|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 2 | Page : 201-202
Three squamous cell carcinomas of different sites in three years: A mere coincidence?
Mawaddah Azman, Mohd Razif Mohd Yunus
Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Ya'akob Latiff, Bandar Tun Razak, Kuala Lumpur, Malaysia
|Date of Web Publication||5-Feb-2016|
Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Ya'akob Latiff, Bandar Tun Razak, Kuala Lumpur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Azman M, Mohd Yunus MR. Three squamous cell carcinomas of different sites in three years: A mere coincidence?. Indian J Cancer 2015;52:201-2
A 64-year-old gentleman presented with two months history of painful bloody otorrhoea associated with upper neck swelling. He gives history of psoriasis treated with Ultraviolet Light (UVL) Phototherapy with significant occupational exposure to sunlight. He initially presented with a non-healing ulcer on the left shin with enlarged left inguinal nodes. The ulcer and nodal involvement were excised surgically then, adjuvant radiotherapy given, following a histopathological diagnosis of Squamous Cell Carcinoma (SCC) with nodal metastasis. A year after, he presented similarly, now on the dorsum of the left hand which was managed in the same way. He then remained disease free for three years. Examination now revealed a friable mass at the middle third of the right external auditory canal, with a firm parotid swelling measuring 3 × 3 cm. Computed Tomography showed a soft tissue density mass of the right middle ear and external auditory canal [Figure 1] with enlarged right intraparotid nodes [Figure 2]. He underwent radical radiotherapy of 66 Guy to the ear and neck. However, a week following completion of radiotherapy, he had residual parotid area swelling which was progressively increasing in size. Examination revealed a parotid swelling of 4 × 4 cm, no palpable neck nodes, with intact facial nerve and no obvious mass appreciated in the ear. Two weeks later, Right Total Parotidectomy with Facial Nerve Preservation and Type 3 Modified Radical Neck Dissection was performed. Histopathological examination showed malignant infiltration of the deep lobe of the parotid gland and Level 2b lymph nodes with SCC. He recovered well with no evidence of tumour recurrence at six months post operatively. Further workup for immunosuppression included negative serology for HIV, normal leucocyte count as well as normal C3 and C4 levels. He also did not give any other significant medical or drug history.
|Figure 1: Axial cuts of HRCT temporal bone showing a soft tissue mass at the right external auditory canal (EAC) (a) and middle ear (b) with punch out lytic lesion of the posterior wall of right EAC (black arrowhead)|
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|Figure 2: Axial (a) and coronal (b)cuts of contrasted CT neck showing an enhancing right intraparotid node measuring 1.4 cm (black arrow)|
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Multiple SCC with metastatic nodal involvement is rarely observed in healthy patients such as ours. There are only four cases reported of patients with multiple SCC and metastatic nodal involvement. However, all of them are either receiving long term immunosuppressive therapy or has underlying lymphoproliferative disease: for which our patient is neither. Hence, this case is unique as it portrays interplay of multiple risk factors giving rise to SCC, entities that should not be missed in managing cancer.
The incidence of SCC differs according to geographic latitude, being highest at the equator: Our patient worked outdoor more than 40 hours per week for 30 years posing significant occupational exposure to ultra violet light, an implied carcinogen in SCC. Apart from that, another risk factor identified in this patient is UVL phototherapy, which is known to be immunosuppressive and is associated with higher risk of SCC:, This has sprouted new interests on relationship between psoriasis and SCC. Two theories are investigated, psoriasis causing chronic skin injury predisposing to SCC  and genetic coding for SCC (SCC antigen SCCA1 and SCCA2) over-expression giving rise to psoriatic disease activity.
In conclusion, SCC is a common malignancy with rare instances of multiple primaries in a lifetime. Keystones in managing similar patients with multiple risk factors for developing SCC include lifestyle modification, close follow up and early management and intervention of suspicious lesions.
| » Acknowledgement|| |
The Computed Tomography films and description is a courtesy of the Department of Radiology and Diagnostic Imaging, UKM Medical Centre.
| » References|| |
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[Figure 1], [Figure 2]