The clinical and histologic presentation of gingival squamous cell carcinoma: a study of 519 cases

A new approach: Cervical approach for marginal resection of the posterior mandible

Gingival squamous cell carcinoma (SCC) of the posterior mandible often requires marginal resection of the mandible in conventional surgery. However, the posterior location of the lesion can limit surgical visibility, which is critical for complete tumor removal and minimizing recurrence. Typically, marginal resection of the posterior mandible is achieved through a midline lower lip incision and mental nerve transection, providing adequate exposure but resulting in nerve damage, lip numbness, and facial scarring. In this paper, we describe a case using a submandibular incision for neck dissection, extending from the mandibular angle to the mental foramen, to fully expose the posterior mandible. The intraoral incision, extending 1 cm beyond the tumor margin, connected with the submandibular incision. Under direct vision, we performed a marginal resection of the mandible, preserving the inferior alveolar neurovascular bundle and the mental nerve, and maintaining at least 1 cm of the inferior mandibular margin. This technique achieved complete tumor removal while preserving mental nerve function and lower lip integrity, reducing surgical difficulty and patient trauma. This approach maintains nerve function and aesthetics as much as possible, with a faster postoperative recovery. In treating gingival SCC of the posterior mandible, it is essential to preserve surrounding healthy tissue and critical anatomical structures, minimizing postoperative complications while ensuring complete tumor resection.

Reconstructive surgery and adjuvant radiotherapy for the multimodal approach in oral cancer: a single cancer centre experience

Introduction and importance

Ablative surgery for oral cancer, irrespective of the histological subtype, causes large tissue defects, functional and aesthetic damage. Microsurgical free flaps have been widely used in reconstruction after resection, with satisfactory success rates in conjunction with adjuvant radiotherapy (RT). This study aims to describe our clinical institutional experience based on the multimodal treatment performed in four cases diagnosed with oral squamous cell carcinoma with the use of different microvascular free flaps and RT.

Case series presentation

Four patients underwent reconstructive microsurgery after surgical resection of oral cancer, using three types of free flap: radial forearm fasciocutaneous, osteomyocutaneous fibular, and anterolateral thigh musculocutaneous flaps; RT was performed in Case 2 and Case 3. In the period of 3 years after microsurgical reconstruction and RT, flaps remain clinically stable without failure signs in full patients submitted to multimodal treatment.

Clinical discussion

After resection of oral carcinomas, extensive tissue defects can be successfully treated with reconstructive microsurgery using different types of microvascular free flaps. RT for locoregional control is a feasible option and did not seem to interfere with the survival of flaps.

Conclusion

An enhance long-term follow-up to assess overall and disease-free survival rates and quality of life must be carried out; however, cohort studies would be necessary for better understanding of the role of each treatment in the multimodal scheme.

Progression to malignancy in oral potentially malignant disorders: a retrospective study of 5,036 patients in Ontario, Canada

OBJECTIVES

Determine the rate of malignant transformation (MT) of oral potentially malignant disorders (OPMDs) and risk factors for transformation.

STUDY DESIGN

The OPMD database (2001-2015) from 2 biopsy services in Ontario, Canada, was linked to the Ontario Cancer Registry to determine the rate of progression to oral squamous cell carcinoma (OSCC). Clinical and histologic features of progressed and non-progressed cases were compared to determine risk factors for progression.

RESULTS

The MT rate was 6.4% (322/5,036 cases). The mean time for cancer development was 51.2 months. 33.6% of cases (107/322) progressed after over 60 months. The risk of cancer increased with age and was higher in non-smokers. The MT rate was highest in the tongue (11.4%), followed by the floor of mouth (7.1%) and gingiva (6.5%). Histologic grade was associated with progression to cancer (P < .0001). Atypical verrucous-papillary lesions with no or mild dysplasia predominantly affected older patients' gingiva, and the progression rate was significantly higher than conventional mild dysplasia (9.2% vs 3.2%, P = .0002).

CONCLUSIONS

Our population-based retrospective study showed that <10% of OPMDs progressed to cancer, which could take many years. Atypical papillary-verrucous proliferation without high-grade dysplasia is a subtype of OPMD requiring further study.

Gingival and Alveolar Ridge Overgrowths: A Histopathological Evaluation from Saudi Arabia

Background

Focal tissue overgrowths on the gingiva and edentulous alveolar ridge are occasionally perplexing to periodontists, owing to the wide variety of differential diagnoses that may be responsible. As such, biopsy and microscopy are often required to establish a definitive diagnosis. The present study aimed to retrospectively evaluate focal gingival and alveolar ridge overgrowths at a single institution in Saudi Arabia.

Materials and Methods

Histopathology reports and slides from patients presenting to King Saud University Hospital between 1984 and 2016, particularly those with focal gingival enlargements other than those due to gingivitis and periodontitis, were collected and analyzed based on age, sex, and location.

Results

A total of 624 patient records were evaluated, with a mean age of 35 years (range, 1 week–91 years), peak incidence in the third decade of life, male-to-female ratio of 1:1.4, and a slightly higher prevalence of lesions in the mandible. The majority (88%) of the lesions were reactive or hyperplastic, followed by malignant (10%) and benign (2%) tumors. A total of 24 distinct histological entities were diagnosed across the three groups. The most common histologically diagnosed lesions were pyogenic granulomas (38%), fibromas (33%), peripheral ossifying fibromas (9%), squamous cell carcinomas (7%), peripheral giant cell granulomas (6%), neurofibromas (1%), and non-Hodgkin lymphomas (1%).

Conclusion

Similar to what has been reported by most previous studies, reactive hyperplastic lesions were the most prevalent focal overgrowths found in the gingival and alveolar mucosae. Carcinomas at these sites, however, may be an understated but significant clinical and epidemiological problem in Saudi Arabia. Gingival and alveolar ridge lumps can serve as a nexus for cooperation between periodontologists and oral pathologists to improve diagnosis, disease classification, and patient management.

Managing misdiagnosed gingival squamous cell carcinoma (GSCC) with occult symptoms: A report of two cases

Introduction

importance: Gingival squamous cell carcinoma (GSCC) is a rare neoplasm. GSCC has nonspecific features which commonly misdiagnosed with a simple toothache.

Case presentation

These are two cases; the first one describes a 62-year-old female who presented with pain in her right posterior mandibular teeth, and she was misdiagnosed with periodontal disease, but later histopathological tests confirmed gingival squamous cell carcinoma (GSCC). Consequently, the patient underwent surgery, and the gingival tumor was totally resected. Afterward, the patient was receiving chemotherapy, and the radiotherapy was postponed until the chemotherapy completion.

The second case is of a 58-year-old female who presented with pain in her mandibular incisors, and she developed a dermal fistula on her chin and therefore underwent several gingival curettages. The following histopathologic tests confirmed GSCC so she underwent surgery, after the surgery it was planned to give her chemotherapy.

Clinical discussion

GSCC is a rare neoplasm with a 6% incidence of all oral malignancies. GSCC is a very challenging cancer for a physician or a pathologist to diagnose because GSCC usually mimics the characteristics of a large variety of diseases and abnormalities. Unlike oral neoplasms, GSCC has the least association with smoking. This may lead to make mistakes in the treatment or misdiagnose it until the late-stage of GSCC.

Conclusion

Despite the rare incidence of Gingival squamous cell carcinoma (GSCC), clinicians should consider GSCC while investigating any localized lesion with nonspecific oral symptoms.

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GSCC usually presents with non-specific symptoms.

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Doctors should think of GSCC as a probable diagnosis of oral lesions with vague presentation.

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Suspicious oral lesions should be biopsied as soon as possible.

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The primary or metastatic malignancy must be surgically removed.

Nomogram forecasting 3-, 5-, and 8-year overall survival and cancer-specific survival of gingival squamous cell carcinoma

No nomogram models addressing the personalized prognosis evaluation of patients with gingival squamous cell carcinoma (GSCC) have been documented. We sought to establish nomograms to forecast overall survival (OS) and cancer-specific survival (CSS) of patients with GSCC. We collected the detailed clinicopathological information of 2505 patients with GSCC from the Surveillance, Epidemiology and End Results (SEER) program. Afterward, we divided the 2505 cases into a modeling group (n = 1253) and an external validation cohort (n = 1252) via random split-sample method. We developed the nomograms on the basis of the Kaplan-Meier and multivariate Cox survival analysis of the modeling group and then split the modeling cohort into two parts based on cut-off values: high- and low-risk cohorts. An improved survival was shown in the low-risk group compared to their counterpart, with a significant difference after the log-rank test. The performance of the nomograms was evaluated via concordance-index (C-index), the area under the receiver operating characteristic curve (AUC), and calibration curves. All the C-indexes and AUCs were greater than 0.7, showing high accuracy. Moreover, the calibrations showed that the actual observations were close to the 45° perfect reference line. In conclusion, we successfully developed two nomograms to provide individualized, patient-specific estimates of OS and CSS available for risk-stratification.

Marginal linear gingival leukoplakia progressing to "ring around the collar"-An ominous sign of proliferative verrucous leukoplakia

BACKGROUND

Potentially malignant lesions of the gingiva may frequently present as well-demarcated white lesions confined to the marginal gingiva. These lesions often become thick and verrucoid and spread along the marginal gingiva to encircle the tooth. Some cases of marginal gingival leukoplakia, over time, progress to extensively involve the gingiva fulfilling the criteria for proliferative verrucous leukoplakia (PVL). The objective of this study is to raise awareness of this pattern of leukoplakia by reporting a series of cases of marginal gingival leukoplakia.

METHODS

An Institutional Review Board approved retrospective search of University of Florida and University of Nebraska Medical Center oral biopsy services was performed for all gingival biopsies. Inclusion criteria included cases exhibiting marginal gingival leukoplakia, and with accompanying clinical images.

RESULTS

A total of 30 cases of marginal gingival leukoplakia were included. All cases presented as well-demarcated leukoplakias, either on the buccal or lingual gingival margin, or circumferentially forming a "ring around the collar" of single or multiple teeth. Eight patients had recurrent lesions and 12 had multifocal involvement. Six of the 12 patients with multifocal involvement presented with a "ring around the collar." The histopathologic diagnoses were representative of benign lesions in seven cases, premalignant in 13, and malignant or suggestive of malignancy in 10 cases. Seven patients had carcinoma at the time of first biopsy, whereas 6 cases showed progression at time of follow-up.

CONCLUSION

This study aims to raise awareness that marginal gingival leukoplakia may represent potentially malignant lesions, and if circumferential and/or thick, may be the first manifestation of PVL.

Localized gingival enlargements. A clinicopathological study of 1187 cases

Background

To describe the incidence, demographic and clinical features of 1187 localized gingival enlargements.

Material and Methods

1187 cases of localized gingival enlargements diagnosed during a 20-year period were retrospectively collected. The patients’ gender and age, as well as the main clinical features of the tumors were retrieved from the biopsy report forms.

Results

The 1187 localized gingival enlargements represented 6.23% of 19.044 biopsies performed during the study period. 756 females and 427 males were affected with a mean age of 41.92±19.68 years. The lesions appeared as smooth (52.4%), granular (17.9%) or rough (13.16%) tumors, elastic (50.73%) or soft (29.56%) in consistency and red (60.8%), normal (28.58%) or white (8.17%) in color. The majority of the lesions (85.17%) were reactive in origin with pyogenic granuloma being the most common. In 1.1% of the cases a diagnosis of malignant lesion was rendered.

Conclusions

All localized gingival enlargements should be submitted for microscopic examination because in approximately 1% of cases they are malignant.

Key words:Localized gingival enlargements, gingival mass, gingival lesions, gingival reactive lesions, gingival malignant lesions.

Clinical implications of recent exodontia before diagnosis of gingival squamous cell carcinoma: A new classification

BACKGROUND

The purpose of this study was to clarify the clinical implications of cases with recent dental extractions to establish a new classification of gingival squamous cell carcinoma (SCC).

METHODS

A total of 156 patients were enrolled in this study. The subjects were divided into 3 groups: type I (dentate; n = 46), type II (edentulous; n = 55), and type III (dental extraction; n = 55). Continuous clinical and treatment variables were analyzed by 1-way analysis of variance (ANOVA) or t test, and categorical variables were evaluated by chi-square tests. Assessment of 5-year survival rates were carried out by the Kaplan-Meier analysis, and the influence of related factors was evaluated by the log-rank test.

RESULT

The 55 type III patients showed a high probability of bony invasion (80%) and a lower 5-year survival rate (48%) than the other 2 groups.

CONCLUSION

Our proposed classification may help clinicians to identify patients with gingival SCC who present with more advanced disease status.

Cancer of the gingiva

Cancer of the gingiva is a rare disease in the Western World. It most commonly affects elderly population. Because of its rarity, the reporting on the disease is sparse and often grouped with other subsites of oral cancer, which makes conclusions difficult to interpret. The aim of this paper is to review the literature on gingival cancer as a specific subsite of oral cancer and report on published prognostic factors as well as treatment of local and regional disease. We also present differences between gingival cancer subgroups, mandibular and maxillary gingival cancer. In addition, both surgical and oncological treatments are reviewed. It seems that surgery is the preferred initial treatment approach for the majority of patients with gingival cancer, although adjuvant radiation, with or without chemotherapy, is commonly recommended to increase locoregional control.

Papillary variant of squamous cell carcinoma arising on the gingiva: 61 cases reported from within a larger series of gingival squamous cell carcinoma

Papillary squamous cell carcinoma (PSCCA) is a rarely occurring variant of squamous cell carcinoma (SCCA) with distinctive exophytic and papillary features and a more favorable prognosis than conventional SCCA. The larynx is the most commonly affected site in the head and neck. The oral cavity, oropharynx, sinonasal tract, and nasopharynx are also affected. Within the oral cavity cases have been reported on the alveolar ridge, oral mucosa, floor of the mouth, ventral tongue, and rarely other areas. We identified 61 cases of gingival PSCCA within the parameters of a larger study of 519 cases of gingival SCCA. We evaluated the clinical and histologic features of these lesions. The average age of the PSCCA patient was 74 years, with a very slight male predominance of 1.2:1. The mandible was affected nearly twice as often (64 %, n = 39) as the maxilla (35 %, n = 21, and 1 % of cases unspecified), and the most common location by far was the mandibular posterior region (52 %, n = 32). Most lesions were reportedly present over 2 months in duration (48 %, n = 29) prior to biopsy but a significant amount of clinicians were unsure of the duration of the lesion as well (36 %, n = 22). Only 10 cases (16 %) were reportedly present less than 2 months. The most common clinical presentation was that of an erythematous or mixed white and red exophytic mass (74 %, n = 45). 62 % (n = 38) of submitting clinicians considered a malignant or premalignant lesion in their differential diagnosis, but other clinical impressions included papillomas, reactive gingival lesions, and fungal infections. Histologically, 88 % (n = 52 of 59 cases graded) of the lesions were either well or moderately-well differentiated. PSCCA is a rare subtype of SCCA which has been reported infrequently involving the gingiva or alveolar ridges but should be considered by clinicians for the differential diagnosis of papillary gingival masses.

Terahertz imaging of excised oral cancer at frozen temperature

The feasibility of terahertz (THz) imaging at frozen temperature for the clinical application of oral cancer detection was investigated by analyzing seven oral tissues resected from four patients. The size, shape, and internal position of the oral cancers were mapped by THz radiation in the frequency range of 0.2-1.2 THz at -20 °C and 20 °C, and compared with those identified in the histological examination. THz imaging of frozen tissue was found to offer greater sensitivity in distinguishing cancerous areas from surrounding tissue and a larger THz-frequency spectral difference between the oral cancer and normal mucosa than room-temperature THz imaging. A cancerous tumor hidden inside tissue was also detected using this method by observing the THz temporal domain waveform. The histological analysis showed that these findings resulted from cell structure deformations involving the invasion of oral tumor and neoplastic transformations of mucous cells. Therefore, a cytological approach using THz radiation at a frozen temperature might be applied to detect oral cancer.