Case Report

Laryngeal metastasis from lung cancer

Umasankar Kalai, Karan Madan, Deepali Jain1, Anant Mohan, Randeep Guleria
Departments of Pulmonary Medicine and Sleep Disorders and 1Pathology, All India Institute of Medical Sciences, New Delhi, India

ABSTRACT

Metastatic tumors of the larynx are rare. The most common tumors metastasizing to the larynx are melanoma and renal
cell carcinoma. Bronchogenic carcinoma metastasizing to the larynx has been rarely described. Herein, we report the
case of a 49‑year‑old, chronic smoker, who incidentally had a laryngeal growth detected during flexible bronchoscopy
examination for evaluation of suspected lung cancer. Histopathological examination of the laryngeal nodule and the
biopsy obtained from the main bronchus growth confirmed the diagnosis of metastatic squamous cell carcinoma to the
larynx from primary lung cancer.

KEY WORDS: Carcinoma, laryngeal neoplasms, lung cancer, metastasis, squamous cell

Address for correspondence: Dr. Anant Mohan, Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences,
Ansari Nagar, New Delhi ‑ 110 029, India. E‑mail: anantmohan@yahoo.com

INTRODUCTION any improvement in his symptoms. The sputum smear

Metastatic tumors of the larynx are uncommon and may
pose a diagnostic challenge, especially when the laryngeal
lesion is the sole clinical manifestation. These tumors
may remain clinically silent even in the presence of
disseminated primary malignancy or uncommonly may be
the primary clinical manifestation. Laryngeal infiltration
from tumors arising in the nearby head and neck structures
is well known and has been described. However, metastatic
tumors to the larynx from other primary sites (secondary
laryngeal tumors) are uncommon and account for less than
1% of all laryngeal tumors.[1]
examination for acid fast bacilli (AFB) had been negative
on three occasions previously. He was a chronic smoker
with a 30‑pack‑year history of smoking. He denied a history
of chest pain, change in voice or dysphagia.
On clinical examination, the pulse rate was 84/minute,
respiratory rate 16 breaths/minute, and there was no
peripheral lymph node enlargement. The rest of the general
physical examination was unremarkable. On examination
of the respiratory system, the trachea was central, there
was a stony dull note to percussion on the left hemithorax,
and breath sounds were absent on the left side.

Chest radiographs demonstrated an opaque, white left

CASE REPORT hemithorax without any shift of the trachea [Figure 1, Left
Panel]. Contrast‑enhanced computed tomography (CECT)
A 49‑year‑old male farmer presented with a history of fever,
examination of the thorax [Figure 1, Right Panel] revealed
shortness of breath, and streaky hemoptysis for a duration a massive pleural effusion on the left side, with pleural
of six months. He reported loss of appetite and weight loss nodularity, as well as subcarinal and right paratracheal
of six kilograms over the last three months. He was taking lymph node enlargement. Diagnostic thoracentesis
antitubercular medications for two months from another revealed a hemorrhagic pleural fluid, exudative, with
center, based on the chest X‑ray abnormality, without low adenosine deaminase (ADA) levels (12 U/L). Three
cytological examinations were negative for malignant
Access this article online cells. A flexible bronchoscopy examination revealed a
Quick Response Code: small nodule (5 × 5 mm) on the inferior surface of the
Website:
epiglottis, just above the anterior commissure of the
www.lungindia.com vocal cord [Figure 2, Left Panel]. The left main stem
bronchus was completely occluded by an exophytic
DOI: endobronchial growth (approximately 1.5 cm × 1.5 cm).
10.4103/0970-2113.156249 Histopathological examination of the biopsy from both
the laryngeal nodule [Figure 2, Middle Panel] and the

268 Lung India • Vol 32 • Issue 3 • May - Jun 2015

 Kalai, et al.: Laryngeal metastasis from lung cancer
endobronchial growth demonstrated squamous cell
carcinoma (moderately differentiated) [Figure 2, Right
Panel]. An immunohistochemical examination for
TTF‑1 (thyroid transcription factor 1) expression was
negative on both the histopathological specimens.
Keeping a diagnosis of non‑small cell (squamous) carcinoma
of the lung (Stage IV), with asymptomatic laryngeal
metastasis, treatment was initiated with platinum‑based
doublet chemotherapy (Paclitaxel with Cisplatin) in view
of the metastatic disease. No specific intervention was
performed for the laryngeal nodule. However, the patient
declined further chemotherapy following two cycles of
chemotherapy and was lost to follow‑up.
DISCUSSION
Ferlito et al., in 1993, reported 134 cases of secondary/
metastatic laryngeal tumors.[1] The most common primary
site in metastatic laryngeal tumors was malignant
melanoma followed by renal cell carcinoma.[2] The other
reported sites included the breast, lung, prostate, colon,
stomach, and ovary. Laryngeal metastasis from lung cancer
is rarely described. Till the year 1996, only 16 cases of
metastatic laryngeal tumors from primary lung cancer had
been reported.[2]
Larynx is a terminally located organ with regard to
lymphatic and vascular circulation.[3] This fact likely
explains why it is a rare site of metastases from tumors
at other primary sites. The supraglottic and subglottic
regions are the common locations for laryngeal metastases,
Figure 1: (Left panel) Chest radiograph showing a complete opaque
left hemithorax, without any contralateral shift of the trachea. (Right
panel) CT of the thorax demonstrating a large left pleural effusion with
collapse of the underlying left lung
Figure 2: (Left panel) Flexible bronchoscopy image showing the presence of a nodular supraglottic growth on the inferior surface of the epiglottis,
just above the normal glottic opening. Histopathological examination of the bronchoscopic biopsy obtained from the laryngeal (middle panel) and
main bronchus growth (right panel) confirms the diagnosis of squamous cell carcinoma (Hematoxylin and Eosin ×100)
Lung India • Vol 32 • Issue 3 • May - Jun 2015 269
as these sites have a rich lymphatic and vascular supply.
In our patient, the location of the metastatic laryngeal
nodule was supraglottic. The pathway for primary
pulmonary tumor metastasis to the larynx could be either
hematogenous or via lymphatics. A hematogenous spread
may occur in an orderly fashion from the right heart to the
left heart, coursing through the aorta and external carotid
artery before eventually reaching the larynx through
the upper thyroid artery and upper laryngeal artery.
A retrograde route is also possible via the vertebral venous
plexus.[1] Retrograde lymphatic spread to the supraglottic
larynx from the thoracic duct can occur via the left
supraclavicular and internal jugular chain nodes. There
are lymphatic vascular interconnections of the lymphatics
of the supraglottic space, which communicate with the
superior laryngeal vessels.[4]
Signs and symptoms of metastatic laryngeal tumors do not
differ from primary laryngeal tumors and vary according
to the site and the size of involvement. Large‑sized lesions
can lead to significant upper airway obstruction. Our
patient was asymptomatic for the laryngeal growth and
it was incidentally detected during bronchoscopy. This
finding highlights the importance of performing a flexible
bronchoscopy examination in patients with lung cancer as
part of the staging evaluation, as it enables identification
of radiologically normal sites of malignant involvement,
as in our patient. Metastasis from bronchogenic carcinoma
can be clinically silent or may be the presenting
manifestation.[5] No other site of metastasis has been
detected in the present case on the CECT scan of the thorax
and abdomen. A positron emission tomography (PET)
computed tomography (CT) scan was not performed in
view of the advanced nature of the disease and no surgical
intervention was being contemplated. Patients with lung
cancer, especially the small cell variant, can have small
asymptomatic primary tumors that can be associated with
extensive symptomatic systemic metastatic involvement.[6]
Patients with metastatic involvement of the larynx usually
have a poor prognosis, as involvement of the larynx might
be a pointer toward widespread lymphohematogenous
dissemination. No specific management is required in
patients with asymptomatic laryngeal involvement.
Palliative laser resection of the metastatic laryngeal
growth has been attempted, to treat symptomatic airway
 Kalai, et al.: Laryngeal metastasis from lung cancer
obstruction, with minimal morbidity.[7] In some patients
with significant laryngeal obstruction, tracheostomy may
also be required.[8]
In our patient, similar to the previously published cases,
lung cancer as the primary site was considered based
on the clinical presentation and supporting radiological
features. The limitation of immunohistochemistry in this
setting is that the TTF‑1 positivity is found in only about
7 – 10% of the squamous cell carcinoma of the lung and the
same is negative in head and neck carcinoma.[9] There are
no reliable immunochemistry markers or histopathological
features to differentiate the primary and metastatic sites
in metastatic squamous cell carcinoma, wherein the
involved sites are the head and neck region and the lung.
To ascertain the nature and origin of a particular tumor by
immunohistochemistry, application of a series of markers
are usually required. Although a marker may occasionally
be positive in a certain neoplasm (e.g. TTF‑1 in 1.53% of
the cases of squamous cell carcinoma originating from
the lung), it is the combination of different markers that
confers the final diagnosis, along with the morphology.
Although markers like CK 5/6, low MW cytokeratins,
p63, and desmocollin‑3 may sometimes be useful to
ascertain the nature and origin of the tumor, they have
not been applied in the present case because they are less
suitable to determine the site or non‑availability.[10] In such
circumstances, diagnosis of the primary site is based on
the clinicoradiological features only.
270 Lung India • Vol 32 • Issue 3 • May - Jun 2015
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How to cite this article: Kalai U, Madan K, Jain D, Mohan A,
Guleria R. Laryngeal metastasis from lung cancer. Lung India
2015;32:268-70.
Source of Support: Nil, Conflict of Interest: None declared.
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