Cervical Node Metastasis as the First Sign of Cancer of the Caecum

ANTICANCER RESEARCH 27: 3589-3592 (2007)
Abstract. The unusual case of an adenocarcinoma of the
caecum undiagnosed until the appearance of a large neck and
axillary mass is reported. To our knowledge, this is the first
reported case of cervical node metastasis as the first sign of a
caecal cancer, and 18 fluorine-18-labeled 2-fluoro-2-deoxy-Dglucose
positron emission tomography (FDG-PET) proved
critical in achieving the correct diagnosis. When an
adenocarcinoma is found in the neck or axilla, even an
abdominal primary location such as the large bowel can be
taken into account and employment of FDG-PET should be
considered.
Metastases to the cervical lymph nodes from an unknown
primary tumour commonly originate from the upper
aerodigestive tract (1) and the need for a careful work-up
in patients with asymmetric enlargement of cervical nodes
has been stressed since 1952 (2). We report the unusual case
of an adenocarcinoma of the caecum undiagnosed until the
appearance of a large neck and axillary mass.
Case Report
Cervical Node Metastasis as the First
Sign of Cancer of the Caecum
LUIGI BASSO 1 , LUCIANO IZZO 1 , ERIKA CALISI 1 , GIUSEPPE CAVALLARO 1 , UMBERTO COSTI 1 ,
ANTONIO CIARDI 2 , FRANCESCA FORNARI 1 , ANDREA POLISTENA 1 and GIORGIO DE TOMA 1
1 Cattedra di Chirurgia Generale, Divisione di Chirurgia "B", Department of Surgery "Pietro Valdoni" and
2 Department of Experimental Medicine and Pathology, University of Rome
"La Sapienza" First Medical School, Policlinico "Umberto I", Rome, Italy
A 73-year-old male came under our care three months after
he noticed a lump on the left side of his neck. His previous
bowel habits were regular and stayed unchanged. Eight weeks
after the outbreak of these two lumps, before coming under
our observation, his attending General Practitioner requested
a cervical ultrasonography (US) which showed multiple
Correspondence to: Professor Luigi Basso, Department of Surgery
"Pietro Valdoni", University of Rome "La Sapienza" Medical
School, Policlinico "Umberto I", viale del Policlinico 155, 00161
Rome, Italy. Tel: +39 06 49972167, Fax: +39 06 49972197, e-mail:
luigi.basso@uniroma1.it / lgbasso@yahoo.it
Key Words: Occult, primary, neck, axilla, cancer, caecum, lymph
nodes, positron-emission tomography, PET.
0250-7005/2007 $2.00+.40
enlarged lymph nodes on the left side of the neck, with a
maximum diameter of 1.5 cm. A month later, after
unsuccessful conservative treatment, the patient was referred
to our surgical outpatient department. General examination
was unremarkable, except for enlarged left cervical and left
axillary nodes, which one month before were clinically normal.
General blood results, physical examination, careful
assessment of tonsils and a posterior laryngoscopy were all
negative for clinical indications, while a computed tomography
(CT) of the neck and chest with intravenous contrast
confirmed and assessed the enlarged nodes described above
(Figure 1). Fine-needle aspiration (FNA) of the cervical lump
was performed, showing a poorly metastatic carcinoma (CK+,
Pan Leu–). Oesophago-gastro-duodenoscopy, chest radiograph
and US of salivary and thyroid glands were all unremarkable.
As no primary lesion had yet been detected, 18 fluorinelabeled
2-fluoro-2-deoxy-D-glucose positron emission
tomography (FDG-PET) imaging was performed, confirming
areas of uptake in the left cervical and axillary areas and also
revealing uptake in the right iliac fossa (RIF) (Figure 2). A full
colonoscopy was therefore performed and a vegetating,
partially ulcerated neoplasm was seen in the caecum, with a
maximum diameter of 5 cm. Multiple biopsies were taken,
showing adenocarcinoma of the large bowel. Serum
carcinoembryonic antigen (CEA) and CA 19-9 were elevated.
The patient at this stage received a CT of the abdomen,
which confirmed a solid neoplasm in the caecum, with no
sign(s) of abdominal secondaries. Surgery consisted of right
hemicolectomy and left lateral neck dissection and axillary
dissection. The liver and other abdominal organs were free
from disease on gross examination. Pathologically, an ulcerated
lesion measuring 7 cm in maximum diameter with raised
everted edges was seen in the caecum. The neoplasm involved
the whole thickness of the wall of the bowel and the lumen was
moderately stenotic. Microscopically, a poorly-differentiated
adenocarcinoma infiltrating the subserosal adipose tissue, with
metastasis in 1 out of 23 examined lymph nodes was observed.
The cervical specimen consisted of a lump of 3 cm, containing
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several lymph nodes of which two were enlarged, with fixation,
firmness and a white-grey colour. Histological examination
showed proliferation of cohesive neoplastic cells, with a sharp
interface towards the residual nodal tissue and multiple areas
of necrosis. Immunohistochemistry was positive for cytokeratin
20, and negative for cytokeratin 7 and leukocyte common
antigen, reflecting the same profile of the caecal tumour, thus
associating both neoplasms (3). Comparative microscopic
slides of both tumours with immunohistochemistry are shown
in Figure 3. The tumour was pathologically staged as pT3 pN1
pM1 (stage IV), poorly-differentiated (G3) according to the
International Union Against Cancer (4). The postoperative
course was uneventful and the patient was discharged on the
13th postoperative day. However, he died nine months after
surgery and chemotherapy.
Discussion
Metastases to the cervical lymph nodes from an unknown
primary tumour are rare, representing about 2% of all new
head and neck cancers (5), and the primary lesion, in these
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ANTICANCER RESEARCH 27: 3589-3592 (2007)
Figure 1. Computed tomography of the neck with intravenous contrast showing an enlarged cervical lymph node (arrow).
Figure 2. 18 Fluorine-labeled 2-fluoro-2-deoxy-D-glucose positron emission
tomography (FDG-PET) imaging showing areas of uptake in the left cervical
(A) and axillary lymph nodes (B), and in the right iliac fossa (C).

instances, is later to be commonly found in the upper
aerodigestive tract. In a historical series of 157 patients of
the Memorial Sloan-Kettering Center of New York, U.S.A.
with unexplained cervical node metastasis, 79 patients were
reported to have epidermoid carcinoma, 29 adenocarcinoma,
13 anaplastic carcinoma and 11 melanoma (1). Evaluation of
patients with cervical node metastasis of occult origin should,
therefore, include: thorough medical history, detailed
physical examination of the skin, evaluation of the upper
respiratory and digestive systems complemented by
Basso et al: Cervical Metastasis as Sign of Caecal Cancer
Figure 3. Comparative slides, showing positive immunohistochemistry (cytokeratin 20) of poorly-differentiated adenocarcinoma in both the specimen of
the large bowel (A) and of the cervical lymph nodes (B) (PAP-DAB, x250).
endoscopy, careful assessment of tonsils, salivary and thyroid
glands, FNA of the mass(es), chest radiographs and imaging
studies (US, CT scan, magnetic resonance imaging,
scintigraphy). Recently, FDG-PET has shown itself to be a
useful diagnostic imaging tool in these patients. Thoracic and
abdominal primaries (especially from the lungs, oesophagus,
stomach, ovary, biliary tract, or pancreas) should be sought
in case of an adenocarcinoma discovered in a cervical lump.
A recent review showed that of 52 patients with head and
neck metastases from an occult primary site reported in the
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literature, 33 (63.5%) had metastases to the cervical lymph
nodes, 3 (5.8%) to the thyroid gland, 6 (11.5%) to the
paranasal sinus, 3 (5.8%) to the tonsils, 3 (5.8%) to the
parotid gland, 2 (3.8%) to the ear, and 1 each (1.9%) to the
larynx and to the mandibula, respectively. Of the 33 patients
with metastases to the cervical lymph nodes, 17 (51.5%) had
secondaries from a primary in the gastrointestinal tract, but
only 2 out of 33 (6.1%) had primary abdominal digestive
neoplasms, one arising from the liver and one being a
carcinoid tumour of the terminal ileum (6, 7). In any case,
all of these advanced stage IV malignancies imply ominous
outcomes.
To our knowledge, this is the first reported case of
cervical node metastasis as the first sign of a caecal cancer.
It is not known how cancer cells could have reached the
neck from the large bowel, without grossly involving the
hepatic filter. Lymphatic spread through retrograde or
unusual flow should be considered, while haematogenous
dissemination can be ruled out due to the existence of
hepatic and pulmonary filters. Indeed, somewhat bizarre
secondaries can be the first sign of abdominal malignancies,
such as Sister Mary Joseph’s umbilical nodule, which,
however, is located at an abdominal level (8).
FDG-PET allows detection of the primary tumour in about
21% of cases located above the diaphragm (9), while it proves
more sensitive than CT and monitoring of CEA and CA 19-9
levels in detecting abdominal secondaries and/or recurrences
of colorectal cancer (10, 11). In the case we report, FDG-PET
proved critical in identifying the primary lesion, while CT had
initially been aimed only to the chest and neck, as they are the
common site of origin of these tumours.
In conclusion, distant metastases to the cervical, or
axillary lymph nodes from an unknown primary neoplasm
are rare and have a poor prognosis. When an
adenocarcinoma is found in these areas, even an
abdominal primary location such as the large bowel should
be taken into account and employment of FDG-PET
should be considered.
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ANTICANCER RESEARCH 27: 3589-3592 (2007)
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Received April 16, 2007
Revised July 12, 2007
Accepted July 24, 2007