Squamous Cell Lung Cancer Presenting as a Malar Mass

Abstract

Introduction

Lung cancer metastasizing to the face has rarely been reported and is an even more unusual presentation.

Case

This is the case of a 49-year-old man diagnosed with squamous cell carcinoma of the face, scheduled for resection. Preoperative radiographs revealed a left upper lobe mass, found to be squamous cell carcinoma. Diagnosis was changed to Stage IV primary lung cancer. The patient did not undergo resection.

Discussion

No previous cases of primary lung cancer presenting as a malar mass have been reported. Facial lesions can be the presenting feature of primary lung cancer. Discovery of the true primary lesion can alter therapy and prognosis.

Introduction

Primary lung cancers commonly involve other structures by direct extension or metastasis. Metastatic disease may involve lymph nodes, mediastinal structures, chest wall, pleura, other areas of lung parenchyma, and extrathoracic organs. Extrathoracic metastases occur in over one third of cases and typically reflect pulmonary microvascular invasion [1]. Extrathoracic manifestations occur but are seldom the presenting finding [2]. The potential for metastasis occurs more commonly in small cell cancer than in non small cell cancer [1]. Of non small cell lung cancers, large cell carcinoma and adenocarcinoma have a greater propensity for metastasis than do squamous cell cancers [1]. Common sites for metastases include the brain, liver, bone, and adrenal glands, but virtually any organ may be affected. Lung cancer metastasizing to the face has rarely been reported and is even more unusual as the initial presentation. We present a patient who was initially diagnosed with a primary head and neck malignancy, which was later found to be a metastatic lesion from primary non small cell lung cancer.

Case Report

A 49-year-old man presented for evaluation of a rapidly expanding mass on his right cheek. He initially noted a small nodule adjacent to his zygomatic arch 2 months prior. He presented subsequent loss of peripheral vision due to the lesion's mass effect. He also reported dyspnea on exertion, cough, night sweats, malaise, anorexia, and a 20-lb unintentional weight loss over the preceding 2 months. The patient reported a current 54 pack year history of smoking, but denied excessive alcohol use.

On presentation, the patient was found to have a 4-cm, firm, and immobile mass of his right malar ridge. Field of vision was limited by mass effect, but extraocular muscles were intact. The buccal mucosa and oropharynx were without lesions and there was no significant adenopathy. Vital signs and laboratory values were within normal limits. A computed tomography (CT) scan showed a 3.4 x 3.0 x 3.9 cm enhancing soft tissue mass within the right premalar region with associated bony destruction and extension into adjacent structures (Figure 1). Needle biopsy showed poorly differentiated carcinoma and surgical resection was scheduled.

Figure 1.

CT of the head. CT of the face with contrast showed a 3.4 x 3.0 x 3.9 cm enhancing soft tissue mass involving the right premalar tissues with sinus and orbit extension.

Preoperative chest radiographs and subsequent CT (Figure 2) showed a 3-cm mass in the left upper lobe with lobar collapse, chest wall extension, and mediastinal adenopathy. Fiber optic bronchoscopy revealed a near-complete obstruction of the left mainstem bronchus with complete collapse of the left upper lobe. Cytobrush and endobronchial biopsies revealed squamous cell carcinoma. Surgical biopsy confirmed similar pathology in the malar mass.

Figure 2.

CT of the chest. CT of chest with contrast revealed a 2.9 x 2.7 cm mass compressing the left upper lobe bronchus with lobar collapse, chest wall extension, and mediastinal adenopathy.

The patient's diagnosis was changed to Stage IV primary non small cell lung cancer. Surgical resection of his malar mass was cancelled and he was referred to medical and radiation oncology for palliative therapy. He began external beam radiation, with 5000 cGy to the right malar eminence, 3500 cGy to the mediastinum, and 5000 cGy to the left lung mass, followed by carboplatin (Paraplatin; Bristol-Myers Squibb, New York, NY) and paclitaxel (Taxol; Bristol-Myers Squibb).

Discussion

Metastatic disease is a frequent complication of primary lung cancer. Lung cancer may metastasize by both lymphatic and hematogenous spread. Potential for metastasis is more likely related to the location, and not the size, of the primary tumor [3]. The frequency of extrathoracic metastasis varies according to histological findings and degree of cancer differentiation [3]. Poorly differentiated squamous cell lung cancers have a greater risk of extrathoracic metastasis than do well-differentiated tumors of the same cell type [3].

The most common sites of extrathoracic metastases include the adrenal glands, brain, bone, and liver, typically by hematogenous spread. Adrenal metastases are present at autopsy in 35% of patients with non small cell lung cancer [1]. Central nervous system metastasis occurs in 10% of cases at presentation, and 50% to 60% at autopsy [1]. Liver metastases are found in 30% to 45% of patients at autopsy [1]. Bone metastases are found at autopsy in 25% to 40% of cases and typically results in osteolytic lesions to the trabeculae [1].

Primary lung cancer metastasizing to facial structures has rarely been reported. Barnard [4] reports a patient who present with a squamous cell carcinoma of the buccal mucosa, later found to be metastasis from a primary lung cancer. Whyte [5] describes a patient presenting with undifferentiated oat cell carcinoma of the temporal fossa secondary to a primary lung cancer. One previous report describes recurrence of squamous cell carcinoma involving the malar ridge in a patient with a known history of lung cancer [6]. The presented patient is the first reported case of primary non small cell lung cancer presenting as a malar mass.

Although uncommon, facial lesions can be the presenting feature of a primary lung cancer. Symptoms, such as dyspnea and cough, are less commonly associated with other primary cancers and should raise suspicions for an underlying pulmonary malignancy. Common malignancies can metastasize to uncommon sites and, although infrequent, may be the presenting feature. Less common malignancies, especially when associated with symptoms suggestive of another primary malignancy, should raise the suspicion for metastatic disease. Discovery of the true primary lesion, as in this case, can alter the therapy and prognosis in patients with cancer.