oprm-web-case-op-st-45

Patient: Young adult, either sex

Chief Complaint:
The patient complains of a persistent, progressive, tender swelling of three weeks duration. The patient is not aware of the lesion bleeding, and there is no history of trauma to the area.

Medical History:
No abnormalities are identified.

Dental History:
No abnormalities are identified.

Clinical Findings:
The lesion is a circumscribed, 2 x 3 cm swelling posterior to the right maxillary tuberosity with extension onto the soft and hard palate. The ulcerated portion of the lesion bleeds during the examination. The lesion appears to be of submucosal origin because the epithelium is not thickened, rough, or uneven. The lesion is firm, mildly tender, and fixed to surface mucosa and underlying structures. The surface is smooth and does not blanch. Lymphadenopathy is not present.

There are no radiographs available for this case.

There are no lab reports available for this case.

There are no charts available for this case.

Summary:
The patient complains of a persistent, progressive, tender swelling of three weeks duration.  The patient is not aware of the lesion bleeding and there is no history of trauma to the area.  The lesion is a firm, tender, circumscribed, 2 x 3 cm swelling posterior to the right maxillary tuberosity with extension onto the soft and hard palate.  The ulcerated portion of the lesion bleeds during the examination.  The lesion appears to be of submucosal origin because the epithelium in not thickened, rough, or uneven.  The lesion is fixed to the surface mucosa and underlying structures.  The surface of the lesion is smooth and does not blanch.  Cervical lymphadenopathy is not present.

Lesions to Exclude from the Differential Diagnosis:
The lesion is described as a soft tissue enlargement.  Reactive soft tissue enlargements may be excluded from the differential diagnosis because the lesions is described as persistent, progressive, and is not associated with tender lymphadenopathy or systemic manifestations.  Also, there is no cause for a reactive lesion that can be identified.

Within the category of tumors, benign tumors and soft tissue cysts may be excluded  because the lesion in this case is rapidly growing, fixed to surface mucosa and underlying structures (even the soft palate), and has an ulcerated surface in the absence of a history of trauma.

From the category of malignant tumors, squamous cell carcinoma is unlikely because the lesion in this case is a submucosal mass, while squamous cell carcinoma arises from the surface epithelium and is associated with alterations of the surface, such as thickening, roughening, or other alterations in texture.   Metastatic carcinoma can be excluded in a patient this young without a history of cancer.  Carcinoma arising in pleomorphic adenoma can be excluded because these occur in pre-existing benign pleomorphic adenomas of long duration.  

Lesions to Include in the Differential Diagnosis:
The differential diagnosis includes malignant tumors, most likely of salivary gland origin.  Included would be adenoid cystic carcinoma, acinic cell adenocarcinoma, high-grade mucoepidermoid carcinoma, and other salivary gland adenocarcinomas not otherwise specified.  Lymphoma, and sarcoma are also included in the differential diagnosis.

Initial Management:
The patient requires an incisional biopsy for definitive microscopic diagnosis and also further local and systemic evaluation by an oncologist. 

Final Diagnosis:
High-grade salivary gland adenocarcinoma, not otherwise specified.

Further Management and Prognosis:
The prognosis depends upon the extent of local tumor invasion and the presence of metastases.  Treatment would involve surgery, radiation therapy, chemotherapy, or a combination of these modalities.