Yonago Acta medica 2013;56:57–58

Patient Report

Skin Metastasis of Hypopharyngeal Carcinoma to the Nasal Tip
Masahisa Shindo,*† Yuichi Yoshida,† Kyoko Tominaga† and Osamu Yamamoto†*Clinic of Dermatology, National Hospital Organization Hamada Medical Center, Hamada 697-8511, Japan and †Division of Dermatology, Department of Medicine of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago 6838504, JapanABSTRACT
Head and neck squamous cell carcinoma (SCC) rarely
metastasizes to the skin. Metastases to the nasal tip fromhypopharyngeal malignancies are extremely rare. We
present a patient with nasal tip metastasis from hypopharyngeal SCC. A 74-year-old man with hypopharyngeal and esophageal carcinomas had a red nodule on hisnasal tip (so-called “clown nose”). Histopathologically,
atypical squamoid cell nests had proliferated in a lobular
fashion from the dermis to subcutaneous tissue. Thoseatypical cells were identical to primary tumor cells in
the hypopharynx. Based on these findings, a diagnosisof skin metastasis from hypopharyngeal SCC was made.
In patients with malignant disease, biopsy should be
performed for any suspicious skin lesion. In a patient
like ours, “clown nose” might be a symptom of cutaneous metastasis. When clinicians note a “clown nose”,
they should consider malignancies in the neck and chestareas.

epithelium (T1b, N0, M0: Stage I). There were no metastatic foci in regional lymph nodes of the esophagus. On
physical examination in our clinic, there was a red nodule of 1 cm in diameter on his nasal tip (so-called “clownnose”) (Fig. 1). Dermoscopic examination showed a yellowish white area, dilated follicular openings and vasodilation (Fig. 2). Histopathologically, atypical squamoidcell nests had proliferated in a lobular fashion from thedermis to subcutaneous tissue. There were no atypicalcells in epidermis (Figs. 3a and b). The tumor stroma
in the upper dermis showed significant vasodilatation.
Those atypical cells were identical to primary tumor
cells in the hypopharynx. Based on these findings, adiagnosis of skin metastasis from hypopharyngeal SCC
was made. Then, chemotherapy, operation and radiation
were done.
DISCUSSION
Cutaneous metastases commonly appear as round,discrete and painless nodules, which can have a firm,rubbery or fixed consistency. They can occur as a single
lesion or multiple lesions anywhere on the body but
are found predominantly on the anterior trunk or on
the head and neck region.3 The average survival timeof patients with cutaneous metastasis is a few months.4
Cutaneous metastases occur in 0.7 to 9% of all patientswith cancer, and the most common primary tumors
associated with skin metastasis are breast cancer inwomen and lung cancer in men.5 Head and neck SCC
rarely metastasizes to any areas of the skin. The mostcommon sites are the chest wall (28.4%) and abdomen(20.2%). In descending order of incidence, other sites are
the extremities (12%), neck (11%), back (11%), scalp (7%),
pelvis (6%) and face (5%).2 The nasal tip is, however,an extremely rare site for cutaneous metastasis. In theEnglish medical literature, 18 patients with nasal tip metastases, including the one in this paper, have been documented over the last 20 years, more than half of whichwere associated with lung cancer.6, 7, 8, 9, 10 Other mainsites of primary cancer for cutaneous metastases to thenasal tip include the kidney11, 12 and esophagus.7 To ourKey words hypopharyngeal; nasal tip; metastasis

Head and neck squamous cell carcinoma (SCC) rarely
metastasizes to the skin, and the incidence has beenreported to be less than 1%.1, 2 The discovery of skinmetastasis may be the first evidence of disseminated disease or visceral cancer. Chest or abdominal skin is themost preferential site for cutaneous metastases, whereas
the least common site is the face or scalp skin.2 The nasal tip is an extremely rare site for cutaneous metastaticspread. We report a rare case of a patient with nasal tip
metastasis from hypopharyngeal SCC.
PATIENT REPORT

A 74-year-old man had a 2-week history of a skin lesion
on his nasal tip. He had been diagnosed with hypopharyngeal and esophageal carcinomas 3 years before thefirst visit to the dermatology clinic of Tottori UniversityHospital. He had undergone an operation of the double
cancer and chemotherapy. Microscopic examination of
the hypopharyngeal tissue showed a poorly differentiated SCC. Regional lymph nodes had metastatic foci (T3,N2b, M0: Stage IV-A). Histopathological examinationof esophageal tissue revealed that moderately to welldifferentiated SCC remained in the esophageal mucosal

Corresponding author: Masahisa Shindo
shindo-m@hamada2.hosp.go.jp
Received 2013 February 2
Accepted 2013 March 5
Abbreviation: SCC, squamous cell carcinoma

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M. Shindo et al.

knowledge, only 4 patients with nasal metastasisoriginated from primary malignancies
on head and neck regions.6, 8, 9, 10 Nasal tipmetastasis was from hypopharyngeal SCC in
1 of them;6 from basaloid SCC of the larynx
in 2 others8, 9 and from pharyngeal rhabdomyosarcoma in the rest.10 Nasal metastasis
in our patient probably occurred throughhematogenous dissemination.
It is not absolutely clear whether theprimary site of the cutaneous metastatic fociFig. 2. Dermoscopic image: a yellowish white area,dilated pores and vasodilation.
was esophageal or hypopharyngeal. The
esophageal SCC, however, was a moderately
to well-differentiated tumor in histologicalFig. 1. Clinical feature: a red nodule on the nasal tip.
grading, remained only in the esophageal
mucosal epithelium, and showed no regional
lymph node metastases. On the other hand,
the hypopharyngeal SCC was an undifferentiated tumor and metastasized to regional
lymph nodes. Therefore, it seems reasonable
to assume that the nasal lesion was metastasis from the hypopharyngeal SCC.
Soyer et al.13 reported a case of a patient with nasal skin metastasis from breast
cancer in 1990 and first introduced the term“clown nose” for describing the characteristic clinical feature. However, the term
is not widely accepted now. Differential Fig. 3. Histopathologic examination: nests of atypical cells from the dermis to subdiagnosis of “clown nose” should include cutaneous tissue (hematoxylin and eosin).
a: Bar = 1 mm.
rosacea, pseudolymphoma, sarcoidosis andb: Bar = 100 µm.
metastatic skin cancer. In patients with malignant disease, biopsy should be performed
6 Kocak Z, Uygun K, Uzal MC, Cicin I, Yalcin O. Unusual metfor any suspicious skin lesion even if it is in an unusual
astatic site in a case of carcinoma of the hypopharynx: nasal
location. In a patient like ours, “clown nose” might betip. J Otolaryngol. 2005;34:250-2. PMID: 16048695.
a symptom of cutaneous metastasis. The term “clown
7 Chau CH, Siu WT, Li MK. Nasal tip metastasis from esopha13nose” proposed by Soyer et al. should be appreciatedgeal carcinoma. Can J Surg. 2002;45:224-5. PMID: 12067183.
more. When clinicians note a “clown nose”, they should
8 Shvili Y, Talmi YP, Gal R, Kessler E, Kolkov Z, Zohar Y. Basaloid-squamous carci-noma of larynx metastatic to the skin ofconsider malignancies in the neck and chest areas.

bathe nasal tip. J Craniomaxillofac Surg. 1990;18:322-4. PMID:
2262555.
9 Koutis EV, Assimakopoulos DA, Doukas MG, Zinovieva I.
A rare nasal tip skin metastasis of a basaloid squamous cell
carcinoma of the larynx. Am J Med. 2008;121:e3-4. PMID:
18724953.
10 Türegün M, Bozkurt M, Sengezer M, Külahçi Y. Nasal tip
metastasis of pharyngeal rhabdomyosarcoma. Ann Plast Surg.
2001;46:656. PMID: 11405372.
11 Friedman I, Osborn DA. Metastatic tumors in the ear, nose,and throat region. J Laryngol Otol. 1965;79:576-91. PMID:14335137.
12 Bernstein JM, Montgomery WW, Balogh K, Jr. Metastatictumors to the maxilla, nose, and paranasal sinuses. Laryngoscope. 1966;76:621-50. PMID: 5930356.
13 Soyer HP, Cerroni L, Smolle J, Kerl H. [“Clown nose”--skinmetastasis of breast cancer]. Z Hautkr. 1990;65:929-31. German. PMID: 2291293.

The authors declare no conflict of interest.
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