Exam 2 - Malignant Bone Lesions Flashcards
Malignancy showing malignant mesenchymal cells producing _______ (ugly looking pleomorphic cells that make bone).
Fill in the blank and name that lesion.
osteoid; osteosarcoma
What is the most common primary (originating within) bone malignancy?
Note: twice as common chondrosarcoma
osteosarcoma
Name the lesion:
Typically fast-growing mass around knees in children and young adults (mean age = 18 yrs. old)
Osteosarcoma
T/F Individuals who have osteosarcoma will often see metastasis to the jaws.
False there can be but its not often only 6% affect the jaws with the means age being around 33 yrs old
some cases of osteosarcoma arise in ______ disease or ______ bone.
Pagets; radiated
T/F - In osteosarcoma the “sunburst” pattern is uncommon in jaws.
True - sunburst pattern is usually not in the jaws more likely to be in knees of children etc.
Name the lesion:
* Usually mixed lesion with ill-defined borders
* Symmetrically widened PDL of teeth in the area may be seen
* Growth of bone above the crestal height
* “Sunburst” pattern is uncommon in jaws
* Metastasis to lung and brain
* Bone production
Osteosarcoma
What is the most common cancer involving bone?
Metastatic carcinoma
Metastatic carcinoma: Metastatic deposits from malignancies below the neck may affect the jaw through _________ ___________ plexus of veins - no valves.
Batson’s paravertebral
T/F The jaw is commonly affected if a pt has metastatic carcinoma.
False; only occasionally
What is the demographic for metastatic carcinoma?
Over half of affected pt are over the age of 50
Metastatic disease stats:
Mandible is affected in ___% of cases
Maxilla is affected in ___% of cases
Soft tissue is affected in __% of cases
Mandible is affected in 61% of cases
Maxilla is affected in 24% of cases
Soft tissue is affected in 15% of cases
In metastatic carcinoma is in the soft tissue what does the gingiva often resemble?
Pyogenic granuloma
Name the lesion:
* Pain, paresthesia (NUMB CHIN syndrome).
* Tooth mobility (mimicking periodontal disease) with PDL widening
* Swelling
* Hemorrhage
* Pathologic Fracture
* Trismus
metastatic carcinoma
Numb chin syndrome was talked about with what malignant lesion?
Metastatic carcinoma
T/F Most of the time metastatic carcinoma is RL.
True
Name the pathology:
Pathologic fracture
Trismus
Poorly defined “moth eaten” RL less commonly RO
Metastatic carcinoma
Metastatic carcinoma:
___% of jaw metastasis represent the initial manifestation of the malignant process. (Meaning dentist first to diagnose pt has cancer)
22%
Most common primary tumors that metastasize to the jaw are:
________ or __________(May be RO)
Thyroid, lung, kidney, colon
Breast or prostate
Most common primary tumors that metastasize to the jaw are:
Breast or prostate (May be RO)
_____, ________, _______, _________
Thyroid, lung, kidney, colon
In soft tissue metastasis - most often see primary tumors from _______, __________, ________, and ________
breast, lung, kidney and melanoma
Describe metastatic carcinoma radiographically
Poorly defined, “moth eaten” RL less commonly RO
With Lack of healing of a tooth socket clinically consider:
Granulation tissue
Lymphoma
Metastatic Disease
What is the histology of Metastatic carcinoma?
Looks like tissue of origin, may show diffuse infiltration or scattered tumor cells (“seeded” effect)
T/F Once metastatic disease found in the mouth the disease is typically widely disseminate disease (Stage IV) once it appears in the oral cavity.
True
What is metastatic disease prognosis?
Very poor; most pt die within one year of diagnosis
How to tx metastatic disease?
Palliation, usually with radiation therapy
Bisphosphonates given to slow progression of bone mets and decrease bone pain and fracture risk
Name the lesion: Acute or chronic inflammatory process in the medullary space or cortical surface of bone that extends away from initial site of infection. “Inflammation of the bone”
Osteomyelitis
What are the two main types of osteomyelitis?
- Bacterial related - “suppurative osteomyelitis”
- “Diffuse sclerosing osteomyelitis” Idiopathic inflammation of bone w/out suppuration or sequestra
Describe Suppurative osteomyelitis
Lytic destruction with suppuration and sequestra formation (dead pieces of bone coming off); bacterial in origin
What does Suppurative osteomyelitis often arise from?
Tooth infection
Trauma/fracture that gets secondarily infected
Setting of immunosuppression or diseases that decrease bone vascularity
T/F Diffuse sclerosing osteomyelitis / idiopathic inflammation has no sequestra but has suppuration. It is non-responsive to antibiotics.
False It has no sequestra or suppuration.
It does lead to bone sclerosing and is non-responsive to antibiotics.
T/F Acute suppurative osteomyelitis can cause paresthesia of lower lip mimicking malignancy.
True
Describe process of acute suppurative osteomyelitis:
Starts off as an Ill-defined RL with drainage or separation and exfoliation of necrotic bone (called these pieces sequestrum).
Then Necrotic bone can be surrounded by new vital bone (called involucrum).
All of this process is happening over the course of <1 month
S/S: Fever, leukocytosis, LAD, pain and soft tissue swelling for <1 month
How do you tx acute suppurative osteomyelitis?
Resolve source of infection (EXT tooth or fix fracture)
Remove infected bone
Drain
Empiris use of antibiotics while awaiting culture and antibiotic sensitivity results to make sure the antibiotics you are giving the bacterial organism are sensitive to (PCN with metronidazole or clindamycin)
Multiple procedures may be require over days to weeks to eliminate infection and reconstruct
T/F acute suppurative osteomyelitis is mostly RL.
True
Name the pathology:
Defensive response produces granulation tissue that remodels into dense scar tissue attempting to wall off the infected area. This dead space harbors bacteria and antibiotics have difficulty reaching the area which can lead to a smoldering process with periodic acute exacerbations.
How does Chronic suppurative osteomyelitis arise?
Can arise de novo or from unresolved acute osteomyelitis
What space harbors bacteria in Chronic suppurative osteomyelitis?
The dead space
Note: antibiotics have difficulty reaching the area which can lead to a smoldering process with periodic acute exacerbations.
T/F Radiographically chronic suppurative osteomyelitis has more of a mixed appearance compared to acute suppurative osteomyelitis.
True - because chronic has more opaque sequestra
How do you treat chronic suppurative osteomyelitis?
Removal of all infected material to good bleeding bone (ranges from resection to curretage)
IV Antibiotics to get high dose to dead space
Hyperbaric oxygen used in refractory cases or for disease arising in hypervascularized bone (osteoradionecrosis, paget disease, COD)
T/F IV antibiotics is used to tx acute suppurative osteomyelitis.
False that is for chronic suppurative osteomyelitis
What is Hyperbaric oxygen used for?
to tx suppurative osteomyelitis
- used in refractory cases
- diseases arising in hypervascularized bone
Medication-related to osteonecrosis of the jaw (MRONJ)
Is defined by current or previous tx with either class of medication:
______________ (bisphosphonate and denosumab).
______________ agents [tyrosine kinase inhibitors (sunitinib, sorafenib), VEGF inhibitors (Bevacizumab)]. Cancer therapies designed to stop the growth of blood vessels.
Antiresorptive (bisphosphonate and denosumab).
Antiangiogenic agents [tyrosine kinase inhibitors (sunitinib, sorafenib), VEGF inhibitors (Bevacizumab)].
Exposed bone in maxillofacial region for > 8 weeks
No hx of radtx or obvious metastatic disease to jaw
Name the medication:
A. Treating osteoporosis or cancer involving bone (multiple myeloma, breast/prostate carcinoma)
B. Used to treat cancer. Designed to stop growth of blood vessels.
A. Antiresorptive - bisphosphonate and denosumab
B. Antiangiogenic agents - tyrosine kinase inhibitors (Suni and Soraf), VEGF inhibitors (Bevacizumab)
Name the pathology: Exposed bone in the maxillofacial region for > 8 wks. No hx of radtx or obvious metastatic disease.
Medication-related Osteonecrosis of the Jaw (MRONJ)
~90% of MRONJ cases occur in pt receiving ___ _________ for metastatic cancer.
IV bisphosphonates
__% of pt taking IV bisphosphonates develop MRONJ.
1%
Bisphosphonates for osteoporosis differs in that ____% of pt will develop MRONJ. Also in these pt necrosis usually does not occur within the first ___ - _____ years.
0.01% ; 2-4 yrs
Describe MRONJ (5 things)
- Beings as increased RO of the crestal bone
- Then pain, necrosis, and infection
- Both jaws can be involved
- Can happen after trauma, or follow EXT, or spontaneously
- Tori often involved because mucosa is thin
MRONJ Tx:
Small areas of necrosis usually tx with _____ may heal slowly without surgery.
Large areas of necrosis much more difficult to tx surgically.
chlorhexidine
