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Multiple distant metastasis of tongue squamous cell carcinoma after surgical operation and radiotherapy - a case report and literature review

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Multiple distant metastasis of tongue squamous cell carcinoma after surgical operation and radiotherapy - a case report and literature reviewof,cell,after

    Multiple distant metastasis of tongue

    squamous cell carcinoma after surgical operation and radiotherapy - a case report

    and literature review

    Multipledistantmetastasisoftonguesquamouscell

    carcinomaaftersurgicaloperationandradiotherapy

    ---

    acasereportandliteraturereview

    WeizhongLi,LeitaoZhang,YuHuang

    DepartmentofOralandMaxillofacialSurgery,NanfangHospital,SouthernMedicalUniversity,Guangzhou510515

    China

    Received:15August2010/Revised:3September2010/Accepted:5October2010 @HuazhongUniversityofScienceandTechnologyandSpringer-VerlagBerlinHeidelberg2010

    AbstractThisarticlereporteda36

    yearmalepatientwithtonguesquamouscellcarcinomawhoshowednegativecervicaI Iymphaden0palhybyclinicalexaminationbulcervicallymphnodemetastasesdiagnosedbypathologicaJexamination.The

    patientunderwenltonguelumorresectionandIeftforearmradialskinflaprepair.andlhenreceived50Gy3.DconformaI

    radiotherapyandchemotherapycombining5

    fluorouraci1withcarboplatin.Oneyearafterlheoperation.althoughIhepatienl showednotumorrecurrenceinprimarysiteandnometastasisofcervicallymphnodes,metastasisoccurredinseveraltissues

    includingspine,ribs,mandible,skeletaImusclesofupperextremityaswelIaslymphnodesoft

hemediastinumandlunghilum.

    whichcausedlhepatienttodiequickly.AccordingtolheIiterature.weconcludelhaldistanfm

    etastasisoflonguesquamous

    cellcarcinomawaslesscommon,butonceitoccurs,theprognosisofthepatientisextremelypo

    or.

    Keywordsneoplasmmetastasis;carcinoma,squamouscell;tongueneoplasms

    Thefailureoftreatmentofheadandnecksquamous cellcarcinomasmainlyattributestolocalrecurrence andlymphnodemetastasis.Oncemetastasis(especially distantmetastasis)occurs,theprognosisispoor[1.The

    mainmetastasisrouteoftonguecarcinomaislymphatic metastasis,whilethehematogenousmetastasis,andthe primaryrouteofdistantmetastasis,arerare.Therecog

    nizedcommonsitesofdistantmetastasisarelung,skel

    etonandsoon[2_However,recentstudieshavereported

    metastasisoftonguesquamouscellcarcinomainheart, intracranialsites,spinalcord,wristbonesandfootafter operation[3-6].Distantskeletalmusclemetastasisofhead andnecksquamouscellcarcinomasisveryrare.Upto date,only2patientswithskeletalmusclemetastasisof tonguecarcinomahavebeenreported,onewasinlumbar musclesandanotherwasinshouldermuscles7t8.The

    mechanismofdistantmetastasisremainsunknown,and itisstillcontrOversialwhetheritsoccurrenceisrelatedto thetumorsize,lymphadenopathyandcelldifierentiation [9,101.Thepatientreportedherehadoneyearhistoryof carcinomainrighttonguemargin,clinicalexamination showednocervicallymphadenopathy,buttheintraop

    erativefrozensectionshowedcervicallymphnodeme

    tastasis.Althoughextendedtongueresectionandradical

    Correspondenceto:WeizhongLi.Email:gzliwz@126.com neckdissectionwereperformed,andpostoperativeradio

    therapyandchemotherapyinprimarylesionandneck weregiven,thepatientdiedofsystemicdistantmultiple metastasesoneyearlaterwithoutlocalrecurrenceand cervicallymphnodemetastasis.Accordingtothefitera

    ture,postoperativesystemicmetastasesinmultipletis

    suesandorganswhichoccurinthepatientswithtongue carcinomaarerare,inwhichtheinvolvedtissueswere primarilybilateralinfraspinousmuscles,fighttriceps,left erectorspinae,posteriorpleura,spine,ribs,mandible,as wellaslymphnodemetastasesofmediastinumandlung hilum.withoutlocalrecurrenceandcervicallymphnode metastasjs.

    Casereport

    A36yearmalepatientwashospitalizedtotheDepart

    mentofOralandMaxillofacialSurgery.NanfangHos

    pital,SouthernMedicalUniversity(Guangzhou,China) becauseoftherighttonguebodyulcerationforoneyear. Physicalexaminationshowedthattherewasanulcer

    ativemass(about4cmx5cm)inhisrighttongue,andthe masswasfirmonthebaseandhadunclearmarginwith surroundingtissues.Themasshadreachedmidline,and thetonguemovementwasslightlyrestricted(Fig.1a). Therewasnolymphadenopathyinbilateralneck,sub

    670

    mandibularandsubmentalregions.andXrayrevealed

    noabnormalityinthelung.Thepatientreceivedbiopsy onDecember25,2007andwasdiagnosedasmoderately differentiatedsquamouscellcarcinoma.0nDecember

    27,2007,enhancedCTscanningrevealedanabnormaHy enhancedregion(1.8cm×2.0cmx2.7cm)attheright

    tonguemarginwithunclearmargin,withnonotablede

    structioninbones,symmetricsofttissuesofneck,and noabnormalmassshadow.Tracheawasinthemidfine, thyroidglandwasnotenlargedandwassymmetric,no abnormalitieswereidentifiedincervicalmuscles,and severalsmalllymphnodeshadowswereseenintheneck. AccordingtotheUnionInternationaleContreLeCancer (UICC)classificationandstagingstrategy,thepatientwas diagnosedasrighttonguesquamouscellcarcinoma(clini

    calstaging:T3NOM0).

    OnDecember28,2007,thepatientreceivedrighthemi

    tongueresectionwithelectivecervicallymphnoderesec

    tionandtongueandmouthfloordefectrepairingwith skinflapfromtheradialsideoftheleftforearmunder generalanesthesia.Firstly,methylenebluewasinjected aroundthetonguetumortotracesentinellymphnodes whichwerethenperformedwithcontinuousfrozensec

    tionforpathologicalexamination.Theexaminationre

    ,)lr,?w.springerlink.com/contenffl6139089

    intherightmandible,theSUVmaxwas3.2.andnoab

    normaldensityshadowwasseeninthisregion(Fig.2). Therewereseveralnodularincreaseduptakeshadows inthemediastinum(1eftsuperiormediastinum,primary pulmonaryarterywindowandtrachealsubcarina)and theleftlunghilum.withthemaximumnodularsizeof

    0.9cm×0.8cmandSUVmaxof2.8.CTscan 1.8cm×

    revealedlymphadenoPathyinthecorrespondingregion

fFig.3and4).Therewereseveralincreaseduptakeshad

    owsinbilateralinfraspinousmuscles,righttricepsand lefterectorspinaewiththemaximumsizeof3.2cmx1.0 cm×1.3cmandSUVmaxof3.8,andCTscanrevealed lowdenseshadowinthecorrespondingregion.Abnor

    maluptakeofradioactivitywasseenatlefttransverse processofthe6ththoracicvertebraeandtherootofthe 6thrib,theSUVmaxwas5.2,andCTscanrevealedob

    V1OUSbonedestructioninthecorrespondingregion(Fig. 5,.Therewasnodularshadowswithincreaseduptakeof radioactivity(2.3cm×1.5cm×2.7cm,SUVmaxwas3.7)

    attheleftposteriorpleura,andCTscanrevealedlimited thickeningofthepleurainthecorrespondingregion(Fig. 61.Craniocerebralimageswerenorma1.Partialsofttis

    suesoftherightsuperiorneckwerethickenedandPET scanrevealednoabnormalities.Severalquasinodularor

    vealedonelymphnodemetastasisintherightcervicalpatchyshadowswereseeninbilaterallu

    ngs,PETscan

    superiordeepregionbutnometastasisinotherregional lymphnodes(1evelII;Fig.1bandlc).Postoperativerou

    tinepathologicalexaminationshowedthattonguemod

    eratelydifferentiatedsquamouscel1carcinoma(Fig.1d), allcervicallymphnodeswerenegativeexceptforone sentinellymphnodeinlevelIIregion.andthefinaldi

    agnoslswasfighttonguesquamouscellcarcinomawith cervicallymphnodemetastasis(pT3NIM0).

    Thepatientreceivedthreedimensionalconformalra

    diotherapyontherightfacialandneckregiononJanu

    ary14,2008(twoweeksaftertheoperation),and25ra

    diationswereperformedwithin35days(2Gy/dayeach

time,total50Gv).

    Thepatientreceivedoralcavityandneckexaminations onMarch,IulyandNovember,2008,respectively,andno abnormalitieswereseen.Thenchemotherapycombining 5fluorouracilwithcarboplatinwasgiventoreducethe riskofrecurrence,localanddistantmetastases.OnDe

    cember15,2008,thepatientwashospitalizedagainfor rightbackpain,andtheexaminationrevealedneither

     tumorrecurrenceatprimarysitenorcervicallymphade

    nopathy.However,thetendernessattherightbackand thoracolumbarvertebraewasremarkable,aswellasthe rightupperextremityandshouldermusclewhereseveral nodularmasseswerefound.OnDecember17,2008,the patientreceivedPET/CT(GEDiscoveryLSPET/CTscan

    ner,GE,Healthcare,andWaukesha,WI)scanningwhich revealednoincreaseduptakeorhighdensityshadows. However,theincreaseduptakeofradioactivitywasseen revealedslightlyincreasedradioactiveuptakeinpartial lesionsandtheSUVmaxwas1.4.whichwasconsidered tobepulmonaryinflammation.

    AccordingtotheclinicalexaminationandPETCT

    xmaglng,thepatientwasdiagnosedasdistantmetastasis insystematicmultipletissuesandlymphnodesafterop

    eratlonforfighttonguecarcinoma,includingspine,ribs, mandible,musclesofupperextremity,pleura,aswellas mediastinallymphnodesandlefthilarlymphnodes.Due totherapidprogressofthedisease,thepatientabandoned treatmentanddiedonFebruary27,2009.

    Discussion

    oralcarcinomaisoneofthetoptenmahgnanciesin

termsofincidence.Thereareapproximatelyover300000

    neworalcarcinomapatientsannuallyandaround200000

    diedintheworld[11,12].Inrecentyears,theincidenceof carcinomakeepsrising,theageofonsetbecomesyounger

    andyounger.Ithasbeenoneofthefactorsinfluencing

    humanhealth.Duringthepastdecades,despiteofthead

    vancementofsurgicaloperation,radiotherapyandche

    motherapyandtheirapplicationinoralcarcinoma,the

    5yearsurvivalrateofpatientswithoralcarcinomagets littleimprovementandremainsabout50%to55%13..

    Cervicallymphnodemetastasisisamajorproblemof

    tonguesquamouscellcarcinomapatients,andabout30%

    patientswithoralsquamouscellcarcinomahadcervical

    lymphnodemetastasisatinitialtreatment.Compared

    ChineseGermanTClinOncol,November2010,Vo1.9,No.11

    

    Fig.1(a1Therightsideofthepatient'stongueshowedulcerativemass presentinginvasivegrowth,nocewicaJlVmphadenOpalhVwasseenby clinicalexamination.andlhepathologicafexaminationshowedmoder- atelydifferentiatedsquamouscelIcarcinoma:Methyleneblueinjection showedsentinellymphnodesalalIregionsoflheneck.amongwhich. alymphnodeatrightcervicaIdeepsuperiorregionshowednoobvious enlargemenI(b)bulsinailcarcinomametastasisbypathologicalfrozen sectionexaminationfc1c(x200),lhepathologicalexaminationofprimary fesionshowedmoderatelytohighlydifferentiatedsquamouscellcarci. noma(d1(×200)

    ,l?Fig.2CTrevealednoabnormaldensi~shadowatrightmandible body,whilePETimagingshowedincreasedradioactiveuptakeofthecor- respondingsiteatrightmandiblebody(redarrow),andPET/CTclearly revealedincreasedradioactiveuptakeatrightmandiblebody(SUVmax

was3.2)

    withanyotheroralcarcinomas,forpatientswithtongue carcinoma,especiallythosewithlocalinvasivegrowth, theirincidenceofcervicallymphnodemetastasisishigh

    er|15J.

    Cervicallymphnodecanbedividedintofollowing

    levelsaccordingtoanatomicalsites.Thesubmentaland submandibulartrianglesmakeuplevelI,andtheupper, middle,andlowerjugularnodalgroupsareconsidered levelsII,III,andIV,respectively;posteriorcervicaltri

    angleislevelV;prelaryngeal(Delphian),pretrachealand pratracheallymphnodesarelevelVI;andlevelVIIin

    cludeslymphnodesofuppermediastinum[2,1.Tongue containsabundantlymphaticvesselswhichcompriseof threedrainagepathways[21.Theanteriorpathwaypri

    madlydrainsthetipoftonguetolevelIorII;thelateral pathwayprimarilydrainslateralonethirdofthedorsum

    ofthetonguefromthetiptothecircumvallatepapillae 671

    Fig.5CT,PETandPET,CTimagingrevealedthatthemetastaticle- sionatrighttricepswas1.1cmx0.9cm,andSUVmaxwas2.2(green arrow).Themetastaticlesionatleftthe6thposteriorribandneighboring lefttransverseprocessofthe6ththoracicve~ebraewas3.8cmx2.6cm, andtheSUVmaxwas5.2(redarrow)

    //Fig.6CT,PETandPET/CTimagingrevealedthatthemetastaticle- sionatlefthilarlymphnodeswas1.1cmx1.0cm.andSUVmaxwas3.0 (greenarrow).Themetastaticlesionatleftposteriorpleurawas2.5cmx 1.5cm,andtheSUVmaxwas5.2(redarrow)

    tolevelsI,IIorIII;thecentralpathwaydrainscentral

twothirdsoftonguetolevelIortolevelIIIthroughsub

    linguallymphnodes.Thus,themostcommonlyaffected regionallymphnodesarelevelsI,IIandIII.According tothestatistics,theincidencesofcervicallymphnode metastasisofpatientswithtonguecarcinomaare:level I:18%64%:levelII:43%73%;levelIIh0(26%;level

    672

    IV:0%10%:levelV:0%_2%[1720.ItisobviOilsthatthe

    mostcommonlyaffectedregionsarelevelsI,IIandIII, andlymphnodesattheposteriorcervicaltriangleandsu

    praclavicularregionarerarelyaffected.However,some studieshavereporteddirectmetastasistolymphnodesin regionIVwithoutinvolvementoflymphnodesinlevels IIII,namely,skipmetastasis[16].Sincetonguelymphatic vesselnetworksdistributeextensivelyinthemidlineof tongue,bilateralcarvicallymphnodemetastasismayoc

    curwhentheprimarylesionisneartoorinvolvesinthe midline.

    Thefailureoftreatmentofpatientswithtonguesqua

    mouscellcarcinomamainlyattributestolocalrecurrence andlymphaticmetastasis.The2-yearsurvivalrateofearly tonguecarcinomapatientscanreach85%[21].whilethat ofpatientswithcervicallymphaticmetastasisisaslow as50%.Grandietaldemonstratedthatthe5-yearsur

    vivalrateoftonguecarcinomapatientwithcervicallym

    phaticmetastasisdecreasedfrom65%to29%_22].Myers etalperformedprimarylesionresectionandradicalcer

    vicallymphnoderesectionfor266patientswithtonRue carcinoma,withorwithoutadjuvantradiotherapyafter

    operation[23.Theirretrospectivestudyshowedthatthe overallanddiseasespecificsurvivalratesofthosewith positivecervicallymphnodewereMerylow.Pathological examinationshowedthatthe5yearoverallsurvivalrates

    ofnegativegroup(pN0)andpositivegroup(pN+)were 73%and43%,respectively,andthe5yeardiseasespe

    cificsurvivalrateswere88%and59%,respectively[231. Extracapsularspread(ECS)referstothattumorthat

     penetrateslymphnodecapsuleandfurtherinvadespe

    riphera1connectivetissue.Studieshavedemonstrated thatthe5yearsurvivalrateofepatientswith1ymph

    nodemetastasisbutwithoutpenetrationintocapsuleis 50%70%,butthatofECSpatientsis25%30%.Mean

    while,theECSalsocontributestotheincreaseddistant metastasisrate.Histopathologicalstudyshowthat

    about60%ofpatientswithcervicallymphnodemetasta

    ,)lr,.springerlink.com/contenffl6139089

    marytumorandclinicalstage,theoccurrenceofdistant metastasisisalsoassociatedwithcervicallymphnode status,histologicalfeaturesoflymphaticorvascularin

    vasion,andextracapsularspread.Distantmetastasisrate ofNo_N1patientsislessthan10%,whileN2andN3pa

    tientscanreach30%.Thediagnosisofdistantmetastasis canbemadeat9to12monthsafterconfirmingprimary tumor,andfor84%ofpatientsitiswithintwoyearsafter diagnosis.Lungandbonearethemostcommonsitesof distantmetastasisoftonguesquamouscellcarcinoma[27. 9_

    .Calhounetalinvestigated727patientswithheadand neckcarcinomasandfoundthattheincidenceofdistant

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