Scientific Letter
Skeletal Muscle Metastasis: An Uncommon Finding in Lung Cancer
Metástasis musculoesqueléticas: hallazgo infrecuente asociado al cáncer de pulmón
Blanca de Vega Sáncheza,
, Ignacio Lobato Astiárragaa, Rafael Lopez Castrob, Maria Rosa López Pedreirac, Carlos Disdier Vicentea,d
Corresponding author
a Servicio de Neumología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
b Servicio de Oncología Médica, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
c Servicio de Radiodiagnóstico, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
d Centro de Investigación en Red Enfermedades Respiratorias (CIBERES), Spain
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(B) Axial T2 magnetic resonance image: musculoskeletal metastasis on flexor digitorum superficialis muscle of the hand; (B1) pre-treatment; (B2) post-treatment. (C) Chest PET-CT: musculoskeletal metastasis on the left iliopsoas muscle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Lung cancer (LC) is the fifth leading cause of death worldwide.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Unfortunately, at the time of diagnosis almost half of patients have distant metastases (most frequently in the brain, bone, liver, and adrenal glands),<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> and it is estimated that 60% of patients with early stage disease may present micrometastases.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The metastatic spread of CP in the skeletal muscle is an uncommon finding (<1%), associated with poor prognosis and an average life expectancy of 6 months. Three theories have emerged to explain the low affinity of tumor cells for muscle tissue: the immunological theory (the role of humoral and cellular immunity); the metabolic theory (possible involvement of oxygen fluctuations, variable pH, and lactic acid production); and the mechanical theory (possible protective effect of muscle contractions due to high pressure and variable blood flow).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The clinical presentation of musculoskeletal metastases (MSM) varies widely, from lesions that can be asymptomatic or painful and/or palpable, or can cause functional limitation in the affected area, to incidental findings in complementary imaging test.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2–4</span></a> The initial diagnostic approach in patients with suspected MSM usually begins with a computed tomography (CT) scan of the chest. Surov et al. proposed 5 radiologic patterns<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> for the characterization of MSM: type <span class="elsevierStyleSmallCaps">I:</span> intramuscular mass; type <span class="elsevierStyleSmallCaps">II:</span> abscess-like lesion; type <span class="elsevierStyleSmallCaps">III:</span> diffuse muscle tissue infiltration; type <span class="elsevierStyleSmallCaps">IV:</span> lesion with multiple calcifications, and type <span class="elsevierStyleSmallCaps">V:</span> intramuscular bleeding pattern.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> The use of additional techniques, such as magnetic resonance imaging (very useful for differentiating between MSM and primary malignant muscle lesions), and positron emission tomography with <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose (greater proven sensitivity for detecting MSM and skin lesions) should also be considered.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> However, a definitive diagnosis requires histological analysis of the lesion.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Below, we discuss 3 clinical cases of MSM in patients with LC and the different imaging diagnostic tests that were performed. The first patient was a 57-year-old woman who reported constitutional symptoms, dyspnea, and a non-painful deep adherent mass in the right flank. Chest CT revealed a right hilar lesion with multilevel mediastinal involvement, and a tumor on the left abdominal oblique muscle, classified according to its CT radiological pattern<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> as type I (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The second case was an 83-year-old man with a painful tumor (necrotic cystic mass measuring 35<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>26<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>46<span class="elsevierStyleHsp" style=""></span>mm on the flexor digitorum superficialis muscle of the hand) and a 4-month history of lack of function in the right forearm. The extension study revealed 2 pulmonary masses, consistent with pulmonary adenocarcinoma (tumor classification cT4NxM1b<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a>). The patient received local palliative radiation therapy and chemotherapy with platinum/pemetrexed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B1 and B2). The third case was a 73-year-old man receiving active treatment guided by sensitivity testing results for documented <span class="elsevierStyleItalic">Mycobacterium xenopi</span> infection. Positron emission tomography showed a lesion measuring 40<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>25<span class="elsevierStyleHsp" style=""></span>mm with central cavitation in the left upper lobe (SUVmax 28.38) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) and a hypermetabolic focus located in the left iliopsoas muscle with SUVmax 13.43, suggestive of MSM.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In all 3 cases, histological specimens were obtained for characterization, and the results were consistent with high grade undifferentiated tumor, striated muscle infiltrated with adenocarcinoma, and squamous carcinoma, respectively, all originating in the lung. The clinical progress of the patients differed: death 2 weeks after diagnosis, pain control, and reduced tumor size (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B2) after targeted oncological treatment; clinical stabilization was achieved in the last 2 cases described.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given the low prevalence of MSM, a detailed differential diagnosis that includes the more common malignant and benign entities (sarcomas, primary muscle lymphomas, and myxomas/hemangiomas) must be made. Although no clinical guidelines are available for the specific management of MSM, treatment is based on general oncological principles guided by clinical picture, site, and life expectancy, and approaches include observation, surgical excision (persistent solitary lesions after a period of remission), chemotherapy and radiation therapy (useful for pain control and for the reduction of tumor size).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The correct identification of MSM in LC patients is essential for clinical management and prognosis. For this reason, the possible neoplastic etiology of any muscle lesion, whether symptomatic or not, detected in LC patients must be evaluated with combined radiological procedures and histological confirmation of the lesion.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de Vega Sánchez B, Lobato Astiárraga I, Lopez Castro R, López Pedreira MR, Vicente CD. Metástasis musculoesqueléticas: hallazgo infrecuente asociado al cáncer de pulmón. Arch Bronconeumol. 2018;54:390–391.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1307 "Ancho" => 3000 "Tamanyo" => 397083 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Axial and coronal computed tomography: musculoskeletal metastasis on the left abdominal oblique muscle. (B) Axial T2 magnetic resonance image: musculoskeletal metastasis on flexor digitorum superficialis muscle of the hand; (B1) pre-treatment; (B2) post-treatment. (C) Chest PET-CT: musculoskeletal metastasis on the left iliopsoas muscle.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Sociedad Española de Oncología Médica. Las cifras del cáncer en España 2017. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 1 | 5 |
| 2024 October | 43 | 21 | 64 |
| 2024 September | 46 | 15 | 61 |
| 2024 August | 63 | 35 | 98 |
| 2024 July | 55 | 21 | 76 |
| 2024 June | 73 | 36 | 109 |
| 2024 May | 79 | 26 | 105 |
| 2024 April | 43 | 29 | 72 |
| 2024 March | 44 | 25 | 69 |
| 2024 February | 28 | 20 | 48 |
| 2023 March | 12 | 4 | 16 |
| 2023 February | 52 | 22 | 74 |
| 2023 January | 33 | 33 | 66 |
| 2022 December | 62 | 40 | 102 |
| 2022 November | 55 | 28 | 83 |
| 2022 October | 60 | 61 | 121 |
| 2022 September | 33 | 45 | 78 |
| 2022 August | 44 | 53 | 97 |
| 2022 July | 37 | 47 | 84 |
| 2022 June | 40 | 36 | 76 |
| 2022 May | 60 | 51 | 111 |
| 2022 April | 41 | 52 | 93 |
| 2022 March | 43 | 41 | 84 |
| 2022 February | 43 | 35 | 78 |
| 2022 January | 58 | 36 | 94 |
| 2021 December | 46 | 43 | 89 |
| 2021 November | 50 | 39 | 89 |
| 2021 October | 49 | 54 | 103 |
| 2021 September | 34 | 51 | 85 |
| 2021 August | 22 | 34 | 56 |
| 2021 July | 49 | 19 | 68 |
| 2021 June | 48 | 32 | 80 |
| 2021 May | 67 | 68 | 135 |
| 2021 April | 80 | 85 | 165 |
| 2021 March | 38 | 16 | 54 |
| 2021 February | 66 | 18 | 84 |
| 2021 January | 24 | 20 | 44 |
| 2020 December | 30 | 24 | 54 |
| 2020 November | 32 | 28 | 60 |
| 2020 October | 22 | 18 | 40 |
| 2020 September | 21 | 9 | 30 |
| 2020 August | 28 | 16 | 44 |
| 2020 July | 28 | 20 | 48 |
| 2020 March | 14 | 27 | 41 |
| 2020 February | 45 | 46 | 91 |
| 2020 January | 73 | 23 | 96 |
| 2019 December | 50 | 15 | 65 |
| 2019 November | 31 | 24 | 55 |
| 2019 October | 23 | 10 | 33 |
| 2019 September | 29 | 13 | 42 |
| 2019 August | 25 | 16 | 41 |
| 2019 July | 24 | 32 | 56 |
| 2019 June | 27 | 12 | 39 |
| 2019 May | 28 | 24 | 52 |
| 2019 April | 27 | 31 | 58 |
| 2019 March | 31 | 21 | 52 |
| 2019 February | 24 | 16 | 40 |
| 2019 January | 21 | 13 | 34 |
| 2018 December | 4 | 1 | 5 |
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