distant metastases in laryngeal carcinoma are rare and when present , most commonly involve the lung . we report a rare case of laryngeal carcinoma presenting with metastases to all five distal phalanges of left hand with simultaneous metastasis to multiple sites after 2 years of receiving radical chemo - radiation to the head and neck region with complete local control . a 55-year - old man was diagnosed as a case of carcinoma supraglottic larynx ( stage t4n1m0 ) in august 2007 . histopathology of primary site was squamous cell carcinoma , and fine needle aspiration cytology ( fnac ) of neck node was also squamous cell carcinoma . the patient was planned for radical chemo - radiation after complete clinical and investigative workup . he received external beam radiotherapy ( ebrt ) using 6 mv photon to a total dose of 66 gy in 33 fractions over six and half weeks ( from 07 - 08 - 2007 to 22 - 08 - 2007 ) with concurrent cisplatin chemotherapy at 3 weeks interval . at 1 month after completion of treatment , patient was free from disease both clinically and on direct laryngoscopic examination and kept on regular follow up . patient presented after 2 years with complaints of swelling on tip of all fingers and nail bed of left hand [ figure 1 ] , multiple subcutaneous nodule in upper and lower limb , and loss of appetite with significant weight loss . an fnac from tip of fingers and subcutaneous swelling was suggestive of metastatic carcinoma [ figure 2 ] . contrast - enhanced computed tomography ( cect ) of chest , abdomen , and pelvis , revealed metastasis in bilateral lungs and liver [ figure 3a  b ] . local examination of neck and direct laryngoscopic examination was suggestive of no evidence of disease ( ned)/essentially normal . in view of his very poor general condition and widespread dissemination of disease , the patient was offered palliative treatment only and he died within 2 months at home . metastatic swelling of all five distal phalanx of left hand photomicrograph showing cluster of malignant cells with extensive necrosis and apoptosis in background ( hematoxylin and eosin stain , original 400 ) ( a ) multiple bilateral lungs metastases , ( b ) multiple liver metastases the incidence of distant metastases in squamous cell carcinoma of head and neck ( scchn ) approaches 20%25% . the most common sites of metastases are lung ( 70%75% ) , liver ( 17%38% ) , and bone ( 23%44%).[24 ] skin metastases has been reported to occur in 1%2% of patients with scchn and account for fewer than 10% of all distant metastases . other malignancies associated with skin metastases include carcinoma of bronchus , breast , colon , and kidney . cancers arising in the oral cavity are the commonest head and neck cancers metastasizing to skin . review of the surgical literature revealed only seven previously reported cases of cutaneous metastases from squamous cell carcinoma of the larynx . the site of skin metastases include neck , chest , scalp , face , lips , axilla , areola , back , arms , and digits , with the most common being the neck and chest . it is evident on literature search that multiple metastases from a laryngeal carcinoma involving all five distal phalanges , bilateral lung , liver and multiple subcutaneous nodule in upper and lower extremities , as described above is not reported till date . the skin metastases may evolve through three possible mechanisms , direct spread , local spread , and distant spread . local spread can be ascribed to spread through dermal lymphatics with resultant implantation in the skin . this route of hematogenous spread could be either through pulmonary circulation or bypassing pulmonary circulation via azygous and vertebral venous plexus . in the indexed case , the acrometastasis is most likely due to spread by hematogenous route via pulmonary circulation as the patient has multiple bilateral lung , liver , multiple subcutaneous nodules along with cutaneous phalangeal metastasis . cutaneous metastases from laryngeal carcinoma may present as non - tender firm nodules , as sclerodermoid lesions or may mimic an inflammatory process . the diagnosis should be confirmed by cytology or histopathological examination of the lesions and in this case it was confirmed with a positive cytology report . treatment is essentially aimed at providing symptomatic relief and improving the quality of life . in solitary acral metastases , the patient presented with disseminated disease with involvement of all five distal phalanges , so further treatment offered was essentially palliative as numerous metastases developed rapidly at different sites and because of poor general condition . the indexed case , at initial presentation in 2007 , had localized disease to supraglottic region with ipsilateral neck node involvement . despite a disease - free interval of 2 years this case underscores the importance of considering metastases in the differential diagnosis of a new swelling appearing in a patient previously treated for head and neck cancer .
subcutaneous metastasis from carcinoma larynx is a rare presentation and to the phalynx is the rarest . 
 we herein describe a case report of carcinoma supraglottic larynx , which is involving all five distal phalanges of left hand with simultaneous metastases to lung and liver . 
 acrometastasis is an unusual presentation , which might mimic an infectious or inflammatory pathology . 
 the brief report highlights the importance of clinical awareness of metastatic dissemination to unusual sites in the face of increasing cancer survivorship .