Download Lung Adenocarcinoma Metastatic to an Indirect Inguinal Hernia Sac

DOI 10.3966/181020932016061402003
Case Report
Lung Adenocarcinoma Metastatic to an Indirect
Inguinal Hernia Sac: A Case Report and Literature
Review
Hui-Yu Lin1 Chun-Hou Liao1,2 Yu-Wei Chou1,*
An inguinal hernia is a common medical condition in daily practice. Indeed, the
lifetimeprevalence of inguinal hernias is 47% in patients > 75 years of age, but it is rare to have
metastatic cancer of an inguinal hernia sac. Most cases of intraperitoneal malignant inguinal
hernias arise from the gastrointestinal tract. Extraperitoneal inguinal metastases most commonly
occur in males with testicular cancer; there have been no reported cases that have metastasized
from lung adenocarcinoma. Here we report a 77-year-old male with possible cancerous peritonitis
that led to the finding of metastases in a hernia sac. The patient presented with disease progression
after chemo-radiation therapy with multiple metastases to the liver and bone. This report highlights
the importance of a pathologic evaluation of the inguinal hernia sac in preventing misdiagnosis.
Key words: Adenocarcinoma metastasis, Hernia sac, Inguinal hernia, Lung cancer
INTRODUCTION
Case report
Inguinal hernias are one of the most common
A 77-year-old Asian male with type II diabe-
medical conditions in surgical practice, but it is
tes mellitus and essential hypertension for decades
rare to have metastatic cancer in an inguinal her-
presented with a right inguinal painless mass for
nia sac. Although few cases of metastatic cancer
> 1 year. He reported no change in bowel habits.
in an inguinal hernia sac have reported in review
He also reported right groin pain and right lower
articles, no metastases from lung adenocarcinoma
abdomen tenderness, which first developed 1 week
have been reported. Based on the report herein,
prior to an evaluation by a urologist. The physi-
lung adenocarcinoma metastasis should be con-
cal examination revealed a painful, regularly-
sidered when a patient has a clear history of lung
shaped, fixed, non-reducible bulging mass in the
cancer, even when the origin is distant from the
right inguinal area. The tentative diagnosis was an
inguinal area.
inguinal hernia. To rule out an incarcerated inguinal hernia, an abdominal CT was arranged, which
Division of Urology, Department of Surgery, Cardinal Tien Hospital, New Taipei, Taiwan1
School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan2
Submitted March, 18, 2014; final version accepted December, 01, 2015.
*Correspondence author: Yu-Wei Chou ([email protected])
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Hui-Yu Lin Chun-Hou Liao Yu-Wei Chou
showed a hepatic hemangioma and right inguinal
patient presented with disease progression after
hernia with a small segment of small bowel in the
chemo-radiation therapy with multiple metastases
herniation sac (Fig. 1). Intra-operatively, indirect
to the liver and bone. The patient died after 3 years
hernia sac should be smooth in texture, but this
of follow-up.
case with multiple pieces of yellow granule-like
tissue seeding the internal ring were noted, it feels
grainy and which originated from the abdomen and
was confirmed by opening the sac, The opened sac
extruded ascites in the form of turbid, serous fluid.
Surprisingly, special immunostaining of
the sac showed the following: thyroid transcription factor (TTF)-1 and cytokeratin (CK)-7 were
strongly positive; CK-20 was focally positive;
Figure 1. Right inguinal hernia contents with small bowel
loops (arrow).
CDX-2 was negative; and PAS and mucin staining
were also positive.
Further study showed that among tumor markers, only CEA was elevated. Stool occult blood
testing was negative. PSA was within the normal
range. Plain chest films showed a patch with faint
opacity over the right upper lung. Chest computed
tomography revealed a 7 x 4.4 cm mass in the
right lung. Bronchoscopy demonstrated stenosis of
the orifice of the right B2 bronchus due to external
compression. Biopsy and brushing were performed
over the mucosa. The patient underwent video-as-
Figure 2. Special staining of lung adenocarcinoma of
inguinal metastases was positive for TTF-1.
sisted thoracic surgery (VATS) decortication with
a pleural biopsy, and the pathology showed poorly
differentiated adenocarcinoma metastatic to the
pleura. The pathologist reviewed the microscopic
slides of the bronchial brushing and biopsy, and
found extreme similarity between the morphology of adenocarcinoma and the ingunal hernia sac.
Based on medical history of the patient and clinical findings, the metastatic adenocarcinoma was
thought to originate from the right lung. Although
peritoneal signs were limited to the right lower
quadrant, the final diagnosis was right lung adeno-
Figure 3. Special staining of lung adenocarcinoma
metastatic to the inguinal area was CK
7-positive.
carcinoma with metastasis (stage T4N0M1). The
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Fu-Jen Journal of Medicine Vol.14 No.2 2016
Lung adenocarcinoma in inguinal hernia sac
losa cell tumors, gastric cancer, and retroperitoneal
liposarcomas have been diagnosed incidentally
within the inguinal canal based on published reports[1,7,10]. Most intraperitoneal malignant inguinal
hernias arise from cancers of the gastrointestinal
tract; it is not uncommon to find advanced sigmoid
colon cancer metastases within an inguinal hernia
sac[2]. In extraperitoneal cancers, testicular cancer
is the most common origin of extraperitoneal inFigure 4. Special staining of lung adenocarcinoma
metastatic to the inguinal area was CDX-2negative (400x).
guinal metastases in males, while ovarian cancer is
the origin of most common extraperitoneal inguinal metastases in females[9]. Prostate adenocarcinoma with metastases to the inguinal sac after radical
prostatectomy have also been reported[16]. These
cancers have direct contact with the posterior wall
of the inguinal canal, which made local tissue
invasion more likely[5]. Distal lung metastases to
the inguinal canal has not been reported, thus this
is the first reported case of metastatic lung cancer
to the inguinal canal. In this case, the use of CK7/
CK20 and TTF-1 may be helpful in distinguishing
between primary and metastatic pulmonary adeno-
Figure 5. Special staining of lung adenocarcinoma
metastatic to the inguinal area was TTF-1positive (400x).
Discussion
carcinoma[11]. Primary pulmonary adenocarcinoma
would be expected to show CK7+/CK20-/TTF1+[3,6]. TTF-1 is very important in distinguishing
between primary and metastatic lung adenocarcinoma because most primary lung adenocarcinomas
are TTF-1-positive[4,11-15].
An inguinal hernia is a common medical con-
The patient might have had cancerous peri-
dition with a lifetime prevalence as high as 47%
tonitis, which would enable the cancer cells to
[8]
in patients > 75 years of age . Malignant masses
spread to the hernia sac. To distinguish cancerous
in the inguinal canal appear in < 0.5% of excised
peritonitis from gastrointestinal adenocarcinoma,
[1]
sacs . Accordingly, the metastatic tumor described
CDX-2 was stained and was shown to be negative.
in this case can be classified as a saccular hernia
Therefore, origin from the lung was a greater pos-
[10]
sac tumor . The most common cause of saccular
tumors is metastases from abdominal malignan[1]
sibility[6].
The systemic therapy is the primary approach
cies . Malignant mesotheliomas, cecal adnocarci-
to the management of metastatic lung cancer, and
nomas, colon cancer, prostate cancer, adult granu-
therapy directed against specific sites of disease
輔仁醫學期刊　第 14 卷　第 2 期　2016
79
Hui-Yu Lin Chun-Hou Liao Yu-Wei Chou
may also play an important role. In this situation,
immunostaining in separating pulmonary ad-
surgical resection or definitive radiation therapy of
enocarcinomas from colonic adenocarcinomas.
the metastatic disease may produce durable ben-
Am J Clin Pathol 1994; 102: 764–767.
[17]
efit . The most frequent sites of such metastases
are the brain and the adrenal gland
[18]
7. Wilson JM, Duncan AN, Ignjatovic A, et al.
. The final
Inguinal herniae: valuable clues to concurrent
outcomes in the treatment of patients with lung
abdominal pathology. A series of case stud-
cancer depends upon the cell type (non-small cell
ies describing unusual findings in “routine”
versus small cell), tumor stage, molecular charac-
hernia operations which demonstrate the need
teristics, and an assessment of the patient's overall
for thorough surgical training. Intl J Surg Case
medical condition
[19]
. This report highlights the
Reports 2011;2:198-200.
importance of evaluation of inguinal hernia sacs in
8. Kingsnorth A, LeBlanc K. Hernias: inguinal
aiding the correct diagnosis and preventing misdi-
and incisional. Lancet 2003;362:1561-1571.
agnosis.
9. Yang XJ, Zheng FY, Xu YS, et al. Ovarian cancer initially presenting with isolated ipsilateral
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16.Chung SD, Yu HJ, Lin WC. Metastatic pros-
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Hui-Yu Lin Chun-Hou Liao Yu-Wei Chou
肺腺癌轉移至腹股溝疝氣：病例報告及文獻回顧
林惠鈺 1　廖俊厚 1,2 周有偉 1,*
腹股溝疝是在我們醫療工作中，是一種相當常見的的疾病。在患者的年齡超過了 75
歲的族群中，其終生患病率約為 47％，但其病因非常罕見的是由癌症轉移所致。而大多
數腹膜惡性腫瘤轉移至腹股溝疝多是來自胃腸道。在非腹膜惡性腫瘤轉移中，睾丸癌是最
常見的腹膜外腹股溝轉移，但是從來沒有一例報告是從肺腺癌轉移。患者可能有惡性腫瘤
轉移而引發腹股溝疝氣。這份報告提醒我們的腹股溝疝病理評價的重要性。否則，潛在的
病理可能被錯過。
關鍵字：肺癌轉移，腹股溝疝氣
天主教耕莘醫院外科部泌尿科 1　輔仁大學醫學系 2
投稿日期：2014 年 03 月 18 日
接受日期：2015 年 12 月 01 日
* 通訊作者：周有偉　電子信箱：[email protected]
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