Metastatic salivary duct carcinoma presenting as cannonball lung lesions on radiology: Case Report

Metastatic salivary duct carcinoma presenting as cannonball lung lesions on radiology: Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Metastatic salivary duct carcinoma presenting as cannonball lung lesions on radiology: Case Report Aleksandra Ignatowicz, Andrew Strike, Nivedha Balaji, Christopher Chew, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3898801/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Salivary duct carcinoma (SDC) is a rare, aggressive salivary gland tumor with a high rate of metastasis and overall poor prognosis. SDC is commonly diagnosed at stage 3 or stage 4 with progression to local, regional lymph nodes or distant metastatic disease predominantly to the lung, bone, brain or skin. The case presents a 44 year old with an unusual presentation of distant metastasis appearing as cannon ball lesions in the lungs. Case presentation: The patient is a 44 year old male tobacco user with a history of recent incarceration who presented with a several month history of weight loss and enlarging right neck mass. He was found to have multiple bilateral lung masses with brain metastasis on imaging. Biopsy of the neck mass was consistent with salivary duct carcinoma with a rare basal-like phenotype. The patient was ultimately treated with targeted radiotherapy palliatively; however, he was not a candidate for chemotherapy due to extensive disease burden. He declined clinically and was transitioned to hospice care. Conclusions: The case provides a new presentation of an atypical salivary duct carcinoma with bilateral cannonball disease on imaging in addition to a rare histopathologic variant originating likely from an ex pleomorphic adenoma. The basal-like variant was found to have differing gene expression compared to the most commonly seen histological types. Considering the expression noted, the findings provide further information on the expression pattern of basal-like SDC for future targeted therapy and also clarify concerns with accurate diagnosis in SDC in comparison to other morphologically similar malignancies. Salivary duct carcinoma tobacco use submandibular mass cannon ball lesions head and neck cancer lung metastasis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Salivary duct carcinomas (SDC) are rare subtypes of very aggressive salivary gland tumors accounting for 5–10% of salivary gland malignancies. It is commonly found in major glands such the parotid gland, followed by submandibular gland, sublingual gland and minor salivary glands, respectively (Liu et al., 2023 ; Schmitt et al., 2017 ). The high-grade malignant tumors arise from ductal epithelium of salivary glands either de novo and approximately 20% arise from malignant transformation of pre-existing pleomorphic adenomas or carcinoma ex pleomorphic adenoma. SDC tumors associated with carcinoma ex pleomorphic adenoma have been found to have an aggressive clinical course and poor prognosis compared to their counterparts found within pleomorphic adenomas (Nakaguro et al., 2020 ; Simpson, 2013 ). SDC is a highly aggressive malignancy often presenting as a rapidly growing mass with a propensity for distant metastases. Since it is commonly diagnosed at an advanced stage, SDC is associated with an overall poor prognosis and high mortality rate (Simpson, 2013 ; Anwer et al., 2018 ). Diagnosis is dependent on imaging and immunohistopathologic findings that must be differentiated from other malignancies with glandular origins (Udager et al., 2017). This case encompasses a rapid progression of the malignancy with a rare pathologic phenotype in order to provide more supporting information on the diagnosis and management of SDC. Case Presentation The patient is a 44-year-old male with a 10 pack year smoking history and recent incarceration initially presented to the emergency department with progressively worsening symptoms of nausea, night sweats, diarrhea, fever, and an unintentional weight loss of approximately 30 pounds over the past couple of months. Vitals at time of evaluation were unremarkable. He was afebrile, blood pressure 131/ 77, heart rate of 85 beats per min, respiratory rate of 19, and oxygen saturation 96% on room air. Laboratory testing revealed sodium 127. Physical exam was notable for significant cachexia, a palpable right submandibular mass with adjacent lymphadenopathy, and diffuse midline tenderness of the lower back. Lungs were clear to auscultation on exam without wheezing, rales, or rhonchi. He had tested positive for influenza at that time. The patient noticed the right submandibular mass several months prior and endorsed enlargement of the mass since his release from prison two months prior. Due to clinical concerns of potential malignancy, imaging was obtained. Chest x-ray (Figure Ia and Ib) revealed numerous bilateral pulmonary lesions with a right hilum prominence. The CT scan of the chest, abdomen, and pelvis with contrast (Figure IIa and IIb) was significant for numerous bilateral pulmonary parenchymal and pleural nodes suggestive of metastatic disease. An abnormal right hilar node was also present, along with left iliac lytic lesions of the bone. CT brain without contrast (Figure IIIa and IIIb) revealed two lesions in the left frontal lobe and right occipital lobe measuring 2.3 cm and 1.2 cm. The right occipital lobe lesion was accompanied by vasogenic edema without significant midline shift. Follow up MRI of the brain without contrast (Figure IVa and IVb) demonstrated further numerous bilateral metastases in the parietal and occipital lobes accounting to approximately eight lesions at that time. CT of the soft tissue of the neck (Figure V) showed a 3.7 by 3.1 cm right submandibular gland mass with significant cervical adenopathy. Patient underwent ultimately underwent a biopsy of the right neck mass. The histologic sections were consistent with a salivary gland neoplasm with basal-like features associated with fibromyxoid stroma and focal chondroid features. The tumor was composed of ductal epithelial cells surrounded by basal-like myoepithelial cells forming nests, cords and ducts within a prominent fibromyxoid and focal chondromyxoid stoma. There was focal cytologic atypia but no prominent mitotic activity or definitive infiltrative growth. The biopsy samples were sent to a third party for further evaluation due to the abnormality and needing a secondary pathological review. Immunohistochemistry showed positive staining for pankeratin, CK 7, CK 5, p16, SOX-10, p63, p40, increased Ki-67 expression, CAM-5.2 and CD-117 consistent with ductal epithelial components (Figures VI a-f). EBER, AR, PAX-8, synaptophysin, TTF-1, cytokeratin 20, DOG-1, SALL-4 was negative. INI-1 and BRG1 expression was retained. The patient was diagnosed with an advanced stage atypical salivary duct carcinoma with rare basal-like features as per immunohistochemistry. With the prominence of the myoepithelial cells within a chondromyxoid stroma, it was believed that the patient had a basal-like salivary duct carcinoma with in situ pleomorphic adenoma with transformation to ex pleomorphic adenoma or adenoid cystic carcinoma. After extensive discussion regarding progression of the malignancy and metastasis, he was referred to hematology-oncology and radiation-oncology for outpatient follow up after his hospital discharge. In the following months, the patient underwent several sessions of stereotactic radiotherapy. The patient continued to demonstrate progression of the metastatic disease and clinical deterioration. He had worsening respiratory failure requiring 4 to 6 liters of oxygen, additional 30–40 lb weight loss, and diffuse uncontrolled pain. Follow up imaging showed progression of metastatic disease within the chest and increase in size and quantity of intracranial masses despite systemic therapy. At that time, the patient was not deemed a candidate for chemotherapy or further radiation therapy, and ultimately hospice was recommended. Discussion Salivary duct carcinoma is commonly diagnosed at the middle to late stage of the disease course with local infiltration and distant metastasis. Due to its highly aggressive nature, there is rapid onset and progression to distant sites including the lung, brain, liver, bone and skin. SDC has propensity of extra-scapular spread with perineural and lympho-vascular invasion (Simpson, 2013 ). Patients will present with a rapidly growing painful or painless neck mass with fixation to the overlying skin or muscle and presence of cervical lymphadenopathy. Local infiltration of parotid tumors has the potential to cause facial nerve paralysis with metastasis to the temporal bone. Submandibular tumors can invade the mandible which can involve the lingual and sublingual nerves and other surrounding tissue (Anwer et al., 2018 ; Udager et al., 2017). Diagnosis is made with imaging modalities including MRI, CT scan, and PET scan. Imaging is usually non-specific, although it assists with determining the extent of metastasis and the malignant nature of the tumor (Mlika et al., 2012 ). Contrast enhanced CT and MRI scans will reveal ill-defined borders, local invasion into surrounding tissues, and necrosis (Schmitt et al., 2017 ). Calcifications can also be detected which may be suggestive of an in situ pleomorphic adenoma and would require further workup to rule out differentials such as sialadenitis (Naguro et al., 2020). PET/ CT detects regional and distant metastases. Further pathological diagnosis depends on ultrasound guided fine needle aspiration or guided core biopsy followed by immunohistochemistry and histopathological studies to determine treatment course and prognosis (Schmitt et al., 2017 ). Immunohistochemistry is necessary to distinguish SDC from morphologic mimics and further differentiate the tumors by their histologic features. SDC can histologically resemble invasive and intraductal metastatic breast cancer with apocrine expression, other salivary gland carcinomas, and metastatic squamous cell carcinoma (Udager et al., 2017). The morphology variants include papillary, basal-like, mucin-rich, sarcomatoid, micropapillary, and anaplastic findings (Eveson, 2006 ; Syrnioti et al., 2023 ). The most commonly seen morphological variant includes papillary-cribriform growth patterns (Schmitt et al., 2017 ). Expression of immunomarkers varies according to the case and the variant, although positive results occur with the following: cytokeratins CK 5/6/7/14, epithelial membrane antigens (EMA), pankeratins, androgen receptors, S-100 protein from medial myoepithelial cells, and p40 and p63, p16, cancer proliferation marker Ki-67, CD 117, SOX-10, CAM5.2, GATA-3, and TTF-1 (Mlika et al., 2012 ; Nakaguro et al., 2020 ; Schmitt et al., 2017 ; Udager et al., 2017). CK 7 is a marker indicative of glandular tissue which often used to differentiate salivary duct carcinoma from other metastatic disease since immuno-expression of CK 7 has positive immunoreactivity with most salivary gland malignancies (Chandrasekar et al., 2016 ). This patient’s immunohistochemistry showed positive staining for pankeratin, CK 5 and 7, p16, SOX-10, p63, p40, increased Ki-67 expression, CAM-5.2 and CD-117. Androgen receptor was negative. However, approximately 90% of SDC cases do have androgen receptor expression and 15 to 40% have HER-2 expression (Kantamini et al., 2021). HER-2 expression was not evaluated in this case. Of the morphology variants, the basal-like variants have positive basal-myoepithelial markers including CK 5, 6, 14 and p63 and negative androgen receptor expression (Simpson, 2014; Syrnioti et al., 2023 ; Udager et al., 2017). Poor prognosis is associated with positive AR, and increased expression of Ki-67 is indicative of active cellular value consistent with higher malignancy and metastatic rates (Liu et al., 2023 ; Simpson, 2014). Salivary duct carcinomas have a high incidence of recurrence and relapse, distant metastasis, and an overall poor prognosis despite aggressive treatment. Statistics have shown that up to 60% will expect a life expectancy of 5 years after the initial diagnosis despite treatment (Liu et al., 2023 ; Syrnioti et al., 2023 ). Local recurrence or distant metastasis is approximately seen in 33% and 50% of the patients respectively and can occur within 2 to 3 years with associated multiorgan involvement (Liu et al., 2023 ; Syrnioti et al., 2023 ). Often times, many present with distant metastasis with a mean survival rate of 5 months despite following appropriate treatment guidelines (Matsumiya-Matsumoto, et al., 2022 ). Per the National Comprehensive Cancer Network guidelines recommend complete surgical resection for major salivary gland tumors and ipsilateral neck dissection in addition to postoperative radiation therapy with or without adjuvant chemotherapy (Anwer et al., 2018 ; Matsumiya-Matsumoto, et al., 2022 ). Chemotherapy, commonly anti-androgen rather than cytotoxic, is considered for patients with distant metastases or palliatively (Kantamani et al., 2021 ; Nakaguro, et al., 2018). Several studies reported use of androgen deprivation therapy with androgen receptor inhibitors as monotherapy or in combination with gonadotropin hormone-releasing hormone, luteinizing hormone-releasing agonists or HER-2 targeted therapy and a taxane (Eveson, 2006 ; Matsumiya-Matsumoto, et al., 2022 ). Immunotherapy and other targeted therapies are being considered as alternative or second line treatment strategies, although the studies are limited due to the rarity of the malignancy. Conclusion Salivary duct carcinoma is a highly aggressive tumor with rapid progression, very poor prognosis, and high relapse rate despite surgical resection with adjuvant radiotherapy. Chemotherapy in SDC is considered controversial due to lack of efficacy in the late disease states and is primarily reserved for palliative purposes or in metastatic disease. Certain patients with positive apocrine expression such as HER-2 and androgen receptors may benefit from androgen deprivation therapy, cytotoxic chemotherapy, or immunotherapy in addition to recommended therapy. Abbreviations SDC Salivary Duct Carcinomas CT scan Computed tomography MRI scan Magnetic resonance imaging scan PET scan Positron emission tomography CK Cytokeratins EMA Epithelial Membrane Antigens HER-2 Human epidermal growth factor receptor 2 SOX-10 Sry-related HMg-Box gene 10 CD-117 cluster of differentiation 117 EBER Epstein-Barr virus-encoded RNA AR Androgen Receptor PAX-8 Paired-box gene 8 TTF-1 Thyroid transcription factor 1 DOG-1 Discovered on GIST1 GATA-3 GATA Binding Protein 3 SALL-4 Sal-like protein 4 INI-1 Integrase interactor 1 BRG1 Brahma-related gene-1 Declarations Financial or non-financial Interests The authors declare that is no financial or non-financial conflicts of interest to disclose in preparation of this manuscript. Sources of Funding There is no financial funding to disclose. This research received no specific grant or any sources of funding from any funding agency in the public, commercial, or not-for-profit sectors. Ethical Approval Informed consent was obtained from the participant for submission of the case report to the journal and publishing their data and photographs. Author Contribution A.I. wrote the main manuscript.A.S., N.B., S.B. and C.C. contributed to the manuscript text.F.F. and C.S. were part of the clinical team.J.C. prepared Figure 6. All authors reviewed the manuscript. Availability of Data and Materials Not applicable References Liu, F., Fan, L., Lu, L., Guo, H., Nan, J., & Han, F. (2023). Comprehensive diagnosis and treatment of ductal carcinoma of the submandibular gland: case report and literature review. International journal of clinical and experimental pathology, 16(3), 67–75. Schmitt, N. C., Kang, H., & Sharma, A. (2017). Salivary duct carcinoma: An aggressive salivary gland malignancy with opportunities for targeted therapy. Oral oncology, 74 , 40–48. https://doi.org/10.1016/j.oraloncology.2017.09 .008 Nakaguro, M., Tada, Y., Nakaguro, M., Tada, Y., Faquin, W. C., Sadow, P. M., Wirth, L. J., & Nagao, T. (2020). Salivary duct carcinoma: Updates in histology, cytology, molecular biology, and treatment. Cancer cytopathology, 128 (10), 693–703. https://doi.org/10.1002/cncy.22288 Simpson R. H. (2013). Salivary duct carcinoma: new developments–morphological variants including pure in situ high grade lesions; proposed molecular classification. Head and neck pathology , 7 Suppl 1 (Suppl 1), S48–S58. https://doi.org/10.1007/s12105-013-0456-x Anwer, A. W., Faisal, M., Adeel, M., Waqas, O., Abu Bakar, M., Qadeer, S., Koukab, M., Hussain, R., & Jamshed, A. (2018). Clinicopathological Behavior and Treatment-related Outcome of Rare Salivary Duct Carcinoma: Salivary Duct Carcinoma: Case Reports and Brief Review of the Literature.The Shaukat Khanum Memorial Cancer Hospital Experience. Cureus, 10 (8), e3139. https://doi.org/10.7759/cureus.3139 Udager, A. M., & Chiosea, S. I. (2017). Salivary Duct Carcinoma: An Update on Morphologic Mimics and Diagnostic Use of Androgen Receptor Immunohistochemistry. Head and neck pathology, 11 (3), 288–294. https://doi.org/10.1007/s12105-017-0798-x Kantamani, D., Bandaru, S. S., Miatech, J. L., & Stagg, M. P. (2021). Salivary Duct Carcinoma: Case Reports and Brief Review of the Literature. Case reports in oncological medicine , 2021 , 2672772. https://doi.org/10.1155/2021/2672772 Mlika, M., Kourda, N., Zidi, Y., Aloui, R., Zneidi, N., Rammeh, S., Zermani, R., & Jilani, S. B. (2012). Salivary duct carcinoma of the parotid gland. Journal of oral and maxillofacial pathology: JOMFP, 16 (1), 134–136. https://doi.org/10.4103/0973-029X.92992 Nakaguro, M., Tada, Y., Faquin, W. C., Sadow, P. M., Wirth, L. J., & Nagao, T. (2020). Salivary duct carcinoma: Updates in histology, cytology, molecular biology, and treatment. Cancer cytopathology, 128 (10), 693–703. https://doi.org/10.1002/cncy.22288 Syrnioti, G., Syrnioti, A., Abdullah, A., Lui, X., & Mendoza, E. (2023). Myoepithelial Carcinoma Ex Pleomorphic Adenoma of the Submandibular Gland: A Case Report. Cureus, 15 (3), e35722. https://doi.org/10.7759/cureus.35722 Eveson JW. Malignant neoplasms of the salivary gland. In: Tompson LD (ed.) Head and Neck Pathology. Philadelphia: Churchill Livingstone, 2006: 321–370. Matsumiya-Matsumoto, Y., Morita, Y., & Uzawa, N. (2022). Pleomorphic Adenoma of the Salivary Glands and Epithelial-Mesenchymal Transition. Journal of clinical medicine , 11 (14), 4210. https://doi.org/10.3390/jcm11144210 Uijen, M. J. M., Lassche, G., van Engen-van Grunsven, A. C. H., Tada, Y., Verhaegh, G. W., Schalken, J. A., Driessen, C. M. L., & van Herpen, C. M. L. (2020). Systemic therapy in the management of recurrent or metastatic salivary duct carcinoma: A systematic review. Cancer treatment reviews , 89 , 102069. https://doi.org/10.1016/j.ctrv.2020.102069 Chandrasekar, C., Salati, N., Rao, L., & Radhakrishnan, R. (2016). Salivary duct carcinoma in the mandibular anterior region: The role of immunohistochemical markers in its definitive diagnosis. Journal of oral and maxillofacial pathology: JOMFP, 20 (3), 505–509. https://doi.org/10.4103/0973-029X.190955 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3898801","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":271027764,"identity":"9097926b-6779-4b47-85e0-8c47e2410d77","order_by":0,"name":"Aleksandra Ignatowicz","email":"data:image/png;base64,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","orcid":"","institution":"Northeast Georgia Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Aleksandra","middleName":"","lastName":"Ignatowicz","suffix":""},{"id":271027765,"identity":"c673831c-a6ba-4b95-b192-c914582e3f3b","order_by":1,"name":"Andrew Strike","email":"","orcid":"","institution":"Northeast Georgia Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Strike","suffix":""},{"id":271027766,"identity":"d73d96ba-a66d-47f6-9439-bbde90f53d58","order_by":2,"name":"Nivedha Balaji","email":"","orcid":"","institution":"Northeast Georgia Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nivedha","middleName":"","lastName":"Balaji","suffix":""},{"id":271027767,"identity":"db50b05a-c59a-436e-8ac5-7544d270569f","order_by":3,"name":"Christopher Chew","email":"","orcid":"","institution":"LSU Health Shreveport","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Chew","suffix":""},{"id":271027768,"identity":"5d313089-67ca-48fb-b091-6890f814d6d5","order_by":4,"name":"Steven Barker","email":"","orcid":"","institution":"Northeast Georgia Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Steven","middleName":"","lastName":"Barker","suffix":""},{"id":271027769,"identity":"5c8c355f-e942-4422-ba83-9b46191fcaff","order_by":5,"name":"Christine Sykalo","email":"","orcid":"","institution":"Northeast Georgia Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"Sykalo","suffix":""},{"id":271027770,"identity":"d6f3dc82-1b62-46c6-bb72-c4b2b6d321b9","order_by":6,"name":"Joseph Conway","email":"","orcid":"","institution":"Northeast Georgia Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Conway","suffix":""},{"id":271027771,"identity":"6fd29b60-6755-49b1-93dc-cd521ef62974","order_by":7,"name":"Franklin Fontem","email":"","orcid":"","institution":"Northeast Georgia Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Franklin","middleName":"","lastName":"Fontem","suffix":""}],"badges":[],"createdAt":"2024-01-26 02:59:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3898801/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3898801/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50745323,"identity":"625c531c-a19d-41aa-87a3-85e883ffa27d","added_by":"auto","created_at":"2024-02-06 17:00:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":217125,"visible":true,"origin":"","legend":"\u003cp\u003eChest X-ray revealed numerous bilateral pulmonary nodules with prominence of the right hilum in the coronal (\u003cstrong\u003ea\u003c/strong\u003e) and sagittal view (\u003cstrong\u003eb\u003c/strong\u003e), respectively\u003c/p\u003e","description":"","filename":"Figure1ab.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3898801/v1/c69e6d21af57b3db344df3d7.jpg"},{"id":50744354,"identity":"a6566c5d-e8ff-4c5e-99d4-f0d78d8c519f","added_by":"auto","created_at":"2024-02-06 16:44:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":291996,"visible":true,"origin":"","legend":"\u003cp\u003eCT Chest, Abdomen, and Pelvis revealed numerous bilateral pulmonary parenchymal and pleural nodules and right hilar lesion measuring 4.0 x 3.8 cm (\u003cstrong\u003ea\u003c/strong\u003e, axial view). It also showed a small left iliac bone lytic lesion (\u003cstrong\u003eb\u003c/strong\u003e, coronal view)\u003c/p\u003e","description":"","filename":"Figure2ab.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3898801/v1/aa034f56e99102b47a01c4f4.jpg"},{"id":50745115,"identity":"5965426a-9abb-41a9-8deb-d7bdd436fd71","added_by":"auto","created_at":"2024-02-06 16:52:43","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":198716,"visible":true,"origin":"","legend":"\u003cp\u003eCT brain revealed two lesions in the left frontal lobe (\u003cstrong\u003ea\u003c/strong\u003e, axial view, green circle) and right occipital lobe measuring 2.3 cm and 1.2 cm (\u003cstrong\u003eb\u003c/strong\u003e, axial view, green circle)\u003c/p\u003e","description":"","filename":"Figure3ab.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3898801/v1/63285d5ad5a49f00b2e1cb60.jpg"},{"id":50744357,"identity":"508d3dfa-9bb6-4506-8783-067cd2492418","added_by":"auto","created_at":"2024-02-06 16:44:43","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":227816,"visible":true,"origin":"","legend":"\u003cp\u003eMRI brain revealed a 26 x 20 mm lesion in the right occipital lobe (green circle) with mild surrounding edema (\u003cstrong\u003ea\u003c/strong\u003e, sagittal view) and a13 mm left frontal white matter lesion (green circle) with internal hemorrhage and minimal surrounding edema (\u003cstrong\u003eb,\u003c/strong\u003e sagittal view)\u003c/p\u003e","description":"","filename":"Figure4ab.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3898801/v1/4028adf5f40d34d7a0f43c4e.jpg"},{"id":50745324,"identity":"8a61d0fa-6761-4ed2-9a77-af567261079f","added_by":"auto","created_at":"2024-02-06 17:00:43","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":89148,"visible":true,"origin":"","legend":"\u003cp\u003eCT soft tissue of the neck demonstrated right submandibular gland heterogeneous density measuring 3.7 by 3.1 cm\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3898801/v1/69cabcce2ae794a39fe8a106.jpg"},{"id":50745117,"identity":"eaca52d6-a297-47cb-a0a9-7c73630aa615","added_by":"auto","created_at":"2024-02-06 16:52:43","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":594964,"visible":true,"origin":"","legend":"\u003cp\u003eImmunohistochemistry of the submandular mass. Hematoxylin and eosin-stained section of the core biopsy showed salivary gland neoplasm with basaloid features associated with fibromyxoid stroma and focal chondroid features at 40X magnification (\u003cstrong\u003ea\u003c/strong\u003e) and 400X magnification (\u003cstrong\u003eb\u003c/strong\u003e). The tumor was composed of ductal epithelial cells surrounded by basaloid myoepithelial cells forming nests and ducts. \u003cstrong\u003ec\u003c/strong\u003e, Focally increased Ki67 proliferation index (Magnification 400X). Neoplastic cells are positive for Keratin 7 (\u003cstrong\u003ed\u003c/strong\u003e), Pankeratin and Sox10 (\u003cstrong\u003ee\u003c/strong\u003e) (Magnification 400X). f, CD117 and CAM 5.2 highlighted the ductal epithelial component (Magnification 400X). \u003cstrong\u003eg\u003c/strong\u003e, P63 and P40 were focally positive in the outer myoepithelial cell layer.\u003c/p\u003e","description":"","filename":"Figure6ag.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3898801/v1/39ecb943b0221fd755a0024d.jpg"},{"id":51074553,"identity":"e41b19cb-6bf7-48ed-be42-a3d16cff6189","added_by":"auto","created_at":"2024-02-13 17:37:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":777539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3898801/v1/52720278-5366-456b-b67c-3a923c3dd933.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Metastatic salivary duct carcinoma presenting as cannonball lung lesions on radiology: Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eSalivary duct carcinomas (SDC) are rare subtypes of very aggressive salivary gland tumors accounting for 5\u0026ndash;10% of salivary gland malignancies. It is commonly found in major glands such the parotid gland, followed by submandibular gland, sublingual gland and minor salivary glands, respectively (Liu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Schmitt et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The high-grade malignant tumors arise from ductal epithelium of salivary glands either de novo and approximately 20% arise from malignant transformation of pre-existing pleomorphic adenomas or carcinoma ex pleomorphic adenoma. SDC tumors associated with carcinoma ex pleomorphic adenoma have been found to have an aggressive clinical course and poor prognosis compared to their counterparts found within pleomorphic adenomas (Nakaguro et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Simpson, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSDC is a highly aggressive malignancy often presenting as a rapidly growing mass with a propensity for distant metastases. Since it is commonly diagnosed at an advanced stage, SDC is associated with an overall poor prognosis and high mortality rate (Simpson, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Anwer et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Diagnosis is dependent on imaging and immunohistopathologic findings that must be differentiated from other malignancies with glandular origins (Udager et al., 2017). This case encompasses a rapid progression of the malignancy with a rare pathologic phenotype in order to provide more supporting information on the diagnosis and management of SDC.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eThe patient is a 44-year-old male with a 10 pack year smoking history and recent incarceration initially presented to the emergency department with progressively worsening symptoms of nausea, night sweats, diarrhea, fever, and an unintentional weight loss of approximately 30 pounds over the past couple of months. Vitals at time of evaluation were unremarkable. He was afebrile, blood pressure 131/ 77, heart rate of 85 beats per min, respiratory rate of 19, and oxygen saturation 96% on room air. Laboratory testing revealed sodium 127. Physical exam was notable for significant cachexia, a palpable right submandibular mass with adjacent lymphadenopathy, and diffuse midline tenderness of the lower back. Lungs were clear to auscultation on exam without wheezing, rales, or rhonchi. He had tested positive for influenza at that time.\u003c/p\u003e \u003cp\u003eThe patient noticed the right submandibular mass several months prior and endorsed enlargement of the mass since his release from prison two months prior. Due to clinical concerns of potential malignancy, imaging was obtained. Chest x-ray (Figure Ia and Ib) revealed numerous bilateral pulmonary lesions with a right hilum prominence.\u003c/p\u003e \u003cp\u003eThe CT scan of the chest, abdomen, and pelvis with contrast (Figure IIa and IIb) was significant for numerous bilateral pulmonary parenchymal and pleural nodes suggestive of metastatic disease. An abnormal right hilar node was also present, along with left iliac lytic lesions of the bone.\u003c/p\u003e \u003cp\u003eCT brain without contrast (Figure IIIa and IIIb) revealed two lesions in the left frontal lobe and right occipital lobe measuring 2.3 cm and 1.2 cm. The right occipital lobe lesion was accompanied by vasogenic edema without significant midline shift.\u003c/p\u003e \u003cp\u003eFollow up MRI of the brain without contrast (Figure IVa and IVb) demonstrated further numerous bilateral metastases in the parietal and occipital lobes accounting to approximately eight lesions at that time.\u003c/p\u003e \u003cp\u003eCT of the soft tissue of the neck (Figure V) showed a 3.7 by 3.1 cm right submandibular gland mass with significant cervical adenopathy.\u003c/p\u003e\u003cp\u003ePatient underwent ultimately underwent a biopsy of the right neck mass. The histologic sections were consistent with a salivary gland neoplasm with basal-like features associated with fibromyxoid stroma and focal chondroid features. The tumor was composed of ductal epithelial cells surrounded by basal-like myoepithelial cells forming nests, cords and ducts within a prominent fibromyxoid and focal chondromyxoid stoma. There was focal cytologic atypia but no prominent mitotic activity or definitive infiltrative growth. The biopsy samples were sent to a third party for further evaluation due to the abnormality and needing a secondary pathological review. Immunohistochemistry showed positive staining for pankeratin, CK 7, CK 5, p16, SOX-10, p63, p40, increased Ki-67 expression, CAM-5.2 and CD-117 consistent with ductal epithelial components (Figures VI a-f). EBER, AR, PAX-8, synaptophysin, TTF-1, cytokeratin 20, DOG-1, SALL-4 was negative. INI-1 and BRG1 expression was retained.\u003c/p\u003e \u003cp\u003eThe patient was diagnosed with an advanced stage atypical salivary duct carcinoma with rare basal-like features as per immunohistochemistry. With the prominence of the myoepithelial cells within a chondromyxoid stroma, it was believed that the patient had a basal-like salivary duct carcinoma with in situ pleomorphic adenoma with transformation to ex pleomorphic adenoma or adenoid cystic carcinoma.\u003c/p\u003e \u003cp\u003eAfter extensive discussion regarding progression of the malignancy and metastasis, he was referred to hematology-oncology and radiation-oncology for outpatient follow up after his hospital discharge. In the following months, the patient underwent several sessions of stereotactic radiotherapy. The patient continued to demonstrate progression of the metastatic disease and clinical deterioration. He had worsening respiratory failure requiring 4 to 6 liters of oxygen, additional 30\u0026ndash;40 lb weight loss, and diffuse uncontrolled pain. Follow up imaging showed progression of metastatic disease within the chest and increase in size and quantity of intracranial masses despite systemic therapy. At that time, the patient was not deemed a candidate for chemotherapy or further radiation therapy, and ultimately hospice was recommended.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSalivary duct carcinoma is commonly diagnosed at the middle to late stage of the disease course with local infiltration and distant metastasis. Due to its highly aggressive nature, there is rapid onset and progression to distant sites including the lung, brain, liver, bone and skin. SDC has propensity of extra-scapular spread with perineural and lympho-vascular invasion (Simpson, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Patients will present with a rapidly growing painful or painless neck mass with fixation to the overlying skin or muscle and presence of cervical lymphadenopathy. Local infiltration of parotid tumors has the potential to cause facial nerve paralysis with metastasis to the temporal bone. Submandibular tumors can invade the mandible which can involve the lingual and sublingual nerves and other surrounding tissue (Anwer et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Udager et al., 2017).\u003c/p\u003e \u003cp\u003eDiagnosis is made with imaging modalities including MRI, CT scan, and PET scan. Imaging is usually non-specific, although it assists with determining the extent of metastasis and the malignant nature of the tumor (Mlika et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Contrast enhanced CT and MRI scans will reveal ill-defined borders, local invasion into surrounding tissues, and necrosis (Schmitt et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Calcifications can also be detected which may be suggestive of an in situ pleomorphic adenoma and would require further workup to rule out differentials such as sialadenitis (Naguro et al., 2020). PET/ CT detects regional and distant metastases. Further pathological diagnosis depends on ultrasound guided fine needle aspiration or guided core biopsy followed by immunohistochemistry and histopathological studies to determine treatment course and prognosis (Schmitt et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImmunohistochemistry is necessary to distinguish SDC from morphologic mimics and further differentiate the tumors by their histologic features. SDC can histologically resemble invasive and intraductal metastatic breast cancer with apocrine expression, other salivary gland carcinomas, and metastatic squamous cell carcinoma (Udager et al., 2017). The morphology variants include papillary, basal-like, mucin-rich, sarcomatoid, micropapillary, and anaplastic findings (Eveson, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Syrnioti et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The most commonly seen morphological variant includes papillary-cribriform growth patterns (Schmitt et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Expression of immunomarkers varies according to the case and the variant, although positive results occur with the following: cytokeratins CK 5/6/7/14, epithelial membrane antigens (EMA), pankeratins, androgen receptors, S-100 protein from medial myoepithelial cells, and p40 and p63, p16, cancer proliferation marker Ki-67, CD 117, SOX-10, CAM5.2, GATA-3, and TTF-1 (Mlika et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Nakaguro et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Schmitt et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Udager et al., 2017). CK 7 is a marker indicative of glandular tissue which often used to differentiate salivary duct carcinoma from other metastatic disease since immuno-expression of CK 7 has positive immunoreactivity with most salivary gland malignancies (Chandrasekar et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). This patient\u0026rsquo;s immunohistochemistry showed positive staining for pankeratin, CK 5 and 7, p16, SOX-10, p63, p40, increased Ki-67 expression, CAM-5.2 and CD-117. Androgen receptor was negative. However, approximately 90% of SDC cases do have androgen receptor expression and 15 to 40% have HER-2 expression (Kantamini et al., 2021). HER-2 expression was not evaluated in this case. Of the morphology variants, the basal-like variants have positive basal-myoepithelial markers including CK 5, 6, 14 and p63 and negative androgen receptor expression (Simpson, 2014; Syrnioti et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Udager et al., 2017). Poor prognosis is associated with positive AR, and increased expression of Ki-67 is indicative of active cellular value consistent with higher malignancy and metastatic rates (Liu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Simpson, 2014).\u003c/p\u003e \u003cp\u003eSalivary duct carcinomas have a high incidence of recurrence and relapse, distant metastasis, and an overall poor prognosis despite aggressive treatment. Statistics have shown that up to 60% will expect a life expectancy of 5 years after the initial diagnosis despite treatment (Liu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Syrnioti et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Local recurrence or distant metastasis is approximately seen in 33% and 50% of the patients respectively and can occur within 2 to 3 years with associated multiorgan involvement (Liu et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Syrnioti et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Often times, many present with distant metastasis with a mean survival rate of 5 months despite following appropriate treatment guidelines (Matsumiya-Matsumoto, et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Per the National Comprehensive Cancer Network guidelines recommend complete surgical resection for major salivary gland tumors and ipsilateral neck dissection in addition to postoperative radiation therapy with or without adjuvant chemotherapy (Anwer et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Matsumiya-Matsumoto, et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Chemotherapy, commonly anti-androgen rather than cytotoxic, is considered for patients with distant metastases or palliatively (Kantamani et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Nakaguro, et al., 2018). Several studies reported use of androgen deprivation therapy with androgen receptor inhibitors as monotherapy or in combination with gonadotropin hormone-releasing hormone, luteinizing hormone-releasing agonists or HER-2 targeted therapy and a taxane (Eveson, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Matsumiya-Matsumoto, et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Immunotherapy and other targeted therapies are being considered as alternative or second line treatment strategies, although the studies are limited due to the rarity of the malignancy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSalivary duct carcinoma is a highly aggressive tumor with rapid progression, very poor prognosis, and high relapse rate despite surgical resection with adjuvant radiotherapy. Chemotherapy in SDC is considered controversial due to lack of efficacy in the late disease states and is primarily reserved for palliative purposes or in metastatic disease. Certain patients with positive apocrine expression such as HER-2 and androgen receptors may benefit from androgen deprivation therapy, cytotoxic chemotherapy, or immunotherapy in addition to recommended therapy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSalivary Duct Carcinomas\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT scan\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI scan\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging scan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePET scan\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePositron emission tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCytokeratins\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEpithelial Membrane Antigens\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHER-2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman epidermal growth factor receptor 2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOX-10\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSry-related HMg-Box gene 10\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCD-117\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecluster of differentiation 117\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEpstein-Barr virus-encoded RNA\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAndrogen Receptor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAX-8\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePaired-box gene 8\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTTF-1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThyroid transcription factor 1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDOG-1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiscovered on GIST1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGATA-3\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGATA Binding Protein 3\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSALL-4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSal-like protein 4\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eINI-1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntegrase interactor 1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBRG1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrahma-related gene-1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cb\u003eFinancial or non-financial Interests\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe authors declare that is no financial or non-financial conflicts of interest to disclose in preparation of this manuscript.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSources of Funding\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere is no financial funding to disclose. This research received no specific grant or any sources of funding from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from the participant for submission of the case report to the journal and publishing their data and photographs.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.I. wrote the main manuscript.A.S., N.B., S.B. and C.C. contributed to the manuscript text.F.F. and C.S. were part of the clinical team.J.C. prepared Figure 6. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAvailability of Data and Materials\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiu, F., Fan, L., Lu, L., Guo, H., Nan, J., \u0026amp; Han, F. (2023). 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Journal of oral and maxillofacial pathology: JOMFP, \u003cem\u003e20\u003c/em\u003e(3), 505\u0026ndash;509. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/0973-029X.190955\u003c/span\u003e\u003cspan address=\"10.4103/0973-029X.190955\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Salivary duct carcinoma, tobacco use, submandibular mass, cannon ball lesions, head and neck cancer, lung metastasis","lastPublishedDoi":"10.21203/rs.3.rs-3898801/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3898801/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSalivary duct carcinoma (SDC) is a rare, aggressive salivary gland tumor with a high rate of metastasis and overall poor prognosis. SDC is commonly diagnosed at stage 3 or stage 4 with progression to local, regional lymph nodes or distant metastatic disease predominantly to the lung, bone, brain or skin. The case presents a 44 year old with an unusual presentation of distant metastasis appearing as cannon ball lesions in the lungs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase presentation:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe patient is a 44 year old male tobacco user with a history of recent incarceration who presented with a several month history of weight loss and enlarging right neck mass. He was found to have multiple bilateral lung masses with brain metastasis on imaging. Biopsy of the neck mass was consistent with salivary duct carcinoma with a rare basal-like phenotype. The patient was ultimately treated with targeted radiotherapy palliatively; however, he was not a candidate for chemotherapy due to extensive disease burden. He declined clinically and was transitioned to hospice care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe case provides a new presentation of an atypical salivary duct carcinoma with bilateral cannonball disease on imaging in addition to a rare histopathologic variant originating likely from an ex pleomorphic adenoma. The basal-like variant was found to have differing gene expression compared to the most commonly seen histological types. Considering the expression noted, the findings provide further information on the expression pattern of basal-like SDC for future targeted therapy and also clarify concerns with accurate diagnosis in SDC in comparison to other morphologically similar malignancies.\u003c/p\u003e","manuscriptTitle":"Metastatic salivary duct carcinoma presenting as cannonball lung lesions on radiology: Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-06 16:44:38","doi":"10.21203/rs.3.rs-3898801/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5fa8ef4e-9a27-40cc-85c1-c6e253d9003e","owner":[],"postedDate":"February 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-23T07:45:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-06 16:44:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3898801","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3898801","identity":"rs-3898801","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}