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Metastatic carcinoma in tongue
Metastatic carcinomain tongue Report
of a case
Weitzner, M.D., and William Stanley Albuquerque, N. Mex. PATHOLOGY VERSITY
DEPARTMENT, OF NEW
MEXICO
VETERANS SCHOOL
Hentel,
ADMINISTRATION
M.D., HOSPITAL,
AND
UNI-
OF MEDICINE
M
etastatic lesions in the tongue are exceedingly rare. They have occurred with carcinoma of the lung,1-3 breast,4j 5 kidney,O-s prostate,s uterus,10 pharynx,‘l and esophagus,12 malignant melanoma,13~l4 and sarcoma of the esophagus15 and lung.16 At the Montefiore Hospital in New York, an analysis of metastases found in 1,000 consecutive autopsies of patients with carcinoma disclosed only one secondary lesion in the tongue,17 but the primary site in this case was not indicated. WilliP encountered a single instance of metastatic involvement of the tongue in his 500 cancer autopsies. A review of 745 postmortem examinations of patients with disseminated malignant neoplasms, excluding malignant lymphoma, at the Veterans Administration Hospital in Albuquerque, New Mexico, from 1947 through 1966 disclosed one casewith metastasis in the tongue. A case of adenocarcinoma of the stomach with symptomatic metastatic involvement of the tongue is presented. CASE REPORT A BO-year-old Caucasian man was readmitted to the hospital because of a “lump” of two months’ duration on the inferior surface of the tongue, which was painful following meals. The patient had also experienced some weight loss. Six months earlier, he had undergone a total gastrectomy, splenectomy, and partial hepatectomy because of adenocarcinoma of the stomach with extension into the liver. The pertinent findings on physical examination were a firm, tender, egg-sized mass in the inferior surface and base of the tongue, and a hard left submandibular lymph node. The patient salivated abundantly and had some difficulty in speaking. The clinical laboratory data were essentially normal. A chest roentgenogram revealed pulmonary emphysema, flattening of the left diaphragm, and obliteration of the left costophrenic angle. The lingual lesion was biopsied, and the histopathologic interpretation was metastatic adenocarcinoma in the tongue.
278
Metastatic
Volume 25 Number 2
Fig.
2. Gross photograph
of hemisection
of tongue
with
carcinoma in tongue
diffuse
Fig. 2. Metastatic adenocarcinoma in striated musculature cbhannel of tongue. (Hematoxylin and eosin stain. Magnification,
neoplastie
and x40.)
The patient’s condition deteriorated rapidly. During the last complai ned of abdominal and lingual pain and marked enlargement with inc :reasing difficulty in deglutition and speech. Posi
perineural
279
involvemtSnt.
lyrnpllatic
6 weeks of life he of the lingual mass, anterior two thirds floor of the mouth. tongue was diffusely beneath the intact
280
O.S.,OX & OP.
?Veitzner and Hentel
Fig. 3. Higher-power view of lingual striated musculature noma. (Hematoxylin and eosin stain. Magnification, x204.)
February,
with
metastatic
1968
adenocarci-
muscle fibers were mucosa. On microscopic examination (Figs. 2 and 3), the striated separated by clusters of malignant cells with acinar formation. There was occasional perineural lymphatic involvement. The secondary adenocarcinoma in the tongue was essentially identical to the primary malignant tumor of the stomach. Other pertinent findings at autopsy were secondary adenocarcinoma in the pancreas, of the small intestine, jeright adrenal gland, retroperitoneal lymph nodes, mesentery junum, and peritoneum; there was neoplastic obstruction of the jejunum with dil.atation of the jejunum and esophagus and aspiration of intestinal contents into the tracheobronchial tree.
COMMENT
Metastatic lesions in the tongue are usually small and clinically insignificant and are noted either sometime after discovery of the primary neoplasm or at autopsy. In several cases, however, the metastatic lesion in the tongue has been the presenting symptom and only after its biopsy was the probable occult primary neoplasm suggested. Coenen’@ case and the case reported here are apparently the only published examples of a metastatic lesion in the tongue producing noteworthy symptomatic difficulty with deglutition. In the present case there was also prominent interference with speech. It is virtually impossible to ascertain the incidence of metastatic involvement of the tongue because of the paucity of information. From the available data, it would seem to be 0.1 to 0.2 per cent, but it is probably much less. The remarkable immunity of skeletal muscle to metastatic tumor is well known but poorly understood. In the present case, the tongue was the only site of secondary adenocarcinoma above the diaphragm. It is difficult to explain this massive metastatic involvement of the tongue, but perhaps Batson’s plexus or a subtle lymphatic or vascular anomaly was the underlying basis, In any
Volume 25 Number 2
Metastatic
carcinoma in tongue
281
event, this case well illustrates the many vagaries of malignant neoplasms and their metastaseswhich remain to be clarified. SUMMARY
A case of massive metastatic involvement of the tongue with adenocarcinoma, producing prominent symptomatic interference with deglutition and speech, has been presented. It would appear from the available data that secondary tumor in the tongue accounts for 0.1 to 0.2 per cent of all metastases. Batson’s plexus or an anomaly of the lymphatic or vascular circulation is offered as a possible avenue of spread to the tongue in this case. REFERENCES 1 . Fitzwilliams, 2.
3.
8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
D. C. L.: Specimen of Carcinoma of Tongue Secondary to a Primaq Growth in a Bronchus, Proc. Roy. Sot. Med. 31: 551552, 1938. Forster: Ein Fall von Markschwamm mit ungewohnlich vielfacher metastatiseher Verbreitung, Virchows Arch. path. Anat. 13: 271-274, 1858. Grove, J. S., and Kramer, 5. E.: Primary Carcinoma of the Lung: A Clinical and Pathological Study From Cook County Hospital, With a Report of 21 Necropaies and 3 Biopsies, Am, J. M. Se. 171: 250-282, 1926. Fink, I., and Garb, J.: Carcinoma of the Tip of the Tongue: A Case of Metastasis From a Malignant Tumor of the Breast, Am. J. Surg. 62: 138-141, 1943. Kolson, H.: Adenoearcinoma of the Breast Metastatic to Base of Tongue: A Case Rcport, Laryngoscope 76: 531-536,1966. Berl. klin. Wchnschr. 51: 1626-1627, Coenen, H. : Hypernephrom des Zungengrundes, 1914. MacKenzie, D. W., and Waugh? T. R.: Cystadenoma Pseudopapilliferum Malignum of Surgeons 20: the Kidney With Metastases In the Tongue, Tr. Am. A. Genito-Urin. 121-135. 1927. McNattin, R. F., and Dean, A. L.: A Case of Renal Adenocarcinoma With Unusual Manifestations, Am. J. Cancer 15: X70-1576, 1931. Stern, A.: Das Schicksal eingeschwemmter Geschwulstzellen in der Lunge, Virchow s Arch. path. Anat. 241: 219-231, 1923. Winkler, K.: tfber die Betheiligung des Lymphgefassystems an der Versehleppung biisartiger Geschwulste, Virchows Arch. path. Anat. 151: Supp. 195271, 1898. Willis, R. A.: The Spread of T umors in the Human Body, ed. 2, London, 1952, Butterworth & Co., Ltd., p, 282. Robinson, E. R., and Stuteville, 0. R.: Metastatic Tumors to the Tongue: Review of the Literature and Report of a Case, ORAL &no., ORAL MED. & ORAL PATH. 15: 980-985, 1962. Coley, W. B., and Hoguet, J. P.: Melanotic Cancer: With a Report of 91 Cases, Ana. Surg. 64: 206-241, 1916. Schmidt, J.: Ein Beitrag zum Melanom der Nebenniere, Frankfurt. Ztschr. Path. 9: 400-421, 1912. James, G. B.: Sarcoma of Oesophagus With Secondary Deposit in Tongue, Tr. Path. Sot. London 49: 91, 1898. Crymes, T., and Taylor, R. G.: Angiosarcoma Metastatic to the Tongue: Report of a Case. J. Oral Surg.. Anesth. & HOSD. D. Serv. 24: 63-66. 1966. Abrams, H. L., Spiro, R., and Goldstein, N.: Metastases in Carcinoma: snalysis of 1,000 Autopsied Cases, Cancer 3: 74-85, 1950.
of a case
Weitzner, M.D., and William Stanley Albuquerque, N. Mex. PATHOLOGY VERSITY
DEPARTMENT, OF NEW
MEXICO
VETERANS SCHOOL
Hentel,
ADMINISTRATION
M.D., HOSPITAL,
AND
UNI-
OF MEDICINE
M
etastatic lesions in the tongue are exceedingly rare. They have occurred with carcinoma of the lung,1-3 breast,4j 5 kidney,O-s prostate,s uterus,10 pharynx,‘l and esophagus,12 malignant melanoma,13~l4 and sarcoma of the esophagus15 and lung.16 At the Montefiore Hospital in New York, an analysis of metastases found in 1,000 consecutive autopsies of patients with carcinoma disclosed only one secondary lesion in the tongue,17 but the primary site in this case was not indicated. WilliP encountered a single instance of metastatic involvement of the tongue in his 500 cancer autopsies. A review of 745 postmortem examinations of patients with disseminated malignant neoplasms, excluding malignant lymphoma, at the Veterans Administration Hospital in Albuquerque, New Mexico, from 1947 through 1966 disclosed one casewith metastasis in the tongue. A case of adenocarcinoma of the stomach with symptomatic metastatic involvement of the tongue is presented. CASE REPORT A BO-year-old Caucasian man was readmitted to the hospital because of a “lump” of two months’ duration on the inferior surface of the tongue, which was painful following meals. The patient had also experienced some weight loss. Six months earlier, he had undergone a total gastrectomy, splenectomy, and partial hepatectomy because of adenocarcinoma of the stomach with extension into the liver. The pertinent findings on physical examination were a firm, tender, egg-sized mass in the inferior surface and base of the tongue, and a hard left submandibular lymph node. The patient salivated abundantly and had some difficulty in speaking. The clinical laboratory data were essentially normal. A chest roentgenogram revealed pulmonary emphysema, flattening of the left diaphragm, and obliteration of the left costophrenic angle. The lingual lesion was biopsied, and the histopathologic interpretation was metastatic adenocarcinoma in the tongue.
278
Metastatic
Volume 25 Number 2
Fig.
2. Gross photograph
of hemisection
of tongue
with
carcinoma in tongue
diffuse
Fig. 2. Metastatic adenocarcinoma in striated musculature cbhannel of tongue. (Hematoxylin and eosin stain. Magnification,
neoplastie
and x40.)
The patient’s condition deteriorated rapidly. During the last complai ned of abdominal and lingual pain and marked enlargement with inc :reasing difficulty in deglutition and speech. Posi
perineural
279
involvemtSnt.
lyrnpllatic
6 weeks of life he of the lingual mass, anterior two thirds floor of the mouth. tongue was diffusely beneath the intact
280
O.S.,OX & OP.
?Veitzner and Hentel
Fig. 3. Higher-power view of lingual striated musculature noma. (Hematoxylin and eosin stain. Magnification, x204.)
February,
with
metastatic
1968
adenocarci-
muscle fibers were mucosa. On microscopic examination (Figs. 2 and 3), the striated separated by clusters of malignant cells with acinar formation. There was occasional perineural lymphatic involvement. The secondary adenocarcinoma in the tongue was essentially identical to the primary malignant tumor of the stomach. Other pertinent findings at autopsy were secondary adenocarcinoma in the pancreas, of the small intestine, jeright adrenal gland, retroperitoneal lymph nodes, mesentery junum, and peritoneum; there was neoplastic obstruction of the jejunum with dil.atation of the jejunum and esophagus and aspiration of intestinal contents into the tracheobronchial tree.
COMMENT
Metastatic lesions in the tongue are usually small and clinically insignificant and are noted either sometime after discovery of the primary neoplasm or at autopsy. In several cases, however, the metastatic lesion in the tongue has been the presenting symptom and only after its biopsy was the probable occult primary neoplasm suggested. Coenen’@ case and the case reported here are apparently the only published examples of a metastatic lesion in the tongue producing noteworthy symptomatic difficulty with deglutition. In the present case there was also prominent interference with speech. It is virtually impossible to ascertain the incidence of metastatic involvement of the tongue because of the paucity of information. From the available data, it would seem to be 0.1 to 0.2 per cent, but it is probably much less. The remarkable immunity of skeletal muscle to metastatic tumor is well known but poorly understood. In the present case, the tongue was the only site of secondary adenocarcinoma above the diaphragm. It is difficult to explain this massive metastatic involvement of the tongue, but perhaps Batson’s plexus or a subtle lymphatic or vascular anomaly was the underlying basis, In any
Volume 25 Number 2
Metastatic
carcinoma in tongue
281
event, this case well illustrates the many vagaries of malignant neoplasms and their metastaseswhich remain to be clarified. SUMMARY
A case of massive metastatic involvement of the tongue with adenocarcinoma, producing prominent symptomatic interference with deglutition and speech, has been presented. It would appear from the available data that secondary tumor in the tongue accounts for 0.1 to 0.2 per cent of all metastases. Batson’s plexus or an anomaly of the lymphatic or vascular circulation is offered as a possible avenue of spread to the tongue in this case. REFERENCES 1 . Fitzwilliams, 2.
3.
8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
D. C. L.: Specimen of Carcinoma of Tongue Secondary to a Primaq Growth in a Bronchus, Proc. Roy. Sot. Med. 31: 551552, 1938. Forster: Ein Fall von Markschwamm mit ungewohnlich vielfacher metastatiseher Verbreitung, Virchows Arch. path. Anat. 13: 271-274, 1858. Grove, J. S., and Kramer, 5. E.: Primary Carcinoma of the Lung: A Clinical and Pathological Study From Cook County Hospital, With a Report of 21 Necropaies and 3 Biopsies, Am, J. M. Se. 171: 250-282, 1926. Fink, I., and Garb, J.: Carcinoma of the Tip of the Tongue: A Case of Metastasis From a Malignant Tumor of the Breast, Am. J. Surg. 62: 138-141, 1943. Kolson, H.: Adenoearcinoma of the Breast Metastatic to Base of Tongue: A Case Rcport, Laryngoscope 76: 531-536,1966. Berl. klin. Wchnschr. 51: 1626-1627, Coenen, H. : Hypernephrom des Zungengrundes, 1914. MacKenzie, D. W., and Waugh? T. R.: Cystadenoma Pseudopapilliferum Malignum of Surgeons 20: the Kidney With Metastases In the Tongue, Tr. Am. A. Genito-Urin. 121-135. 1927. McNattin, R. F., and Dean, A. L.: A Case of Renal Adenocarcinoma With Unusual Manifestations, Am. J. Cancer 15: X70-1576, 1931. Stern, A.: Das Schicksal eingeschwemmter Geschwulstzellen in der Lunge, Virchow s Arch. path. Anat. 241: 219-231, 1923. Winkler, K.: tfber die Betheiligung des Lymphgefassystems an der Versehleppung biisartiger Geschwulste, Virchows Arch. path. Anat. 151: Supp. 195271, 1898. Willis, R. A.: The Spread of T umors in the Human Body, ed. 2, London, 1952, Butterworth & Co., Ltd., p, 282. Robinson, E. R., and Stuteville, 0. R.: Metastatic Tumors to the Tongue: Review of the Literature and Report of a Case, ORAL &no., ORAL MED. & ORAL PATH. 15: 980-985, 1962. Coley, W. B., and Hoguet, J. P.: Melanotic Cancer: With a Report of 91 Cases, Ana. Surg. 64: 206-241, 1916. Schmidt, J.: Ein Beitrag zum Melanom der Nebenniere, Frankfurt. Ztschr. Path. 9: 400-421, 1912. James, G. B.: Sarcoma of Oesophagus With Secondary Deposit in Tongue, Tr. Path. Sot. London 49: 91, 1898. Crymes, T., and Taylor, R. G.: Angiosarcoma Metastatic to the Tongue: Report of a Case. J. Oral Surg.. Anesth. & HOSD. D. Serv. 24: 63-66. 1966. Abrams, H. L., Spiro, R., and Goldstein, N.: Metastases in Carcinoma: snalysis of 1,000 Autopsied Cases, Cancer 3: 74-85, 1950.