Access the full text.
Sign up today, get DeepDyve free for 14 days.
Hindawi Case Reports in Oncological Medicine Volume 2018, Article ID 5719382, 3 pages https://doi.org/10.1155/2018/5719382 Case Report Pulmonary Adenocarcinoma Presenting as Paraspinal Muscle Metastatic Mass 1 1 2 Matthew Harrison, Amanda Jones, and Abebe Abebe Department of Internal Medicine, Internal Medicine Residency, University of Kansas Medical Center, 3901 Rainbow Blvd. MS 1020, Kansas City, KS 66160, USA Department of Internal Medicine, Division of General and Geriatric Medicine, University of Kansas Health System, 4000 Cambridge MS 1020, Kansas City, KS 66160, USA Correspondence should be addressed to Abebe Abebe; email@example.com Received 28 March 2018; Accepted 27 June 2018; Published 19 July 2018 Academic Editor: Constantine Gennatas Copyright © 2018 Matthew Harrison et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A 39-year-old male presented with a painful paraspinal mass, which had been present for several weeks. The mass had previously been treated with oral sulfamethoxazole and trimethoprim DS, as the patient reported a history of “boils,” with no improvement in his pain or size of the mass. No further diagnostic workup was pursued until he was admitted with intractable pain. Eventual biopsy revealed adenocarcinoma, likely of pulmonary origin. This report, as well as other incoming cases, highlights this rare phenomenon of muscular metastases as the sole presentation of a distant primary malignancy. 1. Introduction Remaining complete blood count values included hemoglo- bin of 17.5 gm/dl and a platelet count of 441 k/μl. A chemis- Skeletal muscle metastases are very uncommon with varying try panel was notable for a bicarbonate of 33 mmol/l and a reported incidence rates from 0.8 to 1.6% derived from creatinine of 1.31 mg/dl. Computed tomography described autopsy series [1, 2]. The most frequent presentation of a 2.7 × 3.3 cm mass involving the right inferior trapezius muscular metastasis is pain with or without swelling . muscle without gas or ﬂuid collections as well as a 3.9 cm We report an unusual case of muscular metastases as the sole right apical lung lesion (Figure 2). An MRI of the T-spine presentation of a distant primary malignancy. showed the initial mass with additional smaller masses in the paraspinous musculature (Figure 3). Percutaneous biopsy 2. Case Report was consistent with metastatic adenocarcinoma of unknown primary, likely from GI or pulmonary source. Staging PET A 39-year-old male presented with a one-week history of a revealed hypermetabolic right apical lung mass and paratra- progressive, painful right paraspinal mass. He reported a cheal nodes, as well as hepatic, left adrenal, and paraspinous history of subcutaneous abscesses which were typically muscle masses. The patient received the ﬁrst 5 of 10 frac- treated with oral antibiotics. His current mass progressed in tions of radiation therapy during his initial admission and size and became exquisitely painful despite a recent trial of was discharged with outpatient oncology and radiation outpatient Bactrim (sulfamethoxazole and trimethoprim) oncology follow-up. DS. Examination revealed a ﬁrm, tender, nonﬂuctuant, and nonmobile right-sided paraspinal mass with mild erythema 3. Discussion and without drainage (Figure 1). Slight ptosis of his right eye and intermittent right arm numbness were also noted. Lung cancers are diagnosed at a metastatic stage in 40–50% His laboratory data demonstrated no evidence of infection of cases . Skeletal muscle metastases are uncommon and with a white blood cell count of 5.9 k/μl without bandemia. usually discovered at autopsy with studies suggesting an 2 Case Reports in Oncological Medicine cancer, include the thigh, iliopsoas, and paraspinous muscles, though lesions in the orbit and pectoral muscles have been described [4, 8–11]. A retrospective series by Surov et al. reviewed 5170 patients with metastatic cancer, 61 of which were found to have skeletal muscle metastases. Of these, the iliopsoas muscle and paravertebral muscles were the most common sites of metastases at 27.5% and 25%, respectively. Interest- ingly, genital (24.6%) and gastrointestinal (21.3%) tumors were the most common primary sources while pulmonary malignancies accounted for only 0.8% . Paravertebral involvement, as in the presented case, is thought to be of venous route via paravertebral venous plexus which dons Figure 1: Initial clinical presentation of mass. connections to the inferior vena cava and mesenteric venous system . An isolated, painful skeletal muscle metastasis as the initial manifestation of an otherwise asymptomatic primary malignancy, as in our patient, is uncommon [6, 9, 14]. Muscular metastases typically present as a painful and fre- quently palpable mass with or without localized swelling . In 17 cases of skeletal muscle metastases of lung cancer reviewed by Di Giorgio et al., 7 of 17 had a metastatic mass as the sole manifestation of their neoplasm, with the mean age of diagnoses being 55.4 years. Eleven of these patients had concomitant nonmuscular distant metastases . In the described case, a subsequent MRI revealed multiple Figure 2: Mass noted on CT imaging. additional intramuscular metastases—a phenomenon which has been described as exceedingly unusual—particularly in a relatively young patient of 39 years . When a mass is seen on imaging, it is often diﬃcult to distinguish between a primary sarcoma, a metastatic lesion, or an abscess as each can manifest with a broad spectrum of radiological features. It has been suggested that MRI is a superior modality for discovering muscle metastasis; how- ever, masses can show identical characteristics on MRI or CT [3, 17]. Surov et al. described the most common CT ﬁnd- ings of muscular metastases, from all origins, as a mass with homogenous enhancement. A subgroup analysis revealed that masses of pulmonary origin had low central attenuation with rim enhancement as the most common ﬁnding on CT . Correlation with FDG-PET is recommended in all patients with a history of malignancy or a suspicion lesion [3, 8, 9, 18]. Biopsy of these masses is mandatory for proper diagnosis and further management [6, 9, 19]. The optimal strategy for addressing skeletal muscle metastases is unknown, but the presence of these lesions does Figure 3: Intramuscular mass well demarcated with MRI imaging. not currently modify regimens of chemotherapy or radiation incidence as low as 0.8–1.6% [2, 3]. This metastatic rarity is per current guidelines . The presence of skeletal muscle metastases has been considered to herald a particularly thought to be because of the unfavorable environment for tumor cells due to the muscle contraction, lactic acid produc- aggressive tumor and linked to poor survival (often less tion, low pH, variability of blood ﬂow, and strong immune than a year) by the time muscular metastases are diagnosed response of skeletal muscles . as the staging of the primary neoplasm is already advanced Nearly all types of lung carcinoma, along with renal, [2, 10, 15, 20, 21]. Pain, the most frequent complaint of these masses, is often drug resistant. In such cases, reports bladder, and gastrointestinal tract carcinomas, have been known to metastasize to skeletal muscle [3, 5, 6]. The most have described pain control and tumor reduction with common metastatic sites of lung cancer are the adrenal palliative radiation [10, 15]. Wide excision of the mass, often glands, liver, bone, and brain—as seen with the renal and coupled with radiation, has also been linked with pain con- liver lesions discovered in our case . Frequent sites of trol in addition to prolonged survival after muscle metastasis diagnosis [4, 19, 22]. skeletal muscle metastatic involvement, speciﬁcally in lung Case Reports in Oncological Medicine 3 tomography,” Indian Journal of Nuclear Medicine, vol. 28, 4. Conclusion no. 1, pp. 34-35, 2013. Maintaining a high index of suspicion for malignancy when  K. Kaira, T. Ishizuka, N. Yanagitani et al., “Forearm muscle evaluating a persistent, painful soft tissue mass is essential metastasis as an initial clinical manifestation of lung cancer,” in reaching a diagnosis early in the clinical course. In a review Southern Medical Journal, vol. 102, no. 1, pp. 79–81, 2009. by Pop et al., 5-year survival in those patients whose skeletal  C. Olali and M. Gupta, “Simultaneous pectoralis major muscle muscle metastases were identiﬁed early enough to allow for and orbital metastasis as the primary presentation of pulmo- surgical resection was nearly twice than that of those patients nary adenocarcinoma,” West African Journal of Medicine, only treated with chemotherapy . This case fuels the vol. 33, no. 81, pp. 80–1, 2014. need for increasing awareness of muscular metastases as  A. Surov, M. Hainz, H. J. Holzhausen et al., “Skeletal muscle manifestations of a distant, lethal neoplasm. metastases: primary tumours, prevalence, and radiological fea- tures,” European Radiology, vol. 20, no. 3, pp. 649–658, 2010.  A. Surov, J. Köhler, A. Wienke et al., “Muscle metastases: Conflicts of Interest comparison of features in diﬀerent primary tumours,” Cancer Imaging, vol. 14, p. 21, 2014. The authors declare they have no conﬂicts of interest.  H. H. Kwas, I. Zendah, and H. Ghedira, “Skeletal muscle metastases from lung cancer,” Asian Cardiovascular & Authors’ Contributions Thoracic Annals, vol. 21, no. 6, pp. 741–743, 2013.  A. Di Giorgio, P. Sammartino, C. L. Cardini et al., “Lung All authors contributed to data collection and drafting of the cancer and skeletal muscle metastases,” The Annals of Thoracic manuscript. All authors approved the content of the ﬁnal Surgery, vol. 78, no. 2, pp. 709–711, 2004. version of this manuscript.  M. Yilmaz, U. Elboga, Z. Celen, F. Isik, and E. Tutar, “Multiple muscle metastases from lung cancer detected by FDG PET/ CT,” Clinical Nuclear Medicine, vol. 36, no. 3, pp. 245– References 247, 2011.  A. Sudo, Y. Ogihara, Y. Shiokawa, S. Fujinami, and  M. Sariaydin, E. Gunay, S. S. Ulasli et al., “An unusual S. Sekiguchi, “Intramuscular metastasis of carcinoma,” Clinical metastasis of lung adenocarcinoma: biceps brachii muscle,” Orthopaedics and Related Research, vol. 296, pp. 213– Lung India, vol. 33, no. 6, pp. 669–671, 2016. 217, 1993.  M. L. Dominguez, J. I. Rayo, J. Serrano, J. R. Infante, L. García,  A. R. Razak, R. Chhabra, A. Hughes, S. England, P. Dildey, and and M. Moreno, “Uncommon isolated distant subcutaneous R. McMenemin, “Muscular metastasis, a rare presentation tissue and skeletal muscle metastasis from oesophageal cancer of non-small-cell lung cancer,” Medscape General Medicine, diagnosed by F-FDG PET/CT,” Revista Española de Medi- vol. 9, no. 3, p. 20, 2007. cina Nuclear e Imagen Molecular (English Edition), vol. 35,  C. M. Heyer, G. J. Rduch, P. Zgoura, U. Stachetzki, E. Voigt, no. 1, pp. 38–41, 2016. and V. Nicolas, “Metastasis to skeletal muscle from esophageal  Y. Tuoheti, K. Okada, T. Osanai et al., “Skeletal muscle metas- adenocarcinoma,” Scandinavian Journal of Gastroenterology, tases of carcinoma: a clinicopathological study of 12 cases,” vol. 40, no. 8, pp. 1000–1004, 2005. Japanese Journal of Clinical Oncology, vol. 34, no. 4, pp. 210–  J. B. Strauss, A. P. Shah, S. S. Chen, B. T. Gielda, and A. W. 214, 2004. Kim, “Psoas muscle metastases in non-small cell lung cancer,”  P. P. McKeown, P. Conant, and L. E. Auerbach, “Squamous Journal of Thoracic Disease, vol. 4, no. 1, pp. 83–87, 2012. cell carcinoma of the lung: an unusual metastasis to pectoralis  P. Azadeh, A. Yaghobi Joybari, S. Sarbaz, H. A. Ghiasi, and muscle,” The Annals of Thoracic Surgery, vol. 61, no. 5, M. Farasatinasab, “Solitary psoas muscle metastasis of gas- pp. 1525-1526, 1996. troesphageal junction adenocarcinoma,” Iranian Journal of  K. S. Sridhar, R. K. Rao, and B. Kunhardt, “Skeletal muscle Pathology, vol. 11, no. 1, pp. 76–79, 2016. metastases from lung cancer,” Cancer, vol. 59, no. 8,  I. Pergolini, S. Crippa, A. Santinelli, and C. Marmorale, pp. 1530–1534, 1987. “Skeletal muscle metastases as initial presentation of gastric  T. Iwase, T. Sangai, M. Sakakibara et al., “The case of a patient carcinoma,” American Journal of Case Reports, vol. 15, with invasive lobular carcinoma with solitary metastasis in pp. 580–583, 2014. pectoralis major muscle,” Gan to Kagaku Ryoho, vol. 42,  K. Pantel, M. Angstwurm, G. Riethmüller et al., “Frequency no. 12, pp. 1815–1817, 2015. and prognostic signiﬁcance of isolated tumour cells in bone  D. Pop, A. S. Nadeemy, N. Venissac et al., “Skeletal muscle marrow of patients with non-small-cell lung cancer without metastasis from non-small cell lung cancer,” Journal of overt metastases,” Lancet, vol. 347, no. 9002, pp. 649– Thoracic Oncology, vol. 4, no. 10, pp. 1236–1241, 2009. 653, 1996.  K. A. Gharaibeh, A. Lopez-Ruiz, and T. Yousuf, “Psoas muscle inﬁltration masquerading distant adenocarcinoma,” Case Reports in Gastrointestinal Medicine, vol. 2014, Article ID 986453, 5 pages, 2014.  K. Agrawal, A. Bhattacharya, N. Singh, C. N. Harisankar, and B. R. Mittal, “Skeletal muscle metastases as the initial manifes- tation of an unknown primary lung cancer detected on F-18 ﬂuorodeoxyglucose positron emission tomography/computed MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Hindawi Publishing Corporation Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 http://www www.hindawi.com .hindawi.com V Volume 2018 olume 2013 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 International Journal of Journal of Immunology Research Endocrinology Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Submit your manuscripts at www.hindawi.com BioMed PPAR Research Research International Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2013 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018
Case Reports in Oncological Medicine – Hindawi Publishing Corporation
Published: Jul 19, 2018
Access the full text.
Sign up today, get DeepDyve free for 14 days.