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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 140-143

Squamous cell carcinoma of tongue with isolated inguinal node metastasis: A case report and literature review


1 Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh, India
2 Department of Radiation Oncology, Acharya Harihar Regional Cancer Center, SCB Medical College, Cuttack, Odisha, India

Date of Submission09-Aug-2021
Date of Acceptance24-Nov-2021
Date of Web Publication23-Feb-2022

Correspondence Address:
Dr. Chitta Ranjan Kundu
Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jco.jco_29_21

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  Abstract 

Most of the patients with squamous cell carcinoma of tongue present with distant metastasis to lung, bone, and liver. However, some rare presentation of tongue cancer metastasizing to cutaneous, cardiac, and axillary lymph nodes has been reported. We present a case of 55-year-old man diagnosed with squamous cell carcinoma of right lateral border of tongue, underwent right hemiglossectomy and right modified neck dissection, levels 1–5 with pathological staging pT2N0M0 (AJCC 8th edition) followed by adjuvant radiotherapy to a total dose of 60 Gy in 30 fractions. After 6-month post-treatment, the patient presented with right inguinal swelling which was associated with pain. Ultrasonography of the groin region confirmed lymphadenopathy and fine-needle aspiration cytology (FNAC) from lymph node came out as metastatic deposits of squamous cell carcinoma. Positron emission tomography and computed tomography (PET-CT) showed isolated right inguinal lymph node metastasis. He underwent right inguinal block dissection and adjuvant radiotherapy. Hence, isolated inguinal node metastasis is extremely rare but possible. Patient should be examined thoroughly during follow-up.

Keywords: Fine needle aspiration cytology (FNAC), head and neck squamous cell carcinoma (HNSCC), inguinal node metastasis, positron emission tomography and computed tomography (PET-CT), tongue cancer


How to cite this article:
Keerthiga K, Kundu CR, Patro KC, Bhattacharyya PS, Pilaka VK, Padhi S, Rao M M, Reddy P S, Mohanapriya A, Avidi VP, Damodara VN. Squamous cell carcinoma of tongue with isolated inguinal node metastasis: A case report and literature review. J Curr Oncol 2021;4:140-3

How to cite this URL:
Keerthiga K, Kundu CR, Patro KC, Bhattacharyya PS, Pilaka VK, Padhi S, Rao M M, Reddy P S, Mohanapriya A, Avidi VP, Damodara VN. Squamous cell carcinoma of tongue with isolated inguinal node metastasis: A case report and literature review. J Curr Oncol [serial online] 2021 [cited 2022 May 17];4:140-3. Available from: https://www.journalofcurrentoncology.org/text.asp?2021/4/2/140/338055




  Introduction Top


Head and neck squamous cell carcinoma (HNSCC) cancer is the second most common cancer in India. According to GLOBOCAN 2020, lip and oral cavity cancer burden is high in India approximately 10.2 per 100,000.[1] Approximately 70% of cancer (carcinoma lung and oral cavity) in India are due to modifiable causes such as tobacco consumption and air pollution. HNSCC shows an index of 25%–45% lymphatic metastasis which includes all sites and stages of tumor.[2] The lymph nodal metastasis occurs with a variable frequency depending on the site of the lesion, T-stage, and histopathological characteristics of the primary lesion, that is, type, degree of differentiation, perineural, and lymphovascular invasion.[3] Tumor metastases take place through hematogenous spread to distant organs (lung, skin, bone, and liver) and lymphatic spread to distant lymph nodes (mediastinal, abdominal, and axillary nodes). In general, with respect to head and neck cancer, 66% of distant metastases are to the lungs, 22% to the bones, and 9.5% to the liver. Distant metastasis can occur at initial diagnosis or, more often, later as a natural course of the disease. The incidence of nonsquamous histology is less than 10% that includes Adenoid cystic carcinoma, basaloid squamous cell carcinoma, and neuroendocrine carcinomas which are considered as aggressive metastatic tumors.[3] The 5-year locoregional recurrence is approximately 50%, whereas distant metastases are approximately 15% in locally advanced HNSCC. With distant metastasis, the overall survival reduces significantly even with early diagnosis of metastasis. The prevalence of distant metastasis increases significantly (approximately 32%) with the presence of extranodal extension. A 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 Top


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 3 cm × 1.5 cm × 0.5 cm, grade I. All margins were ≥1 cm with lymphovascular (+) and perineural invasion (+). The depth of invasion was 0.5 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 20 days [Figure 1] [Figure 2] [Figure 3]. The onset was sudden associated with mild pain, dragging type. On examination, a single swelling, measuring approximately 1.5 cm × 1 cm over right inguinal region was found which was firm, mobile, and nontender [Figure 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. A radiologist’s 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 [Figure 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. 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.
Figure 1: Postoperative tongue at sixth month follow-up

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Figure 2: Postoperative tongue—no evidence of local recurrence on local examination

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Figure 3: Postoperative tongue—no palpable neck nodes

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Figure 4: A swelling noted over right groin region measuring about 1.5 x 1 cm, firm in consistency, not mobile

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Figure 5: PET-CT showing image with FDG (Fluorodeoxyglucose) avid right inguinal node

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  Discussion Top


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 I 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 et al.[8] have reported approximately 5% distant metastasis in head and neck cancer patients with locoregional control. A rare case of isolated axillary node in carcinoma buccal mucosa presented after 4 years of treatment to the primary (AIIMS, New Delhi).[9] Das Majumdar et al.[10] in their case report described distant metastasis to cutaneous, cardiac region in a patient with anterior tongue carcinoma after 2 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 et al.[11] reported a case with carcinoma of unknown primary with inguinal metastasis, which was developed squamous cell carcinoma of penis after 3 years of inguinal metastasis. Zaren et 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 6 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 Top


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 Top

1.
Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL, Santhappan S, et al; ICMR-NCDIR-NCRP Investigator Group. Cancer statistics, 2020: Report from national cancer registry programme, India. JCO Glob Oncol 2020;6:1063-75.  Back to cited text no. 1
    
2.
Duprez F, Berwouts D, De Neve W, Bonte K, Boterberg T, Deron P, et al. Distant metastases in head and neck cancer. Head Neck 2017;39:1733-43.  Back to cited text no. 2
    
3.
Pisani P, Airoldi M, Allais A, Aluffi Valletti P, Battista M, Benazzo M, et al. Metastatic disease in head & neck oncology. Acta Otorhinolaryngol Ital 2020;40:S1-86.  Back to cited text no. 3
    
4.
Borse V, Konwar AN, Buragohain P Oral cancer diagnosis and perspectives in India. Sens Int 2020;1:100046.  Back to cited text no. 4
    
5.
Bernier J, Cooper JS, Pajak TF, van Glabbeke M, Bourhis J, Forastiere A, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (# 9501). Head Neck 2005;27:843-50.  Back to cited text no. 5
    
6.
Dias FL, Lima RA, Kligerman J, Farias TP, Soares JR, Manfro G, et 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.  Back to cited text no. 6
    
7.
Byers RM, Weber RS, Andrews T, McGill D, Kare R, Wolf P Frequency and therapeutic implications of “skip metastases” in the neck from squamous carcinoma of the oral tongue. Head Neck 1997;19:14-9.  Back to cited text no. 7
    
8.
León X, Quer M, Orús C, del Prado Venegas M, López M Distant metastases in head and neck cancer patients who achieved loco-regional control. Head Neck 2000;22:680-6.  Back to cited text no. 8
    
9.
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 Cancer Res Ther 2019;15:693-5.  Back to cited text no. 9
    
10.
Das Majumdar SK, Sahoo TK, Parida DK Cutaneous and cardiac metastases in carcinoma of anterior tongue. J Cancer Res Ther 2020;16:680-2.  Back to cited text no. 10
    
11.
Sinha M, Katema M, Malata CM Squamous cell carcinoma of penis presenting as groin metastasis 3 years before the primary. J Plast Reconstr Aesthet Surg 2006;59:547-9.  Back to cited text no. 11
    
12.
Zaren HA, Copeland EM 3rd. Inguinal node metastases. Cancer 1978;41:919-23.  Back to cited text no. 12
    
13.
Pavlidis N, Briasoulis E, Hainsworth J, Greco FA Diagnostic and therapeutic management of cancer of an unknown primary. Eur J Cancer 2003;39:1990-2005.  Back to cited text no. 13
    
14.
Hemminki K, Bevier M, Hemminki A, Sundquist J, Survival in cancer of unknown primary site: Population-based analysis by site and histology. Ann Oncol 2012;23:1854-63.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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