Malignant Non –Odontogenic Tumors of the Jaw Bones Dr. T Flashcards
Key Concepts of
Malignant Lesions on
Imaging
Rapidly growing and infiltrative
–finger-like extensions into surrounding anatomy
Remember: in some instances, a benign lesion can mimic a malignant
one.
Therefore we should be wary of all the information that is available.
Key Concept of
Malignant Lesions on
Imaging
ill-defined invasive borders followed by bone destruction
Key Concept of
Malignant Lesions on
Imaging
Destruction of the cortical boundary (floor of maxillary antrum) with an adjacent soft tissue mass (arrows)
Key Concept of
Malignant Lesions on
Imaging
Tumor invasion along the periodontal membrane space causing irregular thickening of this space
Key Concept of
Malignant Lesions on Imaging
Multifocal lesions located at root apices and in the papilla of a developing tooth destroying the crypt cortex and displacing the developing tooth in an occlusal direction (arrow)
Key Concept of
Malignant Lesions on Imaging
Four types of effects on cortical bone and periosteal reaction, from top to the bottom:
•cortical bone destruction without periosteal reaction
•laminated periosteal reaction with destruction of the cortical bone and the new periosteal bone
•destruction of cortical bone with periosteal reaction at the periphery forming Codman’s triangles
•a spiculatedor sunray type of periosteal reaction
Key Concept of Malignant Lesions on Imaging
Bone destruction around existing teeth, producing an appearance of teeth floating in space.
Chondroma & Chondrosarcoma
- *Chondroma –** benign
- *Chondrosarcoma**‐ malignant
- Both are listed here because
- a benign cartilaginous tumor central In the jaw is extremely rare (or may not exist)
- Lesions tend to recur many times and eventually metastasize ( Basically chondromas are not really benign)
Chondrosarcoma
Charcterstics
- Malignant tumor that forms cartilage
- 10% of all primary bone tumors, but rare in the jaws
Chondrosarcoma
Clinical presentations
- Patient’s chief complaint is painless swelling, may be associated with tooth mobility
-
Symmetric widening of the PDL space
- Can be initial presentation with chondrosarcoma and osteosarcoma
-
Along radicular surface of the tooth there is the same rate of widening all the way down the tooth
- In contrast to periodontal disease, where there is a triangular shaped loss of space
Chondrosarcoma
Radiographically
-
Poorly defined radiolucency, often with scattered radiopaque foci
- Radiopaque foci can be seen since the cartilage in the tumor can ossify
What is this radiographic finding?
Chondrosarcoma
- its consistent widening as opposed to seen in periodontitis and inflammatory disease
Case
CC of loose teeth wanted extractions and a
denture
Chondrosarcoma
- Ill defined lesion of anterior maxilla
- Areas of radiolucency
- Classic area of moth‐eaten look
- Circular area of radiolucency with trabecular
- pattern
- Patient left without surgery, not heeding medical advice
Then patient came back
▪ Someone was willing to do the dentures for her
▪ CC‐ denture was not fitting
▪ Expansion of cortical plate
▪ Hyperkeratotic because of denture rubbing
▪ Still has malignancy
▪ Advise for surgery
▪ Refused again
Then the lesion kept on Lesion still growing
▪ Metastasize to lungs
▪ Admitted to breathing issues
▪ About 5 ½ years from initial dx to
pt passing away
What is this clinical finding?
Chondrosarcoma
- Alveolar process and floor of mouth affected
- Limitations of movement of the tongue
Chondrosarcoma
Treatment
-
Radical surgical excision on initial treatment
-
Maxillectomy/Mandibulectomy
- If anterior region they remove the entire anterior portion of the jaw
-
Maxillectomy/Mandibulectomy
- These lesions don’t respond to radiation or chemotherapy
- Although used as adjuncts for lesions that can’t be treated surgically
-
For example a posterior sinus lesion since that is the base of the skull
- These patients have poorer prognosis than those with more accessible sites such as the mandible
- Prognosis is poorer than for osteosarcoma (which contrasts with the prognosis in extragnathicsites)
- Treatment failure (and mortality) is usually due to uncontrolled local disease not metastasis
Why any diagnosis of chondroma in the jaws should be viewed with suspicion?
- Since 20% of chondrosarcomas of the jaw are initially misdiagnosed as chondromas ► any diagnosis of chondromain the jaws should be viewed with suspicion
-
All cartilaginous tumors arising in the jaws should be excised widely
- (>60% of cartilaginous tumors of the jaw recur and ~7% metastasize to the lung and/or bone )
Case
- 83 year old female with nodular areas under denture on anterior mandibular ridge
- ▪ c/c of her denture rocking
Can see in the anterior region there’s an
elevation
histology shows it’s not chondrosarcoma
because it contained Cutright lesion
papule or nodule on alveolar ridge
- Osseous and/or chondromatous metaplasia within the soft tissue of the gingiva
o Lesion is NOT central in bone or connected to bone
▪ NOT a malignant lesion
o Thought to be reactive metaplasia due to a poorly fitting denture
Osteosarcoma
_Demographics & Location_MD > MX, Male > Female
- Most common malignant bone tumor in the jaws is metastatic disease
-
Most commonly primary (meaning started at this location) malignant bone tumor in patients under 40 years old
- 2nd most common overall after multiple myeloma
-
Mean age at presentation for jaw lesions is 33 years old, 10‐15 years older than that for long bones
*
Osteosarcoma
Clinically & Radiographically
- Swelling and pain are the common presenting symptoms (25% have “toothache”)
- Can also have loosening of teeth,** **paresthesia of lip** and **nasal obstruction
- Symmetric widening of the PDL is often an early radiographic change
- Lesions vary from dense sclerotic, mixed sclerotic and radiolucent to all radiolucent
Osteosarcoma
Treatment
- Important to distinguish from chondrosarcoma as treatments are different
- Osteosarcoma is currently treated with pre-op multi-agent chemotherapy followed by surgery
-
Radiation therapy alone is insufficient for cure
- Favorable jaw site – MD symphysis
- Worst site – MX sinus
- 5 year survival is ~ 20% (up to 80% if caught early and treated with radical resection)
What is this clinical finding?
Osteosarcoma
▪ Swelling on left side of face
▪ Difficult opening
What is this clinical finding?
Osteosarcoma
- See something in the operculum
- Infection in third molar?
What is this radiographic finding?
Osteosarcoma
- AP Plain Film
- Most of jaw was missing
- Radiolucency affecting entire ramus and condyle
What is this radiographic finding?
Osteosarcoma
- Classic sunburst pattern
- Fuzzy appearance on outer edges of cortex
What is this radiographic finding?
Osteosarcoma
- cloudy bone formation on surface of cortex on facial and lingual aspect
What is this clinical finding?
Osteosarcoma
a patient with swelling with side of face
What is this radiographic finding?
Osteosarcoma
▪ Lytic lesion
▪ Slightly ill defined
▪ Loss of bone in the inferior aspect of mandible
Peripheral (juxtacortical) Osteosarcoma
Location
- Arise on the surface of the bone (vs. medullary site for usual forms of osteosarcoma)
- Usually long bones
What are the two types of Peripheral (juxtacortical) Osteosarcoma ?
parosteal – well differentiated, but will recur with less than an en bloc or radical surgery
periosteal – higher grade with prominent cartilaginous component
Parosteal Peripheral Osteosarcoma
Charcterstics
o Mushroom like growth on bone surface
o No elevation of periosteum
o No new bone formation
o Low grade
Periosteal Peripheral Osteosarcoma
Charcterstics
o Usually sessile growth on bone surface
o Elevation of periosteum
o New bone fills in space under periosteum
o Prognosis is better than medullary osteosarcoma but worse
thanparosteal type
Langerhans Cell
Disease
also known as
?
- Histiocytosis X (old name)
- Langerhans cell granuloma
- Eosinophilic granuloma
- Langerhans cell histiocytosis