|Year : 2016 | Volume
| Issue : 3 | Page : 194-197
Squamous cell carcinoma of gingiva: An enigmatic lesion
Puneet Bajaj, Deepti Garg, Rupinder Kaur Multani, Swati Gautam
Department of Oral Pathology and Microbiology, Bhojia Dental College and Hospital, Solan, Himachal Pradesh, India
|Date of Web Publication||22-Aug-2016|
Department of Oral Pathology and Microbiology, Bhojia Dental College and Hospital, Bhud, Baddi, Solan, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Squamous cell carcinoma (SCC) is the most frequent malignant neoplasm affecting structures of the oral mucosa, which accounts for more than 90% of all malignant lesions in the mouth. Carcinomas of the gingiva are a unique subset of oral SCC (OSCC), constituting approximately 10% of OSCCs and tend to present as having benign features, and of all the intraoral carcinomas, gingival OSCC is least associated with tobacco abuse and has the greatest predilection for females. They can mimic a multitude of oral lesions, especially those of inflammatory origin with benign features, often leading to delay in the diagnosis, and hence delayed treatment. We are reporting a case of gingival SCC in a 35-year-old female patient who presented with a peripheral growth in the left mandibular gingiva.
Keywords: Dysplasia, gingival mass, oral cancer, squamous cell carcinoma, tobacco
|How to cite this article:|
Bajaj P, Garg D, Multani RK, Gautam S. Squamous cell carcinoma of gingiva: An enigmatic lesion. SRM J Res Dent Sci 2016;7:194-7
| Introduction|| |
Oral squamous cell carcinoma (OSCC) is one of the most aggressive malignancies worldwide and accounts for more than 90% of all oral cancers. It is ranked as the sixth leading cause of cancer mortality worldwide and the second leading cause of cancer mortality in India. The most common sites of OSCC are the lateral border of the tongue, the floor of the mouth, and buccal mucosa. A less frequent site to be affected is the gingiva which comprises about 10% of all OSCCs and affects 91% of patients with gingival carcinoma aged above 66 years. Of all the intraoral carcinomas, gingival OSCC is least associated with tobacco abuse and has the greatest predilection for females. The etiology of SCC remains unknown, but predisposing factors such as smoking associated with heavy alcohol use are well known. Other habits have also been associated with SCC, such as chewing betel leaves and inverted smoking, practices commonly observed in India. Although generally classified as a subset of oral SCC, gingival SCC is a unique malignancy and can mimic a multitude of other lesions, especially those of inflammatory origin. In addition, predisposing and presenting factors are different from those of other OSCCs. Hence, SCC of the gingiva should be considered in the differential diagnosis while dealing with gingival lesions, particularly in elderly individuals and is of paramount importance that the lesion be diagnosed early to initiate treatment and thereby improve prognosis.
| Case Report|| |
A 35-year-old female patient reported to the Department of Oral Pathology and Microbiology with a chief complaint of growth on the mandibular gingiva. The growth was present on the labial aspect of attached gingiva on the left side of the mandible for past 6 months and was initially small in size but has grown to the present size in a span of 4 months. It was not associated with any pain or discomfort and no aggravating, and relieving factors were present. There was no history of weight loss or appetite over the last few months. Social history was negative for contributing factors such as tobacco, alcohol, or chemical exposure. There was no significant family history. Medical history was not contributory. On general physical examination, the patient was well built and nourished. All the vital signs were within the normal limits. Extraoral examination revealed no facial asymmetry and on palpation, no lymph nodes were palpable. Intraoral examination revealed a solitary pedunculated, exophytic spherical growth present on attached gingiva with respect to 37 and measuring approximately 1 cm × 0.5 cm extending anteriorly from the mesial aspect of 37 and posteriorly till the distal aspect of 37, superiorly from the marginal gingiva of 37 and inferiorly terminating above the labial vestibule [Figure 1]. The surface of the lesion appeared slightly erythematous. On palpation, all the inspectory findings were confirmed. The growth was nontender, nonindurated, and no signs of infection were seen. Associated hard tissue did not reveal any abnormality. Based on the history and clinical features, a provisional diagnosis of pyogenic granuloma was considered. Differential diagnosis of peripheral giant cell granuloma, peripheral ossifying fibroma, giant cell fibroma, and amelanotic melanoma was considered. Considering the innocuous appearance of the lesion, perceived lack of risk factors and the unwillingness of the patient to undergo any radiographic examination, an excisional biopsy of the growth was planned. Investigations included complete hemogram which showed a normal blood count. Random blood sugar was within the normal limits. Excisional biopsy of the lesion was done under local anesthesia. Histopathological examination with eosin and hematoxylin revealed a malignant neoplasia of epithelial origin characterized by invasive proliferation of nests and cords of neoplastic epithelial cells into the connective tissue [Figure 2]. These cells exhibited intense cellular and nuclear pleomorphism, nuclear hyperchromatism, loss of cells cohesion, multiple and clearly visible nucleoli, and atypical mitoses. An intense and diffuse mononuclear inflammatory infiltrate were observed in the fibrous connective tissue stroma. The lining epithelium of the mucosa exhibited a parakeratinized stratified pattern showing areas of hyperplasia and features of dysplasia [Figure 3],[Figure 4],[Figure 5]. Periodic acid–Schiff staining was performed, and it revealed a discontinuous basement membrane [Figure 6]. The final diagnosis of well-differentiated squamous cell carcinoma (SCC) was rendered.
|Figure 2: Nests and cords of neoplastic epithelial cells into the connective tissue (H and E, ×40)|
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|Figure 3: Epithelium showing bulbous rete pegs and connective tissue with focal areas of inflammation and numerous blood vessels (H and E, ×4)|
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|Figure 4: Dysplastic epithelium and inflamed connective tissue stroma (H and E, ×10)|
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|Figure 5: Features of dysplasia, i.e. cellular and nuclear pleomorphism, loss of cell adhesion, basilar hyperplasia, and abnormal mitosis in epithelial cells (H and E, ×40)|
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| Discussion|| |
Oral cancer is a major global public health problem with 500,000 new cases diagnosed annually. According to the international classification of diseases, oral cancer refers to a subgroup of head and neck malignancies that develop on the lips, tongue, salivary glands, gingiva, floor of the mouth, oropharynx, buccal surfaces, and other intraoral locations. Nevertheless, the term is synonymous to OSCC of oral mucosal origin. SCC is the most frequent malignant neoplasm of the mouth, corresponding to 96% of all malignant tumors in this region. In general, SCC mainly affects Caucasian male older than 40 years and is extremely rare in young patients. The most affected sites in the mouth are in decreasing order, the lower lip, lateral border of the tongue, retromolar region, floor of the mouth, and gingiva. The oral cavity is amenable to routine screening and clinical examination for malignant changes and therefore, in theory, these changes should be more easily detected and diagnosed at early stages leading to more effective treatment. However, because of its varied site related clinical presentation malignant oral disease is often difficult to distinguish from benign oral lesions. SCC of gingiva more frequently involve mandible than maxilla, and it is mainly observed in older female over 50 years. The present case also had a similar presentation. Gingival OSCC is more aggressive and in its early stage bears a resemblance to common mucosal infection and therefore has frequently led to delay in diagnosis or even to misdiagnosis, thus leading to delay in treatment institution and making the prognosis grave. One important aspect of gingival SCC is its higher risk of causing metastasis and consequent death. Gingival SCC is more aggressive. According to Yoon et al. and Meleti et al., Gingival SCC does not show a strong association with classical risk factors such as actinic radiation, tobacco use, either smoked or chewed in its various forms, especially when associated with excessive consumption of alcohol as seen in our particular case. In a study analyzing a period of 18 years (1975 and 1992), Barasch et al. reported a nonsignificant increase in the proportion of gingival SCC compared to the total number of SCCs affecting other oral sites and also observed an increase of the tumor among females. With respect to age, in that study, gingival SCC was most frequent in the seventh decades of life. In this reported case, which was initially diagnosed as an inflammatory mass, came out to be a well-differentiated SCC on histopathological examination in a patient without any positive history for any habits.
Choosing the best therapy for SCC of the oral cavity is dependent on patient factors and tumor factors. Patient factors include the nutritional status, associated diseases, and oral behaviors, while tumor factors include its size, site, histology, and biologic behavior. In general, oral cancers are treated with surgery or radiation or both. Smaller lesions are typically treated with wide excision alone, and radiation therapy serves as a backup in the event of recurrence. For carcinomas of the gingiva, the proximity of the underlying periosteum and bone usually invites early invasion of these structures. They occasionally, rapidly infiltrate and extend along the periodontal membrane, thus destroying the supporting bone. The prognosis with gingival carcinomas depends on the histological subtype and clinical extent of the tumor. A well-differentiated type such as, in our case, is generally considered to have a favorable prognosis. However, the most important indicator of the prognosis is the clinical stage of the disease. If the neoplasm is small and localized, the 5-year cure rate is around 60–70%; however, if cervical nodal metastasis occurs, the survival rate drops to about 25% suggesting that early diagnosis is imperative. Early detection of SCC is vital as the prognosis is directly related to the size of the lesion. Lesions measuring <1 cm are amenable to treatment and have a long-term prognosis. Thus, it is prudent to biopsy any unexplained lesion which remains after 2 weeks following removal of any suspected etiologic agent to avoid unnecessary delay in diagnosing such conditions.
| Conclusion|| |
The general dentist is frequently presented with oral lesions that are ambiguous in clinical presentation and behavior. Patients with OSCC have a varied etiology, some of which are established while a few of the cases do not elicit classical risk factors. Very often, the dentist is faced with the challenge of making a decision to commence treatment as desired by the patient or pursue further investigation to rule out more potentially morbid diagnosis. Such a cautious stance by the dentist can be possible only if the suspicion index for potentially life-threatening lesions is high on the differential list. Alternatively, these clinical situations necessitate the services of expert opinion that would obviate the chance of missing a diagnosis. A missed diagnosis is a lost opportunity in instituting timely and definitive care for such life-threatening lesions. Gingival OSCC is more aggressive in behavior and in its early stage bears a resemblance to common mucosal infections. This report reiterates the importance of submitting all gingival biopsies for histopathological examination.
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Conflicts of interest
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| References|| |
Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009;45:309-16.
Bharanidharan R, Dineshkumar T, Raghavendhar K, Kumar AR. Squamous cell carcinoma of the gingiva: A diagnostic enigma. J Oral Maxillofac Pathol 2015;19:267.
Cabral LA, de Carvalho LF, Salgado JA, Brandão AA, Almeida JD. Gingival squamous cell carcinoma: A case report. J Oral Maxillofac Res 2010;1:e6.
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.
Tsantoulis PK, Kastrinakis NG, Tourvas AD, Laskaris G, Gorgoulis VG. Advances in the biology of oral cancer. Oral Oncol 2007;43:523-34.
Indira AP, Priscilla D, Roopashri G, Vaishali MR. Gingival Carcinoma in a non-tobacco user. J Clin Dent Res 2011;1:67-74.
Yoon TY, Bhattacharyya I, Katz J, Towle HJ, Islam MN. Squamous cell carcinoma of the gingiva presenting as localized periodontal disease. Quintessence Int 2007;38:97-102.
Meleti M, Corcione L, Sesenna E, Vescovi P. Unusual presentation of primary squamous cell carcinoma involving the interdental papilla in a young woman. Br J Oral Maxillofac Surg 2007;45:420-2.
Li PY, Auyeung L, Huang SC. Squamous cell carcinoma of the mandibular gingiva. Chang Gung Med J 2004;27:777-81.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]