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Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 935-937

Calvarial metastasis from adenocarcinoma of lung: An uncommon initial presentation diagnosed by cytology

Department of Pathology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India

Date of Submission15-Nov-2016
Date of Acceptance23-May-2017
Date of Web Publication21-Jun-2017

Correspondence Address:
Subrata Pal
Kalpataru Apartment, Sahid Colony, BT Road, PS Khardaha, North 24 Pargana, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_1285_16

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 > Abstract 

Bone metastasis from lung primary is not uncommon and about one-third of bone metastases originate from lung. However, skull bone metastasis is uncommon from lung carcinoma. Metastasis to skull bone and scalp as an initial presentation of lung carcinoma is a very rare phenomenon. We have diagnosed a case of calvarial metastasis with scalp swelling as an initial presentation of adenocarcinoma of lung by fine-needle aspiration cytology in an aged female. Radiologically, it was suggested as tuberculous lesion but cytology gave the correct diagnosis. Here, we present a rare case of calvarial metastasis as a presentation of adenocarcinoma of lung in an elderly female.

Keywords: Adenocarcinoma of lung, calvarial metastasis, cytology, initial presentation

How to cite this article:
Pal S, Biswas B, Biswas RR, Pradhan R, Sharma A. Calvarial metastasis from adenocarcinoma of lung: An uncommon initial presentation diagnosed by cytology. J Can Res Ther 2020;16:935-7

How to cite this URL:
Pal S, Biswas B, Biswas RR, Pradhan R, Sharma A. Calvarial metastasis from adenocarcinoma of lung: An uncommon initial presentation diagnosed by cytology. J Can Res Ther [serial online] 2020 [cited 2022 Jan 18];16:935-7. Available from: https://www.cancerjournal.net/text.asp?2020/16/4/935/208751

 > Introduction Top

Lung carcinomas are most common and lethal malignancy in the world.[1] Brain is an important and frequent site of metastasis from lung primary. Approximately 50% of brain metastasis originate from lung primary.[2] Bone metastasis is also common from carcinomas of breast, prostate, and lung.[3] Lung carcinoma was found to be associated with 36% of brain metastasis in a postmortem study.[3],[4] Skull bone metastasis consists only 3% of skeletal metastasis from carcinoma of lung.[5] Skull metastasis with involvement of scalp and brain parenchyma as a presenting feature of adenocarcinoma of lung is an extremely rare incident. Here, we present a rare of calvarial metastasis with scalp mass and brain involvement in a case of adenocarcinoma of lung in an elderly female, which was diagnosed by fine-needle aspiration cytology (FNAC) of scalp mass and subsequently confirmed by core biopsy of the primary lesion.

 > Case Report Top

A 65-year-old female presented with painless cystic swelling at midline region of scalp over parietal bone for the past 2 months [Figure 1]. She had no significant medical history. She was nonsmoker and had no history of cough and respiratory distress. She had no history of convulsion and altered sensorium. Computed tomography (CT) scan of brain revealed a large cystic scalp mass with lytic calvarial lesion of 5 cm × 4 cm diameter without intracranial extension. Another well-demarcated, ring-enhancing lesion of 22 mm × 17 mm diameter was found at frontal lobe without any diffusion restriction or perilesional edema. Magnetic resonance imaging (MRI) brain revealed a heterogeneous peripherally enhancing soft tissue mass at parietal region with internal necrotic areas [Figure 2]. Underlying bony table of parietal bone showed altered signal intensity. The lesion has no intracranial communication. In frontal lobe, it was a large, ring-enhancing, cystic space-occupying lesion (SOL) with disc enhancement. Radiological provisional diagnosis was calvarial tuberculosis and FNAC was suggested. FNAC was done from the scalp swelling and aspiration yielded blood-mixed granular material. The smears were stained with Leishman and PAP stain. The smears were hypercellular and were comprised mainly necroinflammatory elements and clusters of atypical epithelial cells. The atypical epithelial cells showed moderate amount of basophilic cytoplasm, increased N:C ratio, large hyperchromatic nucleoli and prominent nucleoli. There were many mitotic figures and tumor giant cells also [Figure 3]. The cytology was reported as metastatic epithelial malignancy possibly from adenocarcinoma. Subsequently, she was evaluated by ultrasound abdomen and CT scan of thorax. CT scan of thorax showed a solitary mass at the right lung. Ultrasonography abdomen revealed multiple heterogeneous SOL at liver. She was further investigated by CT-guided FNAC of the lung mass and liver SOL and diagnosed as adenocarcinoma of lung with liver metastasis. She was referred to radiotherapy department and palliative cisplatin-based chemotherapy was started. After two cycles, she was died due to agranulocytosis, severe intracranial hemorrhage, and coma.
Figure 1: Gross image of the large boggy scalp swelling of the patient

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Figure 2: Magnetic resonance imaging brain image showing heterogeneous peripherally enhancing soft tissue mass at parietal region with internal necrotic areas and increased signal intensity of underlying bone

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Figure 3: Cytology shows clusters of atypical epithelial cells in clusters increased N: C ratio, highly pleomorphic nuclei, anisokaryosis, and prominent nucleoli. [PAP stain, high-power view]

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 > Discussion Top

Bone metastasis from lung carcinoma is common and accounts for 36% of all bone metastasis.[3] However, lung carcinomas account for only 3% cases of skull metastasis.[3],[5] Skull bone metastasis is relatively uncommon and arises from carcinoma of breast, prostate, thyroid, lung, hepatocellular carcinoma, cholangiocarcinoma, and Ewing's sarcoma.[2],[3],[6] Most of the cases cause bone destruction and lytic lesion. However, skull metastasis as an initial presentation of lung carcinoma is very rare and only few cases have been documented in previous literature. Route of skull metastasis is not established but spread through mandibular lymphatics has been suggested by some researchers.[3] Clinical presentation of skull metastasis is a painless/painful palpable mass at scalp. Metastatic scalp swelling is hard to differentiate from other soft tissue swellings at scalp such as lipoma, epidermal cyst, and adnexal tumors.[7] Most of the cases present after the diagnosis of the primary tumor, and skull bone metastasis is a phenomenon of late and advanced stage of malignancy. High-index suspicion is the key factor for early diagnosis. CT scan of brain and MRI are important noninvasive modalities for diagnosis. However, in the present case, CT scan and MRI were suggestive of calvarial tuberculosis. Calvarial tuberculosis produces lytic bone lesion and CT scan imaging is not specific because similar lytic lesion is also produced by calvarial metastasis, multiple myeloma, Ewing's sarcoma, lymphangioma, aneurysmal bone cyst, giant cell tumor, and Langerhans cell histiocytosis.[8],[9] Cytological (FNAC) or histopathological diagnosis are the key factors for correct diagnosis of the lesion. Smears exhibit atypical epithelial cells in clusters and some in acinar pattern. Individual cells exhibit highly dysplastic cells with increased N:C ratio, highly pleomorphic nuclei, anisokaryosis, and prominent nucleoli. In our case, the smears were typical of metastatic nonsmall cell carcinoma, favoring adenocarcinoma.

Pathogenesis of lytic skull bone metastasis from adenocarcinoma is still not clear. Roato et al. concluded the role of IL-7 from the bone invading cells of nonsmall cell lung carcinoma in producing osteolytic lesion.[2],[10] However, prognosis of calvarial metastasis is poor.[2],[10] Cisplatin-based chemotherapy is the line of management for palliative therapy as it was already spread extensively to brain, calvarium, and liver. The present case was survived for 3 months and died due to agranulocytosis and intracranial hemorrhage.

High-index suspicion and multimodality approach are the key factors for diagnosis of such rare case of calvarial metastasis. We focus the rarity, importance of cytology in diagnosis of the metastatic lesion at scalp and calvarium.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

Jabbabai G, Mokhtari F, Ahmad R, Godazande G. Bronchogenic adenosquamous cell carcinoma with metastasis to skull: A case report. Int J Hematol Oncol Stem Cell Res 2010;4:29-31.  Back to cited text no. 1
Kader I, Strong M, George M. Skull destruction from intracranial metastasis arising from pulmonary squamous cell carcinoma: A case report. J Med Case Rep 2013;7:28.  Back to cited text no. 2
Turner RC, Lucke-Wold BP, Hwang R, Underwood BD. Lung cancer metastasis presenting as a solitary skull mass. J Surg Case Rep 2016;2016. pii: Rjw116.  Back to cited text no. 3
Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 2006;12(20 Pt 2):6243s-9s.  Back to cited text no. 4
Sugiura H, Yamada K, Sugiura T, Hida T, Mitsudomi T. Predictors of survival in patients with bone metastasis of lung cancer. Clin Orthop Relat Res 2008;466:729-36.  Back to cited text no. 5
Guo X, Yin J, Jiang Y. Solitary skull metastasis as the first symptom of hepatocellular carcinoma: Case report and literature review. Neuropsychiatr Dis Treat 2014;10:681-6.  Back to cited text no. 6
Farley R, Manolidis S, Ratner D. Adenocarcinoma of the lung metastatic to the skull presenting as a scalp cyst. J Am Acad Dermatol 2006;54:916-7.  Back to cited text no. 7
Diyora B, Kumar R, Modgi R, Sharma A. Calvarial tuberculosis: A report of eleven patients. Neurol India 2009;57:607-12.  Back to cited text no. 8
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Rosli FJ, Haron R. Tuberculosis of the skull mimicking a bony tumor. Asian J Neurosurg 2016;11:68.  Back to cited text no. 9
[PUBMED]  [Full text]  
Roato I, Caldo D, Godio L, D'Amico L, Giannoni P, Morello E, et al. Bone invading NSCLC cells produce IL-7: Mice model and human histologic data. BMC Cancer 2010;10:12.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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