|Year : 2014 | Volume
| Issue : 6 | Page : 539-541
Isolated gluteus maximus muscle metastasis as an initial presentation and primary asymptomatic nonsmall cell lung cancer detected using fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography imaging
Koramadai Karuppusamy Kamaleshwaran1, Sudhakar Natarajan2, Anjali Malaikkal1, Vyshakh Mohanan1, Ajit Sugunan Shinto1
1 Department of Nuclear Medicine, PET/CT and Radionuclide Therapy, Coimbatore, Tamil Nadu, India
2 Department of Oncology, Kovai Medical Centre and Hospital Limited, Coimbatore, Tamil Nadu, India
|Date of Web Publication||11-Oct-2014|
Koramadai Karuppusamy Kamaleshwaran
Department of Nuclear Medicine, PET/CT and Radionuclide Therapy, Comprehensive Cancer Care Centre, Kovai Medical Centre and Hospital Limited, Coimbatore - 641 014, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Isolated skeletal muscle metastasis in nonsmall cell lung cancer (NSCLC) is a rare event particularly when it is detected at initial staging. Our case report describes the whole body imaging with fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography detecting asymptomatic primary NSCLC causing the solitary symptomatic metastasis to the gluteus maximus muscle. Patient underwent systemic chemotherapy.
Keywords: Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography, gluteus muscle metastases, nonsmall cell lung cancer
|How to cite this article:|
Kamaleshwaran KK, Natarajan S, Malaikkal A, Mohanan V, Shinto AS. Isolated gluteus maximus muscle metastasis as an initial presentation and primary asymptomatic nonsmall cell lung cancer detected using fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography imaging. Clin Cancer Investig J 2014;3:539-41
|How to cite this URL:|
Kamaleshwaran KK, Natarajan S, Malaikkal A, Mohanan V, Shinto AS. Isolated gluteus maximus muscle metastasis as an initial presentation and primary asymptomatic nonsmall cell lung cancer detected using fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography imaging. Clin Cancer Investig J [serial online] 2014 [cited 2019 Oct 13];3:539-41. Available from: http://www.ccij-online.org/text.asp?2014/3/6/539/142662
| Introduction|| |
Lung cancer is one of the leading causes of cancer deaths and despite advances in diagnosis and treatment, the overall 5-year survival remains dismal at 14% for all stages.  Distant metastases in lung cancer commonly involve the adrenal glands, liver, bones, and brain.  Since the extent of disease decides the treatment options, radiological imaging plays an important role in staging evaluation. Positron emission tomography (PET) imaging with fluorine-18 (F-18) fluorodeoxyglucose (FDG) is now being increasingly used for characterizing lung nodules, for initial staging, restaging, treatment planning, and assessing response to treatment in lung cancer.  We report an asymptomatic primary nonsmall cell lung cancer (NSCLC) causing the solitary symptomatic metastasis to the gluteus maximus muscle detected with FDG PET-computed tomography (CT).
| Case report|| |
A 55-year-old man with swelling and pain in the right gluteal region. On clinical examination, he has palpable swelling in the right gluteal region. Ultrasonography (USG) was performed to evaluate the gluteal lesion followed by guided fine-needle aspiration cytology (FNAC) which showed carcinoma. A contrast-enhanced whole body F-18 FDG PET-CT scan was performed for detecting unknown primary [Figure 1]a revealed hypermetabolic 3.1 cm × 2.6 cm × 3.8 cm sized lobulated mass in the left upper lobe that did not involve the chest wall or the mediastinal structures with standardized uptake value (SUV) of 16 [Figure 1]b and c. No mediastinal lymph nodes are noted. Focal increased FDG uptake was also seen in the mass lesion in the right gluteus maximus muscle (SUV 12.0) with heterogeneous peripheral enhancement and necrosis extending into subcutaneous plane [Figure 1]d and e. There were no other areas of increased FDG uptake. In view of skeletal muscle metastasis, the patient was upstaged (Stage IV) and the intent of the treatment changed from potentially curative surgery to palliative systemic chemotherapy.
|Figure 1: Whole body fluorodeoxyglucose-positron emission tomography/ computed tomography (PET/CT) maximum intensity projection image. (a) Axial CT (b) axial fused PET/CT (c) an intense uptake in the primary mass lesion in the left lung upper lobe (d) axial CT and (e) axial fused PET/CT showing lesion in the right gluteus maximus muscle (arrows)|
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| Discussion|| |
Lung cancer is one of the leading causes of cancer death in both men and women worldwide. Most patients present at an advanced stage and hence despite developments in diagnosis and treatment the mortality remains high. Distant metastases of lung cancer commonly involve the adrenal glands, bone, and brain. Contrast-enhanced CT scan of the thorax (including the adrenals) along with a radionuclide bone scan and brain imaging (with CT or magnetic resonance imaging) was considered as optimal staging work up prior to the advent of PET scanning. Metastases to skeletal muscle from primary lung cancer is a rare event with very few reports described in the literature. ,, Various physiological factors like tissue blood flow, pressure, and metabolism have been cited as the possible reasons why metastases to skeletal muscle are rare. According to some studies, the presence of proteases and certain inhibitors in muscle tissue are responsible for blocking tumor invasion and growth. ,
It has been shown that FDG PET-CT is an excellent imaging modality for metastatic evaluation with the exclusion of the brain. It can detect occult metastases in about 10-20% of cases of NSCLC. ,, In a study of 167 patients of NSCLC (Stages IIII), FDG PET-CT detected unsuspected distant metastases in a high proportion of patients who were otherwise candidates for potentially curative treatment.  However, of the 32 cases of distant metastases in the study, there were no cases of skeletal muscle metastasis, emphasizing the rarity of the event. Most of the cases of skeletal muscle metastases described in the literature presented with clinical symptoms of pain and swelling at the affected site. Our patient also had symptoms related to the site of skeletal muscle metastasis. Although focal FDG uptake in the deeper subcutaneous tissue of the gluteal region is not uncommonly observed, as a result, of injection site inflammation, the intense nature of the uptake and its deep location in the muscle were suspicious enough to warrant further evaluation. A USG-guided FNAC confirmed the metastatic nature of the gluteal lesion. Detection of solitary extrapulmonary FDG uptake in patients with recently diagnosed lung cancer, should be critically analyzed as nearly half of these lesions may represent a malignant etiology.  The increasing use of PET-CT as a whole body staging tool for various cancers has recently led to several reports describing unsuspected distant metastases at unusual locations. Unusual metastases of lung cancer to muscles that were detected by PET-CT have been reported. ,
There is no consensus on the optimal treatment strategy for skeletal muscle metastases and although the options could include radiotherapy, chemotherapy, or excision, the outcome remains poor. Although radical treatment of the primary and the solitary metastatic lesion could have been considered as a treatment option, our patient was offered palliative chemotherapy in view of the systemic nature of the disease.
| Conclusion|| |
Skeletal muscle metastasis from any site of malignant neoplasia is a rare occurrence, and the initial presentation with distant soft tissue metastasis is even more uncommon. Our case represents a rare manifestation of NSCLC metastatic to gluteus muscle in the absence of any osseous involvement. Thus, FDG PET-CT due to its whole body screening ability, can unmask primary site and unusual metastatic sites at initial presentation and can help in reducing inappropriate surgeries in these patients.
| References|| |
Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997;111:1710-7.
Pantel K, Izbicki J, Passlick B, Angstwurm M, Häussinger K, Thetter O, et al.
Frequency and prognostic significance of isolated tumour cells in bone marrow of patients with non-small-cell lung cancer without overt metastases. Lancet 1996;347:649-53.
Mavi A, Lakhani P, Zhuang H, Gupta NC, Alavi A. Fluorodeoxyglucose-PET in characterizing solitary pulmonary nodules, assessing pleural diseases, and the initial staging, restaging, therapy planning, and monitoring response of lung cancer. Radiol Clin North Am 2005;43:1-21, ix.
Sridhar KS, Rao RK, Kunhardt B. Skeletal muscle metastases from lung cancer. Cancer 1987;59:1530-4.
McKeown PP, Conant P, Auerbach LE. Squamous cell carcinoma of the lung: An unusual metastasis to pectoralis muscle. Ann Thorac Surg 1996;61:1525-6.
Di Giorgio A, Sammartino P, Cardini CL, Al Mansour M, Accarpio F, Sibio S, et al.
Lung cancer and skeletal muscle metastases. Ann Thorac Surg 2004;78:709-11.
Eisenstein R, Kuettner KE, Neapolitan C, Soble LW, Sorgente N. The resistance of certain tissues to invasion. III. Cartilage extracts inhibit the growth of fibroblasts and endothelial cells in culture. Am J Pathol 1975;81:337-48.
Sorgente N, Kuettner KE, Soble LW, Eisenstein R. The resistance of certain tissues to invasion. II. Evidence for extractable factors in cartilage which inhibit invasion by vascularized mesenchyme. Lab Invest 1975;32:217-22.
Earnest F 4 th
, Ryu JH, Miller GM, Luetmer PH, Forstrom LA, Burnett OL, et al.
Suspected non-small cell lung cancer: Incidence of occult brain and skeletal metastases and effectiveness of imaging for detection - Pilot study. Radiology 1999;211:137-45.
Weder W, Schmid RA, Bruchhaus H, Hillinger S, von Schulthess GK, Steinert HC. Detection of extrathoracic metastases by positron emission tomography in lung cancer. Ann Thorac Surg 1998;66:886-92.
Pieterman RM, van Putten JW, Meuzelaar JJ, Mooyaart EL, Vaalburg W, Koëter GH, et al.
Preoperative staging of non-small-cell lung cancer with positron-emission tomography. N Engl J Med 2000;343:254-61.
MacManus MP, Hicks RJ, Matthews JP, Hogg A, McKenzie AF, Wirth A, et al.
High rate of detection of unsuspected distant metastases by pet in apparent stage III non-small-cell lung cancer: Implications for radical radiation therapy. Int J Radiat Oncol Biol Phys 2001;50:287-93.
Lardinois D, Weder W, Roudas M, von Schulthess GK, Tutic M, Moch H, et al.
Etiology of solitary extrapulmonary positron emission tomography and computed tomography findings in patients with lung cancer. J Clin Oncol 2005;23:6846-53.
Yilmaz M, Elboga U, Celen Z, Isik F, Tutar E. Multiple muscle metastases from lung cancer detected by FDG PET/CT. Clin Nucl Med 2011;36:245-7.
Purandare NC, Rangarajan V, Pramesh CS, Rajnish A, Shah S, Dua SG. Isolated asymptomatic skeletal muscle metastasis in a potentially resectable non-small cell lung cancer: Detection with FDG PET-CT scanning. Cancer Imaging 2008;8:216-9.