Introduction
Head and Neck cancers account for 7th most common malignancy worldwide. Cutaneous metastasis from head and neck cancers are uncommon.1 The incidence of cutaneous metastasis from head and neck cancers is less than 1%.2 Carcinoma larynx is most often associated out of them.3 It is even rare in cancers of the oral cavity. The common sites of distant metastasis cancers of oral cavity are the lung, liver, and bones.4 Here we present a case of carcinoma of floor of mouth with upfront cutaneous metastasis (T4a N2c M1 -Stage 4) treated with Palliative Chemotherapy and Radiotherapy.
Case Presentation
A 55-year-old lady presented to our department with complaints of non-healing ulcer oral cavity and multiple swellings over neck from past 6 months. She had a history of local injury after which an ulcer was formed. She had been taking home remedies with no relief. She had no history of any previous radiation treatment, any immunosuppresive agents, drug abuse, tooth extraction or hot beverages.
Figure 4
Fine needle aspiration cytology cutaneous metastasis showing metastatic deposits (Squamous cell carcinoma)
On examination mouth opening and tongue mobility was restricted with grade 2 trismus. An ulcer proliferative growth approximately of size 3*2 in left GB Sulcus was seen involving the left buccal mucosa . Multiple Bilateral hard fixed lymphadenopathy and multiple hard ulcerated skin nodules on neck and chest wall were noted (Figure 1).
CECT Face and Neck showed heterogenously ehancing mass 6*5.1cm at the floor of mouth involving left buccal mucosa and erosion of mandible, bilateral lymph node mets l2 to 5 cm and multiple skin nodules over neck and upper chest (Figure 2).
Histopathology of floor of mouth as well as skin nodules were suggestive of moderately differentiated squamous cell carcinoma (Figure 3).
ECOGPS was 1. She was treated with palliative systemic chemotherapy and thereafter Palliative radiation in view of locally advanced disease. Now She is having stable disease on metronomic chemotherapy and is on regular follow up.
Discussion
The overall incidence of Cutaneous Metastasis from underlying internal malignancies ranges between 0.7% and 9%, but that from HNSCC is rare (0.7%– 2.4%) with only few cases reported in the literature.5 Cutaneous metastasis are defined as isolated or multiple intradermal collections of tumor cells remote from the primary or loco-regional disease.6 It is important to differentiate these lesions from extensions from the primary cancer, scar metastasis, metastasis from other primary skin cancers and primary cutaneous disorders.7 There are three possible modes of spreadnamely direct spread, local spread and distant spread. Skin metastasis is thought to involve hematogenous spread where pulmonary circulation and filtration can be theoretically bypassed via the azygous, venous and vertebral venous system via Batson’s plexus, allowing skin implantation.8
Berger and Fletcher in their study reported that average survival was only around 3 months after skin metastasis becomes clinically evident in HNSCC.9 The treatment of cutaneous metastasis is, in general, palliative. Options available are surgical excision, radiotherapy, and chemotherapy or combination of these. As for now, all patients do poorly and succumb rapidly to the disease.10, 11 Prakash et al.12 reported a case of a 78-year-old male with carcinoma of the right buccal mucosa post surgical treatment presented with a near local site recurrence and subsequently developed distant skin metastases to the lower neck and upper trunk during treatment. Verma et al.13 also reported a biopsy confirmed cutaneous metastasis from ca tongue post treatment with Surgery and CTRT. Bedi et al.[14] also reported a case of radically treated case of Ca tongue who presented later on with cutaneous metastasis , treated with palliative chemotherapy and expired 4 months after diagnosis of cutaneous mets. The patient in the present study was treated with palliative chemotherapy and palliative radiation. Now patient is on Metronomic Chemotherapy with stable disease and regular follow up. The patient has been on treatment for more than 14 months. At present, it is difficult to comment on overall survival of the patient.
Conclusion
Cutaneous metastasis is a rare presentation in head and neck cancers. Proper investigations and workup should be done for appropriate treatment in such cases. Our case has highlighted that cutaneous metastasis can be seen in the cancers of floor of mouth. Palliative Chemotherapy and Radiotherapy can significantly increase Progression free survival and hence the Quality of life of patients with such presentation.
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