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Interesting Cases

CASE REPORT

SYNCHRONOUS BILATERAL CARCINOMA BREAST  AND CARCINOMA BUCCAL MUCOSA- A RARE PRESENTATION

Dr. S. Jain , Dr. Meenakshi Mittal, Dr. R. Vashishta, Dr. Nidhi Aggarwal, Dr. Sandeep Jhanjee, Dr. Rupinder Singh, Dr. S. Dogra et. al.

Deptt. of Surgery, Deptt. of Radiation Oncology, Deptt. of Orthopaedics, Department of Dentistery, M.D.Oswal Cancer Treatment
And Research Foundation, Ludhiana, Punjab.

ABSTRACT
Synchronous presentation of carcinoma buccal mucosa with bilateral carcinoma breast is a very rare presentation.
Medline search for review literature has not shown such a case report in the last 30 years. A 59 year old female came to our institute as a diagnosed case of carcinoma buccal mucosa right side. The histopathology report was squamous cell carcinoma, keratinizing type. She was initially treated with pre-operative radiotherapy, followed by commando operation ( Local wide excision and right radical neck dissection with pectoralis major flap reconstruction). She was also diagnosed to have bilateral carcinoma breast for which she underwent bilateral total mastectomy and axillary clearance. The histopathology report of which was infiltrating carcinoma breast bilateral. Later on she developed distant metastasis to bones. The detail case report is being presented.

INTRODUCTION
The synchronous occurrence of multiple primary malignant neoplasms in different tissues is becoming more widely recognized.
The suggested factors in the etiology of multiple primary neoplasms include: Genetic, Hormonal, Iatrogenic, Immunological and
Environmental causes, the exact cause still unknown. Warren and Gates [1] established three criteria for the diagnosis of multiple
primary malignancies.
These include
a) each tumor should be distinct,
b) present a definitive picture of malignancy,
c) the probability that one tumor is a metastatic lesion from the other must be excluded.

CASE REPORT
A 59 year old female with C.R.No.316647 came to our institute on 4th Feb. 2002 as a diagnosed case of carcinoma buccal mucosa right side. Biopsy from the right buccal mucosa done outside our institute in the month of Oct. 2001 was reported as squamous cell carcinoma, keratinizing type. On local examination there was marked trismus and a big ulcerative 4 x 3 cm through and through oedamatous crater on the right sideof face extending upto the retromolar trigone on palpation. There was associated bleeding from the site. Multiple maggots were also present inside the lesion. Right sided submandibular lymph node was significantly enlarged clinically. C.T.Scan Head and Neck showed a soft tissue attenuation lesion in right cheek adjacent to the body of the mandible with infiltration into the right buccinator and masseter muscles and no evidence of osseous erosion of the mandible. Enlarged nodes were seen in submandibular location bilaterally. Nasopharynx, oropharynx, laryngopharyx were normal in C.T. appearance.

The patient was planned for pre-operative chemoradiation and was given 15Gy in 6 fractions (250cGy/fraction) initially, followed by 30Gy in 17 fractions (180cGy/fraction) by one right lateral and one right anterior face portals (in total 45Gy was given) from 11-2-2002 to 13-3-2002.

Concomitant with radiotherapy two cycles of chemotherapy, Paclitaxel 100mg were given. At the end of the radiotherapy there was marked reduction in the size of the lesion but residual disease along with a persistent oro-cutaneous fistula was present. The patient than underwent commando operation which consisted of local wide excision and right sided radical neck dissection with pectolaris major flap (double barrel) reconstruction on 8-4-2002. At the time of surgery a lump in the upper outer quadrant of the right breast suspected clinically to be fibroadenoma was also excised. The histopathology report of the commando operation done was squamous cell carcinoma buccal mucosa with evidence of numerous cell nest formation and areas of keratinization. Posterior margin and superior margin, the lymph nodes of the neck and the excised part of the mandible were all free of tumour. The histopathology report of the excision biopsy specimen of the right breast lump was infiltrating carcinoma breast with no evidence of squamous change in the tumour cells.

After one month gap, a lump was noted in the upper outer quadrant of the opposite (left) breast which was 5 x 4cm in size, hard in consistency adherent to the overlying skin but with no adherence to the underlying structures. No enlarged lymph nodes were palpable in the left axilla. Also a vague lump (?seroma) was felt in the upper outer quadrant of the right breast. A significantly enlarged lymph node was palpable in the right axilla. Mammography was done which showed a malignant lesion in the left breast and a large vascular mass in the right breast, ? angioma, ? chronic organized abscess.

Bilateral total mastectomy and axillary clearance was done on 6th May 2002. The histopathology report was Right breast- Sections from the right breast lumpectomy site showed abundant fibrin clots, areas of haemorrhage, unhealthy granulation tissue and heavy infiltration with both chronic and acute inflammatory cells. The base was free of tumor cells.

The axillary lymph nodes were negative for metastasis but the axillary tail lymph node was positive for metastasis with extension of tumor cells into the surrounding lymphatics. Left breast- Infiltrating duct carcinoma. 2/5 axillary lymph nodes were positive for metastasis with perinodal extension of the disease. Apical lymph node was also positive for metastasis. The patient was advised combination chemotherapy which was refused by her. The estrogen and progesteron receptor status was positive ( ER 60% and PR 10% positive).

The patient was put on tab. tamoxifen 20mg O.D. Further EBRT was given to the right side face 10Gy in 5 fractions from 19-6-2002 to 25-6-2002 post-operatively.

She came on 16th July 2002 with the complaints of pain left leg which was not relieved with medication for which a bone scan was performed which
showed increased tracer uptake in the
 1) glenoid fossa of the right scapula and shoulder,
 2) mid-shaft region of left femur and
 3) neck and trochanteric region of left femur anteriorly and posteriorly
.
Her other investigations included liver and renal function tests, chest X- ray and USG (abd.) which were all within normal limits. Her hormonal treatment was changed from tab. tamoxifen to tab.letrozole 2.5mg once daily. She was alright for one month when she came to the casualty with a history of fall and inability to walk and associated pain in the left leg. After clinical examination and X-ray left leg she was diagnosed to have a pathological fracture left femur neck. Bipolar hemiarthroplasty (left) was done on 8th Aug. 2002. The histopathology report was metastatic deposists, head of femur. On follow-up X-Ray of the left leg showed another lytic lesion in the shaft of tibia just distal to the prosthesis. She was then given palliative radiotherapy to the left femur and left knee 30Gy in 10 fractions (300cGy/fraction). There was marked symptomatic relief to the patient. She is
doing fine at present and is on tab. letrozole.

DISCUSSION
Synchronous carcinoma breast and carcinoma buccal mucosa is a very rare presentation. Medline search for review literature has not shown such a case report in the last 30 years. Rare Case of complete Pancreatic Transaction Managed Successfully

Dr. Satish Jain, Dr. Sandeep Jhanjee, Dr. V. Tiku, Dr. Ajay Gupta.

On 4th April 2003 - Patient Roahal Lal 20 year Male presented to casualty with History of Road Side Accident half an hour back with chief complaints of pain abdomen. Per abdomen -There was abrasion in right iliac fossa, abdomen was Tense, tender. There was Guarding, Rigidity with no Bowel Sounds. N/ G tube was inserted through which bile stained fluid came, Patient was catheterized & urine was clear. Patient was put on I/V fluids, Antibiotics and analgesics. X-ray showed No air under diapheagm. Ultra Sound Abdomen was suggestive of Haemorrhagic fluid in Prehepatic, Perisplenic area and pelvis, with a suspicious area of increased echogenicity at junction of left and right lobe of liver .

Patient was managed conservatively as pain abdomen decreased, but again had pain and rebound tenderness with haemorrhagic fluid in peritoneal tap on 7th April 2003 and then was taken for exploratory laparotomy.

Operative Finding were – Haemoperitoneum, Superficial Liver Abrassion, Retroperitoneal Haematoma And Complete Pancreatic Transsesion near the neck. Patient was managed with Peritoneal lavage with distal pancreatectomy and splenectomy.  

- From Post OP. day 1 Patient was put on octreotide 50 mg s/c 8 hourly. On 5th Post OP day Patient’s N/G was removed and oral liquids were allowed. Patient had a uneventful recovery and was discharged on 11th Post OP day. Patient is doing will and on regular follow up.
 

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