An elderly case of lung cancer presenting with symptoms of orbital metastasis

An 88-year-old woman was first referred to an eye clinic in mid-May 2000 because of limitation of ocular movement. A right orbital tumor was recognized on orbital CT scans and she was referred to our hospital. A chest X-ray film showed an abnormal mass in the right middle lung field, so she was admitted for further investigations. Adenocarcinoma was diagnosed by transbronchial lung biopsy. The right orbital tumor was thought to be a metastasis from the lung cancer. She received radiation therapy for the metastatic orbital tumor. However, two months after the onset of symptoms, she died due to progressive systemic metastasis. In summary, we report an elderly lung cancer patient whose initial symptoms were related to orbital metastasis.     

Tongue metastasis as an initial presentation of a lung cancer

Metastasis to the tongue seldom occurs, and lingual metastasis as an initial sign of cancer occurs even less frequently. We report a case of lung cancer in which the patient's initial symptom was related to the tongue metastasis. A 63-year-old man had a submucosal tumor on the left posterolateral aspect of the tongue and a biopsy specimen of the tongue tumor showed poorly differentiated squamous cell carcinoma. A chest X-ray showed a mass in the right lung and cytological examination of the specimen obtained by bronchial brushing showed poorly differentiated squamous cell carcinoma, whose appearance was similar to that of the tongue. Based on these findings, the tongue lesion was diagnosed a metastatic tumor from the lung cancer. The patient received radiation therapy combined with systemic chemotherapy, however, he died 5 months after the diagnosis of lung cancer. An autopsy revealed a lung cancer in the right lower lobe with metastatic tumors in the tongue, right middle lobe, left upper lobe, liver, adrenal gland, pericardium, heart, and subcutaneous tissues. No other possible primary cancer that may have been the cause of the metastases was identified.     

Cavitary pulmonary metastasis from bladder cancer: a case report]

A 69 year-old [correction of 63] man who had had a radical cystectomy for bladder cancer was admitted to our hospital because of hemosputum and right femoral pain. His chest radiograph and computed tomogram showed a mass shadow with a cavity in the left upper lung field. Sputum cytology showed class V squamous cell carcinoma and a bone scintigram showed right femoral metastasis. Despite radiotherapy to the left upper lung and the right femur, the patient's condition worsened, and he died of respiratory failure after hospitalization for about 1 month. At autopsy, pathologic studies of lung cancer revealed mixed-type transitional cell carcinoma, squamous cell carcinoma and adenocarcinoma. A diagnosis of metastatic lung cancer from bladder cancer was made. Cavitating pulmonary metastasis is uncommon. We report a rare case of pulmonary metastasis from bladder cancer, with mixed-type histopathology at both primary and metastatic sites.     

Adrenal metastasis of a papillary thyroid cancer

Adrenal metastases of the papillary thyroid carcinoma (PTC) are very rare. We report one case. A 63-year-old woman had undergone 15 years earlier left lobo-ishmectomy for a papillary thyroid cancer (PTC) and 7 years earlier right adrenalectomy for a tumor. Histologic examination showed a benign cortical tumor. In 1999, when the patient was admitted for worsening of glycemic control, a recurrence of the adrenal mass was detected. According to the hormone evaluation it was a non-functional tumor. Adrenalectomy was performed in June 2002 because the patient had initially declined surgery. Histologic examination and thyroglobulin immunochemistry identified metastatic PTC. Re-reading the histology slide of the first adrenalectomy agreed with the diagnosis. Thyroidectomy was completed in March 2003. Although iodine-131 therapy and thyroxine treatment were given, bone metastases were detected in August 2004. PTC usually spreads to the cervical and mediastinal lymph nodes. Distant spread may occur to bone or lung, but exceptionally to the adrenal gland. The adrenal localization is often associated with lung or bone metastasis. In our patient, the adrenal metastasis remained isolated for many years. It has been reported that survival rate decreases considerably after appearance of a distant metastasis. Although given delayed radical treatment, our patient remained alive 13 years after.     

Atypical presentation of lung cancer

The authors present the clinical case of a 61-year-old male admitted to the emergency department, with arthritis of his right wrist and left knee as well as left leg cellulitis, digital clubbing and 'hourglass' nails. Subsequent clinical work-up led to the final diagnosis of stage IV adenocarcinoma of the lung, with bone metastasis. The authors discuss the association between this type of lung neoplasm and osteoarticular manifestations as well as its first presentation as bone metastasis.     

A case of lung cancer with hyperthyroidism]

We here report a case of metastasis from lung cancer to the thyroid. On presentation, this patient showed painful anterior cervical swelling and right supraclavicular lymph node swelling. Laboratory data showed primary hyperthyroidism. Although subacute thyroiditis was suspected, echo-guided needle aspiration biopsy and lymph node biopsy revealed poorly differentiated squamous cell carcinoma. As a result, primary lung cancer with thyroid metastasis was diagnosed based on mediastinal enlargement on chest X ray films and normal findings in organs other than the lung and thyroid. Chemotherapy for lung cancer induced a decrease in the size of tumor and the normalization of thyroid function. However, 2 months after the normalization, cervical swelling enlarged and a lung mass in right upper lobe and skin tumor appeared. Despite treatment with chemotherapy, she died. Postmortem revealed that the right upper lung carcinoma was the primary lesion and immunohistochemical staining for surfactant protein was positive in the thyroid, skin tumor and lymph node, which revealed these carcinomas had metastasized from lung cancer. To the best of our knowledge, thyrotoxicosis induced by thyroid metastasis of lung cancer is an uncommon case.     

A case of stage IV primary lung cancer with no metastasis except in the choroid plexus]

A 69-year-old man become aware of myiodesopsia. He visited the Department of Ophthalmology at Keio University Hospital and choroidal metastasis of the right eye was diagnosed. A tumor shadow was detected in the lower lobe of the left lung on chest radiographs, and the serum CEA concentration was found to be significantly increased. Through bronchoscopic examinations, he was confirmed to have primary lung cancer (histological classification: adenocarcinoma). Although detailed systemic examinations were performed, no metastasis to lymph nodes or distant organs except the choroid plexus was detected, which is very rare in a case of stage IV primary lung cancer. In conclusion, it is suggested to be very important to look for ophthalmological abnormalities, even in the case of apparently early lung cancer that seems to be resectable.     

Malignant Perivascular Epithelioid Cell Neoplasm of the Mediastinum and the Lung: One Case Report

A perivascular epithelioid cell neoplasm (PEComa) in the chest is rare, let alone in the mediastinum and lung.A 63-year-old man was admitted to our hospital with chest pain for more than 2 months and was found to have an opacity in his mediastinum and lung for 3 weeks. Enhanced chest computed tomography (CT) revealed a mass in both the left upper lobe and central anterior mediastinum. To identify the disease, a CT-guided percutaneous transthoracic needle biopsy of the upper left lung lesions was performed. The pathology result was consistent with epithelioid angiomyolipoma/PEComa. After a standard preparation for surgery, the neoplasms in the mediastinum and left lung were resected. The operative findings revealed extensive mediastinal tumor invasion in parts adjacent to the pericardium, including the mediastinal pleura, left pulmonary artery and vein, and phrenic nerve. The left lung tumor had invaded the lung membranes. The final pathologic diagnosis was malignant epithelioid angioleiomyoma in the left upper lung and mediastinum. Later, the mediastinal tumor recurred. The radiography of this case resembles left upper lobe lung cancer with mediastinal lymph node metastasis. Because this tumor lacks fat, the enhanced CT indicated that it was malignant but failed to identify it as a perivascular epithelioid cell neoplasm.This case reminds clinicians that, although most PEComa are benign, some can be malignant. As the radiology indicated, chest PEComas lack fat, which makes their preoperative diagnosis difficult. Therefore, needle biopsy is valuable for a definitive diagnosis.     

Orbital metastasis as primary manifestation of thyroid carcinoma.

A 59-year-old woman with unknown primary tumor developed progressive painless left upper eyelid swelling and exophthalmos. Computed tomography (CT) showed a well-circumscribed left orbital mass producing bone lysis. Immunohistologic staining of the incisional biopsy specimen was positive for thyroglobulin, suggesting an orbital metastasis from thyroid carcinoma. At this time, thyroglobulin was high (1400 ng/dL). Total thyroidectomy with lymph node dissection disclosed a follicular carcinoma with microscopic foci of papillary variant follicular carcinoma. Two months after radioiodine treatment, the CT showed a regression of the orbital tumor mass with concomitant decrease in thyroglobulin (428 ng/dL). Although orbital metastases of thyroid carcinoma are uncommon, thyroid carcinoma has to be considered as a potential primary tumor in a patient with an orbital metastasis.     

A resected case of metachronous liver metastasis from lung cancer producing alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist II (PIVKA-II)

A resected case of huge liver metastasis of hepatoid adenocarcinoma of the lung is described. A 77-year-old man who presented a solitary huge liver tumor was admitted to our hospital. He had undergone right lower lobectomy of the lung for lung cancer one year before. The view of imaging studies was not a typical one of hepatocellular carcinoma. Serum levels of AFP and PIVKA-II were 334,500ng/mL and 3,890mAU/mL, respectively, and the proportion of AFP L3 was 97.9%. It was thought that they were strongly diagnostic for hepatocellular carcinoma. Extended right lobectomy of the liver was performed. Microscopically, it was poorly differentiated adenocarcinoma and diagnosed as liver metastasis from the formerly resected lung cancer. The tumor was composed of cells with both sheet-like growth and tubule formation. The neoplastic cells, in the sheet-like growth resembled hepatocellular carcinoma cells. By immunohistochemical staining with anti-AFP and anti-PIVKA-II antibodies, cancer cells of both the primary and metastatic lesions were positive. The patient eventually died of multiple liver and bone metastasis 6 months after the operation.     

A case report of invasive thymoma presenting as a solitary metastatic lesion of the lung]

A 66-year-old woman visited our hospital for further investigation of a coin-shaped lesion in the right lower lung field. After admission, CT-scan revealed an anterior mediastinal tumor. Thymoma and lung metastasis from thymoma were suspected. At thoracotomy, an invasive thymoma involving the left phrenic nerve, the left upper lobe, and the pericardium was found, and the diagnosis of lung metastasis was made. Postoperative pathological findings showed a predominantly lymphocytic thymoma with round and oval-shaped epithelial cells, and the metastatic lung lesion revealed the same findings. Postoperative radiotherapy (4000 rads) and chemotherapy with a combination of CDDP, VDS, and CPA were administered. The metastasis of thymoma is not rare, but most often it is found after operation. In this case the diagnosis of metastatic thymoma was made pre-operatively from a solitary lung lesion.     

Atypical metastatic site of lung adenocarcinoma

The case concerns a 40 years old smoker male, treated for an adenocarcinoma of the left upper lobe, metastatic in muscle extended to the right femur cortex. The patient had first a surgical excision of the mass of the thigh, an intramedullary femoral nailing, and six courses of chemotherapy (cisplatin-vinorelbine) with concurrent thoracic radiotherapy. This treatment led to disease stability. One year later, hematuria revealed a bladder tumor. Cystoscopy with biopsy concluded to an adenocarcinoma pulmonary origin. The PET-scanner showed an uptake of the bladder mass, a hypermetabolic right adrenal gland and subcutaneous left shoulder nodule. The patient had a partial cystectomy associated with enterocystoplasty and left ureteral reimplantation, plus excision of the subcutaneous nodule located in the left shoulder and a right adrenalectomy during the same time. All of the sites were metastasis from adenocarcinoma of pulmonary origin. A salvage chemotherapy was initiated. In the vast majority of cases, bladder metastasis as primary bladder tumours is revealed by hematuria, cystitis or sometimes vague pelvic pain. Our case is a very unusual bladder metastatic site from lung cancer. We will discuss the different procedures and the therapeutic strategies on the basis of the published data.     

Cardiac metastasis of hepatocellular carcinoma in a young non-cirrhotic patient, to the left ventricle

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver.(1,2) The most common extrahepatic metastatic sites are lung, abdominal lymph nodes and bone, while its cardiac metastasis is rare.(2,3) Metastasis of HCC into the cardiac cavity is mostly caused by direct tumor invasion of vena cava inferior with continuous extension into the right cardiac cavity.(4,5) Right heart metastasis without invasion of inferior vena cava, which may be caused by hematogenous spread of cancer cells, is rarely reported.(6,7) This paper announces an unusual case of isolated involvement of left ventricle (LV) together with myocardial invasion of HCC. Our patient is known to be the first case with isolated HCC metastasis to the left ventricle. Strikingly, the patient was young and non-cirrhotic with negative serum HBsAg, and anti-HCV results.     

A Coin-Like Peripheral Small Cell Lung Carcinoma Associated with Acute Paraneoplastic Axonal Guillain-Barre-Like Syndrome

A 65-year-old previously healthy male heavy smoker was hospitalized with a 2-week history of progressive muscle weakness in the lower and upper extremities. After 10 days of hospitalization, urinary sphincter incompetence and fecal incontinence were added and tetraparesis was established. The computer-tomography scan examination revealed a massive right hydrothorax and multifocal solid acinar structures with peripheral localization in the left lung, which suggested pulmonary cancer. Bone marrow metastases were also suspected. Based on the examination results, the final diagnosis was acute paraneoplastic axonal Guillain-Barre-like syndrome. The patient died 3 weeks after hospitalization. At autopsy, bronchopneumonia and a right hydrothorax were confirmed. Several 4 to 5-mm-sized round peripherally located white nodules were identified in the left lung, without any central tumor mass. Under microscope, a coin-shaped peripheral/subpleural small cell carcinoma was diagnosed, with generalized bone metastases. A huge thrombus in the abdominal aorta and acute pancreatitis was also seen at autopsy. This case highlights the difficulty of diagnosis of lung carcinomas and the necessity of a complex differential diagnosis of severe progressive ascending neuropathies. This is the 6th reported case of small cell lung cancer-associated acute Guillain-Barre-like syndrome and the first report about an association with a coin-like peripheral pattern.     

Distal phalanx metastasis in operated bronchial carcinoma

A 54 years old man who admitted with thoracolomber pain and pain at left knee had history of left pneumonectomy four months ago for squamous cell lung carcinoma. At physical examination swelling and hotness at the left knee, swelling and redness of the distal phalanx of the right third finger were found. Distal phalanx was not observed at the X-ray which was taken for suspect of metastasis. Incision biopsy was performed from this lesion and microscopic findings of the material were evaluated as metastatic squamous cell carcinoma. Bone metastasis are seen frequently at bronchial carcinoma, but hand metastasis are seen in 0.2% of all cases. This case is represented because of the rare metastatic localisation of bronchial carcinoma.     

肿瘤骨转移误诊为畸形性骨炎1例

1例25岁男性患者,主因颈椎、左上肢痛22个月,腰背痛12个月就诊。多次疑诊为"畸形性骨炎"。查体:消瘦,颈部可及肿大淋巴结,颈部活动受限,腰椎前屈受限,腰椎棘突叩痛阳性。辅助检查:血清碱性磷酸酶(ALP)水平239U/L,血清肿瘤标记物水平显著升高;X线:双肱骨及胸6-9椎体密度增高、右侧第6后肋下缘骨质增厚影。CT:肺内小结节影,心包及双侧胸腔积液,肝内多发低密度病变。骨髓活检病理提示转移性腺癌,心包积液病理见可疑瘤细胞。淋巴结病理提示肺来源的转移性腺癌。该患者被诊断为肺腺癌,肝脏、淋巴结及骨骼转移,心包转移。本例患者及文献复习提示对骨痛并伴有显著体重减轻、起病年龄小于40岁或高龄患者、受累骨骼逐渐增多,以及骨骼病变与ALP水平不平行,诊断畸形性骨炎时要注意与肿瘤骨转移相鉴别。     

Tonsillar Metastasis of Small Cell Lung Cancer in a Patient With Idiopathic Pulmonary Fibrosis: A Case Report

Small cell lung cancer (SCLC) metastasizes widely, but palatine tonsil is an extremely unusual site for metastasis. Idiopathic pulmonary fibrosis (IPF) is associated with increased risk of lung cancer. However, the most common histological findings among patients of lung cancer with IPF are known as non-SCLC such as adenocarcinoma and squamous cell carcinoma. In addition, the majority of them are located in IPF-associated fibrotic peripheral lesions.A 77-year-old man visited for 1-month persistent cough and dyspnea, with inspiratory dry crackles on both lower lung fields and a large oval mass in his throat. Chest computed tomography revealed 2 masses in the left lower lobe, 1 mass in the right upper lobe, and multiple enlarged mediastinal lymph nodes of the lung accompanying with IPF, which were diagnosed as SCLC pathologically. Very interestingly, the tonsillar mass was also confirmed as the metastatic lesion of SCLC. Chemotherapy for SCLC and medical treatment for IPF were applied. However, in following-up, he expired due to respiratory failure by an acute exacerbation of IPF 3 months after the diagnosis.In this current report, we describe, for the first time, a case of tonsillar metastasis of SCLC with IPF detected simultaneously in a 77-year-old man.     

A case of solitary endobronchial metastasis of prostatic cancer]

We report the case of a 67-year-old man found to have an abnormal chest shadow in February 2003, who was referred to our hospital in April 2003, and was admitted in July 2003 because of the expansion of this shadow. Chest radiography and CT on admission showed a small nodular shadow in the right S6. Bronchoscopy revealed a soft polypoid mass in the lumen of the right B6b ii, which was considered to be an endobronchial neoplasm. A CT scan performed as a routine screening was found to be abnormal and revealed a prostatic tumor that was diagnosed as adenocarcinoma by pathologic examinations of lung and prostate tissue. We confirmed the diagnosis of prostatic cancer and its endobronchial metastasis by immunohistological staining with prostate specific antigen (PSA). An endobronchial metastatic tumor arising from prostatic cancer is a rare phenomenon that appears on the chest radiograph as a solitary mass.     

Jejunal intussusception with gastrointestinal bleeding caused by metastatic lung cancer]

Intestinal intussusception caused by metastatic tumor is uncommon. Symptomatic small bowel metastases from lung cancer have been rarely reported. Here we report a case of intussusception with gastrointestinal bleeding induced by jejunal metastasis of non-small cell lung cancer with a review of the literature. A 52-year-old man was admitted to our hospital because of melena. He had underwent right pneumonectomy and received systemic chemotherapy with radiotherapy for squamous cell lung cancer. Esophagogastroduodenoscopy and colonoscopy failed to reveal bleeding focus. Abdominal CT scan revealed jejunal intussusception and histologic examination of resected jejunum showed metastatic mass from lung cancer. In patients with small bowel obstruction and history of malignancies, possibility of small bowel metastatic tumor should be considered.     

A case of occult thyroid cancer detected as a solitary nodular lung metastasis

An 82-year-old woman was admitted to our hospital with cough and back pain. A chest radiograph showed a solitary nodular lesion in the right lower lung field. It was diagnosed by a transbronchial biopsy as lung metastasis of a papillary adenocarcinoma of the thyroid. However, her cervical CT and ultrasonography showed only a cyst in a right lobe of the thyroid, and its biopsy did not show evidence of malignancy. In addition, multiple bone metastasis and pituitary metastasis were revealed. We therefore diagnosed this case as systemic metastasis of papillary adenocarcinoma of the thyroid. She was given best supportive care and she died seven months later. Autopsy revealed two tiny lesions (3mm and 6mm) in the thyroid right lobe to be papillary adenocarcinoma. We report this case because occult thyroid cancer caused systemic metastasis and the chest X-ray showed lung metastasis from the thyroid cancer as a solitary nodular lesion.