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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 142-144

Small-cell carcinoma of the lung with inguinal lymph node metastasis at initial presentation


Department of Radiotherapy, IGMC, Shimla, Himachal Pradesh, India

Date of Submission27-Nov-2019
Date of Decision31-May-2020
Date of Acceptance09-Oct-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Shabnum Thakur
Department of Radiotherapy, IGMC, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/oji.oji_40_19

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  Abstract 


Groin node metastases are predominantly seen in primary malignancies of infradiaphragmatic location. However, sparse cases of inguinal metastases from tumors above the diaphragm have been reported in the medical literature. Here, we report a case of small-cell carcinoma of the lung with metastatic inguinal lymph node at the initial presentation in a 57-year-old man. The case was diagnosed and managed congruously as per the stage of the disease, which was metastatic. However, the patient was died due to disease progression after 8 months of diagnosis. This case edifies to a clinical oncologist's knowledge that patients with commodious and disseminated malignancies of supradiaphragmatic location may present with lymph nodes in the inguinal region.

Keywords: Inguinal lymph node, initial presentation, metastasis, small cell lung carcinoma


How to cite this article:
Thakur S, Vias P, Gupta M. Small-cell carcinoma of the lung with inguinal lymph node metastasis at initial presentation. Oncol J India 2020;4:142-4

How to cite this URL:
Thakur S, Vias P, Gupta M. Small-cell carcinoma of the lung with inguinal lymph node metastasis at initial presentation. Oncol J India [serial online] 2020 [cited 2021 Apr 10];4:142-4. Available from: https://www.ojionline.org/text.asp?2020/4/3/142/301585




  Introduction Top


Small cell lung cancer (SCLC) accounts for approximately 15% of lung neoplasms.[1] It carries the greatest propensity for early dissemination and is accompanied by a worse prognosis compared to other histologic types. Delays in therapeutic interventions should not be done due to the aggressive nature of this disease if left untreated. Despite its aggressiveness, nearly all cases respond dramatically well to chemotherapy. However, most tumors finally relapse, eventually leading to widespread disease. The most common sites of tumor metastasis involve the liver, adrenals, bone marrow, and brain. However, uncommon sites can also be affected and reported in the literature.[1],[2] After extensive PubMed-based literature search, no case of SCLC was found to be reported with infradiaphragmatic metastasis particularly to the inguinal node at presentation. Here, we reported the first case of inguinal lymph node metastasis in SCLC at the initial presentation.


  Case Report Top


A 57-year-old male presented with a 2-months history of cough, mild dyspnea, loss of appetite, and hemoptysis that had become severe in the previous 2 weeks. He had smoked a pack of cigarettes a day for 32 years. On physical examination, the patient appeared fatigued and there was a hard, nontender, and semi-mobile lymph node of 6 cm × 4 cm in size in the left groin [Figure 1]. Genitalia were clinically normal and rectal examination revealed no abnormalities. As patient presented with the same complaints in private clinic before he came to us, where magnetic resonance imaging (MRI) of the pelvis was done showing an enhanced soft-tissue mass (lymphadenopathy) with a size of 6 cm × 5 cm in the right inguinal region. The rest of the pelvic study was within the normal limits. As the inguinal lymph node region was an unusual site for metastasis from carcinoma of the lung, it was not suspected that the patient had developed metastatic disease. The computed tomography (CT) scan (plain) of the chest and abdomen, demonstrated the presence of a mass of size 6.8 cm × 8.35 cm × 9 cm in the posterior parahilar zone of the superior segment of the left lower lobe and extending to adjoining apicoposterior segment of the left upper lobe [Figure 2]a and [Figure 2]b. Medially, it is abutting the left lateral wall of the left descending aorta. There was enlarged paraaortic (2.8 cm × 1.5 cm), subaortic (2.7 cm × 1.5 cm), and left lower paratracheal (1.7 cm × 1.9 cm) lymph nodes along with subcentimetric mediastinal lymph nodes. The findings were suggestive of the left lung neoplastic mass with abdominal lymphadenopathy. Fiberoptic bronchoscopy showed the presence of a fleshy growth in the lower one-third trachea with narrowing of the lumen and microscopic examination of the endobronchial biopsy (EBB) sample revealed the presence of hyperchromatic nuclei, inconspicuous nucleoli, scant eosinophilic cytoplasm, nuclear folding, and frequent mitotic figures. The findings are consistent with SCLC [Figure 3]a. Contrast-enhanced MRI of the brain revealed the absence of any brain metastasis. Biopsy from inguinal lymph node depicts the presence of tumor cells infiltrating the stroma, cells were with high nuclear-cytoplasmic ratio, nuclear pleomorphism, coarse granular chromatin, nuclear molding, and inconspicuous nucleoli, features were consistent with metastatic small cell carcinoma [Figure 3]b. Immunohistochemistry markers for the custom panel was done on EBB sample which revealed strong positivity of cytokeratin and synaptophysin, chromogranin focally positive, Ki67 >90% with thyroid transcription factor-1 negative [Figure 4]a and [Figure 4]b, in favor of SCLC. With the diagnosis of extensive-stage SCLC (T3N2M1b), the patient was started on cisplatin and etoposide-based palliative chemotherapy. After receiving two cycles of chemotherapy, he attended the emergency department due to the development of confusion, dizziness, and headache. Contrast-enhanced CT scan of the brain was done showing a well defined, peripherally enhancing lesion in vermis suggestive of brain metastasis. The patient was started on palliative whole-brain radiotherapy (WBRT) with a dose-fractionation schedule of 30 Gy in 10 fractions, 3 Gy per fraction, 5 fractions per week, and over 2 weeks period. After 3 weeks of completion of WBRT, the patient started with procarbazine based chemotherapy. However, due to disease progression after three cycles of chemotherapy and symptomatic, external beam radiotherapy was delivered to local disease site and inguinal nodal metastatic site in palliative intent with a substantial response to the treatment. The patient died after 6 months of receiving WBRT due to disseminated and progressive disease.
Figure 1: Left inguinal lymphadenopathy

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Figure 2: Axial section of plain computed tomography of the thorax in the mediastinal window (a) and lung window (b) showing a mass in the left posterior parahilar zone of the superior segment of the left lower lobe

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Figure 3: (a) Endobronchial biopsy (H and E, ×20) showing small round tumor cells infiltrating the subepithelial tissue, and (b) lymph node biopsy (H and E, ×20) showing involvement by small round tumor cells with nuclear molding

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Figure 4: (a) Chromogranin A immunostain focally positive (×40) and (b) Synaptopysin immunostain positive (×40)

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  Discussion Top


The incidence and mortality of SCLC worldwide make this disease a notable health-care issue. Approximately 60%–70% of patients with SCLC have clinically disseminated or extensive disease at presentation. Extensive stage SCLC is incurable. Most patients with this disease present with a short duration of symptoms, usually only 8–12 weeks before presentation. The clinical manifestations of SCLC can result from local tumor growth, intrathoracic spread, distant spread, and/or paraneoplastic syndromes. The prognosis in SCLC is poor. Median survival without treatment has been reported as 2–4 months.[3] The most reproducible prognostic factor is disease extent, although a few other prognostic factors have been identified: performance status, sex, and some routine laboratory tests show some merit.[4],[5] SCLCs usually grow rapidly and metastasize to mediastinal lymph nodes relatively early in the course of the disease. At presentation, patients may have very large intrathoracic tumors, and distinguishing the primary tumor from lymph node metastases may be impossible.

However, infradiaphragmatic metastases from tumors above the diaphragm are rare. Inguinal node metastases were more frequently seen with primary malignancies of genital and reproductive organs, skin, rectum or anus, or urinary bladder. Few rare cases of inguinal node metastases from primary tumors above the diaphragm have been reported.[6],[7],[8] These primary malignancies are salivary duct carcinoma, breast cancer, and malignant mesothelioma. Few of the NSCLC cases had been reported with inguinal lymph node metastasis. Kocak et al. reported a case of inguinal lymph node metastasis as the only evidence of progressive NSCLC.[9] Grandić et al. in their case report found inguinal lymph node metastases as the first sign of disease relapse for NSCLC.[10] However, no cases of SCLC reported with inguinal node metastasis till now. Hence, our case will be the first case to be reported with inguinal node metastasis for SCLC.

In our case patient presentation make us think about the sites such as genital, reproductive organs, skin, rectum, or anus at first impression for inguinal lymph node metastasis clinically which after a thorough radiological, pathological, and immunohistochemical investigations confirm the primary of SCLC. This can also be interpreted as the presence of inguinal lymph node metastasis at presentation and suggest a poor prognosis.


  Conclusion Top


The presence of inguinal lymphadenopathy in carcinoma lung is rare and has poor prognosis. Although rare, primary lung carcinoma can be a differential diagnosis, whenever encountered with groin nodes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms for his images and other clinical information to be reported in the journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
van Meerbeeck JP, Fennell DA, De Ruysscher DK. Small-cell lung cancer. Lancet 2011;378:1741-55.  Back to cited text no. 1
    
2.
Chen XH, Bao YY, Zhou SH, Wang QY, Zhao K. Palatine tonsillar metastasis of small-cell neuroendocrine carcinoma from the lung detected by FDG-PET/CT after tonsillectomy: A case report. Iran J Radiol 2013;10:148-51.  Back to cited text no. 2
    
3.
Kato Y, Ferguson TB, Bennett DE, Burford TH. Oat cell carcinoma of the lung. A review of 138 cases. Cancer 1969;23:517-24.  Back to cited text no. 3
    
4.
Cerny T, Blair V, Anderson H, Bramwell V, Thatcher N. Pretreatment prognostic factors and scoring system in 407 small-cell lung cancer patients. Int J Cancer 1987;39:146-9.  Back to cited text no. 4
    
5.
Albain KS, Crowley JJ, LeBlanc M, Livingston RB. Determinants of improved outcome in small-cell lung cancer: An analysis of the 2,580-patient Southwest Oncology Group data base. J Clin Oncol 1990;8:1563-74.  Back to cited text no. 5
    
6.
Bhalla R, Parker DC, Tadros TS. Salivary duct carcinoma metastatic to inguinal lymph node: A case report of salivary duct carcinoma with distant metastasis diag-nosed by fine-needle aspiration. Diagn Cytopathol 2006;34:41-4.  Back to cited text no. 6
    
7.
Baba M, Tatsuta M, Miya A, Ishida H, Masutani S, Kawasaki T, et al. A case of breast cancer diagnosed by inguinal lymph node metastasis. Breast Cancer 2000;7:173-5.  Back to cited text no. 7
    
8.
King JA, Listinsky CM, Tucker JA. An intriguing case: Malignant mesothelioma presenting as inguinal lymph node metastases. Ultrastruct Pathol 2004;28:109-13.  Back to cited text no. 8
    
9.
Kocak Z, Saynak M, Oz-Puyan F, Cicin I, Cosar-Alas R, Caloglu M, et al. Inguinal ganglion as the only evidence of cancer progressive lung. Rev Port Pneumol 2008;14:709-13.  Back to cited text no. 9
    
10.
Grandić L, Pogorelić Z, Banović J, Forempoher G, Ilić N, Perko Z. Atypical non-small cell lung cancer presentation: Inguinal lymph node metastases as the first sign of disease relapse. Acta Clin Croat 2010;49:441-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 Adenocarcinoma of the Lung With Inguinal Lymph Node Metastasis
Venkatkiran Kanchustambham,Swetha Saladi
Cureus. 2021;
[Pubmed] | [DOI]



 

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