Main complaint and medical history:
A 41 year old female presented at Groote Schuur oral medicine clinic complaining of a persistent and painful ulcer affecting the right side of her palate. The lesion was initially noticed 1 month ago and has progressively enlarged and increasing in pain. She had reported no history of local trauma preceding the onset of the lesion.
Her medical history revealed a history of breast cancer diagnosed in January 2014 from which she was supposedly in remission. A bilateral mastectomy was completed in February 2014 which was soon followed by chemotherapy (completed in July 2014) and radiotherapy (completed in August 2014). Tamoxifen (antioestrogen medication used since diagnosis) was prescribed for long term use in order to reduce the risk of developing a new primary tumour. Ibuprofen, Paracetamol and a glycerine based mouthrinse were prescribed by her physician however they only provided temporary relief.
No other comorbidities were reported she reported that she felt healthy and has regained her strength following her oncology treatment. Her diet has improved and she has returned to her pre- oncology treatment weight.
Clinical examination:
Bilateral, mobile and non tender submandibular nodes could be palpated. Facial symmetry appeared normal although a reduced occlusal vertical dimension was detected. No other pathology was noted extra-orally and the patient indicated the absence of skin and mucosal lesions from the neck down.
Intra oral examination revealed that she was partially edentureless and displayed poor oral hygiene with visible plaque deposits detected. She had indicated that some teeth were removed prior oncology treatment and she had not seen a dentist since.
The lesion presented on the right side of the hard palate at the region of the palatal rugae mainly apical to the 13 and missing 14 regions. The lesion itself was described as an irregular painful ulcer with mildly indurated margins and a densely necrotic central zone. An erythematous zone extended from the margins and radiated coronally towards the alveolar ridge and distally into the hard palate until blending seamlessly into the surrounding keratinized tissue. The extension of the ulceration measured approximately 1.5cm wide and the peri-marginal erythema did not cross the palatal midline (Figures 1 and 2).
Maxillary teeth were vital upon percussive and thermal testing and were non mobile. Although a periodontal chart was not completed a provisional diagnosis of plaque induced gingivitis was given.
Figure 1: lesion viewed from an extra-oral perspective
Figure 2: Palatal ulcer as described
Lesion specific differential diagnosis:
- Neoplasia –
- metastasis of breast CA
- Lymphoma
- Luekemia
- SCC
- Granulomatous ulceration? Tuberculous, Syphilis fugal etc.
- Traumatic ulceration or TUGSE
Management:
Immediate treatment plan included:
- Immediate dental prophylaxis- scaling and polishing
- Incisional biopsy:
Following local anaesthesia with Xylotox E80-A, three 5mm punch specimens from different sites which included lesional and peri-lesional tissue was sent for urgent diagnostic histopathology.
- General haematology screens including anaemic screens, coagulation profile, kidney and liver function, HIV and Syphillus serology
- Referral to radiology for panoramic radiograph.
A histopathologic diagnosis of an extramedullary myeloid tumour was provided.
Figure 3: Histopathology report
The patient was immediately referred to haematology at GSH to conduct a marrow biopsy and further investigations. A diagnosis of acute promyelocytic leukaemia was the n finalised. She is currently under continued management at GSH haematology.
