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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 41  |  Issue : 3  |  Page : 151-153

Squamous cell carcinoma of buccal mucosa metastasizing to bone marrow: a case report and review of the literature


1 Department of Oncopathology, Delhi State Cancer Institute, Delhi, India
2 Department of Clinical Oncology, Delhi State Cancer Institute, Delhi, India

Date of Submission05-Feb-2016
Date of Acceptance09-Feb-2016
Date of Web Publication27-Dec-2016

Correspondence Address:
Monica Jain
Department of Oncopathology, Delhi State Cancer Institute, Dilshad Garden, Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1067.196223

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  Abstract 

Bone marrow metastasis in patients with oral squamous cell carcinoma is a very rare phenomenon. A 38-year-old male patient presented with carcinoma of the buccal mucosa postoperatively. The histopathological diagnosis was that of a moderately differentiated squamous cell carcinoma. Biochemical, fine-needle aspiration findings, and PET scan suggested distant spread. The bone marrow showed involvement by squamous cell carcinoma, which was confirmed immunohistochemically. Clinical, biochemical, hematological, and radiological findings are essential for detecting early bone marrow metastasis in head and neck cancer patients, especially squamous cell carcinoma, and timely detection of bone marrow infiltration prevents unwarranted radical surgery.

Keywords: bone marrow metastasis, immunohistochemistry, squamous cell carcinoma


How to cite this article:
Chauhan K, Jain M, Shukla P. Squamous cell carcinoma of buccal mucosa metastasizing to bone marrow: a case report and review of the literature. Egypt J Haematol 2016;41:151-3

How to cite this URL:
Chauhan K, Jain M, Shukla P. Squamous cell carcinoma of buccal mucosa metastasizing to bone marrow: a case report and review of the literature. Egypt J Haematol [serial online] 2016 [cited 2020 Jan 25];41:151-3. Available from: http://www.ehj.eg.net/text.asp?2016/41/3/151/196223


  Introduction Top


Distant metastases in patients with oral squamous cell carcinoma carry a dismal prognosis or clinical outcome. Bone metastasis is generally thought to be a late event that occurs in the setting of other widespread metastases [1]. Toner et al. [2] had reported the first case of squamous cell carcinoma of the head and neck metastasizing to bone marrow in 1989. Second only to lung, previous studies have shown bone to be the most common site of distant metastasis, with reported frequencies ranging from 17 to 31% of the sites involved [3],[4]. We report a case of squamous cell carcinoma of the buccal mucosa, undergoing chemotherapy and radiotherapy, showing bone marrow metastasis.


  Case report Top


A 38-year-old male patient, a diagnosed case of carcinoma of the buccal mucosa, presented with complaints of backache, difficulty in sitting, and inability to walk since 1 week. He had undergone right composite resection earlier comprising right marginal mandibulectomy, right upper alveolectomy, right buccal mucosal excision, and right modified neck dissection-II with right pedicle pectoralis major myocutaneous flap reconstruction 6 months back. The postoperative histopathological diagnosis was a moderately differentiated squamous cell carcinoma of the right buccal mucosa. All of the resection margins, bone and skin, were free of tumor. Lymphovascular emboli were identified. Four out of 15 dissected lymph nodes showed the presence of metastatic tumor (4/15) with extranodal extension. Pathologically, the tumor was staged as PT2N2bMx. Following this he received concurrent radiation up to 60 Gy in 30 fractions to the whole face and neck along with concurrent cisplatin.

On examination, the patient had a 3 × 3-cm2-sized right temporal region swelling. There was decrease in power in the bilateral lower limbs. There was no growth at the primary site. The patient underwent a whole-body fluorine-18 fluorodeoxyglucose contrast-enhanced PET/computed tomographic scan, which showed hypermetabolic heterogenous lesions in the right temporal fossa eroding adjacent bones with multiple lytic lesions involving the right sacral ala, the right ischium, the left ilium, and the left pubic bone. Fine-needle aspiration cytology was done from the right side temporal swelling, which showed a homogenous population of polygonal epithelioid cells with eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli in a background of necrosis and blood. His brain MRI showed a heterogeneously enhancing soft tissue density lesion involving subcutaneous tissues of the right front temporal region. Biochemical investigations revealed raised serum calcium (16.6 mg/dL) and raised serum alkaline phosphatase levels (291 U/L). Subsequent hemograms and peripheral smears showed normocytic normochromic anemia, neutrophilic leukocytosis with mild shift to the left, few nucleated red blood cells, and adequate platelets. On the basis of all these findings, a bone marrow aspirate and biopsy were performed.

The bone marrow aspirate smears were moderately cellular, showing prominence of neutrophilic series of cells along with singly placed as well as clusters of malignant cells showing pleomorphic and hyperchromatic nuclei, inconspicuous nucleoli, and moderate to abundant deep blue cytoplasm in a background of fibroblastic proliferation and few osteoclastic giant cells. Megakaryocytes were seen. Hematoxylin and eosin-stained bone marrow biopsy showed complete replacement of bone marrow spaces by malignant cells with high N : C ratio, pleomorphic vesicular nuclei, and scant to moderate pale cytoplasm in a background of fibrosis. Normal hematopoietic elements were markedly suppressed. On immunohistochemical analysis, the tumor cells showed strong positivity for cytokeratin ([Figure 1]). On the basis of these findings, a diagnosis of bone marrow infiltration by squamous cell carcinoma was made.
Figure 1 (a) Bone marrow aspirate, Giemsa (×40); (b) bone marrow biopsy, hematoxylin and eosin (×20); (c) immunohistochemistry with pancytokeratin (×40)

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The patient was given whole pelvic radiotherapy to a total dose of 30 Gy in 10 fractions and is being planned for chemotherapy.


  Discussion Top


Distant metastasis from squamous cell carcinoma of the head and neck is rare and metastasis to the bone marrow is an extremely rare phenomenon. Probert et al. [5] in an autopsy series of 779 patients with head and neck cancer found bone marrow involvement in only three cases. Saikia et al. [6] and Mathew et al. [7] have reported a case of squamous cell carcinoma from the tonsil and buccal mucosa, respectively, antemortem showing bone marrow metastasis. Because of the poor prognosis only palliative treatment may be offered to these patients. Tumor stage (pT3 or pT4 tumors), nodal metastases (pN2), poor differentiation, lymph invasion, and extracapsular spread have been found to be the common risk factors associated with distant metastases in patients with locoregional control [8],[9]. Laio et al. [8] had found that the number of positive lymph nodes and extracapsular spread were independent unfavorable prognostic factors. The index case had a moderately differentiated pT2 tumor with nodal metastasis (pN2) showing extracapsular spread and presence of lymphovascular emboli suggesting a potential for distant metastasis. In a study by Carlson and Ord [10], it was observed that bone metastases tend to be diagnosed readily on clinical aspects and less frequently for the first time during autopsy as compared with earlier studies.

Pain and hypercalcemia were the common complaints in the patients, which were also observed in our patient. Use of fluorine-18 fluorodeoxyglucose-enhanced PET/computed tomographic scan in staging head and neck squamous cell carcinomas allows for early and accurate detection of occult bone metastasis [11].

Another common finding associated with involvement of the bone marrow by a malignant tumor is leukoerythroblastosis. It can present with overt myelocytes and nucleated red cells in the blood or with only a few tear drop-shaped red cells on a blood film [11]. It occurs because of premature release of hematopoetic elements into the circulation because of reduced available space in the bone marrow and associated compensatory extramedullary hematopoiesis [12]. However, in our case the only significant finding on peripheral smear was neutrophilic leukocytosis.

Hence, correlation of clinical, biochemical, hematological, and radiological findings is essential to detect early bone marrow metastasis in head and neck cancer patients, especially squamous cell carcinoma, which is the most common malignancy of the head and neck because timely detection of bone marrow infiltration can definitely prevent unwarranted radical surgery. More locally advanced lesions are more likely to metastasize and need more aggressive treatment. Moreover, the importance of bone marrow involvement in such cases lies in their antemortem detection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
De Bree R, Deurloo EE, Snow GB, Leemans CR. Screening for distant metastases in patients with head and neck cancer. Laryngoscope 2000; 110:397-401.  Back to cited text no. 1
    
2.
Toner GC, Thomas RL, Schwarz MA. Metastatic bone marrow involvement from supraglottic squamous cell carcinoma. J Laryngol Otol 1989; 103:225-226.  Back to cited text no. 2
    
3.
Merino OR, Lindberg RD, Fletcher GH. An analysis of distant metastasis from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer 1977; 40:145-151.  Back to cited text no. 3
    
4.
Calhoun KH, Fulmer P, Weiss R, Hokanson JA. Distant metastases from head and neck squamous cell carcinomas. Laryngoscope 1994; 104:1199-1205.  Back to cited text no. 4
    
5.
Probert JC, Thomas RW, Bagshaw MA. Patterns of spread of distant metastases in head and neck cancer. Cancer 1974; 33:127-133.  Back to cited text no. 5
    
6.
Saikia B, Varma N, Mohan C, Radotra BD, Sharma SC Metastatic bone marrow involvement by squamous cell carcinoma of the tonsil. J Otolarngol 2002; 31:184-186.  Back to cited text no. 6
    
7.
Mathew BS, Jayasree K, Madhavan J, Nair MK, Rajan B Skeletal metastases and bone marrow infiltration from squamous cell carcinoma of the buccal mucosa. Oral Oncol 1997; 33:454-455.  Back to cited text no. 7
    
8.
Laio 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; 110:1501-1508.  Back to cited text no. 8
    
9.
Papac RJ. Distant metastases from head and neck cancer. Cancer 1984; 53:342-345.  Back to cited text no. 9
    
10.
Carlson ER, Ord RA. Vertebral metastases from oral squamous cell carcinoma. J Oral Maxillofac Surg 2002; 60:858-862.  Back to cited text no. 10
    
11.
Basu D, Siegel BA, McDonald DJ, Nussenbaum B, Detection of occult bone metastases from head and neck squamous cell carcinoma: impact of positron emission tomography-computed tomography with fluorodeoxyglucose F 18. Arch Otolaryngol Head Neck Surg 2007; 133:801-805.  Back to cited text no. 11
    
12.
Makoni SN, Laber DA. Clinical spectrum of myelopthisis in cancer patients. Am J Hematol 2004; 76:92-93.  Back to cited text no. 12
    


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