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Distant cutaneous metastases in a patient with squamous-cell carcinoma of the lip
Distant cutaneousmetastasesin a patient with squamous-cellcarcinomaof the lip Gerald M. Bordin, M.D.,” and Stanley Weitxner, M.D., Albuquerque, N. M. DEPARTMENT UNIVERSITY
OB’ PATHOLOGY, OF NEW
MEXICO
VETERANS SCHOOL
ADMINISTRATION
HOSPITAL,
AND
OB MEDICINE
The rare occurrence of cutaneous metastases in the arm and thorax of a man with a 3.0 cm. squamous-cell carcinoma of the lower lip who had been treated exclusively with radiation therapy is reported. The incidence and sites of distant metastases from squamous-cell carcinoma of the lip are reviewed, and the significance of cutaneous metastases is discussed.
D
istant metastases from squamous-cell carcinoma of the lip to sites below the clavicle are uncommon. In seven reports of carcinoma of the lip,l-’ metastases below the clavicle were present in only fourteen (1.6 per cent) of the total of 845 cases. The lungs, liver, heart, spleen, and thoracic and abdominal lymph nodes were the sites most frequently involved. There was no instance, however, of metastasesto the skin below the clavicle. It is the purpose of this report to present the caseof a patient with squamouscell carcinoma of the lower lip in whom cutaneous metastases in the skin of the arm and thorax developed 4 years after initial diagnosis and therapy and to discuss briefly cutaneous metastases. CASE REPORT A 57syear-old Caucasian man was admitted on Feb. 2, 1971, because of two firm nodules in the right supraclavicular area. In August, 1966, he was seen elsewhere for evaluation and treatment of a 3 cm. firm, ulcerated lesion in the midline of the lower lip, Biopsy revealed moderately well-differentiated squamous-cell carcinoma (Fig. 1). The tumor appeared to regress completely following radiation therapy (4,800 rads). His first admission to the Albuquerque Veterans Administration Hospital was in April, 1970, because of 6 by 8 cm. left cervical abscess and enPresented at the twenty-sixth annual meeting of the American Colorado Springs, Colo., April 12 to 15, 1972. *Advanced Clinical Fellow, American Cancer Society.
Academy
of Oral Pathology,
445
Oral Burg. September, 1972
tion
Fig. 2. Lip biopsy (1966) showing and adjacent chronic inflammation.
squamous-cell carcinoma with (Magnification, x205.)
cpithelial
pearl
forma-
larged left anterior and posterior cervical lymph nodes. The abscess healed following incision and drainage and antibiotic therapy. Excision of the remaining enlarged posterior cervical lymph node revealed poorly differentiated squamous-cell carcinoma. Chest x-ray, laryngoscopy, bronchoscopy, esophagoscopy, an upper gastrointestinal series, and a barium enema failed to reveal any lesion. Bronchial washings and sputum examinations were negative for malignant cells. An x-ray survey of the skeleton revealed no osseous metastases. The patient received 3,000 rads to the left cervical area, and on July 28, 1970, left radical neck dissection and exploration of the superior mediastinum disclosed metastatic, poorly differentiated squamous-cell carcinoma in five cervical and one superior mediastinal lymph nodes. The pa&operative course was uncomplicated. The patient was discharged 1 month later after receiving an additional 4,000 rads to the left side of the neck and superior mediastinum. The remarkable findings on physical examination at the time of the present admission were two 5 mm. right supraclavicular lymph nodes, a well-healed left cervical cicatrix, and light brown discoloration of the skin of the left side of the neck and shoulder. Microscopic examination of these nodes, excised the next day, disclosed metastatic, poorly dserentiated squamous-cell carcinoma simiIar to that found previously. On March 4, 1971, during the course of radiation therapy to the right supraclavicular area, several firm, well-circumscribed, slightly elevated nodules ranging to 6 mm. in diameter were found in the skin of the midportion of the upper left arm (Fig. 2). Excisional biopsy of one of these cutaneous nodules revealed metastatic, poorly differentiated squamous carcinoma in the dermis (Fig. 3) similar to that found in the lymph nodes. The other cutaneous nodules completely disappeared after the administration of 3,030 rads, Concurrently, the patient received 3,000 rads to the right side of the neck. The patient returned after 2 months, on June 13, in a severely deteriorated condition, with prominent lymphedema of the left arm and shoulder. A left second to fifth cervical
Volume 34 Number 3
Distant
Fig.
metastases of squamous-cell
8. Cutaneous
metastases,
Fig. J. Representative microscopic field poorly diff emmtiated squamous-cell carcinoma fication, x500.)
upper
left
carcinoma
of lip
447
arm.
of nodule shown in Fig. 2 showing metastatic, with several keratinizing cells (arrows). (Magni-
rhizotomy was performed because of severe pain. The patient developed pneumonia and died 5 weeks later. The pertinent finding at necropsy was metastatic, poorly differentiated squamous-cell carcinoma in the right supraclavicular lymph nodes, left lobe of the thyroid (several small foci), and in multiple sites in the skin and subcutaneous tissue of the thorax.
DISCUSSION Metastases The cutaneous and radiation were present,
reach the skin through blood vessel and lymphatic dissemination. metastases in our patient developed after radical neck dissection therapy to the cervical region. Because no other distant metastases retrograde lymphatic flow due to surgical and radiation oblitera-
448
Bordin
and M7eitzner
Oral Surg. September,
1972
tion of lymphatic channels in the neck is proposed as the most likely route of dissemination, Skin metastases typically appear in the form of one or more firm, discrete, painless, nonulcerated nodules. Those that arise from an internal carcinoma occur most often in the general vicinity of the primary neoplasm, but metastases to sites unusual such as the extremities, scalp, and lip have been described.8 The incidence of cutaneous metastases is low. In an autopsy series of both men and women with internal carcinoma, skin metastases occurred in 4.4 per cent.g The breast was the most common primary site, followed by the gastrointestinal tract. The incidence of cutaneous metastases from internal carcinoma in three studies limited to men, however, was 0.7 to 1.4 per cent.1°-12 The primary neoplasm in these three studies combined was pulmonary in 42.2 per cent, genitourinary in 23.9 per cent, gastrointestinal in 21.1 per eent, pancreatic in 5.7 per cent, of undetermined origin in 5.7 per cent, and upper respiratory in 1.4 per cent. Recognition of cutaneous metastases is of considerable clinical importance, for such metastases may serve as a readily accessible source of tumor tissue for histologic diagnosis. Slthough the clinical features of cutaneous metastases are not distinctive from the more common cutaneous nodules, such as intradermal nevus, dermatofibroma, and keratinous cyst, microscopic examination demonstrates their true nature and their histologic type and may even indicate the exact primary site, as in renal cell carcinoma. The most common histologic pattern encountered in cutaneous metastases is adenocarcinoma. The only reference to cutaneous metastases in squamous-cell carcinoma of the lip is in an article by Bernier and Clark. 4 Four of their patients were classified as having both lymph node and skin metastases. However, they do not specify the sites of skin involvement or state whether or not they represented true cutaneous metastases or direct extension through lymph node capsules. Cutaneous metastases are indicative of widespread dissemination and, therefore, carry a poor prognosis. In one studyI survival from the time of diagnosis of metastatic carcinoma in the skin from an internal carcinoma varied from 2 to 34 weeks, with six of the nine patients dead within 8 weeks. Appreciation is extended to Dr. Henry D. Garett of El Paso, Texas, for providing the patient’s initial clinical history and for permission to review and photograph the original biopsy specimen. REFERENCES
1. Price, L. W.: Metastasis in Squamous Cell Carcinoma, Am. J. Cancer 22: l-16, 1934. 2. Burke, E. M.: Metastases in Squamous Cell Carcinoma, Am. J. Cancer 30: 493503, 1937. 3. Martin, H., Macomb, W. J., and Blady, J. V.: Cancer of the Lip, Ann. Surg. 114: 226s 242, 1941. 4. Bernier, J. L.. and Clark, M. L.: Squamous Cell Carcinoma of the Lip, Milit. Surg. 109: 379397, i951. ’ 5. Peltier, L. F., Thomas, L. B., Crawford, T. H., Barclay, M. B., and Kreman, A. J.: The Incidence of Distant Metastases Among Patients Dying With Head and Neck Cancers, Surgery 30: 827833, 1951. 6. Hoye, R. C., Herrold, K. McD., Smith, R., and Thomas, L. B.: A Clinieopathological Study of Epidermoid Carcinoma of the Head and Neck, Cancer 15: 741-749, 1962. 7. DeVries. N.C.T.: Metastases of Souamous Cell Carcinoma of the Skin and Lip,-. Dermatologica’l38: 333.339, 1969. A 8. Beerman, H.: Some Aspects of Cutaneous Malignancy, Arch. Dermatol. 99: 617626, 1909,
Volume 34 Number 3
Distant metastases of squamous-cell carcinoma of lip
449
in Carcinoma, Cancer 3: 9. Abrams, H. L., Spiro, R., and Goldstein, N.: Metastases 76-85, 1950. 10. Winer, L. H., and Wright, E. T.: tiber den sekundaren (metastatischen) Hautkrebs: Kliuische und pathologische Untersuchungen, Hautarzt 11: 23-27, 1960. 11. Bordin, G. M., and Weitzner, S.: Cutaneous Metastases as a Manifestation of Internal Carcinoma: Their Diagnostic and Prognostic Significance! Am. Burg. (In press.) 12. Reingold, I. M.: Cutaneous Metastases From Internal Carcmoma, Cancer 19: 162-165, 1966.
Reprint requests to : Dr. Stanley Weitzner Department of Pathology Veterans Administration Hospital 2100 Ridgecrest Dr., 8. E. Albuquerque, N. M. 87108
OB’ PATHOLOGY, OF NEW
MEXICO
VETERANS SCHOOL
ADMINISTRATION
HOSPITAL,
AND
OB MEDICINE
The rare occurrence of cutaneous metastases in the arm and thorax of a man with a 3.0 cm. squamous-cell carcinoma of the lower lip who had been treated exclusively with radiation therapy is reported. The incidence and sites of distant metastases from squamous-cell carcinoma of the lip are reviewed, and the significance of cutaneous metastases is discussed.
D
istant metastases from squamous-cell carcinoma of the lip to sites below the clavicle are uncommon. In seven reports of carcinoma of the lip,l-’ metastases below the clavicle were present in only fourteen (1.6 per cent) of the total of 845 cases. The lungs, liver, heart, spleen, and thoracic and abdominal lymph nodes were the sites most frequently involved. There was no instance, however, of metastasesto the skin below the clavicle. It is the purpose of this report to present the caseof a patient with squamouscell carcinoma of the lower lip in whom cutaneous metastases in the skin of the arm and thorax developed 4 years after initial diagnosis and therapy and to discuss briefly cutaneous metastases. CASE REPORT A 57syear-old Caucasian man was admitted on Feb. 2, 1971, because of two firm nodules in the right supraclavicular area. In August, 1966, he was seen elsewhere for evaluation and treatment of a 3 cm. firm, ulcerated lesion in the midline of the lower lip, Biopsy revealed moderately well-differentiated squamous-cell carcinoma (Fig. 1). The tumor appeared to regress completely following radiation therapy (4,800 rads). His first admission to the Albuquerque Veterans Administration Hospital was in April, 1970, because of 6 by 8 cm. left cervical abscess and enPresented at the twenty-sixth annual meeting of the American Colorado Springs, Colo., April 12 to 15, 1972. *Advanced Clinical Fellow, American Cancer Society.
Academy
of Oral Pathology,
445
Oral Burg. September, 1972
tion
Fig. 2. Lip biopsy (1966) showing and adjacent chronic inflammation.
squamous-cell carcinoma with (Magnification, x205.)
cpithelial
pearl
forma-
larged left anterior and posterior cervical lymph nodes. The abscess healed following incision and drainage and antibiotic therapy. Excision of the remaining enlarged posterior cervical lymph node revealed poorly differentiated squamous-cell carcinoma. Chest x-ray, laryngoscopy, bronchoscopy, esophagoscopy, an upper gastrointestinal series, and a barium enema failed to reveal any lesion. Bronchial washings and sputum examinations were negative for malignant cells. An x-ray survey of the skeleton revealed no osseous metastases. The patient received 3,000 rads to the left cervical area, and on July 28, 1970, left radical neck dissection and exploration of the superior mediastinum disclosed metastatic, poorly differentiated squamous-cell carcinoma in five cervical and one superior mediastinal lymph nodes. The pa&operative course was uncomplicated. The patient was discharged 1 month later after receiving an additional 4,000 rads to the left side of the neck and superior mediastinum. The remarkable findings on physical examination at the time of the present admission were two 5 mm. right supraclavicular lymph nodes, a well-healed left cervical cicatrix, and light brown discoloration of the skin of the left side of the neck and shoulder. Microscopic examination of these nodes, excised the next day, disclosed metastatic, poorly dserentiated squamous-cell carcinoma simiIar to that found previously. On March 4, 1971, during the course of radiation therapy to the right supraclavicular area, several firm, well-circumscribed, slightly elevated nodules ranging to 6 mm. in diameter were found in the skin of the midportion of the upper left arm (Fig. 2). Excisional biopsy of one of these cutaneous nodules revealed metastatic, poorly differentiated squamous carcinoma in the dermis (Fig. 3) similar to that found in the lymph nodes. The other cutaneous nodules completely disappeared after the administration of 3,030 rads, Concurrently, the patient received 3,000 rads to the right side of the neck. The patient returned after 2 months, on June 13, in a severely deteriorated condition, with prominent lymphedema of the left arm and shoulder. A left second to fifth cervical
Volume 34 Number 3
Distant
Fig.
metastases of squamous-cell
8. Cutaneous
metastases,
Fig. J. Representative microscopic field poorly diff emmtiated squamous-cell carcinoma fication, x500.)
upper
left
carcinoma
of lip
447
arm.
of nodule shown in Fig. 2 showing metastatic, with several keratinizing cells (arrows). (Magni-
rhizotomy was performed because of severe pain. The patient developed pneumonia and died 5 weeks later. The pertinent finding at necropsy was metastatic, poorly differentiated squamous-cell carcinoma in the right supraclavicular lymph nodes, left lobe of the thyroid (several small foci), and in multiple sites in the skin and subcutaneous tissue of the thorax.
DISCUSSION Metastases The cutaneous and radiation were present,
reach the skin through blood vessel and lymphatic dissemination. metastases in our patient developed after radical neck dissection therapy to the cervical region. Because no other distant metastases retrograde lymphatic flow due to surgical and radiation oblitera-
448
Bordin
and M7eitzner
Oral Surg. September,
1972
tion of lymphatic channels in the neck is proposed as the most likely route of dissemination, Skin metastases typically appear in the form of one or more firm, discrete, painless, nonulcerated nodules. Those that arise from an internal carcinoma occur most often in the general vicinity of the primary neoplasm, but metastases to sites unusual such as the extremities, scalp, and lip have been described.8 The incidence of cutaneous metastases is low. In an autopsy series of both men and women with internal carcinoma, skin metastases occurred in 4.4 per cent.g The breast was the most common primary site, followed by the gastrointestinal tract. The incidence of cutaneous metastases from internal carcinoma in three studies limited to men, however, was 0.7 to 1.4 per cent.1°-12 The primary neoplasm in these three studies combined was pulmonary in 42.2 per cent, genitourinary in 23.9 per cent, gastrointestinal in 21.1 per eent, pancreatic in 5.7 per cent, of undetermined origin in 5.7 per cent, and upper respiratory in 1.4 per cent. Recognition of cutaneous metastases is of considerable clinical importance, for such metastases may serve as a readily accessible source of tumor tissue for histologic diagnosis. Slthough the clinical features of cutaneous metastases are not distinctive from the more common cutaneous nodules, such as intradermal nevus, dermatofibroma, and keratinous cyst, microscopic examination demonstrates their true nature and their histologic type and may even indicate the exact primary site, as in renal cell carcinoma. The most common histologic pattern encountered in cutaneous metastases is adenocarcinoma. The only reference to cutaneous metastases in squamous-cell carcinoma of the lip is in an article by Bernier and Clark. 4 Four of their patients were classified as having both lymph node and skin metastases. However, they do not specify the sites of skin involvement or state whether or not they represented true cutaneous metastases or direct extension through lymph node capsules. Cutaneous metastases are indicative of widespread dissemination and, therefore, carry a poor prognosis. In one studyI survival from the time of diagnosis of metastatic carcinoma in the skin from an internal carcinoma varied from 2 to 34 weeks, with six of the nine patients dead within 8 weeks. Appreciation is extended to Dr. Henry D. Garett of El Paso, Texas, for providing the patient’s initial clinical history and for permission to review and photograph the original biopsy specimen. REFERENCES
1. Price, L. W.: Metastasis in Squamous Cell Carcinoma, Am. J. Cancer 22: l-16, 1934. 2. Burke, E. M.: Metastases in Squamous Cell Carcinoma, Am. J. Cancer 30: 493503, 1937. 3. Martin, H., Macomb, W. J., and Blady, J. V.: Cancer of the Lip, Ann. Surg. 114: 226s 242, 1941. 4. Bernier, J. L.. and Clark, M. L.: Squamous Cell Carcinoma of the Lip, Milit. Surg. 109: 379397, i951. ’ 5. Peltier, L. F., Thomas, L. B., Crawford, T. H., Barclay, M. B., and Kreman, A. J.: The Incidence of Distant Metastases Among Patients Dying With Head and Neck Cancers, Surgery 30: 827833, 1951. 6. Hoye, R. C., Herrold, K. McD., Smith, R., and Thomas, L. B.: A Clinieopathological Study of Epidermoid Carcinoma of the Head and Neck, Cancer 15: 741-749, 1962. 7. DeVries. N.C.T.: Metastases of Souamous Cell Carcinoma of the Skin and Lip,-. Dermatologica’l38: 333.339, 1969. A 8. Beerman, H.: Some Aspects of Cutaneous Malignancy, Arch. Dermatol. 99: 617626, 1909,
Volume 34 Number 3
Distant metastases of squamous-cell carcinoma of lip
449
in Carcinoma, Cancer 3: 9. Abrams, H. L., Spiro, R., and Goldstein, N.: Metastases 76-85, 1950. 10. Winer, L. H., and Wright, E. T.: tiber den sekundaren (metastatischen) Hautkrebs: Kliuische und pathologische Untersuchungen, Hautarzt 11: 23-27, 1960. 11. Bordin, G. M., and Weitzner, S.: Cutaneous Metastases as a Manifestation of Internal Carcinoma: Their Diagnostic and Prognostic Significance! Am. Burg. (In press.) 12. Reingold, I. M.: Cutaneous Metastases From Internal Carcmoma, Cancer 19: 162-165, 1966.
Reprint requests to : Dr. Stanley Weitzner Department of Pathology Veterans Administration Hospital 2100 Ridgecrest Dr., 8. E. Albuquerque, N. M. 87108