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Authors: Dr. Kratika Baldua, Dr. Ravikiran, Dr. Hemang Mangukia

ABSTRACT

Squamous cell carcinoma encompasses 90% of all malignant neoplasm of oral cavity. Gingival squamous cell carcinomas are relatively rare and may mimic common inflammatory lesions with benign features and this leads to late diagnosis or misdiagnosis many a times. Early diagnosis is critical for the successful management of the disease. This case report documents the detection and management of a gingival squamous cell carcinoma in a 60 year old male who reported with a chief complaint of pain and ulceration. Clinical examination revealed a white ulcerative and proliferative non scrapable lesion in relation to the marginal and attached gingiva of mandibular left posterior region (canine to molar region). Incisional biopsy was obtained from the lesion. Biopsy revealed early changes of squamous cell carninoma and patient was referred for surgical excision of the tumour. Early detection and diagnosis were ascendant in limiting invasiveness and extent of surgical resection of mandible in this case.

Key words:-

Biopsy, Gingiva, Squamous cell carcinoma

Figure 1:- White ulceroproliferative lesion involving marginal and attached gingiva and alveolar mucosa of teeth 43 - 47 Figure 2:- orthopantomogram showing horizontal bone loss
INTRODUCTION

Cancer can have abstruse social and economic consequences for people in India, often leading to family destitution and societal prejudice. Slightly more than 1 million new cases of cancer are diagnosed every year in an Indian population of 1·2 billion.1 Oral Squamous Cell Carcinoma (OSCC) accounts for 2–4% of all cancer cases in the world. In India prevalence of OSCC is higher ie. around 45%. It is estimated that more than 90% of all malignant lesions of the mouth are OSCC. Despite the advances of therapeutic approaches, percentages of morbidity and mortality of OSCC have not improved significantly during the last 30 years. Percentages of morbidity and mortality in males are 6.6/100,000 and 3.1/100,000 respectively, while in females the same percentages are 2.9/100,000 and 1.4/100,000.2 This neoplasm occurs more commonly in males than in females except for OSCC of gingiva. In general, OSCC is common after fifth decade of life.

OSCC is most commonly seen at vermilion border of lip, tongue and floor of mouth and less commonly on soft palate, gingiva and buccal mucosa. 3 The greatest risk factor for oral cancer in the western world is the use of tobacco and alcohol. Although the risk factors are independent, their action seems to be combined. Tobacco smoking is associated with 75% of all cases of OSCC. Tobacco smokers and alchohol drinkers carries a six-fold risk of developing OSCC. Hence, the combination of tobacco and alcohol use poses a fifteen-fold risk of oral cancer for users compared to non-users. While tobacco and alcohol use are traditionally the greatest risk factors, it is important to consider that other risk factors, such as betel quid chewing, areca nut chewing and reverse smoking are commonly observed in India. OSCC is most common in older males belonging with lower socioeconomic groups.

Besides these risk factors other factors that are related to the development of OSCC includes an impaired ability to repair DNA damaged by Mutagens, an impaired ability to metabolize carcinogens, deficiencies of vitamins A, E or C or trace elements and immune defects. The inadequate immune response may predispose to cancer development. The most common oral malignancy in individuals with HIV infection is Kaposi’s sarcoma. There is a high prevalence in patients with B cell Hodgkin lymphoma. There is an increased risk of developing OSCC in HIV infected patients and patients submitted to organ transplantations and those who are under immunosuppressive therapy. 2

OSCC exibits exophytic (verrucous or papillary), endophytic, ulcerated, leukoplastic, erythroplastic or erythroleukoplastic forms. Depending on their extent and/or location, these lesions may cause painful symptoms and resorption of adjacent bone seen as a “moth-eaten” appearance on radiographs. On the contrary, OSCC of the gingiva is normally painless and it is located in the keratinized portion. In its initial stage, it appears as a red or/and white spot slightly vegetant, extending on the surface due to the resistance offered by the periosteum. As advances, it adopts a tumoral shape, it may invade the bones, produce loosening of teeth and cause pain or trismus. Its progress through the lymph affects the submental, submandibular and carotid regions. The antero inferior lesions progress towards the floor of the mouth and to the ventral side of the tongue. If the tumor is located in the posterior zone, it invades the floor of the mouth as well as the masticatory muscles. The clinical aspect of OSCC can range from a white plaque to an ulcerated lesion. 3 Importantly, when located in the gingiva it may resemble inflammatory lesions frequently observed in this region that is why is most commonly misdiagnosed.

 
Figure 3:- incisional biopsy Figure 4:- Histopathologic view of the lesion, showing the loss of the epithelial-connective tissue (hematoxylin and eosin stain, original magnification x40).
 

Despite advances in surgery and radiotherapy, which remain the standard treatment options, the mortality rate has remained largely unchanged for decades, with a 5-year survival rate of around 50%. In the primary (I and II) stages the treatment of choice is surgery and/or radiotherapy, which usually result in permanent cure. Combination of surgery, radiotherapy or chemotherapy is used for the treatment of the 3rd or 4th stage of OSCC. Treatment of OSCC of the gingiva is primarily surgical. Radical neck dissection, or its modification, is the standard treatment for the metastatic lymph nodes. Radiotherapy is usually not the preferred modality of treatment for early gingivobuccal complex cancer. It is used either postoperative adjuvant treatment or as definitive treatment for advanced cancer with or without chemotherapy. Chemotherapy has been used as neo-adjuvant, adjuvant or palliative treatment.4 In current treatment advances, targeted molecular therapy with monoclonal antibodies and gene therapy has been applied to OSCC patients. This treatment modality has nonexistent side effects on normal cells of the body, unlike surgery, chemotherapy and radiotherapy. Targeted molecular therapy can also act as a complement to other existing cancer therapies and has been mainly focused on four molecules which are associated with the proliferation and the differentiation of OSCC, epidermal growth factor receptor (EGFR), cyclooxygenase- 2 (COX-2), peroxisome proliferator-activated receptor (PPAR) and progesterone receptor. 5

Early diagnosis remains the key element for the sufficient therapy of OSCC. Clinicians should be aware that single ulcers, tumors, red or white plaques, particularly if any of these are persisting for more than two weeks, may be manifestations of malignancy. In these cases a biopsy from the suspicious lesion is needed. New emerging technologies are developing and targeting to early diagnosis of OSCC through molecular analysis of cytologic smears or saliva samples.

This case report documents the early detection and management of a gingival squamous cell carcinoma in a 60 year old male presenting with a white ulcerative and proliferative non scrapable lesion in relation to the buccal aspect of marginal and attached gingiva of mandibular left posterior teeth.

Figure 5: Higher magnification showing a keratin pearl in the centre and cellular and nuclear pleomorphism (hematoxylin and eosin stain, original magnification x100). Figure 6: Postoperative image showing hemimandibulectomy.
CASE REPORT

A 60 year old male reported to the Out Patient Department of Periodontology at Darshan dental college and hospital, Udaipur, Rajasthan with a chief complaint of pain and ulceration in gums of right lower area of mouth from 15 days. Pain started 15 days before while eating and on self examination he noticed white ulcerations in lower right area of gums around the teeth. Patient kept the lesion under observation for 7-10 days and he did not get any relief in that time. He consulted his elder brother who is Master in Surgery and working in a community hospital in Udaipur, where he was informed that he just has inflammed gingiva and also advised to get a biopsy done for the same. He immediately followed his instructions and visited Darshan dental college and hospital. Patient was hypertensive since 5-6 years and was on amlodipine 2.5mg + metoprolol 25mg and aspirin 75mg. Patient had a habit of pan and gutkha chewing (3-4 pan/day), alcohol and cigarette smoking (1 pack/day) 10-15 years back. He had left all these habits 15 years back. Patient did not have any family history of carcinoma.

On extraoral examination, Level Ib (submandibular) lymph nodes were palpable, approximately 2×2 cm in size, slight tender and mobile. On intraoral clinical examination, stains and calculus was present and oral hygiene status was fair. White pathological, ulcero-proliferative, non-scrapable lesion was seen in relation to buccal aspect of marginal and attached gingiva of mandibular left posterior teeth extending to the buccal/ labial vestibule. Base of the ulcer was surrounded by erythematous area. (Fig. 1) Also there was generalised marginal gingival recession seen. Radiographically, horizontal bone loss seen. (Fig. 2)

Patient’s vitals were checked and found to be normal. In view of the clinical aspects of the lesion differential diagnosis was of an infectious proliferative process caused by human pappiloma virus (HPV) and squamous cell carcinoma. Incisional biopsy was obtained from buccal aspect of the lesion. (Fig. 3)

Histopathological analysis of biopsy specimen revealed squamous epithelium showing individual cell keratinisation, hyperchromatic nuclei, anisonucleosis, loss of polarity and characterstic “keratin pearl” formation suggestive of early changes of Oral Squamous Cell Carcinoma. (Fig. 4,5) Also Contrast Enhanced Computed tomography (CECT) of oral cavity and neck was done and showed mild enlargement of tonsils bilaterally with multiple tiny calcifications suggestive of tonsilloliths. Multiple subcentrimetric sized lymphnodes were seen in bilateral level Ib and II 6 measuring 12 × 8 mm.

In a view of this diagnosis, the patient was referred for the surgical interve4ntion that was performed by means of the removal of lesion observing a safety margin with peripheral osteotomy of the alveolar bone. (Fig. 6) Patient was also referred for radiotherapy fractioned in seven weeks each session of 50 Gy. At present, one year after the end of treatment patient continued for follow up and does not showed any signs of recurrence.

DISCUSSION

OSCC accounts for about 45% of all cases of cancer in India. More than 90% malignant neoplasms of oral cavity are OSCC.

CONCLUSION

The prognosis of gingival squamous cell carcinoma depends on the histological grading and clinical extent of the tumor. The grading of a tumor is determines by determining differenciation of tumour cells microscopically. An early lesion such as in our case is generally considered to have a favorable prognosis. But the most important indicator of the prognosis is the clinical stage of the disease.

REFERENCES
  • Mallath KM, Taylor DG, Badwe AR, Rat GK, Shanta V, Pramesh CS et al. The growing burden of cancer in India: epidemiology and social context. Lancet Oncol 2014; 14: 1-8.
  • Yoon TY, Bhattacharyya I, Katz J, Towle HJ, Islam MN. Squamous cell carcinoma of the gingiva presenting as localized periodontal disease. Quintessence Int. 2007 Feb;38(2):97-102.
  • Markopoulos AK. Current Aspects on Oral Squamous Cell Carcinoma. Open Dent J 2012; 6: 126-130.
  • Cabral LA, Carvalho LF, Salgado JA, Brandão AA, Almeida JD. Gingival Squamous Cell Carcinoma: a Case Report. J Oral Maxillofac Res 2010; 1(3): 1-6.
  • Hamakawa H, Nakashiro K, Sumida T, et al. Basic evidence of molecular targeted therapy for oral cancer and salivary gland cancer Head Neck 2008; 30: 800-9.
  • Nicolás Bolesina, Fabián L. Femopase, Silvia A. López de Blanc, Rosana A. Morelatto and María Alicia Olmos (2012). Oral Squamous Cell Carcinoma Clinical Aspects, Oral Cancer, Dr. Kalu U. E. Ogbureke (Ed.), ISBN: 978-953-51-0228-1, InTech, Available from: http://www.intechopen.com/books/oral-cancer/oral-squamous cell-carcinoma-clinical-aspects

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