Imaging Analysis

A 57-year-old man with squamous cell carcinoma metastases in unusual sites

A 57-year-old man with history of stage IIIB esophageal squamous cell carcinoma underwent esophagectomy.

Surgical pathology revealed squamous cell carcinoma in the distal esophagus invading through the muscularis propria and into the adventitia, with negative margins. Twelve of 19 lymph nodes tested positive.

He never received chemotherapy or radiation therapy.

Munir Ghesani, , MD, FACNM
Munir Ghesani

A year later, he presented with left jaw pain and painful finger swelling.

Imaging results

FDG PET/CT performed from the base of the skull to the mid-thighs revealed a large confluent soft tissue mass in the mediastinum — including in the precarinal, subcarinal and retrocaval spaces — compatible with nodal recurrence (Figures 1 through 3). Although the mass was in close proximity to the superior vena cava, there were no clinical indicators of superior vena cava obstruction.

Figure 1: Coronal PET image demonstrates focal uptake in the right mediastinum.
Figure 1: Coronal PET image demonstrates focal uptake in the right mediastinum. Physiologic uptake in the larynx, as well as the pelvicalyceal system and urinary bladder, is evident.

Images courtesy of M. Ghesani, MD reprinted with permission.

 Figure 2: Intense uptake is evident in the precarinal nodal mass.
Figure 2: Intense uptake is evident in the precarinal nodal mass.
Figure 3: An axial-fused image demonstrates intensively FDG–avid right paratracheal soft tissue nodal mass just anterior to the reconstructed esophagus.
Figure 3: An axial-fused image demonstrates intensively FDG–avid right paratracheal soft tissue nodal mass just anterior to the reconstructed esophagus.

There also was an intensely FDG–avid soft tissue nodule adjacent to the left body of the mandible compatible with metastasis (Figure 4). CT images showed no architectural changes in the body of the mandible.

Figure 4: Focal intense uptake is evident in the left lower gingiva, adjacent to the body of the mandible.
Figure 4: Focal intense uptake is evident in the left lower gingiva, adjacent to the body of the mandible.

There was abnormal focal uptake in distal phalanx of the left index finger. The patient reported local finger pain at the site of abnormal FDG uptake, raising the possibility of index finger metastasis.

Further dedicated radiograph of the finger revealed a lytic destructive soft tissue at the tip of index finger with associated nondisplaced pathological fracture (Figures 5 and 6).

Figure 5: Focal uptake is observed at the distal phalanx of the second digit of the left hand.
Figure 5: Focal uptake is observed at the distal phalanx of the second digit of the left hand.
Figure 6: A soft tissue mass is shown causing lytic destruction of the distal phalanx.
Figure 6: A soft tissue mass is shown causing lytic destruction of the distal phalanx.

Additionally, dedicated chest CT with IV contrast was performed for further evaluation of superior vena cava obstruction suspected on PET/CT.

On chest CT, the mediastinal nodal mass was seen encasing the superior vena cava beyond two-thirds of its circumference, with its focal narrowing compatible with superior vena cava invasion (Figures 7 and 8).

Figure 7: Axial post-contrast chest CT shows invasion of the superior vena cava.
Figure 7: Axial post-contrast chest CT shows invasion of the superior vena cava.
Figure 8: Reconstructed right parasagittal image shows invasion of the superior vena cava.
Figure 8: Reconstructed right parasagittal image shows invasion of the superior vena cava.

Biopsy of the finger lesion confirmed metastatic disease from primary esophageal squamous cell carcinoma.

The patient subsequently underwent finger amputation and excision of the left gingival mass. Endoscopic biopsy of the reconstructed esophagus revealed no local recurrence.

The patient is scheduled to receive systemic chemotherapy for mediastinal disease and radiotherapy if the mediastinal mass becomes symptomatic.

Discussion

Squamous cell carcinoma of the esophagus is an aggressive disease that generally metastasizes to the lymph nodes, liver and lungs. In our case, recurrent esophageal carcinoma occurred in very rare locations.

Subungual metastases are uncommon. They most frequently develop from primary malignancies of the lung and kidney, as well as breast carcinoma.

The gingiva is the most common site of metastasis in the oral cavity, followed by the tongue and tonsils. Metastases most frequently develop from primary tumors of the lung, kidney, skin and breast. The average life expectancy after detection of gingival metastasis is 3.7 months.

PET/CT can identify unusual distant sites of disease. Radiographic evidence of underlying bone destruction is apparent in more than 90% of cases at the time of presentation and occurs in nearly all cases at some point during the course of the disease.

Presentation of a painful finger swelling and jaw pain in the settings of prior known malignancy requires further imaging evaluation to rule out a recurrent tumor.

References:

Allon I, et al. J Periodontol. 2014;doi:10.1902/jop.2013.130118.

Cohen PR. Dermatol Surg. 2001;27:280-293.

Longhurst WD, et al. Int J Dermatol. 2015;doi:10.1111/ijd.12980.

For more information:

Munir Ghesani, MD, FACNM, is assistant professor of radiology and director of PET/CT fellowship at NYU Langone Medical Center in New York. He also serves as a HemOnc Today Editorial Board member. He can be reached at munir.ghesani@nyumc.org.

Ajit Karakbelkar, MD, is a PET/CT fellow at NYU Langone Medical Center.

Disclosure: Ghesani and Karakbelkar report no relevant financial disclosures.

A 57-year-old man with history of stage IIIB esophageal squamous cell carcinoma underwent esophagectomy.

Surgical pathology revealed squamous cell carcinoma in the distal esophagus invading through the muscularis propria and into the adventitia, with negative margins. Twelve of 19 lymph nodes tested positive.

He never received chemotherapy or radiation therapy.

Munir Ghesani, , MD, FACNM
Munir Ghesani

A year later, he presented with left jaw pain and painful finger swelling.

Imaging results

FDG PET/CT performed from the base of the skull to the mid-thighs revealed a large confluent soft tissue mass in the mediastinum — including in the precarinal, subcarinal and retrocaval spaces — compatible with nodal recurrence (Figures 1 through 3). Although the mass was in close proximity to the superior vena cava, there were no clinical indicators of superior vena cava obstruction.

Figure 1: Coronal PET image demonstrates focal uptake in the right mediastinum.
Figure 1: Coronal PET image demonstrates focal uptake in the right mediastinum. Physiologic uptake in the larynx, as well as the pelvicalyceal system and urinary bladder, is evident.

Images courtesy of M. Ghesani, MD reprinted with permission.

 Figure 2: Intense uptake is evident in the precarinal nodal mass.
Figure 2: Intense uptake is evident in the precarinal nodal mass.
Figure 3: An axial-fused image demonstrates intensively FDG–avid right paratracheal soft tissue nodal mass just anterior to the reconstructed esophagus.
Figure 3: An axial-fused image demonstrates intensively FDG–avid right paratracheal soft tissue nodal mass just anterior to the reconstructed esophagus.

There also was an intensely FDG–avid soft tissue nodule adjacent to the left body of the mandible compatible with metastasis (Figure 4). CT images showed no architectural changes in the body of the mandible.

Figure 4: Focal intense uptake is evident in the left lower gingiva, adjacent to the body of the mandible.
Figure 4: Focal intense uptake is evident in the left lower gingiva, adjacent to the body of the mandible.

There was abnormal focal uptake in distal phalanx of the left index finger. The patient reported local finger pain at the site of abnormal FDG uptake, raising the possibility of index finger metastasis.

Further dedicated radiograph of the finger revealed a lytic destructive soft tissue at the tip of index finger with associated nondisplaced pathological fracture (Figures 5 and 6).

Figure 5: Focal uptake is observed at the distal phalanx of the second digit of the left hand.
Figure 5: Focal uptake is observed at the distal phalanx of the second digit of the left hand.
Figure 6: A soft tissue mass is shown causing lytic destruction of the distal phalanx.
Figure 6: A soft tissue mass is shown causing lytic destruction of the distal phalanx.

Additionally, dedicated chest CT with IV contrast was performed for further evaluation of superior vena cava obstruction suspected on PET/CT.

On chest CT, the mediastinal nodal mass was seen encasing the superior vena cava beyond two-thirds of its circumference, with its focal narrowing compatible with superior vena cava invasion (Figures 7 and 8).

Figure 7: Axial post-contrast chest CT shows invasion of the superior vena cava.
Figure 7: Axial post-contrast chest CT shows invasion of the superior vena cava.
Figure 8: Reconstructed right parasagittal image shows invasion of the superior vena cava.
Figure 8: Reconstructed right parasagittal image shows invasion of the superior vena cava.

Biopsy of the finger lesion confirmed metastatic disease from primary esophageal squamous cell carcinoma.

The patient subsequently underwent finger amputation and excision of the left gingival mass. Endoscopic biopsy of the reconstructed esophagus revealed no local recurrence.

The patient is scheduled to receive systemic chemotherapy for mediastinal disease and radiotherapy if the mediastinal mass becomes symptomatic.

Discussion

Squamous cell carcinoma of the esophagus is an aggressive disease that generally metastasizes to the lymph nodes, liver and lungs. In our case, recurrent esophageal carcinoma occurred in very rare locations.

Subungual metastases are uncommon. They most frequently develop from primary malignancies of the lung and kidney, as well as breast carcinoma.

The gingiva is the most common site of metastasis in the oral cavity, followed by the tongue and tonsils. Metastases most frequently develop from primary tumors of the lung, kidney, skin and breast. The average life expectancy after detection of gingival metastasis is 3.7 months.

PET/CT can identify unusual distant sites of disease. Radiographic evidence of underlying bone destruction is apparent in more than 90% of cases at the time of presentation and occurs in nearly all cases at some point during the course of the disease.

Presentation of a painful finger swelling and jaw pain in the settings of prior known malignancy requires further imaging evaluation to rule out a recurrent tumor.

References:

Allon I, et al. J Periodontol. 2014;doi:10.1902/jop.2013.130118.

Cohen PR. Dermatol Surg. 2001;27:280-293.

Longhurst WD, et al. Int J Dermatol. 2015;doi:10.1111/ijd.12980.

For more information:

Munir Ghesani, MD, FACNM, is assistant professor of radiology and director of PET/CT fellowship at NYU Langone Medical Center in New York. He also serves as a HemOnc Today Editorial Board member. He can be reached at munir.ghesani@nyumc.org.

Ajit Karakbelkar, MD, is a PET/CT fellow at NYU Langone Medical Center.

Disclosure: Ghesani and Karakbelkar report no relevant financial disclosures.