Case Letters
Superior vena cava syndrome due to metastasis from acinic cell carcinoma of the parotid gland Sir, Acinic cell carcinoma is a rare malignancy of salivary gland origin.[1] The parotid gland is the most common primary site. It can recur many years after the primary diagnosis and subsequent removal.[1,2] Distant metastases from salivary gland tumors are relatively atypical and their occurrence is associated with high‑grade tumors. [2] We report the first case of a patient with superior vena cava syndrome (SVCS) due to an acinic cell carcinoma of a parotid gland metastasizing to the mediastinum 2 years after resection of the primary tumor. A 53‑year‑old Hispanic female presented to the emergency department with complaints of progressive increase in size of a painful mass in the right mandibular area. Her physical exam was significant for a 5 × 4 cm nontender, mobile, firm mass over right mandibular area with normal overlying skin. Rest of the physical exam was unremarkable. Lab studies were within normal limits. The computed tomography (CT) scan of the neck revealed a parotid gland tumor. A total right parotidectomy with sacrifice of the facial nerve was carried out. The final pathologic diagnosis was consistent with acinic cell carcinoma and the facial nerve showed fibroneural tissue with tumor deposits. The patient refused chemotherapy so only radiation was given for 6 months. Two years later, the patient came to the emergency department again with complaints of painful right mandibular swelling associated with dyspnea, facial plethora and edema. The CT scan of the neck and chest with intravenous contrast revealed an abnormally enhancing lesion with a necrotic center at the site of the right parotid bed extending into the right preauricular subcutaneous fat. It also showed a right suprahilar lung mass with massive mediastinal adenopathy invading the superior vena cava and right pulmonary artery [Figure 1]. Histopathology of the biopsy specimens of the mass in parotid bed and right lung mass and the clinical presentation together were consistent with a diagnosis of SVCS secondary to recurrent acinic cell carcinoma of the parotid gland [Figure 2a and b]. The patient refused chemotherapy and hence was discharged home on pain relief medication and palliative radiotherapy for symptomatic relief. She is currently under hospice care. Management for SVCS associated with malignancy involves both treatment of the underlying malignancy and relief of the obstructive symptoms.[3‑5] In our patient, palliative radiation therapy was initiated to reduce
Figure 1: Computed tomography scan demonstrating a right suprahilar lung mass with massive mediastinal adenopathy invading the superior vena cava and right pulmonary artery
Figure 2a: Photomicrographs of tissue biopsy from parotid bed showing acinar arrangement of malignant tumor cells (H and E, x100)
Figure 2b: Photomicrographs of tissue biopsy from the lung revealing acinar differentiation of malignant tumor cells (H and E, x200)
Lung India • Vol 32 • Issue 1 • Jan - Feb 2015 87
Case Letters
hydrostatic pressure and edema of the face. Patients with this condition usually have a poor prognosis and median life expectancy is approximately 6 months.[4]
2. 3. 4.
Hamid Shaaban, Tejas Modi, Hiren Patel , Abhishek Kumar1, Michael Maroules1 1
5.
Departments of Hematology and Oncology, Saint Michael’s Medical Center, Newark, 1Saint Joseph’s Regional Medical Center, Paterson, New Jersey, USA. E‑mail: [email protected]
Tavora F, Rassaei N, Shilo K, Foss RD, Galvin JR, Travis WD, et al. Occult primary parotid gland acinic cell adenocarcinoma presenting with extensive lung metastasis. Arch Pathol Lab Med 2007;131:970‑3. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med 2012;40:2212‑22. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007;356:1862‑9. Yim CD, Sane SS, Bjarnason H. Superior vena cava stenting. Radiol Clin North Am 2000;38:409‑24.
Access this article online Quick Response Code:
Website:
REFERENCES 1.
www.lungindia.com
Brandwein‑Gensler MS, Gnepp DR. Low‑grade cribriform cystadenocarcinoma. In: Barnes L, Evenson JW, Reichart P, Sidransky D, editors.World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours. Lyon: IARC Press; 2005. p. 233.
DOI: 10.4103/0970-2113.148464
Double fistula: Bronchopleural and pleurocutaneous Sir, A 55‑year‑old male patient came to chest outpatient department with complaints of discharging sinus through the left anterolateral chest wall for the past 1 week. The discharge was serosanguinous and intermittent. The patient was a known case of sputum‑positive pulmonary tuberculosis and is on antitubercular treatment for the past 5 months. There was no previous history of surgery, however, intercostal tube drainage was done for left tubercular hydropneumothorax 5 months back and the tube was kept for 8 days following which it was removed. Initially a possibility of tubercular osteomyelitis of rib with discharging sinus was thought. Patient was referred for computed tomography (CT) scan of chest. CT scan chest showed imaging features of sequelae of pulmonary tuberculosis in both lungs with loculated left pneumothorax. There was presence of left bronchopleural fistula with upper lobe bronchus communicating with the left pleural cavity [Figure 1] with another fistula extending from left pleural cavity to left anterolateral chest wall [Figure 2a and b]. Hence a diagnosis of left sided double fistula, that is, bronchopleural and pleurocutaneous fistula was made. The patient was unfit for surgery, hence bronchoscopic closure of bronchopleural fistula was done using glue injection. The external opening of pleurocutaneous fistula was closed using skin sutures and patient was continued antituberculosis treatment. Patient improved symptomatically and the discharge from the cutaneous site stopped after 2 weeks. 88
Figure 1: Axial CT chest showing direct communication of left upper lobe bronchus with the loculated pneumothorax (black arrow) suggestive of bronchopleural fistula
a
b
Figure 2: (a and b) Coronal and axial reformatted CT chest sections showing fistulous communication of loculated left pneumothorax with the external surface of left anterolateral chestwall (black arrows) Lung India • Vol 32 • Issue 1 • Jan- Feb 2015
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Superior vena cava syndrome due to metastasis from acinic cell carcinoma of the parotid gland Sir, Acinic cell carcinoma is a rare malignancy of salivary gland origin.[1] The parotid gland is the most common primary site. It can recur many years after the primary diagnosis and subsequent removal.[1,2] Distant metastases from salivary gland tumors are relatively atypical and their occurrence is associated with high‑grade tumors. [2] We report the first case of a patient with superior vena cava syndrome (SVCS) due to an acinic cell carcinoma of a parotid gland metastasizing to the mediastinum 2 years after resection of the primary tumor. A 53‑year‑old Hispanic female presented to the emergency department with complaints of progressive increase in size of a painful mass in the right mandibular area. Her physical exam was significant for a 5 × 4 cm nontender, mobile, firm mass over right mandibular area with normal overlying skin. Rest of the physical exam was unremarkable. Lab studies were within normal limits. The computed tomography (CT) scan of the neck revealed a parotid gland tumor. A total right parotidectomy with sacrifice of the facial nerve was carried out. The final pathologic diagnosis was consistent with acinic cell carcinoma and the facial nerve showed fibroneural tissue with tumor deposits. The patient refused chemotherapy so only radiation was given for 6 months. Two years later, the patient came to the emergency department again with complaints of painful right mandibular swelling associated with dyspnea, facial plethora and edema. The CT scan of the neck and chest with intravenous contrast revealed an abnormally enhancing lesion with a necrotic center at the site of the right parotid bed extending into the right preauricular subcutaneous fat. It also showed a right suprahilar lung mass with massive mediastinal adenopathy invading the superior vena cava and right pulmonary artery [Figure 1]. Histopathology of the biopsy specimens of the mass in parotid bed and right lung mass and the clinical presentation together were consistent with a diagnosis of SVCS secondary to recurrent acinic cell carcinoma of the parotid gland [Figure 2a and b]. The patient refused chemotherapy and hence was discharged home on pain relief medication and palliative radiotherapy for symptomatic relief. She is currently under hospice care. Management for SVCS associated with malignancy involves both treatment of the underlying malignancy and relief of the obstructive symptoms.[3‑5] In our patient, palliative radiation therapy was initiated to reduce
Figure 1: Computed tomography scan demonstrating a right suprahilar lung mass with massive mediastinal adenopathy invading the superior vena cava and right pulmonary artery
Figure 2a: Photomicrographs of tissue biopsy from parotid bed showing acinar arrangement of malignant tumor cells (H and E, x100)
Figure 2b: Photomicrographs of tissue biopsy from the lung revealing acinar differentiation of malignant tumor cells (H and E, x200)
Lung India • Vol 32 • Issue 1 • Jan - Feb 2015 87
Case Letters
hydrostatic pressure and edema of the face. Patients with this condition usually have a poor prognosis and median life expectancy is approximately 6 months.[4]
2. 3. 4.
Hamid Shaaban, Tejas Modi, Hiren Patel , Abhishek Kumar1, Michael Maroules1 1
5.
Departments of Hematology and Oncology, Saint Michael’s Medical Center, Newark, 1Saint Joseph’s Regional Medical Center, Paterson, New Jersey, USA. E‑mail: [email protected]
Tavora F, Rassaei N, Shilo K, Foss RD, Galvin JR, Travis WD, et al. Occult primary parotid gland acinic cell adenocarcinoma presenting with extensive lung metastasis. Arch Pathol Lab Med 2007;131:970‑3. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med 2012;40:2212‑22. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007;356:1862‑9. Yim CD, Sane SS, Bjarnason H. Superior vena cava stenting. Radiol Clin North Am 2000;38:409‑24.
Access this article online Quick Response Code:
Website:
REFERENCES 1.
www.lungindia.com
Brandwein‑Gensler MS, Gnepp DR. Low‑grade cribriform cystadenocarcinoma. In: Barnes L, Evenson JW, Reichart P, Sidransky D, editors.World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours. Lyon: IARC Press; 2005. p. 233.
DOI: 10.4103/0970-2113.148464
Double fistula: Bronchopleural and pleurocutaneous Sir, A 55‑year‑old male patient came to chest outpatient department with complaints of discharging sinus through the left anterolateral chest wall for the past 1 week. The discharge was serosanguinous and intermittent. The patient was a known case of sputum‑positive pulmonary tuberculosis and is on antitubercular treatment for the past 5 months. There was no previous history of surgery, however, intercostal tube drainage was done for left tubercular hydropneumothorax 5 months back and the tube was kept for 8 days following which it was removed. Initially a possibility of tubercular osteomyelitis of rib with discharging sinus was thought. Patient was referred for computed tomography (CT) scan of chest. CT scan chest showed imaging features of sequelae of pulmonary tuberculosis in both lungs with loculated left pneumothorax. There was presence of left bronchopleural fistula with upper lobe bronchus communicating with the left pleural cavity [Figure 1] with another fistula extending from left pleural cavity to left anterolateral chest wall [Figure 2a and b]. Hence a diagnosis of left sided double fistula, that is, bronchopleural and pleurocutaneous fistula was made. The patient was unfit for surgery, hence bronchoscopic closure of bronchopleural fistula was done using glue injection. The external opening of pleurocutaneous fistula was closed using skin sutures and patient was continued antituberculosis treatment. Patient improved symptomatically and the discharge from the cutaneous site stopped after 2 weeks. 88
Figure 1: Axial CT chest showing direct communication of left upper lobe bronchus with the loculated pneumothorax (black arrow) suggestive of bronchopleural fistula
a
b
Figure 2: (a and b) Coronal and axial reformatted CT chest sections showing fistulous communication of loculated left pneumothorax with the external surface of left anterolateral chestwall (black arrows) Lung India • Vol 32 • Issue 1 • Jan- Feb 2015
Copyright of Lung India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
