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An unusual presentation of multiple cavitated lung metastases from colon carcinoma
© Seminara et al; licensee BioMed Central Ltd. 2011
Received: 27 December 2010
Accepted: 31 May 2011
Published: 31 May 2011
Consolidation with or without ground-glass opacity is the typical radiologic finding of lung metastases of adenocarcinoma from the gastrointestinal tract. Lung excavated metastases from gastrointestinal carcinoma are very rare.
The authors describe an unusual presentation of multiple cavitated lung metastases from colon adenocarcinoma and discuss the outcome of a patient. The absence both of symptoms and other disease localizations, the investigations related to different diagnostic hypotheses and the empirical treatments caused a delay in correct diagnosis. Only a transparietal biopsy revealed the neoplastic origin of nodules.
This report demonstrates that although lung excavated metastases are described in literature, initial failure to reach a diagnosis is common. We would like to alert clinicians and radiologists to the possibility of unusual atypical features of pulmonary metastases from colon adenocarcinoma.
Typical radiologic findings of pulmonary metastases include multiple round variable-sized nodules, generally located in peripheral parenchyma and diffuse thickening of interstitial [1, 2]. Among cases of multiple nodules detected with CT-scan, 73% were reported to be pulmonary metastases . The characteristic radiological findings of primary tumors and differential diagnoses of atypical lung metastases are reported by J. B. Seo et al. .
Consolidation with or without ground-glass opacity is the typical radiologic finding of lung metastases of adenocarcinoma from the gastrointestinal tract. Cavitating lesions are detected only in 4% of metastatic nodules and about 70% of them are due to metastatic squamous cell carcinoma. Lung excavated metastases from osteosarcoma are very rare and those from adenocarcinomas of various primary sites (gastrointestinal, breast, ovary, etc) are only occasional.
Herein the authors report a case of excavated pulmonary metastases from colon adenocarcinoma, whose unusual presentation and the absence both of symptoms and other sites of disease caused delay of correct diagnosis.
C.E., a 78 year-old Caucasian woman, underwent radical surgery for adenocarcinoma of the sigma (pT4, pN1, and G2). The patient presented a history of coronary heart disease, but at that time she had been taking a long action nitrate, she was free of symptoms even when exposed to moderate physical exercises and ECG was normal. She completed six cycles of adjuvant chemotherapy with Raltitrexed (3 mg/sqm every 21 days), a good tolerable treatment.
The lung is a common site for metastases. Most cases of pulmonary metastases can be diagnosed radiologically on the basis of typical findings, including multiple round variable-sized nodules and a diffuse thickening of interstitium, respectively hematogenous metastases and lymphangitic carcinomatosis. In case of atypical radiologic features of pulmonary metastases, it is crucial to carry out an accurate diagnosis. Differential diagnostic hypotheses for these appearances include infective conditions either bacterial or fungal in origin, rheumatoid nodules and vasculitic processes, lymphomas and all metastatic diseases from a distal primary tumor [4, 5].
As regards adjuvant chemotherapy with Raltitrexed, our patient was elderly with a previous personal history of coronary disease. This therapeutic choice was in relation to the results of three randomized trials [6–8], demonstrating equivalence in response rate of Raltitrexed and 5-FU/leucovorin schedules in patients with advanced colorectal carcinoma. There is a small statistically significant difference for time to progression and, in one study a shorter median survival, but these minimal differences may not be clinically relevant for an individual therapeutic decision, considering also that patients with coronary disease are more likely to experience 5-FU cardiotoxicity .
In our case, first diagnostic hypothesis was pulmonary infection, featuring very limited lung excavated lesions at a follow-up planned chest radiograph. The absence both of symptoms and other disease localizations by CT-scan contributed to infectious diagnosis. But investigations and empiric treatment caused a delay of correct diagnosis and treatment. Therefore, only biopsy of lung lesion allowed the diagnosis of EGFR positive colon carcinoma metastases (Figure 2). The mis-diagnosis of infection diseases has been reported in literature for 10% of metastatic lung adenocarcinomas presenting the features of multiple cavitating nodules .
Considering the biology of cancer this case history shows its polyphenotipic nature. Despite the grading (G2), this phenotype of cancer appeared to be rather aggressive, characterized by devastating course, absence of serum tumor markers increase and resistance to chemotherapy based on updated agents . Progress in molecular biology and its use in clinical practice are strongly justified to identify patients with peculiar clinical course and prognosis.
According to our experience and literature data, in daily practice unusual cavitated lung metastases are not rare and it is often difficult to distinguish metastases from other non-malignant pulmonary diseases. In this case only multiple excavated lung nodules were found, without other sites of metastasis, and the mis-diagnosis of infectious disease caused a delay in administering effective anticancer therapy. After histological diagnosis of lung metastases from primary colon adenocarcinoma, the first CT-scan was submitted again to other radiologists who confirmed the difficulty in interpreting initial features of cavitated lung lesions.
In conclusion, although other cases of cavitated lung metastases are reported in literature, these atypical secondary lung lesions are still diagnosed late. The aim of this report is to alert clinicians and radiologists to the possibility of unusual features of pulmonary metastases due to colon adenocarcinoma.
Written informed consent was obtained from her relatives for publication of this case report and any accompanying images.
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