we report a case of a 63-year - old male who presented to the outpatient department with complaints of hoarseness of voice and throat pain of three months duration .
clinical , otorhinolaryngological and cytological examination revealed squamous cell carcinoma of supraglotic larynx ( stage t2 n1 m0 , t = tumor , n = lymph node , m= metastasis ) .
he was treated with radiotherapy to neck ( field : 1 cm above mandible to clavicle , laterally vertical line through mastoid process ) with a dose of 68 grey in 34 fractions over seven weeks with 6 mega volt photon .
no evidence of disease could be detected clinically or by imaging at the first follow up .
he presented two years following initial treatment with swellings over the left inguinal region and left side of neck of one month duration .
pallor was present . examination of the left inguinal region revealed a 6 cm by 5 cm nontender swelling , firm to hard in consistency with irregular surface and margin .
it was clinically suspected to be matted left inguinal lymph nodes ( figure 1 ) .
level iii neck ( jugulodigastric ) lymph nodes on the left side were palpable , hard , and nontender . there was no evidence of the disease process on otorhinolaryngological examination .
all the hematological indices were within normal limits except hemoglobin ( 8 gm / dl ) .
a thorough work - up ( chest rhoentgenogram , computerized tomography of brain , abdominal sonography , colonoscopy , gastrointestinal endoscopy and fibre - optic laryngoscopy ) did not suggest any evidence of other metastases .
fine needle aspiration cytology from left inguinal and cervical lymph nodes revealed metastatic poorly differentiated squamous cell carcinoma . the patient was admitted and cytotoxic chemotherapy with paclitaxel and cisplatin was instituted .
unfortunately , the general condition of the patient deteriorated after completion of two cycles of chemotherapy and , despite the best available treatment , the patient expired .
laryngeal carcinoma is staged according to the extent of the original tumor site and its local spread ( t ) , lymph node involvement ( n ) , and the presence of metastases ( m ) .
t1 is the tumor limited to one sub - site of supraglottis , such as ventricular bands , arytenoids , suprahyoid epiglottis , infrahyoid epiglottis , aryepiglottic folds , with normal vocal cord mobility .
t2 includes the tumors invading mucosa of more than one adjacent aforementioned subsites of supraglottis .
t3 includes the tumors limited to larynx with vocal cord fixation and/or to tumors invading either the postcricoid area or the preepiglottic tissues .
t4 describes tumors invading the thyroid cartilage , and/or extends into soft tissues of the neck , thyroid , and/or esophagus .
n1 means metastasis in a single ipsilateral lymph node , 3 cm or less in its greatest dimension .
n2 includes metastasis in a single ipsilateral lymph node , more than 3 cm but less than 6 cm in greatest dimension , or in multiple ipsilateral lymph nodes , none more than 6 cm in the greatest dimension , or in bilateral or contralateral lymph nodes , none more than 6 cm in greatest dimension .
m0 indicates no metastases , m1 indicates presence of distant metastasis such as lungs , brain , liver etc.1 supraglottic laryngeal carcinomas are common and have a good prognosis.1 relapse is uncommon in early stage presentation.2,3 advanced stage cancer do recur predominantly locally or locoregionally .
contiguous spread to cervical lymph nodes , especially level iii and iv , can occur .
the reported overall three - year survival rate of supraglottic cancer was 60% and the five - year survival rate was 51.2% with nodal metastases and
64% without.4,5 forty - five percent of the patients with histologically confirmed nodal metastases survived three years
. the reported five - year relapse - free survival rate ( rfs ) is 53% and corrected survival ( cs ) rate is 83% for t2 tumors versus rfs of 39% and cs of 52% for t4 tumors.6 age more than 60 was associated with a 2.2 times higher risk of dying due to laryngeal cancer .
a retrospective tumor registry analysis of patients with squamous cell carcinoma ( scc ) of the larynx and hypopharynx reported that the age , sex , and tumor differentiation did not affect the incidence of distant metastases.7 the overall incidence of distant metastases was 8.5% with the following distribution : glottis 4.4% , supraglottis 3.6% , subglottis 14% , aryepiglottic fold 16% , pyriform sinus 17% and posterior hypopharynx 17.6%.7 the overall five - year disease - specific survival for distant metastases was 6.4% .
distant metastases were related to advanced local disease ( t3 + t4 ) , lymph node metastases at presentation , tumor location ( hypopharynx ) and locoregional tumor recurrence .
a meta - analysis of variables that predispose to a higher incidence of distant metastases include tumor location ( hypopharynx more than larynx ) , advanced primary disease ( t3 + t4 ) , regional disease , locoregional recurrences , and advanced regional metastases ( n2 + n3 ) .
the most common site of distant metastasis via blood stream is the lung ; however , metastsases to the brain , the adrenal , and the liver have also been reported.8 metastasis to inguinal lymph nodes , as in our case , is very rare.9 the probable explanation of this metastasis is the retrograde lymphatic spread through thoracic duct , para - aortic lymphatic channels to inguinal lymph nodes .
 head and neck cancers are common among men in developing countries . among head and neck cancers in the united states , 
 supraglottic laryngeal cancer accounts for 12,500 new cases per year . 
 it responds favorably to radiotherapy with or without chemotherapy depending on the stage of disease . 
 recurrence is local or locoregional . 
 we report a unique case of carcinoma of the larynx with rare distal recurrence in the left inguinal lymph nodes . 
Case Report
Discussion