A Curious Case With A Tricky Diagnosis
This was a 64-year-old male who presented with a painful, mostly smooth-surfaced pink gingival swelling. It was similar to the surrounding tissue except focally, where surface ulceration was noted. It was present lingual to and between teeth 31 and 41 ( mandibular central incisors). The swelling was slow growing. It had presented two years earlier and had been conservatively excised in 2014, but it recurred in the same site, growing at a faster rate than previously. Tooth mobility was also noted.
This patients past medical history is significant for leiomyosarcoma (smooth muscle connective tissue tumor) of the extremities diagnosed in 1984. In 2013, he presented with high-grade leiomyosarcoma of the right kidney, liver and the regional lymph nodes. Treatment included surgery and multiple courses of chemotherapy and immunotherapy. In 2014, he presented with a single gingival swelling lingual to teeth 31 and 41 which was conservatively excised. The lesion recurred recently in the same site and was again conservatively excised.
Clinical and Radiographic Findings-
The oral gingival swelling was slow-growing and painful which was removed in 2014. The area healed with no evidence of recurrence for two years. The current lesion presented in the same site and was similar in size and color to the previous lesion, but was faster growing and was associated with tooth mobility and increased diastema between teeth 31 and 41.
Under local anesthesia the swelling was conservatively removed to improve symptoms. Using an internal bevel incision, the lesion was excised with 1-2mm of clear margins. The area was sutured with 5/0 gut and the specimen was submitted for microscopic evaluation. Chlorhexidine rinses were prescribed.
Incisional and Excisional Biopsy-
Histologic examination of both specimens (2014 and the current) reveals multiple pieces of soft tissue composed of a neoplasm of spindle cell origin. This neoplasm is covered by thin but well differentiated layer of mature surface epithelium. The neoplasm is made up of spindle-shaped cells crisscrossing each other in long bundles. The neoplastic cells show evidence of pleomorphism and nuclear hyperchromatism . There is also evidence of high mitotic activity, some of which are atypical. There is evidence of focal necrosis. The histology is similar to that of the same neoplasm removed from the kidney in 2013. The kidney tumor shows less than 50 perc tumor necrosis and 21 mitoses in 10 HPFs. By immunohistochemistry staining, the neoplastic cells of both the oral and the kidney tumors are uniformly positive with antibodies to smooth muscle actin and desmin .
Can You Make The Accurate Diagnosis From the Below Options?
1. Metastatic Disease
2. Solitary Benign Soft Tissue Neoplasm
3. Peripharal Odontogenic Neoplasm
4. Reactive Gingival Swelling