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E-IJD CASE REPORT
Year : 2016  |  Volume : 61  |  Issue : 4  |  Page : 468
Distant skin metastases from carcinoma buccal mucosa: A rare presentation


1 Department of Radiation Oncology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
2 Department of Surgical Oncology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
3 Department of Pathology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India

Date of Web Publication7-Jul-2016

Correspondence Address:
Shashank Srinivasan
B-3/126, Manu Apartments, Mayur Vihar - I, New Delhi - 110 091
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.185764

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   Abstract 

Cancer of the oral cavity makes up approximately 30% of all head and neck region tumors. Skin metastasis is rare with an incidence ranging between 0.7% and 2.4%. Skin metastasis usually occurs in the neck, scalp, and over the skin near the primary site. We report a patient with carcinoma left buccal mucosa who presented with distant skin metastases to the right side chest wall.


Keywords: Buccal mucosa, head and neck cancers, skin metastasis


How to cite this article:
Srinivasan S, Leekha N, Gupta S, Mithal U, Arora V, De S. Distant skin metastases from carcinoma buccal mucosa: A rare presentation. Indian J Dermatol 2016;61:468

How to cite this URL:
Srinivasan S, Leekha N, Gupta S, Mithal U, Arora V, De S. Distant skin metastases from carcinoma buccal mucosa: A rare presentation. Indian J Dermatol [serial online] 2016 [cited 2019 Sep 17];61:468. Available from: http://www.e-ijd.org/text.asp?2016/61/4/468/185764

What was known?
Skin metastases from head and neck squamous cell carcinoma are rare and usually occur near the primary site.



   Introduction Top


Cancer of the oral cavity makes up approximately 30% of all head and neck region tumors. Carcinoma of the buccal mucosa is the most common carcinoma of the oral cavity in South-East Asia because of the widespread use of betel nut. [1] With multimodality treatment, locoregional control of head and neck squamous cell carcinoma (HNSCC) has improved nowadays. However, this has not led to improved survival due to failure at distant sites. Common sites of metastasis are lung, bone, and liver. Skin metastasis is rare with an incidence ranging between 0.7% and 2.4%. [2],[3],[4] Skin metastasis usually occurs in the neck, scalp, and over the skin near the primary site. We report a patient with carcinoma left buccal mucosa who presented with distant skin metastases to the right side chest wall.


   Case Report Top


A 30-year-old male, chronic tobacco chewer, presented to the oncology clinic with 2 months history of an ulcer over left buccal mucosa. The patient was well built and had Eastern Cooperative Oncology Group performance score of 1. On locoregional examination, he had a 3 cm × 4 cm ulceroproliferative growth over the left buccal mucosa involving the angle of mouth reaching up to left retromolar trigone involving the upper gingivobuccal sulcus. No lymph nodes were palpable. Contrast enhanced computed tomography (CECT) scan neck reported diffuse soft tissue thickening along the left buccal mucosa extending along upper and lower lip to mid-sagittal plane and reaching up to superior gingivobuccal sulcus posteriorly in the region of premolars. Biopsy from the growth reported keratinizing squamous cell carcinoma. All other baseline investigations including a complete hemogram, kidney function tests, liver function tests, and chest X-ray were within normal limits. In view of the above findings, the patient was diagnosed as carcinoma of the left buccal mucosa cT4aN0M0 (AJCC) Stage IVA. The patient underwent wide local excision of the lesion with left modified neck dissection with flap reconstruction. Postoperative histopathology reported well differentiated squamous cell carcinoma of size 1 cm × 0.8 cm × 0.7 cm with the involvement of overlying skin and 5 out of 36 lymph nodes dissected were positive - pT4aN2bMx stage IVA. In view of the histopathology findings patient received adjuvant external beam radiotherapy 66 Gy in 33 fractions to the planning target volume by inverse planned intensity modulated radiotherapy technique on Varian Clinac iX by 6 MV photons with weekly concurrent cisplatin-based chemotherapy. The patient subsequently remained in follow-up. He reported again after 3 months with complaints of a lump over the right side of the chest wall for which he had consulted a local doctor and underwent excision of the lump at a local hospital. No histopathology report was available for the same. On local examination, a 5 cm × 4 cm subcutaneous lump was palpable over the right lateral chest wall. Whole body positron emission tomography-CT scan was done which reported hypermetabolic subcutaneous nodular lesion along right lateral chest wall-likely metastatic, no evidence of residual primary lesion or abnormal uptake at any other site [Figure 1]. The patient underwent wide excision of the right chest wall lesion [Figure 2]. Histopathological examination reported metastatic squamous cell carcinoma [Figure 3]. Postoperatively, he received external radiotherapy to the postoperative region by electron beam (50 Gy/20 fractions). He reported after 4 months with complaints of drowsiness and severe weakness. His blood investigations revealed hypercalcemia and was managed conservatively but patient defaulted from further treatment.
Figure 1: Positron emission tomography-computed tomography showing isolated hypermetabolic nodular lesion along right lateral chest wall

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Figure 2: Subcutaneous nodule over right side chest wall

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Figure 3: Squamous cell carcinoma involving the subcutaneous fat (H and E, ×200) sections show nests and sheets of dysplastic cells with intercellular bridges displaying high N: C ratio, abundant cytoplasm, a vesicular nucleus with prominent nucleoli. Many of these show intracytoplasmic keratin with keratin pearls. The tumor is infiltrating the subcutaneous fat

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   Discussion Top


The frequency of skin metastasis from all internal malignancies varies from 0.7% to 9% [5] of all cancer patients. There are very few reports in the literature about skin metastasis from HNSCC. Schultz and Schwartz [6] had reported a rare presentation of cutaneous metastasis from carcinoma of the hypopharynx way back in 1985. Veraldi et al., [7] noted rarity of skin metastasis from laryngeal cancers and showed only 12 reported cases in literature. The exact mechanism of skin metastasis in HNSCC is not completely understood. There are three possible mechanisms as outlined by Kmucha and Troxel [8] viz., direct spread, local spread, and distant spread. Skin metastasis is thought to involve hematogenous spread where pulmonary circulation and filtration can be theoretically bypassed via the azygos venous and vertebral venous system in Batson's plexus allowing skin implantation. Skin metastasis indicates a poor prognosis. [9] Berger and Fletcher [10] in their study reported that length of survival was approximately 3 months after skin metastasis becomes clinically evident in HNSCC. The treatment intent is usually palliative with the available options being surgical excision, chemotherapy, External beam radiotherapy or a combination of these. Surgery has been shown to increase survival in these patients. Whatever the nature of the primary lesion, the course of the disease or treatment (s) administered, it appears that skin metastasis is an equalizing factor for all patient groups in carcinoma of head and neck, all patients do poorly and succumb rapidly to the disease. [11]


   Conclusion Top


The incidence of skin metastases from HNSCCs ranges from 0.7% to 2.4%. Majority of these metastases occur at sites which are near the primary lesion. Distant skin metastasis from HNSCC is hardly reported in literature to the best of our knowledge. The appearance of new skin lesions in patients of HNSCC mandates a vigilant history and thorough physical examination. All such lesions should be viewed with a high index of suspicion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Manon RR, Meyers JN, Skinner HD, Harari PM. Oral cavity. In: Halperin EC, Wazer DE, Perez CA, Brady LW, editors. Perez and Brady's Principles and Practice of Radiation Oncology. 6 th ed. Philadelphia: Lippincott Williams and Wilkins; 2013. p. 795.  Back to cited text no. 1
    
2.
Yoskovitch A, Hier MP, Okrainec A, Black MJ, Rochon L. Skin metastases in squamous cell carcinoma of the head and neck. Otolaryngol Head Neck Surg 2001;124:248-52.  Back to cited text no. 2
    
3.
Pitman KT, Johnson JT. Skin metastases from head and neck squamous cell carcinoma: Incidence and impact. Head Neck 1999;21:560-5.  Back to cited text no. 3
    
4.
Fletcher OH. Textbook of Radiotherapy. Philadelphia: Lea and Febiger; 1980. p. 315-7.  Back to cited text no. 4
    
5.
Spencer PS, Helm TN. Skin metastases in cancer patients. Cutis 1987;39:119-21.  Back to cited text no. 5
[PUBMED]    
6.
Schultz BM, Schwartz RA. Hypopharyngeal squamous cell carcinoma metastatic to skin. J Am Acad Dermatol 1985;12 (1 Pt 2):169-72.  Back to cited text no. 6
    
7.
Veraldi S, Cantu A 2 nd , Sala F, Schianchi R, Gasparini G. Cutaneous metastases from laryngeal carcinoma. J Dermatol Surg Oncol 1988;14:562-4.  Back to cited text no. 7
    
8.
Kmucha ST, Troxel JM. Dermal metastases in epidermoid carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg 1993;119:326-30.  Back to cited text no. 8
    
9.
Kumar N, Bera A, Kumar R, Ghoshal S, Angurana SL, Srinivasan R. Squamous cell carcinoma of supraglottic larynx with metastasis to all five distal phalanges of left hand. Indian J Dermatol 2011;56:578-80.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Berger DS, Fletcher GH. Distant metastases following local control of squamous-cell carcinoma of the nasopharynx, tonsillar fossa, and base of the tongue. Radiology 1971;100:141-3.  Back to cited text no. 10
[PUBMED]    
11.
Cole RD, McGuirt WF. Prognostic significance of skin involvement from mucosal tumors of the head and neck. Arch Otolaryngol Head Neck Surg 1995;121:1246-8.  Back to cited text no. 11
    

What is new?
Distant skin metastasis from head and neck squamous cell carcinoma (HNSCC) has hardly been reported in the literature. In the event of the appearance of new skin lesions in a previously diagnosed patient of HNSCC, the possibility of skin metastasis from the primary site should be ruled out.


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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    Abstract
   Introduction
   Case Report
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