|Year : 2020 | Volume
| Issue : 2 | Page : 114-118
Basaloid squamous cell carcinoma of the head and neck: Our experience
Jaimanti Bakshi1, Anil K Dash2, Naresh K Panda1, Amanjit Bal3, Debajyoti Chatterjee3, Sourabha K Patro1
1 Department of ENT and Head and Neck Surgery, PGIMER, Chandigarh, India
2 Department of ENT and Head and Neck Surgery, PGIMER, Chandigarh; Department of ENT, Fakir Mohan Medical College & Hospital, Balasore, Odisha, India
3 Department of Histopathology, PGIMER, Chandigarh, India
|Date of Submission||28-Aug-2020|
|Date of Decision||04-Sep-2020|
|Date of Acceptance||13-Sep-2020|
|Date of Web Publication||8-Dec-2020|
Sourabha K Patro
Department of ENT and Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, ENT Office, Ground Floor, Nehru Extension Block, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Basaloid squamous cell carcinoma (BSCC) of the head and neck is a distinctive variant of squamous cell carcinoma known for its basaloid appearance and aggressive behavior. Being a rare variant, clear evidence is lacking for the management and outcome of the lesion. In this observational study, we have tried to evaluate the clinical, radiological, and histopathological characteristics along with the management and treatment outcome of ten patients diagnosed with having BSCC of the head and neck who were diagnosed and treated at our hospital.
Keywords: Basaloid squamous cell cancers, head and neck basaloid squamous cell carcinoma, variants of squamous cell carcinoma of the head and neck
|How to cite this article:|
Bakshi J, Dash AK, Panda NK, Bal A, Chatterjee D, Patro SK. Basaloid squamous cell carcinoma of the head and neck: Our experience. J Head Neck Physicians Surg 2020;8:114-8
|How to cite this URL:|
Bakshi J, Dash AK, Panda NK, Bal A, Chatterjee D, Patro SK. Basaloid squamous cell carcinoma of the head and neck: Our experience. J Head Neck Physicians Surg [serial online] 2020 [cited 2021 Apr 21];8:114-8. Available from: https://www.jhnps.org/text.asp?2020/8/2/114/302631
| Introduction|| |
Basaloid squamous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma of the head and neck, and was initially described and classified in 1986. Since then, various cases have been reported in the world literature. This management dilemma in BSCC is the same as other rare histological variants of squamous cell lesions in the head and neck. Among the various head and neck sites and subsites, BSCC primarily affects the buccal cavity, floor of mouth, tonsils, gingiva, palate, nasopharynx, trachea, sinonasal tract, esophagus, and thymus.,, It has also been reported to involve the lung, anus, and cervix.
The usual clinical presentations of BSCC are at advanced stages, the tumor does have a very aggressive behavior, and delay in suspicion due to various hidden sites in the head and neck contributes toward this aggressive behavior. Quite often, the patients present at a stage where the tumor has already metastasized. The presentation is similar to that of the squamous cell carcinoma and has the same etiological risk factors, e.g., tobacco and alcohol consumption. The recommended treatment for BSCC is surgery, followed by radiotherapy and chemotherapy.
The cells of origin for BSCC are believed to be either basal layer of the mucosa, which contains stem cells or the epithelium of the salivary ducts. Histological diagnosis is hence difficult and is always a diagnostic surprise for the surgeon due to its aggressive clinical behavior, lack of clear management guidelines, and rarity.
We planned to actively observe, review, and evaluate all operated cases of BSCC in the department and present the review of our experience with ten cases of BSCC, which will help to inform practitioners and histologists for recognition of the characteristics of BSCC and clinical suspicion will, in turn, help the professionals for early diagnosis and adequate management.
| Materials and Methods|| |
We reviewed ten patients of BSCC, who were treated at our department in a tertiary care referral teaching institute of North India. All of them had BSCC of different sites of the head and neck regions and were treated with surgery and radical radiotherapy with 60 Gy dose, according to the departmental protocol. Patients were staged as per the tumor, node, and metastasis staging, considering clinical findings, radiological evaluation, computed tomography or magnetic resonance imaging scans [Figure 1] and [Figure 2], ultrasonography, and scintigraphy. Following preoperative investigation and workup, including a biopsy to establish the diagnosis, wide local excision with modified neck dissections were planned. Adjuvant therapy was given as desired and indicated with radiotherapy or chemoradiotherapy. Statistical analyses were done using SPSS software version 20.0. ( IBM Corp, Armonk, NY).
|Figure 1: (a) Computed tomography coronal picture showing a case of basaloid squamous cell carcinoma of the maxilla with orbital invasion and (b) postoperative cavity of the patient after 6 months of completion of treatment|
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|Figure 2: (a) Lesion in a case of basaloid squamous cell carcinoma of maxilla and nose, (b) basaloid squamous cell carcinoma of the oral tongue which was operated, and (c) the clinical picture of a patient with basaloid squamous cell carcinoma of the right buccal mucosa|
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| Results|| |
Out of ten patients, there were six males and four females in the age range between 38 and 69 years with a mean age of 55.5 years. All cases had presented in different sites of the head and neck, as shown in [Table 1]. The clinical presentation varies according to the sites, as shown in [Table 2]. Eight out of ten patients presented with nodal metastasis. The patients underwent different surgical procedures according to the sites affected by the disease, as shown in [Table 3]. [Figure 1],[Figure 2],[Figure 3],[Figure 4] demonstrate a few of the presentations of cases of basaloid squamous cell cancers. After surgical excision, the specimens were sent for histopathology. The histological picture showed nests and cords of closely packed pleomorphic basaloid cells that had peripheral nuclear palisading. These neoplastic regions were surrounded by fibrous stroma with prominent areas of comedo necrosis. [Figure 5] and [Figure 6] show the histological pictures for basaloid squamous cell cancers. Four patients were in Stage III, and six patients were in Stage IV. After 2 years of follow-up, six patients were on regular follow-up, and out of six patients, three were disease free (all three belonged to Stage III). In all three cases, the surgical resection margins were free of disease. The rest four patients, two of which lost to follow-up and two died because of disease recurrence, had involved resection margins and positive neck node metastasis. Although the sample size is small, the 2-year survival rate of 60% was found in our series and the disease-free survival rate of 30% is encouraging.
|Table 1: Involved sites of head and neck by basaloid squamous cell carcinoma|
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|Figure 3: A case of basaloid squamous cell carcinoma of nose, which presented with irregular swelling in nasofacial groove (a), ulcerative lesion in the nasal cavity (b), and smooth globular bulge in the hard palate (c), which suggests involvement of the hard palate and floor of the nose|
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|Figure 4: A case of basaloid squamous cell carcinoma of buccal mucosa which presented with huge exophytic lesion of the cheek (a) with extensive involvement of the contiguous structures and posteriorly reaching up to the retromolar trigone (b). (c) Axial computed tomography picture of another case of basaloid squamous cell carcinoma of larynx with destruction of the thyroid cartilage and extra laryngeal extension into the surrounding soft tissues|
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|Figure 5: Biopsy shows an invasive carcinoma arising from the overlying epithelium (H and E, ×100)|
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|Figure 6: The tumor is composed of islands of basaloid cells with high nuclear-to-cytoplasmic ratio and show peripheral palisading (H and E, ×200)|
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| Discussion|| |
BSCC is a rare and aggressive variant of squamous cell carcinoma. The peak incidence is in the elderly population in their 6th–7th decades. The etiological factors in basaloid squamous cell cancers are similar to that of the squamous cell cancers of the head and neck, and majority of the cases in Indian subcontinent are tobacco and alcohol use, which is consistent with the etiological associations observed in our study. In our study, the major site of origin of BSCC was oral cavity with five out of ten cases showed origin and involvement of oral cavity. The presentation of BSCC in our series was at advanced stages in all of our cases, which validates earlier evidence in literature, which shows BSCC as a clinically aggressive tumor with high rates of nodal (64%) and distant metastases (44%).,, The aggressive nature was previously documented in the case–control study by Soriano et al. who noticed 6 times higher risk of distant metastases contrast to the squamous cell carcinomas of the head and neck.
The histology of basaloid squamous cell cancer needs suspicion for diagnosis at the initial biopsy. This will help in early intervention and management. Wain et al. and, recently, Barnes et al. had described criteria to diagnose cases of BSCC decades back, which still holds true and can be safely used. They mentioned about:
- Ulcerated or exophytic mass with submucosal soft tissue infiltration
- Solid basaloid appearing dysplastic islands with biphasic pattern showing comedo type necrosis and pseudoglandular pattern
- Abrupt foci of squamous differentiation with or without keratin pearls and surface mucosal epithelium showing dysplastic features.
In this present series, we took help of these criteria to diagnose the cases.
The treatment for basaloid squamous cell cancer in practice is complete wide surgical resection of the lesion with neck dissection supplemented by radiotherapy or adjuvant chemotherapy.
Nodal metastasis is common and known in BSCC. Winzenburg et al. reported 75% incidence of regional nodal metastasis and 25%–50% incidence of distant metastasis, with lung being the most common site. In our series, 8 (80%) patients had nodal metastasis, and there was no clinical or radiographic evidence of lung metastasis. We noticed a 2-year survival of 60% and 2-year disease-free survival of 30% in our series.
| Conclusion|| |
BSCC is a distinct clinic pathological entity which affects various head and neck sites and has aggressive clinical behavior. It needs pathologic suspicion and aggressive management in a team approach. The rarity of the disease prevents formulation of clear guidelines, and high histological suspicion can warn the pathologist and clinician regarding this aggressive variant of squamous cell cancer. In cases of ambiguous histology, patients can be discussed for the option of complete surgical excision and histopathological examination on clinical grounds. Postoperative radiotherapy should be offered to the patient. High suspicion, prompt diagnosis and treatment, and follow-up can help us fight the disease as was seen in our series with a 60% 2-year survival rates.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]