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\begin{document}

\title{Axillary lymph node metastasis from squamous cell lung cancer: an
unusual site of metastatic spread: A case report}



\author[1]{Ayat   Aljuba}%
\author[1]{Balqis   Shawer}%
\author[2]{Yazan  Abugharbieh}%
\author[2]{Yousef  Abu Asbeh}%
\author[3]{Mohammed abdulrazzak}%
\author[4]{Afnan Jobran}%
\affil[1]{Palestine Polytechnic University}%
\affil[2]{Al Ahli Hospital}%
\affil[3]{University of Aleppo Faculty of Medicine}%
\affil[4]{Al Quds University}%


\vspace{-1em}



  
  \date{May 28, 2024}


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\textbf{Axillary lymph node metastasis from squamous cell lung cancer:
an unusual site of metastatic spread: A case report~}

\textbf{Abstract:}

Lung cancer was the most often diagnosed cancer and the leading cause of
death among men. it is usually discovered in the late metastatic stage.
Metastasis of lung cancer to axillary lymph nodes is extremely rare.
This case report presents A 73-year-old male with a productive cough and
shortness of breath admitted to the emergency department. Physical
assessment revealed tenderness in the upper chest and lower sternal
area, as well as other symptoms. Lab results were normal, but a scan
showed various lesions in the lungs, lymph nodes, liver, and spine. A
biopsy confirmed metastatic squamous cell carcinoma originating from the
lungs, and the patient started immunotherapy. Metastasis of lung cancer
to axillary lymph nodes is rare. Normally, lymphatic drainage to the
axillary lymph nodes comes from the upper limbs and chest wall instead
of the lungs. There have been many theories hypothesized to explain the
unusual pattern of ALN metastases from lung cancer. Lung cancers,
including squamous cell carcinoma, rarely metastasize to axillary lymph
nodes, but should be considered in cases with chest wall invasion.

\textbf{Keywords:}

Lung cancer; Squamous cell carcinoma; Axillary lymph nodes; Metastasis;
Case report.

\textbf{Introduction:}

Lung cancer is the most prevalent form of cancer, and the leading cause
of cancer-related mortality in both men and women. in 2018, the
incidence and mortality rates of lung cancer showed an increase,
compared to the rates reported in 2012. It is estimated a total of 2.09
million new cases, accounting for 11.6\% of all cancer cases, and 1.76
million deaths, representing 18.4\% of all cancer-related deaths.
Additionally, it ranks as the third most common cancer type and the
second most common cause of cancer death among women specifically. (1)

When lung cancer is discovered, it is usually in metastatic stage IV.
Distant metastasis is estimated to be 30--40\% at the time of diagnosis
of non-small-cell lung cancer (NSCLC) (2). Axillary lymph node
metastasis (ALNM) from lung cancer is a rare occurrence, affecting less
than 1\% of patients, and it is classified as a distinct type of distant
lymph node metastasis according to the 8th grading system.~(3,4)

This case report shows a~case of 73-year-old man with axillary lymph
node metastasis from squamous cell lung cancer, and provides valuable
insights into the unique instance of axillary lymph node metastasis from
squamous cell lung cancer, shedding light on the diagnostic challenges
associated with such cases.

\textbf{Case presentation}

A 73-year-old previously healthy male patient presented to the emergency
department due to a productive cough, and shortness of breath for
several months. He has been working as a mechanic for many years, and
recalled no family history of cancer.

Upon admission, the physical assessment revealed right upper chest and
lower sternal tenderness as well as vesicular breathing and expiratory
wheezes. A reducible inguinal hernia was also noted. The laboratory test
results were in normal ranges. Upon that, chest x-ray revealed right
upper lobe consolidation (Figure 1).

For that reason, a scan with contrast was performed, which showed a
right upper lobe cavitary lesion with a thick wall adjacent to the
ipsilateral pleural surface measuring about 5x5 cm as well as
pathologically appearing multiple hilar mediastinal and single right
axillary lymph nodes. Vertebral pedicle lesions and two hypo-enhancing
liver lesions were also seen (Figures 2--3).

The multidisciplinary team (MDT) meeting decided that a biopsy should be
taken from the hepatic lesion at segment VI and from the right axillary
lymph node. The result of the histopathology report was diagnostic for
metastatic poorly differentiated squamous cell carcinoma consistent with
lung origin. In light of our findings, the patient began immunotherapy.

\textbf{Discussion}

Lung cancer is a highly aggressive and deadly disease, accounting for
the highest number of cancer-related deaths worldwide. The main reason
behind this high mortality rate is the asymptomatic nature of lung
cancer during its early stages, leading to late-stage diagnosis when
treatment options are limited.(5)

Various occupational exposures have been identified as potential lung
carcinogens, such as arsenic, asbestos, beryllium, cadmium, chloromethyl
ethers, chromium, nickel, radon, silica, and vinyl chloride. Studies
have estimated that approximately 10\% of lung cancer deaths in men and
5\% in women globally may be attributed to exposure to these
occupational carcinogens, particularly asbestos, arsenic, beryllium,
cadmium, chromium, nickel, silica, and diesel fumes. In our case, the
patient has a history of working as a mechanic for an extended period of
time, which is considered a potential risk factor for lung cancer. (1)

All patients who are suspected or confirmed to have non-small cell lung
cancer (NSCLC) should have a comprehensive clinical assessment and a
contrast-enhanced CT scan of the chest. If both the clinical evaluation
and CT scan do not reveal any abnormalities outside of the thoracic
region, a PET scan is advised to assess for the presence of metastases.
In cases where the stage of NSCLC is not clearly defined as very early
or advanced, it is recommended to perform lymph node staging within the
thoracic cavity. (5)

Metastasis of lung cancer to axillary lymph nodes is rare. In a 1941
report, Ochsner and DeBakey discussed axillary lymph node metastases for
lung cancer for the first time. They reported a 6.6\% incidence of ALNM
in 1,298 lung cancer cases (6). However, Riquet et al. discovered ALNM
in 9 of 1,486 (0.61\%) postoperative patients with lung cancer (4).
Satoh et al. additionally noted a 0.75\% rate of ALNM from lung cancer
(10 of 1,340 patients). (3)

typically, lymphatic drainage to the ALN comes from the upper limbs and
chest wall instead of the lungs. There have been many theories
hypothesized to explain the unusual pattern of ALN metastases from lung
cancer. The first hypothesis proposed was that ALNM arises through newly
created lymphatic channels developing in the chest wall or a pleural
adhesion (7).

Another possible pathway for ALNM is retrograde spread, which might give
rise to the formation of SCLNM. It has been hypothesized that
involvement of the ipsilateral ALNs in the absence of involvement of the
chest wall requires metastatic diseases to the ipsilateral mediastinal
lymph nodes (MLNs) and subsequent involvement of the cervical lymph
nodes (7--9).

A third pathway of ALNM The involvement of intercostal lymphatics via
dissemination from MLNM is the third suggested mechanism for ALNM (6).
The other suggested mechanism is that ALNM develops as a result of a
systemic disorder.

This was possibly the mechanism in our case, wherein the ipsilateral
axillary lymph node metastasis probably resulted from the ipsilateral
mediastinal lymph nodes (MLNs) and subsequent involvement of the
cervical lymph nodes.

According to TNM staging systems, non-regional lymph node dissemination,
such as ALNM, is categorized as a type of distant metastasis. Patients
with non-regional metastases have a poor prognosis, with survival times
varying from 1 to 10 months (3,4).

In recent years, various therapeutic approaches have been attempted to
combat lung cancer, but they face significant challenges. However, novel
cancer immunotherapy and alternative therapeutic options show promising
potential in improving patient outcomes. Chemotherapy with
platinum-based regimens is the standard treatment for patients with
stage IV non-small cell lung cancer (NSCLC). However, recent
advancements have led to the development of targeted therapies for
specific driver mutations in NSCLC. Additionally, testing for programmed
death ligand-1 expression levels can help guide treatment decisions
involving immunotherapies. While a medical oncologist will oversee the
management of these therapies, it is beneficial for referring clinicians
to be knowledgeable about the available options. (5)

Early detection methods have the potential to significantly impact the
outcomes of lung cancer. This can be achieved through the implementation
of screening programs, increased awareness and recognition of lung
cancer symptoms, and the establishment of clear referral pathways. The
use of low dose CT scanning for lung cancer screening is currently being
evaluated by the UK National Screening Committee. Studies have
demonstrated that this approach is effective in detecting early-stage
lung cancers and has shown improved mortality rates compared to
traditional chest X-ray screenings. (10)

\textbf{Conclusion:}

All lung cancers, including squamous cell lung cancer, have a rare
incidence of axillary lymph node metastasis. Therefore, clinicians
should maintain a high index of suspicion and consider this rare
condition in the differential diagnosis when examining axillary lymph
nodes in cases of any lung carcinoma with chest wall invasion.

\textbf{Abbreviations}

\textbf{ALN:} axillary lymph nodes, \textbf{NSCLC:} non-small-cell lung
cancer, \textbf{ALNM:} Axillary lymph node metastasis,
\textbf{MDT:}multidisciplinary team, \textbf{SCLNM:} Squamous Cell
Carcinoma Lymph Node Metastasis, \textbf{MLN:} mediastinal lymph nodes,
\textbf{MLNM:}mediastinal lymph nodes Metastasis.

\textbf{Declarations:}

\textbf{FUNDING INFORMATION}

The authors declare no source of funding for this manuscript from any
organization or any institution\textbf{.}

\textbf{CONFLICT OF INTEREST STATEMENT}

The authors want to declare that none of them is or was employed by any
government agency that has any function other than research and
education, and none of them is submitting this manuscript as an official
representative or on behalf of the government.

\textbf{DATA AVAILABILITY STATEMENT}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{ETHICS STATEMENT}

Not applicable.

\textbf{CONSENT}

Written informed consent was obtained from the patient for publication
of this case report and accompanying images. A copy of the written
consent is available for review by the Editor-in-Chief of this journal
on request.

\textbf{References:}

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8. ONUIGBO WI. Contralateral cervical node metastases in lung cancer.
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9. Baird JA. The pathways of lymphatic spread of carcinoma of the lung.
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Intensive Reanim. 2019;28(4):290--9.

\textbf{Hosted file}

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