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)