Non small-cell lung cancer with metastasis to thigh muscle and mandible: two case reports
© Giugliano et al.; licensee BioMed Central Ltd. 2013
Received: 27 November 2012
Accepted: 10 February 2013
Published: 8 April 2013
Lung cancer is the leading cause of cancer-related death in Europe and the US. Isolated metastases to skeletal muscle and the mandible are very uncommon.
This report presents two cases. Case 1 concerns a 45-year-old Caucasian woman affected by muscle metastasis of the right thigh from non-small-cell lung cancer. Case 2 concerns a 61-year-old Caucasian man affected by mandible metastasis from non-small-cell lung cancer. Both metastases were detected by diagnostic imaging studies. Both patients were treated with radiation therapy with palliative and antalgic intent.
Radiation therapy was effective and well tolerated in both cases. Both our patients are alive, with follow-up of 18 months and five months, respectively.
KeywordsNon-small-cell lung cancer Muscle metastasis Bone mandible metastasis Radiation therapy
Lung cancer is the leading cause of cancer-related death worldwide and the second most common cancer in both men and women. Despite improvements in imaging technologies over the past two decades, the majority of lung cancers are discovered because of the development of distant metastases. Hematogenous spread with multiple organ involvement is frequently reported. Commonly, metastases from lung cancer involve the liver, adrenal glands, bone and brain. Muscle metastases are uncommon. Mandible metastasis from lung cancer is a rare condition that may occur in the late stages of the disease. We describe two cases of non- small-cell lung cancer (NSCLC) metastasis to thigh muscle and mandible bone (as first clinical evidence), and discuss treatments and outcomes.
This report presents the cases of two patients affected by NSCLC, metastatic to the right thigh muscle and left mandible. Both patients were treated with RT to the involved area, in addition to systemic chemotherapy. Few data are reported about metastases to muscle from primary lung cancer. Moreover, metastases to soft tissue can be misdiagnosed histologically as primary soft tissue sarcomas. The treatment and prognosis for a metastatic neoplasm of the soft tissue and a primary soft tissue sarcoma are different. Various mechanical factors, such as tissue blood flow, arterial pressure, muscle contraction and trauma, have been described as possible causes for rare metastases to muscle. Often these metastases are diagnosed at different time intervals from the discovery of the primary tumor, being discovered in some cases more than five years later. The most commonly involved sites are the muscles of the trunk, particularly the paraspinal and psoas muscles. In our first patient’s case, however, the region of interest was the lower extremity. Many cases of skeletal muscle metastases described in the literature showed clinical symptoms and signs, such as in our patient with edema and phlebitis. Although several reports underline that these events are not common, a recent study by Haygood et al. explores the epidemiology of metastases to skeletal muscle and their detection by PET/CT, concluding that skeletal muscle metastases are not unusual and the most common source is lung cancer. The increasing use of PET/CT has recently led to diagnosis of unsuspected distant/solitary metastases at rare locations, including the colon and extra-ocular muscles. There is no agreement on the optimal therapeutic strategy for muscle metastases from NSCLC, although several therapeutic options can be offered to patients such as radiation therapy, chemotherapy or surgical excision. Unfortunately, the outcome remains poor and the prognosis of these patients with muscle metastasis from NSCLC remains doubtful. In this report, with regard to our first patient, the use of radiation therapy on muscle metastasis can be considered as a potentially successful treatment option, giving patients the possibility to avoid an aggressive treatment such as surgery and reducing the possible side effects.
Likewise, the clinical presentation of mandibular metastases are similar to common conditions such as toothache or, less frequently, temporo-mandibular joint pain, osteomyelitis, or trigeminal neuralgia. Consequently the diagnostic and therapeutic investigation of these patients may be difficult. Metastases to the jaw involve the mandible in 80 percent of cases, and the most common locations for oral metastasis are the molar and pre-molar regions of the mandibular bone. Most studies of oral metastatic disease indicate its predilection for the posterior mandible[12, 13] because of its rich blood supply in active areas of hematopoiesis; conversely, in our study, the anterior of the mandible was involved. Metastatic bone lesions are generally determined after the detection of the primary tumor; they may be the first symptom of metastatic disease in approximately 30 percent of cases. Data from the literature reveal that autopsies detected muscle metastases in about 17 percent of patients. In the second case report, we described the clinical history of a patient affected by metastasis to the mandible that disclosed the presence of a silent primary lung cancer. Pruckmayer et al. evaluated 763 patients retrospectively who suffered from jaw pain. They concluded that a selected subgroup of individuals, specifically patients with a history of cancer or those not responding to conventional management, should undergo specific investigations such as bone scans to rule out a neoplastic cause.
Although radical surgery treatment of the solitary metastatic bone lesion or of muscle metastasis in patients who are oligometastatic and plurimetastatic could be considered as therapeutic options, palliative radiation therapy was offered to our patients obtaining good control of tumor size and pain. Both patients are alive, with follow-up of five and 18 months. Palliative radiation therapy is one of the major contributors to the care of patients with oncological issues, and also, in selected cases, a second radiation therapy treatment is feasible, well tolerated and offers the possibility of symptomatic relief. Our treatments were carefully chosen to maintain the quality of life of our patients in both cases, and we obtained good results without serious side effects although it should be noted the prognosis in metastatic NSCLC remains poor.
Written informed consent was obtained from both patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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