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Lung cancer metastasis presenting as a solitary skull mass

Lung cancer metastasis presenting as a solitary skull mass Lung cancer has been well documented to spread to bone and the axial skeleton after metastasis to adjacent organs. Bony metastasis is not, however, the typical presenting manifestation. The differential diagnosis for a tissue mass on the skull should warrant a workup for metastatic disease. Bony metastasis plays an important role in treatment and disease manage- ment. We report an exceptionally rare case of stage IV lung adenocarcinoma that presented with a solitary skull metastasis and a significant soft-tissue component. The lesion was treated by excision via craniotomy and subsequent medical man- agement of the adenocarcinoma. This case illustrates a very rare presentation of lung adenocarcinoma and also represents what the authors believe to be the first report of a solitary skull mass originating from a lung primary. We also present a review of the literature surrounding bony metastasis to the skull and implications for patient care. INTRODUCTION lung cancer. Likewise, no evidence in the literature describes a Bony metastases are a common finding in numerous cancers, solitary skull metastasis as the primary presenting feature for particularly breast, prostate and lung. Lung cancer specifically lung adenocarcinoma. is associated with bony metastases in up to 36% of patients on In this report, we present the case of a 69-year-old female post-mortem studies [1]. Similarly, bony metastases are the that presented to the clinic complaining of an expanding soft- most common cause of cancer-related pain and can be utilized tissue mass on her left frontoparietal skull associated with as a marker for monitoring disease progression and prognosti- facial pain. The patient received a complete oncological cation [1, 2]. It is the pain, often associated with pathological workup and surgical excision of the mass. The excised mass fracture that often leads patients to seek medical treatment in was pathologically consistent with metastatic lung adenocar- the case of bony metastases. Generally a bony metastasis by cinoma.Thisisthe first such presentation of primary lung itself is unlikely to lead to medical presentation and eventual adenocarcinoma metastasis to the skull in the literature and diagnosis of the primary malignancy. This is especially true dictates caution and careful clinical consideration when when the metastasis is located within the skull and can be mis- evaluating expanding lesions on the skull. This is especially taken for soft tissue swelling from injury. In fact, Sugiura et al.[2] important for lung adenocarcinoma where early diagnosis can identified skullmetastasesinonly3%ofskeletalmetastasesfrom affect overall prognosis. Received: April 17, 2016. Accepted: June 7, 2016 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 R.C. Turner et al. Neurosurgical examination revealed grossly intact cranial CASE REPORT nerves with no upper motor neuron signs or motor weakness The patient, a 69-year-old white female, was referred by her in all extremities. Sensation was also intact bilaterally. Due to primary care provider to a plastic surgeon at United Hospital slight effacement of the subarachnoid space and for surgical Center for treatment of what was believed to be a soft-tissue planning, MRI brain was ordered. MRI demonstrated a 2.8-cm mass of the left forehead (frontoparietal region) (Fig. 1). The lesion that extended from the subcutaneous fat through the mass had increased in size for the prior 2–3 months and inner and the outer table of the left frontal bone with slight resulted in a radiating pain down the left side of the face. The encroachment on the dural space. Minimal mass effect was mass was non-mobile and tender to touch. Prior to this referral, observed with only slight asymmetry of the fluid signal in the the patient was relatively healthy with a past medical history frontoparietal region on the left (Fig. 3). At this time, the deci- significant for arthritis, depression and hypertension. Her surgi- sion was made to proceed with a surgical excision. No apparent cal history was positive for tonsillectomy and partial hysterec- invasion of the dura or brain parenchyma was noted, thereby tomy. Her social history is significant for a 60-pack-year satisfying therapeutic and diagnostic aims. The lesion was smoking history (1.5 packs/day for 40 years). The soft tissue mass had been managed conservatively for presumptive der- matological infection (subcutaneous/sebaceous cyst) with a 10- day course of levofloxacin 500 mg tablets taken once daily. The tablets, however, provided no symptomatic relief. Imaging (computed tomography (CT)) of the maxillofacial area and brain without contrast was obtained in addition to plain films of the skull. These images revealed a lytic lesion of the skull in the left frontopartietal region (Fig. 2). The patient was referred to the oncology department for further workup. The primary differential considered by the oncologist based on the significant smoking history was metastatic neoplasm versus multiple myeloma. Therefore, a CT of the chest/abdo- men/pelvis was ordered as well as blood work (CBC, chemistry, molecular monoclonal gammopathy workup). Imaging demon- strated one speculated right hilar nodule concerning for neo- plasm in the lung that was measured at 2.4 × 2.4 cm. No other evidence of metastatic disease was present within the chest, abdomen or pelvis. Workup for multiple myeloma was negative based on the results of serum protein electrophoresis and immunofixation. The patient was subsequently referred for bronchoscopy and to neurosurgery for biopsy of the skull mass. Figure 2: CT soft tissue demonstrating the presence of a lytic lesion in the left frontopartietal region. (A) Axial cut, (B) coronal cut and (C) sagittal cut. Figure 3: MR imaging redemonstrating the presence of a left frontoparietal Figure 1: Schematic representation of the lesion location. The soft-tissue com- mass that does not appear to invade the dura. (A) Sagittal T1, (B) axial T1, (C) ponent was measured at a diameter of 3.3 cm and located on the left forehead axial T1 with contrast, (D) axial T2, (E) axial FLAIR, (F) coronal pre-contrast and near the hairline. (G) coronal post-contrast. Solitary skull metastasis 3 excised successfully (3.5 × 3.5 × 1.5 cm) with no surgical compli- CONFLICT OF INTEREST STATEMENT cations. Histological analysis of the lesion revealed adenocar- None declared. cinoma that was CK7 positive, CK20 negative and TTF-1 positive. These findings were consistent with a metastatic adenocarcinoma from a lung primary. With stage IV adenocar- FUNDING cinoma, the patient was started on chemotherapy following surgical excision and managed by the oncology service. Her A Neurosurgery Research Funding and Development Grant, management included a full oncological workup complete with American Medical Association Foundation Seed Grant, and full-body PET scan. American Foundation of Pharmaceutical Education Pre-doctoral Fellowship supported Brandon Lucke-Wold. DISCUSSION While the rate of bony metastases associated with lung cancer REFERENCES is relatively high, estimated at ~36%, only 3% of these are gen- erally found within the skull. The first presenting sign of lung 1. Coleman RE. Clinical features of metastatic bone disease adenocarcinoma being skull metastasis is exceptionally rare and risk of skeletal morbidity. Clin Cancer Res 2006;12: and has not been previously reported in the literature. This 6243s–9s. case provides an example of such findings. This is in contrast 2. Sugiura H, Yamada K, Sugiura T, Hida T, Mitsudomi T. to other malignancies, such as hepatocellular carcinoma (HCC), Predictors of survival in patients with bone metastasis of which has been widely reported to present as a solitary skull lung cancer. Clin Orthop Relat Res 2008;466:729–36. metastsis [3]. Hepatic cholangiocarcinoma, in particular, is 3. Guo X, Yin J, Jiang Y. Solitary skull metastasis as the first exceptionally prone to metastasize to the skull [4]. Therefore, it symptom of hepatocellular carcinoma: case report and lit- is clear for diagnostic, therapeutic and prognostic purposes erature review. Neuropsychiatr Dis Treat 2014;10:681–6. that a biopsy must be obtained, which was excisional in nature 4. Singh M, Ricci JA, Talbot SG, Chiocca EA, Dunn IF, in the reported case. Caterson EJ. Reconstruction of rare skull metastases using The route of metastasis in this case is not clear but possible free Latissimus Dorsi flap and the role of preoperative routes have been discussed at length in the literature and embolization in hypervascular skull tumors. JCraniofac include transmission from mandibular lymphatics. Once seeded, Surg 2015;26:2289–92. the tumor develops a rich vasculature supply and spreads into 5. Nagamine Y, Suzuki J, Katakura R, Yoshimoto T, Matoba N, adjacent soft-tissue [5]. In rare cases, skull metastasis can lead Takaya K. Skull metastasis of thyroid carcinoma. Study of to epidural hematoma [6]. The important component for treat- 12 cases. J Neurosurg 1985;63:526–31. ment is TNM staging. CT scans have become the gold standard 6. Hayashi K, Matsuo T, Kurihara M, Daikoku M, Kitange G, for diagnosis and staging of lung adenocarcinoma [7]. Evidence Shibata S. Skull metastasis of hepatocellular carcinoma suggests that CT scan is even better than radionucleotide associated with acute epidural hematoma: a case report. imaging for skull metastasis [8]. With regard to treatment, the Surg Neurol 2000;53:379–82. initial extent of the disease dictates overall survival [9]. 7. Mintz BJ, Tuhrim S, Alexander S, Yang WC, Shanzer S. Clinical suspicion should be high when evaluating an isolated Intracranial metastases in the initial staging of broncho- soft-tissue lesion with skull penetration. Skull biopsy with genic carcinoma. Chest 1984;86:850–3. tumor excision followed by aggressive chemotherapy is often 8. Deck MD, Messina AV, Sackett JF. Computed tomography required [10]. Sugiura et al. [2] found that in women with lung in metastatic disease of the brain. Radiology 1976;119: adenocarcinoma and bony metastasis that early initiation of 115–20. systemic chemotherapy was associated with a good overall 9. Besbeas S, Stearns MW Jr. Osseous metastases from carcin- survival and prognosis. omas of the colon and rectum. Dis Colon Rectum 1978;21: Based on the findings from this case, the authors recom- 266–8. mend a careful and thorough evaluation for any persistent 10. Fukutomi M, Yokota M, Chuman H, Harada H, Zaitsu Y, soft-tissue mass on the skull. Early diagnosis and treatment Funakoshi A, et al. Increased incidence of bone metastases can lead to good overall prognosis. Clinical suspicion should be in hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2001;13: high for this potentially life-threatening disease. 1083–8. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Lung cancer metastasis presenting as a solitary skull mass

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2016.
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2042-8812
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10.1093/jscr/rjw116
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Abstract

Lung cancer has been well documented to spread to bone and the axial skeleton after metastasis to adjacent organs. Bony metastasis is not, however, the typical presenting manifestation. The differential diagnosis for a tissue mass on the skull should warrant a workup for metastatic disease. Bony metastasis plays an important role in treatment and disease manage- ment. We report an exceptionally rare case of stage IV lung adenocarcinoma that presented with a solitary skull metastasis and a significant soft-tissue component. The lesion was treated by excision via craniotomy and subsequent medical man- agement of the adenocarcinoma. This case illustrates a very rare presentation of lung adenocarcinoma and also represents what the authors believe to be the first report of a solitary skull mass originating from a lung primary. We also present a review of the literature surrounding bony metastasis to the skull and implications for patient care. INTRODUCTION lung cancer. Likewise, no evidence in the literature describes a Bony metastases are a common finding in numerous cancers, solitary skull metastasis as the primary presenting feature for particularly breast, prostate and lung. Lung cancer specifically lung adenocarcinoma. is associated with bony metastases in up to 36% of patients on In this report, we present the case of a 69-year-old female post-mortem studies [1]. Similarly, bony metastases are the that presented to the clinic complaining of an expanding soft- most common cause of cancer-related pain and can be utilized tissue mass on her left frontoparietal skull associated with as a marker for monitoring disease progression and prognosti- facial pain. The patient received a complete oncological cation [1, 2]. It is the pain, often associated with pathological workup and surgical excision of the mass. The excised mass fracture that often leads patients to seek medical treatment in was pathologically consistent with metastatic lung adenocar- the case of bony metastases. Generally a bony metastasis by cinoma.Thisisthe first such presentation of primary lung itself is unlikely to lead to medical presentation and eventual adenocarcinoma metastasis to the skull in the literature and diagnosis of the primary malignancy. This is especially true dictates caution and careful clinical consideration when when the metastasis is located within the skull and can be mis- evaluating expanding lesions on the skull. This is especially taken for soft tissue swelling from injury. In fact, Sugiura et al.[2] important for lung adenocarcinoma where early diagnosis can identified skullmetastasesinonly3%ofskeletalmetastasesfrom affect overall prognosis. Received: April 17, 2016. Accepted: June 7, 2016 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 R.C. Turner et al. Neurosurgical examination revealed grossly intact cranial CASE REPORT nerves with no upper motor neuron signs or motor weakness The patient, a 69-year-old white female, was referred by her in all extremities. Sensation was also intact bilaterally. Due to primary care provider to a plastic surgeon at United Hospital slight effacement of the subarachnoid space and for surgical Center for treatment of what was believed to be a soft-tissue planning, MRI brain was ordered. MRI demonstrated a 2.8-cm mass of the left forehead (frontoparietal region) (Fig. 1). The lesion that extended from the subcutaneous fat through the mass had increased in size for the prior 2–3 months and inner and the outer table of the left frontal bone with slight resulted in a radiating pain down the left side of the face. The encroachment on the dural space. Minimal mass effect was mass was non-mobile and tender to touch. Prior to this referral, observed with only slight asymmetry of the fluid signal in the the patient was relatively healthy with a past medical history frontoparietal region on the left (Fig. 3). At this time, the deci- significant for arthritis, depression and hypertension. Her surgi- sion was made to proceed with a surgical excision. No apparent cal history was positive for tonsillectomy and partial hysterec- invasion of the dura or brain parenchyma was noted, thereby tomy. Her social history is significant for a 60-pack-year satisfying therapeutic and diagnostic aims. The lesion was smoking history (1.5 packs/day for 40 years). The soft tissue mass had been managed conservatively for presumptive der- matological infection (subcutaneous/sebaceous cyst) with a 10- day course of levofloxacin 500 mg tablets taken once daily. The tablets, however, provided no symptomatic relief. Imaging (computed tomography (CT)) of the maxillofacial area and brain without contrast was obtained in addition to plain films of the skull. These images revealed a lytic lesion of the skull in the left frontopartietal region (Fig. 2). The patient was referred to the oncology department for further workup. The primary differential considered by the oncologist based on the significant smoking history was metastatic neoplasm versus multiple myeloma. Therefore, a CT of the chest/abdo- men/pelvis was ordered as well as blood work (CBC, chemistry, molecular monoclonal gammopathy workup). Imaging demon- strated one speculated right hilar nodule concerning for neo- plasm in the lung that was measured at 2.4 × 2.4 cm. No other evidence of metastatic disease was present within the chest, abdomen or pelvis. Workup for multiple myeloma was negative based on the results of serum protein electrophoresis and immunofixation. The patient was subsequently referred for bronchoscopy and to neurosurgery for biopsy of the skull mass. Figure 2: CT soft tissue demonstrating the presence of a lytic lesion in the left frontopartietal region. (A) Axial cut, (B) coronal cut and (C) sagittal cut. Figure 3: MR imaging redemonstrating the presence of a left frontoparietal Figure 1: Schematic representation of the lesion location. The soft-tissue com- mass that does not appear to invade the dura. (A) Sagittal T1, (B) axial T1, (C) ponent was measured at a diameter of 3.3 cm and located on the left forehead axial T1 with contrast, (D) axial T2, (E) axial FLAIR, (F) coronal pre-contrast and near the hairline. (G) coronal post-contrast. Solitary skull metastasis 3 excised successfully (3.5 × 3.5 × 1.5 cm) with no surgical compli- CONFLICT OF INTEREST STATEMENT cations. Histological analysis of the lesion revealed adenocar- None declared. cinoma that was CK7 positive, CK20 negative and TTF-1 positive. These findings were consistent with a metastatic adenocarcinoma from a lung primary. With stage IV adenocar- FUNDING cinoma, the patient was started on chemotherapy following surgical excision and managed by the oncology service. Her A Neurosurgery Research Funding and Development Grant, management included a full oncological workup complete with American Medical Association Foundation Seed Grant, and full-body PET scan. American Foundation of Pharmaceutical Education Pre-doctoral Fellowship supported Brandon Lucke-Wold. DISCUSSION While the rate of bony metastases associated with lung cancer REFERENCES is relatively high, estimated at ~36%, only 3% of these are gen- erally found within the skull. The first presenting sign of lung 1. Coleman RE. Clinical features of metastatic bone disease adenocarcinoma being skull metastasis is exceptionally rare and risk of skeletal morbidity. Clin Cancer Res 2006;12: and has not been previously reported in the literature. This 6243s–9s. case provides an example of such findings. This is in contrast 2. Sugiura H, Yamada K, Sugiura T, Hida T, Mitsudomi T. to other malignancies, such as hepatocellular carcinoma (HCC), Predictors of survival in patients with bone metastasis of which has been widely reported to present as a solitary skull lung cancer. Clin Orthop Relat Res 2008;466:729–36. metastsis [3]. Hepatic cholangiocarcinoma, in particular, is 3. Guo X, Yin J, Jiang Y. Solitary skull metastasis as the first exceptionally prone to metastasize to the skull [4]. Therefore, it symptom of hepatocellular carcinoma: case report and lit- is clear for diagnostic, therapeutic and prognostic purposes erature review. Neuropsychiatr Dis Treat 2014;10:681–6. that a biopsy must be obtained, which was excisional in nature 4. Singh M, Ricci JA, Talbot SG, Chiocca EA, Dunn IF, in the reported case. Caterson EJ. Reconstruction of rare skull metastases using The route of metastasis in this case is not clear but possible free Latissimus Dorsi flap and the role of preoperative routes have been discussed at length in the literature and embolization in hypervascular skull tumors. JCraniofac include transmission from mandibular lymphatics. Once seeded, Surg 2015;26:2289–92. the tumor develops a rich vasculature supply and spreads into 5. Nagamine Y, Suzuki J, Katakura R, Yoshimoto T, Matoba N, adjacent soft-tissue [5]. In rare cases, skull metastasis can lead Takaya K. Skull metastasis of thyroid carcinoma. Study of to epidural hematoma [6]. The important component for treat- 12 cases. J Neurosurg 1985;63:526–31. ment is TNM staging. CT scans have become the gold standard 6. Hayashi K, Matsuo T, Kurihara M, Daikoku M, Kitange G, for diagnosis and staging of lung adenocarcinoma [7]. Evidence Shibata S. Skull metastasis of hepatocellular carcinoma suggests that CT scan is even better than radionucleotide associated with acute epidural hematoma: a case report. imaging for skull metastasis [8]. With regard to treatment, the Surg Neurol 2000;53:379–82. initial extent of the disease dictates overall survival [9]. 7. Mintz BJ, Tuhrim S, Alexander S, Yang WC, Shanzer S. Clinical suspicion should be high when evaluating an isolated Intracranial metastases in the initial staging of broncho- soft-tissue lesion with skull penetration. Skull biopsy with genic carcinoma. Chest 1984;86:850–3. tumor excision followed by aggressive chemotherapy is often 8. Deck MD, Messina AV, Sackett JF. Computed tomography required [10]. Sugiura et al. [2] found that in women with lung in metastatic disease of the brain. Radiology 1976;119: adenocarcinoma and bony metastasis that early initiation of 115–20. systemic chemotherapy was associated with a good overall 9. Besbeas S, Stearns MW Jr. Osseous metastases from carcin- survival and prognosis. omas of the colon and rectum. Dis Colon Rectum 1978;21: Based on the findings from this case, the authors recom- 266–8. mend a careful and thorough evaluation for any persistent 10. Fukutomi M, Yokota M, Chuman H, Harada H, Zaitsu Y, soft-tissue mass on the skull. Early diagnosis and treatment Funakoshi A, et al. Increased incidence of bone metastases can lead to good overall prognosis. Clinical suspicion should be in hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2001;13: high for this potentially life-threatening disease. 1083–8.

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Journal of Surgical Case Reports – Oxford University Press

Published: Jun 1, 2016

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