Huge ameloblastoma associated with hypercalcemia, leukocytosis, and elevated tumor markers via production of parathyroid hormone-related protein and granulocyte colony-stimulating factor

Squamous cell carcinoma of mandibular gingiva producing both parathyroid hormone-related protein and granulocyte colony-stimulating factor: a case report

We describe a case of mandibular gingival carcinoma with hypercalcaemia and leukocytosis caused by tumour-derived parathyroid hormone-related protein (PTHrP) and granulocyte colony-stimulating factor (G-CSF). A 54-year-old man presented to our Department of Oral and Maxillofacial Surgery with a chief complaint of a left-sided mandibular gingival ulcer. A 42 mm × 20 mm sized ulcer was found on the left lower molar gingiva. Squamous cell carcinoma was pathologically diagnosed. The patient underwent a hemimandibulectomy, left-sided radical neck dissection, plate reconstruction, pectoralis major musculocutaneous flap reconstruction, and tracheostomy under general anaesthesia. Pathologically, two metastatic lymph nodes were identified. Residual tumour was suspected at the resection margins. Eight weeks after surgery, the patient started postoperative concurrent chemoradiotherapy (CCRT). Two weeks after CCRT, the patient developed hypercalcaemia. Serum levels of PTHrP and G-CSF increased in parallel with the progression of hypercalcaemia and leukocytosis. Immunohistochemical analysis of the surgical specimen showed positivity for G-CSF. Based on these clinical and pathological findings, the patient was diagnosed with hypercalcaemia and leukocytosis associated with malignancy and was treated with denosumab. Irradiation was terminated at 50 Gy because CT showed rapid disease progression. Chemotherapy was initiated, however, four weeks after the start of chemotherapy, a CT scan showed increased metastases and pleural dissemination. Therefore, chemotherapy was discontinued. One week after the chemotherapy was discontinued, the patient died of respiratory failure.

Giant Mandibular Ameloblastoma with Rare Hypercalcemia: A Case Report and Literature Review

Ameloblastoma is the most common benign odontogenic tumor with local invasion and high recurrence, which generally occurs in the jaw bones. Hypercalcemia is a common paraneoplastic syndrome that is commonly observed in patients with malignancies but rarely encountered in patients with benign tumors. Thus far, not many cases of ameloblastoma with hypercalcemia have been reported, and the pathogenic mechanism has not been studied in depth. This paper presents a case report of a 26-year-old male diagnosed with giant ameloblastoma of the mandible, accompanied by rare hypercalcemia. Additionally, a review of the relevant literature is conducted. This patient initially underwent marsupialization, yet this treatment was not effective, which indicated that the selection of the appropriate operation is of prime importance for improving the prognosis of patients with ameloblastoma. The tumor not only failed to shrink but gradually increased in size, accompanied by multiple complications including hypercalcemia, renal dysfunction, anemia, and cachexia. Due to the contradiction between the necessity of tumor resection and the patient's poor systemic condition, we implemented a multi-disciplinary team (MDT) meeting to better evaluate this patient's condition and design an individualized treatment strategy. The patient subsequently received a variety of interventions to improve the general conditions until he could tolerate surgery, and finally underwent the successful resection of giant ameloblastoma and reconstruction with vascularized fibular flap. No tumor recurrence or distance metastasis was observed during 5 years of follow-up. Additionally, the absence of hypercalcemia recurrence was also noted.

Recurrent ameloblastoma with both hypercalcemia and BRAF mutation: A case report

This case report describes a mandibular ameloblastoma with both BRAF V600E mutation and rare hypercalcemia. The patient without distant metastasis underwent subtotal mandibulectomy using double flaps of fibula and anterolateral thigh. A whole body computed tomography scan taken 69 months after surgery revealed neither recurrence nor metastasis.

Radiographic estimation of the growth rate of initially underdiagnosed ameloblastomas

BACKGROUND

To evaluate the specific growth rate (SGR) of ameloblastoma.

MATERIAL AND METHODS

cases of ameloblastoma initially underdiagnosed (e.g. cases overlooked or diagnosed as reactive lesions) which had adequate radiographic documentation to evaluate their progression were retrospectively selected. Two panoramic radiographs were analyzed to determine the specific growth rate (SGR) of each tumor, defined as the logarithm of the ratio of final tumor area (when the diagnosis of ameloblastoma was made) to the initial tumor area (when the lesion was underdiagnosed), divided by the time interval between the radiographic images. The tumor area was measured using the software ImageJ.

RESULTS

Twelve patients with mandibular ameloblastomas were selected, including 5 males and 7 females, with a mean age of 24.9 years (range: 14-61 years). In four cases, the lesion was associated with the crown of an impacted third molar. In three cases, it was initially diagnosed as a periapical lesion. Three cases were extrafollicular and were not noticed in the initial radiographs. Two cases were initially diagnosed as ameloblastoma, but the surgery was delayed for personal reasons. The mean interval of time between the two radiographic images was 4.3 years (range: 0.4-9 years). Based on our analysis, ameloblastoma grows in average 40.4% per year (range: 14.9-88.7%).

CONCLUSIONS

Ameloblastoma is a progressively growing tumor, but its growth rate seems to be smaller than initially reported in the literature. Better understanding the radiographic progression of ameloblastoma might improve its early diagnosis, management, and prognosis.

Expression of parathyroid hormone related protein (PTHRP) in ameloblastomas

BACKGROUND

Presence of parathyroid hormone related protein (PTHrP) might suggest that ameloblastomas recapitulate features of the enamel epithelium and induce bone resorption, which would facilitate their growth and local invasion. The aim of this study was to determine the expression of PTHrP in ameloblastomas.

MATERIAL AND METHODS

An observational research study was designed including 39 cases of histologically diagnosed ameloblastomas (39 out of 42 patients gave consent for the use of their medical records and all data required for this study). Gender, age, tumor location, histological type and subtype of the tumor were recorded and PTHrP expression was determined by indirect immunohistochemistry using monoclonal anti-human PTHrP (1D1 / Santa Cruz Biotechnology). Protein expression and intensity were evaluated under light microscope and finally data recorded and statistically analyzed. This research was approved by the Caracas West General Hospital review board.

RESULTS

39 cases of ameloblastomas were evenly distributed between genders (49% male and 51% female) with a mean age of 33 ± 3.53 years, mainly affecting the posterior mandible. 20 cases (51.28%) showed positive cytoplasmic immunoreactivity to PTHrP. 8 out of 15 cases of solid/multicystic ameloblastomas and 12 out of 23 cases of unicystic ameloblastomas were PTHrP positive. Intense expression of PTHrP was observed in 4 unicystic ameloblastomas (all luminal subtype) and in 5 cases of conventional ameloblastomas.

CONCLUSIONS

In the present study PTHrP expression in solid multicystic and unicystic ameloblastoma suggests its possible function in the biological behavior of the tumor. More studies are needed in order to determine the possible role of this protein related to bone invasion processes. Key words:Parathyroid hormone related protein, PTHrP, ameloblastoma, bone.

Tongue squamous cell carcinoma producing both parathyroid hormone-related protein and granulocyte colony-stimulating factor: a case report and literature review

BACKGROUND

Paraneoplastic syndrome generally results from tumor-derived hormones or peptides that cause metabolic derangements. Common metabolic conditions include hyponatremia, hypercalcemia, hypoglycemia, and Cushing's syndrome. Herein, we report a very rare case of tongue carcinoma presenting with leukocytosis and hypercalcemia.

CASE PRESENTATION

A 57-year-old man was admitted to our hospital with tongue squamous cell carcinoma (cT4aN0M0, stage IV). He underwent radical resection following preoperative chemoradiotherapy, but locoregional recurrence was detected 2 months after surgery. He presented with marked leukocytosis and hypercalcemia with elevated serum levels of granulocyte colony-stimulating factor (G-CSF) and parathyroid hormone-related protein (PTHrP). He was therefore managed with intravenous fluids, furosemide, prednisolone, elcatonin, and pamidronate. However, the patient died 1 month later of carcinomatous pleuritis following distant metastasis to the lung. Immunohistochemical analyses of the resected specimens revealed positive staining for PTHrP and G-CSF in the cancer cells.

CONCLUSIONS

In this case, it was considered that tumor-derived G-CSF and PTHrP caused leukocytosis and hypercalcemia.

Establishing the natural history and growth rate of ameloblastoma with implications for management: systematic review and meta-analysis

Background

Ameloblastoma is the second most common odontogenic tumor, known to be slow-growing, persistent, and locally aggressive. Recent data suggests that ameloblastoma is best treated with wide resection and adequate margins. Following primary excision, bony reconstruction is often necessary for a functional and aesthetically satisfactory outcome, making early diagnosis paramount. Despite earlier diagnosis potentially limiting the extent of resection and reconstruction, an understanding of the growth rate and natural history of ameloblastoma has been notably lacking from the literature.

Method

A systematic review of the literature was conducted by reviewing relevant articles from PubMed and Web of Science databases. Each article’s level of evidence was formally appraised according to the Centre of Evidence Based Medicine (CEBM), with data from each utilized in a meta-analysis of growth rates for ameloblastoma.

Results

Literature regarding the natural history of ameloblastoma is limited since the tumor is immediately acted upon at its initial detection, unless the patient voluntarily refuses a surgical intervention. From the limited data, it is derived that the highest estimated growth rate is associated with solid, multicystic type and the lowest rate with peripheral ameloblastomas. After meta-analysis, the calculated mean specific grow rate is 87.84% per year.

Conclusion

The growth rate of ameloblastoma has been demonstrated, offering prognostic and management information, particularly in cases where a delay in management is envisaged.