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Case Report

Metastatic inguinal lymph nodes with two different histological types in
a case of carcinoma of unknown primary site

Mukur Dipi Ray, Shivam Vatsal, Sunil Kumar
Department of Surgical Oncology, Dr. BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India.
Correspondence to: Dr. Sunil Kumar, Department of Surgical Oncology, Dr. BRA Institute Rotary Cancer Hospital, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi 110029, India. E-mail: dr_sunilk@hotmail.com

ABSTRACT
Cancer of unknown primary site is a group of uncommon cancers where patients present with metastatic disease and the primary
site is not identifi ed, even after a complete workup to establish the diagnosis. Inguinal metastasis with unknown primary is even
more uncommon, and histological type is the most important guiding factor to look for the primary. This report describes the rare
situation of inguinal metastasis with an unknown primary site where a combination of squamous and transitional cell carcinoma
was found on fi nal histopathology. It highlights the importance of multimodality approach including an aggressive surgical resection
combined with adjuvant radiation therapy to achieve an optimal outcome.
Key words: Carcinoma of unknown primary site, inguinal metastasis, squamous cell carcinoma, transitional cell carcinoma

Introduction due to the conglomeration of inguinal lymph nodes, about
5 cm in diameter, fi xed to the skin and deeper structures,
Cancer of unknown primary site (CUPS) is a clinical and superfi cially ulcerated [Figure 1]. Bilateral hydroceles
syndrome that is considered in patients where, even after were also present. No other enlarged lymph nodes in
extensive standard clinical, pathological and radiological other regions were palpable. Per rectal examination and
evaluation, the primary site cannot be identifi ed. clinical evaluation, the genitals were normal. Fine-needle
Patients with CUPS account for 0.5-4% of all cancers aspiration cytology of the node was suggestive of
diagnosed. Within this heterogeneous group, there is a squamous cell carcinoma. For better categorization,
[1]
wide variation of clinical presentations and histological a biopsy was performed, which was suggestive of
types. Most present as a metastatic disease, which poorly differentiated squamous cell carcinoma. On
is often diffi cult to categorize using histology alone.
Immunohistochemistry (IHC) is helpful in separating contrast-enhanced computed tomography (CT) scan, an
carcinomas from a neoplasm of other lineages. CUPS is ill-defi ned mass lesion of 5 cm × 4 cm was noted over
more common in the head and neck and axillary regions, right inguinal region encasing the femoral vein and
and inguinal involvement accounts for < 5% of cases. [2,3] having 180° contact with the femoral artery [Figure 2].
Metastatic inguinal lymphadenopathy mainly originates Right external iliac and obturator nodes were also
from the genitalia and anorectal areas. In this case enlarged. The remainder of the abdomen and chest
report, we describe an uncommon case of two different were normal. Positron emission tomography (PET) scan
histological types of metastases in inguinal nodes with showed increased tracer uptake in right inguinal, external
unknown primary sites. iliac, and obturator nodes, but a primary site could not
be visualized. Ultrasound evaluation of the testes was
Case Report normal. Upper and lower gastrointestinal endoscopy
were normal. Serum carcinoembryonic antigen, CA19-9,
A 49-year-old male patient, a farmer, presented in October alpha-fetoprotein, prostate specifi c antigen, and beta
2012 to the surgical oncology clinic with swelling in the human chorionic gonadotropin were within normal range.
right groin crease for 2 years, which had been increasing
progressively in size and subsequently became ulcerated. With no primary site of cancer identifi ed, the patient
On examination the mass was hard, irregular in shape was taken for a right ilioinguinal lymph node dissection.
The nodal mass, along with the encased segment of the
femoral vein, was resected, and an autologous internal
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jugular vein graft was placed [Figures 3 and 4]. Lymph
Quick Response Code: nodal clearance up to the aortic bifurcation was done.
Website:
www.jcmtjournal.com The postoperative period was uneventful. Histopathology
was suggestive of squamous cell carcinoma with islands
of transitional cells in interposed [Figure 5]. IHC
DOI:
10.4103/2394-4722.157178 stainings for CK20, CK5, CK6, and CK7 were negative.
In view of the transitional cell elements, cystoscopy,

Journal of Cancer Metastasis and Treatment ¦ Volume 1 ¦ Issue 2 ¦ July 15, 2015 ¦ 101