An Earlobe Lesion and a Lung Nodule

Schneiderman and Sridhar. Both letters highlight the difficulty in differentiating basal cell carcinomas and squamous cell carcinomas.' There is certainly the remote-although unproven-possibility that this patient had two and perhaps even three separate primary tumors: basal cell carcinoma of the ear, head and neck tumor and a primary lung carcinoma. The presence of citrulline in the histochemical stain for keratin from a lesion is often definitive in characterizing the tumor as a basal cell carcinoma.' However. bronchoscopy and histochemical staining for keratin were not performed in this patient. Louis L. Cregler; M.D .• Assistant Professor of Medicine. Mount Sinai School of Medicine. New York

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mm H~, pulmonary capillary pressure 5 , central venous pressure 1. Therapy with cristalloids (2.5 L), methylprednisolone (40 mg), erythromicin (500 mg) and theophylline was administered . A chest x-ray film showed diffuse in/lltrates (Fi~ 1). Echocardiogram was normal. Twelve hours later. arterial blood ~ses (on Flo, of 0.4) were: Po, 124 mm H~ , Peo, 57 . pH 7.35 , Hco, 29.8 meq/L, On the second day the patient was extubated. Arterial blood gases (with 02.3 L per min by nasal prongs) were: Po, 88 , Pco, 52, pH 7.37, lIeo, 30. Blood chemistry showed: Na 137 meq/L, K 3.8 meq/L, creatinine 1.2 wdl, glucose 95 mg%. lib 14.2 WL, WBC 16,100 , prothrornbine time 100 percent. A chest x-ray film (Fig 2) was normal. A consultant in otolaryngology performed a laryngoscopic examination which disclosed hypertrophic chronic laryngitis. A fibrobronchoscopy was performed , which showed hypertrophic vocal cords, Spirometry showed an FEV, of 1.32 (56 percent. predicted 2.42) and FVC of 1.85 (61 percent, predicted 3.03). A consultant in endocrinology found signs of hypothyroidism (dry skin. constipation) and thyroid hormone studies were performed: T4 was 7.5 ILwdl (normal 8 to 12), T3 0 .56 nwml (normal 0.8 to 2 ng/ml), TSII 4.41 ILUlMI (normal less than 4). The patient was begun on therapy with thyroxine and hronchodilators; six months after discharge he is doing well. Hypothyroidism is occasionally associated with sleep apnea" and mucoprotein deposition in the oropharynx is a proposed mechanism of obstructive apnea in these patients. Possibly, the mild hypothyroidism of our patient was playing a role in the development of upper airway obstruction and pulmonary edema.

A. Lopez , M.D .. F.C.C .P.; J A. Lorente , M.D., VICente[erez , M.D ., and J A. Julia , M.D .. Intensive Care Unit, Hospital Infanta Cristina. Badajox , Spain REFERENCES

1 Willms D, Shure D. Pulmonarv edema due to upper airway obstruction in adults. Chest 1988; 94:1090-92 2 Grusntein RR, Sullivan CE o Sleep apnea and hypothyroidism: mechanisms and management. Am] Med 1988; 85:775-79

An Earlobe Lesion and a Lung Nodule To the Editor. We described a patient with an earlobe lesion and a lung nodule (Chest 1989; 95: 908-09). We appreciate the comments by Drs .

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Wermuth BM, Fajardo LF. Metastatic basal cell carcinomas. Arch Patho11970; 90:458-62 2 Holmes E]. Bennington ]L, Haber SL. Citrulline-contain basal cell carcinomas. Cancer 1968; 22:663-70

To the Editor: Although the report of Cregler and Landor (Chest 1989; 95:90809) is of interest, their data fail to prove that the diagnosis is metastatic basal cell carcinoma. The histology of the supraclavicular mass was squamous carcinoma, not basal. Criteria for metastatic basal cell carcinoma specifically exclude metastases that contain or consist of squamous cell carcinoma. The "ear primary" was basal , not basisquamous, so that even apart from these criteria one cannot reasonably invoke relatively selective phenotypic expression in the metastatis as an explanation. Furthermore, those basal cell carcinomas that metastasize have usually produced far more extensive local tumor formation and tissue destruction by the time of metastatis; a 1 x 1 centimeter primary is not a likely source. Finally, cr of the chest showed a pulmonary lesion consistent with an endobronchial primary squamous cell carcinoma of the lung. The authors do not relate whether bronchoscopy was performed. The pattern of supraclavicular nodal metastasis with carotid sheath and osseous destruction, without extensive intrapulmonary metastases, is also more suggestive of lung cancer than of metastasizing basal cell carcinoma. Henry Schneidennan. M .D., F.C.C .P.. Associate Professor of Medic ine and Pathology. University of Connecticut School of Medicine, Fannington

To the Editor: Drs . Cregler and Landor' reported a very interesting patient. I disagree with the answer published by the author. Based on the incidence' and the patterns of metastases,' it is more likely for a patient to have two primary cancers (skin cancer and a primary lung carcinoma) than the rarer event of metastases from a smallsized basal cell carcinoma to the lower cervical and mediastinal lymph nodes, respectively, and to the lung . A single lesion in the lung, supraclavicular and mediastinal lymph nodes favors a primary lung carcinoma, '7 rather than a metastases in the patient described .' Biopsy of the sites of tumor will often establish whether the patient has one or two primary cancers.' In the patient under discussion, biopsy of the supraclavicular mass is reported as squamous cell carcinoma and the biopsy of the ear lesion a basal cell carcinoma, suggesting two primaries (despite the occasional patient in whom Communications to the Editor