Colon carcinoma metastatic to the thigh--an unusual site of metastasis. Report of a case

Skeletal muscle metastasis from colorectal adenocarcinoma: A literature review

BACKGROUND

Colorectal adenocarcinoma is the third most common cancer worldwide. It accounts for almost 10% of all cancer-related deaths. Skeletal muscle is a very unusual site for metastasis from colorectal cancers and is associated with a poor prognosis and high mortality.

AIM

To review the literature for cases of skeletal muscle metastasis (SMM) from colorectal adenocarcinoma.

METHODS

A systematic literature search using a validated search strategy was carried out to identify the incidence of SMM associated with colorectal adenocarcinoma. The studies identified were tabulated in a PRISMA, and data was extracted in a tabulated form.

RESULTS

Twenty-nine studies were included in this literature review. SMM was most commonly detected in the thigh muscles. Most of the tumours had originated from the rectum or the right colon. The histopathology of the primary tumour was generally advanced. The mean time interval between the primary tumour and onset of SMM was 22 mo. In 3 cases, asymptomatic SMM had been picked up by advanced imaging systems, like fluorodeoxyglucose-positron emission tomography scan.

CONCLUSION

SMM from colorectal adenocarcinomas is a rare complication. However, it is possible that the low incidence could be due to under-reporting. Early use of advanced imaging techniques and a high index of clinical suspicion might increase the reporting of SMM from colorectal adenocarcinoma.

Skeletal muscle metastasis with bone metaplasia from colon cancer: A case report and review of the literature

BACKGROUND

Colon cancer is a common malignant disease of the gastrointestinal tract and usually occurs at the junction of the rectum and sigmoid colon. Lymphatic and hematogenous metastases occur frequently in colon cancer and the most common metastatic sites include the liver, lung, peritoneum, bone, and lymph nodes. As a manifestation of advanced tumor spread and metastasis, soft tissue metastasis, especially skeletal muscle metastasis with bone metaplasia caused by colon cancer, is rare, accounting for less than 1% of metastases.

CASE SUMMARY

A 43-year-old male patient developed skeletal muscle metastasis with bone metaplasia of the right proximal thigh 5 mo after colon cancer was diagnosed. The patient was admitted to the hospital because of pain caused by a local mass on his right thigh. Positron emission tomography-computed tomography showed many enlarged lymph nodes around the abdominal aorta but no signs of lung or liver metastases. Color ultrasound revealed a mass located in the skeletal muscle and the results of histological biopsy revealed a poorly differentiated adenocarcinoma suspected to be distant metastases from colon cancer. Immunohistochemistry showed small woven bone components that were considered to be ossified.

CONCLUSION

This case reminds us that for patients with advanced colorectal tumors, we should be alert to the possibility of unconventional metastasis.

Primary esophageal adenocarcinoma with distant metastasis to the skeletal muscle

Hematogenous metastasis of esophageal adenocarcinoma to the skeletal muscle is uncommon. We report a rare case of esophageal adenocarcinoma with metastasis to the skeletal muscle. During pretherapeutic examination, a painful mass was detected in the left thigh of a 49-year-old man. Endoscopic biopsy identified poorly differentiated, advanced esophageal adenocarcinoma. Computed tomography (CT) revealed wall thickening in the distal esophagus. Two enlarged lymph nodes were detected--the middle thoracic paraesophageal lymph node in the mediastinum and the right cardiac lymph node. (18)F-fluorodeoxyglucose (FDG) positron emission tomography demonstrated left thigh metastasis, which had not been detected by CT 3 weeks previously, with increased accumulation of FDG. Therefore, ultrasound-guided core-needle biopsy was performed. Histologic and immunohistochemical findings supported a diagnosis of poorly differentiated adenocarcinoma. The final diagnosis was primary esophageal adenocarcinoma with distant metastasis to the skeletal (left thigh) muscle. The rate of disease progression in this case emphasizes the malignant potential of esophageal adenocarcinoma. A few cases of skeletal metastasis from advanced esophageal adenocarcinoma have been previously reported. However, rapid metastasis to a distant skeletal muscle with no other hematogenous metastasis is quite rare. Early detection and rapid treatment are especially important in cases of esophageal adenocarcinoma.

Rectal adenocarcinoma metastatic to the tonsil; PET-CT observations with pathological confirmation: A case report

Metastasis of rectal adenocarcinoma develops by lymphatic or hematogenous spread. The usual sites of metastasis from rectal adenocarcinoma include local and distant lymph nodes, the liver and the lungs. The current case report presents a unique case of a mass that was identified in the tonsil by positron emission tomography-computed tomography (PET-CT), indicating a metastasis from rectal adenocarcinoma. Metastatic tumor to the tonsil is extremely rare and to the best of our knowledge, no previous studies have reported a case of tonsil metastasis from rectal adenocarcinoma. PET-CT scanners represent an important evolution in technology that is helping to bring anatomical imaging togeother with functional imaging in cancer diagnosis and therapy. Written informed consent was obtained from the patient.

Inguinal lymph node metastasis of colon cancer

We present a case of adenocarcinoma of colon with unusual metastasis to inguinal lymph nodes. Our patient is a young male with bilateral inguinal lymphadenopathy, bone pains, and jaundice who presented as carcinoma of unknown primary. He was diagnosed as widely metastatic adenocarcinoma of colon for which he received chemotherapy and has had a good response to the treatment.

Case report: soft tissue metastasis from immature teratoma of the testis: second case report and review of the literature

BACKGROUND

Testicular cancer, like other histopathologic types, commonly metastasizes to the lungs, liver, and brain. Spread to soft tissue, however, is rare with only four cases with seminoma reported. However, one case with metastasis of testicular immature teratoma to soft tissue was documented previously.

CASE DESCRIPTION

We report the case of a 38-year-old man with recurrent immature teratoma of the testis who presented with a painless soft tissue mass in the left thigh previously treated with standard chemotherapy. After removal of the soft tissue mass, his serum alpha-fetoprotein level had returned to the normal range.

LITERATURE REVIEW

To our knowledge, this is the second case of immature teratoma of the testis metastasized to soft tissue.

PURPOSES AND CLINICAL RELEVANCE

We suggest that for a man with testicular cancer who has a soft tissue mass, metastasis of soft tissue from testicular cancer and other solid malignancies should be considered in the differential diagnosis of a soft tissue mass together with primary soft tissue sarcoma.

Soft-tissue metastases

In our database of 7935 patients referred for investigation of a soft-tissue mass, only 100 were found to have a soft-tissue metastasis (1.3%). Our aim was to define the clinical features of such patients and to identify the site of their primary tumour.

The most common presentation was a painful lump, deep to the fascia, ranging between 2 cm and 35 cm (mean 8.3 cm) with 78% of the lumps located deep to the fascia. The mean age of the patients at presentation was 64 years (22 to 84) and there were almost equal numbers of men and women. Of 53 patients with a history of malignancy, 52 had metastases from the same primary (lung in 12, melanoma in ten, kidney in nine, gastrointestinal track in four, breast in five, bladder in four, and others in eight). The other 47 had no history of malignancy and the metastasis was the first presentation. The primary sites in these cases were the lung in 19, gastro-intestinal track in four, kidney in two, melanoma in nine, other in three, and unknown (despite investigations) in ten. There was no correlation between the site of the metastases and the primary tumour.

Of the 7935 patients, 516 had a history of malignancy. Of these, only 10% had a soft-tissue metastasis, 29% had a benign diagnosis, 55% a soft-tissue sarcoma and 6% another malignancy. Patients with soft-tissue metastases have similar clinical features to those with soft-tissue sarcomas and should be considered for assessment at appropriate diagnostic centres for patients with suspicious soft-tissue lumps.

Metastases to soft tissue: a review of 118 cases over a 30-year period

BACKGROUND

Metastatic tumors presenting as soft tissue masses are relatively rare and can be the source of diagnostic confusion both clinically and pathologically. The authors' experience was reviewed at a large academic medical center over a 30-year period (1971-2000) with metastases to soft tissue.

METHODS

The tumors in the study included mainly lesions involving skeletal muscle or skeletal muscle and subcutaneous tissue of the upper and lower limbs, trunk, shoulders, and buttocks. Direct extension from tumors originating in bone or adjacent organs, tumors involving the skin or areas known to contain abundant lymph nodes (ie, axilla, groin), and hematopoietic malignancies were excluded.

RESULTS

One hundred and eighteen cases were identified; 60 patients were women and 58 were men. The age range was 20 to 87 years (median of 53.5 years). The primary tumor was located in the skin (19 patients), lung (13 patients), breast (13 patients), kidney (12 patients), colon and rectum (12 patients), uterus (8 patients), ovary (5 patients), head and neck (tongue, pharynx, larynx, nasal cavity, and mandible) (5 patients), esophagus (2 patients), stomach (2 patients), cervix (2 patients), small bowel (2 patients), bone (2 patients), adrenal gland (1 patient), eye (1 patient), testis (1 patient), urinary bladder (1 patient), and salivary gland (1 patient). In 27% (32 of 118 cases) of cases, the soft tissue metastasis was the initial manifestation of the disease. In 13.5% (16 of 118 cases) of cases the primary site of origin could not be identified. The sites of metastasis included the abdominal wall (25 patients), back, including scapular region (20 patients), thigh (17 patients), chest wall (15 patients), arm (15 patients), shoulder (11 patients), buttock (5 patients), perineum (3 patients), leg (2 patients), foot (1 patient), umbilical area (1 patient), ankle (1 patient), scalp (1 patient), and elbow (1 patient). The histologic classification of the tumors included carcinoma (83 patients), malignant melanoma (20 patients), sarcoma and carcinosarcoma (9 patients), malignant mixed Mullerian tumor (2 patients), seminoma (1 patient), malignant teratoma (1 patient), malignant gastrointestinal stromal tumor (1 patient), and neuroblastoma (1 patient). Many of the tumors displayed histologic features that created difficulties for diagnosis and could be easily mistaken on routine histopathologic examination for a variety of primary soft-tissue sarcomas. Routine use of immunohistochemical stains aided in their proper recognition.

CONCLUSIONS

Metastases are not an infrequent finding in soft tissue and they may represent the initial manifestation of the disease. Use of a basic panel of immunohistochemical stains is recommended for defining the cell type and arriving at the correct diagnosis.

Unusual sites of colorectal cancer metastasis

We present 2 separate cases of adenocarcinoma of the colon with metastasis to the chin and the bladder, both of which are unusual sites of colorectal cancer metastasis. Patient 1 is a 77-year-old man who was diagnosed with adenocarcinoma of the colon, American Joint Committee on Cancer (AJCC) T4 N0 M0 (stage II), and underwent a right hemicolectomy. Fourteen months later he developed a firm 2.5-cm mass involving the chin. Excisional biopsy revealed moderately differentiated adenocarcinoma, consistent with the known colon primary tumor. Patient 2 is a 75-year-old man who was diagnosed with AJCC T3 N1 M0 (stage III) adenocarcinoma of the colon and underwent sigmoid colectomy. Ten years later, he was found to have transitional cell carcinoma involving retroperitoneal nodes with no identifiable bladder or ureteral primary, for which he received chemotherapy. Eighteen months following this diagnosis, he developed hematuria and was found to have metastatic colon adenocarcinoma involving the bladder. Details of both patient cases are presented here.

Metastatic non-small cell lung carcinoma with involvement of extremity musculature: case report and review of the literature

Hematogenous dissemination of non-small cell lung carcinoma (NSCLC) metastatic to skeletal musculature in the absence of osseous involvement is an infrequent occurrence. We retrospectively reviewed our institution's indexed database for patients evaluated from 1975 through 1997 who were diagnosed as having skeletal musculature metastases from NSCLC. Eight men and 2 women were identified (age range, 51-80 years at time of metastases). Four primary adenocarcinomas, 4 primary lung squamous cell carcinomas (SCCs), and 2 poorly differentiated primary NSCLCs were identified. Approximate tumor sizes ranged from 10 cm3 to 288 cm3. External-beam radiation therapy was used in 7 of 10 cases; complete surgical excision was performed in 3 cases. Patients with known neoplasm who have extremity pain and negative findings on bone scan should be evaluated for soft tissue tumor involvement because such findings significantly affect clinical management. One case of lung SCC metastatic to the quadratus femoris muscle in a 63-year-old man is discussed in detail.

Management of metastatic disease to soft tissue

Metastases to soft tissue are rare clinical problems. Most metastases are caused by carcinomatous deposits in the skeletal muscle, with lung carcinoma being the most common primary cause. Pain is more commonly observed in association with metastatic soft tissue masses than for soft tissue sarcomas. Treatment should be individualized, but for most carcinomas, initial radiotherapy treatment is recommended. Prognosis varies with the underlying disease, but for the typical patient with a metastatic carcinoma, mean survival duration is approximately 6 months.

Distant soft tissue metastases: a series of 30 new patients and 91 cases from the literature

BACKGROUND

Thirty patients with soft-tissue metastases were reviewed retrospectively and compared with 91 cases previously reported. Soft tissue metastases were most commonly presented to the musculoskeletal oncologist as a painful mass in patients with no history of cancer. In this setting, lung carcinoma was the most frequent primary source. The purpose of this article is to report the largest single series of distant soft-tissue metastases and to compare the findings with those of the literature.

METHODS

Thirty consecutive patients were referred to musculoskeletal oncologists. Their cases were reviewed retrospectively for comparison with 91 cases from the clinical literature.

RESULTS

The most common clinical presentation of the soft-tissue mass was as the presenting symptom of previously undiagnosed cancer or concurrent with the primary source of cancer. A minority of cases were discovered in the setting of widespread metastases. Twenty-one new patients had carcinomas, 6 sarcomas, and 1 each multiple myeloma, lymphoma, and melanoma. Lung carcinoma was the most common primary source. The most common presenting symptom was that of a painful mass. Skeletal muscle of the thigh was the most common site. Radiological features were not specific. Soft tissue sarcoma was a common clinical misdiagnosis. Twenty-one new patients were dead of disease at a mean 5.4 months (range 1-19 months) after diagnosis of the metastasis: this percentage was similar to that reported in the literature.

CONCLUSIONS

In this musculoskeletal oncology referral-based clinical series, soft tissue metastases most commonly occur in patients with a painful soft tissue mass and no history of cancer. Lung is the most frequent primary source. Treatment should be individualized according to the underlying disease and its prognosis.

[Atypical metastatic sites in rectal cancer]

We report the case of a 48-year-old woman operated on for rectal carcinoma and subsequently for metastasis located in three unusual sites (i.e., laryngeal, muscular and cutaneous). Three months after the last surgery, the patient was still alive, without any detectable metastasis.

Ossifying intramuscular metastasis from colon cancer: report of a case

PURPOSE

This report presents a patient who developed severe buttock pain because of an ossified intramuscular metastasis from a sigmoid colon cancer.

METHODS

This is a case report and review of the literature for intramuscular metastasis from colon cancer.

RESULTS

Computed tomography and magnetic resonance imaging showed a soft-tissue mass with heavy calcification. Histologically, mature compact bone was observed with adenocarcinoma cells dispersed among the bony trabeculae.

CONCLUSION

When an intramuscular mass is seen, even if it contains extensive calcification, metastasis from colon cancer should be included in differential diagnosis.

An unusual mass in the thigh

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Metastatic carcinoma to skeletal muscle. A report of 15 patients

The records of 15 patients with metastatic carcinoma to skeletal muscle treated between 1979 and the present were reviewed. Fourteen patients were referred with a diagnosis of soft tissue sarcoma and one with suspected infection. There was a previous diagnosis of carcinoma in eight patients but seven patients had no prior diagnosis of a known malignancy. Primary tumors were lung (eight), melanoma (two), gastrointestinal (one), kidney (one), and bladder (one). No primary tumor could be identified in two patients. Local control of metastatic lesions was achieved by radiotherapy in 11 patients as an initial measure. Two patients underwent wide excision and one declined treatment for local tumor control. Eight patients died within 12 months of presentation and survival analysis indicated a 25% overall survival at 60 months. Two patients remained free of disease at 132 months and 72 months. From this study and a review of 52 cases reported in the literature, the authors are unable to find any clinical or radiographic characteristics that distinguish metastatic carcinoma to muscle from soft tissue sarcomas. Surgical resection can be reserved for cases in which radiation does not provide local control.

Femoral neuropathy: unusual presentation for recurrent large-bowel cancer

PURPOSE

The recurrence of colon or rectal cancer may be signaled by serial carcinoembryonic antigen assays, patient symptoms, or radiologic tests such as abdominal and pelvic computed tomographic scans. There are unusual clinical presentations of recurrent disease.

METHODS

Retrospectively, six patients with recurrent appendix, colon, or rectal cancer had a femoral neuropathy. Their clinical features and results of reoperative surgery were reviewed.

RESULTS

All six patients had thigh weakness and atrophy, and four complained of leg pain. Each of the six patients underwent a reoperation, with a complete cancer resection in four. Pain control was excellent, but only one of the six patients, a patient with appendix cancer, demonstrated prolonged survival.

CONCLUSIONS

Leg pain, thigh weakness, and atrophy are compatible with femoral neuropathy and are symptoms and signs compatible with recurrent large-bowel cancer. These findings may alert the clinician to the need for further investigation and treatments.