C, Massone PB, Giudice G, et al. Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms. Ann Surg Oncol 2002;9:472–9.
The American Journal of the Medical Sciences
Volume 346, Number 5, November 2013
IN THE
MEDICAL SCIENCES
Sternal Mass Presenting as a First Manifestation of Lung Cancer Pedro J. Marcos, MD* and Andrés Rodríguez-Lorenzo, MD, PhD *
Servicio de Neumología, Complejo Hospitalario Universitario A Coruña, Xubias de arriba 84, 15006 A Coruña, Spain (E-mail: [email protected])
FIGURE 2
FIGURE 1
B
one metastases although frequently present in the form of lung cancer, a sternal metastasis has rarely been described in the literature. In this clinical case study, we discuss a 61-year-old male patient who presented with a sternal mass as the first manifestation of lung cancer. A 61-year-old man, with a history of smoking 60 packs per year, presented at our clinic for a consultation due to the appearance of a growing centrothoracic mass during the past 4 months with local pain. The patient described that he was feeling unwell and had lost 10 kg during the past month, but he did not complain of dyspnea, fever, or hemoptysis. The patient’s sternum had a 10-cm-diameter erythematous mass with petrous consistency that was painful upon palpation (Figure 1). Computed tomography (CT) showed a destructive lesion affecting the sternal manubrium and sternal body associated with big soft tissue tumefaction, and a 4-cm mass localized near the left hilum with hilar and mediastinal adenopathies (Figure 2). A fine needle puncture aspiration showed malignant cellularity, but bacterial and mycobacterial results were negative. A biopsy of the mass was diagnostic for adenocarcinoma. An immunohistochemical analysis of the tissue mass showed focal positivity with epithelial membrane positivity and a positive nuclear focal result for the thyroid transcription factor-1 marker, suggesting a primary lung-originating cancer. Because of the deteriorating status of the patient, radiotherapy treatment over the sternal lesion commenced immediately. The patient died 3 weeks after the diagnosis. Bones are one of the most frequent localizations for lung cancer metastases. In a review of patients who underwent surgical resection for tumors involving the sternum, only 3.8% of cases were due to lung cancer metastases.1 Unique, large mass-volume, sternal metastasis, as in the present case, is uncommon. Some published data have described unique sternal metastases of the breast, liver, thyroid, kidney, and laryngeal
420
cancer. A unique sternal metastasis from a lung cancer is infrequent and is usually localized on the sternal body. Confirmation of the presence of a destructive sternal and lung mass was performed initially by chest x-ray and later with a CT. Use of a fine needle puncture aspiration for diagnosing lung lesions is controversial because of an important number of false negatives related with the technique; however, when immunohistochemical analyses are performed, the diagnostic yield could be higher. In this present case, the definite diagnosis came from performing an incisional biopsy of the lesion. The puncture procedure was helpful to rule out other causes such as infection, which could manifest itself in similar ways. Although treatment is not completely standardized, a therapeutic approach must be combined with radiotherapy, chemotherapy, and surgery. External radiotherapy can control bone pain to a significant extent. Good results have been achieved with sternal resectional surgery in cases that required reconstruction, such as primary sternal tumors and breast metastases.2 Surgical experience is more limited with other types of tumors, and it is possible that the approach should be on a case-by-case basis. In this case, the deteriorated state of the patient persuaded the authors to choose palliative treatment, which resulted in radiotherapy of the lesion. In conclusion, although the presentation of a lung cancer as a sternal mass is rare, it should be considered when presented with a chest wall tumor, particularly in a high-risk population. Early diagnosis and rapid intervention could lead to a better outcome. REFERENCES 1. Incarbone M, Nava M, Lequaglie C, et al. Sternal resection for primary or secondary tumors. J Thorac Cardiovasc Surg 1997;114:93–9. 2. Lequaglie C, Massone PB, Giudice G, et al. Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms. Ann Surg Oncol 2002;9:472–9.
The American Journal of the Medical Sciences
Volume 346, Number 5, November 2013
