Squamous cell carcinoma (SCC) of the buccal mucosa accounts for 23% to 37% of all intraoral cancers. ¹ SCC is the most prevalent cancer of the mouth. The highest incidence rate is observed in India, Australia, Brazil, France and South Africa. ¹ A male to female ratio is about 2:1 with the largest number of Oral SCCs developing in the fourth and fifth decades of life. ²

Because of the high recurrence rate and invasive behavior of this tumor, the prognosis is generally poor. ³ Diaz et al′s showed that buccal Squamous cell carcinoma (SCC) is an aggressive cancer, with a tendency to recur locoregionally. ⁴ Strome et al′s revealed that 80% of patients had evidence of recurrence by 5 years, ⁵ while Lin CS et al′s found that recurance rate was 34% by 5 years. ⁶ According to our search in Pubmed medical data bases there was no similar reported case about the locoregional invasion and recuurence of buccal SCC in Iran.

Patient case presentation

In March 2012, ,a 32-year-old admitted in alzahra hospital medical center of Isfahan,Iran due to the swelling in the right cheek region that initiated from 6 months ago but rapidly grow during one month ago. He had a history of right cheek surgery with cervical lymph node dissection 2 years ago that was histopathologicaly diagnosed as Squamous cell carcinoma (SCC) at stage II (T2N0M0) ⁷ that justified no lymph node involvement in examination. Extra oral examination, revealed a swelling of 3 × 2 cm in the right cheek region with a firm consistency. There was no fever, redness and secretion in the region. Themouth opening was limited due to the trismous. There were no palpable lymph node in the submandibular and cervical region and facial muscle paralysis was not existed. Intraoral examination revealed an erythematous mass in the buccal region without bleeding or necrosis. Also the scar of the previous surgery was visible in the buccal mucosa.

Physical examination of lung, heart, and abdomen were normal. Chest x-ray was normal. Brain CT scan had no finding for metastasis. Liver-ultrasonography was normal. Head and neck CT with soft tissue windowingin 2010, February showed a lesion in the right buccal region with dimensions of z 3.1 × 2.7 Figure 1. that was surgically excised with all the involved surrounding tissues under the general anesthesia at that time. Figure 1

CT image, Axial view, soft tissue windowing, showe a soft tissue mass lesion with dimension of 3.1 × 2.7 in the right buccal mucosa. (January 2010)

Buccal SCC is an important cause of morbidity and mortality worldwide with an incidence rate that varies widely by geographic location, sex, age and habit. Buccal SCC is an aggressive cancer with a high tendency to recur. ¹ .

The incidence of buccal carcinoma is much higher in Asia. In India, buccal carcinoma is the most common cancer in men. ¹ Sharma et al revealed a male to female ratio of 2.2:1 with the largest number of SCCs developing in the fourth and fifth decades of life. ² Most of the reported cases of SCC have a history of alcoholism and/or nicotine addiction, ⁸ while our case didn′t have any history of nicotine and alcohol consumption. Squamous cell carcinoma (SCC) of the buccal mucosa is a rare, but especially aggressive form of oral cavity cancer, associated with a high rate of recurrence. In contrast other oral cancer, buccal SCC has a worse stage that affects the survival and become poor prognosis. ⁴

SCC of buccal mucosa has a failure rate even in patient with T1, 2 N0 stage that can be due to inadequate therapy and aggressive nature. There was a 100% overall incidence of local disease recurrence in patients with stage I and II tumors treated with wide local excision alone and followed up for more than 2 years. ⁵

Patients with T1- or T2-sized tumors had only a 78% and 66% 5-year survival, respectively. Surgical salvage for patients with locoregional recurrence after radiation therapy has been rarely successful. ⁴ Postoperative radiotherapy was effective in decreasing locoregional failure in patients with close surgical margins, tumor thicker than 10 mm, high-grade tumors, positive node, and bone invasion. ⁹ Intra-arterial chemotherapy followed by radiotherapy is to be considered in advanced cases. ³ Similar to the presented case. The treatment of buccal carcinoma requires a multidisciplinary team approach because most of the patients are elderly and present with an advanced stage.

Nearly one-third of patients have localized disease, that is, T1 or T2 (stage I or stage II) lesions without detectable lymph node involvement or distant metastases, These lesions are treated with curative intent by either surgery or radiation therapy. ¹⁰ Iin CS et al showed that SCC of the buccal mucosa is an aggressive cancer with a high locoregional failure rate even in patients with T1-2N0 disease, ⁶ so Postoperative radiotherapy could led to a better locoregional control rate for patients and should be recommended for patients with T1-2N0 disease.

The 5-year actuarial survival rates were 80% after surgery and 82% after surgery and postoperative radiation therapy. ⁷ Pop et al, showed a local recurrence rate of 45%, while schiza et al found the frequency as 56% in their research. Postoperative radiotherapy has resulted in a better locoregional control rate for patients and should also be considered for patients with the T1-2N0 disease ¹⁰ for whom adjuvant therapy after radical surgery currently is not recommended by most guidelines. ⁶ In the head and neck cancer, the most important prognostic factor is the presence or absence of neck metastasis. ¹¹

Deconde et al found that Performance of neck dissection may decrease the risk of recurrence in primary SCC of the buccal mucosa. ¹²

Finally the search in a procedure that diminishes recurrence may open the window of knowledge in treatment and increase survival. Because of low survival and high recurrence, more research needs to perform to understanding the pathogenesis of the disease that led to new therapeutic strategies. ¹²

This study was performed under the support of the Isfahan university of medical sciences, Schooles of medicine and dentistry and Torabinejad research center.