A case of palatine tonsillar metastasis of lung adenocarcino
A 75-year-old man was admitted with a history of hemoptysis and mild productive cough for 2 weeks. He had neither fever, weight loss, dyspnea, or dysphagia, nor pharyngeal foreign body sensation. His past medical and surgical history included hypertension and gastroesophageal reflux disease. He used to be a smoker and a betel nut chewer but had quit both for 15 years. There was neither history of ear, nose, and throat problems nor family history of such.

Physical examination revealed mildly decreased breathing sounds on the right side. There were no remarkable findings in the head and neck region. Laboratory findings were within normal range. The chest X-ray showed opacity in right lower lung, and a subsequent computed tomography (CT) scan revealed a mass of 5 × 4.1 cm in right lower lung and small solid nodules in the right upper lung. The CT-guided lung biopsy of the right lower lobe showed necrotic atypical cells on histopathological examination. The patient underwent a video-assisted thoracoscopic surgery (VATS) right lower lobectomy with lymph nodes dissection and VATS wedge resection of right upper lobe, which confirmed moderately differentiated lung adenocarcinoma with epidermal growth factor receptor (EGFR) exon 19 deletions in the right lower lobe (pT2bN0) and minimally invasive, well-differentiated lung adenocarcinoma in the right upper lobe (pT1miN0).

Two months after first presentation, the patient still presented with hemoptysis. Head and neck examination revealed a mass in the upper pole of left palatine tonsil. The mass was exophytic with necrotic and hemorrhagic areas. A biopsy confirmed carcinoma, positive for thyroid transforming factor-1 and AE1/AE3 but negative for p40 and thyroglobulin, which is consistent with the carcinoma of lung origin. A neck CT scan revealed a 29 × 20 mm homogenous lesion with enhancing soft tissue in the left palatine tonsil, without suspicious lymph node metastasis. Wide excision of the left palatine tonsil was performed, and specimens of lung and tonsil shared morphological similarities in side-by-side comparison. The neoplastic cells are immunoreactive for thyroid transforming factor-1, cytokeratin-7, but not for p40 and cytokeratin-20, confirming metastatic adenocarcinoma with pulmonary origin.

The final diagnosis was right lower lung adenocarcinoma with left oropharynx metastasis, pT2bN0M1b, stage IVA, with the follow-up period being 6 months till now. There was no local recurrence in the left oropharynx. The patient was undergoing targeted therapy with the EGFR inhibitor, afatinib 40 mg/d by oral administration for 3 months, and had regular follow up at the chest and otorhinolaryngology outpatient departments.

Source: Medicine: May 2019 - Volume 98 - Issue 22 - p e15763

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