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LETTER TO THE EDITOR |
General and Oncologic Surgery, South Miami, Florida.
Comment on the article "Distant Soft Tissue Metastases: A Series of 30 New Patients and 91 Cases from the Literature," by Damron and Heiner, August, 2000, Annals of Surgical Oncology
The evolution of soft tissue metastases, either as the first sign of cancer or as a subsequent metastatic event in patients with existing cancers, has been described by many authors. Several years ago, my colleagues and I used the term "inflammatory oncotaxis" to describe groups of patients who had developed trauma at distant sites, with subsequent evolution of metastatic disease to those points of injury. The breakdown in the capillary membrane from injuries, severe or minor, can facilitate the transcapillary movement of cancer cells in the patients that Drs. Damron and Heiner describe. A history of trauma preceding the metastatic event, might be useful.
SUNY Upstate Medical University, Syracuse
University of Wisconsin, Madison
Reply to Letter to the Editor from Robert DerHagopian, MD
We thank Dr. DerHagopian for his very pertinent comments. Indeed, soft tissue masses due to metastatic disease have been the subject of numerous reports, as evidenced by the numerous cases we identified and cited in our recently published review in this journal.1
In 1974, Dr. DerHagopian and colleagues reported four cases of metastatic carcinomas that occurred in sites of previous trauma, both blunt and surgical.2 Their cases included two patients not included in our review who had metastases to the soft tissues of the extremities. One patient recalled having a non-resolving and enlarging "hematoma" at the site of a subsequently discovered metastatic adenocarcinoma from the colon to the thigh. Another patient was found to have metastatic renal cell carcinoma in the femoral and popliteal incision sites from a femoral-popliteal vein graft done just before discovering the primary tumor in the kidney. In their discussion, Dr. DerHagopian and his colleagues present a compelling argument for the etiology of some metastatic deposits in soft tissue of the extremities and viscera.
Twenty-seven years after Dr. DerHagopian and colleagues’ report, the etiology of soft-tissue metastases remains poorly understood. Although a discussion of the etiology and pathogenesis of soft-tissue metastases is beyond the scope of our recent report, we have reviewed this topic in a book chapter soon to be published.3
The theory of malignancy developing at the site of trauma is not limited to "inflammatory oncotaxis" of carcinomas as described by DerHagopian et al. Soft tissue sarcomas have also been diagnosed at sites of previous trauma. The most compelling such cases are those of fibrosarcomas and malignant fibrous histiocytomas developing within scars of thermal and acid burns.4 Epithelioid sarcomas have also developed within surgical scars.4
However, both for metastatic deposits in the soft tissues and for soft tissue sarcomas, in the vast majority of cases where there is a history of blunt trauma, the trauma is viewed as the event which brought attention to the preexisting mass rather than contributing directly to its development. Because the normality of the region in question before an acute injury is rarely known with certainty, proof of trauma as an etiologic factor remains elusive.
Both in our own reported cases and in the cited cases in our recent review published in the Annals of Surgical Oncology, a history of trauma was infrequently reported and even less frequently implicated in the etiology of the mass. Certainly, as in those cases reported by DerHagopian and colleagues, trauma may play a role in the development of some soft tissue metastases. Based on our review, well documented cases are rare.
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