Indian Journal of Pathology and Oncology | 2019
Carcinoma tongue presenting as pathological fracture of right femur
Abstract
Occurrence of distant metastasis from a primary in head and neck squamous cell carcinoma is relatively rare when compared to malignancies from other sites. Carcinoma arising from the hypopharynx, oropharynx and oral cavity are associated with the highest incidence of distant metastases. Knowledge of the metastatic potential and also the presentation helps in an early surgical intervention for improving the life expectancy as well as in the quality of life. We report a rare case of oropharyngeal carcinoma with no neck nodes, where the initial presenting complaint was a pathological fracture in the right femur. The case is being presented due to its rarity. Introduction Squamous cell carcinoma arising in the head and neck region metastasise less frequently as compared to that from other sites. Involvement of the jugular vein increases the incidence of spread. Among primary in the head and neck area hypopharynx, oropharynx and the oral cavity have the highest rate of spread. The size of the primary does not predict or regulate metastasis. An unusual case of carcinoma tongue without any metastasis in the cervical lymph nodes presenting initially with pathological fracture of the right femur is being reported herewith. Case Report A man aged 40 years complained of fracture of the right femur, after a minor trauma. As stated by the patient, he was apparently asymptomatic 15 days back when he started feeling excruciating pain in the right thigh which was sudden in onset, progressive in nature, continuous throughout the day and was aggravated by movement of limb and walking and was relieved to some extent by lying down. He had difficulty in walking since he could not bear the weight on his right leg. A day prior to his admission in the hospital, he fell from the bicycle and developed pain and swelling in the right thigh. On examination the limb movements were painful. X-Ray pelvis showed pathological fracture in the right subtrochanteric region (Fig. 1a). Ultrasound abdomen did not reveal anything significant. His haematological profile was within normal limits. Serum calcium levels were low 7.8 mg/dl (N=8.5-10.0 mg/dl). The patient was as a case of squamous cell carcinoma of the left lateral tongue 1 year back for which he got operated upon followed by six cycles of radiotherapy. There has been no history of Tuberculosis, Diabetes or Hypertension. Curettings from the fracture site were done and the tissue was sent for histopathology. Microscopy showed necrosed bony trabeculae with replacement of the marrow spaces by invading sheets and nests of neoplastic cells. The neoplastic cells were characterized by hyperchromatic to vesicular nuclei showing mild to moderate pleomorphism and clumped chromatin. Cytoplasm was deeply eosinophilic (Fig.1b,1c). Keratin pearls were appreciated (Fig. 1d). The neoplastic cells were invading the nearby skeletal muscles and tissues. The final diagnosis signed out was distant metastasis of squamous cell carcinoma to right femur with primary in the tongue. Even after two years during the postoperative period the patient remained well and healthy. Article Info Received: 20th April, 2019 Accepted: 18th May, 2019 Published Online: 9th August, 2019