Small cell lung carcinoma metastasis to palatine tonsils

1 MD Fellowship Plastica Facial do departamento de Otorrinolaringologia Faculdade de Medicina da Universidade de Sao Paulo. 2 MD Preceptor da Disciplina de Otorrinolaringologia da Faculdade de Medicina da Universidade de Sao Paulo. 3 MD Medico assistente da disciplina Otorrinolaringologia-Oncologia do Instituto do Câncer do Estado de Sao Paulo. 4 MD Medico assistente da disciplina Otorrinolaringologia Faculdade de Medicina da Universidade de Sao Paulo. 5 Medico preceptor (2010) da divisao de Anatomia Patologica Faculdade de Medicina da Universidade de Sao Paulo (Medico Patologista). Faculdade de Medicina da Universidade de Sao Paulo (FMUSP). Endereco para correspondencia: Helena Hotz Arroyo. Rua Oscar Freire, no 2040, apto 65. Sao Paulo SP. Brasil. CEP: 05409-011. E-mail: helenaharroyo@hotmail.com Este artigo foi submetido no SGP (Sistema de Gestao de Publicacoes) do BJORL em 11 de junho de 2012. cod. 9259. Artigo aceito em 30 de agosto de 2012. CASE REPORT Braz J Otorhinolaryngol. 2013;79(5):645.


INTRODUCTION
Small-cell lung carcinomas (SCLC) are aggressive tumors 1 which rarely metastasize to the palatine tonsils 2,3 . Dissemination of disease to the tonsils seems to occur after antegrade movements of tumor cells through the neck lymphatic system 1 . The reasons that led the authors to report this case were the rarity of the occurrence in itself and the importance of carrying out thorough patient physical examination.

CASE REPORT
A 64-year-old male individual came to our service complaining of dysphagia and odynophagia evolving for six months and a lesion in his left oropharynx. He had had dysphonia for two months and mild dyspnea while performing physical effort. The subject claimed antibiotics failed to improve his condition. He had been a smoker for 50 years.
Physical examination revealed an ulcerated lesion of approximately four centimeters covered with fibrin in the left tonsillar bed ( Figure 1A). Laryngoscopy showed he had left vocal fold paresis. Neck palpation showed coalescent nodes on levels II and III on the left side.
Neck CT scans revealed a tumor with heterogeneous contrast uptake infiltrating the left oropharynx and extending into the soft palate, associated with clustering nodes on levels IIA/IIB, with liquefied areas and signs of capsular leakage; other similar but smaller nodes were seen on levels III, IV, V, and VI ( Figure 1B).
Chest CT scans showed lung emphysema and a tumor in the left upper lobe suggestive of lung carcinoma, in addition to enlarged mediastinal and bilateral supraclavicular lymph nodes ( Figure 1C).
Endobronchial biopsy indicated the patient had SCLC, as confirmed by IHC.
The patient died before the beginning of radiation and chemotherapy.

DISCUSSION
Small-cell lung carcinoma is a relatively common type of lung carcinoma, accounting for 15-25% of the cases 1-3 . It is considered to be an aggressive tumor, as it involves a significant portion of the lung. Metastasis occurs early on and involves the liver, abdominal lymph nodes, bones, the brain, the adrenal gland, the skin, the kidneys, and the pancreas. Palatine tonsillar involvement is rare 1,4 .
Palatine tonsillar metastasis originating from other primary tumors account for a small portion of tonsillar tumors (0.8%), and has been more frequently associated with breast, lung, kidney, testicular, skin, and rectal tumors 1,5,6 . Such pattern of disease spread may stem from antegrade movements of tumor cells through neck lymph nodes, the thoracic duct, and neck veins into the tonsils 1 .
A review covering 76 cases of tonsillar metastasis showed that ten of the 12 patients with lung cancer in the series had SCLC. In ten of the 12 cases there was evidence of metastasis in other tissues 5 .
Yaren et al. 2 and Hisa et al. 3 reported one case each of tonsillar metastasis by SCLC after treatment with chemoradiotherapy.
Mastronikolis et al. 6 reported cases of tonsillar tumors with metastasis to the liver, spleen, and ribs. Seddon et al. 1 reported a case of tonsillar metastasis in a patient with SCLC and exuberant pulmonary symptoms.
Unlike other cases, our patient's ENT complaints were more marked than the pulmonary symptoms as a result of the tonsillar metastasis, which accounted for the disease's early manifestations.
Despite the poor prognosis usually seen for subjects with SCLC, late diagnosis may impact the chances of managing the disease. In the described case, the patient had been treated with antibiotics for having signs of disease consistent with tonsillitis. Accurate diagnosis was delayed because the patient was subject to inadequate interviews, lack of follow-up, and disregard for the possibility of his disease being cancer.

CLOSING REMARKS
Given the simple nature of oropharynx examination and how often tumors in this area produce symptoms, careful oral examination must be performed even in patient with tumors in other sites. Tumors must be considered in patients with ulcerated lesions refractory to clinical management to expedite diagnosis and medical intervention.