Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 40, Num. 1, 2003, pp. 37-38

Indian Journal of Cancer, Vol. 40, No. 1, (January - March 2003) , pp. 37-38

Letter to Editor

Carcinoma of Esophagus with Unusual Metastasis to Gingiva and Phalanx

Dimri Kislay, Rastogi Neeraj, Lal Punita

Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow - 26014, India.
Correspondence to: Dr. Neeraj Rastogi. E-mail: nrastogi@sgpgi.ac.in

Code Number: cn03007

Sir,
A 60-year-old male with history of chronic tobacco chewing presented with progressive dysphagia of 5 months duration. Endoscopy revealed a non-negotiable growth starting at 30cms and histopathology showed squamous cell carcinoma. CT scans showed a circumferential lower-thirds esophageal growth, which was approximately 6cms long and without extra-esophageal spread or significant regional lymphadenopathy. The patient underwent transhiatal-esophagectomy. Operative and histopathologic findings revealed a 6cms long growth in the lower-third of esophagus with transmural extension. There was a satellite nodule in the middle esophagus and enlarged paracardiac lymph nodes, which were also positive for malignancy. In view of poor prognostic factors such as transmural extension and lymph node positivity, the patient was given post-operative external radiotherapy to a dose of 50.4Gy in 28 fractions at 1.8Gy per fraction by telecobalt. Two months following completion of radiotherapy, the patient presented with swellings in the upper gingiva and terminal phalanx of the little finger of right hand. The upper gingival swelling was firm, non tender and measured 4 x 2cms (Figure 1), while the swelling in the right little finger was soft, cystic 1.5 x 1.5cms in size (Figure 2). FNAC from both sites revealed squamous cell carcinoma. These 2 lesions were considered metastatic as they appeared simultaneously and were reported as squamous cell carcinoma on FNAC. For the same reason, the gingival lesion was not considered a second primary in the oral cavity. A subsequent metastatic work up did not reveal any other site of metastases. The patient was planned for palliative chemotherapy and radiotherapy to metastatic sites but they could not be given as the condition started deteriorating because of poor intake due to gingival tumor and he succumbed to disease within 1 month of diagnosis of metastasis.

Metastatic tumors to the oral region are uncommon and mostly located in the mandible, while only few are in the soft tissue of the oral cavity. Review of literature has revealed only 63 cases of gingival soft tissue metastasis with commonly encountered primary sites being lung, liver and kidney, of which lung was the commonest.² The prognosis of such cases is poor, as the disease has generally disseminated by the time gingival metastases are diagnosed. The median survival in these patients is quite dismal and it usually ranges from 2 to 3 months.² Esophageal carcinoma metastasizing to gingiva is uncommon and has been reported only once in the literature.³ Metastases to the digits of hand commonly arise from cancer of the lung, genito-urinary tract and breast.⁴ So far, only 2 cases of metastasis to the phalanx or digital pulp from an esophageal primary have been described.^4,5 Radiological evidence of bone involvement of the respective digit is either initially present or subsequently develops in approximately 90% of patients. These patients have a poor prognosis, with survival following the diagnosis of digital metastasis being only a few months.⁴

In conclusion, primary esophageal carcinoma metastasizing simultaneously to distal phalanx of hand and upper gingiva as reported here is an extremely rare presentation and is generally associated with a poor outcome.

Dimri Kislay, Rastogi Neeraj, Lal Punita

Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow - 26014, India.
Correspondence to: Dr. Neeraj Rastogi. E-mail: nrastogi@sgpgi.ac.in

References

1. Aisner J, Forastiere A, Aroney R. Patterns of recurrence for cancer of lung and esophagus. In: Wittes RE, editor. Cancer treatment symposia: Proceedings of the workshop on patterns of failure after cancer treatment. Washington DC: US Department of Health and Human Services; 1983. Vol 2. pp. 87.
2. Shimizu T, Nishimura T, Kaneko M, Morita T, Mizuno A, Sugiyama A. Metastatic tumours of the gingiva- report of 3 cases. Gan No Rinsho 1990;36:719-27.
3. Ide F, Shimoyama T, Haga H, Horie N. Basaloid squamous cell carcinoma of the esophagus metastatic to the gingiva: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:584-7.
4. Houston JD, Telepak RJ. An isolated digital metastasis of esophageal basaloid squamous cell carcinoma. Clin Nucl Med 2000;25:557-8.
5. Silfen R, Amir A, Tobar A, Hauben DJ. The digital pulp as a presenting site of metastatic esophageal carcinoma. Ann Plast Surg 2001;46:183-4.

Copyright 2003 - Indian Journal of Cancer

The following images related to this document are available:

Photo images