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An unusual presentation of oat cell carcinoma

Article in The Journal of Laryngology & Otology · July 1993

DOI: 10.1017/S0022215100123709 · Source: PubMed

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The Journal of Laryngology and Otology June 1993, Vol. 107, pp. 559-560

An unusual presentation of oat cell carcinoma

• R. CAPPER, F.R.C.S.I.,* T. J. STEWART, F.R.C.S.,* J. P. MAGENNIS, F.F.D., R.C.S.I.**

Abstract A case is reported of oat cell carcinoma of the lung presenting with unusual sites of metastasis to the orofacial region. Dis- tant metastases are common in oat cell carcinoma but a literature review did not reveal any reports of metastases either to the hard palate or to medial canthus of the eye. Key words: Lung neoplasms; Carcinoma, oat cell; Neoplasm metastasis, head and neck Introduction Oat cell carcinoma is well recognized for producing extra- thoracic metastases. These were present in more than 95 per cent

• f postmortem studies performed on patients who died of the

disease (Brodsky and Rabsien, 1985). Less frequently, the disease is diagnosed initially after recognition of such metasta-

• ses. A case of oat cell carcinoma of the lung is reported where the

initial presenting features were metastases to the palate and to the right infra-orbital region. Case report A 55-year-old man (S.W.), was referred by his general medical practitioner to the Ear, Nose and Throat Outpatient Department with a two-week history of a painless, rapidly grow- ing swelling on the hard palate and a four-week history of a similarly painless swelling inferior to the right medial canthus. He complained of some difficulty in swallowing and in artic-

• ulation. He had no respiratory symptoms and his general health

was good. He had smoked 12 cigarettes per day for many years. On examination there was a soft, non-tender, mobile, well- delineated swelling measuring 2 x 2 x 1 cm at the medial can- thus of the right eye. The intra-oral swelling was similar in appearance and consistency, measuring 3 x 3 x 3 cm in the midline of the hard palate. On nasal examination, the septum was deviated to the left with no view of the posterior airway on this

• side. The right nasal airway was clear. It was impossible to view

the post-nasal space as the patient could not tolerate a mirror in his pharynx. There were no palpable cervical lymph nodes. X-rays of skull and sinuses (Fig. 1) showed soft tissue shadowing to the right of the nose with no involvement of under- lying bone. In view of the unusual nature of the swellings a pro- visional diagnosis of neoplastia was made. Blood tests were taken and a chest X-ray requested. An appointment was arranged

• FIG. 1

X-ray of sinuses showing soft tissue shadowing at the right inner canthus.

• FIG. 2

Chest X-ray showing a large lesion at the right hilum. From the *Department of Otolaryngology, Ulster Hospital, Belfast and **The Queen's University, Belfast. Accepted for publication: 30 January 1993. 559

560

• R. CAPPER, T. J. STEWART, J. P. MAGENNIS

for further investigation of the lesions in one week's time fol- lowing a course of broad spectrum antibiotics. After this time, the swellings had increased in size. The chest X-ray was reported as showing a large infiltrating mass at the right hilum with a paratracheal stripe on the right, suggesting associated paratracheal lymphadenopathy (Fig. 2). The full blood picture, urea and electrolytes and bone profile were

• normal. ESR was 13 mm in the first hour. Liver function tests

showed elevation of alkaline phosphatase and y-glutamine- transferase in keeping with secondary tumour deposits within the liver. The patient was admitted to hospital. The hard palate lesion was biopsied and a fine needle aspiration was performed on the facial swelling. The histopathology and aspiration cytology were reported as being in keeping with metastases from a poorly differentiated oat cell carcinoma of the bronchus. His lung tumour was judged to be too advanced for surgery by a thoracic surgeon and he was referred for palliative chemotherapy. Three weeks later he was readmitted to hospital as the lesion

• n the palate had grown rapidly and now completely filled the

arch of the hard palate. He had severe candidiasis of the mouth and was experiencing difficulty maintaining an adequate oral fluid intake. The lesion on the right malar region now completely

• ccluded the right eye. Multiple small subcutaneous nodules had

appeared on his face and upper thorax. Further chemotherapy was abandoned and he was transferred to the regional Hospice for terminal care. He died seven weeks after his initial presentation. Discussion Oat cell carcinoma of the lung accounts for approximately 25 per cent of all bronchial carcinomas. It is an aggressive tumour and early metastasis is common. In the majority of cases, the tumour has spread beyond the lung by the time of diagnosis. The most frequent sites for metastases are hilar lymph nodes (96 per cent), liver (77 per cent), bone (59 per cent), adrenal glands (49 per cent), brain (25 per cent) and kidney (24 per cent) (Falk et al., 1980). The orofacial region is an uncommon site for any secondary

• tumour. In a series of 2409 oral and jaw malignant tumours only

24 (1 per cent) were metastatic, 12 presenting as lesions in the bone of the mandible or maxilla and 13 in the soft tissue (12 gin- gival and 1 lip). Sixteen per cent of metastatic lesions arise in the lung (Wu, 1990). In two review articles, between 13 per cent (Kaugars and Svirsky, 1981) and 22.5 per cent (Zachariades, 1989) of all metastatic lung lesions to the orofacial region were

• at cell in type.

Review of the reported cases of bronchial oat cell carcinoma metastasizing to the perioral region reveals a predilection for soft tissue, with the most common sites being the base of the tongue and the gingivae. Metastatic oat cell carcinoma has also been described in the major salivary glands (Brodsky and Rabsien, 1985; Cantera and Hernandex, 1989); tonsils (Seddon, 1989); tongue (Sridhar et al., 1985) and pre-auricular area (Falk et al, 1980). Multiple subcutaneous nodules, as seen in this case, have also been described (Brodsky and Rabsien, 1985). This case is unusual in that the initial presentation of a rela- tively common tumour was with a rare metastatic lesion to the hard palate. It was this intra-oral lesion which caused the pres- enting problems of dysphagia and dysarthria but a cutaneous lesion at the medial canthus predated it by two weeks. Where an unusual or atypical swelling is encountered, the importance of biopsy or aspiration cytology in its diagnosis can- not be stressed too highly.

References Brodsky, G., Rabsien, A. B. (1985) Metastases to the submandibular gland as the initial presentation of small cell carcinoma. Oral Sur- gery, Oral Medicine and Oral Pathology 58: 76-80. Camera, J. M. G., Hernandex, A. V. (1989) Bilateral parotid gland metastasis as the initial presentation of a small cell lung car-

• cinoma. Journal of Oral and Maxillofacial Surgery 47 (part II):

1199-1201. Coslett, L. M., Katlic, M. R. (1990) Lung cancer with skin metasta-

• sis. Chest 97: 757-759.

Falk, H. J., Samit, A. M., Leban, S. G., Mashberg, A. (1980) Pre- auricular oat cell carcinoma metastases. Surgical Oncology 13: 295-300. Kaugars, G. E., Svirsky, J. A. (1981) Lung malignancies metastatic to the oral cavity. Oral Surgery, Oral Medicine and Oral Pathol-

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Seddon, D. J. (1989) Tonsillar metastases at presentation of small cell carcinoma of the lung. Journal of Royal Society of Medicine 82: 688. Sridhar, K. S., Chaninian, P., Schwartz, I. S. (1985) Tongue metasta- sis from undifferentiated small cell (oat cell) lung cancer. Journal

• f Florida Medical Association 72 (part 6): 28-30.

Wu, Y. T. (1990) Metastatic carcinoma of the oral tissues and jaws: a study of 25 cases. Chung-Hua Kou Ching I Hseueh Tsa Chih 25 (5): 258-261, 317. Zachariades, N. (1989) Neoplasms metastatic to the mouth, jaws and surrounding tissues. Journal of Cranio-Maxillo-Facial Surgery 17: 283-290. Address for correspondence: Miss Ruth Capper, F.R.C.S.I., Longwood Cottage, The Bath Clinic, Claverton Down, Bath BA2 7BR.

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