- Email: [email protected]
Carcinoma of the uterine cervix metastatic to behind the zygomatic arch: A case report
Carcinoma of the Uterine Cervix Metastatic to Behind the Zygomatic Arch: A Case Report Jagathi D. Challagalla, MD, Richard Smith, MD, Robin Mitnick, Dwayne Breining, MD, and Scott Wadler, MD
MD,
Purpose: We propose to present a novel case of a genital malignancy metastatic to the head and neck. Carcinoma of the uterine cervix is the third most frequent malignancy of the female genital tract. Early detection and improved radiation and surgical techniques have resulted in better control of the pelvic tumor and a greater incidence of distant metastasis. Metastases to the soft tissue of the head and neck region have not been reported. Methods: We present the first known case of a 35year-old woman with cancer of the uterine cervix who presented with metastasis to the soft tissue behind the zygomatic arch. Results: The patient received radiation therapy to the zygomatic region and cisplatin therapy with a near-complete remission. Conclusion: This case shows that not all squamous cell cancers detected above the clavicles are from a thoracic or a head and neck primary tumor. The atypical location should alert the physician to suspect distant metastasis, rather than locoregional disease. (Am J Otolaryngol 1999;20:195-197. Copyright 0 1999 by W.B. Saunders Company)
(Editorial Comment: This case shows the difficulty in establishing the location of the primary tumor that originates outside of the head and neck. The atypical position of this metastasis should perhaps alert the physician to suspect an unusual primary tumor. The molecular techniques may prove useful in the future to assist in establishing diagnoses such as these.)
Carcinoma of the cervix is the third most frequent cancer of the female genital tract.r It is the seventh most common cancer in women in the United States and the most common cancer in women in some developing countries2 Early detection and improved radiation and surgical techniques used within the past four decades in the management of this malignancy have resulted in better control of the pelvic tumor and longer survival3 These improved results have been accompanied by a greater incidence of distant metastases.3-5 Spread by hematogenous dissemination is relaFrom the Departments of Oncology, Otorhinolaryngology, Neuroradiology, and Cytopathology, Montefiore Medical Center, Bronx, NY. Supported in part by Cancer Center Support Grants CA 13330 and 63422 from the National Cancer Institute, Bethesda, MD. Address reprint requests to Scott Wadler, MD, Department of Oncology, Hofheimer 100, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467. Copyright 0 1999 by W.B. Saunders Company 0196-0709/99/2003-0013$10.00/0 American
Journal
of Otolaryngology,
Vol20,
tively unusual, but the risk increases with more advanced stages .4,6The lo-year actuarial incidence of distant metastases in patients treated with radiation alone was 3% in stage IA, 16% in stage IB, 26% in stage IIA, 31% in stage IIB, 39% in stage III, and 75% in stage IVA.3 The most commonly involved sites are lung, bone, liver, and extrapelvic lymph nodes.7,8 We present the first known patient with cervical cancer who presented with metastasis to the soft tissue of the left zygomatic region. CASE REPORT A %-year-old woman presented initially at Metropolitan Hospital (New York, NY) with anemia and a history of increased vaginal bleeding. The patient was referred to Montefiore Medical Center for further evaluation and treatment. The patient was initially seen on November 22,1995. On physical examination, she had no lymphadenopathy. A genital examination showed a pelvic mass with extension to the pelvic sidewalls. A biopsy of the mass showed a moderately differentiated squamous cell cancer of cervical origin (Fig 1). The patient was staged as IIIB cervical cancer and was treated on a clinical protocol with parenteral hydroxyurea, external-beam radiation therapy, and brachytherapy, which she tolerated well. On a follow-up visit on February 28,1996, a 2 X 2-cm right supraclavicular mass was palpated. A fine needle aspiration was performed, which was positive for squamous cell No 3 (May-June),
1999:
pp 195-197
195
196
CHALLAGALLA
ET AL
Fig 1. Cervical biopsy specimen showing invasive moderately differentiated squamous cell carcinoma. (Hematoxylin and eosin, original magnification x300.)
cancer. The patient subsequently developed trismus and pain in the left mandible. On examination, 1.5- X 1.5-cm mass in the left zygomatic region was palpated. A computed tomographic (CT) scan showed a 2.5-cm lesion at the left temporal region with asymmetry of the temporalis muscle consistent with metastasis and infiltration of the underlying muscle (Fig 2). The patient was referred to the Otorhinolaryngology service for evaluation. On examination, a z-cm fixed mass at the superior border of the left zygoma was visualized. A complete head examination including fiberoptic endoscopy failed to show a primary lesion above the diaphragm. A fine needle aspiration showed a moderately to poorly differentiated squamous cell cancer identical to the primary biopsy (Fig 3). The patient received radiation therapy to the zygomatic region and the right supraclavicular region with improvement in the patient’s trismus. The patient also received 9-cis-retinoic acid without any clinical response. The patient developed a new left supraclavicular mass in May 1996 and was treated with cisplatin, with a 75% decrease in the neck masses by July 1996. By November 1996, a repeat CT scan showed a near-complete remission. The patient remained in partial remission until
September 1997, when she was last seen, and was subsequently lost to follow-up.
DISCUSSION Squamous
cell cancer
of the cervix
accounts
for more than 90% of all cervical cancers9 Metastasis usually occurs by means of lymphatics, although blood-borne metastasis does occur.8’10 The incidence of metastasis to the soft tissue of the head and neck region in carcinoma of the cervix, as in this case, is very rare.
A Medline
search
did
not show
any case
of metastasis of a cancer of the cervix to the soft tissue of the head and neck, although metastasis to the supraclavicular lymph nodes is well known. This case shows that not all squamous cell cancers detected above the clavicles are from a head and/or neck or thoracic primary lesion. The difficulty in the diagnosis of squamous cell carcinoma to the cervical lymph nodes
METASTATIC
CERVICAL
CANCER
197
Fig 3. Fine needle aspiration specimen from left zygomatic region showing moderately to poorly diitiatsd squamous cell carcinoma. (Papanicolau stain, original magnification x600.)
has been well described.ll This case shows the problematic nature of such a diagnosis when the primary tumor is outside the head and neck. One unusual feature in this case is the atypical location of the metastasis in the soft tissue behind the zygomatic arch. Thus, this unusual pattern should alert the physician to suspect distant metastasis, rather than locoregional disease. In the future, it is likely that molecular techniques will prove useful in more accurately determining the source of a squamous cell metastasis presenting in such a fashion, and such techniques are already being used.12-14 Finally, whereas the vast majority of cases of cervical carcinoma, such as squamous cell carcinomas of the head and neck, spread locoregionally, this case shows that in the late stages of the disease, it can also have unpredictable patterns of spread. Thus, this case serves as a reminder that the proper diagnosis and management of such cases may require a broader focus than is normally assumed. REFERENCES 1. Boring CC: Cancer statistics. CA Cancer J Clin 41:1936,1991
2. Parkin DM, Muir CS, Whelan SL: Cancer Incidence in Five Continents, vol VI. Lyon, International Agency for Research on Cancer, 1992 3. Badib AO, Kurohara SS, Webster JH, et al: Metastases to distant organs in carcinoma of the uterine cervix:
Influence of treatment on incidence and distribution. Cancer 21:434-439,1968 4. Carlson V, Delclos L, Fletcher GH, et al: Distant metastases in squamous cell carcinoma of uterine cervix. Radiology 88:961-966, 1967 5. Sotto LSJ: Postmortem findings in cancer of the cervix: An analysis of 108 autopsies in the past five years. Am J Obstet Gynecol80:791-794,196O 6. Fagundes H, Perez CA, Grigsby PW, et al: Distant metastases after irradiation alone in carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 24:197-204, 1992 7. Kim RY, Weppelmann B, Salter MM, et al: Skeletal metastases from cancer of the uterine cervix; Frequency, patterns and radiotherapeutic significance. Int J Radiat Oncol Biol Phys 13:705-708, 1987 8. Van Nagell JR, Rayburn W, Donaldson ES, et al: Therapeutic implications of patterns of recurrence in cancer of the uterine cervix. Cancer 44:2354-2361, 1979 9. Lagasse LD, Greasman WT, Shingleton HM, et al: Results and complications of operative staging in cervical cancer: Experience of the Gynecologic Oncology Group. Gynecol Oncol9:90-98, 1980 10. Buchsbaum HJ: Extrapelvic lymph node metastasis in cervical carcinoma. Am J Obstet Gynecol 133:814-824, 1979 11. de Braud F, al-Sarraf M: Diagnosis and management of squamous cell carcinoma of unknown primary tumor site of the neck. Semin Oncol20:273-278,1993 12. Brennan JA, Mao L, Hruban RH, et al: Molecular assessment of histopathological staging in squamous cell carcinoma of the head and neck. N Engl J Med 332:429435,1995 13. Shin
DM, Lee JS, Lippman SM, et al: p53 expressions: Predicting recurrence and second tumors in head and neck squamous cell carcinoma. J Nat1 Cancer Inst 88:519-529, 1996 14. Ilson DH, Motzer RJ, Rodriguez E, et al: Genetic analysis in the diagnosis of neoplasms of unknown primary tumor site. Semin Oncol20:229-237,1993
MD,
Purpose: We propose to present a novel case of a genital malignancy metastatic to the head and neck. Carcinoma of the uterine cervix is the third most frequent malignancy of the female genital tract. Early detection and improved radiation and surgical techniques have resulted in better control of the pelvic tumor and a greater incidence of distant metastasis. Metastases to the soft tissue of the head and neck region have not been reported. Methods: We present the first known case of a 35year-old woman with cancer of the uterine cervix who presented with metastasis to the soft tissue behind the zygomatic arch. Results: The patient received radiation therapy to the zygomatic region and cisplatin therapy with a near-complete remission. Conclusion: This case shows that not all squamous cell cancers detected above the clavicles are from a thoracic or a head and neck primary tumor. The atypical location should alert the physician to suspect distant metastasis, rather than locoregional disease. (Am J Otolaryngol 1999;20:195-197. Copyright 0 1999 by W.B. Saunders Company)
(Editorial Comment: This case shows the difficulty in establishing the location of the primary tumor that originates outside of the head and neck. The atypical position of this metastasis should perhaps alert the physician to suspect an unusual primary tumor. The molecular techniques may prove useful in the future to assist in establishing diagnoses such as these.)
Carcinoma of the cervix is the third most frequent cancer of the female genital tract.r It is the seventh most common cancer in women in the United States and the most common cancer in women in some developing countries2 Early detection and improved radiation and surgical techniques used within the past four decades in the management of this malignancy have resulted in better control of the pelvic tumor and longer survival3 These improved results have been accompanied by a greater incidence of distant metastases.3-5 Spread by hematogenous dissemination is relaFrom the Departments of Oncology, Otorhinolaryngology, Neuroradiology, and Cytopathology, Montefiore Medical Center, Bronx, NY. Supported in part by Cancer Center Support Grants CA 13330 and 63422 from the National Cancer Institute, Bethesda, MD. Address reprint requests to Scott Wadler, MD, Department of Oncology, Hofheimer 100, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467. Copyright 0 1999 by W.B. Saunders Company 0196-0709/99/2003-0013$10.00/0 American
Journal
of Otolaryngology,
Vol20,
tively unusual, but the risk increases with more advanced stages .4,6The lo-year actuarial incidence of distant metastases in patients treated with radiation alone was 3% in stage IA, 16% in stage IB, 26% in stage IIA, 31% in stage IIB, 39% in stage III, and 75% in stage IVA.3 The most commonly involved sites are lung, bone, liver, and extrapelvic lymph nodes.7,8 We present the first known patient with cervical cancer who presented with metastasis to the soft tissue of the left zygomatic region. CASE REPORT A %-year-old woman presented initially at Metropolitan Hospital (New York, NY) with anemia and a history of increased vaginal bleeding. The patient was referred to Montefiore Medical Center for further evaluation and treatment. The patient was initially seen on November 22,1995. On physical examination, she had no lymphadenopathy. A genital examination showed a pelvic mass with extension to the pelvic sidewalls. A biopsy of the mass showed a moderately differentiated squamous cell cancer of cervical origin (Fig 1). The patient was staged as IIIB cervical cancer and was treated on a clinical protocol with parenteral hydroxyurea, external-beam radiation therapy, and brachytherapy, which she tolerated well. On a follow-up visit on February 28,1996, a 2 X 2-cm right supraclavicular mass was palpated. A fine needle aspiration was performed, which was positive for squamous cell No 3 (May-June),
1999:
pp 195-197
195
196
CHALLAGALLA
ET AL
Fig 1. Cervical biopsy specimen showing invasive moderately differentiated squamous cell carcinoma. (Hematoxylin and eosin, original magnification x300.)
cancer. The patient subsequently developed trismus and pain in the left mandible. On examination, 1.5- X 1.5-cm mass in the left zygomatic region was palpated. A computed tomographic (CT) scan showed a 2.5-cm lesion at the left temporal region with asymmetry of the temporalis muscle consistent with metastasis and infiltration of the underlying muscle (Fig 2). The patient was referred to the Otorhinolaryngology service for evaluation. On examination, a z-cm fixed mass at the superior border of the left zygoma was visualized. A complete head examination including fiberoptic endoscopy failed to show a primary lesion above the diaphragm. A fine needle aspiration showed a moderately to poorly differentiated squamous cell cancer identical to the primary biopsy (Fig 3). The patient received radiation therapy to the zygomatic region and the right supraclavicular region with improvement in the patient’s trismus. The patient also received 9-cis-retinoic acid without any clinical response. The patient developed a new left supraclavicular mass in May 1996 and was treated with cisplatin, with a 75% decrease in the neck masses by July 1996. By November 1996, a repeat CT scan showed a near-complete remission. The patient remained in partial remission until
September 1997, when she was last seen, and was subsequently lost to follow-up.
DISCUSSION Squamous
cell cancer
of the cervix
accounts
for more than 90% of all cervical cancers9 Metastasis usually occurs by means of lymphatics, although blood-borne metastasis does occur.8’10 The incidence of metastasis to the soft tissue of the head and neck region in carcinoma of the cervix, as in this case, is very rare.
A Medline
search
did
not show
any case
of metastasis of a cancer of the cervix to the soft tissue of the head and neck, although metastasis to the supraclavicular lymph nodes is well known. This case shows that not all squamous cell cancers detected above the clavicles are from a head and/or neck or thoracic primary lesion. The difficulty in the diagnosis of squamous cell carcinoma to the cervical lymph nodes
METASTATIC
CERVICAL
CANCER
197
Fig 3. Fine needle aspiration specimen from left zygomatic region showing moderately to poorly diitiatsd squamous cell carcinoma. (Papanicolau stain, original magnification x600.)
has been well described.ll This case shows the problematic nature of such a diagnosis when the primary tumor is outside the head and neck. One unusual feature in this case is the atypical location of the metastasis in the soft tissue behind the zygomatic arch. Thus, this unusual pattern should alert the physician to suspect distant metastasis, rather than locoregional disease. In the future, it is likely that molecular techniques will prove useful in more accurately determining the source of a squamous cell metastasis presenting in such a fashion, and such techniques are already being used.12-14 Finally, whereas the vast majority of cases of cervical carcinoma, such as squamous cell carcinomas of the head and neck, spread locoregionally, this case shows that in the late stages of the disease, it can also have unpredictable patterns of spread. Thus, this case serves as a reminder that the proper diagnosis and management of such cases may require a broader focus than is normally assumed. REFERENCES 1. Boring CC: Cancer statistics. CA Cancer J Clin 41:1936,1991
2. Parkin DM, Muir CS, Whelan SL: Cancer Incidence in Five Continents, vol VI. Lyon, International Agency for Research on Cancer, 1992 3. Badib AO, Kurohara SS, Webster JH, et al: Metastases to distant organs in carcinoma of the uterine cervix:
Influence of treatment on incidence and distribution. Cancer 21:434-439,1968 4. Carlson V, Delclos L, Fletcher GH, et al: Distant metastases in squamous cell carcinoma of uterine cervix. Radiology 88:961-966, 1967 5. Sotto LSJ: Postmortem findings in cancer of the cervix: An analysis of 108 autopsies in the past five years. Am J Obstet Gynecol80:791-794,196O 6. Fagundes H, Perez CA, Grigsby PW, et al: Distant metastases after irradiation alone in carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 24:197-204, 1992 7. Kim RY, Weppelmann B, Salter MM, et al: Skeletal metastases from cancer of the uterine cervix; Frequency, patterns and radiotherapeutic significance. Int J Radiat Oncol Biol Phys 13:705-708, 1987 8. Van Nagell JR, Rayburn W, Donaldson ES, et al: Therapeutic implications of patterns of recurrence in cancer of the uterine cervix. Cancer 44:2354-2361, 1979 9. Lagasse LD, Greasman WT, Shingleton HM, et al: Results and complications of operative staging in cervical cancer: Experience of the Gynecologic Oncology Group. Gynecol Oncol9:90-98, 1980 10. Buchsbaum HJ: Extrapelvic lymph node metastasis in cervical carcinoma. Am J Obstet Gynecol 133:814-824, 1979 11. de Braud F, al-Sarraf M: Diagnosis and management of squamous cell carcinoma of unknown primary tumor site of the neck. Semin Oncol20:273-278,1993 12. Brennan JA, Mao L, Hruban RH, et al: Molecular assessment of histopathological staging in squamous cell carcinoma of the head and neck. N Engl J Med 332:429435,1995 13. Shin
DM, Lee JS, Lippman SM, et al: p53 expressions: Predicting recurrence and second tumors in head and neck squamous cell carcinoma. J Nat1 Cancer Inst 88:519-529, 1996 14. Ilson DH, Motzer RJ, Rodriguez E, et al: Genetic analysis in the diagnosis of neoplasms of unknown primary tumor site. Semin Oncol20:229-237,1993