Authors:  
Santosh Patil, MDS*, Nitin Kalla. BDS, Harshwardhan Singh, BDS,
*Assistant Professor, **Lecturer, *** Intern.

Institution:  Dept of oral medicine and radiology, Jodhpur Dental College, Jodhpur National University, Jhanwar road, Naranadi, Jodhpur (Raj).342001. India.

Corresponding Author:  

Dr. Santosh Patil,
Dept of oral medicine and radiology, Jodhpur Dental College, Jodhpur National University,
Jhanwar road, Naranadi, Jodhpur (Raj).342001.  India.

E-mail – This email address is being protected from spambots. You need JavaScript enabled to view it.

Abstract:

Squamous cell carcinoma is the most common malignant neoplasm of the oral cavity, usually affecting individuals over 50 years of age with male predominance.  It rarely affects patients who are less than 40 years old. Many oral cancers are preceded by clinically evident premalignant mucosal changes that give a warning of risk and present an opportunity for its early detection and preventive measures to be undertaken.  We herein report a case of malignant transformation of oral leukoplakia in a young Indian female with special emphasis on epidemiology, etiology, clinical features and preventive measures.

Introduction:

Cancer is one of the major threats to public health in the developed world and is the second most common cause of death.¹  Oral cancer although prevalent worldwide and is very common in some developing countries such as India, Pakistan and some parts of France.²  Squamous cell carcinoma represents 90 percent of all malignant neoplasms of the oral cavity with its site localization primarily being the lateral posterior border of the tongue.  It generally shows affinity towards men over 50 years of age giving history of tobacco and alcohol consumption.  Along with this dietary factor, viruses and genetic predisposition have also been found to be associated with occurrence of oral cancer.³  In India oral cancer ranks number one among all cancers in male patients and number three among cancers in female patients. The age of its occurrence in Indian population is reported to be a decade earlier in comparison to the western scenario.⁴

Case History:

A 20 year old female patient reported with a complaint of a white lesion over cheek and gums for two years.  Later, she noticed pain and secondary changes in the same area for two months.  On examination, an erosive white non-scrapable lesion involving the lower anterior gingiva, labial and buccal mucosa was observed along with gingival recession and loss of attachment buccally exposing root of the 1st molar.  Erosion of the vestibule was also noted (Figures 1,2).  The patient had a habit of tobacco consumption and placed quid in the vestibule during the past 5 years.  Her medical history was not significant and no regional lymphadenopathy was noted.  Intraoral periapical radiograph revealed interdental bone loss between the molar teeth (Figure 3).  A provisional diagnosis of leukoplakia transforming into malignancy was made and the biopsy of the lesion was performed. 

Click on Pictures to Enlarge

Histopathological examination: Histopathological features revealed (Figures 4, 5 above), atypical mitotic figures and keratin pearls, suggesting moderately differentiated squamous cell carcinoma.

Discussion:

Oral Squamous cell carcinoma is the most common cancer of the head and neck, and many of these are believed to develop from antecedent dysplastic oral mucosal lesions.⁵  Leukoplakia is a commonly occurring precancerous lesion.  The term leukoplakia was first used by Schwimmer in 1877 to describe a white lesion on the tongue which probably represented syphilitic glossitis.⁶  WHO defined leukoplakia as a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.⁷  Pindborg, et al., classified homogenous and nonhomogeneous leukoplakia into four sub types for each.  Homogenous types were classified into flat, corrugated, wrinkled and pumice types, whereas nonhomogeneous types were grouped into verrucous, nodular, ulcerated and erythroleukoplakia types.  The pumice type of leukoplakia was mostly associated with tobacco smoking.  Generally nonhomogeneous types are considered to show a greater degree of malignant transformation.⁸ 

The onset of leukoplakia usually takes place after the age of 30 years; resulting in a peak incidence over the age of 50 years.  The gender distribution in most studies varies, ranging from a strong male predominance in different parts of India, to almost 1: 1 in the western world.⁹  The frequency of dysplastic or malignant alteration in oral leukoplakia has ranged from 15.6 to 39.2 percent, while a five year cumulative malignant transformation ranges from 0.13 to 17.5 percent.⁸  In two studies from India carried out by Gupta PC, et al., and Silvennan S, et al., annual malignant transformation rates of 0.3% and 0.06% respectively have been reported,¹⁰ which is low in comparison to the studies undertaken by Shepman KP, et al., who noted an annual malignant transformation rate of 8.9%.¹¹  Oral leukoplakia is managed according to patients’ characteristics.  Close surveillance, including multiple follow up visits per year is mandatory and may require the need for another biopsy to be performed for diagnosis and to manage symptoms and signs.  Unfortunately, it has not been determined whether chemoprevention or surgical removal of dysplastic lesions prevents malignant transformation of the lesion in the long term, and therefore, close followup is desirable.  The above reported case is of young Indian female showing clinical and histopathological features of squamous cell carcinoma involving the gingiva, vestibule and buccal mucosa.  This case being unique in its own as malignancy of the gingiva is reported to be seen in only 10% of all malignant tumors of the oral cavity, having male predominance, the average age affected being 61 years.¹²

Conclusion:

Despite the great strides that have been made in recent decades to improve the prognosis for a number of cancers throughout the body, the prognosis for oral cancer has not experienced a similar improvement.  Because five year survival is directly related to stage at diagnosis, prevention and early detection efforts have the potential not only for decreasing the incidence, but also for improving the survival of those who develop the disease.  Early diagnosis depends upon an astute clinician or patient who may identify a suspicious lesion or symptom while it is still at an early stage.  However, it is apparent that many clinicians, including dentists and physicians may not be knowledgeable about the risk factors, diagnosis and early detection of these cancers and/or are not performing routine oral cancer examinations.

References:

Oral Squamous cell carcinoma is the most common cancer of the head and neck, and many of these are believed to develop from antecedent dysplastic oral mucosal lesions.⁵  Leukoplakia is a commonly occurring precancerous lesion.  The term leukoplakia was first used by Schwimmer in 1877 to describe a white lesion on the tongue which probably represented syphilitic glossitis.⁶  WHO defined leukoplakia as a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.⁷  Pindborg, et al., classified homogenous and nonhomogeneous leukoplakia into four sub types for each.  Homogenous types were classified into flat, corrugated, wrinkled and pumice types, whereas nonhomogeneous types were grouped into verrucous, nodular, ulcerated and erythroleukoplakia types.  The pumice type of leukoplakia was mostly associated with tobacco smoking.  Generally nonhomogeneous types are considered to show a greater degree of malignant transformation.⁸ 

The onset of leukoplakia usually takes place after the age of 30 years; resulting in a peak incidence over the age of 50 years.  The gender distribution in most studies varies, ranging from a strong male predominance in different parts of India, to almost 1: 1 in the western world.⁹  The frequency of dysplastic or malignant alteration in oral leukoplakia has ranged from 15.6 to 39.2 percent, while a five year cumulative malignant transformation ranges from 0.13 to 17.5 percent.⁸  In two studies from India carried out by Gupta PC, et al., and Silvennan S, et al., annual malignant transformation rates of 0.3% and 0.06% respectively have been reported,¹⁰ which is low in comparison to the studies undertaken by Shepman KP, et al., who noted an annual malignant transformation rate of 8.9%.¹¹  Oral leukoplakia is managed according to patients’ characteristics.  Close surveillance, including multiple follow up visits per year is mandatory and may require the need for another biopsy to be performed for diagnosis and to manage symptoms and signs.  Unfortunately, it has not been determined whether chemoprevention or surgical removal of dysplastic lesions prevents malignant transformation of the lesion in the long term, and therefore, close followup is desirable.  The above reported case is of young Indian female showing clinical and histopathological features of squamous cell carcinoma involving the gingiva, vestibule and buccal mucosa.  This case being unique in its own as malignancy of the gingiva is reported to be seen in only 10% of all malignant tumors of the oral cavity, having male predominance, the average age affected being 61 years.¹²

Conclusion:

Despite the great strides that have been made in recent decades to improve the prognosis for a number of cancers throughout the body, the prognosis for oral cancer has not experienced a similar improvement.  Because five year survival is directly related to stage at diagnosis, prevention and early detection efforts have the potential not only for decreasing the incidence, but also for improving the survival of those who develop the disease.  Early diagnosis depends upon an astute clinician or patient who may identify a suspicious lesion or symptom while it is still at an early stage.  However, it is apparent that many clinicians, including dentists and physicians may not be knowledgeable about the risk factors, diagnosis and early detection of these cancers and/or are not performing routine oral cancer examinations.

References:

Oral Squamous cell carcinoma is the most common cancer of the head and neck, and many of these are believed to develop from antecedent dysplastic oral mucosal lesions.⁵  Leukoplakia is a commonly occurring precancerous lesion.  The term leukoplakia was first used by Schwimmer in 1877 to describe a white lesion on the tongue which probably represented syphilitic glossitis.⁶  WHO defined leukoplakia as a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.⁷  Pindborg, et al., classified homogenous and nonhomogeneous leukoplakia into four sub types for each.  Homogenous types were classified into flat, corrugated, wrinkled and pumice types, whereas nonhomogeneous types were grouped into verrucous, nodular, ulcerated and erythroleukoplakia types.  The pumice type of leukoplakia was mostly associated with tobacco smoking.  Generally nonhomogeneous types are considered to show a greater degree of malignant transformation.⁸ 

The onset of leukoplakia usually takes place after the age of 30 years; resulting in a peak incidence over the age of 50 years.  The gender distribution in most studies varies, ranging from a strong male predominance in different parts of India, to almost 1: 1 in the western world.⁹  The frequency of dysplastic or malignant alteration in oral leukoplakia has ranged from 15.6 to 39.2 percent, while a five year cumulative malignant transformation ranges from 0.13 to 17.5 percent.⁸  In two studies from India carried out by Gupta PC, et al., and Silvennan S, et al., annual malignant transformation rates of 0.3% and 0.06% respectively have been reported,¹⁰ which is low in comparison to the studies undertaken by Shepman KP, et al., who noted an annual malignant transformation rate of 8.9%.¹¹  Oral leukoplakia is managed according to patients’ characteristics.  Close surveillance, including multiple follow up visits per year is mandatory and may require the need for another biopsy to be performed for diagnosis and to manage symptoms and signs.  Unfortunately, it has not been determined whether chemoprevention or surgical removal of dysplastic lesions prevents malignant transformation of the lesion in the long term, and therefore, close followup is desirable.  The above reported case is of young Indian female showing clinical and histopathological features of squamous cell carcinoma involving the gingiva, vestibule and buccal mucosa.  This case being unique in its own as malignancy of the gingiva is reported to be seen in only 10% of all malignant tumors of the oral cavity, having male predominance, the average age affected being 61 years.¹²

Conclusion:

Despite the great strides that have been made in recent decades to improve the prognosis for a number of cancers throughout the body, the prognosis for oral cancer has not experienced a similar improvement.  Because five year survival is directly related to stage at diagnosis, prevention and early detection efforts have the potential not only for decreasing the incidence, but also for improving the survival of those who develop the disease.  Early diagnosis depends upon an astute clinician or patient who may identify a suspicious lesion or symptom while it is still at an early stage.  However, it is apparent that many clinicians, including dentists and physicians may not be knowledgeable about the risk factors, diagnosis and early detection of these cancers and/or are not performing routine oral cancer examinations.

References:

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6. Neville BW, Day TA . Oral cancer and precancerous lesions. CA Cancer J Clin 2002; 52:.195

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8. Amagasa T, Yamashiro M, Ishikawa H. Oral leukoplakia related to malignant transformation. J Oral Sci Int 2006; 3(2):45-55.

9. Rajendran R. Oral leukoplakia (leukokeratosis): Compilation of facts and figures. J Oral Maxillofac Pathol 2004; 8:58-68.

10. Schepman KP, van der Meij EH, Smeele LE, van der Waal I. Malignant transformation of oral leukoplakia: a follow-up study of a hospital-based population of 166 patients with oral leukoplakia from The Netherlands. Oral Oncol 1998; 34(4):270-5.

11. Epstein J, Zhang L, Rosin M. Advances in the diagnosis of oral premalignant and malignant lesions. J Can Dent Assoc 2002; 68(10):617-621.

12. Rajendran R, Sivapathasundharam B. Shafer’s Text book of oral pathology. In: Benign and malignant tumors of of the oral cavity.5th ed. Elsvier; 2006. pp 159-161.