Calf metastasis of colorectal cancer: report of a case
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783-787_Iusco 23-11-2005 8:21 Pagina 783
CHIRURGIA ITALIANA 2005 - VOL. 57 N. 6 PP 783-787 783
Calf metastasis of colorectal
cancer: report of a case
DOMENICO IUSCO, LEOPOLDO SARLI, ANTONIO MAZZEO, ENRICO DONADEI, LUIGI RONCORONI
Surgical Department
Section of Surgical Clinic and Surgical Therapy
University of Parma
Riassunto Il cancro colorettale raramente metastatizza al di fuori di fegato, polmoni e linfonodi, ecce-
zionalmente nel tessuto muscolare scheletrico. La rarità di quest’ultima localizzazione è da
attribuire sia alla sottostima del problema sia alla sua effettiva scarsa incidenza. Riportiamo
un caso di metastatizzazione da cancro colorettale a livello surale sinistro che si è manife-
stato come una massa dolorosa e fissa e proponiamo una revisione della letteratura.
Parole chiave: cancro colorettale, metastasi surale
Summary Calf metastasis of colorectal cancer: report of a case. D. Iusco, L. Sarli, A. Mazzeo,
E. Donadei, L. Roncoroni
Colorectal cancer metastases rarely develop outside liver, lungs and lymph nodes, and only
exceptionally in skeletal muscle. The very low incidence of such metastasis sites may be due
either to underestimation of the problem or to their intrinsic rarity. We report a case of meta-
stasis from colorectal cancer that developed in the left calf and manifested itself as a pain-
ful non-fluctuating mass. The relevant literature is also reviewed.
Key words: colorectal cancer, calf metastasis
Chir Ital 2005; 57, 6: 783-787
Correspondence to: Dr. Domenico Iusco - Istituto Clinica Chirurgia Generale e Terapia Chirurgica - Azienda Ospedale - Via
Gramsci, 14 - 43100 Parma.783-787_Iusco 23-11-2005 8:21 Pagina 784
784 CALF METASTASIS OF COLORECTAL CANCER: REPORT OF A CASE
Introduction right hemicolectomy for a Dukes C adenocarcinoma
in another institution.
The most common sites of metastases from col- Her medical history included appendectomy,
orectal cancer are regional lymph nodes, liver and cholecystectomy and left saphenectomy, type 2 dia-
lungs1. Limited extravisceral metastases are rare, betes, atrial fibrillation and hepatitis C.
being decribed only in 4% of cases2, among which On physical examination, a painful, non-fluctuat-
skeletal muscle metastases are exceptional3. To the ing mass was detected, located deep within the left
best of our knowledge only 9 cases of skeletal muscle popliteal space. The remaining clinical examination
metastasis are described in the literature (Table I). was normal.
We report here on an unusual case of metastasis to Laboratory values were normal except for a CEA
the skeletal muscle of the left calf from an adenocarci- level of 21.9 ng/mL (normal range: 0.01-5.50 ng/mL).
noma of the right colon presenting with pain and Colonoscopy, ultrasonography and CT ruled out a
swelling. local recurrence of colon tumours and thoracic or
abdominal metastases.
Leg ultrasonography revealed the presence of a
Case report hypoechogenic mass in the interosseous space
between the tibia and fibula of the left leg.
A 73-year-old woman was referred to our depart- An aspiration biopsy was taken from the calf mass,
ment in October 2002, because of a one year history showing atypical cells compatible with metastasis
of left calf discomfort. In 2000 she had undergone a from colorectal adenocarcinoma.
Table I. Reports of skeletal muscle metastases found in the literature.
Author Patient Presenting Skeletal Treatment Outcome
age/sex symptoms muscle
involved
70/F Painful mass and Right calf None Generalised
oedema of the leg metastasis – death
Laurence14
51/M Pain and Right forearm Excision Generalised
paraesthesia and hand of the mass metastasis – death
Torosian1 68/F Left thigh mass Left thigh Excision Not described
and progressive lower of the mass
limb discomfort
Lampenfeld10 75/F Progressive growth Left gluteus Excision Not described
of left buttock mass maximus of the mass
and medius
Araki15 66/M Right shoulder Right major Excision Muscular
pain teres of the mass recurrence –
death after 2 years
and 7 months
Chang 16 62/M Left leg pain Left tibialis Excision Not described
anterior muscle of the mass
Danikas 17 62/M Facial swelling Masseter Radiotherapy Generalised
metastasis –
death after 2 months
Yoshikawa18 54/M Pain in right buttock En bloc Death 8 months
resection later with liver
and lung metastasis
Hasegawa19 60/M Not described Right extensor Excision Not reported
carpis ulnaris muscle of the mass783-787_Iusco 23-11-2005 8:21 Pagina 785
CHIRURGIA ITALIANA 2005 - VOL. 57 N. 6 PP 783-787 785
Fig. 1. CT scan showing a 3.5 × 5 cm mass in the left calf.
Computerised axial tomography and contrast- The postoperative period was uneventful and the
enhanced computerised tomography confirmed a 3.5 patient was discharged 4 days after surgery.
× 5 cm mass, situated in the mid third of the calf, with She then underwent adjuvant radiotherapy and
a vascularised capsule that appeared to be adjacent to showed no sign of recurrence at a 2-year follow-up.
the soleus muscle, without invading any structures
(Fig. 1).
The patient underwent surgery (Fig. 2) which con- Discussion
sisted in a longitudinal median incision of the calf
region and the opening of the tricipides fascia revealing Among the tumours producing skeletal muscle
a vascularised mass measuring 3.5 × 5 cm which metastases the most common are lung and kidney
included the tibialis nerve. The mass was then excised. tumours, and the least common breast, bladder, cervix
Fig. 2. Intraoperative picture and surgical specimen.783-787_Iusco 23-11-2005 8:21 Pagina 786
786 CALF METASTASIS OF COLORECTAL CANCER: REPORT OF A CASE
or thyroid cancers4,5. Skeletal muscle metastasis from increase the susceptibility to development of metasta-
colorectal cancer are exceptional and to the best of our tic disease at such sites. Weiss et al. found that cancer
knowledge have been reported in only 9 cases (Table I). cells survive best in denervated muscle compared
Skeletal muscle tissue is in any event one of the most with electrically stimulated muscle12.
unusual sites of metastasis for any malignancy, despite Seely suggested the following reason for the resist-
the fact that skeletal muscle tissue makes up a large part ance of skeletal muscle to metastatic cancer: lactid
of the body – almost 50% – and receives an abundant acid signals anoxia, and blood vessels tend to respond
blood supply6. The reason for the very low incidence of by identifying the site of the anoxia and vascularising
such metastases may be either clinical underestimation it. Neovascularisation of tumours occurs because of
of the problem due to the lack of symptoms often asso- their lactic acid-producing activities. However, since
ciated with them or to their intrinsic rarity. muscles also produce lactic acid, their blood vessels
Underdiagnosis of muscle metastases may con- must be conditioned to tolerate a higher level of lactic
tribute to their apparently low incidence. Muscle acid than other tissues13.
metastases may remain asymptomatic and undetected Colorectal cancer muscular metastases have been
by physical examination or during diagnostic imaging described more frequently in the thigh and in the gluteus.
studies. Thus, the true incidence of such metastases Metastasis to the calf has been reported only in one case
may be determined by a review of autopsy data. Garcia in which the presenting symptoms were similar to our
et al. reported a series of autopsies in 194 patients with case, consisting in a painful mass and oedema of the calf.
malignant cancers in which gross metastases to skeletal It is worth noting that in almost all the cases de-
muscle were noted in 11% and microscopic metas- scribed excision of the mass was possible. Only in one
tases in an additional 6%7. This contribution to the lit- case of masseter localisation the treatment of choice
erature is in any case the only one that reports a very was radiotherapy because the disease had already
high number of skeletal metastases found at autopsy, spread to the lungs bilaterally.
while other autopsy series have reported an incidence In most cases described in the literature (Table I) the
of this kind of metastasis ranging from 1% to 6%8,9. outcome of the patient with skeletal muscle metastasis
Carcinomas were responsible for two-thirds of skeletal from colorectal cancer rapidly proved negative, irrespec-
muscle metastases, while the remainder were due to tive of the possibility of performing a resection or not. In
lymphoma and leukaemia10. Although the true inci- the case we describe here, there has been no recurrence
dence of muscle metastases is most certainly underesti- of the disease in the two years after resection of the
mated, they are undoubtedly less common than metastasis and 4 years after the first operation.
lymph-node and visceral metastases. Even if it is not possible to claim that this case
Previous reports have cited factors such as con- report is sufficient to justify searching for skeletal
tractile activity, pH changes, metabolite accumula- muscle metastases as part of the routine follow-up of
tion, intramuscular blood pressure, local temperature patients operated for colorectal cancer, one should
and the ability to remove tumour-produced lactic acid always bear in mind this kind of problem, especially
as reasons for muscle resistance to malignancy11. when unusual symptoms, such as pain or swelling in
Muscle motion itself may result in mechanical a limb, occurs in patients with colorectal cancer, par-
tumour destruction. It should be noted that skeletal ticularly in view of the fact that they can be treated
muscle injuries, by altering muscle physiology, with excision in most cases.
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metastasis, report of a case. Dis Colon Rectum 1978; 30: 805-8.
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tion of colonic carcinoma. Ann Surg 1984; 200: 685-90.
3. Malcolm AW, Perencevich NP, Olson RM, Hanley JA, Chaffey JT, Wilson RE. Analysis of recur-
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tal carcinoma. A case report. Clin Orthop 1990; 256: 193-6.
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12. Weiss L. Biomechanical destruction of cancer cells in skeletal muscle: a rate-regulator for hema-
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