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BRIEF COMMUNICATION
Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 693-695

Carcinoma buccal mucosa with left axillary lymph node metastasis: First reported case and review of the literature


1 Department of Radiation Oncology, Dr. BRA IRCH, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
3 Department of Surgical Oncology, Artemis Hospital, Gurgaon, Haryana, India

Date of Web Publication29-May-2019

Correspondence Address:
Dr. Rituparna Biswas
Department of Radiation Oncology, Dr. BRA IRCH, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_49_18

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 > Abstract 


Head-and-neck squamous cell carcinomas are tumors with propensity mostly for locoregional spread. The most frequent sites of metastasis include lung, bone, liver, adrenal, heart, and kidney. Distant metastasis to axillary lymph nodes from buccal mucosa cancer is extremely rare. To the authors' knowledge, this is the first case reported where a gentleman who was treated for carcinoma right buccal mucosa developed left axillary lymph node metastasis at 6th year of follow-up.

Keywords: Axillary lymph nodes, buccal mucosa cancer, squamous cell carcinomas


How to cite this article:
Pandey R, Biswas R, Halder A, Pandey D. Carcinoma buccal mucosa with left axillary lymph node metastasis: First reported case and review of the literature. J Can Res Ther 2019;15:693-5

How to cite this URL:
Pandey R, Biswas R, Halder A, Pandey D. Carcinoma buccal mucosa with left axillary lymph node metastasis: First reported case and review of the literature. J Can Res Ther [serial online] 2019 [cited 2019 Jun 24];15:693-5. Available from: http://www.cancerjournal.net/text.asp?2019/15/3/693/244464




 > Introduction Top


Carcinoma of oral cavity including buccal mucosa has a propensity for locoregional spread. The most common primary sites of squamous cell carcinoma (SCC) of oral cavity causing distant metastases are known to be tongue and gingiva. Distant metastasis to bones, lungs, liver, and skin may rarely be seen with these malignancies.[1] Although the combined modality treatment for the oral cavity cancer has resulted in an improvement in locoregional control, distant metastases are still incurable. We report a patient with carcinoma right buccal mucosa who developed left axillary node metastasis. Extensive literature search suggests that this scenario has never been reported.


 > Case Report Top


An otherwise well, a 50-year-old male was diagnosed with carcinoma of the right buccal mucosa in 2009. He underwent wide local excision of the tumor along with selective right neck dissection and flap reconstruction. Postoperative histopathologic examination (HPE) suggested a well-differentiated SCC of tumor size 3 cm × 2.5 cm with closest margin of 1 mm and depth of infiltration being 15 mm. All eight lymph nodes dissected were free of tumor. He received adjuvant radiotherapy of dose 64 Gy in conventional fractionation. After a disease-free interval of 2 years, he developed local recurrence at right lower lip adjacent to flap for which he underwent oral composite resection. Postoperative HPE revealed a 2 cm tumor, well-differentiated SCC, Grade 2, and all the resected margins were free of tumor. Then, he was kept under close surveillance. Following a gap of 4 years, he developed isolated left axillary lymph node metastasis without evidence of disease elsewhere on May 2016 [Figure 1]a for which left axillary clearance was done on June 2016. Postoperative HPE showed that one out of 21 lymph nodes dissected was involved by SCC. In view of Stage IV disease, he was started on palliative chemotherapy with paclitaxel, carboplatin, and cetuximab. Interim positron-emission tomography (PET) computed tomography (CT) scan showed residual axillary disease [Figure 1]b. He received a total of 12 cycles till December 2016. Follow-up PET CT scan showed residual axillary disease, and clinically, left axillary swelling was progressively increasing. He was then administered palliative radiotherapy to a dose of 20 Gy in 5 fractions over 1 week to left axilla in January 2017. The patient was then put on palliative chemotherapy with 5FU and methotrexate. His condition was stable for 5 months followed by which there was a rapid downhill course with left axillary swelling started increasing rapidly and he succumbed to local hemorrhage and subsequent complications on July 2017.
Figure 1: (a) Positron-emission tomography-computed tomography scan showing isolated left axillary lymph node metastasis with increased fluorodeoxyglucose uptake. (b) Positron-emission tomography-computed tomography scan showing residual left axillary lymph node metastasis with increased fluorodeoxyglucose uptake

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 > Discussion Top


Carcinoma of buccal mucosa is the most common cancer of the oral cavity in Indian men and the third most common oral cancer in women, while its incidence is low in the West perhaps due to higher tobacco consumption in the Indian subcontinent.[2] These cancers typically present with local symptoms; distant metastases are relatively uncommon. A multidisciplinary approach is paramount in the management of buccal mucosa cancer patients. Surgery is most commonly the treatment of choice. For patients with advanced lesions and high-risk features, adjuvant radiotherapy with or without chemotherapy has been seen to augment tumor control rates.[3] Similarly, our patient received adjuvant radiotherapy in view of close margin and depth of infiltration >5 mm. About 90% of recurrences occur within the first 1.5 years after treatment. Local recurrence is more common than regional recurrence and has been reported between 23% and 32%.[4] Presented case also developed local flap recurrence which was adequately salvaged by surgery. Distant metastases are uncommon in buccal carcinoma and correlate with advanced stages of cancer.[5] An exhaustive English literature search suggests this to be the first reported case of carcinoma buccal mucosa with axillary lymph node metastasis. Late presentation of distant metastatic disease from oral SCC is increasingly being reported, even though locoregional control of the primary tumor was achieved [6] as is also seen in our case. Although reports of metastatic buccal mucosa cancer are scarce, most cases are reported to occur in vertebrae, skin, thyroid, lung, brain, bone, adrenal, and heart.[7] A number of drugs have been demonstrated in clinical trials to have activity in head-and-neck SCCs, and the list is well summarized in prior reviews.[8],[9] The most commonly used include methotrexate, cisplatin, carboplatin, 5FU, paclitaxel, and docetaxel with reported major response rates ranging from 15% to 42%. Epidermal growth factor receptor (EGFR) is highly expressed in most head-and-neck SCCs, and the degree of expression is inversely associated with prognosis.[10] Treatment with EGFR inhibitors (cetuximab; a chimeric immunoglobulin G antibody) with chemotherapy can significantly downregulate EGFR expression and inhibit cancer growth.


 > Conclusion Top


Distant metastasis from carcinoma buccal mucosa is not so common an event, however, because it mostly occurs in the advanced stages of a malignancy or may appear late; this scenario should be kept in mind during cancer treatment as it has a significant impact on a patient's life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Calhoun KH, Fulmer P, Weiss R, Hokanson JA. Distant metastases from head and neck squamous cell carcinomas. Laryngoscope 1994;104:1199-205.  Back to cited text no. 1
    
2.
Misra S, Chaturvedi A, Misra NC. Management of gingivobuccal complex cancer. Ann R Coll Surg Engl 2008;90:546-53.  Back to cited text no. 2
    
3.
Cooper JS, Pajak TF, Forastiere AA, Jacobs J, Campbell BH, Saxman SB, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004;350:1937-44.  Back to cited text no. 3
    
4.
Diaz EM Jr., Holsinger FC, Zuniga ER, Roberts DB, Sorensen DM. Squamous cell carcinoma of the buccal mucosa: One institution's experience with 119 previously untreated patients. Head Neck 2003;25:267-73.  Back to cited text no. 4
    
5.
Betka J. Distant metastases from lip and oral cavity cancer. ORL J Otorhinolaryngol Relat Spec 2001;63:217-21.  Back to cited text no. 5
    
6.
Taillibert S, Delattre JY. Palliative care in patients with brain metastases. Curr Opin Oncol 2005;17:588-92.  Back to cited text no. 6
    
7.
Irani S. Distant metastasis from oral cancer: A review and molecular biologic aspects. J Int Soc Prev Community Dent 2016;6:265-71.  Back to cited text no. 7
    
8.
A phase III randomised trial of cistplatinum, methotrextate, cisplatinum + methotrexate and cisplatinum + 5-FU in end stage squamous carcinoma of the head and neck. Liverpool head and neck oncology group. Br J Cancer 1990;61:311-5.  Back to cited text no. 8
    
9.
Gibson MK, Li Y, Murphy B, Hussain MH, DeConti RC, Ensley J, et al. Randomized phase III evaluation of cisplatin plus fluorouracil versus cisplatin plus paclitaxel in advanced head and neck cancer (E1395): An intergroup trial of the eastern cooperative oncology group. J Clin Oncol 2005;23:3562-7.  Back to cited text no. 9
    
10.
Gibson MK, Li Y, Murphy B, Hussain MH, DeConti RC, Ensley J, et al. Randomized phase III evaluation of cisplatin plus fluorouracil versus cisplatin plus paclitaxel in advanced head and neck cancer (E1395): An intergroup trial of the eastern cooperative oncology group. J Clin Oncol 2005;23:3562-7.  Back to cited text no. 10
    


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