The Silent Swell that Spoke Cancer

The Silent Swell that Spoke Cancer

1) Diagnosis

• Primary: Squamous Cell Carcinoma (SCC) of the Left Buccal Mucosa (T2N1M0, Stage III – AJCC 8th Edition).
• Secondary: Anemia of chronic disease, tobacco-induced leukoplakia changes.

2) History of Present Illness (HPI)

• Chief Complaint: Non-healing ulcer in left buccal mucosa × 3 months.
• Progression: Initially small, painless ulcer → gradually increased in size with pain on chewing & mild trismus.
• Associated Symptoms: Weight loss (4 kg in 2 months), halitosis.
• Negative History: No bleeding from ulcer, no dysphagia, no hoarseness.

3) Past Medical History

• HTN (well controlled on Amlodipine 5 mg OD).
• No prior surgeries/ICU admissions.
• Medications: Amlodipine 5 mg (Ca²⁺ channel blocker, vasodilator → lowers BP).

4) Physical Examination

• General: Cachectic, mild pallor, ECOG performance status 1.
• Oral Exam:
  • Ulcer proliferative lesion, left buccal mucosa, ~3 × 2.5 cm.
  • Indurated margins, non-tender, limited mobility.
  • Trismus: mouth opening 2.5 cm.
• Neck: Single palpable ipsilateral cervical lymph node (1.5 cm, firm, mobile, non-tender).
• Systemic Exam: No organomegaly, chest clear, CVS normal.

5) Vitals on Admission

• HR: 92
• bpm BP: 138/84 mmHg
• RR: 18/min
• Temp: 37.2°C
• SpO₂: 97% RA
• GCS: 15/15

6) Investigations

• Baseline (Day 0):
  • CBC: Hb 10.8 g/dL (mild anemia), WBC 8,500, Plt 2.1 lakh.
  • RFT: Normal.
  • LFT: Mildly ↑ SGOT/SGPT.
  • Electrolytes: Normal.
  • FNAC of cervical node: Positive for metastatic SCC.
  • Biopsy (from buccal lesion): Moderately differentiated SCC.
  • CXR: Normal (no lung mets).
  • CECT Face & Neck: Tumor confined to left buccal mucosa, extension to retromolar trigone, ipsilateral LN involvement, no mandibular bone invasion.

7) Imaging

• CT scan: Stage III (T2N1M0).
• Chest X-ray/USG Abdomen: No distant metastasis.

8) Emergency Stabilization (Day 0 – ER)

• Symptoms: Painful non-healing ulcer in left buccal mucosa × 3 months, mild trismus, weight loss, halitosis.
• Exam: Ulcer 3 × 2.5 cm, indurated margins, palpable ipsilateral cervical LN (1.5 cm).
• Vitals: HR 92, BP 138/84, RR 18, Temp 37.2°C, SpO₂ 97%, GCS 15.
• Investigations:
  • CBC: Hb 10.8 g/dL, WBC 8,500, Plt 2.1 lakh.
  • RFT: Cr 0.9, Urea 24.
  • LFT: Mild ↑ SGOT/SGPT.
  • CECT Face & Neck: Tumor confined to left buccal mucosa + ipsilateral LN, no bone invasion.
  • Biopsy: Moderately differentiated SCC.
• Treatment:
  • IV fluids (DNS 100 mL/hr).
  • Analgesia: Inj Tramadol 50 mg IV TDS.
  • Oral hygiene: Betadine gargle QID.
  • Nutrition: High-protein NG tube feed.
  • Plan: Optimize for surgery

9) Day-by-Day ICU/Pre-op & Operative Course

• Day 1 – Preoperative Optimization
  • Findings: Mild pallor, ECOG 1, trismus persists.
  • Investigations: ECG – Normal sinus rhythm. CXR – clear lungs.
  • Treatment:
    • Inj Iron Sucrose 200 mg IV (to correct anemia).
    • Multivitamins + high-protein diet via NG tube.
    • BP controlled on Amlodipine 5 mg OD.
  • Event: Pre-anesthesia clearance obtained
• Day 2 – Surgery Day
  • Procedure: Wide local excision of buccal mucosa lesion + Marginal Mandibulectomy + Ipsilateral Modified Radical Neck Dissection (Levels I–IV).
  • Reconstruction: Pectoralis Major Myocutaneous (PMMC) flap.
  • Intra-Op Events:
    • Blood loss ~500 mL (1 PRBC transfused).
    • Margins taken – frozen section negative.
  • Post-Op Orders:
    • Ventilated overnight in ICU.
    • IV Ceftriaxone 1 g BD + Inj Metronidazole 500 mg TDS.
    • Analgesia: PCA Morphine (1 mg bolus, lockout 10 min, max 6 mg/hr).
    • IV Fluids: DNS + RL, 100 mL/hr each.
    • NG feeding deferred until bowel sounds return.
    • Vitals stable.
• Day 3 – Immediate Post-Op
  • Event: Extubated successfully in morning.
  • Findings: Flap viable (pink, warm, good capillary refill).
  • Investigations: Hb 10.4 g/dL, WBC 9,200, Cr 1.0.
  • Treatment:
    • Restarted NG tube feeding (liquid diet, 200 mL every 3 hr).
    • Inj Pantoprazole 40 mg IV OD.
    • DVT prophylaxis: Enoxaparin 40 mg SC OD.
    • Analgesia shifted to Inj Paracetamol 1 g IV TDS + Tramadol SOS.
• Day 4–5 – Early Recovery
  • Symptoms: Pain reduced, able to sit up, no respiratory distress.
  • Exam: Flap healthy, sutures intact, drains minimal serosanguinous.
  • Investigations: CBC stable, electrolytes normal.
  • Treatment:
    • Continue NG feeding.
    • Daily saline + betadine oral care.
    • Physiotherapy for neck/shoulder started.
  • Plan: Monitor until final histopathology report (HPR).
• Day 6–7 – Post-Op Ward Stay
  • Event: Drain removed (output <30 mL/24 hr).
  • HPR: Moderately differentiated SCC, clear surgical margins, 1/14 nodes positive → Stage III, T2N1M0.
  • Plan: Adjuvant concurrent chemo-radiotherapy.
• Day 8 – Discharge
  • Medications:
    • Tab Amlodipine 5 mg OD.
    • Tab Tramadol 50 mg SOS.
    • Tab Pantoprazole 40 mg OD.
    • Oral multivitamins, zinc.
  • Advice: Oral hygiene, NG feeding until adequate mouth opening, follow-up in 2 weeks.
• Day 14 – OPD Follow-Up
  • Findings: Flap well-settled, no infection. Mouth opening improved.
  • Event: Planned for chemoradiation start.

10) Adjuvant Therapy Course

• Week 3 (Day 21) – Start of Chemoradiation
  • Radiotherapy: IMRT 60 Gy in 30 fractions (2 Gy × 5 days/week).
  • Chemo: Inj Cisplatin 100 mg/m² IV Day 1, 22, 43.
  • Prehydration: 2 L NS + KCl + MgSO₄.
  • Antiemetics: Inj Ondansetron 8 mg IV BD, Inj Dexamethasone 8 mg IV OD.
  • Supportive:
    • NG feeding continued.
    • Oral care to prevent mucositis.
  • Monitoring: CBC, RFT, Electrolytes twice weekly.
• Week 4–5 – During Radiation
  • Symptoms: Oral mucositis Grade II, mild dysphagia, nausea.
  • Investigations: Hb 10.2 g/dL, Cr 1.1, WBC 5,800.
  • Treatment:
    • Topical Lignocaine viscous before meals.
    • Tab Paracetamol 650 mg TDS.
    • IV fluids on chemo days.
• Week 7 – End of Radiation
  • Event: Completed 60 Gy/30 fractions + 3 cycles Cisplatin.
  • Symptoms: Oral mucositis resolving, weight loss ~2 kg.
  • Treatment: Nutritional rehabilitation, high-protein feeds, antifungal (Fluconazole) for oral thrush.

11) 3-Month Follow-Up

• Findings: Healing flap, good oral intake, no recurrence clinically.
• Investigations: CECT Neck – no residual/recurrent disease.
• Patient Status: ECOG 0, returned to daily activities.

12) Key Clinical Pearls

• Early biopsy of any non-healing oral ulcer (>2 weeks) is critical.
• Tobacco + betel nut chewing = strongest risk factor.
• Surgery + adjuvant chemoradiation = best outcome in Stage III.
• Regular flap monitoring avoids catastrophic necrosis.
• Nutrition & oral hygiene play a major role in recovery.

13) Case Storytelling

“Mr. R, a 52-year-old farmer with a long history of chewing tobacco, walked in with a wound inside his cheek that refused to heal. For months, he thought it was a simple sore — until pain made even a sip of water a challenge. On the day of surgery, a team worked meticulously to remove the cancer and rebuild his cheek with muscle from his chest. A week later, as he smiled weakly and sipped his first spoon of soup, he whispered — ‘Doctor, it feels like a new life.’”

14) MCQ Q&A Section

• Q1. Most common histological type of buccal mucosa cancer?
  Ans: Squamous Cell Carcinoma (≈90%).
• Q2. Best adjuvant therapy for Stage III oral cavity SCC post-surgery?
  Ans: Concurrent chemoradiation (Cisplatin-based + IMRT).
• Q3. Radiation dose commonly used in buccal mucosa SCC?
  Ans: 60–66 Gy in 30–33 fractions.
• Q4. Which flap is most commonly used for reconstruction in buccal mucosa carcinoma?
  Ans: Pectoralis Major Myocutaneous Flap (PMMC).
• Q5. Most important prognostic factor?
  Ans: Nodal status (lymph node involvement).