Carcinoma Buccal Mucosa with Axillary Nodal Metastasis: A Case Report

Dr M Venkataramana M.D.¹, Dr Y Sree Sowmya M.D *²

1. Radiation oncology, Head of Department, Department of Radiation Oncology, GEMS Ragolu, Andhra Pradesh, 532484.

2. Radiation oncology, Senior Resident, Department of Radiation Oncology, GEMS Ragolu, Andhra Pradesh, 532484.

*Correspondence to: Dr Y Sree Sowmya. Radiation oncology, Senior Resident, Department of Radiation Oncology, GEMS Ragolu, Andhra Pradesh, 532484.

Copyright

© 2023 Dr Y Sree Sowmya. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 25 July 2023

Published: 10 August 2023

Abstract

Introduction:

Head and neck malignancies tend to spread locoregionally. Distant metastasis from oral cancers are commonly seen in lungs, liver and bones. Metastasis to axillary lymph nodes is extremely rare.

Case presentation:

We present the case of a patient with carcinoma of the buccal mucosa who underwent surgery followed by adjuvant radiation therapy and consequently developed distant metastasis to axillary lymph nodes. The patient underwent local excision followed by chemotherapy.

Discussion and conclusion:

Distant metastasis from carcinoma of buccal mucosa to axillary lymph nodes is extremely rare and individualised treatment is executed based on the patient's performance status.

Keywords: carcinoma buccal musa, Axillary lymph nodes, squamous cell carcinoma.

Introduction

Malignancies of the oral cavity including cancers of buccal mucosa tend to spread locoregionally (1). Most commonly involved lymph nodal stations include levels 1 to IV in oral cavity cancers (2). Distant metastasis from head and neck carcinomas usually occur in the lungs, bones, or liver (3). A multidisciplinary treatment approach is of utmost importance to facilitate coordination in the management of oral cavity cancers among various disciplines (4). We discuss a very rare case of carcinoma right buccal mucosa who presented with right axillary node metastasis post radical treatment of the primary. Literature search showed that this scenario has been reported only once.

Case Report
A 64-year-old male, who was otherwise well, presented to our hospital in november 2021 with the chief complaint of ulceroproliferative growth over right buccal mucosa for 3 months. He was evaluated and diagnosed as a case of carcinoma right buccal mucosa. He underwent right sided composite resection with modified radical neck dissection in December 2021. Post-operative histopathology showed poorly differentiated squamous cell carcinoma of size 1.5 x 1.2 cm with tumour thickness of 1 cm and closest margin being 0.5cm. One out of sixteen resected lymph nodes showed metastatic deposits of squamous cell carcinoma. He received adjuvant radiotherapy of 66 gray with conventional fractionation at 2 Gray per fraction, 5 days a week for 7 weeks. After six months of disease free interval,  the patient presented with right sided axillary nodal mass. It was 3 x 3 cm in size, hard and mobile with respect to the underlying structures. Ultrasound guided fine needle aspiration cytology from the swelling revealed features of metastatic squamous cell carcinoma. No other metastases were noted elsewhere on imaging. The patient underwent right sided axillary clearance and was started on adjuvant chemotherapy with injection paclitaxel and cisplatin. Post the third cycle of chemotherapy, the patient had disease progression with metastasis to lungs and succumbed to the disease.

Discussion

Oral cavity cancers are the most common cancers in Indian men (5). Its incidence might be higher in the Indian subcontinent than the West probably due to higher tobacco consumption (6). These cancers present with locoregional symptoms, with distant metastasis being relatively uncommon (7). Multidisciplinary management is necessary for patients with oral cavity cancers. The NCCN guidelines recommend surgery as the primary treatment modality for early stage lesions and a combined modality approach with surgery followed by adjuvant radiation or chemoradiation in more advanced diseases (8). Definitive radiotherapy might be a treatment option for patients who are not eligible or refuse surgery. Our patient underwent local surgery followed by adjuvant radiation due to the presence of high risk factors such as depth of invasion more than 1 cm and node positivity.

Local recurrences are more commonly reported than distant metastasis (9). Once treatment is completed, the patient is advised regular follow up for early detection of recurrence. Distant metastasis in carcinomas of the oral cavity are rare and occur in approximately 8%-17%. In head and neck cancers, the commonest sites of distant metastasis include lungs, bones and liver (10). In distant recurrences, systemic therapy is of primary importance. Most commonly used regimens include combination of docetaxel, cisplatin, and 5-FU or a platinum doublet (plus a taxane or 5FU) with or without combination of cetuximab (11).

Conclusion

Distant metastasis from head and neck malignancies to axillary lymph nodes is highly unusual. Such rare presentations should also be kept in mind and individualized treatment should be offered accordingly.

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