Abstract
Distant metastases from oral squamous cell carcinoma are unusual, but generally occur in lungs, bone, and liver. Cutaneous metastasis is extremely rare, and it often reflects an advanced stage with sinister prognosis. The authors report an 81-year-old male patient with multifocal cutaneous metastases from a recurrent squamous cell carcinoma of the hard palate 5 months after primary treatment.
Oral squamous cell carcinoma (OSCC) accounts for over 90% of all oral cancers and is the eighth most common cancer worldwide. The sites commonly involved include the tongue, the floor of the mouth and the buccal mucosa, whilst hard palate involvement is comparatively less. The prognosis of OSCC is generally poor, with no significant improvement in overall 5-year survival rates (45–55%) in the past two decades. Survival of OSCC patients, including those with SCC of the hard palate, is influenced by tumour stage, cervical lymph node status, histological grade, and distant metastasis status.
OSCC has a predilection for cervical lymph node metastasis, with a 27–40% incidence even in early stage tumours (T1/T2), but the distant metastasis is only about 10%. Common sites for distant metastasis are lung, bone and liver; cutaneous metastasis is rare. The authors present a rare case of multifocal cutaneous metastases from a recurrent hard palate SCC.
Case report
The patient was an 81-year-old Chinese man who presented with a 3-month history of a deep non-healing ulcer at the left posterior hard palate with occasional epistaxis. The painless ulcer was over 2 cm in diameter with little swelling. His medical history was unremarkable.
The patient used to smoke 20 cigarettes a day for over 30 years and drank unspecified amounts of alcohol ‘socially’. CT scans showed thickening of the soft tissues at the roof of the oral cavity, abutting the hard palate and eroding the hard and soft palate and floor of the nasal cavity. Several small volume lymph nodes were found bilaterally at levels II and III, but were classified as unenlarged on radiographic criteria. The diagnosis, confirmed by biopsy, was SCC of the left hard palate (T 2 N 0 M 0 ). The treatment plan was local surgical excision without neck dissection. After routine preoperative examination, the tumour was excised with good margins of hard and soft palate. Four dental implants were placed simultaneously under general anaesthesia. During the operation, frozen sections of all the margins were clear of tumour. The histopathological diagnosis of the lesion was confirmed to be moderately differentiated SCC. The hard palate defect was rehabilitated with an obturator. Reconstruction was not planned until the disease was controlled locally.
Three months after the primary operation, epistaxis reappeared. A CT scan showed new erosion of the posterior floor of the left sphenoid sinus, and a 10 mm soft tissue nodule in the anterior wall of the left maxillary sinus with associated bone erosion. The recurrence, located at the skull base, was confirmed by biopsy. The patient’s family refused extensive surgery because of his frail condition, so he was scheduled for radiotherapy followed by chemotherapy. Two months after radiation of the recurrent region, except the neck, multiple painless nodules appeared in the skin of the face ( Fig. 1 ), neck ( Fig. 2 ), back ( Fig. 3 ), toe ( Fig. 4 ) and oral mucosa.
Pathological examination found these nodules to be infiltrative SCC invading the subcutaneous tissue. The histologic features were consistent with SCC, and appeared compatible with a clinical diagnosis of multifocal metastatic lesions from the previous hard palate SCC. A chest X-ray revealed multiple round opacities of various sizes in both lungs. This patient was too weak to undergo chemotherapy, though several skin metastatic nodules were excised at the patient’s request. The patient died 2 months after the diagnosis of multifocal cutaneous metastases.
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