A Look at Adenocarcinoma
Young Man With a Numb Chin
Pamela Havlen, MD, and
Rachel E. Salas, MD
University of Texas Medical Branch at Galveston
A 25-year-old man was admitted to the hospital because of upper back pain. He had a history of rectal adenocarcinoma with metastases to the bladder, which had been diagnosed 2 years earlier. An MRI scan of the spine revealed multiple spinal metastases; there was a large epidural mass at C7-T4 with anterior cord compression. The patient then started palliative radiation therapy to the spine.
Within a few days the patient complained of being unable to feel the left side of his chin. He pointed out that he had bitten the left side of his lip while trying to eat. Physical examination revealed a deficit only in the sensation of pain, temperature, and light touch in the area of his left chin below the lip. The remainder of the facial sensory examination was normal. Facial muscle movement was intact. All other cranial nerves were intact.
Discussion
Numb chin syndrome has been described in the literature since the 1960s and has been recognized as a sign of possible serious illness since that time.1 It is defined as a numbness or paresthesia over the territory of the mental nerve, which includes the chin and lower lip.
This syndrome can result from nonmalignant etiologies—such as trauma, drugs, diabetes mellitus, syphilis, amyloidosis, sarcoidosis, sickle cell anemia, and vasculitis—but the most common and most worrisome cause is metastatic malignancy.2,3 Numb chin syndrome has most frequently been associated with breast cancer and lymphoma; however, it has also been linked to many other malignancies.4 Often a marker for recurrence of a known and now widespread malignancy, it has also been the initial presenting symptom of a new and advanced malignancy.3 In fact, Massey and colleagues5 found that in 47% of cases, numb chin syndrome preceded the diagnosis of the primary tumor.
Symptoms in this syndrome are linked to the inferior alveolar nerve. This nerve has only sensory capabilities and innervates the lower lip and chin as well as the lower gingiva and teeth.2 It originates as part of the posterior trunk of the mandibular division of the trigeminal nerve. It enters the mandible at the mandibular foramen and travels along the mandible until it exits at the mental foramen. Upon exit from the mental foramen, the inferior alveolar nerve becomes the mental nerve.2
Thus, the neuropathy has been hypothesized to be caused by several different mechanisms. The possibilities include compression of the inferior alveolar nerve itself by mandibular metastases, mandibular nerve compression by skull-base tumors, leptomeningeal metastases, and tumor cell infiltration of the inferior alveolar nerve sheath.3 Lossos and Siegal4 found in a report of 42 patients with numb chin syndrome that mandibular metastases were the most common cause of this syndrome and leptomeningeal metastases occurred next most commonly. They stated that these 2 etiologies may sometimes be differentiated by the presence of other cranial neuropathies indicating a leptomeningeal origin. Burt and associates2 argued that mandibular metastases are by far the most common cause of numb chin syndrome and if such metastases have not been found, then it is likely they were simply not detectable at that time and by current technology.
In addition to a thorough history and physical examination, the recommended studies in the evaluation of numb chin syndrome include a panoramic radiograph of the mandible, CT of the brain and skull base, MRI, and nuclear bone scintigraphy. If the cause of the patient’s symptoms remains uncertain, cerebral spinal fluid examination may be useful in identifying leptomeningeal metastases.3
Therapy is usually directed at the specific cause, whether it is malignant or benign. In the case of mandibular metastases, systemic therapy should be initiated or changed. Skull-base tumors may respond to local radiation therapy, and leptomeningeal metastases may respond to whole brain irradiation or intrathecal methotrexate injection.4 Unfortunately, the appearance of the numb chin syndrome in the setting of malignancy is a sign of poor prognosis, and treating the syndrome does not improve the outcome.3 Patients with mandibular metastases survive approximately 5 months, and patients with leptomeningeal metastases survive about 12 months.4
Outcome of the case. The patient in this case had already received a diagnosis of metastatic adenocarcinoma that was clearly progressive. An MRI scan of the brain revealed multiple meningeal metastases (Figure). No further investigations of his numb chin syndrome were undertaken. It was believed that the meningeal metastases were the cause of his symptoms, and he started whole brain radiation after completing the local radiation to his epidural metastasis. He may have had a mandibular metastasis, but obtaining this information would not have affected his already poor prognosis. He was referred to hospice care. ■
References:
1. Calverly JR, Mohnac AM. Syndrome of the numb chin. Arch Intern Med. 1963;112:819-821.
2. Burt RK, Sharfman WH, Karp BI, Wilson WH. Mental neuropathy (numb chin syndrome): a harbinger of tumor progression or relapse. Cancer. 1992;70:877-881.
3. Marinella MA. Numb chin syndrome: a subtle clue to possible serious illness. Hospital Physician. 2000;36:54-56.
4. Lossos A, Siegal T. Numb chin syndrome in cancer patients: etiology, response to treatment, and prognostic significance. Neurology. 1992;42:1181-1184.
5. Massey EW, Moore J, Schold SC. Mental neuropathy from systemic cancer. Neurology. 1981;31:1277-1281.
Jejunal Metastasis from Adenocarcinoma of the Lung
Fadi I. Jabr, MD
A 59-year-old woman was evaluated for epigastric discomfort and iron deficiency anemia of 2 months' duration. Two years earlier, she had undergone left upper lung lobectomy and adjuvant radiation for T2 N0 M0 poorly differentiated adenocarcinoma of the lung.
Results of a fecal occult blood test were positive. Esophagogastroduodenoscopy showed gastritis and duodenitis; a Campylobacter-like organism test was positive for Helicobacter pylori. Colonoscopy revealed 3 tubular adenomatous polyps; these were resected. Abdominal and chest CT scans showed only mild hepatomegaly and volume loss in the left lung, consistent with the previous lobectomy.
A proton pump inhibitor and an antibiotic were prescribed. However, the anemia persisted and the abdominal pain increased and was now accompanied by melena. There were no symptoms of obstruction. The image shown here from the upper GI series revealed a filling mass defect in the jejunum.
Segmental resection of the small bowel showed a 4 × 3 × 3-cm tumor, 20 cm from the Treitz ligament and about three fourths the circumference of the small intestine. Microscopic examination revealed a poorly differentiated adenocarcinoma that recapitulated the morphology and pattern of the lung neoplasm resected 2 years earlier. The tumor involved the mucosa, submucosa, and muscularis propria. Adjacent mesenteric lymph nodes and the resection margin were free of tumor. Immunohistochemical studies showed neoplastic cell expression of carcinoembryogenic antigen and cytokeratins. Results of bone scintigraphy were normal.
Although jejunal metastasis from adenocarcinoma of the lung is relatively rare, it must be considered in all lung cancer patients who have abdominal pain, GI bleeding, or a positive fecal occult test result. Since most patients are asymptomatic, fecal occult blood testing may provide an early clue to the diagnosis of GI metastases. If upper and lower endoscopies and CT scans of the abdomen are unremarkable, then a conventional study, such as an upper GI series, may reveal the diagnosis.
Unfortunately, the prognosis remains poor. Surgical resection provides only palliative treatment of the disease. This patient recovered uneventfully and underwent chemotherapy. ■
Cutaneous Metastasis of Prostatic Adenocarcinoma
Emily Stevens, Andrew Dubois, MD, and Ivan Damjanov, MD, PhD
University of Kansas Medical Center, Kansas City
This lesion had appeared in the right groin of a 60-year-old man and had slowly enlarged over a month (Figure A). Two years before this evaluation, he had undergone total prostatectomy with lymph node dissection for prostate carcinoma. Metastatic disease was found in a resected lymph node, and he underwent multiagent chemotherapy.
Histopathological examination of a shave biopsy specimen from the nodule revealed adenocarcinoma in the dermis with an intact overlying epidermis (Figure B). In view of the patient’s history, metastasis from the primary carcinoma in the prostate was considered the most likely diagnosis. Immunohistochemical staining with the antibody to prostate-specific antigen confirmed prostatic adenocarcinoma (Figure C).
Carcinoma of the prostate tends to metastasize to many organs, including bone, lung, liver, and adrenal glands.1 However, metastases to the skin are rare; they occur in fewer than 1% of patients with metastatic disease.2 Most of these metastases are located on the skin of the abdomen, especially the suprapubic area, the anterior thighs, and the groin.
Prostatic carcinomas that have metastasized to the skin are associated with a poor prognosis; death from disseminated cancer generally occurs within 1 year.3 This patient died within 6 months of the skin biopsy. ■
References:
1.Nebesky JM, Abangan DL, Kauffman CL. Infiltrated groin plaque in an 81-year-old man. Arch Dermatol. 2001;137:495-500.
2. Fukuda H, Saito R. A case of Sister Mary Joseph’s nodule from prostatic cancer. J Dermatol. 2006;33:46-51.
3. Powell FC, Venencie PY, Winkelmann RK. Metastatic prostate carcinoma manifesting as penile nodules. Arch Dermatol. 1984;120:1604-1606.
Man With GI Symptoms and Weight Loss Attributable to Primary Duodenal Adenocarcinoma
John Godino, MD
A 71-year-old man presented with a 2-week history of early satiety, decreased appetite, postprandial nausea and vomiting, jaundice, dark urine, acholic stools, and generalized pruritus. In addition, he reported a 4.5-kg (10 lb) weight loss within the past 2 months.
He has a history of hypertension, diabetes mellitus, coronary artery disease, and alcohol abuse. His current medications include lisinopril, atenolol, and glyburide. He denied recent alcohol consumption and tobacco use. The patient underwent a screening colonoscopy 9 months earlier, which revealed a 5-mm tubulovillous adenoma and a 15-mm tubular adenoma in his transverse colon.
His sister died of pancreatic cancer at age 46. Breast cancer was diagnosed in his mother at age 60, and colorectal cancer was diagnosed in his maternal aunt at age 65.
Three months before the current symptoms developed, the patient had an episode of upper GI bleeding manifested by melena; there was no change in the hemoglobin level. An esophagoduodenoscopy revealed a “clean-based ulcer” in the descending portion of the duodenum (Figure 1). Biopsy of the ulcer was not performed at that time. Antral biopsies were negative for Helicobacter pylori. Pantoprazole (40 mg/d) was prescribed, and the patient was instructed to discontinue aspirin.
Vital signs were normal. Physical findings are essentially unremarkable except for jaundice. Abnormal serologic values include total bilirubin, 11.2 mg/dL (normal, 0-1 mg/dL); direct bilirubin, 7.5 mg/dL (normal, 0-0.3 mg/dL); alkaline phosphatase, 993 U/L (normal, 59-146 U/L); aspartate aminotransferase, 1262 U/L (normal, 0-37 U/L); alanine aminotransferase, 2096 U/L (normal, 0-40 U/L); amylase, 110 U/L (normal, 0-88 U/L); and lipase, 189 mIU/mL (normal, 16-63 mIU/mL). Results of a complete blood cell count, coagulation profile, and hepatitis profile were normal.
A CT scan of the abdomen reveals a markedly dilated stomach with an obstructive mass in the descending portion of the duodenum; these findings are consistent with gastric outlet obstruction (Figure 2). In addition, biliary and pancreatic ductal dilatation and multiple liver masses were noted. Esophagoduodenoscopy showed near complete luminal obstruction by the mass (Figure 3). The scope was unable to pass beyond the markedly narrowed lumen. Results of biopsies of the duodenal mass revealed moderately differentiated invasive adenocarcinoma (Figure 4).
The patient subsequently went palliative bypass surgery, which includes gastrojejunostomy and cholecystojejunostomy. Liver and peritoneal metastases were confirmed. The patient was referred to the oncology department for consideration of palliative chemotherapy. ■
Gastric Adenocarcinoma
Drs N. K. Akrritidis and K. G. Kistis
A 75-year-old man was admitted to the hospital because of weight loss (7 kg over the past 5 months) and easy fatigability. Physical examination revealed cachexia and hyperkeratosis of the soles of both feet. The patient said that the latter condition had developed within the past 5 months. Laboratory tests showed iron deficiency anemia, an elevated erythrocyte sedimentation rate (110 mm/h), and an elevated serum level of lactate dehydrogenase. An abdominal ultrasonogram revealed multiple small lesions on the liver, which were compatible with metastases.
Gastroscopic examination showed a huge mass in the minor curvature; histologic examination proved it to be an adenocarcinoma. This is a rare case of adenocarcinoma of the stomach that first appeared clinically with a paraneoplastic manifestation: hyperkeratosis of the soles. ■