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T4 squamous cell cancer of buccal mucosa successfully treated combination of interstitial brachytherapy, concurrent chemo-radiotherapy and salvage surgery

Incidence of oral cavity and pharynx cancer cases in India in 2016 is 1,88,969 in both sexes combined (95% UI 106 000–118 000). There is relatively high incidence of oral cancer in India is mainly because of the habit of chewing betal nut leaves rolled with lime and tobacco (mixture known as “paan”) which results in prolonged carcinogen exposure of the buccal mucosa. It results in condition called as oral submucous fibrosis (OSF) Initially these premalignant lesions are characterized by blanching of the mucosa with marble like appearance. At advanced stages palpable fibrous bands become more evident along buccal mucosa and mouth opening. It is estimated that as many as 5 million individuals are affected by OSF. Treatment in early stages remains surgery. Radiotherapy in form of interstitial implants along with chemoradiotherapy is an attractive strategy providing a chance of cure in patients deemed inoperable due to large tumor burden. CASE REPORT


INTRODUCTION
Incidence of oral cavity and pharynx cancer cases in India in 2016 is 1,88,969 in both sexes combined (95% UI 106 000-118 000). 1 There is relatively high incidence of oral cancer in India is mainly because of the habit of chewing betal nut leaves rolled with lime and tobacco (mixture known as "paan") which results in prolonged carcinogen exposure of the buccal mucosa. 2 It results in condition called as oral submucous fibrosis (OSF) Initially these premalignant lesions are characterized by blanching of the mucosa with marble like appearance. 3 At advanced stages palpable fibrous bands become more evident along buccal mucosa and mouth opening. It is estimated that as many as 5 million individuals are affected by OSF. Treatment in early stages remains surgery. Radiotherapy in form of interstitial implants along with chemoradiotherapy is an attractive strategy providing a chance of cure in patients deemed inoperable due to large tumor burden.

CASE REPORT
We present a case of 40-year-old male of CA Rt Buccal Mucosa. Patient presented in our department with complaint of an ulcerative lesion in right angle of mouth since past 3 months. He was apparently well 3 months back when he had complaint of an ulcerative lesion in rt sided buccal mucosa of cheek. It was initially small in size and gradually progressed in size to extend up to rt angle of mouth. It was associated with pain and relieved on taking painkillers. Patient had no comorbidities at presentation. He was a non-vegetarian, ex bidi smoker 1bundle/day for 10 years, ex tobacco chewer for past 10 years and ex chronic alcoholic.
He was conscious cooperative well oriented to time place and person and there was no significant finding on general physical examination and systemic examination.

Oral cavity
Dental staining was present, and an ulcer proliferative lesion was present on right buccal mucosa extending from right angle of mouth to the 2nd molar 5×3 cm involving gingivobuccal sulcus and was tender on palpation.
Histopathology from right buccal mucosa lesion biopsy revealed well differentiated squamous cell cancer.
CECT from base of skull to neck revealed a localised homogenous isodense mass lesion of size 3.9×2.3×2 cm in the right perioral region. Lesion apparently involved the right orbicularis oris levator anguli oris and zygomaticus minor.

Treatment modality
Patient was treated with 2 cycles of NACT based on TPF.
Otolaryngology opinion was sought, and patient was considered inoperable. In view of patient inoperable patient was planned on upfront interstitial brachytherapy followed by EBRT to buccal mucosa and neck.
12 catheter double plane implant was done under GA on right buccal mucosa. Dose prescribed was 25 Gy/8# (3.125 Gy/# 6 hours apart with lead shield between right buccal mucosa and right mandible.
Patient reported after 2 and half weeks after procedure with good general condition. Implant scar healed 4x3 cm induration present with ulceration at the angle of mouth trismus present.
Patient reported after 1 and half weeks after EBRT with complaints of change in taste and dryness of mouth. Interstitial needle scar marks were present and there was a raw area over the angle of mouth. There was no palpable cervical LAP. On digital palpation there were post RT changes and no evidence of growth.
Patient was kept on 2 monthly follow up. Patient came after 2 months on 2nd follow up with complaints of dry mouth decreased appetite and on local examination there was raw area on right angle of mouth extending posteriorly. There was no LAP. Otolaryngology review was taken, and a punch biopsy was advised which revealed moderately differentiated squamous cell carcinoma right angle of mouth.
In view of raw area revealing the small recurrent disease, Otolaryngology opinion was again sought for salvage surgery. Further workup of the patient was done at same department.
MRI revealed enhancement with total thickness of 9 mm length of 3.5 mm right buccal space with loss of fat planes.
Wide local excision of squamous cell carcinoma of right buccal mucosa with supraomohyoid neck dissection with reconstruction was performed with 1cm margin and split skin graft harvested from left thigh.
On HPE depth of invasion was 2 mm, tumor involved subepithelial connective tissue with uninvolved facial skin. Margins were uninvolved by invasive carcinoma and distance from closest margin was 6 mm There was no LVSI or PNI identified. 24 lymph nodes were resected all free from tumor metastasis.

DISCUSSION
This case report reveals a successful management of an advanced case of right sided buccal mucosa with the modalities of interstitial brachytherapy and concurrent CRT with the residual disease managed with the help of surgical salvage. Patient is disease free since past one year and is on follow up. He has a better quality of life as assessed by EORTC QLQ-H and N35, EORTC QLQ-C30 questionnaire and improvement in dysphagia as assessed by The MD Anderson dysphagia inventory. 5 Buccal mucosa is the most common cancer of oral cavity in India. There are many challenges in the treatment of advanced stage cancers which are deemed inoperable. Interstitial brachytherapy implants (which has a long history initially starting from radium needles being implanted in superficial tumors in 1930s) systems have been developed in course of time and offer a chance of cure6 to those patients who are not surgical candidates/ deemed inoperable. In our setup the patient benefitted in terms of cure from the disease and attained good quality of life with the help of interstitial brachytherapy and CRT.

CONCLUSION
Interstitial Brachytherapy is an excellent treatment modality with not only the major advantages of organ preservation better cosmetic and functional outcomes but also a better quality of life in oral cavity cancers. It may offer a last chance of cure in patients of advanced stage cancer who are deemed inoperable.