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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 256-260
Squamous cell carcinoma of mandible with unusual clinical presentation: A rare case report and review of literature


1 Professor & Chairman, Department of Oral Medicine & Radiology/ Oral Pathology, Dr Ziauddin Ahmed Dental College & Hospital, Aligarh Muslim University, Aligarh (Uttar Pradesh), India
2 Assistant Professor, Department of Dental Hygiene, College of Applied Health Sciences in Al Rass, Qassim University, Saudi Arabia
3 Department of Pedodontics & Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences & Research, Punjab, India
4 Associate Professor, Department of Periodontology & Oral Medicine, College of Dentistry, Qassim University, Saudi Arabia

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Date of Submission07-Sep-2019
Date of Decision12-Mar-2020
Date of Acceptance22-Nov-2020
Date of Web Publication22-Nov-2021
 

   Abstract 


Squamous cell carcinoma (SCC) is commonly seen malignant epithelial neoplasm of the oral cavity, which is characterized by variable clinical manifestations. It arises from dysplastic squamous epithelium. Majority of the spread of oral SCC (OSCC) to mandibular bone occurs by direct infiltration of the tumour through alveolar ridge or lingual cortical plate. Only 6% of the OSCC present with primary tumour; hence, a comprehensive whole body imaging needs to be done for ruling out primary tumour anywhere else in the body along with a proper clinical examination. Here, we present an unusual case of long-standing aggressive primary malignancy with unusual clinical presentation in mandibular anterior region associated with chronic tobacco chewing in a 65-year-old male patient.

Keywords: Imaging, malignant, mandibular anterior region, metastasis

How to cite this article:
Verma P, Muzammil, Kaur P, Al Asmari DS. Squamous cell carcinoma of mandible with unusual clinical presentation: A rare case report and review of literature. Indian J Dent Res 2021;32:256-60

How to cite this URL:
Verma P, Muzammil, Kaur P, Al Asmari DS. Squamous cell carcinoma of mandible with unusual clinical presentation: A rare case report and review of literature. Indian J Dent Res [serial online] 2021 [cited 2021 Dec 8];32:256-60. Available from: https://www.ijdr.in/text.asp?2021/32/2/256/330862



   Introduction Top


According to Wills[1], “neoplasm is an abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of normal tissues and persists in the same excessive manner after cessation of the stimuli which evoked the change.” Squamous cell carcinoma (SCC) of the oral cavity accounts for 4% of malignancies in the men and 2% malignancies in women and is responsible for 3% of all cancer deaths.[2] The men to women ratio is about 2:1 and associated mostly with tobacco and alcohol use.[3] The incidence of oral SCC (OSCC) is increasing among young individuals aged between 18 and 44 years, although it is more commonly seen in older males of lower socio-economic groups. The cause of OSCC is multifactorial, both intrinsic and extrinsic factors may be responsible. The extrinsic factors include external agents such as tobacco, smoke, betelnut, alcohol and sunlight. Intrinsic factors include systemic or generalized states such as general malnutrition or iron deficiency anaemia. The inadequate immune response may also predispose to oral cancer.[4] All forms of tobacco have been strongly linked to the cause of oral cancer. The most common site of intraoral carcinoma is tongue and tip of the vermilion. Other sites of involvement in frequency of decreasing order are the soft palate, gingival, buccal mucosa, labial mucosa and hard palate. The lesions of buccal mucosa and gingival each account for approximately 10% of all SCC.[5] The gingival and alveolar ridge carcinomas are painless and most frequently arise from keratinized mucosa. The clinical feature varies from white patch to a non-healing ulcer or an explosive lesion. The prevalence of mandibular bone involvement ranges from 12% to 56%.[6] The mandibular involvement occurs mainly due to direct infiltration by tumour. The main route of entry into mandible is reported to be through alveolar crest and lingual cortex if the tumour is located medial to the mandible. Other routes of infiltration are also described, of which spread through the canal of the inferior alveolar nerve is the most common.[7] The lymph node metastasis affects the prognosis of patients suffering with SCC. Not only cervical metastasis with extranodular spread, but also occult metastasis reduces survival. Therefore, physical examination, computed tomography (CT), ultrasonography (USG), magnetic resonance imaging (MRI), positron emission tomography (PET) combined with CT, sentinel node biopsy should be used to detect metastasis of OSCC.[8] Whenever OSCC presents with typical clinical forms of non-healing ulcers, other ulcerative conditions such as verrucous carcinoma, metastatic tumour, tuberculosis, deep fungal infections should be considered. We reported a long-standing malignancy with unusual clinical presentation in mandibular anterior region associated with chronic tobacco chewing in a 65-year-old male patient.


   Case Report Top


A 65-year-old male patient reported to the Department of Oral Medicine & Radiology/ Oral Pathology, Dr Ziauddin Ahmed Dental College & Hospital, Aligarh, Uttar Pradesh with a complaint of non-healing ulcer in the lower one-third regions of face since 6 months. History of presenting illness revealed that there was a solitary large cauliflower-shaped mildly painful ulcero-proliferative growth that appeared 6 months back in the lower one-third region of jaw which was gradual in onset, increased in size to attain the present status and still enlarging progressively. There was a break in the continuity of overlying outer layer skin 3 months back and the lesion was pinkish brown in colour with scattered whitish deposits [Figure 1]. History of similar hard swelling appeared below the tongue in front region 4-5 months back, which was also progressively enlarging and causing difficulty in making tongue movements and chewing food. History of decreased mouth opening revealed for 3 months with mild to moderate bleeding from below the tongue intermittently. Also there was a history of an excessive salivation with numbness of the lower lip since 2 months. The patient noticed recent weight loss since last month. There was no history of trauma or systemic rise in temperature. The past medical history revealed that patient visited local Cancer Hospital 1 month back where he underwent extraction of five lower anterior teeth (31, 32, 33, 41, 42) due to their mobility. The family history was non contributory. The personal history revealed that patient has a deleterious habit of tobacco chewing in the form of “Zarda” since 25 years (3-4 times/day) and places the quid in lower labial vestibular region and H/O alcohol consumption (60-80 ml/day) since 25 years. The general physical examination showed that he was conscious, cooperative and well oriented to time, place and person. All the vital signs were within normal limits. No signs were observed pallor, icterus, cyanosis, edema, anemia and clubbing of fingers.
Figure 1 : Lesion with intraoral lingual extension

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On extra-oral examination, there was large oval-shaped ulcero-proliferative growth measuring 5.5 cm × 7.6 cm over the mental region extending superior-inferiorly from vermilion border of the lower lip and extending 2 cm below the mental protuberance, medio-laterally from right gonial angle to left gonial angle. On palpation, the mass was mild tender. A solitary submental lymph-node was palpable which was tender, stony hard in consistency, fixed to underlying structures with size of 1 cm × 1.5 cm in maximum dimensions along with localized rise in temperature. The overlying skin was pinchable.

On intra-oral examination, there was an exophytic whitish coloured mass in the anterior part of floor of mouth extending from 45 up to 32 causing obliteration of lingual vestibule. Also there is total obliteration of lower labial vestibule. On palpation, there was mild tenderness with bleeding on provocation. The hard tissue examination showed missing 31, 32, 41, 42, 43.

Based on history and clinical examination, the case was provisionally diagnosed as malignant ulcer involving the mandible. Differential diagnoses considered were metastatic carcinoma, verrucous carcinoma, primary intraosseous carcinoma, deep fungal infection, lymphoma and vascular lesion.

A panoramic radiograph revealed a huge ill-defined oval-shaped non-homogenous radiopacity having corrugated borders measuring 12.5 cm × 10.3 cm in size, extending superiorly from alveolar ridge in relation to 31, 32, 41, 42, 43 up to 6.2 cm below the mental ridge of the body of mandible inferiorly. Laterally, it is extending from 36 to 46 regions. There was a loss of alveolar bone i.r.t to 31, 32, 41, 42, 43 [Figure 2].
Figure 2: OPG showing extend of lesion

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The contrast enhanced CT (CECT) neck plus chest showed a soft tissue density subcutaneous lesion in the submental region (predominately in the right half measuring 3 cm × 2.4 cm) contiguous along the gingivo buccal lining mucosa with marginal erosion of the adjacent outer cortical lining of the mandible. Also there were subtle subpleural nodules noted in the lateral segments of the right middle lobe and in the posterolateral basal segments of the right lower lobe of the lung.

The whole body contrast enhanced 18F-FDG PET- CT scan revealed active disease uptake in the erosive lesion involving right lower alveolus, extending from the midline to the right side. Also few non-FDG avid sub cm-sized level 1A and bilateral 1B submandibular lymph nodes were seen. Tiny non-FDG avid subpleural opacities were noted in the right upper and middle lung lobes. Hypermetabolic subcranial and bilateral hilar nodes were also seen [Figure 3]a, [Figure 3]b.
Figure 3: a: 18F-FDG PET-CT scan showing erosive lesion involving right lower alveolus, extending from the midline. b: 18F-FDG PET- CT scan showing subpleural opacities in the right upper and middle lung lobes

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The ultrasound (USG) of whole abdomen was done to rule out primary malignant lesion that showed only mild diffused steatosis of the liver with dilated common bile duct.

The haematological investigation showed raised ESR (56 mm/hour) and slight decreased haemoglobin concentration (8 mg%). The Mantoux tuberculin skin test was done and found to negative.

The incisional biopsy was done which comprised of six grey brown soft tissue pieces from different areas of the lesion from lingual vestibule and sent for histopathological examination. The H/P report was suggestive of moderately differentiated SCC [Figure 4]. Immunohistochemical examination (Bcl-X protein expression) was performed whose elevated expression was associated with the aggressiveness of neoplastic tumour.
Figure 4: Histopathological picture of biopsied tissue

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Based upon the clinical, haematological, radiological and histopathological examinations the final diagnosis of SCC of body mandible with Stage IV c (T4a N1a M1; moderately differentiated) was made and the patient was referred to oncology centre for combined surgery and radiation therapy.


   Discussion Top


Among all the head and neck cancers, OSCC is the most common carcinoma (>90%). It commonly affects the elderly males during the fifth to eighth decades.[9] OSCC has various clinical presentations such as exophytic, endophytic, leukoplakic and erythroplakic, which all of them show visible changes in the surface. Lesions occurring in mandibular alveolar ridge often involve mandible mostly by direct extension and seldom by other routes.[6] The prevalence of mandibular bone involvement ranges from 12% to 56% [Table 1].[10],[20],[21],[22],[23],[24],[25],[26] Main route of entry into mandible is reported to be through alveolar crest and lingual cortex if the tumour is located medial to mandible.
Table 1: Review of Literature

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The most common initial symptoms of oral cancer are ulcerations of the mucous membrane in the oral cavity, pain, redness of mucous membrane, displacement of teeth, buccal and the floor of the mouth muscle contracture, trismus in cases when the medial pterygoid muscles are affected, halitosis, dysphagia and odynophagia. It is crucial to early detect cancer lesions and evaluate them with appropriate imaging techniques in order to properly stage the disease.[11]

The commonly used modalities for both diagnosis and the planning of treatment include plain film radiography, orthopantomography (OPG), CT, MRI, USG and PET. The characteristic features of malignant lesions in plain radiographs include – atrophy of cortical lamina, osteolytic defects – both single and multilocular with an initial osteosclerotic capsule. In later stages, the ridges of bone defects become sharp and the teeth lose their bony support at the site of infiltration. It has been shown that the assessment of bone involvement on panoramic radiographs has a sensitivity of 75% and specificity of 100%, respectively.[12] CT is a standard tool for detecting the primary tumors as well as their local bone infiltration. CECT can accurately determine lymph node metastases, which can initially look normal despite the presence of micrometastases detected in microscopic studies.[13] The sensitivity of CT in detecting tumours is 41%–82% (specificity 82%–100%) and in determining bone infiltration 63%–80% (specificity 81%–100%), respectively.[14] 18F-fluorodeoxy-D-glucose positron emission tomography-computed tomography (18F-FDG PET-CT) has become an important diagnostic tool for evaluation of head and neck squamous cell carcinomas (HNSCCs). The main indication of 18F-FDG PET-CT in newly diagnosed HNSCCs is detection of cervical lymph node involvement, which is one of the most important prognostic factors. It can be used for the detection of metastatic lymph nodes (sensitivity 83%, specificity 88%).[15] Ultrasonography is used to evaluate superficial lesions, lymph nodes and to guide needle aspiration biopsies (NAB). NAB is used to confirm metastatic lymph nodes (sensitivity 79%, specificity 69%).[16]

Management of oral cavity SCC depends on the stage of disease. Stages I and II cancers (T1-T2, N0) are treated with single modality therapy, surgery or radiotherapy (RT) for the primary, the former being favoured. Management of the neck is discussed in the section on neck node metastases. Locally advanced cancers (Stages III and IV) are treated with combination of surgery, radiotherapy and chemotherapy for both primary and the neck.

Mandibular bone could be preserved if there is a normal tissue intervening between tumour and the bone; however, in our case, we found a spread through the dental canal of the inferior alveolar nerve which often excludes the preservation of mandible. Only 6% of the OSCC present with primary tumour;[17] hence, a comprehensive whole body imaging needs to be done for ruling out primary anywhere else in the body along with proper clinical examination. The differential diagnosis in the present case included PIOC, verrocous carcinoma and metastatic deposit. To distinguish OSCC from the PIOC, diagnostic criteria include intact oral mucosa with absence of surface ulceration, tumours in physical and radiographic examination at the time of diagnosis.[18] Exclusion of any other primary or metastatic deposits was fulfilled too with whole body PET scan and abdominal USG. Adequately optimized and validated immunohistochemical examination is highly specific and considered as a reliable diagnostic tool to differentiate between OSCC and verrucous carcinoma[19] as was done in the present case. The fungal ulcer was ruled out by PA chest radiograph and absence of fungal hyphae on histopathological examination. The information from imaging helps for accurate staging, assessing respectability and planning multimodality treatment of OSCC. The most important indicator of the prognosis of OSCC is the clinical staging of the lesion and in the present case because the lesion exceeded T2 stage, prognosis is not good. The OSCC are generally resistant to chemotherapeutic measures. Moreover, radiotherapy is more effective on less well-differentiated lesions. Accordingly, the treatment was planned in present case (moderately differentiated OSCC).


   Conclusion Top


This case report highlights the importance of higher diagnostic imaging modalities (CECT, PET, USG, etc.) for the accurate diagnosis, staging, grading and treatment planning of OSCCs along with systematic clinical examination and histopathological reports. To summarize, imaging is essential in the management of oral cancers. It augments clinical findings to plan appropriate therapy. When surgery is contemplated, it provides information about resectability, extent of resection and reconstruction. Information from imaging can also indicate treatment outcomes.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Correspondence Address:
Dr. Pradhuman Verma
Professor & Chairman; Department of Oral Medicine & Radiology / Oral Pathology; Dr Ziauddin Ahmed Dental College & Hospital; AMU Campus; Medical Rd; Civil Lines; Aligarh; Uttar Pradesh - 202002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_700_19

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