|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 3 | Page : 401-402
An unusual case of squamous cell carcinoma of buccal mucosa with distant metastases
G Kaur, P Bakshi, SP Gupta, K Verma
Department of Cytopathology, Sir Ganga Ram Hospital, New Delhi and North Delhi Nursing Home Pvt. Ltd., New Delhi, India
|Date of Web Publication||18-Feb-2016|
Department of Cytopathology, Sir Ganga Ram Hospital, New Delhi and North Delhi Nursing Home Pvt. Ltd., New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kaur G, Bakshi P, Gupta S P, Verma K. An unusual case of squamous cell carcinoma of buccal mucosa with distant metastases. Indian J Cancer 2015;52:401-2
Squamous cell carcinoma of oral cavity including buccal mucosa has a propensity for loco-regional spread. Distant metastasis in lungs, bones, liver, and skin may be rarely seen with these tumors. Further spread to serous cavities is even rarer. We describe a case of squamous cell carcinoma (SCC) of buccal mucosa with rare presentation of distant metastasis including peritoneal cavity.
A 40-year-old man, chronic tobacco chewer, had oral leukoplakia for last 7 years. Tooth extraction was done in an outside hospital, and a biopsy taken simultaneously revealed a well-differentiated SCC. Patient declined surgery and subsequently developed a large oral ulcer with oro-cutaneous fistula. He received two cycles of platinum-based chemotherapy. Few days later, he presented to the hospital with sub-acute intestinal obstruction. X-ray abdomen revealed air fluid levels. Ultrasound abdomen revealed mild hepatomegaly, cholelithiasis, and ascitis.
Two liters of straw-colored ascitic fluid was aspirated. Cytospin smears were prepared and were stained with Papanicolaou and May Grunwald Giemsa stains.
The smears showed large numbers of macrophages, inflammatory cells, and few mesothelial cells. Amongst these cells, few atypical cells were identified lying singly. These cells were round with abundant dense cyanophilic cytoplasm [Figure 1]. Ocassional small fragments of atypical cells were also observed [Figure 2]. The nuclei were hyperchromatic with irregular nuclear contours and prominent nucleoli. Morphologic possibilities considered on these cells were non-keratinizing cells of SCC or reactive mesothelial cells. Since these cells were very few in number, a cell block was prepared from the fluid. The hematoxylin and eosin stained smears also showed few single atypical cells similar to those observed in smears and did not further assist in confirming the nature of these cells. On immunostaining, these cells showed strong nuclear positivity with p63 (1:100, BioSB, Santa Barba, CA, USA) and were negative with calretinin (prediluted, Novocastra, UK) [Figure 1], inset]. Based on these cytological and immunohistochemial findings, a diagnosis of metastatic SCC in ascitic fluid was rendered.
|Figure 1: Few single atypical cells (center of image) in background of inflammatory cells, Pap, ×600. Inset atypical cells show strong nuclear staining with p63 antibody|
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Follow-up computed tomographic scan (CT scan) of the patient revealed deposits in omentum, spleen, and multiple bones including sternum, ribs, lumbar spine, and pelvis. Later, the patient also developed bilateral pleural effusion.
Distant metastases in oral cavity SCC are seen 0.5% to 2% cases  and are expected in cases with advanced tumors and advanced regional disease. In a large study of oral cavity SCC, distant metastases at presentation were observed in 1.95% patients only.
The finding of SCC in serous effusions and particularly peritoneal is an uncommon event. In a review of serous effusions of 7,389 patients, SCC was found in only 46 patients, out of which 8 were ascitic fluid.
In serous effusions, cells of SCC tend to be present singly. These may be overlooked or misinterpreted as mesothelial cells when definite evidence of keratinization is not present.
The transcription factor p63 has recently emerged as a promising marker to indicate squamous differentiation in poorly-differentiated carcinomas. Kaufmann et al. evaluated the value of p63 for the differential diagnosis of poorly-differentiated carcinomas and found that 81% (59/73) of SCC showed diffuse nuclear positivity with p63. All mesotheliomas (14 cases) in this study were negative. Some reactive pleural and peritoneal cells showed only weak positivity.
This case illustrates uncommon presentation of SCC of buccal mucosa and highlights the role of immunocytology as an indispensable adjunct in increasing diagnostic accuracy in routine cytology practice.
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[Figure 1], [Figure 2]