|Year : 2020 | Volume
| Issue : 2 | Page : 141-145
Non-small Cell Lung Cancer Presenting as Parotid and Scalp Swellings: A Rare Clinical Presentation
Sankalp Singh1, Niharika Bisht2, Arti Sarin3, Prabha Shankar Mishra4, Amul Kapoor5
1 Department of Radiation Oncology, Command Hospital (CC), Lucknow, Uttar Pradesh, India
2 Department of Radiation Oncology, Command Hospital (SC), Pune, India
3 Department of Radiation Oncology, INHS Asvini, Mumbai, Maharashtra, India
4 Department of Pathology, Command Hospital (SC), Pune, Maharashtra, India
5 Medical Oncology, Command Hospital (SC), Pune, Maharashtra, India
|Date of Submission||02-Mar-2020|
|Date of Decision||29-Apr-2020|
|Date of Acceptance||03-Jun-2020|
|Date of Web Publication||8-Dec-2020|
Command Hospital (SC), Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Metastases to the parotid gland as first presentation of lung cancer are extremely rare and occur in <1% cases most of which are small cell carcinomas. We present such a case of squamous cell carcinoma of the lung who presented with swellings of the parotid gland and over the scalp. He was diagnosed on the basis of fine needle aspiration cytology followed by investigative imaging to search for the primary. He was treated with palliative radiotherapy and chemotherapy but succumbed to his disease at 9 months from the diagnosis. Parotid and skin metastases in lung cancer can occur by both lymphatic and hematogenous spread. Metastases to such visible and accessible parts of the body can help in the early detection of disease, though in most cases, it occurs as a sign of progression in preexisting cancer. Management options are limited in such patients, and overall, the prognosis is poor.
Keywords: Lung cancer, metastases, parotid, scalp, squamous cell carcinoma
|How to cite this article:|
Singh S, Bisht N, Sarin A, Mishra PS, Kapoor A. Non-small Cell Lung Cancer Presenting as Parotid and Scalp Swellings: A Rare Clinical Presentation. J Head Neck Physicians Surg 2020;8:141-5
|How to cite this URL:|
Singh S, Bisht N, Sarin A, Mishra PS, Kapoor A. Non-small Cell Lung Cancer Presenting as Parotid and Scalp Swellings: A Rare Clinical Presentation. J Head Neck Physicians Surg [serial online] 2020 [cited 2021 Apr 18];8:141-5. Available from: https://www.jhnps.org/text.asp?2020/8/2/141/302701
| Introduction|| |
Metastases to the parotid gland as a first sign of lung cancer is exceedingly rare and reported in <1% cases. We present an unusual case of a patient who presented with swellings in the parotid and scalp region which were detected to be metastases from an adenocarcinoma a squamous carcinoma of the lung. The relevance of this case report lies in the possible differential diagnosis of metastatic disease in parotid and cutaneous swellings.
| Case Report|| |
A 60-year-old male, with a history of smoking one packet of beedis (Indian cigars) every day for the past 30 years, presented to our hospital with complaints of gradually enlarging swelling over the right side of his face for the past 3 months and another smaller swelling over the right side of his head for the past 2 months. The swelling over his head had also started oozing blood over the past 2 weeks. In addition, he complained of loss of appetite and an unquantified reduction in bodyweight over the previous 3 to 4 weeks.
On clinical examination, the patient had a performance score of 1 as per the ECOG scale. He was afebrile with his vital signs within the normal limits. There was no pallor, cyanosis, or clubbing. He had a firm, lobulated, nontender mass, 3 cm × 3 cm in size over the right parotid region just anterior to the right earlobe. The mass was fixed to the underlying structures while the overlying skin was free and mobile. Another swelling, 2 cm × 2 cm in size, hard and fixed to underlying structures, was present over the right parietal region of his scalp. The skin over this swelling was ulcerated and was oozing blood. The swelling was mildly tender. There were no other swellings or lumps in any other part of the body. A thorough examination of the ear, nose, and throat did not reveal any suspicious lesion. Auscultation of his chest revealed widespread bilateral expiratory wheeze with reduced air entry in the left middle and left lower lung lobes.
Fine-needle aspiration cytology of both the swellings revealed poorly differentiated squamous cell carcinoma. Ultrasonography of the neck showed multiple, irregular, lobulated hypoechoic focal lesions in the right parotid gland. With the suspicion of these two swellings being secondaries from an undetected primary, an investigative imaging was carried out to look for the primary in the form of a contrast-enhanced computed tomography (CECT) scan of the face, neck, chest, and abdomen. This CECT scan showed a 5.6 cm × 5.4 cm mass lesion in the posterior segment of the right upper lobe of the lung [Figure 1]a with irregular margins and heterogeneous contrast enhancement and associated mediastinal and left hilar lymphadenopathy. A 3.1 cm × 2.6 cm enhancing soft-tissue lesion was also seen in the right parotid gland [Figure 1]b and another enhancing soft-tissue lesion 1.8 cm × 1.5 cm in size was seen over the right parietal region of the scalp [Figure 1]c without any erosion of the underlying bone. The patient underwent a fiberoptic bronchoscopy which showed a proliferative growth in the left main bronchus. Biopsy of this growth [Figure 2] revealed a poorly differentiated squamous cell carcinoma. Immunohistochemistry (IHC) marker results were diffusely positive for CK 5/6 and p63 but negative for thyroid transcription factor-1, chromogranin and synaptophysin confirming the squamous origin of the malignant growth. A CECT of the abdomen and a bone scan showed no other metastases other than those to the scalp and the right parotid gland.
|Figure 1: Contrast-enhanced computed tomography scan images showing the metastatic mass lesions in the right parotid gland (a) and the right parietal region of the scalp (b). As well the large mass seen in the upper lobe of the right lung (c)|
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|Figure 2: (a) ×20 photomicrograph of a Giemsa-stained smear showing clusters of poorly differentiated carcinoma cells in a hemorrhagic background. (b) ×20 photomicrograph of a hematoxylin and eosin stained slide showing poorly differentiated malignant squamous cells seen in nests and clusters. Immunohistochemistry with (c) CK 5/6 and (d) p63 showing diffuse positivity in tumor cells confirming a squamous differentiation of malignant cells|
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The case was discussed in a multimodality tumor board attended by surgical, radiation and medical oncologists, radiologists, and oncopathologists. Three possible differential diagnoses were considered: Either a lung primary with metastases to scalp and parotid, or synchronous dual primary lesions in the lung and scalp with metastases to parotid from scalp, or synchronous triple primary lesions in the lung, scalp, and parotid. As triple synchronous primaries and primary squamous carcinoma of the parotid are both extremely rare, the third differential was ruled out. Both the other two scenarios are feasible and have been described in the literature. As per the pathologists, the cells from all three tumor sites had similar morphology. The parotid lesion appeared to be parenchymal and not lymph nodal on axial imaging. Hence, the tumor board consensus was to diagnose the patient as a case of metastatic nonsmall cell carcinoma of the lung with secondaries in the parotid and scalp
In view of metastatic disease, he was treated with palliative intent radiotherapy simultaneously to the lung mass, the parotid and the scalp lesions to a dose of 30 Gy in 10 fractions. The patient achieved good palliation and symptom control with control in pain and bleeding from the scalp lesion and regression in size of all three lesions. The patient was then taken up for palliative combination chemotherapy with gemcitabine with cisplatin. Post 04 cycles, the patient had progressive disease with the appearance of 02 more metastatic lymph nodes in the right supraclavicular and cervical region, respectively. He also complained of reappearance of chest pain. His general condition had deteriorated with his ECOG scale score falling to 2. He was placed on second-line chemotherapy with docetaxel and cisplatin. However, his condition worsened, and after 02 cycles he was found unfit for further chemotherapy and was placed on supportive care at home. His total survival from the time of diagnosis till death was 9 months.
| Discussion|| |
Parotid swellings and for that matter scalp swellings are fairly common finding in any general surgical outpatient department, and most of these swellings have benign etiologies. However, the possibility of a primary or secondary malignancy should always be kept as a possible differential diagnosis, especially in the presence of clinical features of a malignant swelling or an existing history of malignancy in the patient. Fine-needle aspiration is a convenient and valuable tool that can help in the diagnosis of these tumors.
Secondary cancers of the parotid gland are an unusual and rare phenomenon as evidenced by limited reports in the literature and are often difficult to diagnose. They may be the first presentation of disease or may occur as a distant recurrence and if a careful examination is not performed, primary focus may be overlooked, negatively affecting the life expectancy and the prognosis of the patient. Histopathology and IHC play an important role in differentiating them from primary parotid malignancies.
Nearly, all the secondary malignant deposits in the parotid gland arise from primary cancers in the mucosa or the skin of the head-and-neck region. Incidences of metastatic deposits in the parotid gland from outside the head and neck region, i.e., below the clavicle are rare but have been reported from cancers of the lung, breast, and kidney. Together, these primaries constitute around 10%–20% of all secondary cancers of parotid.
Though metastases to parotid gland from lung cancer has been reported before, the histology involved usually is small cell carcinomas.,, Nonsmall cell lung carcinomas (both squamous and adenocarcinomas) metastasizing to the parotid are much rarer with very few reports in literature.,
The metastases to the parotid gland are almost equally likely to occur in the gland parenchyma or the associated parotid lymph nodes. The spread to lymph nodes is likely through the rich lymphatic drainage present in and around the gland parenchyma. Although regional lymph nodal involvement is also seen in up to 90% lung cancers, there is no channel through which these lymph nodes can drain to the lymphatic system above the clavicle without involvement of the supraclavicular or cervical lymph nodes. In our opinion, these metastases have occurred through the hematogenous route by back flowing of malignant cells through the venous circulation.
Skin is another uncommon site of secondary malignant deposits with <5% cases of lung cancer known to develop these metastases despite lung being the commonest primary tumor in men that gives rise to skin metastases. Other common sources of secondary skin deposits include breast, colorectal, ovarian, and renal tumors.,
Early diagnosis of skin metastases is important because rarely, it may be the first clinical manifestation of a malignancy and may help in its detection, though more commonly it occurs as a sign of disease progression in a preexisting cancer.
The common sites of skin metastases are usually near the primary tumor. Chest is the commonest site of cutaneous metastases affecting around 28% cases while the scalp is involved in about 7%–9% cases., Other common sites include back, abdomen, scalp, and neck, while extremities are usually not affected. Lung cancer is known to be able to reach every part of the skin surface through the blood and the lymphatic system. Though histologically, adenocarcinomas are known to show the greatest tendency to extend to the skin, most reports of lung cancer metastasizing to the scalp are of small cell carcinomas. The presence of distant metastases is an indicator of poor prognosis and especially in the presence of cutaneous metastases the expected survival usually ranges from 3 to 6 months.,
As described under the case report, another possible explanation of the clinical situation of three different sites of squamous carcinoma could have been triple primary cancers or dual primary cancers in the lung and scalp with metastases from the scalp to the parotid. Dual primaries of head-and-neck region and lung are relatively common and seen in 21% cases in an old study, though none of the head and neck lesions were from the skin or the scalp. Though it is impossible to discern with absolute certainty whether the lesions in the scalp and parotid were primary or secondary, in view of the pathological and radiological inputs, the consensus of the multimodality tumor board was to treat the patient as a lung primary with metastases to scalp and parotid.
Our patient presented with both parotid and scalp metastases as the first sign of nonsmall cell lung cancer (squamous carcinoma), and interestingly, he did not have any other sites of metastatic disease at that time. However, though these lesions helped us to detect and diagnose his primary cancer, the lack of effective management strategies in a metastatic squamous cell carcinoma of the lung meant that the early metastases to a visible and accessible part of the body did not help in improvement in the patient’s overall survival.
Systemic therapy remains the cornerstone of treatment in patients with metastatic lung cancer, either in the form of cytotoxic chemotherapy or targeted therapies in more recent times. Radiotherapy is often used in short, hypofractionated courses for palliation of symptoms such as pain, bleeding, and disfigurement due to skin fungation.
Surgical treatment of parotid and skin metastases, in the form of parotidectomy, or metastatectomy of skin deposits has been carried out and reported by several clinicians,,, sometimes even followed by adjuvant radiotherapy to improve local control but its benefit, if any, on the overall survival or even disease free survival remains uncertain. Surgery, if at all considered, should be in carefully selected patients with metachronous, solitary, or isolated metastases with the primary disease under remission, or in the setting of an oligometastatic disease being addressed along with the primary disease with definitive surgery.
In the scenario that the patient was treated as a case of dual primary malignancies with metastases from scalp to parotid, more aggressive treatment could have been offered. This could have included surgery of the parotid and scalp lesions followed by adjuvant radiotherapy. The lung lesion, in view of mediastinal lymph nodes, would have been precluded from surgery and would have been treated with sequential or concurrent radiotherapy and chemotherapy. As the disease progressed even while the patient was on full dose chemotherapy, in the authors view, this would not have contributed toward improving the patient’s survival.
| Conclusion|| |
Parotid gland and scalp are the rare sites for secondary deposits of lung cancer but a high index of suspicion must be kept when dealing with lesions in these sites. Our case was unusual to have metastases at both these rare sites simultaneously.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was financially supported by Command Hospital (SC), Pune.
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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