Journal of Indian Society of Periodontology

: 2012  |  Volume : 16  |  Issue : 3  |  Page : 300--301

Response to "Gingival squamous cell carcinoma: A diagnostic impediment"

Poramate Pitak-Arnnop1, Alexander Hemprich1, Kittipong Dhanuthai2, Niels Christian Pausch1,  
1 Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, Scientific Unit for Clinical and Psychosocial Research, Evidence-Based Surgery and Ethics in Oral and Maxillofacial Surgery, Faculty of Medicine, University Hospital of Leipzig, Leipzig, Germany
2 Department of Oral Pathology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand

Correspondence Address:
Poramate Pitak-Arnnop
Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, Faculty of Medicine, University Hospital of Leipzig, Nürnberger Str. 57, 04103 Leipzig

How to cite this article:
Pitak-Arnnop P, Hemprich A, Dhanuthai K, Pausch NC. Response to "Gingival squamous cell carcinoma: A diagnostic impediment".J Indian Soc Periodontol 2012;16:300-301

How to cite this URL:
Pitak-Arnnop P, Hemprich A, Dhanuthai K, Pausch NC. Response to "Gingival squamous cell carcinoma: A diagnostic impediment". J Indian Soc Periodontol [serial online] 2012 [cited 2020 Aug 13 ];16:300-301
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Full Text


We read with great interest the article by Koduganti et al.[1] regarding a case of gingival squamous cell carcinoma (SCC). Although this report reveals useful information, there are some areas for discussion upon which we would like to expand.

First, before the patient received supragingival debridement, the authors included SCC, metastatic carcinoma, and speckled erythroplakia in their differential diagnosis. At that time, oral brush biopsy with cytological examination should be performed. Although this diagnostic method is technically sensitive, its specificity and sensitivity are up to 100% with the aid of novel developments, such as a specialised brush that collects a full-thickness epithelial sample and not just superficially sloughed cells, sample analysis with computer assistance, adjunctive techniques for the diagnosis of the cytologic specimens (DNA analysis, immunocytochemistry, molecular analysis, and liquid-based preparations). This technique has now been recommended for (1) diagnosing clinically suspected premalignant/malignant oral lesions, or large lesions where excision of the entire tissue is not possible; (2) evaluating patients with recurrent malignancies; and (3) monitoring premalignant lesions. [2],[3]

Second, once the definite diagnosis of SCC was made by histopathologic examination, the patient was opted to chest radiography. In fact, the preoperative investigations in oral cancer patients should include computed tomography (CT) with contrast and/or magnetic resonance imaging (MRI) with contrast of the primary site and neck, chest radiography, ultrasonography of the neck and abdomen, panendoscopy (direct laryngoscopy, bronchoscopy, and esophagoscopy) or pharyngeal inspection, and for stage III-IV disease, positron emission tomography-CT (PET-CT) or single-photon emission computed tomography (SPECT) of the whole body. Dental health care is also essential before radiotherapy in order to prevent osteoradionecrosis. [2],[4],[5]

Lastly, the authors understated that the patient was treated with marginal mandibulectomy with level 5 neck dissection (ND) of the involved side. This seems to be a misnomer or misunderstanding. Based on the ND's classification by the Academy's Committee for Head and Neck Surgery and Oncology, "level 5" of the neck means the posterior triangle of the neck, which is bounded by the posterior border of sternocleidomastoid muscle, the clavicle, and the anterior border of trapezius muscle [Figure 1]. Indeed, the treatment of choice for lower alveolar rim and retromolar trigone SCCs with staging of T1 N0/N1 is surgical resection plus selective ND (or sentinel lymph node biopsy for T1N0 tumors) with/without postoperative radiotherapy. This will extirpate all lymph nodes most commonly involved with metastases from the oral cavity: the ipsilateral nodes found above the omohyoid muscle (level 1-3 and sometimes the superior parts of level 4). Bilateral ND is recommended for tumors at or near the midline and/or for tumor sites with bilateral lymphatic drainage. [4],[5],[6],[7]

Level 5 NDs are performed for certain primary sites (such as larynx and hypopharynx) as required to resect the primary tumor and any clinically evident neck nodes. Elective ND depends on primary tumor extent and site. Infraglottic laryngeal cancers are sites where elective level 5 NDs are often considered appropriate. [5],[6] Dissection of level 5 lymph nodes in oral cancer patients is "rarely" required. [4],[5],[7]{Figure 1}

Disclosure of potential conflicts of interest

The authors indicate full freedom of manuscript preparation and no potential conflicts of interest.


1Koduganti RR, Sehrawat S, Reddy PV. Gingival squamous cell carcinoma: A diagnostic impediment. J Indian Soc Periodontol 2012;16:104-7.
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