Letters to the Editor
that is composed of spindle cells without significant atypia and absent mitotic figures. Diffuse CD31 and HHV8 immunoreactivity also militated against diagnosis of bacillary angiomatosis that formed as another differential diagnosis. Rarely, intranodal KS has also been found to be coexistent with mycobacterial infection and Hodgkin lymphoma in district case reports.[6‑8,11] Of these, only a single case that occurred in another African male, who additionally had skin lesions, documented by Lanjewar et al.,[8] was confirmed with positive HHV8 immunostaining. Apart from an intranodal KS, no additional histopathological findings were seen in the present case. This patient was a candidate for highly active antiretroviral therapy treatment. However, he left for his home country for further management. To sum up, the present case is the second documentation of a primary intranodal KS from our country, but occurring in an African male , objectively confirmed on biopsy with positive HHV8 LANA1 immunostaining. Presence of vascular pattern and spindly cells, especially in the lymph node of an HIV‑positive patient are useful diagnostic ‘‘clues’’ for this diagnosis that should be reinforced with necessary IHC markers, including HHV8. Unfortunately, our patient was lost to follow‑up. Bharat Rekhi, Haider Rangwalla1, Roshan F. Chinoy2 Department of Pathology, Tata Memorial Hospital, Parel, Departments of Surgery and 2Pathology, Prince Aly Khan Hospital, Mazagaon, Mumbai, Maharashtra, India
1
For correspondence: Dr. Bharat Rekhi, Department of Pathology, Tata Memorial Hospital, Dr. Ernest Borges Road, Parel, Mumbai - 400 012, Maharashtra, India. E-mail: [email protected]
REFERENCES 1. Braun M. Classics in Oncology. Idiopathic multiple pigmented sarcoma of the skin by Kaposi. CA Cancer J Clin 1982;32:340‑7. 2. Mentzel T, Knuutila S, Lamovec J. Kaposi sarcoma. In: Fletcher CD, Bridge JA, Hogendoorn PC, Mertens F, editors. World Health Organization (WHO) Classification of Tumors of Soft Tissue and Bone. Lyon: IARC Press; 2013. p. 151‑3. 3. Patel RM, Goldblum JR, Hsi ED. Immunohistochemical detection of human herpes virus‑8 latent nuclear antigen‑1 is useful for the diagnosis of Kaposi sarcoma. Mod Pathol 2004;17:456‑60. 4. Schwartz RA, Brenden LD, Breeden JH, Lambert WC. Indolent lymphadenopathic Kaposi’s sarcoma. J Surg Oncol 1987;34:243‑7. 5. Ioachim HL, Adsay V, Giancotti FR, Dorsett B, Melamed J. Kaposi›s sarcoma of internal organs. A multiparameter study of 86 cases. Cancer 1995;75:1376‑85. 6. Croxson TS, Ebanks D, Mildvan D. Atypical mycobacteria and Kaposi's sarcoma in the same biopsy specimens. N Engl J Med 1983 16;308:1476. 7. Bodhireddy H, Rivas S, Seshadri T. Coexistent Kaposi›s sarcoma and atypical mycobacterial infection involving lymph node: A case report and review of literature. Indian J Pathol Microbiol 2010;53:805‑7. 8. Lanjewar DN, Lanjewar SD, Chavan G. Coexistent lymphoma with tuberculosis and Kaposi›s sarcoma with tuberculosis occurring in lymph node in patients with AIDS: A report of two cases. Indian J Pathol Microbiol 2010;53:551‑4. 9. Finkbeiner WE, Egbert BM, Groundwater JR, Sagebiel RW. Kaposi›s sarcoma in young homosexual men: A histopathologic study with particular reference to lymph node involvement. Arch Pathol Lab Med 1982;106:261‑4. 10. Z u k e r b e rg L R , N i c k o l o f f B J , We i s s S W. K a p o s i f o r m hemangioendothelioma of infancy and childhood: An aggressive neoplasm associated with Kasabach‑Merrittt syndrome and lymphangiomatosis. Am J Surg Pathol 1993;17:321‑8. 11. Carbone A, Volpe R. Kaposi›s sarcoma in lymph nodes concurrent with Hodgkin›s disease. Am J Clin Pathol 1983;80:228‑30.
Thymoma: Clinical experience from a tertiary care institute from North India Access this article online Website: www.cancerjournal.net
Quick Response Code:
DOI: 10.4103/0973-1482.131440 PMID: ***
Sir, We read the manuscript with interest and discussed it in our journal club.[1] We would like to congratulate the authors for highlighting an untold story. Series on thymoma are sparse from India and authors have done a commendable job. However, there are certain observations in the article which need further clarification and comments. 214
For myasthenia gravis, thymus can have hyperplasia or a thymoma. Thymus can also be normal or may contain a cyst in cases of myasthenia gravis. A large series had been published on surgical outcome of thymectomy on myasthenia gravis from a nearby geographic area from the same country by Kumar et al.,[2] They had highlighted the different pathologic phenomenon within the thymus gland. Thymoma is considered to have poorer prognosis as compared to hyperplasia. Were there any patients in which histopathology revealed thymic hyperplasia instead of thymoma? Had the authors compared their results of surgery for thymic hyperplasia versus thymoma in cases of myasthenia gravis? The patients with Cushing’s syndrome form a special subset because they are most likely to have a thymic carcinoid. Was this possibility considered and whether histopathology slides were reviewed by an expert pathologist? Thymic carcinoids, though rare,
Journal of Cancer Research and Therapeutics - January-March 2014 - Volume 10 - Issue 1
Letters to the Editor
form an important component of multiple endocrine neoplasia type I (MEN1) syndrome. Were these patients having thymoma with Cushing’s syndrome evaluated for MEN1 syndrome? Can the authors elaborate on the results of treatment for myasthenia gravis and Cushing’s syndrome separately?
Ritesh Agrawal, Balaguruswamy Kanchana, Gobichettipalayam Kanniappan Venkatachalam, Udit Narayan Department of General Surgery, Aarupadai Veedu Medical College, Kirumampakkam, Puducherry, India For correspondence: Dr. Ritesh Agrawal, Endocrine and Breast Surgeon, Department of General Surgery, Aarupadai Veedu Medical College, Puducherry ‑ 607 402, India. E-mail: [email protected]
What was the author’s strategy for managing a thymoma? Do they offer surgery in every patient of a thymoma regardless of size, diagnosis, and stage or they select patients for surgery. If yes, what was the selection criteria used?
REFERENCES
Few patients (nine) were not operated. It is important to know their profile. What was the reason for not performing surgery in nine patients? Was surgery offered to them also and they denied or whether they were advanced tumors? If they were advanced tumors, it will form a subset and their inclusion in overall data will provide aberrant analysis.
1. Kumar N, Kumar R, Bera A, Ghoshal S, Kapoor R, Radotra BD, et al. Thymoma: Clinical experince from a tertiary care institute from North India. J Cancer Res Ther 2013;9:235‑9. 2. Kumar N, Verma AK, Mishra A, Agrawal G, Agrawal A, Mishra UK, et al. Factors predicting surgical outcome of thymectomy in myasthenia gravis: A 16‑year experience. Ann Indian Acad Neurol 2011;14:267‑71.
Author's Reply Access this article online Website: www.cancerjournal.net
Quick Response Code:
DOI: 10.4103/0973-1482.131442 PMID: ***
Sir, We appreciate the observations and questions raised regarding the article.[1] The questions definitely need a few clarifications and we hope that we would be able to do the same. The series presented by us focused on the clinical outcomes in patients of thymoma per se and mentioned the various paraneoplastic syndromes associated with thymoma.[1] Our series differs from the series by Kumar et al.,[2] which focused on the myasthenia gravis patients who underwent thymectomy and on histopathological analysis revealed thymic hyperplasia, thymoma, normal thymus, involuted thymus, thymic cysts, and unremarkable thymus. In our series, the patients with a confirmed histopathological diagnosis of thymoma were analyzed and the patients with hyperplasia, cysts, or carcinoid were not a part of the analysis. Management of the paraneoplastic syndromes was done as per the standard guidelines, while the patients with histopathological diagnosis of thymoma were staged as per Masaoka-Koga staging system and then managed accordingly with surgery as the cornerstone of therapy and further adjuvant treatment in form of radiotherapy and chemotherapy was decided as per stage, histopathology and prognostic features.[3] In locally advanced cases or inoperable cases, a neoadjuvant
approach was usedand then the patient was assessed for surgical removal.[4] Thenine patients did not underwent surgery because of locally advanced disease status with poor responseto neoadjuvant therapy and poor surgical suitability but were symptomaticallyimproved with radiotherapy and/or chemotherapy. This is a small and rare series of outcome of thymoma with multimodality approach, so further multivariate analysis was not possible due to small sample size. Narendra Kumar, Ritesh Kumar, Anjan Bera, Sushmita Ghoshal, Rakesh Kapoor, B. D. Radotra1, Suresh Chander Sharma Departments of Radiotherapy and Oncology and 1Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India For Correspondence: Dr. Ritesh Kumar, Department of Radiotherapy and Regional Cancer Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: [email protected]
REFERENCES 1. Kumar N, Kumar R, Bera A, Ghoshal S, Kapoor R, Radotra BD, et al. Thymoma: Clinical experince from a tertiary care institute from North India. J Cancer Res Ther 2013;9:235-9. 2. Kumar N, Verma AK, Mishra A, Agrawal G, Agrawal A, Mishra UK, et al. Factors predicting surgical outcome of thymectomy in myasthenia gravis: A 16-year experience. Ann Indian Acad Neurol 2011;14:267-71. 3. Falkson CB, Bezjak A, Darling G, Gregg R, Malthaner R, Maziak DE, et al. The management of thymoma: A systematic review and practice guideline. J Thorac Oncol 2009;4:911-9.
Journal of Cancer Research and Therapeutics - January-March 2014 - Volume 10 - Issue 1
215
Letters to the Editor
4. Lucchi M, Ambrogi MC, Duranti L, Basolo F, Fontanini G, Angeletti CA, et al. Advanced stage thymomas and thymic
carcinomas: Results of multimodality treatments. Ann Thorac Surg 2005;79:1840-4.
Metastatic soft tissue squamous cell carcinoma: Unusual presentation of lung cancer Access this article online Website: www.cancerjournal.net
Quick Response Code:
DOI: 10.4103/0973-1482.131443 PMID: ***
a
Sir, 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.[1,2] 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 1a]. 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 1b]. Nuclei showed moderate nuclear pleomorphism, prominent nucleoli, and mitotic figures [Figure 1c]. Tumor emboli were seen in occasional blood vessel [Figure 1c, 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 1d]. A diagnosis of lung carcinoma was suggested. CT guided transthoracic fine needle aspiration (FNA) confirmed the diagnosis of squamous cell carcinoma of the lung. 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 216
c
b
d
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
of metastasis include liver, adrenal glands, brain, bone, kidney, and abdominal lymph nodes. Spread occurs through hematogenous, lymphatic, and perineural spread.[1] In our case, arterial emboli were seen [Figure 1c, 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.[2] Most frequently reported locations of soft tissue metastasis include back, chest wall, neck, posterior abdominal wall, thigh muscles, iliopsoas muscles, and paraspinous muscles.[2‑4] 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,
Journal of Cancer Research and Therapeutics - January-March 2014 - Volume 10 - Issue 1
Copyright of Journal of Cancer Research & Therapeutics 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.
that is composed of spindle cells without significant atypia and absent mitotic figures. Diffuse CD31 and HHV8 immunoreactivity also militated against diagnosis of bacillary angiomatosis that formed as another differential diagnosis. Rarely, intranodal KS has also been found to be coexistent with mycobacterial infection and Hodgkin lymphoma in district case reports.[6‑8,11] Of these, only a single case that occurred in another African male, who additionally had skin lesions, documented by Lanjewar et al.,[8] was confirmed with positive HHV8 immunostaining. Apart from an intranodal KS, no additional histopathological findings were seen in the present case. This patient was a candidate for highly active antiretroviral therapy treatment. However, he left for his home country for further management. To sum up, the present case is the second documentation of a primary intranodal KS from our country, but occurring in an African male , objectively confirmed on biopsy with positive HHV8 LANA1 immunostaining. Presence of vascular pattern and spindly cells, especially in the lymph node of an HIV‑positive patient are useful diagnostic ‘‘clues’’ for this diagnosis that should be reinforced with necessary IHC markers, including HHV8. Unfortunately, our patient was lost to follow‑up. Bharat Rekhi, Haider Rangwalla1, Roshan F. Chinoy2 Department of Pathology, Tata Memorial Hospital, Parel, Departments of Surgery and 2Pathology, Prince Aly Khan Hospital, Mazagaon, Mumbai, Maharashtra, India
1
For correspondence: Dr. Bharat Rekhi, Department of Pathology, Tata Memorial Hospital, Dr. Ernest Borges Road, Parel, Mumbai - 400 012, Maharashtra, India. E-mail: [email protected]
REFERENCES 1. Braun M. Classics in Oncology. Idiopathic multiple pigmented sarcoma of the skin by Kaposi. CA Cancer J Clin 1982;32:340‑7. 2. Mentzel T, Knuutila S, Lamovec J. Kaposi sarcoma. In: Fletcher CD, Bridge JA, Hogendoorn PC, Mertens F, editors. World Health Organization (WHO) Classification of Tumors of Soft Tissue and Bone. Lyon: IARC Press; 2013. p. 151‑3. 3. Patel RM, Goldblum JR, Hsi ED. Immunohistochemical detection of human herpes virus‑8 latent nuclear antigen‑1 is useful for the diagnosis of Kaposi sarcoma. Mod Pathol 2004;17:456‑60. 4. Schwartz RA, Brenden LD, Breeden JH, Lambert WC. Indolent lymphadenopathic Kaposi’s sarcoma. J Surg Oncol 1987;34:243‑7. 5. Ioachim HL, Adsay V, Giancotti FR, Dorsett B, Melamed J. Kaposi›s sarcoma of internal organs. A multiparameter study of 86 cases. Cancer 1995;75:1376‑85. 6. Croxson TS, Ebanks D, Mildvan D. Atypical mycobacteria and Kaposi's sarcoma in the same biopsy specimens. N Engl J Med 1983 16;308:1476. 7. Bodhireddy H, Rivas S, Seshadri T. Coexistent Kaposi›s sarcoma and atypical mycobacterial infection involving lymph node: A case report and review of literature. Indian J Pathol Microbiol 2010;53:805‑7. 8. Lanjewar DN, Lanjewar SD, Chavan G. Coexistent lymphoma with tuberculosis and Kaposi›s sarcoma with tuberculosis occurring in lymph node in patients with AIDS: A report of two cases. Indian J Pathol Microbiol 2010;53:551‑4. 9. Finkbeiner WE, Egbert BM, Groundwater JR, Sagebiel RW. Kaposi›s sarcoma in young homosexual men: A histopathologic study with particular reference to lymph node involvement. Arch Pathol Lab Med 1982;106:261‑4. 10. Z u k e r b e rg L R , N i c k o l o f f B J , We i s s S W. K a p o s i f o r m hemangioendothelioma of infancy and childhood: An aggressive neoplasm associated with Kasabach‑Merrittt syndrome and lymphangiomatosis. Am J Surg Pathol 1993;17:321‑8. 11. Carbone A, Volpe R. Kaposi›s sarcoma in lymph nodes concurrent with Hodgkin›s disease. Am J Clin Pathol 1983;80:228‑30.
Thymoma: Clinical experience from a tertiary care institute from North India Access this article online Website: www.cancerjournal.net
Quick Response Code:
DOI: 10.4103/0973-1482.131440 PMID: ***
Sir, We read the manuscript with interest and discussed it in our journal club.[1] We would like to congratulate the authors for highlighting an untold story. Series on thymoma are sparse from India and authors have done a commendable job. However, there are certain observations in the article which need further clarification and comments. 214
For myasthenia gravis, thymus can have hyperplasia or a thymoma. Thymus can also be normal or may contain a cyst in cases of myasthenia gravis. A large series had been published on surgical outcome of thymectomy on myasthenia gravis from a nearby geographic area from the same country by Kumar et al.,[2] They had highlighted the different pathologic phenomenon within the thymus gland. Thymoma is considered to have poorer prognosis as compared to hyperplasia. Were there any patients in which histopathology revealed thymic hyperplasia instead of thymoma? Had the authors compared their results of surgery for thymic hyperplasia versus thymoma in cases of myasthenia gravis? The patients with Cushing’s syndrome form a special subset because they are most likely to have a thymic carcinoid. Was this possibility considered and whether histopathology slides were reviewed by an expert pathologist? Thymic carcinoids, though rare,
Journal of Cancer Research and Therapeutics - January-March 2014 - Volume 10 - Issue 1
Letters to the Editor
form an important component of multiple endocrine neoplasia type I (MEN1) syndrome. Were these patients having thymoma with Cushing’s syndrome evaluated for MEN1 syndrome? Can the authors elaborate on the results of treatment for myasthenia gravis and Cushing’s syndrome separately?
Ritesh Agrawal, Balaguruswamy Kanchana, Gobichettipalayam Kanniappan Venkatachalam, Udit Narayan Department of General Surgery, Aarupadai Veedu Medical College, Kirumampakkam, Puducherry, India For correspondence: Dr. Ritesh Agrawal, Endocrine and Breast Surgeon, Department of General Surgery, Aarupadai Veedu Medical College, Puducherry ‑ 607 402, India. E-mail: [email protected]
What was the author’s strategy for managing a thymoma? Do they offer surgery in every patient of a thymoma regardless of size, diagnosis, and stage or they select patients for surgery. If yes, what was the selection criteria used?
REFERENCES
Few patients (nine) were not operated. It is important to know their profile. What was the reason for not performing surgery in nine patients? Was surgery offered to them also and they denied or whether they were advanced tumors? If they were advanced tumors, it will form a subset and their inclusion in overall data will provide aberrant analysis.
1. Kumar N, Kumar R, Bera A, Ghoshal S, Kapoor R, Radotra BD, et al. Thymoma: Clinical experince from a tertiary care institute from North India. J Cancer Res Ther 2013;9:235‑9. 2. Kumar N, Verma AK, Mishra A, Agrawal G, Agrawal A, Mishra UK, et al. Factors predicting surgical outcome of thymectomy in myasthenia gravis: A 16‑year experience. Ann Indian Acad Neurol 2011;14:267‑71.
Author's Reply Access this article online Website: www.cancerjournal.net
Quick Response Code:
DOI: 10.4103/0973-1482.131442 PMID: ***
Sir, We appreciate the observations and questions raised regarding the article.[1] The questions definitely need a few clarifications and we hope that we would be able to do the same. The series presented by us focused on the clinical outcomes in patients of thymoma per se and mentioned the various paraneoplastic syndromes associated with thymoma.[1] Our series differs from the series by Kumar et al.,[2] which focused on the myasthenia gravis patients who underwent thymectomy and on histopathological analysis revealed thymic hyperplasia, thymoma, normal thymus, involuted thymus, thymic cysts, and unremarkable thymus. In our series, the patients with a confirmed histopathological diagnosis of thymoma were analyzed and the patients with hyperplasia, cysts, or carcinoid were not a part of the analysis. Management of the paraneoplastic syndromes was done as per the standard guidelines, while the patients with histopathological diagnosis of thymoma were staged as per Masaoka-Koga staging system and then managed accordingly with surgery as the cornerstone of therapy and further adjuvant treatment in form of radiotherapy and chemotherapy was decided as per stage, histopathology and prognostic features.[3] In locally advanced cases or inoperable cases, a neoadjuvant
approach was usedand then the patient was assessed for surgical removal.[4] Thenine patients did not underwent surgery because of locally advanced disease status with poor responseto neoadjuvant therapy and poor surgical suitability but were symptomaticallyimproved with radiotherapy and/or chemotherapy. This is a small and rare series of outcome of thymoma with multimodality approach, so further multivariate analysis was not possible due to small sample size. Narendra Kumar, Ritesh Kumar, Anjan Bera, Sushmita Ghoshal, Rakesh Kapoor, B. D. Radotra1, Suresh Chander Sharma Departments of Radiotherapy and Oncology and 1Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India For Correspondence: Dr. Ritesh Kumar, Department of Radiotherapy and Regional Cancer Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: [email protected]
REFERENCES 1. Kumar N, Kumar R, Bera A, Ghoshal S, Kapoor R, Radotra BD, et al. Thymoma: Clinical experince from a tertiary care institute from North India. J Cancer Res Ther 2013;9:235-9. 2. Kumar N, Verma AK, Mishra A, Agrawal G, Agrawal A, Mishra UK, et al. Factors predicting surgical outcome of thymectomy in myasthenia gravis: A 16-year experience. Ann Indian Acad Neurol 2011;14:267-71. 3. Falkson CB, Bezjak A, Darling G, Gregg R, Malthaner R, Maziak DE, et al. The management of thymoma: A systematic review and practice guideline. J Thorac Oncol 2009;4:911-9.
Journal of Cancer Research and Therapeutics - January-March 2014 - Volume 10 - Issue 1
215
Letters to the Editor
4. Lucchi M, Ambrogi MC, Duranti L, Basolo F, Fontanini G, Angeletti CA, et al. Advanced stage thymomas and thymic
carcinomas: Results of multimodality treatments. Ann Thorac Surg 2005;79:1840-4.
Metastatic soft tissue squamous cell carcinoma: Unusual presentation of lung cancer Access this article online Website: www.cancerjournal.net
Quick Response Code:
DOI: 10.4103/0973-1482.131443 PMID: ***
a
Sir, 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.[1,2] 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 1a]. 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 1b]. Nuclei showed moderate nuclear pleomorphism, prominent nucleoli, and mitotic figures [Figure 1c]. Tumor emboli were seen in occasional blood vessel [Figure 1c, 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 1d]. A diagnosis of lung carcinoma was suggested. CT guided transthoracic fine needle aspiration (FNA) confirmed the diagnosis of squamous cell carcinoma of the lung. 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 216
c
b
d
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
of metastasis include liver, adrenal glands, brain, bone, kidney, and abdominal lymph nodes. Spread occurs through hematogenous, lymphatic, and perineural spread.[1] In our case, arterial emboli were seen [Figure 1c, 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.[2] Most frequently reported locations of soft tissue metastasis include back, chest wall, neck, posterior abdominal wall, thigh muscles, iliopsoas muscles, and paraspinous muscles.[2‑4] 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,
Journal of Cancer Research and Therapeutics - January-March 2014 - Volume 10 - Issue 1
Copyright of Journal of Cancer Research & Therapeutics 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.
