2. Keerthiga K., etĀ al.: Squamous cell carcinoma of tongue
āāāāāāJournal of Current Oncology Ā¦ Volume 4 Ā¦ Issue 2 Ā¦ July-December 2021 141āā
survival reduces significantly even with early diagnosis of
metastasis. The prevalence of distant metastasis increases
significantly (approximately 32%) with the presence of
extranodal extension. AĀ multivariate analysis of the
tumor characteristics has shown that only depth of tumor
as an absolute predictive value for cervical and distant
metastasis in lingual neoplasms.[3]
However, an isolated
nonregional node metastasis has not been reported before.
Case Report
A 55-year-old man presented with ulceroproliferative
lesion over right lateral border of tongue, diagnosed
as squamous cell carcinoma of tongue in 2020 and
underwent right hemiglossectomy with right modified
neck dissection. Postop histopathology report had
shown tumor size to be 3ā
cm Ć 1.5ā
cm Ć 0.5ā
cm, grade
I.Ā All margins were ā„1ācm with lymphovascular (+) and
perineural invasion (+). The depth of invasion was
0.5ā
cm from basal layer and the risk score was 1, that
is, intermediate risk (Brandwein Gensler Risk score).
No lymph nodes were positive out of 36 dissected. He
received adjuvant radiotherapy with total tumor dose
of 6000cGy/30#/5 weeks @ 2Gy/#. He was on regular
follow-up and remained disease free for 6 months. On
his sixth-month follow-up, he presented with a swelling
over right inguinal region for a period of 20Ā days
[Figures 1ā3]. The onset was sudden associated with
mild pain, dragging type. On examination, a single
swelling, measuring approximately 1.5ā
cm Ć 1ā
cm over
right inguinal region was found which was firm, mobile,
and nontender [Figures 4]. The patient was examined
thoroughly to rule out any local cause of his inguinal
swelling. The physical examination did not reveal any
assignable cause to the swelling. The patient was reviewed
after a week with a course of antibiotics. On review, the
swelling was found to be persistent with no changes in
the characteristics. AĀ radiologistās opinion was sought,
and he was subjected to ultrasonography and fine-needle
aspiration cytology (FNAC) from the swelling. The
cytology came to be positive for metastatic deposits of
squamous cell carcinoma. Positron emission tomography
and computed tomography (PET-CT) confirmed it to be
a localized metastasis confined to right inguinal region
only [Figures 5]. Patient underwent right inguinal block
dissection and the histopathology report shows that 5 out
of 11 lymph nodes were positive for metastatic deposits
of squamous cell carcinoma with extranodal extension.
FigureĀ 1: Postoperative tongue at sixth month follow-up
FigureĀ 2: Postoperative tongueāno evidence of local recurrence on
local examination
FigureĀ 3: Postoperative tongueāno palpable neck nodes
FigureĀ 4: A swelling noted over right groin region measuring about
1.5Ā x 1 cm, firm in consistency, not mobile
FigureĀ 5: PET-CT showing image with FDG (Fluorodeoxyglucose) avid
right inguinal node
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3. Keerthiga K., etĀ al.: Squamous cell carcinoma of tongue
āāāāāā
142 142āāJournal of Current Oncology Ā¦ Volume 4 Ā¦ Issue 2 Ā¦ July-December 2021
Immunohistochemistry study showed CK7 and p63
positive favoring squamous cell carcinoma. Patient
received adjuvant radiotherapy 50Gy/25#/5weeks to the
right groin region. Patient was kept under follow-up.
Discussion
Worldwide, oral cancer is the sixth most common cancer.
India contributes one-third to the global oral cancer
burden. Among oral cavity cancers, carcinoma of tongue
is the most common cancer.[4]
Tongue has extensive
lymphatic drainage that leads to local, regional, and
distant metastasis. The regional and distant metastasis in
head and neck cancer depends on the high-risk features
such as stage III and IV, lymphovascular invasion,
perineural invasion, more than 2 lymph Node positive,
extranodal extension, and margin positivity.[5]
Significant
occult metastasis had been observed in the early stage
of lingual carcinoma also.[4]
This leads to the need for
neck dissection in clinically node-negative patients.
Incidence of skip metastasis in lingual carcinoma to level
III and IV without involving level IĀ and II nodes is also
significantly high.[6]
The frequency of distant metastases
varies extensively, ranging between 4% and 26% in
clinical studies and between 37% and 57% in autopsy
studies.[7]
In patients, in whom loco-regional control
has not been achieved, distant metastasis occurs as the
disease progresses. However, in patients with locoregional
control, distant metastasis is rare. It has been thought
that distant metastases in these patients develop because
of a subclinical distant metastatic spreading that has
already occurred, when treatment of locoregional
tumor is carried out. These metastatic foci develop
during the course of follow-up and become clinically
apparent. Leon etĀ al.[8]
have reported approximately 5%
distant metastasis in head and neck cancer patients with
locoregional control. AĀ rare case of isolated axillary
node in carcinoma buccal mucosa presented after 4Ā years
of treatment to the primary (AIIMS, New Delhi).[9]
Das Majumdar etĀ al.[10]
in their case report described
distant metastasis to cutaneous, cardiac region in a
patient with anterior tongue carcinoma after 2Ā years of
complete treatment with surgery followed by concurrent
chemoradiation to the primary.
However, the differential diagnosis can also be unknown
primary with isolated inguinal nodal metastasis. The
most common sites for inguinal node metastasis are skin
of lower extremities, vulva, anus, glans, foreskin of penis,
rectum, anus, cervix, and ovary. Sinha etĀ al.[11]
reported
a case with carcinoma of unknown primary with
inguinal metastasis, which was developed squamous cell
carcinoma of penis after 3Ā years of inguinal metastasis.
Zaren etĀ al.[12]
reviewed 2232 patients with inguinal node
metastasis and concluded the most common primary
site to be skin of lower extremities, cervix, vulva, skin
of trunk, rectum, and anus. In only 1% of patients, the
primary site remained undiagnosed. It is difficult to
differentiate by pathology whether it is metastasis or
carcinoma of unknown primary as it will be squamous
cell carcinoma with tongue cancer or skin/penile cancer.
Carcinoma of unknown primary with single metastatic
site and favorable histology such as squamous are
managed locoregionally with surgery and/or radiation.[13]
Survival in carcinoma of unknown primary and head
and neck cancer with isolated inguinal nodes had an over
50% survival as compared to metastasis to other lymph
nodes.[14]
In our case, we have recorded an isolated inguinal node
metastasis within 6Ā months of completion of surgery
and radiation. After an extensive literature search, we
conclude that this is the first case being reported with
isolated distant metastasis to inguinal node without any
loco-regional recurrence.
Conclusion
Distant metastasis to inguinal node in squamous cell
carcinoma of tongue after complete treatment is rare but
technically feasible, and it did happen, this case being one
example. Hence, thorough clinical examination of the
patient during follow-up is essential.
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
1. MathurĀ P, SathishkumarĀ K, ChaturvediĀ M, DasĀ P, SudarshanĀ KL,
SanthappanĀ S, etĀ al.; ICMR-NCDIR-NCRP Investigator Group.
Cancer statistics, 2020: Report from national cancer registry
programme, India. JCO Glob Oncol 2020;6:1063-75.
2. DuprezĀ F, BerwoutsĀ D, DeĀ NeveĀ W, BonteĀ K, BoterbergĀ T, DeronĀ P,
etĀ al. Distant metastases in head and neck cancer. Head Neck
2017;39:1733-43.
3. PisaniĀ P, AiroldiĀ M, AllaisĀ A, AluffiĀ VallettiĀ P, BattistaĀ M,
BenazzoĀ M, etĀ al. Metastatic disease in head neck oncology. Acta
Otorhinolaryngol Ital 2020;40:S1-86.
4. BorseĀ V, KonwarĀ AN, BuragohainĀ P. Oral cancer diagnosis and
perspectives in India. Sens Int 2020;1:100046.
5. BernierĀ J, CooperĀ JS, PajakĀ TF, vanĀ GlabbekeĀ M, BourhisĀ J,
ForastiereĀ A, etĀ al. Defining risk levels in locally advanced head and
neck cancers: AĀ comparative analysis of concurrent postoperative
radiation plus chemotherapy trials of the EORTC (#22931) and
RTOG (# 9501). Head Neck 2005;27:843-50.
[Downloaded free from http://www.journalofcurrentoncology.org on Wednesday, February 23, 2022, IP: 10.232.74.27]
4. Keerthiga K., etĀ al.: Squamous cell carcinoma of tongue
āāāāāāJournal of Current Oncology Ā¦ Volume 4 Ā¦ Issue 2 Ā¦ July-December 2021 143āā
6. DiasĀ FL, LimaĀ RA, KligermanĀ J, FariasĀ TP, SoaresĀ JR, ManfroĀ G,
etĀ al. Relevance of skip metastases for squamous cell carcinoma of
the oral tongue and the floor of the mouth. Otolaryngol Head Neck
Surg 2006;134:460-5.
7. ByersĀ RM, WeberĀ RS, AndrewsĀ T, McGillĀ D, KareĀ R, WolfĀ P.
Frequency and therapeutic implications of āskip metastasesā in
the neck from squamous carcinoma of the oral tongue. Head Neck
1997;19:14-9.
8. LeĆ³nĀ X, QuerĀ M, OrĆŗsĀ C, delĀ PradoĀ VenegasĀ M, LĆ³pezĀ M. Distant
metastases in head and neck cancer patients who achieved loco-
regional control. Head Neck 2000;22:680-6.
9. PandeyĀ R, BiswasĀ R, HalderĀ A, PandeyĀ D. Carcinoma buccal
mucosa with left axillary lymph node metastasis: First reported case
and review of the literature. J Cancer Res Ther 2019;15:693-5.
10. DasĀ MajumdarĀ SK, SahooĀ TK, ParidaĀ DK. Cutaneous and cardiac
metastases in carcinoma of anterior tongue. J Cancer Res Ther
2020;16:680-2.
11. SinhaĀ M, KatemaĀ M, MalataĀ CM. Squamous cell carcinoma of
penis presenting as groin metastasis 3Ā years before the primary. J
Plast Reconstr Aesthet Surg 2006;59:547-9.
12. ZarenĀ HA, CopelandĀ EM 3rd. Inguinal node metastases. Cancer
1978;41:919-23.
13. PavlidisĀ N, BriasoulisĀ E, HainsworthĀ J, GrecoĀ FA. Diagnostic and
therapeutic management of cancer of an unknown primary. Eur J
Cancer 2003;39:1990-2005.
14. HemminkiĀ K, BevierĀ M, HemminkiĀ A, SundquistĀ J, Survival in
cancer of unknown primary site: Population-based analysis by site
and histology. Ann Oncol 2012;23:1854-63.
[Downloaded free from http://www.journalofcurrentoncology.org on Wednesday, February 23, 2022, IP: 10.232.74.27]