Spindle cell carcinoma of the gingiva: A rare occurrence
A 46-year-old male patient reported to the Department of Periodontology, Faculty of Dental Sciences, Sri Ramachandra University, Chennai, India with an intraoral swelling in relation to the lower left first and second premolars for the past 8 months associated with a dull pain. The swelling was initially small and gradually increased in size. He was a known asthmatic, but not under any systemic medication. He gave a history of smoking cigarettes (2 packets/day) for the past 30 years and keeping the tobacco quid on the left side of the vestibular area, but had stopped the habit because of burning sensation. On clinical examination, a single sessile erythematous swelling with a fungating whitish mass in the center was seen []. On palpation, it was firm in consistency measuring about 1.5 cm (apicocoronally) and 2.0 cm (mesiodistally) extending from the mesial aspect of tooth 34 to the mesial aspect of tooth 36. Both the premolars exhibited grade 1 mobility with tenderness on vertical percussion and no attachment loss. A single submandibular lymph node was palpable on the left side.\nPatient was counseled regarding the cessation of the smoking habit. Scaling was performed on the first visit and selective grinding of the opposing cusp in occlusion was carried out. At the recall visit, the surface necrosis had disappeared (which could have probably been due to withdrawal of tobacco quid usage).\nComplete hemogram, intraoral periapical radiograph and orthopantomograph were taken. Except for an increase in the eosinophil count, all the other blood parameters were within normal range. No significant alterations were evident in the radiographs []. Based on the clinical findings, a provisional diagnosis of SCC was given.\nAn incisional biopsy of the growth was performed under local anesthesia. The tissue specimen was immediately transferred into 10% buffered formalin solution, sent for routine histopathological examination and were further subjected to immunohistochemical (IHC) analysis.\nHistologically, the tumor showed an ulcerated parakeratotic stratified squamous epithelium [] with a focus of epithelial pearl formation []. The underlying connective tissue stroma revealed richly cellular pleomorphic spindle cells arranged in fascicles resembling a herring bone pattern characteristic of a fibrosarcoma []. The sections were further subjected to IHC for cytokeratin, vimentin and CD34 expression. IHC analysis revealed spindle shaped cells that showed positive reactions for cytokeratin [] and vimentin [] but negative for CD34 []. Antibody to podoplanin, a molecule expressed in lymphatic endothelial cells was used. Positive membrane immunoreactivity was observed in the basal cell layer and connective tissue stroma with a relatively increased lymphatic network complexity as compared with the tumor free zone [].\nA whole body plain and contrast computed tomography (CT) view was performed. CT view of mandible with contrast revealed a 17.8 mm × 4.7 mm sized soft-tissue density lesion in the buccal aspect of the body of the mandible on the left side with no evidence of bony erosion []. Few sub centimeter sized lymph nodes were present in the left submandibular [] and bilateral deep cervical (level II) regions [].\nPatient was referred to an oncologist. Following chemotherapy, the patient was subjected to surgical management that involved a segmental resection of the mandible with supraomohyoid neck dissection followed by radiation therapy.