COM July 2009

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July 2009: Large ulcerated swelling left posterior palate

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by
Drs. Michael DaBell and Ross Beirne
Department of Oral Surgery, University of Washington, WA

Case Summary and Diagnostic Information

This is a 69-year-old African American female with a slowly growing lesion initially described to be “like a scar” or a “bony spicule” on the left posterior, lateral soft palate bordering on the junction of hard palate. The patient is edentulous and wears full dentures. The lesion grew continuously for two years and the dentist trimmed the maxillary denture to avoid “rubbing” against the denture. The swelling was initially pink but became red and purple and eventually ulcerated. However, it was not painful. At the patient’s first presentation at the Oral Surgery clinic, the lesion measured 2.5 x 3.5 cm and was exophytic and ulcerated. It was located at the junction of hard and soft palate (Figure 1).

Diagnostic Information Available

History of present Illness

This is a 69-year-old African American female with a slowly growing lesion initially described to be “like a scar” or a “bony spicule” on the left posterior, lateral soft palate bordering on the junction of hard palate. The patient is edentulous and wears full dentures. The lesion grew continuously for two years and the dentist trimmed the maxillary denture to avoid “rubbing” against the denture. The swelling was initially pink but became red and purple and eventually ulcerated. However, it was not painful. At the patient’s first presentation at the Oral Surgery clinic, the lesion measured 2.5 x 3.5 cm and was exophytic and ulcerated. It was located at the junction of hard and soft palate (Figure 1).

Figure 1 This photograph was taken at the first clinical presentation; note the swelling on the left and lateral posterior soft palate bordering at the junction of hard palate. The swelling is ulcerated and reddish in color.

Medical History

The patient’s past medical history is significant for lung cancer which was treated with surgery only.

Clinical and Radiographic Findings

The patient reported a slowly enlarging lesion in the anterior soft palate and junction of hard palate. It was asymptomatic and non-ulcerated for almost two years but with time it changed color, became larger and ulcerated. At the time of the patient’s presentation to the UW Oral Surgery clinic, the lesion was ulcerated (Figure 1) and measured 2.5 x 3.5 cm.

Excisional Biopsy

Treatment

Under local anesthesia, an incisional biopsy was performed. Based on the biopsy results, the patient was referred for complete surgical removal with clean margins. Under general anesthesia, the lesion was completely excised leading to an opening between the oral and nasal cavity. The opening was closed with soft tissue reapproximation. Healing was slow and antibiotics and pain medications were prescribed post-operatively.

Incisional Biopsy

Histologic examination of the H & E section revealed a partially well-demarcated neoplasm of salivary gland origin. It was focally invasive and was made up predominantly of simple tubular structures lined by cuboidal epithelial cells (Figure 2). The tubules were mostly arranged in small clusters and in rows. The cuboidal epithelial cells showed no evidence of atypia and the nuclei were bland and uniform (Figure 3). Mitotic activity was scant to absent.

Figure 2 Low power (x40) H & E histology demonstrates clusters and cords of tubules and duct-like structures suspended on focally collagenous connective tissue stroma.

Figure 3 Higher power (x200) H & E histology demonstrates closer look at the tubules lined by one or two layers of cuboidal epithelial cells. The latter are uniform and show no evidence of atypia. The nuclei are uniform and bland.

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