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Non-Small Cell Lung Cancer Stage IV Long-Term Survival With Isolated Spleen Metastasis

2013; Elsevier BV; Volume: 95; Issue: 4 Linguagem: Inglês

10.1016/j.athoracsur.2012.08.086

1552-6259

Rodrigo A. S. Sardenberg, Clóvis A. Lopes Pinto, Cynthia Aparecida Bueno de Toledo Osório, Riad Naim Younes,

Amyloidosis: Diagnosis, Treatment, Outcomes

Splenic metastasis is rare and generally associated with disseminated disease, often seen in breast cancer, colorectal and ovarian carcinoma, and melanoma. Isolated metastasis to the spleen is rare, with only 93 cases from all sources having been reported up to 2007. Moreover, isolated splenic metastasis from primary lung cancer is extremely rare, with only 11 cases reported to date. We report a case of isolated splenic metastasis in a woman 8 months after lobectomy for an adenocarcinoma in the right lung completely resected. After 8 years of follow-up, the patient is still alive with no evidence of metastatic recurrence. Splenic metastasis is rare and generally associated with disseminated disease, often seen in breast cancer, colorectal and ovarian carcinoma, and melanoma. Isolated metastasis to the spleen is rare, with only 93 cases from all sources having been reported up to 2007. Moreover, isolated splenic metastasis from primary lung cancer is extremely rare, with only 11 cases reported to date. We report a case of isolated splenic metastasis in a woman 8 months after lobectomy for an adenocarcinoma in the right lung completely resected. After 8 years of follow-up, the patient is still alive with no evidence of metastatic recurrence. It is well known that the spleen is a much more protected organ against metastases by anatomical, physiologic, and lymphoid characteristics when compared with other organs [1Marymont J.H. Gross S. Patterns of metastatic cancer in the spleen.Am J Clin Pathol. 1963; 40: 58-66PubMed Google Scholar]. Splenic metastasis is rare and is generally associated with disseminated disease, often seen in breast cancer, colorectal and ovarian carcinoma, lung cancer, and melanoma [1Marymont J.H. Gross S. Patterns of metastatic cancer in the spleen.Am J Clin Pathol. 1963; 40: 58-66PubMed Google Scholar]. The prevalence ranges between 2.3% and 7.1%, is usually diagnosed at the time of autopsy, and is associated with other intraabdominal metastases [2Schon C.A. Gorgb C. Ramaswamya A. et al.Splenic metastases in a large unselected autopsy series.Pathol Res Pract. 2006; 202: 351-356Crossref PubMed Scopus (52) Google Scholar]. Skin melanoma has the highest rate of splenic metastases per primary tumor, with more than 30% of patients with skin melanoma having splenic metastases at autopsy [1Marymont J.H. Gross S. Patterns of metastatic cancer in the spleen.Am J Clin Pathol. 1963; 40: 58-66PubMed Google Scholar, 3Lam K.Y. Tang V. Metastatic tumors to the spleen: a 25-year clinicopathologic study.Arch Pathol Lab Med. 2000; 124: 526-530Crossref PubMed Google Scholar]. Splenic metastases also occur as a solitary splenic mass, synchronous or metachronous to the primary tumor [3Lam K.Y. Tang V. Metastatic tumors to the spleen: a 25-year clinicopathologic study.Arch Pathol Lab Med. 2000; 124: 526-530Crossref PubMed Google Scholar]. When isolated, more than 60% of splenic metastases are asymptomatic. Symptoms such as fatigue, weight loss, fever, abdominal pain, splenomegaly, anemia or thrombocytopenia due to hypersplenism, and more rarely, by splenic rupture, might occur [4Agha-Mohammadi S. Calne R.Y. Solitary splenic metastasis: case report and review of the literature.Am J Clin Oncol. 2001; 24: 306-310Crossref PubMed Scopus (37) Google Scholar]. Isolated metastasis to the spleen is rare, with only 93 cases from all sources having been reported to 2007. Moreover, isolated splenic metastasis from primary lung cancer is extremely rare, with only 11 cases reported to date. Herein, we report a rare case of isolated splenic metastasis in a 49-year-old woman 7 months after lobectomy for an adenocarcinoma in the right upper lobe completely resected. The only symptom the patient presented with was abdominal pain. The abdominal computed tomography (CT) showed a spleen mass with no other remarkable findings. After 8 years of follow-up, the patient was still alive, with no symptoms and no evidence of metastatic recurrence. The 49-year-old woman presented to the department of thoracic surgery with dry cough over 3 months in April 2004 with no pertinent medical history. She was a former 30 pack-year smoker who quit in 2002. Physical examination was unremarkable, and blood tests were within normal ranges. Chest contrast-enhanced CT revealed a 5-cm speculated mass in the right upper lobe, suggestive of neoplastic disease without evidence of hilar or mediastinal adenopathy (Fig 1). Fiberoptic bronchoscopic examination showed no endobronchial lesion. The pathologic transbronchial biopsy was reported as adenocarcinoma consistent with primary lung cancer. Brain magnetic resonance imaging, abdominal CT scan, and bone scintigraphy were normal. The patient underwent a right lateral thoracotomy, and a radical upper lobectomy was performed. She had an uneventful postoperative period and was discharged on the fourth day. The final pathology section showed an adenocarcinoma moderately differentiated (G2) 5.0 × 3.0 × 2.5 cm in size, and immunohistochemistry confirmed the lung as the primary site (Fig 2). Two mediastinal lymph nodes (R2 and R4) were confirmed as metastatic disease. According to the sixth TNM classification at that time, the patient was staged as having T2N2M0 disease (IIIA). After surgery, the patient received adjuvant chemotherapy (vinorelbine with cisplatin) for three cycles. Seven months after surgery, the patient suddenly presented with abdominal pain at the emergency department. The abdominal CT showed a single spleen mass 4 cm in size with a solid component. Metastatic workup (scans of the brain, liver, adrenals, and bones) was performed and revealed no other metastatic disease. At that time, 18F-fluorodeoxyglucose positron emission tomography scan was not available at our institution. Splenectomy was performed on November 2004, and the specimen revealed a 4.0-cm solid, necrotic mass in the middle pole of the spleen. Pathology study demonstrated moderately differentiated metastatic carcinoma compatible with the lung primary carcinoma (Fig 3). After splenectomy, the patient was discharged in a good clinical condition. She received another cycle of chemotherapy (paclitaxel with cisplatin) 1 month later. Because the patient could not tolerate the adverse effects, she refused to receive any further chemotherapy. Long-term follow-up to date (96 months) has not demonstrated any evidence of recurrent metastatic disease. Adenocarcinoma is the type of cancer in which metastases to spleen are most commonly seen [5Kinoshita A. Nakano M. Fukuda M. et al.Splenic metastasis from lung cancer.Neth Med. 1995; 47: 219-223Crossref PubMed Scopus (37) Google Scholar, 6Lee S.S. Morgenstern L. Phillips E.H. Hiatt J.R. Margulies D.R. Splenectomy for splenic metastases: a changing clinical spectrum.Am Surg. 2000; 66: 837-840PubMed Google Scholar].The left lung is more commonly involved than the right lung; the most probable reason for this is the left lung's higher blood flow ratio compared with the right lung [5Kinoshita A. Nakano M. Fukuda M. et al.Splenic metastasis from lung cancer.Neth Med. 1995; 47: 219-223Crossref PubMed Scopus (37) Google Scholar, 6Lee S.S. Morgenstern L. Phillips E.H. Hiatt J.R. Margulies D.R. Splenectomy for splenic metastases: a changing clinical spectrum.Am Surg. 2000; 66: 837-840PubMed Google Scholar]. The physical barrier effect of the splenic capsule, the spleen's rhythmic contractility, and sharp curl of splenic artery complicate the constitution of tumor embolism. Lack of afferent lymphatics and antitumor activity (production of angiogenesis-inhibiting factors) in relation with the dense lymphoid tissue concentration was also reported to decrease the possibility of tumor metastases to spleen [7Schmidt B.J. Smith S.L. Isolated splenic metastasis from primary lung adenocarcinoma.South Med J. 2004; 97: 298-300Crossref PubMed Scopus (34) Google Scholar]. Splenic metastases appear usually at older ages, generally in the seventh decade of life [6Lee S.S. Morgenstern L. Phillips E.H. Hiatt J.R. Margulies D.R. Splenectomy for splenic metastases: a changing clinical spectrum.Am Surg. 2000; 66: 837-840PubMed Google Scholar]. They are usually asymptomatic, and only 8% are determined as symptomatic. The symptomatic patients are frequently female and teenagers with pain and splenomegaly [3Lam K.Y. Tang V. Metastatic tumors to the spleen: a 25-year clinicopathologic study.Arch Pathol Lab Med. 2000; 124: 526-530Crossref PubMed Google Scholar]. A metastatic tumor of the spleen diagnosed in patients with widespread visceral dissemination of primary tumor has no clinical importance because the overall prognosis for these advanced cancers is generally very poor. However, splenectomy in the setting of metastatic disease can be performed as palliation with acceptable morbidity in patients with symptomatic splenomegaly, to improve the quality of life and to prevent massive bleeding and splenic vein thrombosis [8Comperat E. Bardier-Dupas M. Camparo P. Capron F. Charlotte F. Splenic metastases: clinicopathologic presentation, differential diagnosis, and pathogenesis.Arch Pathol Lab Med. 2007; 131: 965-969Crossref PubMed Google Scholar]. Splenectomy was performed in most of the reviewed cases reported, either because of the symptoms of metastasis or as a part of therapeutic strategies, although, at present, no guidelines are available for the application of splenectomy in the treatment of isolated splenic metastasis. Nevertheless, according to the therapeutic principle of solitary brain or adrenal metastasis, splenectomy might be a good option for isolated splenic metastases [7Schmidt B.J. Smith S.L. Isolated splenic metastasis from primary lung adenocarcinoma.South Med J. 2004; 97: 298-300Crossref PubMed Scopus (34) Google Scholar]. Splenic metastases can present as three main macroscopic patterns: macronodular, micronodular, and diffuse. In the macronodular pattern, the splenic parenchyma is partially replaced by macroscopically discernible, solitary or multiple large nodules of varying sizes. The micronodular pattern is characterized by a relatively uniform miliary aspect. In the diffuse pattern, the splenic parenchyma is completely replaced by the tumor cells. Further follow-up studies of patients with solitary splenic metastases detected by new imaging techniques such as positron emission tomography are needed to better understand the significance of this clinical manifestation [1Marymont J.H. Gross S. Patterns of metastatic cancer in the spleen.Am J Clin Pathol. 1963; 40: 58-66PubMed Google Scholar]. Except for metastasis, the differential diagnosis of splenic masses and nodules includes hemangioma, hamartoma, inflammatory pseudotumor, non-Hodgkin's lymphoma and Hodgkin's disease, granulomatous diseases involving the spleen, such as sarcoidosis, tuberculosis, and histoplasmosis [8Comperat E. Bardier-Dupas M. Camparo P. Capron F. Charlotte F. Splenic metastases: clinicopathologic presentation, differential diagnosis, and pathogenesis.Arch Pathol Lab Med. 2007; 131: 965-969Crossref PubMed Google Scholar]. This case history, along with other published similar cases, suggests that splenic metastases might result from the growth of early blood-borne disseminated cancer cells within the spleen after a period of clinical latency. That could explain why isolated splenic metastatic foci do not necessarily mean cancer at terminal stage because long-term remission has been achieved in patients treated with splenectomy, as reported in our case.