MULTIPLE PRIMARY SYNCHRONOUS CARCINOMAS OFALVEOLUS AND HYPOPHARYNX

Sunder Singh, Assistant ProfessorE. N. T. Department, Government Medical College,Rajendra Hospital, Patiala.

Multiple primary cancers though initially thought to be an extremely rare occurrence havebeen reported recently to involve various organs of body in synchronous or metachronousfashion. Aerodigestive tract is most frequently involved with such type of lesions andrecent reports show its increasing incidence. A case of multiple primary cancers involvingalveolus and hypopharynx is presented.

Multiple primary cancers though initiallythought to be an extremely rare occurrencehave been reported to involve various organsof the body in synchronous or metachronousfashion. It is known as synchronous whenmultiple primary lesions appear or, arebeing diagnosed simultaneously, while thecancers that develop subsequently, to thediagnosis and treatment of the initial lesion,usually within the first year are known asmetachronous.

The upper aerodigestive tract is mostvulnerable to such types of lesions.Recent reports show the incidence of multipleprimary cancers in this region vary from 1% to20% with an average of 5%. These reportsgenerally refer to metachronous lesions.However, a small but definite percentage ofpatients have synchronous primary tumourswhich are detected at the time of their initialappearance.Agarwal and Bansal (1977) reported two casesof multiple synchronous primary cancers.Dutta (1977) also reported double malignantlesion in the upper food passage.Jack (1979) showed an incidence of 9.2% ofsynchronous primary cancers in his series of162-panendoscopies.A rare case of synchronous multiple primarycancers involving right upper alveolus andhypopharynx is presented.

Case ReportG. D., 40 years female was admitted in theE.N.T. Department of Government MedicalCollege, Patiala with the chief complaint ofprogressive dysphagia for the last 3 monthsand was unable to take even liquid properly forthe last 20 days. For the last one and a halfmonth patient also had an ulcerated lesion overthe right upper alveolus, which was painless.She had marked loss of weight and appetite.General physical examination revealedematiated, anaemic female of about 40 yearswith pulse 102/mt. and B.P. 110/80 mm of Hg.Orodental hygeine was very poor. No significantlymphadenopathy was present.

Systemic examination revealed bilateralcrepitations over the lower portion of chest,which were more significant on right side.

Local examination revealed ulcero-exophyticlesion involving the right upper alveolus sFig.1).It bled on touching. No significantlymphadenopathy was present. Laryngealcrepitus was absent. Indirect laryngoscopyshowed pooling of secretions in both thepyriform fossae.Various investigations done were within normalrange, except for low haemoglobin, level of 8gm% and total serum proteins of 4 gm%.X-ray soft tissue neck was normal. X-ray chestshowed no secondary deposits. Bilateral honey-combing was present. Heart size was normal.

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develop in a cancer prone individual.But before, diagnosis of a synchronous secondprimary lesion can be made the criteria as laiddown by Warren and Gates (1932) should befulfilled. These following criteria while generallyaccepted, are at times difficult to fulfil :

The neoplasms must be clearly malignant.

2. Each neoplasm must be geographicallyseparate and distinct. The lesion should also beseparated by normal non•neoplastic mucosa. Ifthe second lesion is contiguous to the primarylesion or arises adjacent to an area of insituchange contiguous to the primary lesion, itshould be considered as a multifocal primarylesion rather than a second primary lesion.

Fig. 1: Clinical photograph showing ulcero-exophytic involving right upper alveolus

Barium swallow showed partial obstruction tothe flow of contrast medium in the hypopharynxwith evidence of mucosal destruction andimproper filling of the involved segment (Fig. 2).

Biopsy from alveolar growth was taken.Endoscopic examination of nasopharynx andlarynx was normal. While hypopharyngealexamination revealed exophytic growthinvolving posterior wall of hypopharynxalongwith oedema of lateral wall aru post-cricoid region. Lower limit of the growth couldnot be reached. Biopsy was taken.

Ryle's tube could not be negotiated through thehypopharyngeal obstruction.

Histopathological examination of both biopsies(fig. 3 and 4) revealed squamous cellcarcinomas.

Patient was put on intravenous fluids andprophylactic antibiotics, pending gastrostomy.Following gastrostomy patient developedsevere diarrhoea and her condition deteriorateddrastically and patient expired.

Discussion

The upper aerodigestive tract though extremelyvulnerable to a wide variety of exogenous,ingested and inhaled carcinogens, but multipleprimary cancers were thought to be anextremely rare occurrence, until Billroth in 1889pointed out that two independent cancers can

Fig. 2 : Barium swallow X-ray showing partialobstruction and improper filling of involved segmentof hypopharynx with mucosal destruction

3. The possibility that one lesion is ametastasis from the other should be excluded ;therefore, when confronted by an unusualmetastasis, the possibility of a second primarylesion should be considered.

The present case fulfils the criteria as laid byabove authors.

In addition to exogenous carcinogens otherlocal factors like poor oro-dental hygeine, ironand riboflavin deficiencies in Plummer-Vinsonsyndrome also render the mucosa morevulnerable to multiple tumours. The combinationof poor orodental hygeine and poor nutritionincluding Plummer-Vinsion syndrome are notunusual findings in female patients from poor

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patient, brief history and rapid deterioration incondition of the patient are indicators in thatdirection.The present day increasing frequency ofdetection of multiple primary cancers may alsobe due to better follow up of the patients,improved diagnostic aids and treatment andpossible a true increase in frequency, and thelast but not the least by the extensive searchfor multiple primary lesions of aerodigestivesystem by panendoscopies as advocated byJack (1979). He recommended panedoscopiesin all cases of carcinoma of upper aerodigestivesystem despite the additional inconvenienceand expense involved.

Fig. 3 : Microphotograph showing welldifferentiated squamous cell carcinomafrom Alveolar lesion (H & Ex100)

socio-economic group; but multicentric/multipleprimary cancers is an unusual phenomenon,although both these factors are important in theconstellation of aetiological factors in head andneck malignancies.Immunological incompetance may well accountfor the development of multiple tumours inmany patients. I feel that rare presentation ofsuch like case may be related to thebreakdown of the immune response within thebody. Such a response although notsubstantiated in epidermoid carcinoma in headand neck on the basis of specific tumourantigens, has been referred by Berlinger andGood (1976). The poor nutritional status of the

References

Fig. 4 : Microphotograph showing welldifferentiated squamous cell carcinomafrom Hypopharyngeal lesion (H & Ex400)

1. Agarwal, K. K. and Bansal, R. S. (1977) : Multiple primary synchronous carcinomas. IndianJournal of Otolaryngology, 29: 147.

2. Berlinger, N. T. and Good, R. A. (1976) : Concomitant immunopathology with squamouscell carcinoma of Head and Neck regions. Trans. Am. Acad. Ophthalmol. Otolaryngol. 82:588-594.

3. Biltroth, T. (1889) : Die allgemeine chirurgishe pathalogie and therapie in 51 Varessugen:Ein Hanbuch Fur studirende and Arzte. Berlin, G Riemer, p. 908.

4. Dutta, N. N. (1977) : Double malignant lesion in the upper food passage. Indian Journal ofOtolaryngology, 29: 148.

5. Jack, L. Gluckman (1979) : Synchronous multiple primary lesions of the upper aerodigestivesystem. Archives of Otolaryngology, 105: 597-598.

6. Warren, S., Gates, O. (1932) : Multiple malignant tumours : A survey of literature and statisticalstudy. American Journal of Cancer, 51 : 1358-1414.

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