CASE REPORTS PAUL A. LMNE, MD Ca.. I.part Editor
Tumor implantation in a tracheotomy MICHAEL ARMSTRONG, JR., MD, and JOHN C. PRICE, MD. Baltimore, Maryland
It is well known that tumor cells can seed the tract aftera biopsyor recurat the margins afterlocalexcision of a tumor. Great care is generally taken to excise previous biopsy incisions, remove contaminated instruments from the field, and irrigate the wound before closure. We present an unusual case of squamous cell carcinoma of the mobile tongue recurring at the site of a tracheotomy performed at the timeof initialresection. Webelieve thisrecurrence is a resultof seeding of tumor cells in the adjacent surgical field.
CAII-.on The patient was a 69-year-old man with a T:zNoMo squamous cell carcinoma of the right side of the tongue who underwent panendoscopy, placement of a temporary tracheotomy, and right hemiglossectomy. He had smoked one pack of cigarettes per day for 50 years and was a recovering alcoholic. Pathology demonstrated positive surgical margins and so he was treated with 6840 rad external beam radiation to the head and neck and an additional 5040 rad to the supraclavicular fossa, with a midline block. His wounds healed without incident. Seven months after the initial procedure, he noticed a draining ulcer at the site of his previously healed tracheotomy. He also reported moderate pain in the left neck. He remained dysarthric from his hemiglossectomy, but denied any hoarseness. He was referred to us for further treatment, at which time a biopsy of the tracheotomy scar revealed metastatic squamous cell carcinoma that was consistent with the pathology from the previous tumor. His medical history was notable for chronic obstructive pulmonary disease with dyspnea and right leg claudication at less than one block. His only medication was acetaminophen with codeine.
From the Department of Otolaryngology-Head and Neck Surgery.
JohnsHopkins Hospital (Drs. Armstrong and Price), and the Department of Otolaryngology-Head andNeckSurgery. Greater Baltimore Medical Center (Dr. Price). Received for publication Oct. 18. 1991; accepted Dec. II, 1991. Reprint requests: Michael Armstrong, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, 600 North Wolfe St.• Baltimore. MD 21205. 13/4/35677
On physical examination the right hemiglossectomy was found to be well healed, with no evidence of local recurrence. Indirect and fiberoptic examination of the larynx demonstrated an exophytic, ulcerated, subglottic mass obstructing the anterior two-thirds of the airway. The true vocal cords were edematous but mobile. Externally, there was a 3 x 3 cm mass at the site of the old tracheotomy. The tumor was fixed to the skin, with satellite nodules extending for 2 em in all directions. The center was ulcerated and contained a tracheocutaneous fistula. A hard 2 cm cervical node was palpated in the right posterior triangle. Magnetic resonance imaging (MRI) and computed tomography (CT) of the neck confirmed the presence of a mass arising anterior to the trachea at the level of the tracheotomy (Fig. I) and also demonstrated the 2 em neck node, as well as smaller nodules. cr scans of the chest and abdomen, with and without contrast, were negative for distant metastases. He underwent a right radical neck dissection, left modified radical neck dissection, and total laryngectomy at the level of the fifth tracheal ring. Reconstruction was performed with a right pectoralis major myocutaneous flap, bringing the tracheostoma through the center of the flap after excision of the nipple-areolar complex. Pathologic examination demonstrated moderately-to-well differentiated squamous cell carcinoma arising in the pretracheal skin at the site of the previous tracheotomy. There was invasion into and around the trachea to a depth of 4 cm (Fig. 2). The postoperative course was complicated by a cerebrovascular accident on postoperative day three. at which time the patient fell and tore open his suture line. Although his neurologic symptoms cleared over the next few days, a pharyngocutaneous fistula with an exposed carotid artery developed in his right neck, and a thoracic duct leak into his left neck. He was treated with dressing changes. bowel rest, and total parenteral nutrition. On postoperative day 13, he was returned to the operating room, where he underwent closure . of his fistulae and coverage with a left pectoralis major flap. Four days later. the wound reopened. exposing the carotid arteries on both sides. Ligation of either carotid was considered contraindicated because of his recent stroke. Despite aggressive local therapy, the wound failed to heal and he died from carotid hemorrhage on postoperative day 55.
DISCUSSION This unfortunate case is probably a resultof implantationof tumorcellsoccurring at the timeof the primary
Volume 106 Number 4 April 1992
Case Reports 0401
Fig. 1. T2-welghted MRI of ttle neck In ttle mldsaglftal plane. which Illustrates a large tumor In ttle skin of ttle lower neck met almost completely obstructs ttle subglottic trachea (arrow).
resection. The close temporal relationship of the recurrence after surgery and the rapid growth of the tumor within the scar of the tracheotomy are consistent with this hypothesis. The absence of local recurrence in the mouth or pharynx rules out contiguous spread. Hematogenous spread of tumor is also unlikely, given the absence of pulmonary or other distant metastases. Finally, the midline location of the recurrence makes lymphatic spread to this location improbable. Seeding of tumor cells within the surgical field, recognized as early as 1907 by Butlin, I is a well-known but uncommon cause of tumor recurrence. Alagaratnam and Ong' presented a patient with stage IV squamous cell carcinoma of the tongue base who underwent open gastrostomy, total glossectomy, right partial mandibulectomy, total laryngectomy, and en bloc bilateral radical neck dissections. Two years later recurrent carcinoma developed at the gastrostomy site. This was resected, but the tumor recurred again and he died 6 months later, with no evidence of disease in the head and neck. Robbins and Woodson3 described a case of T 2N I squamous cell carcinoma of the lateral anterior
tongue that recurred and resulted in a submandibular fistula. The patient then underwent a total glossectomy, laryngectomy, and partial pharyngectomy with reconstruction using a pectoralis major myocutaneous flap. Two months later, recurrent tumor developed at the chest donor site. A second patient underwent a total laryngectomy, and later a total glossectomy for recurrent laryngeal carcinoma. He too was closed with a pectoralis major myocutaneous flap, but recurrence took place at the chest wall four months later. Schouten" performed a total laryngectomy, radical neck dissection, and deltopectoral flap for squamous cell carcinoma of the piriform sinus. The flap was returned to the chest wall after a fistula developed in the immediate postoperative period. Two years later the patient had a recurrence on the chest wall with nodal metastases in the axilla. Carr and Gilbert" described a patient who had recurrence at the donor site of a temporalis muscle flap used to close a defect in the retromolar trigone after recurrent tongue cancer. Recht et al." have presented three cases of esophageal carcinoma that metastasized to the thoracotomy incision after
ot02
Cose Reports
otolaryngologyHead and Neck SurgetY
Fig. 2. Gross appearance of the resected tumor demonstrating A, extensive skin Involvement. as well as '. a large exophytic mass projecting Into the subglottic trachea.
esophagogastrectomy. Most recently. Preyer and Thul? reported a case of hypopharyngeal carcinoma that metastasized to the abdominal wall after a percutaneou s endoscopic gastrostomy. These cases of tumor recurrence probably represent intraoperative seeding of wound edges. Blood aspirated
from the surgical field during head and neck cancer operations contains tumor cells that can grow in culture. K In 1936. Saphir? demonstrated that apparently viable tumor cells could be collected from scalpels used to cut into breast tumors. It remained for Safour et aJ. 1O (1984) to prove this theory by demonstrating that seal-
Volume 106 Number 4 April 1992
pels used to perform biopsy on hamster cheek pouch carcinomas universally were contaminated with malignant cells. When these scalpels were used to make incisions in the tongue or lip, metastases arose in 36% and 41% of the incisions, respectively. Tracheostomal recurrence after total laryngectomy is a well known and generally fatal complication that occurs in 3% to 40% of laryngectomies. 11 Although multiple risk factors for stomal recurrence have been implicated, the most important factor appears to be subglottic extension of tumor.":" Others have observed that a tracheotomy performed more than 24 hours before definitive surgery increases the risk of stomal recurrenee." While the relative risk of delaying definitive resection after emergent tracheotomy continues to be debated, this case supports the hypothesis that some of the local recurrences after total laryngectomy may result from tumor seeding. It is conceivable that either the emergent tracheotomy violates the tumor and spills cells that are not later resected, or that granulation tissue that develops in the tracheotomy before laryngectomy provides a fertile bed for implants seeded at the later resection. CONCLUSION
Implantation of distant metastases after resection of head and neck carcinoma is uncommon. Nevertheless, squamous cell carcinoma can metastasize by intraoperative seeding, and recurrent carcinoma should be considered in any wound that fails to heal as expected. As previous authors have stressed since the tum of the century, 14 care should be taken to minimize tumor spillage anywhere in the surgical field. In our institution, all ancillary procedures (tracheotomy, gastrostomy, etc.) are completed before the tumor is violated. The drapes are placed in such a way as to isolate the field of surgery as much as possible. Gloves and instruments are exchanged after removal of the specimen. Finally,
Case Reports 403
the wound is thoroughly irrigated and suctioned before closure. This is no different from the infection control practices we use when resecting unsterile specimens such as the large bowel. While no technique can absolutely prevent the spillage of tumor cells, strict adherence to these guidelines should minimize the frequency of this unfortunate complication. REFERENCES
1. ButIin HT. The contagion of cancer in human beings: autoinoculation. Lancet 1907;2:279-83. 2. Alagaratnam 17. Ong GB. Wound implantation-a surgicalhazard. Br J Surg 1977;64:872-5. 3. Robbins KT. Woodson GE. Chest wall metastasis as a complication of myocutaneous ftap reconstruction. J Otolaryngol 1984;13:13-4. 4. Schouten JT. Tumor implantation in a skin ftap. JAMA 1983;250:2690. 5. Carr RJ, Gilbert PM. Tumorimplantationto a temporalismuscle Dap donor site. Br J Oral Maxillofac Surg 1986;24:102-6. 6. Recht MP. ColemanBG. Barbot OJ, et al. Recurrentesophageal carcinomaat thoracotomy incisions: diagnosticcontributions of CT. J Comput Assist Tomogr 1989;13:58-60. 7. Preyer S, Thul P. Gastric metastasisof squamouscell carcinoma of head and neck after percutaneous endoscopic gastrostomyreport of a case. Endoscopy 1989;21:295. 8. Atiyah RA, Krespi YP, Hidvegi D, Sisson GA Sr. The mechanical spread of viable tumor during surgery. OroLARYNOOL HEAD NECK SURa 1986;94:278-81. 9. Saphir O. The transfer of tumor cells by the surgicalknife. Surg GynecolObstet 1936;63:775-6. 10. Safour 1M, Wood NK, Tsiklakis K, Doemling DB, Joseph G. Incisionalbiopsyand seedingin hamstercheekpouchcarcinoma. J Dent Res 1984;63:1116-20. 11. Davis RK, Shapshay SM. Peristomal recurrence: pathophysiology, prevention, treatment. Otolaryngol Clin North Am 1980;13:499-508. 12. Griebie MS, Adams GL. Emergency laryngectomy and stomal recurrence. Laryngoscope 1987;97:1020-4. 13. Keirn WF, Shapiro MJ, Rosen HO. Study of postlaryngectomy stomal recurrences. Arch Otolaryngol 1965;81:183-6. 14. Ryall C. The technique of cancer operations with reference to the danger of cancer infection. Br Med J 1908;2:1005-8.
Tumor implantation in a tracheotomy MICHAEL ARMSTRONG, JR., MD, and JOHN C. PRICE, MD. Baltimore, Maryland
It is well known that tumor cells can seed the tract aftera biopsyor recurat the margins afterlocalexcision of a tumor. Great care is generally taken to excise previous biopsy incisions, remove contaminated instruments from the field, and irrigate the wound before closure. We present an unusual case of squamous cell carcinoma of the mobile tongue recurring at the site of a tracheotomy performed at the timeof initialresection. Webelieve thisrecurrence is a resultof seeding of tumor cells in the adjacent surgical field.
CAII-.on The patient was a 69-year-old man with a T:zNoMo squamous cell carcinoma of the right side of the tongue who underwent panendoscopy, placement of a temporary tracheotomy, and right hemiglossectomy. He had smoked one pack of cigarettes per day for 50 years and was a recovering alcoholic. Pathology demonstrated positive surgical margins and so he was treated with 6840 rad external beam radiation to the head and neck and an additional 5040 rad to the supraclavicular fossa, with a midline block. His wounds healed without incident. Seven months after the initial procedure, he noticed a draining ulcer at the site of his previously healed tracheotomy. He also reported moderate pain in the left neck. He remained dysarthric from his hemiglossectomy, but denied any hoarseness. He was referred to us for further treatment, at which time a biopsy of the tracheotomy scar revealed metastatic squamous cell carcinoma that was consistent with the pathology from the previous tumor. His medical history was notable for chronic obstructive pulmonary disease with dyspnea and right leg claudication at less than one block. His only medication was acetaminophen with codeine.
From the Department of Otolaryngology-Head and Neck Surgery.
JohnsHopkins Hospital (Drs. Armstrong and Price), and the Department of Otolaryngology-Head andNeckSurgery. Greater Baltimore Medical Center (Dr. Price). Received for publication Oct. 18. 1991; accepted Dec. II, 1991. Reprint requests: Michael Armstrong, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, 600 North Wolfe St.• Baltimore. MD 21205. 13/4/35677
On physical examination the right hemiglossectomy was found to be well healed, with no evidence of local recurrence. Indirect and fiberoptic examination of the larynx demonstrated an exophytic, ulcerated, subglottic mass obstructing the anterior two-thirds of the airway. The true vocal cords were edematous but mobile. Externally, there was a 3 x 3 cm mass at the site of the old tracheotomy. The tumor was fixed to the skin, with satellite nodules extending for 2 em in all directions. The center was ulcerated and contained a tracheocutaneous fistula. A hard 2 cm cervical node was palpated in the right posterior triangle. Magnetic resonance imaging (MRI) and computed tomography (CT) of the neck confirmed the presence of a mass arising anterior to the trachea at the level of the tracheotomy (Fig. I) and also demonstrated the 2 em neck node, as well as smaller nodules. cr scans of the chest and abdomen, with and without contrast, were negative for distant metastases. He underwent a right radical neck dissection, left modified radical neck dissection, and total laryngectomy at the level of the fifth tracheal ring. Reconstruction was performed with a right pectoralis major myocutaneous flap, bringing the tracheostoma through the center of the flap after excision of the nipple-areolar complex. Pathologic examination demonstrated moderately-to-well differentiated squamous cell carcinoma arising in the pretracheal skin at the site of the previous tracheotomy. There was invasion into and around the trachea to a depth of 4 cm (Fig. 2). The postoperative course was complicated by a cerebrovascular accident on postoperative day three. at which time the patient fell and tore open his suture line. Although his neurologic symptoms cleared over the next few days, a pharyngocutaneous fistula with an exposed carotid artery developed in his right neck, and a thoracic duct leak into his left neck. He was treated with dressing changes. bowel rest, and total parenteral nutrition. On postoperative day 13, he was returned to the operating room, where he underwent closure . of his fistulae and coverage with a left pectoralis major flap. Four days later. the wound reopened. exposing the carotid arteries on both sides. Ligation of either carotid was considered contraindicated because of his recent stroke. Despite aggressive local therapy, the wound failed to heal and he died from carotid hemorrhage on postoperative day 55.
DISCUSSION This unfortunate case is probably a resultof implantationof tumorcellsoccurring at the timeof the primary
Volume 106 Number 4 April 1992
Case Reports 0401
Fig. 1. T2-welghted MRI of ttle neck In ttle mldsaglftal plane. which Illustrates a large tumor In ttle skin of ttle lower neck met almost completely obstructs ttle subglottic trachea (arrow).
resection. The close temporal relationship of the recurrence after surgery and the rapid growth of the tumor within the scar of the tracheotomy are consistent with this hypothesis. The absence of local recurrence in the mouth or pharynx rules out contiguous spread. Hematogenous spread of tumor is also unlikely, given the absence of pulmonary or other distant metastases. Finally, the midline location of the recurrence makes lymphatic spread to this location improbable. Seeding of tumor cells within the surgical field, recognized as early as 1907 by Butlin, I is a well-known but uncommon cause of tumor recurrence. Alagaratnam and Ong' presented a patient with stage IV squamous cell carcinoma of the tongue base who underwent open gastrostomy, total glossectomy, right partial mandibulectomy, total laryngectomy, and en bloc bilateral radical neck dissections. Two years later recurrent carcinoma developed at the gastrostomy site. This was resected, but the tumor recurred again and he died 6 months later, with no evidence of disease in the head and neck. Robbins and Woodson3 described a case of T 2N I squamous cell carcinoma of the lateral anterior
tongue that recurred and resulted in a submandibular fistula. The patient then underwent a total glossectomy, laryngectomy, and partial pharyngectomy with reconstruction using a pectoralis major myocutaneous flap. Two months later, recurrent tumor developed at the chest donor site. A second patient underwent a total laryngectomy, and later a total glossectomy for recurrent laryngeal carcinoma. He too was closed with a pectoralis major myocutaneous flap, but recurrence took place at the chest wall four months later. Schouten" performed a total laryngectomy, radical neck dissection, and deltopectoral flap for squamous cell carcinoma of the piriform sinus. The flap was returned to the chest wall after a fistula developed in the immediate postoperative period. Two years later the patient had a recurrence on the chest wall with nodal metastases in the axilla. Carr and Gilbert" described a patient who had recurrence at the donor site of a temporalis muscle flap used to close a defect in the retromolar trigone after recurrent tongue cancer. Recht et al." have presented three cases of esophageal carcinoma that metastasized to the thoracotomy incision after
ot02
Cose Reports
otolaryngologyHead and Neck SurgetY
Fig. 2. Gross appearance of the resected tumor demonstrating A, extensive skin Involvement. as well as '. a large exophytic mass projecting Into the subglottic trachea.
esophagogastrectomy. Most recently. Preyer and Thul? reported a case of hypopharyngeal carcinoma that metastasized to the abdominal wall after a percutaneou s endoscopic gastrostomy. These cases of tumor recurrence probably represent intraoperative seeding of wound edges. Blood aspirated
from the surgical field during head and neck cancer operations contains tumor cells that can grow in culture. K In 1936. Saphir? demonstrated that apparently viable tumor cells could be collected from scalpels used to cut into breast tumors. It remained for Safour et aJ. 1O (1984) to prove this theory by demonstrating that seal-
Volume 106 Number 4 April 1992
pels used to perform biopsy on hamster cheek pouch carcinomas universally were contaminated with malignant cells. When these scalpels were used to make incisions in the tongue or lip, metastases arose in 36% and 41% of the incisions, respectively. Tracheostomal recurrence after total laryngectomy is a well known and generally fatal complication that occurs in 3% to 40% of laryngectomies. 11 Although multiple risk factors for stomal recurrence have been implicated, the most important factor appears to be subglottic extension of tumor.":" Others have observed that a tracheotomy performed more than 24 hours before definitive surgery increases the risk of stomal recurrenee." While the relative risk of delaying definitive resection after emergent tracheotomy continues to be debated, this case supports the hypothesis that some of the local recurrences after total laryngectomy may result from tumor seeding. It is conceivable that either the emergent tracheotomy violates the tumor and spills cells that are not later resected, or that granulation tissue that develops in the tracheotomy before laryngectomy provides a fertile bed for implants seeded at the later resection. CONCLUSION
Implantation of distant metastases after resection of head and neck carcinoma is uncommon. Nevertheless, squamous cell carcinoma can metastasize by intraoperative seeding, and recurrent carcinoma should be considered in any wound that fails to heal as expected. As previous authors have stressed since the tum of the century, 14 care should be taken to minimize tumor spillage anywhere in the surgical field. In our institution, all ancillary procedures (tracheotomy, gastrostomy, etc.) are completed before the tumor is violated. The drapes are placed in such a way as to isolate the field of surgery as much as possible. Gloves and instruments are exchanged after removal of the specimen. Finally,
Case Reports 403
the wound is thoroughly irrigated and suctioned before closure. This is no different from the infection control practices we use when resecting unsterile specimens such as the large bowel. While no technique can absolutely prevent the spillage of tumor cells, strict adherence to these guidelines should minimize the frequency of this unfortunate complication. REFERENCES
1. ButIin HT. The contagion of cancer in human beings: autoinoculation. Lancet 1907;2:279-83. 2. Alagaratnam 17. Ong GB. Wound implantation-a surgicalhazard. Br J Surg 1977;64:872-5. 3. Robbins KT. Woodson GE. Chest wall metastasis as a complication of myocutaneous ftap reconstruction. J Otolaryngol 1984;13:13-4. 4. Schouten JT. Tumor implantation in a skin ftap. JAMA 1983;250:2690. 5. Carr RJ, Gilbert PM. Tumorimplantationto a temporalismuscle Dap donor site. Br J Oral Maxillofac Surg 1986;24:102-6. 6. Recht MP. ColemanBG. Barbot OJ, et al. Recurrentesophageal carcinomaat thoracotomy incisions: diagnosticcontributions of CT. J Comput Assist Tomogr 1989;13:58-60. 7. Preyer S, Thul P. Gastric metastasisof squamouscell carcinoma of head and neck after percutaneous endoscopic gastrostomyreport of a case. Endoscopy 1989;21:295. 8. Atiyah RA, Krespi YP, Hidvegi D, Sisson GA Sr. The mechanical spread of viable tumor during surgery. OroLARYNOOL HEAD NECK SURa 1986;94:278-81. 9. Saphir O. The transfer of tumor cells by the surgicalknife. Surg GynecolObstet 1936;63:775-6. 10. Safour 1M, Wood NK, Tsiklakis K, Doemling DB, Joseph G. Incisionalbiopsyand seedingin hamstercheekpouchcarcinoma. J Dent Res 1984;63:1116-20. 11. Davis RK, Shapshay SM. Peristomal recurrence: pathophysiology, prevention, treatment. Otolaryngol Clin North Am 1980;13:499-508. 12. Griebie MS, Adams GL. Emergency laryngectomy and stomal recurrence. Laryngoscope 1987;97:1020-4. 13. Keirn WF, Shapiro MJ, Rosen HO. Study of postlaryngectomy stomal recurrences. Arch Otolaryngol 1965;81:183-6. 14. Ryall C. The technique of cancer operations with reference to the danger of cancer infection. Br Med J 1908;2:1005-8.
![[Trophoblastic implantation, a model of tumor and metastasis implantation].](/assets/img/hold.png)
