CDA Essentials 2018 • Volume 5 • Issue 7

35 Issue 7 | 2018 | S upporting Y our P ractice weeks, despite seeking care multiple times for the problem. He had first seen his periodontist, who diagnosed this as an inflammatory reaction, removed the lesion, and debrided his teeth. A couple of weeks later, the lesion recurred and it was removed again. The patient developed an infection and was put on amoxicillin. His chief complaint at the time of his emergency examination in the dental oncology department was that if he kept having this lesion cut away from his gums, he would eventually have no gums left. Examination The patient presented with a large exophytic mass between teeth 35 and 36, with clear regions of leukoplakia and erythema ( Fig. 1 ). This mass had rapidly enlarged over two weeks, after it had last been removed by his periodontist. A radiographic examination was performed. The radiograph showed an abnormal appearance involving the cortex of the height of the mandibular alveolus between teeth 35 and 36 which is characterized by ill-defined and irregular resorption. There was also abnormal and focal periodontal ligament space widening associated with the distal surface of tooth 35 and mesial surface and apex of tooth 36 (Fig. 2). Although it was possible that this could represent an inflammatory lesion, in a patient with this medical history, clinicians should have a high level of suspicion that it might represent a malignancy. Dr. Watson attempted to locate the patient’s otolaryngologist, who was not present in clinic at that time. In light of this, an incisional biopsy was taken and submitted in an appropriate medium for histopathological analysis. The biopsy result came back a few days later as squamous cell carcinoma. Making a plan for the patient When presenting abnormal (in this case, malignant) biopsy results to a patient, it is advisable to have a clear plan in place for the patient. Ideally, this would include a timely referral to a specialist who treats the condition so that the patient can leave the results appointment with an appropriate consult in hand. In most instances, this patient would have been referred to an oral pathologist or oral and maxillofacial surgeon who would have a referral network in place. In this case, where a patient has previously been treated for oral cancer, it is clear who needs to be contacted in order to formulate a plan for the patient. Prior to obtaining the patient’s biopsy results, both his otolaryngologist and medical oncologist were contacted and an image of the lesion was sent via secure email. Once the biopsy result was obtained, the patient’s otolaryngologist and medical hematologist were again contacted and an urgent visit was arranged. About three weeks later, the patient had a significant portion of his jaw resected. Unfortunately, his cancer rapidly progressed in the following months to involve the left neck and the patient is now in palliative care. a Take-home messages ➤ When in doubt about a soft tissue lesion, always perform an incisional biopsy and send tissue for histopathological confirmation OR refer to an appropriate specialist. ➤ For patients who have had allogenic transplants, who are at increased risk of developing solid cancers, clinicians should have a high level of suspicion. ➤ Have a plan when presenting a patient with a positive biopsy result. References 1. Atsuta Y, Suzuki R, Yamashita T , Fukuda T, Miyamura K et al. Continuing increased risk of oral/esophageal cancer after allogenic hematopoietic stem cell transplantation in adults in association with chronic graft-versus-host disease. Ann Oncol. 2014; 25(2): 435-41. 2. Weng X, Xing Y, Cheng B. Multiple and recurrent squamous cell carcinoma of the oral cavity after graft-versus-host disease. J Oral Maxillofac Surg. 2017; 75(9):1899-1905. This case study was adapted from an interview with Dr. Watson that originally appeared on Oasis Discussions. To watch the case presentation, visit wp.me/p2Lv6A-5Sh It is always the best course of action if you have a patient with a soft tissue lesion and radiographic changes to assume that this is a malignancy until proven otherwise, and to take an incisional biopsy for histopathological confirmation.”