Radiographic manifestations of multiple myeloma in the mandible: a retrospective study of 77 patients

Malignant Lesions of the Oral Region

This article focuses on the radiographic presentations of various malignant conditions that affect the oral region and delineates the role of CT, MR imaging, and PET in oral cancer imaging.

Fine-needle aspiration cytology for the diagnosis of plasma cell neoplasms in the head and neck region: A systematic analysis of the literature

BACKGROUND

Cytopathologic analysis is feasible and provides detailed morphological characterisation of head and neck lesions.

AIMS

To integrate the available data published on fine-needle aspiration cytology (FNAC) used for the diagnosis of plasma cell neoplasms (PCN) of the head and neck region.

MATERIALS AND METHODS

Searches on PubMed, Web of Science, Embase, and Scopus were performed to compile data from case reports/case series published in English. The Joanna Briggs Institute tool was used for the critical appraisal of studies.

RESULTS

A total of 82 studies comprising 102 patients were included in this review. There was a predilection for men (68.6%) (male/female ratio: 2.1:1). Individuals in their 50s (29.4%), 60s (22.5%), and 70s (22.5%) were more often affected. The thyroid gland (26.2%) was the main anatomical location, followed by scalp (15.5%), neck/cervical region (15.5%), jaws (13.6%), and major salivary glands (13.6%). For FNAC analysis, a smear was employed in 41 (40.6%) cases and a cell block was used in four (3.9%). In 56 (55.4%) reports, no cytological methods were available. Morphologically, 34 (56.7%) cases had a diagnosis of PCN with agreement between cytopathology and histopathology. The rate of wrong diagnoses when using cytology was 27.5%. Immunophenotyping was performed in 49 (48%) of the cases. The 69-month disease-free survival rate was 60.2%, while the 27-month overall survival rate was 64.1%.

CONCLUSION

This study reinforces that FNAC can be an ancillary tool in the first step towards the diagnosis of PCN of the head and neck region, especially when applying a cell block for cytological analysis.

Avaliação Radiográfica da Maxila e da Mandíbula de Pacientes Diagnosticados com Mieloma Múltiplo: Estudo Retrospectivo

Introdução: O mieloma múltiplo e caracterizado como uma neoplasia maligna plasmocitária com a proliferação anormal de plasmócitos clonais na medula óssea de etiologia desconhecida. Objetivo: Caracterizar os pacientes com mieloma múltiplo atendidos no Setor de Estômato-Odontologia e Prótese do INCA, por meio de dados sociodemográficos, clínicos, laboratoriais e radiográficos. Método: Estudo transversal retrospectivo de pacientes com diagnostico de mieloma múltiplo, no período de 2000 a 2018, que realizaram radiografia panorâmica no período do diagnóstico da doença. Os dados sociodemográficos e clinico-radiográficos da população em estudo foram coletados nos prontuários dos pacientes, armazenados em banco de dados, analisados de forma descritiva e submetidos ao teste não paramétrico X2 (qui-quadrado). Resultados: Na amostra final, foram totalizados 163 casos. A maioria era de homens (56,4%), brancos (55,8%), com idade ≤55 anos (54%), ensino fundamental incompleto (30,7%), não fumantes (54,6%) e não bebedores (54,6%). Havia lesões líticas em 46 pacientes (28,2%) com predileção pela mandíbula (82,6%; p=0,000). Houve maior frequência de margens parcialmente definidas (50,0%), não escleróticas (78,2%) e de aspecto unilocular (43,5%). Dos 46 pacientes que apresentaram lesão lítica maxilomandibular, 27 pacientes tinham >55 anos (p=0,042). Conclusão: Ha maior ocorrência de lesões ósseas na mandíbula quando comparada a maxila.

Parotid gland swelling as an initial presentation of Multiple Myeloma: a case report

INTRODUCTION

Parotid swellings are commonly encountered in ENT Clinics, the cause of which could range from neural conditions, endocrine problems, vitamin deficiencies, and sialadenitis, which may even be a manifestation of an underlying systemic disease. Multiple myeloma represents a clonal proliferation of plasma cells and is a condition in which a parotid swelling might be present, although very uncommon.

CASE PRESENTATION

We report a case of 60-year-old female presented with unilateral parotid swelling, which led to a diagnosis of multiple myeloma based on the investigations.

CONCLUSION

Various imaging modalities are currently available to assess the extent of the swelling and evaluate the soft tissue and osseous involvement. The clinician must have a rigorous insight into the several clinical manifestations and the sites of involvement of the different conditions to make a proper diagnosis.

Rare Distribution of Sclerotic Bony Lesions in Multiple Myeloma: A Case Report

ABSTRACT

A 66-year-old man was referred to our hospital due to a newly discovered left chest wall mass, which was diagnosed as plasmacytoma on biopsy. The patient underwent 18F-FDG PET/CT scanning before treatment. PET imaging revealed intense FDG signal in osseous lesions, and the CT showed most of the lesions were osteoblastic. The osseous lesions were predominantly localized to the humerus, femur, tibia, and phalanx of toe.

The status of jaw lesions and medication-related osteonecrosis of jaw in patients with multiple myeloma

BACKGROUND/PURPOSE

Myeloma jaw lesions are not uncommon. The study aimed to investigate the status of jaw lesions and medication-related osteonecrosis of jaw (MRONJ) in multiple myeloma (MM) patients.

METHODS

One hundred and twenty-two consecutive newly-diagnosed MM patients seeking dental care at a hospital of southern Taiwan was examined according to jaw lesions with complete follow-up data.

RESULTS

Median age of the patients was 67.8 years, and 88.5% of patients were of DS stage III and 41.0% were of ISS stage III at diagnosis. Median survival was 37.9 months for 43 (35.2%) patients with jaw lesions and 57.4 months for 79 patients without jaw lesions. 1-year, 5-year and >7-year overall survival rates for patients with jaw lesions versus patients without jaw lesions were 94.9%, 67.2%, 56.7% vs 83.7%, 51.8%, 26.8% respectively. Patients with jaw lesions had the worse survival (P = 0.03). Neither age nor stage affected survival. Jaw lesions involved the mandible more often than the maxilla and stopped progressing during remission, but did not repair. Jaw lesions were the first evidence or recurrent sign of MM in six (4.9%) patients. Long-term monthly antiresorptive therapy changed the radiographic patterns of jawbones and induced MRONJ developing in 16.7% (8/48) of patients. Five (62.5%) MRONJ sites spontaneously occurred without local risk factors.

CONCLUSION

Nearly one-third of MM patients develop osteolytic jaw lesions that seem to be associated with poorer survival. Jaw lesion is an independent prognostic predictor of survival in myeloma. Antiresorptive drugs at less frequent dosing regimen are crucial to minimize spontaneous MRONJ.

A Wolf in Sheep's clothing: A case report series of oral manifestations of multiple myeloma

Multiple myeloma is the most common haematological malignancy accounting for 10 % of all haematological cancers. Treatment of myeloma has evolved in recent years leading to improved survival. Lesions related to myeloma are frequently observed within the oral cavity and jawbone. In addition, many of the therapeutic agents have side effects with implications for provision of dental treatment. This case series aims to highlight some of these presentations to remind dental practitioners to be vigilant. Observation of suspicious lesions within the oral cavity or jawbone might warrant further investigation.

Radiographic patterns of multiple myeloma in the jawbones of patients treated with intravenous bisphosphonates

BACKGROUND

The purpose of this study was to evaluate whether intravenous (IV) bisphosphonate (BP) therapy can change the radiographic patterns of multiple myeloma (MM) in the jawbones.

METHODS

The authors evaluated panoramic radiographs obtained from 188 patients with MM for the presence of solitary osteolytic lesions, multiple osteolytic lesions, diffuse osteoporosis, diffuse sclerosis, lamina dura abnormalities, nonhealing alveolar sockets, and bone sequestration. The authors compared results obtained from patients treated with IV BPs with those obtained from patients who had never been exposed to BPs.

RESULTS

Multiple osteolytic lesions (P = .001), diffuse osteoporosis (P = .001), and diffuse sclerosis (P = .0036) occurred more often in the mandible in both groups. Solitary osteolytic lesions occurred less frequently in the BP group (P = .0078). Lamina dura abnormalities (P = .0006) and nonhealing alveolar sockets (P = .0021) were associated with BP treatment.

CONCLUSIONS

IV BP therapy changes the radiographic patterns of MM in the jawbones.

PRACTICAL IMPLICATIONS

The effect of BPs in the maxillofacial area is a matter of concern for health practitioners because this type of medication causes several alterations of the jawbones in patients with cancer.

Oral health status of patients with multiple myeloma

Objective

To describe the oral health status of patients with multiple myeloma and compare to a control group.

Materials and methods

The medical history of the studied subjects was obtained from the medical records and through interviews. Trained examiners evaluated the oral mucosa, teeth, periodontium and imaging aspects. The dental status was evaluated by the decayed, missing and filled teeth index. The presence of bone lesions was investigated with cone beam computer tomography images of the jaws.

Results

The most common oral mucosa features were paleness (31%) and coated tongue (14.3%) in the multiple myeloma group (N = 42); and coated (21.4%) and fissured tongue (10.7%) in the control group (N = 28). The mean DMFT index of patients with multiple myeloma was high, but not significantly different from controls (14.57 versus 19.69, p = 0.975). Hypodense lesions suggestive of multiple myeloma were observed in the jaws of 73.8% of the patients. Hypodense lesions related to teeth were detected in 33.3% of the patients and in 53.6% of the controls (p = 0.832).

Conclusions

The studied population of multiple myeloma patients presented many oral health issues that needed attention. Thus, oral care should be included in the routine treatment to improve the quality of the oral status in these patients.

Imaginological characterization of multiple myeloma lesions of the jaws through cone-beam computed tomography

PURPOSE

To establish an evaluation protocol for the identification and description of the variations in multiple myeloma (MM) lesions of the jaws, by means of cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Tomography exams from 33 MM patients were evaluated in this retrospective observational study. The reconstructions were analyzed simultaneously, according to the established protocol, with the following description criteria: anatomic location, size, margins, inner aspect, relationship with adjacent structures, and presence or absence of a punched-out aspect. The exams were further subdivided into groups of patients using, or not bisphosphonates.

RESULTS

There were osteolytic lesions in 100% of cases, most of which were extended to more than one anatomical region. Poorly defined margins were more frequent in the maxilla than in the mandible. Extensive bone resorption presenting multilocular areas was the most frequently observed aspect, being 86.2% for maxilla and 87.9% for mandible. In relation to bisphosphonates, patients who used the medication had more poorly defined bone margins and contortions (68.6%) than those who did not undergo drug therapy (31.4%). No well-defined lesions were observed (p = 0.34%).

CONCLUSION

It was possible to establish a protocol for evaluation of MM lesions in CBCT images and to identify that when evaluated three-dimensional, lesions tend to be poorly defined and have no pattern of description, as described in two-dimensional "punched-out".

Twenty classic signs in oral and maxillofacial radiology

Teachers of radiology often employ the use of classic signs to help learners identify the typical appearance of various pathologies. This article is a compendium of simply-described classic signs in oral and maxillofacial radiology, including their use in differential diagnoses.

Solitary Plasmacytoma of the Jaw Occurring in an Elderly Woman Affected by Hepatitis C Virus Infection: A Case Report

Solitary plasmacytoma accounts for a small percentage of plasma cell neoplasms. The disease often affects older people and is potentially curable. Only a few cases of solitary jaw plasmacytoma have been described in the literature. Here we report the case of a 76-year-old woman affected by chronic hepatitis C infection and isolated plasmacytoma of the left jaw. Plasmacytoma was diagnosed in January 2001, but the swelling of the mandible had been present since 1993. Two different pathologists made the diagnosis on the basis of biopsy material from the mandibular swelling.

Panoramic and skull imaging may aid in the identification of multiple myeloma lesions

BACKGROUND

The purpose of this study was to investigate the presence of punched-out lesions in craniofacial bones using three different radiographic protocols in a large cohort of patients.

MATERIAL AND METHODS

One hundred fifty-five MM patients were evaluated using panoramic and skull (frontal and lateral) radiographs, which were performed in all patients at the time of MM diagnosis. The diagnostic potential for detecting punched-out lesions was compared among the radiographic techniques.

RESULTS

MM punched-out lesions were identified in 135 (87%) panoramic radiographs, 141 (91%) frontal and 144 (93%) lateral skull radiographs. Punched out-lesions were synchronously present in skull and jawbones in 129 (83.23 %) cases. The lesions were detected exclusively in skull in 18 (11.61%) cases and exclusively in jawbones in 6 (3.87%) cases. Punched out-lesion mainly affected the skull and the jawbones in a synchronous way (p<0.001) rather than separately.

CONCLUSIONS

All investigated radiographic techniques (panoramic, frontal and lateral skull approaches) demonstrated high detection rates for MM punched-out lesions in craniofacial bones. Panoramic radiography may aid to the radiographic protocols to identify multiple myeloma bone lesions.

Can dentists detect multiple myeloma through oral manifestations?

Objective

To review published data on oral manifestations of multiple myeloma.

Methods

An electronic database search was performed of articles published from 1971 to November 2016 in order to identify studies that reported oral manifestations of patients with multiple myeloma. Case reports and case series with oral manifestations of multiple myeloma in English were included in the study. An additional search was performed of the references of the selected articles.

Results

Thirty-seven articles that reported 81 patients with oral manifestations of multiple myeloma were selected: 30 case reports (82%) and seven case series (18%). The most common clinical features in the dental cavity were swelling (65.4%), bone pain (33.3%), paresthesia (27.1%) and amyloidosis lesions (11.1%). Osteolytic lesions detected on imaging exams were reported in the majority of the patients (90.1%) as plasmacytomas or ‘punched-out’ lesions.

Conclusions

Swelling and osteolytic lesions represent the most common clinical and radiographic signs of the jaws relating to multiple myeloma, respectively.

Malignant Lesions in the Dentomaxillofacial Complex

Malignancies in the maxillofacial region are rare but comprise a broad spectrum of lesions. Given the potential for malignancies to mimic dental/sinus/temporomandibular joint pathology or remain asymptomatic, the judicious radiologist will be familiar with the initial and unique malignant changes affecting the dentition, periodontium, and supporting osseous structures on conventional film, dental, and sinus imaging. This article is meant to serve as a complement to the many excellent texts dedicated to advanced imaging techniques for the staging of known malignancies. The lesions discussed are a representative sample of malignancies involving hard tissues of the maxillofacial complex but are far from complete.

Amyloidosis Presenting as Macroglossia and Restricted Tongue Movement

Amyloidosis (AL) is a well recognized cause of macroglossia. A case of localized deposition of systemic amyloidosis secondary to multiple myeloma is reported in a 63-year-old female presenting with restricted tongue movement in the dental setting. Amyloidosis secondary to multiple myeloma is well documented in the literature, with amyloid deposits being found at various sites throughout the oral cavity and systemically. This case emphasizes the importance of a full oral soft tissue examination, including the need to examine mobility of the tissues, as it was the restricted movement of the tongue that ultimately alerted the clinician to the diagnosis. This report also highlights other dental implications of managing patients with multiple myeloma and amyloidosis. Clinical relevance: To provide an understanding of what multiple myeloma and amyloidosis are whilst, importantly, relating this to how these conditions can impact on routine dental treatment.

Cancer and Referred Facial Pain

Orofacial pain may be a symptom of diverse types of cancers as a result of local or distant tumor effects. The pain can be presented with the same characteristics as any other orofacial pain disorder, and this should be recognized by the clinician. Orofacial pain also can arise as a consequence of cancer therapy. In the present article, we review the mechanisms of cancer-associated facial pain, its clinical presentation, and cancer therapy associated with orofacial pain.

Multimodality imaging of osseous involvement In haematological malignancies

The purpose of this article is to provide a comprehensive review of the imaging features of osseous involvement in haematological malignancies. Osseous involvement can be seen in various haematological malignancies including lymphomas, plasma cell neoplasms, leukaemias and myeloproliferative neoplasms. Imaging plays a crucial role in initial diagnosis, staging and in the assessment of treatment response in these patients.

Maxillary Swelling as the First Evidence of Multiple Myeloma

Multiple myeloma is a malignant neoplasm of plasma cells characterized by proliferation of a single clone of abnormal immunoglobulin-secreting plasma cells. Since the amount of hemopoietic bone marrow is decreased in the maxilla, oral manifestations of multiple myeloma are less common in the maxilla than in the mandible. We report the case of 33-year-old Japanese man who presented with a mass in the right maxillary alveolar region. Computed tomography and magnetic resonance images showed a soft tissue mass in the right maxilla eroding the anterior and lateral walls of the maxillary sinus and extending into the buccal space. The biopsy results, imaging, and laboratory investigations led to the diagnosis of multiple myeloma. This case report suggests that oral surgeons and dentists should properly address oral manifestations as first indications of multiple myeloma.

Facial Swelling as a Primary Manifestation of Multiple Myeloma

Facial swellings are commonly encountered in the dental office, the cause of which could range from a congenital etiology to an acquired one or it may even be a manifestation of an underlying systemic disease. The clinician must have a thorough knowledge of the various clinical and imaging manifestations and the sites of occurrence of the various conditions to arrive at the appropriate diagnosis. Facial swellings can be classified into different groups which include acute swellings with inflammation, nonprogressive swellings, and slowly or rapidly progressive swellings. The various imaging modalities like CT and MRI are useful for assessing the extent of the swelling as well as evaluating the soft tissue and osseous involvement of the swelling. Multiple myeloma represents clonal proliferation of plasma cells and is a condition in which a facial swelling might be present, though not common. This paper reports a case of a patient with a unilateral facial swelling, which on investigation led to a diagnosis of multiple myeloma.

Multiple myeloma presenting with a maxillary lesion as the first sign

Multiple myeloma is a clonal neoplastic proliferation of terminally differentiated B-lymphocytes involving the skeletal system in a multifocal fashion. Its oral manifestations are less common in the maxilla than in the mandible due to the lower amount of hemopoietic bone marrow in the maxilla. We report the case of a 50-year-old man who presented with a mass in the left maxillary alveolar region with tooth mobility. The mass had become enlarged after the teeth were extracted 15 days previously. Radiographs demonstrated multiple punched-out radiolucent lesions in the skull and pelvic region. Computed tomography images showed a soft tissue density mass in the left maxilla, eroding the floor and walls of the maxillary sinus. Although several analytical techniques were used to characterize the lesion, it was finally confirmed as multiple myeloma through immunohistochemistry.

Multiple myeloma presenting as plasmacytoma of the jaws showing prominent bone formation during chemotherapy

A 65-year-old female visited our hospital complaining of a swelling on the left cheek area of 2 years' duration. A panoramic radiograph revealed an ill-defined osteolytic radiolucent bony lesion involving the left mandibular angle, ascending ramus, coronoid process and condylar process. Histological examination showed the mandibular lesion to be a plasmacytoma, and a systemic work-up was obtained to rule out multiple myeloma. Contrast-enhanced CT images showed a well-defined and slightly enhanced round mass on the left ramal area, accompanied by the destruction of the left ramus and posterior maxilla. An (18)F-fluorodeoxy-glucose positron emission tomography CT ((18)F-FDG PET/CT) scan revealed a hypermetabolic mass extending from the left mandible to the left maxillary sinus. The patient had M-protein in serum and urine, plasma cells up to 36.5% on bone marrow biopsy and anaemia as a clinical complication. The patient was diagnosed with multiple myeloma and received chemotherapy with thalidomide, cyclophosphamide and dexamethasone. A PET/CT scan taken 6 months later revealed that the hypermetabolic mass had disappeared and there was remarkable bone formation on the left mandible compared with a previous PET/CT scan. A panoramic radiograph taken 8 months later also demonstrated a prominent bone formation of the affected site. To the best of our knowledge, the current case is the first report of multiple myeloma presenting as plasmacytoma of the mandible with an FDG PET/CT scan. The lesion was solitary at diagnosis, and remarkable bone formation was newly observed on the radiographic examination during chemotherapy.

Radiologic bone loss in patients with bisphosphonate-associated osteonecrosis of the jaws: a case-control study

OBJECTIVES

Most patients with bisphosphonate-associated osteonecrosis of the jaws (BP-ONJ) report a previous tooth extraction at the necrosis site before the diagnosis was made. At older ages, most teeth are extracted due to periodontal disease, which is per se another BP-ONJ trigger factor. The aim of this study was to evaluate the periodontal status of BP-ONJ patients using panoramic radiographs compared to a control.

MATERIALS AND METHODS

All patients treated for BP-ONJ up to January 1, 2010 comprised the study. The very first panoramic radiograph was analyzed. The number of remaining teeth and the radiographic bone loss from the cemento-enamel junction to the crestal bone were measured. For each patient, one control was analyzed (matching for gender and age).

RESULTS

One hundred twenty-nine BP-ONJ panoramic radiographs and 129 controls were analyzed (68 women, 61 men; 67.3 ± 9.7 years; osteoporosis [n = 11], breast cancer [n = 33], multiple myeloma [n = 61], prostate cancer [n = 24]). The average number of remaining teeth was 12.9 ± 8.4 for BP-ONJ and 16.4 ± 9.4 for the control (p = 0.02). The average radiographic bone loss was 5.5 ± 2.3 mm for BP-ONJ and 3.1 ± 1.1 mm for the control (p < 0.001); 96.6 % of BP-ONJ and 77.5 % had radiographic bone loss of more than 5 mm. Radiographic bone loss in the molar region was the highest for both groups (BP-ONJ 6.0 ± 2.3 mm; control 3.6 ± 1.4 mm).

CONCLUSION

Prevalence and severity of periodontal disease in patients with BP-ONJ is higher compared to healthy controls.

CLINICAL RELEVANCE

Patients with periodontal disease might be at a higher risk of developing BP-ONJ; therefore, periodontal disease therapy in patients who are about to receive bisphosphonates should be undertaken.

Abnormal radiological features in a multiple myeloma patient: a case report and radiological review of myelomas

Multiple myeloma is the prototype of malignant monoclonal gammopathies. The most common skeletal sites are pelvis, skull, spine, ribs and femoral and humeral shafts. The classic radiographic presentation of multiple myeloma is lytic skeletal lesions. Other types of presentation include sclerotic and porotic changes. Primary sclerotic manifestations are rare and occur in only 3% of cases. Although exceptional, multiple myeloma must be borne in mind in the presence of bone sclerosis. This report presents a patient with multiple myeloma with a sunburst/hair-on-end pattern on the radiograph and sclerotic skeletal lesions.

Pathologic mandibular fracture as the presenting manifestation of multiple myeloma

The authors report on the management of a patient who presented with a pathologic mandibular fracture as the initial presenting sign of multiple myeloma. The patient underwent surgical resection of the mandibular area involved by the pathologic fracture and osteolytic lesion. Then, he was prescribed combined thalidomide, melphalan, and prednisone for systemic treatment. The patient tolerated his treatment well and is currently being followed up on outpatient basis. The treatment of a mandibular pathologic fracture associated with a solitary multiple myeloma lesion should include a segmental resection of the mandibular bone that is involved by the lesion. An appropriate reconstruction can be immediately performed or delayed. Anyway, the importance of an early beginning of systemic treatment should always be remembered.

Multiple Myeloma presenting as Gingival mass

Maxillofacial presentations in patients with multiple myeloma are not uncommon, but multiple myeloma is often overlooked. Because the symptoms are various, it is very difficult to diagnose multiple myeloma in the oral and maxillofacial region. On the basis of the pathologic and clinical findings, the patient was diagnosed with multiple myeloma. Hematologic screening and a radiographic survey further confirmed the diagnosis.

Acute lymphoblastic leukaemia: an unusual radiological presentation

A 14-year-old female patient attended Bristol Dental Hospital for an oral screening prior to undergoing a bone marrow transplant as treatment for her acute lymphoblastic leukaemia. Maxillofacial radiographs revealed multiple, well-defined, non-corticated radiolucent lesions throughout the vault of her skull and mandible. These radiological features (coupled with the patient's age) would have correlated with a diagnosis of Langerhans cell histiocytosis. However, a previous bone marrow biopsy confirmed that the patient did indeed have acute lymphoblastic leukaemia. The lytic lesions were present throughout her entire skeletal frame and had previously led to episodes of leg and abdominal pain. We feel that this radiological presentation of leukaemia needs to be reported as these features could easily have been confused with other haematological or even malignant conditions.

Extramedullary myeloma in an HIV-seropositive subject. Literature review and report of an unusual case

Myeloma is characterized by monoclonal bone marrow plasmacytosis, the presence of M-protein in serum and/or in urine and osteolytic bone lesions. HIV-seropositive subjects with myeloma are younger at the time of diagnosis of the tumour and usually the myeloma has a more aggressive clinical course than it does in HIV-seronegative subjects.

A case of an HIV-seropositive woman in whom myeloma was diagnosed following progressive swelling of the face, is reported. In addition to bone marrow plasmacytosis and the presence of M-protein in the serum, the patient had an extramedullary lesion affecting the oral cavity, maxilla, parotid gland and paranasal sinuses, and extending intracranially and intraorbitally.

Plasmacytoma of the mandible associated with a dental implant failure: a clinical report

The case report of a patient is presented who had been suffering from a plasmacytoma of the spine several years back, and who had developed a new plasmacytoma of the mandible, 3 years subsequent to the insertion of a dental implant. This second solitary lesion occurred 15 years after the first one, and without signs of conversion to multiple myeloma. Research in animal models has shown multinucleated giant cells, belonging to the monocyte-macrophage lineage, persisting between the titanium surface and the lymphohemopoietic compartment, at least 1.5 years after implant insertion. Factors that increase the proliferative activity of precursor B cells, for example a protracted macrophage activation, are likely to increase the risk of B cell oncogenesis. A possible role of the titanium surface in an increase of precursor B cell proliferative activity, thus facilitating a new localization, was evaluated.

Orofacial pain in cancer: part II--clinical perspectives and management

Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.

Jaw osteonecrosis associated with use of bisphosphonates and chemotherapy: paradoxical complication of treatment of bone lesions in multiple myeloma patients

It has been demonstrated that bisphosphonate-based supportive therapy (pamidronate or zoledronate) reduces skeletal events (onset or progression of osteolytic lesions) both in patients with multiple myeloma (MM) and in cancer patients with bone metastasis. Bisphosphonates (eg, alendronate) are also indicated in the treatment of osteoporosis. Nevertheless, osteonecrosis of the jaw (ONJ) has been reported in some patients being treated with bisphosphonates. We present a series of 9 MM patients who developed ONJ after treatment with bisphosphonates and chemotherapy. All the patients in this case series had undergone tooth extraction for recurrent dental abscesses while taking bisphosphonates. We also review the diagnostic and therapeutic implications of this paradoxical complication associated with treatment of bone lesions in MM.

Radiologic and pathologic characteristics of benign and malignant lesions of the mandible

Mandibular lesions develop from both odontogenic and nonodontogenic origins and have varying degrees of destructive potential. Common benign cystic lesions include periapical (radicular) cysts, follicular (dentigerous) cysts, and odontogenic keratocysts. Benign solid tumors represent a broad spectrum of lesions such as ameloblastomas, odontomas, ossifying fibromas, and periapical cemental dysplasia. Malignant tumors that often involve the mandible include squamous cell carcinomas, osteosarcomas, and metastatic tumors. In addition, vascular lesions such as hemangiomas and arteriovenous malformations may develop, further expanding the differential diagnosis. Because mandibular lesions have a wide range of pathologic features but similar imaging appearances, familiarity with embryologic characteristics and secondary findings is crucial. Patient age at manifestation, prevalence, location within the mandible, cystic or solid appearance, border contour, and effect of the lesion on adjacent structures are all considerations in making the diagnosis. Despite this information, however, many lesions are impossible to differentiate without biopsy. In such cases, defining the degree of malignant potential is very helpful. Although imaging will not always provide a specific diagnosis, it should help narrow the differential diagnosis, thereby helping to guide patient treatment.

Unusual combination of presenting features in multiple myeloma

Initial oral signs of multiple myeloma may involve pain, paraesthesia, swelling, tooth mobility and radiolucency. A 62-year-old female patient presented with the chief complaint of numbness in the right lower jaw. Intraoral examination revealed no abnormalities and her history was non-contributory. A panoramic radiograph revealed an irregular, small radiopacity in the premolar region and small, multiple and diffuse osteolytic alterations in the mandible. Computed tomography revealed maxillary and mandibular cortical destruction. An incisional biopsy was performed. The histopathological diagnosis was plasma cell myeloma and further investigations lead to the diagnosis of multiple myeloma. Dysfunction of a nerve coursing through diseased bone is an ominous sign and may be an indication that a malignant process is present.

Neurologic Complications of Plasma Cell Disorders

Plasma cell disorders are associated with a wide spectrum of neurologic complications that predominantly involve the peripheral nervous system. Distinct clinical syndromes have been recognized, and antibodies to several glycoproteins of the peripheral nervous system have been identified. The main clinical, laboratory, immunologic, and pathologic features of neurologic complications that occur in patients with monoclonal gammopathies of unknown significance, multiple myeloma, plasmacytoma, plasma cell leukemia, Waldenstrom's macroglobulinemia, and immunoglobulin-related amyloidosis are summarized in this review. Knowledge of the pathogenesis in this group of disorders has increased in recent years, allowing better diagnosis and treatment.

Unusual presentation of multiple myeloma with unilateral visual loss and numb chin syndrome in a young adult

A 39-year-old man presented with unilateral visual loss as the first sign of multiple myeloma (MM). His visual loss was due to a plasmacytoma in the sphenoid sinus compressing the optic nerve with resultant optic nerve atrophy. Shortly after this presentation he developed numb chin syndrome due to a mandibular plasmocytoma compressing the mental nerve. His MM progressed rapidly despite treatment with high-dose steroids and alkylating agents and he required allogeneic bone marrow transplantation in order to achieve a remission. We reviewed the published medical literature on the presentation of MM with visual impairment and present a summary in tabular form in this paper. This is the first reported case of MM presenting with isolated complete visual loss due to intracranial extrinsic compression of the optic nerve since the advent of modern cross-sectional imaging. Multiple myeloma needs to be included in the differential diagnosis of cranial neuropathies and skull base neoplasms even in adults under 40 years of age.