Acrocutaneous metastasis - A rare presentation.

INTRODUCTION: Cutaneous metastasis from head and neck cancer is uncommon and it is seen from laryngeal cancer. Acrocutaneous metastasis from the base of tongue is relatively rare. CASE REPORT: We present a case of a 84-year-old male, previously diagnosed to have moderately differentiated squamous carcinoma of the base of tongue with lung and liver metastases and received palliative chemoradiation. He, now presented with ulcero-proliferative growth over the right 5th finger. In the present case, the patient initially presented with a nodule which later ulcerated and increased in size. There was associated discharge. There was clinical suspicion of underlying osteomyelitis. Hence right 5th finger amputation upto the middle phalanx was done. The histopathology report of the specimen was moderately differentiated squamous cell carcinoma. This is a case of skin metastasis from squamous carcinoma of the base of Tongue is rare at a short span of time following the completion of treatment. This case has highlighted the probable presence of occult skin metastasis at the time of diagnosis, which became apparent after the completion of treatment.
CONCLUSION: Fine needle aspiration cytology should be done in cutaneous nodules associated with head and neck cancers to rule out malignancy, even if it clinically appears to be benign in nature.

Introduction

Acrometastasisis a rare presentation, and it accounts for approximately 0.1% of metastases. The most common primary site of malignancy is lung, followed by the colo-rectal malignancies, malignancies involving breast and genito-urinary tract. Cutaneous metastasis from head and neck cancer is uncommon and it is seen more commonly from laryngeal cancer. Acrocutaneous metastasis from the base of tongue is relatively rare. In our case, the patient was a known case of carcinoma base of the tongue T4N2cM0 presented with non-healing ulcer over right little finger mimicking osteomyelitis. The amputated finger sent for histopathology showed evidence of cutaneous metastasis to right little finger from the carcinoma involving base of tongue. Our case report is in accordance with Consensus based Surgical Case Report (SCARE criteria) [1].

Clinical background

A 66 year old man, a case of carcinoma base of the tongue T4N2cM0 [moderately differentiated Squamous cell carcinoma] diagnosed in April 2012 and loco-regional radiation and chemotherapy [with 4 cycles of weekly Carboplatin], till June 2012.

Later in march 2014, was found to have Recurrence, with lung metastases on CECT thorax. Though there was no obvious growth noted at base of tongue, indicating good loco-regional control after first line chemotherapy. He was treated with second line chemotherapy [4 cycles of Carbotaxol -Carboplatin + Paclitaxel] and discontinued due to Transient ishemic attack (TIA). Repeat CECT thorax done, showed no evidence of metastases.

In March 2016, patient presented with a 3 month history of a non-healing ulcer over right little finger. There was a recent increase in size noted with pain and developed discharge from the ulcer. On examination, an ulcerated lesion was present the distal phalanx of right 5th finger approximately 2.5 × 2.5 cm in size, with minimal discharge. There was tenderness surrounding the ulcer and enlargement of the area was present. Based on all the clinical symptoms and signs, a provisional diagnosis of osteomyelitis of distal phalanx of right 5th finger was made. Laboratory investigations- biochemistry, hematocrit, leukocyte, platelet count and ECG was normal. Chest X-ray of the patient showed cannon ball metastases (Fig. 1). Right 5th finger amputation upto middle phalanx was done (Fig. 2).

Fig. 1

Chest x-ray showing cannon ball metastases.

Fig. 2

Amputated specimen with ulcerated lesion over the tip of distal phalanx.

Histopathology of the specimen showed infiltrating tumor composed of confluent clusters and nest of malignant squamous cells and scattered among dyskeratotic cells (Fig. 3). Occasional keratin pearls noted. Atypical mitoses present with areas of necrosis surrounded by fibrocollagenous stroma with myxoid change and areas of hyalinisation (Fig. 4). It was suggestive of Squamous cell carcinoma-moderately differentiated.

Fig. 3

Microscopic image – 5× magnification.

Fig. 4

Microscopic image – 20× magnification.

Conclusion

Acrocutaneous metastasis from squamous carcinoma of the Base of Tongue is rare and indicates a disseminated disease, carrying a poor prognosis. Acrocutaneous metastasis from squamous carcinoma of the Base of Tongue is rare and indicates a disseminated disease, carrying a poor prognosis. It can be presenting symptom of occult primary. It more often mimics benign condition and hence can be misdiagnosed. In cases of proven malignancy with metastasis, Fine needle aspiration cytology (FNAC) or biopsy from the lesions should be considered and metastasis should be ruled out, even if it clinically appears to be benign in nature.

Discussion

Acrocutaneous metastases are a rare presentation. This presentation is more commonly seen in pre-terminal patients presenting with wide-spread disseminated disease. The prognosis in these patients is very poor, with an average survival time of only a few months. Although the clinical presentation varies, the presentation is usually confused with an infectious or inflammatory process, and often misdiagnosed as osteomyelitis. This delays the diagnosis [2]. Rarely, they may be the first presentation of occult silent cancer, often presenting like a benign condition. When they are located on the fingers, the most frequent cause is lung carcinoma [3].In most acrometastases, first the bone and then the skin are affected. Treatment is palliative and includes surgical resection or amputation.

The incidence of distant metastases in squamous cell carcinoma of the tongue is relatively small as compared with other malignancies. It is influenced by location of the primary tumor, initial stage, and the presence or absence of loco-regional control [4]. The most frequent metastatic sites include lung, followed by bone and liver. Acrocutaneous metastases from squamous carcinoma of the Base of Tongue are exceedingly rare with only a few cases reported in the literature [5]. It is also rare to present at a short span of time following the completion of treatment.

In our case, there was a recurrence of the disease with distant metastases despite adequate chemotherapy and radiotherapy given and good locoregional control. There is also a rare presentation of acrocutaneous metastasis which mimicked osteomyelitis, presented after completion of chemo-radiation.

Conflicts of interest

None.

Funding

None.

Ethical approval

Ethical clearance has been exempted by the Institutional ethics committee Manipal university, Manipala.

Consent

Informed consent was obtained from the patient's son for publication of this case report and accompanying images.

Author contribution

Study conception and design: Srujana Reddy M and Annappa Kudva.

Acquisition of data: Srujana Reddy M and Annappa Kudva.

Analysis and interpretation of data: Srujana Reddy M and Annappa Kudva.

Drafting of manuscript: Srujana Reddy M.

Critical revision: Srujana Reddy M and Annappa Kudva.

Registration of research studies

NA.

Guarantor

Srujana Reddy M and Annappa Kudva.