[ SHORT C O M M U N I C A T I O N

Multiple Tumors in Head and Neck Region Ishwar Singh, S. P. S. Yadav, Satvir Singh, Brahma Dhanuka, R. C. Sharma

Departments of Otolaryngology and Ophthalmology, Medical College and Hospital, Rohtak-124 001

Eight cases of multiple tumors involving head and neck region which formed 4% of all head and neck cancer are reported to highlight that second primary should not be overlooked in aerodigestive tract which has a bearing on overall management and prognosis.

Billroth (1889) first reported multiple turnouts in the head and neck region. Their presence changes the whole management strategy both by surgery as well as radiotherapy (Brownson et al, 1973). Ifa second tumor is found simultaneously or within a period of six months from the diagnosis of primary, the second tumor is considered to be synchronous. All malignancies found later than six months after the first primary are considered to be metachronous (Gluckman et al, 1980).

MATERIAL AND METHODS The study comprise of 200 consecutive cases of head and neck cancer who attended otolaryngology service spread over a period of almost a year, eight of these found to have more than one primary tumour. All the cases were confirmed by histological examination and were treated with surgery and/or radiotherapy depending upon the site and stage of the tumor. There were five males and three females. Age ranged between 35 to 60 years (Table I). Incidence of multiple tumors was 4%. Seven cases had two primary tumors and one had three primary tumors (Table I). All the cases were of squamous cell carcinoma both synchronous as well as metacronous except ca~e no.1 who had synchronous squamous and basal cell carcinoma.

CASE REPORT K 45 years old female, a case of squamous cell

carcinoma supraglottis (T3NoMo) was given 5,000 Gy rads in February 1991. She,had recurrence within 6 months but total laryngectomy was carried out in January 1992 as she refused surgery earlier. One month later she developed 2 separate growths in both tonsils. These on histopathology were diagnosed as squamous cell carcinoma. Thus she had both synchronous (both tonsils) and metachronous (larynx and tonsilar growths) tumors. At the time of surgery there was no growth in the tonsils and margins of the excised larynx were free of growth. Other cases are depicted in table I.

DISCUSSION Gluckman and Crissman (1983) reported the incidence of more than one tumor to be as high as 30 percent. In the present study it was 4 percent. Presence of three tumors or more is however very rare with a reported incidence of 0.25-1 percent (Gluckman, 1979; Vrabee, 1979; Parker and Hill, 1988). One of our case had lesions in the larynx and in both the tonsils. Primary tumors are common in the larynx (40%) and oral cavity (30%). The commonest sites for the second primary are oral cavity, lung and oropharynx (Gluckman et al 1980). Dutta (1980) found the second primary in base of tongue in more than 50% of cases. In the present series also 75% of the cases had a second primary in oropharynx and oral cavity. None had any lesion in the lungs.

The upper aerodigestive tract is exposed to a wide variety of carcinogens and cocarcinogens. Other factors which may be responsible are : smoking, alcohol, poor orodental hygiene, malnutrition and impaired immunity. More than one factor operates in most cases. A number of theories have

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Mul t i p le Tumors in Head and Neck Reg ion - - l shwar Singh et al.

been put forward to explain the multicentric nature of upper aerodigestive tract cancer. The most accepted theory is field cancerization (Michaels, 1987). Multicentric tumors are more common in one organ system e.g. aero-digestive or urinary tract than between two different systems (Michaels, 1987). On the contrary in this study one case had synchronous tumor in the eye and skin of the dorsum of the nose, while another case had first primary in the post cricoid regior~ and second primary in the scalp. Although both these cases were not classical head and neck tumours, but both the primaries in each case were present in the head and neck region.

Since multiple tumors are known to occur in aerodigestive tract, a thorough work up of these

cases should be carried out including x ray chest, barium swallow and panendoscopy (Gluckman et al 1983; Michaels, 1987). Parker and Hill 1988 said that 80% of the synchronous tumors can be picked up by meticulous clinical examination and relevant investigation. This is of paramount importance as it has a definite bearing on treatment policy and ultimate progonosis. In the present study all the cases were diagnosed clinically as the second site was obvious and confirmed histopathologically. These are being reported to re-emphasize, the existence of multiple tumors in the head and neck region which can only be detected with a high degree of suspicion.

Table -I

Clinical details of the multiple tumors cases

S. No. Name Age Sex Primary tumor Treatment 2nd tumor Time interval

1 M 60 yr M Sq. cell. ca Lt Eye Excision both Basal cell.Ca < 6 months (conjunctiva) tumors nose

2 O 55 yr M Sq. cell ca Lt Radiotherapy Sq.cell Ca < 6 months tonsil epiglottis

3. R 35 yr M Sq. cell. Ca Radiotherapy Sq. cell. base < 6 months Anterior alvelous of tongue

4. D 55 yr M Sq. cell. Ca Rt Radiotherapy Sq. cell. Ca Lt > 6 months aryepiglottic fold Tracheostomy tonsil

5. B 40 yr F Sq. cell. Ca Post Radiotherapy Sq. cell. Ca > 6 months cricoid region Tracheostomy Scalp

Feeding gastrotomy

6. B 50 yr M Sq. cell. Ca Radiotherapy Sq. cell. Ca > 6 months It tonsil Base of tongue

7. S 60 yr M Sq. cell. Ca Radiotherapy Sq. cell. Ca > 6 months rt tonsil Base og tongue

8. K 45 yr F Sq. cell. Ca Total Sq. cell. Ca > 6 months L a r y n x Laryngectomy both tonsils

References 1. Billroth, T. (1889) : Die Allegemeine Chirurgishe pathologie and theraie in 51 vorlesungen : Ein Handbuch Fur Studirende

vnd Aertze, Berlin, G reimer, 908.

2. Brownson, R.J., 5essions, D.G., Poroubsky, E.5. and Ogura, J.H. (1973) : Simultaneous malignant tumors in patients with head and neck cancer, archives of Otolaryngology 97 : 347-349.

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Multiple Tumors in Head and Neck Region--lshwar 5ingh et al.

3. Dutta, N.N., (1980) : Multiple primary cancers in E.N.T. domain-A carcinogenic field defect. Indian Journal of Otolaryngology. 32 : 37-42.

4. Gluckman, J.L. (1979) : 5ynchronous multiple primary lesions of the upper aerodigestive system, Archives of Otolaryngology 105 : 597-598.

5. Gluckman, J.L. and Crissman, J.D. (1983): 5urvival rates in 548 patients with multiple neoplasms of the upper aerodigestive tract, Laryngoscope 93 : 71-74.

6. Gluckman, ].L., Crissman, i.D. and Donegan, J.O. (1980) : Multicentric 5quamous cell carcinoma of the upper-aerodigestive system. Journal of Heacl Neck 5urgery 3 : 90-96.

7. Michaels, L. (1987) : Ear Nose and Throat histopathology London, Springer Verlag publciations, 380-381.

8. Parker, J.I. and Hill, J.H. (1988) : Panencloscopy in screening for synchronous primary malignancies, Laryngoscope, 98 : 147-149.

9. Vrabee, D.P. (1979) : Multiple primary malignancies of the upper aerodigestive tract, Annals of Otology Rhinology and Laryngology 85 : 846-854.

C.M.E. CONFERENCE AOI-Hyderabad Branch

A.O.I. Hyderabad Branch has conducted "Micro Ear Surgical Workshop on 9th and 10th of August, 1997 by Dr. A. Mahadevaiah. About 125 delegates attended the workshop from A.P. and the neighbouring states.

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