Journal of Cancer Research and Practice xxx (2017) 1e3

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Journal of Cancer Research and Practice

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research-and-practice

Case Report

An exceptional case of cutaneous metastasis of squamous cell

carcinoma of the lip
Vinita Trivedi, Muneer Abdul khalam*, Manashi Ghosh, Richa Chauhan, Syeda Naseera
Department of Radiation Oncology, Mahavir Cancer Sansthan, India

a r t i c l e i n f o a b s t r a c t

Article history: Majority of head and neck cancers are squamous cell carcinomas. Distant metastases of squamous cell
Received 15 April 2017 carcinoma of the head and neck (HNSCC) occur at many sites, especially in the lung and bone. However,
Received in revised form metastases to the skin are unusual and rare. Here, we report a case of a patient with squamous cell
23 June 2017
carcinoma of right side of the lower lip, who underwent radiotherapy after surgical excision of the tumor.
Accepted 19 July 2017
Available online xxx
One month post radiotherapy, multiple subcutaneous nodules appeared on his chest, abdomen, back,
buttocks, and thighs. Pathological diagnosis of the excised subcutaneous nodule was suggestive of
metastatic squamous cell carcinoma. To the best of our knowledge, this is the first report on multiple
Keywords:
Carcinoma lip
subcutaneous metastases of squamous cell carcinoma of the lip.
Cutaneous metastasis © 2017 The Chinese Oncology Society. Production and hosting by Elsevier B.V. This is an open access
Skip metastasis article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Annual incidences of head and neck cancers worldwide are
more than 550,000 cases with around 300,000 deaths each year.1
Male to female ratio ranges from 2:1 to 4:1. About 90% of all head
and neck cancers are squamous cell carcinomas (HNSCC). It is the
sixth leading cancer by incidence worldwide.1
The most common mode of spreading HNSCC is via regional
lymph nodes to the cervical drainage areas. Distant metastases
related to lip carcinomas occur very rarely (0.5e2%). In general,
distant metastases of HNSCC occur at many sites, especially in the
lung and bone. However, metastases to the skin are unusual and
rare.2 Skin metastasis (SM) usually occurs in the neck, scalp, and
over the chest wall that is near to the primary site.
We report a case of carcinoma of the right lower lip with mul-
tiple skin metastases on the chest, abdomen, back, buttocks, and
thighs one month after the treatment.
2. Case report
A 60-year-old male, who was chronic khaini chewer, was pre-
sented to our out-patient department (OPD) with chief complaints
* Corresponding author. Department of Radiation Oncology, Mahavir Cancer
Sansthan, Patna, Bihar 801505, India.
E-mail address: muneerkhalam@hotmail.com (M. Abdul khalam).
Peer review under responsibility of Taiwan Oncology Society.
of ulcer in the right lower lip since 2 month without other relevant
co-morbidities and family history. He was average built with the
Eastern Cooperative Oncology Group (ECOG) performance status of
1. Local Examination revealed 2.5  2.5 cm ulceroproliferative
growth in the right lower lip; right level I B lymph node was
palpable, firm, mobile, 2  2 cm in size, and non-tender with
normal overlying skin. Punch Biopsy taken from the growth
showed keratinizing squamous cell carcinoma grade II (Fig .1). Fine
needle aspiration cytology (FNAC) using samples from the right
level I lymph node was suggestive of reactive hyperplasia. Routine
laboratory examination showed a normal picture. Chest X-ray
revealed no evidence of metastatic disease. He underwent right
lower lip wide excision with supra omohyoid neck dissection
(SOHD). Post-operative period was uneventful. Gross examination
of the specimen revealed an ulceroproliferative mass of
4.5  3.5  1.5 cm on the mucosal surface of lip. All margins were
free, and the distance of the lesion from the closest surgical margin
was 1.5 cm. Cut surfaces were tan white and homogenous. Micro-
scopic findings revealed poorly differentiated keratinizing squa-
mous cell carcinoma grade III (high grade) with depth of invasion 2
cm, indeterminate lymphovascular invasion (LVI) and positive
perineural invasion. Regarding lymph node status, all 3 lymph
nodes were negative in level I and all six lymph nodes were
negative in level II; however at level III, one out of seven lymph
nodes was positive for tumor metastasis with no extra nodal
extension. Pathological staging was pT3N1M0 (stage III). Adjuvant
radiotherapy was given to the face and neck region with a total dose
of 60 Gy in 30 fractions from 25/11/2016 to 10/01/2017 with Cobalt-

http://dx.doi.org/10.1016/j.jcrpr.2017.07.003
2311-3006/© 2017 The Chinese Oncology Society. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Trivedi V, et al., An exceptional case of cutaneous metastasis of squamous cell carcinoma of the lip, Journal of
Cancer Research and Practice (2017), http://dx.doi.org/10.1016/j.jcrpr.2017.07.003
2 V. Trivedi et al. / Journal of Cancer Research and Practice xxx (2017) 1e3
Fig. 1. Biopsy: H&E x 40 squamous cell carcinoma.
60 gamma rays using parallel opposing bilateral fields. Six cycles of
concurrent weekly cisplatin (30 mg/m2) were given. The patient
had tolerated the chemo-radiotherapy well and was advised to visit
head and neck cancer clinic regularly for follow-up. After 15 days of
completion of radiotherapy, he noticed a small nodule over the
abdomen with gradual progression in different parts of the body.
Thereafter, he reported to our OPD with the complaint of multiple
painless subcutaneous nodules all over the body. On examination,
general condition was found average, and the primary disease was
found locally controlled with no palpable nodes in neck. There were
small, multiple, mobile, non-tender, and palpable subcutaneous
nodules all over the chest, abdomen, back, buttocks, and thighs
with largest size of 3  3 cm (Fig. 2). Excision biopsy from both
abdominal and chest wall nodule showed neoplastic cells with
moderate atypia, high N:C ratio, and moderate amount of eosino-
philic cytoplasm, which altogether suggested metastatic squamous
cell carcinoma. Two months after the diagnosis of skin metastases,
patient had complaints of cough. Routine chest-x-ray showed
metastatic deposits in the bilateral lung parenchyma. Hence, the
patient was put on palliative chemotherapy.
3. Discussion
Cutaneous or skin metastasis (SM) is defined as isolated or
Fig. 2. Photograph of multiple skin metastases on the chest, abdomen, back, buttocks, and thighs post one month of radiotherapy.
Please cite this article in press as: Trivedi V, et al., An exceptional case of cutaneous metastasis of squamous cell carcinoma of the lip, Journal of
Cancer Research and Practice (2017), http://dx.doi.org/10.1016/j.jcrpr.2017.07.003
multiple intradermal collections of tumor cells remote from the
primary or loco-regional disease.3 SMs are recognized as painless,
solitary or multiple, subcutaneous nodules. SMs are distinguishable
from primary cutaneous squamous cell carcinomas (SCCs) because
SMs are completely separated from the overlying epidermis.4 The
frequency of SM from internal malignancies varies from 0.7% to 9%
depending on types of cancers, and most common primary tumors
associated with skin metastasis are breast cancer in women and
lung cancer in men.5
Distant metastases related to lip carcinomas occur very rarely
(0.5e2%) and can be expected in cases of advanced tumors from
advanced regional disease. In general, SMs can be diagnosed early
because of its good accessibility, accounting for its detection at
initial stage in 93% of cases.6 In general, distant metastases of
HNSCC occur at many sites; most common sites of distant metas-
tases are usually lung (70e75%), liver (17e38%), and bone
(23e44%).7 Skin metastasis has been reported to occur in 0.8e1.3%
of patients with HNSCC.8 It can occur as a single lesion or multiple
lesions anywhere over the body but are found predominantly on
the anterior trunk or head and neck region.9 The majority occur
above the diaphragm.3
The exact mechanism of SM of HNSCC is incompletely under-
stood. There are three possible mechanisms as outlined by kmucha
et al.10: direct spread, local spread, and distant spread. The so-called
direct spread is an extension of tumor through tissue planes
without an actual metastasis to the skin. Local skin metastases are
believed to be the result of tumor cells spreading through dermal
lymphatics with subsequent deposition of tumor cells in the skin.
Distant metastases are believed to be the result of hematogenous
spread. These modes of metastasis are largely speculative, which
are not based on experimental evidences.10
SM involving hematogenous spread via the valve less azygos
venous system and vertebral venous system, known as Batson's
plexus, may bypass the pulmonary filtering mechanism, thus,
allowing embolic metastases to any site draining into this system,
including pelvis, scalp, neck, and much of the body's surface.10
The presence of dermal metastases is a harbinger of poor
prognosis. Median survival from the onset of cutaneous metastases
ranges from 3 to 7 months with 0% one year survival rate.2 The
rapid development of SMs and poor prognosis associated with it
speaks for the aggressive nature of tumors that preferentially
metastasize to the skin.
Disease stage does not appear to predict the occurrence of
cutaneous metastases.4 Pitman et al. have reported that the
 V. Trivedi et al. / Journal of Cancer Research and Practice xxx (2017) 1e3
development of cutaneous metastases is more common if two or
more cervical lymph node metastases are present or due to extra
capsular spread of tumor in the cervical nodes.2 This was not the
scenario in our case because the patient had metastasis in the
solitary lymph node without any extranodal extension; however,
this patient had skip metastasis to level III lymph node without the
involvement of level I & II, which is extremely rare.
Skip Metastasis to inferior cervical nodes at levels III or IV in the
absence of demonstrable involvement of levels I and II has been
reported in cancers of the oral cavity. In 1997, Byers et al.,11 have
published an interesting paper reporting 277 previously untreated
patients with SCC of the tongue. Of all patients, 15.8% had either
level IV metastasis as the only manifestation in the neck or level III
metastasis without diseases in levels I and II. Skipping of anatom-
ical levels and “peppering” have been seen only in association with
tongue tumors, apart from the single case of a tumor of the anterior
midline of the mouth.12 Kerawala and Martin (1998)13 have re-
ported two patients with cancer of the mouth floor who were
presented with skip metastasis. In 2000, Hamakawa et al.,14 have
reported skip metastasis in a patient with tongue cancer.12
It is also found that chances of skip metastasis present a high
rate of tumor recurrence with decreased survival.15 However in the
present case, we observed skip metastasis of the lip carcinoma,
which is the first case report in literature as per best of our
knowledge.
The treatment of SM is inconclusive. Given the metastatic nature
of disease, the treatment of these patients, in general, is-palliative.
Options available are surgical excision, chemotherapy, external
beam radiotherapy, or combination of these, depending on clinical
circumstances. Surgical excision has been shown to increase sur-
vival time16; however, other forms of treatment are usually
ineffective.
In our case, patient had multiple subcutaneous nodules all over
the body; so, surgery was not offered, and in view of lung metas-
tasis, the patient was put on palliative chemotherapy.
4. Conclusion
It's a case of carcinoma of the right lower lip with multiple skin
metastases on the chest, abdomen, back, buttocks, and thighs. Skin
metastases of HNSCC are uncommon. There is no agreed consensus
on the management and treatment of these kinds of cancers.
Regarding treatment, the palliative treatment and surgical excision
Please cite this article in press as: Trivedi V, et al., An exceptional case of cutaneous metastasis of squamous cell carcinoma of the lip, Journal of
Cancer Research and Practice (2017), http://dx.doi.org/10.1016/j.jcrpr.2017.07.003
3
are recommended; radiotherapy and chemotherapy have also been
used depending on clinical circumstances. To the best of our
knowledge and according to the literature, this is perhaps the first
case report of lip carcinoma to develop multiple skin metastases all
over the body.
Conflict of interest
None.
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