|Year : 2015 | Volume
| Issue : 3 | Page : 666
Unusual metastatic presentation of carcinoma hypopharynx
D Niharika1, Sham Sunder1, Geeta S Narayanan1, Manjunath Nandennavar2
1 Department of Radiation Oncology, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bengaluru, Karnataka, India
2 Department of Medical Oncology, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bengaluru, Karnataka, India
|Date of Web Publication||9-Oct-2015|
Flat No. 106, Saptagiri Enclave, Achar Layout, Immidahalli Road, Whitefield, Bengaluru - 560 066, Karnataka
Source of Support: None, Conflict of Interest: None
Cutaneous metastases from hypopharyngeal cancers is rare constituting about 0.8-1.3% and represent a sub-group of head and neck cancer patients who have very poor prognosis even when treated. We report a case of 65-year-old male diagnosed as carcinoma hypo pharynx stage IV who was on radiotherapy when he developed cutaneous metastasis over the chest wall, which initially presented as small nodules and later progressed into a proliferative lesion. Patient received further radiation to the metastatic lesion, but the disease was progressive, demonstrating that head and neck squamous cell cancer patients with skin metastasis fare poorly.
Keywords: Chest wall metastasis, hypopharynx, prognosis
|How to cite this article:|
Niharika D, Sunder S, Narayanan GS, Nandennavar M. Unusual metastatic presentation of carcinoma hypopharynx. J Can Res Ther 2015;11:666
| > Introduction|| |
Hypo- and oro-pharyngeal malignancies constitute about 1.1% of all malignancies in the world and about 3.8% of all malignancies in India.  On an average 65-75% of tumors of hypopharynx arise from pyriform sinus, which is the most common sub site, 10-20% arise from the posterior pharyngeal wall, and 5-15% originate from the postcricoid region.  At least 50% of patients manifest clinically with positive cervical lymph nodes at the time of diagnosis. Treatment recommendations range from radical chemoradiation to palliative radiation or chemotherapy, depending on stage of disease and performance status of the patient.
| > Case report|| |
A 65-year-old male presented with swelling over the left side of neck since 3 months associated with pain for 1 month. Magnetic resonance imaging (MRI) scan of head and neck revealed a 3.2 cm × 2.2 cm × 1 cm lesion in the left pyriform sinus, the lesion was seen extending inferiorly up to the false vocal cords without involving the true cords, posteriorly the lesion involved the posterior pharyngeal wall from C5 to C6 vertebral level, crossing the midline and laterally it was seen to obliterate the left para-laryngeal space [Figure 1].
|Figure 1: Axial magnetic resonance imaging sections showing contrast-enhanced lesion in the left pyriform fossa|
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Multiple enlarged enhancing left side level II, III, and IV cervical lymph nodes and multiple subcentimetric bilateral cervical lymph nodes were also noted on MRI [Figure 2]. Histopathology from the primary lesion and node showed features suggestive of moderately differentiated squamous cell carcinoma (Grade 2), without lymphovascular space invasion and other risk features, rest of the metastatic workup, including clinical examination, chest radiograph, and ultrasound of the abdomen was normal. Patient was diagnosed as squamous cell carcinoma of hypopharynx stage IV (T2N2cM0). He was planned for radiotherapy to the primary and neck with no chemotherapy, in view of his age and performance status. One week after starting treatment patient developed multiple cutaneous nodules over the left chest wall; around six in number, with size ranging from 5 to 10 mm, these nodules gradually increased in size and coalesced to form an ulceroproliferative lesion of size 6 cm × 6 cm [Figure 3].
|Figure 2: Pretreatment axial magnetic resonance imaging section showing left level IV lymph node with discontinuous skin margins|
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|Figure 3: (a) Initial skin nodules over the chest wall. (b) 6 cm × 6 cm ulceroproliferative lesion over the left chest wall with cutaneous nodule over the upper edge|
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Biopsy from this lesion showed features of irregularly hyperplastic stratified squamous epithelium with areas of squamoid tumor cells focally involving the epidermis, the cells possessed moderate nuclear pleomorphism, prominent nucleoli and abundant cytoplasm, suggestive of moderately differentiated squamous cell carcinoma [Figure 4], without any risk features. Patient was planned and received palliative radiation of 2000 cGy in five fractions with 6 MV photons with bolus to the chest wall, with adequate dose coverage of the metastatic lesion. In view of his metastatic disease, the radiation to the primary and neck was also made palliative and he received 3000 cGy in 10 fractions to the primary and neck.
|Figure 4: (a) 4× resolution showing normal and discontinued epithelial margins. (b) 40× resolution showing irregular hyperplastic stratified squamous epithelium with areas of squamoid tumor cells|
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Following treatment patient had symptomatic relief at the primary site, but the chest wall metastatic lesion was progressive with appearance of new nodules over adjacent areas of irradiation. He was put on follow-up postradiation with supportive care, during which he expired 2 months in follow-up.
| > Discussion|| |
Etiology of hypopharyngeal malignancies shows a strong association with tobacco use, over 90% of patients with hypopharynx cancer report past history of cigarette smoking and approximately 20-25% of patients with hypopharynx cancer test positive for human papillomavirus DNA. Due to the rich lymphatic network in this anatomic region, patients commonly present with regional nodal metastases of 50%, jugular chain nodes, levels II through IV, as well as retropharyngeal nodes, are all at high-risk to harbor regional metastases. In parallel to cancers of the nasopharynx, retropharyngeal nodes may be the first site of nodal spread. Postcricoid tumors may also spread directly to pre- and para-tracheal nodal basins. Due to the high propensity for advanced primary disease as well as regional nodal involvement, the majority of hypopharynx cancer patients present with stage III and IV disease. Distant metastasis has incidence ranging from 4.3% to 30% in patients with head and neck squamous cell carcinoma.  Common metastatic sites involved in order of incidence are lungs (36.4%), bone (34.0%), and liver (23.8%).  Head and neck carcinomas rarely metastasize to the skin, which constitutes about 0.8-1.3%. Metastases to the chest wall from hypopharyngeal malignancies are extremely rare, which is most commonly due to hematogenous spread through seed and soil hypothesis,  however lymphatic spread cannot be ruled out. The prognosis of such cases is extremely poor,  and treatment is aimed only at palliation of symptoms and improving the quality of life.
In one of the largest series of head and neck cancers reported, Spector et al.  identified 2550 patients with squamous cell carcinomas of the larynx and hypopharynx treated in a single center over two decades. Among 1667 patients of carcinoma larynx and 853 patients of hypopharynx (408 are pyriform sinus), 16.3% of hypopharyngeal patients reported distant metastases which is more than twice as high as that of laryngeal cancers (7.3%). Most common distant sites are the lung, bone, skin, and central nervous system.
In the study conducted in Eastern Taiwan,  to evaluate the clinical manifestations and possible risk factors for distant metastases in the head and neck squamous cell carcinoma patients results suggested that the overall incidence of distant metastases was 20% among 735 patients enrolled in the study. Most frequent sites of metastases are to lungs (36.4%), bone (34%), liver (23.8%) and it is dependent on the stage of the primary tumor, loco regional control and the tumor site. Among head and neck malignancies which metastasize to skin, hypopharyngeal tumors contributed about 1%, oral cavity tumors 5%, other pharyngeal tumors 1%. They concluded that advanced stage carcinomas need more aggressive treatments for loco regional control and distant failure, and also prognosis of these patients is poor.
Doweck et al.,  in their study on the analysis of risk factors predictive of distant failure after targeted chemoradiation for advanced head and neck cancers concluded that patients with more than one level of clinical nodal involvement and those with hypopharyngeal carcinoma have the highest risk of developing distant metastasis as the initial site of failure. Survival of head and neck patients with distant metastasis is in the range of 4-16 months.
Our patient also presented with stage IV hypopharyngeal carcinoma, which metastasized as ulcerative cutaneous nodules over the left chest wall when the patient was being treated for the primary disease; this demonstrates the aggressive nature of the disease. Even though, the patient received palliative radiation his survival was just 2 months posttreatment, though there is a partial response of the disease after radiation.
| > Conclusion|| |
Hypopharyngeal cancer patients fare poorly compared to other head and neck tumors. Prognosis of the patient depends mainly on the age at presentation, primary tumor site, genetic mutations and personal habits. Cutaneous metastasis in hypopharyngeal cancers is extremely rare (about 1%), and this is accompanied with poor outcome with average survival of 3 months after developing skin metastasis.
| > Acknowledgments|| |
I take this opportunity to thank my professors Dr. Geeta. S. Narayanan, Dr. Bhaskar Viswanathan, Dr. Bhanumathy; Medical oncologists Dr. Shashidhar. V. Karpurmath, Dr. Manjunath Nandenavvar; Surgical oncologists Dr. Ganesh and my collegues Dr. Kavitha, Dr. Satyesh Nadella, Dr. Naveen, Dr. Mallik, Dr. Shravan, Dr. Santosh, Dr. Rajshree and Dr. karthik for their support.
| > References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]