Year : 2009 | Volume
: 20 | Issue : 4 | Page : 496--498
Phalange metastasis from carcinoma of alveolus
Rajeev Shrivastava1, KK Singh1, BR Umbarker1, R Karle2, M Shrivastava2,
1 Department of Radiotherapy & Oncology, Rural Medical College, Loni, Ahmednagar, Maharastra, India
2 Department of Pathology, Rural Medical College, Loni, Ahmednagar, Maharastra, India
Department of Radiotherapy & Oncology, Rural Medical College, Loni, Ahmednagar, Maharastra
Metastatic involvement of a phalanx by head and neck cancers is rare. We report a case of a 66-year-old man with squamous cell carcinoma of the alveolus who had no residual disease or local recurrence after treatment but presented with metastasis to the middle phalanx of the middle finger.
|How to cite this article:|
Shrivastava R, Singh K K, Umbarker B R, Karle R, Shrivastava M. Phalange metastasis from carcinoma of alveolus.Indian J Dent Res 2009;20:496-498
|How to cite this URL:|
Shrivastava R, Singh K K, Umbarker B R, Karle R, Shrivastava M. Phalange metastasis from carcinoma of alveolus. Indian J Dent Res [serial online] 2009 [cited 2021 Jun 17 ];20:496-498
Available from: https://www.ijdr.in/text.asp?2009/20/4/496/59452
Cancers of the head and neck have traditionally been considered to be locoregional disease, as distant spread from the primary is rare. Crile  in 1923 reported distant metastasis in only 1% (45/4500) of patients with head and neck cancers. Subsequently, Merino et al.,  in 1977 reported an overall incidence of distant metastasis of 10.9%. Over the last two decades improvements in surgery, chemotherapy, and radiotherapy have changed the scenario. Due to better control of disease, with patients surviving for longer periods, metastasis is being seen at new, unusual, sites. In head and neck cancers, the most common sites for distant metastasis are lung (52%), skeletal system (20.3%), and liver (6%).  In the skeletal system it is uncommon to have metastasis distal to the elbow or the knee joint. It is very rare for head and neck cancers to involve the phalanges, though bronchogenic carcinoma does sometimes present with metastasis to a phalanx.  We report a case of alveolar carcinoma who presented with a swollen middle finger at follow-up, which was later diagnosed to be due to a metastatic lesion.
A 66-year-old male presented as a postoperative case of carcinoma of the lower alveolus (T4N0M0). He had been operated 20 days back at another institution for a proliferative mass over the alveolus that had spread to involve the mandible. A right-sided mandibular composite resection with right modified neck dissection type II had been done. The postoperative histopathological specimen had revealed it to be a poorly differentiated squamous cell carcinoma that had infiltrated connective tissue and bone. At presentation to Rural Medical College, Loni, institution, the expected postoperative changes were present but there was no evidence of any macroscopic disease. After examination and metastatic work-up, he was started on locoregional radiotherapy. He received 66 Gy/33 fractions/6.5 weeks. He was then kept on regular follow-up. After 1 year he developed a swelling in his left middle finger, which was painless and increased in size gradually over a period of 6 months [Figure 1]. X-ray showed destruction of the middle phalanx [Figure 2]. Bone scan showed a hot spot, suggestive of skeletal metastasis [Figure 3]. The rest of the skeletal system was normal. Fine needle aspiration cytology (FNAC) was performed, which showed poorly differentiated malignant cells [Figure 4]. The patient was planned for radiotherapy by mould technique using a high- dose- rate remote afterloading brachytherapy system. He received 52.5 Gy/15 fractions/8 days, with two fractions per day given 6 hours apart. After completion of radiotherapy he was started on chemotherapy with paclitaxel and carboplatin. Four weeks after he had received the first cycle of chemotherapy, he complained of severe pain in his lower back region. There was tenderness over the lumber spine with loss of power in both legs (grade III - WHO criteria). The X-ray showed compression of the L4 vertebrae with right pedicle destruction. He was given palliative radiotherapy to the lumbar spine (30 Gy/10 fractions/2 weeks) followed by the second cycle of chemotherapy. After completion of radiotherapy, power in both legs improved to grade IV. One week prior to the date for his third cycle of chemotherapy the patient died at home. The cause of death is unknown as the relatives did not take the patient to the hospital and an autopsy could not be performed.
Improvements in treatment modalities and disease control at the primary site better in the recent years, has lead to a change in the recurrence pattern and metastases to unusual sites. ,,,,, In 2002, Shridhar Iyer et al.,  reported two cases of hypopharyngeal carcinoma which spread to the percardium. Similarly, Schwender et al.,  reported a case of carcinoma of the oral cavity which had spread to the pericardium, lung, and thyroid. Recently, Zemann et al.,  reported a case of carcinoma of the buccal mucosa with metastasied to the myocardium.
Bronchogenic carcinoma has been known to spread to the fingers. Sanchez et al.,  reported a case of bronchogenic carcinoma which had metastasized to the fingers. Kerin et al.,  reported that bronchogenic carcinoma was the most common primary to metastasize to part of the finger, followed by breast cancer.
In the present case, the patient had received radical treatment for carcinoma of the alveolus, undergoing both surgery and adjuvant radiotherapy. Nevertheless, during the follow-up period he had developed a swelling in his middle finger which was confirmed on FNAC to be metastatic disease. Although disease at the primary site was controlled, he had developed secondaries in a phalanx; this is a rare occurrence in head and neck cancers. Later, he also had involvement of the L4 vertebrae.
Treatment modalities are today more refined, and more and more patients are being treated with organ preservation intent. With the use of concurrent chemotherapy and radiotherapy, better locoregional control is now possible. However, as patients survive for longer periods, distant metastasis will be seen more often and, in addition, clinicians can expect to encounter many more atypical presentations as metastasis to new and unusual sites may occur.
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