99 Tüberküloz ve Toraks Dergisi 2007; 55(1): 99-102
A squamous cell lung carcinoma with abscess-like distant metastasis
Neşe DURSUNOĞLU1, Sevin BAŞER1, Fatma EVYAPAN1, Göksel KITER1, Sibel ÖZKURT1, Bahattin POLAT1, Nevzat KARABULUT2
1Pamukkale Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı,
2 Pamukkale Üniversitesi Tıp Fakültesi, Radyodiagnostik Anabilim Dalı, Denizli.
ÖZET
Uzak organ metastazlarını apseler şeklinde gösteren bir akciğer epidermoid karsinomu olgusu
Bu olgu, karaciğer, akciğerler, lenf düğümleri, kemik ve cilt altı yağlı dokuya apse benzeri metastazlar gösteren bir akciğer epidermoid karsinomudur. Ateş, öksürük, hemoptizi, gece terlemesi, göğüs-karın ağrısı ve kilo kaybı ile başvuran 55 yaşında erkek hastada, kısa süre içinde her iki akciğerde, karaciğerde, kemik ve cilt altı dokusunda yaygın apseler gelişti.
Klinik tablo infeksiyöz bir durumu taklit etse de antimikrobiyal tedaviye yanıtın olmaması ve alınan doku kültürlerinde hiçbir mikrobiyolojik ajanın üretilememesi ileri tetkik için şüphe uyandırmıştır. Apselerden alınan örneklerin histopatolo- jik incelemeleri, lezyonların akciğer epidermoid karsinomuna ait uzak metastazlar olduğunu göstermiştir. Bu olgu kısa bir süre içinde yaygın apse benzeri uzak metastazlar göstermesiyle nadir rastlanan bir olgudur.
Anahtar Kelimeler:Akciğer kanseri, karaciğer metastazı, cilt metastazı, kemik metastazı, apse.
SUMMARY
A squamous cell lung carcinoma with abscess-like distant metastasis
Neşe DURSUNOĞLU1, Sevin BAŞER1, Fatma EVYAPAN1, Göksel KITER1, Sibel ÖZKURT1, Bahattin POLAT1, Nevzat KARABULUT2
1Department of Chest Diseases, Faculty of Medicine, Pamukkale University, Denizli, Turkey,
2 Department of Radiology, Faculty of Medicine, Pamukkale University, Denizli, Turkey.
Yazışma Adresi (Address for Correspondence):
Dr. Neşe DURSUNOĞLU, Pamukkale Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı, DENİZLİ - TURKEY e-mail: [email protected]
Lung cancer is a major health problem worldwi- de. Non-small cell lung cancer (NSCLC) acco- unts for 80% to 85% of all lung cancers, while small-cell lung cancer (SCLC) accounts for 15%
to 20% of cases (1). Although the cure rates of patients with resected stage I and II NSCLC are 50% and 40%, respectively, only 20% of patients treated with chemotherapy (CT) and radiation for locally advanced NSCLC are cured of their ill- ness. Patients with metastatic NSCLC do not ha- ve curative potential with available therapies (2).
CASE REPORT
A fifty-five-years old man admitted to the out- patient clinic with cough, hemopthysis, night sweats, chest pain, abdominal pain and weight loss. He had these symptoms since two months.
He was a farmer and has a hobby of hunting ani- mals in the mountains since his teenage years.
He had 20 packs/year smoking history. Physical examination revealed pectus excavatum, fever 38°C, pulse rate 96/min, respiratory rate 22/min, blood pressure 100/70 mmHg. Organ systems were normal on examination. Routine laboratory tests were normal except his full blo- od count which showed leukocytosis (white blo- od cell count: 17.000/mm3with 72% of neutrop- hils), anemia (Hb: 11.7 g/dL, Htc: 36%), throm- bocytosis (platelet count: 483.000/mm3), and high erythrocyte sedimentation rate (82 mm 1 hour). Human immunodeficiency virus (HIV) status of the patient was negative. Chest roent- ganogram (CXR) showed consolidation on left lower zone and bilateral hilar enlargement (Figu- re 1). Thoracal helical CT revealed pneumonic consolidation on posterobasal segment of left lung, bilateral and subcarinal lymphadenopathy (Figure 2). Antibiotherapy was initiated with int-
ravenous administration of levofloxacin 500 mg bid. Fiberoptic bronchoscopy detected no en- dobronchial lesion and normal cytological fin- dings were found with bronchial lavages, brush specimens and transbronchial needle aspiration of lymph nodes and microbiological cultures we-
A squamous cell lung carcinoma with abscess-like distant metastasis
100 Tüberküloz ve Toraks Dergisi 2007; 55(1): 99-102
This is a metastatic spread of squamous cell lung carcinoma to lungs, liver, lymph node, bone and subcutanous region as multiple abscess-like lesions. A fifty-five years old man admitted to the out-patient clinic with fever, cough, hemopthysis, night sweats, chest pain, abdominal pain and weight loss. In a short period of time abcess like lesions developed in his lungs, liver, lymph node, bone and subcutanous region. Though the clinical presentation is suggestive for an infectious con- dition, no success to antimicrobial treatment and negative results of microbiological studies have arised a need to further investigations. Histopathological studies of the abscess wall ultimately gave the definitive diagnosis as metastatic squa- mous cell carcinoma. We believe that case report is interesting because of the uncommon metastatic lesions masquerading the abscesses and also wide-spread multiple distant invasions of a squamous cell lung carcinoma in a short time period.
Key Words:Lung cancer, liver metastasis, skin metastasis, bone metastasis, abcess.
Figure 1. Chest roentganogram showed consolidati- on on left lower zone and bilateral hilar enlargement.
Figure 2. Thoracal helical CT revealed pneumonic consolidation on posterobasal segment of left lung, bilateral and subcarinal lymphadenopathy.
re negative for tubercle bacilli, fungus and nons- pesific organisms. Abdominal ultrasonography showed a thick walled cystic lesion with irregu- lar internal surface having central necrosis 4 cm in diameter in left lobe of liver and it was interp- retted as hepatic abscess, thus the treatment with metronidasole flacon 750 mg tid was added intravenously to the current treatment. But in the clinical course the fever insisted and blood le- ukocytosis increased to 36.100 with 88.2% ne- utrophils. Drainage was decided in the second week of the treatment to the liver abscess with guidance of abdominal tomography. A thick pus was drained with needle aspiration and exami- ned microbiologically and cytologically. Lesions on the CXR progressed and new thoracal CT re- vealed multiple cavitating nodules in lung pa- renchyma, enlarged mediastinal lymph nodes, right axillary lymphadenopathy, osteolytic lesi- ons in the corpus of 4ththoracal vertebra and 6th rib and bilateral loculated pleural effusions (Fi- gure 3,4). Transthoracic aspiration biopsy with a 18 Gauge tru-cut needle was administered to the nodule in anterior segment of left upper lobe of lung. While the patient was being evaluated and treated in chest clinic, one subcutaneous nodule 5 cm in diameter have appeared in the right up- per region of abdominal wall. With the fine need- le aspiration, a thick pus was aspirated. Additi- onally, the histological examination of lung no- dule showed squamous cell carcinoma, cytolo- gical examination of liver abscess and subcuta- neous lesion revealed metastatic squamous cell carcinoma. CT and radiotheraphy (RT) were
Dursunoğlu N, Başer S, Evyapan F, Kıter G, Özkurt S, Polat B, Karabulut N.
101 Tüberküloz ve Toraks Dergisi 2007; 55(1): 99-102 Figure 3. Lesions on the chest roentganogram
progressed.
Figure 4. Thoracal CT revealed multiple cavitating nodules in lung parenchyma, enlarged mediastinal lymph nodes, right axillary lymphadenopathy, oste- olytic lesions in the corpus of 4th thoracal vertebra and 6thrib and bilateral loculated pleural effusions.
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planned to the patient, but the patient died due to a sustained ventricular tachycardia during ob- servation. Though the autopsy couldn’t perfor- med because the patient’s relatives didn’t give permission, the clinical course was accepted as a disseminated squamous cell lung carsinoma with liver, skin, lymph node and bone metasta- sis, possibly invading into myocardium.
DISCUSSION
Lung cancers frequently causes distant metasta- sis. As a most frequent organ for metastasis, li- ver metastasis are found in 30-45% of cases with non-small cell lung carcinoma (NSCLC) coming to autopsy. Usually liver metastasis are asymto- matic until they become very extensive. Rarely, a large metastatic deposit in the porta hepatis produces jaundice (3). Nassenstein, et al. report a case of a 45 years old man with NSCLC, who developed symptoms of acute cholecystitis ca- used by a metastasis of the gallbladder wall (4).
In our case, presentation mimicked a pyogenic hepatic abscess with fever, right upper abdomi- nal pain and leukocytosis. Since its apparence in the abdominal CT was very suggestive for abscess, drainage has priority in the manage- ment. Unless previously diagnosed malignancy, it is uncommon to think of metastasis for abs- cess-like lesions in the liver. Actually, this is the first case of lung cancer with such a hepatic me- tastasis in the literature.
Srikanth et al. has been reported a case with a metastasis of bronchogenic carcinoma mimic- king gluteal abscess (5). Though they suggested magnetic resonance imaging (MRI) for the diag- nosis as a helpful method, they also emphasied the importance of histopathological confirmati- on from the biopsy of cavity wall.
Pulmonary cavities may occur in many benign disorders such as septic emboli, Wegener’s gra- nulomatosis, rheumatoid lung disease and also
in malignant disorders such as lymphoma and lung carcinomas. Five percent of squamous lung carcinomas have a tendency to cavitate.
This is generally the primary tumor which cavi- tates.
Cutaneous metastasis are rarely the first clinical manifestation of NSCLC; usually other metasta- sis are evident and the prognosis is extremely poor (6).
Unless the satisfactory success to antimicrobial treatment and sterile results of samples sent to microbiological studies should address the need for further investigations. In that situation, the histopathological examination of cavity walls is a good method for confirming the diagnosis.
According to our knowledge, that case is the first report in literature with an uncommon me- tastatic lesions masquerading the abscesses and the wide-spread multiple distant invasions of a squamous cell lung carsinoma in a short time period.
REFERENCES
1. Ettinger DS. Overview and state of the art in the manage- ment of lung cancer. Oncology (Huntingt) 2004; 18: 3-9.
2. Govindan R. Management of patients with non-small cell lung cancer and poor performance status. Curr Treat Op- tions Oncol 2003; 4: 55-9.
3. Obara M, Satoh H, Yamashita YT, et al. Metastatic small cell lung cancer causing biliary obstruction. Med Oncol 2000; 17: 342-3.
4. Nassenstein K, Kissler M. Gallbladder metastasis of non- small cell lung cancer. Onkologie 2004; 27: 398-400.
5. Srikanth B, Sankar NS, Kong KC, Bassily. Lessons to be learned: A case study approach: Metastatic bronchoge- nic carcinoma presenting as a gluteal abscess. J R Soc Health 1999; 119: 264-7.
6. Hidaka T, Ishii Y, Kitamura S. Clinical features of skin me- tastasis from lung cancer. Intern Med 1996; 35: 459-62.
A squamous cell lung carcinoma with abscess-like distant metastasis
102 Tüberküloz ve Toraks Dergisi 2007; 55(1): 99-102
