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Lingual Tonsillar Metastasis From Rectal Carcinoma A Rare Occurrence Minggang Su, MD, Chong Jiang, MD, Lin Li, MD, Fanglan Li, MD, and Rong Tian, MD Abstract: A 66-year-old man presenting with sacral pain 18 months after radical transabdominal resection of rectal mucinous adenocarcinoma underwent 18F-FDG PET/CT cancer surveillance. Detection of multiple nodules in lingual tonsil and left neck by imaging initially suggested tonsillar squamous carcinoma (as a second primary) with spread to cervical nodes, given the rarity with which rectal carcinoma metastasizes to the head and neck. Ultimately, the tonsillar neoplasm proved to be adenocarcinoma of colorectal origin based on its shared histologic features and compatible immunostaining profile. Key Words: 18F-FDG PET/CT, rectal neoplasm, mucinous adenocarcinoma, tonsil neoplasm, metastasis (Clin Nucl Med 2014;39: 573Y575)
Received for publication October 21, 2013; revision accepted February 12, 2014. From the Department of Nuclear Medicine, National Key Discipline of Medical Imaging and Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China. Drs Minggang Su and Chong Jiang contributed equally to this work. Conflicts of interest and sources of funding: none declared. Reprints: Lin Li, MD, Department of Nuclear Medicine, National Key Discipline of Medical Imaging and Nuclear Medicine, West China Hospital, Sichuan University, 37 Guoxue Xiang, Chengdu 610041, Sichuan, China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3906Y0573
Clinical Nuclear Medicine
& Volume 39, Number 6, June 2014
REFERENCES 1. Hong W, Wang X, Yu X, et al. Palatine tonsillar metastasis of lung cancer during chemotherapy. Int J Clin Exp Pathol. 2012;5:468Y471. 2. Al-Ibraheem A, Souvatzoglou M, Buck A, et al. Melanoma metastases to palatine tonsils obscured by physiological FDG uptake on PET/CT. Clin Nucl Med. 2010;35:101Y102. 3. Sellars SL. Metastatic tumours of the tonsil. J Laryngol Otol. 1971;85: 289Y292. 4. Goldenberg D, Golz A, Arie YB, et al. Adenocarcinoma of the rectum with metastasis to the palatine tonsil. Otolaryngol Head Neck Surg. 1999;121: 653Y654. 5. Vaule´on E, De Lajarte-Thirouard AS, Le Prise´ E, et al. Tonsillar metastasis revealing signet-ring cell carcinoma of the rectum. Gastroenterol Clin Biol. 2005;29:70Y72. 6. Wang WS, Chiou TJ, Pan CC, et al. Signet-ring cell carcinoma of the rectum with tonsillar metastasis: a case report. Zhonghua Yi Xue Za Zhi (Taipei). 1996;58:209Y212. 7. Vasilevsky CA, Abou-Khalil S, Rochon L, et al. Carcinoma of the colon presenting as tonsillar metastasis. J Otolaryngol. 1997;26:325Y326. 8. Gu¨venc¸ MG, Ada M, Acio?lu E, et al. Tonsillar metastasis of primary signetring cell carcinoma of the cecum. Auris Nasus Larynx. 2006;33:85Y88. 9. Low WK, Sng I, Balakrishnan A. Palatine tonsillar metastasis from carcinoma of the colon. J Laryngol Otol. 1994;108:449Y451. 10. Vijayan R, Darroch R, Daniel F. A case of rectal cancer metastasizing to tonsil. Clin Oncol (R Coll Radiol). 2003;15:219Y220. 11. Sheng LM, Zhang LZ, Xu HM, et al. Ascending colon adenocarcinoma with tonsillar metastasis: a case report and review of the literature. World J Gastroenterol. 2008;14:7138Y7140. 12. Park KK, Park YW. Tonsillar metastasis of signet-ring cell adenocarcinoma of the colon. Ear Nose Throat J. 2010;89:376Y377. 13. Lemay F, Cervera P, de Gramont A. A man with colon cancer and tonsil swelling. Tonsillar metastasis from colon cancer. Gastroenterology. 2012;142: 1423, 1625.
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573
Clinical Nuclear Medicine
Su et al
& Volume 39, Number 6, June 2014
FIGURE 1. A 66-year-old man experiencing sacral pain was admitted to our hospital. He had been treated for rectal cancer 18 months earlier. At that time, the preoperative screening result for distant metastases was negative, so radical transabdominal resection was performed. The tumor was a poorly differentiated mucinous adenocarcinoma that had breached muscularis propria, invaded subjacent tissues (T3), and spread to 4 regional lymph nodes (N2a), thus qualifying as stage IIIB disease by the 7th edition of the AJCC Cancer Staging Manual (AJCC-7). For 6 months, he received an oxaliplatin-based adjuvant regimen (modified FOLFOX6) plus bevacizumab. 18F-FDG PET/CT scanning was done on this occasion for cancer surveillance, prompted by recent sacral pain. PET images were acquired 60 minutes after IV 18F-FDG (0.15 mCi/kg) injection, and CT was performed concurrently, using a low-dose noncontrast protocol for attenuation and localization of abnormal FDG activity. PET/CT images revealed perianastomotic tumor recurrence and sacral metastasis, with SUVmax of 3.5 and 4.3, respectively (AYD). The tumors of lingual tonsil and left neck initially were suggestive of a tonsillar squamous carcinoma (SUV, 8.9), as a second primary with cervical node metastasis (SUV, 2.6), given the rarity of rectal cancer metastasis in the head and neck region (A, EYG).
574
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 6, June 2014
Lingual Tonsillar Metastasis From Rectal Carcinoma
FIGURE 2. Physical examination revealed an ulcerated mass of lingual tonsil with no palpable cervical nodes. A punch biopsy of the tonsillar mass confirmed the presence of poorly differentiated adenocarcinoma. In histologic review, both rectal tumor (AYB, hematoxylin-eosin, original magnification 50 and 400, respectively) and tonsillar mass (CYD, hematoxylin-eosin, original magnification 50 and 400, respectively) appeared similar, with less abundant mucin in the tonsillar biopsy. Immunostained sections of the tonsillar neoplasm (positive for CDX2, muc-1, and CK7 markers; negative for thyroid-transforming factor) likewise were compatible with adenocarcinoma of colorectal origin. The patient received second-line irinotecan-based chemotherapy (FOLFIRI), in combination with cetuximab and concurrent radiotherapy to the pelvis and mouth. Four months later, he died of tumor progression and Acinetobacter baumannii pneumonia. Metastatic cancer of the tonsil is extremely rare, with only about 100 case reports published to date in the English literature, but palatine tonsil is typically involved in this context.1 The tumors generally arise from primary malignancies of the lung, kidney, and skin (melanoma) or occasionally from gastrointestinal tract and liver.1,2 To the best of our knowledge, there are only 11 recorded instances of tonsillar metastasis by colorectal carcinoma.3Y13 It is particularly difficult to distinguish distant metastasis by an unusual source from a second primary cancer, especially if its corresponding SUV differs from SUVs of synchronous tumors in disparate organs, as seen here. However, metastasis cannot be excluded on the basis of such imaging discrepancies because differing SUVs may simply reflect biologic divergence, which in this instance was the production of mucin.
* 2014 Lippincott Williams & Wilkins
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
575
Lingual Tonsillar Metastasis From Rectal Carcinoma A Rare Occurrence Minggang Su, MD, Chong Jiang, MD, Lin Li, MD, Fanglan Li, MD, and Rong Tian, MD Abstract: A 66-year-old man presenting with sacral pain 18 months after radical transabdominal resection of rectal mucinous adenocarcinoma underwent 18F-FDG PET/CT cancer surveillance. Detection of multiple nodules in lingual tonsil and left neck by imaging initially suggested tonsillar squamous carcinoma (as a second primary) with spread to cervical nodes, given the rarity with which rectal carcinoma metastasizes to the head and neck. Ultimately, the tonsillar neoplasm proved to be adenocarcinoma of colorectal origin based on its shared histologic features and compatible immunostaining profile. Key Words: 18F-FDG PET/CT, rectal neoplasm, mucinous adenocarcinoma, tonsil neoplasm, metastasis (Clin Nucl Med 2014;39: 573Y575)
Received for publication October 21, 2013; revision accepted February 12, 2014. From the Department of Nuclear Medicine, National Key Discipline of Medical Imaging and Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China. Drs Minggang Su and Chong Jiang contributed equally to this work. Conflicts of interest and sources of funding: none declared. Reprints: Lin Li, MD, Department of Nuclear Medicine, National Key Discipline of Medical Imaging and Nuclear Medicine, West China Hospital, Sichuan University, 37 Guoxue Xiang, Chengdu 610041, Sichuan, China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3906Y0573
Clinical Nuclear Medicine
& Volume 39, Number 6, June 2014
REFERENCES 1. Hong W, Wang X, Yu X, et al. Palatine tonsillar metastasis of lung cancer during chemotherapy. Int J Clin Exp Pathol. 2012;5:468Y471. 2. Al-Ibraheem A, Souvatzoglou M, Buck A, et al. Melanoma metastases to palatine tonsils obscured by physiological FDG uptake on PET/CT. Clin Nucl Med. 2010;35:101Y102. 3. Sellars SL. Metastatic tumours of the tonsil. J Laryngol Otol. 1971;85: 289Y292. 4. Goldenberg D, Golz A, Arie YB, et al. Adenocarcinoma of the rectum with metastasis to the palatine tonsil. Otolaryngol Head Neck Surg. 1999;121: 653Y654. 5. Vaule´on E, De Lajarte-Thirouard AS, Le Prise´ E, et al. Tonsillar metastasis revealing signet-ring cell carcinoma of the rectum. Gastroenterol Clin Biol. 2005;29:70Y72. 6. Wang WS, Chiou TJ, Pan CC, et al. Signet-ring cell carcinoma of the rectum with tonsillar metastasis: a case report. Zhonghua Yi Xue Za Zhi (Taipei). 1996;58:209Y212. 7. Vasilevsky CA, Abou-Khalil S, Rochon L, et al. Carcinoma of the colon presenting as tonsillar metastasis. J Otolaryngol. 1997;26:325Y326. 8. Gu¨venc¸ MG, Ada M, Acio?lu E, et al. Tonsillar metastasis of primary signetring cell carcinoma of the cecum. Auris Nasus Larynx. 2006;33:85Y88. 9. Low WK, Sng I, Balakrishnan A. Palatine tonsillar metastasis from carcinoma of the colon. J Laryngol Otol. 1994;108:449Y451. 10. Vijayan R, Darroch R, Daniel F. A case of rectal cancer metastasizing to tonsil. Clin Oncol (R Coll Radiol). 2003;15:219Y220. 11. Sheng LM, Zhang LZ, Xu HM, et al. Ascending colon adenocarcinoma with tonsillar metastasis: a case report and review of the literature. World J Gastroenterol. 2008;14:7138Y7140. 12. Park KK, Park YW. Tonsillar metastasis of signet-ring cell adenocarcinoma of the colon. Ear Nose Throat J. 2010;89:376Y377. 13. Lemay F, Cervera P, de Gramont A. A man with colon cancer and tonsil swelling. Tonsillar metastasis from colon cancer. Gastroenterology. 2012;142: 1423, 1625.
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
573
Clinical Nuclear Medicine
Su et al
& Volume 39, Number 6, June 2014
FIGURE 1. A 66-year-old man experiencing sacral pain was admitted to our hospital. He had been treated for rectal cancer 18 months earlier. At that time, the preoperative screening result for distant metastases was negative, so radical transabdominal resection was performed. The tumor was a poorly differentiated mucinous adenocarcinoma that had breached muscularis propria, invaded subjacent tissues (T3), and spread to 4 regional lymph nodes (N2a), thus qualifying as stage IIIB disease by the 7th edition of the AJCC Cancer Staging Manual (AJCC-7). For 6 months, he received an oxaliplatin-based adjuvant regimen (modified FOLFOX6) plus bevacizumab. 18F-FDG PET/CT scanning was done on this occasion for cancer surveillance, prompted by recent sacral pain. PET images were acquired 60 minutes after IV 18F-FDG (0.15 mCi/kg) injection, and CT was performed concurrently, using a low-dose noncontrast protocol for attenuation and localization of abnormal FDG activity. PET/CT images revealed perianastomotic tumor recurrence and sacral metastasis, with SUVmax of 3.5 and 4.3, respectively (AYD). The tumors of lingual tonsil and left neck initially were suggestive of a tonsillar squamous carcinoma (SUV, 8.9), as a second primary with cervical node metastasis (SUV, 2.6), given the rarity of rectal cancer metastasis in the head and neck region (A, EYG).
574
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 6, June 2014
Lingual Tonsillar Metastasis From Rectal Carcinoma
FIGURE 2. Physical examination revealed an ulcerated mass of lingual tonsil with no palpable cervical nodes. A punch biopsy of the tonsillar mass confirmed the presence of poorly differentiated adenocarcinoma. In histologic review, both rectal tumor (AYB, hematoxylin-eosin, original magnification 50 and 400, respectively) and tonsillar mass (CYD, hematoxylin-eosin, original magnification 50 and 400, respectively) appeared similar, with less abundant mucin in the tonsillar biopsy. Immunostained sections of the tonsillar neoplasm (positive for CDX2, muc-1, and CK7 markers; negative for thyroid-transforming factor) likewise were compatible with adenocarcinoma of colorectal origin. The patient received second-line irinotecan-based chemotherapy (FOLFIRI), in combination with cetuximab and concurrent radiotherapy to the pelvis and mouth. Four months later, he died of tumor progression and Acinetobacter baumannii pneumonia. Metastatic cancer of the tonsil is extremely rare, with only about 100 case reports published to date in the English literature, but palatine tonsil is typically involved in this context.1 The tumors generally arise from primary malignancies of the lung, kidney, and skin (melanoma) or occasionally from gastrointestinal tract and liver.1,2 To the best of our knowledge, there are only 11 recorded instances of tonsillar metastasis by colorectal carcinoma.3Y13 It is particularly difficult to distinguish distant metastasis by an unusual source from a second primary cancer, especially if its corresponding SUV differs from SUVs of synchronous tumors in disparate organs, as seen here. However, metastasis cannot be excluded on the basis of such imaging discrepancies because differing SUVs may simply reflect biologic divergence, which in this instance was the production of mucin.
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
575
