JOURNAL: NURSING

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Buccal metastasis in a case of
carcinoma breast: A rare case
report with review of literature
Abstract
INTRODUCTION

Metastatic lesions to oral cavity from distant tumours account for 1% of all oral cavity
malignancies. Oral cavity is a rare site of metastasis from the breast. We describe case
report of breast cancer patient with metastasis to buccal mucosa.

PRESENTATION OF CASE

We report a case of pre-menopausal woman with left side infiltrating ductal

carcinoma breast – T4aN1M0. She received three cycles of neo-adjuvant
chemotherapy followed by modified radical mastectomy (MRM) and three cycles
of adjuvant chemotherapy and loco-regional EBRT. She presented with a lump in
region of MRM scar and a painful swelling in the right cheek, one year
afterwards. Core needle biopsy from scar site revealed infiltrating ductal carcinoma.
CECT revealed a heterogeneous lesion (1.1 cm × 1.7 cm) in right masticator space,
which on biopsy revealed metastatic deposit consistent with infiltrating ductal
carcinoma.

Keywords

Carcinoma breast
Oral cavity
Metastasis

1. Introduction
Metastatic lesions to the oral cavity from distant tumours are uncommon, accounting
for only 1% of all oral cavity malignancies. They mainly involve the bony structures
(particularly the mandible), whereas primary metastases to soft tissues are extremely
rare (only 0.1% of oral malignancies).1 The most common sites of metastasis are the
tongue and gingiva followed by the lips, with occasional case reports of metastasis to
the palatal or buccal mucosa.2 We describe a case report of a patient of breast cancer
with metastasis to the buccal mucosa.

2. Case presentation
We report a case of 30-year-old pre-menopausal woman who presented with a left
sided breast lump, which was diagnosed as a case of infiltrating ductal
carcinoma (triple negative) on core needle biopsy (T4aN1M0). Patient also had
mobile Axillary lymph nodes in the ipsilateral axilla. Her metastatic work-up at the
time of diagnosis was normal. Her computed tomography scan at that time reported a
6.1 cm × 5.7 cm × 7.2 cm heterogeneously enhancing mass lesion in left breast upper
outer quadrant; involving pectoralis major and pectoralis minor. Left axilla shows
heterogeneously enhancing node of 1.8 cm × 2 cm, fatty hila is lost. Clinically the
mass was fixed to the chest wall. The patient was started on neo-adjuvant
chemotherapy (NACT) with cyclophosphamide, doxorubicin, 5-fluorouracil (CAF)
regimen and patient underwent modified radical mastectomy (MRM) after three
cycles of NACT. Histological examination of the specimen revealed infiltrating ductal
carcinoma (Fig. 1) with 4 out of 12 Axillary lymph nodes positive (Fig. 2). Patient
then received three cycles of adjuvant chemotherapy and was being planned
for adjuvant radiotherapy. Patient was treated on outpatient basis and was
given external beam radiotherapy using Co-60 teletherapy machine. Patient was laid
supine with arm abducted at 90° and head turned to opposite side. Breast tilt board
with arm rest was used to stabilize the position. Radiotherapy was given using
bilateral tangential fields along with supraclavicular and Axillary lymph nodal
irradiation. Entire chest wall was included in the field with upper margin placed at
head of the clavicle and lower margin was 2 cm inferior to the infra mammary fold.
Medial border was 1 cm over the midline and lateral-posterior border in the
mid Axillary line. Patient received a total tumour dose of 50 Gy/25#/5 weeks at
2 Gy/#/day for 5 days a week. For supraclavicular lymph node irradiation lower
border was matched to the upper border of the tangential field and medial border was
1 cm across the midline, extending upwards following medial border of
sternocleidomastoid to thyrocricoid groove. Lateral border was extended laterally to
cover 2/3 of the humoral head to treat full axilla and a dose of 50 Gy/25#/5 weeks was
given. Additional posterior Axillary boost was given after 17# of EBRT. Following
which patient was lost to follow-up.

Fig. 1. Microscopic picture depicting infiltrating ductal carcinoma breast with BR score

of 8. Inset (a) shows focal DCIS was observed in this case with comedo necrosis.

Fig. 2. Microscopic picture showing lymph node infiltration by the tumour.

She presented one year later to the surgical clinic with complaints of a lump in the
region of the MRM scar and another hard, painful swelling in the right cheek, which
was progressively increasing in size for the last 2 months. Fine needle aspiration
cytology (FNAC) and core needle biopsy from the scar site lump revealed infiltrating
ductal carcinoma.
A contrast enhanced computed tomography (CT) scan of the head and neck revealed a
round heterogeneous lesion with rim enhancement measuring 1.1 cm × 1.7 cm in the
right masticator space (Fig. 3). FNAC (fine needle aspiration cytology) from the
cheek swelling, revealed a metastatic deposit of malignant cells. A biopsy from the
swelling revealed a metastatic deposit consistent with infiltrating ductal carcinoma
(Fig. 4). Immunohistochemistry revealed a triple negative carcinoma. A bone scan and
abdominal ultrasound were normal.

Fig. 3. A 1.1 cm × 1.7 cm peripherally enhancing lesion is noted in right masticator space
anterior to masseter muscle. The central part does not enhance suggestive of necrosis.
Mild stranding is noted in surrounding fat. Posteriorly the lesion abuts masseter muscle.
In k/c/o Ca breast findings are suggestive of deposit in masticator space.
 Fig. 4. A trucut biopsy the nodule in masticator space showing malignant cell cluster with
a lymphoplasmacytic inflammatory response. Inset (b) shows a high power field of the
same nodule.
Patient was explained about the surgical procedure, associated complications and
prognosis after the procedure. However, the patient did not consent for surgery.
Following which she was taken up for palliative
treatment with docetaxel and cisplatin based chemotherapy regimen.

3. Discussion
The diagnosis of metastasis to the oral cavity is a challenge to the clinician because of
the lack of pathognomonic signs and symptoms. A high index of clinical suspicion is
necessary when evaluating patients with a history of no head and neck carcinoma.
Metastatic lesions to the oral cavity from distant tumours are uncommon, accounting
for only 1% of all oral malignancies. They mainly involve the bony structures
(particularly the mandible), whereas primary metastases to soft tissues are
extraordinarily rare (only 0.1% of oral malignancies). The most common sites of soft
tissue involvement are the gingiva, tongue, lips and the buccal and palatal mucosa.
The primary tumours are mainly lung, breast, kidney and colon. 1
Detection of oral lesions has great importance because they might be diagnosed first
by the patient's dentist or the maxillofacial surgeon. The clinical presentation of
metastatic lesions is different in various oral sites. 3 Patients often have vague or
innocuous symptoms that can mimic dental infections, and sometimes the disease
might be totally asymptomatic.4, 5 In a review of 114 cases of metastatic jaw
tumours, D'Silva et al.4 found that the most common jaw symptom was pain. Other
signs and symptoms included swelling, presence of intraoral mass, loose or extruded
teeth, cortical expansion, regional lymphadenopathy, gum irritation, ulceration,
exophytic growth, halitosis, numbness or paresthesia of the lower lip, and
trismus.5 Special attention should be given to patients with numb-chin syndrome or
mental nerve neuropathy, a symptom that should always raise the suspicion of a
metastatic disease in the mandible.6
In most cases of oral metastasis, the distant primary tumour has already been
diagnosed and often treated. Sometimes, however, the discovery of an oral metastasis
leads to the detection of an occult primary malignancy elsewhere in the body.3, 7 In
about one third of patients the oral lesion is diagnosed before the primary tumour.7, 8
In our case, the patient presented simultaneously with scar recurrence and distant
metastasis at an unusual site. Had it not been for the scar recurrence, the patient might
not have presented to the out patient department (OPD) with the oral swelling. A high
degree of clinical suspicion and previous history of breast cancer led to the detection
of the metastatic deposit.
The clinical presentation and radiographic findings of a metastatic lesion can be
deceiving, leading to a misdiagnosis of a benign process; therefore in such cases,
especially in patients with a history of malignant disease, biopsy is mandatory for
exact histopathological co relation. 3 Taking a thorough medical history along with a
panel of immunohistochemical stains may be helpful in making the diagnosis. 4 In our
case, after the history of breast cancer was established, a biopsy was performed. In
addition, the pathologic slides of the breast tumour were requested and compared with
the buccal lesion, which confirmed the final diagnosis.
Most of the patients with a metastases in the oral cavity also develop metastases at
other sites, often leaving no other option than palliation.7, 8, 9, 10 However,
Anderson Cancer Center has reported a 15-year disease-free survival rate of 24% in
134 patients with solitary loco regional recurrences or metastases treated with surgical
resection, systemic therapy, and in selected cases, radiotherapy. 11 Nieto et al. reported
the outcome of 60 patients with minimal metastatic disease treated with surgery
and/or radiation therapy and high-dose chemotherapy. Included in this group were 17
patients with distant metastases at the time of breast cancer diagnosis. After a median
follow-up of 62 months, 51.6% of the entire patient group (95% CI, 39–64%)
remained alive and free of disease. In the patients with metastatic disease at
presentation, 46% of those with distant metastases and three of four with
supraclavicular metastases were alive and free of disease. 12 Herein this case the patient
did not consent for the surgery. Local treatment gives relief in pain and may also
prevent loss of function.7 In general, survival of patients with advanced disease
including metastases is poor, with maximum number of patients dying within a year
of detection of the bony metastasis.4
Conflict of interest
None.

Funding
None.

Ethical approval
Informed consent was taken.

Author's contribution
Besides, writing the full content, Sunny Jain had done data collection with the help of
Mohit Kadian and Rohan Khandelwal, and Sunny Jain had made data analysis
teaming with Usha Agarwal and K.T. Bhowmik.

References
1
A. Nandakumar, P.C. Gupta, P. Gangadharan, R.N. Visweswara, D.M. ParkinGeographi
c pathology revisited: development of an atlas of cancer in India
International Journal of Cancer, 116 (2005), pp. 740-754
CrossRefView Record in ScopusGoogle Scholar
2
M.P. Solomon, M. Gormley, W. Jarrett, Y. RosenMetastatic lesions to the oral soft
tissues
Journal of Oral Surgery, 33 (1975), pp. 53-56
View Record in ScopusGoogle Scholar
3
A. Hirshberg, A. Shnaiderman-Shapiro, I. Kaplan, R. BergerMetastatic tumours to the
oral cavity – pathogenesis and analysis of 673 cases
Oral Oncology, 44 (2008), pp. 743-752
ArticleDownload PDFView Record in ScopusGoogle Scholar
4
N.J. D'Silva, D.J. Summerlin, K.G. Cordell, R.A. Abdelsayed, C.E. Tomich, C.T. Hanks, 
et al.Metastatic tumors in the jaws: a retrospective study of 114 cases
Journal of the American Dental Association, 137 (2006), pp. 1667-1672
 ArticleDownload PDFCrossRefView Record in ScopusGoogle Scholar
5

REFLICTION PAPER:

Because of its rarity, the diagnosis of a metastatic lesion in the masticator space
(buccal mucosa) is challenging. This case emphasized the importance of a complete
and careful work-up, with particular attention to detailed medical history as well as
careful clinical and radiographic inspection for unusual signs and
symptoms. Immunohistochemistry correlation of the metastatic lesion in line with
primary site also plays an important role in ruling out second primary in such cases of
rare presentations.