Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 3, 2010, pp. 397-399

Journal of Cancer Research and Therapeutics, Vol. 6, No. 3, July-September, 2010, pp. 397-399

Case Report

Massive scapular metastasis as a presenting feature of carcinoma of the lip

Ranjana Bandyopadhyay¹, Dipanwita Nag¹, Sanjay K Bandyopadhyay²

¹ Department of Pathology, Medical College, Kolkata - 700 073, India
² Department of Medicine, Nil Ratan Sircar Medical College, Kolkata - 700 014, India

Correspondence Address:Sanjay K Bandyopadhyay, 1B/3, Uttarpara Housing Estate, 88 B, G T Road, P.O.- Bhadrakali, Dist- Hooghly - 712 232, West Bengal, India, drsanjaygastro@gmail.com

Code Number: cr10100

PMID: 21119290

DOI: 10.4103/0973-1482.73338

Abstract

Keywords: Carcinoma of the lip, scapular metastasis, squamous cell carcinoma

Introduction

Carcinoma of the lip accounts for 30% of oral cavity cancers and is classically a slow-growing locally-advanced disease that occurs more commonly in males with exposure to sunlight. ^[1] The incidence of distant metastasis is low and the common sites are lungs, liver, skin, and spleen. ^[2] Distant metastasis adversely impact survival and may significantly affect treatment planning. ^[3] Bone metastasis is rare; most have been reported in autopsy series. ^[4] We present a case of node-negative squamous cell carcinoma (SCC) of the lower lip with extensive distant skeletal metastasis where symptoms due to massive left scapular deposits were the only presenting complaints.

Case Report

A 58-year-old male laborer developed rapidly increasing swelling of the left scapular bone along with persistent dull pain, aggravated by limb movements and weight bearing. After about six months, he presented to us with severe local pain unresponsive to round-the-clock analgesics and maximum at night. On examination, the entire left scapula was massively enlarged and deformed having loss of anatomic landmarks with irregular surface and tenderness on palpation [Figure - 1]. The overlying skin was normal. The entire range of shoulder movement was unrestricted but painful. Fine needle aspiration was performed from scapular swelling that revealed features of metastatic SCC [Figure - 2].

Patient was a heavy smoker for last 35 years with an average intake of 20 cigarettes per day. However, he was not addicted to tobacco or betel quid. When asked specifically, patient admits having noticed a slowly growing painful ulcerated lesion on the outer aspect of the right lower lip for last two years. The lesion was neglected initially as it caused no inconvenience to the patient. For the last two months, the ulcer had grown rather rapidly to involve the inner aspect of the lower lip extending up to the right angle of the mouth. Rest of his past, personal and family history was non-contributory.

On examination, a small shallow ulcer (about 1 cm in diameter) with everted rolled-up margin and necrotic base was identified near the right angle of mouth [Figure - 3]. There was no adenopathy in the cervical region or elsewhere. Systemic examination was unrevealing. A biopsy examination performed from the lesion showed features of infiltrating well differentiated squamous cell carcinoma. Routine biochemical and hematological investigations were normal except low hemoglobin (9 g/dl) with normocytic normochromic blood picture. Direct laryngoscopy and an upper gastrointestinal endoscopy examination were unremarkable. Screening of whole body was performed next to look for other areas of metastatic deposit. Computed tomography (CT) scan of soft tissues of neck could not find out any neck node. CT thorax revealed no pulmonary parenchymal deposit or mediastinal node. On whole body bone scan (after intravenous injection of 20 mCi ⁹⁹ mTc - MDP), a large photopenic area over inferior and lateral aspect of left scapula with markedly increased concentration of radiotracer over its superomedial margin was noted [Figure - 4]. Increased tracer uptake was also found on both shoulder joints, right humeral shaft, left ischial tuberosity, proximal third of right femoral shaft and mid third of left femoral shaft suggesting metatasis [Figure - 4]. The histopathology slides form oral lesion was reviewed. The depth of tumor invasion was measured according to Breslow scale and was found to be a deep infiltrating tumor (depth of invasion 4.9 mm).

A diagnosis of metastatic SCC of the lip with extensive scapular involvement was made. Patient was treated with combination chemotherapy ( docetaxel 80 mg/ m ² body surface area and cisplatin 75 mg/ m ² body suface area in weekly doses) for metastatic disease with local application of external beam radiation for pain. Patient succumbed to his illness three weeks later.

Discussion

The occurrence of distant metastasis related to carcinoma of the lip is very exceptional (0.5-2%) and can be expected in cases of advanced tumors with advanced regional disease. ^[5] Lungs are the most common sites accounting for two third of the cases. ^[4] The incidence of distant skeletal metastasis is 2.14%. ^[1] Common sites include the spinal vertebrae and long bones of the extremities. ^[1],[6] The scapula is a very uncommon site and only one case of clinically recognizable scapular metastasis has been reported till date in literature. ^[7]

Various parameters have been shown to be associated with increased risk of distant metastasis in SCC of the lip. ^[8],[9] These are advanced tumor grade, depth of invasion (denoted by Breslow score), presence of plasma cells, three or more lymph node metastasis (50% risk), bilateral lymph node metastasis, lymph nodes of 6 cm or larger, low jugular lymph node metastasis, locoregional tumor recurrence and second primary tumor. The case we presented did not have any clinically palpable neck node or any lymph node detectable by cross sectional imaging of neck and thorax. However on histological examination, the primary tumor showed higher depth of invasion.

Three unique points merit consideration in the present case. First, is the absence of neck node in this disseminated malignancy with fatal termination. Second, extensive skeletal metastasis occurred in absence of any involvement of lungs and liver, which are rather common sites for distant metastasis. Finally, disfiguring symptomatic massive scapular metastasis was the only presenting complaint that led to the ultimate discovery of the underlying pathology.

References

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