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Journal of Clinical Oncology, Vol 26, No 28 (October 1), 2008: pp. 4690-4692 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2008.18.2436
Small-Cell Lung Carcinoma Presenting With Otalgia and Hearing ImpairmentDepartment of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China
Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China
Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China A 79-year-old male presented to the department of otorhinolaryngology due to progressive right otalgia and hearing impairment for 3 months. Pure-tone audiogram revealed increased hearing threshold of the right ear. Local examination disclosed one yellowish round tumor at right external auditory canal. Punch biopsy of the tumor was performed. The pathological examination revealed tumor cells with scant cytoplasm, finely granular nuclear chromatin, and absence of nucleoli (Fig 1A, hematoxylin and eosin staining). Immunohistochemically, the tumor cells are reactive to synaptophysin (Fig 1B), cytokeratin, and thyroid transcription factor-1 protein (Fig 1C). A diagnosis of small-cell carcinoma was established. The patient was admitted for further survey of the primary site. He had a smoking history of 15 pack-years and denied significant respiratory symptoms. He also had hepatitis C-related liver cirrhosis. On physical examination, he appeared weak but reasonably alert. No lymphadenopathy was palpable at the neck and supraclavicular areas. The examination of chest and abdomen was normal. The hemogram revealed a WBC count of 3,190/µL and alkaline phosphatase of 316 U/L. Serum carcinoembryonic antigen level was 8.26 ng/mL. Chest radiography disclosed a tumor near the left hilum. A computed tomography (CT) of the chest showed a 4.4-cm lobulated mass at left lower lung. A magnetic resonance imaging of head showed multiple tumors at bilateral cerebellum and hemisphere. T1-weighted magnetic resonance imaging revealed one 1.4- x 1.0-cm nodule within the external auditory canal with intact bony structure (Fig 2A, arrowhead). CT-guided biopsy for the lung tumor was performed, and the pathology disclosed scattered nests of crushed small and hyperchromatic tumor cells with marked necrosis. The tumor cells were immunoreactive to cytokeratin, chromogranin, synaptophysin, and thyroid transcription factor-1 protein. A diagnosis of small-cell lung carcinoma (SCLC) with external auditory canal and brain metastasis was established. Whole brain radiotherapy and chemotherapy with etoposide and carboplatin were instituted. Otalgia and tinnitus improved after two cycles of chemotherapy. Follow-up CT scan of the head showed disappearance of the tumor at the right external auditory canal (Fig 2B); however, his performance status deteriorated as cancer progressed with new hepatic and bone metastasis. He eventually passed away due to neutropenic fever with septic shock.
Small-cell carcinoma usually arises in the lung, whereas extrapulmonary small-cell carcinoma is extremely rare.1 SCLC is known for rapid growth and early widespread metastases. Most patients with SCLC have extensive stage at presentation. SCLC tends to spread to the liver (21% to 36%), adrenals (5% to 31%), bone (27 to 41%), bone marrow (15% to 30%), and brain (10% to 14%).2 To our knowledge, there has been no report of metastasis to the external auditory canal for SCLC in the previous literature. Patients with metastasis of brain and liver have the worst outcome.3,4 The numbers of organs involved also inversely affects the outcome.5 Patients with distant metastasis usually present with nonspecific constitutional symptoms such as weight loss and weakness, which make the early diagnosis challenging in clinical practice.6 In our patient, right otalgia and hearing impairment were the first symptoms that caused him to seek help, which resulted in a prompt diagnosis. Secondary neoplasm in the ear is rare. Among patients with ear metastasis, 40% had hearing impairment and 8% had otalgia, while 36% had no otologic and vestibular symptoms.7 The most common site in the ear to develop distant metastases is the temporal bone.7 Among the cancers metastatic to temporal bone, breast cancer was the most common primary malignancy (22%), followed by lung cancer (12%).7 Our case showed no evidence of temporal bone involvement and the intact cranial vault. To our knowledge, this is the first case report of SCLC metastasis to the external auditory canal. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
REFERENCES 1. Galanis E, Frytak S, Lloyd RV: Extrapulmonary small-cell carcinoma. Cancer 79:1729-1736, 1997[CrossRef][Medline] 2. Argiris A, Murren JR: Staging and clinical prognostic factors for small-cell lung cancer. Cancer J 7:437-447, 2001[Medline] 3. Christodolou C, Pavlidis N, Samantas E, et al: Prognostic factors in Greek patients with small-cell lung cancer (SCLC). A Hellenic Cooperative Oncology Group study. Anticancer Res 22:3749-3757, 2002[Medline] 4. Bremnes RM, Sundstrom S, Aasebo U, et al: The value of prognostic factors in small-cell lung cancer: Results from a randomised multicenter study with minimum 5-year follow-up. Lung Cancer 39:303-313, 2003[CrossRef][Medline] 5. Albain KS, Crowley JJ, Livingston RB: Long-term survival and toxicity in small-cell lung cancer: Expanded Southwest Oncology Group experience. Chest 99:1425-1432, 1991[CrossRef][Medline] 6. Chute CG, Greenberg ER, Baron J, et al: Presenting conditions of 1539 population-based lung cancer patients by cell type and stage in New Hampshire and Vermont. Cancer 56:2107-2111, 1985[CrossRef][Medline] 7. Gloria-Cruz TI, Schachern PA, Paparella MM, et al: Metastases to temporal bones from primary nonsystemic malignant neoplasms. Arch Otolaryngol Head Neck Surg 126:209-214, 2000
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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