- Email: [email protected]
Carcinoma of the maxillary sinus with eosinophilia
lilt. J. Oral Surg. 1981: 10: 62-67 (Key words: rumor, malignant,' carcinoma: sinus.
ma.~illary.·
eosinophilia)
Carcinoma of the maxillary sinus with eosinophilia Report of a case MITSUNOBU SATO, HIDEO YOSHIDA, TETSUO YANAGAWA, YOSHIAKI YURA, MASAKAZU sum, SUGURU HAMADA AND TADASHI MIYAZAKI Second Department of Oral and Maxillofacial Surgery, Tokushima University School of Dentistry, Tokushima, and First Department oj Oral and Maxillofacial Surgery, Osaka University Dental School, Osaka, Japan
A patient with carcinoma of the maxillary sinus presented with a blood eosinophilia and infiltration of eosinophilic leukocytes into the (umor tissue. Immediately after cancer therapy with intraarterial infusion of 5-fluorouracil into the superficial temporal artery, necrotomy and resection of the maxilla including radical neck dissection, the number of eosinophilic leukocytes was suddenly decreased and thereafter a transient increase in blood eosinophilic leukocyte count was observed. In this communication, a tentative mechanism for these events is suggested. ABSTRACT -
(Received for publication 9 June, accepted 25 July 1980)
Various kinds of non-reticular malignant tumors such as carcinoma of the gastrointestinal tract20 , uterus!D, kidney3, thyroid4 , bronChUS!,16, and metastatic carcinoma17 have infrequently been reported to be infiltrated with numerous eosinophilic leukocytes accompanied by massive eosinophilia. Although interrelationship between tumor cells and eosinophilic leukocyte infiltration remains to be understood, the accompanying eosinophilia is considered to be indicative of a responsive process of an allergic reaction lO • The authors report a case of carcinoma of the maxillary sinus with massive eosino-
philic leukocyte infiltration into the tumor tissue and eosinophilia, and discuss a possible mechanism for these events.
Case report Patient T.A., a 46-year-old male, was first seen on June 28, 1978, with the chief complaint of moderately painful swelling around the light buccal area. He related the following clinical details. About one month earlier, he experienced spontaneous pain and swelling of the buccal gingiva in the region of the maxillary right molars. This lesion had been diagnosed clinically as an alveolar abscess and incised. However, a soft tissue mass had grown from the incised wound and formed a tumorous le-
0300-9785/81/010062-06$02.50/0 © 1981 Munksgaard, Copenhagen
CANCER WITH EOSINOPHILIA
63
Fig. 1. Photograph of the tumor formed on the buccal gingiva extending from the maxillary second premolar to the maxillary first molar.
sion. Thus he was referred for further detailed examinations of this lesion his private physician. On oral examination, an ulcerated and elastic mass measuring 2.5 X 1.2 cm in diameter was observed on the buccal gingiva in an area extending from the maxillary right second premolar to the maxillary right first molar (Fig. 1). Though fairly well-demarcated, this lesion extended into the buccal mucosa over the bucco-gingival sulcus. The consistency was elastic, hard and blood coagulum covered in part the surface of this lesion. Although the buccal mucosa around the orifice of the right Stensen's duct was reddish and the salivary flow from the duct was decreased as compared with the left one, the saliva was serous and showed no pus discharge. Moreover, a reddish swelling and hyposthesia were observed from the infraorbital to paranasal region. The regional submandibular lymph nodes including the lymph nodes along the posterior margin of the right stel'nocleidomastoid muscle were palpable and induced slight pain by tOllch. When the right maxilla was examined radiographically the maxillary sinus was moderately cloudy, suggesting that a soft tissue mass had filled up the sinus (Fig. 2). Radiographic tomographs showed destruction of an area extending from the right maxillary tuberosity to the inferior lateral
Fig. 2. Sinus radiograph (Water's view) of this patient showing destruction of lateral wall of the maxillary sinus (arrow) and presence of the soft tissue mass (dotted line).
wall of the sinus and presence of tumor mass 4-6 cm from the anterior of the maxilla (Fig. 3). The chest radiograph indicated nothing unusual. The biopsy material taken from the anterior margin of this lesion was histopathologically diagnosed as a poorly differentiated squamous cell carcinoma with massive eosinophilic leukocyte infiltration into the tumor tissue (Fig. 4). Laboratory data included red blood cell count (477 X 104/mm3); white blood cell count (11000/mm 3 ); hemoglobin (13.8 g/ dl); hematocrit (40.8 %), differential analysis of leukocytes; neutrophil (57 %), eosinophil (16 %), basophil (1 %), lymphocyte (20 %), monocyte (6 %), CRP positive, and erythrocyte sedimentation rate (49 mm/h). These hematologic data showed eosinophilia and moderate acceleration of erythrocyte sedimentation rate. The other laboratory data including liver and kidney function tests, showed no abnormalities. Distant metastases, such as to the lungs and liver, were not observed. Radiation therapy (1000 rads/week) by Coco was started on July
64
SATO ET AL.
Fig. 3. Tomography showing bone destruction of the lateral wall of the maxillary sinus 4-6 cm from anterior ridge of maxilla (arrows).
3, 1978. Intraarterial infusion of 5-fluorouracil (5-Fu; 500 mg/week) into right superficial temporal artery and antrostomy of the maxillary sinus were performed on July 14, 1978. A total
Fig. 4. Microscopic photograph of the biopsy specimen, showing poorly differentiated squamous cell carcinoma with pleomorphism and anisocytism, and with massive infiltration of eosinophilic leukocytes into the tumor cells.
irradiation of 5000 rads and infusion of 2400 mg of 5-Fu were carried out until August 8, resulting in a good effect. The inner surface of the maxillary sinus was covered with a white coating and in part necrotic tumor tissue. The necrotic tissue was thus removed by curettage and 5-Fu ointment was applied to the surface of the fresh granulation tissue. After waiting recovery from severe stomatitis and xerostomia which appeared as side effects of the combination therapy of radiation and 5-Fu, the right side of the maxilla including the part of infraorbital basis, nasal bone, zygomatic arch and the part of buccinator muscle was resected under general anesthesia on August 29, 1978. At the same time, in order to remove the metastatic lymph nodes of the submandibular and neck regions, radical neck dissection was performed. Postoperatively, the clinical course was uncomplicated except for moderate trismus. The patient was discharged from the hospital 46 days after the operation and was observed periodically. In May 21, 1980, the surgical wound healed without evidence of residual or recur-
CANCER WITH EOSINOPHILIA
65
Table 1. The eosinophil and leukocyte counts during the course of the patient's illness
--
Radiation (60 Co ; 5000rad) Intraarterial infusion (5-FU
2400mg)
Antrostomy
~
-
5-Fu-ointment I Resection of maxilla including radical neck dissection
(xIO~ Imm 3 )
+
:: f
10
.. '0 ••••••••• c ••••••• 4
•
O•• 'Q. ••• o(l • • a ••··-· ,.0 ••• .0. ••• ... Qo'·.a. .. - o ••• 0 0
"-n"~_O'"
§
(lI 0 -IJ U
~
'621 Ill:>' g
5 ~
'3
.-l
Jun. Jul. Aug. Sep. Oct. Nov. Dec. Jan.
1978
1979
Jan. 1980
absolute eosinophil count absolute leukocyte count
rent lesion in the area of excision, and no metastastic lesion was present in this case. As shown in Table 1, the number of eo,sinophilic leukocytes was surprisingly decreased immediately after cancer therapy, but was accompanied by massive eosinophilia on the first visit. Thereafter, although a transiently sudden increase of the number of blood eosinophilic leukocytes was observed in September 1978, the differential count of eosinophilic leukocytes was within normal limits, ranging from 2 % to 0%.
Discussion For appearance of eosinophilia, the following causes are considered 21 : Allergic disorders such as bronchial asthma, urticaria and angioneurotic edema; skin disease, especially pemphigus and dermatitis herpetiformis; parasitic infestations; Loeffler's syndrome; PIE syndrome; tropical eosinophilia; certain infection such as scarlet fever and chorea; disorders of the hematapoietic system such as chronic myelocytic leukemia, Hodgkin's disease and pernicious anemia; malignant diseases of any type; following ir-
radiation; autoimmune diseases such as pe~ riarteritis nodosa and rheumatoid arthritis; and inherited anomalies. In the case reported in this commimication, no causes other than carcinoma of the maxillary sinus and Co60 irradiation to the primary lesion were present. Therefore, the biphasic eosinophilia being observed in this case seems to be caused by the malignant tumor and radiation therapy. ISAACSON & RAPOPORTB reported that eosinophilia was noted in 0.5 % of malignant neoplastic diseases of various. types' including chronic myelocytic leukemia and Hodgkin's disease. Although the true cause of this eosinophilia is unknown,' eosinophilia has been described to appear especially: in malignant tumorous lesions accompanying. disseminated metastases and tumor neere>sis15• On the other hand,LrrTl1 repoited that. eosinophilia appears as a consequence of immunologic reaction, namely that eosi-' nophils accumulate in large numbers at sites of antigen-antibody deposition, and one of
66
SATO ET AL.
the functions of the cells is to phagocytize these complexes. Moreover, BASTEN & BEESON2 have found that thymus-derived lymphocytes play an essential role as mediators of eosinophilia. From the above considerations, in the patient with a malignant tumor, followed by eosinophilia and infiltration of eosinophilic leukocytes into the tumor tissue, mechanism of immunological surveilance is considered essentially, but not yet damaged. Also in the case reported in this communication, the authors examined the degree of the immunologic defense, reflected by a positive reaction to the tuberculin-and DNCB skin tests. These reactions have remained unchanged from the first visit until now. Although the present case demonstrated a moderately necrotizing lesion with metastasis to the regional lymph nodes of the neck, distant metastases, such as to the lungs and liver were not found. Moreover, considering the combination of radiation therapy and chemotherapy such as 5-Fu and radical surgery including necrotomy, the number of eosinophilic leukocytes was surprisingly decreased. For this sudden decrease of eosinophilic leukocyte count, the following mechanisms are considered: (1) If some component of the tumor cell functions as a nonself antigen, and the antibody generated by this antigenic stimulus forms a complex with the antigen on the surface of the tumor cells, eosinophilia might be induced as described in the repoTt by LTIT. Thus a decreased amount of antigen-antibody complex by surgical removal of the tumor tissue or degradation of the antigen with radiation and chemotherapy might cause sudden decrease of the eosinophilic leukocyte count. (2) DELMONTE & LmBEL'T5 have found that a transplantable mouse mammary cancer produces a granulocytosis-promoting factor. Thus the tumor cells might produce an eosinophilia-promoting factor, though this type of factor is not yet known. An acute
inactivation of the tumor cells by can<:cr therapy might result in a suddenly decreased production of this factor from the tumor cells. Consequently, a number of eosinophilic leukocytes might be surprisingly decreased. Although it is not determined which of the above possibilities is actual, eosinophilia which was observed on the first visit of this patient could be considered as a consequence of immunologic reaction. Eosinophilia that appeared immediately after the completion of progressive treatments for carcinoma of the maxillary sinus seems to be caused by Co~O irradiation to the primary lesion. Eosinophilia has been reported in the irradiated population including radiological workers and atomic bomb survivors, and in patients following a course of irradiation over tnmk areas B,7, P, 13,14,18. However, it has described that irradiation to the head and neck regions hardly induces eosinophilia l4 , namely that only in the patients irradiated to a wide area of the trunk, including the hematopoetic system, does eosinophilia occur frequently. Recently, a case of eosinophilia which seemed to occur following eoO O irradiation for treatment of carcinoma of the mandibular gingiva has been reported l2 • Also in the present case, eosinophilia which appeared about five weeks after ending the radiation therapy could be considered to be caused by COBO irradiation to the head and neck areas.
References 1. BAlU\BTT, A. J. & BARRETT, A.: Bronchial
carcinoma with eosinophilia and cardiomegaly. Br. J. Dis. Chest. 1975: 69: 287-292. 2. BA!ITEN, A. & BEESON, P. B.: Mechanism of eosinophilia. II Role of the lymphocyte. J. Exp. Med. 1970: 131: 1288-1305.
3. BAUKE, J. & PORTIOLl, R. 1.: Hochgradige Eosinophilie Reaktion bei Hypemephrom. Med. Welt. 1966: 16: 865-869. 4. BOTTI, G. & PORTIOLl, R. I.: Eosinophilic leukaemoid reaction caused by thyroid adenocarcinoma. Rev. Anat. Path. Oneal. 1963: 23: 37-41.
CANCER WITH EOSINOPHILIA
5.
DELMONTE, L. & LIEBELT, R. A: Granulocytosis-promoting extract of mouse tumor tissue: partial purification. Science 1965: 148: 521-523. 6. GHOSSEIN, N. A. .& STACEY, P. R. T.: The prognostic significance of radiation-related eosinophilia. Radiology 1973: 107: 631-
7.
633.
A., BOSBORTII, J. L., STACEY, P. R. T., MUGOlA, F. M. & KISHNASWAY, V.: Radiation-related eosinophilia. Radiology 1975: 117: 413-417. 8. ISAACSON, N. H. .& RApOPORT, P.: Eosinophilia in malignant tumors: Its significance. Ann. Intern. Med. 1946: 25: 893-905. 9. KUROHARA, S. S., HEMP'ELMANN, L. H., ENGLANDER, C. L. S., FUU.IER, L. M. & RUBIN, P.: Eosinophilia after exposure to ionizing radiation. Radiation Res. 1964: 23:
14. MUOGIA, F. M., GHOSSEIN, N. A. & WOHL, 15.
16.
GHOSSEIN, N.
357-368. 10. Lrrr, M.: Studies in experimental eosino-
philia. III. The induction of peritoneal eosinophilia by the passive transfer of serum antibody. J. lmmunol. 1961: 87: 522--529. 11. Lrrr, M.: Eosinophils and antigen-antibody reactions. Ann. N.Y. Acad. Sci. 1964: 116: 964-985. 12. Moo, K., MATSUMURA, T., MORISHITA, M.,
NAMBA, K. & K:!NOSHlTA, F.: A case of eosinophilia related to irradiation. Japan J. Oral Surg. 1978: 24: 109-112 in Japanese. 13. MINOT, G. R . .& SPURLlNG, R. G.: The effect on the blood of irradiation, especially short-wave length roentgen ray therapy. Amer. J. Med. Sci. 1924: 168: 215-241.
67
17. 18.
19.
20.
21.
H.: Eosinophilia following radiation therapy. Oncology 1973: 27: 118-127. MURRAY, R. C.: The use of the absolute eosinophil count in the diagnosis of neoplasms. Preliminary report. N. Eng. J. Med. 1953: 248: 848-850. ORICOU, L.: Su di un caso eli neoplasia pleuro-polmonare ad eosinofili. Minerva Med. 1970: 61; 1981-1985. SATALINE, L. R. & MOBLEY, E.: Eosinophilia associated with metastatic carcinoma. Ohio State Mecl. J. 1967: 63: 1474-1481. SNELL, F. M. & NoEL, J. V.: Hematologic studies in Hiroshima and a control city two years after the atomic bombing. Arch. 111tern. Med. 1953; 84: 569-604. VArNA, G. & PUGUSI, A: Relation between circulating eosinophils in the blood and cancer of the uterus. Gaz. Int. Med. Chir. 1962: 67: 1965-1969. WASOWSKA, T. & RACzyNSKI, J.: Hiperleukocytoza z wyzoka eozynofilia w przebiegu raka trzustki z prezerzutami do watroby. Nowotwory. 1966: 16: 191-196. WINTROBE, M. M. (ed): Causes of eosinophilia. CUlt. Remotal. 7th ed. 1974, pp. 1283-1286.
Address:
Mitsunobu Sato The Second Depm-tmeil( of Oral and Maxillofacial Surgery Tokushima University, School of Dentistry 3 Kuramoto-eho, Tokushima 770, Japan
ma.~illary.·
eosinophilia)
Carcinoma of the maxillary sinus with eosinophilia Report of a case MITSUNOBU SATO, HIDEO YOSHIDA, TETSUO YANAGAWA, YOSHIAKI YURA, MASAKAZU sum, SUGURU HAMADA AND TADASHI MIYAZAKI Second Department of Oral and Maxillofacial Surgery, Tokushima University School of Dentistry, Tokushima, and First Department oj Oral and Maxillofacial Surgery, Osaka University Dental School, Osaka, Japan
A patient with carcinoma of the maxillary sinus presented with a blood eosinophilia and infiltration of eosinophilic leukocytes into the (umor tissue. Immediately after cancer therapy with intraarterial infusion of 5-fluorouracil into the superficial temporal artery, necrotomy and resection of the maxilla including radical neck dissection, the number of eosinophilic leukocytes was suddenly decreased and thereafter a transient increase in blood eosinophilic leukocyte count was observed. In this communication, a tentative mechanism for these events is suggested. ABSTRACT -
(Received for publication 9 June, accepted 25 July 1980)
Various kinds of non-reticular malignant tumors such as carcinoma of the gastrointestinal tract20 , uterus!D, kidney3, thyroid4 , bronChUS!,16, and metastatic carcinoma17 have infrequently been reported to be infiltrated with numerous eosinophilic leukocytes accompanied by massive eosinophilia. Although interrelationship between tumor cells and eosinophilic leukocyte infiltration remains to be understood, the accompanying eosinophilia is considered to be indicative of a responsive process of an allergic reaction lO • The authors report a case of carcinoma of the maxillary sinus with massive eosino-
philic leukocyte infiltration into the tumor tissue and eosinophilia, and discuss a possible mechanism for these events.
Case report Patient T.A., a 46-year-old male, was first seen on June 28, 1978, with the chief complaint of moderately painful swelling around the light buccal area. He related the following clinical details. About one month earlier, he experienced spontaneous pain and swelling of the buccal gingiva in the region of the maxillary right molars. This lesion had been diagnosed clinically as an alveolar abscess and incised. However, a soft tissue mass had grown from the incised wound and formed a tumorous le-
0300-9785/81/010062-06$02.50/0 © 1981 Munksgaard, Copenhagen
CANCER WITH EOSINOPHILIA
63
Fig. 1. Photograph of the tumor formed on the buccal gingiva extending from the maxillary second premolar to the maxillary first molar.
sion. Thus he was referred for further detailed examinations of this lesion his private physician. On oral examination, an ulcerated and elastic mass measuring 2.5 X 1.2 cm in diameter was observed on the buccal gingiva in an area extending from the maxillary right second premolar to the maxillary right first molar (Fig. 1). Though fairly well-demarcated, this lesion extended into the buccal mucosa over the bucco-gingival sulcus. The consistency was elastic, hard and blood coagulum covered in part the surface of this lesion. Although the buccal mucosa around the orifice of the right Stensen's duct was reddish and the salivary flow from the duct was decreased as compared with the left one, the saliva was serous and showed no pus discharge. Moreover, a reddish swelling and hyposthesia were observed from the infraorbital to paranasal region. The regional submandibular lymph nodes including the lymph nodes along the posterior margin of the right stel'nocleidomastoid muscle were palpable and induced slight pain by tOllch. When the right maxilla was examined radiographically the maxillary sinus was moderately cloudy, suggesting that a soft tissue mass had filled up the sinus (Fig. 2). Radiographic tomographs showed destruction of an area extending from the right maxillary tuberosity to the inferior lateral
Fig. 2. Sinus radiograph (Water's view) of this patient showing destruction of lateral wall of the maxillary sinus (arrow) and presence of the soft tissue mass (dotted line).
wall of the sinus and presence of tumor mass 4-6 cm from the anterior of the maxilla (Fig. 3). The chest radiograph indicated nothing unusual. The biopsy material taken from the anterior margin of this lesion was histopathologically diagnosed as a poorly differentiated squamous cell carcinoma with massive eosinophilic leukocyte infiltration into the tumor tissue (Fig. 4). Laboratory data included red blood cell count (477 X 104/mm3); white blood cell count (11000/mm 3 ); hemoglobin (13.8 g/ dl); hematocrit (40.8 %), differential analysis of leukocytes; neutrophil (57 %), eosinophil (16 %), basophil (1 %), lymphocyte (20 %), monocyte (6 %), CRP positive, and erythrocyte sedimentation rate (49 mm/h). These hematologic data showed eosinophilia and moderate acceleration of erythrocyte sedimentation rate. The other laboratory data including liver and kidney function tests, showed no abnormalities. Distant metastases, such as to the lungs and liver, were not observed. Radiation therapy (1000 rads/week) by Coco was started on July
64
SATO ET AL.
Fig. 3. Tomography showing bone destruction of the lateral wall of the maxillary sinus 4-6 cm from anterior ridge of maxilla (arrows).
3, 1978. Intraarterial infusion of 5-fluorouracil (5-Fu; 500 mg/week) into right superficial temporal artery and antrostomy of the maxillary sinus were performed on July 14, 1978. A total
Fig. 4. Microscopic photograph of the biopsy specimen, showing poorly differentiated squamous cell carcinoma with pleomorphism and anisocytism, and with massive infiltration of eosinophilic leukocytes into the tumor cells.
irradiation of 5000 rads and infusion of 2400 mg of 5-Fu were carried out until August 8, resulting in a good effect. The inner surface of the maxillary sinus was covered with a white coating and in part necrotic tumor tissue. The necrotic tissue was thus removed by curettage and 5-Fu ointment was applied to the surface of the fresh granulation tissue. After waiting recovery from severe stomatitis and xerostomia which appeared as side effects of the combination therapy of radiation and 5-Fu, the right side of the maxilla including the part of infraorbital basis, nasal bone, zygomatic arch and the part of buccinator muscle was resected under general anesthesia on August 29, 1978. At the same time, in order to remove the metastatic lymph nodes of the submandibular and neck regions, radical neck dissection was performed. Postoperatively, the clinical course was uncomplicated except for moderate trismus. The patient was discharged from the hospital 46 days after the operation and was observed periodically. In May 21, 1980, the surgical wound healed without evidence of residual or recur-
CANCER WITH EOSINOPHILIA
65
Table 1. The eosinophil and leukocyte counts during the course of the patient's illness
--
Radiation (60 Co ; 5000rad) Intraarterial infusion (5-FU
2400mg)
Antrostomy
~
-
5-Fu-ointment I Resection of maxilla including radical neck dissection
(xIO~ Imm 3 )
+
:: f
10
.. '0 ••••••••• c ••••••• 4
•
O•• 'Q. ••• o(l • • a ••··-· ,.0 ••• .0. ••• ... Qo'·.a. .. - o ••• 0 0
"-n"~_O'"
§
(lI 0 -IJ U
~
'621 Ill:>' g
5 ~
'3
.-l
Jun. Jul. Aug. Sep. Oct. Nov. Dec. Jan.
1978
1979
Jan. 1980
absolute eosinophil count absolute leukocyte count
rent lesion in the area of excision, and no metastastic lesion was present in this case. As shown in Table 1, the number of eo,sinophilic leukocytes was surprisingly decreased immediately after cancer therapy, but was accompanied by massive eosinophilia on the first visit. Thereafter, although a transiently sudden increase of the number of blood eosinophilic leukocytes was observed in September 1978, the differential count of eosinophilic leukocytes was within normal limits, ranging from 2 % to 0%.
Discussion For appearance of eosinophilia, the following causes are considered 21 : Allergic disorders such as bronchial asthma, urticaria and angioneurotic edema; skin disease, especially pemphigus and dermatitis herpetiformis; parasitic infestations; Loeffler's syndrome; PIE syndrome; tropical eosinophilia; certain infection such as scarlet fever and chorea; disorders of the hematapoietic system such as chronic myelocytic leukemia, Hodgkin's disease and pernicious anemia; malignant diseases of any type; following ir-
radiation; autoimmune diseases such as pe~ riarteritis nodosa and rheumatoid arthritis; and inherited anomalies. In the case reported in this commimication, no causes other than carcinoma of the maxillary sinus and Co60 irradiation to the primary lesion were present. Therefore, the biphasic eosinophilia being observed in this case seems to be caused by the malignant tumor and radiation therapy. ISAACSON & RAPOPORTB reported that eosinophilia was noted in 0.5 % of malignant neoplastic diseases of various. types' including chronic myelocytic leukemia and Hodgkin's disease. Although the true cause of this eosinophilia is unknown,' eosinophilia has been described to appear especially: in malignant tumorous lesions accompanying. disseminated metastases and tumor neere>sis15• On the other hand,LrrTl1 repoited that. eosinophilia appears as a consequence of immunologic reaction, namely that eosi-' nophils accumulate in large numbers at sites of antigen-antibody deposition, and one of
66
SATO ET AL.
the functions of the cells is to phagocytize these complexes. Moreover, BASTEN & BEESON2 have found that thymus-derived lymphocytes play an essential role as mediators of eosinophilia. From the above considerations, in the patient with a malignant tumor, followed by eosinophilia and infiltration of eosinophilic leukocytes into the tumor tissue, mechanism of immunological surveilance is considered essentially, but not yet damaged. Also in the case reported in this communication, the authors examined the degree of the immunologic defense, reflected by a positive reaction to the tuberculin-and DNCB skin tests. These reactions have remained unchanged from the first visit until now. Although the present case demonstrated a moderately necrotizing lesion with metastasis to the regional lymph nodes of the neck, distant metastases, such as to the lungs and liver were not found. Moreover, considering the combination of radiation therapy and chemotherapy such as 5-Fu and radical surgery including necrotomy, the number of eosinophilic leukocytes was surprisingly decreased. For this sudden decrease of eosinophilic leukocyte count, the following mechanisms are considered: (1) If some component of the tumor cell functions as a nonself antigen, and the antibody generated by this antigenic stimulus forms a complex with the antigen on the surface of the tumor cells, eosinophilia might be induced as described in the repoTt by LTIT. Thus a decreased amount of antigen-antibody complex by surgical removal of the tumor tissue or degradation of the antigen with radiation and chemotherapy might cause sudden decrease of the eosinophilic leukocyte count. (2) DELMONTE & LmBEL'T5 have found that a transplantable mouse mammary cancer produces a granulocytosis-promoting factor. Thus the tumor cells might produce an eosinophilia-promoting factor, though this type of factor is not yet known. An acute
inactivation of the tumor cells by can<:cr therapy might result in a suddenly decreased production of this factor from the tumor cells. Consequently, a number of eosinophilic leukocytes might be surprisingly decreased. Although it is not determined which of the above possibilities is actual, eosinophilia which was observed on the first visit of this patient could be considered as a consequence of immunologic reaction. Eosinophilia that appeared immediately after the completion of progressive treatments for carcinoma of the maxillary sinus seems to be caused by Co~O irradiation to the primary lesion. Eosinophilia has been reported in the irradiated population including radiological workers and atomic bomb survivors, and in patients following a course of irradiation over tnmk areas B,7, P, 13,14,18. However, it has described that irradiation to the head and neck regions hardly induces eosinophilia l4 , namely that only in the patients irradiated to a wide area of the trunk, including the hematopoetic system, does eosinophilia occur frequently. Recently, a case of eosinophilia which seemed to occur following eoO O irradiation for treatment of carcinoma of the mandibular gingiva has been reported l2 • Also in the present case, eosinophilia which appeared about five weeks after ending the radiation therapy could be considered to be caused by COBO irradiation to the head and neck areas.
References 1. BAlU\BTT, A. J. & BARRETT, A.: Bronchial
carcinoma with eosinophilia and cardiomegaly. Br. J. Dis. Chest. 1975: 69: 287-292. 2. BA!ITEN, A. & BEESON, P. B.: Mechanism of eosinophilia. II Role of the lymphocyte. J. Exp. Med. 1970: 131: 1288-1305.
3. BAUKE, J. & PORTIOLl, R. 1.: Hochgradige Eosinophilie Reaktion bei Hypemephrom. Med. Welt. 1966: 16: 865-869. 4. BOTTI, G. & PORTIOLl, R. I.: Eosinophilic leukaemoid reaction caused by thyroid adenocarcinoma. Rev. Anat. Path. Oneal. 1963: 23: 37-41.
CANCER WITH EOSINOPHILIA
5.
DELMONTE, L. & LIEBELT, R. A: Granulocytosis-promoting extract of mouse tumor tissue: partial purification. Science 1965: 148: 521-523. 6. GHOSSEIN, N. A. .& STACEY, P. R. T.: The prognostic significance of radiation-related eosinophilia. Radiology 1973: 107: 631-
7.
633.
A., BOSBORTII, J. L., STACEY, P. R. T., MUGOlA, F. M. & KISHNASWAY, V.: Radiation-related eosinophilia. Radiology 1975: 117: 413-417. 8. ISAACSON, N. H. .& RApOPORT, P.: Eosinophilia in malignant tumors: Its significance. Ann. Intern. Med. 1946: 25: 893-905. 9. KUROHARA, S. S., HEMP'ELMANN, L. H., ENGLANDER, C. L. S., FUU.IER, L. M. & RUBIN, P.: Eosinophilia after exposure to ionizing radiation. Radiation Res. 1964: 23:
14. MUOGIA, F. M., GHOSSEIN, N. A. & WOHL, 15.
16.
GHOSSEIN, N.
357-368. 10. Lrrr, M.: Studies in experimental eosino-
philia. III. The induction of peritoneal eosinophilia by the passive transfer of serum antibody. J. lmmunol. 1961: 87: 522--529. 11. Lrrr, M.: Eosinophils and antigen-antibody reactions. Ann. N.Y. Acad. Sci. 1964: 116: 964-985. 12. Moo, K., MATSUMURA, T., MORISHITA, M.,
NAMBA, K. & K:!NOSHlTA, F.: A case of eosinophilia related to irradiation. Japan J. Oral Surg. 1978: 24: 109-112 in Japanese. 13. MINOT, G. R . .& SPURLlNG, R. G.: The effect on the blood of irradiation, especially short-wave length roentgen ray therapy. Amer. J. Med. Sci. 1924: 168: 215-241.
67
17. 18.
19.
20.
21.
H.: Eosinophilia following radiation therapy. Oncology 1973: 27: 118-127. MURRAY, R. C.: The use of the absolute eosinophil count in the diagnosis of neoplasms. Preliminary report. N. Eng. J. Med. 1953: 248: 848-850. ORICOU, L.: Su di un caso eli neoplasia pleuro-polmonare ad eosinofili. Minerva Med. 1970: 61; 1981-1985. SATALINE, L. R. & MOBLEY, E.: Eosinophilia associated with metastatic carcinoma. Ohio State Mecl. J. 1967: 63: 1474-1481. SNELL, F. M. & NoEL, J. V.: Hematologic studies in Hiroshima and a control city two years after the atomic bombing. Arch. 111tern. Med. 1953; 84: 569-604. VArNA, G. & PUGUSI, A: Relation between circulating eosinophils in the blood and cancer of the uterus. Gaz. Int. Med. Chir. 1962: 67: 1965-1969. WASOWSKA, T. & RACzyNSKI, J.: Hiperleukocytoza z wyzoka eozynofilia w przebiegu raka trzustki z prezerzutami do watroby. Nowotwory. 1966: 16: 191-196. WINTROBE, M. M. (ed): Causes of eosinophilia. CUlt. Remotal. 7th ed. 1974, pp. 1283-1286.
Address:
Mitsunobu Sato The Second Depm-tmeil( of Oral and Maxillofacial Surgery Tokushima University, School of Dentistry 3 Kuramoto-eho, Tokushima 770, Japan