A soft-tissue metastasis in neck: An unusual presentation of squamous cell carcinoma of the tongue in young adult

Shirish Sahebrao Chandanwale; Pubali Ghoshal; Shraddha Yadav; Mangesh Londhe

doi:10.4103/jorr.jorr_6_22

CASE REPORT

Year : 2023 | Volume : 15 | Issue : 1 | Page : 54-56

A soft-tissue metastasis in neck: An unusual presentation of squamous cell carcinoma of the tongue in young adult

Shirish Sahebrao Chandanwale, Pubali Ghoshal, Shraddha Yadav, Mangesh Londhe
Department of Pathology, Dr. D Y Patil Medical College, DPU, Pune, Maharashtra, India

Date of Submission	04-Feb-2022
Date of Decision	22-Feb-2022
Date of Acceptance	08-Mar-2022
Date of Web Publication	28-Dec-2022

Correspondence Address:
Shirish Sahebrao Chandanwale
75/1 + 2/1, Krishna Apartments, New Sangvi, Pune - 411 027, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jorr.jorr_6_22

Abstract

There is an alarming increase in the incidence of both oral and base of the tongue squamous cell carcinoma during the past decades, especially in women and younger patients without the traditional risk factors of alcohol or tobacco use. Locoregional spread of tumor via lymphatics to submandibular and jugulodigastric lymph nodes is common. Soft-tissue metastasis (STM) in the neck of oral tongue squamous cell carcinoma is very rare and represents nonnodal-based metastasis. It has a significant adverse impact on the survival of patients. STM in the neck as a presenting symptom of oral tongue carcinoma is very unusual and extremely rare.

Keywords: Carcinoma, metastasis, soft tissue, squamous

How to cite this article:
Chandanwale SS, Ghoshal P, Yadav S, Londhe M. A soft-tissue metastasis in neck: An unusual presentation of squamous cell carcinoma of the tongue in young adult. J Oral Res Rev 2023;15:54-6

How to cite this URL:
Chandanwale SS, Ghoshal P, Yadav S, Londhe M. A soft-tissue metastasis in neck: An unusual presentation of squamous cell carcinoma of the tongue in young adult. J Oral Res Rev [serial online] 2023 [cited 2023 May 31];15:54-6. Available from: https://www.jorr.org/text.asp?2023/15/1/54/365921

Introduction

Soft-tissue metastasis (STM) of squamous cell carcinoma in the neck is nonnodal-based metastasis and is rare.^[1] They represent aggressive tumors with a tendency to have an early visceral metastasis. They act as a surrogate marker for systemic dissemination of tumor cells.^[2] Carcinoma of the tongue is more common in Southeast Asia because of the widespread use of betel nut. Most cases occur in men over the age of 50 years. Incidence in women and younger patients seems to be increasing. STM as a presenting symptom of squamous cell carcinoma of the tongue is extremely rare. We report one such case of a 32-year-old male who presented with swelling over the left side of the neck.

Case Report

A 32-year-old male came into the surgical outpatient unit with a complaint of gradually increasing swelling over the left side neck for 1 ½ months. He was completely asymptomatic before that. He gave a history of tobacco chewing for 4 years and occasional alcohol consumption.

On physical examination, firm swelling (5 cm × 5 cm) was palpable over the left side of the neck [[Figure 1]a arrow]. It did not move with deglutition. Cervical lymph nodes were not palpable. Ultrasonography (USG) using high-frequency linear transducer revealed well-defined solid cystic lesion with lobulated margins measuring 47 mm × 42 mm × 47 mm with thick internal echoes and septa anterior to the sternocleidomastoid muscle. Both the thyroid lobes and bilateral submandibular and parotid glands were normal. Multiple subcentimetric lymph nodes with maintained fatty hilum were noted at levels II, III, IV, and V. Findings were suggestive of TIRADS IV lesion with reactive lymphadenopathy.

Figure 1: (a) Swelling on the left side of neck, (b) squamous cell carcinoma deposits in fibro-fatty tissue and muscle tissue (H and E, ×100, arrow), (c) small swelling on the lateral part of oral tongue, and (d) invasive squamous cell carcinoma of the tongue (H and E, ×100, arrow)

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Computed tomography (CT) scan of the neck and chest showed a large hypodense soft-tissue lesion (43 × 47 × 53) anterior to the sternocleidomastoid muscle over the left side of the neck along the jugular chain. It showed peripheral soft-tissue attenuation with the central large irregular hypodense area. Adjacent structures were displaced. Multiple homogenously enhancing subcentimeter-sized lymph nodes were seen at levels Ia, Ib, II, III, and IV bilaterally. Visualized portions of nasopharynx and oropharynx appeared normal. Both the lungs were normal. Neoplastic etiology was suggested.

Fine-needle aspiration was attempted and was inconclusive because it showed only blood. Three biopsy cores from the swelling were received for histopathological examination. Microscopy showed fibro-fatty tissue infiltrated by lobules of tumor cells comprised squamous cells. Tumor cells showed large pleomorphic nuclei and prominent nucleoli. Muscle tissue was free from tumor cells [[Figure 1]b arrow]. A histopathology diagnosis STM of squamous cell carcinoma was made. Primary from oral cavity and oropharynx were suggested.

After careful reexamination of oral cavity, a small, red, slightly elevated lesion was noted on the lateral surface of anterior two-third of the tongue [[Figure 1]c arrow]. Biopsy from the lesion showed well-differentiated invasive squamous cell carcinoma [[Figure 1]d arrow]. The patient was referred to the oncosurgery unit for further management.

Discussion

Anterior two-third of the tongue is considered a part of oral cavity and posterior one-third (base of the tongue) is considered as a subsite of oropharynx. Many studies suggest an alarming increase in the incidence of both oral and base of the tongue squamous cell carcinoma during the past decades, especially in women and younger patients without the traditional risk factors of alcohol or tobacco use. It is believed to be related to dramatic spike in Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma.^[3],[4]

Localized discomfort is the most common complaint related to squamous cell carcinoma of oral tongue. Symptoms associated with the base of the tongue lesion include neck masses, dysphagia, ear pain, and weight loss.^[5] Locoregional spread of tumor via lymphatics, especially to submandibular and jugulodigastric lymph nodes is common. The more the anterior tumor, the lower the position of cervical lymph node metastasis.^[6],[7]

The STM of squamous cell carcinoma is defined as carcinoma deposits in soft tissues with no evidence of adjacent lymph node involvement. Extra lymphatic spread is defined as tumor extension beyond lymph node capsule with desmoplastic stromal response.^[2] Possible mechanisms of STM from primary site involve permeation of tumor cells in lymphatic vessels, vascular, and neuronal routes.^[8]

In our case, there were no clinically palpable significant nodes. USG and CT scan suggested reactive nature of lymph node. On histopathology examination, no lymph node tissue was identified.

Jose et al.^[2] in their study demonstrated that STM has a significant adverse impact on the survival of patients with squamous cell carcinoma of upper aerodigestive tract.

Survival was significantly lower for patients with soft-tissue deposits as compared with negative lymph node group or even with positive lymph node group without extracapsular spread. We are tempted to report this case because of its unique clinical presentation.

Conclusion

STM of squamous cell carcinoma in the neck as a presenting symptom of carcinoma of oral tongue is extremely rare. The possible route for spread is hematogenous.

STM has a significant adverse impact on the survival of patients with squamous cell carcinoma of upper aerodigestive tract. These patients may have a tendency to produce early visceral metastasis. While examining radicle neck dissection specimens, their presence should be carefully searched.

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.

References

1.	Mooney CP, Gao K, Clark JR, Gupta R, Shannon K, Palme CE, et al. Soft tissue metastases in head and neck cutaneous squamous cell carcinoma. Laryngoscope 2021;131:E1209-13.
2.	Jose J, Moor JW, Coatesworth AP, Johnston C, MacLennan K. Soft tissue deposits in neck dissections of patients with head and neck squamous cell carcinoma: Prospective analysis of prevalence, survival, and its implications. Arch Otolaryngol Head Neck Surg 2004;130:157-60.
3.	Paderno A, Morello R, Piazza C. Tongue carcinoma in young adults: A review of the literature. Acta Otorhinolaryngol Ital 2018;38:175-80.
4.	Kato MG, Baek CH, Chaturvedi P, Gallagher R, Kowalski LP, Leemans CR, et al. Update on oral and oropharyngeal cancer staging – International perspectives. World J Otorhinolaryngol Head Neck Surg 2020;6:66-75.
5.	Gorsky M, Epstein JB, Oakley C, Le ND, Hay J, Stevenson-Moore P. Carcinoma of the tongue: A case series analysis of clinical presentation, risk factors, staging, and outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:546-52.
6.	Hussein AA, Helder MN, de Visscher JG, et al. Global incidence of oral and oropharynx cancer in patients younger than 45 years versus older patients: a systematic review. Eur J Cancer 2017;82:115-27.
7.	Poling JS, Ma X-J, Bui S, et al. Human papillomavirus (HPV) status of non-tobacco related squamous cell carcinomas of the lateral tongue. Oral Oncol 2014;50:306-10.
8.	Blanchard P, Belkhir F, Temam S, et al. Outcomes and prognostic factors for squamous cell carcinoma of the oral tongue in young adults: a single-institution case-matched analysis. Eur Arch Otorhinolaryngol 2017;274:1683-90.