Sheikh, Popat, Kapadia, and Chaudhari: Clinical, radiological and morphological spectrum of squamous cell carcinoma


Introduction

Squamous cell carcinoma (SCC), which is a malignant tumor of the squamous epithelium, has been a major cause of morbidity and mortality worldwide.

It has been major health problem worldwide as well as in Indian population, recorded in the National Cancer Registry Program. Recently an increasing incidence of squamous cell carcinoma is observed among young persons in many regions of the world—a trend which is particularly concerning.1

Squamous cell carcinomas are important from clinical point of view and have relevance to a wide variety of fields, including Medicine, Pathology, Surgery and Radiotherapy.

The main purpose of this study is to present a detailed analysis of existing literature with emphasis on the clino-pathological variables of squamous cell carcinoma and apply this information to the clinical setting, providing a reasonable approach when confronted with a patient with these disorders. The study has been inspired by the understanding that a good insight in establishing relationship between the clinical presentation, radiological, cytopathological and histopathological findings of the biopsy can contribute to early detection of the malignancy and reduce the incidence and prevalence of different squamous cell carcinoma after certain intervention of course.

Aims and Objectives

  1. To study the spectrum of squamous cell carcinoma cases presenting at G. G. G. Hospital, Jamnagar, during 2 years (i.e., 2019–2020).

  2. To study the morphological patterns of squamous cell carcinoma lesions and its correlation with radiological findings.

  3. To determine the incidence of squamous cell carcinoma at G G G Hospital, Jamnagar

  4. To analyse the incidence of metastasis of squamous cell carcinoma in various anatomical site

  5. To review the literature available on squamous cell carcinoma and compare it with our findings.

Materials and Methods

This study was carried out at the Department of Pathology, M. P. Shah Government Medical College, Jamnagar. It included cases of squamous cell carcinoma presenting at various departments- ENT, TBCD, Surgery and Radiotherapy of G. G. G. Hospital, during year 2019 and 2020. In all 115, such cases were reported to be squamous cell carcinoma during the period of 2 years. Clinical details were obtained from patient’s record. H&E stained slides of the lesions were retrieved and then were reviewed. Further, following parameters were examined: Age, gender, clinical features, anatomical site of tumour with radiological and cytological findings.

Observation and Results

Total 115 cases of various presentations and of various sites, diagnosed as squamous cell carcinoma, of which 47 cases were of lung, 57 of lymph node and 11 of other miscellaneous sites were studied.

Table 1

Age and Gender Wise Distribution of Lung cases (n=47)

Age

Sex

Male

Female

Total

<40 Years

02(4.25%)

00(00 %)

02(4.25%)

>40 Years

41(87.23%)

04(8.51%)

45(95.74%)

Total

43(91.48%)

04(8.51%)

47(100 %)

Table 1 Maximum incidence (45 cases: 95.74%) of lung carcinoma was observed in the age group of >40 years of age including male and female population, with a male preponderance (87.23%).

Table 2

Distribution of cases according to clinical presentations and radiologically confirmed site of lung pathology (n=47)

Site of Pathology

Clinical Presentation

Cough with chest pain

Cough with dyspnea on exertion

Cough with hemoptysis

Dyspnea on exertion with chest pain

Total

Upper Lobe Mass

03

07

01

01

12

Middle Lobe Mass

12

10

04

04

30

Lower Lobe Mass

01

02

01

01

05

Total

16

19

06

06

47

Table 2 Out of 47 cases of lung, maximum cases (30 cases: 63.82%) showed involvement of Middle lobe of lung and the commonest clinical presentation was observed to be cough with chest pain.

Table 3

Distribution of cases according to Radiologically confirmed site of metastasis from primary lung mass (n=23)

Site of Metastasis

No of Cases

Adrenal Gland

02

Liver

03

Mediastinal Lymphnode

13

Pleural Effusion

02

Ipsilateral Pulmonary region

04

Total Cases

23

Table 3 In present study, 23 cases out 47 of squamous cell carcinoma of lung Radiologically showed metastasis to various organs. Most common site for lung metastasis was observed to be mediastinal lymphnode (13/23 cases) followed by ipsilateral pulmonary region (4/23 cases). Least common incidence of metastasis from lung was seen in Adrenal gland.

Table 4

Classification and comparison of cases of Lung according to Cytopathology, Histopathology and Immunohistochemistry (n=47)

IHC confirmed Diagnosis Of Lung

Cytopathology Diagnosis Of Lung

Non-small cell carcinoma-Poorly differentiated carcinoma

Non-small cell carcinoma-Squamous Cell Carcinoma

Primary Non small cell carcinoma- Squamous Cell Carcinoma

10 (21.27%)

36 (76.59%)

Metastasis in lung

00 (00%)

01 (2.12%)

Total Cases

10 (21.27%)

37 (78.72%)

Table 4 In present study, 10 cases were cytologically diagnosed as Non small cell carcinoma-Poorly differentiated carcinoma with diagnostic dilemma between squamous cell carcinoma and adenocarcinoma. These cases were confirmed with histopathological examination and immunohistochemistry marker study. 36 (76.59%) cases had diagnostic concordance with histopathological diagnosis.

Table 5

Age and gender wise distribution of lymphnode lesions (n=57)

Age

Sex

Male

Female

Total

<40 Years

06 (10.52%)

03 (5.26%)

09 (15.78%)

>40 Years

43 (75.43%)

05 (8.77%)

48 (84.21%)

Total

49 (85.96%)

08 (14.03%)

57 (100%)

Table 5 Out of the total 115 cases, 57 were involving the lymph node. Maximum incidence (48/57 cases: 84.21%) of metastasis in lymphnode from squamous cell carcinoma was observed to in age group of > 40 years of age. Of these 48 cases, 43 were male and 05 cases were female, hence showing a male preponderance.

Table 6

Distribution of cases of lymph node according to the clinically presenting site and their corresponding Radiological features (n=57)

Radiological Features of presenting lymph node

Site of clinically presenting Lymphnode

Cervical neck lymphnode

Axillary Lymph node

Inguinal Lymph node

Total

Cervical level I

Cervical level II

Cervical level III

Cervical level VI

Necrotic

05

15

01

05

00

00

26

Conglomerated

01

10

01

02

00

00

14

Loss of Fatty Hilum

00

02

01

00

01

00

04

Calcification Foci

02

02

02

00

00

00

06

Neoplastic Mass

00

06

00

00

00

01

07

Total

08

35

05

07

01

01

57

Table 6 In case of metastasis in lymphnode by squamous cell carcinoma, the most common clinical presentation of patient was observed to be cervical neck swelling. In radiological findings, 15 cases (26.31%) showed necrotic cervical lymphadenopathy most commonly at level II lymphnode. One case presented as inguinal swelling, highly suspicious for metastasis was confirmed as primary Lymphoepithelial cyst with Moderately differentiated keratinizing squamous cell carcinoma of the same site, hence being an exception to other cases in Lymph node.

Table 7

Distribution of cases of Lymphnode according to their primary site of malignancy (n=57)

Site Of Primary

Cervical Lymphnode

Inguinal Lymphnode

Axillary Lymphnode

Total

Buccal Mucosa

06

00

00

06

Supraglottis

08

00

00

08

Hard Palate

02

00

00

02

Tongue

03

00

00

03

Tonsillar Fossa

01

00

00

01

Lip

01

00

00

01

Lung

02

00

00

02

Hypopharynx

02

00

00

02

Esophagus

01

00

00

01

Unknown Primary

29

01

01

31

Total

55

01

01

57

Table 7 Maximum cases (31/57 cases) of lymphnode metastasis had an unknown primary. The primary site for metastasis to cervical lymphnode were as follows: Supraglottis (14.03%), Buccal mucosa (10.52%), Tongue (5.26%). Hardpalate, Hypopharynx and Lung showing same incidence (3.50%). Metastasis of SCC from esophageal carcinoma to lymph node showed least incidence.

Table 8

Distribution of cases of Squamous cell carcinoma according to miscellaneous (n=11)

Site of presentation

Total Cases

Primary

Metastatic

Recurrence

Oral cavity

02

02

00

00

Lip

02

02

00

00

Cheek

02

01

00

01

Midline Neck swelling (Larynx)

01

01

00

00

Preauricular region

01

00

00

01

Anterior Chest wall

02

00

02

00

Umbilical region

01

00

01

00

Total

11

06

03

02

Table 8 Out of the total 115 cases, 11 cases belonged to miscellaneous sites. Of these 11 cases, 06 were Primary SCC. Of these primary cases, involvement of Oral cavity, lip, cheeks and Anterior chest wall showed most common involvement, whereas Umbilical region showed least involvement. The remaining 3 out of 11 cases were secondaries, 2 of which involved anterior chest wall and remaining 1 involved umbilical region.

Table 9

Correlation of Cytopathological and histopathological diagnosis of squamous cell carcinoma of miscellaneous sites (n=11)

S. No.

Site

Cytopathological Diagnosis

Histopathological Diagnosis

Total Cases

1

Oral cavity

Recurrence of squamous cell carcinoma

Moderately differentiated keratinizing squamous cell carcinoma with therapy induced changes

02

Squamous cell carcinoma

Moderately differentiated keratinizing squamous cell carcinoma OF HARD PALATE

2

Lip

Squamous cell carcinoma

Well differentiated keratinizing squamous cell carcinoma of lower lip

02

Squamous cell carcinoma - Keratinizing type

Moderately differentiated keratinizing squamous cell carcinoma upper lip

3

Cheek

Recurrence of Squamous cell carcinoma

Moderately differentiated keratinizing squamous cell carcinoma with therapy induced changes

02

Squamous cell carcinoma

Moderately differentiated keratinizing squamous cell carcinoma of Buccal mucosa

4

Midline Neck swelling(Larynx)

Squamous cell carcinoma

Well differentiated keratinizing squamous cell carcinoma of Larynx

01

5

Preauricular region

Recurrence of Squamous cell carcinoma

Moderately differentiated keratinizing squamous cell carcinoma with therapy induced changes

01

6

Anterior chest wall

Metastatic squamous cell carcinoma

Metastasis from Moderately differentiated keratinizing squamous cell carcinoma of Buccal mucosa

02

Metastatic squamous cell carcinoma

Metastasis from non keratinizing squamous cell carcinoma of cervix

7

Umbilical region

Metastatic squamous cell carcinoma

Metastasis from Moderately differentiated keratinizing squamous cell carcinoma of lung

01

Total

11

Table 9 Squamous cell carcinoma of various Head & Neck region had 100% concordance on both cytopathological and histopathological diagnosis.

Figure 1

A: H & E stained FNAC smear (40 x) from lungmass show cluster of pleomorphic epithelial cells showing high N : C ratio andmoderate amount of eosinophilic cytoplasm suggestive of Non small cellcarcinoma-Poorly differentiated carcinoma. B: H & E stained section (40 x) from lung mass show small cluster ofmalignant epithelial cells showing nuclear pleomorphism, individual cellkeratinization and hyperchromatic nucleus suggestive of Non-small cellcarcinoma-Squamous cell carcinoma.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/763472b7-5b55-4a54-a16b-660c5af7d501/image/0a60917c-efd8-4022-bd6b-624844f4c082-uimage.png

Figure 2

A: H & E stainedFNAC smear(40 x)from Cervical lymphnode show cluster of hyperchromatic nucleus,nuclear pleomorphism and eosinophilic cytoplasm against lymphoid backgroundsuggestive of metastatic lymphadenopathy from Squamous cell carcinoma. B: H & E stainedsection (10 x) from cervical lymphnode show sheets of Squamous cells withlymphoid cells suggestive of metastasis from Squamous cell carcinoma.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/763472b7-5b55-4a54-a16b-660c5af7d501/image/dbf54f96-44f3-423a-8194-abba9d6743b3-uimage.png

Figure 3

A: H & E stained FNACsmear (40 x) from lip swelling show sheets of cells showing hyperchromaticnuclei, individual cell keratinization with background shows mature squamouscell suggestive of Squamous cell carcinoma. B: H & E stainedsection (10 x) from lip swelling show squamous epithelial cells with mild dysplasia,individual cell keratinization and well-formed keratin pearls suggestive ofWell differentiated keratinizing squamous cell carcinoma.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/763472b7-5b55-4a54-a16b-660c5af7d501/image/9b5a9a55-2038-454e-9512-c46d1b9ffa7a-uimage.png

Discussion

Lung cancer is now the leading cause of cancer mortality. 2 The mean age of carcinoma lung patients in the present study was 61.43 years. This showed that carcinoma lung is the disease of the older age. In the study of Wagner et al. 3, the age ranged between 37 to 82 years which is comparable to the age group in the present study. The average age of the carcinoma lung patients in the present study is also comparable to some of the major Indian studies. 4, 5, 6 The sex ratio reported in various Indian studies ranged from 4.5:1 to 8.2:1. 6, 7, 8, 9 The sex ratio in our study was 10.7:1 with a clear male preponderance. Cough was the most common symptom and was present in 87.23% patients in the present study. This is similar to other studies from India and abroad. 6, 7, 8, 9, 10 Haemoptysis has been reported to be present in 11% to 24% carcinoma lung patients in various studies. 5, 9, 10 Pandhi et al. 5 and Jindal and Behera. 6 have reported a higher percentage of haemoptysis in their studies (50% and 69.2% respectively). In the present study haemoptysis was present in 12.76% patients.

It is well known that squamous cell carcinoma presents mostly as a central tumour. In this study 63.82% of squamous cell carcinoma patients had central lesion. In Gupta R et al study about 75% of the patients with squamous cell carcinoma had central tumours. 11 This again is in concordance with most reports published from elsewhere.

In our study 10 cases were cytologically diagnosed as Non small cell carcinoma-Poorly differentiated carcinoma with diagnostic dilemma between squamous cell carcinoma and adenocarcinoma. These cases were confirmed with histopathological examination and immunohistochemistry marker study as Non small cell carcinoma- Squamous cell carcinoma. 36 cases had diagnostic concordance with histopathological diagnosis of Non small cell carcinoma- Squamous cell carcinoma. Study show 1 case which is diagnosed as Non small cell carcinoma- Squamous cell carcinoma in cytology. Further radiological evaluation, histopathological examination and immunohistochemistry marker study proved the case as metastasis in lung from mediastinal mass as a primary lesion.

Computed tomography of the chest and upper abdomen has already been shown to be an important tool in the diagnosis and staging of lung cancer. 12, 13 In our study the computed tomography of chest and upper abdomen (including adrenals) was done in all 47 patients. The reported incidence of adrenal metastasis diagnosed by computed tomography is 10-15 percent. 14 In our study computed tomography diagnosed adrenal metastasis in 4.25% patients. Moreover computed tomography of chest diagnosed significant mediastinal lymphadenopathy in 13 patients in our study which was most common site of metastatic involvement. In our study 3 patient presented with liver metastasis. In Gupta R et al.11 reported mediastinal lymphadenopathy in about 121 patients and liver metastasis in 38 cases.

Enlarged lymph nodes are accessible for FNAC and are of importance specially to diagnose secondary or primary malignancies. It plays a significant role in developing countries like India, as it is a relatively cheap procedure, simple to perform and has minimal or no complications. 15, 16, 17 The diagnosis given on the cytological material is often the only diagnosis accepted and sometimes there is no further correlation with histopathology, especially in cases of advanced malignancies. It also provides clues for occult primaries and sometimes also surprises the clinician who does not suspect a malignancy. The primary sites identified in each lymph node group in our study correlated with other similar studies. 16, 18, 19 A full history, radiological investigations and immunohistochemistry in difficult cases may help to arrive at a definitive diagnosis.19Specialized investigations such as ultrasonography-guided FNAC's of sentinel lymph nodes in the head and neck area have been found to be good in picking up metastases in clinically undetectable lymph nodes. 20

In present study, 57 cases presented with lymphnode swelling suggesting primary or metastatic lymphadenopathy of squamous cell carcinoma based on their clinical presentation and radiological features. These 57 cases belonged to age group 30 to 90 years with sex ratio of male to female- 6.15:1, showing a clear male preponderance. Maximum incidence (84.21%) was observed in age group of >40 years of age. Cervical group of lymphnode (Cervical level II) was found to be the most common group of lymph nodes to be involved by metastasis of squamous cell carcinoma. 54.38% cases had an unknown primary or lesion.

In present study we found one rare case of Carcinoma of Unknown Primary Site (CUPS) at inguinal region. Fine needle aspiration of the inguinal region swelling was suggestive of high grade metastasis from epithelial malignancy from poorly differentiated squamous cell carcinoma. On further histopathological investigation, it was confirmed as Moderately differentiated keratinizing squamous cell carcinoma in lymphoepithelial cyst of inguinal lymphnode. Incidence of known primary lesion was commonly seen in oral cavity like Supraglottis (14.03%), Buccal mucosa (10.52%), Tongue (5.26%), Hard palate, Hypopharynx (3.50%) and tonsillar fossa.

Various site of presentation of head and neck and other region as squamous cell carcinoma occur as primary (54.54%), metastatic (27.27%) and recurrence (18.18%). Squamous cell carcinoma of various Head & Neck region had 100% concordance both cytopathological and histopathological diagnosis.

Conclusion

The spectrum of morphology, clinical presentation and radiological examination of squamous cell carcinoma with its cytological and histopathological features was studied. Correlation of these findings are important tools to predict prognosis and to facilitate the diagnosis of squamous cell carcinoma and diagnostic dilemma can be prevented.

Source of Funding

No financial support was received for the work within this manuscript.

Conflict of Interest

The authors declare they have no conflict of interest.

References

1 

S Narang N Kanungo R Jain Squamous cell carcinoma: morphological & topographical spectrum: a two year analysisIndian J Surg20147621041010.1007/s12262-012-0621-6.

2 

A. Jemal A. Thomas T. Murray M. Thun Cancer Statistics, 2002CA: A Cancer J Clin2002521234710.3322/canjclin.52.1.23

3 

E D Wagner I Ramzy S D Greenberg J M Gonzalez Transbronchial Fine-Needle Aspiration: Reliability and LimitationsAm J Clin Pathol1989921364110.1093/ajcp/92.1.36

4 

A Dey SK Saha S Kundu D Biswas S Kundu A Sengupta Comparison study of clinicoradiological profile of primary lung cancer cases: An Eastern India experienceIndian J Cancer2012491899510.4103/0019-509x.98930

5 

N Pandhi B Malhotra N Kajal R R Prabhudesai C L Nagaraja N Mahajan Clinicopathological profile of patients with lung cancer visiting Chest and TB Hospital AmritsarSch J App Med Sci201532D8029

6 

S K Jindal D Behera Clinical spectrum of primary lung cancer: Review of Chandigarh experience of 10 yearsLung India19908948

7 

R C Gupta S D Purohit M P Sharma S Bhardwaj Primary bronchogenic carcinoma: Clinical profile of 279 cases from mid-west RajasthanIndian J Chest Dis Allied Sci19984010916

8 

S Kashyap P R Mohapatra R S Negi P-83 Pattern of primary lung cancer among Bidi smokers in North-Western Himalayan region of IndiaLung Cancer2003412S11110.1016/s0169-5002(03)92052-6

9 

J Rawat G Sindhwani D Gaur R Dua S Saini Clinico-pathological profile of lung cancer in UttarakhandLung India200926374610.4103/0970-2113.53229

10 

J J Lee R L M Lin C H Chen Clinical manifestations of bronchogenic carcinomaJ Formos Med Assoc199291146

11 

R Gupta I Chowdhary P Singh Clinical, Radiological and Histological profile of Primary Lung CarcinomasJ K Sci201517314651

12 

E R Heitzman The role of computed tomography in the diagnosis and management of lung cancer. An overviewChest1986892375415

13 

G Buccheri P Barberis M S Delfino Diagnostic, Morphologic, and Histopathologic Correlates in Bronchogenic CarcinomaChest19919948091410.1378/chest.99.4.809

14 

R G Fraser J P Pare P D Pare Fraser RG Neoplastic disease of the lungDiagnosis of Disease of the ChestPhiladelphia: WB Saunders19891327475

15 

I N Bagwan S V Kane R F Chinoy Cytologic evaluaton of the enlarged neck node: FNAC utility in metastatic neck diseaseInt J Pathol200762

16 

K Alam A Khan F Siddiqui A Jain N Haider V Maheshwari Fine needle aspiration cytology (FNAC): A handy tool for metastatic lymphadenopathyInt J Pathol2010102

17 

R Khajuria K C Goswami K Singh V K Dubey Pattern of lymphadenopathy on fine needle aspiration cytology in JammuJK Sci200681579

18 

S K Sinha K Basu A Bhattacharya U Banerjee D Banerjee Aspiration cytodiagnosis of metastatic lesions with special reference to primary sitesJ Cytol200320168

19 

N. Gupta A. Rajwanshi R. Srinivasan R. Nijhawan Pathology of supraclavicular lymphadenopathy in Chandigarh, north India: an audit of 200 cases diagnosed by needle aspirationCytopathol200617294610.1111/j.1365-2303.2006.00285.x

20 

S Hoft C Muhle W Brenner E Sprenger S Maune Fine-needle aspiration cytology of the sentinel lymph node in head and neck cancerJ Nucl Med200243158590



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