Facial adenocarcinoma treated with intra-arterial chemotherapy
Authors: Yu-Yuan Chen, Yen-Ting Sheen, Chih-Pang Lin, Maw-Chang Sheen
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Facial adenocarcinoma is extremely rare. Treatments include excision, radiotherapy and chemotherapy.1Iorio M.L. Ter Louw R.P. Kauffman C.L. Davison S.P. Evidence-based medicine: facial skin malignancy.Plast Reconstr Surg. 2013; 132: 1631-1643Crossref PubMed Scopus (9) Google Scholar We present a case of facial adenocarcinoma that was successfully treated with intra-arterial chemotherapy (IAC) after excision and radiotherapy failed.A 90-year-old woman presented with a nonhealing 2- × 2-cm ulcer on the right cheek in June 2011. Biopsy revealed adenocarcinoma. Excision was recommended, but the patient declined due to her advanced age and medical comorbidities. Surveys including computed tomography of chest and abdomen, gastroduodenoscopy, colonoscopy, and positron emission tomography revealed no evidence of visceral malignancy. Immunohistochemical studies demonstrated CK 7 (focal +), CK20 (−) S-100 (−), CEA (−), vimentin (−), GFAP (−), actin (−), and p63(+). A positive p63 stain had the highest sensitivity (96%) for primary adenexal tumors.2Sariya D. Ruth K. Adams-McDonnell R. Cusack C. Xu X. Elenitsas R. et al.Clinicopathologic correlation of cutaneous metastases: experience from a cancer center.Arch Dermatol. 2007; 143: 613-620Crossref PubMed Scopus (129) Google Scholar The immunohistochemical staining pattern favored a primary adenocarcinoma, possibly from sweat glands or the parotid gland. Radiotherapy 5000 cGy in 25 fractions over 5 weeks was given in July 2011 with a poor response. The patient underwent wide excision with histologically negative margins in September 2011. Tumor recurred 4 months later. She underwent another 2 excisions, 1 in January and 1 in April 2012. Tumor was present at the tissue margins following each excision. The tumor progressed.The patient was referred for IAC in July 2012 because comorbidities precluded treatment with systemic chemotherapy. On admission, several masses (1 × 1 cm to 3 × 2 cm) were noted on the right cheek (Fig 1).An implantable port-catheter was inserted through the right superficial temporal artery into the external carotid artery with the tip located proximal to the branching of the facial artery. Methotrexate 50 mg/day was first infused continuously for 4 days without any appreciable effect. Subsequently, 5-fluorouracil (5-FU) infusion 50 mg/day was given in a continuous infusion for 7 days, which was then stopped because of thrombocytopenia and elevation of GOT/GPT (grade 2). No other adverse event was noted. The patient was given a weekly IAC of 5-FU 250 mg until all tumors disappeared. In total, 21 infusions were given from August to December 2012.The tumors shrank slowly beginning 1 week after treatment began and were resolved completely 5 months later (Fig 2). At the most recent follow-up in January 2014, complete remission was sustained. However, a right side submandibular mass of about 2 × 2 cm was noted incidentally in June 2013. Computed tomography revealed a cystlike lesion. The patient and family refused further evaluation of the mass. The size of the mass was unchanged during 6 months of follow-up.Fig 2Facial adenocarcinoma 5 months after treatment with intra-arterial chemotherapy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)IAC has the advantage of delivering a high concentration of drug to the lesion. Studies by Harker and Stephen3Harker G.J. Stephen F.O. Comparison of intra-arterial versus intravenous 5-fluorouracil administration on epidermal squamous cell carcinoma in sheep.Eur J Cancer. 1992; 28A: 1437-1441Abstract Full Text PDF PubMed Scopus (13) Google Scholar showed that a greater concentration of 5-FU in the tumor region is achieved by intra-arterial than by intra-venous administration. In studies by Claudio et al4Claudio F. Cacace F. Comella G. Coucourde F. Claudio L. Bevilacqua A.M. et al.Intraarterial chemotherapy through carotid transposition in advanced head and neck cancer.Cancer. 1990; 65: 1465-1471Crossref PubMed Scopus (20) Google Scholar after IAC, 87.5% of the carcinoma of the facial skin attained resectability. However, none of the cases was an adenocarcinoma. IAC has potential for the treatment of refractory neoplasms, and may have advantages in terms of cosmetic and functional preservation. To the Editor: Facial adenocarcinoma is extremely rare. Treatments include excision, radiotherapy and chemotherapy.1Iorio M.L. Ter Louw R.P. Kauffman C.L. Davison S.P. Evidence-based medicine: facial skin malignancy.Plast Reconstr Surg. 2013; 132: 1631-1643Crossref PubMed Scopus (9) Google Scholar We present a case of facial adenocarcinoma that was successfully treated with intra-arterial chemotherapy (IAC) after excision and radiotherapy failed. A 90-year-old woman presented with a nonhealing 2- × 2-cm ulcer on the right cheek in June 2011. Biopsy revealed adenocarcinoma. Excision was recommended, but the patient declined due to her advanced age and medical comorbidities. Surveys including computed tomography of chest and abdomen, gastroduodenoscopy, colonoscopy, and positron emission tomography revealed no evidence of visceral malignancy. Immunohistochemical studies demonstrated CK 7 (focal +), CK20 (−) S-100 (−), CEA (−), vimentin (−), GFAP (−), actin (−), and p63(+). A positive p63 stain had the highest sensitivity (96%) for primary adenexal tumors.2Sariya D. Ruth K. Adams-McDonnell R. Cusack C. Xu X. Elenitsas R. et al.Clinicopathologic correlation of cutaneous metastases: experience from a cancer center.Arch Dermatol. 2007; 143: 613-620Crossref PubMed Scopus (129) Google Scholar The immunohistochemical staining pattern favored a primary adenocarcinoma, possibly from sweat glands or the parotid gland. Radiotherapy 5000 cGy in 25 fractions over 5 weeks was given in July 2011 with a poor response. The patient underwent wide excision with histologically negative margins in September 2011. Tumor recurred 4 months later. She underwent another 2 excisions, 1 in January and 1 in April 2012. Tumor was present at the tissue margins following each excision. The tumor progressed. The patient was referred for IAC in July 2012 because comorbidities precluded treatment with systemic chemotherapy. On admission, several masses (1 × 1 cm to 3 × 2 cm) were noted on the right cheek (Fig 1). An implantable port-catheter was inserted through the right superficial temporal artery into the external carotid artery with the tip located proximal to the branching of the facial artery. Methotrexate 50 mg/day was first infused continuously for 4 days without any appreciable effect. Subsequently, 5-fluorouracil (5-FU) infusion 50 mg/day was given in a continuous infusion for 7 days, which was then stopped because of thrombocytopenia and elevation of GOT/GPT (grade 2). No other adverse event was noted. The patient was given a weekly IAC of 5-FU 250 mg until all tumors disappeared. In total, 21 infusions were given from August to December 2012. The tumors shrank slowly beginning 1 week after treatment began and were resolved completely 5 months later (Fig 2). At the most recent follow-up in January 2014, complete remission was sustained. However, a right side submandibular mass of about 2 × 2 cm was noted incidentally in June 2013. Computed tomography revealed a cystlike lesion. The patient and family refused further evaluation of the mass. The size of the mass was unchanged during 6 months of follow-up. IAC has the advantage of delivering a high concentration of drug to the lesion. Studies by Harker and Stephen3Harker G.J. Stephen F.O. Comparison of intra-arterial versus intravenous 5-fluorouracil administration on epidermal squamous cell carcinoma in sheep.Eur J Cancer. 1992; 28A: 1437-1441Abstract Full Text PDF PubMed Scopus (13) Google Scholar showed that a greater concentration of 5-FU in the tumor region is achieved by intra-arterial than by intra-venous administration. In studies by Claudio et al4Claudio F. Cacace F. Comella G. Coucourde F. Claudio L. Bevilacqua A.M. et al.Intraarterial chemotherapy through carotid transposition in advanced head and neck cancer.Cancer. 1990; 65: 1465-1471Crossref PubMed Scopus (20) Google Scholar after IAC, 87.5% of the carcinoma of the facial skin attained resectability. However, none of the cases was an adenocarcinoma. IAC has potential for the treatment of refractory neoplasms, and may have advantages in terms of cosmetic and functional preservation.