Abstract. Laryngeal squamous cell carcinoma (SCC) tends to exhibit local spread with a low incidence of distal metastases. The majority of distal metastases are ...
The British Journal of Radiology, 72 (1999), 1117±1119
E
1999 The British Institute of Radiology
Case report
Renal metastases from a squamous cell carcinoma of the larynx 1
N S PAUL, MRCP, FRCR, 2P HARDEN, MD, PhD, MRCPath, 3R C FOWLER, MRCP, FRCR and 3 A G CHALMERS, MRCP, FRCR 1
Department of Radiology, Bradford Royal In®rmary, Duckworth Lane, Bradford BD9 6RJ, and Departments of 2Pathology and 3Radiology, Leeds General In®rmary, Leeds, UK
Abstract. Laryngeal squamous cell carcinoma (SCC) tends to exhibit local spread with a low incidence of distal metastases. The majority of distal metastases are to the lungs and renal involvement is extremely rare. We present a case of laryngeal SCC with metastatic spread to the left kidney presenting as a large, mainly cystic mass. The radiological differentiation of renal metastases from primary renal tumours is discussed.
A 42-year-old male smoker presented with hoarseness. Laryngoscopy and biopsy demonstrated an invasive squamous cell carcinoma involving the right vocal cord and false cord. CT of the larynx con®rmed the presence of the tumour and its extension across the midline. The tumour also extended through the right lamina of the thyroid cartilage. Several enlarged regional lymph nodes were noted. The patient underwent small total laryngectomy which was complicated by the development of a tracheo-oesophageal ®stula, subsequently managed by insertion of a Grongingen valve. The patient re-presented 2 years later with a 2 month history of left-sided abdominal discomfort. Abdominal ultrasound demonstrated a 13 cm cystic renal mass with an irregular solid rim (Figures 1a and b). CT of the thorax and abdomen con®rmed a left-sided mainly cystic renal tumour with evidence of invasion into the adjacent psoas muscle (Figures 2a and b). The thin, irregular solid rim of the tumour showed little enhancement following intravenous contrast medium. A solitary 8 mm pulmonary nodule in the basal segment of the right lower lobe was felt to represent a solitary metastasis and remained unchanged throughout follow-up. Radical nephrectomy con®rmed that tumour had in®ltrated the psoas and quadratus lumborum. Total tumour removal was not possible. Histological analysis of the resected specimen showed a moderately differentiated squamous cell carcinoma (SCC). The patient subsequently developed small bowel obstruction owing to tumour spread in the renal bed in®ltrating adjacent loops of Received 8 December 1998 and in revised form 5 March 1999, accepted 17 March 1999. The British Journal of Radiology, November 1999
small bowel. Histology of the resected small bowel loops demonstrated a well differentiated SCC compatible with the primary laryngeal tumour. The patient succumbed 30 months after initial presentation. Primary carcinomas of renal parenchyma do not show squamous differentiation but possibilities to consider were those of a transitional cell carcinoma showing squamous differentiation or a pure SCC arising from the renal pelvis. However, the tumour was separable from the pelvicalyceal system which showed no evidence of squamous differentiation or dysplasia. It was therefore felt that the renal tumour most probably represented a metastatic deposit from the previous laryngeal SCC, rather than a primary renal cell carcinoma.
Discussion Carcinoma of the larynx accounts for less than 2% of all noti®ed fatal malignancies [1, 2] and was responsible for the death of more than 880 people in England and Wales in 1992 [3]. The incidence is eight times higher in males [4], and peak mortality is in the 70±74 year age group. The incidence is increasing [5] owing to increased tobacco and alcohol use [6±8]. Laryngeal tumours are described according to their anatomical position as arising from the true cords (glottic), above (supraglottic) or below (subglottic) the cords. Squamous cell carcinoma represents over 95% of malignant tumours arising from the larynx [2, 7]. The main route of spread is via the lymphatic system. The glottis has a poor lymphatic drainage, which accounts for a relatively poor rate of spread to regional nodes (4%) at presentation. In contrast, the supraglottic region is richly invested with lymphatic vessels, 1117
N S Paul, P Harden, R C Fowler and A G Chalmers
(a)
(b)
Figure 1. (a,b) Ultrasound images of the cystic left renal mass revealing an irregular, solid component.
with local spread to cervical lymph nodes noted in 40% of tumours at presentation [2, 9, 10]. The prognosis and treatment options vary according to the anatomical site and degree of spread from a 3 year tumour free survival of 80±90% for an early glottic cancer treated with radiotherapy to 46% in advanced supraglottic carcinoma treated with total laryngectomy and radiotherapy [10]. Distal metastases relate to blood stream dissemination and are rarely discovered during life. In large post-mortem series the incidence of distant metastasis was only 8% [4]. The majority of metastases from laryngeal primary tumours are single lesions and arise within 2 years of diagnosis of the primary tumour [4]. Metastatic spread from laryngeal and hypopharyngeal carcinomas is typically to the lungs although metastases to the skin, small bowel and even to the penis have been reported [4, 11±13]. Renal metastases from a
laryngeal primary are exceedingly rare. We can ®nd only two cases in the literature and in these cases it is unclear whether the primary was a laryngeal or hypopharyngeal carcinoma [4]. Metastatic renal tumours outnumber primary renal carcinomas by a ratio of at least 2:1 [14, 15]. The common primaries are lung, stomach and breast [15, 16] and there is typically bilateral renal involvement [16]. 80% of patients with renal metastases will be asymptomatic despite extensive renal involvement in many cases [1, 16, 17]. Metastases showing squamous differentiation are most often from bronchial carcinoma but uncommonly arise from other sites such as the anal canal [18]. The majority (96%) of renal cell carcinomas (RCCs) are, on average, larger than metastatic lesions, with most primary tumours measuring over 6 cm at the time of presentation compared
(a)
(b)
Figure 2. (a,b) Contrast enhanced axial CT con®rming the complex nature of the left renal mass and invasion into the adjacent psoas muscle (arrow). 1118
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Case report: Renal metastases from an SCC of the larynx
with less than 4 cm for a metastases [19, 20]. Exceptions to this rule include secondaries from the gastrointestinal tract which may be larger than 4 cm and tend to be exophytic [21]. Metastases tend to be less exophytic and wedge shaped than primary RCC. Their frequently observed subcapsular location is explained by tumour seeding into the vascular renal cortex, with subsequent radially elongated growth being limited by the renal capsule and producing a wedge shaped appearance [19]. Melanoma and lung metastases may in®ltrate the perirenal space [21]. Metastases tend to be of relatively high attenuation (20±40 HU) with minimal contrast enhancement and still retain thin, smooth walls. CT in our patient showed the 13 cm renal mass to be largely cystic with irregular thickened walls which showed little contrast enhancement. This description ®ts the criteria for a complex cystic renal mass [22]. The differential diagnoses for small (,3 cm) lesions include an haemorrhagic simple cyst, a renal abscess or a cystic RCC [22]. With a larger lesion, such as in our patient, the diagnosis lies between a cystic metastasis or a cystic RCC. The majority of RCCs are solid tumours with the cystic variety representing 5± 15% [23, 24]. Cystic RCCs present either as a unilocular cystic mass (50%), a multilocular cystic mass (30%) or as a discrete nodule within a renal cyst [24]. In a RCC of this size it would be unusual not to detect invasion of the renal vein or metastases to the local lymph nodes [17]. This is, to our knowledge, the ®rst histologically documented case of a laryngeal carcinoma with renal metastasis.
Acknowledgment We would like to thank Mr Ian Eardley, Consultant Urologist.
References 1. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma: analysis of 1000 autopsied cases. Cancer 1950;3:74±85. 2. Shaw H. Tumours of the larynx. In: J Ballantyne, J Groves, editors. Diseases of the ear, nose and throat, Vol. 4 (3rd edn). London: Butterworths, 1971:375±459. 3. Of®ce of Population Censuses and Surveys. Mortality statistics: cause. England and Wales, HMSO Series DH2 no. 19. London: HMSO, 1992:12.
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4. Alonso JM. Metastasis of laryngeal and hypopharyngeal carcinoma. Acta Otolaryngol 1967; 64:353±60. 5. Of®ce of Population Censuses and Surveys. Mortality statistics: serial tables 1841±1990. England and Wales, HMSO Series DH1 no. 25. London: HMSO, 18, 1992. 6. Tuyns A. Laryngeal cancer. Cancer Surv 1994; 19±20:159±73. 7. Cann CI, Fried MP, Rothman PH. Epidemiology of squamous cell cancer of the head and neck. Otolaryngol Clin North Am 1985;18:367±88. 8. Pradier R, Gonzalez A, Matos E, Loria D, Adan R, Saco P, et al. Prognostic factors in laryngeal carcinoma: experience in 296 male patients. Cancer 1993;71:2472±6. 9. Gray RF, Hawthorne M. Neoplasms and cysts of the larynx. In: Synopsis of otolaryngology (5th edn). Oxford: Butterworth Heinemann, 1992:469±78. 10. Shapshay SM, Hybels RL. Treatment of cancer of the larynx: analysis of success and failure. Otolaryngol Clin North Am 1985;18:461±8. 11. Airoldi M, Gabriele P, Succo G, Valente G, Brando V. Small bowel metastases from squamous cell carcinoma of larynx. A case report. Tumosi 1993;79:286±7. 12. Perez LM, Shumway RA, Carson CC 3rd, Fisher SR, Hudson WR. Penile metastasis secondary to supraglottic squamous cell carcinoma: review of the literature. J Urol 1992;147:157±60. 13. Horiuchi N, Tagami H. Skin metastasis in laryngeal carcinoma. Clin Exp Dermat 1992;17:282±3. 14. Bhatt GH, Bernadino ME, Graham SD JR. CT diagnosis of renal metastases. JCAT 1983;7:1032±4. 15. Newsam JE, Tulloch WS. Metastatic tumours in the kidney. Br J Urol 1966;38:1±6. 16. Klinger ME. Secondary tumours of the genitourinary tract. J Urol 1951;65:144±53. 17. Massry SG, Glassock RJ. Tumours of the kidney and urinary tract. In: SG Massry, RJ Glassock, editors. Textbook of nephrology (2nd edn). Baltimore: Williams and Wilkins, 1989:977±8. 18. Royce PL, Smith RB. Bilateral renal metastases from squamous cell carcinoma of the anus. J Urol 1987;137:95±6. 19. Honda H, Coffman CE, Berbaum KS, Barloon TJ, Masuda K. CT analysis of metastatic neoplasms of the kidney: comparison with primary renal cell carcinoma. Acta Radiol 1992;33:39±44. 20. Hietala SO, Wahlqvist L. Metastatic tumours to the kidney: a postmortem, radiological and clinical investigation. Acta Radiol Diagn 1982;23:585±91. 21. Choyke PL, White EM, Zeaman RK, Jaffe MH, Clark LR. Renal metastases: clinicopathologic and radiologic correlation. Radiology 1987;162:359±63. 22. Bosniak MA. The small (,3.0 cm) renal parenchymal tumour: detection, diagnosis and controversies. Radiology 1991;179:307±17. 23. Chapman S, Nakielny R. The urinary tract. In: Aids to radiological differential diagnosis (2nd edn). London: BallieÁre Tindall, 1990:270. 24. Hartman DS, Davis CJ, Johns T, Goldman SM. Cystic renal cell carcinoma. Urology 1986;28:145±53.
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