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Journal of Postgraduate Medicine, Vol. 48, Issue 1, 2002 pp. 32-33 Cutaneous Metastasis from Carcinoma of Tonsil Dasmajumdar SK, Gairola M, Sharma DN, Mohanti BK Department of Radiation Oncology, All India Institute of Medical Sciences,
New Delhi - 110 029, India. Code Number: jp02009 Abstract: Hematogenous spread from carcinoma of tonsil is an uncommon event and skin is an extremely rare site of metastasis. We encountered a 40 year old male patient who initially presented with carcinoma of the tonsil with T3N2cMO disease and treated by curative radiotherapy. After about 2 years, he developed a skin lesion in the periorbital region which on cytological examination turned out to be metastasis from tonsillar carcinoma. The present paper describes this rare case report along with a brief review of the literature. Key Words: Tonsil, carcinoma, cutaneous metastasis. Carcinoma of palatine tonsil accounts for 10% of all head and neck epithelial cancers.1 Like most head and neck cancers, tonsillar carcinomas remain confined to above clavicles. Besides local spread, neck node metastasis is the usual mode of spread. About 75-80% patients with advanced tonsillar carcinoma have lymph node metastases at the time of presentation.1 The incidence of distant metastasis is, though, rare, rises with neck node metastasis. The common sites of metastasis are lung, liver and bone.2 Cutaneous metastasis is extremely rare. We report a case of carcinoma of tonsil with metastasis to periorbital skin.
Case History A 40 years old male, chronic smoker, presented to our head and neck cancer clinic in July 1998 with chief complaints of pain during swallowing of three months duration and bilateral neck swellings of one-month duration. He was well built but poorly nourished. His Karnofsky Performance Score (KPS) was 80. Examination of the oral cavity revealed an ulceroproliferative growth of approximately 5.0 cm size involving the left tonsillar fossa, both anterior and posterior pillars, soft palate and left side of base of tongue. There were bilateral, multiple, hard, discrete, partially mobile nodes present with normal overlying skin. Histopathological examination of the biopsy from tonsillar growth showed well-differentiated squamous cell carcinoma. All the baseline investigations including complete hemogram, liver function test, renal function test, X-ray chest, were well within normal limits. In view of the above findings patient was diagnosed as a case of carcinoma of left tonsil T3 N2c MO (AJC 1997) stage IVB. He was treated with external radiotherapy with a dose of 70 Gy in 35 fractions in 7 weeks on Cobalt-60 teletherapy machine using lateral opposing fields to face and neck. Patient tolerated radiotherapy well and was advised to attend head and neck cancer clinic regularly for follow up. He was disease free for about 2 years and in September 2000 he reported with the complaint of a swelling in the left periorbital region (Figure). There was no sign of recurrence at the local or nodal site. Fine needle aspiration cytology of the swelling revealed metastatic squamous cell carcinoma, which was consistent with primary squamous cell carcinoma of tonsillar region. Considering the advanced and metastatic nature of the disease, patient was managed by palliative course of radiotherapy to the periorbital lesion with a dose of 20 Gy/5F/l week by 12 MeV electron beam. The swelling showed about 50% regression in size when patient was last seen in January 2001. Discussion The frequency of cutaneous metastasis from internal malignancies varies from 0.7 to 9% of all cancer patients.3 It is very rare from cancers of head and neck region. Though it is general assumption that cutaneous metastasis indicates poor prognosis for the patient, information is lacking regarding the survival and the proper treatment of this group of patients. Berger et al4 in their study reported that length of survival was approximately three months after skin metastasis become clinically evident in head and neck cancer. Other primary tumor such as breast carcinoma is associated with prolonged clinical course after skin metastasis. There are very few reports in the literature about the skin metastasis from head and neck cancer. Veraldi et al,5 noted the rarity of skin metastasis from laryngeal cancers. A review of literature showed only 12 cases of skin metastasis from primary epidermoid carcinoma of larynx. We could not find any such series/reports in the literature on the dermal metastasis from carcinoma of the tonsil. In view of the metastatic nature of the disease, the treatment of these patients is, in general, palliative. Whatever the nature of the primary lesion, the course of the disease or the treatment(s) administered, it appears that skin metastasis is an equalizing factor for all patient groups in carcinoma of the head and neck; all patients do poorly and succumb rapidly to their disease. Our patient has a short follow up of 4 months after the treatment of skin metastasis, it is difficult to predict the longevity of survival, but he will be curiously followed up to know the course of such rare disease entity.
References
This article is also available in full-text from http://www.jpgmonline.com/ © Copyright 2002 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp02009f1.jpg] |
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