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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 174-177

Carcinoma glottis with parotid metastasis


Department of Radiation Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

Date of Submission29-Apr-2020
Date of Acceptance14-May-2020
Date of Web Publication23-Nov-2020

Correspondence Address:
Dr. Shah Aastha Ashokkumar
Department of Radiation Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_18_20

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  Abstract 


Introduction: Glottic carcinomas represent approximately one third of the laryngeal cancers. True glottis includes both true vocal cords including anterior and posterior commissures. True vocal cord are as such devoid of lymphatics, so the chances of lymph node metastasis as such is very low. The chances of distant metastasis is also very rare. Herein we report a case of glottic cancer metastasising to parotid gland. Case report: A sixty eight year old male non smoker reported to our department with complaint of change of voice since three months. On computed tomography scan of head and neck, soft tissue thickness of about seven millimeter was seen over right true and false vocal cord and 2.3 * 1.9 cm lesion was seen involving the left lobe of the parotid gland. MRI of neck and paranasal sinuses was performed immediately following tomography which showed 2.6*1.9*3.1 cm lesion was seen involving deep lobe of left parotid gland which appeared isointense on T1w, hyperintense on T2w, not suppressed on STIR. There was no any evidence of capsular breach. Seven millimeter thickness was seen over right true and false vocal cord. These findings were further confirmed by direct laryngoscopic examination which showed mucosal irregularity over right true and false vocal cord with normal mobility of both vocal cords and punch biopsy was taken from it which came out to be well differentiated squamous cell carcinoma. Ultrasonography guided biopsy was taken from the deep lobe of the left parotid gland which came out to be metastatic squamous cell carcinoma. Patient was offered curative radiotherapy to a dose of 55 Gy in 20 fractions and the parotid lesion was addressed by parotidectomy, which showed no evidence of malignancy which might be considered to be an abscopal effect. Conclusion: The involvement of the parotid gland in case of glottic cancer is a very rare occurrence.

Keywords: Glottic cancer, parotid metastasis, radiotherapy


How to cite this article:
Suryanarayan U, Ashokkumar SA, Shah I, Shah R. Carcinoma glottis with parotid metastasis. J Radiat Cancer Res 2020;11:174-7

How to cite this URL:
Suryanarayan U, Ashokkumar SA, Shah I, Shah R. Carcinoma glottis with parotid metastasis. J Radiat Cancer Res [serial online] 2020 [cited 2021 Apr 17];11:174-7. Available from: https://www.journalrcr.org/text.asp?2020/11/4/174/301333




  Introduction Top


Glottic carcinomas represent approximately one-third of the laryngeal cancers. True glottis includes both true vocal cords, including anterior and posterior commissures. True vocal cord is as such devoid of lymphatics, and hence, the chances of lymph node metastasis as such are very low.[1] The chances of distant metastasis are also very rare. Herein, we report a case of glottic cancer metastasizing to the parotid gland.


  Case Report Top


A 68-year-old male nonsmoker reported to our department with a complaint of change of voice for 3 months. There were no other associated complaints such as throat pain, difficulty in swallowing, difficulty in breathing, and fever. On history and physical examination, there was no abnormality detected in the oral cavity. There was no palpable lymphadenopathy. Laryngeal click was present. On indirect laryngoscopic examination no abnormality was noted in the oropharynx; however, an irregularity was seen on the right true and false vocal cord with no restriction of mobility in any of the vocal cord. On computed tomography scan of the head and neck, soft-tissue thickness of about 7 mm was seen over the right true and false vocal cord and 2.3 cm × 1.9 cm lesion was seen involving the left lobe of the parotid gland. Magnetic resonance imaging (MRI) of the neck and paranasal sinuses was performed immediately following computed tomography which showed 2.6 cm × 1.9 cm × 3.1 cm lesion was seen involving deep lobe of the left parotid gland which appeared isointense on T1w, hyperintense on T2w, and not suppressed on short inversion time inversion recovery. [Figure 1],[Figure 2],[Figure 3],[Figure 4] show the MRI view of the parotid and the glottic lesion. There was no evidence of the capsular breach. Seven-millimeter thickness was seen over the right true and false vocal cord. These findings were further confirmed by direct laryngoscopic examination, which showed mucosal irregularity over the right true and false vocal cord with normal mobility of both vocal cords and punch biopsy was taken from it which came out to be well-differentiated squamous cell carcinoma. Ultrasonography guided biopsy was taken from the deep lobe of the left parotid gland, which came out to be metastatic squamous cell carcinoma. [Figure 5],[Figure 6],[Figure 7] show the histopathological section of the glottic and parotid squamous cell carcinoma and parotid section post radiation showing no evidence of tumor cells. Chest X-ray and routine blood investigations include complete hemogram, renal and liver function tests, coagulation profile, and viral markers. Intense literature review and tumor board discussion were done following which decision was taken to offer curative radiation for the lesion of the larynx and to treat the parotid lesion by the surgery. Radiotherapy offered was to a dose of 55 Gray in 20 fractions at 2.75 Gy per fraction[2] considering the lesion of the glottis to be T2N0M1 as per the American Joint Cancer Committee eighth edition. The patient was treated by conventional parallel opposed open fields. The patient was simulated in the supine position with thermoplastic or fit used for immobilization, which was comfortable to the patient. The portals were kept according to standard protocol. The superior border was kept at the top of the thyroid cartilage, inferior border below the cricoid cartilage, anterior border as 1 cm skin flash, and posterior border over the anterior edge of the vertebral body. After a gap of 8 weeks, the patient underwent total parotidectomy and lymph node dissection of ipsilateral Levels I and II lymph nodes to a total of fourteen, which on histopathology showed no evidence of malignancy. No neoadjuvant or concurrent chemotherapy was offered to the patient. Posttreatment patient has no evidence of disease both clinically and radiologically.
Figure 1: Irregularity over left true and false vocal cord shown on computed tomography scan

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Figure 2: Lesion is shown in the right parotid gland on computed tomography scan

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Figure 3: Lesion is shown on the left true and false vocal cord on magnetic resonance imaging

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Figure 4: Lesion in the left parotid gland seen on magnetic resonance imaging

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Figure 5: Slide from the vocal cord showing invasive squamous cell carcinoma

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Figure 6: Slide from the left parotid gland showing tumor cells

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Figure 7: Slide of parotidectomy specimen showing no evidence of tumor cells

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  Discussion Top


The ultimate goal in a case of laryngeal cancer is the locoregional control with the preservation of voice, including its quality, airway preservation, and swallowing ability. In patients with early-stage glottic cancer, surgery and radiation both offer high locoregional control and overall survival, but radiation offers the benefit of voice preservation.[3] There is a low incidence of occult lymph node metastasis (<5%) in early-stage glottic cancer. Hence, the elective irradiation of lymphatics, is generally not done. Computed tomography scan is the preferred modality of imaging for the lesions of the larynx and hypopharynx, while MRI is used in case of a dilemma.[4] The involvement of the parotid gland in the case of laryngeal cancer primary is very rare. The parotid gland can harbor metastasis from the head-and-neck region, including cases of squamous cell carcinoma from the scalp, face, and neck.[5] The incidence of metastasis to the parotid gland has been seen mostly from cutaneous primaries, with majority being squamous cell carcinoma followed by malignant melanoma.[6] Some of the studies reported to evaluate and treat the metastatic lesion first followed by the primary lesion while some others consider the vice versa to be the standard.[6] Herein, the radiation was offered to the larynx, which had a small standard field size of 6 cm × 6 cm, which might have incurred an immunological response to the malignant lesion of the parotid gland which might have responded, which is known as the abscopal effect. The abscopal effect is defined as the effect of radiation on a site distant to the irradiated site. Radiotherapy incurs biological effector cells outside the treatment field and thus can show systemic effects too.[7],[8] The abscopal effect due to radiation can, however, be also considered as immunity conferred by radiation against cancer cells. This effect is generally seen with high dose per fractionation; in our case, a dose of 2.75 Gy per fractionation, which is actually hypofractionation, was given.


  Conclusion Top


The involvement of the parotid gland in the case of glottic cancer is a very rare occurrence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Waldfahrer F, Hauptmann B, Iro H. Lymph node metastasis of glottic laryngeal carcinoma. Laryngorhinootologie 2005;84:96-100.  Back to cited text no. 1
    
2.
Ermis E, Teo M, Dyker KE, Fosker C, Sen M, Prestwich RJ. Definitive hypofractionated radiotherapy for early glottic carcinoma: Experience of 55Gy in 20 fractions. Radiat Oncol 2015;10:203.  Back to cited text no. 2
    
3.
Silver CE, Beitler JJ, Shaha AR, Rinaldo A, Ferlito A. Current trends in initial management of laryngeal cancer: The declining use of open surgery. Eur Arch Otorhinolaryngol 2009;266:1333-52.  Back to cited text no. 3
    
4.
Becker M, Burkhardt K, Dulguerov P, Allal A. Imaging of the larynx and hypopharynx. Eur J Radiol 2008;66:460-79.  Back to cited text no. 4
    
5.
Bron LP, Traynor SJ, McNeil EB, O'Brien CJ. Primary and metastatic cancer of the parotid: Comparison of clinical behavior in 232 cases. Laryngoscope 2003;113:1070-5.  Back to cited text no. 5
    
6.
Franzen AM, Günzel T, Lieder A. Parotid gland metastases of distant primary tumours: A diagnostic challenge. Auris Nasus Larynx 2016;43:187-91.  Back to cited text no. 6
    
7.
Formenti SC, Demaria S. Systemic effects of local radiotherapy. Lancet Oncol 2009;10:718-26.  Back to cited text no. 7
    
8.
Schuler G, Steinman RM. Dendritic cells as adjuvants for immune-mediated resistance to tumors. J Exp Med 1997;186:1183-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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