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Successful management of solitary malar metastasis from lung cancer
Lung Cancer 36 (2002) 337 /339 www.elsevier.com/locate/lungcan
Case report
Successful management of solitary malar metastasis from lung cancer Kimihiro Shimizu a,*, Kanji Nagai a, Junji Yoshida a, Mituyo Nishimura a, Ryuichi Hayashi b, Tomoyuki Yokose c a
Division of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan Division of Head and Neck Surgery, National Cancer Center East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan c Pathology Division, National Cancer Center Research Institute East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan b
Received 17 December 2001; accepted 27 December 2001
Abstract A right malar mass developed in a 68-year-old man who had undergone right upper and middle bilobectomy for lung cancer 2 years previously. The mass was diagnosed to be a malar metastasis from lung cancer and was surgically resected because no other metastases were found. The patient is well without signs of recurrence 5 years after resection of the malar mass. This is the first report of a malar metastasis from lung cancer and of successful resection for malar metastasis. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Lung cancer; Malar metastasis; Surgical resection
1. Introduction Metastatic recurrence following resection of nonsmall cell lung cancer (NSCLC) is generally associated with a poor outcome. Chemotherapy has been reported to improve survival only marginally [1,2]. Radiation therapy has been used successfully to reduce local recurrence or as a palliative measure for associated symptoms. Recently, some investigators reported that long-term survival was achieved after resection of a solitary brain, adrenal gland or bone metastasis from NSCLC [3 /5]. However, only a few case reports dealt with metastases at other sites [5]. We report the first case of successful surgical management for a malar metastasis from NSCLC.
2. Case report A 66-year-old man underwent right upper and middle bilobectomy and systematic lymph node dissection for double primary NSCLC in August 1994. Pathological
* Corresponding author. Tel.: /81-471-33-1111; fax: /81-471-314724. E-mail address: [email protected] (K. Shimizu).
diagnosis of the resected specimen revealed a welldifferentiated adenocarcinoma in the upper lobe, and a moderately differentiated squamous cell carcinoma in the middle lobe. Both tumors were pathologically staged as T2N0M0 (Stage IB). Vascular invasion was observed only in the middle lobe tumor. Two years later, a mass developed in the right malar area, which grew gradually. Magnetic resonance images (MRI) showed a mass around the masseter muscle. The right zygomatic bone was invaded (Fig. 1). Needle biopsy of the mass revealed squamous cell carcinoma. Brain, chest and abdominal computed tomography scans depicted no other lesions. We diagnosed the malar mass as a solitary metastasis from the pulmonary squamous cell carcinoma. On October 16, 1996 we resected the mass with the masseter muscle and zygomatic bone. The resected specimen showed a white tumor with a well-defined margin, 5.3 /4.0 /3.0 cm in size. Pathological examination of the tumor showed moderately differentiated squamous cell carcinoma that invaded the masseter muscle and zygomatic bone. The histological section of the primary lung cancer in the right middle lobe resected 2 years earlier also showed moderately differentiated squamous cell carcinoma. The histological characteristics of the malar tumor were identical to those of the primary lung cancer (Fig. 2).
0169-5002/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 9 - 5 0 0 2 ( 0 2 ) 0 0 0 0 6 - 5
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K. Shimizu et al. / Lung Cancer 36 (2002) 337 /339
Fig. 2. (a) Histologic section of the malar tumor. (b) Histologic section of the lung cancer resected 2 years earlier showing a moderately differentiated squamous cell carcinoma that was morphologically similar to the malar tumor.
3. Discussion
Fig. 1. Gadolinium enhanced MRI. (a) A large soft tissue mass (arrow) around the right posterior zygomatic arch is depicted. Bony involvement of the zygomatic arch is noted (arrowhead). (b) The mass was centered in the masseter muscle (arrow).
These findings support the diagnosis of the malar tumor as a metastasis from pulmonary squamous cell carcinoma. The patient was discharged on the 10th postoperative day. He is doing well without adjuvant therapy, with no signs of recurrence 5 years after the resection of the metastatic lesion.
Primary squamous cell carcinoma in the malar region is very rare, except for maxillary cancer. Squamous cell carcinoma of the parotid gland is also reported to be rare [6]. In our case, the tumor was centered in the masseter muscle, while the maxillary sinus and the parotid gland were intact on MRI and surgical findings. The microscopic features of the resected specimen were identical to those of the primary squamous cell carcinoma of the lung, indicating that the malar tumor was a metastasis from the primary lung cancer. MRI and pathological findings suggested that the metastasis was centered in the masseter muscle with invasion to the zygomatic bone. Lung cancer metastases to the soft tissue, including skeletal muscles are rare. Thirty-eight patients were described in 16-report [7]. However, no patients had facial diseases among the 38 patients. Malar metastasis is extremely rare. Only three cases have been reported in the literature. In 1975, Ohba et al.
K. Shimizu et al. / Lung Cancer 36 (2002) 337 /339
[8] reported the first case. Their patient developed zygomatic bone and other bone metastases. The other two cases were metastases to the soft tissue in the zygomatic area. Challagalla et al. [9] reported a patient with uterine cervical cancer who presented with metastasis to the soft tissue behind the zygomatic arch, who received radiation therapy to the zygomatic region and chemotherapy with almost complete remission. However, the patient was lost to follow-up 1 year later. Danikas et al. [10] reported a patient with rectal carcinoma metastasis to the soft tissue around the left anterior zygomatic arch. The patient subsequently developed a mass in the bilateral sylvian areas, and the 4th metastatic lesion in the right lateral thalamus. She underwent radiation therapy, but died 2 months later. The present case differs from the previous reports that the solitary malar metastasis was managed surgically and the patient survived longer than 5 years without further recurrence. Recurrence after NSCLC resection is generally associated with a poor outcome and is treated with systemic chemotherapy or palliative irradiation. However, long-term survival has been reported following resection of a solitary brain, adrenal gland, and bone metastasis from NSCLC [3 /5]. Luketich et al. [5] reported that long-term survival was possible after treatment of isolated metastases to various sites from NSCLC, if the primary NSCLC was completely resected and the isolated metastasis amenable to curative resection or radiation. In our case, the primary NSCLC was completely resected, and the solitary nature of the metastasis was confirmed by careful physical and radiological examinations. Thus, we chose to perform surgical resection of the malar metastasis, and the patient has no evidence of local recurrence or distant metastases 5 years later. In summary, malar metastasis from lung cancer developed after complete NSCLC resection was reported. This is the first report of malar metastasis from lung cancer, and of successful surgical management for the disease. This case shows that not all squamous cell carcinoma detected in the face is a primary tumor in this area, and that if a solitary
339
metastasis from NSCLC is localized within the malar region, surgical resection can be a choice for cure.
Acknowledgements We thank Prof. J. Patrick Barron (International Medical Communication Center, Tokyo Medical University) for reviewing the English manuscript. This work was supported in part by a Grant-in-Aid for cancer research from the Ministry of Health, Labour and Welfare, Japan.
References [1] Schaake-Koning C, van den Bogaert W, Dalesio O, et al. Effects of concomitant cisplatin and radiotherapy on inoperable nonsmall-cell lung cancer. N Engl J Med 1992;326:524 /30. [2] Kojima A, Shinkai T, Eguchi K, et al. Analysis of three-year survivors among patients with advanced inoperable non-small cell lung cancer. Jpn J Clin Oncol 1991;21:276 /81. [3] Patchell RA, Tibbs PA, Walsh JW, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990;322:494 /500. [4] Raviv G, Klein E, Yellin A, Schneebaum S, Ben-Ari G. Surgical treatment of solitary adrenal metastases from lung carcinoma. J Surg Oncol 1990;43:123 /4. [5] Luketich JD, Martini N, Ginsberg RJ, Rigberg D, Burt ME. Successful treatment of solitary extracranial metastases from nonsmall cell lung cancer. Ann Thorac Surg 1995;60:1609 /11. [6] Flynn MB, Maguire S, Martinez S, Tesmer T. Primary squamous cell carcinoma of the parotid gland: the importance of correct histological diagnosis. Ann Surg Oncol 1999;6:768 /70. [7] Damron TA, Heiner J. Distant soft tissue metastases: a series of 30 new patients and 91 cases from the literature. Ann Surg Oncol 2000;7:526 /34. [8] Ohba T, Katayama H, Nakagawa E, Takeda N. Mandibular metastasis of osteogenic sarcoma. Report of a case. Oral Surg Oral Med Oral Pathol 1975;39:821 /5. [9] Challagalla JD, Smith R, Mitnick R, Breining D, Wadler S. Carcinoma of the uterine cervix metastatic to behind the zygomatic arch: a case report. Am J Otolaryngol 1999;20:195 /7. [10] Danikas D, Theodorou SJ, Arvanitis ML, Zinterhofer LM, Rienzo AA. Malar metastasis from rectal carcinoma: a case report. Am Surg 1999;65:1150 /2.
Case report
Successful management of solitary malar metastasis from lung cancer Kimihiro Shimizu a,*, Kanji Nagai a, Junji Yoshida a, Mituyo Nishimura a, Ryuichi Hayashi b, Tomoyuki Yokose c a
Division of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan Division of Head and Neck Surgery, National Cancer Center East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan c Pathology Division, National Cancer Center Research Institute East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan b
Received 17 December 2001; accepted 27 December 2001
Abstract A right malar mass developed in a 68-year-old man who had undergone right upper and middle bilobectomy for lung cancer 2 years previously. The mass was diagnosed to be a malar metastasis from lung cancer and was surgically resected because no other metastases were found. The patient is well without signs of recurrence 5 years after resection of the malar mass. This is the first report of a malar metastasis from lung cancer and of successful resection for malar metastasis. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Lung cancer; Malar metastasis; Surgical resection
1. Introduction Metastatic recurrence following resection of nonsmall cell lung cancer (NSCLC) is generally associated with a poor outcome. Chemotherapy has been reported to improve survival only marginally [1,2]. Radiation therapy has been used successfully to reduce local recurrence or as a palliative measure for associated symptoms. Recently, some investigators reported that long-term survival was achieved after resection of a solitary brain, adrenal gland or bone metastasis from NSCLC [3 /5]. However, only a few case reports dealt with metastases at other sites [5]. We report the first case of successful surgical management for a malar metastasis from NSCLC.
2. Case report A 66-year-old man underwent right upper and middle bilobectomy and systematic lymph node dissection for double primary NSCLC in August 1994. Pathological
* Corresponding author. Tel.: /81-471-33-1111; fax: /81-471-314724. E-mail address: [email protected] (K. Shimizu).
diagnosis of the resected specimen revealed a welldifferentiated adenocarcinoma in the upper lobe, and a moderately differentiated squamous cell carcinoma in the middle lobe. Both tumors were pathologically staged as T2N0M0 (Stage IB). Vascular invasion was observed only in the middle lobe tumor. Two years later, a mass developed in the right malar area, which grew gradually. Magnetic resonance images (MRI) showed a mass around the masseter muscle. The right zygomatic bone was invaded (Fig. 1). Needle biopsy of the mass revealed squamous cell carcinoma. Brain, chest and abdominal computed tomography scans depicted no other lesions. We diagnosed the malar mass as a solitary metastasis from the pulmonary squamous cell carcinoma. On October 16, 1996 we resected the mass with the masseter muscle and zygomatic bone. The resected specimen showed a white tumor with a well-defined margin, 5.3 /4.0 /3.0 cm in size. Pathological examination of the tumor showed moderately differentiated squamous cell carcinoma that invaded the masseter muscle and zygomatic bone. The histological section of the primary lung cancer in the right middle lobe resected 2 years earlier also showed moderately differentiated squamous cell carcinoma. The histological characteristics of the malar tumor were identical to those of the primary lung cancer (Fig. 2).
0169-5002/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 9 - 5 0 0 2 ( 0 2 ) 0 0 0 0 6 - 5
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K. Shimizu et al. / Lung Cancer 36 (2002) 337 /339
Fig. 2. (a) Histologic section of the malar tumor. (b) Histologic section of the lung cancer resected 2 years earlier showing a moderately differentiated squamous cell carcinoma that was morphologically similar to the malar tumor.
3. Discussion
Fig. 1. Gadolinium enhanced MRI. (a) A large soft tissue mass (arrow) around the right posterior zygomatic arch is depicted. Bony involvement of the zygomatic arch is noted (arrowhead). (b) The mass was centered in the masseter muscle (arrow).
These findings support the diagnosis of the malar tumor as a metastasis from pulmonary squamous cell carcinoma. The patient was discharged on the 10th postoperative day. He is doing well without adjuvant therapy, with no signs of recurrence 5 years after the resection of the metastatic lesion.
Primary squamous cell carcinoma in the malar region is very rare, except for maxillary cancer. Squamous cell carcinoma of the parotid gland is also reported to be rare [6]. In our case, the tumor was centered in the masseter muscle, while the maxillary sinus and the parotid gland were intact on MRI and surgical findings. The microscopic features of the resected specimen were identical to those of the primary squamous cell carcinoma of the lung, indicating that the malar tumor was a metastasis from the primary lung cancer. MRI and pathological findings suggested that the metastasis was centered in the masseter muscle with invasion to the zygomatic bone. Lung cancer metastases to the soft tissue, including skeletal muscles are rare. Thirty-eight patients were described in 16-report [7]. However, no patients had facial diseases among the 38 patients. Malar metastasis is extremely rare. Only three cases have been reported in the literature. In 1975, Ohba et al.
K. Shimizu et al. / Lung Cancer 36 (2002) 337 /339
[8] reported the first case. Their patient developed zygomatic bone and other bone metastases. The other two cases were metastases to the soft tissue in the zygomatic area. Challagalla et al. [9] reported a patient with uterine cervical cancer who presented with metastasis to the soft tissue behind the zygomatic arch, who received radiation therapy to the zygomatic region and chemotherapy with almost complete remission. However, the patient was lost to follow-up 1 year later. Danikas et al. [10] reported a patient with rectal carcinoma metastasis to the soft tissue around the left anterior zygomatic arch. The patient subsequently developed a mass in the bilateral sylvian areas, and the 4th metastatic lesion in the right lateral thalamus. She underwent radiation therapy, but died 2 months later. The present case differs from the previous reports that the solitary malar metastasis was managed surgically and the patient survived longer than 5 years without further recurrence. Recurrence after NSCLC resection is generally associated with a poor outcome and is treated with systemic chemotherapy or palliative irradiation. However, long-term survival has been reported following resection of a solitary brain, adrenal gland, and bone metastasis from NSCLC [3 /5]. Luketich et al. [5] reported that long-term survival was possible after treatment of isolated metastases to various sites from NSCLC, if the primary NSCLC was completely resected and the isolated metastasis amenable to curative resection or radiation. In our case, the primary NSCLC was completely resected, and the solitary nature of the metastasis was confirmed by careful physical and radiological examinations. Thus, we chose to perform surgical resection of the malar metastasis, and the patient has no evidence of local recurrence or distant metastases 5 years later. In summary, malar metastasis from lung cancer developed after complete NSCLC resection was reported. This is the first report of malar metastasis from lung cancer, and of successful surgical management for the disease. This case shows that not all squamous cell carcinoma detected in the face is a primary tumor in this area, and that if a solitary
339
metastasis from NSCLC is localized within the malar region, surgical resection can be a choice for cure.
Acknowledgements We thank Prof. J. Patrick Barron (International Medical Communication Center, Tokyo Medical University) for reviewing the English manuscript. This work was supported in part by a Grant-in-Aid for cancer research from the Ministry of Health, Labour and Welfare, Japan.
References [1] Schaake-Koning C, van den Bogaert W, Dalesio O, et al. Effects of concomitant cisplatin and radiotherapy on inoperable nonsmall-cell lung cancer. N Engl J Med 1992;326:524 /30. [2] Kojima A, Shinkai T, Eguchi K, et al. Analysis of three-year survivors among patients with advanced inoperable non-small cell lung cancer. Jpn J Clin Oncol 1991;21:276 /81. [3] Patchell RA, Tibbs PA, Walsh JW, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990;322:494 /500. [4] Raviv G, Klein E, Yellin A, Schneebaum S, Ben-Ari G. Surgical treatment of solitary adrenal metastases from lung carcinoma. J Surg Oncol 1990;43:123 /4. [5] Luketich JD, Martini N, Ginsberg RJ, Rigberg D, Burt ME. Successful treatment of solitary extracranial metastases from nonsmall cell lung cancer. Ann Thorac Surg 1995;60:1609 /11. [6] Flynn MB, Maguire S, Martinez S, Tesmer T. Primary squamous cell carcinoma of the parotid gland: the importance of correct histological diagnosis. Ann Surg Oncol 1999;6:768 /70. [7] Damron TA, Heiner J. Distant soft tissue metastases: a series of 30 new patients and 91 cases from the literature. Ann Surg Oncol 2000;7:526 /34. [8] Ohba T, Katayama H, Nakagawa E, Takeda N. Mandibular metastasis of osteogenic sarcoma. Report of a case. Oral Surg Oral Med Oral Pathol 1975;39:821 /5. [9] Challagalla JD, Smith R, Mitnick R, Breining D, Wadler S. Carcinoma of the uterine cervix metastatic to behind the zygomatic arch: a case report. Am J Otolaryngol 1999;20:195 /7. [10] Danikas D, Theodorou SJ, Arvanitis ML, Zinterhofer LM, Rienzo AA. Malar metastasis from rectal carcinoma: a case report. Am Surg 1999;65:1150 /2.