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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 3  |  Page : 149-152

Perplexing presentation of squamous cell carcinoma as gingival lesion


Department of Periodontology, Nanded Rural Dental College and Research Center, Nanded, Maharashtra, India

Date of Submission14-Mar-2020
Date of Decision21-Apr-2020
Date of Acceptance06-May-2020
Date of Web Publication14-Aug-2020

Correspondence Address:
Aruna Namdev Daware
Flat No. 202, Narayandri Apartment, Bajaj Nagar, Chhatrapati Chauk, Nanded - 431 605, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_40_20

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  Abstract 


Squamous cell carcinoma (SCC) is a malignant epithelial neoplasm, and the gingiva is the third most common site when the oral SCCs are concerned. The diagnosis of such gingival lesions is confusing because of its variable and chronic inflammatory lesion-like presentation. Because of its benign features, early detection is difficult, which reduces the high cure rate. A 50-year-old female patient was reported with a 4-month history of painless gingival overgrowth in the maxillary palatal aspect in relation to 21–24 with evident right submandibular lymphadenopathy. The diagnosis was made on the basis of a thorough history of the patient, clinical examination, and histopathological findings. The patient was referred for contrast-enhanced computed tomography to record the extent of metastasis, and the decision of surgical excision of the lesion was taken.

Keywords: Contrast-enhanced computed tomography, gingiva, malignant neoplasm, squamous cell carcinoma


How to cite this article:
Reddy NM, Daware AN, Dhonge RP, Gaidhankar S. Perplexing presentation of squamous cell carcinoma as gingival lesion. Indian J Dent Sci 2020;12:149-52

How to cite this URL:
Reddy NM, Daware AN, Dhonge RP, Gaidhankar S. Perplexing presentation of squamous cell carcinoma as gingival lesion. Indian J Dent Sci [serial online] 2020 [cited 2020 Sep 23];12:149-52. Available from: http://www.ijds.in/text.asp?2020/12/3/149/292276




  Introduction Top


Oral squamous cell carcinoma (OSCC) is an invasive neoplasm which shows uncontrolled differentiation of squamous epithelial cells. SCC is considered as the 6th most common cause of death in the world and the second-most common cause in India. Around 90%–95% of squamous malignant lesions are of the oral cavity.[1] Most commonly involved sites are tongue, floor of the mouth, and rarely seen on gingiva (10%). Around 40% of patients with oral cancer show lymph node metastasis. SCC is a male predominant but seen in females >50 years with tobacco, alcohol, and smoking as risk factors.[2]

Clinically, OSCC presents leukoplakia or erythroplakia (premalignant conditions). The lesions have varied appearance, ranging from the broad-based exophytic mass with relatively smooth surface texture, verrucous, or pebbled. Radiographically, it shows ill-defined margins with a lack of cortication. The involved teeth show mobility, migration, and root resorption. The surrounding bone shows a saucer-shaped defect and pathological fracture as progress.

The treatment plan for SCC depends on the stage of the disease. At the initial stages of the disease, surgery and brachytherapy are preferred, but the multidisciplinary approach is considered at the advanced stage. In cNO (no clinically palpable metastasis) neck cases elective neck dissection and in cN+ (clinically palpable metastasis) neck cases, modified radical neck dissection is preferred. In cases of multiple lymph node metastasis or extracapsular spread, radiotherapy or chemotherapy is given postoperatively.[3]


  Case Report Top


A 50-year-old female patient reported to the department of periodontics with the complaint of gingival overgrowth on the right side of the maxilla in palatal aspect in relation to teeth 21–24 for the past 4 months [Figure 1]. The lesion was initially small but has slowly grown to present size in 4 months. It was not associated with pain, but there was discomfort while chewing because of its extent. The patient was having a history of hypertension and uncontrolled diabetes, which may have contributed to the progression of the lesion with overlapping periodontitis. The patient had negative history of adverse habits such as tobacco or smoking.
Figure 1: Preoperative

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Extraoral examination disclosed palpable submandibular lymph nodes on the right side. Intraoral examination revealed ulceroproliferative gingival overgrowth involving hard palate measuring approximately 3 cm × 2 cm in size. The lesion was slightly elevated, bright red in color and bled on slight provocation. The intraoral periapical and occlusal radiograph was taken, which revealed severe bone loss from 21 to 24 [Figure 2] and [Figure 3]. For evaluation of metastasis, contrast-enhanced computed tomography was done, which reported an enhancing lesion extending from alveolus on the right side involving the palatal region [Figure 4] and [Figure 5]. It also revealed that there was level I and II enlargement of submandibular lymph nodes. The case was diagnosed with SCC, and treatment was planned.
Figure 2: Intraoral periapical radiograph

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Figure 3: Occlusal radiograph

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Figure 4: Computed tomography of the head

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Figure 5: Computed tomography of the neck

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The first patient was monitored for uncontrolled diabetes and hypertension, and the decision of surgical excision was taken. Partial maxillectomy with modified radical neck dissection was done [Figure 6]. Macroscopically, the right partial maxillectomy specimen with eight teeth measuring about 4.9 cm × 3.2 cm × 2.4 cm was removed. The mucosa showed ulceroproliferative lesion measuring around 2.6 cm × 1.6 cm.
Figure 6: Postoperative

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Histopathological findings

A focal ulcerated stratified squamous epithelium with an infiltrating tumor of squamous cells, which were arranged in nests, islands, cords, and trabeculae. The neoplastic cells were polygonal with moderate eosinophilic cytoplasm, pleomorphic nuclei with fine chromatin, and prominent 1–2 nucleoli. Average mitosis recorded was 3–4/hpf. Intracytoplasmic keratin and keratin pearls were seen. The tumor invaded into the subepithelial stroma. The surrounding stroma was desmoplastic with moderately dense lymphoplasmacytic infiltrate with few eosinophils.


  Discussion Top


Oral cancer is one of the fatal conditions, in which 90%–95% of the cases are SCC. According to the WHO, 11% were the growing rate recorded for SCC. Intraorally, SCC generally involves the tongue, floor of the mouth, and gingiva. The occurrence of gingival SCC (GSCC) is a very rare finding with <10% of involvement in the oral cavity. Intraosseous involvement of SCC found to be more in the mandible than the maxilla. It is more commonly seen in males than females, but it may not be same in cases of GSCC.[4],[5]

Barasch et al. reported a nonsignificant increase in the proportion of GSCC compared to the total number of SCCs affecting other oral sites and also observed an increased prevalence of the tumor among females.[4]

The age factor is considered to be controversial in cases of SCC. Perussi et al.[5] reported old age involvement, whereas Bill et al.[6] reported a case where neoplasm was seen in a 14-year-old male. In this case report, a female patient with 50 years of age was diagnosed as GSCC, which is in accordance with the case series analysis by Barasch et al. who reported that SCC occurred after the 5th decade of their life.[4]

The clinical presentation of neoplasm involving gingiva shows well-demarcated margins with the underlying destruction of bony structure, which leads to mobility in the involved teeth.[7] A similar clinical presentation is seen with ulceroproliferative overgrowth, which mimics as the chronic gingival inflammatory lesion. Severe bone loss and mobility were seen around the multiple teeth like a case of periodontitis. Due to its presentation, periodontist plays an important role which helps in the early diagnosis of such lesions.

The patient was a known case of diabetes mellitus (DM) and hypertension. DM is considered as a risk factor for periodontal diseases and also contributes in the progression of oral carcinomas and reduces lifespan.[8] Permanent increase in glycemic index results in the release of free radicals and increase in oxidative stress, which responsible for the destruction of tissue.[9] Increase in glucose concentration facilitates the DNA synthesis in cancer cell. Due to oxidative imbalance, advanced glycation-end products accumulate, which causes the release of cytokines, free radicals, and growth factors. Insulin and insulin-like growth factors (IGF) can promote tumor cell proliferation, survival, migration, invasion, and angiogenesis.[10],[11],[12] Increased levels of insulin/IGF act as a potential mitogen for neoplastic cells.[13] This case report explains the multifactorial etiology of cancer, which is uncertain in each case.


  Conclusion Top


  • Periodontist can play a major role in the early diagnosis such as lesions mimicking as periodontitis
  • Periodic oral screening of diabetic patient is needed for early diagnosis and prevention
  • Early diagnosis is the only key for a better prognosis and to prolong lifespan.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Varshitha A. Prevalece of oral cancer in India. J Pharma Sci Res 2015;7:845-8.  Back to cited text no. 1
    
2.
Xinhua W, Ji X, Lijuan W, Chao L, Huiming W. The role of cigarette smoking and alcohol consumption in the differentiation of oral squamous cell carcinoma for the males in China. J Cancer Res Ther 2015:11;1:141-5.  Back to cited text no. 2
    
3.
Moreno-Sanchez M. Elective neck dissection in oral squamous cell carcinoma of the upper maxilla: Necessary. Plast Aesthetic Res 2016;3:175-80.  Back to cited text no. 3
    
4.
Barasch A, Gofa A, Krutchkoff DJ, Eisenberg E. Squamous cell carcinoma of the gingiva. A case series analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:183-7.  Back to cited text no. 4
    
5.
Perussi MR, Denardin OV, Fava AS, Rapoport A. Squamous cell carcinoma of the mouth in the elderly in São Paulo. Rev Assoc Med Bras 2002;48:341-4.  Back to cited text no. 5
    
6.
Bill TJ, Reddy VR, Ries KL, Gampper TJ, Hoard MA. Adolescent gingival squamous cell carcinoma: Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:682-5.  Back to cited text no. 6
    
7.
Levi PA Jr., Kim DM, Harsfield SL, Jacobson ER. Squamous cell carcinoma presenting as an endodontic-periodontic lesion. J Periodontol 2005;76:1798-804.  Back to cited text no. 7
    
8.
Tseng KS, Lin C, Lin YS, Weng SF. Risk of head and neck cancer in patients with diabetes mellitus: A retrospective cohort study in Taiwan. JAMA Otolaryngol Head Neck Surg 2014;140:746-53.  Back to cited text no. 8
    
9.
Baynes JW, Thorpe SR. Role of oxidative stress in diabetic complications: A new perspective on an old paradigm. Diabetes 1999;48:1-9.  Back to cited text no. 9
    
10.
LeRoith D, Roberts CT Jr. The insulin-like growth factor system and cancer. Cancer Lett 2003;195:127-37.  Back to cited text no. 10
    
11.
Khandwala HM, McCutcheon IE, Flyvbjerg A, Friend KE. The effect of insulin like growth factors on tumorigenesis and neoplastic growth. Endocr Rev 2000;21:215-44.  Back to cited text no. 11
    
12.
Bowers LW, Rossi EL, O'Flanagan CH, deGraffenried LA, Hursting SD. The role of insulin/IGF system in cancer: Lessons learned from clinical trials and the energy balanced cancer link. Front Endocrinol (Lausanne) 2015;6:77.  Back to cited text no. 12
    
13.
Yu H, Rohan T. Role of the insulin like growth factor like family in cancer development and progression. J Natl Cancer Instit 2000;92:1472-89.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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