Squamous Cell Carcinoma of Tongue with Isolated Inguinal Node Metastasis: A Case Report and Literature Review

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DOI:
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Address for correspondence: Dr. Chitta Ranjan Kundu,
Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and
Research Institute, Visakhapatnam, Andhra Pradesh, India.
E-mail: drcrkundu@gmail.com
Received: 09 August 2021; Revised: 02 October 2021;
Accepted: 24 November 2021; Published: 23 February 2022
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How to cite this article: Keerthiga K, Kundu CR, Patro KC,
Bhattacharyya PS, Pilaka VK, Padhi S, et al. Squamous cell carcinoma
of tongue with isolated inguinal node metastasis: A case report and
literature review. J Curr Oncol 2021;4:140-3.
Case Report
Squamous Cell Carcinoma of Tongue with Isolated Inguinal
Node Metastasis: A Case Report and Literature Review
Keerthiga K., Chitta Ranjan Kundu, Kanhu Charan Patro, Partha Sarathi Bhattacharyya, Venkata Krishna Reddy Pilaka, Sanjukta Padhi1
,
M. Mrityunjaya Rao, P
. Srinivasuslu Reddy, A. Mohanapriya, V. S. Premchand Kumar Avidi, Venkata Naga Priyasha Damodara
Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh, 1
Department of Radiation Oncology,
Acharya Harihar Regional Cancer Center, SCB Medical College, Cuttack, Odisha, India
Abstract
Most of the patients with squamous cell carcinoma of tongue present with distant metastasis to lung, bone, and liver. However, some
rare presentation of tongue cancer metastasizing to cutaneous, cardiac, and axillary lymph nodes has been reported. We present a case
of 55-year-old man diagnosed with squamous cell carcinoma of right lateral border of tongue, underwent right hemiglossectomy and
right modified neck dissection, levels 1–5 with pathological staging pT2N0M0 (AJCC 8th edition) followed by adjuvant radiotherapy
to a total dose of 60 Gy in 30 fractions. After 6-month post-treatment, the patient presented with right inguinal swelling which
was associated with pain. Ultrasonography of the groin region confirmed lymphadenopathy and fine-needle aspiration cytology
(FNAC) from lymph node came out as metastatic deposits of squamous cell carcinoma. Positron emission tomography and computed
tomography (PET-CT) showed isolated right inguinal lymph node metastasis. He underwent right inguinal block dissection and
adjuvant radiotherapy. Hence, isolated inguinal node metastasis is extremely rare but possible. Patient should be examined thoroughly
during follow-up.
Keywords: Fine needle aspiration cytology (FNAC), head and neck squamous cell carcinoma (HNSCC), inguinal node metastasis,
positron emission tomography and computed tomography (PET-CT), tongue cancer
Introduction
Head and neck squamous cell carcinoma (HNSCC)
cancer is the second most common cancer in India.
According to GLOBOCAN 2020, lip and oral cavity
cancer burden is high in India approximately 10.2 per
100,000.[1]
Approximately 70% of cancer (carcinoma lung
and oral cavity) in India are due to modifiable causes
such as tobacco consumption and air pollution. HNSCC
shows an index of 25%–45% lymphatic metastasis which
includes all sites and stages of tumor.[2]
The lymph nodal
metastasis occurs with a variable frequency depending
on the site of the lesion, T-stage, and histopathological
characteristics of the primary lesion, that is, type, degree
of differentiation, perineural, and lymphovascular
invasion.[3]
Tumor metastases take place through
hematogenous spread to distant organs (lung, skin, bone,
and liver) and lymphatic spread to distant lymph nodes
(mediastinal, abdominal, and axillary nodes). In general,
with respect to head and neck cancer, 66% of distant
metastases are to the lungs, 22% to the bones, and 9.5% to
the liver. Distant metastasis can occur at initial diagnosis
or, more often, later as a natural course of the disease. The
incidence of nonsquamous histology is less than 10% that
includes Adenoid cystic carcinoma, basaloid squamous
cell carcinoma, and neuroendocrine carcinomas which are
considered as aggressive metastatic tumors.[3]
The 5-year
locoregional recurrence is approximately 50%, whereas
distant metastases are approximately 15% in locally
advanced HNSCC. With distant metastasis, the overall
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2. Keerthiga K., et al.: Squamous cell carcinoma of tongue
Journal of Current Oncology ¦ Volume 4 ¦ Issue 2 ¦ July-December 2021 141
survival reduces significantly even with early diagnosis of
metastasis. The prevalence of distant metastasis increases
significantly (approximately 32%) with the presence of
extranodal extension. A multivariate analysis of the
tumor characteristics has shown that only depth of tumor
as an absolute predictive value for cervical and distant
metastasis in lingual neoplasms.[3]
However, an isolated
nonregional node metastasis has not been reported before.
Case Report
A 55-year-old man presented with ulceroproliferative
lesion over right lateral border of tongue, diagnosed
as squamous cell carcinoma of tongue in 2020 and
underwent right hemiglossectomy with right modified
neck dissection. Postop histopathology report had
shown tumor size to be 3
cm × 1.5
cm × 0.5
cm, grade
I. All margins were ≥1 cm with lymphovascular (+) and
perineural invasion (+). The depth of invasion was
0.5
cm from basal layer and the risk score was 1, that
is, intermediate risk (Brandwein Gensler Risk score).
No lymph nodes were positive out of 36 dissected. He
received adjuvant radiotherapy with total tumor dose
of 6000cGy/30#/5 weeks @ 2Gy/#. He was on regular
follow-up and remained disease free for 6 months. On
his sixth-month follow-up, he presented with a swelling
over right inguinal region for a period of 20 days
[Figures 1–3]. The onset was sudden associated with
mild pain, dragging type. On examination, a single
swelling, measuring approximately 1.5
cm × 1
cm over
right inguinal region was found which was firm, mobile,
and nontender [Figures 4]. The patient was examined
thoroughly to rule out any local cause of his inguinal
swelling. The physical examination did not reveal any
assignable cause to the swelling. The patient was reviewed
after a week with a course of antibiotics. On review, the
swelling was found to be persistent with no changes in
the characteristics. A radiologist’s opinion was sought,
and he was subjected to ultrasonography and fine-needle
aspiration cytology (FNAC) from the swelling. The
cytology came to be positive for metastatic deposits of
squamous cell carcinoma. Positron emission tomography
and computed tomography (PET-CT) confirmed it to be
a localized metastasis confined to right inguinal region
only [Figures 5]. Patient underwent right inguinal block
dissection and the histopathology report shows that 5 out
of 11 lymph nodes were positive for metastatic deposits
of squamous cell carcinoma with extranodal extension.
Figure 1: Postoperative tongue at sixth month follow-up
Figure 2: Postoperative tongue—no evidence of local recurrence on
local examination
Figure 3: Postoperative tongue—no palpable neck nodes
Figure 4: A swelling noted over right groin region measuring about
1.5 x 1 cm, firm in consistency, not mobile
Figure 5: PET-CT showing image with FDG (Fluorodeoxyglucose) avid
right inguinal node
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3. Keerthiga K., et al.: Squamous cell carcinoma of tongue
142 142 Journal of Current Oncology ¦ Volume 4 ¦ Issue 2 ¦ July-December 2021
Immunohistochemistry study showed CK7 and p63
positive favoring squamous cell carcinoma. Patient
received adjuvant radiotherapy 50Gy/25#/5weeks to the
right groin region. Patient was kept under follow-up.
Discussion
Worldwide, oral cancer is the sixth most common cancer.
India contributes one-third to the global oral cancer
burden. Among oral cavity cancers, carcinoma of tongue
is the most common cancer.[4]
Tongue has extensive
lymphatic drainage that leads to local, regional, and
distant metastasis. The regional and distant metastasis in
head and neck cancer depends on the high-risk features
such as stage III and IV, lymphovascular invasion,
perineural invasion, more than 2 lymph Node positive,
extranodal extension, and margin positivity.[5]
Significant
occult metastasis had been observed in the early stage
of lingual carcinoma also.[4]
This leads to the need for
neck dissection in clinically node-negative patients.
Incidence of skip metastasis in lingual carcinoma to level
III and IV without involving level I and II nodes is also
significantly high.[6]
The frequency of distant metastases
varies extensively, ranging between 4% and 26% in
clinical studies and between 37% and 57% in autopsy
studies.[7]
In patients, in whom loco-regional control
has not been achieved, distant metastasis occurs as the
disease progresses. However, in patients with locoregional
control, distant metastasis is rare. It has been thought
that distant metastases in these patients develop because
of a subclinical distant metastatic spreading that has
already occurred, when treatment of locoregional
tumor is carried out. These metastatic foci develop
during the course of follow-up and become clinically
apparent. Leon et al.[8]
have reported approximately 5%
distant metastasis in head and neck cancer patients with
locoregional control. A rare case of isolated axillary
node in carcinoma buccal mucosa presented after 4 years
of treatment to the primary (AIIMS, New Delhi).[9]
Das Majumdar et al.[10]
in their case report described
distant metastasis to cutaneous, cardiac region in a
patient with anterior tongue carcinoma after 2 years of
complete treatment with surgery followed by concurrent
chemoradiation to the primary.
However, the differential diagnosis can also be unknown
primary with isolated inguinal nodal metastasis. The
most common sites for inguinal node metastasis are skin
of lower extremities, vulva, anus, glans, foreskin of penis,
rectum, anus, cervix, and ovary. Sinha et al.[11]
reported
a case with carcinoma of unknown primary with
inguinal metastasis, which was developed squamous cell
carcinoma of penis after 3 years of inguinal metastasis.
Zaren et al.[12]
reviewed 2232 patients with inguinal node
metastasis and concluded the most common primary
site to be skin of lower extremities, cervix, vulva, skin
of trunk, rectum, and anus. In only 1% of patients, the
primary site remained undiagnosed. It is difficult to
differentiate by pathology whether it is metastasis or
carcinoma of unknown primary as it will be squamous
cell carcinoma with tongue cancer or skin/penile cancer.
Carcinoma of unknown primary with single metastatic
site and favorable histology such as squamous are
managed locoregionally with surgery and/or radiation.[13]
Survival in carcinoma of unknown primary and head
and neck cancer with isolated inguinal nodes had an over
50% survival as compared to metastasis to other lymph
nodes.[14]
In our case, we have recorded an isolated inguinal node
metastasis within 6 months of completion of surgery
and radiation. After an extensive literature search, we
conclude that this is the first case being reported with
isolated distant metastasis to inguinal node without any
loco-regional recurrence.
Conclusion
Distant metastasis to inguinal node in squamous cell
carcinoma of tongue after complete treatment is rare but
technically feasible, and it did happen, this case being one
example. Hence, thorough clinical examination of the
patient during follow-up is essential.
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.
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