Leukemoid reaction as a paraneoplastic syndrome in hypopharyngeal squamous cell carcinoma with cutaneous metastasis: an exceedingly rare occurrence.

Head and neck squamous cell carcinoma is considered a locoregional disease, with a distinct chance of metastasis, however, skin is an unusual site. Haematological paraneoplastic syndromes are even rarer, and may be the only presenting feature in these malignancies, producing diagnostic confusion. Cutaneous metastasis, in addition to signifying poor response to treatment and prognosis, can cause diagnostic difficulty if the metastasis is located with an occult primary, and is associated with a higher incidence of multiple synchronous primaries. This article describes a 52-year-old patient with multiple swellings on the left side of the neck and hoarseness of voice. On evaluation, the multiple swellings were found to be cutaneous metastasis from a hypopharyngeal squamous cell carcinoma, with a leukemoid reaction. He opted for palliative radiotherapy and succumbed to his illness within 3 months of presentation. This article discusses the importance of this unusual presentation and diagnostic difficulties associated with it.

18F-FDG PET-CT as a supplement to CT/MRI for detection of nodal metastasis in hypopharyngeal SCC with palpably negative neck.

OBJECTIVES/HYPOTHESIS: To determine the diagnostic value of (18) F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) compared with CT or magnetic resonance (MR) imaging for the detection of nodal metastasis in patients with hypopharyngeal squamous cell carcinoma (SCC) with palpably negative neck and to assess the role of PET-CT as a supplement to CT/MR. STUDY DESIGN: Retrospective analysis. METHODS: A total of 39 patients with palpably negative neck (36 men and 3 women; average age 65.4 years) underwent tumor resection and neck dissection as primary treatment. All patients were preoperatively evaluated with PET-CT and CT and/or MR, and imaging data were retrospectively reviewed. The diagnostic performance of PET-CT, CT/MR, and a combination of PET-CT and CT/MR was assessed using histopathologic results as a gold standard. RESULTS: Twenty (51.3%) of the 39 patients were found to have neck metastases. On a level-based analysis, the sensitivity of PET-CT, CT/MR, and combined interpretation of PET-CT and CT/MR was 65.7%, 57.1%, and 65.7%, respectively, but without statistical significance. Of the six patients who showed false negative neck findings based on CT/MR in addition to palpation, four cases were still missed with additional PET-CT. CONCLUSIONS: The addition of PET-CT examination to anatomic imaging involving CT and MR did not provide additional benefit for the preoperative evaluation of cervical nodal metastasis in patients with hypopharyngeal SCC with nonpalpable neck, yielding insufficient data to spare elective neck dissection.

Transoral robotic retropharyngeal lymph node dissection with or without lateral oropharyngectomy.

Retropharyngeal lymph node (RPLN) metastases can occur from advanced head and neck malignancies. Surgical access to RPLNs can be challenging. Considering the more aggressive conventional approach methods, there is an increasing need for minimally invasive techniques. Applying transoral robotic surgery (TORS) to access the RPLN has never been reported in the literature. The purpose of this study was to describe our experience with transoral robotic RPLN dissection for oropharyngeal and hypopharyngeal squamous cell carcinomas. We conducted a retrospective review of TORS cases performed at Severance Hospital, a tertiary care medical center from December 2011 to July 2012. Demographic, clinicopathologic, and treatment characteristics were abstracted from the medical record as well as complications and were analyzed descriptively. A total of 5 TORS procedures with transoral robotic RPLN dissection have been performed at Severance Hospital. Of these, 4 patients were treated for oropharyngeal squamous cell carcinoma and 1 for hypopharyngeal squamous cell carcinoma. The mean operation time for TORS including the robotic RPLN dissection was 84 ± 18.5 minutes. The operation time included time for docking of the robotic arms (4.8 ± 1.3 minutes), console working time for primary tumor removal (50 ± 8.9 minutes), and console working time for RPLN dissection (29.2 ± 9.4 minutes). No patients experienced complications related to the transoral robotic RPLN dissection. Transoral robotic RPLN dissection is a feasible approach for accessing retropharyngeal lymph nodes. This particular operative technique can serve as a minimal invasive surgery in removing pathologic RPLNs.

Primary pleural malignant mesothelioma with delayed metastasis to the piriform sinus: report of a case.

Piriform sinus tumors are uncommon and silent lesions. Their prognosis is poor because these tumors are usually not detected until they have reached an advanced stage. Almost all piriform sinus cancers are primary squamous cell carcinomas; other primary and metastatic tumors of the hypopharynx are exceedingly rare. One of the rare tumors in the laryngopharyngeal area is sarcomatoid carcinoma, which is an unusual type of squamous cell carcinoma. Another uncommon malignant tumor that is histologically similar to sarcomatoid carcinoma is malignant mesothelioma, which is a rare form of lung carcinoma. The macroscopic appearance and histologic characteristics of sarcomatoid carcinoma and malignant mesothelioma are so similar that differentiation is usually achieved by immunohistochemical examination. To the best of our knowledge, no case of primary or metastatic laryngohypopharyngeal malignant mesothelioma has been previously reported in the literature. In this article, we describe a case of isolated malignant mesothelioma of the piriform sinus that resembled a sarcomatoid carcinoma in a 50-year-old man with a history of lung mesothelioma.

Case report: Metastatic breast cancer presenting as a hypopharyngeal mass.

Although carcinoma of the breast has a propensity toward distant metastasis, metastasis to the head and neck is uncommon. Most patients with metastasis to the head and neck region present with cervical lymphadenopathy; however, spread to the upper aerodigestive tract has been described previously. We present a case of a patient found to have a pedunculated mass in her right piriform sinus. When she swallowed, the mass would completely prolapse into the esophagus and cause symptoms. Subsequent workup revealed widespread metastatic disease, for which the patient was treated with chemoradiotherapy. Microlaryngoscopy with excision of the mass was performed for palliation of her dysphagia, and a diagnosis of metastatic breast carcinoma was obtained. The patient healed well from the excision and went on to be treated for the metastatic breast cancer. To our knowledge, our report represents the first case of metastatic breast carcinoma presenting as severe dysphagia.

Radiolocalization of sentinel lymph nodes in clinically N0 laryngeal and hypopharyngeal cancers.

OBJECTIVES: We sought to analyze the characteristics of radioactive lymph nodes with metastatic disease and to explore methods for the localization of sentinel lymph nodes (SLNs) with radionuclide in clinically N0 laryngeal and hypopharyngeal cancer. METHODS: Forty-five patients with T1-T4 and clinically N0 laryngeal and hypopharyngeal cancer were recruited. For each patient, a peritumoral submucosal injection of 99mTc-labeled sulfur colloid was administered, and lymph node mapping was performed by lymphoscintigraphy 2 hours after injection. The SLNs were localized during operation by a hand-held gamma probe 10 to 12 hours after the injection, and we defined the radioactive counts from the parotideomasseteric region as background values. All lymph nodes that had accumulated radioactivity were harvested and initially termed as SLNs. Selective neck dissection was performed in all patients. The SLN specimens were sent for formal paraffin-embedded sectioning, serial sectioning, and immunohistochemical assay. The results were compared to those for the remaining lymphadenectomy specimen. Resection of the primary tumor depended on its location and the T classification. RESULTS: Sentinel lymph nodes were identified in 41 of 45 patients (51 necks). Sentinel lymph nodes with occult metastases were found in 13 patients (15 necks). In a false-negative case, metastasis was found in a nonsentinel lymph node in 1 of the neck specimens. The SLN identification rate was 92.7%, the sensitivity was 93.7%, the false-negative rate was 6.3%, and the accuracy was 98.0%. In 11 of the 15 necks (73.3%) with pathologically positive SLNs, metastasis was found in the node with the highest radioactivity. Harvesting the first 3 nodes with the highest radioactive counts may identify patients with occult metastatic disease. CONCLUSIONS: Excision of the first 3 SLNs with the highest radioactive counts can be used to accurately identify the status of cervical lymph node metastases in patients with clinically N0 laryngeal or hypopharyngeal cancer.

Significance of retropharyngeal lymph node dissection in hypopharyngeal cancer.

OBJECTIVE: We investigated the risk factors for metastasis to retropharyngeal lymph nodes (RPLNs) and the significance of dissection of RPLNs in hypopharyngeal cancer. Metastasis to the RPLNs is an important prognostic factor in head and neck cancer, especially in hypopharyngeal cancer. METHODS: Study subjects were 129 cases who received primary treatment at nine leading medical facilities in the field of head and neck cancer management in Japan. Focusing on RPLNs, we compared prognosis in RPLN-metastasis-positive, RPLN-metastasis-negative, RPLN-dissected and RPLN-non-dissected cases. RESULTS: The 5-year survival rate for the entire study group was 41.1%. Metastasis to RPLNs occurred during the follow-up period in 13.2%. RPLN dissection was performed in 32 of the 129 cases at the time of primary treatment. In the RPLN-dissected group, the 5-year survival rate in the RPLN-metastasis-positive subgroup was 30.0%, whereas that in the RPLN-metastasis-negative subgroup was 41.2%, showing no statistically significant difference. Among 17 cases having RPLN metastasis, 30.0% in the RPLN-dissected group (n = 10) survived for 5 years versus none in the RPLN-non-dissected group (n = 7). The rate of RPLN metastasis was higher in primary hypopharyngeal cancer of the posterior wall/post-cricoid area (PC/PW) compared with that of the piriform sinus (P = 0.020). CONCLUSIONS: We recommend RPLN dissection at the time primary of treatment of hypopharyngeal cancer, especially in cases with cancer at subsites PC/PW, as RPLN dissection is expected to improve prognosis. The primary subsites PC/PW are associated with a risk of RPLN metastasis.

Cervical lymph node metastasis model of pyriform sinus carcinoma.

OBJECTIVE: To establish a cervical lymph node metastasis model of pyriform sinus VX2 carcinoma and investigate its metastatic features. METHODS: VX2 tumor tissue suspension was transplanted into the pyriform sinus submucosa of 15 rabbits under direct laryngoscopy. Rabbits were randomly placed into 1 of 3 groups, each comprised of 5 rabbits. Health evaluation and histopathological analysis were performed on days 14 (group 1), 21 (group 2), and 28 (group 3) after transplantation. RESULTS: VX2 tumors were transplanted successfully in all rabbits. Dysphagia, weight loss, rhinorrhea, and dyspnea were observed 28 days after transplantation. Deep cervical lymph node metastasis occurred in all rabbits at all time points. The rate of submandibular lymph node metastasis was 60% in group 1, 80% in group 2, and 100% in group 3. The rate of paratracheal lymph node metastasis was 0% in group 1, 80% in group 2, and 100% in group 3. CONCLUSIONS: A model of metastatic pyriform sinus carcinoma was established. This model could be used in future studies evaluating diagnostic and treatment methods.

Unsedated transnasal esophagogastroduodenoscopy for the evaluation of dysphagia following treatment for previous primary head neck cancer.

Dysphagia is not uncommon after curative treatment for primary head and neck cancer. Local recurrences or second primary cancers in the upper digestive tract need to be excluded firstly before treatment for dysphagia. However, many patients have trismus or pharyngeal stenosis following treatment, both of which prevent rigid/flexible transoral laryngoscopy/esophagoscopy evaluating the entire upper digestive tract. The purpose of this study was to prospectively investigate the diagnostic value of unsedated transnasal esophagogastroduodenoscopy (EGD) in 36 primary head and neck cancer patients with post-treatment dysphagia. Except three patients with very narrow space or the presence of the tumor in the neopharynx, transnasal EGD could completely evaluate the upper digestive tract in 33 patients and found one patient with local recurrent hypopharyngeal cancer, seven patients with newly diagnosed hypopharyngeal cancer, four patients with esophageal cancer, and one patient with simultaneous hypopharyngeal and esophageal cancers, which were all successfully biopsied and proven microscopically. Five patients previously receiving total laryngectomy had various degrees of stenosis of the neopharynx without local recurrence or esophageal cancer. Thirteen patients had no significant organic or pathological lesions. One patient had a benign tumor on the epiglottis and the other NPC patient had extensive soft tissue necrosis in the pyriform sinus as a cause of dysphagia. The mean duration of the entire procedure was 16min. All patients tolerated the procedure well. No significant complications were noted during and after examination. The present study indicates that unsedated transnasal EGD is feasible to confidently distinguish between functionally/anatomically-related dysphagia and newly growing tumors in the upper digestive tract, and to obtain biopsy specimens for pathological diagnosis from the tumors in a single session.

Is dissection of levels 4 and 5 justified for cN0 laryngeal and hypopharyngeal cancer?

CONCLUSION: Dissecting levels 2 and 3 and sparing the dissection of level 4 and the contralateral neck when frozen section results are negative are reasonable options for the selective dissection of cN0 necks. Our findings show that dissection of level 5 is considered unnecessary, unless there is overt metastasis. OBJECTIVE: The level of node involvement and recurrence rates were assessed in cN0 laryngeal and hypopharyngeal carcinoma patients in order to develop appropriate guidelines for the treatment of the neck. MATERIALS AND METHODS: A total of 328 cN0 necks operated with selective dissection were reviewed retrospectively. Patients were monitored for at least 24 months and regional recurrences were evaluated. RESULTS: The prevalence of level 4 occult metastases was 3.4%; 1.5% of them were isolated to level 4. We observed regional recurrence in 5.6% of the necks. No case of metastasis or regional relapse was observed in level 5.

Upper mediastinal node dissection for hypopharyngeal and cervical esophageal carcinomas.

OBJECTIVES: Hypopharyngeal cancer (HPC) and cervical esophageal cancer (Ce) are aggressive tumors with a poor prognosis. Multiple lymph node metastases often occur in the upper mediastinum, as well as in the neck, and thus upper mediastinal dissection (MD) is crucial to improving the cure rate. However, excessive MD can increase postoperative morbidity and mortality, making it important to employ the proper technique and appropriate extent of dissection. In the present retrospective study we aimed to determine the proper extent of upper MD according to tumor site and stage. The benefit and risk of upper MD are also discussed. METHODS: Chart review was completed for patients who underwent upper MD, including 64 patients with HPC, 21 patients with Ce, and 9 patients with Ce extending to involve the upper thoracic esophagus (Ce/Ut). The incidence and distribution of lymph node metastases in the upper mediastinum were assessed by postoperative histopathologic examination. Postoperative complications of upper MD, as well as the impact on survival and locoregional control, were also reviewed. RESULTS: Upper mediastinal metastases were detected in 7.8% of HPC patients, 33.3% of Ce patients, and 55.6% of Ce/Ut patients. In HPC patients, mediastinal metastases were usually associated with T4 primary tumors (80%), whereas positive nodes in the upper mediastinum were detected regardless of T stage in both Ce and Ce/Ut. Only 1 Ce/Ut patient with a T4 tumor developed late nodal metastasis in the lower mediastinum. The 5-year disease-specific survival and locoregional control rates were 58.6% and 90.2% in HPC, 45.5% and 94.1% in Ce, and 38.9% and 77.7% in Ce/Ut, respectively. Rupture of the greater vessels after MD was observed in 5 cases (5.3%). CONCLUSIONS: The present results indicate excellent locoregional control rates following upper MD, while major complications such as arterial breakdown were rare. It is suggested that upper MD may be an essential and adequate procedure for patients with Ce or Ce/Ut tumors, and may also be required for cases of HPC with a T4 primary to improve locoregional control of the disease.

Treatment results for 84 patients with base of tongue cancer.

CONCLUSIONS: For T2 tumors, surgery was indicated if functional preservation was possible. For T3/T4 tumors, the rate of primary disease control was not high and surgery frequently involved total laryngectomy. Points that surgeons must heed when performing such surgery were delineated. OBJECTIVES: Because tumors originating from the base of the tongue are rare, few large-scale studies of such tumors have been performed. We reviewed treatments and outcomes at our department to establish effective future therapeutic plans. PATIENTS AND METHODS: From 1971 to 2000, 84 patients with previously untreated and resectable squamous cell carcinoma of the base of the tongue were treated at the Head and Neck Department of the Cancer Institute Hospital, Tokyo. Treatment selection and results were investigated. RESULTS: The main treatment options were radiotherapy for primary lesions < or = T2 and surgery for primary lesions > or = T3. Overall disease-specific 5-year cumulative survival rate was 59.8%, but there was no significant difference in survival rate at each stage between the two treatments. Among patients who died of the primary disease, the area that was most difficult to control was the superior margin of the lateral wall of the oropharynx (n=7). The incidence of contralateral or retropharyngeal lymph node metastasis was low if tumors neither crossed the midline nor infiltrated the lateral wall. While total laryngectomy was performed on 48 patients, the larynx was operatively preserved in 5 T3 patients and one T4 patient.

[Clinical pathology feature and prognostic factors of cervical lymph node metastases in hypopharyngeal carcinoma].

OBJECTIVE: To investigate the risk clinicopathological factors of primary tumor in the prediction of cervical lymph node metastases and the cervical lymph node prognostic factors in hypopharyngeal squamous cell carcinoma. METHODS: A retrospective study was carried out to review the histopathological data from 98 hypopharyngeal squamous cell carcinoma patients. The relationship between histopathological parameters and cervical lymph node metastases were evaluated by means of a univariate chi2 test and multivariate stepwise logistic regression model. And the Cox regression model was used to define possible pathological parameters of neck node affecting survival including N staging, presence of cervical lymph node metastases and extracapsular nodal spread, size and number of positive neck nodes, and levels of positive neck nodes. RESULTS: The overall 5-year survival rate of patients with hypopharyngeal carcinoma was 28.6%. In a univariate and multivariate analysis, it was confirmed that size and growth pattern of primary tumor correlated to cervical lymph node metastases. In a multivariate Cox regression analysis, the most significant prognostic factors of cervical lymph node were the size of positive neck nodes and level involved. CONCLUSIONS: Cervical lymph node metastases were one of the most significant prognostic factors of hypopharyngeal carcinoma. The identification of patients at risk for cervical lymph node metastases and the management of the neck by coping with pathological factors of cervical lymph node affecting survival are very important to improve the treatment and prognosis of hypopharyngeal carcinoma.

[Diagnostic impact of multiplanar reformations in multi-slice CT of laryngeal and hypopharyngeal carcinomas]. / Diagnostischer Nutzen multiplanarer Reformationen bei der Mehrschicht-CT von Larynx- und Hypopharynxkarzinomen.

PURPOSE: Assessment of the diagnostic value of multiplanar reformations (MPR) in multi-slice computed tomography (MSCT) by comparing relevant anatomic structures of the larynx and hypopharynx. MATERIALS AND METHODS: MSCT of the neck was performed in 69 consecutive patients (including 30 laryngeal and 12 hypopharyngeal carcinomas). From a 4 x 1.0 mm collimation data set, 3.0-mm and 1.25-mm axial slices as well as 3-mm coronal and sagittal slices were reconstructed. Using the histological examination as gold standard, sensitivity and specificity regarding tumor infiltration for all relevant anatomical structures of the larynx and the hypopharynx were determined for each reconstruction and compared with the McNemar test. Moreover, 42 patients with laryngeal and/or hypopharyngeal carcinoma were subjectively evaluated to determine whether the respective reconstructions enables a better topographical visualization of the tumor in relation to surrounding structures and, furthermore, whether this has an influence on the therapeutical strategy (operation versus radiation therapy, type of operation, surgical approach). RESULTS: Sensitivities and specificities were not significantly different between the reconstructions. However, coronal and sagittal MPR provided a better topographical visualization of the tumor in 14 of 42 (33 %) of the patients, and influenced the therapeutical strategy in 8 of 42 (19 %) of the patients. A lowered signal-to-noise ratio impeded the evaluation of the relatively thin 1.25-mm axial slices in more than 23 % of the cases. CONCLUSION: Besides the 3-mm axial slices, coronal and sagittal MPR can improve the topographical visualization of laryngopharyngeal tumors and are recommended for preoperative MSCT of laryngeal and/or hypopharyngeal carcinomas. Additionally reconstructed 1.25-mm axial slices can be discarded since they do not hold a higher value compared to 3-mm axial reconstructions.

Extraosseous metastases of hepatocellular carcinoma detection and therapeutic assessment with Tc-99m PMT SPECT.

Owing to recent advances in imaging technology and radiologic intervention, survival rates in patients with hepatocellular carcinoma have improved markedly. However, such prolonged survival has resulted in an increase in extrahepatic metastases. Tc-99m (Sn)-N-pyridoxyl-5-methyltryptophan (Tc-99m PMT), developed for hepatobiliary scintigraphy, has been used to visualize extrahepatic metastases, with most related reports limited to osseous metastases. The authors report two cases of hepatocellular cancer presenting as a hypopharyngeal metastasis and intraperitoneal dissemination along the tract of a fine-needle biopsy. Lesions undetectable on planar imaging could be visualized by Tc-99m PMT SPECT.

[A rare case of metastatic tumor in the neck with unknown primary focus]. / Rzadki przypadek przerzutowego guza szyi z nieznanego ogniska pierwotnego.

The authors present a rare case of metastatic tumor in lymphoid gland in the neck without primary identification of the cancer. The authors discussed the clinical picture, as well as diagnostic and therapeutic procedures.

Mycosis fungoides involving the cervical esophagus.

Review of the otolaryngologic literature reveals no case reports of mycosis fungoides involving the esophagus. Post-mortem studies report 12 cases of esophageal involvement in 131 autopsies of patients with mycosis fungoides. We describe a 54-year-old man with mycosis fungoides involving the larynx, hypopharynx, and esophagus. Treatment consisted of radiation to this area, with resolution of the patient's hoarseness and dysphagia. The charts of 96 patients with mycosis fungoides treated at our institution were retrospectively reviewed. Three additional cases involving the aerodigestive tract, but not the esophagus, were found. Esophageal mycosis fungoides was an incidental finding in two of seven autopsies at our institution.

[A case of metastasis of clear cell carcinoma of the kidney to the hypopharynx]. / Przypadek przerzutu raka jasnokomórkowego nerek do gardla dolnego.

A rare case of kidneys clear cell carcinoma metastasis to the laryngopharynx was described. The observed metastasis manifested itself only just three months after total left-sided nephrectomy and partial right-side nephrectomy because of clear cell carcinoma.

Flow cytometric DNA analysis of primary and concurrent metastatic squamous cell carcinoma of the head and neck.

Adequate flow cytometric DNA analysis comparing primary and concurrent metastatic squamous cell carcinoma of the head and neck has not been done in the past. The purpose of this study was to define any differences between the primary and concurrent metastasis of each patient with respect to flow cytometric parameters and histologic grade. Paraffin-embedded archival specimens from 28 patients with primary and metastatic tumors were prepared into nuclei and analyzed by flow cytometry using human lymphocyte standards. The mean DNA index was 0.82 for primary tumors and 0.83 for the metastases. Aneuploidy was found in 68 percent of primary tumors and in 82 percent of metastases. The percentage of cells in the proliferative fraction was 40.4 in the primary tumors and 24.5 in the metastases. A direct correlation was found between the differentiation of the primary and metastatic tumors. No survival difference was discovered among the flow cytometric parameters and histologic grade. We conclude that there is no difference between the primary and concurrent metastasis in squamous cell carcinoma of the head and neck with regard to DNA index, aneuploidy, or histologic grade.