A Case of Tumor Recurrence from a 81-year old Male with Squamous Cell Carcinoma

in STEMGeeks2 months ago

A case of an 81 year old male previously diagnosed as having Squamous Cell Carcinoma (SCC). The specimen below is a fine needle aspiration for a left axillary mass suspected to be a tumor recurrence. Even if an excision biopsy was done to remove the tumor locally, the chance that metastasis has already occurred can't be ruled out.

Appreciate what malignant cells look like~

Taken at 400x magnification under H and E stains:

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Taken at low power magnification 100x:

4.jpg

Hyperchromatic, round to markedly pleomorphic nuclei with inconspicuous nucleoli and scant to abundant eosinophilic cytoplasm.

Features that makes those cells look really malignant are described above, but another simple way to put it is the dark nucleus being "hyperchromatic" means it's really active and ready to divide, attaching the word pleomorphic means it's assuming an irregular to bizarre forms. Some giant forms really make this case easy to call.

I just said it has an inconspicuous nucleoli because I couldn't appreciate the nucleoli on the stains but generally, if a cell is reactive or just kicking its cellular machinery into high gear, you'll see prominent nucleoli within the nucleus. This is readily seen on tissue sections. The scant to abundant cytoplasm just adds weight to the increase in nucleus to cytoplasmic ratio commonly expected from malignant cells.

The red background is made up of mature blood elements (RBCs, and mixed inflammatory cells, necrotic debris, fibrin and hemorrhage.) SCC is often has an abundant necrotic debris. I was also looking for keratin flakes and pearls on the background to further raise my case as this being a Squamous Cell Carcinoma. The ideal way to diagnosed these type of cases was examining a tissue section so calling it definitively as SCC requires a lot of guts given how it's just probably a small sample overall. There's still a chance that it could be Adenosquamous Cell Carcinoma (a different disease entity but that's beyond the scope of this blog).

Seeing these clusters of cells made me instantly call it malignant and favoring SCC recurrence. It's not often do I get to see a clear cut picture that some set of cells are malignant especially if they came from well differentiated tumors. Well differentiated gives me an idea they look close to the normal ones in operation.

Based from these findings, I'd say it's consistent with a moderate to poorly differentiated squamous cell carcinoma. The patient was previously diagnosed as moderately differentiated SCC. Giving more weight that this is a recurrence and not some other disease process at work.

For cases like these, the likelihood of the patient just undergoing palliative care is high given how the age of the patient and health status may pose little benefit from chemotherapy. Recurrence also raises the possibility that this set of neoplastic cells are resistant to the the previous chemo drugs used (if the patient did undergo chemotherapy). Their body may not be able to handle the chemo drugs.

There are two sides of looking at this case from my point of view:

  1. I get excited to see first hand what the textbooks say. I'm applying what I learned and this is an even higher form of education.
  2. At the end of the day, someone is suffering for this learning experience.

This is how I looked at all the interesting cases I've encountered.

I own the photos. You stumbled upon my medical blog.
If you made it this far reading, thank you for your time.

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I know about oral SCC in cats and they are extremely aggressive, untreatable cancers: death can occur within weeks of diagnosis - are they as fast for humans?

are they as fast for humans?

This is a tricky question as the prognosis will depend on where it arise if a source can be located, the nature of SCC (keratinizing vs non-keratinizing), and how early was it detected. Generally, yeah it's bad and aggressive but the stuff that makes it better are factors mentioned above.

On cervical SCC, HPV dependent has a better response to chemo than HPV independent SCC as an example.

DO you guys do some investigation for biomarkers using immunohistochemistry?
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Immunohistochemistry is about detecting presence of those biomarkers but these aren't specific all the time. There are stains for PSA, Calcitonin, CEA, and AFP to name a few. Those can be detected on serum too.

It was also known as Bowen disease but now it is known as SSC. The major cause is excessive exposure to sunlight and sunburn.

I think Hugh Jackman had that kind of cancer on his nose, he was treated and got out of it.

Thanks for an insightful article on cancer.

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Hugh Jackman

Had Basal Carcinoma, I googled this one to confirm but right before doing so, I had a feeling it was BCC since the face was involved. It's the same energy as a word association that comes to mind. SCC can still present in the face but I'll be thinking BCC first than SCC.

You are absolutely right I just did same thing, but I applaud you intuition that already clicked the exact name of cancer.

I further found that SCC and BCC both have one thing common in causes of the disease, which is weak immune system. And according to a Harvard Study it is not as common vs BCC cases, and also treatable at most and lies in between melanoma and BCC.

But, I think one reason is that people in US rush to beaches and soak sunlight for hours which quite harmful, some do it for tanning and some for Vit D. For Vid D a half an hour is enough to soak up the sun, but for tanning it turns out to be fairly dangerous for the skin.

Thanks for proving a healthy reply.

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