- Email: [email protected]
Multifocal cutaneous metastases from squamous cell carcinoma of hard palate
Int. J. Oral Maxillofac. Surg. 2012; 41: 807–809 doi:10.1016/j.ijom.2011.12.007, available online at http://www.sciencedirect.com
Case Report Head and Neck Oncology
Multifocal cutaneous metastases from squamous cell carcinoma of hard palate
J. Sun1, Q. Gao1,2, V. T. W. Fan2,3 1 Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China; 2Department of Oral and Maxillofacial Surgery, National University Health System, National University of Singapore, Singapore; 3Gleneagles Hospital Medical Centre, Singapore
J. Sun, Q. Gao, V. T. W. Fan: Multifocal cutaneous metastases from squamous cell carcinoma of hard palate. Int. J. Oral Maxillofac. Surg. 2012; 41: 807–809. # 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Distant metastases from oral squamous cell carcinoma are unusual, but generally occur in lungs, bone, and liver. Cutaneous metastasis is extremely rare, and it often reflects an advanced stage with sinister prognosis. The authors report an 81-year-old male patient with multifocal cutaneous metastases from a recurrent squamous cell carcinoma of the hard palate 5 months after primary treatment.
Oral squamous cell carcinoma (OSCC) accounts for over 90% of all oral cancers and is the eighth most common cancer worldwide.1 The sites commonly involved include the tongue, the floor of the mouth and the buccal mucosa, whilst hard palate involvement is comparatively less. The prognosis of OSCC is generally poor, with no significant improvement in overall 5year survival rates (45–55%) in the past two decades.5 Survival of OSCC patients, including those with SCC of the hard palate, is influenced by tumour stage, cervical lymph node status, histological grade, and distant metastasis status.8 OSCC has a predilection for cervical lymph node metastasis, with a 27–40% incidence even in early stage tumours (T1/T2), but the distant metastasis is only about 10%.5,7 Common sites for distant metastasis are lung, bone and liver; cutaneous metastasis is rare. The authors present a rare case of multifocal cutaneous metastases from a recurrent hard palate SCC. 0901-5027/070807 + 03 $36.00/0
Case report
The patient was an 81-year-old Chinese man who presented with a 3-month history of a deep non-healing ulcer at the left posterior hard palate with occasional epistaxis. The painless ulcer was over 2 cm in diameter with little swelling. His medical history was unremarkable. The patient used to smoke 20 cigarettes a day for over 30 years and drank unspecified amounts of alcohol ‘socially’. CT scans showed thickening of the soft tissues at the roof of the oral cavity, abutting the hard palate and eroding the hard and soft palate and floor of the nasal cavity. Several small volume lymph nodes were found bilaterally at levels II and III, but were classified as unenlarged on radiographic criteria. The diagnosis, confirmed by biopsy, was SCC of the left hard palate (T2N0M0). The treatment plan was local surgical excision without neck dissection. After routine preoperative examination, the tumour was excised with good margins
Accepted for publication 1 December 2011 Available online 29 December 2011
of hard and soft palate. Four dental implants were placed simultaneously under general anaesthesia. During the operation, frozen sections of all the margins were clear of tumour. The histopathological diagnosis of the lesion was confirmed to be moderately differentiated SCC. The hard palate defect was rehabilitated with an obturator. Reconstruction was not planned until the disease was controlled locally. Three months after the primary operation, epistaxis reappeared. A CT scan showed new erosion of the posterior floor of the left sphenoid sinus, and a 10 mm soft tissue nodule in the anterior wall of the left maxillary sinus with associated bone erosion. The recurrence, located at the skull base, was confirmed by biopsy. The patient’s family refused extensive surgery because of his frail condition, so he was scheduled for radiotherapy followed by chemotherapy. Two months after radiation of the recurrent region, except the neck, multiple painless nodules
# 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
808
Sun et al. were excised at the patient’s request. The patient died 2 months after the diagnosis of multifocal cutaneous metastases. Discussion
Fig. 1. Cutaneous metastases in the face.
Fig. 2. Cutaneous metastases in the neck.
appeared in the skin of the face (Fig. 1), neck (Fig. 2), back (Fig. 3), toe (Fig. 4) and oral mucosa. Pathological examination found these nodules to be infiltrative SCC invading the subcutaneous tissue. The histologic features were consistent with SCC, and
Fig. 3. Cutaneous metastasis in the back.
appeared compatible with a clinical diagnosis of multifocal metastatic lesions from the previous hard palate SCC. A chest Xray revealed multiple round opacities of various sizes in both lungs. This patient was too weak to undergo chemotherapy, though several skin metastatic nodules
The mechanism of distant metastasis, including cutaneous metastasis, is incompletely understood. Distant metastasis is a complex process consisting of a series of yet to be elucidated steps. The ‘soil–seed’ hypothesis and organ-specific metastasis theory are two of the mechanisms described so far. True metastatic spread is via the haematogenous and lymphatic routes and not by direct contiguous tissue invasion or iatrogenic implantation. Some organ tissues express different amount of molecular factors, such as chemokines, which may influence metastasis. For example, depending on what receptors are present, breast cancer cells and melanoma cells will metastasize to different matched organ, lung and skin.2 For cutaneous metastasis, the skin provides a fertile microenvironment for the survival and colonisation of malignant tumour cells. In clinical studies, the risk of distant metastasis in patients with carcinoma of the oral cavity, pharynx or larynx is influenced by the local and regional extension of the tumour, the histological differentiation, the location of the primary tumour, achievement of locoregional control, and in some cases, the patient’s age.3,6 In terms of local and regional extension of the primary tumour, the risk of distant metastasis is related more to the regional extension than to the local extension of the primary tumour.6 The cutaneous metastatic process in this patient was from the recurrent foci to the lung at first, and then the skin and other distant organs via the haematogenous route. The close metastasis to the face, oral cavity and neck, could have been through the subdermal lymphatics. The primary reason for multifocal cutaneous metastases might be the highly aggressive nature of the cancer cells. There was one metastatic tumour on the face in the region previously covered by radiotherapy. Even with considerable advances in therapeutic management, the most effective treatments for OSCC are still surgery and radiotherapy, with chemotherapy as an adjuvant treatment for advanced diseases. Though adjuvant chemotherapy can significantly improve disease-free survival, surgery is still the gold standard for management of OSCC because it can significantly increase overall survival time.10 Selective neck dissection is controversial
Distant metastases from oral squamous cell carcinoma
4.
5.
6.
Fig. 4. Cutaneous metastasis in the toe. 7.
for hard palate or maxillary carcinoma.9 In the present case, even though wide local resection of the primary tumour, with clear margins in frozen sections and the final histological specimen, was performed, the cancer recurred, with distant metastases soon after, without any evidence of regional involvement of the cervical lymph nodes. Local control was achieved by radiotherapy for the recurrent tumour but, as expected, it did not have any effect on the distant metastases. As this patient was very weak, meaningful therapeutic options were limited; several skin metastatic nodules were excised at the patient’s request, but he could not accept palliative chemotherapy. Cutaneous metastasis is thought to reflect very advanced disease and has a sinister prognosis, as most patients have concomitant visceral metastases to the lung, bone, and liver. The median survival is about 8 months after establishing the diagnosis of cutaneous metastases from different internal malignancies,4 but the present patient only survived for 2 months. In summary, distant metastases may present in several different organs. Cutaneous metastasis is extremely rare in OSCC and is mainly via the haematogen-
ous and lymphatic routes. It reflects a very advanced stage with sinister prognosis. For the patient, treatment remains unsatisfactory and difficult.
8.
Competing interests
None declared. Funding
None. Ethical approval
9.
10.
809
Arch Otolaryngol Head Neck Surg 2006; 132:762–6. Hu SC, Chen GS, Lu YW, Wu CS, Lan CC. Cutaneous metastases from different internal malignancies: a clinical and prognostic appraisal. J Eur Acad Dermatol Venereol 2008;22:735–40. Jerjes W, Upile T, Petrie A, Riskalla A, Hamdoon Z, Vourvachis M, et al. Clinicopathological parameters, recurrence, locoregional and distant metastasis in 115 T1-T2 oral squamous cell carcinoma patients. Head Neck Oncol 2010;2:9. Leon X, Quer M, Orus C, del Prado Venegas M, Lopez M. Distant metastases in head and neck cancer patients who achieved locoregional control. Head Neck 2000;22: 680–6. Liao CT, Wang HM, Chang JT, Ng SH, Hsueh C, Lee LY, et al. Analysis of risk factors for distant metastases in squamous cell carcinoma of the oral cavity. Cancer 2007;110:1501–8. Lin HW, Bhattacharyya N. Survival impact of nodal disease in hard palate and maxillary alveolus cancer. Laryngoscope 2009;119: 312–5. Simental Jr AA, Johnson JT, Myers EN. Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate. Laryngoscope 2006;116:1682–4. Sklenicka S, Gardiner S, Dierks EJ, Potter BE, Bell RB. Survival analysis and risk factors for recurrence in oral squamous cell carcinoma: does surgical salvage affect outcome? J Oral Maxillofac Surg 2010;68: 1270–5.
Not required. References 1. Bagan J, Sarrion G, Jimenez Y. Oral cancer: clinical features. Oral Oncol 2010;46:414–7. 2. Chambers AF, Groom AC, MacDonald IC. Dissemination and growth of cancer cells in metastatic sites. Nat Rev Cancer 2002;2: 563–72. 3. Garavello W, Ciardo A, Spreafico R, Gaini RM. Risk factors for distant metastases in head and neck squamous cell carcinoma.
Address: Qinghong Gao Department of Head and Neck Oncology West China Hospital of Stomatology Sichuan University No. 14 Section 3 South Renmin Road Chengdu 610041 China Tel: +86 028 85501428; Fax: +86 028 85582167 E-mail: [email protected]
Case Report Head and Neck Oncology
Multifocal cutaneous metastases from squamous cell carcinoma of hard palate
J. Sun1, Q. Gao1,2, V. T. W. Fan2,3 1 Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China; 2Department of Oral and Maxillofacial Surgery, National University Health System, National University of Singapore, Singapore; 3Gleneagles Hospital Medical Centre, Singapore
J. Sun, Q. Gao, V. T. W. Fan: Multifocal cutaneous metastases from squamous cell carcinoma of hard palate. Int. J. Oral Maxillofac. Surg. 2012; 41: 807–809. # 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Distant metastases from oral squamous cell carcinoma are unusual, but generally occur in lungs, bone, and liver. Cutaneous metastasis is extremely rare, and it often reflects an advanced stage with sinister prognosis. The authors report an 81-year-old male patient with multifocal cutaneous metastases from a recurrent squamous cell carcinoma of the hard palate 5 months after primary treatment.
Oral squamous cell carcinoma (OSCC) accounts for over 90% of all oral cancers and is the eighth most common cancer worldwide.1 The sites commonly involved include the tongue, the floor of the mouth and the buccal mucosa, whilst hard palate involvement is comparatively less. The prognosis of OSCC is generally poor, with no significant improvement in overall 5year survival rates (45–55%) in the past two decades.5 Survival of OSCC patients, including those with SCC of the hard palate, is influenced by tumour stage, cervical lymph node status, histological grade, and distant metastasis status.8 OSCC has a predilection for cervical lymph node metastasis, with a 27–40% incidence even in early stage tumours (T1/T2), but the distant metastasis is only about 10%.5,7 Common sites for distant metastasis are lung, bone and liver; cutaneous metastasis is rare. The authors present a rare case of multifocal cutaneous metastases from a recurrent hard palate SCC. 0901-5027/070807 + 03 $36.00/0
Case report
The patient was an 81-year-old Chinese man who presented with a 3-month history of a deep non-healing ulcer at the left posterior hard palate with occasional epistaxis. The painless ulcer was over 2 cm in diameter with little swelling. His medical history was unremarkable. The patient used to smoke 20 cigarettes a day for over 30 years and drank unspecified amounts of alcohol ‘socially’. CT scans showed thickening of the soft tissues at the roof of the oral cavity, abutting the hard palate and eroding the hard and soft palate and floor of the nasal cavity. Several small volume lymph nodes were found bilaterally at levels II and III, but were classified as unenlarged on radiographic criteria. The diagnosis, confirmed by biopsy, was SCC of the left hard palate (T2N0M0). The treatment plan was local surgical excision without neck dissection. After routine preoperative examination, the tumour was excised with good margins
Accepted for publication 1 December 2011 Available online 29 December 2011
of hard and soft palate. Four dental implants were placed simultaneously under general anaesthesia. During the operation, frozen sections of all the margins were clear of tumour. The histopathological diagnosis of the lesion was confirmed to be moderately differentiated SCC. The hard palate defect was rehabilitated with an obturator. Reconstruction was not planned until the disease was controlled locally. Three months after the primary operation, epistaxis reappeared. A CT scan showed new erosion of the posterior floor of the left sphenoid sinus, and a 10 mm soft tissue nodule in the anterior wall of the left maxillary sinus with associated bone erosion. The recurrence, located at the skull base, was confirmed by biopsy. The patient’s family refused extensive surgery because of his frail condition, so he was scheduled for radiotherapy followed by chemotherapy. Two months after radiation of the recurrent region, except the neck, multiple painless nodules
# 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
808
Sun et al. were excised at the patient’s request. The patient died 2 months after the diagnosis of multifocal cutaneous metastases. Discussion
Fig. 1. Cutaneous metastases in the face.
Fig. 2. Cutaneous metastases in the neck.
appeared in the skin of the face (Fig. 1), neck (Fig. 2), back (Fig. 3), toe (Fig. 4) and oral mucosa. Pathological examination found these nodules to be infiltrative SCC invading the subcutaneous tissue. The histologic features were consistent with SCC, and
Fig. 3. Cutaneous metastasis in the back.
appeared compatible with a clinical diagnosis of multifocal metastatic lesions from the previous hard palate SCC. A chest Xray revealed multiple round opacities of various sizes in both lungs. This patient was too weak to undergo chemotherapy, though several skin metastatic nodules
The mechanism of distant metastasis, including cutaneous metastasis, is incompletely understood. Distant metastasis is a complex process consisting of a series of yet to be elucidated steps. The ‘soil–seed’ hypothesis and organ-specific metastasis theory are two of the mechanisms described so far. True metastatic spread is via the haematogenous and lymphatic routes and not by direct contiguous tissue invasion or iatrogenic implantation. Some organ tissues express different amount of molecular factors, such as chemokines, which may influence metastasis. For example, depending on what receptors are present, breast cancer cells and melanoma cells will metastasize to different matched organ, lung and skin.2 For cutaneous metastasis, the skin provides a fertile microenvironment for the survival and colonisation of malignant tumour cells. In clinical studies, the risk of distant metastasis in patients with carcinoma of the oral cavity, pharynx or larynx is influenced by the local and regional extension of the tumour, the histological differentiation, the location of the primary tumour, achievement of locoregional control, and in some cases, the patient’s age.3,6 In terms of local and regional extension of the primary tumour, the risk of distant metastasis is related more to the regional extension than to the local extension of the primary tumour.6 The cutaneous metastatic process in this patient was from the recurrent foci to the lung at first, and then the skin and other distant organs via the haematogenous route. The close metastasis to the face, oral cavity and neck, could have been through the subdermal lymphatics. The primary reason for multifocal cutaneous metastases might be the highly aggressive nature of the cancer cells. There was one metastatic tumour on the face in the region previously covered by radiotherapy. Even with considerable advances in therapeutic management, the most effective treatments for OSCC are still surgery and radiotherapy, with chemotherapy as an adjuvant treatment for advanced diseases. Though adjuvant chemotherapy can significantly improve disease-free survival, surgery is still the gold standard for management of OSCC because it can significantly increase overall survival time.10 Selective neck dissection is controversial
Distant metastases from oral squamous cell carcinoma
4.
5.
6.
Fig. 4. Cutaneous metastasis in the toe. 7.
for hard palate or maxillary carcinoma.9 In the present case, even though wide local resection of the primary tumour, with clear margins in frozen sections and the final histological specimen, was performed, the cancer recurred, with distant metastases soon after, without any evidence of regional involvement of the cervical lymph nodes. Local control was achieved by radiotherapy for the recurrent tumour but, as expected, it did not have any effect on the distant metastases. As this patient was very weak, meaningful therapeutic options were limited; several skin metastatic nodules were excised at the patient’s request, but he could not accept palliative chemotherapy. Cutaneous metastasis is thought to reflect very advanced disease and has a sinister prognosis, as most patients have concomitant visceral metastases to the lung, bone, and liver. The median survival is about 8 months after establishing the diagnosis of cutaneous metastases from different internal malignancies,4 but the present patient only survived for 2 months. In summary, distant metastases may present in several different organs. Cutaneous metastasis is extremely rare in OSCC and is mainly via the haematogen-
ous and lymphatic routes. It reflects a very advanced stage with sinister prognosis. For the patient, treatment remains unsatisfactory and difficult.
8.
Competing interests
None declared. Funding
None. Ethical approval
9.
10.
809
Arch Otolaryngol Head Neck Surg 2006; 132:762–6. Hu SC, Chen GS, Lu YW, Wu CS, Lan CC. Cutaneous metastases from different internal malignancies: a clinical and prognostic appraisal. J Eur Acad Dermatol Venereol 2008;22:735–40. Jerjes W, Upile T, Petrie A, Riskalla A, Hamdoon Z, Vourvachis M, et al. Clinicopathological parameters, recurrence, locoregional and distant metastasis in 115 T1-T2 oral squamous cell carcinoma patients. Head Neck Oncol 2010;2:9. Leon X, Quer M, Orus C, del Prado Venegas M, Lopez M. Distant metastases in head and neck cancer patients who achieved locoregional control. Head Neck 2000;22: 680–6. Liao CT, Wang HM, Chang JT, Ng SH, Hsueh C, Lee LY, et al. Analysis of risk factors for distant metastases in squamous cell carcinoma of the oral cavity. Cancer 2007;110:1501–8. Lin HW, Bhattacharyya N. Survival impact of nodal disease in hard palate and maxillary alveolus cancer. Laryngoscope 2009;119: 312–5. Simental Jr AA, Johnson JT, Myers EN. Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate. Laryngoscope 2006;116:1682–4. Sklenicka S, Gardiner S, Dierks EJ, Potter BE, Bell RB. Survival analysis and risk factors for recurrence in oral squamous cell carcinoma: does surgical salvage affect outcome? J Oral Maxillofac Surg 2010;68: 1270–5.
Not required. References 1. Bagan J, Sarrion G, Jimenez Y. Oral cancer: clinical features. Oral Oncol 2010;46:414–7. 2. Chambers AF, Groom AC, MacDonald IC. Dissemination and growth of cancer cells in metastatic sites. Nat Rev Cancer 2002;2: 563–72. 3. Garavello W, Ciardo A, Spreafico R, Gaini RM. Risk factors for distant metastases in head and neck squamous cell carcinoma.
Address: Qinghong Gao Department of Head and Neck Oncology West China Hospital of Stomatology Sichuan University No. 14 Section 3 South Renmin Road Chengdu 610041 China Tel: +86 028 85501428; Fax: +86 028 85582167 E-mail: [email protected]