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Chronic myeloid leukemia in association with squamous cell carcinoma of tonsillar region submitted to postsurgical irradiation

Abstracts

Surgery and postsurgical radiotherapy are the standard treatment of advanced squamous cell carcinoma of the tonsillar region and they are based on specimen findings, such as margins, vascular embolization, perineural infiltration or metastatic lymph nodes. Apparently, radiotherapy has the potential to bear malignant neoplasms, although this fact is uncommon. A case of a 54-year-old Caucasian male with squamous cell carcinoma of the tonsillar region treated by surgery and radiotherapy (50Gy) eleven years ago is described. After three years of follow-up, he suddenly presented sudden fainting and weakness. The laboratorial exam revealed higher rate of leucocytes and myelogram confirmed the diagnosis of chronic myeloid leukemia. The patient received Hydroxyurea and then Interferon. After eight years of follow-up, he showed no evidence of disease.

squamous cell carcinoma; leukemia; tonsillar region


O tratamento de escolha para o carcinoma epidermóide avançado de tonsila consiste em cirurgia e radioterapia pós-operatória. A indicação de radioterapia pós-operatória baseia-se no exame do espécime operatório, considerando as margens cirúrgicas, a presença de embolização neoplásica, infiltração perineural ou de linfonodos cervicais metastáticos. Segundo a literatura, o tratamento ionizante tem o potencial de induzir uma neoplasia, embora a evidência clínica seja escassa. O presente relato descreve um paciente portador de carcinoma epidermóide de tonsila, submetido à irradiação ionizante que evoluiu com quadro clínico de leucemia mielóide crônica, três anos após o tratamento inicial. Um paciente do sexo masculino de 54 anos, branco, operado há 11 anos de um carcinoma epidermóide de tonsila e submetido à radioterapia (50Gy), após três anos apresentou desmaio súbito e fraqueza. O exame laboratorial mostrou tratar-se de leucose e o mielograma revelou uma leucemia mielóide crônica. O paciente foi submetido à quimioterapia com Hidroxiuréia e interferon, sem sinais de recidiva após um seguimento de 8 anos (até novembro de 2003).

carcinoma epidermóide; leucemia; região tonsilar


CASE REPORT

Chronic myeloid leukemia in association with squamous cell carcinoma of tonsillar region submitted to postsurgical irradiation

Sergio Altino FranziI; Ali AmarI; Milena Mendes IncertiII; Abrão RapoportI; José Pedro Zampieri FilhoIII; Andréia Gomes MonteiroIV

ISurgeon, Department o Head and Neck Surgery and Otorhinolaryngology, Hospital Heliópolis, HOSPHEL, Sao Paulo

IIResident Physician, Service of Clinical Pathology, Hospital Heliópolis, HOSPHEL, Sao Paulo

IIIHematologist, Hospital Heliópolis, HOSPHEL, Sao Paulo

IVTechnician, Laboratory of Clinical Pathology, Hospital Heliópolis, HOSPHEL, Sao Paulo

Correspondence Correspondence to Milena Mendes Incerti Av.Nova Cantareira, 20 apt 82 Santana 02330-000 São Paulo SP E-mail: mmincerti@yahoo.com.br

SUMMARY

Surgery and postsurgical radiotherapy are the standard treatment of advanced squamous cell carcinoma of the tonsillar region and they are based on specimen findings, such as margins, vascular embolization, perineural infiltration or metastatic lymph nodes. Apparently, radiotherapy has the potential to bear malignant neoplasms, although this fact is uncommon. A case of a 54-year-old Caucasian male with squamous cell carcinoma of the tonsillar region treated by surgery and radiotherapy (50Gy) eleven years ago is described. After three years of follow-up, he suddenly presented sudden fainting and weakness. The laboratorial exam revealed higher rate of leucocytes and myelogram confirmed the diagnosis of chronic myeloid leukemia. The patient received Hydroxyurea and then Interferon. After eight years of follow-up, he showed no evidence of disease.

Key words: squamous cell carcinoma, leukemia, tonsillar region.

INTRODUCTION

The treatment of choice for advanced squamous cell carcinoma of the tonsil consists of surgery and postsurgical radiotherapy. Indication of postsurgical radiotherapy is based on examination of the surgical specimen, taking into account the surgical margins, presence of neoplastic embolization, perineural infiltration or metastatic cervical lymph nodes, particularly if capsular rupture is identified.

Nicu1, Miller2 and Ilbery and Rickinson3 have related the carcinogenic effects to ionizing irradiation in human beings. Caquet4 conducted a study in which the effects of ionizing radiation as potential agent in the development of head and neck neoplasias were described. The study was based on a patient with laryngeal squamous cell carcinoma who was submitted to ionizing irradiation and developed a clinical case of chronic myeloid leukemia.

The anatomical sites which most frequently develop a second tumor within an estimated period of 10 years when exposed to ionizing radiation are: mouth, oropharynx, larynx and thyroid (Wang5, Jackson6).

Cases of squamous cell carcinoma of the tonsil that develop a second primary tumor in the form of chronic myeloid leukemia after being submitted to postsurgical radiotherapy are rare. A case of a clinical stage IVB squamous cell carcinoma of the right palatine tonsil submitted to postsurgical radiotherapy is presented below.

CASE STUDY

A 54-year-old Caucasian male worker (contact with iron and aluminum as a boiler operator) was admitted to the Department of Head and Neck Surgery and Otorhinolaryngology of Hospital Heliópolis in November 1992 with complaint of slow-growth (5 months) lump on the neck and sore throat. The patient stated that there were no dysphasia, hoarseness, dyspnea, otalgia, personal or family history of cancer. Oroscopy revealed ulcerative-vegetative lesion with infiltration to the right tonsil, measuring 3 X 3 cm, limited to the anterior right pillar; then, the posterior pillar was also affected, involving the upper region of the soft palate as an erythroplastic lesion, 1cm distally from the uvula and preserving the lingual-tonsillar sulcus. A hard-consistency lymph node block in the neck - measuring 8.5 X 6.5 cm - involved the upper and the right middle jugular-carotid chains, presenting mobility at the deepest layers, though not affecting the skin. Moreover, the lesion was painless and with bosselated surface.

A biopsy of the primary site was performed, revealing clinical stage T2 N3 M0 well- differentiated squamous cell carcinoma (Figures 1-2). Furthermore, right-retromolar- type surgery was carried out. Due to posterior exiguous margin, the patient received a 5000-cGy postsurgical radiotherapy dosage on the cervical-facial fields, as well as on the supraclavicular fossa, in the period between October and November 1992.


Three years later (1995), the patient presented hypothyroidism and was prescribed with Levothyroxine. Chronic myeloid leukemia was also diagnosed (Figures 3 and 4), which was treated with Hydroxyurea (20-30 mg/kg/day). The disease was controlled and the patient started taking Interferon – 6 million units/5x/week. In September 2003, the patient was well, with no symptoms nor evidence of disease (Figure 3).



DISCUSSION

The knowledge that head and neck neoplasias submitted to ionizing irradiation may develop a lymphoreticular neoplasia is attributed to Hazen (1966) 7. This concept was reinforced by a study published by Nicu1, in which he reported the carcinogenic effects of irradiation in humans. Mays8 suggested that the onset of a second primary tumor could be related to "internal" radioactivity in the human economy.

In the mentioned case, the development of leukocytosis (around 78,000) after the third year of combined treatment led to the diagnosis of chronic myeloid leukemia, which was confirmed by a myelogram (Figures 3 and 4). Moreover, hypothyroidism was detected - a not-so-uncommon sequel when the thyroid is included in the irradiation field - and, as it presents only a few symptoms, it is usually diagnosed later.

Considering that squamous cell carcinoma of aerodigestive tract upper airways developing a second lymphoreticular primary tumor when submitted to postsurgical irradiation is a rare occurrence, a causal association is not considered. Although the causes are still under investigation, the risk of cancer induction by radiation has been corroborated by several epidemiological studies, in which translocations and loss of genetic material8 are the main cytogenetic changes described. Follow up of patients treated with radiotherapy should always take into consideration the potential rise of a second primary tumor as a result of the therapeutic modality employed.

REFERENCES

Article submited on September 14, 2004.

Article accepted on November 11, 2004.

Study conducted at Department of Head and Neck Surgery and Otorhinolaryngology, Hospital Heliópolis – HOSPHEL, Sao Paulo, Brazil.

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    Nicu MD. [Carcinogenic effect of radiations in humans]. Stud Cercet Endocrinol 1970; 21:19-29.
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    Miller RW. Radiation-induced cancer. J Natl Cancer Inst 1972; 49:1221-6.
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    Ilbery PL, Rickinson AB. Radiation carcinogenesis. Australas Radiol 1973; 17:66-77.
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    Caquet R, Festal G, Laroche C, LeCharpentier M, Bernadou A. [Letter: Cancer of the larynx. Radiotherapy-chronic myeloid leukemia].Nouv Presse Med 1975; 17: 20:1510.
  • 5
    Wang MB, Kuber N, Kerner MM, Lee SP, Juilliard GF, Abemayor E. Tonsilar carcinoma: analysis of treatment results. J Otolaryngol 1998; 27: 1221-7.
  • 6
    Jackson SM, Hay JH, Flores AD, Weir L, Wong LW, Schwindt C, Baerg B. Cancer of tonsil: the results of ipsilateral radiation treatment. Radiother Oncol 1999; 51:123-8.
  • 7
    Hazen RW, Pifer JW, Toyooka ET, Livingood J, Hempelmann LH. Neoplasms following irradiation of the head. Cancer Res 1966; 26: 305-11.
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    Mays CW. Cancer induction in man from internal radioactivity. Health Phys 1973; 25: 585-92.
  • Correspondence to

    Milena Mendes Incerti
    Av.Nova Cantareira, 20 apt 82
    Santana
    02330-000
    São Paulo SP
    E-mail:
  • Publication Dates

    • Publication in this collection
      19 Apr 2005
    • Date of issue
      Dec 2004

    History

    • Accepted
      11 Nov 2004
    • Received
      14 Sept 2004
    ABORL-CCF Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial Av. Indianápolis, 740, 04062-001 São Paulo SP - Brazil, Tel./Fax: (55 11) 5052-9515 - São Paulo - SP - Brazil
    E-mail: revista@aborlccf.org.br