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162]

E-JCRT Correspondence

Unusual metastatic presentation of

carcinoma hypopharynx
ABSTRACT
Cutaneous metastases from hypopharyngeal cancers is rare constituting about 0.8-1.3% and represent a subgroup of head and neck
cancer patients who have very poor prognosis even when treated. We report a case of 65yearold male diagnosed as carcinoma
hypo pharynx stage IV who was on radiotherapy when he developed cutaneous metastasis over the chest wall, which initially
presented as small nodules and later progressed into a proliferative lesion. Patient received further radiation to the metastatic lesion,
but the disease was progressive, demonstrating that head and neck squamous cell cancer patients with skin metastasis fare poorly.
KEY WORDS: Chest wall metastasis, hypopharynx, prognosis

INTRODUCTION
Hypoand oropharyngeal malignancies constitute
about 1.1% of all malignancies in the world and
about 3.8% of all malignancies in India.[1] On an
average 65-75% of tumors of hypopharynx arise
from pyriform sinus, which is the most common
sub site, 10-20% arise from the posterior pharyngeal
wall, and 5-15% originate from the postcricoid
region.[2] At least 50% of patients manifest clinically
with positive cervical lymph nodes at the time of
diagnosis. Treatment recommendations range from
radical chemoradiation to palliative radiation or
chemotherapy, depending on stage of disease and
performance status of the patient.
CASE REPORT
A 65yearold male presented with swelling over
the left side of neck since 3months associated
with pain for 1month. Magnetic resonance
imaging(MRI) scan of head and neck revealed a
3.2cm2.2cm1cm lesion in the left pyriform
sinus, the lesion was seen extending inferiorly up
to the false vocal cords without involving the true
cords, posteriorly the lesion involved the posterior
pharyngeal wall from C5 to C6 vertebral level,
crossing the midline and laterally it was seen to
obliterate the left paralaryngeal space[Figure1].
Multiple enlarged enhancing left side levelII,III,
and IV cervical lymph nodes and multiple
subcentimetric bilateral cervical lymph nodes
were also noted on MRI[Figure2]. Histopathology
from the primary lesion and node showed features
suggestive of moderately differentiated squamous

cell carcinoma(Grade2), without lymphovascular

space invasion and other risk features, rest of the
metastatic workup, including clinical examination,
chest radiograph, and ultrasound of the abdomen
was normal. Patient was diagnosed as squamous
cell carcinoma of hypopharynx stage IV(T2N2cM0).
He was planned for radiotherapy to the primary
and neck with no chemotherapy, in view of his age
and performance status. One week after starting
treatment patient developed multiple cutaneous
nodules over the left chest wall; around six in
number, with size ranging from 5 to 10mm, these
nodules gradually increased in size and coalesced
to form an ulceroproliferative lesion of size
6cm6cm[Figure3].
Biopsy from this lesion showed features of
irregularly hyperplastic stratified squamous
epithelium with areas of squamoid tumor cells
focally involving the epidermis, the cells possessed
moderate nuclear pleomorphism, prominent
nucleoli and abundant cytoplasm, suggestive
of moderately differentiated squamous cell
carcinoma[Figure4], without any risk features.
Patient was planned and received palliative
radiation of 2000 cGy in five fractions with 6 MV
photons with bolus to the chest wall, with adequate
dose coverage of the metastatic lesion. In view of
his metastatic disease, the radiation to the primary
and neck was also made palliative and he received
3000 cGy in 10 fractions to the primary and neck.
Following treatment patient had symptomatic relief
at the primary site, but the chest wall metastatic
lesion was progressive with appearance of new
nodules over adjacent areas of irradiation. He was

D. Niharika,
Sham Sunder,
Geeta S.
Narayanan,
Manjunath
Nandennavar1
Departments of
Radiation Oncology
and 1Medical
Oncology, Vydehi
Institute of Medical
Sciences and Research
Centre, Whitefield,
Bengaluru, Karnataka,
India
For correspondence:
Dr.D. Niharika,
Flat No.106,
SaptagiriEnclave,
Achar Layout,
Immidahalli
Road, Whitefield,
Bengaluru560066,
Karnataka, India.
Email:darasanihari@
yahoo.in

Access this article online

Website: www.cancerjournal.net
DOI: 10.4103/0973-1482.140804
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Niharika, etal.: Unusual metastatic presentation of carcinoma hypopharynx

Figure 2: Pretreatment axial magnetic resonance imaging section

showing left level IV lymph node with discontinuous skin margins
Figure 1: Axial magnetic resonance imaging sections showing contrastenhanced lesion in the left pyriform fossa

Figure 3: (a) Initial skin nodules over the chest wall. (b) 6 cm 6 cm
ulceroproliferative lesion over the left chest wall with cutaneous nodule
over the upper edge

put on followup postradiation with supportive care, during

which he expired 2months in followup.
DISCUSSION
Etiology of hypopharyngeal malignancies shows a strong
association with tobacco use, over90% of patients with
hypopharynx cancer report past history of cigarette smoking
and approximately 20-25% of patients with hypopharynx
cancer test positive for human papillomavirus DNA. Due
to the rich lymphatic network in this anatomic region,
patients commonly present with regional nodal metastases
of 50%, jugular chain nodes, levels II through IV, as well as
retropharyngeal nodes, are all at highrisk to harbor regional
metastases. In parallel to cancers of the nasopharynx,
retropharyngeal nodes may be the first site of nodal spread.
Postcricoid tumors may also spread directly to preand
paratracheal nodal basins. Due to the high propensity
for advanced primary disease as well as regional nodal
involvement, the majority of hypopharynx cancer patients
present with stage III and IV disease. Distant metastasis has
incidence ranging from 4.3% to 30% in patients with head
and neck squamous cell carcinoma.[3] Common metastatic
sites involved in order of incidence are lungs(36.4%),
bone(34.0%), and liver(23.8%).[4] Head and neck carcinomas
rarely metastasize to the skin, which constitutes about
0.8-1.3%. Metastases to the chest wall from hypopharyngeal
malignancies are extremely rare, which is most commonly due

Figure 4: (a) 4 resolution showing normal and discontinued epithelial

margins. (b) 40 resolution showing irregular hyperplastic stratified
squamous epithelium with areas of squamoid tumor cells

to hematogenous spread through seed and soil hypothesis,[5]

however lymphatic spread cannot be ruled out. The prognosis
of such cases is extremely poor,[6] and treatment is aimed only
at palliation of symptoms and improving the quality of life.
In one of the largest series of head and neck cancers reported,
Spector etal.[7] identified 2550patients with squamous cell
carcinomas of the larynx and hypopharynx treated in a single
center over two decades. Among 1667patients of carcinoma
larynx and 853patients of hypopharynx(408 are pyriform
sinus), 16.3% of hypopharyngeal patients reported distant
metastases which is more than twice as high as that of
laryngeal cancers(7.3%). Most common distant sites are the
lung, bone, skin, and central nervous system.
In the study conducted in Eastern Taiwan,[4] to evaluate the
clinical manifestations and possible risk factors for distant
metastases in the head and neck squamous cell carcinoma
patients results suggested that the overall incidence of distant
metastases was 20% among 735patients enrolled in the
study. Most frequent sites of metastases are to lungs(36.4%),
bone(34%), liver(23.8%) and it is dependent on the stage of
the primary tumor, loco regional control and the tumor site.
Among head and neck malignancies which metastasize to skin,
hypopharyngeal tumors contributed about 1%, oral cavity
tumors 5%, other pharyngeal tumors 1%. They concluded that
advanced stage carcinomas need more aggressive treatments

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Niharika, etal.: Unusual metastatic presentation of carcinoma hypopharynx

for loco regional control and distant failure, and also prognosis
of these patients is poor.
Doweck etal.,[8] in their study on the analysis of risk factors
predictive of distant failure after targeted chemoradiation
for advanced head and neck cancers concluded that patients
with more than one level of clinical nodal involvement and
those with hypopharyngeal carcinoma have the highest risk
of developing distant metastasis as the initial site of failure.
Survival of head and neck patients with distant metastasis is
in the range of 4-16months.
Our patient also presented with stage IV hypopharyngeal
carcinoma, which metastasized as ulcerative cutaneous nodules
over the left chest wall when the patient was being treated for
the primary disease; this demonstrates the aggressive nature
of the disease. Even though, the patient received palliative
radiation his survival was just 2months posttreatment, though
there is a partial response of the disease after radiation.
CONCLUSION
Hypopharyngeal cancer patients fare poorly compared to
other head and neck tumors. Prognosis of the patient depends
mainly on the age at presentation, primary tumor site, genetic
mutations and personal habits. Cutaneous metastasis in
hypopharyngeal cancers is extremely rare(about 1%), and this
is accompanied with poor outcome with average survival of
3months after developing skin metastasis.
ACKNOWLEDGMENTS
I take this opportunity to thank my professors Dr.Geeta. S. Narayanan,
Dr.Bhaskar Viswanathan, Dr.Bhanumathy; Medical oncologists

Dr.Shashidhar. V. Karpurmath, Dr.Manjunath Nandenavvar;

Surgical oncologists Dr.Ganesh and my collegues Dr.Kavitha,
Dr.SatyeshNadella, Dr.Naveen, Dr.Mallik, Dr.Shravan, Dr.Santosh,
Dr.Rajshree and Dr.karthik for their support.

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Cite this article as: Niharika D, Sunder S, Narayanan GS, Nandennavar M.
Unusual metastatic presentation of carcinoma hypopharynx. J Can Res
Ther 2015;11:666.
Source of Support: Nil, Conflict of Interest: None declared.