CLINICAL COMMUNICATION TO THE EDITOR
Head and Neck Cancer with Metastatic Spread to the Breast To the Editor: Head and neck cancer patients with metastatic disease present unique challenges typically associated with an 8-month median survival.1 We report on a patient with human papilloma virus-positive laryngeal cancer who developed an unusual pattern of metastasis to the breast.
CLINICAL SUMMARY A 55-year-old female active smoker presented with human papilloma virus (þ), stage 4B (T3N3M0), squamous cell carcinoma of the supraglottic larynx. Pretreatment staging did not reveal metastatic disease. She completed 7 weeks of concurrent cisplatin and radiation, but continued to smoke during treatment. After chemoradiation, she underwent neck dissection with no residual tumor seen. Sixteen months afterwards, she had a 1.1-cm biopsy-proven left upper-lobe lung metastasis, for which she underwent stereotactic radiosurgery with complete response. A restaging scan and biopsy 6 months afterwards demonstrated a left breast metastasis. The 6-cm breast metastasis was treated with 2 weeks of palliative radiation, but continued to grow. She underwent resection for palliation, and is now 30 months after treatment for her original cancer, with no other known areas of metastatic disease. She is still smoking.
DISCUSSION Initial reports on chemoradiation for laryngeal cancer demonstrated a decreased incidence of distant metastases, although this disappears with longer follow-up.2 Her continued smoking increases the risk of cancer recurrence.3 The spread of head and neck cancer to the breast is unusual. While the clinical significance of human papilloma virus (þ) cancer of the larynx is unknown,4 human papilloma virus (þ) cancers of the oropharynx exhibit later and more diffuse Funding: None. Conflict of Interest: GW, EO, AL, WL, and AD each report no conflict of interest. PHA has a patent pending on a “Patient positioning system and methods for diagnostic radiology and radiotherapy.” Authorship: All authors had access to the case information and collaborated in writing this manuscript. Requests for reprints should be addressed to Peter H. Ahn, MD, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
metastases, with spread to sites not generally seen with head and neck cancer.5 Although breast cancer is known to disseminate to the head and neck, to our knowledge this is only the sixth case in the literature of a head and neck cancer and the first laryngeal cancer reported to develop metastases to the breast.6-8 Our work highlights that in any patient with a head and neck cancer history, including that involving human papilloma virus, a new breast mass or nonspecific finding must always prompt the clinician to include the possibility of unusual hematogenous metastases in the differential diagnosis. The clinician also must be aware that certain patients with metastatic head and neck cancer are living longer, due in large part to the changing biology of the disease. Peter H. Ahn, MDa Gregory Weinstein, MDb Eric Ojerholm, MDa Alexander Lin, MDa William Levin, MDa Arati Desai, MDc a Department of Radiation Oncology Department of OtorhinolaryngologyeHead and Neck Surgery c Department of Medical Oncology University of Pennsylvania Philadelphia
b
http://dx.doi.org/10.1016/j.amjmed.2014.12.003
References 1. Vermorken JB, Trigo J, Hitt R, et al. Open-label, uncontrolled, multicenter phase II study to evaluate the efficacy and toxicity of cetuximab as a single agent in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck who failed to respond to platinumbased therapy. J Clin Oncol. 2007;25(16):2171-2177. 2. Forastiere AA, Zhang Q, Weber RS, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013;31(7):845-852. 3. Browman GP, Wong G, Hodson I, et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med. 1993;328(3):159-163. 4. Gorgoulis VG, Zacharatos P, Kotsinas A, et al. Human papilloma virus (HPV) is possibly involved in laryngeal but not in lung carcinogenesis. Hum Pathol. 1999;30(3):274-283. 5. Huang SH, Perez-Ordonez B, Weinreb I, et al. Natural course of distant metastases following radiotherapy or chemoradiotherapy in HPV-related oropharyngeal cancer. Oral Oncol. 2013;49(1):79-85. 6. Toombs BD, Kalisher L. Metastatic disease to the breast: clinical, pathologic, and radiographic features. AJR Am J Roentgenol. 1977;129(4):673-676. 7. Nunez DA, Sutherland CG, Sood RK. Breast metastasis from a pharyngeal carcinoma. J Laryngol Otol. 1989;103(2):227-228. 8. Chauhan A, Singh H, Gupta V. Breast metastasis from carcinoma of the posterior pharyngeal wall. JK Science: J Med Educ Res. 2010;12: 149-150.
Head and Neck Cancer with Metastatic Spread to the Breast To the Editor: Head and neck cancer patients with metastatic disease present unique challenges typically associated with an 8-month median survival.1 We report on a patient with human papilloma virus-positive laryngeal cancer who developed an unusual pattern of metastasis to the breast.
CLINICAL SUMMARY A 55-year-old female active smoker presented with human papilloma virus (þ), stage 4B (T3N3M0), squamous cell carcinoma of the supraglottic larynx. Pretreatment staging did not reveal metastatic disease. She completed 7 weeks of concurrent cisplatin and radiation, but continued to smoke during treatment. After chemoradiation, she underwent neck dissection with no residual tumor seen. Sixteen months afterwards, she had a 1.1-cm biopsy-proven left upper-lobe lung metastasis, for which she underwent stereotactic radiosurgery with complete response. A restaging scan and biopsy 6 months afterwards demonstrated a left breast metastasis. The 6-cm breast metastasis was treated with 2 weeks of palliative radiation, but continued to grow. She underwent resection for palliation, and is now 30 months after treatment for her original cancer, with no other known areas of metastatic disease. She is still smoking.
DISCUSSION Initial reports on chemoradiation for laryngeal cancer demonstrated a decreased incidence of distant metastases, although this disappears with longer follow-up.2 Her continued smoking increases the risk of cancer recurrence.3 The spread of head and neck cancer to the breast is unusual. While the clinical significance of human papilloma virus (þ) cancer of the larynx is unknown,4 human papilloma virus (þ) cancers of the oropharynx exhibit later and more diffuse Funding: None. Conflict of Interest: GW, EO, AL, WL, and AD each report no conflict of interest. PHA has a patent pending on a “Patient positioning system and methods for diagnostic radiology and radiotherapy.” Authorship: All authors had access to the case information and collaborated in writing this manuscript. Requests for reprints should be addressed to Peter H. Ahn, MD, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
metastases, with spread to sites not generally seen with head and neck cancer.5 Although breast cancer is known to disseminate to the head and neck, to our knowledge this is only the sixth case in the literature of a head and neck cancer and the first laryngeal cancer reported to develop metastases to the breast.6-8 Our work highlights that in any patient with a head and neck cancer history, including that involving human papilloma virus, a new breast mass or nonspecific finding must always prompt the clinician to include the possibility of unusual hematogenous metastases in the differential diagnosis. The clinician also must be aware that certain patients with metastatic head and neck cancer are living longer, due in large part to the changing biology of the disease. Peter H. Ahn, MDa Gregory Weinstein, MDb Eric Ojerholm, MDa Alexander Lin, MDa William Levin, MDa Arati Desai, MDc a Department of Radiation Oncology Department of OtorhinolaryngologyeHead and Neck Surgery c Department of Medical Oncology University of Pennsylvania Philadelphia
b
http://dx.doi.org/10.1016/j.amjmed.2014.12.003
References 1. Vermorken JB, Trigo J, Hitt R, et al. Open-label, uncontrolled, multicenter phase II study to evaluate the efficacy and toxicity of cetuximab as a single agent in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck who failed to respond to platinumbased therapy. J Clin Oncol. 2007;25(16):2171-2177. 2. Forastiere AA, Zhang Q, Weber RS, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013;31(7):845-852. 3. Browman GP, Wong G, Hodson I, et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med. 1993;328(3):159-163. 4. Gorgoulis VG, Zacharatos P, Kotsinas A, et al. Human papilloma virus (HPV) is possibly involved in laryngeal but not in lung carcinogenesis. Hum Pathol. 1999;30(3):274-283. 5. Huang SH, Perez-Ordonez B, Weinreb I, et al. Natural course of distant metastases following radiotherapy or chemoradiotherapy in HPV-related oropharyngeal cancer. Oral Oncol. 2013;49(1):79-85. 6. Toombs BD, Kalisher L. Metastatic disease to the breast: clinical, pathologic, and radiographic features. AJR Am J Roentgenol. 1977;129(4):673-676. 7. Nunez DA, Sutherland CG, Sood RK. Breast metastasis from a pharyngeal carcinoma. J Laryngol Otol. 1989;103(2):227-228. 8. Chauhan A, Singh H, Gupta V. Breast metastasis from carcinoma of the posterior pharyngeal wall. JK Science: J Med Educ Res. 2010;12: 149-150.
