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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 73-75

Solitary cutaneous metastasis in the palmer aspect of the hand, along with pulmonary metastasis: A rare presentation in an early laryngeal primary and review of literature


Department of Radiotherapy, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission09-Jan-2020
Date of Decision05-Apr-2020
Date of Acceptance23-Apr-2020
Date of Web Publication17-Aug-2020

Correspondence Address:
Mrinalini Verma
Department of Radiotherapy, King George's Medical University, Lucknow - 226 013, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/oji.oji_1_20

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  Abstract 


Cutaneous metastasis from head-and-neck cancer is extremely rare, reported in 1%–2% of patients. We report the case of a 67-year-old male with squamous cell carcinoma of epiglottis, who was treated with concurrent chemoradiotherapy. However, the patient developed metastatic nodule on the right palm proven by fine-needle aspiration cytology along with lung metastasis after 8 months of treatment completion despite the complete resolution of carcinoma at the primary site. In view of metastatic disease with poor functional status and controlled primary, he was started on weekly injectable methotrexate, palliative radiotherapy (RT) to palmar nodule with other measures of palliative care. However, he succumbed to disease after 8 months of postpalliative RT. This case report highlights that a seemingly curable disease within the larynx could take an aggressive turn in the form of lung metastasis and solitary palm nodule.

Keywords: Cutaneous metastasis, laryngeal primary, palm, pulmonary


How to cite this article:
Verma M. Solitary cutaneous metastasis in the palmer aspect of the hand, along with pulmonary metastasis: A rare presentation in an early laryngeal primary and review of literature. Oncol J India 2020;4:73-5

How to cite this URL:
Verma M. Solitary cutaneous metastasis in the palmer aspect of the hand, along with pulmonary metastasis: A rare presentation in an early laryngeal primary and review of literature. Oncol J India [serial online] 2020 [cited 2020 Sep 24];4:73-5. Available from: http://www.ojionline.org/text.asp?2020/4/2/73/291899




  Introduction Top


Distant metastasis from laryngeal cancer occurs mainly through the hematogenous route, and the most common sites are lung, liver, and bones. Cutaneous metastasis from head-and-neck cancer is a rare occurrence, reported in 1%–2% of patients.[1] Skin metastasis is often associated with other visceral metastasis and signifies poor prognosis. Locoregional site, chest and abdomen are the common sites for skin metastasis in head and neck squamous carcinoma, however, the metastasis to skin of the hand is further rare. We report a rare presentation of cutaneous metastasis to the palmar aspect of the hand and lung metastasis in the patient of carcinoma epiglottis treated with chemoradiation.


  Case Report Top


A 67-year-old male chronic smoker and tobacco chewer with no known medical risk factors presented in the outdoor clinic with complaints of difficulty in swallowing and pain in the right side of the neck for the past 2 months. He was investigated by contrast-enhanced computed tomographic (CECT) scan of the face and neck, direct laryngoscopy with biopsy, and diagnosed as a case of moderately differentiated squamous cell carcinoma (SCC) of epiglottis bulky CT2N0M0. Other routine checkups including hemogram and liver and kidney function tests with X-ray chest were within the normal limits. He was planned for radiotherapy (RT) with a radical dose of 66 Gy in 30 fractions in 6 weeks with intensity-modulated RT technique on X-6MV Linear accelerator with concurrent weekly cisplatin (35 mg/m2). He received the planned treatment without any treatment gaps. During treatment, he lost 3 kg of weight, that is, 5% of the baseline weight. He was on regular follow-up and doing fine with no residual primary disease on the direct laryngoscopy. After 8 months of completion of treatment, he presented with the right side chest pain for the past 15 days with a visual analog scale score of 8 and a nodule over the palmar aspect of the right hand [Figure 1]. On direct laryngoscopy, there was no residual primary disease. Palmar nodule was of 3 cm × 2 cm in size, firm in consistency with clearly defined margin and bleed on touch. The patient denied any history of trauma. X-ray chest and followed by CECT scan chest showed multiple pleural deposits and rib destruction with multiple bilateral parenchymal nodules and multiple mediastinal nodules. Fine-needle aspiration cytology from palm nodule showed metastatic deposits of epithelial malignancy (SCC) [Figure 2]. In view of metastatic disease with Karnofsky performance scale of 70 and controlled primary disease, he was planned for weekly injectable methotrexate with other measures of palliative care including pain management. On methotrexate and pain management, the patient became comfortable, his weight improved during this period; there was progression of palm nodule and it started bleeding, so was planned for palliative RT with a dose of 20 Gy in 5 fractions over a period of 1 week. He responded to palliative RT at the palmer site in terms of achieved pain relief, control of bleeding, and discharge. The patient succumbed to disease (florid lung metastasis) at home after 8 months of postpalliative RT.
Figure 1: Gross view of palm nodule metastasis

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Figure 2: Pathological view of palm nodule metastasis

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  Discussion Top


We present a case of carcinoma supraglottic larynx (early disease) which following treatment, threw a metastasis to skin after 8 months of completion of treatment. The cutaneous metastatic presentation was rare and was associated with spread to the lungs. Several theories are suggested to explain the mechanism responsible for the deposition of metastatic tumor cells within the skin. One school of thought is deterioration of lymphatic drainage and residual tumor cell in the skin after radical treatment for primary tumor.[2],[3] Hematogenous spread through pulmonary circulation could be another possibility, and our case had lung metastasis, which may be a possible explanation for such cutaneous metastasis.[4] Retrograde communication between thoracic-abdominal lymphatics is another possible mechanism.[2] Review of literature revealed that only a few cases of cutaneous metastases from SCC of the larynx have been published in English literature.[1],[3],[5],[6],[7],[8],[9],[10] In all these cases, the age of patients ranged from 58 to 76 years, and all were males. The appearance of skin metastasis was within 2 years after initial diagnosis in most of the cases. Trehan et al. reported cutaneous metastasis over the dorsum of the right hand along with multiple subcutaneous nodules on the right forearm at 18-month follow-up for a treated case of supraglottic cancer.[1] Das et al. in a report found multiple cutaneous metastases after 3 months of completion of treatment for SCC of the vocal cord.[7] One case had skin metastasis after 4 years of primary surgical treatment.[11] Skin metastasis usually is a harbinger of spread elsewhere, that is, it may represent locoregional recurrence or suggest distant metastasis. Skin metastases from SCC of the larynx are mainly reported in the supradiaphragmatic area, that is, the head and neck, thorax, or upper extremities. Skin metastasis to infradiaphragmatic area is rarer.[3],[5]

Isolated skin metastasis may consider for local wide excision in curative intent, which may increase the survival time.[7] As majority of patients in the reported series had metastasis at other sites as well, hence the treatment was generally palliative in the form of pain management and palliative RT, as in our case. Prognosis is usually very poor in patients of laryngeal cancer with skin metastasis, and survival is quite short in these cases, and 90% of patients died within a median time of 3 months of clinically evident skin metastasis.[3],[5],[6],[7],[8],[9],[10]

Our case is a unique one due to several accounts such as the initial disease was small (T2) with no nodal disease; the disease took an aggressive turn and spread rapidly to both lungs and skin; solitary cutaneous metastasis in the palm is extremely rare; and the patient remained free of disease locally, till the very last.

To conclude, a seemingly curable disease within the larynx took an aggressive turn and spread to lungs and solitary palm nodules. As would be expected in such rare case scenario, the patient succumbed to the disease within 8 months despite cancer-directed therapy in palliative settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Trehan R, Pandey AK, Khosla D, Dimri K, Punia RS. Apropos of a case of cutaneous metastasis from laryngeal cancer with review of literature. J Cancer Res Ther 2015;11:655.  Back to cited text no. 1
    
2.
Yoskovitch A, Hier MP, Okrainec A, Black MJ, Rochon L. Skin metastasis in squamous cell carcinoma of the head and neck. Otolaryngol Head Neck Surg 2001;124:248-52.  Back to cited text no. 2
    
3.
Kavgaci H, Yildiz B, Cobanoglu U, Fidan E, Ozdemir F, Aydin F. Laryngeal squamous cell carcinoma with knee and heel skin metastases: A case report. Acta Dermatovenerol Croat 2010;18:32-4.  Back to cited text no. 3
    
4.
Schoenlaub P, Sarraux A, Grosshans E, Heid E, Cribier B. Survival after cutaneous metastasis: A study of 200 cases. Ann Dermatol Venereol 2001;128:1310-5.  Back to cited text no. 4
    
5.
Ramin A, Mohammad HT, Mohammad JG, Bijan A. Skin metastasis: A rare localization from laryngeal carcinoma and overview of similar cases. Indian J Dermatol 2009;54:S5-7.  Back to cited text no. 5
    
6.
Kumar N, Bera A, Kumar R, Ghoshal S, Angurana SL, Srinivasan R. Squamous cell carcinoma of supraglottic larynx with metastasis to all five distal phalanges of left hand. Indian J Dermatol 2011;56:578-80.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Das K, Krishnatreya M, Baishya N, Sarma A, Kataki AC. Multiple cutaneous metastases in laryngeal carcinoma: A rare occurrence. Clin Cancer Investig J 2014;3:533-5.  Back to cited text no. 7
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8.
Kumar N, Kumar R, Bera A, Kumar P, Angurana SL, Ghosal S, et al. Palliative and supportive care in acrometastasis to the hand: Case series. Indian J Palliat Care 2011;17:241-4.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Jain A, Chauhan M, Pandit A, Kumar R, Sharma A, Dubey I. FDG PET/CT in a rare case of multiple cutaneous metastases in carcinoma larynx. Indian J Nucl Med 2012;27:259-61.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Aravamuthan R, Rajendrabose RG, Krishna AB, Palanisamy AP. Cutaneous metastases from primary carcinoma larynx: A rare presentation. Online J Otolaryngol 2013;3: 61-7.  Back to cited text no. 10
    
11.
Bottoni U, Innocenzi D, Mannooranparampil TJ, Richetta A, Del Giudice M, Calvieri S. Inflammatory cutaneous metastasis from laryngeal carcinoma. Eur J Dermatol 2001;11:124-6.  Back to cited text no. 11
    


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