|Year : 2008 | Volume
| Issue : 3 | Page : 104-106
A rare case of bilateral oral carcinoma
Sonia Behal, Shailesh M Lele
Department of Oral Medicine and Radiology, Bharati Vidyapeeth University Dental College and Hospital, Pune-411 043, India
|Date of Web Publication||16-Jun-2009|
Department of Oral Medicine and Radiology, Bharati Vidyapeeth University Dental College and Hospital, Pune-411 043
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Tobacco in different forms is an acknowledged etiologic factor in development of oral cancer. Due to the habit pattern, mostly a single malignant lesion develops. While multiple oral malignancies and second primaries are well reported in the literature, a truly bilateral oral malignancy seems to be a rare occurrence. We report such an occurrence in an individual with an unusual pattern of tobacco habit.
Keywords: Bilateral, carcinoma, oral and tobacco habit pattern
|How to cite this article:|
Behal S, Lele SM. A rare case of bilateral oral carcinoma. J Indian Acad Oral Med Radiol 2008;20:104-6
| Introduction|| |
Squamous cell carcinoma (SCC) is the most common malignant neoplasm of the oral tissues. The disease is characterized by marked geographic differences in site preference. Like elsewhere in the body, multiple malignancies of oral tissues are rare. The mechanism of development of such lesions is poorly understood. Among the multiple oral malignancies reported in the literature, only a few are bilaterally located on same type of tissue. We present a case of bilateral intra-oral SCC.
| Case Report|| |
A fifty-year-old man reported to our department with a complaint of pain and growth in the right and left posterior regions of the lower jaw. Pain was mild and continuous, which increased in intensity after eating food, and at night. The growth had gradually increased in size. Both these complaints were present for the last 15 days. He also complained of mobile lower right posterior teeth. His medical history was not contributory. He was used to keeping tobacco in the mandibular buccal vestibule 5-6 times a day, for the last 20-25 years. Tobacco-lime preparation was placed randomly, either in the right or left vestibule. For the last 40 years, he was also used to applying roasted and powdered tobacco ( mishri ) on his teeth once a day.
On extraoral examination, a single, diffuse, tender swelling with soft consistency was present anterior to right masseter muscle. A single, enlarged and tender submandibular lymph node was palpable on both the sides. Both these lymph nodes were firm and fixed.
Intraorally on the right side, a large non-scrapable predominantly white patch was seen on buccal gingiva from mandibular canine to second molar, on the adjacent vestibular mucosa, and on the buccal mucosa to the level of occlusal plane. The white patch on the buccal mucosa showed few red speckled areas especially in the anterior and superior regions. In continuation with the white patch, posteriorly, a nodular growth was present adjacent to second and third molars. The growth was approximately 3 x 2 cm in size, sessile, tender and firm on palpation. The overlying mucosa showed both red and white patches [Figure 1]. The second and third molars showed mild to moderate mobility.
On the left side, a large non-scrapable predominantly homogenous white patch was seen involving mandibular buccal gingiva, vestibular mucosa and adjacent buccal mucosa from first premolar to retromolar area. Peripherally, some degree of melanin pigmentation was evident. The white lesion was interspersed with two nodular growths - one in the vestibule adjacent to the first molar and the other in the buccal mucosa adjacent to second and third molars. While the mucosa of the vestibular nodule was speckled with red and white areas, that over the buccal nodule was homogenously white. Additionally, a large ulceration was seen on the buccal mucosa with raised borders and indurated base [Figure 2]. The entire lesion was tender on palpation.
Periapical, occlusal and panoramic radiographs were obtained. An ill-defined, irregular radiolucency was seen in the periapical and interdental alveolar bone in the right mandibular second and third molar region [Figure 3]. A diagnosis of bilateral malignancy arising from leukoplakias involving gingival, vestibular and buccal mucosa in both mandibular posterior regions was made.
Histopathological examination of tissue obtained from both the sides showed features commensurate with diagnosis of moderately differentiated squamous cell carcinoma, viz. hyperkeratosis with severe epithelial dysplasia, several epithelial and few keratin pearls, break in the basement membrane, and dysplastic epithelial cells in islands and sheets in underlying connective tissue. Chronic inflammatory cell infiltrate - chiefly lymphocytes - was also seen [Figure 4] and [Figure 5]. The patient was referred to an oncology center for further evaluation and treatment.
| Discussion|| |
Approximately 9 out of every 10 oral malignancies are SCCs.  Oral smokeless tobacco is a major cause of oral and oropharyngeal SCC in the Indian subcontinent, parts of Southeast Asia, China and Taiwan and in emigrant communities therefrom, especially when consumed in betel quids containing areca nut and calcium hydroxide. In India, chewing accounts for nearly 50% of cancers of the oral cavity and oropharynx in men and over 90% in women. 
Oral cancer shows marked variations in involvement of intraoral sites in different geographic areas. Such a variation is attributable to the type of tobacco habit practiced by the affected individual. In India, tobacco habits are practiced in various different forms, viz. smoking ( bidi, chilum ), chewing (betel quid), tobacco-lime preparation ( khaini ), and as a dentifrice ( mishri ). Moreover, practices differ from region to region, e.g., khaini is placed in the lower labial vestibule in some parts of the country, while elsewhere, it is placed in premolar region of lower buccal vestibule. There appears to be some preponderance for cancer to occur in left buccal mucosa than the right. This is perhaps due to the tendency to keep the betel quid or khaini on the left side.  Our patient had the habit of khaini placement randomly in the right or left lower buccal vestibule 5-6 times a day for about 25 years. In addition, he had a habit of mishri application once a day for about 40 years. This habit pattern explains simultaneous development of oral cancer almost symmetrically on both the sides.
A case of bilateral identical oral carcinomas was reported by Lesney in 1959,  in which two identical alveolar lesions were present under and extending beyond the periphery of loose-fitting mandibular denture prosthesis. Trauma from the mandibular denture was considered to be the cause of these lesions. Lesney makes a conjecture that "cancer is an all-systemic phenomenon that becomes focused in local areas rather than developing as a local problem and then spreading systemically". However, he felt that this conjecture cannot be founded on fact.
Sham et al .  reported a case of two bilateral lesions occurring synchronously on right and left buccal mucosa in a patient with habit of chewing pan and beedi smoking. While one of the lesions was ulcero-proliferative with histopathological diagnosis of carcinoma - in situ , the other was diffuse yellowish-white plaque with histopathological diagnosis of well-differentiated SCC. The article also discusses the concept of field cancerization leading to development of oral SCC in a multifocal fashion within the field of tissue bathed by carcinogens.
On the basis of review of literature, it appears that metachronous occurrence of oral carcinoma is more common than synchronous. Among the synchronous variety, only a few cases of bilaterally symmetrical oral carcinomas have been reported. Development of synchronous multiple primaries seems to support the concept of 'field cancerization'. Majority of these lesions are occult, and hence not amenable to clinical detection. Therefore, the clinician must use all possible means such as vital staining, exfoliative cytology, biopsies, and autofluorescence to detect such lesions. This is an uncommon case of bilaterally symmetrical primary malignancies associated with habit of tobacco-lime preparation, with similar histopathologic grade.
| Acknowledgments|| |
We thank Department of Oral Pathology (BVU Dental College and Hospital, Pune) for histopathological images and diagnosis.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]