UROPATHOLOGY
CARCINOMA OF PROSTATE METASTASIZING TO VOCAL CORD DAVID J. GRIGNON, M.D.*
ALBERTO G. AYALA, M.D.
JAE Y. RO, M.D., PH.D.
CLAYTON C H O N G , M.D.
From the Departments of Pathology and Medical Oneology, The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston, Texas
~ j ~ A C T - - M e t a s t a t i c involvement of the larynx by carcinoma of the prostate is a rare event: ~,ii],~ '~":~i~ cases .... are recorded in the English literature. We report a case of prostatic carcinoma with ~ i t b ~ a t i c metastasis to the right vocal cord. Five months after the diagnosis of metastatic disease ~ i l ~ 6 c a l cord the patient died of widespread metastases. We report the sixth case of this event ~ ' ~ v i e w the reported cases ,n the hterature.
prostate typieally metasta',s and bone; visceral spread [y~ and later in the course of ,~ment of the larynx is rare: ~een reported in the literacle we d o c u m e n t an addiiew the relevant literature. nterest because of the prescomponent. This case was in a series of small cell car:ate reported by Tetu et al. 6 Case Report white m a n was re.~valuation and treat~ma. Sixteen months 'ith obstructive syrupprostatic resection reLated c a r c i n o m a . A i n g a bone scan was eared with external', approximately 6,000 mths, at which time a metastatic disease, ninistration was be. . . . . . . . ce months later docu~ ]°'~1~ il ~° g x~C l e ; Pathology and recipient of MeEachern ' "~/;~e ~anaoian Cancer Society. ....
....
~'~':' J
Y 1990
/
VOLUME XXXVI, NUMBER 1
m e n t e d further progression of disease, diethylstilbestrol diphosphate (Stilphostrol) was substituted. After a t w o - m o n t h trial with no clinical evidence of benefit this also was stopped and a course of 5-fluorouraeil begun. Bone pain cont i n u e d to w o r s e n , n e c e s s i t a t i n g local radiotherapy to the right rib cage and l u m b a r vertebrae regions. The patient was then referred to this institution for assessment. The patient also suffered from glaucoma and narcolepsy, for which he was taking piloearpine and methylphenidate (Ritalin), respectively. He was a pipe smoker and drank alcohol socially. His m o t h e r h a d died of pancreatic carcinoma. On review of systems he noted that his voice h a d c h a n g e d recently a n d he t h o u g h t his hearing was reduced in his right ear. He denied dysphagia, hemoptysis, or tinnitus. On physical examination he was found to be well developed, well nourished, and in no distress. The eyes, ears, nose and m o u t h were normal. No masses were palpable in the neck. Chest, c a r d i o v a s c u l a r , a n d a b d o m i n a l examinations were unremarkable. The left lobe of the prostate was smooth and soft and the right lobe absent. No masses were palpable. There was tenderness over the lumbosaeral region. Indirect laryngoscopy was not performed. Results of routine hematology and serum biochemistry studies were within normal limits.
85
FIGURE 1. V o c a l c o r d biopsy shows nests of small m a l i g n a n t cells in fibrous connective tissue. No glandular differentiation is present Insert: Higher magnification of tumor cells s h o w s f i n e l y dispersed chromatin, ill-defined, scanty cytoplasm, a n d occasional small nucleoli. ( H e m a t o x y l i n a n d eosin; original magnifications x 100 a n d x 400, respectively.)
;,i o.~ ~*~"*:~ " ". ..... , ,o~ . ~ :, . • ~. .~. ~.. .. " "'"" " "" ~g"~:*~,.,,,."~,,-."~. '""'.. ;z.'"".~-,~.
". . . . . . . " ~;- -" ~
:° L' ' ''~ ""~.
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q~
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d}.~,: o~:: ~ ° ' , ~ , ; 2 2 ~ ' ~ .~'~".~;, ~.....e-'~-'.:.~,~32 ~ ~ " ~. . . . ~ ."'*'" ~ ~ e, :~,,*~., " ~" ~,~.,.;~,~;"~(. ~, '~*".'~..... -
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%:% The serum level of prostatic acid phosphatase (PAP) was not elevated. A bone scan demonstrated widespread bony metastases. Chest roentgenogram and computerized tomogram (CT) of the abdomen and pelvis were unremarkable. On the patient's return visit one month later he complained of increased hoarseness of his voice and production of blood-streaked sputum. Indirect laryngoscopy showed swelling of the right true and false vocal cords. The vocal cord had adequate mobility. Direct laryngoscopy confirmed the findings, and a biopsy from the right true vocal cord revealed a metastatic carcinoma. A chest roentgenogram and CT of the chest to locate a possible chest primary disease were negative. Chemotherapy was begun with vineristine, doxorubiein hydroehloride (Adriamyein), and eyclophosphamide (Cytoxan). There was initial response with improvement in the hoarseness and bone pain; however, this was short-lived, and two months after the vocal cord biopsy the bone scan showed a significant increase in bony metastases. Aspiration biopsy of a rib lesion showed metastatic prostatic adenoeareinoma. A course of vinblastine, doxorubiein, and mitom y e i n - C was a d m i n i s t e r e d . T h e patient's further care was turned over to his physician in his hometown. Three months later and six months after his first evaluation seen at U.T.M. D. Anderson Hospital he was reported to have died of disseminated metastases.
logically the tissue consisted of nests of malig~ nant cells in fibrous connective tissue. Individi ual cells were small and contained oval nucl~ and finely dispersed chromatin. Small nucle0f were present in some of the cells. Cytoplas was scant and ill defined (Fig. 1). There w foeal necrosis of tumor cells. No evidence glandular differentiation was found. Thirteen slides stained with hematoxylin an~ eosin from the previous transurethral prosta!~ resection were available for review. The Pi~ mary prostatic carcinoma had a mixed p a t t e r ~ containing areas of well-defined gland form~ tion and of solid growth. The glands were lin by a single to pseudostratified layer of euboi( epithelial cells with enlarged vesicular nuc] and small well-defined nueleoli. Cytoplai was eosinophilie and moderate in amou] These areas merged imperceptibly with sol areas composed of cells with smaller roundoval nuclei eontaining dispersed ehromatin a small nucleoli (Fig. 2). In these cells the cy plasm was scant and not well defined. Th~ areas were morphologically similar to the ! mor present in the voeal cord lesion. Immu staining for prostate-specific antigen (PSA) ai PAP was positive in the glandular component the prostatic carcinoma; however, the s0i areas and the metastatie carcinoma in [1 larynx demonstrated no reactivity. Aspiratii biopsy of a rib lesion showed clusters of tunil cells that demonstrated strong immunoreact~ ity to PSA and PAP.
Pathology Findings
Comment
The vocal cord biopsy was a single piece of dark brown tissue 0.4 x 0.3 x 0.9, em. Histo-
Carcinoma of the prostate is the second m ~ common malignancy in males 7 and is the thi~
86
UROLOGY
/ JULY 1990 /
VOLUME XXXVI, NUMI3~!~
~tJl~E 2. (A) Primary prostate carcinoma shows area of gland formation on right and solid growth with B a l l cell component on the left. (B) Higher magnification of (A) showing details of glandular component ~ l s m a l l cell components. (Hematoxylin and eosin; original magnifications x 100 and x 400, respectively). ause of cancer deaths in m e n fifty-five. 8 Carcinoma of the eteristieally metastasizes to t bone in 68.0 percent and 66.8 vely, of autopsied eases.' Other n patients w h o die of meta,qude the lungs (49.1%), blad~r (35.6 % ), and adrenal glands e variety of unusual metastatic ported, including the skin, 9 orais, 12 and thyroid. 1 Among the reported sites is the larynx, 5 cases in the English literaprostatic carcinoma metasta: was reported by Ehrlieh in J a seventy-year-old patient :atie carcinoma with wideAn incidental finding at the ~s the presence of metastatic oid and thyroid cartilages. ~ea reported 2 cases, the first year-old m a n w h o presented i the left side that radiated to i of a 1-em mass on the left ,'e revealed a "papilliferous " A subsequent prostatie ive of adenocareinoma. The a seventy-four-year-old m a n ~rseness and a mass involving ge. The prostate gland was to be eareinomatous, and ation of the neek mass renoma. Both patients were ttie prostate eareinoma with ~nd bilateral orehieetomy; -up data were provided. The 7oakley and Ranson 4 is the . . . . . . . . ted ease of symptomatic me-
~I*QcY
l JULY 1990
/
VOLUME XXXVI, NUMBER 1
tastasis to the larynx. In their patient, a sixtyfour-year-old, stridor developed six months aft e r t h e h i s t o l o g i e d i a g n o s i s of p r o s t a t i c adenoeareinoma was m a d e after transurethral resection. Biopsy of a subglottie mass revealed metastatic a d e n o e a r e i n o m a morphologically similar to the p r i m a r y lesion. Batsakis, Luna, and Byers s added a fifth ease as part of a review of 11 eases of laryngeal involvement by metastatic tumors. Details of the ease were not provided. Clinical details of reported eases are summarized in Table I. In our ease, a seventy-one-year-old m a n with k n o w n adenoeareinoma of the prostate and bone metastases noted a gradual change in his voice sixteen months after the initial diagnosis. Subsequent biopsy of a swollen right true vocal cord revealed a p o o r l y d i f f e r e n t i a t e d eareinoma. The t u m o r h a d the appearance of a small eell carcinoma without glandular differentiation. T h e initial prostatic tissue had shown a t u m o r with foei of adenoearcinoma merging with solid undifferentiated small cell areas. The areas morphologically resembled the t u m o r in the vocal cord substantiating the diagnosis of metastasis. E x t r a p u l m o n a r y small cell carcinomas have been reported in a large n u m b e r of sites, the larynx among the most frequent. 13 Small cell carcinoma of the prostate has recently been delineated as a distinct entity with an aggressive behavior. 6 Schron, Gipson, and Mendelsohn 14 and Tetu et al. ~ suggest that the small cell eareinoma c o m p o n e n t in the prostate could represent the terminal phase of an otherwise regular adenoeareinoma. Data from the recent study by Tetu et al. 6 indicate that 14 of 20 patients (70 % ) had a prostatic adenoeareinoma preceding or present at the time of diagnosis of the 87
TABLE I.
Case No. (Author) 1
Carcinoma o] prostate metastasizing to larynx: summary o] clinical ]eatures
Site of Local Other Survival ( M o s ) ~ Age Metastasis Symptoms Metastases Initial 70 Thyroid and None Liver, adrenals, 48, ericoid cartilage lungs 83 Left arytenoid Pain, left side of None detected at NFU eminence throat radiating time of diagnosis to left ear 74 Thyroid cartilage; Increasing hoarseness None detected at NFU ?left true vocal x 12 months; time of diagnosis cord anterior neck mass 64 Subglottie Stridor Bone 6, AWD
(Ehrlich2) 2 (Quinn and McCabe 3) 3 (Quinn and MeCabe3) 4 (Coakley and Ranson4) 5 NS NS (Batsakis et al. ~) 6 71 Right true vocal (Grignon et al.) cord
NS Change in voice
NS
DOD
Bone
22, DOD
KEY: DOD, dead of disease; AWD, alive with disease; NFU, no follow-up; NS, not stated.
small cell component. After the small cell carcinoma component was recognized regardless of a prior history of adenocarcinoma, death followed within one and a half years. In the series reported by Tetu et al.,6 12 patients underwent hormonal therapy (estrogens, orchiectomy, or both); all had early development of progressive disease with no or transient benefit after the appearance of the small cell component. They also stated that chemotherapy could beneficially treat this type of tumor. Ro et al. ~5 reported the immunoeytochemieal features of 18 eases of small cell carcinoma. In all eases with an adenoeareinoma component, this element showed positive reactivity with both PSA and PAP. The small cell carcinoma component demonstrated three patterns of reactivity: (1) positive staining for neuron-specific enolase (NSE) and negative for PSA and PAP, (2) positive for PSA and PAP but negative for NSE, and (3) negative for all three. Our ease is consistent with the last pattern: the small cell component was negative for NSE, PAP, and PSA. As in the eases of Ro et al., the adenoeareinoma component of our patient's tumor demonstrated positive reactivity for PSA and PAP in both the primary tumor and a rib metastasis. In summary, we have reported a ease of prostatie carcinoma with metastasis to the vocal cord complicating the clinical course. This ease brings to 6 the total reported instances of metastases to the larynx in the English literature. It is also of interest because the tumor had a mixed small cell eareinoma-adenoearein0ma histology with the metastasis in the larynx having a pure small cell appearance.
88
Houston, Texas 7 ~
CARCINOMA OF PROSTATE METASTASIZING TO VOCAL CORD DAVID J. GRIGNON, M.D.*
ALBERTO G. AYALA, M.D.
JAE Y. RO, M.D., PH.D.
CLAYTON C H O N G , M.D.
From the Departments of Pathology and Medical Oneology, The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston, Texas
~ j ~ A C T - - M e t a s t a t i c involvement of the larynx by carcinoma of the prostate is a rare event: ~,ii],~ '~":~i~ cases .... are recorded in the English literature. We report a case of prostatic carcinoma with ~ i t b ~ a t i c metastasis to the right vocal cord. Five months after the diagnosis of metastatic disease ~ i l ~ 6 c a l cord the patient died of widespread metastases. We report the sixth case of this event ~ ' ~ v i e w the reported cases ,n the hterature.
prostate typieally metasta',s and bone; visceral spread [y~ and later in the course of ,~ment of the larynx is rare: ~een reported in the literacle we d o c u m e n t an addiiew the relevant literature. nterest because of the prescomponent. This case was in a series of small cell car:ate reported by Tetu et al. 6 Case Report white m a n was re.~valuation and treat~ma. Sixteen months 'ith obstructive syrupprostatic resection reLated c a r c i n o m a . A i n g a bone scan was eared with external', approximately 6,000 mths, at which time a metastatic disease, ninistration was be. . . . . . . . ce months later docu~ ]°'~1~ il ~° g x~C l e ; Pathology and recipient of MeEachern ' "~/;~e ~anaoian Cancer Society. ....
....
~'~':' J
Y 1990
/
VOLUME XXXVI, NUMBER 1
m e n t e d further progression of disease, diethylstilbestrol diphosphate (Stilphostrol) was substituted. After a t w o - m o n t h trial with no clinical evidence of benefit this also was stopped and a course of 5-fluorouraeil begun. Bone pain cont i n u e d to w o r s e n , n e c e s s i t a t i n g local radiotherapy to the right rib cage and l u m b a r vertebrae regions. The patient was then referred to this institution for assessment. The patient also suffered from glaucoma and narcolepsy, for which he was taking piloearpine and methylphenidate (Ritalin), respectively. He was a pipe smoker and drank alcohol socially. His m o t h e r h a d died of pancreatic carcinoma. On review of systems he noted that his voice h a d c h a n g e d recently a n d he t h o u g h t his hearing was reduced in his right ear. He denied dysphagia, hemoptysis, or tinnitus. On physical examination he was found to be well developed, well nourished, and in no distress. The eyes, ears, nose and m o u t h were normal. No masses were palpable in the neck. Chest, c a r d i o v a s c u l a r , a n d a b d o m i n a l examinations were unremarkable. The left lobe of the prostate was smooth and soft and the right lobe absent. No masses were palpable. There was tenderness over the lumbosaeral region. Indirect laryngoscopy was not performed. Results of routine hematology and serum biochemistry studies were within normal limits.
85
FIGURE 1. V o c a l c o r d biopsy shows nests of small m a l i g n a n t cells in fibrous connective tissue. No glandular differentiation is present Insert: Higher magnification of tumor cells s h o w s f i n e l y dispersed chromatin, ill-defined, scanty cytoplasm, a n d occasional small nucleoli. ( H e m a t o x y l i n a n d eosin; original magnifications x 100 a n d x 400, respectively.)
;,i o.~ ~*~"*:~ " ". ..... , ,o~ . ~ :, . • ~. .~. ~.. .. " "'"" " "" ~g"~:*~,.,,,."~,,-."~. '""'.. ;z.'"".~-,~.
". . . . . . . " ~;- -" ~
:° L' ' ''~ ""~.
"
"
q~
~"
4 "~ ' i ~
~_
"
d}.~,: o~:: ~ ° ' , ~ , ; 2 2 ~ ' ~ .~'~".~;, ~.....e-'~-'.:.~,~32 ~ ~ " ~. . . . ~ ."'*'" ~ ~ e, :~,,*~., " ~" ~,~.,.;~,~;"~(. ~, '~*".'~..... -
~'s,
~ "
:
ilk V ~ ~ ; ~ ' ~ ~I~
,.
~:
~ ~~ .......
::
": ',,.
~
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.
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~
%:% The serum level of prostatic acid phosphatase (PAP) was not elevated. A bone scan demonstrated widespread bony metastases. Chest roentgenogram and computerized tomogram (CT) of the abdomen and pelvis were unremarkable. On the patient's return visit one month later he complained of increased hoarseness of his voice and production of blood-streaked sputum. Indirect laryngoscopy showed swelling of the right true and false vocal cords. The vocal cord had adequate mobility. Direct laryngoscopy confirmed the findings, and a biopsy from the right true vocal cord revealed a metastatic carcinoma. A chest roentgenogram and CT of the chest to locate a possible chest primary disease were negative. Chemotherapy was begun with vineristine, doxorubiein hydroehloride (Adriamyein), and eyclophosphamide (Cytoxan). There was initial response with improvement in the hoarseness and bone pain; however, this was short-lived, and two months after the vocal cord biopsy the bone scan showed a significant increase in bony metastases. Aspiration biopsy of a rib lesion showed metastatic prostatic adenoeareinoma. A course of vinblastine, doxorubiein, and mitom y e i n - C was a d m i n i s t e r e d . T h e patient's further care was turned over to his physician in his hometown. Three months later and six months after his first evaluation seen at U.T.M. D. Anderson Hospital he was reported to have died of disseminated metastases.
logically the tissue consisted of nests of malig~ nant cells in fibrous connective tissue. Individi ual cells were small and contained oval nucl~ and finely dispersed chromatin. Small nucle0f were present in some of the cells. Cytoplas was scant and ill defined (Fig. 1). There w foeal necrosis of tumor cells. No evidence glandular differentiation was found. Thirteen slides stained with hematoxylin an~ eosin from the previous transurethral prosta!~ resection were available for review. The Pi~ mary prostatic carcinoma had a mixed p a t t e r ~ containing areas of well-defined gland form~ tion and of solid growth. The glands were lin by a single to pseudostratified layer of euboi( epithelial cells with enlarged vesicular nuc] and small well-defined nueleoli. Cytoplai was eosinophilie and moderate in amou] These areas merged imperceptibly with sol areas composed of cells with smaller roundoval nuclei eontaining dispersed ehromatin a small nucleoli (Fig. 2). In these cells the cy plasm was scant and not well defined. Th~ areas were morphologically similar to the ! mor present in the voeal cord lesion. Immu staining for prostate-specific antigen (PSA) ai PAP was positive in the glandular component the prostatic carcinoma; however, the s0i areas and the metastatie carcinoma in [1 larynx demonstrated no reactivity. Aspiratii biopsy of a rib lesion showed clusters of tunil cells that demonstrated strong immunoreact~ ity to PSA and PAP.
Pathology Findings
Comment
The vocal cord biopsy was a single piece of dark brown tissue 0.4 x 0.3 x 0.9, em. Histo-
Carcinoma of the prostate is the second m ~ common malignancy in males 7 and is the thi~
86
UROLOGY
/ JULY 1990 /
VOLUME XXXVI, NUMI3~!~
~tJl~E 2. (A) Primary prostate carcinoma shows area of gland formation on right and solid growth with B a l l cell component on the left. (B) Higher magnification of (A) showing details of glandular component ~ l s m a l l cell components. (Hematoxylin and eosin; original magnifications x 100 and x 400, respectively). ause of cancer deaths in m e n fifty-five. 8 Carcinoma of the eteristieally metastasizes to t bone in 68.0 percent and 66.8 vely, of autopsied eases.' Other n patients w h o die of meta,qude the lungs (49.1%), blad~r (35.6 % ), and adrenal glands e variety of unusual metastatic ported, including the skin, 9 orais, 12 and thyroid. 1 Among the reported sites is the larynx, 5 cases in the English literaprostatic carcinoma metasta: was reported by Ehrlieh in J a seventy-year-old patient :atie carcinoma with wideAn incidental finding at the ~s the presence of metastatic oid and thyroid cartilages. ~ea reported 2 cases, the first year-old m a n w h o presented i the left side that radiated to i of a 1-em mass on the left ,'e revealed a "papilliferous " A subsequent prostatie ive of adenocareinoma. The a seventy-four-year-old m a n ~rseness and a mass involving ge. The prostate gland was to be eareinomatous, and ation of the neek mass renoma. Both patients were ttie prostate eareinoma with ~nd bilateral orehieetomy; -up data were provided. The 7oakley and Ranson 4 is the . . . . . . . . ted ease of symptomatic me-
~I*QcY
l JULY 1990
/
VOLUME XXXVI, NUMBER 1
tastasis to the larynx. In their patient, a sixtyfour-year-old, stridor developed six months aft e r t h e h i s t o l o g i e d i a g n o s i s of p r o s t a t i c adenoeareinoma was m a d e after transurethral resection. Biopsy of a subglottie mass revealed metastatic a d e n o e a r e i n o m a morphologically similar to the p r i m a r y lesion. Batsakis, Luna, and Byers s added a fifth ease as part of a review of 11 eases of laryngeal involvement by metastatic tumors. Details of the ease were not provided. Clinical details of reported eases are summarized in Table I. In our ease, a seventy-one-year-old m a n with k n o w n adenoeareinoma of the prostate and bone metastases noted a gradual change in his voice sixteen months after the initial diagnosis. Subsequent biopsy of a swollen right true vocal cord revealed a p o o r l y d i f f e r e n t i a t e d eareinoma. The t u m o r h a d the appearance of a small eell carcinoma without glandular differentiation. T h e initial prostatic tissue had shown a t u m o r with foei of adenoearcinoma merging with solid undifferentiated small cell areas. The areas morphologically resembled the t u m o r in the vocal cord substantiating the diagnosis of metastasis. E x t r a p u l m o n a r y small cell carcinomas have been reported in a large n u m b e r of sites, the larynx among the most frequent. 13 Small cell carcinoma of the prostate has recently been delineated as a distinct entity with an aggressive behavior. 6 Schron, Gipson, and Mendelsohn 14 and Tetu et al. ~ suggest that the small cell eareinoma c o m p o n e n t in the prostate could represent the terminal phase of an otherwise regular adenoeareinoma. Data from the recent study by Tetu et al. 6 indicate that 14 of 20 patients (70 % ) had a prostatic adenoeareinoma preceding or present at the time of diagnosis of the 87
TABLE I.
Case No. (Author) 1
Carcinoma o] prostate metastasizing to larynx: summary o] clinical ]eatures
Site of Local Other Survival ( M o s ) ~ Age Metastasis Symptoms Metastases Initial 70 Thyroid and None Liver, adrenals, 48, ericoid cartilage lungs 83 Left arytenoid Pain, left side of None detected at NFU eminence throat radiating time of diagnosis to left ear 74 Thyroid cartilage; Increasing hoarseness None detected at NFU ?left true vocal x 12 months; time of diagnosis cord anterior neck mass 64 Subglottie Stridor Bone 6, AWD
(Ehrlich2) 2 (Quinn and McCabe 3) 3 (Quinn and MeCabe3) 4 (Coakley and Ranson4) 5 NS NS (Batsakis et al. ~) 6 71 Right true vocal (Grignon et al.) cord
NS Change in voice
NS
DOD
Bone
22, DOD
KEY: DOD, dead of disease; AWD, alive with disease; NFU, no follow-up; NS, not stated.
small cell component. After the small cell carcinoma component was recognized regardless of a prior history of adenocarcinoma, death followed within one and a half years. In the series reported by Tetu et al.,6 12 patients underwent hormonal therapy (estrogens, orchiectomy, or both); all had early development of progressive disease with no or transient benefit after the appearance of the small cell component. They also stated that chemotherapy could beneficially treat this type of tumor. Ro et al. ~5 reported the immunoeytochemieal features of 18 eases of small cell carcinoma. In all eases with an adenoeareinoma component, this element showed positive reactivity with both PSA and PAP. The small cell carcinoma component demonstrated three patterns of reactivity: (1) positive staining for neuron-specific enolase (NSE) and negative for PSA and PAP, (2) positive for PSA and PAP but negative for NSE, and (3) negative for all three. Our ease is consistent with the last pattern: the small cell component was negative for NSE, PAP, and PSA. As in the eases of Ro et al., the adenoeareinoma component of our patient's tumor demonstrated positive reactivity for PSA and PAP in both the primary tumor and a rib metastasis. In summary, we have reported a ease of prostatie carcinoma with metastasis to the vocal cord complicating the clinical course. This ease brings to 6 the total reported instances of metastases to the larynx in the English literature. It is also of interest because the tumor had a mixed small cell eareinoma-adenoearein0ma histology with the metastasis in the larynx having a pure small cell appearance.
88
Houston, Texas 7 ~
