Page 35 - Read Online

mucosa was 9.9% of all head and neck cancers and 2.6% Table 1: Four patients developing bone metastases all had
of all malignancies. It was more common in males than locally advanced disease
females, with a ratio of 4:1. Tobacco chewing and poor No. pT stage pN stage Invasion Tumor grade
oral hygiene were common factors associated with the 1 2 2b Deep muscle I
patient characteristics. Carcinoma of the buccal mucosa 2 4 2b Mandible II
was more common in younger individuals, with median 3 4 2b Deep muscle II
age at diagnosis of 45.87% patients presented in stage 4 4 2b Muscle and II
III and IV and 75% of patients reported after surgery mandible
for adjuvant treatment. Four patients all developed
bone metastases. All 4 patients had locally advanced with cisplatin and paclitaxel. After radiotherapy, all
disease [Table 1] and all underwent hemi-mandibulectomy patients had complete bone pain relief. Despite treatment,
with ipsilateral neck node dissection. Patients then the disease progressed and all patients died within
received postoperative concurrent chemotherapy and 6-9 months of development of bone metastasis.
radiotherapy, 60 Gy in 6 weeks with 6 MeV photons
by linear accelerator. Upon completion of treatment, Discussion
all 4 patients had local control but within 2-8 months,
all 4 patients developed bone metastases. At the time Head and neck squamous cell carcinoma has a high
of diagnosis of bone metastasis, patients received local propensity for loco-regional spread through lymphatic
radiotherapy, 30 Gy in 10 fractions to the involved bone, and/or hematogenous spread and occurs in about 10%
followed by chemotherapy with cisplatin and paclitaxel. of cases. Sites of metastases most commonly include
[4]
None completed the planned six cycles of chemotherapy the lungs, brain, bones, and skin. Newer diagnostic
and had died within 6-9 months. regimens and more thorough work-up at diagnosis have
improved our understanding of squamous cell carcinoma
Results and consequently loco-regional control of cancer above
[5]
the clavicles has increased. However, the overall
Carcinoma buccal mucosa was reported in 9.9% of disease-free survival rate has not improved and the
[6]
all head and neck cancers, although most patients did incidence of distant metastases and second primary
not complete the planned treatment. On follow-up, of tumors has increased. Risk factors for hematogenous
[7]
148 patients, 24 (16.2%) had local recurrence within spread include higher tumor stage, size of the primary
one year, one patient developed second primary after lesion (T4), tumor grade, and the lesion site. The
8 years, and 2 patients had lung metastasis and 4 incidence of distant metastasis is hypopharynx 60%, base
patients developed bone metastasis. The incidence of tongue 53%, and anterior tongue cancer 50%. [8]
of bone metastasis was 0.2% of all head and neck
cancer as compared to 0.1% reported in the literature Distant metastasis to bones from buccal mucosa is
[9]
worldwide. Sacrum, pelvis, vertebrae and index fi nger extremely rare and we could fi nd only one report. In
[1]
were commonly involved. Bone metastases developed contrast, in the last 5 years, our center diagnosed 4 cases
6-9 months upon completion of primary treatment, of squamous cell carcinoma of the buccal mucosa which
with all 4 patients presenting with locally advanced had metastasized to bones. All patients were young, had
disease and nodal metastasis. All 4 patients underwent T4 disease, and grade I-II squamous cell carcinoma and
surgery as the primary treatment, followed by adjuvant were using chewing tobacco.
concurrent chemotherapy and radiotherapy. All patients Distant metastases were all seen within one year
had grade II to III squamous cell carcinoma. Our of completion of primary treatment. Thus, there is
incidence of bone metastasis of all carcinomas of buccal probably subclinical seeding of malignant cells before
mucosa was 2.71%. We could not fi nd the reported the eradication of the primary tumor. The average
incidence in the literature worldwide. All 4 patients survival with distant metastasis ranged between 21 and
had advanced local (T4) lesions and 3-8 nodes were 33 weeks. [10,11] In this series, bone metastases occurred
involved. None had extra nodal spread but one had within an average of 9 months from diagnosis and
perineural spread. All had deep muscle infi ltration, with survival was only 6-9 months after development of bone
2 patients also having mandibular bone involvement. metastasis.
After postoperative radiotherapy, all had local control
but within 6-9 months, patients complained of severe There was one study of patients with locally advanced
local bone pain and an X-ray/computed tomography scan head and neck cancers at presentation who developed
[12]
showed lytic bone lesion at the site of involvement in all metastases. The usual primary sites were base of
4 cases [Figures 1-3]. Fine needle aspiration cytology tongue and tonsil, with solitary bone metastases and
from the bone metastatic sites of all four cases indicated a postoperative buccal mucosa case where multiple
pathology consistent with metastatic disease [Figure 4]. osteolytic bone lesions were seen. The cause of distant
All patients received palliative local radiotherapy to the metastases after local control is not known although all
involved bone to relieve pain, followed by chemotherapy patients who developed bone metastasis had advanced

28 Journal of Cancer Metastasis and Treatment ¦ Volume 1 ¦ Issue 1 ¦ April 15, 2015 ¦