short communication

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British Journal of Oral and Maxillofacial Surgery (2004) 42, 264—266 SHORT COMMUNICATION Axillary metastases from recurrent oral carcinoma S.S. Rayatt a, * , A.L. Dancey a , J. Fagan b , S. Srivastava a a Department of Plastic and Reconstructive Surgery, George Eliot Hospital, College Street, Nuneaton CV10 7DJ, UK b Department of Oral and Maxillo-Facial Surgery, George Eliot Hospital, College Street, Nuneaton CV10 7DJ, UK Accepted 18 December 2003 KEYWORDS Squamous cell carcinoma; Oral; Recurrent; Axillary disease Summary The rationale for surgical treatment of head and neck cancer is based on a predictable pattern of metastasis. There is aberrant or unpredictable spread rarely and typically only in recurrent disease. There are few published reports to our knowledge of axillary metastases from squamous cell cancer (SCC) of the head and neck. We present a patient who developed axillary node disease on the other side after recurrence of a squamous cell carcinoma of the floor of the mouth. She died 11 months after excision of the recurrence. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Introduction The single most important prognostic factor in can- cer of the head and neck is nodal status at presen- tation. Treatment is based on the knowledge that the pattern of metastatic spread is predictable, and related to the histological stage of the tumour and the site of origin. The most common site is to the cervical lymph nodes, with distant haematogenous metastasis to the lung, liver and bones. Any dis- turbance of the normal drainage by operation, ra- diotherapy or recurrent disease, can result in other pathways of lymphatic drainage with dissemination of cancer cells below the clavicles. There are few published reports to our knowledge about axillary *Corresponding author. Present address: Department of Plas- tic Surgery, University Hospital of North Staffordshire, Stoke City Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG, UK. Tel.: +44-1782-715444; fax: +44-1782-552813. E-mail address: [email protected] (S.S. Rayatt). metastases from head and neck cancer and even fewer from oral cancer. We present a patient who developed axillary node disease on the opposite side after recurrence of a squamous cell carcinoma (SCC) of the floor of the mouth. Case report A 58-year-old lady presented with a numb lower lip and unhealed sockets 6 weeks after extraction of two lower molar teeth. Radiographs showed a lytic lesion in the mandible and biopsy of the area showed a well-differentiated SCC. She had a left partial mandibulectomy with a plate reconstruction and a modified radical neck dissection on the same side. Histological examination confirmed clear mar- gins, with nodal disease at levels I and II. She was given additional radiotherapy to total of 60 Gy. Nine months later she represented with disease in the opposite side of the neck and had a right modi- 0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2003.12.004

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Page 1: Short Communication

British Journal of Oral and Maxillofacial Surgery (2004) 42, 264—266

SHORT COMMUNICATION

Axillary metastases from recurrent oralcarcinoma

S.S. Rayatta,*, A.L. Danceya, J. Faganb, S. Srivastavaa

a Department of Plastic and Reconstructive Surgery, George Eliot Hospital, College Street,Nuneaton CV10 7DJ, UKb Department of Oral and Maxillo-Facial Surgery, George Eliot Hospital, College Street,Nuneaton CV10 7DJ, UK

Accepted 18 December 2003

KEYWORDSSquamous cellcarcinoma;Oral;Recurrent;Axillary disease

Summary The rationale for surgical treatment of head and neck cancer is basedon a predictable pattern of metastasis. There is aberrant or unpredictable spreadrarely and typically only in recurrent disease. There are few published reports to ourknowledge of axillary metastases from squamous cell cancer (SCC) of the head andneck. We present a patient who developed axillary node disease on the other sideafter recurrence of a squamous cell carcinoma of the floor of the mouth. She died 11months after excision of the recurrence.© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by ElsevierLtd. All rights reserved.

Introduction

The single most important prognostic factor in can-cer of the head and neck is nodal status at presen-tation. Treatment is based on the knowledge thatthe pattern of metastatic spread is predictable, andrelated to the histological stage of the tumour andthe site of origin. The most common site is to thecervical lymph nodes, with distant haematogenousmetastasis to the lung, liver and bones. Any dis-turbance of the normal drainage by operation, ra-diotherapy or recurrent disease, can result in otherpathways of lymphatic drainage with disseminationof cancer cells below the clavicles. There are fewpublished reports to our knowledge about axillary

*Corresponding author. Present address: Department of Plas-tic Surgery, University Hospital of North Staffordshire, StokeCity Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG, UK.Tel.: +44-1782-715444; fax: +44-1782-552813.

E-mail address: [email protected] (S.S. Rayatt).

metastases from head and neck cancer and evenfewer from oral cancer.We present a patient who developed axillary node

disease on the opposite side after recurrence of asquamous cell carcinoma (SCC) of the floor of themouth.

Case report

A 58-year-old lady presented with a numb lowerlip and unhealed sockets 6 weeks after extractionof two lower molar teeth. Radiographs showed alytic lesion in the mandible and biopsy of the areashowed a well-differentiated SCC. She had a leftpartial mandibulectomy with a plate reconstructionand a modified radical neck dissection on the sameside. Histological examination confirmed clear mar-gins, with nodal disease at levels I and II. She wasgiven additional radiotherapy to total of 60Gy. Ninemonths later she represented with disease in theopposite side of the neck and had a right modi-

0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjoms.2003.12.004

Page 2: Short Communication

Axillary metastases from recurrent oral carcinoma 265

Figure 1 Lump in the right axilla.

fied radical neck dissection. Histological examina-tion showed level III disease.Two years later she developed a local recurrence

that was treated by wide local excision and repairwith a local tongue flap. After 3 months, she reat-tended with extra oral exposure of her mandibularplate and on examination was found to have a lumpin the opposite axilla (Fig. 1). Carcinoma of thebreast was suspected and she was referred to thebreast team. Fine needle aspiration, ultrasoundand mammography failed to show any malignancy.A chest radiograph showed no abnormality. Openincision biopsy of the lump also failed to show anyevidence of malignancy and the mass was treatedas an axillary abscess. Biopsy of the extra orallesion showed recurrent SCC. Her recurrent dis-ease was resected under frozen section controland the defect repaired with pedicled latissimusdorsi and pectoralis major flaps. The right axillarymass failed to heal and a subsequent open excisionbiopsy showed inoperable tumour involving the ax-illary vein and extending above pectoralis minorinto the cervicoaxillary canal. Histological exam-ination was reported as metastatic SCC. She died11 months later.

Discussion

Lymphatic drainage of tissues in the head and neckis by both superficial and deep systems. The super-ficial or outlying group of nodes includes the occip-ital, postauricular, parotid, facial, submandibular,submental and superficial cervical nodes, which liealong the external jugular vein. The deep or ter-minal group of nodes consists of the deep cervicalchain, which lies along the internal jugular vein. Alltissues eventually drain into the deep system eitherdirectly or indirectly through the superficial system.

Drainage is largely predictable and depends on thesite, size and histological status of the primary tu-mour. However, complex and variable connectionswith other lymphatics in the chest and axilla do ex-ist. In certain conditions, such as after resection orradiotherapy, the axilla can become the major lym-phatic drainage site from the anterior and lateralneck.1 It is also possible that the tumour itself canproduce alterations in lymphatic drainage. Axillarymetastases have been documented at necropsy in2—9% of patients with head and neck cancer.2 Theincidence is probably higher, as impalpable nodesare not routinely dissected during necropsy.3 In areview of the University of California Los AngelesMedical Centre Tumour Registry, 1.5% of patientswere found to have metastases to the infraclavicu-lar lymph nodes.4

Our patient had a resection, radiotherapy andrecurrent disease, all characteristics identified byKoch as being present in patients with axillarymetastases from head and neck cancer.1 He rec-ommended that such patients should have regularmonitoring of the axillary lymph nodes as part oftheir routine follow up. If the axilla is suspicious, acomputed tomogram should be done.Our case was unusual in that the primary lesion

was oral, spread was to the opposite side, and in-vestigations by the breast oncology team were in-conclusive. We suspect that her disease had spreadfrom the right side of the neck through the cervi-coaxillary canal into the right axilla, despite a rightneck dissection and radiotherapy. Distant metas-tases usually preclude aggressive treatment and ifwe had known this preoperatively it might havealtered our treatment plan. However, there havebeen case reports of long-term survival after rad-ical axillary dissection for well-differentiated SCCwith no evidence of further metastases. Nelson andSisk reported a patient who survived 25 years af-ter bilateral dissection for axillary metastases fromSCC of the larynx.5

Although axillary spread is rare, clinicians shouldbe aware of the possibility in advanced or recur-rent head and neck cancer, particularly when con-sidering salvage operations. In such cases follow upshould include clinical examination of the axilla,with magnetic resonance imaging as appropriate.Patients should also be taught the importance ofregular self-examination.

References

1. Koch WM. Axillary nodal metastases in head and neck cancer.Head Neck 1999;21:269—72.

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266 S.S. Rayatt et al.

2. Gowen GF, Desuto-Nagy G. The incidence and sites of distantmetastasis in head and neck carcinoma. Surg Gynecol Obstet1963;116:603—7.

3. Kowalski LP. Noncervical lymph node metastasis from headand neck cancer. ORL J Otorhinolaryngol Relat Spec2001;63(4):252—5.

4. Alavi S, Namazie A, Sercarz JA, Wang MB, Blackwell KE.Distant lymphatic metastasis from head and neck cancer.Ann Otol Rhinol Laryngol 1999;108:860—3.

5. Nelson WR, Sisk M. Axillary metastasis from carcinoma ofthe larynx: a 25 year survival. Head Neck 1994;16:83—7.