Small cell lung cancer (SCLC) occurs almost exclusively in smokers and invariably presents with a central pulmonary mass. In the majority of cases, it is metastatic on presentation, with predilection for spread to the liver, adrenal glands, bone and brain. We report an unusual case of SCLC presenting with a massive left adnexal mass.
A 53-year-old post menopausal caucasian woman with a history of smoking, hypertension, mild intermittent asthma and dyslipidemia presented to the ER with a one month history of lower abdominal fullness, pain and recent vaginal bleeding. Review of systems revealed one month of intermittent fevers, chills, nausea and vomiting as well as a 40 pound weight loss over the last six months. She also described mild exertional dyspnea but no other cardiopulmonary symptoms. Initial examination revealed wasting, pallor, and a tender lower abdominal mass. Chest auscultation was normal. Abdominal CT scan revealed a 20 cm heterogeneous left adnexal mass which was initially believed to be a primary ovarian cancer. She was discharged for an outpatient workup. A week later the patient returned with progressive symptoms. A chest CT indicated a 6 cm left hilar mass with significant compression of the left pulmonary artery and left main stem bronchus resulting in almost complete left sided atelectasis. Subsequently she developed hypoxic respiratory failure requiring intubation. Pulmonary embolus was excluded. When stable, she underwent abdominal hysterectomy with bilateral salpingo-oophorectomy and tumor removal. Bronchoscopy noted a large friable fleshy mass occupying most of the left main stem bronchus. Histology from both sites indicated small cell carcinoma. Immunostains of the endobronchial lesion were positive for chromogranin, neuron specific enolase and synaptophysin which indicated an almost certain diagnosis of primary small cell carcinoma of the lung(1). Further staging was negative. Once extubated, our patient underwent focal thoracic radiation therapy directed at the compressive pulmonary lesion and then began an outpatient systemic chemotherapy regimen.
This case is highlighted by a typical central SCLC with a massive adnexal tumor deposit. Review of the literature has identified only ten cases where lung cancer has spread to the ovaries(2,3). Five of these cases have been small cell carcinoma(2,3). Based upon the rarity of the metastasis of SCLC to the ovary, initial assumptions lead to the incorrect diagnosis of a primary ovarian carcinoma. Frozen section of the adnexal tumor at surgery revealed small cell carcinoma (SCC). Differential diagnosis of ovarian SCC deposits includes pulmonary and extra-pulmonary metastases (intestine, thymus, skin, salivary glands, esophagus, bladder, prostate, cervix and undetermined) as well as primary ovarian cancer(4). In view of the latter being rare and having a defined pulmonary source with corroborative histological staining, it was concluded that this patient has SCLC with an ovarian metastasis(5).
To our knowledge, this is a rare report of SCLC with ovarian metastases.
Steven Kadiev, None.