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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 35-37

Acral metastasis in carcinoma of buccal mucosa: An unusual presentation


1 Department of Radiotherapy, Acharya Harihara Regional Cancer Centre, Cuttack, Odisha, India
2 Department of Medical Oncology, Acharya Harihara Regional Cancer Centre, Cuttack, Odisha, India

Date of Web Publication21-Jun-2018

Correspondence Address:
Dr. Surendra Nath Senapati
Department of Radiotherapy, Acharya Harihara Regional Cancer Centre, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/oji.oji_13_18

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  Abstract 


Acral metastasis is rare in incidence with poor prognosis due to presence of widespread metastases during presentation. Lung is the most common primary for acral metastases followed by breast and kidney. Acrometastasis with head and neck primary is an extremely rare situation with only few cases reported in the literature. Here, we present a case of acral metastases in a 40-year-old male. The patient was previously diagnosed as a case of squamous cell carcinoma of gingivobuccal sulcus on the left side, and for which, he had undergone radical surgery followed by adjuvant concurrent chemoradiation 6 months back. The patient had local recurrence with multiple metastatic pleural nodules during diagnosis of acral metastasis. The patient was treated with one cycle of palliative chemotherapy followed by amputation of the metastatic finger. However, after 2 months of treatment, the patient was died due to the disease progression.

Keywords: Acral metastasis, gingivobuccal sulcus, squamous cell carcinoma


How to cite this article:
Mohanty SN, Samanta DR, Avinash A, Senapati SN. Acral metastasis in carcinoma of buccal mucosa: An unusual presentation. Oncol J India 2018;2:35-7

How to cite this URL:
Mohanty SN, Samanta DR, Avinash A, Senapati SN. Acral metastasis in carcinoma of buccal mucosa: An unusual presentation. Oncol J India [serial online] 2018 [cited 2018 Sep 18];2:35-7. Available from: http://www.ojionline.org/text.asp?2018/2/2/35/234901




  Introduction Top


Bone metastasis usually occurs in 30% of malignancies, and prostate, lung, breast, kidney, and gastrointestinal are the common possible primaries for the bone metastasis.[1] The acral metastasis is a rare entity among all bone metastases with incidence ranging from 0.007% to 0.3%.[2] Usually, there is no red bone marrow at the distal end of the bone, for which the metastasis to the distal part of the long bone is a rare entity. The most common primary for acrometastsis is lung followed by breast cancer and renal cell carcinoma.[3] Here, we report a case of acral metastasis to middle finger of the right hand in a treated case of squamous cell carcinoma (SCC) of the left gingivobuccal sulcus.


  Case Report Top


A 40-year-old male with a history of tobacco chewing was initially diagnosed with carcinoma of the left side gingivobuccal sulcus with clinical tumor, node, metastasis (TNM) staging of T2N1M0. He was initially treated with a composite resection of the lesion and followed by adjuvant concurrent chemoradiation to a total dose of 60 Gy in 30 fractions in view of postoperative pathological TNM staging of PT3N2bMX (American Joint Committee on Cancer 7th Edition) and three out of 18 lymph nodes positive with extracapsular extension spread. After 6 months of follow-up, he developed a painful swelling over the right middle finger with redness and an ulcerative lesion measuring approximately 2 cm × 2 cm in the left gingivobuccal sulcus area. The patient received oral antibiotics for the finger swelling suspecting as an infectious etiology. After taking antibiotics, the finger swelling did not subside. X-ray of the right hand showed a lesion in the middle finger with pathological fracture [Figure 1]. In view of existing primary SCC of gingivo-buccal sulcus and suspicious recurrent lesions, we performed biopsy from the oral cavity lesion and cytology from the finger lesion that showed the presence of recurrent SCC in the oral cavity and metastatic squamous cell deposits in the finger, respectively. Positron emission tomography scan showed a hypermetabolic mildly enhancing lesion in the left gingivobuccal sulcus and metastatic deposits in the left pleura and right middle finger [Figure 2]a,[Figure 2]b,[Figure 2]c. The patient was started on chemotherapy with paclitaxel, carboplatin, and 5-fluorouracil-based combination regimen in palliative intent. The patient received three cycles of same chemotherapy with poor response. The pain and swelling of the finger increased which were unbearable, for which he had undergone amputation of the finger. The operated specimen on microscopic examination revealed features of SCC [Figure 3]a and [Figure 3]b. The patient refused to take further palliative chemotherapy, and after 2 months, the patient succumbed to death due to disease progression.
Figure 1: X-ray of the right hand showing a soft-tissue swelling over the middle finger with pathological fracture

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Figure 2: Positron emission tomography-computed tomography scan showing metastatic lesion over the middle finger of the right hand, recurrent primary lesion at the left buccal mucosa, and metastatic pleural deposit (a-c)

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Figure 3: (a) Presence of tumor cells in sheets (H and E, ×40) and (b) presence of tumor cells with nuclear pleomorphism, few mitoses, and squamous pearls (H and E, ×400)

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  Discussion Top


Bone metastasis usually occurs in 30% of the cancers with axial or appendicular bones, especially spine being common site of metastasis. Acral metastasis is a rare entity constituting 0.1% of all bony metastases.[4] Majority of acral metastases occur in the dominant hand with bilateral involvement seen in only 10% of cases. Third finger being the common site of acral metastases among all, the digits and distal phalanx were the predominant sites in the finger.[5] Seventy-five percent of cases metastasize to phalanges, followed by metacarpals and carpals.[1],[3]

The most common primary for acrometastsis is lung constituting 40%–50%, followed by breast cancer (15%) and renal cell carcinoma (10%).[3] The other possible primaries for acral metastasis are colon, stomach, liver, prostate, and rectum. A primary from the buccal mucosa is an extremely rare entity.

Majority of the trials emphasizes locoregional control in head and neck cancer due to common pattern of therapeutic failure. However, distant metastases can occur up to 15% of the patients resulting dismal prognosis.[6] Lung is the most common site for distant metastasis constituting 66% followed by bones (22%), liver (10%), skin, mediastinum, etc.[7]

Acral metastasis may initially arise in bone with gradual increase in size involving skin or may involve skin first.[3] The presentation in acral metastases usually simulates infections or inflammation with sign or symptoms of edema, hyperemia, ulcerated lesions, and pain. This leads to delay in diagnosis and consequently worsening of prognosis with a median survival of 6 months.[5] Therefore, early confirmation of the diagnosis of acral metastasis is crucial to prevent unnecessary amputation or inadequate treatment.

Metastasis in head and neck cancer may occur as a result of detachment of cells from tumor tissue, regulation of cell motility, and invasion, proliferation, and evasion through the lymphovascular channels. However, the mechanism of acral metastasis in head and neck cancer is unclear. The possible mechanisms are direct spread through contiguous spread via tissue plane, local spread through dermal lymphatics causing implantation of skin, and hematogenous spread.[8]

Only few cases of acral metastasis reported with primary of head and neck cancer. Lewin et al. reported the first case of metastasis to thumb in laryngeal cancer, and the thumb was used for digital occlusion during tracheoesophageal speech, resulting possible metastasis due to direct implantation from contact with contaminated pulmonary secretions via tracheostomy.[9] However, Nayak et al. reported a case of acral metastasis in a previously treated laryngeal carcinoma, suspecting hematogenous metastasis as the possible root due to involvement of multiple fingers in both the hands.[8] Cagney and Fraser reported a case of acral metastasis in a previously treated case of hypopharyngeal carcinoma, suspecting hematogenous metastasis as the possible root due to involvement of multiple sites of the right hand.[7] In a study, Bhandari reported a case of acral metastasis to the proximal phalanx of index finger in a treated case of carcinoma of the buccal mucosa.[10]

The treatment of acral metastasis is usually palliative due to disseminated disease during presentation and have short median survival. Amputation is the most common method for finger metastasis treatment, whereas local radiotherapy or curettage may be preferred options in some cases.[3]

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.
Kanbay A, Oguzulgen KI, Ozturk C, Memis L, Demircan S, Kurkcuoglu C, et al. Malignant pleural mesothelioma with scalp, cerebellar, and finger metastases: A rare case. South Med J 2007;100:63-5.  Back to cited text no. 1
[PUBMED]    
2.
van Veenendaal LM, de Klerk G, van der Velde D. A painful finger as first sign of a malignancy. Geriatr Orthop Surg Rehabil 2014;5:18-20.  Back to cited text no. 2
[PUBMED]    
3.
Sahoo TK, Das SK, Majumdar SK, Senapati SN, Parida DK. Digital acrometastasis as initial presentation in carcinoma of lung A case report and review of literature. J Clin Diagn Res 2016;10:XD01-2.  Back to cited text no. 3
    
4.
Kerin R. Metastatic tumors of the hand. A review of the literature. J Bone Joint Surg Am 1983;65:1331-5.  Back to cited text no. 4
[PUBMED]    
5.
Soylemez S, Demiroglu M, Yayla MA, Ozkan K, Alpan B, Ozger H, et al. Lung metastasis mimicking fingertip infection. Case Rep Oncol Med 2015;2015:708789.  Back to cited text no. 5
    
6.
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. 6
[PUBMED]    
7.
Cagney D, Fraser I. Acral metastasis from head and neck squamous cell carcinoma. J Case Rep 2015;5:219-21.  Back to cited text no. 7
    
8.
Nayak J, Zhong Y, Haigentz M Jr. Acral metastases from laryngeal carcinoma. J Clin Oncol 2011;29:e220-1.  Back to cited text no. 8
[PUBMED]    
9.
Lewin JS, Cleary KR, Eicher SA. An unusual metastasis to the thumb in a laryngectomized tracheoesophageal speaker. Arch Otolaryngol Head Neck Surg 1997;123:1007-9.  Back to cited text no. 9
[PUBMED]    
10.
Bhandari V. Incidence of bone metastasis in carcinoma buccal mucosa. Indian J Med Paediatr Oncol 2016;37:70-3.  Back to cited text no. 10
[PUBMED]  [Full text]  


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  [Figure 1], [Figure 2], [Figure 3]



 

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