Regional spread of cutaneous squamous cell carcinoma of the face via facial vein tumor thrombus: a case report Aysenur Meric Teker, MD a , Robert R. Lorenz, MD a, ⁎ , Walter T. Lee, MD a , Aaron Hoschar, MD b a Cleveland Clinic Head and Neck Institute Cleveland, OH, USA b Cleveland Clinic Anatomic Pathology Cleveland, OH, USA Received 14 October 2007 Abstract Cutaneous squamous cell carcinoma of the head and neck most often spreads via direct extension or through lymphatics to regional lymph nodes. This is a unique case of a cutaneous squamous cell carcinoma of the nasal dorsum with direct vascular invasion of the facial vein. This was initially incorrectly identified as a regional level Ib lymph node metastases, and the intervening venous structures were neither extirpated during an initial surgery nor recognized during subsequent radiation therapy. The patient then presented with a sizable recurrence in the right suborbital subcutaneous tissue region extending into the neck and internal jugular vein. During further resection, direct tumor invasion into the facial vein was pathologically confirmed. This unusual involvement is presented as the first documented report of regional spread via tumor thrombosis within the facial vein as demonstrated in the facial vein with a tumor thrombus, as demonstrated by computed tomography and microscopic findings. Published by Elsevier Inc. 1. Case report Malignancies have been reported to develop along a venous tumor thrombus and may even metastasize through retrograde venous flow. Cancer spread to a vein is a poor prognostic indicator in patients with carcinoma. This may be because of the high incidence of concomitant locoregional spread and distant organ metastasis. Cutaneous squamous cell carcinoma (CSCC) is known to be more invasive lymphatically than vascularly [1]. Venous thrombosis from direct tumor invasion of the facial vein is extremely rare. We present a case in which the facial vein tumor thrombosis was not initially recognized and resulted in a regional recurrence. A 74-year-old male had a history of multiple CSCCs of the face, with recent removal of lesions from the left temple and dorsum of the nose. Eight months before presenting to our institution, the patient underwent Mohs surgery for a nasal dorsum lesion. Three months later, the patient developed a 3-cm right submandibular mass. Preoperative computed tomography (CT) of the neck was performed. Assuming that the patient had developed regional adeno- pathy, the patient underwent a right selective neck dissection removing the right submandibular gland and the surrounding lymph nodes in levels I to III at an outside hospital. Postoperatively, the patient received chemoradiation therapy centered upon the face and neck based on pathologically proven SCC. One month after completing the chemoradia- tion therapy, he developed numbness to his right cheek as well as a mass beneath the right orbit. He was then referred to our institution for a recurrent mass at right aspect of the neck and right suborbit. Results of physical examination noted a 2.5-cm sub- epithelial mass inferior to the right orbit that was compres- sing the eyelid shut, as well as a mass in the right submandibular gland region. The previous excision sites over the nasal dorsum and left temporal area were unremarkable. The patient's previous CT scans were reviewed and demonstrated that before the neck dissection and chemoradiation therapy, right facial vein thromboses could be seen with an ill-defined nodular density lateral to the angle of the mandible measuring 1.4 cm (Fig. 1). There appeared to be tumor throughout the course of the facial vein involving the masseter muscle and parotid gland, ending in a Available online at www.sciencedirect.com American Journal of Otolaryngology – Head and Neck Medicine and Surgery 29 (2008) 423 – 425 www.elsevier.com/locate/amjoto ⁎ Corresponding author. Cleveland Clinic Head and Neck Institute, 9500 Euclid Avenue A-71, Cleveland, OH 44195, USA. Tel.: +1 212 444 3006; fax: +1 216 445 9409. E-mail address: lorenzr@ccf.org (R.R. Lorenz). 0196-0709/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.amjoto.2007.10.007