A Wolf in Sheep’s Clothing

A 41 year old male presented to the Department of Oral Pathology and Microbiology with mobile front teeth and pain and swelling in upper front region of gums since 4 months

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- Patient was Gutkha chewer since 20 years consumed 2 to 4 times a day.

- Intraoral examination revealed:

- Inflammed gingiva with 11 and 12 with bleeding on probing.

- Diffuse swelling extending from 12 to 21 region , non tender on palpation .

- Gingival recession was observed with 11 to 21, associated with cortical plate expansion.

- IOPA showed diffuse osteolytic lesion in relation to 11, involving entire root area extending to apex of 12.

 

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- Due to significant tooth mobility patient was finally advised tooth extraction of 12.

- Post extraction, the alveolar socket was curetted and tissue was sent for histopathologic examination.

 – On histopathological examination, H & E stained section showed parakeratinized stratified squamous epithelium and underlying connective tissue stroma. Connective tissue stroma was composed of proliferating columnar to polygonal tumor cells atypically arranged in ductal pattern with moderate amount of chronic inflammatory cell infiltration. Extravasated blood vessels were seen.

- We arrived at a Differential Diagnosis of: Angiosarcoma,   Amelanotic melanoma, Metastatic tumor

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- IHC was done for CD34 and S-100 marker which were negative.

- Patient was advised PET scan or full body C.T. scan to rule out primary in any other part of the body.

- Ultrafast CT Scan Of Neck & Thorax

- Lung lesion noted in posterobasal segment of left lower lobe of size 33 x 31 mm with cut off of the subsegmental bronchiole, perilesional interlobular septal thickening and abutting the adjacent posterior mediastinal and costal pleura with minimal loculated pleural effusion.

- There are two other smaller lung nodules noted, one in apicoposterior segment of left upper lobe and medial basal segment of right lower lobe.

Lung lesions

Size

Posterolateral segment of left lower lobe

33 x 31 mm

Apicoposterior segment of left upper lobe

2 mm

Medial basal segment of right lower lobe

7.1 mm

Final Diagnosis: Metastatic Adenocarcinoma with primary lesion of  the lung.

TAKE HOME MESSAGE:

Oral cavity is a mirror to general health. Even a naïve looking lesion in the oral cavity cannot be neglected as it could be a manifestation of something much more grave in the body.