Squamous cell carcinoma of supraglottic larynx with metastasis to all five distal phalanges of left hand.

Subcutaneous metastasis from carcinoma larynx is a rare presentation and to the phalynx is the rarest. We herein describe a case report of carcinoma supraglottic larynx, which is involving all five distal phalanges of left hand with simultaneous metastases to lung and liver. Acrometastasis is an unusual presentation, which might mimic an infectious or inflammatory pathology. The brief report highlights the importance of clinical awareness of metastatic dissemination to unusual sites in the face of increasing cancer survivorship.

Introduction

Distant metastases in laryngeal carcinoma are rare and when present, most commonly involve the lung.[1] We report a rare case of laryngeal carcinoma presenting with metastases to all five distal phalanges of left hand with simultaneous metastasis to multiple sites after 2 years of receiving radical chemo-radiation to the head and neck region with complete local control.

Case Report

A 55-year-old man was diagnosed as a case of carcinoma supraglottic larynx (stage T4N1M0) in August 2007. Histopathology of primary site was squamous cell carcinoma, and fine needle aspiration cytology (FNAC) of neck node was also squamous cell carcinoma. The patient was planned for radical chemo-radiation after complete clinical and investigative workup. He received external beam radiotherapy (EBRT) using 6 MV Photon to a total dose of 66 Gy in 33 fractions over six and half weeks (from 07-08-2007 to 22-08-2007) with concurrent cisplatin chemotherapy at 3 weeks interval. At 1 month after completion of treatment, patient was free from disease both clinically and on direct laryngoscopic examination and kept on regular follow up. Patient presented after 2 years with complaints of swelling on tip of all fingers and nail bed of left hand [Figure 1], multiple subcutaneous nodule in upper and lower limb, and loss of appetite with significant weight loss. An FNAC from tip of fingers and subcutaneous swelling was suggestive of metastatic carcinoma [Figure 2]. Contrast-enhanced computed tomography (CECT) of chest, abdomen, and pelvis, revealed metastasis in bilateral lungs and liver [Figure 3a–b]. Local examination of neck and direct laryngoscopic examination was suggestive of no evidence of disease (NED)/essentially normal. In view of his very poor general condition and widespread dissemination of disease, the patient was offered palliative treatment only and he died within 2 months at home.

Figure 1

Metastatic swelling of all five distal phalanx of left hand

Figure 2

Photomicrograph showing cluster of malignant cells with extensive necrosis and apoptosis in background (Hematoxylin and eosin stain, original ×400)

Figure 3

(a) Multiple bilateral lungs metastases, (b) Multiple liver metastases

Discussion

The incidence of distant metastases in squamous cell carcinoma of head and neck (SCCHN) approaches 20%–25%. The most common sites of metastases are lung (70%–75%), liver (17%–38%), and bone (23%–44%).[2-4] Skin metastases has been reported to occur in 1%–2% of patients with SCCHN and account for fewer than 10% of all distant metastases.[5] Other malignancies associated with skin metastases include carcinoma of bronchus, breast, colon, and kidney. Cancers arising in the oral cavity are the commonest head and neck cancers metastasizing to skin.[6] Review of the surgical literature revealed only seven previously reported cases of cutaneous metastases from squamous cell carcinoma of the larynx.[78]

The site of skin metastases include neck, chest, scalp, face, lips, axilla, areola, back, arms, and digits, with the most common being the neck and chest.[79] It is evident on literature search that multiple metastases from a laryngeal carcinoma involving all five distal phalanges, bilateral lung, liver and multiple subcutaneous nodule in upper and lower extremities, as described above is not reported till date.

The exact mechanism of skin metastases in SCCHN is incompletely understood. Several hypotheses have been postulated. The skin metastases may evolve through three possible mechanisms, direct spread, local spread, and distant spread.[10] Direct extension is due to contiguous spread via tissue planes. Local spread can be ascribed to spread through dermal lymphatics with resultant implantation in the skin. Distant metastases are the result of hematogenous spread. This route of hematogenous spread could be either through pulmonary circulation or bypassing pulmonary circulation via azygous and vertebral venous plexus.[11] In the indexed case, the acrometastasis is most likely due to spread by hematogenous route via pulmonary circulation as the patient has multiple bilateral lung, liver, multiple subcutaneous nodules along with cutaneous phalangeal metastasis.

Cutaneous metastases from laryngeal carcinoma may present as non-tender firm nodules, as sclerodermoid lesions or may mimic an inflammatory process.[6] The diagnosis should be confirmed by cytology or histopathological examination of the lesions and in this case it was confirmed with a positive cytology report.

Treatment is essentially aimed at providing symptomatic relief and improving the quality of life. In solitary acral metastases, amputation of finger or localized radiation is recommended.[12] In the indexed case, the patient presented with disseminated disease with involvement of all five distal phalanges, so further treatment offered was essentially palliative as numerous metastases developed rapidly at different sites and because of poor general condition.

The prognosis for these patients remains dismal after diagnosis of distant cutaneous metastases. The indexed case, at initial presentation in 2007, had localized disease to supraglottic region with ipsilateral neck node involvement. Despite a disease-free interval of 2 years, the presentation with distant cutaneous metastases heralded rapid dissemination of the disease. This case underscores the importance of considering metastases in the differential diagnosis of a new swelling appearing in a patient previously treated for head and neck cancer.