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Case Report

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

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.

Key words: Bilateral, carcinoma, oral and tobacco habit pattern

DOI: 10.4103/0972-1363.52776
DOI

INTRODUCTION On extraoral examination, a single, diffuse, tender swelling

with soft consistency was present anterior to right masseter
Squamous cell carcinoma (SCC) is the most common muscle. A single, enlarged and tender submandibular lymph
malignant neoplasm of the oral tissues. The disease node was palpable on both the sides. Both these lymph
is characterized by marked geographic differences in nodes were firm and fixed.
site preference. Like elsewhere in the body, multiple
malignancies of oral tissues are rare. The mechanism of Intraorally on the right side, a large non-scrapable
development of such lesions is poorly understood. Among predominantly white patch was seen on buccal gingiva
the multiple oral malignancies reported in the literature, from mandibular canine to second molar, on the adjacent
only a few are bilaterally located on same type of tissue. vestibular mucosa, and on the buccal mucosa to the level
We present a case of bilateral intra-oral SCC. of occlusal plane. The white patch on the buccal mucosa
showed few red speckled areas especially in the anterior
CASE REPORT and superior regions. In continuation with the white patch,
posteriorly, a nodular growth was present adjacent to
A fifty-year-old man reported to our department with a second and third molars. The growth was approximately
complaint of pain and growth in the right and left posterior 3 x 2 cm in size, sessile, tender and firm on palpation. The
regions of the lower jaw. Pain was mild and continuous, overlying mucosa showed both red and white patches
which increased in intensity after eating food, and at [Figure 1]. The second and third molars showed mild to
night. The growth had gradually increased in size. Both moderate mobility.
these complaints were present for the last 15 days. He
also complained of mobile lower right posterior teeth. On the left side, a large non-scrapable predominantly
His medical history was not contributory. He was used homogenous white patch was seen involving mandibular
to keeping tobacco in the mandibular buccal vestibule buccal gingiva, vestibular mucosa and adjacent buccal
5-6 times a day, for the last 20-25 years. Tobacco-lime mucosa from first premolar to retromolar area. Peripherally,
preparation was placed randomly, either in the right or some degree of melanin pigmentation was evident. The white
left vestibule. For the last 40 years, he was also used to lesion was interspersed with two nodular growths - one in the
applying roasted and powdered tobacco (mishri) on his vestibule adjacent to the first molar and the other in the buccal
teeth once a day. 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
Address for correspondence:
correspondence Sonia Behal, Department of Oral Medicine
and Radiology, Bharati Vidyapeeth University Dental College and Hospital, white. Additionally, a large ulceration was seen on the buccal
Pune-411 043, India. E-mail: [email protected] mucosa with raised borders and indurated base [Figure 2].

104 Journal of Indian Academy of Oral Medicine and Radiology / July - September 2008 / Volume 20 / Issue 3
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Behal and Lele: A rare case of bilateral oral carcinoma

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
Figure 1: Clinical picture showing homogenous and speckled in the basement membrane, and dysplastic epithelial cells
leukoplakia with nodular growth in islands and sheets in underlying connective tissue.

Figure 2: Clinical picture showing homogenous leukoplakia, ulceration Figure 3: Periapical radiograph showing irregular, ill-defined
and nodular growth radiolucency in periapical and interdental areas

Figure 4: Left side: Severe epithelial dysplasia with malignant cells in Figure 5: Right side: Epithelial and keratin pearls, and chronic
underlying connective tissue (H&E, x10) inflammatory cells (H&E, x40)

Journal of Indian Academy of Oral Medicine and Radiology / July - September 2008 / Volume 20 / Issue 3 105
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Behal and Lele: A rare case of bilateral oral carcinoma

Chronic inflammatory cell infiltrate - chiefly lymphocytes occurring synchronously on right and left buccal mucosa
- was also seen [Figures 4 and 5]. The patient was in a patient with habit of chewing pan and beedi smoking.
referred to an oncology center for further evaluation While one of the lesions was ulcero-proliferative with
and treatment. histopathological diagnosis of carcinoma - in situ, the other
was diffuse yellowish-white plaque with histopathological
DISCUSSION diagnosis of well-differentiated SCC. The article also
discusses the concept of field cancerization leading to
Approximately 9 out of every 10 oral malignancies are development of oral SCC in a multifocal fashion within the
SCCs.[1] Oral smokeless tobacco is a major cause of oral field of tissue bathed by carcinogens.
and oropharyngeal SCC in the Indian subcontinent, parts
of Southeast Asia, China and Taiwan and in emigrant On the basis of review of literature, it appears that
communities therefrom, especially when consumed in betel metachronous occurrence of oral carcinoma is more
quids containing areca nut and calcium hydroxide. In India, common than synchronous. Among the synchronous variety,
chewing accounts for nearly 50% of cancers of the oral only a few cases of bilaterally symmetrical oral carcinomas
cavity and oropharynx in men and over 90% in women.[2] have been reported. Development of synchronous
multiple primaries seems to support the concept of ‘field
Oral cancer shows marked variations in involvement of cancerization’. Majority of these lesions are occult, and
intraoral sites in different geographic areas. Such a variation hence not amenable to clinical detection. Therefore, the
is attributable to the type of tobacco habit practiced by the clinician must use all possible means such as vital staining,
affected individual. In India, tobacco habits are practiced exfoliative cytology, biopsies, and autofluorescence to
in various different forms, viz. smoking (bidi, chilum), detect such lesions. This is an uncommon case of bilaterally
chewing (betel quid), tobacco-lime preparation (khaini), symmetrical primary malignancies associated with habit
and as a dentifrice (mishri). Moreover, practices differ from of tobacco-lime preparation, with similar histopathologic
region to region, e.g., khaini is placed in the lower labial grade.
vestibule in some parts of the country, while elsewhere, it is
placed in premolar region of lower buccal vestibule. There ACKNOWLEDGMENTS
appears to be some preponderance for cancer to occur in
left buccal mucosa than the right. This is perhaps due to the We thank Department of Oral Pathology (BVU Dental
tendency to keep the betel quid or khaini on the left side.[3] College and Hospital, Pune) for histopathological images
Our patient had the habit of khaini placement randomly and diagnosis.
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
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Source of Support: Nil, Conflict of Interest: Nil
Sham et al.[5] reported a case of two bilateral lesions

106 Journal of Indian Academy of Oral Medicine and Radiology / July - September 2008 / Volume 20 / Issue 3