Unusual Appearance of Basaloid SCC in Tonsil: A Case Report

Abstract

Basaloid squamous cell carcinoma (BSCC) is a variant of oral squamous cell carcinoma, is an aggressive, high grade variant and rare subtype of the head and neck SCC that less common in tonsils. Here, we are reporting a case of BSCC involving the tonsil with an extension on the cervical lymph node region.

Introduction

Basaloid squamous cell carcinoma (BSCC) is a variant of oral squamous cell carcinoma, is defined by the World Health Organization as an aggressive, high grade variant and rare subtype of the head and neck SCC [1, 2]. Described for the first time by Wain et al. [3]. 15% of all SCCs encountered in the head and neck [4] and 5% of all node-positive SCCs are estimated as BSCC [5, 6].

BSCC being most frequently found in the upper aerodigestive tract, usually occurring in the nasopharynx, hypopharynx, larynx, and base of the tongue. Less common sites include the mouth, oral mucosa palate, tonsils, and trachea [7]. Few cases reported BSCC in the tonsil. Here, we are reporting a case of BSCC involving the tonsil with an extension on the cervical lymph node region.

Case Presentation

A 50-year-old male was referred to the educational and therapeutic center of Bu-Ali Sina Sari hospital for evaluation of an asymptomatic lesion with a 5-month history. With complaints of Sore throat, dysphagia, reflux and pain in left ear that exacerbated since 2 months before the referral. He had a history of cigarette and opium consumption and controlled Diabetes.

Intraoral examination revealed a normal size tonsil with multiple ulcers on left tonsil without any lymph node swelling in the submandibular area. The patient underwent tonsillectomy. Surgery was done under general anesthesia. The biopsy was taken and received in formalin consist of a cream-brownish tonsil measuring 2.5 × 2 × 1 cm on surface an ill-defined ulcer is seen. Its cut surface was cream-brownish and non homogenous.

A Histopathological examination of the sections revealed a malignant epithelial neoplasm composed of sheets and nests of squamous cells with basaloid feature and abnormal down ward growth into lymphoid tissue of tonsil. These neoplastic cells are characterized by enlarged vesicular to hyperchromatic nuclei, eosinophilic cytoplasm and some mitotic figures. The diagnosis of Basaloid squamous cell carcinoma (BSCC) in the tonsil was confirmed; the patient underwent chemotherapy and radiotherapy. Written consent is obtained from the patient to access the details of the case and to publish the results.

Discussion

Basaloid squamous cell carcinoma has an ulcerating infiltrative growth pattern, peripheral nuclear palisading and present as a more aggressive, poor-prognostic lesion and tendency to metastasize [1, 8]. Clinical signs and symptoms are related to tumor location [7]. Here, the patient presented a history of sore throat, dysphagia, reflux and pain in left ear.

Differential diagnoses are adenoid cystic carcinoma and neuroendocrine carcinoma and cell antigens such as keratins, vimentin, synaptophysin and chromogranin-A help to differentiate BSCC from other tumors [9, 10]. Its etiology is multifactorial and is associated to tobacco and alcohol consumption, often seen in men between 40 and 85 years [11], as seen in our case, he was 50 years old and abusive tobacco consumption was reported.

Immunohistochemical staining for specific cytokeratins and neuroendocrine markers help for BSCC diagnosis. The histological hallmark is dimorphic pattern of presentation with a characteristic basal cell component associated with squamous component [12]. In this case Histopathological examination of the sections revealed a malignant epithelial neoplasm and BSCC in the tonsil was confirmed.

Tonsil as the site of Basaloid squamous cell carcinoma is an almost rare presentation. According to the literature, there are limited reports of detected basaloid squamous cell carcinoma in the tonsil. Chaidas et al. reported a case of BSCC in the tonsil. A 56-year-old male with a history of mild dysphasia and he was heavy smoker. Oropharynx examination revealed a bullky mass on right tonsil. Excision biopsy of the tonsil was done. Histopathological examination revealed Basaloid squamous cell carcinoma in the tonsil. The patient had pulmonary metastase and treated with chemotherapy and concurrent radiation [13]. Shetty et al. reported a case of BSCC in the tonsil. A 53-year-old male with a history of difficulty in swallowing and foreign body sensation in the throat, for 3 months. Oropharynx examination revealed an enlarged left tonsil which was crossing the midline. Excision biopsy of the tonsil was done under general anaesthesia. Histopathological examination revealed lymphoid tissue (tonsillar) with an infiltrating neoplasm composed and BSCC in the tonsil was confirmed. The patient was administered chemoradiation postoperatively [14].

In our case cervical lymph node metastases were present at initial diagnosis. The recommended treatment for this tumor with no evidence of metastases is complete surgical excision supplemented by radiotherapy [5]. Tonsil as the site of BSCC is an uncommon presentation, because of this reason Diagnosis is not done quickly, In our case, Patient underwent tonsillectomy and after Histopathological examination of biopsy BSCC in the tonsil diagnosed. Because of the cervical lymph nodes involvement surgical intervention was not indicated. Thus, our patient was treated with chemotherapy and concurrent radiation. The response to therapy was quite good, and the patient has already exceeded the median survival time.

Conclusion

The present case appears to have developed BSCC in the tonsil. Our patient presented with Sore throat, dysphagia, reflux and pain in left ear for 5 months, that exacerbated since 2 months before the referral. The Patient underwent tonsillectomy under general anaesthesia and the biopsy was taken. According to Histopathological examination, BSCC in the tonsil and cervical lymph nodes involvement diagnosed. Then the patient was referred to the radiotherapy and chemotherapy center for follow up treatment.

Compliance with Ethical Standards

Conflict of interest

The author has no public and private financial support in this study and no Conflict of interest.

Ethical standard

The report adhered to the ethical principles outlined in the Declaration of Helsinki as amended in 2013. Written consent is obtained from the patient to access the details of the case and to publish the results. The author would like to thank the Clinical Research Development Unit of Bu-Ali Sina Hospital, Mazandaran University of Medical Sciences, Sari, Iran for their cooperation and assistance throughout the period of study.