management of jaw tumors

Department of Oral and Maxillofacial Surgery, CODS, BPKIHSManagement of Jaw TumorsPresented byUjwal GautamRoll no 431BDS 2009

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ContentsDiagnosisTreatment PlanningPrinciples of Surgical excisionRadiotherapy: indicationsReconstructionComplicationsSurvival and Prognosis

DiagnosisHistory and ExaminationBiopsyImaging

History & Examination

History of the lesion

DurationMode of onset and progressExact site and shapeChange in character of the lesionAssociate symptomsSimilar swelling elsewhereLoss of body weightRecurrenceHabit

Non healing sore in the mouth, loosening of teeth, ill fitting dental prosthesis, change in voice, dysphagia, trismus, otalgia, or weight loss.4


InspectionNumberSizeSite or anatomical locationShape and sizeColourSurfacePedunculated/sessileOverlying skinClinical Examination of the LesionPalpationConsistency of lesionPresence of pulsationFixityLymph node examination



BleedingDuration >2 wksErythroplasiaFixidity

Rapid growthIndurationUlceration

Characteristics of malignant Lesion:


BiopsyIndications;Any persistent pathologic condition that cannot be clinically diagnosedLesions with no identifiable cause that persists for greater than 2 weeks despite local therapyEnlarging intrabony lesionsVisible/ palpable submucosal swelling beneath clinically normal mucosaAny lesion with malignant/ premalignant characteristicsConfirmation of clinical diagnosisLesions not responding to routine clinical management over 2 weeksAny lesion that is of extreme concern for patient

Brush cytology differs from exfoliate cytology in that it removes an entire transepithelial layer for cytologic evaluation as opposed to the sloughing surface layer of the mucosa.7

BiopsyCytologic techniquesIncisional biopsyExcisional biopsyAspiration biopsy

Brush cytology differs from exfoliate cytology in that it removes an entire transepithelial layer for cytologic evaluation as opposed to the sloughing surface layer of the mucosa.8

Incision BiopsyIndications:Large lesion > 1 cm diameterLocation in risky or hazardous regions

PrinciplesSite is carefully chosen after thorough clinical and radiological examinationAspiration is always tried beforeIncision in wedge shaped fashionNormal tissue should be includedTissue specimen should not be crushedDeeper biopsies over superficial onesProper hemostasis before closureSpecimen should be well oriented and markedTissue is immediately placed in formalin

Usually edge except in post radiotherapy pt. where blood supply is severely compromised at edges and tumor proliferates at the centre11

Intraosseous BiopsyPerformed after thorough Neck examination as cervical lymphadenitis is inevitable after the procedure rendering clinical neck examination to produce false positive resultsNecessary because diagnosis from frozen section not possibleSite: Extraction socket or flap reflection

Full thickness mucoperiosteal flap of adequate extention is made.Flap should rest entirely on sound bone for closure. Eroded area of cortical bone should be approached from the lesion margins over sound bone.Major neurovascular structures should be avoided.Precautionary aspiration performed before biopsy to prevent inadverant excision into vascular lesion.Osseous window created on the cortical plate either with bur of rongeurs.Specimen can be curetted from the surrounding bone.

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Imaging

OPGCTMRIPET

Tumors of odontogenic epithelium

Ameloblastoma Malignant ameloblastoma Ameloblastic carcinomaCalcifying epithelial odontogenic tumorSquamous odontogenic tumorClear cell odontogenic carcinomaPrimary intraosseous carcinomaTumors of odontogenic epithelium With odontogenic ectomesenchyme dental hard tissue formation

Ameloblastic fibromaAmeloblastic fibro-odontomaAmeloblastic fibrosarcomaOdontoameloblastomaOdontoma Compound composite Complex compositeAdenomatoid odontogenic tumorTumors of odontogenic ectomesenchyme included odontogenic epithelium

Odontogenic fibromaGranular cell odontogenic tumorOdontogenic myxomaCementoblastomaBenign Odontogenic tumors

The fact that odontogenic tumors are common can be mainly explained by the fact that the odontogenic structures are formed rather d/t complex interaction between epithelial and mesenchymal component beginning from 5-6th wk of IUL lasting till 16th yr of birthDifference depends on embryonic stage of initiation and histology. Overlap and combination of features are possible. Histopathologic investigations to some extent helps to predict the biologic activity of the lesion14

Benign Non-odontogenic tumorsOsteogenic neoplasm

Ossifying fibromaOsteoma

Non neoplastic bone lesions

Fibrous DysplasiaCementoosseous dysplasiaPeriapical cementoosseous dysplasiaFocal cementoosseous dysplasiaFlorid cementoosseous dysplasiaOther cementoosseous dysplasia

CherubismCentral Giant Cell Granuloma

Odontogenic Carcinomas

Malignant (metastasizing) ameloblastomaAmeloblastic carcinomaPrimaryDedifferentiatedPeripheralPrimary intraosseous squamous cell carcinomaSolidCystogenicNonkeratinizing cystOdontogenic keratocystClear cell odontogenic carcinoma Malignant epithelial odontogenic ghost cell tumorOdontogenic Sarcoma

Ameloblastic fibrosarcoma

Odontogenic malignancies

Others: squamous cell carcinoma, adenocarcinoma, secondaries/mets16

Non Odontogenic malignancies

OsteosarcomaFibrosarcoma and chondrosarcomaSquamous cell carcinomaSecondary (metastatic) bone tumours

Peak age Adults, about 40 years old.

Frequency Rare, but still the most common odontogenic tumour; 1% of all oral tumors, 18% of all odontogenic tumors

Site Posterior body/angle/ramus of mandible, very occasionally involves the maxilla.

Clinical Feature asymptomatic, slow growing, hard, non tender, ovoid swelling; may be associated with mobile teeth, exfoliation of teeth, ill fitting dentures, malocclusion, paraesthesia or ulcerations; large lesion may present with egg shell cracklingAmeloblastoma

Malignant transformation 2.4% with chance to metastasize into lungs

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Shape Multilocular, distinct septa dividing the lesion into compartments with large, apparently discrete areas centrally and with smaller areas on the periphery; Occasionally monolocular in early stages Honeycomb or soap-bubble appearance or multicystic shape varies with different histological subtypes.

Outline Smooth and scalloped; Well defined, Well corticated.

Radiodensity Radiolucent with internal radiopaque septa.

Effects Adjacent teeth displaced, loosened, often resorbed Extensive expansion in all dimensions; Buccolongual cortical expansion prominentThin eggshell cortical bone Maxillary lesions can extend into the paranasal sinuses, orbit or base of the skull

Non encapsulated (excision margin with 2 cm >SOLID, 1-1.5 cm> CYSTIC); enlarges and invades by replacing tissues rather than pushing themExpansion of bony plate with remodeling but if it cannot keep pace with expansion causes thinning of cortices19

Follicular, Plexiform, Acanthamatous, Granular, Desmoplastic, Basal cell typeSheets and islands of tumor cellsOuter rim of ameloblasts like cell is polarized away from basement membraneCenter looks like stellate reticulum20

OdontomesAge 1st and 2nd decades

Site commonly seen in; posterior mandible, anterior maxilla esp in third molar region

Clinical Features asymptomatic, no obvious bony or facial asymmetry; may be associated with unerupted teeth

Hamartoma: overgrowth of disorganised normal tissue that have a limite growth potential21

Compound odontome It is made up of several small toothlike denticles. The miniature tooth shapes are of dental tissue radiodensity, with a surrounding radiolucent line, and are easily identified radiographically.

Complex odontomeThis odontome is made up of an irregular, confused mass of dental tissues bearing no resemblance in shape to a tooth. The enamel content provides the dense radiopacity, suggestive of dental tissue and again the mass is surrounded by a radiolucent line

Fibrous dysplasiaAge 10-20 year-old adolescents.

Site Maxilla usually posteriorly, more commonly than the mandible. Maxillary lesions may spread to involve adjacent bones such as the zygoma, sphenoid, occiput and base of skull.

Size Variable and difficult to define.

Shape Round.

Outline Poorly defined with the margins merging imperceptibly with adjacent normal bone Not corticated.

Radiodensity Initially radiolucent (but rarely seen clinically at this stage) Gradually becomes opaque to produce the typical ground glass, orange peel and finger print appearances resulting from superimposition of many fine, poorly-calcified bone trabeculae arranged in a disorganized fashion. Continuing to become more opaque with age.

Effects Adjacent teeth sometimes displaced but rarely resorbed loss of associated lamina dura Buccal and lingual alveolar expansion Encroachment on, or obliteration of, the antrum Involvement of adjacent bones including the base of the skull.

Mx: recontouring; surgical shave down procedure24

Fibrous dysplasia. A Periapical showing the overall fine stippled trabecular pattern (orange peel), and loss of the lamina dura around the j. B Lower 90 occlusal centred on the right side again showing the ground glass appearance and expansion but involving the mandible in the premolar and molar regions (arrowed). The anterior part of the mandible is unaffected. C 0 OM showing expansion of the right posterior maxilla and total obliteration of the right antrum25

Age Younger adults lesser than 30 years old.

Frequency Rare, but the most common primary malignant bone tumour.

Site Usually the mandible.

SizeShapeOutlineRadiodensityFrom a radiological viewpoint, there are three main types:Osteolytic no neoplastic bone formationOsteosclerotic neoplastic osteoid and bone formedMixed lytic and sclerotic patches of neoplastic bone formed.

All very variabledepending on the type oflesion (lytic or sclerotic)and how long it has beenpresent.Osteosarcoma

Presentation 1 decade earlier than in long bones26

EffectsEarly features: Non-specific, poorly defined radiolucent area around one or more teeth. Widening of the periodontal ligament space.Later features: Osteolytic lesion: Monolocular, ragged area of radiolucency Poorly defined, moth-eaten outline. Cumulous cloud densities So-called spiking resorption and/or loosening of associated teeth. Osteosclerotic and mixed lesions: Poorly defined radiolucent area Variable internal radiopacity with obliteration of the normal trabecular pattern Perforation and expansion of the cortical margins by stretching the periosteum, producing the classical, but rare sun ray or sunburst appearance Spiking resorption and/or loosening of associated teeth Distortion of the alveolar ridge

a poorly denned ragged area of radiolucency (arrowed) with resorption of the lateral aspect of 12. rootPeriapical showing a similar smaller poorly defined area of bone destruction between/34 (arrowed) which was again shown to be an osteosarcomaRight side of a PA jaws of a 7-year-old showing an osteosarcoma in the ascending ramus of the mandible.Thesunray or sunburst appearance is evident medially and laterally28

Squamous cell carcinomas of the oral mucosadirectly overlying bone, in their latter stages, often invade the underlying bone to produce a destructive radiolucency.

Age Adults over 50 years old.

Frequency Rare, but the most common oral malignant tumour.

Site Mandible, or maxilla if originating in the antrum.

Size Variable.Squamous cell carcinoma

Shape Irregular area of bone destruction often initially saucer-shaped.

Outline Irregular and moth-eaten Poorly defined Not corticated.

Radiodensity Radiolucent, radiodensity dependent on degree of destruction.

Effects Adjacent teeth may be displaced, loosened and/or resorbed or left floating in space Destruction of surrounding bone may lead to pathological fracture.

patient who presented with a large squamous cell carcinoma on the left ventral surface of his tongue and the floor of his mouth. The radiograph shows two areas of poorly defined radiolucency (arrowed) with a ragged or moth-eaten appearance. B Left side of a lower 90 occlusal of the same patient showing the bony destruction (arrowed) of the lingual surface of the mandible as the soft tissue tumour invades the bone.31

Sentinel Node BiopsySentinel NodeFirst node to receive lymphatic drainage

Open biopsies not performed as it violates the field and can cause seeding33

Treatment PlanningDiagnosis confirmed by biopsyImaging for assessment of extensionFor malignant lesions;Evaluation for staging; Neck assessmentApproach for primaries: surgery/chemotherapy/radiotherapyApproach for secondariesPalliative approachFor benign lesions;Surgical approachReconstruction

Complete eradication of lesionPreservation of normal tissue as permissibleExcision with least morbidityRestorationLong term follow up

Tt planning only after thoro correl of clinical, radio and histopath findings34

General principlesFactors influencing treatment planning;Site of diseaseStageHistologyAgePrevious radiotherapyField change

Lymphoma: radiotherapySCC: resistant to radiotherapy. So, surgeryBenign: excision

Reccurence: radioresistant; difficult surgery d/t fibrous scar

Field change: surgery preferred; extensive premalignant change of the oral mucosa in multiple primary tumors

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Primary Tumors (T)TX Primary tumor cannot be assessedT0 No evidence of primary tumorTis Carcinoma in situT1 Tumor 2 cm but 4 cm in greatest dimensionT4a Tumor invades adjacent structures (eg, through cortical bone, into deep[extrinsic] muscle of the tongue, maxillary sinus, skin of face) (resectable)T4b Tumor invades masticator space, pterygoid plates, or skull base or encasesinternal carotid artery (unresectable)Nodal Involvement (N)NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastasis in a single ipsilateral lymph node, 3 cm but

management of jaw tumors

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