Download Atypical metastases from squamous cell cancers

Grand Rounds Vol 2 pages 43–45
Speciality: Oncology
Article Type: Case report
DOI: 10.1102/1470-5206.2002.0008
c 2002 e-MED Ltd
GR
Atypical metastases from squamous cell
cancers
J. Stebbing, J. Crane, A. S. Greenstein and D. G. Ezra
University College Hospital, London, WCE1 6JF, The Royal London Hospital,
Whitechapel Road, Whitechapel, London E1 1BB, UK
Corresponding address: Dr Daniel Ezra, 12a Sunningfields Crescent, London, NW4 4RD, UK.
E-mail: daniel [email protected]
Date accepted for publication March 2002
Abstract
Relapse of squamous cell carcinomas usually occurs in a predictable pattern. We present
two patients with rare metastases. The first developed peritoneal disease without evidence of
intra-thoracic spread due to a laryngeal cancer. The second, a patient with a vulval squamous
tumour was presented with distant disease following foot pain.
Keywords
Carcinoma; laryngeal carcinoma; vulval carcinoma; metastases.
Case reports
Patient 1
A 61-year-old man presented with one month of lymphadenopathy in the right side of his neck
without systemic symptoms. He smoked 20 cigarettes a day and drank 40 units/week of alcohol.
A fine needle aspiration and biopsy confirmed Laryngeal squamous cell carcinoma. A subsequent
CT scan demonstrated a pyriform fossa lesion with endoscopy showing that this extended into the
right lingual tonsil. A radical neck dissection was performed and the patient went on to receive
radiotherapy.
Three months following this treatment a 1 cm soft swelling on the right buccal mucosa was
confirmed to be a recurrent squamous carcinoma. At this time, he was suffering with weight loss,
nausea and on examination, had abdominal ascites with no lymphadenopathy. A chest X-ray was
normal although a CT scan of his abdomen demonstrated peritoneal thickening. Paracentesis of this
abdominal fluid revealed numerous squamous cell carinoma cells (Fig. 1). He thereafter declined
further treatment and died 4 months after initial diagnosis.
Patient 2
A 53-year-old woman presented with increasing abdominal distension. After preliminary
investigations, she underwent laparotomy with bilateral salpingo-oophorectomy and omentectomy
revealing a stage Ia grade 2 right ovarian papillary mucinous cystadenocarcinoma.
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44
J. Stebbing et al.
Fig. 1. Ascitic fluid (× 100) demonstrating numerous large squamous cells with hyperchromatic and pleomorphic nuclei.
Smaller mesothelial cells, polymorphs and macrophages can also be seen.
Fig. 2. Plain radiograph of the right ankle (left) revealing almost complete lytic destruction with cortical erosion of the
distal tibia, calcaneus and talus by tumour. Bone scan showing increased tracer uptake in the right foot bones, most
obviously the calcaneum. The right tibia and possibly the mid-shaft of the left femur also appears to be affected.
She received 6 cycles of carboplatin as surgical clearance was technically difficult and thought
to have been incomplete. Her CA 125 normalised and 8 months later a squamous cell carcinoma
of the vulva was diagnosed and completely excised. A bilateral lymph node dissection showed no
lymph node involvement but excision margins were narrow.
Eighteen months later she noticed increasing pain in the right foot and a destructive lesion of the
calcaneum was identified, biopsy of which showed squamous cell carcinoma consistent with the
vulval lesion (see plain X-ray and bone scan in Fig. 2). The calcaneum was treated with 15 fractions
of radiotherapy leading to symptomatic improvement. The bony disease has however progressed
and further radiotherapy is being considered.
Discussion
Laryngeal squamous cell carcinoma spreads locally with the majority of distant metastases
presenting in the lung. There are several documented cases of bone and cutaneous secondaries,
which were associated with a poor prognosis[1, 2] . Cancer of the vulva most frequently relapses
locally and the most frequent sites of metastases are the vertebral column, particularly the lumbar
spine followed by the pelvic bones[3] . The staging and survival of these carcinomas are included in
Tables 1 and 2.
The peritoneal and bone diseases presented here were associated with a poor prognosis, possibly
reflecting a more aggressive phenotype in spite of the disease stage. Immunohistochemical and
Atypical metastases from squamous cell cancers
45
Table 1: Supraglottic Laryngeal
squamous cell carcinoma 5-year
survival, age adjusted by extent (T).
Stage
T1
T2
T3
T4
5-year survival %
100
95
90
70
Table 2: Vulval squamous cell carcinoma, 5-year survival, age adjusted.
Stage
I
II
III
IV
5-year survival %
91.1
80.9
484
15.3
molecular analysis has shown that mutation of the tumour suppressor gene p53 may be indicative
of an unfavourable prognosis with a reduced overall survival[4] .
Lesson
These cases emphasize the importance of being vigilant to unusual presentations of metastatic
disease. Furthermore their occurrence at these sites may indicate that improved attempts to control
disease locally can result in the development of distant metastases. Local control of the disease in
the primary site affecting the natural history of tumour growth appears to be the most likely cause
of the subsequent distant presentation of disease[5] .
References
1. Loughran CF. Bone metastases from squamous-cell carcinoma of the larynx. Clin Radiol 1983;
34: 447–50.
2. Bhandarkar P, Green KM, de Carpentier JP. Multiple cutaneous metastases from laryngeal
carcinoma. J Laryngol Otol 1997; 111: 654–5.
3. Rhodes CA, Cummins C, Shafi MI. The management of squamous cell vulval cancer: a
population based retrospective study of 411 cases. Br J Obstet Gynaecol 1998; 105: 200–4.
4. Chen HY, Hsu CT, Lin WC, Tsai HD, Chang WC. Prognostic value of p53 expression in stage 1B1
cervical carcinoma. Gynecol Obstet Invest 2000; 49: 266–71.
5. Yucel OT, Yilmaz T, Unal OF, Turan E. Distant metastases in laryngeal squamous cell carcinoma.
J Exp Clin Cancer Res 1999; 18: 285–7.