|Ahead of print publication
Dorsal spinal metastases secondary to squamous cell carcinoma tongue: A rare case report and review of literature
Vikas Maheshwari, Arun Kumar, Rohit Pandey, Abhinav Debnath
Department of Neurosurgery, Command Hospital, Pune, Maharashtra, India
|Date of Submission||18-Mar-2020|
|Date of Decision||06-Jun-2020|
|Date of Acceptance||03-Jul-2020|
Department of Neurosurgery, Command Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Oral squamous cell carcinoma metastasizes commonly to the lung, brain, skin, and occasionally to the bones such as vertebra and ribs. However, spread to the dorsal vertebra with cord compression is an extremely rare presentation. This case highlights this rare entity which was managed surgically. It enabled in ameliorating patient's distressing pain and restoring quality of life.
Keywords: Head-and-neck squamous cell carcinoma, oral squamous cell carcinoma, visual analog scale
|How to cite this URL:|
Maheshwari V, Kumar A, Pandey R, Debnath A. Dorsal spinal metastases secondary to squamous cell carcinoma tongue: A rare case report and review of literature. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 May 10]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=308991
| Introduction|| |
Oral carcinoma ranks among the top five malignancies. Carcinoma tongue is the most common oral carcinoma. Oral squamous cell carcinoma (OSCC) constitutes 95% of these cancers and the remaining 5% is formed by adenocarcinoma and mixed variants.
| Case Report|| |
A 37-year-old male a known case of Myasthenia gravis noticed a painless nonhealing ulcer on the left side of the tongue of 6 months duration. He was a chronic smoker and tobacco chewer. He had a history of significant weight loss over the past 6 months. Local examination showed 3.5 cm × 3 cm ulceroproliferative growth on the left lateral aspect of the tongue along with multiple bilateral cervical lymphadenopathy. Wedge biopsy taken from the margin of ulcer showed well-differentiated squamous cell carcinoma (SCC). He then underwent wide local excision along with modified radical neck dissection and reconstruction of the defect by a radial forearm free flap [Figure 1]. Histopathology (HPE) showed moderately differentiated SCC with regional lymph node involvement-16/42 (pT2 N3b Mo)-Stage IVB. He was given concomitant chemoradiation and at 6 months follow-up he complained of severe mid backache with radiation to the left lower limb. Neurological examination showed a truncal weakness with power grade 4/5 in both lower limbs and 40% hypoesthesia below the D4-D5 level. His contrast-enhanced magnetic resonance imaging of the spine showed mass lesion involving body, right pedicle, and transverse process of D4 causing significant cord compression [Figure 2]a, [Figure 2]b, [Figure 2]c. PET scan showed multiple metabolically active metastatic lesions in the DV4 vertebrae, left fifth rib, left acetabulum, and both lobes of the liver. The patient was symptomatic with severe mid backache which was impairing his daily activities, causing insomnia despite escalating doses of analgesics and opioid patches. Despite all these measures, his pain visual analog scale (VAS) score remained 10/10. In view of significant cord compression and persistent pain, he was taken up for decompressive laminectomy D4, D5 along with pedicle screw fixation DV3, DV5-DV6 [Figure 3]. HPE was consistent with metastatic deposits of SCC [Figure 4]a and [Figure 4]b. He was discharged on the 10th postoperative day without any neurological worsening. His VAS score improved significantly from 10/10 (preoperative) to 3/10 (postoperative) [Figure 5].
|Figure 2: (a and b) Magnetic resonance imaging of the dorsal spine sagittal and axial view (T1 and T2) showing metastasis at DV4 with significant cord compression which is hypointense on T1 and hyperintense on T2|
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|Figure 3: Computed tomography of the dorsal spine showing pedicle screw with rod fixation at D3, D5–6|
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|Figure 4: (a and b) Squamous cell nests infiltrating in cell nests (Blue arrrow). Cell keratinization seen|
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|Figure 5: Decrease in visual analog scale score from 10 (preoperative) to 3 (postoperative)|
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| Discussion|| |
Crile has reported an incidence of 1% for the distant metastasis from 4500 cases of the head-and-neck SCCs reviewed by him. He stated that “the collar of lymphatics about the neck forms an almost impassable barrier through which cancer rarely penetrates” signifying the rarity of hematogenous spread. However, several subsequent studies have shown the incidence of distant metastases to be much higher than mentioned by Crile. The incidence of spinal metastatic neoplasm out numbers primary spinal neoplasms by more than twenty-to-one. The tongue has a dense lymphatic network, with three main deep muscular lymphatic drainage pathways, and hence, lymphatic spread is the most common modality for metastases. Hematogeneous metastasis is extremely rare.
De Bree et al. reported that three or more lymph-node metastases (almost 50% risk), bilateral lymph node metastases, lymph nodes of 6 cm or larger, low jugular lymph node metastases, and second primary tumor are the risk factors for developing distant metastasis. Our patient at the initial presentation had multiple bilateral lymph nodes. Multiple clinical studies have brought out the correlation of incidence of metastases and recurrence of the primary tumor with the primary stage of the tumor and the initial nodal involvement., In general, clinically palpable neck nodes (N1–N3) with histological evidence, extra-capsular spread, and three or more positive lymph nodes are at greater risk of metastasis to distant sites.
OSCC can metastasize to the lung, bone, liver, adrenal, and mediastinum., In our literature review, we came across several case reports of OSCC with metastasis to the bones such as vertebrae, ribs, metacarpals, and phalanges [Table 1]. However, many clinical studies concluded that osseous involvement of metastatic involvement from OSCC is secondary to the involvement of the lung. In our case, there were no metastases to the lung.
|Table 1: Case reports on bony involvement in metastatic oral squamous cell carcinoma|
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In the axial skeleton, the lumbar spine is the most common site of bony metastasis whereas in the appendicular skeleton proximal end of the femur is a common site of metastases. Lee et al. have reported two cases of the carcinoma tongue with metastasis to the lumbar vertebra. In our extensive literature search, we could not find any case report of metastases of carcinoma tongue to dorsal vertebrae managed surgically.
Management of spinal metastasis is multidisciplinary. This includes palliative radiotherapy, surgery, or a combination of both. The surgery in spinal metastasis is indicated in case of significant neural compression or fresh onset of neurological deficits. The aim of surgery is to decompress the affected spinal segment, provide spinal stability, relieve the intractable pain, and thereby improve the quality of life as was done in our case. Preciado et al., advocate surgery in patients with a life expectancy of >6 months and having neurological symptoms. The ultimate prognosis for patients with bone metastasis is poor with a median survival of few months only.
| Conclusion|| |
Spinal metastasis from OSCC is generally a terminal disease which can severely affect the quality of life. The surgery should be considered in all patients with intractable severe pain or progressive neurological deficits. Although the surgery does not alter the overall prognosis, it enables in self-care, decreased drug dependence, and leads to significant improvement in the quality of life.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]