The Case of Suspected Bilateral Squamous Cell Carcinoma

A 48-year-old male reported to the oral surgery department with a complaint of teeth in the lower left side. During the intraoral examination the dental student noted an ulcer in close proximity, the patient told her that the sore had been there for a while but it did not bother him much. Preoperative radiograph of the area showed radiolucency around lower molars. These teeth exhibited grade 3 mobility and were easily extracted. 

Preoperative radiograph of the 48-year-old

The student then went to the clinic supervisor to report that the extractions were complete. During her report she mentioned the ulceration at the site. The clinic supervisor reviewed the patient's history form that was absent of any red flags. She then asked the patient if there was any significant social history. The patient revealed that he had been using smokeless tobacco (niswar in the local language) for several years. Since this side was sore, he was now placing the quid on the opposite side. Intervention at this point was difficult due to the bleeding socket, the patient was instructed to return for a follow up visit in one week's time.

On one week's follow up, the patient presented with a distinct ulcer on the buccal side of the alveolar mucosa.

Ulceration at the site of extraction

A panoramic film was taken. It showed areas of radiolucency bilaterally at the sites of quid placement. The one on the left side was ill-defined and ragged in appearance, highly suggestive of malignancy. The clinic supervisor performed an incisional biopsy at this point. 

Histopathological findings showed a soft tissue specimen consisting of dyspalstic oral epithelium with fibrovascular connective tissue and a malignant neoplasm demonstrating epithelial differentiation. The tumor was invading the underlying connective tissue in nests and cords. The nests exhibited prominent keratin pearl formation in the central areas.

Keratin pearl formation in oral squamous cell carcinoma

Based on the histological findings, a diagnosis of oral squamous cell carcinoma was made.

The patient did not take the news of his cancer well. It took us a while to convince him to let us biopsy the other side. Another incisional biopsy was done in the right mandibular site of placement following extraction of teeth in the region. On histopathology sections, we saw stratified squamous epithelium in association with connective tissue and occasional fragments of bone. The surface oral epithelium showed prominent parakeratinization and what Dr. K calls a "busy" basal layer. The underlying connective tissue showed a chronic inflammatory infiltrate. Dr. K did not like the look of this tissue, she did not think that the cells were maturing appropriately, so she called this tissue atypical and made a comment of close clinical follow up. 

Hyperkeratosis with epithelial atypia, and chronic mucositis

The patient was asked to bring in his imaging studies and was offered partial mandibulectomy with selective neck dissection. He hasn't been back since. If he returns, we might have more images of his resection to share with you.