Treatment

Under local anesthesia, an excisional biopsy was performed. The excision was carried down to the periostium with 2mm clinical margins and interproximal tissue was removed down to bone. Upon notification of the histopathologic diagnosis, the patient was referred to an otolaryngologist. A CT scan of the mandible, neck and chest was negative except for an enlarged lymph node near the left submandibular gland. Definitive surgical treament was performed by the otolaryngologist and Dr. Weber. Under general endotracheal anesthesia, a left supraomohyoid neck dissection and left segmental mandibulectomy including removal of teeth # 19, 20, and 21 were performed. The inferior alveolar neurovascular bundle was spared. The defect was reconstructed with a split thickness skin graft. Dental implants are planned in the future.

Incisional Biopsy

Histologic examination of the H & E sections of the incisional biopsy showed surface epithelium exhibiting neoplastic changes and invading the underlying connective tissue. The epithelial changes were manifested in loss of maturation, alteration in the nuclear/cytoplasmic ratio, nuclear and cellular pleomorphism, increased mitotic activity, individual cell keratinization and keratin pearls. The invasion took the form of sheets, islands and nests of neoplastic epithelial cells. The connective tissue was also infiltrated by plasma cells, lymphocytes and neutrophils.

Figure 2 Low power (x40) the H & E histology reveals a piece of oral mucosa exhibiting an ulcerated/eroded neoplastic surface epithelial cells invading the underlying connective tissue.

Figure 3 Low power (x100) the H & E histology of a slightly higher power shows the neoplastic epithelial cells invading the connective tissue in form of sheets. The neoplastic epithelial cells show evidence of loss of maturation, frequent mitotic figures, large nuclei with prominent nucleoli, individual cell keratinization, keratin pearls and other type of atypical changes.

Figure 4 High power (x400) the H & E histology shows the neoplastic epithelial cells at a closer look.