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Indian Journal of Medical and Paediatric Oncology
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PRACTITIONER SECTION
Year : 2016  |  Volume : 37  |  Issue : 4  |  Page : 300-302  

A rare case of lung cancer presenting as an ischioanal fossa mass


1 Department of Medical Oncology, Father Muller Medical College, Mangalore, Karnataka, India
2 Department of Medicine, RCSM Government Medical College, CPR Hospital, Kolhapur, Maharashtra, India
3 Department of Medicine, CMH Lahore Medical College, Lahore, Pakistan
4 Department of Medicine, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
5 Department of Medicine, Byramjee Jeejeebhoy Medical College, Pune, Maharashtra, India

Date of Web Publication14-Dec-2016

Correspondence Address:
Ranvijay Singh
Department of Medicine, RCSM Government Medical College, CPR Hospital, Near Dasara Chowk, Kolhapur - 416 002, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-5851.195743

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  Abstract 


Lung cancer metastasis commonly involves the adrenal glands, liver, bone, and brain. However, it can have some rarer forms of metastatic presentation making diagnosis difficult, especially in nonsmokers. We describe a rare case of lung cancer with metastasis to the ischioanal fossa. Overall, this case emphasizes that consideration should be given to wide range of diagnosis in atypical cases of anorectal masses. Lung cancer presenting as an ischioanal mass is not reported so far.

Keywords: Ischioanal fossa, lung cancer, metastasis


How to cite this article:
Shetty N, Singh R, Naveed M, Ronghe AM, Barot FS. A rare case of lung cancer presenting as an ischioanal fossa mass. Indian J Med Paediatr Oncol 2016;37:300-2

How to cite this URL:
Shetty N, Singh R, Naveed M, Ronghe AM, Barot FS. A rare case of lung cancer presenting as an ischioanal fossa mass. Indian J Med Paediatr Oncol [serial online] 2016 [cited 2017 Mar 27];37:300-2. Available from: http://www.ijmpo.org/text.asp?2016/37/4/300/195743




  Introduction Top


Lung cancer is one of the most frequent and commonly diagnosed cancers worldwide, with a high mortality rate.[1] The most common sites for distant metastases of lung cancer are adrenal glands, liver, brain, and bone.[2],[3] We present a case of a 75-year-old nonsmoker male who presented with an ischioanal mass. The biopsy showed adenocarcinoma without any colorectal mucosal lesion, which prompted a positron emission tomography (PET) computed tomography (CT) scan evaluation, leading to the diagnosis of Stage 4 lung cancer with metastasis to the ischioanal fossa and adrenal glands.


  Case Report Top


A 75-year-old male, nonsmoker, diabetic, hypertensive, postcoronary bypass was referred to our hospital with complaints of burning sensation in perianal area with a mass-like sensation causing hindrance to sit. There was no history of constipation, bleeding per-rectum, pain or mass per-abdomen or weight loss. On examination, a hard mass was felt on the external side around the perianal region. Per-rectum revealed a growth on the left lateral part around the anal region, no growth felt in the rectal mucosa, and the upper extent of the tumor could not be delineated. There was no other palpable mass or peripheral lymphadenopathy. Other systemic examination was normal. Contrast-enhanced CT of the abdomen and pelvis done outside showed a 3.7 cm × 4.2 cm × 2.8 cm mass in the perianal region, medially extending up to the external sphincter close to the anal verge. The mass was free from the prostate. The patient had undergone a biopsy from the mass outside, which was suggestive of moderately differentiated adenocarcinoma. No immunochemical (IHC) evaluation was done. With a suspicion of a skip lesion from a higher growth, we performed a sigmoido-colonoscopy which showed a hard mass on the left side of perianal region with no clear growth arising from the rectal or anal mucosa. Carcinoembryonic antigen was 205.7 ng/ml. In view of unusual site of adenocarcinoma in the perianal region, a PET/CT scan was done which revealed a 2.6 cm × 2.3 cm mass in the right lower lobe of lung with hilar and axillary lymphadenopathy, bilateral lung nodules with a small adrenal nodule along with a 4.8 cm × 3.5 cm mass in the left ischioanal fossa [Figure 1] and [Figure 2]. We finally concluded that the patient has Stage 4 adenocarcinoma lung with metastases to ischioanal fossa, bilateral lung, and adrenal gland. Epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutation analyses were negative. The patient was started on pemetrexed-carboplatin chemotherapy. After two cycles of pemetrexed-carboplatin, the patient did not have any benefit. Hence, subsequently, his chemotherapy was changed to paclitaxel-carboplatin and after the first cycle itself the mass began to shrink.
Figure 1: Positron emission tomography computed tomography showing fluorodeoxyglucose avid lesion in the ischioanal fossa

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Figure 2: Positron emission tomography computed tomography showing fluorodeoxyglucose avid lung primary

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  Discussion Top


Here, we present a case of lung adenocarcinoma with a rare presentation of an ischioanal mass in a nonsmoker which was diagnosed on PET/CT. Lung cancer metastases commonly involve the adrenal glands, bone, and brain.[4] Some rare sites of metastasis published in the literature are subcutaneous nodules, thyroid gland, intracranial tumor-meningioma, and multiple cavitary lesions in a patient with wild-type EGFR.[4],[5],[6],[7] Primary neoplasms occurring in the ischiorectal fossa are very uncommon. Angiomyxoma is a rare neoplasm which can also present with a well-defined lobulated mass in the ischiorectal fossa as in our case.[8]

Lung cancer is generally believed to be smoker's disease as compared to nonsmoker's which many at times leads to delayed diagnosis in nonsmokers. In our patient, detailed imaging excluded primary origin in the abdominal cavity as well as from epithelial lining of the rectal and anal mucosa. The histopathology report suggested moderately differentiated adenocarcinoma which led to the suspicion of skip lesion, and later on, PET scan was done which showed the origin in the lung with metastasis to adrenal too. It is essential to distinguish pulmonary adenocarcinoma with intestinal differentiation from metastatic colorectal carcinoma because of critical differences in therapeutic strategies and prognosis, which can be done by IHC and EGFR analysis.[9]

EGFR mutations seem to influence the site of metastasis with a positive EGFR status favoring pleural metastasis in pulmonary adenocarcinoma.[10],[11] Since EGFR and AKL mutation were found to be negative in our case, the treatment was started on pemetrexed (folate antagonist)-carboplatin chemotherapy and later on shifted to paclitaxel-carboplatin therapy which showed more effectiveness in suppressing the mass.

Overall, this case emphasizes that consideration should be given to wide range of diagnosis in atypical cases of anorectal masses. There are no similar reported cases of primary lung adenocarcinoma presenting as ischioanal fossa mass and this case represents a challenge in both diagnosis and long-term management.


  Conclusion Top


There are no case reports of lung cancer presenting as an ischioanal fossa mass as the initial presentation. This case report emphasizes the varied forms of lung cancer presentation which is a diagnostic challenge, especially in nonsmokers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
GLOBOCAN Cancer Fact Sheets:Lung Cancers. Globocan.iarc.fr. N.p.2016. Available from: http://www.globocan.iarc.fr/Pages/fact_sheets_cancer.aspx?cancer=lung. [Last accessed on 2016 Jan 28].  Back to cited text no. 1
    
2.
Riihimäki M, Hemminki A, Fallah M, Thomsen H, Sundquist K, Sundquist J, et al. Metastatic sites and survival in lung cancer. Lung Cancer 2014;86:78-84.  Back to cited text no. 2
    
3.
Young WF Jr. Management approaches to adrenal incidentalomas. A view from Rochester, Minnesota. Endocrinol Metab Clin North Am 2000;29:159-85, x.  Back to cited text no. 3
    
4.
Zhao Q, Wang ZT, Sun JL, Han D, An DZ, Zhang DK, et al. Intratumoral heterogeneity of subcutaneous nodules in a never-smoker woman of lung squamous cell carcinoma detected on 18F-fluorodeoxyglucose positron emission tomography and computed tomography: A case report. Medicine (Baltimore) 2015;94:e851.  Back to cited text no. 4
    
5.
Murakami T, Taki M, Nambu T, Wakasa T, Kato T, Matsuda Y, et al. Diffuse thyroid enlargement following metastasis of lung adenocarcinoma. Intern Med 2015;54:807-12.  Back to cited text no. 5
    
6.
Glass R, Hukku SR, Gershenhorn B, Alzate J, Tan B. Metastasis of lung adenosquamous carcinoma to meningioma: Case report with literature review. Int J Clin Exp Pathol 2013;6:2625-30.  Back to cited text no. 6
    
7.
Murakami S, Manabe S, Yamada K. A case of lung adenocarcinoma with multiple cavitary metastases. Jpn J Clin Oncol 2015;45:504-5.  Back to cited text no. 7
    
8.
Clancy C, Iqbal Z, Sheehan M, Joyce MR. An unusual ischiorectal fossa mass. Int J Surg Case Rep 2014;5:79-81.  Back to cited text no. 8
    
9.
Na II, Park JH, Choe du H, Lee JK, Koh JS. Association of epidermal growth factor receptor mutations with metastatic presentations in non-small cell lung cancer. ISRN Oncol 2011;2011:756265.  Back to cited text no. 9
    
10.
Wu SG, Gow CH, Yu CJ, Chang YL, Yang CH, Hsu YC, et al. Frequent epidermal growth factor receptor gene mutations in malignant pleural effusion of lung adenocarcinoma. Eur Respir J 2008;32:924-30.  Back to cited text no. 10
    
11.
Hoffman PC, Mauer AM, Vokes EE. Lung cancer. Lancet 2000;355:479-85.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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