Squamous cell carcinoma

Abstract

Basaloid squamous cell carcinoma is a variant of squamous cell carcinoma. This malignancy has a predilection for the upper aerodigestive tract, although it has been found in multiple other sites. The tumor is highly aggressive biologically, and the overall prognosis is poor de spite intensive treatment. We describe a case of basaloid squamous cell carcinoma of the larynx that metastasized to the spine.

Introduction

Various types of tumors affect the upper aerodigestive tract, the most common of which is squamous cell carcinoma. Squamous cell carcinoma itself has many variants, including the bimorphic variant basaloid squamous cell carcinoma. (1) These neoplasms have been found in multiple sites in the body--including the anus, cervix, and lungs--but they have a predilection for the upper aerodigestive tract. The most common of these sites are the supraglottic larynx, hypopharynx, and base of the tongue. (2) Other sites include the floor of the mouth, tonsils, nasal cavity, paranasal sinuses, nasopharynx, palate, buccal mucosa, esophagus, and trachea. (3) In this article, we report the case of a patient with basaloid squamous cell carcinoma of the larynx that metastasized to the spine.

Case report

A 48-year-old man was referred to our outpatient department for evaluation of a 2-month history of progressive hoarseness that was associated with cough and expectoration of mucoid sputum. He was a chronic cigarette smoker.

Indirect laryngoscopy detected the presence of an ulceroexophytic growth that involved the right true vocal fold, right false vocal fold, right aryepiglottic fold, and right arytenoid with fixity of the right hemilarynx. The remainder of the larynx and the pharynx were normal, and there were no palpable neck nodes. After a routine blood and urine examination, direct laryngopharyngoscopy was performed under local anesthesia to assess the extent of the lesion, and these findings confirmed those found on indirect laryngoscopy.

A biopsy specimen was taken and sent for histopathologic examination, which identified the mass as a basaloid squamous cell carcinoma. The tumor was made up of small-to-medium-sized cells that featured hyperchromatic nuclei and scant cytoplasm (figure 1). The cells were arranged in lobules in a trabecular pattern. There were areas of comedo-type necrosis, adenoid cystic pattern, and extensive necrosis. The patient underwent a right-sided, vertical partial hemiliaryngectomy. His postoperative period was uneventful, and oral feeding resumed on postoperative day 10.

On postoperative day 12, the patient complained of back pain, which radiated to the upper abdomen and was aggravated by straining and movement. Physical examination of his back revealed tenderness over the T11 vertebra, but no motor or sensory deficits in the lower limbs. An x-ray of the thoracolumbar spine showed that T11 had collapsed and was destroyed (figure 2). The patient experienced a progressive worsening of his pain, and he began to notice weakness in his right lower limb. The results of liver function tests and ultrasound scanning of the abdomen were within normal limits. Findings on x-ray of the chest and the rest of the bony skeleton were also normal. After consultation with an orthopedic surgeon, we made a preliminary clinical diagnosis of tuberculosis of the spine. To confirm the diagnosis, we obtained a fine-needle aspiration biopsy specimen, guided by computed tomography (CT), from T11 (figure 3). Analysis of the spinal specimen revealed that it represented a metastasis of the laryngeal basalo id squamous cell carcinoma.

The patient was fitted with a spinal brace and referred for radiotherapy. He was irradiated with 3,800 cGy to T11 (800 cGy in one fraction followed by 3,000 cGy in 10 fractions) and with 4,500 cGy to the primary site (in 15 fractions). Following radiotherapy, the patient's back pain subsided. He no longer has any back complaints, and he is physically fit.

Discussion

The term basaloid squamous cell carcinoma was first used by Wain et al in their 1986 report of 10 cases that had occurred in the tongue, hypopharynx, and larynx. (4) This malignancy generally affects elderly men who are smokers and/or alcoholics. (5) In a series of cases reported by Ferlito et al, the average age of patients at their initial evaluation was 63.33 years. (1) At 48 years of age, our patient was relatively young.

Clinically, basaloid squamous cell carcinoma is a highly aggressive tumor. It is characterized by a high incidence of early regional and distant metastasis to the lungs, liver, bones, brain, and skin. (5) Another peculiarity in our patient was the metastasis to the spine, even though the regional lymph nodes were uninvolved. In light of this development, the absence of metastasis to the cervical lymph nodes cannot be considered to be a favorable prognostic sign because the tumor might have already spread to distant sites. Therefore, an extensive work-up--including whole-body CT--is mandatory in all cases of basaloid squamous cell carcinoma.

Histopathologically, the tumor is most likely to be confused with adenoid cystic carcinoma and small-cell undifferentiated carcinoma. Differentiation can be made on clinical, histologic, and immunohistochemical grounds. (2) By the time they are evaluated, most of these patients are already at an advanced stage--usually stage III or IV. Our patient was at stage III and had already developed a distant metastasis, which demonstrates the aggressive nature of this tumor.

Treatment consists of radical surgery, radiotherapy, or both, with or without chemotherapy; adjuvant chemotherapy might have a role in patients with metastasis. (5)

References

(1.) Ferlito A, Altavilla G, Rinaldo A, Doglionl C. Basaloid squamous cell carcinoma of the larynx and hypopharynx. Ann Otol Rhinol Laryngol 1997;106:1024-35.

(2.) Morice WG, Ferreiro JA. Distinction of basaloid squamous cell carcinoma from adenoid cystic and small cell undifferentiated carcinoma by immunohistochemistry. Hum Pathol 1998;29:609-12.

(3.) Barnes L, Ferlito A, Altavilla G, et al. Basaloid squamous cell carcinoma of the head and neck: Ciinicopathological features and differential diagnosis. Ann Otol Rhinol Laryngol 1996;105:75-82.

(4.) Wain SL, Kier R, Vollmer RT, Bossen EH. Basaloid-squamous carcinoma of the tongue, hypopharynx, and larynx: Report of 10 cases. Hum Pathol 1986;17:1158-66.

(5.) Schwartz RM. Pathology of laryngeal tumors, In: Thawley SE, Panje WR, Batsakis JG, Lindberg RD, eds. Comprehensive Management of Head and Neck Tumors. 2nd ed., vol. 2. Philadelphia: W.B. Saunders, 1999:959-60.

From the Department of Otolaryngology, Government Wenlock District Hospital, and the Department of Otolaryngology, Kasturba Medical College, Mangalore, India.

Reprint requests: Dr. Kishore Chandra Prasad, Chief of Otolaryngology, First Floor, Nethravathi Bldg., Balmatta Rd., Mangalore, Dakshina Kannada, India. Phone: +91-824-447-394; fax: +91-824-428-183; e-mail: kishorecprasad@yahoo.com

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