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ATYPICAL METASTASIS FROM LARYNGEAL CANCER
Authored By: Keith Fischer and Archana Kantawala.
Patient: 44 year old
History: 44 year old patient: laryngeal squamous cell carcinoma presented to the emergency department with painful, swollen left wrist while receiving chemotherapy. There was clinical concern for septic arthritis.
Image Size:[small][as-submitted]

Fig. 1
Plain films 1- Two months prior to bone scan

Fig. 2
Plain films 2 - One day after previous plain film

Fig. 3
Plain films3 - Two months after first plain film and prior to bone scan.

Fig. 4
Angiographic phase dorsum

Fig. 5
Angiographic phase palmar

Fig. 6
Immediate blood pool

Fig. 7
Delayed images

Fig. 8

Fig. 9
CLockwise from left- STIR, T2 and T1postgad

Fig. 10
T2(left) and T1post gad(right)
Image Size:[small][as-submitted]

Findings:

Plain films 1 - Normal

Plain films 2 (one day after prior) - Increased soft tissue swelling over the left wrist with a 1 cm diameter round well-circumscribed lytic lesion in the lunate which may represent a cyst or less likely osteomyelitis.

Plain films 3 - A month later.

MR - left wrist synovitis and extensor tenosynovitis with a large pannus eroding into the dorsal lunate. DDx atypical infection versus inflammatory or crystalline arthritis.

Bone scan - There is increased blood flow and uptake within the left wrist which demonstrates soft tissue swelling. On the delayed images, there is decreased uptake within the left lunate bone as well as increased uptake in the distal radius and distal ulna, representing known metastatic disease with extensive destruction in the carpus. No additional foci of abnormal radionuclide uptake are seen within the axial or appendicular skeleton.(The diagnosis of metastatic involvement of the lunate bone was known at the time of the bone scan.)

Diagnosis: Metastatic laryngeal squamous cell carcinoma to the lunate bone.
General Discussion:

Synovial biopsy done 2 months prior to the bone scan, showed acute and chronic inflammation- treated with steroids and pain medications and symptoms continued.

A CT guided biopsy of soft tissue mass in the dorsum of left wrist and lunate done after the last set of plain films demonstrated metastatic poorly differentiated squamous cell carcinoma of the lunate.

 Squamous cell carcinoma of the head and neck has a predilection for cervical lymph node metastasis, and hematogenous spread is less frequent. However, with improvements in locoregional disease control associated with modern therapies the reported rate of distant spread appears to have risen.

Distant metastasis from laryngeal cancer is distinctly uncommon. Abramson et al (1975) cited a clinical estimate of 1.3% to 4.1%. Autopsy studies have demonstrated a metastasis rate of up to 88% with a compiled incidence of 26.5% in advanced laryngeal malignancy. Papac (1984) noted a high incidence of distant metastases in advanced laryngeal cancer (58.6%). Kotwall et al (1987) found a 44% incidence of distant metastasis at autopsy; most of these (89%) also had residual or recurrent locoregional disease. The most common sites for metastasis is the lung, followed by mediastinal nodes. Less frequent are osseous, hepatic, and other distal sites.

 

References:

http://emedicine.medscape.com/article/383230-overview#a01

  • Taneja C, Allen H, Koness RJ, et al.(2002) Changing patterns of failure of head and neck cancer. Arch Otolaryngol Head Neck Surg 128:324–327.

  • Yucel EA, Demirel T, Demiryont M, et al. (2003) An unusual metastatic site of laryngeal carcinoma: Scapular muscles. J Laryngol Otol 117:85–87

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    Additional Details:

    Case Number: 323115Owner(s): Keith Fischer and Archana KantawalaLast Updated: 02-07-2013
    Anatomy: Skeletal System   Pathology: Neoplasm
    Modality: Conventional Radiograph, MR, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
    Keywords: bsnm

    Case has been viewed 15 times.
    Certified by Keith Fischer on 02-05-2013

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