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BREAST METASTASIS FROM CARCINOMA OF THE TONGUE

Sanjay B Dudhat*, Sheherbanoo U Gullar**, Shashank R Shinde***
*Senior Research Fellow, Dept. of Surgery; **Scientific Officer "SE", Cytology Division; ***Surgeon, Chief-Breast and oesophagus Service, Tata Memorial Hospital, Parel,
Mumbai - 400 012. India.

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The reported incidence of metastatic disease in head and neck cancer is increasing. The most frequent site of metastatic involvement in squamous cell carcinoma of head and neck is the lung followed by liver, mediastinal nodes and bone. Metastatic deposits to the breast from extra mammary neoplasms are very rare (0.4 to 2%). We present a case of a 34 year old female who was treated for cancer of the left lateral border of the oral tongue by partial glossectomy and subsequently left radical neck dissection and post operative radiotherapy. The patient developed metastatic lesion in the left breast after 9 months from the detection of the primary. Fine needle aspiration cytology showed the presence of metastatic squamous carcinoma. The patient was given chemotherapy. (Cisplatin and 5 Flurouracil). The patient died 4 months after this presentation.

INTRODUCTION

The incidence and location of distant metastasis from head and neck cancer was first documented by Crile in 1906 and was reported that the incidence is less than 1%. [1] The rise in the incidence of distant metastasis in recent years is probably due to recent advances in the therapy, both curative and palliative of the primary site which has allowed these patients to survive in the later stages of the disease, where distant metastasis are more likely to become evident. [2] Some studies have shown that the incidence of distant metastasis is higher which ranges from 34 to 46.5% for autopsy studies [3,4] and from 4.3 to 30.7% for clinical studies. [5,6]

O’ Brien’s autopsy series showed that the most common sites of metastasis in the head and neck carcinomas are lungs (70%), liver (38%) and bone (23%). [4] Other sites are uncommon, although gastrointestinal, cardiac and renal have been identified in all series. The breast metastasis from head and neck squamous cell carcinoma is exceedingly rare. In this report, we present a case of breast metastasis from cancer of the tongue.

CASE REPORT

A 34 year old female presented with a small ulcer over the left lateral border of the tongue of 2 months duration. Clinically the lesion was measuring about 1 x 1 cm with no evidence of neck node involvement (T1 No Mo). Rest of the oral cavity, base tongue and larynx were normal. The biopsy report showed squamous carcinoma. The blood chemistry and chest X-ray were within normal limits.

Partial glossectomy was performed on 6th September 1996. Gross pathology showed an ulcerative lesion measuring 1 x 1 cm with depth of 0.3 cm. Histopathology report was moderately differentiated squamous carcinoma, superficially invading the skeletal muscle. Margins of excision and base were free. After eight weeks on follow up, the patient presented with enlargement of the left level II node in the neck. Fine needle aspiration cytology (FNAC) of the enlarged node revealed meatastatic squamous carcinoma. Left radical neck dissection was performed on 8th Nov. 96. Histopathology report showed metastatic involvement of the Level II node and the rest of the nodes at all levels were negative. The patient was given post operative radiotherapy (50 Gy) to the neck and the primary site. The patient was on regular follow up.

In May 97, the patient presented with a lump in the left breast and backache. On examination, the lump was present in left breast occupying lower outer quadrant, measuring 5 x 5 cm. The lump appeared cystic in nature. There was no axillary lymphadenopathy. Loco regional sites were normal.

The bilateral film mammography showed a well defined, rounded and a homogeneous mass lesion in the left breast (Fig. 1). Bone scan showed increased uptake in D9 to D12 and L1 to L5 vertebrae. The chest X-ray and ultrasound of the abdomen were normal. On FNAC of the breast lump, 20 ml of haemorrhagic fluid was obtained which showed the presence of metastatic squamous carcinoma (Fig. 2 and 3).

After the diagnosis of the metastatic lesions the patient was given chemotherapy (Cisplatin and 5-Flurouracil - 3 courses). Patient was also given palliative radiation therapy (24 Gy) to the dorso lumbar spine for pain relief. The patient did not show any significant improvement after this therapy and died in August 97.

	Fig. 2 : Beast cyst aspirate - singly occurring keratinizing squamous carcinoma cell in an inflammatory and necrotic background. (Papanicolaou's staining x 400).
Fig. 1 : Flim mammogram of the left breast showing a well defined, rounded, homogeneous mass lesion.	Fig. 3 : Breast cyst aspirate - "tadpole" from of keratinizing squamous cancer cell. (Papanicolaou's staining x 400).

CYTOMORPHOLOGY

In a background of tumour diathesis were seen a number of singly occurring keratinized squamous carcinoma cells showing deeply eosinophilic or orangeophilic cytoplasm and enlarged, deeply stained and hyperchromatic nuclei with raised nuclear : cytoplasmic ratio (Fig. 2). A few caudate forms were noted (Fig. 3). Many non-keratinized squamous carcinoma cells were also seen showing degenerative changes such as hypochromatism and disintegration of cytoplasm. Many inflammatory cells and RBCs were present. No evidence of glandular malignancy was found.

DISCUSSION

Distant metastasis from squamous cell carcinoma of head and neck are becoming more common, as patients survive longer following multidisciplinary treatment for their initial loco regional disease. Involvement of the breast in head and neck squamous cell carcinoma has been rarely reported. The incidence of metastatic involvementof breast by non mammary carcinomas has been reported in an autopsy series as 5.3% and in clinical series as 0.5 to 2%.7 Malignant melanoma, lymphoma/leukaemia and primary lung carcinoma are the commonest malignancies which are found to be metastatic to the breast. [8] The most common breast metastasis in men is from prostatic carcinoma [9] and in children from rhabdomyosarcoma. [10]

The first autopsy findings of a breast metastasis in a primary squamous cell carcinoma of the maxilla was reported by Hajdu and Urban in 1972. [8] The first clinically detected cases, both of oral cavity origin were described by Toombs and Kalisher in 1977. [11] Clinically a breast metastasis usually presents as a rapidly growing, single, movable lump, more frequent in left breast and in upper outer quadrant. [12]

The incidence of metastasis is influenced by T and N stage, as well as control of the primary lesion. Locally advanced lesions (T3, T4), poorly differentiated tumours and lymph node metastasis increases risk of distant metastasis. Cancer of nasopharynx, larynx and hypopharynx have greater predilection for distant metastasis than oral lesions. [2], [13]

Before arriving at the diagnosis of the metastatic squamous carcinoma of the breast it is important to consider the possibility of a primary ductal carcinoma with a malignant squamous component, pure squamous cell carcinoma and benign lesions, such as an epidermoid cyst. In this case all neoplastic cells were of malignant squamous type. No malignant columnar differentiation or other features of glandular differentiation were observed.

In this case, the patient had an early primary lesion (T1 N0 M0), but developed nodal metastasis eight weeks after the surgery of the primary. Distant metastasis appeared after the interval of 9 months from the detection of primary lesion. The patient was given chemotherapy (Cisplatin and 5-Flurouracil, 3 courses) and palliative radiotherapy to the spine for the relief of pain. The disease progressed rapidly on treatment. The patient died after 4 months from the onset of metastatic lesion.

CONCLUSION

Mammary metastasis is a poor prognostic sign and indicates the beginning of the wide spread dissemination of the disease. Usually, most of the patients die within one year after its onset, regardless of therapeutic intervention.

REFERENCES

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