Intraoperative Management of Recurrent Leukoplakia at Red Zone.

Oral leukoplakia (OL) is a potentially malignant oral disorder (PMOD) that sometimes trans-form into oral squamous cell carcinoma (OSCC). OL is one of the most frequent PMODs seen in the oral cavity. The global prevalence of OL is approximately 2.6%, with its worst prognosis of undergoing a malignant transformation. Leukoplakia is clinically divided into red zones (tongue and floor of mouth) and nonred zones (buccal mucosa, palate, and soft palate) areas. The red zone areas have more potency of transforming into malignancy. Hence, patients with red zone areas need to be followed up more frequently and treated appropriately. This case report signifies the importance of treating one such case of leukoplakia at red zone area. Copyright:

INTRODUCTION

The term “leukoplakia” arises from the Latin term of “Leukos” meaning white and “Plakia” meaning patch like or plaque. Oral leukoplakia (OL) is defined as 'a predominantly white lesion of the oral mucosa that cannot be characterized as any other definable lesion; some OL will transform into cancer by Axell et al. in the year 1996. It is technically used as a term of clinical diagnosis. Histopathologically, it is composed of hyperkeratosis, acanthosis, and basal cell hyperplasia. Epithelial dysplasia of varying degrees may be present in some cases, and it needs to be diagnosed critically to rule out the same. Tobacco in the form of smoking has been strongly implicated in the etiology of leukoplakia.[1]

CASE REPORT

A 60-year-old male came to the department of oral and maxillofacial surgery in the month of March 2020 with a complaint of white patch of about of 0.5 cm × 0.5 cm and burning on taking spicy foods over his right lateral border of tongue. He gave a history of similar complaint 6 months ago in the same site, for which he underwent biopsy elsewhere, the results of which were suggestive of epithelial inflammation.

A thorough clinical history was obtained, and the patient was advised to undergo excisional biopsy. The excisional biopsy was performed for the same and was reported as leukoplakia. The patient was advised regarding the recurrence and continuous follow-up every month. Owing to the coronavirus pandemic situation and nation-wide lockdown, the patient could report back to our OP only by November in 2020. During this period, the lesion had grown into a 2 cm × 1 cm raised patch over the same site of right lateral border of tongue [Figure 1]. The patient was worked thoroughly for COVID 19 screening protocol through polymers chain reaction and computed tomography of the oral cavity, neck, and thorax was advised before the surgery. The 60-year-old patient had several comorbidities including hypertension, diabetes, and reduced renal parameters with a hemoglobin concentration of 10 g%. With all these conditions, posting the patient for another round of surgery was considered to be as a high risk. Therefore, the patient and his attenders were explained about the procedure of intraoperative frozen section and its advantages. With the advent of frozen section, the diagnosis of red zone leukoplakic tongue could be examined for the presence of malignancy at a faster rate and in case of confirmed malignancy; he could be treated as that of an early case of tongue carcinoma on table. After educating the patient about frozen sections, a written consent for the same was obtained.

Figure 1

Patient photograph depicting the white lesion over the right lateral border of the tongue

The patient was then intubated under nasotracheal intubation along with Ryle's tube insertion. The face and oral cavity of the patient were painted and draped. The pathologist was informed and kept ready to receive the frozen tissue. The lesion was excised and sent for frozen sections. The frozen report findings were consistent with oral squamous cell carcinoma (OSCC). The attender was explained about the report, and further surgical management of the lesion was done [Figure 2]. Partial glossectomy was done along with 1 cm clearance after the confirmation of tumor-free margins using frozen sections [Figure 3]. Although the patient had no neck node enlargement, a selective neck dissection was done from lymph node Group I–IV [Figure 4]. Postoperatively, the patient was comfortable and discharged after 5 days. The Ryle's tube was removed after 10 days after which the patient consumed oral diet. The final histopathological report of the partial glossectomy done was confirmed to be OSCC with a staging of T1N0M0. This case was then presented in the hospital tumor board that advised nil adjuvant therapy such as radiation and chemotherapy. The patient was recalled after 2 weeks for a review, and wound healing was found to be satisfactory [Figure 5].

Figure 2

Excisional biopsy surgical site

Figure 3

Partial glossectomy with surgical margin clearance

Figure 4

Selective neck lymph node dissection from Group I to IV

Figure 5

Satisfactory wound healing during postsurgical follow-up after 2 weeks

DISCUSSION

Frozen sections constitute a vital part of intraoperative histopathological diagnosis. It helps in confirming the presence of a malignancy, adequacy of surgical margins, and ascertaining neck node status.[23] It is a rapid and an effective method with more than 95% accuracy rate. The surgeons opt for this method while dealing with cases with a doubtful diagnosis that can be ascertained on table after the frozen section report is obtained.[4]

Leukoplakia is the most common precancerous lesion with a prevalence rate of 0.1%–0.5%. The term “precancerous lesion” has been re-designated to “potentially malignant disorders” by the WHO owing to its potential to transform into malignancy. Microscopically, leukoplakia is a mass of tissue composed of hyperkeratotic stratified squamous epithelium. Some lesions could portray features of cellular atypia that could further be graded as mild, moderate, or severe based on standard criteria for classification of epithelial dysplasia.[14] According to the literature, about 20% of clinically diagnosed cases of leukoplakia demonstrate dysplasia during histopathological reporting.[56]

The time of diagnosis plays a vital role in the treatment of any disease. It is more so in the case of dysplastic and potentially malignant lesions as sooner the treatment rendered better is the prognosis. In our case, the patient had reported to the OP with a clinical lesion of a raised plaque that was diagnosed histopathologically as hyperkeratosis that translates to leukoplakia as the clinical diagnosis. Owing to the pandemic situation, regular follow-up and further treatment of the lesion could not be pursued. Later when the patient reported nearly 8 months after the initial diagnosis, the lesion had grown in size. Owing to its location in a high-risk area, a rapid diagnosis technique involving frozen section reporting helped in establishing the final diagnosis of the lesion. The usage of such rapid and efficient reporting technique had helped to avoid unwarranted delay in proper treatment of the lesion.

CONCLUSION

This article brings out the necessity of a thorough and routine follow-up that is needed while treating potentially malignant disorders, especially in high-risk red zones. It also highlights the importance of using advanced rapid diagnostics for an early and effective intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.