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Osteosarcoma of MandibleChandra Shekhar1, Ramesh2, Pavan Kumar B3, Shwetang Goswami4

ABSTRACT:

Osteosarcomaarises in bone during periods of rapid growth andprimarily affects adolescents and young adults. Osteosarcomais a highly malignant bone forming tumor. Most of the cliniciansconsider osteosarcoma of head and neck to be distinct fromosteosarcomas that arise from long bones. Jaw osteosarcomapresents a wide spectrum of clinical and radiological featuresalong with highly variable histopathology. In the present casereport, a 33 year old patient reported to our college with acomplaint of pain and swelling in left lower back tooth regionwhich was diagnosed to be a periodontal infection and treatedlocally followed by extraction of the teeth. The pain and swellingdid not subside but increased in size. Biopsy and radiologicalinvestigations revealed osteosarcomatous changes in the jaw.The patient was treated with segmental resection andreconstruction with reconstruction plate followed bychemotherapy.

Key words: Osteosarcoma, Sarcoma, Osteosarcoma of jaw,Mandible

C A S E R E P O R T

doi: 5866/2013.531349

1Reader2Senior Lecturer3Professor4Post Graduate StudentDepartment of Oral SurgeryKamineni Institute of Dental SciencesNarketpally, Nalgonda Dist. A.P. India

Article Info:

Received: April 8, 2013Review Completed: May 10, 2013Accepted: June 10, 2013Available Online: October, 2013 (www.nacd.in)© NAD, 2013 - All rights reserved

Email for correspondence:jeevan1983@yahoo.com

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INTRODUCTION

Osteosarcoma (OS) is a malignant mesenchymal tumor characterized by formation of osteoid tissue.1 Itis most common primary malignant bone tumor, accounting for approximately 20% of sarcomas but only 5%osteosarcomas occur in jaws.2 Osteosarcoma of jaw is uncommon and despite its histopathologic similaritieswith long bones osteosarcoma, it is biologically different.

Osteosarcoma of jaw bones have some distinct features such as older age at presentation, longer mediansurvival, rare metastases and local recurrences difficult to control, typically leading to death of the patients.3

Case report

A 33 year old female patient reported to the institution with a chief complaint of swelling in left posteriormandible region. Initially it was diagnosed as periodontal abscess irt 36 and was treated with curettage. Butthe pain and swelling did not subside and mobility irt 36 and 37 increased and hence 36 and 37 were extracted.

Patient came back after 2 weeks with an increased swelling in left posterior mandibular region whichwas now evident extra orally.

An occlusal radiograph (Fig 1) showed sun burst appearance leading to a provisional diagnosis asosteosarcoma. An OPG (Fig 2) revealed widening of periodontal ligament irt 33 to 38 and also widening ofthe inferior alveolar neurovascular bundle. A CT scan and MRI were advised to see extent of soft tissueinvolvement.

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The serial axial section (Fig 3a) of CT showedextension of lesion into the adjacent soft tissue andossifications with in the tissue on the buccal sideand on the lingual side there was a breach in theperiosteum and it resulted in elevation of periosteumand bone deposition between elevated periosteumand adjacent normal bone.The serial coronal sections(Fig 3b), showed the radioopacity within the marrowspace of left mandible compared to that of rightsuggestive of osteoblastic proliferation.In 3Dreconstruction images (Fig 3c), we found the newbone formation both on the buccal and lingual sides.

The MRI(Fig 4a) sections showed the extent ofsoft tissue involvement both on the buccal andlingual sides. Anterior border of masseter on thebuccal side and a portion of mylohyoid on the lingualside are involved.The coronal sections (Fig 4b)showed thebucco lingual extension. And thisextension appears to be connected through theextraction socket.

A biopsy was done. The histopathologic (Fig 5)variant showed cellular connective tissue withpresence of osteoid surrounded by tumor cells.Tumor cells are spindle shaped, plump and few areround cells. These tumor cells are arranged aroundimmature osteoid. Immature osteoid is showingbizzare osteocytes. There is also presence ofextravasated RBCs and skeletal muscle tissue. Thehistopathologic features were suggestive ofosteoblastic variant of osteosarcoma.Henceconfirmed as osteosarcoma of mandible.

The patient was treated with segmentalresection and reconstruction with reconstructionplate followed by chemotherapy.

DISCUSSION

Osteosarcoma of the jaw bones is a rare entity(6.5% to 7% of all osteosarcoma), but it is still acommonprimary bone tumour of the jaw4.Inmandible tumours, the body of the mandible isusually the primary site, which is the presentingsite in our case, followed by the symphysis andascending ramus; the alveolar ridge and antrum arethe most common sites in the maxilla.5,6 The usualpresentation is of a rapidly growing swelling withloosening and displacement of teeth which maycause dysaesthesias.7 In our present case, evenloosening of teeth was seen with severe pain.

Radiologicallythe findings may be the same asthose of osteosarcoma in other sites-osteolytic,

osteoblastic, or a mixture of the two with the poorlydefined irregular margins that are characteristic ofmalignant lesions. The radiographic appearance isusually suggestive of malignancy but it is certainlynot a dependable criterion for definitive diagnosis.CT and magnetic resonance imaging are helpful inshowing intramedullary and extramedullaryinvolvement, tumour calcification, and invasion intoadjacent tissue, particularly the pterygo palatinefossa, infratemporal fossa, and cranial cavity.5,8,9 Inour case osteoblastic appearance was seen.

Because of the complexity of the clinical featuresand radiography, the final diagnosis can be madeonly after histopathological investigations.Thepredominant histological components described byvarious groups have been osteoblastic,5,10

fibroblastic8 and chondroblastic11. In the jaws thetumour often has a mixed appearance4. There areother variants of Osteosarcoma present such asjuxtacortical,12 periosteal and central low grade(fibrous dysplasia like and osteoblastoma like).13,14

The treatment of osteosarcoma of the jaw shouldbe approached in two ways. Primary treatmentshould be directed towards eradication of the localdisease, which requires operation15,6 andchemotherapy.16

Radiotherapy has been used for residual, andrecurrent disease and for unresectabletumours.Alone or in combination with surgery, it has resultedin long term survival.6,10,17,18

Ever since Jaffe et al19, 20 reported good resultswith high dose methotrexate for the treatment ofosteosarcoma of the long bones, chemotherapy hasbecome an important therapeutic adjunct in thetreatment of osteosarcoma at all sites.

The effective therapy for management ofosteosarcoma of the jaws is wide surgical excisionwith tumor free margins and addition to thatadjuvant therapy like radiation and chemotherapy.

CONCLUSION

As surgical methods have improved andimportant diagnostic tools have emerged (such asCT scanning), early diagnosis, better treatmentplanning and improved follow up have probablyaccounted for the improved survival. Moreimportant, the introduction of aggressivemultiagentchemotherapy as adjuvant treatment inhigher-grade lesions, appears to offer a still betterprognosis for jaw lesions in the future.

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Fig 1: OCCLUSAL RADIOGRAPHOcclusal radiographs showing sunburst appearance

on lingual side

Fig 2: OPG showing PDL widening irt 33 to 38

Fig 3a: Axial CT showing ossificationson buccal side

Fig 3b: Coronat CT showing moreradiopacity on left side than right

Fig 3c: 3D CT showing boneformation on buccal side

Fig 4a: Axial MRI showing softtissue involvement

Fig 4b: Coronal MRI showingconnection through the

extraction socket

Fig 5: Histopathology

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PRE OPERATIVE

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