581942
letter2015
CMSXXX10.1177/1203475415581942Journal of Cutaneous Medicine and SurgeryRaj K. A. Prithvi
Letter to the Editor
Oral Squamous Cell Carcinoma Mimicking Cervico-Facial Actinomycosis: A Rare Presentation and Review of Literature
Journal of Cutaneous Medicine and Surgery 2015, Vol. 19(4) 346–348 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1203475415581942 jcms.sagepub.com
To the Editor: Squamous cell carcinoma (SCC) of oral mucosa constitutes almost half of all cancer burden in India and is a major cause of morbidity and mortality.1 Often presenting as an ulcerative/ulcero-proliferative growth in the oral cavity, at times oral SCC can be a great mimicker. Herein we describe an unusual morphological presentation of oral SCC simulating cervico-facial actinomycosis.
Case Report A 65-year-old-female homemaker presented with 3-month history of multiple pus discharging sinuses over left cheek. Six months back she had noticed a painless ulcer over the left buccal mucosa following extraction of left lower second and third molars. This had gradually progressed to form a diffuse swelling involving most of the left lower jaw. There was restricted mouth opening, thus decreased oral intake and significant weight loss. She was a tobacco quid chewer since early childhood. There was no history of discharge of granules/bony spicules in pus, fever, cough, voice change, or use of immunosuppressive medications. She had received multiple courses of intravenous antibiotics, including penicillin with minimal response. Clinical examination revealed an indurated plaque measuring12 × 6 cm over left jaw. Multiple pus discharging nodules with sinuses having adherent yellowish brown crust was seen on the surface of the plaque (Figure 1). Oral examination showed 4 × 3 cm indurated, proliferative lesion over left gingivo-labial sulcus extending into buccal mucosa. There was no cervical lymphadenopathy. Rest of the muco-cutaneous and systemic examination was normal. A punch biopsy was obtained from the mucosal lesion for histopathology and culture with an initial diagnosis of cervico-facial actinomycosis. Histopathology showed features suggestive of well-differentiated squamous cell carcinoma (Figure 2). Pus culture showed the growth of pseudomonas aeroginosa. Mycobacterial and fungal culture of the same revealed no growth. Contrast-enhanced computer tomography of head and neck showed ill-defined heterogenous soft tissue in left masticator and submandibular spaces with mandibular destruction (Figure 3). Multiple
Figure 1. Clinical photography of the left cheek showing erythematous, indurated plaque with multiple overlying nodules, and pus discharging sinuses.
subcentimetric non-necrotic lymph nodes were seen in bilateral levels I, II, III, and IV cervical lymph nodes. These nodes were too small to perform fine-needle aspiration cytology (FNAC). Based on investigations, she was finally diagnosed and staged as IV B SCC according to AJCC staging.2 Since the tumor was surgically unresectable, patient was given palliative radiotherapy.
Discussion Morphologically, ulcerative (49%) and ulcero-proliferative (34%) followed by exophytic (16%) are the most common presentations of SCC.3 Squamous cell carcinoma presenting as multiple discharging sinuses mimicking cerfico-facial actinomycosis, as in our case, is very rare. Literature review showed only two previous reports of such presentation4,5 (Table 1). Such uncommon presentations always cause diagnostic dilemma even to the most trained physician. A simple biopsy of the suspicious lesion clinched the diagnosis of SCC. The differentials needed to be considered here are actinomycosis, scrofuloderma, mycetoma, and invasive
347
Letter to the Editor
Figure 2. Photomicrograph showing invasive squamous cell tumor with keratinization and dyskeratosis along with surrounding areas of hyperplasia and dysplasia and infiltrating lymphocytes. H&E, 400×.
Figure 3. Computerized tomography image of the neck showing heterogenous enhancing mass in the left mandibular region with destruction of fat planes and mandibular cortex and invading into submandibular space and deeper tissues (arrows).
Table 1. Summary of Similar Case Presentations. Author
Year
Presenting Features
4
Pahwa et al
2011
Sehgal et al5
2013
Present report
2015
65-year-old male presenting with ill-defined, nontender firm plaque over chin with multiple pus discharging sinuses; infiltrated oral mucosa and enlarged submandibular lymph nodes 40-year-old female with history of tobacco chewing clinically had reddish indurated plaque over mandibular area with multiple sinuses producing serous discharge; infiltrated oral mucosa with enlarged submandibular lymph nodes was also present 65-year-old female with history of tobacco chewing presenting clinically with ill-defined indurated plaque over left mandibular region having multiple pus discharging sinuses and infiltrated left buccal mucosal lesion; clinically there was no cervical lymphadenopathy
aspergillosis.4,6 Indeed, actinomycosis formed a very close differential in our case because of history of dental extraction and clinical absence of lymphadenopathy. These were excluded by relevant microbiological investigations, histopathology, and imaging. There are isolated case reports of other malignancies like sarcomatoid SCC, thyroid carcinoma, melanoma, and non-Hodgkins lymphoma presenting in similar way.4 In our case, delay in diagnosis was not only due to the poor awareness but also due to the atypical clinical presentation of SCC as “wolf in the sheep’s skin.” This write-up portends to exemplify the importance of having high index of suspicion and to carry out simple histopathological examination at times of nonhealing of lesion to prevent delay in diagnosis and its subsequent poor prognosis.
Provisional Diagnosis
Final Diagnosis
Mycetoma, cutaneous tuberculosis, actinomycosis
Cutaneous squamous cell carcinoma
Subcutaneous fungal infection
Oral squamous cell carcinoma
Cervico-facial Oral squamous cell actinomycosis, invasive carcinoma aspergillosis
K. A. Prithvi Raj Keshavamurthy Vinay Uma N. Saikia Muthu Sendhil Kumaran Postgraduate Institute of Medical Education and Research, Chandigarh, India [email protected] Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
348 References 1. Petersen PE. Strengthening the prevention of oral cancer: the WHO perspective. Community Dent Oral Epidemiol. 2005;33:397399. 2. Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010. 3. Sharma RG, Bang B, Verma H, Mehta JM. Profile of oral squamous cell cancer in a tertiary level medical college hospital: a 10 yr study. Indian J Surg Oncol. 2012;3:250-254.
Journal of Cutaneous Medicine and Surgery 19(4) 4. Pahwa P, Sharma VK, Chouhan K, Shukla B. Squamous cell carcinoma presenting as multiple discharging sinuses on the chin. Clin Exp Dermatol. 2011;36:641-644. 5. Sehgal VN, Sehgal S, Oberai R, et al. Oral squamous cell carcinoma of the mandibular region presenting as multiple discharging sinuses: imperative of magnetic resonance imaging and computerized tomography. Skinmed. 2013;11:181-184. 6. Vinay K, Khullar G, Yadav S, et al. Granulomatous invasive aspergillosis of paranasal sinuses masquerading as actinomycosis and review of published literature. Mycopathologia. 2014;177:179-185.
letter2015
CMSXXX10.1177/1203475415581942Journal of Cutaneous Medicine and SurgeryRaj K. A. Prithvi
Letter to the Editor
Oral Squamous Cell Carcinoma Mimicking Cervico-Facial Actinomycosis: A Rare Presentation and Review of Literature
Journal of Cutaneous Medicine and Surgery 2015, Vol. 19(4) 346–348 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1203475415581942 jcms.sagepub.com
To the Editor: Squamous cell carcinoma (SCC) of oral mucosa constitutes almost half of all cancer burden in India and is a major cause of morbidity and mortality.1 Often presenting as an ulcerative/ulcero-proliferative growth in the oral cavity, at times oral SCC can be a great mimicker. Herein we describe an unusual morphological presentation of oral SCC simulating cervico-facial actinomycosis.
Case Report A 65-year-old-female homemaker presented with 3-month history of multiple pus discharging sinuses over left cheek. Six months back she had noticed a painless ulcer over the left buccal mucosa following extraction of left lower second and third molars. This had gradually progressed to form a diffuse swelling involving most of the left lower jaw. There was restricted mouth opening, thus decreased oral intake and significant weight loss. She was a tobacco quid chewer since early childhood. There was no history of discharge of granules/bony spicules in pus, fever, cough, voice change, or use of immunosuppressive medications. She had received multiple courses of intravenous antibiotics, including penicillin with minimal response. Clinical examination revealed an indurated plaque measuring12 × 6 cm over left jaw. Multiple pus discharging nodules with sinuses having adherent yellowish brown crust was seen on the surface of the plaque (Figure 1). Oral examination showed 4 × 3 cm indurated, proliferative lesion over left gingivo-labial sulcus extending into buccal mucosa. There was no cervical lymphadenopathy. Rest of the muco-cutaneous and systemic examination was normal. A punch biopsy was obtained from the mucosal lesion for histopathology and culture with an initial diagnosis of cervico-facial actinomycosis. Histopathology showed features suggestive of well-differentiated squamous cell carcinoma (Figure 2). Pus culture showed the growth of pseudomonas aeroginosa. Mycobacterial and fungal culture of the same revealed no growth. Contrast-enhanced computer tomography of head and neck showed ill-defined heterogenous soft tissue in left masticator and submandibular spaces with mandibular destruction (Figure 3). Multiple
Figure 1. Clinical photography of the left cheek showing erythematous, indurated plaque with multiple overlying nodules, and pus discharging sinuses.
subcentimetric non-necrotic lymph nodes were seen in bilateral levels I, II, III, and IV cervical lymph nodes. These nodes were too small to perform fine-needle aspiration cytology (FNAC). Based on investigations, she was finally diagnosed and staged as IV B SCC according to AJCC staging.2 Since the tumor was surgically unresectable, patient was given palliative radiotherapy.
Discussion Morphologically, ulcerative (49%) and ulcero-proliferative (34%) followed by exophytic (16%) are the most common presentations of SCC.3 Squamous cell carcinoma presenting as multiple discharging sinuses mimicking cerfico-facial actinomycosis, as in our case, is very rare. Literature review showed only two previous reports of such presentation4,5 (Table 1). Such uncommon presentations always cause diagnostic dilemma even to the most trained physician. A simple biopsy of the suspicious lesion clinched the diagnosis of SCC. The differentials needed to be considered here are actinomycosis, scrofuloderma, mycetoma, and invasive
347
Letter to the Editor
Figure 2. Photomicrograph showing invasive squamous cell tumor with keratinization and dyskeratosis along with surrounding areas of hyperplasia and dysplasia and infiltrating lymphocytes. H&E, 400×.
Figure 3. Computerized tomography image of the neck showing heterogenous enhancing mass in the left mandibular region with destruction of fat planes and mandibular cortex and invading into submandibular space and deeper tissues (arrows).
Table 1. Summary of Similar Case Presentations. Author
Year
Presenting Features
4
Pahwa et al
2011
Sehgal et al5
2013
Present report
2015
65-year-old male presenting with ill-defined, nontender firm plaque over chin with multiple pus discharging sinuses; infiltrated oral mucosa and enlarged submandibular lymph nodes 40-year-old female with history of tobacco chewing clinically had reddish indurated plaque over mandibular area with multiple sinuses producing serous discharge; infiltrated oral mucosa with enlarged submandibular lymph nodes was also present 65-year-old female with history of tobacco chewing presenting clinically with ill-defined indurated plaque over left mandibular region having multiple pus discharging sinuses and infiltrated left buccal mucosal lesion; clinically there was no cervical lymphadenopathy
aspergillosis.4,6 Indeed, actinomycosis formed a very close differential in our case because of history of dental extraction and clinical absence of lymphadenopathy. These were excluded by relevant microbiological investigations, histopathology, and imaging. There are isolated case reports of other malignancies like sarcomatoid SCC, thyroid carcinoma, melanoma, and non-Hodgkins lymphoma presenting in similar way.4 In our case, delay in diagnosis was not only due to the poor awareness but also due to the atypical clinical presentation of SCC as “wolf in the sheep’s skin.” This write-up portends to exemplify the importance of having high index of suspicion and to carry out simple histopathological examination at times of nonhealing of lesion to prevent delay in diagnosis and its subsequent poor prognosis.
Provisional Diagnosis
Final Diagnosis
Mycetoma, cutaneous tuberculosis, actinomycosis
Cutaneous squamous cell carcinoma
Subcutaneous fungal infection
Oral squamous cell carcinoma
Cervico-facial Oral squamous cell actinomycosis, invasive carcinoma aspergillosis
K. A. Prithvi Raj Keshavamurthy Vinay Uma N. Saikia Muthu Sendhil Kumaran Postgraduate Institute of Medical Education and Research, Chandigarh, India [email protected] Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
348 References 1. Petersen PE. Strengthening the prevention of oral cancer: the WHO perspective. Community Dent Oral Epidemiol. 2005;33:397399. 2. Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010. 3. Sharma RG, Bang B, Verma H, Mehta JM. Profile of oral squamous cell cancer in a tertiary level medical college hospital: a 10 yr study. Indian J Surg Oncol. 2012;3:250-254.
Journal of Cutaneous Medicine and Surgery 19(4) 4. Pahwa P, Sharma VK, Chouhan K, Shukla B. Squamous cell carcinoma presenting as multiple discharging sinuses on the chin. Clin Exp Dermatol. 2011;36:641-644. 5. Sehgal VN, Sehgal S, Oberai R, et al. Oral squamous cell carcinoma of the mandibular region presenting as multiple discharging sinuses: imperative of magnetic resonance imaging and computerized tomography. Skinmed. 2013;11:181-184. 6. Vinay K, Khullar G, Yadav S, et al. Granulomatous invasive aspergillosis of paranasal sinuses masquerading as actinomycosis and review of published literature. Mycopathologia. 2014;177:179-185.
