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E-JCRT CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 3  |  Page : 655

Apropos of a case of cutaneous metastasis from laryngeal cancer with review of literature


1 Department of Radiotherapy and Oncology, Government Medical College and Hospital, Chandigarh, India
2 Department of Pathology, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication9-Oct-2015

Correspondence Address:
Divya Khosla
Department of Radiotherapy and Oncology, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.143348

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 > Abstract 

Cutaneous metastasis from laryngeal carcinoma is a rare occurrence. A 55-year-old male patient with supraglottic cancer was treated with concurrent chemoradiation. Eighteen months later, he presented with ulceroproliferative growth on dorsum of the right hand. Biopsy revealed metastatic squamous cell carcinoma. Further investigations revealed underlying bone destruction with lung metastasis. In view of poor general condition and widespread dissemination of disease, palliative radiotherapy was delivered to the hand of the patient. He achieved satisfactory palliation in form of pain relief, control of bleeding, and discharge. The present report serves to emphasize the importance of properly diagnosing metastatic spread to unusual sites. Such metastasis is rare and is associated with a poor prognosis. Treatment is usually aimed at providing pain relief in these patients with limited life expectancy. Hence, we present a case of extensive cutaneous metastasis from laryngeal carcinoma with review of the literature.

Keywords: Cutaneous metastasis, laryngeal cancer, palliation, prognosis, treatment


How to cite this article:
Trehan R, Pandey AK, Khosla D, Dimri K, Punia RS. Apropos of a case of cutaneous metastasis from laryngeal cancer with review of literature. J Can Res Ther 2015;11:655

How to cite this URL:
Trehan R, Pandey AK, Khosla D, Dimri K, Punia RS. Apropos of a case of cutaneous metastasis from laryngeal cancer with review of literature. J Can Res Ther [serial online] 2015 [cited 2019 Nov 17];11:655. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/655/143348


 > Introduction Top


Cutaneous metastasis is a rare entity itself, representing <10% of all distant metastasis. [1] In squamous cell carcinoma (SCC) of head and neck, skin metastasis has been reported in only 1-2% of patients. [2] Distant metastasis from SCC of the larynx occurs mainly through hematogenous route and the most common sites involved are lung, liver, and bones. Skin metastasis is rare and signifies poor prognosis. We report a rare presentation of cutaneous metastasis with underlying bone destruction and lung metastasis in the patient of laryngeal cancer with controlled primary disease.


 > Case report Top


A 55-year-old male, farmer by occupation, who was a chronic smoker, presented with a history of hoarseness of voice and difficulty in swallowing in October 2010. Patient was diagnosed as a case of supraglottic laryngeal cancer with T3N0M0 stage. Histopathology from the lesion revealed moderately differentiated SCC. Patient received external beam radiation therapy using cobalt-60 to a total dose of 66 Gy in 33 fractions over 6½ weeks along with weekly cisplatin. Patient completed treatment without any interruption and had a complete clinical response. However, at 18 months follow-up, he presented with generalized weakness and an ulceroproliferative growth over dorsum of the right hand with edema and multiple subcutaneous nodules on right forearm [Figure 1]a. A biopsy from growth revealed tumor cells in deep dermis arranged as nests and islands with brisk mitosis and areas of necrosis [Figure 1]b. Diagnosis of metastatic carcinoma was made X-ray of the hand revealed underlying bone destruction [Figure 1]c. X-ray of the chest revealed bilateral multiple lung metastases [Figure 1]d. Ultrasound of the abdomen was normal. Local examination of the primary site showed no evidence of disease. The lesion was rapidly progressive. In view of poor general condition and widespread dissemination of disease, a single 6 Gy fraction of palliative radiotherapy was delivered to the hand of the patient. The patient achieved satisfactory palliation in form of pain relief, control of bleeding, and discharge.
Figure 1: (a) Photograph showing ulceroproliferative growth over dorsum of the right hand with multiple subcutaneous nodules. (b) Microphotograph of the biopsy showing a moderately differentiated squamous cell carcinoma. The tumor cells are showing occasional cytoplasmic clearing and intracytoplasmic keratin. Brisk mitotic activity is seen (H and E, ×400) (c) X-ray of the hand showing destruction of underlying bones. (d) Chest X-ray showing bilateral lung metastasis

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 > Discussion Top


Squamous cell carcinoma is responsible for 95% of laryngeal cancer in adults and is the most common tumor of the upper respiratory tract. Most common sites of distant metastasis from SCC of head and neck are lungs (70-75%), liver (17-38%), and bone (23-44%). [3] Skin metastasis from laryngeal cancer is rare. To the best of our knowledge, eleven cases of skin metastasis from laryngeal carcinoma have been reported in the literature. [4-14] The age of patients ranged from 58 to 75 years. All the patients were males. Time period between initial diagnosis and appearance of skin metastasis was within 2 years in most of the cases. In one case, skin metastasis appeared 5 years after initial diagnosis. [8] Majority of patients had metastasis at other sites also, mainly lung metastasis. Hence, the treatment intent was generally palliative in the form of pain management or palliative radiotherapy. Veraldi et al. [4] reported a case of skin metastasis from laryngeal carcinoma in which nodules were localized to the forehead and left arm. Horiuchi and Tagami [5] reported a case of subcutaneous nodules on abdomen in 64-year-old patient of laryngeal carcinoma. Debois [6] reported a case of skin metastasis few months after treatment in laryngeal cancer patient. Bhandarkar et al. [7] described a case of multiple cutaneous metastases from laryngeal cancer. Bottoni et al. [8] reported inflammatory cutaneous metastasis on right supra and infra clavicular region in 64-year-old patient of laryngeal cancer after 5 years of treatment. Shamsadini et al.[9] described a case of unilateral grouped nodules on shoulder in 58-year-old patient of laryngeal carcinoma after 9 months of primary treatment. Aydin et al.[10] reported a mass in the left hand of the patient of laryngeal carcinoma after 18 months of primary treatment. Krunic et al. [11] reported a case of skin metastasis with infradiaphragmatic presentation in a patient of laryngeal carcinoma. Ramin et al.[12] reported a case of cutaneous nodules on left buttock in 75-year-old male 18 months after treatment. Patient also had lung metastasis. Kavgaci et al. [13] reported a case of laryngeal carcinoma with knee and heel skin metastasis. Kumar et al. [14] reported a case of multiple subcutaneous nodules in upper and lower limb and at tip of fingers and nail bed in a patient of laryngeal carcinoma 2 years after treatment.

The mechanism responsible for the deposition of metastatic tumor cells within the hand is unclear, but an increase in blood flow or trauma has been suggested in the past. Healey et al. [15] reported that most of the patients acquire lesion in the dominant hand, and our patient also developed lesion in the dominant hand. It is assumed to be the result of dominant hand receiving larger quantity of blood and more prone to trauma than nondominant hand.

Distant spread as a result of hematogenous spread could be through pulmonary circulation. In this case, it may be the same route as patient has bilateral lung metastasis. Treatment intent in such cases is mainly palliation and is aimed at providing symptomatic relief.

We are reporting this case as the first case, in which extensive skin metastasis is associated with underlying bone involvement with very aggressive disease course in which disease progressed in just 2 weeks. We also emphasize the importance of properly diagnosing metastatic spread to unusual sites. The high prevalence of laryngeal cancer and rarity of such presentation makes this case report important and informative.


 > Conclusion Top


Cutaneous metastasis from laryngeal carcinoma is a rare presentation and is associated with poor prognosis. The cooperation of the oncologist, dermatologist, and pathologist is imperative for the accurate diagnosis and the avoidance of overtreatment. Due to poor prognosis, patients should be treated with the aim to improve the quality of life and palliate symptoms.

 
 > References Top

1.
Brenner S, Tamir E, Maharshak N, Shapira J. Cutaneous manifestations of internal malignancies. Clin Dermatol 2001;19:290-7.  Back to cited text no. 1
    
2.
Shingaki S, Suzuki I, Kobayashi T, Nakajima T. Predicting factors for distant metastases in head and neck carcinomas: An analysis of 103 patients with locoregional control. J Oral Maxillofac Surg 1996;54:853-7.  Back to cited text no. 2
    
3.
Calhoun KH, Fulmer P, Weiss R, Hokanson JA. Distant metastases from head and neck squamous cell carcinomas. Laryngoscope 1994;104:1199-205.  Back to cited text no. 3
    
4.
Veraldi S, Cantu A 2 nd , Sala F, Schianchi R, Gasparini G. Cutaneous metastases from laryngeal carcinoma. J Dermatol Surg Oncol 1988;14:562-4.  Back to cited text no. 4
    
5.
Horiuchi N, Tagami H. Skin metastasis in laryngeal carcinoma. Clin Exp Dermatol 1992;17:282-3.  Back to cited text no. 5
    
6.
Debois JM. Skin metastases from a laryngeal carcinoma: Report of a case. Cutis 1996;57:264-6.  Back to cited text no. 6
    
7.
Bhandarkar P, Green KM, de Carpentier JP. Multiple cutaneous metastases from laryngeal carcinoma. J Laryngol Otol 1997;111:654-5.  Back to cited text no. 7
    
8.
Bottoni U, Innocenzi D, Mannooranparampil TJ, Richetta A, Del Giudice M, Calvieri S. Inflammatory cutaneous metastasis from laryngeal carcinoma. Eur J Dermatol 2001;11:124-6.  Back to cited text no. 8
    
9.
Shamsadini S, Taheri A, Dabiri S, Damavandi KF, Salahi S. Grouped skin metastases from laryngeal squamous cell carcinoma and overview of similar cases. Dermatol Online J 2003;9:27.  Back to cited text no. 9
    
10.
Aydin O, Ustündag E, Boyaci Z, Müezzinoglu B. Skin metastasis: an unusual localization from laryngeal carcinoma. Kulak Burun Bogaz Ihtis Derg 2004;12:103-6.  Back to cited text no. 10
    
11.
Krunic AL, Cockerell CJ, Truelson J, Taylor RS. Laryngeal squamous cell carcinoma with infradiaphragmatic presentation of skin metastases. Clin Exp Dermatol 2006;31:242-4.  Back to cited text no. 11
    
12.
Ramin A, Mohammad HT, Mohammad JG, Bijan A. Skin metastasis: A rare localization from laryngeal carcinoma and overview of similar cases. Indian J Dermatol 2009;54:S5-7.  Back to cited text no. 12
    
13.
Kavgaci H, Yildiz B, Cobanoglu U, Fidan E, Ozdemir F, Aydin F. Laryngeal squamous cell carcinoma with knee and heel skin metastases: A case report. Acta Dermatovenerol Croat 2010;18:32-4.  Back to cited text no. 13
    
14.
Kumar N, Bera A, Kumar R, Ghoshal S, Angurana SL, Srinivasan R. Squamous cell carcinoma of supraglottic larynx with metastasis to all five distal phalanges of left hand. Indian J Dermatol 2011;56:578-80.  Back to cited text no. 14
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15.
Healey JH, Turnbull AD, Miedema B, Lane JM. Acrometastases. A study of twenty-nine patients with osseous involvement of the hands and feet. J Bone Joint Surg Am 1986;68:743-6.  Back to cited text no. 15
    


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